American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Updates from Mount Sinai Health System

In our continuing series, we include reflections from Anthony J. Vine, MD, FACS, Assistant Clinical Professor of Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, and Member, Board of Governors, American College of Surgeons. Dr. Vine writes about his experience on the job in New York City.

He states, “Every evening at 7:00 pm for the last week or 10 days, New Yorkers have been coming out onto their balconies, opening their windows, and coming out to the street to clap, cheer, shout, and ring bells for the first responders: Emergency medical services workers, doctors, nurses, grocers, sanitation crews. It is as loud as being at a baseball or football game. It’s hard to describe the feeling as one come home from ‘the front.’” Watch a video of New Yorkers cheering health care workers.


Third Day

Our replacement team arrived promptly at 4 pm. Although I was anxious to escape from what felt like a leper colony, it was important to give the new team—their first shift in this new environment—a complete sign out of all the emergency room (ER) patients and the lay of the land, including: 12 COVID-19 pneumonia patients “stable” enough for transfer; five ventilated patients on high O2 and PEEP; and a sixth 58-year-old ventilated gentleman with COVID-19 pneumonia and multiple comorbidities, whom my resident, Dr. LaChapelle, the brave respiratory therapist (RT), and I had just transported up to a palliative care unit, since the family finally had agreed to make him DNR (do not resuscitate). This patient had arrested while sitting in the ER waiting room, and although he had been resuscitated after 15 minutes of advanced cardiac life support, he had remained unresponsive and hypotensive on high-dose vasopressors, an insulin drip, and maximum ventilator settings with an oxygen saturation of 90 percent. While my resident remained upstairs assisting the floor nurse and respiratory therapist (RT), I wheeled the stretcher and cardiac monitor from the third floor back down to the ER entry bay, and was joined by my colleague, Dr. Marco Harmaty, a Mount Sinai plastic surgery attending on my team, to wipe and scrub the COVID-19-laden equipment with Clorox, so they could be ready for the next patient. We understood that it was not beneath us, two attending surgeons, to perform a housekeeping chore, as those also valiant hospital workers are equally overwhelmed.

Having escorted the new team around the hospital to orient them to the intensive care unit (ICU) and the floors, I was ready to get out of there and drive my resident back to our Upper East Side of Manhattan haven, but as I was doffing my personal protective equipment (PPE), the ER business associate paged me: it was a phone call for me from the nurse aboard the USS Comfort Navy vessel to accept sign out for one of the only two COVID-19 negative patients in the ER, an 88-year-old woman who had suffered a repeat transient ischemic attack/“mini stroke,” awaiting her transfer out of Mount Sinai Brooklyn.

Another 15 minutes on the phone and a second 10-minute phone call with the patient’s niece, Minnie, to assuage her and tell her the disposition of her aunt, so now I could leave.

5:00 pm
End of watch.
Three days off.
Three days to reflect.

After arriving back at my apartment and performing the quotidian end-of-shift decontamination ritual, I donned fresh clothes and went out for some fresh air—naturally filtered by a surgical mask. With a craving for pizza, I got two slices from the local Italian place a few blocks away. As I turned back down my street, still a little dazed from work, I was stunned by the sudden voluminous din: people (properly socially distanced) were on their balconies, on the street, opening their windows to shout, clap, ring bells, bang on pans, and cheer. It was 7 pm on the dot: the time ALL New Yorkers have designated to stop whatever they are doing to applaud the first responders, be they health care workers, grocers, delivery men, or sanitation crews. My neighbors out walking their dogs were out participating, my building superintendent was in his first-floor apartment ringing a bell, and my doorman said as I entered the threshold, “This is for you, Doc!” I could not hold back the tears: so many of us working, but even more people suffering, and too many dying. A true New York minute.

My father was a captain in the Dental Corps of the U.S. Army during the Korean Conflict. One of his drab tattered green hats with the silver bars still sits atop my dresser. He passed away two years ago January at the age of 93, and I hope it is not a sinful thought, but I feel relieved that he did not have to live through this crisis, or that I did not have to worry about his welfare while trying to do my work.

