By Dr. Omesh Toolsie
Clinical training in America’s most populous city is known for being vigorous. If you’ve done any residency or fellowship training in New York City, you know that there is little downtime—chances are you’re busy year-round! The patient population here is perhaps the most diverse in the world and that fact is reflected in the rich clinical exposure; training in NYC is a qualification in itself. My wife and I, both physicians, moved from Trinidad and Tobago in June 2014 to pursue residency training in internal medicine at the BronxCare Health System. After completing residency, I completed a fellowship in pulmonary diseases at the same institution before moving to Montefiore Medical Center for training in critical care medicine. After almost six years in NYC, I found myself feeling comfortable managing very sick patients in almost any clinical context, but I was soon to be put out of my comfort zone.
I had mixed reactions to the first reports of a rapidly progressive respiratory illness coming from China. Was it really that serious? Is it just the flu? Was it ever going to arrive in the U.S.? As the reports of deaths kept coming and the highly infectious nature of this novel virus became apparent, we all knew it was just a matter of time. But even when that realization became apparent, no one had any idea what we were in for and the all-encompassing toll it would have on healthcare systems in NYC.
Critical care training at Montefiore is robust. Fellows rotate through every subspecialty ICU and play an essential role in critical care consult services, which operate in three campuses and respond to all rapid response and cardiac arrest codes, in addition to screening all critical care consults for ICU admission. We are a full-service team, responsible not just for evaluating and assisting in the management of every patient we are called to see, but also to perform all necessary procedures where indicated. This can include intubations, central lines, chest tubes and focused ultrasound examinations, among others. We were well trained and ready, and felt like front-line soldiers going into battle. It was exhilarating and bone-chilling all at the same time. At first, we got sporadic consults and a few patients of interest in our ICUs that we suspected of being infected with the coronavirus disease 2019 (COVID-19), who all tested negative. But as we approached late-March things changed dramatically.
COVID-19 engulfed the NYC healthcare system. The emergency department became filled with patients complaining of cough, fever and shortness of breath, many of whom were testing positive for COVID-19 and with varying degrees of respiratory distress. Consults were pouring in from previously admitted patients on the floors, who while stable on presentation were quickly deteriorating, requiring escalation in their ventilatory support and clearly requiring admission into a medical ICU. We quickly became overwhelmed.
Apart from the clinical experience gained from this ordeal, I had the opportunity to see what authentic leadership looked like. Our chair mobilized resources very quickly and she sought input from everyone, including the fellows. I genuinely felt valued and part of a team. We were given the resources we needed: masks, goggles, gowns and even new portable video laryngoscopes—we kept that consult bag fully stocked. The hospital created new surge ICUs within days and a command center was set up within two weeks. It was fully staffed by an intensivist 24/7 who filtered questions, consults and concerns from services across the Montefiore system. It was truly a remarkable feat. We went into battle every day and night, with the support of our division behind us.
At the peak of the pandemic, there was not a moment to rest. Rapid responses and cardiac arrest codes were being called one after the other, in what felt like an avalanche. Even with two teams, we were stretched. At the peak, I intubated 13 patients in a single shift, and many of my colleagues had similar or even higher numbers. The helplessness I felt was especially heartbreaking. As critical care fellows, we are trained to create control in the most chaotic situations, to rapidly assess a clinical scenario and find clinical solutions. This was a new, rapidly progressing respiratory illness with only few associations and trends noted at that time. We did not fully know what we were dealing with and people were still dying, both young and old, despite us doing everything we knew to do. The psychological implications of this cannot be overstated—it was traumatic, and the trauma was repetitive. What kept us sane was the teamwork, and the support we found in our attendings who worked the trenches with us. A daily email with “happy” news was started, updated from across the critical care division. We celebrated each other’s successes: the extubations, the ICU transfer outs, and the patients who made it despite prolonged hospitalizations. We were all in the darkness but shared the light.
I would eventually have a very personal encounter with COVID-19. As I woke up one morning to go to work in early April, I felt very fatigued, cold and had a dry cough. I tried not to panic, but knew that this was very likely COVID-19 infection. At that time my wife was working in Connecticut. I called and asked her to stay there with our 16-month-old son and my father-in-law, and not return to NYC. I couldn’t risk spreading any potential infections to them. I contacted my program director immediately who arranged for me to get tested. Unsurprisingly, I tested positive. I was home for the next 14 days, with fever for the first 10. I forced myself to stay hydrated and to eat and still lost 10 pounds during this time. Despite this however, I felt ok, I never developed shortness of breath or any other respiratory complaints apart from a dry cough. I thank God that I pulled through as I had seen many young people, without medical problems like myself, who had different outcomes.
As I recovered and went back out to work, I noticed the pace on the consult services slowed down, but every ICU (medical and subspecialty) was now a COVID unit. We took on a leadership role—rounding the COVID units with the house staff, PAs, nurses, and respiratory therapists—and made recommendations on proning, sedation, need for paralytics, ventilator adjustments and weaning parameters, just to name a few. Families were contacted and updated daily and with video where possible. This became an essential part of our day as many relatives had no access to see their loved ones. We were aggressive and unremitting in our approach and made a difference in the lives of many.
I consider it an honor to have served as a critical care fellow in NYC alongside some of the best people I have ever worked with. I am a stronger intensivist and a better human being for my experience at Montefiore, one that I will never forget. What this ordeal has taught me is that strong and effective leadership, with genuine teamwork, can whether any storm. Six years ago, when I left Trinidad and Tobago, I could never have anticipated where I would be in the spring of 2020. But I dare say that despite everything, I was exactly where I was meant to be.