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Foreword

Critical Care for Coronavirus Disease 2019: Perspectives From the PICU to the Medical ICU

Joyce, Christine L. MD; Howell, Joy D. MD; Toal, Megan MD; Wasserman, Emily MD; Finkelstein, Robert A. MDCM; Traube, Chani MD; Killinger, James S. MD; Joashi, Umesh MBBS; Greenwald, Bruce M. MD; Nellis, Marianne E. MD, MS

Author Information
doi: 10.1097/CCM.0000000000004543
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  • COVID-19

Abstract

On March 3, 2020, the first patient with coronavirus disease 2019 (COVID-19) was admitted in New York (1). New York City (NYC) quickly became the epicenter of the pandemic in the United States, and as of May 18, 2020, had over 190,000 documented cases and 15,888 deaths (2). As part of the surge response that our hospital system developed to meet this growing demand, the care of all inpatient pediatric patients was centralized to a single children’s hospital within our network. The 23-bed PICU at our hospital was converted into a 20-bed medical ICU (MICU). We describe our unique perspectives as pediatric intensivists managing a COVID-19 MICU in the epicenter of the pandemic.

On Wednesday, March 25, 2020, our 23-bed PICU was given a mandate to clear out all patients within 72 hours. Our PICU would be transformed into a MICU for critically ill adults with COVID, to meet the needs of a surge of patients in NYC. Our faculty, a group of 13 pediatric intensivists at the New York Presbyterian Hospital-Weill Cornell Medical Center, would continue to staff the unit with support from the adult pulmonary/critical care physicians.

Before receiving our first adult, we faced the clinical and emotional challenge of saying goodbye to our patients. Several children, with complex chronic conditions and multiple organ system failure, had been in our care for months and considered as part of their extended families. By Friday, March 27, 2020, all PICU patients had been transferred to our sister institution or discharged home. Our physical space (20 beds in multipatient neutral pressure rooms and three beds in negative pressure isolation rooms) underwent a 3-day transformation into a 20-bed negative pressure MICU.

On Tuesday, March 31, 2020, we admitted our first adult patient. Within 3 days, the unit reached capacity, with 20 intubated adults, and a median patient age of 68 years. All admitted patients were COVID positive, with either acute or impending hypoxemic respiratory failure.

Our staffing model included two teams. Initially, a pediatric intensivist led one team and an adult pulmonary/critical care intensivist led the other. As the NYC surge progressed, the medical intensivists were needed elsewhere, although they remained available for consultation at all times. Daily MICU run calls involved intensivists and other physicians caring for COVID-19 patients in all of the institution's ICUs. These calls covered various facets of care and provided additional expertise and guidance. By the second week, we expanded to two pediatric intensivist-led teams, with a MICU fellow on one team (and a PICU fellow on the other). The MICU fellow additionally served in a consultant role to the second PICU team, familiarized pediatric staff with the management of conditions rarely seen in children, such as myocardial infarction, as well as adult-dosing of medications, and added their perspectives regarding the impact of factors such as frailty, comorbidity burden, and baseline functional status on critical care outcomes. Medicine residents, pediatric residents, and pediatric physician assistants rounded out the teams. A medicine hospitalist was initially present but also transitioned elsewhere as the needs continued to grow. Nursing care was provided exclusively by PICU nurses (following orientation consisting of one or two MICU shifts), with assistance from general pediatric nurses. The pediatric staffing necessary for this crossover to occur ultimately included nine PICU attending physicians, six PICU fellows, six PICU physician assistants, and 63 PICU nurses. Additionally, 10 pediatric residents completed shifts in the unit. Pediatric respiratory therapists, physical therapists, and occupational therapists remained in the PICU and were supported by therapists from other units and outside agencies. Credentialing requirements, waived under New York State Governor Andrew Cuomo’s Executive Order, allowed for immediate practice transitions. Pocket-sized cards were quickly printed to familiarize the pediatric staff with adult medication doses and protocols.

The speed with which this transition occurred left little time for emotional processing. Feelings ranged from relief and pride (for the opportunity to put our critical care skills to use and participate in the care of those most affected by the COVID-19 pandemic) to severe anxiety and fear. Numerous questions arose: Do we go home to our families? Who will watch our children? Will we get sick ourselves? Are we adequately trained to care for adults and will our best be good enough? Some of these questions are universal to providers during this pandemic crisis; others are unique to our perspective as pediatric providers.

Problems arose surrounding availability of adequate personal protective equipment (PPE), rationing of essential medical equipment, and quality of care. We have watched patients’ oxygen saturations plummet due to mucous plugging of their endotracheal tubes while we struggled to don PPE as quickly as possible, hoping to get to the bedside in time. Rates of ventilator-associated pneumonia are higher than usual, likely due (at least in part) to limited suctioning and chest physical therapy as a result of restrictions put in place to limit patient contact and protect front line staff. Although we were never forced to ration ventilators, a shortage in continuous renal replacement therapy machines forced us to limit patients with acute renal failure to only 8 or 12 hr/d of continuous venovenous hemofiltration so that machines could be shared.

Concerns regarding end-of-life care occurred on a regular basis. This was far from the comfort zone of most pediatric intensivists. In our usual practice, our pediatric patients rarely present with a laundry list of underlying comorbidities. Recovery from viral illness and acute respiratory distress syndrome in pediatrics, even when associated with multiple organ system failure, is routinely high. As intensivists, we are accustomed to doing everything humanly possible to save the lives of our patients. While we are forced to ask questions surrounding futility of care in the PICU, it is not nearly to the scale we were faced with here. Yet, here we are confronted with death in numbers that seemed staggering to us.

