Improvisation And Retraining May Be Key To Saving Patients In New York's ICUs

"An ICU. What is it?" asks Dr. Robert Foronjy. It's late afternoon. He's in his office at University Hospital Brooklyn.

"It's people," he says. "You think of an ICU, maybe you think four walls, some beds. But really it's people."

Foronjy is the chief of pulmonary and critical care medicine at University Hospital Brooklyn, and under normal circumstances he is one of the doctors in his hospital's intensive care unit — directly treating patients with respiratory illness. But COVID-19 has required doctors like Foronjy to change the way they work, and spread their expertise more broadly in order to accommodate the enormous number of people who are severely ill with the virus.

"Logistically, to keep this going is such a challenge," Foronjy says of his hospital. "I'm amazed the system has really held up well. No one is dying because care is not being delivered to them. They're dying despite the fact that care is being delivered to them."

Across New York City, many doctors who usually do plastic surgery or treat children are learning how to monitor people who need to be on ventilators to breathe. Some medical residents who were supposed to be learning how to repair broken bones or deliver babies are instead learning how to manage patients who have fluid in their lungs.

To maximize the number of severe cases that can be treated, many hospital pulmonologists are acting as clinical supervisors, overseeing teams of doctors and nurses that have less experience treating seriously ill patients.

"Certainly I have never experienced a situation like this in all the time I've been a physician," says Dr. Cara Agerstrand, a critical care physician and pulmonologist at NewYork-Presbyterian/Columbia University Irving Medical Center in Manhattan. "We have filled our ICUs. We have converted operating rooms into additional ICU space. We have converted regular medicine floors that would normally take care of much less sick patients into ICU space."

Agerstrand says she and other pulmonologists, critical care doctors and anesthesiologists at the hospital are overseeing teams that are treating patients with COVID-19 "as an extra level of safety and, sort of, scrutiny from the perspective of ventilator management, respiratory failure in general [and] ICU needs."

So far, she says, she's been impressed with how her colleagues have learned new skills.

"Humility is perhaps a very good word for it. I think people have come in with a very open mind," she says. "We're working across disciplines in ways we wouldn't be doing nearly as frequently or nearly as intimately."

Still, the situation at many hospitals is sobering. In normal times, intensive care units require a large number of nurses — generally at least one nurse for every two patients. But nurses are getting sick, which makes it difficult to keep ICUs running smoothly, and puts an additional burden on nurses who are working closely with the sickest patients.

Foronjy says making sure there are enough nurses to treat critically ill patients is the most difficult challenge his hospital has faced. At least two nurses at University Hospital Brooklyn have severe cases of COVID-19, and he says many others are staying home because they're ill.

At many other hospitals, top pulmonary doctors are also trying to plan for the worst case scenario, even as they adjust the way they do their job.

"What horrifies me most is a moment where I would have to decide — or someone else would have to decide — between two patients and one ventilator. And who would get that ventilator?" says Dr. Hooman Poor, a pulmonologist at Mount Sinai Hospital in Manhattan.

So far, no New York City hospitals have publicly reported ventilator shortages, but it is a possibility that has loomed for weeks as the outbreak in the city has spread, and state officials have scrambled to create a ventilator stockpile. The concern has led respiratory experts at some hospitals to investigate methods for sharing ventilators and to look into retrofitting less powerful breathing machines. Neither option is an ideal alternative, Poor says, because patients who need help breathing are already fragile, so machines must be carefully calibrated and monitored.

Nonetheless, Poor says, he and a team of doctors at Mount Sinai have figured out how to attach a monitoring device and a filter to machines known as VPAPs (variable positive airway pressure devices) so they could be safely used to help patients with COVID-19 breathe.

While these machines (also known as bilevel positive airway pressure machines) are not as complex or powerful as hospital ventilators, Poor says they could help deliver oxygen to some seriously ill patients if there was a ventilator shortage. The hospital has 1,300 VPAP machines.

"It's been a trying time, but I've been impressed with the collaboration," says Poor.

Asked how he's doing personally, Poor is silent for a moment. "I am exhausted," he eventually replies. "These patients are extraordinarily sick, and there are many, many many of them."

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