But I know that in the Armed Forces, the soldiers receive furloughs during their tours of duty—and here was mine: a time to relax, a time to ponder, and a time to renew love with family and friends (albeit by FaceTime or Zoom at this juncture).

I had just returned from foreign soil (yes, Brooklyn is somewhere over to the east of Manhattan, perhaps near Gibraltar or Paris, is it?—everyone is familiar with the famous New Yorker magazine’s cover depicting Manhattan as the center of the world...). The first feeling one senses in an unfamiliar land is disorientation, despite the fact that all ERs and ICUs essentially look the same. That feeling eases a bit as one starts to focus on work, but the hint of anxiety is omnipresent.

Yes, I had those sensations on Day One, but suddenly, our Surgical CO and Chairman, Mike Marin, MD, FACS, appeared in the Mount Sinai Brooklyn ER. He was upbeat, encouraging, and taking pictures (I was on the phone with the ever-so-patient Mount Sinai Transfer Operator at the time). We all have seen the classic unforgettable D-Day photo of General Eisenhower, the Supreme Allied Commander, greeting the 101st Airborne Troops, the first to be parachuted behind enemy lines. And then, as I transported a ventilated patient up to the ICU, there were more familiar faces: my friend and colleague, Chief of General Surgery at Mount Sinai, Celia Divino, MD, FACS; another of our stellar senior residents, Dr. Stewart Whitney; and Linda Zhang, MD, a younger attending colleague of mine and former Mount Sinai surgical resident.

It almost began to feel like I was home, at my Mount Sinai Hospital on the Upper East Side. And then, as I stepped out of the stairwell, there stood Michael McCarry, BS, MS, RN, our Senior Vice-President of Perioperative Services at “home”—our “facilitator,” the man who has been given the Herculean task of making our Mount Sinai New York ORs run smoothly and efficiently. But here, he had been given a more complex role: Chief Operating Officer of Mount Sinai Brooklyn during this petrifying pandemic that is battering brutally the New York State hospital systems.

But now, an epiphany: I felt the connection of our platoon to the Allied operation, and how all the divisions and branches of our Mount Sinai Forces were poised to battle this plague in New York.
No matter the situation, our Mount Sinai training modules for this pandemic have been invaluable. While caring for the patients, we must also protect our coworkers. Although I had only just met the tireless ER nurses, doctors, respiratory therapists, and desk staff in Mount Sinai Brooklyn, they would come to represent the troops stationed alongside our platoon in the trenches, whom we had to keep safe from harm. Two examples—

Day One, 8:00 am: First set of rounds, I noticed that no ER patients were wearing surgical masks over their faces while on NC O2 or FM O2 (non-rebreather), an important maneuver to help prevent aerosolization of virus. Job #1: have my team place masks over all of them.

Day Three, Emergency medical services (EMS) transported to an ER bay a COVID-19 pneumonia patient who had been incubated in the field. As the ED attending and nurses rushed toward the patient to administer care, I noticed from afar that there was no HEPA filter between the ambu-bag and the endotracheal tube (ET). I could see the EMS’s cardiac monitor, which showed a heart rate of 90, so I shouted, “STOP! No one may enter that cubicle until RT brings down a HEPA filter. The EMS crew can continue ambu-ing the patient for two minutes.” As soon as RT brought the filter, I covered the patient’s entire face/head—except for the ET—with a sheet and a towel. We then expeditiously placed the filter at the appropriate respiratory interval, and only then would treatment be able to start. The patient did not suffer and the risk to the staff was greatly diminished.

Lesson: It is the nature of emergency or surgical trauma care to work quickly, but working quickly does not necessarily mean working fast and reaching for items indiscriminately: rather, it entails preparing what you need first with forethought, and then performing the maneuvers only once. Efficiency always “trumps” (may I use that word?) chaotically rapid movements.

