'It seems that the peak has passed': a diary of a Russian-speaking doctor about the epidemic in New York

New York today is one of the main foci of coronavirus in the world: more than 4000 deaths from an insidious disease are recorded in the city. We offer you excerpts from the Facebook diary emigrant from Russia Eugene Pinelis - a pulmonologist, a doctor in the intensive care unit of one of the New York hospitals. This is a first-person view of the fight against COVID-19.

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America came out on top in the number of coronavirus infected. Here, by the beginning of April, there are 400 patients with COVID-000 people. The focus of the epidemic in the United States is the largest city in New York, where the number of cases is more than 19, and the victims are more than 77.

Eugene is a resuscitator in a New York hospital. After graduating from Moscow Medical University. Pirogov in 2003, he left for the USA. There, Eugene graduated from the residency in general therapy and received a specialization in pulmonology and intensive care. Since 2012, he lives and works in New York. Eugene chronicles what is happening, what is happening in the hospital and beyond.

Below is the diary of a Russian-speaking doctor who shares the news “from the battlefield”.

March 17

Some news from the battlefields. Patients are being received, so far, units of heavy, many - moderate and light patients with high suspicion. Fortunately, tests were brought and there are isolation beds. I’m afraid, not for long, and I’ll have to do subtle branches. In my opinion, there are more patients in the Bronx and in the north of Manhattan than in Midtown and Brooklyn, which is generally logical, given the cluster in New Rochelle. The main problem is personnel protection. There are not enough masks of all kinds, eye protection, and bio-suits. And it’s almost everywhere. The staff is scared, many are affected, and there are more and more fears that health workers will not be enough.

I constantly write to everyone: be sure to continue quarantine. Our only chance not to turn into a landfill with appropriate sorting and to continue to help patients in hospitals is to slow down the spread of the virus. Isolation works, with strict quarantine, the glorious Ro number (in epidemiology, the basic reproductive number Ro, determines the number of people infected with one infected person throughout the entire infectious period. - Ed.) drops below one for several weeks. Donate surplus masks to the hospitals in the neighborhood. At home, masks will not help in any way.

March 19

So far we have been living the first week in conditions of medium isolation, in Italy it has been hard quarantine for several weeks now, China is starting to get out of isolation. There are some restrictions in all countries. A new reality is coming. We all will really miss the warm tube DO-shaped (I patent this adjective) world. But for now this is not a reason to go crazy. Most of us will survive this time and, unlike the Second World War, most families will not count the victims. But at the same time, mental tension is already felt in the air. Young people with a mild form or with a suspicion of infection, or even just healthy people, are terribly hard to bear mental pressure. A mild physiological course is accompanied by insomnia, mania, the absorption of a huge amount of information on the topic. This is very serious, it can happen to many, and most likely will not go unnoticed for mental health. Find some outlet, favorite books, games, films, individual sports. The same meditation after all. Do not think about it all day, do not read the news about the virus. When something good happens, they will probably tell you. Good luck to everyone, I'm back to the Reserve.

March 22

I plan to write about life on the battlefield during an epidemic. I can’t imagine what will happen, whether I can write often or have to rush around. Just like everyone else, I know very little about this virus. Information appears constantly, changes daily. Now something is happening that will change life for many years.

March 24

The weather is clearly not going to help us. Freezing rain with wind and plus two. In the metro announcement: use public transport only in case of vital or professional need and be at least two meters from each other. True, they forgot to increase the area of ​​wagons. There were few people, but to find a free site at a distance of two meters proved to be an impossible task. For professional reasons, I was traveling and, judging by the suit, a nurse. The remaining ten passengers apparently had a vital need. A huge guy with all the indicators of complex intubation shouted to his friend, who was sitting through the aisle, about his hopes for the resumption of the basketball season by summer. He actively compensated for the distance of two meters with an incredible volume and a non-stop stream of words. Insulation.

Arriving at the hospital, I once again realized how difficult it is to move around without touching anything. The road to my office / decontamination zone and from there to BIT (intensive care box. - Ed.) turns out to be full of handles that can only be turned. A bunch of doors separating these geographical points opens in both directions, on the way there and back, some doors need to be pulled over. The road to the toilet turns into a non-trivial special operation. New strategy: I pick up a handful of antiseptics on the road in one direction and, arriving at the place, wash my hands. In any case, my left hand is atavism, but I can keep an antiseptic in it.

