COVID-19 Update from Dr. Smith: 4/6/20

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,

Dams are thickest at the bottom.  Thickness combats the point of greatest pressure, described quantitatively as p=ρgh (pressure = fluid density x force of gravity x height of the dam).  It is popular to conceptualize our enterprise as a pyramid.  NYP/CU leadership is perched at the top, with doctors just below, then residents and fellows, then advanced-practice extenders, and so on.  A pyramidal gradient represents the numbers of people at each level reasonably well.  With greatest mass at the bottom, a pyramid would make a good dam, allowing for odd angles.  However, some implications of this thought experiment are costing me sleep.  At the base of our pyramid, hands-on bedside nursing is possibly the most critical mortar we have.  In my entire career, I can’t recall a time when ICU nurses were bountiful.  Imagine the impact of tripling ICU capacity.  I worry that nursing is the vulnerability that could break our dam.  Not for lack of effort, commitment, or professionalism, just lack of people.  Lack of thickness where it counts most.  In my personal month or so of cumulative experiences as an inpatient it was nurses who took care of me.  In total, I saw my various MDs for an hour or two.  Those of us in the layers above nursing have much more elasticity.  We have that luxury...p=ρgh.

We may yet avoid our own Johnstown, if recent data is a real harbinger of change.  ER visits per 100,000 population in NYC have tipped negative beginning about 4/1/20 (Department of Health data).  NYP and CU daily case data show a consistent decrease in calculated slope since 4/2/20.  In other words, the rate of change in slope is tipping negative, although the slope itself is still positive.  Taken together, this suggests we are approaching peak.  Meanwhile, PPE is definitely more plentiful, so it will be easier to protect our employees who might be redeployed to front line support roles, such as patient transport.  Testing availability has increased enough that NYP can implement PCR testing for antigen in all symptomatic health care workers.  Limited serologic testing for antibody has begun.  Our redeployed Surgery faculty and extenders are playing critical roles in all of the expanded ICUs, along with colleagues from Anesthesiology and Medicine.  Department of Surgery SWAT team members are the ones who go into each newly-admitted patient’s room to start lines and place tubes; few roles are more front-line than that.

Today I received this email from a breast surgeon just finishing an overnight shift in one of our new ICUs:  "This experience will make us better.  We are learning the names of colleagues we never knew, we are witnessing bravery, within ourselves and others, we didn’t know existed.  We are a more human humanity.”

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

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