While of course physically challenging, the time spent in this environment is emotionally draining. Extremes of emotions are the norm: I felt the sincere gratitude of the son whose sick mother I had to transfer from their Brooklyn home base to a temporary tent facility in New York’s Central Park built by the Good Samaritans outside of Mount Sinai, 20 plus miles away. Four times I called him over a six-hour period: the first to tell him how she was faring medically; next, to ask for his permission to transfer her; the third time, an update on her status; and finally, to tell him that the EMS were here to pick her up. Diametrically opposite to that were the multitude of more somber interactions: giving pejorative updates on critically ill family members on ventilators; finding out patients’ end-of-life desires from their next of kin; the dreaded discussion of asking for permission to make a loved one DNR. Doing the latter by phone is hard enough, but knowing that these patients are deteriorating and dying without a loved one at the bedside creates depression for all. It is an unnatural and incomprehensible situation, how this invisible microscopic organism is now in control of and the totalitarian dictator of human suffering and mortality.

A few final thoughts from New York before my next deployment Wednesday— as currently I am in the process of trying to get OR time for a COVID-19 negative patient I had met in the ER in Brooklyn three days ago with acute cholecystitis, who now has a fever of 102° and continued severe right upper quadrant pain, despite IV antibiotics:

  • We do not know in New York City whether we have plateaued or whether the peak is yet to come.
  • Governor Cuomo has a clear comprehension of the issues involving the battle of New York City and New York State Speaking in my capacity as a member of the American College of Surgeons (ACS) Board of Governors and a member of the ACS Legislative Committee, the Fellows of the ACS need to make President Trump understand the dire circumstances revolving around PPE, ventilators, hospital beds, and the allocation of these resources, all of which are becoming scarce, as the number of critically ill patients mounts.
  • The team/“platoon” approach allows for the best care of patients and the protection of our health care colleagues.

And finally, I appeal to all who can volunteer or help in any way possible, since this is a fight for society and our humanity. On this very Holy Week of Passover, Easter, and Ramadan, which so many are perversely celebrating in isolation, I would quote two of the famous teachings of Rabbi Hillel: “If not now, when?!” and “If I am for myself alone, then who am I?”

I wish all of you safety and good health through this crisis.
Sincerely,
Anthony J. Vine, MD, FACS


An Update from Mount Sinai Health System

Anthony J. Vine, MD, FACS, Assistant Clinical Professor of Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, and an ACS Board of Governor delivers a second report for our newsletter. This message focuses on a poignant meeting he and his colleagues had before entering the COVID-19 battlefield. Read more below.

Prior to my deployment tomorrow—and yes, I use battlefield terminology—we had such a Zoom meeting with our Surgical Commander-in-Chief, Michael Marin, MD, FACS, and with his military aide-Vice Chair of Administration, Paige McMillan, MHA. 

As Dr. Marin addressed the platoon, the first segment of his speech alluded to the harrowing nature of the beast we are fighting: this is nothing like anything we ever have encountered. For now, we are no longer surgeons, nurse practitioners, residents—we all are equal healthcare soldiers. There will be chaos. People will die: we will witness this and we may be powerless to prevent this outcome. 

However, as Dr. Marin had each of us on the team—visible on the Zoom Gallery mode—introduce ourselves, he also requested that we reveal a personal, perhaps intimate, detail beyond our credentials. Here was a single mother, trying to prepare for Passover with her son and daughter; a plastic surgery resident with young children; myself, a violinist and chamber musicians. 

As the conference progressed, Dr. Marin outlined the team approach, designating the Chief/Senior Resident as the group’s Platoon leader—in charge of a duffle bag of PPE, of coordinating the team members (2 MDs/Chief Resident/NP or PA/2 medical assistants)—the go-to central figure. And no different from a platoon or seal team, we must all look out for one another at all times, even while caring for the sick. We must prioritize the team’s safety and welfare—physical and emotional—while still providing the best care possible. 

Then silence. Few or no questions asked. 

As we all signed off and wished each other good luck, I had simultaneous sensations of terror and sadness, but I realized two other feelings surfacing that Dr. Marin had communicated and exuded: the overriding, more controlling emotions of calmness and inspiration—and it is with these latter two that tomorrow morning I will march to the (to me) unfamiliar front line of Mount Sinai Brooklyn, proud that I am a Mount Sinai NY Surgeon. 


