Prior to January 2020 when clinicians read about the history of the 1918 flu, and epidemiologists predicted we were overdue for another serious pandemic, the question in the back of many people's minds was how they would act when the arrival day came for a new modern plague. In just a couple months, health systems and their clinicians worldwide went from wondering to being thrown into the thick of that scenario with the arrival of COVID-19 (SARS-CoV-2).
Cardiology, like all the departments in all hospitals, has undergone some major changes since March 2020, namely a huge reduction in procedure volumes, halting clinical trials and finding new ways to communicate with patients via telehealth. It also forced cardiology clinicians to think differently, such as what procedures and tests are "elective" and how to triage which patients will get revascularization or transcatheter heart valve repairs or replacements, and which patients are well enough to hold off on for weeks or months.
More dire questions have also come up for serious discussion, such as not resuscitating patients who code if suspected of being COVID positive, and developing contingency plans to use lytic therapy in place of PCI in heart attack patients if a hospital becomes completely overwhelmed with COVID-19 patients.
In many of the epicenters like New York City, New Jersey and Detroit, with the majority of cardiology cases postponed, cardiology staff became part of the all-hands-on-deck response to the surge of COVID patients. Some of these hospitals were overwhelmed. Faculty at university teaching hospitals were reassigned to help with COVID-related care in many of these epicenters. Cardiology fellows were reassigned to help in ICUs to care for COVID patients. Cardiology research teams that ran clinical trials changed gears to support and run COVID-19 trials.
There were several haunting take-aways in the COVID-19 sessions at the virtual meeting in May for the Society of Cardiovascular Angiography and Interventions (SCAI). Ajay J. Kirtane, M.D., associate professor of medicine at Columbia University Irving Medical Center and director of the cardiac catheterization laboratories at NewYork-Presbyterian Hospital, delivered an especially passionate description of the surge in New York City and how his center responded.
“Until things hit close to home, we really had no idea what we were in for,” Kirtane said. “None of us could really have predicted how this would happen or how we could ever prepare for it. When people see pictures and they say that isn't real, I assure you it was definitely real and it was horrific,” Kirtane explained. “We were simply overrun. We did not have enough PPE, and there were hospitals where nurses were actually wearing garbage bags. These are true stories. There was rationing of PPE, there were not enough N95 or even surgical masks to go around. Our hospital was overrun by COVID cases, where almost 90 percent of our patient volume was COVID only, so we had no room to accommodate any other disease processes in the hospital had we continued to operate business as usual.”
Read more in the article How Cardiology Dealt With the COVID-19 Surge in New York City.
Coronavirus, originally thought to mainly affect the pulmonary system, turns out to have a lot of impacts on the cardiovascular system. Patients with comorbidities who are infected with COVID-19 have much higher rates of mortality, and those with cardiovascular diseases by far have the highest death rates. COVID-19 can induce myocarditis, heart failure, arrhythmias from both the virus and several front-line drugs being used to treat patients, shock, STEMI mimic, thrombo-embolism leading to stroke and pulmonary embolism, and a new Kawasaki-like inflammatory syndrome in children. Cardiologists quickly became part of the increasingly more complex critical care teams for these patients. They also are involved in providing hemodynamic support for some of the most complicated patient cases, including use of ECMO, which was granted FDA emergency use authorization for use in COVID-19 patients when ventilators are not enough.
Read more in the article The Cardiovascular Impact of COVID-19.
Clinicians always have some level of risk they face from infection from their patients, HIV probably being the most pronounced concern in recent years. But the pandemic has brought this concern to a new level, where personal safety and the safety of friends and family is now directly tied to helping patients. In cardiology, basic PPE is worn to protect the patient from any germs from the clinician, but COVID-19 has now made everyone in cardiology fearful of their patients, especially because up to 45 percent of COVID-infected patients are asymptomatic. PPE now plays a much more serious and central role for everything in cardiology, from imaging to cath lab and surgical procedures. All patients are now treated as if they have the highly infectious virus. The continuing issues with false negative results from genetic PCR test kits used to screen for coronavirus has not helped alleviate any of those fears.
The Most Devastating 6 Months in Modern Healthcare
In February, when containment efforts for the small number of U.S. cases appeared to be holding, the Centers for Disease Control and Prevention (CDC) said in its Feb. 21 press briefing that is was working to buy time with containment efforts, but that the arrival of the virus in force was not a question of if, but when. The CDC warned that U.S. hospitals needed time stock up on personal protective equipment (PPE) and ready emergency plans to keep them running in case the virus made a rapid spread across the country.
