Dr. Mark Weller only sees COVID-19 patients whose lives are on the line.
Roughly half of the patients he intubates to put on a ventilator at NewYork-Presbyterian/Columbia University Irving Medical Center on West 168th Street in New York City will die. That mortality rate increases when more complications arise beyond the patient’s already severe lung issues.
“Initially about a week or 10 days ago it was terrible,” Weller said last Friday. “When I was there I intubated 20 or 25 patients a day. The only thing I did was run around the hospital and wait for calls from the emergency department for another admission that needs a ventilator.”
What Scarsdale resident Weller, who prior to the outbreak spent most of his time as director of anesthesia at NYP/Och Spine Hospital (formerly Allen Hospital for Spine Surgery) on Broadway, is seeing now is less overwhelming for both the facility and the staff, perhaps the beginning of a plateau. The hospital is only taking in as many patients as it is losing and taking off the ventilators, so the demand seems to be headed in the right direction. Weller takes that as a positive sign that social distancing works and will continue to work as long as sheltering in place continues.
“At some point we have to open the country — everybody agrees with this,” Weller said. “The magic is to find the right time and the safe time to do this. People lose their jobs and they need to make money and I understand this, of course, but I wish we could determine that [safe] spot. You don’t want to have a rebound or God forbid have a case in your family or for yourself. It’s a terrible disease.”
Weller is an anesthesiologist who returned to the role of intensivist last month when the pandemic began to overwhelm hospitals. In his area of expertise he doesn’t lose patients on the operating table, maybe one in every five or 10 years in extreme cases. Now, he only sees coronavirus patients who are fighting a virus that is beyond anyone’s control.
Performing intubations is the highest risk contact with COVID-19 patients and it brings a myriad of challenges for medical facilities, frontline workers and families alike.
The most severe patients are dropped at the hospital, where they lose contact with their loved ones for the duration of their time on the ventilator. Most often the hospital won’t have real news for them for weeks, and there’s a 50-50 chance that news will be bad.
“Loved ones potentially bring their loved one to the hospital and they get a coffin two weeks later,” Weller said, adding, “Nobody likes it if a patient under one’s care dies. There’s no families. It’s a very eerie feeling.”
Often the last voice patients hear is the doctor before he or she puts them under prior to intubation. It’s not uncommon for the conversation to go like this after the doctor introduces himself:
Doctor: “I’m going to put this breathing tube into you now and help you breathe. I’m going to have to put you to sleep.”
Patient: “What does that mean?”
Doctor: “The breathing tube will stay there for a while.”
Patient: “Will I die?”
“Then what do you say?” Weller said. “It’s a very hard situation. The problem with this disease is that the patients are all by themselves… If they wake up again and can be taken off the ventilator it takes at least two or three weeks.”
The endotracheal intubation is a noninvasive procedure, but when the doctor puts the breathing tube into the patient’s throat, it’s “very high risk” and “highly aerosolizing,” according to Weller.
“All the saliva gets aerosolized in the air and you can potentially breathe it in and get infected yourself,” Weller said.
COVID-19 is like nothing medical professionals have seen. Weller said the kidneys are often affected, as are other organs in the more extreme of the already severe cases. “They become septic,” he said. “But the main accompanying problem is kidney failure. If patients are on the ventilator and they have kidney failure that [mortality] number goes up to 60, 65%. It’s extremely high.”
Monitoring the ventilators with COVID-19 patients also offers an added obstacle. Patients are more sensitive to small changes in the ventilator’s settings, unlike what Weller has ever seen before.
“The goal is to slowly wean the support, the need for the breathing machine, to get this breathing tube out of them so they can breathe on their own,” he said. “It’s very, very difficult — they need a lot of support for a long time. I’m estimating the minimum time patients stay on the ventilator is two weeks and the average is higher at two and a half to three weeks.”
Deciding when to start the weaning process is another tricky part, but the medical staff looks at certain parameters like improved lung elasticity and capacity, having adequate oxygen levels in the blood, the ability to maintain breathing with less oxygen from the ventilator and the positive end-expiratory pressure (PEEP).