On the subject: What is happening in New York: quarantine life in the city through the eyes of four Russian-speaking immigrants

COVID now occupies about half of the hospital’s beds and two-thirds of the beds in intensive care. The spread of ages, someone is very difficult, someone is slowly improving. There are enough fans, but the problem is with insulating beds. There are masks so far, everything is under lock and key. Test results continue to linger unclear where. In hospitals that have purchased PCR machines (polymerase chain reaction, method for the diagnosis of coronavirus / - Ed.), the return is very fast, but, unfortunately, we do not have such a diagnosis, so we are waiting for a few days. All suspicious patients with severe to moderate severity are hydroxychloroquine and azithromycin. There were no arrhythmias, no miraculous cures either, so by the end of the week all the beds will be filled.

March 25

About ten years ago I tried to become a pulmonologist and at the same time a resuscitator. Historically, this was considered a joint specialization. I had a dozen interviews, three months of insane dashes from Atlanta to Boston. Newark lurked in the middle of this geography. The one in New Jersey. The program directors were called Thiruvingadam Anandarangam. I trained to say “Dr. Anandarangam” in front of the mirror. It didn’t work out very well.

Now they are in the centers of this hell, they continue to do everything possible to increase the chances of patients who are more seriously ill than most of these experienced doctors can imagine.

Buddy Anandarangam turned out to be the most efficient, fun and ruthless of the mentors I knew. He liked to catch me at eight in the evening and drag me somewhere to do thoracocentesis (procedure for puncture of the chest cavity. - Ed.), or even drive 45 minutes according to the formulas of Svan-Ganz sitting in those difficult patients at that time (pulmonary artery catheter .– Ed.) The stock of resuscitation learned from him was enough for many years, as well as the stock of pulmonology from another colorful character from that interview, the director of the Center for lung transplantation Sean Studer.

The interview ended with Dr. Studer speaking about lung transplantation, from which I did not understand almost a word, but laughed at the jokes from pop culture in time and actively nodded to the place. And after a couple of months I found out that they took me to the Newark hospital of the sons of Israel. He began to work and study at about the same time as the H1N1 epidemic began. Then ARDS (acute respiratory distress syndrome, severe manifestation of respiratory failure. - Ed.) was everywhere. We, joyful young specialists, ran around the hospital, intubated, tried crazy methods of ventilation, the famous ECMO (invasive extracorporeal method of oxygen saturation of the blood. - Ed.), oscillators. Everything seemed to work, although the patients improved insofar as many died.

Ten years have passed and we are in the world of COVID. The same ARDS, which improves even more slowly than usual. ARDS, for which there is no particular treatment, and which, apparently, has come for a long time.

No special news from the inside. Patients arrive and settle. Young people are improving, but not enough for withdrawal from mechanical ventilation (mechanical ventilation. - Ed.), and more and more. A new intensive care unit is being deployed, a plan to deploy a third. There are still enough fans, there was a rumor about the purchase of new protective equipment. Today, a patient with metabolic encephalopathy, renal failure, and a lack of suspicion of COVID was called for examination. Seeing the normal level of lymphocytes, I experienced a surge of almost forgotten joy. The case when you know for sure that everything will turn out well with the patient. Well, at least until the next attempt to mix all your medicines in a blender, including “pills from Haiti” (narcotic drugs, slang - Ed.), Because the sugar level did not go down.

For ten years I have worked with a lot of intensiveists (resuscitation doctors. - Ed.) in BITs of a dozen hospitals. They are now in the hotbeds of this hell, continuing to do everything possible to increase the chances of patients who are more seriously ill than most of these experienced doctors can imagine.

March 26

In the car now no more than seven to eight people. Finally isolation. Pretty asocial. Tired, poorly dressed people gloomily move from the Bronx and Upper Manhattan to Brooklyn. What for? Sometimes beggars pass. I have no one-dollar bills left, now I always serve. Occasionally, surgical-dressed doctors or nurses come across. Usually they look very tortured, and it seems to me that I can distinguish flickering rugs on their clothes.

They say about each change in patients that this is probably not due to covid, but who knows.

The battle continues with varying success in the hospital. Two more half-fronts are opening, a small (for now) BIT for the coovid and another for the illiquid. It seems that we have cured everything. Septic shocks and gastrointestinal bleeding have disappeared. Quick response teams, ready to attack any pulmonary thromboembolism, "gather dust" idle, and the administration is thinking where to apply their highly specialized skills. Even the eternal contingent of patients - a drunken injury and delirium tremens - disappeared somewhere, taking with them an inexhaustible supply of "brothers" - heroes of heroin overdoses.

