If Not Us, Who? And If Not Now, When? Perspective From a COVID-19 Intensive Care Unit Run by Otolaryngology Residents | Critical Care Medicine | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Reflections
October 1, 2020

If Not Us, Who? And If Not Now, When?Perspective From a COVID-19 Intensive Care Unit Run by Otolaryngology Residents

Author Affiliations
  • 1Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York
JAMA Otolaryngol Head Neck Surg. 2020;146(11):997-998. doi:10.1001/jamaoto.2020.3232

Elmhurst Hospital Center (EHC) sits tightly wedged between the cramped apartments of Jackson Heights and the bustle of Flushing Meadows, in central Queens, New York City (NYC). The hospital provides primary, emergency, and inpatient care for one of the poorest and most diverse districts in the nation. Like the city that surrounds it, EHC is a true melting pot, with physicians, nurses, and other essential workers from around the world. Owing to the economic and cultural roots of the patient population, EHC acts as the truest version of a safety net for some of NYC’s most disenfranchised patients.1 Unfortunately, its diversity and open arms caused it to be a prime target for coronavirus disease 2019 (COVID-19). At the height of the pandemic in NYC, 95% of EHC inpatients tested positive, and our hospital was operating at 500% surge intensive care unit (ICU) capacity. Eventually, EHC aptly began to be referred to as “the epicenter of the epicenter.”2

As the pandemic reared its ugly head with 1 of every 25 people infected with the disease and over 700 patients a day dying in NYC,3 it was at EHC that we found ourselves, a few otolaryngology residents, wondering what was going to happen to us, the patients we treat, and our city. We saw the numbers begin to climb at the hospital. Emergency department wings turned into COVID-19 wards; surgeries were cancelled left and right. Our training became paused. We waited.

As this happened, other departments in our hospital system dispatched clinicians to the front lines in the emergency department (ED), the floors, and the ICUs. In contrast, in an effort to reduce our exposure, keep us healthy, and not lose our emergency airway teams, our residency program divided us otolaryngology (ENT) residents into hospital-specific “pods,” often alternating weeks on and off, sheltering us from the rising tide. With days passing, and clinical exposure replaced with endless virtual education sessions, we watched as many of our colleagues, family members, and friends responded on the front lines, and we worried for them. However, for some of us, especially those stationed at EHC, it began to feel as if we were hiding. We felt useless, while others put themselves in harm’s way.

Because of this fear and empathy for those working on the front lines, one of us (A.K.B.) led the charge and was the first in our residency to volunteer at EHC. The first 24-hour shift in that ICU was harrowing. Working in the freshly minted “SURGE/Overflow COVID ICU” (EHC’s former postanesthesia care unit), the day was spent praying no patients were admitted. That changed soon enough as patient after patient was transported up from the ED—what had unfortunately become a medical war zone with rows of intubated patients on every version of portable ventilator; a mix of alarms, sirens, and codes; and overburdened clinicians and staff rationing a dwindling stock of basic supplies to care for NYC’s sickest patients. This was a time when there were freezers of dead bodies outside, and as they filled up, the dead were being boarded in the ED until there was room. As the day ended, one of us (A.K.B) pondered, “Are we going to survive this? Do I have to go back?” But turning a blind eye on EHC’s darkest hour was no longer an option.

After an emotional call to action, 7 additional coresidents volunteered. Before we began, we reflected on our privilege. How lucky were we to have the opportunity, the choice, to volunteer in contrast to some of our colleagues? We, as otolaryngologists, as subspecialists, were in this moment not special, but physicians like everyone else. It was our duty to help lighten the load of our colleagues. With the support our otolaryngology attendings and critical care specialists at the hospital, we formed another surge COVID-19 ICU—staffed 24/7 by ENT residents. A single negative-pressure room with 7 “ICU beds” (most patients remained on stretchers with portable vents when resources were scarce). Our program director, motivated by the cause herself, deployed another 4 volunteer residents to help us form a true platoon. Four teams of 3 ENT residents each would now attempt to learn everything possible about COVID-19 critical care in a matter of days to staff what we, and the hospital, would come to call the “ENT COVID ICU.”