Two weeks later hospitals across the country began placing travel bans on staff to keep them available locally for any emergency response, leading to all medical conferences from early March on either being cancelled or going to a virtual meeting format. Another two weeks later and the virus made its rapid spread, many states and cities began shutting down their economies and asked residents to shelter in place unless they were considered essential workers, including all healthcare workers. The usually bustling streets of major cities like New York and Chicago became ghost towns with nearly all stores being closed and the streets wide open with no traffic.
Hospitals feared they would be overwhelmed and run out of supplies, especially PPE, which staff began using at fast and unsustainable rates at their usual supply levels, and now the entire world was competing for the limited supply of PPE. In March and April, all major medical societies scrambled to issue expert guidelines on how to conserve PPE, drugs and other supplies for the main fight against the infection. In March, the Centers for Medicare and Medicaid Services (CMS) called for immediately cancelling or postponing all elective, nonessential procedures, tests and imaging to ensure PPE was available for the fight against COVID-19.
Originally there was hope that hospitals would reopen after a couple weeks to a month, but four months on, many hospitals are still dealing with the shutdowns or have a hobbled ability to reopen their profit making operations. This has forced layoffs, staff furloughs, salary cuts, benefit cuts and raised questions about what hospital operations might be greatly reduced or eliminated to help cut costs. Hospital are looking for ways to stay solvent.
Many hospitals started reopening operations to non-emergency, non-COVID patients in May, but volumes remain low everywhere because of new protocols now in place to ensure safety of both patients and staff. Even for outpatient operations, there are limits on the number of patients allowed into buildings to prevent crowded waiting rooms, staff and patients all have their temperatures taken, everyone wears masks, all staff wear gloves, and higher levels of PPE are required for staff who need to be include contact with patients for exams, echocardiograms and procedures. Everything from rooms, scanning equipment and waiting rooms are now cleaned repeatedly during the course of each day, limiting the number of patients that can be seen. This is now the new normal in healthcare for the foreseeable future.
The pandemic also has not allowed clinicians to fully disconnect from work when they leave the hospital, as the new normal in society in many areas is governed by required face masks, social distancing, order out-only restaurants, one-way aisles in stores, closed parks, markers reminding people to stay 6 feet apart and COVID-related signs everywhere. There also is the daily decontamination ritual when clinicians arrive at home, to wipe down and transition from work shoes and clothes to at-home apparel to keep others at home safe.
Millions have lost jobs since the COVID-19 shutdowns across the U.S. economy, which also means millions are now without health insurance. This may be another serious impact that could effect healthcare systems in both the short and long term, depending on how long the virus continues to cause spikes or new surges.
The polarization of U.S. politics in recent years, especially in this very divisive election year, has also caused COVID-19 to become politicized. Masks, travel restrictions, social distancing, shopping and restaurant restrictions designed to aid containment efforts are seen by some as a restrictions on their personal freedoms. Some feel all these things are part of a larger conspiracy from one party or the other to cause harm politically or make things seem worse than it really is. This has not helped the COVID-19 situation and has led to much frustration with healthcare workers. Keep in mind, there were many who also opposed the wearing of masks, forced social distancing and closure of events and businesses during the 1918 flu. Many were only made to accept the restrictions after several million flu deaths. We learned from that history, and were much more proactive in 2020, regardless of whether people liked it or not.
Despite these issues and what others might say about conspiracies or effectiveness of these strategies, they have impacted the spread of the virus and prevented hospitals from becoming completely overwhelmed. Some critics of the heavy-handed COVID-19 restrictions cite numbers of deaths pale in comparison to the estimated 50 million who perished from the 1918-1919 flu pandemic. COVID might not be as terrible as the 1918 flu, but the containment efforts and the heroic efforts of clinicians working the front lines should be clearly noted as having prevented much higher numbers of deaths and infections than what we would have faced without their efforts and containment strategies.
For those who worked in hospitals during the surge in cities like New York and Detroit, they have a pretty good idea of what could have been a much worse situation if the virus was allowed to run rampant and unchecked.
Excellent work so far and all deserve thanks, but the fight is still far from over.
Related Cardiology COVID-19 Content:
Heroism in the Face of the COVID-19 Pandemic - Commentary from Ajay Kirtane, Roxana Mehran, et al.
VIDEO: Why QT-prolongation Occurs in COVID-19 Patients on Hydroxychloroquine and Azithromycin — Interview with Andrew D. Krahn, M.D.,
VIDEO: CT and POCUS Emerge As Frontline Cardiac Imaging Modalities in COVID-19 Era — Interview with Geoffrey Rose, M.D.
VIDEO: Impact of COVID-19 on the Interventional Cardiology Program at Henry Ford Hospital — Interview with William O'Neill, M.D.