Surge still manageable for Dr. Lee
Heart complications; intravenous drug supply concerns
This is the sixth conversation between Dr. Jarone Lee, a frontline critical care and emergency physician at Massachusetts General Hospital and associate professor at Harvard Medical School, and Dr. Paul Hattis, an associate professor at the Tufts University Medical School who participates in CommonWealth’s Health or Consequences Codcast. Find links for past conversations at the end of the story.
PAUL HATTIS: This is the COVID-19 surge week in Massachusetts. What are any key changes from when we spoke a week ago?
JARONE LEE: This has clearly been a surge week at MGH, especially this last weekend. Over the last week we have seen our COVID-19 cases go from the mid-200s to the 400s. Officially, this morning our hospitals report 421 COVID-19 confirmed and suspect cases, with 145 in our ICUs. Last week, COVID patients represented about 30 percent of our inpatient beds at MGH; now it is around 40 percent. Some of this increase has come from our Partners-affiliated hospitals, but also transfers from hospitals not in our system. One example is that Boston Medical Center recently reported that they were near the limit of ICU capacity and, between Brigham and Women’s Hospital and MGH, we helped off-load some of their critical care volume.
Across our Partners system, there has also been a significant increase in cases. Many of our community affiliates have a good amount of COVID-19 patients in their ICUs as well as on their regular hospital floors. They all still have surge plans and can take additional patients as needed. The current discussion is whether it would be better to help by taking COVID cases from our community hospitals into either the Brigham or MGH. Alternatively, we may instead decide to bolster resources by sending some additional staff out to help at the community hospitals.
HATTIS: You mentioned staffing. How is that going right now at MGH?
LEE: We still are OK. Of course, we continue to worry about our staff, and we will continue worrying about our front-line workers until this pandemic ends. To reiterate, our frontline staff includes everyone and not just our nurses and physicians. Our response requires everyone from our janitorial staff and logistics teams to our cafeteria staff, and we are trying to protect all of them from infection. Interestingly, some of our ICU nurses have told me that they feel safer and more protected from getting infected while at work in the hospital than while at home in the community.
HATTIS: How are you doing with ventilators right now?
LEE: We are OK on ventilators. Every day the number of patients requiring ventilators continues to grow. We have enough ventilators for our current patients and have others in reserve for the projected need in the days and weeks to come. As I noted last week, we are using ventilators that are not traditionally used in the ICUs, including ventilators from the operating rooms typically used for anesthesia and also ones when we transport patients.
Additionally, we are working with the ventilator manufacturers to upgrade some home-based ventilators to meet the need of COVID-19 patients, if necessary. But since these home-based ventilators are made for home use and homes do not have high-powered oxygen delivery lines, these ventilators typically do not have the connections required to get to high oxygen levels. As a joint project between us and one ventilator manufacturer, we are working on minor modifications that will get these modified machines to the needed oxygen levels.
Interestingly, we have received multiple donations of ventilators, some from other countries. They are great ventilators and work well from our internal testing. Unfortunately, we cannot use them on patients as they are not yet FDA approved in the US. We are working with the FDA to see if we can get these cleared for use here.
Last, as reported in the media, other hospitals are looking for ways to take care of COVID-19 patients without use of ventilators. As there are definitely patients who could be treated this way, it is preferable if we can identify that cohort who are able to maintain adequate oxygenation through putting them on their belly. This could potentially avoid their needing a ventilator.
LEE: Same as last week. Our demographics of the critically ill continue to be primarily the elderly with certain chronic conditions and mostly men. We also continue to see younger patients without much underlying medical conditions that get horribly ill. The proportion of Hispanic patients remains higher than expected, but that higher proportion could be more a function of our geography (we are near Chelsea and East Boston) than anything else. I am aware that our hospital’s community health team is aggressively reaching out to support these hot spot communities.
HATTIS: What is happening these days with hospitalized patients who are not infected with COVID-19?
LEE: It is important to remind folks that we still have a steady stream of patients that are non-COVID. Patients still have heart attacks, strokes, and traumatic injuries that need hospitalization and ICU care. I just finished in one of our clean ICUs, where we are co-locating all of our patients without COVID-19 disease. It was very busy, and we expect it to continue being so.
HATTIS: It is being reported that people with COVID-19 may be facing life-threatening cardiac complications in addition to lung complications. Any observations to share on that?
