Above photo: Screenshot of CNN report on Brooklyn hospitals and COVID-19.
Note: COVID-19 is becoming the leading cause of death in the United States. The chart below shows a one week total of COVID-19 deaths from April 6 to April 12, compared to other leading causes of deaths that normally occur this time of year.
The Washington Post summarizes the development of COVID-19 in comparison to other illnesses, writing, “In early and mid-March, when America began widespread closures, quarantines and social distancing, covid-19 caused many fewer deaths than other common causes — fewer in a week than chronic liver disease or high blood pressure, and far fewer than suicide or the common flu. By the end of March, the toll was closer to the average weekly deaths from diabetes and Alzheimer’s disease. Into April, weekly covid-19 deaths climbed past those from accidents and chronic lower respiratory disease. And last week, covid-19 killed more people than normally die of cancer in this country in a week. Only heart disease was likely to kill more people that week.”
And, when this is further broken down to “hot spots” where COVID-19 is spreading most rapidly, it is already probably the leading cause of death in many areas.
Deaths continue to mount at a rapid place and parts of the United States that have not been “hot spots” are becoming areas of increased concentrations of the disease. As the disease becomes more prevalent nationally, it may become the leading cause of death in the United States.
These numbers are probably low as they only include confirmed cases of COVID-19. Many people who have symptoms of COVID-19 and die from causes consistent with the disease are not counted (although that is changing in some states that are seeking a more accurate count). For more on how the US is undercounting deaths, see Margaret Flowers’ article, The United States Is Where COVID-19 Deaths Are Being Under-Reported. – KZ
As the number of those infected with COVID-19 continues to climb in New York — stressing the state’s already underfunded, understaffed and ill-equipped hospital system — we spoke with Maurice Selby, an ER doctor at two hospitals, one in Brooklyn, the other in Long Island.
In an average week, Dr. Selby is averaging three, 12-14 hour shifts at the Long Island facility, which is private, and at least one per-diem shift in Brooklyn at a public medical center. On the condition that we not publish the names of his employers, The Indypendent interviewed Dr. Selby at length, first at the end of March and again last week as he discussed daily life in the ER amid the pandemic, the innovative ways he and his colleagues are grappling with equipment shortages and how he and his family are coping.
What are things looking like in the ER’s you are working in these days?
With the COVID-19 pandemic, we’re seeing a lot of patients with those symptoms and even people with high suspicion of being infected. Right now it’s a lot of people that require hospitalization or observation in the emergency department for extended periods. We also still have people coming in with chest pain, abdominal pain, people coming in with stroke-like symptoms, but overall it’s much less than what we typically see.
At my Brooklyn hospital, the pediatric emergency department is gone now. Where we normally see pediatric patients that area is an extension of our critical care trauma area. Pediatric patients are now seen in the fast track for the emergency department, which is the urgent care side of things. That’s because we haven’t really seen that many pediatric patients come into the hospital. People are just staying home.
Are you able to test patients with symptoms of COVID-19?
Based on New York State Department of Health recommendations, routine testing for everyone is not recommended right now. I would even say it’s prohibited in many ways. Even for people that are symptomatic, maybe they have a cough, they might have some body aches and fevers, but they’re not displaying any concerning signs or anything that would require hospitalization. Those individuals are not tested.
Really the only way you can obtain a test, get officially tested, at this point is if you’re admitted to the hospital.* And typically those people are very, very ill, requiring not only admission to the hospital but sometimes a higher level of care like an intensive care unit setting. That’s when we test for the virus.
In my day-to-day practice, the test really doesn’t affect how I manage the patient. If the patient is under high suspicion, there are certain therapies that might be rendered. There is data pointing to certain antivirals being beneficial like those that we typically use to fight things like HIV, though it’s not conclusive. Researchers are still studying whether these are efficacious or not.
If a person is seriously being considered as having COVID-19, we’ll begin treatment empirically with those medications under the theory that this is a high-suspicion case that could have COVID-19. We do this even without the result of positive tests. In the ER, we’ll send the swab, but those results don’t come back for 24 hours before we officially know whether they’re positive or not.
Do you know what percentage of tested patients have it or is that something that gets figured out later on?
I’m not sure what percentage of people have tested positive — of the ones we have actually run the test on. What I do know is that this disease is very interesting in that a lot of the symptoms that patients come in with are very uniform. A lot of dry coughing. Probably 70 percent of patients will have that dry cough. They may or may not have a fever. About half of them will have body aches.
You can basically make a bedside diagnosis based on a patient’s symptoms, a physical exam and looking at the laboratory test. We look for certain things like lymphocytopenia. That’s when a subset of white blood cells important for the immune system known as lymphocytes decrease. Dehydrogenase enzyme levels can be elevated with COVID-19 too.