During the discharge procedure, where a dozen doctors are forced to communicate in a small room, the humor becomes darker. They say about each change in patients that this is probably not due to covid, but who knows. COVID-19 is credited with superpowers. I imagined how, a week later, talking about a now rare renal failure due to an enlarged prostate gland due to obstruction of the urethra, one of my colleagues will say: “I know that this often happens in older men just like that, but because of cove, everything can be ".

In New York, there are more cases per day than in Italy. We clearly love to run around the field with other people's rake. We are waiting for the army and martial law.

On the subject: Coronavirus spread to New York much earlier than is commonly thought - researchers

Fans and masks are. According to rumors, one large consignment of masks and other protective equipment arrives from the Chinese community and the second from the governor. Rumors about fans are mostly scary. Shortages are already felt in many hospitals. We still have stock. Still pretty uncomfortable. Suddenly, disposable wraps for working with contact patients ended. We found a certain amount in other departments where nurses do not have to go into the wards so often. The crisis was over, but the level of stress was palpable.

Where all this hell is not there yet - take care of yourself, accumulate fans and high-protection masks in hospitals, and not at home. Increase the hope that the curve will wrap up earlier than ours, and the nurses will not fight because of the plastic wraps for four dollars for two dozen.

March 27

While unchanged, we are in order, there are supplies, there are more beds. You can’t say anything more good. Even patients with a moderate course, the nefarious virus manages to get in some indirect way and reduce their chances of recovery. The metro today is almost crowded, the streets are full of people. The sun with pleasure melted the distance. In New York, there are more cases per day than in Italy. We clearly love to run around the field with other people's rake. We are waiting for the army and martial law.

March 28

You dive into the haze of the reception area. Before that, you wrap yourself up in protective junk, as you can. Huge filters roar, chasing air. I am a complete ignoramus in technology, but when something so roars, it is doubtful that it performs its function qualitatively. I’m breathing very shallow, but I immediately want to yawn. Patient 74, diabetes, obesity, pressure, asthma. Smoker. Saturation 85, 100 percent oxygen strips off the mask, breaks out of the hands of two medical residents. When he tears off the mask, oxygen saturation drops to 70.

An intubation team comes running. They complain that they had almost no protective equipment left. We give our own. According to the plan, they have everything that is required for safe intubation. An anesthetist is a great man. Often chatted with him in the cafeteria. Full cheerful Italian about 55 years old. I feel uncomfortable. It can be seen that no one taught him to use protective junk. We notice a torn glove. An anesthetist swears, changes gloves, takes off his mask and glasses. Finally clothed and intubated. He seems to have rubbed his eyes. When he leaves, he speaks in his Brooklyn-Italian, with the intonations of Soprano: “Emigrated to a great country, uh ...” I agree and go to wash my disposable protective suit with chlorine. It's good that near my office there is a small open passage between the buildings with a wonderful view of the center of Brooklyn.

I called the patient's family to report about the deterioration, I talk with my daughter, I find out that my mother is also with temperature. I advise you to test, I try to pretend that everything is fine, but she understands everything. Crying. He promises to think about the refusal of cardiopulmonary resuscitation from the pope.

The next patient is lighter, but still requires ventilation. We get permission for him tocilizumab (a subclass of immunoglobulins), will arrive in the morning. The worst thing is that many patients are fully conscious. Someone prays while we prepare a cocktail of oblivion for intubation.

There are people who have adapted garbage bags under wraps. We are not throwing anything away now. We put phones in the bags from under wraps. Then you do not need to wash it constantly, you can once at the end of the shift.

In the city, disease statistics are getting worse. The weather is too good on the street, festivities. Parties on the promenades and beaches. In a store near our house, an infection was discovered by one of the employees. The store is closed. People come up, crowd at the door, read announcements, gossip.

In a nearby store there is at least some exception to the rule. Only ten customers are allowed at a time. At the box office marks a distance of two meters. But nearby McDonald's works. Only takeaway, but he and the nearby pizzeria are filled with people.

March 30

There will be two of us, one wounded with a Kovid and, in addition, a girl who has just begun a felloship (practice), and they will say that there were three of us.

