In early March, our neurosurgery team at Mount Sinai Medical Center noticed a handful of COVID-19 cases admitted to our medical intensive care unit (MICU), which is just down the hall from the neurosurgical intensive care unit (ICU). The daily news from Asia and Europe was certainly not encouraging, but we proceeded with our normal routine — morning rounds, surgery and academic conference.
Then, for one-week, cases of COVID-19 filled the MICU. Shortly after that, our neurosurgical step-down — followed by the neurosurgical ICU — were rapidly converted into negative pressure rooms for COVID-19 patients. That same week, our hospital system placed a hold on all elective, non-emergent surgeries. By Friday, March 20, at a time when there were 7,102 confirmed cases of COVID-19 in New York (with 46 deaths), Governor Andrew M. Cuomo ordered all non-essential businesses closed and their employees to stay home. The following day, our department leadership held an emergency town hall video conference discussing a re-organization of the department. As of the writing of this article, our 18-bed neurosurgical ICU is at double capacity and frequently caring for more than 40 critically ill, ventilated COVID-19 patients every day — accounting for new admissions, discharges and mortalities.
As health care providers and citizens of New York City, my colleagues and I have witnessed our home become the U.S. epicenter of the COVID-19 pandemic — surpassing all other regions in terms of the number of confirmed cases and deaths. What has transpired over a month here in New York City has completely shifted the way we provide health care — in general, as well as the practice neurosurgery — and how we learn as resident physicians.
There has been a city-wide diversion of health care resources to care for critically ill patients with COVID-19. From the conversion in operating rooms and post-anesthesia care units (PACUs) to ICUs, to the transition of neurocritical care faculty and providers to staff these units, all have led to a shift in focus for residents of neurosurgery. With elective surgeries on hold, our daily routines have changed dramatically. In addition to caring for neurosurgical emergencies, many residents have assumed a greater role in providing critical care — staff both the neurosurgical and respiratory ICUs. This has meant — particularly for more senior residents and neurosurgical attendings — a deep dive into critical care medicine, ventilator management and the latest therapeutic strategies for COVID-19. One piece of expertise that neurosurgery residents can bring to the respiratory ICU is turning patients into the prone position. This maneuver can salvage some patients with significant respiratory compromise. One commonality for all health care providers during this time is the feeling of being outside one’s zone of comfort. Whether this takes the form of a neurosurgical resident staffing the respiratory ICU or a general sense of uncertainty over when this crisis will end, this unified sensation has led to individual and interpersonal growth.
During this time, neurosurgeons have also witnessed the redefinition of a neurosurgical emergency. As providers, we have had to make difficult decisions on both ends of the emergency spectrum — for example, from purely elective spine surgery to active herniating discs. In the current pandemic, physicians worldwide have been needed to decide which COVID-19 patients should not be intubated, given their overall poor prognosis to save the ventilator for a patient with a better chance of a good outcome. We have had to discuss end-of-life care with certain neurosurgical patients who, in other times, would be surgical candidates. Non-emergent but urgent surgeries, including brain tumors, have been pushed back for months — another indirect consequence of COVID-19 that may significantly affect a patient’s overall outcome.
Despite a lack of standard surgical experience, neurosurgical residents have continued to learn during this crisis. Beyond the critical care knowledge, we continue to have didactic sessions, with one significant change — video conferencing. To uphold the sanctity of social distancing, we have been logging in from separate computers in distant locations to participate. We are fortunate to be able to continue our didactic learning. At the same time, our colleagues in internal medicine and other specialties beleaguered by the present pandemic, do not have the capacity for anything besides direct patient care.
Beyond these changes to the health care landscape, we in New York City have experienced an incredible shift in the mentality of daily life. The defining features of the “City That Never Sleeps” — restaurants, subways, cultural landmarks — have been shut down. However, the New York City spirit continues to thrive. We have seen an outpouring of philanthropy, from donations of handmade personal protective equipment (PPE) to deliveries of meals to entire medical units. Like other cities around the world, every night at 7 p.m., one can hear clapping and cheering from apartments and skyscrapers city-wide, an homage to the essential personnel and health care workers keeping New York City on its feet and preparing for a successful emergence in time.
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Kurt A. Yaeger, MD
Mount Sinai Medical Center
New York, N.Y.