Critical-Care doctors from St. Joseph’s hospital share how they fought the pandemic, with help from around the world
In terms of contagious disease, COVID-19 may have posed the biggest threat to human life in 100 years. Practices that had worked with previous coronaviruses worked less well, or not at all. Across the globe medical caregivers had to learn how best to treat it, even as patients were filling hospital beds. Members of the critical care team at St. Joseph’s Health Hospital in Syracuse shared their recollections of how they adapted, and their thoughts on lessons learned. Doctors included:
Brianne Aiello, MD, Pulmonary and Critical Care Medicine, St. Joseph’s Health, Syracuse, NY
Douglas M. Fetterman, MD, Anesthesiology and Critical Care Medicine & Medical Director of Critical Care Services, St. Joseph’s Health
Joshua Piticaru MD, Critical Care Medicine, St. Joseph’s Health
Gagangeet Sandhu, MD, Critical Care Medicine, St. Joseph’s Health
Q: How and why did you get into medicine, and what is your specialty area?
Dr. Aiello: I had a terrific primary care physician as a young adult who showed me what was possible with medicine. After medical school, once I started clinical rotations, I fell in love with Critical Care and haven’t looked back.
Dr. Fetterman: At the age of 8, I watched my grandfather die while he was playing cards at the kitchen table. My desire to help other families in similar situations pulled me toward medicine. I specialize in anesthesiology, especially for patients undergoing heart operations, and also in Critical Care Medicine and Extracorporeal life support/ECMO. I’m also medical director for Critical Care services.
Dr. Piticaru: I wanted a career where I could be a lifelong learner, solve complex problems, and also be able to care for people. Medicine was the perfect career. I got into medical school in Canada at the age of 20 directly out of undergraduate studies. Now, I’m a Critical Care physician.
Dr. Sandhu: Post-high school; my love for science and the fascination to be able to assist in the process of healing the sick was the initial driving force. I’ve been a Critical Care physician for about 6 years.
Q: In what ways did you feel prepared for COVID-19? In what ways did you feel unprepared?
Dr. Aiello: The H1N1 flu pandemic hit as I began my internal medicine training. Those patients were my first exposure to Acute Respiratory Distress Syndrome (ARDS). Prone Positioning was something that I was comfortable with prior to the onset of COVID-19. It has been critical in the management of these patients. Fortunately, we had the benefit of learning from our peers who faced COVID prior to the surge we met in Syracuse. There is still a lot to be learned which has been a frustration as we care for these incredibly ill patients.
Dr. Fetterman: I doubt that you can ever truly be prepared for something of this magnitude. I had treated patients with H1N1 swine flu. I spent many nights taking care of young people with acute respiratory distress syndrome (ARDS). Many were placed on extracorporeal membrane oxygenation (ECMO) machines for lung support.
With COVID-19, I was prepared to treat many sick patients, in many ways. What I was not prepared for was how different this disease was and how little we knew about how to treat it. It did not respond as a typical ARDS. Patients became sicker than we would have normally expected, and took longer to recover, if they ever did.
As a medical director, it was even more challenging. No one knew how many people in CNY would be affected. Would we have to ration care in the community? I am staffed for 38 ICU beds but the predictions initially coming in were to prepare for well over 150 ICU patients. Where would we put them? How would we monitor them? Like every other hospital in the country, we have a shortage of nurses. We needed to figure out how to scale services without putting more pressure on our limited staff. We ended up giving lectures to hospitalists and my non-ICU trained anesthesiologists on ARDS management in case we needed to pull from the bullpen.
All the ICU physicians and nurse practitioners and physician’s assistants ran toward the fire to help. Pulmonologists and surgeons who haven’t done ICU work in years offered their help. It was reaffirming to see how many in practice today still believe in their duty to serve.
I was constantly worried my staff would get sick and end up in the ICU. If ever there was a time when I could imagine what it was like to be a military officer in wartime, this was it. The stress at times was taxing. Prior to COVID, my engagement with the leaders of Crouse or Upstate ICUs was nonexistent; with COVID we have developed a collegial network to bounce ideas off each other.
Dr. Piticaru: We are trained to deal with severe illness. What is unusual with COVID-19 is how severe the disease can be in younger patients, and how long the disease course carries on in those that are fortunate enough to survive. We have had patients as young as 20 require life support. Many that survive only do so after two to three weeks of being on a ventilator. The pandemic has also tested our ability to interpret rapidly evolving evidence and guidelines, and to be comfortable with thinking outside of the box. Normally, medicine progresses rather slowly. New major studies come out a few times a year. Practice guidelines are updated every few years. Treatment and approaches to COVID can change by the week. This is both a blessing and a curse – one must sift through thousands of data points and pick out “truth”.
Dr. Sandhu: It helped that we had the time to prepare (unlike our colleagues in New York City, Italy and China) and had some idea what was working and what was not working. At the same time, it was a novel virus with many unknowns.
Q: As you and your colleagues got more experience treating the disease, how did you change techniques, approaches, or medications?
Dr. Aiello: Early practice in COVID was very much flying blind. For example, steroids were very controversial. There were no conclusive data at the time of the initial outbreaks. We were not consistently using steroids and the dosing was variable. Later, the BMJ (formerly the British Medical Journal) published data demonstrating benefit and that is when we all became more unified in our approach. There had been ongoing debate about the utility of the Anti-IL-6 drugs such as tocilizumab and while the more recent data is stronger, and we are using it more, questions remain on patient selection and timing of dosing. Prone positioning has proven to be valuable throughout.