So when we see a patient coming in with certain symptoms and we find certain things on a physical exam, and look at the laboratory work and conduct imaging tests like chest X rays and the findings are consistent with pneumonia, especially a bilateral pneumonia — at this point we’ve pretty much made a diagnosis of COVID-19 even before the test is sent to the lab.
By the time you see them, people are pretty sure that something’s wrong. People aren’t coming in with minor symptoms.
Not many people are coming in with mild symptoms. As far as the message that’s gotten out through the media and the awareness campaign goes, I feel like a lot of people are just trying to follow the recommendations as best they can. A lot of patients that come in have said, “I’ve had these symptoms for the last week, runny nose and congestion, a dry cough, occasional fevers.” It’s only when they’ve started to get symptoms they can’t manage or have other concerns like chest pain, shortness of breath, that’s when people are coming in. So people have really been trying to do what the Centers for Disease Control and the governmental bodies have been recommending in staying home, self-quarantining, doing supportive care.
What about the mortality rate in your hospitals?
There are definitely a good amount of deaths. Every shift in Brooklyn, multiple times, you’ll hear the codes overhead for people that are having respiratory issues or going into cardiac arrest upstairs. There are even people dying in the ER. They’ve been admitted but they are waiting for beds upstairs and then they’re dying. They are being cared for but they’re dying before we can take them upstairs.
There was one instance with one of the transporters who was transporting bodies to the morgue, he was getting upset because he was worried that some of the bodies were inappropriately tagged or something. They didn’t have the right tag on their foot. Ultimately I think it was straightened out, but he was getting frustrated with that, which I could see. But it’s just unusual because in the main ER, we usually don’t have people expiring like that.
How many are we talking about?
I would say, if I was hearing those codes about once an hour, maybe once every two hours, four to eight deaths per shift. And those are the ones that I hear rapid response for. There are some patients that have do not resuscitates, they have advanced directives. So I might not even hear those codes overhead because they wouldn’t activate a response code over that. They would basically just support the patient, keep them comfortable until they expire. So there might very well be more people that are still dying.
I walked into my hospital in Brooklyn the other day last week and there’s a row of ambulance personnel with their patients waiting to be triaged and checked in.
Are things as bad at the Long Island hospital?
The last time I was at the Long Island hospital, 22 of the 25 patients in the ICU were COVID-19 patients and they were all intubated.
Back to something you said earlier. If someone has symptoms and you can’t admit them to the hospital, how do you treat them?
That’s been among the biggest challenges, managing the symptoms of people that are not sick enough to be admitted. I think one of the big things is reassurance for those patients. I try to help them understand their symptoms. The recommendations right now are for supportive therapy. So really making yourself as comfortable as possible. Taking care of the fever, because that can make you really uncomfortable. Any body aches or pains you might be experiencing, pains in the throat, discomfort, nausea, vomiting — managing those symptoms.
Aside from that one big thing is really giving your body what it needs to fight the infection because the bulk of the work that’s done to beat this infection is done in the immune system. It’s really about giving your body what it needs to fight the infection, which is plenty of rest. You’re not going to be doing your normal day-to-day routine. The important things are resting, allowing your body to clear the infection, drinking plenty of fluids. Then ultimately just be on the lookout for any concerning symptoms like chest pain, shortness of breath, altered mental status, those things are when you will come back to the hospital for reevaluation. And most people are able to carry out that plan.
Do you feel like your colleagues are looking out for each other?
Yeah, and that’s something that’s absolutely critical at all times in the ER but it’s especially important now. Everybody has each other’s back. We had a couple of people that came in who were really, really ill recently and that required intubation. I needed some personal protective equipment — a cap for my hair and another gown because the one that I had on wasn’t working properly. The nurses rallied with me and got me all of that stuff in seconds and it was so awesome. I was like, “Yeah, this is so dope.”
We were really working together at that point, which we always do, but it’s just good to know that people have your back like that. And we all have each other’s backs in that respect.
What about the hospital administrations where you work? Are they giving you the support and the equipment that you need?
The hospitals are making an effort. Obviously they are aware that we’ve had this shortage of equipment. You might see some media reports where medical workers are concerned, saying that they don’t feel protected and talking about the PPE shortages and stuff. It is a real problem and I can understand that frustration. I’m frustrated at times but, at the two hospitals I work at, the vast majority of leadership are concerned too and are really trying to find ways to address the problem. I’m talking about people that I know, people in leadership positions that have been digging into their own pockets to get supplies, even going on the black market to get the materials that we need.
Every shift I’m walking into and I’m like, “Well, where do I get a gown?” You have to go scavenge supplies every night. Every now and then somehow will appear, the charge nurse maybe, and be like, “Okay, I know where to get what you are looking for, I have a stash.” Not that they are keeping anything away, but equipment is being rationed out.
We’re also reusing a lot of stuff.
