It is the last work day! One of the attendings did not show up so me and another attending split the patients of the floor between us and rounded on all of them. Thank God for residency training that prepares you to deal with increased workloads.
One of the hard parts of COVID-19 care is wearing the P95 mask, face shield, gown and gloves for the hours spent in patients' rooms. However, I have to say that compared to the heat of Sierra Leone during the Ebola outbreak, this is not bad at all.
The day was pretty much the same as the previous ones. One 73 year old admitted to another team a few days ago and on whom I rounded yesterday is actively dying. She had made it clear before that she did not want to be intubated. Her blood pressure fell and she is on BiPaP (at the time of this writing). I anticipate that she may die before the shift is over at 8 pm.
So the COVID-19 week in NYC is over. All that is left is to travel back to Buffalo tomorrow. I am grateful for the chance to experience this and be of service. I have made memories of this COVID-19 pandemic up close and personal as a front-line provider. My feelings are mixed: the world has changed on us with COVID-19. On the other hand, just as in the Ebola outbreak, the toll from COVID-19 directly is not as heavy as the toll from people with chronic diseases not getting the care they need in a timely fashion. Systems are working sluggishly, partially shut down and life has changed.
Sunday, May 31, 2020
COVID-19 tour Days #6, 7
I am writing one entry for 2 days. The days have been busy. We have been getting admissions from the Emergency Department -- people with anything from congestive heart failure to generalized weakness to confusion … the typical admissions of a general Medical ward. The only twist: COVID-pending or COVID-positive.
The good news: no-one in my ward has needed intensive care treatment or died from COVID-19. The bad news: wow! We admitted a 31 year old young lady that was quite confused. We did a blood gas on her that showed a pH of 7.64 and a pCO2 of 15! Hitherto, I would not have thought this compatible with life. At the least I would have thought she would need to be in the ICU. I had a hard time convincing my resident that was respiratory alkalosis due to her mental illness and strange breathing. We had to recheck her blood gas. I am proud to say that after all these years of not having done an arterial stick, I got it in the first try after the resident could not get it with ultrasound.
After much struggle, she got an IV. After a night of sleep (thanks to Haldol 2mg), her blood gas was pH 7.4 and pCO2 of 36.
We have had a couple of sad old ladies admitted for generalized weakness and failure to thrive. They live alone. One told me, "the only person I have to talk to is the television. I used to go the Senior Center and play bingo but they closed with COVID."
The good news: no-one in my ward has needed intensive care treatment or died from COVID-19. The bad news: wow! We admitted a 31 year old young lady that was quite confused. We did a blood gas on her that showed a pH of 7.64 and a pCO2 of 15! Hitherto, I would not have thought this compatible with life. At the least I would have thought she would need to be in the ICU. I had a hard time convincing my resident that was respiratory alkalosis due to her mental illness and strange breathing. We had to recheck her blood gas. I am proud to say that after all these years of not having done an arterial stick, I got it in the first try after the resident could not get it with ultrasound.
After much struggle, she got an IV. After a night of sleep (thanks to Haldol 2mg), her blood gas was pH 7.4 and pCO2 of 36.
We have had a couple of sad old ladies admitted for generalized weakness and failure to thrive. They live alone. One told me, "the only person I have to talk to is the television. I used to go the Senior Center and play bingo but they closed with COVID."
Thursday, May 28, 2020
COVID-19 tour Day #5
We are getting busier... not because of a second wave of COVID-19, but because sick people feel a little more comfortable coming to the hospital. We just got a patient with a triglyceride level of 6000 (normal is less than 150). He was on medication but could not afford it and insurance would not cover it. So he ended up in the intensive care and is now transferred to us. He is, of course, COVID-positive.
The day passes quickly. Rounds take longer because we need to put on PPE for every room, take it off and wash our hands and stethoscopes when we come out and do it all again for the next patient. Breathing through a well-fitted N95 is difficult. If it isn't, then the mask does not have a good seal and is not on right.
