My NYC #COVID Lessons learned
1) New York Hospitals are under water. This pandemic is real. Both epidemiologically and pathophysiologically this disease is unlike anything I have ever seen before... 1/

2) NYC is fortunate to have a robust public hospital network. I have been impressed by how much patients and resources have been moved around to cope with surges of patients. I don't know how smaller private hospitals are coping 2/

3)Everyone here at Kings County has been stepping up. Trauma surgeons, neurologists and neurosurgeons managing COVID ICUs. Ortho residents supporting as a proning team. IR and surgery residents as a dedicated line service. Respiratory therapists unsung heroes as well as nurses 3/

4) COVID lung different. I can't speak as eloquently as other to the compliance, but they hypermetabolic. Hypercapnea is a very serious limiting factor for both APRV and low tidal volume strategies typically used for ARDS. Even cytokine storms with fevers as high as 107... 4/

5/ Once patients progress from respiratory failure to cardiac failure and renal failure, their outcomes are dismal. Its clear we need to be aggressive early when patients are starting to show worsening respiratory status... 5/

6) We are using HFNC and BIPAP. But respond at this point aggressive with the therapies listed below. These are aerosolizing and put staff at higher risk. Also these are the highest risk patients who can deteriorate. Mental status is key to ensure adequate ventilation. 6/

6) Proning - This is beneficial in classic ARDS and we are doing early as P/F ratio approaches 150. Have seen improvements in oxygenation but ventilation can be compromised when hypercapnea is an issue. Awake proning or "tummy time" can help even before intubation... 7/

7) We are trying a short course of pulse steroid doses as respiratory status worsens with the idea that this may be an inflammatory process to arrest early before deterioration. 8/

8) We look for reasons to Anticoagulate like elevated D-dimers (say 3000) especially with renal failure or troponemia, or if worsening oxgenation and tachycardia could be related to new PE. Dialysis lines have also been clotting without AC. mortality 9/ https://www.ncbi.nlm.nih.gov/pubmed/32220112 

9) IL-6 antagonists especially with signs inflammation such as elevated CRP and ferritin but this is a very limited resource

10) Still using short course HCQ and zithromax, but data is very limited and I am not confident it is helping. See non-retraction
https://www.isac.world/news-and-publications/official-isac-statement

11) Many patients are initally hypovolemic. Febrile with poor PO, many need resuscitation or are hypotensive after intubation. This may contribute to renal failure.
11/

12) May be a role for more anti-virals (how's Cuban interferon working?) but I leave that up to the ID guys.

13) Role for statins, zinc, Vit C unclear but are safe therapies that might help. 12/

13) Racism and structural violence worsens outcomes of our most vulnerable patients. Stop acts of violence like Wisconsin election that republicans insisted on having, removing 95% of polls while COVID rages in Milwaukee's black neighborhoods. 13/13 https://www.nytimes.com/2020/04/07/us/politics/wisconsin-pandemic-primary-republicans.html

Almost forgot. Long term care facilities, prisons, jails and detention centers are super spreaders

14) test all patients and staff at long term care wherever widespread community transmission to cohort isolate and treat

15) close all ice detention facilities after testing ...

All nonviolent offenders at prison and jail should be released after testing where safe and appropriate. Stop the daily churn of nonviolent offenders through jail during pandemic