Starting this past winter, the coronavirus disease 2019 (COVID-19) pandemic has swept across the world, with the U.S. reporting the highest number of cases globally. New York, NY, and surrounding areas experienced a disproportionately higher number of cases, with their death toll at more than 24,000 at press time, owning 8 percent of the entire world’s carnage. Nassau County specifically had seen nearly 40,000 cases, a rate of nearly 1,861 cases per 100,000 people, one of the highest in the greater New York region.1
Our 450-bed community hospital—Mount Sinai–South Nassau—is located in the heart of that suburban county and thus within the regional epicenter of this deadly virus. Our institution transformed from a primarily suburban center to a global COVID-19 hotbed. We augmented our staff with physicians from across the country, admitted thousands of cases (2,300 as of the publication of this article), and upgraded our critical care unit to five times its pre-COVID-19 capacity. Although we optimistically focused on the more than 60 patients successfully extubated and the nearly 1,000 COVID-19-recovered discharges, sadly we also have lost more than 400 lives to this horrific pandemic.
As residents, we found ourselves powerlessly fighting an invisible enemy and witnessing scenes of fatality that are unlikely to leave our nightmares anytime soon.
As I approached the end of my final year of training, I had envisioned this period as a time to prepare for private practice and study for boards. Instead, as the chief surgical resident at a facility in the heart of this war, I was on the front lines battling its unpredictable sequelae. Our training program was halted, roles were changed, and positions were reassigned, as we were all enlisted to this army of physicians. As residents, we found ourselves powerlessly fighting an invisible enemy and witnessing scenes of fatality that are unlikely to leave our nightmares anytime soon. The following describes some of our experiences.
Acute kidney injury and failed hemodialysis
Our institution recently submitted for publication an article identifying the trend between COVID-19 and the onset of acute kidney injury (AKI). We found that AKI developed in 81 percent (n = 142) of intubated patients, with a greater percentage of patients developing AKI in the expired group when compared with the group of living patients (92 percent versus 72 percent). We further calculated the odds ratio for death after the diagnosis of AKI as 4.5 and thus concluded that intubation was a harbinger to AKI, as well as to eventual expiration.
Our study shows that intubated COVID-19 patients are at risk of developing AKI and that their chance of survival diminishes significantly after its onset. In an attempt to counteract this deleterious sequelae, nephrologists have been recommending hemodialysis (HD). These specialists have extrapolated that by using HD, we could filter the cytokine and other immune factors from the blood, thereby preventing the virus’ deadly effects. Historically, HD has been the most widely used tool in our armamentarium for correcting rising creatinine levels.2
HD, however, is a very expensive, physically taxing, and time-consuming process for patients.3 It requires the placement of a temporary dialysis catheter, which is an invasive procedure that leads to many potential complications (infection being the most pertinent, pneumothorax being the most detrimental).4 Placement of these dual-lumen catheters has become the responsibility of surgical residents, as, historically, vascular surgeons have been tasked with inserting large-bore central venous devices. Until the COVID-19 pandemic, our team placed roughly one HD catheter per week. Since the onset of this kidney-killing virus, our team places an average of three to five urgent HD catheters per day.
Though not yet exclusively studied, anecdotal evidence has shown that HD has no significant positive effect on the COVID-19 patient’s clinical course or AKI progression. This statement is not to fault the nephrologists nor the intensivists; it is just all we know.
Though peritoneal dialysis (PD) has started to be used instead, the shift occurred more out of necessity (limited hemodialysis machines) than improved efficacy. PD also is unstudied in COVID-19-related AKI. Some have theorized it is more cogent to employ continuous renal replacement therapy in the management of COVID-19-induced AKI,5 but no reports on the efficacy of this approach have been published at press time. Highly educated medical professionals are relying on what they have previously seen to work in medicine, rather than any evidence base, because the facts pertaining to this evasive enemy are not yet available.
Pneumothorax, pneumomediastinum, and plenty of pigtails
In the first five weeks since the outbreak of this deadly virus, I placed more pigtail catheters in hypoxic patients than in my previous five years of surgical training. Now, when our thoracic surgery service is called for urgent placement, after a large pneumothorax is noted on a recent chest X ray, the story sounds rehearsed: “COVID-positive, PEEP [positive end-expiratory pressure] above 10 cm H2O and PaO2 less than 50 mm Hg.” On further examination, respiratory rates are universally in the 30s, presumably in an attempt to blow off the severe hypercapnia, typically above 50 mm Hg. As the textbook teaches, the 14Fr Wayne pigtail catheters are placed in the second intercostal space, midclavicular line, without even contacting our attendings.
This drastically increased rate of pneumothorax has again led our institution to investigate the causative connection with the COVID-19 virus. A formal study is under way, but preliminary results show nearly half of the intubated COVID-19 patients required pigtails for clinically significant pneumothorax. Furthermore, our thoracic surgeons were consulted, and have been subsequently following with serial chest X rays in an overwhelming majority of the 80-patient critical care units. In specific cases, we were occasionally required to place surgical chest tubes (30–34Fr in the traditional 5th intercostal space, midaxillary line) and even twice resorted to venting skin incisions to relieve extensive, clinically diminutive, subcutaneous emphysema.
