COVID-19 Update from Dr. Smith: 3/26/20

Each day during the COVID-19 crisis, Dr. Craig Smith, Chair of the Department of Surgery, sends an update to faculty and staff about pandemic response and priorities. Stay up to date with us.

Dear Colleagues,

I can begin today with a sunny ray of optimism regarding our PPE supply. It was just announced by NYP that a surgical mask should be worn in all hospital and clinical areas by anyone working in proximity to other people. The mask is not necessary when alone in an office, or in other non-clinical settings. Even more noteworthy, each “direct care giver” will receive one N95 mask, although use of the N95 is still officially restricted to aerosol-generating procedures. N95s should be covered with a face shield or a surgical mask to prolong their functional lifespans. Resterilization should be available very soon. Importantly, “direct care” giving is not the exclusive province of nurses or physicians. For example, housekeepers working in clinical areas are providing direct care; housekeepers in office areas are usually not. Setting aside Talmudic details of each use-case, this is an important step towards broader use of all masks, and is a signal that supplies are expected to increase soon.

Testing policies also show tentative signs of relaxation. Testing is still not approved for asymptomatic or mildly symptomatic patients, but for mildly symptomatic patients testing might be approved when the result would “make a difference.” That can mean minimizing risk of spread to vulnerable persons (elderly, immunocompromised). It can mean clarifying risks surrounding planned procedures (radiation, chemotherapy, perhaps surgery). The new NYP policy in obstetrics to test all women admitted to labor & delivery falls in the latter category. As with PPE, setting aside the minutia, this is a positive sign. Widespread testing will be an unalloyed good.

Stepping out of the sunshine and back into the cave, I must report that the number of patients on ventilators at CUIMC more than doubled in the past 3 days, a pace that exceeds the overall increase in new cases. We have not exhausted our existing supply of ventilators, but if we keep doubling every three days, we might. This development has placed sudden pressure on ICU capacity. ORs have already been converted to ICUs, and an entire 36-bed floor (7GN) is now fully renovated for conversion to ICU space. Consequently, a call went out yesterday for MD volunteers to staff ICUs. Within a few hours 20 surgeons had volunteered. Once again, the selflessness demonstrated by everyone in the Surgery family inspires me.

On the front page of the NY Times yesterday is a story that deeply distresses me. Across the US pharmacists are pushing back against physicians who are prescribing large amounts of hydroxychloroquine, chloroquine, and azithromycin (HC&A) for themselves and their families—with refills. Doesn’t that make you proud? One of the few positive things we can say about this pandemic is that it gives us a precious opportunity to carry out proper double-blind, randomized controlled trials of therapeutics like HC&A. Because the numbers are so large, and growing so rapidly, such a trial could be carried out very fast. Enrolling large numbers quickly also allows us to rely on meaningful hard end-points, which avoids bundling a bunch of soft end-points into a composite, solely for the purpose of dredging statistical power out of smaller (and cheaper) trials. The hysteria surrounding HC&A is almost entirely anecdotal, propped up by a handful of tiny, unconvincing trials. Ask yourself this: if 98% of patients survive, and many have relatively minor illness that resolves in a week or two, what value is an anecdote in which patient X starts taking HC&A after a few days (when he’s feeling really lousy), then (lo and behold) he improves? Sacre bleu! And now the MDs featured in the New York Times are fanning the flames, nudging us along from ignorance to superstition. Almost 100 years ago (1928) Bertrand Russell said “What is wanted is not the will to believe, but the will to find out, which is the exact opposite.” Our profession’s response to this crisis has been extraordinarily uplifting and reinforcing—I hope we do the right thing here.

Craig R. Smith, MD
Chair, Department of Surgery
Surgeon-in-Chief, NYP/CUIMC


Subscribe to Healthpoints and never miss an update.