Today, Dr. Anthony Vine of Mount Sinai Health System and ACS Governor for Manhattan sent along his personal early experience being a member of Team 6. He reports on his system’s experience over the last two days. Note: These messages have not undergone traditional peer review, but we feel will be of interest to our readers.

Mount Sinai Health System:
COVID-19 Health System Updates, March 30

Dr. Vine Reports

“ ….There were over 500 deaths in the country yesterday—138 of them in NYC alone, so the situation is getting worse here.

Just some personal background—

While I am a “voluntary” (not paid by the hospital) surgeon—of whom there are very few left, I am a more senior surgeon at sinai. We have equal stature in the department, as we are instrumental in the training of residents and fellows, since we still receive a majority of the complex cases. As you can see, I am just as—or more—“academic” than many of my Full time colleagues. I have been at Sinai now for 30 years, over half my life. I hope to turn 58 on the “old” tax day, April 15.

While not doing any elective cases, I still feel a dedication to this institution that trained me and has helped foster my surgical career, so of course, I have volunteered to help in any way I can.

The next attachment I send will explain what we are doing specifically in the Dept of Surgery.

Most sincerely,

Tony

Anthony J. Vine, MD, FACS
Asst. Clinical Professor of Surgery,
Icahn School of Medicine at Mount Sinai Hospital, NY, NY
Member, Board of Governors, American College of Surgeons
Manhattan Council, American College of Surgeons

Daily Memo

TO: All Faculty, Staff, and Trainees
FROM: Vicki R. LoPachin, MD, MBA
Senior Vice President
Chief Medical Officer
Mount Sinai Health System

DATE: March 30, 2020
RE: COVID-19 Health System Updates, March 30

I want to give you an update on our Personal Protective Equipment. As I mentioned last week, we are meeting with success in getting more of it. It is a 24/7 relentless effort. Some of what we are getting in will look unfamiliar to you because we are sourcing from multiple manufacturers. In order to make sure that what we put in the field is safe, we need to send it for testing at certified laboratories. Just yesterday, one of your colleagues dropped everything he was doing to drive out to the laboratory in Ohio in order to bring samples of the recent mask arrivals there for expedited testing. He didn’t want to risk late arrival by the mail system or the possibility of a lost package. Behind the scenes there are so many similar stories of people going above and beyond to support our front-line teams. It is important that you know that.

And on those front-lines, the work has only been getting harder. My heart breaks for everyone struggling to keep up with the volume of critically ill, and near-critically ill patients. This week you will see others joining the fight. We are meeting with success in sourcing additional clinical and support staff and will be deploying them where needed most. I hope you will welcome your new colleagues as members of our family and let them take as much of the burden as they can.

As of yesterday afternoon, we had 1,249 COVID-19 positive patients in our hospitals. That included 233 patients in our ICUs. We had another 135 inpatients under investigation (PUIs).

Last week, we mentioned a treatment that we are spearheading—called human convalescent plasma—and we told you about the extraordinary response when hundreds of you stepped forward to help. As you know, the cutting-edge approach transfuses antibodies from those who were previously infected to those COVID-19 patients who are sick. You can read more about Mount Sinai’s leading role in this here.

Keeping Your Loved Ones Safe
If you have questions about how to protect your families from COVID-19, and what proper practices to employ when you return home after treating patients, we have a new resource, which can be found here.

Information About New Ventilators
We continue to make progress in securing the tools we need to win the fight against COVID-19, including many new respiratory devices and ventilators. They won’t all look familiar so, in addition to training and orientation to the new devices, we have posted a reference sheet and an education packet on our resources site here, under the “Information about Ventilators” tab.

Statewide “PAUSE”
With the pandemic continuing to escalate, Governor Cuomo announced this weekend that the statewide “PAUSE” currently in place, which directs all nonessential workers to work from home, will be extended to April 15.

Your Commute
The MTA has implemented the “NY Essential Service Plan” so that essential personnel like you have the transportation you need at critical times. But changes in public ridership may trigger the MTA to reduce schedules on some subway, bus, and rail service. Please be aware that the MTA may make continuous adjustments to its service, and any service reductions could potentially affect and lengthen your commute. If you need more information, please click here.