“Basically what you’re looking at is how much ventilator support you need to maintain a certain oxygen level in the blood to make sure the carbon dioxide level in the blood is normal,” Weller said. “The other thing the lungs do is they exchange carbon dioxide from blood into the air. Then you look at how acidic the blood is with a normal pH. It’s basically based on blood analysis and basic parameters about the lung you can get off the ventilator.”
And just because a patient is taken off a ventilator does not guarantee they are out of the woods. “Personally I have taken the breathing tube out of one patient who then died three days later,” Weller said.
While certain populations are higher risk — those with preexisting conditions, the immunocompromised, the elderly and those who live in areas where social distancing is challenging — that doesn’t mean others are immune to the worst-case scenarios. “I’ve seen young, healthy patients die or spend weeks on a ventilator,” Weller said. “We should take all measures to avoid the spread.”
In addition to intubating patients and helping manage their care, Weller is also doing administrative work and organizing the rest of the operations that are still taking place in the hospital. There are night shifts and some 24-hour shifts with very little time off as many of the hospital staff are out sick or are at-risk populations themselves and told to stay home, so they were short-staffed right off the bat.
“I have several colleagues who are on ventilators and I just learned last night that the wife of a colleague of mine died of COVID-19,” Weller said Wednesday.
Weller knows he is doing everything he can to help patients survive, risking his own well-being in the process.
“My main fear is to bring something home to the family,” he said. “The problem with the disease is it has an incubation of five days, a week, sometimes two weeks. I go home and I’m potentially infected and can infect my kids and my wife. So far we’ve been lucky. I disinfect everything when I get home. But that’s the biggest fear.”
That said, the Weller family may have had the virus in late February. They all had a cough that lingered for weeks and fevers for a couple of days. At the time they didn’t think anything of it. The world was learning more about COVID-19, but it wasn’t mainstream in the United States just yet.
Scientists are unsure whether you can get COVID-19 again or what type of protection antibodies might offer. There are so many unknowns, which makes it hard to come up with answers. If you survive smallpox, you’re immune for life. If you get influenza, you’re good for the year and then your body can get it the following year when it’s a different strain.
Weller is scheduled to take the antibody test Friday, but no matter the result he’s going to continue to protect himself from head to toe at work.
“It would be a little more assuring going to work knowing I have antibodies for a little more protection, but that doesn’t really change my approach to the whole thing,” Weller said.
Weller and his fellow physician wife, Katarzyna Jankowska, have twins who are juniors at Scarsdale High School, and another daughter who will enroll at Lafayette in the fall after finishing up a year studying and learning the culture and language in Krakow, Poland, Jankowska’s native country. They considered bringing their daughter home before the outbreak, but she wanted to make the most of her time abroad.
“It’s pretty well controlled, but they are very strict with social distancing,” Weller said of Poland. “There’s no gathering at all allowed. Two people can be seen together and no more. That’s it and everything is closed. The university is closed, so she’s getting lessons by Zoom. She’s lucky she has a good friend she lives with to survive there. It’s fairly safe. The numbers in Poland are much lower than here.”
The Wellers considered the risk, though they now believe she’s probably safer there than here. “Nonetheless if something happens you want your kids around you,” Weller said.
In mid-March when the severity of the spread began to intensify, no hospitals in epicenters were fully prepared in terms of ability to house patients and in the ability to supply enough proper personal protective equipment (PPE) to staff. Though there was a peak time when PPEs were being stretched beyond their intended usage lives, Weller believes overall his hospital got ahead of the curve.
“Two months ago we had an inkling that this was coming, but nobody had an idea how difficult or how actually dangerous the virus was going to be,” Weller said. “We got prepared actually fairly quickly. NewYork-Presbyterian was one of the hospitals that can expect a lot of admissions for a crisis like this.”
NewYork-Presbyterian initially canceled elective surgeries, though that list became more well defined as time went on when the hospital was getting even more admissions than expected. “Only dire emergencies were allowed to go to the operating room,” Weller said.