That’s a big thing out on Long Island. We’ve resorted to reusing gowns, something that’s largely gone out of style within the healthcare industry. We put these gowns over our clothes at the start of every shift, and then at the end of the shift, we turn those gowns in so that they can be washed and laundered. I guess it worked out to be cheaper, but before everything was disposable. I was talking with an older practitioner, and he said, “We really need to go back to the day when everything was laundered and reused.”
Are you seeing anybody using trash bags or anything like that?
We’ve used trash bags. We put the trash bags over the other equipment that we’re wearing. So the trash bag is another external barrier, at the end of the encounter, we remove the trash bag. Then we discard it and wipe the stuff we had on underneath down with an antiviral.
At my Brooklyn hospital, our residents are just unbelievable.
We were running out of some of the forms of noninvasive ventilation that we use to support patients in respiratory distress. So we jerry-rigged these devices where we’re giving something called PEEP or positive end-expiratory pressure. Our residents MacGyvered these. They took BiPAP masks, attached them to a viral filter and then put a PEEP valve on the end. With some patients, when we’re really limited, we’ve been using these. Basically, the depth of water that you put it into is the amount of pressure that the patient will receive to keep their lungs expanded.
Are there enough ventilators for the people who need them?
We are definitely strained in that resource as well. I think we have 25 ventilators in my hospital in Long Island. That was the last official count that I heard. I was talking to a physician assistant, and he said, “Im managing 15 to 20 people on ventilators.” We are aware that we’re starting to come up short. We’ve definitely run out of beds in our ICU. That required us to transfer anybody else that required ICU-level care to other regional hospitals within our network. I anticipate that the need for those ventilators will become greater because a lot of the patients that we put on a ventilator require sustained long term ventilatory support.
There are people that have been on for a week or two weeks already and unfortunately are not coming off. Typically with other illnesses, whether there’s some sort of metabolic issue or maybe things like congestive heart failure, we can take the breathing tube out within a couple of days. We’re still trying to understand why with this particular infection people require sustained long-term ventilatory support. There are people that have been on for multiple weeks already and they are not coming off anytime soon.
Are you at the point where you have to make strategic choices? In terms of who can and can’t get ventilators?
Soon we will probably have certain cases where people might not have advanced directives but their prognosis is very poor. How do you tell the patient that? How do you tell the families, “Look, you know, maybe it is best to take a more palliative approach?” That will be one of the major challenges, especially in the weeks to come.
If we haven’t reached the peak yet, that’s going to be the major challenge. Aside from limitations on resources, it’s going to mean having those conversations to maximize resources in an efficient way. If you’ve got a person that’s 90 years old with a bunch of medical problems versus somebody their 50s that might be able to get out of this, it might come down to having that conversation with that 90-year-old patient and their family.
Are you seeing any coworkers getting sick?
One of my friends, he’s a pediatrician in the pediatric ICU in Brooklyn, I think he has been diagnosed with COVID. There a number of people in the ER that are sick, staff members that were sick. One of my old attendants came down with it, and she’s been put on a ventilator up in Westchester where she lives.
You’ve been quarantining from your family, sharing an apartment with another ER doctor. How did you arrive at that situation?
There was one particular case where a guy came in very, very ill. He required multiple lifesaving interventions, including an intubation. We had to intervene rather quickly and in a fashion where we weren’t able to get all of the typical PPE needs that we would normally get because it was such a quick decompensation. I got really exposed to this person. The next day, I called another ER doctor who already had an Airbnb and he invited me in.
When we moved into the apartment, we were bummed out that the television wasn’t working. We said, “Ah, man, this sucks. We can’t watch TV. How are we going to keep up with the news?” But it’s actually been a good thing. I’m actually happy that it’s not working because we really just sort of started to focus on ourselves as we go through this and we’re and staying on top of our game as far as our health goes. I’m trying to stay positive through it all.
How do you visit with your wife and daughter? Do you sit six-feet apart or change all your clothes as soon as you get there? How do you do that?
That’s what we try to do. I’ve tried to stay apart from them, to keep my distance from them. I wear a mask. But one night, it was funny: I was with my family. I brought food with me and they had just woken up from a nap and I had the food and my daughter wanted some and then you know, it’s my daughter, I’m not going to deny her food. I cut a piece off and put it on a little plate. I thought she was going to sit in her highchair but she came over and just sat in my lap.
I hadn’t seen the girl in so long, and there was no way I’m not going to let my daughter come close to me. Even last night she was acting like we were on a subway train, pretending we were going to the museum. She likes to pretend that we take these trips with her, with her little dolls in the stroller. I sat right next to her. I couldn’t help it.
I wash my hands. I keep my hands away from my face. I wear a mask when I’m around them. Ultimately it takes a lot of precaution and a lot of prayer that they don’t get sick and that I don’t get sick too. I do try to be as careful as possible, but it’s hard not to be close to them, especially when I actually go to visit. It’s really hard to keep that distance. Usually, we just communicate through FaceTime and phone calls.
*Since we last spoke, Dr. Selby has informed us that testing has since become more widely available at the hospitals where he works.