But perhaps the most difficult-to-handle aspect of the COVID-19 pandemic has been the high degree of isolation. Patients are intubated, sedated, restrained and alone, with bedside care performed as quickly as possible to limit time spent in rooms and protect the bedside providers. There are no families to comfort patients, no child life specialists to engage them in play, no nurses to hold and console them. This could not be further from our normal environment of care. Anyone who has ever rounded in a PICU knows that to care for a child is to care for their family. The hole left by the absence of families in our ICU is profound, it is unsettling, and it is heartbreaking. It is social distancing taken to an extreme in a time when we and our patients desperately need human connection. We try to remedy this by video conferencing with our patients’ families and by allowing one individual to visit the bedside when death is imminent. Tragically, it is here, at the time of death, where our best efforts seem to fall so unbearably short.

Once again, we ask the question: Is our best good enough? This is something that physicians ask themselves routinely. There should always be room to grow, to be better. But the question evokes additional distress when compounded by the fact that we are caring for patients and medical conditions outside of our specialty. In this extraordinary time, when the need is so great, there is little we can do but move on despite our uncertainty, putting our questions aside to be answered another day.

This experience has been both overwhelming and humbling. Each of us has approached the pandemic from different perspectives, with varying knowledge levels, different comfort levels, and different thresholds to consult our colleagues trained in adult medicine. However, in recognizing our limitations, we have been quickly forced to adapt, to grow, to expand our knowledge, and broaden our comfort zones. This has made us better physicians. And our patient outcomes have demonstrated that we were remarkably well-suited to step up and deliver excellent critical care during this challenging time. We have been asked to continue to care for adult COVID-19 patients well into May, even as other adult ICUs within the institution return to their primary function (such as cardiothoracic, surgical, and neurosurgical intensive care).

In short, we have learned that we are, first and foremost, intensivists. The management of respiratory failure, shock, multiple organ system dysfunction, acute renal failure, titration of vasoactive medications and sedatives, and the application of physiologic principles to the care of patients is our bread-and-butter, it is what we do. The fact that our patients are older, and with multiple comorbidities, has certainly challenged us, but it has not prevented us from providing expert care.

When we leave this experience, what will we take with us? We now have a greater depth of knowledge and a stronger sense of empathy toward families struggling to understand the critical illness that has torn loved ones from their midst. We leave with renewed respect for (and from) our adult-medicine colleagues and the work that they do. We have developed a new sense of collegiality that spans adult and pediatric medicine, and a new appreciation for the true meaning of team. We leave with a sense of awe for the courage and dedication of our nurses, and clear recognition of their many previously untapped capabilities. We will leave with an increased sense of who our physician colleagues really are and greater knowledge of the support that they need. We feel profound gratitude that (to date) children have largely been spared from the ravages of COVID-19 (3,4). And we bring the recognition that, should we ever find ourselves in a similar situation, we are well equipped to be here. Our MICU colleagues have shared a similar sentiment, an appreciation for the opportunity to share best practices, and an expanded view of ventilator management and approaches to analgesia and sedation. Poignantly, a MICU fellow shared with her colleagues the habit of pediatric providers to often refer to patients by their first names, a simple difference that for her, humanized each patient who was otherwise a stranger on a ventilator.

During the course of this pandemic, we had the good fortune to extubate many patients in our ICU. Following each extubation during this time, the entire care team stood outside of the patient’s room and cheered with all the vigor they could muster. They cheered not only for the recovery of the individual patient but also for one another, for hope amidst the overwhelming sadness. After one particular extubation, a member of the environmental services staff, himself on the frontline, stopped by during the physicians’ evening handoff. He told us that he cleans the patients’ rooms daily and comes by at the end of each shift to check on “his” patients. His relief at seeing this patient safely extubated was palpable.

That one small measure of humanity illustrates how we all persevere through this COVID-19 pandemic. We have been privileged to see the overwhelming good in the people of NYC, the beauty of the human spirit, and the collective concern for the well-being of strangers. This virus, for better or for worse, has connected all of us, has connected us to the world. We leave this experience with the profound knowledge that we cannot take care of ourselves without taking care of one another.

ACKNOWLEDGMENTS

We would like to thank all of the members of the healthcare team in our PICU: the clerks, fellows, residents, medical ICU colleagues, consultants, physician assistants, respiratory therapists, social workers, case managers, child life specialists, environmental service workers, physical and occupational therapists, chaplains, and, most of all, nurses. Without the help of each one of you, we could not have successfully cared for these patients. We would also like to acknowledge Dr. Jamuna Krishnan and Dr. Meredith Turetz and thank them for assisting us in the care of critically ill adults and sharing their perspective with us.

REFERENCES

1. Goyal P, Choi J, Pinheiro L, et al. Clinical characteristics of Covid-19 in New York City. N Eng J Med. 2020; 382:2372–2374
2. NYC Health. NYC Covid-19 Daily Summary. 2020. Available at: https://www1.nyc.gov/site/doh/covid/covid-19-data.page. Accessed May 18, 2020
3. Lu X, Zhang L, Du H, et al.; Chinese Pediatric Novel Coronavirus Study Team. SARS-CoV-2 infection in children. N Engl J Med. 2020; 382:1663–1665
4. Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 among children in China. Pediatrics. 2020; 145:e20200702
Keywords:

coronavirus disease 2019; critical illness; perspective

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