What Doctors on the Front Lines Wish They’d Known a Month Ago

Ironclad emergency medical practices — about when to use ventilators, for example — have dissolved almost overnight.



‘What Disease Are We Treating?’: Why Coronavirus Is Stumping Many Doctors

Doctors say the coronavirus is challenging core tenets of medicine, leading some to abandon long-established ventilator protocols for certain patients. But other doctors warn this could be dangerous.

“This disease has challenged everything that we believed was right six weeks ago.” “It’s different than anything we’ve seen before, and maybe the way we’ve taken care of things is not the right way of doing it.” “There is a lively and healthy debate, that I think is a good debate, about what the right thing to do here is.” “I’m concerned that if we continue on the path that we’re on, that hundreds of thousands of lives and lungs may be at risk.” “It’s actually kind of vital that we not deviate from those treatment protocols because we know that they reduce mortality.” “Low oxygen levels.” “They will tire out within a few hours. So what’s your next step?” “Before Covid-19, I would recommend putting you on a breathing machine.” “I would have rushed to intubate.” “Because that was probably the right thing to do.” “I know when to put in a breathing tube. I’ve worked long enough, and I’ve worked enough places with enough people. But in this disease, it is extremely confusing, you know, it just doesn’t make sense. Listen, I stocked up for the apocalypse, like most people. Now, I just can’t believe that I ever thought that I’d somehow be home to make all my frozen food. On a normal day in an I.C.U., you have very sick patients. Patients will — are dying, but this is just different. It’s just — you have a disease we don’t understand that is very deadly with patients that are scared and staff that are scared, and on top of that, it does not appear that we have a good treatment strategy other than a ventilator. And we don’t — we’re not sure when to put a breathing tube in. The crux of it is, we don’t want to put a breathing tube into someone who doesn’t need it knowing that there’s a 70 percent chance they’ll die, and then we don’t want to not put it into someone who would need it too late. When you go to the E.R., and there’s like 40 people that need oxygen, and they all look terrible, but they can all talk to you.” “And no apparent distress whatsoever.” “And then you get them on a monitor, and you look up, and you see this oxygen saturation of 45 percent or 50 percent.” “And telling myself this is impossible. This is not possible. How can this be?” “It’s just not compatible with life to have an oxygen saturation that low.” “You know, this is strange. It’s out of a horror movie.” “I’ve been unable to sleep because I’m trying to wrap my head around it. This goes against anything I’ve ever believed.” “The paradigm of ARDS is not matching with the patients that I’m seeing, so it’s like trying to fit a square peg into a round hole.” “The core of the core of the core — it is just, what disease are we treating? And are we treating something that is naturally ARDS, or are we not?” “We protect the lung against what we do to the lung. Protect it from what? From what we do in mechanical ventilation.” “So what he is saying is that we just have to be gentle. People will need a ventilator, and those that do need as high oxygen as possible, as little pressure as possible, in order to buy time until this demon virus stops.” “These patients have ARDS. I think the editorial has both been misinterpreted, and I think people have misunderstood that it’s just that. It’s an editorial. It’s not a study and it’s not a trial. I don’t doubt that people have seen some cases with some terrifyingly low oxygen numbers. On average, they’re as sick as prior cohorts with ARDS.” “I just think it’s important to say that it’s not a settled question. Every hospital in the world is probably solving its problems slightly differently.” “We’re using an early intubation strategy here, and of our first 66 patients, already a third of them have been extubated. I’m arguing for evidence-based medicine, which is something that we all purported to agree with before this outbreak hit. We have large, randomized, controlled trials. The patients in those trials had met the same diagnostic criteria that our current patients meet. We should apply the results of the trials.” “Today, we do not rush to intubate. Intubate shouldn’t — has become the last resort, and the protocol once they’re intubated has changed drastically.” “So within the last two weeks, I mean, what has been unacceptable has become very acceptable. Some of these patients don’t need to be intubated. You watch them carefully. You make sure their oxygenation is adequate, and they can recover.” “I am not saying we don’t need ventilators, but perhaps we need to think about how we’re using them. Somebody, and preferably people that are not taking care of patients every day, needs to look at the disease and figure out how we can treat it better.” “The truth will come out eventually. In the meantime, the question is: What do we do until that happens? And yes, I’m nervous. I’m scared everyday when I go into work, but I’m just trying to do the best I can.”

Doctors say the coronavirus is challenging core tenets of medicine, leading some to abandon long-established ventilator protocols for certain patients. But other doctors warn this could be dangerous.CreditCredit…The New York Times

Just about a month ago, people stricken with the new coronavirus started to arrive in unending ranks at hospitals in the New York metropolitan area, forming the white-hot center of the pandemic in the United States.

Now, doctors in the region have started sharing on medical grapevines what it has been like to re-engineer, on the fly, their health care systems, their practice of medicine, their personal lives.

Doctors, if you could go back in time, what would you tell yourselves in early March?

“What we thought we knew, we don’t know,” said Dr. Nile Cemalovic, an intensive care physician at Lincoln Medical Center in the Bronx.

Medicine routinely remakes itself, generation by generation. For the disease that drives this pandemic, certain ironclad emergency medical practices have dissolved almost overnight.

The biggest change: Instead of quickly sedating people who had shockingly low levels of oxygen and then putting them on mechanical ventilators, many doctors are now keeping patients conscious, having them roll over in bed, recline in chairs and continue to breathe on their own — with additional oxygen — for as long as possible.

