Transcription:
COVID in New York City

Welcome to the Peds Ethics podcast, where we talk to leaders in pediatric bioethics about a hot topic or a current controversy. Here’s your host, John Lantos from the Children’s Mercy Bioethics Center in Kansas City.

John Lantos, MD (Host):  Hi this is John Lantos from the Children’s Mercy Hospital Bioethics Center in Kansas City.  Welcome back to the Pediatric Ethics Podcast. We’ve been focusing a lot on the ethical issues surrounding the Coronavirus pandemic. And we’re thrilled to have with us today, Dr. George Hardart. He’s an Associate Professor of Pediatrics and Bioethics at Columbia University Medical Center in New York City the epicenter of this pandemic in the United States and perhaps now in the world. Dr. Hardart is Board Certified in Pediatrics, Pediatric Critical Care and Anesthesia and is an Attending Physician in the Pediatric Cardiac Intensive Care Unit at the Morgan Stanley Children’s Hospital there at Columbia. He’s also Chair or past Chair of the Pediatric Ethics Committee and served on the Pediatric Ventilator Allocation Working Group of the New York State Task Force for Life and the Law. Thanks so much for joining us today Dr. Hardart.

George Hardart, MD (Guest):  My pleasure to be here.

Host:  Yeah, can you tell us a little bit about what the last month has been like there in New York City?

Dr. Hardart:  It’s been obviously pretty extraordinary and it really, it’s – I know for many people, that if we are coming out of the woods, but we’re still very much in the middle of the woods. So, this is in essence a midstream debrief and discussion of it all. To give you my context at Columbia Medical Center, is part of New York Presbyterian Hospital which is the largest healthcare system in New York. It is eight large hospitals, the two largest being Columbia University Medical Center and Weill Cornell Medical Center. So, an enormous hospital system and we are the largest children’s hospital within that. And that’s the context for the experience we have had and it really began in New York in mid-March of course and the – we had our first COVID positive pediatric patient on March 13^th and really our experience has been similar in the children’s hospital similar to the experience around the world which is very thankfully, it’s not a pediatric disease.

Host:  how many kids have you had admitted more or less?

Dr. Hardart:  Yeah, we’ve had, I’m not really keeping a formal tally. Currently, today’s snapshot in our unit we have probably four or five minor patients that have COVID. And that’s about the highest it’s been. It hasn’t been more than five or six minor patients during that span. And I would say, since the – since around March 20^th, it’s been around that kind of census. And you have to put that in context with the adult experience is extraordinary. New York Presbyterian expanded from about 300-350 ICU beds to 750, more than doubling of ICU beds. And those are all full of adults with COVID. So, 700 – 750 patients at a time and five ICU patients- five minor patients with COVID. That’s the experience and fortunately for us, the outcome for these minor patients with it has been quite good. So, as part of the context for us with children’s Hospital is that very, very thankfully, children themselves have been really largely spared.

Host:  So, are you taking adults in the PICU?

Dr. Hardart:  Absolutely. It’s an interesting part of our story. I would say New York Presbyterian Hospital, the leadership has been – has handled things really, really wonderfully. It’s been inspiring to see how they’ve done it. One of the major steps they took in the – in the second have of March is to close down all of Cornell Pediatrics, Weill Cornell Pediatrics closed. And they turned those beds and that pediatric ICU into adult beds. That part being managed at least in part by my brethren down at New York Hospital are taking care of adult patients in the Pediatric ICU. So, we absorbed all of the children from the New York Presbyterian System and expanded our pediatric ICU accordingly and we didn’t know how much of our capacity was going to be needed for minors during that period. But it became very clear as the month came to a close, March came to a close, that we were going to have substantial ability to admit adults and that is how it has played out. In April, our pediatric ICU which expanded from 42 to 54 beds, as we’ve probably averaged and averaged approximately anywhere from 14 to 22 adults in our unit at any point in time.

Which has been obviously very, very different than our normal function.

Host:  One of the discussions that’s been taking place among bioethicists has to do with scope of practice and whether pediatricians have the skills to take care of adults. Has that been an issue that has come up there?

