From the Front Line in New York: A Talk with Dr. Mangala Narasimhan

March 27, 2020

Mangala Narasimhan, D.O. is a pulmonary and critical care specialist from Long Island Jewish Medical Center, in Long Island, New York. Dr. Narasimhan spoke with Fujifilm Sonosite Chief Medical Officer Diku Mandavia, M.D. about how the COVID-19 pandemic has impacted her hospital in the heart of New York's outbreak. You can watch the interview on our COVID-19 resource page. 

Dr. Mandavia:
Today is March 26, 2020, and unfortunately, we have hit another milestone in the COVID-19 outbreak. Right now we are at over 82,000 cases in the United States, which is more than anywhere else in the world. And the epicenter of the outbreak is the New York region. And the New York region is literally under assault. Today with me, I have Dr. Mangala Narasimhan. She is a pulmonary critical care physician at North Shore Long Island Jewish Medical Center, and literally in the center of the outbreak. So thank you, Mangala, for joining us here today.

Dr. Narasimhan:
You're very welcome.

Dr. Mandavia:
I know you're really busy, and I know I've seen you on the Wall Street Journal article, and on TV as well, so I know you have been busy at the hospital. Can you give us a little bit of the idea of the current conditions in New York from your vantage point?

Dr. Narasimhan:
So the real conditions are that we are just in surge capacity. We usually have one 18-bedded ICU in both of our tertiary facilities. We are today opening our fifth 18-bedded ICU. So we are just getting ICU volume in every single day. There are rapid responses that are happening constantly through the day, and we are bringing ICU patients into beds all day long. So we're filling up, and these patients take a long time to come off of vents, and so we just keep adding more patients to the point where we are just struggling to find staffing and physicians and nurses to take care of these ICU patients. 

We're now going to the point where we're asking doctors from other subspecialties to come run ICUs with us. So we have a pediatric ICU team, a surgical ICU team, a cardiothoracic ICU team, we have a CCU team, and they're all running full COVID MICUs right now with ARDS patients in every single bed.

Dr. Mandavia:
Oh my God, that is completely an awful situation. Tell me, how are the staff holding up?

Dr. Narasimhan:
Everybody is stressed and tired, and many of our coworkers have gotten ill. So everybody's worried about themselves, about their families, about what they're going through, but everybody is calm and pitching in, coming to work and doing their absolute best to take care of patients every single day, so hats off to them all, like it's amazing to watch all these people come together to do what's right.

Dr. Mandavia: 
And how are you hanging in there? I know you have a family.

Dr. Narasimhan:
I'm okay. I do, I'm okay. Everybody understands that this is a pandemic, and that it's centered around New York and Long Island and Queens, specifically, and it's an ICU pandemic. So they understand, they see what's happening, and it's unfortunate, but it is what it is.

Dr. Mandavia: 
Tell me a little bit more about the demographic of the patients that you're seeing, especially the more severe ones that are admitted, whether they're ventilated or not ventilated.

Dr. Narasimhan:
So everyone who makes it to the ICU is ventilated. They're not even getting into the ICU unless they're ventilated. They are extremely sick, they're all in ARDS, many, half of them are prone right now. We're seeing a predominance of men, definitely 60% at least are men. The average age is 60. We have patients in their 20s, patients in their 30s, patients in their 40s. Risk factors that we see, some of them have hypertension, some of the very young ones have no risk factors, and obesity seems to be a little bit of a higher prevalence in this group as well. That's what we're seeing. Really, their biggest comorbidities are hypertension, diabetes, that's what we're seeing the most. And otherwise, the older people, of course, multiple comorbidities and are not doing well with their ventilator stays, but the young people are also you know, going on and not doing well in their 20s and 30s.

Dr. Mandavia: 
So that's really surprising. Obviously, the initial data that we saw was that it was a lot of older patients, but we're now seeing a trend to a younger group as well.

Dr. Narasimhan:
Yeah, we're definitely seeing a lot of younger patients for sure, there's no question about it. I don't know why that is, and I don't know why that's different than Italy, or is it just the population that we're hitting in Queens is a younger population, I'm not sure.

Dr. Mandavia: 
Well, the risk factors that you mention are a little bit scary when we think about the American population, and that would represent many parts of America that would have similar sorts of risk factors.

Dr. Narasimhan:
Yes, I think this is a huge warning, and an outcry. This is the reason I'm doing this is that I'm hoping that the rest of America sees what's happening here, and just shuts down. Because you definitely don't want this to happen in places where there aren't enough hospitals and supplies and things like that. So it's a warning that it's here, it's big, it's bad, and it takes a long time for people to get better, if they get better, so not to mess around with this in any way. This is a real thing.

Dr. Mandavia: 
Tell me about the supply situation, whether it's PPEs or beds or ventilators.