We first postulated that this procedure was a response to the high levels of PEEP the critical intensivists were using to adequately oxygenate the patients’ COVID-19-infected lungs. After several multidisciplinary meetings, the team universally lowered the PEEP levels, capping them at 10 cm H2O. Despite this effort, we found very little change in the pneumothorax rate. We thus reconsidered its etiology as potentially secondary to the fragility of patients’ lungs. Treated similarly to patients with acute respiratory distress syndrome, the brittle lung parenchyma of COVID-19 is failing with only the smallest amount of positive pressure, even with noninvasive methods. Our surgical team, again, performed the most appropriate intervention to treat the patients’ symptoms, seemingly without altering the clinical course.
A formal study is under way, but preliminary results show nearly half of the intubated COVID-19 patients required pigtails for clinically significant pneumothorax.
Many silver bullets, no cure…yet
University Hospitals Birmingham, U.K., published a research briefing in April that highlighted all the active COVID-19 trials internationally.6 The briefing, though primitive, was intriguing—ivermectin removed the in-vitro viral load in 48 hours; siltuximab and other immunotherapies touted significantly reduced c-reactive protein levels, but some patients actually worsened; angiotensin-converting enzyme inhibitors were reducing mortality and intensive care unit admission rates with an odds ratio of 0.29. These studies, like many regarding COVID-19, have small sample sizes but stimulate significant hope that a cure will emerge.
Our hospital, like most affected around the world, are attempting most of these potential therapies. COVID-19-positive patients are universally receiving ritonavir, tocilizumab, full-dose lovenox, intravenous famotidine, and even the controversial hydroxychloroquine. We also initiated a protocol trial for convalescent plasma exchange. Some colleagues claimed that this therapy was the new silver bullet and would be the long-awaited cure. Recovered COVID-19 victims eagerly donated their plasma which, containing IgG and IgM antibodies, would potentially cure well-selected patients. However, without randomized control trials, it is impossible to prove the efficacy of these treatments compared with a placebo. Overall, what I can state anecdotally, and based on lengthy discussions with my colleagues, is that no therapy yet initiated in our hospital has had any obvious meaningful effect on our patients’ prognoses.
It is with great reluctance that we take on this next revolutionary endeavor. In Israel, a minute group of qualified COVID-19 patients were given pluripotent stem cells with incredible results. The theory is that these placenta-derived mesenchymal cells, because of their unique limitless capabilities, can mitigate the tissue-damaging effects of the virus, particularly in the pulmonary and renal systems. Though inclusive of only a small subset of qualified patients, and therefore, again, a minimally powered study, the results appear very promising. After anxiously awaiting its transatlantic arrival, we gave these 15 intramuscular injections to several specifically selected patients in our critical care unit. The improvement in chest X rays and arterial blood gases have been astounding; in only three days, it looked as if we had tested a different patient. Though we are hesitant to declare victory, with much larger trials to be conducted, this therapy does give hope for the positive outcome of this battle.
Throughout this pandemic, our program’s surgical residents have successfully placed hundreds of HD catheters and pigtails, administered every potentially curative therapy mentioned, and yet our mortality rate in the critical care unit has remained dauntingly high. Again, specialty-trained physicians are treating the symptoms of COVID-19, but apparently not affecting its prognosis. We have spent hundreds of thousands of dollars, countless numbers of hours, and irreplaceable years of our lives training to fight illness. On a scale unlike ever before, all this education, all this research, all this dedication to our trade, is simply not enough. When these patients become critically ill, regardless of our best lifesaving measures, this deadly virus has consistently proven victorious. Though a vaccine, or even our novel stem cell study, may prove to be a successful remedy, the toll this pandemic has taken on health care professionals is one that will not soon be forgotten.
- Statista. COVID-19 death rates by age group in New York City 2020. Available at: www.statista.com/statistics/1109867/coronavirus-death-rates-by-age-new-york-city/. Accessed May 1, 2020.
- Friedrich JO, Wald R, Bagshaw SM, Burns K, Adhikari N. Hemofiltration compared to hemodialysis for acute kidney injury: Systematic review and meta-analysis. Crit Care. 2012;16(4):R146.
- Loubeau PR, Loubeau JM, Jantzen R. The economics of kidney transplantation versus hemodialysis. Prog Transplant. 2001;11(4):291‐297.
- Bevc S, Pecovnik-Balon B, Ekart R, Hojs R. Non-insertion-related complications of central venous catheterization—temporary vascular access for hemodialysis. Ren Fail. 2007;29(1):91-95.
- Tolwani A. Continuous renal-replacement therapy for acute kidney injury. N Engl J Med. 2012;367(26):2505-2514.
- University of Birmingham. COVID-19 research briefing. Available at: www.birmingham.ac.uk/university/colleges/mds/Coronavirus/COVID-19-research-briefing.aspx. Accessed May 1, 2020.