Dr. Hardart:  It has only in so far as controlling limits and as to how old and how complicated the adults we would take would be. We didn’t have a plan as we began this. It’s been an evolving process. And I think it’s fairly natural that it happened that way. When we first we started to take people in their 20s. Then we started to take people in their 30s. Now, we’re taking people up to 52 years old is our oldest. And it’s an interesting experience as a pediatric intensivist we take care of people up to 18 years of age of course as a routine matter. And physiologically, if you consider an 18 year old and somebody until they start to gather adult morbidities; they are fairly similar human beings to take care of. And it’s played out that way. We have tried to avoid people with very specific to adult and elderly individuals, coronary artery disease for example. We haven’t taken anybody with coronary artery disease. We have taken plenty of people with hypertension, type 2 diabetes, obesity, chronic renal disease.

Host:  Things that you are more familiar with from the adolescent population.

Dr. Hardart:  Correct. Correct. So I think as you know John, I mean the idea as you surge and come up with contingency capacity the first hope is that you can maintain a good standard of care in delivering what you want and I feel that we have been very able to do that and it’s borne out by the fact that our staff has been very, very comfortable and again, another inspiring part of this is how our – take away our nursing staff but all of our staff, respiratory therapists, you name it down the line have unflinchingly taken on taking care in for adults in these very try circumstances and not hesitated, not really been feeling as if they are providing inadequate care at all and our outcomes have been outstanding. I think it reflects that we have – that we’re confident at taking care of these individuals. It also reflects the fact that younger adults are going to tend to do better anyway.

So, I’m not at all saying that we are doing better than our adult colleagues in our adult hospital. They are giving us their best patients.

Host:  Have you been surprised by any particular ethical issues that have arisen through this saga?

Dr. Hardart:  I think so. From an ethical standpoint, as you mentioned, I was part of the New York State working group that created our guidelines for ventilator allocation. This of course was borne out of the H1N1 influenza epidemic in 2009 and whenever you make a plan, for a disaster, you are always planning for the last disaster not the next disaster. I can tell you that the Dwight Eisenhower quote about planning is essential, but plans are useless applies to this as it typically does. The plans that we crafted in 2015, were to allocate ventilators because we figured that would be the shortage for the next viral pandemic. And the interesting ethical part of it John the surprising ethical aspect is that as the surge capacity expanded and we’ve all seen it play out in the media how the – eventually the federal government and the state government and a giant hospital system like ours have expanded capacity and tried to optimally use all resources. We haven’t gotten to that crisis of having literally too few ventilators and literally had to make the choice between this patient or that patient who would get it.

It has been a not an absolute shortage of resources. It’s been much more of a relative shortage of resources. And this is – I am part of the broader hospital – the adult hospital view of this. The interesting part of it is without that absolute shortage of ventilators, it’s been such a challenge to define are we in a crisis condition where we are providing inadequate – a lower standard of care which kind of defines crisis conditions as we stretch our nursing resources from two to one nursing care to three to one nurse to patient ratios to four to one. What is that doing to the quality of care. We’re not absolutely short on nurses but we are stretching them thinner and thinner. And that has been an interesting aspect of this. We didn’t at all plan for those relative shortages.

Host:  Is that partly because nurses are getting sick and getting infected or just because of an absolute scarcity?

Dr. Hardart:  It is both. I don’t have the numbers of what fraction of the nursing workforce has had to take time off for illness. But we have quite literally more than doubled the ICU capacity of our hospital. And so, I think that has been at least half of the issue. Has just been an absolute need for more ICU nurses and many other nurses have stepped up and tried to fill the gap.

Host:  So, nurses without specific ICU training have been covering shifts there?

Dr. Hardart:  I don’t want to speak for – I’m not there. I know they are surging to draw physicians and other healthcare staff into positions that they have not done before. What percentage, what percentage aren’t ICU trained, I don’t know. They have tried to at many other institutions like I believe Cleveland Clinic famously has offered to send a substantial cadre of ICU nurses to fill the gap, so they have tried to again, according to the good professional and ethical approach to this, to optimally utilize all resources and draw excess from outside. They’ve done that here. I don’t know how much they’ve been able to fill. But I do know there are nursing ratios which as you know John, should be in an ideal world, no more than one nurse to one patient or one nurse to two patients. That’s the standard for an ICU. But it’s been one nurse for three and four patients which is outside the standard of care. Is it functionally equivalent or does it fall below the standard of care? That’s the ethical surprise for me. That we’ve had to confront that.