Dr. Narasimhan:
I have a very close connection to my colleagues around New York, and around the country through ultrasound and ultrasound teaching and things like that, so I have a sense of how we are. We're very lucky in comparison to the centers around us. I think we had been planning for weeks before this happened, we were able to get supplies in. I work for a health system that is a little bit forward thinking, so I'm very lucky, but I know that people, you know, two miles away from us are struggling, don't have beds, don't have PPE, don't have surge capacity in their hospitals, and their patients are really suffering. Our patients are also suffering, there's no question about it, but we have not yet run out of supplies in PPE, and we are rationing what we do have so that we don't. So we use the same N95s for the day, and we are careful with our gowns and things like that, but we are not at the point yet where we're running out of those.

Dr. Mandavia: 
Are you worried about losing front line workers?

Dr. Narasimhan:
Very worried. I have lost many, many front line workers already, so I'm definitely worried about it. Everyone is doing okay and recovering, so I'm very grateful for that. But this is, I think, the most dangerous time, and this is the warning I give you. When you don't know they have COVID, and when you think that they're a COPD patient, or they're a patient with a pleural effusion, or you think they're a patient that has normal things that we see that people call ICU consults for, or that people come to your office to see…but it’s really the beginning of the COVID that you didn't realize was there, and you're not protected, you don't have PPE on. We have so many physicians in our ICUs that were outpatient doctors that didn't realize that their patients were positive. 

You have a lot of asymptomatic carriers, or they're not symptomatic yet but they will be three days from now, and you're seeing them in your office or you're seeing them in the hospital for a consult, and you don't realize what they have. So we have OBGYNs, we have REI doctors, we have pulmonary critical care physicians who see patients and didn't realize that they had COVID. I think that the warning is as this spreads through the country, to be thinking about this all the time and to take the proper precaution if you can.

Dr. Mandavia: 
Now are you seeing any stabilization of the cases as far as the number of cases, or is it still increasing?

Dr. Narasimhan:
So we have not hit a plateau by any means. My health system covers 23 hospitals across New York, Manhattan, Westchester, Long Island, so we have a big range of hospitals in our health system. I have a bird's eye view over all those hospitals that we oversee them. So I see where the hot spots are at our hospitals and our central region, which is our big tertiaries, have stopped increasing at the same rate, but are still increasing numbers. So they're sort of slowing down their exponential growth, but our hospitals out in Long Island are in a huge surge right now. Small community hospitals with 30 patients on ventilators for ARDS, you can imagine what that's doing to those hospitals. 

So it really depends on the region around New York, there are hot spots where there are breakouts every single day. There was a town that did not cancel their St. Patrick's Day parade, and that town is exploding with cases right now. So the social isolation definitely works, and should be taken seriously. So we're seeing the effects of all of these different things in the different boroughs that we have.

Dr. Mandavia: 
Wow. Tell me about your current diagnostic workup on these patients. Obviously, I know you're a point-of-care ultrasound expert, I'd be curious about that, but in general, what is the standard workup, and what sort of treatments are you doing, and are you doing any experimental work?

Dr. Narasimhan:
Yeah, so the patients, I'm only taking care of the ones who are super sick in ARDS, that's only about 20% of the patients coming into the hospital. The other patients, I don't really see and I'm not 100% sure about what treatment they're giving them. But in the ICU, they're coming in either intubated or about to be intubated as they come in. 

We're proning a lot of people. We are doing low-tidal-volume respiration, keeping our plateau pressures under 34 as much as we possibly can, increasing PEEP. These patients seem to require high amounts of PEEP, like 16 to 20 centimeters of PEEP, so that's an interesting thing. Their compliance is really not bad, it seems to be very much an oxygenation problem right away. 

If they're hypoxemic, then we're using high amounts of oxygen. They seem to recover from that in two or three or four days, and start to get lower on their oxygen requirements. And then some proportion of them go into a second phase where suddenly, their ferritin and CRP, you know, quadruple it and they start to go into a different phase. They seem to have a cytokine surge at that point, and the ones who go through that cytokine surge the second time really don't do well at all. They have cardiac issues, they go into renal failure, and then they end up with multi-organ failure. You know, their liver disfunctioned as well. And that subset of patients, we have not been able to pull back and do well with. 

With the patients that recover and never have that second storm, we've been able to extubate some of those, and those are doing better, but it really depends which direction the patients go at that point, but there seems to be a second phase in some patients.

Dr. Mandavia: 
I read a short study that came out of China where 80% of the intubated ventilated patients in the ICU died. What do you think of that number? Would that be reflective of what you're seeing?

Dr. Narasimhan:
So yes, unfortunately. It does seem to be reflective of what we're seeing. It's early, we've only been doing this for three weeks now, so I'm hopeful that maybe I'm wrong about that and more people will do better than I think. But we are seeing a very large proportion, somewhere between 70% and 80%, of not making it. So yes, we are in line with that.