If one has never experienced burnout, spending a few days in our COVID-19 ICU is the perfect crash course. Prior to COVID-19, it was rare for us to see asystole on a monitor, to run a code, to watch someone die, but here it was far too frequent. It felt as if our unit was reserved for the sickest of patients with the worst prognosis. Patients who showed any signs of improvement were immediately transferred to a traditional ICU, which had access to sinks for dialysis, and importantly full-time critical care staffing. While we had critical care attendings or anesthesiologists available if we needed support, we often managed in their absence as they tended to other units. Because of this, we nicknamed our unit “limbo” because it seemed it was just a sad waiting room, where we watched the patients under our care either improve and be transferred or decompensate and die. Regardless of the outcome, we were always saying goodbye. In reality, as we reflect on our time, we were like every other unit in the hospital. Especially early on, as we received patients who received less-focused care for days in the overburdened ED, we were just playing catch-up on patients. Most of the time, we could not stabilize those who were too far gone. However, for those we transferred out of the unit, we can take solace in the knowing that we had a hand in improving their status so that they could be “worthy” of receiving the limited resources of our hospital at the time. Indeed, some of those patients survived. This setup, however, was difficult for us, as we missed those moments you always hope for: discharges, extubations, and good news. It made working in the unit that much harder.

For the first time, many of us were truly scared to go to work, to hurt the patients, to not be able to emotionally manage what we were seeing. We were not trained in critical care. We spent a few months, years ago for some of us, as interns in an ICU—not enough training to run our own unit for some of the sickest patients. Some debated whether we should do this at all. At this point, would we cause more harm than good? There were certainly physicians more appropriately suited to care for these patients. The problem was that those physicians were already working elsewhere in the hospital. Elmhurst Hospital Center had literally called in the US Army, Navy, and Air Force, and it was still not enough personnel. If it was not us, it would be no one, and these patients would have piled up in the ED, overburdening an already stretched-thin staff. We agreed among ourselves then that we would do this until we were not needed; once the numbers declined, we would gladly pass this off to those with more training.

So, uncertainty, a steady state of unease, and daily fear became our new normal. In the world of COVID-19, our goal was to create some consistency even if only over a 12-hour shift. In other units this consistent team-based care, a cornerstone of good medicine, was missing, as rotating nurses and physicians came and went throughout the hospital. They could often not make well-thought-out gradual changes that these patients needed. We could. Supportive therapy thus became our mantra. “No big moves, and we act as a team.” We prepared daily, discussing critical care concepts with each other each night and throughout the day as we saw the patients. We gave each other “COVID ICU Critical Care lectures,” created “cheat sheets” and shared the most up-to-date research with one another to make sure we were providing the most cutting-edge care we could. We regularly consulted our critical care colleagues and recruited them to the unit to help manage “higher level” critical care issues. We learned and adapted. Soon this scared ENT ICU blossomed into a well-oiled machine filled with competent residents. We often received the remarks from visiting critical care physicians that they were “surprised” we were otolaryngologists!

What we could not prepare for was the emotional toll. The seemingly constant death. The difficult conversations we had to have with families. Having to tell a daughter that her mother would not make it through the day. Holding up video chats to patients to allow families to say their goodbyes, often after they had passed away. A short facetime can never compare to holding someone’s hand as they pass. Unlike typical critical care, where goals of care can be discussed in a stepwise fashion, in the era of COVID-19, patients decompensate so quickly that goals change in minutes. We had to have difficult conversations with families early and often. Going into ENT, we did not expect to have to do this, at least not this frequently. Yet now this was our daily reality. We discussed the best ways to approach bad news, how to allow families time to grieve and make decisions, but also to help them along in making those decisions in a rapidly changing environment. Going forward, it may be of extreme utility for programs to consider more formal training in how to conduct these difficult conversations. What we say and how we say it will last with patients and their families for a lifetime.