A year into this pandemic, I am most proud of how adaptable and resilient our Critical Care Team has been. We have shifted paradigms as new data emerged and have consistently used Evidence Based Medicine as the cornerstone of our care. We have excelled at consistently providing excellent ICU care and brought in new ideas and therapies as they were proven to be of benefit.
The emotional toll of this pandemic on all involved has been tremendous. Patients have been isolated. Families unable to visit their loved ones. For our staff, extended work hours, fear of illness, and monumental demands on personal lives. We are up against a formidable enemy, and we have fought with determination, integrity, compassion, and grace.
Dr. Fetterman: SARS-COV1 and MERS, both Coronaviruses themselves, showed worse outcomes with steroids. When I first started getting reports out of NYC that steroids were working on COVID, I was very skeptical because, in medicine, “Do No Harm” is paramount. As we slowly started using it in our practice, we saw some improvements in patients.
Another difference with this disease was the challenge of when to intubate. Our normal process was to intubate for low blood oxygen. It took time to learn which patients would see greater benefit than harm. Today, we are much less likely to intubate for low blood oxygen as long as a patient is comfortable and not taking such big breaths that they are inducing their own lung injury.
The pandemic became a chance for the public to see the messy way that medicine makes the sausage. In some ways it was good for the public to understand the practice of medicine as an art that is based upon science. The downside was that we in medicine know that evidence changes, studies can be flawed, imperfect, or simply are in the early stages of understanding, but members of the public may not appreciate that medicine is always a work in progress. Intense discussions and debates about therapies generally occur in journal correspondence, at medical society meetings, or in academic gatherings, and those debates are good. Rarely do they play out in the public media.
It was unfortunate that some physicians took to debating their treatment hypothesis on news outlets instead of academic forums. The yearning for answers and miracle therapies during COVID-19 had the public clinging to every word, every possibility, every concern. Some matters of opinion became gospel without evidence — the hydroxychloroquine story and the convalescent plasma story. Even when the evidence changed, it had already become religion and no longer open for debate in some public minds.
Think of these changes over time like the iPhone 1. Would anyone buy it now that we are on version 12? The existence of the iPhone 12 doesn’t mean the iPhone 1 was without value, was wrong, or should have never been released to market. We needed to start somewhere with COVID, test hypotheses based on what we know, then follow the evidence, allow yourself to be open and to question when things don’t work as they seem, and ultimately the process of understanding more over time will result in the delivery of better care.
Dr. Piticaru: The data has definitely shown that survival of COVID is improving. By holding off on putting patients on ventilators unless we absolutely have to, we are keeping a select group of patients from complications that come along with that, and it is quite clear if one can avoid going on a ventilator one has better odds of survival. The anti-inflammatory drugs such as steroids and tocilizumab have demonstrable improvement in survival as well.
Medicine is a field where we generally are comfortable with adapting and integrating new information. COVID has accelerated and expanded that. In early 2020, all we knew was that there was a mysterious virus in China causing an unusual pneumonia and high death rates. We have used the scientific process to observe, test and re-evaluate hypotheses and our understanding of the virus and the disease it causes. We have come incredibly far in just over a year. That result was possible only in an era where we can collaborate globally and share information instantly.
Dr. Sandhu: When you are dealing with a novel enemy and are on the frontlines – you adapt and change to win. That is the only constant fact.
Q: What’s the big thing you learned during this pandemic, and how do you hope that influences our approach to the next one?
Dr. Aiello: Teamwork is absolutely critical. Sharing of knowledge and resources is our surest and fastest way through these events. More broadly, to recognize that we are all in this together. The need for communication, clarity, and strong leadership at all levels is essential.
Dr. Fetterman: There is no magic wand. We kept hoping there was some quick and easy answer to the treatment of these patients. What we learned was patience, stick to what we know works, test out new therapies in small groups and then add them in slowly.
My takeaways: First, resources. Healthcare strives for highly efficient use of physical plant and staff. That leaves little wiggle room when it comes to a sudden influx of patients. Most normal times we operate below the staffing levels we need. There is a lack of staffing resources in Central New York. We need more nurses and doctors in Syracuse.
Second: Advanced care planning. COVID is a reminder that the human condition is frail. We should embrace life, live with passion and purpose. Don’t wait to tell a friend or relative how much they mean to you. Don’t regret being absent in someone’s life. Most importantly, discuss openly with the ones you love what they would want from the doctors should an unexpected situation occur.
Dr. Piticaru: New potential treatments may make headlines and create excitement, but we have learned to keep a healthy level of skepticism and constantly be on the lookout for quality evidence. We saw this with the hype around drugs like hydroxychloroquine and others, which ultimately give patients and families only false hope and may overall be harmful. This has to be balanced with quickly and accurately determining whether treatments or approaches are beneficial. Additionally, we learned that collaboration is essential – locally, nationally and globally. I am not sure we have fully learned this at this point, but it is the only way out of a pandemic of this scale.
Dr. Sandhu: Listen, learn, share, and adapt quickly based on facts and logic. The fact that we are physicians/scientists is more important than to which country or state or an institute we may belong. The power of collaborative teamwork across nations is the key.