The COVID-19 pandemic is not taking place in a vacuum. Car accidents and gunshots and burns and falls and heart attacks and strokes still happen, and those patients too are rushed to Level One trauma centers such as Mount Sinai Hospital, where every patient who rolls in must be treated as if they have COVID-19.
“Your instinct is to run to the patient,” said ER nurse Kimberly Lipetzky, who had just treated a man who had fallen 20 feet off a roof. As medical staff tended to him, they discovered he had been sick for a week, probably with COVID-19, so “then, you have this added level.”
What does that added level mean? If you wear PPE — personal protective equipment — to see a COVID-19 patient, you first must strip off the gown and gloves and booties and hairnets and mask before seeing the next patient, or risk infecting someone who may not have the deadly ailment. And if you’re not suited up and a COVID patient suddenly gets into trouble, you have put on all that PPE, and fast.
“Someone is in respiratory distress. You’ve got to move quickly,” said Lipetzky. “Got to goggle and gown and hair-cover. It’s a lot.”
Getting it one can take three key minutes, and is such a struggle that non-medical staff are jumping in to help.
“You have unit secretaries coming out from behind their desks, putting PPEs on, making sure gowns were tied,” said Michele Mazurek, chief nursing officer for Sinai Health Systems.
Mazurek, who is also leader of Incident Command at Mount Sinai, added: “This is a group effort. We did not need to ask any of these individuals to do what they’re doing.”
Even with all hands on deck, the stress builds up. The hand-washing is endless.
“It’s constant, and then just scrubbing your hands,” she said. “Our hands are ragged.”
Ever patient is carefully questioned. The symptoms of COVID-19 span the range, from none at all to gasping for air.
“It varies, and it’s terrifying,” said Adam Garrison, a nurse at Mount Sinai. “You don’t know what you’ll be looking at. Some people have no distress whatsoever. Walk into the ER, speaking as clear as you or I and have a blood saturation of 76 percent.” (Normal blood oxygen levels are 94 to 100 percent.) “They do not look acutely ill, and end up intubated two days later.”
Or a patient can be checked out, seem fine and sent home only to rapidly decline — ”crump” in medical slang.
“We’re only admitting the sickest ones,” said Garrison. “They can look good, we send them home, and they’re crumping with viral pneumonia and their X-ray looks horrible a week later. ... We have to be on our game at all times.”
It’s too soon for a post-mortem. But confusion at the highest levels of government made the job at places like Mount Sinai all the more difficult. No one seemed sure: Is this disease airborne? Or can it only be conveyed in sprayed droplets — say, through a sneeze? Guidelines were continually being adopted, updated, discarded.
“It changed a lot,” said Raquel Prendkowski, emergency department director for Sinai Health System. “The first week was really rough. Figuring out what to do with changing recommendations. After maybe three days, all of a sudden it turned airborne, and the message was, everybody wanted to be gowned, gloved, masked. You thought if you breathed in, you were going to catch it. A lot of education took place in a short period of time.”
“A lot of those conflicts have come from lack of federal guidance on PPE,” said Garrison. “Those have not been very clear. Multiple hospitals have struggled with that. Add to that mix the concern about adequate number of supplies.”
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The shortages that have plagued other hospitals have not hit Sinai, yet. But the possibility hovers in the background every time a glove is dropped into the trash.
“It weighs on their minds,” said Mazurek.
The shortage of PPE creates some unexpected partnerships: century-old Mount Sinai Hospital gratefully accepting 50 masks from a local nail salon. Construction companies drop off masks, which the ER keeps behind the desk to deter staff from other departments from walking off with them. But that’s inconvenient if a patient is in distress and doctors must rush over to dig out more gear before giving assistance.
Plus there is concern for just having enough space to put patients. An unused fourth-floor pediatric unit was quickly converted into an overflow ward.
It would help to actually know if any given patient has COVID-19, but tests still take up to seven days.
“That’s a travesty,” said Lipetzky. “I don’t understand why that’s happening.”
There are other, less reliable methods than the swab test.
“We take a chest X-ray,” said Garrison. “Typically a hallmark sign is when you see what we call ‘ground glass opacity.’ It literally looks like someone took broken glass and ground it up. A granular appearance in the bottom third of the lung.”
Or the X-ray could show nothing, despite the presence of infection.
“We’re getting X-rays that are clean and they end up testing positive,” Lipetzky said.
A CAT scan is more effective. But CAT scan machines are big, room-filling devices, and pose another problem.
“We can’t contaminate all these rooms,” said Lipetzky. “Putting them through a CAT scanner is not a good way because we have to allow time to decontaminate the rooms between every patient.”
Sinai is hoping this week to get tests that provide results in 15 minutes.
In the meantime, staff is trying to simultaneously keep their patients alive and themselves well — both for their own sake, and so they can remain available for duty, helping both colleagues and patients.
“If we get ill,” Garrison said, “we can’t care for anybody else.”
Coming Friday: ‘Everything is in place’
