A Tribute to Health Care’s First Responders
In my June 2020 column, I briefly reviewed 14 prior major pandemics and epidemics. In the recorded histories of these events, doctors and other health care personnel were always “first responders,” often at great personal peril. COVID-19 has been no exception; it has been our time to be first responders.
This article reviews health care responses from both coasts and from the heartland, as well as the leadership provided by the American College of Surgeons. I would like to stress that these few examples are drawn from the excellent work of thousands of other health care providers in our country.
But first, let me offer several historical footnotes, including concepts that were previously proven to be valid in dealing with a pandemic.
The plague doctors of the 14th century donned their own version of a hazmat suit to administer to the afflicted. They avoided touching the sick and potentially contaminated areas. When not working at their profession, they quarantined themselves.
The 1918-1920 Spanish flu came in two horrendous waves, the second wave being more deadly than the first. The young were the most afflicted, certainly in part because of crowding during World War I, as well as the deaths from cytokine storm induction. Five hundred million people were infected worldwide (28% of the world’s population) and 50 million died (10% mortality).
A towering figure of the time, Dr. Thomas Tuttle, born in Fulton, Mo., in 1869, was the commissioner of health for the state of Washington in 1918. In dealing with the Spanish flu, he made wearing face masks mandatory; he advocated social distancing; he encouraged home isolation and quarantining of individuals who had been exposed to the virus; he raised the notion of asymptomatic transmission; he warned of a resurgence of disease if restrictions were lifted prematurely. However, in an unfortunate prefiguring of our present situation, his efforts were met with great societal opposition, eventually causing his dismissal from the U.S. Public Health Service.
The 2014-2019 Ebola epidemics were prevented from becoming pandemics by enforcing isolation, quarantine, travel restrictions and, eventually, a vaccine. The stunning success of vaccination, initiated as early as 1796 by Edward Jenner, against a pandemic was made evident by the fact that it was responsible for essentially wiping out smallpox from the world. Although nowhere as successful, a flu vaccine has been available for the past 60 years.
Over the centuries, through repeated experience with pandemics, scientists have learned the vital importance of isolation, quarantine and face masks to inhibit transmission. Thus, the history of pandemics clearly indicated that when COVID-19 appeared in Wuhan, China, it would—if not met with preventive measures—spread throughout the world, and, that once the virus reached our continent, rapid implementation of proven methods of resistance and containment should have been mandated. This is not what occurred. Instead, as a nation, we suffered another Pearl Harbor, another 9/11. We rapidly lived up to the slogan, “America First,” as we reached the highest number of confirmed cases and deaths from COVID-19.
To deal with this grave reality, our health care system vaulted into action and true leadership emerged.
The first confirmed case of COVID-19 in the United States, in a man who had returned from Wuhan, was reported on Jan. 21, 2020, by Providence Regional Medical Center in Everett, Wash., a city north of Seattle. The first evidence of community transmission came on Feb. 28, when two critically ill patients hospitalized at EvergreenHealth in Kirkland, Wash., with unexplained lower respiratory infections were tested and found to be positive for SARS-CoV-2. One of those two patients died on the same day. It soon became evident that transmission within a local nursing home was one of the major contributors to early spread of the virus and a significant contributor to the early mortality of COVID-19. America watched as the national tragedy unfolded in a microcosm.
The first health care responders in Washington did more than observe; they acted, and they acted swiftly. Within seven days after identification of the first case of COVID-19, EvergreenHealth initiated more than 10 protocols of response including establishment of a drive-through testing site, an inventory for accountability and preservation of personal protective equipment (PPE), conversion of hospital beds to ICU units with negative airflow, and communication networks linking health care workers and epidemiologists with patients and the public. Within days, the intensivists in greater Seattle had a text thread communication between the ICUs across the city on the number of cases, symptoms, clinical presentations, treatment strategies, and medical and staffing needs. Unprecedented stress faced the caregivers—the emotional impact of observing the isolation of patients, especially those soon to die, without being able to say goodbye to their relatives.
“I was glad to be able to be there with patients, but the isolation can be overwhelming.”
—Katherine Mandell, MD, general surgeon, Seattle
“From the beginning, this has been a collective effort to respond quickly and exchange knowledge with our peers at every step, and we are extremely grateful for our partnerships.”
—Frances X. Riedo, MD, EvergreenHealth Medical Director of Infectious Diseases
New York City
New York City (NYC) was inundated by COVID-19; however, again health care workers, led by our fellow surgeons, rose to the challenge. There are many hospitals in NYC; NewYork-Presbyterian at Weill Cornell Medical Center is my example. The facility has 860 adult beds with 110 ICU beds; by April 15, at the peak of the epidemic in NYC, 560 beds were occupied by COVID-19 patients with half in ventilated ICUs. Hospital COVID-19 capacity was created by cessation of elective surgeries on March 15 and less urgent cases by March 27. ICU capacity was expanded to 230 with the potential of reaching 290 by converting ORs and recovery rooms into ICU units. Over 300 physicians and staff were deployed in this effort. A responders’ safety committee was established that initiated PPE changing areas and negative airflow work units. Backup personnel were recruited, including former chief residents from the past 30 years and Department of Surgery personnel not skilled in intensive care. Telemedicine was initiated, and educational and communication activities moved to Zoom platforms. Some of the Cornell responders fell ill with COVID-19, and several relatives of staff and faculty, as well as a beloved breast surgeon, died of the disease. At present, Cornell is slowly recovering its care initiative, returning to elective surgery, justifiably proud of its achievements.