There were 32: 27 with covids, 23 on fans, three pregnant women, no one was improving. Usually our resuscitation for the same composition of attending physicians is filled with 16-18 patients. In the severe influenza season, they are sometimes 22-24. The morning shift was delayed due to the director's call. Well, at least without a video - my facial expressions are too expressive. The audibility was terrible, since everyone was wearing masks of different calibers, the director interrupted, asked again, sometimes lost the thread, but on the whole almost did not interfere. He quarreled a little when he heard that in one of the departments they found a very elderly man without a pulse at night. Attempts to return the pulse were in vain. In the evening, the director will come to help, which is really valuable, although, seeing him in a mask on one side, crawling on like redoubts, I am always anxious.

On the way to the department, I watched a quarrel between the phlebotomist and the nurse over plastic wraps. They are few, mostly they are not for those who really need. The prey owners do not take their eyes off them. There are people who have adapted garbage bags under wraps. We are not throwing anything away now. We put phones in the bags from under wraps. Then you do not need to wash it constantly, you can once at the end of the shift.

One of the pregnant patients improved for translation, and the other two breathed on their own, so we even perked up. As it turned out, in vain, cheering up with the cove is pretty pointless. Well, just because falling is harder every time. An alarm sounds: the quick response team - to department A. One look - you need to call the great intubators. They appear quickly, but then a second signal is heard, to the compartment three floors higher. There the situation is the same, we do not have a second team. We intubate ourselves, but do not have time. Cardiac arrest, the patient returns for 15 minutes and stops again. This is the wife of a patient who died at night, their daughter is in another hospital, but it seems to be in relative order. I recall funny family picnics with crowds of people in a wonderful park where the windows of our intensive care unit go. Every day last week with good weather.

I worked seven days in a row and saw a well-organized hospital rapidly falling in an uncontrolled peak. We are not even in the middle of the flight.

Needless to say, before the evening they lost a few more patients. The morning situation repeated again and with approximately the same result. Outcomes so far are all expected by the ratio of age, related conditions and other factors. An attempt to convince families to refuse resuscitation and to regret relatives and doctors was unsuccessful. We limit the time of resuscitation and the number of people in the ward. Perhaps this will help someone not to get sick. But both young and healthier patients suffer and rather poorly improve. Beds for new patients, whom the sea, are freed almost in only one direction. Tomorrow meeting of the ethics committee: discussions on the denial of the right to cardiopulmonary resuscitation.

Supply teams fail - you see, the rear bombed. Or plundered. There are no few necessary medicines, the inhaled prostacyclin is almost over, which at least helps a little with hypoxemia. I establish rationalization, in patients whose chances are close to zero, we simply do not start. When the next delivery is unknown.

By evening, they managed to dismantle the rubble, to bandage the wounded. Even a couple of patients with no cove have been enrolled (yet?). In our main BIT, 18 patients now have one patient without him. A young dude who managed to pick up the flu somewhere. He treated him with an overdose of many substances. Among the drugs was a large dose of sleeping pills and anxiolytics, so he slept for four days. A poor fellow woke up in another world.

But no one imagined the scale of this scourge. Yes, and now hard to believe.

I worked seven days in a row and saw a well-organized hospital rapidly falling in an uncontrolled peak. We are not even in the middle of the flight. I admire everyone who continues to do this and comes here every day. According to the administration, we have been preparing for months. But I remember how in vain they remembered the particularly bad flu season in 2018. Many hospital cones performed on all TV channels more than once. Wonderful careers are made in the war. Fortunately, now at least on TV no one has hinted about the flu.

Dovlatov had: "Any humiliation of the authorities is a holiday for me." I write a lot about the fact that we have nothing missing. And this is true, although we really prepared. But no one imagined the scale of this scourge. Yes, and now hard to believe. It seemed to many in the medical community that these were all Asian affairs. I had some reasons not to pay attention to alarmists either. In New York, I survived a couple of hurricanes and an epidemic (ha ha) of Ebola and the mysterious Zika virus, which plunged impressionable citizens into neurosis and panic. The hurricanes were real and one of them hit the city very sensitively. But all the same, the extent of panic and neurosis in New York often does not correspond to the reality of the threat.

My covide skepticism lasted almost until the end of February. I looked at the statistics from South Korea, China, the ship and saw that yes, the sore is more dangerous than the flu, but it affects a lot less people. There was no clear information about the measures taken in Korea and China, but they did not introduce any special insulation on the ship at the beginning, and not so much fell ill. And the contingent there is usually elderly and sick. I have come across patients from these cruises more than once, and I was impressed by the amount of medical resources there. Mortality in a standard cruise is also not zero.

