OBSERVATIONS ON COVID-19 DISRUPTIONS FROM DR. JEFFREY CHIPMAN
July 14, 2020
During the COVID-19 crisis, Dr. Jeffrey Chipman provides his observations.
M Health Fairview Bethesda Hospital (known internally as the COVE) transformed from a long-term acute care hospital, is Minnesota's first hospital dedicated solely to treating patients with severe cases of COVID-19. On March 26, the first patient arrived. I have watched the beds fill and many discharged home to continue their recovery. Inspired by what I have witnessed, I want to share with you my Thoughts from the COVE in these periodic emails.
UPDATE From Dr. Jeffrey Chipman: 07/14/2020
Last time I wrote about not being the naysayer. "I don't want to be the guy who told Lillehei surgery on the heart couldn't be done." Since then, I have another description of the picture I was trying to paint. David Buckner is a business management trainer, adjunct professor at the Columbia University Business School, and a consultant to the City of New York. He articulated the concept that in any change situation, particularly crisis, it is best to start with data. Data leads to good policy. Policy leads to a well-placed passion.
However, too often, we start with passion and let passion lead to policy. What commonly results are bad policy, poor outcomes, lost money, and the promotion (and personal use) of hydroxychloroquine, as well as refusing to wear face masks or socially distance. Starting with data is challenging when the limbic system is so overpowering. Its effect on the endocrine and autonomic nervous system and the resultant stress response of increased cortisol, norepinephrine, glucagon; decreased insulin secretion; and increased blood glucose can conquer rational thought while simultaneously being helpful when we see a saber tooth tiger and need the energy to flee.
Early in the pandemic, when people were out buying ten years' worth of toilet paper, I read an article in USA Today attempting to describe this somewhat irrational but passionate behavior. After interviewing experts in stress, the author concluded, "There isn't any real practical reason to stock up on toilet paper, but it may make people feel a bit in control of a situation rife with unknowns." But acting on passion leads to bad policy and lots of toilet paper to store.
My wife has a bachelor's degree in clothing and textiles. She is an amazing "sewist," which apparently is the new word for a recreational tailor. In response to passionate asks, she was compelled to make face masks for hospitals when personal protective equipment was in short supply. She was disappointed when she found out they wouldn't actually be helpful to protect providers. All I can say is whoever gets them has no idea that their face is covered by haute couture.
People want to help, but we need to make sure that the help is driven by data rather than by passion. Otherwise, while not true, we risk the downstream effect of appearing ungrateful. Likewise, data informing policy may limit overreacting social and political responses that naysayers cite to argue against facemasks and social distancing. Ashley Haase, MD, Regents Professor and Head of the Department of Microbiology and Immunology and Professor of Medicine summarized the data about wearing facemasks in reducing viral spread. It is well worth the read so that data can inform our own personal policies.
UPDATE from Jeffrey Chipman 07/02/2020
I don’t want to be the guy who told Lillehei surgery on the heart couldn’t be done.
In 2014 our surgical alumnus of the year was then 89-year old Russell M. Nelson. He was witness to the first operation using the pump oxygenator wherein he functioned in the role of what is known today as a perfusionist. Among other notable accomplishments, he established the cardiothoracic training program at the University of Utah. During his presentation, he talked about the paradigm of the time that insisted the heart shouldn’t be touched. I asked him how they dealt with repeated failures, especially when they so often resulted in the loss of life. His answer, there weren’t any other options. The patients were “…going to die within the year.” Dr. Montgomery said something similar during his Najarian Lecture given this Spring. In essence, patients are willing to take risks when they are thought out and planned.
Update from Dr. Jeffrey Chipman 06/25/2020
As with any disease, there is a difference of opinion on how to care for patients in respiratory failure due to SARS-CoV-2. Most agree that Acute Respiratory Distress Syndrome (ARDS) is the reason for severe hypoxemia. But it is important to remember that ARDS is the end result of various pathologies, not all of which is infectious. My most memorable patient with ARDS was a young man who developed it after delayed repair of an isolated femur fracture.
Current management for ARDS, like many diseases, has care pathways and algorithms built largely by expert consensus informed by research. In a nutshell, we limit the volume of each breath on the ventilator to assure that the lung doesn’t experience high pressure. The lung becomes stiff, or noncompliant, due to the inflammatory response caused by infection or as collateral damage from the body’s response to pathology elsewhere. To limit the pressure in the lung, we progressively decrease the volume of each breath the ventilator provides. There are charts that guide this volumetric decrease. READ MORE
UPDATE From Dr. Jeffrey Chipman: 06/19/2020
George Floyd’s murder has ignited deep needed social change. In the weeks following his death, it was best to pause the COVID-19 blog as not only as a nation but as a University and health system begin to confront systemic racism and how to create change. As we have heard from University, Medical School, and Health System leaders, there is urgency and focus on addressing issues of inequities, bias, and discrimination. I look forward to partnering with the newly appointed Vice Dean for Diversity, Equity, and Inclusion, Ana Núňez, MD, FACP, who will join us in August. Change typically does not happen quickly, but look how quickly we responded to COVID-19. My hope is that the same energy we harnessed to combat COVID-19 will catalyze the changes needed to ensure equity, diversity and inclusion for our faculty, staff, trainees, and patients.