I am getting a little tired, physically but more so emotionally. It shouldn't bother me, but it does discourage me: I have met very few volunteers. Most of the doctors and nurses who responded to the call for help came through an agency and are being paid a great deal of money to be here. I, on the other hand, had to take vacation days and because I did not give 60 days notice, will return to give up my research days to see patients to make up for sessions I missed. It's also been a little expensive living away from home, although I am grateful the hotel is paid for. I spend money on coffee, breakfast and dinner and because restaurants aren't open, I end up paying for some delivery too.
Anyway, I remind myself that I am doing this because I am a Christian and I go where I am commanded. God has been faithful. My needs are provided for -- one way or the other, I am safe and I am making a difference in the lives of the people -- patients, staff, others that I touch.
The day passes quickly. Rounds take longer because we need to put on PPE for every room, take it off and wash our hands and stethoscopes when we come out and do it all again for the next patient. Breathing through a well-fitted N95 is difficult. If it isn't, then the mask does not have a good seal and is not on right.
I am getting a little tired, physically but more so emotionally. It shouldn't bother me, but it does discourage me: I have met very few volunteers. Most of the doctors and nurses who responded to the call for help came through an agency and are being paid a great deal of money to be here. I, on the other hand, had to take vacation days and because I did not give 60 days notice, will return to give up my research days to see patients to make up for sessions I missed. It's also been a little expensive living away from home, although I am grateful the hotel is paid for. I spend money on coffee, breakfast and dinner and because restaurants aren't open, I end up paying for some delivery too.
Anyway, I remind myself that I am doing this because I am a Christian and I go where I am commanded. God has been faithful. My needs are provided for -- one way or the other, I am safe and I am making a difference in the lives of the people -- patients, staff, others that I touch.
COVID-19 Tour Day #4
Another day on the COVID ward. My impression of Woodhull Hospital in Brooklyn: the hospital seems to serve a very diverse population of mostly poor people. The diversity here is staggering. There are very few white people (to put it crudely). There is a large Puerto Rican population, African American population, people from the islands (Jamaica, especially), Polish (many of whom speak no English though they are in the 60s and above). The doctors (including the residents) seem to come from all over the world. Hearing the nurses on the wards, one hears a number of accents -- several African ones too.
I have been impressed with the severity of illness in the patients here and COVID seems in most of them like the least of their problems. We took off 5.9 L of fluid (ascites) from a gentleman that had alcoholic liver cirrhosis and now hepatorenal syndrome. He needs a liver transplant. The resident (intern) did it with no hesitation. It seems they do so many paracenteses here that most of them are credentialed in the first half of the year. We have a diabetic (HbA1c of 13.6%) who has dry gangrene of a left foot due to occlusion of his distal popliteal artery. He shall be getting a below the knee amputation. Another female -- a 37 year old female came in with a magnesium level of 0.8, a calcium of 6, potassium of 2.8 in tetany. Etiology is uncertain but suspicious for poor nutrition and alcohol use. Another gentleman had bad hypertension that has remodeled his heart. His ejection fracture is 6%! We had a young lady (23 year old) been drinking since 18 who came in with a long QT syndrome (QTC 560 ms) due to taking too much Zofran for vomiting from withdrawals from alcohol. She refused all detox treatment and asked to be discharged in 2 days when we would not give her the sedative medication she wanted.
People come to our ward COVID-suspect. Some leave with their test results still pending, because they are medically well. We had one gentleman who came in with COVID with pneumonia and shortness of breath. He did okay. The time came for discharge -- as he was recovered, but he was still COVID-positive. His 70 year old mother did not want him to return home. He is an invalid (left below the knee amputation, right foot 2 toes amputated, obese, noncompliant with treatment. He refused to go to a hotel or inn or shelter (we would have made arrangements) and because he did not lack capacity to make decisions, we had to send him home.