“The rapid dissemination of the new coronavirus pandemic created a situation of unprecedented emergency. Our lives were dramatically altered as we found ourselves in the center of a situation with many unfamiliar challenges, a great deal of apprehension, and an element of personal risk. The department came together in fighting this pandemic. I have been personally touched by the spirit of selfless altruism that has permeated the response of our faculty, residents and staff, and by former residents who have come back to help us.”
—Fabrizio Michelassi, MD, Surgeon-in-Chief, Weill Cornell Medical Center
Twin Cities, Minn.
A prime example of meeting the nation’s emergency call to action was the inventive steps taken by the University of Minnesota/Fairview Health Services for the Twin Cities of Minneapolis and St. Paul. Bethesda Hospital in St. Paul, which opened its doors in 1883, had been transformed into a long-term acute care hospital in 1989. In 2019, this aging facility was scheduled for a reduction in size, with its future in doubt. However, on March 20, the decision was made to convert Bethesda to the first Minnesota hospital dedicated exclusively to the care of COVID-19 patients. In less than one week, bed capacity increased from 50 to 90, consisting of 35 ICU beds with negative airflow capability and 55 medical–surgical beds to care for acute respiratory patients; additionally, rooms were wired for cardiac telemetry and C-arms to accommodate extracorporeal membrane oxygenation cannulation. Just as rapidly, volunteer hospitalists, intensivists, anesthetists, respiratory therapists, nurses and required support staff were enlisted, with surgeons in the forefront of this effort. And 24/7 laboratory, radiology and pharmacy services were established. In just six days, on March 26, the first COVID-19 patients were transferred from other hospitals to Bethesda. By early April, four COVID-19 clinical research studies were established at this facility.
This effort, and similar accomplishments by health care first responders, working in concert with excellent state mandates initiating adherence to social distancing, self-quarantining of exposed individuals, obedience to regulations for working at home, and the closing of community facilities, allowed Minnesota to suffer, but not to be overwhelmed by, COVID-19.
“Despite an aged and physically limited structure, we succeeded at Bethesda to advantage the benefits of cohorting patients, to concentrate expertise, and potentially to allow other hospitals to maintain and resume their other functions.”
—Jeffrey G. Chipman, MD, Professor, Surgical Critical Care, University of Minnesota, in Minneapolis
American College of Surgeons
The ACS rallied the surgery community, providing moral leadership, setting guidelines, and, above all, publishing fact-based, nonpolitical information. These efforts included launching a twice-weekly digital ACS COVID-19 Update Bulletin to provide clinical guidance, ethical considerations, reviews of the latest clinical and research findings; first-person perspectives from surgeons around the globe; and messages from ACS leadership, as well as referral to a new COVID-19 microsite accessible on the ACS website. The ACS issued guidance documents on, among other topics, recommendations for surgical management of elective operations during COVID-19, triage guidance for nonemergent surgical procedures, and other acute response measures.
The Journal of the American College of Surgeons was among the first scientific journals to call for and to publish COVID-19–related manuscripts. Other proactive ACS activities included the introduction of the ACS-COVID-19 Registry and a call put forth by the ACS “Operation Giving Back” for medical volunteers who could step forward if needed (over 500 surgeons registered). The registry will document the clinical data of COVID-19 patients who did and did not have surgery to evaluate the effect of surgery during the disease and to provide future guidance about when surgery is appropriate under such circumstances.
“In responding to this event, we just built upon the infrastructure that we have, which again is designed to try and serve all—not just all patients—but serve everyone involved with surgery.”
—David B. Hoyt, Executive Director, American College of Surgeons
As we consider this immense challenge to our civilization, I am certain that if there is unabated continuation of the current viral spread, another crippling wave of COVID-19, or a new epidemic, the surgical sector of the health care community will be there from the beginning to the end to serve our nation’s people.
Accolades, therefore, to all: the ambulance personnel; the ER workforce; the orderlies; the cleaners and other laborers who keep a hospital safe and habitable; the secretaries, receptionists and clerical staff; the nurse’s aides; the nurses; and the doctors who have been and continue to be the front line to combat the plague of our generation.
Kudos, cheers, thank-yous and tributes to health care’s first responders.
—Dr. Buchwald is a professor of surgery and biomedical engineering, and the Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery (emeritus), at the University of Minnesota, in Minneapolis.