The silver lining behind all the mortality we saw was becoming the bridge for patients’ families. After a patient would pass away, we took a moment to remember them, their life, their story and to facetime the family. Communicating family wishes, sharing tears, and even facilitating religious ceremonies helped us get our own closure before each stretcher was wheeled away. While the management of critical patients did not come naturally to any of us, communicating with families about a complex disease process is where we did our best work. Sometimes it is easy to forget how much we can offer patients. Regardless of specialty or experience, an innate quality of being a physician is a heightened level of empathy. For some it took a pandemic to remind us that in times of crisis an open ear and heart can be our most valuable skill.

To those of us that worked in the ENT COVID ICU, it felt like a war. In the darkness, the 12 of us searched for signs of hope. Being in this medical apocalypse bound us together, as a team, as brothers and sisters. We reached out to each other, checked up on each other, and took care of each other. We were like our own “residency within a residency” during this time. There is no doubt that this experience changed us. While we may forget the critical care medicine as we settle back into our normal ENT resident roles, we have learned greater lessons on empathy and teamwork than we ever could have without this experience. We are better physicians than we ever could have been and can be proud of what we have done.

To those reading this, embroiled in your own version of this pandemic, we are with you. As you may watch your colleagues drafted into service, we implore you, as difficult as it is, do not sit on the sidelines. We were certainly outside of our comfort zone. But we were there, and that is what counted. Despite being specialists, in this moment we are not special right now.

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Article Information

Corresponding Author: Arvind K. Badhey, MD, Department of Otolaryngology, Icahn School of Medicine, Annenberg 10-40, Department of Otolaryngology, 1468 Madison Ave, New York, NY 10029 (akbadhey@gmail.com).

Published Online: October 1, 2020. doi:10.1001/jamaoto.2020.3232

Conflict of Interest Disclosures: None reported.

Acknowledgements: We would like to acknowledge Luc Morris, MD, for inspiring us to journal our thoughts as we first started the unit. Dr Badhey thanks his wife, Marika Osterbur Badhey, for showing him what it means to be truly brave and not give into fear; and his loving grandmother, Seetha Kethey, who sadly passed away in the midst of this pandemic. Dr Laitman thanks his wife, Megan, and his daughter, Lucy; everything he does is for them.

References
1.
US Census Bureau. American Community Survey 1-year estimates. Retrieved from Census Reporter Profile page for Congressional District 14 (2018). Accessed July 25, 2020. https://censusreporter.org/profiles/50000US3614-congressional-district-14-ny/
2.
Correal  A, Jacobs  A. A Tragedy Is Unfolding: Inside New York's Virus Epicenter. New York Times. April 9, 2020.
3.
New York City Coronavirus Map and Case Count: The Coronavirus Outbreak. New York Times. May 23, 2020.
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    3 Comments for this article
    Thank you!
    Linda Gochfeld, MD | Dept. of Psychiatry, Rutgers Medical School (ret.)
    This moved me to tears. Thank you for what you did, and for sharing this experience. It reminds us again of our calling as physicians.
    CONFLICT OF INTEREST: None Reported
    Thank you ...
    Faye Kolin | Patient Partner, Cambridge Health Alliance, Cambridge, MA
    Thank you, as well as other medical professionals in our country, for all you have done during this pandemic. The bravery and empathy illustrated in this article moved me to tears. The silver lining in these harsh times is seeing these kinds of extraordinary examples of kindness and compassion.
    CONFLICT OF INTEREST: None Reported
    Let us not forget
    Ann Yanagi, MD, Emergency Medicine | UCHealth, retired
    Thank you for taking the time out of your surely busy training schedule to write this very moving article about diving into critical care medicine. You well describe the dread of knowing how lacking your early training can be for these situations. As we move forwards, your experiences of fear, anxiety, then growing confidence in what you could do is inspirational .
    CONFLICT OF INTEREST: None Reported
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