And another very important similar situation is with dialysis. That has come up more in the last week or two. And what we’ve attempted to do to avoid needing to chose which patient gets dialysis is what our teams have done is to use one dialysis machine – normally in the ICU, that’s given continuously 24 hours a day. But what they’ve done is use it – one machine on one patient for 12 hours, take it off that patient and give it to another patient for 12 hours. So, it’s not ideal but it’s enabled them to avoid that absolute shortage situation.

Host:  It’s interesting that most of the plans that people worked so hard on for allocating scarce resources during a crisis did not seem to anticipate bending the rules in these ways. More attention was given to discreet things like a ventilator where one patient would get it and the other one wouldn’t. But this is more a gray zone.

Dr. Hardart:  It is. I have called it a gray zone. I have used the analogy of bending and not breaking. I’ve more used it this quasi crisis condition situation that we’ve been in. And it is ethically and professionally important because as the Institute of Medicine laid it out around the time of H1N1, it’s a very critical step for a state to declare a crisis standard of care. That unlocks a whole institutional, legal, a set of standards for allocating resources that doesn’t exist under conventional circumstances. And so if you’re in this quasi crisis state, this gray zone state, what is the trigger to declare those crisis conditions? If you go from three to one nursing to four to one nursing; should the state declare a crisis condition? Because outcomes are falling. How do you just make that decision?

Host:  The doctors must also be carrying a bigger case load?

Dr. Hardart:  Again, I have nothing but the greatest respect for as the way New York Presbyterian has handled this and the staff in the adult hospital has been remarkable. And the way they’ve done it, and I think they’ve done as good a job as humanly possible is one intensivist is more like a super intensivist now. So, if the normal is to have maybe twelve patients or 14 patients they now are covering more like 40 patients, but they have below them, other very experienced physicians that aren’t ICU physicians but are very experienced good physicians who are their extenders. They may be managing a subset of patients and they are getting important oversight from the intensive care physician. And frankly John, that’s similar to the way we’re doing it with our adult patients in our children’s hospital where every day, we have a consult from the adult medical intensivist so every day, we have discussion with them because they’re adults and we want to optimize their care and our adult intensivists have been just wonderful colleagues in helping us to deliver the goods. And I think in a much more active way, they’re doing that for their own patients to supply all their critical care needs.

Host:  It’s also been true that the ventilator management of COVID patients has been unusual I guess or not typical of other patients with respiratory failure. Have you had surprises in that regard where people are sort of figuring out how to do this as they go along?

Dr. Hardart:  It is – I can tell you, I’ll just tell you from our experience in the Children’s Hospital taking care of children and people in their 20s and 30s and 40s, as I mentioned, we’ve had very good outcomes and in large measure, they have behaved as is often the case for ARDS, acute respiratory distress syndrome, ARDS patients. I’ve said it time and time again, they seem to have read the book on how an ARDS patient should act and react to the treatment we give them. You’re correct John though that the – a lot of what’s in the media and in the medical literature is that they are importantly different in some ways. And I don’t know if that’s possibly more relevant for the older population. It is somewhat – it gets a little medical here, but they are I think- well they are seeing a tremendous inflammatory condition in these patients. And that could be part of the reason that they are needing more blood pressure support medications, but it could also be that their lung disease is different in certain ways. The lungs remain more compliant and therefore there is more blood pressure impact on the ventilator support we give.

But in our pediatric experience, in our young adult experience, they responded beautifully to traditional ARDS management.

Host:  Okay, that’s good. Has there been a city wide coordination of the bioethicists in response to this?

Dr. Hardart:  There has been a coordination. There’s been beautiful coordination I would say within our very large eight hospital organization. It’s a nice feature of this sometimes unwieldy large super hospital is that the command and control structure for a crisis like this was just readily in place. So we could optimize the use of this large system. That has worked beautifully. The structure for city and state coordination, it hasn’t been with coordination among bioethicists. The way it has played out is that our bioethicists within the New York Presbyterian system have been in very close communication daily and with senior leadership of the hospital on the administrative side. And that structure leads to direct communication with both city leadership and state leadership. And so it isn’t the sort of thing where bioethicists are meeting together and communicating directly to the city and state leadership. It is occurring more through hospital leadership. But I believe it’s been very effective.

Host:  A lot of people talk about the issues of keeping families away from critically ill or dying patients. Have there been controversies or problems about that?