I understood that we would have these patients, somewhere already, but I did not think that there would be so many. I suspect that the administration of most hospitals thought about the same thing. That is, there was a plan for extra beds, purchases of some medicines and equipment, curtailing planned operations and other things. But the scale of this reality was impossible to imagine.

I joke, use military vocabulary, and talk about logistics and supplies, but it’s true. The intensive care unit is a constant battle against a decaying organism due to illness. These are very expensive battles that require a lot of resources. And the fact that medicines are running out, there is not enough equipment, unfortunately, is not surprising. For many years we lived with the number of critical X patients who needed gamer resources. Suddenly, X flew up exponentially and has to be caught up in real time. This happens in all New York hospitals. Our situation is even better, there are fans and new ones are expected.

Now is not the most fun time, and something is needed not only to protect against the virus, but also from madness. Therefore, I am writing.

About the medicine: there is no clearly proven pharmacotherapy. There are hopes for tocilizumab, hydroxychloroquine with azithromycin, caletra (combined anti-HIV drug). None of these drugs have been tested in clinical trials of patients with COVID. We give a combination of quinine and azithromycin to all patients with changes in the lungs. In my patients, severe, requiring mechanical ventilation or high oxygen support, I did not notice miracles. Since we give to everyone, it cannot be said what would be without medicine. Perhaps, and I really hope so, in patients with less severe course, this combination prevents the transition to very severe. And this is the best you can hope for now. ARDS is a severe lung function disorder that is difficult to treat in any scenario. The mechanism that triggered this syndrome is often not so important. When there are few patients with this syndrome, we can use high-tech types of therapy, try something that is suitable according to pathophysiological criteria. When there are dozens of such patients, this is no longer the case. In all these patients, the rest of the body is attached to the lungs, which is also affected by the virus, a critical illness in itself. Therefore, one cannot count on miraculous cures. Any success is a huge work of many people and not only doctors.

The worst thing I could imagine in my life was the lack of ventilators. Deny suffocating people in oxygen does not want anyone. I repeat, while they are there, they are urgently being made, they are being collected from the world one by one. Talk about ventilation of two, three or more patients does not come from a good life. Two healthy people of the same age, size and gender have approximately the same lung function. In patients with lung damage, this is not so. It is impossible to accurately assess the level of damage. So we are preparing for this, but we hope that it will not happen.

March 31

After "Bloody Sunday", we were able to somehow return to the new norm. There are very few resuscitation beds; there is talk of re-equipping spaces for co-shaped intensive care units, as in Italy. Several successes in young patients, we got another dose of remdesivir, we are waiting for delivery today. Now it is given only for children and pregnant women, since there are too many requests. Hopes for him are somehow unthinkable, and we don’t even know if it really works. The results of the study at the end of April. A few experiments with tocilizumab, look, wait. Vitamin C is back in the arena.

First successes: physiotherapy and a walk around the room for a young woman taken from mechanical ventilation. After that, the day no longer looks so scary. Some patients agree to lie on their stomach. This helps - at a minimum, delays the need for ventilation.

A little bit about this virus. I’m not very impressionable — I trained in the burn department and worked in a hospital with a high level of trauma. Firearms, knife guns, car wrecks brought there. They, of course, were dealt with more by surgeons, but sometimes we helped with procedures that were not very favorably received by the advice, beds, and, finally, with massive injuries.

The division into weekdays and weekends has lost its meaning. We come every day, shave from a basin with melted snow, put on the used protective equipment and continue.

My friend David once said that resuscitation is “cocaine therapy.” Coronavirus resuscitation - “cocaine and steroid therapy.” Severe course in a patient with covid, like a river with rapids of high complexity. Only we, doctors, even without kayaks, in terms of working proven therapy. The fan settings that are needed for these patients in order to keep oxygen at a decent level, I used a few times for almost 10 years of work in intensive care. The virus, directly or due to the immune response, can affect almost all organs. However, most patients are fully conscious, and it is very difficult to make them sleep. Making them sleep is not because it is convenient for doctors or nurses, but because if they do not sleep, it is terribly unpleasant to endure such ventilation, and patients begin to fight it, sometimes they pull out tubes and catheters that have to be returned to the place urgently and at the risk of staff. The first we end up with droppers with sedatives, patients wake up, fight with a fan. Pharmacologists come up with schemes that can at least somehow prolong the effect of drugs. We use renal failure. Previously, this was the reason not to give certain sedatives, since the duration of the action was lengthened. Now this is a plus. Removing patients from ventilation also gets a lot of bumps, and every mistake and the need to return is a risk for many.

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