Walking down the street, taking the subway, I see a dirty city with shoddy people. Yesterday, I saw a mouse pop up between the cement tiles of my hotel parking area? There is sewage visible in the sewer.
I have seen NYC. I know that every place is not like this. But it does make me sad to see how people are at least in this little part of town.
The hospital could use more staff, doctors, nurses, facilities. They are doing the best they can with what they have.
I have been impressed with the severity of illness in the patients here and COVID seems in most of them like the least of their problems. We took off 5.9 L of fluid (ascites) from a gentleman that had alcoholic liver cirrhosis and now hepatorenal syndrome. He needs a liver transplant. The resident (intern) did it with no hesitation. It seems they do so many paracenteses here that most of them are credentialed in the first half of the year. We have a diabetic (HbA1c of 13.6%) who has dry gangrene of a left foot due to occlusion of his distal popliteal artery. He shall be getting a below the knee amputation. Another female -- a 37 year old female came in with a magnesium level of 0.8, a calcium of 6, potassium of 2.8 in tetany. Etiology is uncertain but suspicious for poor nutrition and alcohol use. Another gentleman had bad hypertension that has remodeled his heart. His ejection fracture is 6%! We had a young lady (23 year old) been drinking since 18 who came in with a long QT syndrome (QTC 560 ms) due to taking too much Zofran for vomiting from withdrawals from alcohol. She refused all detox treatment and asked to be discharged in 2 days when we would not give her the sedative medication she wanted.
People come to our ward COVID-suspect. Some leave with their test results still pending, because they are medically well. We had one gentleman who came in with COVID with pneumonia and shortness of breath. He did okay. The time came for discharge -- as he was recovered, but he was still COVID-positive. His 70 year old mother did not want him to return home. He is an invalid (left below the knee amputation, right foot 2 toes amputated, obese, noncompliant with treatment. He refused to go to a hotel or inn or shelter (we would have made arrangements) and because he did not lack capacity to make decisions, we had to send him home.
Walking down the street, taking the subway, I see a dirty city with shoddy people. Yesterday, I saw a mouse pop up between the cement tiles of my hotel parking area? There is sewage visible in the sewer.
I have seen NYC. I know that every place is not like this. But it does make me sad to see how people are at least in this little part of town.
The hospital could use more staff, doctors, nurses, facilities. They are doing the best they can with what they have.
Tuesday, May 26, 2020
COVID-19 Tour Day #3
It was good to come into work today. Yesterday was Memorial Day and today is the first day of work for most people after the long weekend. I have been walking around with a temporary ID and hope to get a real one today. I am also down to my last set of home scrubs and hope to get scrubs from the scrubs machine on the 9th floor today.
I began to day by checking in with Dr. Z -- the Chair of Internal Medicine. After a brief welcome, I got my wish: I am assigned as the Attending Physician of 8200 -- the COVID ward! I shall spend the rest of my tour here.
Excitedly, I got my PPE and headed off to meet the team. I have a nurse practitioner, Judy Osuoha and an internal medicine intern (soon to be become a second year), Felix Filias. That's it: the 3 of us managing a 3rd of the COVID ward. We started out with 8 patients and got a 9th before the day was over.
Our cases were all interesting. They all had COVID and... One patient had renal and liver failure, another a gangrenous foot, another advanced SLE and so forth. There were some medical mysteries which were fun to tease apart. Nobody dying (yet?).
The day went by quickly.
I should say something about Brooklyn and Woodhull. It is VERY diverse: the doctors, nurses, patients and people out on the streets have so many different accents, languages and ethnic origins. A patient I saw yesterday spoke only Polish and we struggled with a phone interpreter who could not make out what the patient was saying as his speech was slurred from alcohol. I happily chatted in Spanish with several of my patients. The place is a little global community.