That’s also when Weller switched back to being an intensivist “like the old days, many, many years ago,” he said. That’s been common throughout the profession. Jankowska, who has worked at St. John’s Riverside Hospital and AFC Urgent Care in Hartsdale recently, had taken the spring off with plans of spending time with her daughter and parents in Poland, but the pandemic derailed those plans. She’ll start volunteering at NewYork-Presbyterian soon.
“A lot of the physicians that work there are not intensive care trained physicians,” Weller said. “They’re trying to help out because there are so many patients.”
PPEs — or lack thereof — have been a major point of concern during the pandemic. NewYork-Presbyterian wasn’t immune.
“Initially we had huge problems with protective equipment, especially the N95 masks, which were short on supply,” Weller said. “Because of the intensive care unit and because of the fact that we have to intubate all these people, it’s probably the highest risk procedure you can do for a patient so I have a feeling we got preferential treatment by the hospital and they supplied us with masks, but we never had to intubate somebody without an N95 mask or the other protective equipment we needed, like face shields and gowns and so on.”
That didn’t mean the staff wasn’t rationing and elongating the life of their PPEs. Weller was given various masks and face shields from neighbors. N95 masks are meant to be used to see one patient and then disposed of. For a while, the masks were being used until the elastic snapped or they were too moist inside. “Initially we used them as long as we could,” Weller said. “Now we can use a mask for a day or half a day. It’s better now, but still it’s not the way it should be used. You use it once and then a new one for the next patient.”
Every year the staff at NewYork-Presbyterian are personally fitted for the correct brand and size of mask to best fit tightly to their individual faces to “filter the virus particles” and not allow air to flow in. “This time we just used whatever N95 mask was around — whatever brand, whatever size,” Weller said. “Whether this one fits or not, who knows — we have to take what we can get.”
In addition to the professionals adapting to the unpredictable nature of the virus, the hospital itself had to undergo a transformation. Last month, NewYork-Presbyterian converted all of its operating rooms into intensive care units, which was no small task as ORs and ICUs are fundamentally complete opposites. ORs are large rooms that are designed to have air flow out, whereas ICUs are designed to keep air in.
Taking positive pressure rooms and making them negative pressure — essentially keeping any germs in the room — using loud HEPA filters (high-efficiency particulate air) was “a great feat of engineering,” by the hospital’s engineering department, according to Weller. Each OR is now set up for three or four COVID-19 patients in addition to those who are in the ICU. With more than 20 ICU admissions per day at its peak, the hospital filled up quickly.
“When you have to do something with ventilator patients you’re there almost all the time and the breathing tube has to be taken care of, the infusion pumps need to be changed and so on,” Weller said. “It’s very cumbersome because you always have to put your protective equipment on and that takes four or five minutes. You go inside and it’s excessively noisy. You can’t hear and you almost have to shout at each other to communicate. And it’s very warm under all these gowns and masks. It’s very hard work, particularly for nurses and residents. They have to do 12- or 14-hour shifts every day almost, five, six, seven days a week.”
The toll is physical and emotional and the pace is one that will be hard to keep up with as the pandemic continues.
“Particularly the residents and our certified registered nurse anesthetists have a tough schedule,” Weller said. “They had many sick calls, so others had to pick up the slack. It’s not so much the hours, but the type of work. It’s very grueling. The physical demands are very high because of the environment and the disease and the need for protective equipment, but also the psychological toll is very high. Many people die in spite of your best efforts or don’t get better and slowly whither away in your hands. That’s hard for many people.”
Weller doesn’t want people to get frustrated at sheltering in place. He believes social distancing is working, as he said admissions aren’t any higher than discharges at this point. “We’re leveling out,” he said.
“I’d like to let my fellow Scarsdalians know it’s not a disease to take lightly,” Weller said. “Yes, most people don’t get very sick — they have flulike symptoms, maybe a little fever — but if you get really sick then it’s a real problem. It’s very hard to survive. I would at all costs try to avoid it, avoid bringing it home where you have a father or mother at an advanced age with an increased risk. It’s almost unsurvivable at this age.”
Weller urges us to stay home during the COVID-19 pandemic for the same reason he and the other frontline medical staff go to work: so others have a chance to live.