Final Thought
I have been receiving a lot of inspiring emails from members of our Mount Sinai family. This one arrived yesterday from Joseph Uhl, who normally works in our planning and development office but has been deployed to an engineering role at one of our hospitals to help in this fight.


Dr. Vine’s Second Installment

For our “Disaster Protocol,” the Chairman of Surgery has set up approximately 30 “teams” of providers (I hate that word), comprised of two surgeons, one senior/chief resident, one nurse practitioner/PA, and two medical assistants to be deployed at hospitals/ICUs in our Sinai system that are in need or understaffed. While my primary workplace is Mount Sinai proper (upper east side, main facility), I have been assigned to Mount Sinai of Brooklyn as “team 6.”  The first two teams are already there working alternating 12 hour shifts 3 days a week, and as they get tired and the place gets overwhelmed, we will come in.

Interestingly, I called the Navy recruiter in NYC to see if they needed any very experienced civilian Surgeons, but she said no, and only suggested I sign up for the reserves, if I so desired.

All of our senior surgical residents are excellent, and I have one of the best, most skillful and organized ones, Dr. Chris LaChapelle. When we get notified, he is the one who will receive the call and will be in charge of notifying the team and the possessor of a duffle bag of our own PPE, if the hospital is in short supply.

All of the surgical attendings have been required to do refresher ICU and ventilator courses with the depts of Anesthesia and Critical Care.

I am rereading my ACLS protocols.

Of note, I also am on the Mount Sinai Ethics Committee for the whole hospital, so we may very well be called as consultants for those horrible situations that we hope will never occur:  the allocation of scarce resources, ventilators, life and death.

I will keep you posted.

Daily Memo

TO: All Faculty, Staff, and Trainees
FROM: Vicki R. LoPachin, MD, MBA
Senior Vice President
Chief Medical Officer
Mount Sinai Health System

DATE: March 31, 2020
RE: COVID-19 Health System Updates, March 31

Every day presents new challenges in our fight against COVID-19, and I know that each day feels harder than the last. But as our fight intensifies, I am deeply heartened by how all of us are coming together to tackle this crisis head on.

As of yesterday afternoon we had 1,360 COVID-19-positive patients in our hospitals. That included 248 patients in our ICUs. We had another 112 inpatients under investigation (PUIs).

We are currently at 67 percent ventilator utilization and more vents are on the way. The Governor has requested that all hospitals become familiar with protocols for using one vent on two patients at a time should the supply not prove adequate for the need. This is something we would normally never attempt. But these extraordinary times might require it. So, we are developing that capability.

Our biggest collective challenge so far is having enough clinical staffing to meet the growing need. This work is physically and emotionally exhausting—and all the more so as staff-to-patient ratios get stretched to accommodate the growing volumes. We need to do better and are working every angle. In a positive development, Governor Cuomo announced yesterday that staff from upstate hospitals would be coming to our region to join in the fight with us. We are very grateful to the Governor and the Mayor, and to everyone who comes to fight by our side. We are also sourcing extra staff from many other places as well. We welcome them all with open arms. Likewise, many of you are floating from your regular Mount Sinai hospitals to other ones within our system to provide much-needed help. This is never easy, and we are beyond grateful to you.

Also, yesterday, the USNS Comfort—a Navy hospital ship with 1,000 beds and 12 operating rooms—arrived in New York harbor. It could be ready to serve patients as soon as today. These extra beds will help free up space for the battle ahead.

As of this past weekend, our convalescent plasma transfusions have begun. One patient was treated on Saturday and two were treated on Sunday. There is more information about Mount Sinai’s work in this New York Times article.

Some more good news: So far, a total of 4,204 COVID-19 patients have been successfully treated and subsequently discharged from New York State hospitals. Many lives are indeed being saved.

If you have any questions, ideas, or concerns, you can always email CovidQuestions@mountsinai.org and we will be sure to follow up. And the COVID-19 employee resource website is constantly being updated with new information.

Your heroic efforts in this humanitarian mission of our lifetime are making all the difference. This is what I find myself reflecting on when I take my Mount Sinai minute at 12 pm each day. I have never been prouder to be your colleague or to wear the Mount Sinai badge.