So far, I feel well. I have intermittently had a little cough and some nose sniffing but these symptoms resolve. Lots of hand washing and putting on and putting off PPE. Reminds me a little of Sierra Leone, but not as bleak.
I began to day by checking in with Dr. Z -- the Chair of Internal Medicine. After a brief welcome, I got my wish: I am assigned as the Attending Physician of 8200 -- the COVID ward! I shall spend the rest of my tour here.
Excitedly, I got my PPE and headed off to meet the team. I have a nurse practitioner, Judy Osuoha and an internal medicine intern (soon to be become a second year), Felix Filias. That's it: the 3 of us managing a 3rd of the COVID ward. We started out with 8 patients and got a 9th before the day was over.
Our cases were all interesting. They all had COVID and... One patient had renal and liver failure, another a gangrenous foot, another advanced SLE and so forth. There were some medical mysteries which were fun to tease apart. Nobody dying (yet?).
The day went by quickly.
I should say something about Brooklyn and Woodhull. It is VERY diverse: the doctors, nurses, patients and people out on the streets have so many different accents, languages and ethnic origins. A patient I saw yesterday spoke only Polish and we struggled with a phone interpreter who could not make out what the patient was saying as his speech was slurred from alcohol. I happily chatted in Spanish with several of my patients. The place is a little global community.
So far, I feel well. I have intermittently had a little cough and some nose sniffing but these symptoms resolve. Lots of hand washing and putting on and putting off PPE. Reminds me a little of Sierra Leone, but not as bleak.
COVID-19 Tour Day #2
Today is May 25, 2020. I came to work at 8 am. The first thing we did was go through the admissions that happened overnight. Everyone is of course, tested for COVID-19. Since we have run out of the rapid tests, they all got the PCR test, which takes 2-4 days to return results. Until then, they are considered PUI (patients under investigation).
Of course, what strikes me is that COVID or no COVID, people get sick and usually what you end up treating is not just COVID but COVID and...
We admitted a lady that had a blood clot is her lung (pulmonary embolus). She became progressively hypotensive and we had to put a central line in her in the ED. The procedure went well (no complications). Her blood pressure began to stabilize.
The saddest patient of the day was a homeless guy found naked on the street and unresponsive. I learned that he was frequently brought to the ED where a shot of Narcan would wake him up and be would become combative and belligerent. This time was no different. The ED was going to discharge him when he had a seizure. It is possible that the seizure was due to withdrawals from any one of several substances he uses. COVID status pending.
Another patient had a GI bleed and CHF exacerbation and possibly COVID-19
I was at the hospital until 8 pm. 12 hours of work. Let's see what tomorrow brings.
Of course, what strikes me is that COVID or no COVID, people get sick and usually what you end up treating is not just COVID but COVID and...
We admitted a lady that had a blood clot is her lung (pulmonary embolus). She became progressively hypotensive and we had to put a central line in her in the ED. The procedure went well (no complications). Her blood pressure began to stabilize.
The saddest patient of the day was a homeless guy found naked on the street and unresponsive. I learned that he was frequently brought to the ED where a shot of Narcan would wake him up and be would become combative and belligerent. This time was no different. The ED was going to discharge him when he had a seizure. It is possible that the seizure was due to withdrawals from any one of several substances he uses. COVID status pending.
Another patient had a GI bleed and CHF exacerbation and possibly COVID-19
I was at the hospital until 8 pm. 12 hours of work. Let's see what tomorrow brings.
Sunday, May 24, 2020
COVID-19 Tour Day #1
It has been a long time since I wrote anything. Life happens. In April, 2020, I received a phone call from New York State asking for physician volunteers to assist New York City with their COVID-19 crisis. I was asked if I could assist at Woodhull in Brooklyn. Well, at first my work said I could not go because they did not know I would be needed in Buffalo should cases rise abruptly. A month later, I got a second call. This time, after some negotiation (I would have to take vacation and because I did not provide 60-days notice to move patients, I would have to make up the 4 clinical days -- 8 sessions -- that I would be missing), I was allowed to go.
