“An unprecedented challenge”: Vascular surgery in New York during COVID-19

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Darren B Schneider

Darren B Schneider is a vascular surgeon in New York—the US state with the highest number of COVID-19 confirmed cases and deaths at present. Here, for Vascular News, Schneider details how the role of a vascular surgeon has changed dramatically in a short time to adapt to the needs of the hospital and of the wider community during an unprecedented global health emergency.

As I write this, on Thursday 9 April 2020, we are entering what I hope will be the apex and plateau of the COVID-19 pandemic crisis in New York City. This week the expert projections suggest that we will face the peak in hospital and ICU admissions, and, unfortunately, also the peak in deaths due to coronavirus infections. Currently, of the more than 1.5 million documented cases of COVID-19 in the world, more than a quarter are in the USA. New York and New Jersey represent the epicentre of the US outbreak, accounting for nearly half of cases in the USA.  In New York City alone, there are now more than 80,000 confirmed cases and more than 4,000 deaths attributed to the pandemic.1,2

It should come as no surprise that this pandemic represents an unprecedented challenge to our hospitals and vascular surgery practices. Seemingly overnight, the pandemic upended our daily routines as vascular surgeons, changing our roles within our institutions and the treatment of our patients with vascular disease. Almost three weeks ago, we stopped performing “elective” vascular procedures, operating only for true vascular emergencies that represent an immediate threat to life or limb.  Even so-called “urgent elective” procedures to treat large asymptomatic aortic aneurysms or ischaemic rest pain have been deferred until this major crisis has passed. Most of our ORs and recovery rooms now serve as ICUs for ventilated COVID-positive patients and the vast majority of hospitalised patients are COVID-positive.

Although draconian, these measures are critically important in order to conserve resources, especially personal protective equipment (PPE) which periodically has been in short supply, and to avoid exposing our vascular patients to the risk of COVID-19 infection. Other changes we made in the interest of physical distancing to prevent spread of the infection to patients and staff include having all of staff working remotely from home, converting our in-person vascular office visits into telemedicine visits, and closing our outpatient vascular ultrasound lab.  Interestingly, we have seen a drop in the volume of emergency and urgent vascular surgery consults and procedures at our hospital. My vascular colleagues at other New York hospitals also report a similar experience. I suspect many patients are simply too afraid to come to the hospital for fear of contracting a COVID-19 infection and I fear than we may see a surge in urgent vascular cases once current physical distancing measures are relaxed.

We are now being called upon in other ways to help with the fight to save lives during the pandemic. Several of our faculty members have been redeployed as intensivists to provide some of the manpower needed to staff our expanded ICUs. The rest of our faculty help supervise a 24/7 line service that leverages our expertise in vascular access techniques to offload the overburdened ICU teams. Working in two-person teams consisting of a general surgery resident or a vascular surgery fellow and a vascular surgery attending we respond to an endless stream of requests for arterial lines, central venous lines, and haemodialysis catheters to be placed in critically-ill COVID-19 patients. Donning and doffing PPE multiple times during a shift while placing lines throughout the hospital is physically and mentally exhausting, but it is gratifying to know that we are making an essential contribution to help treat the sickest patients.

Traditional vascular fellowship training as we know it also ended abruptly when the pandemic hit New York. Fortunately, our vascular surgery fellows have not been redeployed to other services. The fellows remain busy, volunteering to help staff the line service while also taking care of vascular patients and consults. We have continued our educational conferences, albeit virtually, and we quickly discovered that we could leverage “Zoom” to hold joint educational conferences and journal clubs with vascular divisions from other institutions throughout the USA.  Digital media has become an important way to connect and WhatApp chat groups have brought together vascular surgeons from around the world as a platform to share experiences and advice in dealing with the COVID-19 pandemic.

Hopefully, as hospitalisations in New York are now plateauing, we can envision a time in the next several weeks when the makeshift ICUs will be decanted and reverted back into ORs so we can resume performing urgent “elective” vascular procedures. Still it will take many more months and likely over a year before we are back to anything resembling normal, where surgical masks are no longer required in public, our clinics and practices are fully reopened, and we can gather together for in-person meetings and academic conferences.

It is truly a struggle to see positives arising from such an unprecedented pandemic that globally and regionally has brought so much suffering and disruption to every aspect of life. But, during this crisis we have also witnessed unprecedented and inspiring acts of courage, kindness, and selflessness from medical colleagues, hospital employees and throughout our communities.  Inspirational messages scrawled on the sidewalks in front of our hospitals and people cheering from their windows make us smile on our way to work. Most inspiring, however, is when a critically-ill patient improves, is extubated, and eventually leaves the hospital, validating all of our efforts.

References

  1. https://coronavirus.jhu.edu/map.html Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU)
  2. https://www1.nyc.gov/site/doh/covid/covid-19-data.page City of New York Department of Health COVID-19 website

Darren B Schneider is associate professor of Surgery and chief of the division of Vascular and Endovascular Surgery at Weill Cornell Medicine in New York, USA.


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