LEE: Yes, we are seeing a few different types of cardiac complications. One is most likely from direct injury from the virus itself and it causes the heart to not pump as well. Sometimes patients come in looking like they had a big heart attack and get rushed to the catheterization lab. But it turns out that there is no coronary disease that needs standard heart attack treatment and instead it is injury to the heart from COVID-19 disease.
The other major cardiac injury we are seeing is something not directly related to COVID-19 and is often seen in other ICU patients. When a patient’s body gets severely ill, the heart can be affected too. This leads to heart injury and decreased pump function that is different from the initial disease. In these cases, it’s not the virus causing the injury to the heart but instead the heart shutting down because of how sick the entire body has become. Whatever the cause, an injured heart increases the chances of death.
HATTIS: There is a good deal of interest, as you can imagine, in any drug treatments that appear to be useful to reduce the morbidity and mortality of COVID-19. Remdesivir, which a few weeks ago you said was being tested at MGH, and hydroxychloroquine have both been in the news. There is also talk about drugs that attempt to stop the cytokine storm that appears in some patients and causes them to become very ill. What can you say about these various drugs and treatments?
LEE: We continue to enroll patients in the remdesivir trial here at MGH. Similarly, we are enrolling appropriate patients in trials that stop the cytokine storm you mentioned. Currently we are not in a study involving hydroxychloroquine. However, we are treating patients with hydroxychloroquine if clinical judgement suggests it could help. Patients on this drug do need close monitoring and a thoughtful discussion about whether the benefits of the drug outweigh the risks. Hydroxychloroquine has many side effects, some deadly.
I wish that there was a magic bullet for COVID-19. I do want to caution folks that there are no known evidenced-based treatments for COVID-19 besides good critical care and treatment of severe lung disease. All the drug studies to date for COVID-19 are small with profound methodologic problems. The authors of all these trials specifically state that further studies are required to determine efficacy. Unfortunately, this is true of the recent studies on remdesivir and hydroxychloroquine.
HATTIS: What is happening on the recovery side right now?
LEE: We are seeing patients recover and coming off ventilators. We continue to be hopeful. We also have a group of patients that have been on ventilators for over two weeks now. We have even put a few on extracorporeal membrane oxygenation (ECMO) and have around three patients on ECMO at any given day. (ECMO oxygenates a patient’s blood outside the body.) Our very first patient that required ECMO was recently taken off of ECMO and is improving. As our patients recover, they usually will stay in the hospital a bit longer after their ICU stay, and then most, if not all, will need some sort of post-acute care support. I believe we have already discharged a few patients to the new Boston Hope medical center at the Boston Convention and Exposition Center. From my understanding, a part of Boston Hope is to care for COVID-19 patients after they recover at the hospital.
HATTIS: What about personal protection equipment or other supply shortages.
LEE: PPE seems fine right now here. I am about to reuse for the first time an N95 mask that has been cleaned and sterilized. I do want to highlight a concern, however. We are not running out, but we are concerned about the supply of intravenous drugs that we typically use in the ICU. With COVID-19, we are taking care of more ventilated, ICU patients than we ever have before – not just at MGH but across our system, state, and the US. As such, we are using greater amounts of the drugs we typically use to sedate patients in the ICU. Internally, we are actively planning on measures to extend and expand our supplies. Again, we have enough at this time and for the foreseeable future. If we have a prolonged need of these medications, there could be challenges in the future.
HATTIS: How are staff holding up?
LEE: This is not like anything we have experienced before in our professional lives and it is stressful. Our mental health specialists at MGH have stepped up and are offering a variety of services to our front-line staff. Our Department of Psychiatry is fully integrated with our incident command structure.
HATTIS: What’s happening at home?
LEE: Thank you for asking. I have not experienced this personally, but have heard of reports of anger and some violence against Asian-Americans. My wife continues to remind me to be vigilant when I leave our home. She regularly sends me reminders.
On a lighter note, we continue to learn about remote learning. We now have a tablet computer dedicated to remote learning for our 5-year-old son. The challenge this week was finding a way to keep it upright safely. Unfortunately, the stands we ordered online are greatly delayed in terms of delivery date. So currently we use his Legos to build a makeshift stand; it seems to be working well, though it possibly distracts him a bit and seems to make him want to play Legos during his remote classes.
Previous conversations with Dr. Lee:
The Codcast: A report from the frontlines at MGH
Q&A with MGH doc Jarone Lee: We’re seeing patients of all ages
Dr. Lee: Preparing for the surgeDr. Lee: ICU units won’t beat this disease
Dr. Lee: At MGH patients don’t die alone