Dr. Hardart:  I can tell you that that idea of not having visitors present for adult patients has been one, very, very striking and heart wrenching experience for the healthcare providers. And obviously for the patients and families themselves. It’s seen as a public health necessity and so therefore as heart wrenching as it is; what people have just tempted to do is make the best of the situation and use a lot of technology to try to use Facetime and such to let family members get a sense of what their loved ones are experiencing. For many of these patients, when they are in the ICUs, they are very deeply sedated so the stress and the sadness is very often on the part of the family member who wants to be with their loved one and experience it with them and help and that’s been very hard for everyone involved. Also family members play a – ICU doctors know this, play a very important role at the bedside as well. They function as an often as a nurse extender. And their lack of presence there probably does put more stress on the nursing staff and the physician staff as well.

Host:  Yeah, they help a lot with quality.

Dr. Hardart:  Yeah, they do. They do. For pediatric for minors, the standard has still been to allow one family member to stay with the child. So, that is a difference in that we do limit it to only one. But that is obviously a world better than no presence at all.

Host:  And the hospital must be all COVID, all the time. What’s happening to people with other health problems?

Dr. Hardart:  It is exactly true John that it is that all COVID, all the time. As I mentioned, our Children’s Hospital, is now functioning basically as two Children’s Hospitals since the large excellent Weill Cornell Pediatric Program is closed for the moment and yet the volume, we’ve seen in our ICU has been so surprisingly low. I think what people have referred to is there are clearly fewer injuries occurring and probably because of social distancing there are fewer other communicable viral illnesses occurring. And that often whether you have lung disease or heart disease, or you name it, it is a interceding viral illness that can lead to a cardiac patient needing to be hospitalized. So, for a myriad of reasons, it is very interesting and lucky and helpful that the other diseases have lead to fewer hospitalizations.

Host:  Probably lower pollution levels lead to less asthma as well.

Dr. Hardart:  Probably is true absolutely.

Host:  Well we need to wrap up. Any final comments on lessons learned? You started by saying we’re always planning for the last pandemic. Anything we can take forward from this one that might help with the next one?

Dr. Hardart:  We’re working on that now. We will be ready for the next COVID-19 outbreak. I will tell you that.

Host:  I notice that after H1N1, it only took about six years to develop the guidelines for allocating ventilators.

Dr. Hardart:  Absolutely. And New York was at least not behind the curve on that. Some hospitals just devised theirs during the current crisis. One thing that was interesting. I don’t want to draw things out, but it was very interesting that in planning for a ventilator shortage, even in our hospital system, we started taking the proper steps which is to form triage committees. We came up with a different name for it. But we started to form triage committees if we had to make those difficult decisions, we needed to have those teams in place. The idea for those unfamiliar with it is you don’t want bedside doctors to have to decide to take the ventilator away from the patient they’ve been caring for. Instead it’s moved one level away, one higher level away to a triage committee that has the broader picture in mind and doesn’t have responsibility for that individual patient.

So, our hospital went through the steps of forming the committees, but they didn’t include any triage committees for the pediatric patients. Which is an oversight. Because if allocation decisions were going to be made, according to the New York State guidelines, children are part of those allocation decisions. A minor with a poor outcome, poor prognosis is at risk for having their ventilator taken from them. And it was an interesting part of this that because the focus was so much on adults that they formed triage committees for the adult hospital but not for the pediatric hospital. So, that is one of the few things I think that going forward, we will have learned is that we need to have really a 360 view of incorporating the patients with the targeted disease whether it’s COVID or the next thing with and without the targeted disease and across all age groups to do the work of fairly allocating the resources.

Host:  Yeah, I know there’s been some discussion even of taking vents out of neonatal intensive care units if they’re needed. So, I think set some guidelines are going to address that.

Dr. Hardart:  Yeah and New York State did come up with – New York State did a quite good job of preparing for the last pandemic. Because we have specific neonatal guidelines and specific pediatric guidelines. But then within having those different guidelines, everybody’s at risk if they can’t benefit the most from the intervention whether it’s a ventilator or other to give it to someone else.

Host:  Well George, thanks so much for taking the time. It sounds like your life is crazy. We’ve been talking here to George Hardart, Associate Professor of Pediatrics and Bioethics at Columbia University Medical Center, former Chair of their Pediatric Ethics Committee and a Member of the New York State Task Force of Life and the Laws Pediatric Ventilator Allocation Working Group. I’m John Lantos from the Children’s Mercy Bioethics Center in Kansas City. Thanks again George for doing this.

Dr. Hardart:  Always a pleasure John. Thank you.