I flew into La Guardia airport catching a flight from Buffalo and going through Dulles, Washington, D.C. The flight, fortunately, was paid for by United who generously donated air tickets to the NYC COVID-19 crisis. I was also put up in a hotel (Hotel Indigo in Williamsburg, Brooklyn) thanks again to the generous donation of the hotel line to the cause. The only chagrin was finding out that some of the people here had come through an agency that paid them for their shifts wit hazard pay (numbers like $ 5,000 a week) while the rest of us physician volunteers worked for free.
Today was day 1. It was May 24, 2020 -- a Sunday and part of the long Labor Day weekend. I entered the hospital at 8 am for my 12-hour shift. After a tour by Michael Kopusov, I got to hand out with one of the 'floor teams'. I looked at charts. About halfway through the shift, I found out that my assignment for tomorrow was to be the Admitting Attending. There would be a team of admitting residents working with me. So for the rest of the day, I followed Michael and assisted with the admissions of the day. Everyone got screened for COVID-19 although it seems unlikely that any are going to be positive. One patient had a PE (pulmonary embolus), another had a diabetic foot infection (osteomyelitis of a toe), another CHF exacerbation. All of these are common Internal Medicine admissions -- remains to be seen if they came in COVID-19 flavor.
I got to see some of the patients that came in with COVID-19, in their 20s, 30s and 40s that had to be intubated, ended up getting a tracheostomy, one awaiting placement in a traumatic brain injury unit because of neurological sequelae to the disease.
All in all, this seemed like a good first day -- not too crazy -- and I am a little oriented to the hospital and its system. Epic is reasonably intuitive and since my residents do most of the notes and orders, I am spared the sodded details.
Well, this blog post was interrupted by a Code Blue on a COVID-19 floor -- a 60-something male who just returned from surgery. Fortunately, he had return of spontaneous circulation (ROSC), is intubated and in the unit. A good outcome considering.
I flew into La Guardia airport catching a flight from Buffalo and going through Dulles, Washington, D.C. The flight, fortunately, was paid for by United who generously donated air tickets to the NYC COVID-19 crisis. I was also put up in a hotel (Hotel Indigo in Williamsburg, Brooklyn) thanks again to the generous donation of the hotel line to the cause. The only chagrin was finding out that some of the people here had come through an agency that paid them for their shifts wit hazard pay (numbers like $ 5,000 a week) while the rest of us physician volunteers worked for free.
Today was day 1. It was May 24, 2020 -- a Sunday and part of the long Labor Day weekend. I entered the hospital at 8 am for my 12-hour shift. After a tour by Michael Kopusov, I got to hand out with one of the 'floor teams'. I looked at charts. About halfway through the shift, I found out that my assignment for tomorrow was to be the Admitting Attending. There would be a team of admitting residents working with me. So for the rest of the day, I followed Michael and assisted with the admissions of the day. Everyone got screened for COVID-19 although it seems unlikely that any are going to be positive. One patient had a PE (pulmonary embolus), another had a diabetic foot infection (osteomyelitis of a toe), another CHF exacerbation. All of these are common Internal Medicine admissions -- remains to be seen if they came in COVID-19 flavor.
I got to see some of the patients that came in with COVID-19, in their 20s, 30s and 40s that had to be intubated, ended up getting a tracheostomy, one awaiting placement in a traumatic brain injury unit because of neurological sequelae to the disease.
All in all, this seemed like a good first day -- not too crazy -- and I am a little oriented to the hospital and its system. Epic is reasonably intuitive and since my residents do most of the notes and orders, I am spared the sodded details.
Well, this blog post was interrupted by a Code Blue on a COVID-19 floor -- a 60-something male who just returned from surgery. Fortunately, he had return of spontaneous circulation (ROSC), is intubated and in the unit. A good outcome considering.
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