Flatten the Curve

Days in the lives of three doctors treating COVID-19 patients.

In early March, Andrew Duarte ’13, a third-year rehabilitation medicine resident physician, was working to improve the quality of life for patients who had suffered injuries or impairments at an NYU Langone Health clinic for veterans.

Then the first cases of COVID-19 were identified in New York City. Within weeks, the city became the epicenter of a global pandemic.

Almost overnight, life changed for Duarte.

The veteran’s clinic temporarily closed. Duarte and his colleagues, who never expected to practice internal medicine again, were asked to volunteer to care for COVID patients. Duarte went to work at Bellevue Hospital, one of the largest hospitals in the country.

“It’s been six days a week, 12 to 14 hours a day,” Duarte said. “The hospital is totally flooded with COVID patients.”   

On a normal day in the hospital, Duarte says he’d hear one or two overhead pages for patients who were crashing and in need of emergency intervention. Now, it’s hourly.

“You hear the page and you realize it’s your patient and you are sprinting up the stairs,” he said. “We go in [to treat them] only if absolutely necessary. We are told there is no such thing as an emergency in a pandemic.”

When the first information about COVID-19 began filtering out of China, where the virus is said to have originated, it was reported that those suffering the severest symptoms were older individuals and those with comorbidities. That led some younger people to resist early social distancing measures.

“We’ve seen young people and old people. We’ve seen old people you’d expect to have a bad outcome recover, and then some 20-to-30-year-old patients who are ventilated. We have to figure out why that is,” Duarte said.

“It’s not just your 84-year-old grandmother or your 64-year-old uncle who is a smoker. It could be your friends,” Duarte added.

As the global death toll mounts, doctors and scientists around the world are racing to understand more about COVID-19. Dr. Donald Pasquarello ’86 says he has never seen anything like it in his 23 years in emergency medicine.

“I was in training when HIV surfaced, and it was scary because we didn’t know much about the virus, we just knew people were dying,” said Pasquarello, an emergency medicine physician at Beverly Hospital, about 20 miles north of Boston.

“When Ebola surfaced in the U.S., I think that was a wake-up call for people, but an epidemic never materialized. COVID-19 is different, because it’s so contagious and can be spread by people with minimal to no symptoms,” he said.

To prepare for an influx of COVID-19 patients, Beverly Hospital split its emergency department into zones—one for patients without respiratory symptoms and an isolated zone for people with COVID-19 symptoms.

“As this has progressed, the isolated side of the emergency department is getting bigger and bigger,” Pasquarello said.

But Pasquarello also noticed that the hospital’s regular volume of patients has dropped off significantly. He attributes the decline in part to the stay-at-home orders, which are leading to fewer traumatic injuries, like broken bones and motor vehicle accidents.

Still, that doesn’t explain the drop in cardiac patients or those suffering from abdominal pain and appendicitis, for example.

“I think more and more people are afraid to come to the hospital, afraid they might be exposed and contract the virus,” he said.

That’s a concern for doctors, too. Duarte says that although his hospital has been able to maintain sufficient levels of personal protective equipment (PPE), he purchased his own P100 respirator, which filters out at least 99.97% of airborne particles, on eBay. 

Pasquarello said it’s been an adjustment to wear PPE at all times, and that the hospital has implemented other policies and procedures in an effort to keep staff healthy and prevent the spread of the virus.

“Everybody who is working on the front lines is concerned about contracting this virus and bringing it home to our families. We see the worst of it, because most people who are coming to the hospital are very sick. You think about it, but at the end of the day, you go to work and you do your job,” he said.

Dr. Kimberly Spence ’94 says doctors and nurses are scrambling to keep up with the near-daily policy changes, which impact nearly every aspect of their work.

Spence is both an associate professor of pediatrics at Saint Louis University School of Medicine and a neonatologist at Cardinal Glennon Children’s Hospital in St. Louis. She says changes in visitor policies—designed to protect both patients and hospital faculty and staff—has been particularly hard for labor and delivery and neonatal intensive care (NICU) patients.

“Laboring mothers are limited to one support person, and if they are COVID- positive, it’s no support person. Your support person might be on an iPad,” she said.

Recommendations for how to manage the care of newborns born to COVID-positive mothers are continuously evolving, but in some cases, Spence says, mothers are being instructed to stay at least six feet away from their newborns, or the babies are being cared for in a different room entirely.

“It’s completely the antithesis of what you want new moms and babies to be doing,” she said.

The policy changes have also been devastating for babies in the NICU, particularly older babies who thrive on social interaction.

“They are allowed only one person to come and visit, and that’s a real problem for children who have been here a long time,” Spence said. “We have 8-to-10-month-old children with chronic health issues who really depend on socialization.”

Spence says the policies could be amended with greater testing capacity. Ideally, everyone coming into the hospital would be tested on arrival.

“Right now, we don’t have enough tests to test everybody. We are just burning through PPE because everyone has to be treated as presumed positive,” she said.

“This has unmasked a weakness within our medical care system.”

Spence says more transparency is needed in the medical supply chain throughout the U.S. so states can collaborate and share resources instead of being forced to compete against each other.

“That’s how we can get through this. It comes in waves. When it hits in New York, we should be shipping our ventilators to them. And then when we need them, they ship them back to us.

“But the federal government needs to be able to take the lead on this. You can’t just sit it out.”

Duarte agrees that the pandemic quickly exposed the cracks in the country’s social systems.

“It reinforces the fact that the health care system overall is grossly inadequate,” he said.

“But it’s not just that. We saw how many people lost their jobs so quickly, for example. It’s impacting life in so many different ways. I think there will be lots of conversations going forward about the need for post-COVID societal changes.”

Imagining a post-COVID world, with still so many unknowns, is difficult. Vaccines may not be ready for the general public for more than a year, antibody tests aren’t yet fully reliable or readily available, and experts still don’t know for sure if those who have recovered from COVID-19 will have prolonged immunity.

But there is some good news.

“Staying at home and social distancing really is helping—it is working to flatten the curve,” said Pasquarello. “I like to look at the positives. We know about 80% of people have mild to moderate symptoms. People who have recovered or who have been asymptomatic will develop some protective immunity.

“I think we’ll get through this.”

In New York, Duarte is scheduled to continue working with COVID-19 patients through at least the end of June. But he is beginning to think there is a chance he could return to rehabilitation medicine before then.

“We are definitely seeing a downward trend. We are seeing fewer new diagnoses, and we are collapsing some of the repurposed units,” he said.

“I volunteered not only to help COVID patients but to help out my resident colleagues. There has been great camaraderie, and it has been an honor to work with them. I’ll be there as long as they need me.”

By Amy Martin. Photo by Misha Friedman.