Dr. Mandavia: 
Okay, that’s an absolutely awful mortality. Tell me about the imaging workup, whether ultrasound or CT. What are you doing?

Dr. Narasimhan:
So this was a big issue because we had read all these things about CT in China, and it's not practical, it doesn't change your management to do a CAT scan. It creates a lot of backflow when you have numbers like we have. Trying to move these patients around and take them anywhere is almost impossible. 

This is the perfect example of why point-of-care ultrasound is as useful as it is. These patients all have B lines when they come in, and there's no need to get a CAT scan. Right now, our entire unit is full of COVID, five units full of them, so diagnostically, it has not been. We know that these patients have COVID, there's no question about it, but definitely, there's been several different ways that we've used it. 

So lots of patients who come to the ED who are COVID, we think either suspected or positive, we have to make a decision. Their saturation's okay, are they high risk to stay in the hospital, or can they go home. And we had been using ultrasound in that situation to say hey, they have B lines, they're going to get worse over the next couple of days. [Or] this person has A lines and they're COVID positive, they're probably going to be okay, can go home, call us back, or come back if they don't feel well. So we'd been using it in that way, which is really interesting

There was a paper that come out of China and Italy. In Italy, they were doing the same thing, more as should they stay [in the hospital], but not to diagnose them with COVID to begin with. Because I think if you have A lines, you could still have COVID but you're not symptomatic yet. So I don't think it helps you rule it out, I think it just tells you who's sicker from it. Once they get to the ICU, we see that they have B lines. These people who go into cytokine storm and do worse later in their course, develop consolidations suddenly at that time. 

We also are watching because we are not using a lot of bi-level or high-flow in these patients because of risk of aerosolizing secretions, so we're watching really closely when they get extubated, are they developing atelectasis, and we're doing that all with ultrasound. So we are doing daily bedside ultrasounds on them. We also are looking for the myocarditis, and myopathy phase with ultrasound. So they get a cardiac study every single day. 

And again, we're quick, we're in the rooms, we do a quick lung and then we do a quick heart and we're out again after a physical exam. So we look to see, does their LV function change. As that ferritin goes up, the next day, their LV function is worse, their VTIs go down. We're watching their cardiac output change in front of us, so we know that that patient is going to not do well, going to require cardiac pressors, and we start planning for that and knowing what's going to happen. So point-of-care ultrasound has been extremely useful. 

One more way that we're using it, these patients seem to be very thrombogenic and hypercoagulable, so we've been checking DVT studies on these patients, looking for PEs with big RVs on these patients, titrating PEEP using ultrasound as well, so when they're on 18 of PEEP and their RV is large. We're starting to bring that down because we know that that's, and we're watching that RV get smaller, and we're using this to manage our PEEP titration to manage looking for DVTs, Pes And we're also using it to manage cardiac output and looking for A lines and B lines. So in every way that we always use it, we're using it exponentially with these patients because you really can't take them anywhere.

Dr. Mandavia: 
Wow, that's really helpful, a lot of good advice. We'll have a lot of physicians listening to this, literally around the world, but it sounds like point-of-care ultrasound has a big role within the COVID-19 patient.

Dr. Narasimhan:
It’s just not practical to take them to CAT scan, and not really helpful in changing your management.

Dr. Mandavia: 
So I know you're busy and will need to get back to work I just have a few follow-up questions. Any lessons learned thus far over three weeks?

Dr. Narasimhan:
Yes. I think, over plan if you can. Have what you need, and it's not just ventilators, and it's not just tubing. It's medications, it's fentanyl, it's Propofol, it's paralytics. So think through what you do for a regular patient in ARDS, and multiply it several times. Have what you need because once it gets your area, you're not going to be able to get supplies. Everyone's going to be asking for the same things. Think about surge, where you're going to put these patients, COVID cohorting units and non-COVID cohorting units, and units where you're going to put patients that are suspected COVID as well. Planning for monitors if you're going to move ICU patients to a non-ICU space, to have that ready to go, the monitors are there. 

This is going to happen quickly in your town if it happens, and you're not going to have a lot of time to plan all these things out. So as much of this as you can do, surge planning ahead of time, the better. You'll be in a better place when it actually happens.

Dr. Mandavia: 
Those are very helpful instructions. As we know, this COVID-19 illness is now spreading across America, so your experience in New York can really be helpful to other physicians across the country. So I want to thank you.

Dr. Narasimhan:
You're welcome.

Dr. Mandavia: 
I want to thank all of your team for the work that you're doing. So on behalf of Fujifilm Sonosite, all of our staff, we're here to support you.

Dr. Narasimhan:
You always have been, we appreciate it.

Dr. Mandavia: 
Well you're in a war like we've never seen in modern times before, so thank you for all you're doing. And most importantly, keep safe, and keep doing what you're doing. Thank you.

Dr. Narasimhan:
Thank you, take care.

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