To bring everyone up to date on what is happening at Bethesda, we are starting to see a decrease in the number of patients in the ICUs and ward. This is a welcome drop, to say the least. Recent data suggest the mortality rate at Bethesda is 26%. This is in contrast to the reported rates of 65% in Wuhan, China, > 85% in New York, and around 50% in Washington. It will be fascinating to figure out what affects these outcomes. READ MORE
UPDATE From Dr. Jeffrey Chipman: 05/22/2020
A recent paper published in JAMA reported the outcomes of 5,700 patients with COVID-19 treated in Northwell Health hospitals. Northwell is now the largest academic healthcare system in New York and began with the combination of Long Island Jewish Medical Center and North Shore Hospital. Our own former resident, Rohini Olson, completed her pediatric surgery residency there. Among its affiliates are Maimonides Medical Center in Brooklyn and Lennox Hill in Manhattan as well as the new Hofstra Northwell Medical School. The most common comorbidities were hypertension (56.6%), obesity (41.7%), and diabetes (33.8%). The scariest statistics were the mortality rates for ventilated patients. 76% of patients age 18 – 65 years died, and 97% of patients older than 65 died. Though early and incomplete, these data were disheartening, to say the least. READ MORE
UPDATE From Dr. Jeffrey Chipman: 05/19/2020
My Dad sent me some funny quips about this time.
“Half of us are going to come out of this quarantine as amazing cooks. The other half will come out with a drinking problem.”
“Every few days, try on your jeans to make sure they fit. Pajamas will have you believe all is well in the kingdom.”
“Homeschooling is going fine. Two students suspended for fighting, and one teacher fired for drinking on the job.”
“This morning, I saw my neighbor talking to her cat. It was obvious she thought her cat understood her. I came home and told my dog. We had a good laugh.”
“Day 5 of homeschooling: One of these monsters called in a bomb threat.”
“Day 6 of homeschooling: My child just said, ‘I hope I don’t have the same teacher next year.’ I’m offended.”
My dog, Blue, laughed when I read them to her.
Laughter triggers dopamine, serotonin, and endorphin release in the brain that increase pleasure, improve mood, and induce euphoria. It may have health benefits by relieving tension and stress, improve immunity, and increase blood flow. We need it now more than ever.
UPDATE From Dr. Jeffrey Chipman: 05/15/2020
Despite good care and emerging evidence of good outcomes, not all is great at Bethesda. It's an old building and wasn't designed for modern, computer-dependent patient care. The rooms are deep, and the beds far from the doors. That, combined with the noise of the fans creating negative airflow, makes it challenging to hear alarms on IV pumps, ventilators, and monitors. Not all the beds are modern and radiolucent, making C-arm work difficult. Doors are narrow. Computer workspace is at a premium. Nurses, respiratory therapists, and other ancillary staff vary in experience and expertise. Our current ICU workspace is cramped. Tired legs make sitting on the floor tolerable during sign out. And, there never seems to be enough Diet Coke. READ MORE
UPDATE From Dr. Jeffrey Chipman: 05/12/2020
I started playing the guitar when I was a kid. I’d like to think the only thing that kept me from being a superstar was family stresses combined with a heavy dose of my adolescent indifference. I started playing again after I finished training. I think guitars are like bikes and skis. The number needed to own is calculated by the simple equation n + 1. n = the number currently owned. My wife disagrees even though she thinks that the equation is perfectly applied to sewing machines and shoes. I have found that music has helped me unwind over the last several weeks, to the point that I’m going to have a hard time tying knots for the thick calluses on my fingers. READ MORE
UPDATE From Dr. Jeffrey Chipman: 05/11/2020
I’m reluctantly admitting to the fact that COVID-19 will be on every differential diagnosis for a long time – sort of like acute appendicitis or inflammatory bowel disease. I remember a case presentation Brian Grubbs did many years ago about a patient who swallowed a foreign object. The presentation included an abdominal X-ray demonstrating a gastric opacity in the shape of a toothbrush (clinical correlation recommended). He listed a differential diagnosis for this finding, including - Colgate, Oral-B, GUM, Butler, and inflammatory bowel disease...because every differential diagnosis includes IBD. READ MORE
UPDATE From Dr. Jeffrey Chipman: 05/05/2020
My youngest son returned from his shuttered University last weekend. He’d wandered for a few weeks, finishing courses hastily converted to on-line platforms while living with my sister until she drove him nuts or vice versa. Now that he’s been home a week, I suspect it was the latter. This virus moved his cheese, and he doesn’t know how to find it, let alone where. His college routine has been disrupted.
I’ve been reading that maintaining a routine can be helpful to mental health during life disruptions. I’ve found that when I go to the office, either at the University or at Bethesda, and spend my day on zoom conferences, I feel like I’ve accomplished more than if I do the same thing from home. How many of us have muttered, or even exclaimed out loud in the operating room, “I do it the same way every time!” This phrase was even printed above the scrub sinks at UMMC for a while. Routine is why we create standard operating procedures for patient safety. We rely on it. READ MORE
UPDATE From Dr. Jeffrey Chipman: 05/01/2020
The Troubled Pool
I’ve always thought Bethesda was a good name for a hospital. The name Bethesda is derived from Hebrew and means house of mercy or house of grace. The Bible tells of a pool in Jerusalem that, from time to time, would have unexplainable ripples appear. These “troubled” waters were thought to be caused by the touch of an angel and possessed healing properties. The pool was surrounded by “…a great multitude of impotent folk, of blind, halt, withered, waiting for the moving of the water” because the first person in the water was “…made whole of whatsoever disease….” (John 5:2-4, KJV). This poster sits at the entrance to Bethesda and is a similar sign of hope. READ MORE...
Update from Dr. Chipman: 04/28/2020
Bethesda Hospital has its beginnings in 1883 as an institution to serve Swedish Lutherans. It moved to its current location on the hill above the capitol in 1932. Most of us knew it as a Long-Term Acute Care Hospital (LTACH) that cared for chronically ill patients. Now, of course, it has become the house of SARS-COV2 and the disease COVID-19. It was renewed over 13 days from the LTACH to an acute care hospital to cohort infected patients. Ingenuity is the noun to describe what it took to transform the building. READ MORE...