The idea is to get them off their backs and thereby make more lung available. A number of doctors are even trying patients on a special massage mattress designed for pregnant women because it has cutouts that ease the load on the belly and chest.

Credit…Ken Sutin

Other doctors are rejiggering CPAP breathing machines, normally used to help people with sleep apnea, or they have hacked together valves and filters. For some critically ill patients, a ventilator may be the only real hope.

Then there is the space needed inside of buildings and people’s heads. In an instant, soaring atrium lobbies and cafeterias became hospital wards; rarely-used telemedicine technology has suddenly taken off, and doctors are holding virtual bedside conferences with scattered family members; physicians force themselves to peel away psychically and emotionally from fields of battle where the opponent never observes the cease-fire that the rest of society has entered.

More than 12,000 people have died with coronavirus in Connecticut, New Jersey and New York, where there are more than 260,000 confirmed cases. Those numbers almost certainly understate the casualties, officials acknowledge, as testing of both the living and the dead remains spotty.

The New York-area doctors have not uncovered any surefire way to fight Covid-19 — the disease caused by the virus — and not enough time has passed to say if their improvisations will hold up, said Dr. Anand Swaminathan, an assistant clinical professor of emergency medicine at St. Joseph’s University Medical Center in Paterson, N.J.

No one knows if any of the spaghetti will stick to the wall.

“I’m confident that we will have a lot of answers in months,” said Dr. Reuben Strayer, an emergency medicine physician at Maimonides Medical Center in Brooklyn. “Unfortunately, that doesn’t help us right now. You have to start somewhere.”

“Never in my life have I had to ask a patient to get off the telephone because it was time to put in a breathing tube,” said Dr. Richard Levitan, who recently spent 10 days at Bellevue Hospital Center in Manhattan.

Why is this so odd? People who need breathing tubes, which connect to mechanical ventilators that assist or take over respiration, are rarely in any shape to be on the phone because the level of oxygen in their blood has declined precipitously.

If conscious, they are often incoherent and are about to be sedated so they do not gag on the tubes. It is a drastic step.

Yet many Covid-19 patients remain alert, even when their oxygen has sharply fallen, for reasons health care workers can only guess. (Another important signal about how sick the patients are from Covid-19 — the presence of inflammatory markers in the blood — is not available to physicians until laboratory work is done.)

Some patients, by taking oxygen and rolling onto their sides or on their bellies, have quickly returned to normal levels. The tactic is called proning.

Doctors at Montefiore Medical Center in the Bronx and Mount Sinai Medical Center in Manhattan have described it on Twitter; a flier is posted next to beds at Elmhurst Hospital Center in Queens as a guide for patients on how often to turn themselves.


Awake proning – COVID is the first time I have ever used it clinically – but it is regularly used at the extremes of human physiologic oxygenation challenges. Biking over the Alps. Climbing the highest mountains in the world. And every mammal that runs really fast, runs prone.

View image on TwitterView image on Twitter

Julia Arnsten@DrArnsten

We are proning most non-incubated patients with COVID (all on oxygen by NC or NRB) on the regular internal medicine wards. Watching their O2 sat rise after they turn themselves over is always a happy moment.

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At Lincoln Hospital in the Bronx, Dr. Nicholas Caputo followed 50 patients who arrived with low oxygen levels between 69 and 85 percent (95 is normal). After five minutes of proning, they had improved to a mean of 94 percent. Over the next 24 hours, nearly three-quarters were able to avoid intubation; 13 needed ventilators. Proning does not seem to work as well in older patients, a number of doctors said.

No one knows yet if this will be a lasting remedy, Dr. Caputo said, but if he could go back to early March, he would advise himself and others: “Don’t jump to intubation.”

The total number of people who are intubated is now increasing by 21 per day, down from about 300 at the end of March. The need for mechanical ventilators, while still urgent, has been less than the medical community anticipated a month ago.


One reason is that contrary to expectations, a number of doctors at New York hospitals believe intubation is helping fewer people with Covid-19 than other respiratory illnesses and that longer stays on the mechanical ventilators lead to other serious complications. The matter is far from settled.

“Intubated patients with Covid lung disease are doing very poorly, and while this may be the disease and not the mechanical ventilation, most of us believe that intubation is to be avoided until unequivocally required,” Dr. Strayer said.

This shift has lightened the load on nursing staffs and the rest of the hospital. “You put a tube into somebody,” Dr. Levitan said, “and the amount of work required not to kill that person goes up by a factor of 100,” creating a cascade that slows down laboratory results, X-rays and other care.

By committing all the resources of the hospital to highly complex care, mass mechanical ventilation of patients forms a medical Maginot line.

For heavier patients, Dr. Levitan advocates combining breathing support from a CPAP machine or regular oxygen with comfortable positioning on a pregnancy massage mattress. He had one shipped to the hotel where he was staying in New York and brought it to Bellevue.

The first patient to rest on it arrived with oxygen saturation in the 40s, breathing rapidly and with an abnormally fast heartbeat, he said. After the patient was given oxygen through a nasal cannula — clear plastic tubes that fit into the nostrils — Dr. Levitan helped her to lie face down on the massage table. The oxygen level in her blood climbed to the mid-90s, he said, her pulse slowed to under 100 and she was breathing at a more normal pace. “She slept for two hours,” he said.

His brothers are donating more mattresses.

“We have to see how it pans out, but it makes a lot of sense,” Dr. Swaminathan said. “Obesity is clearly a critical risk factor.”

Dr. Josh Farkas, who specializes in pulmonary and critical care medicine at the University of Vermont, said the risks of proning were low. “This is a simple technique which is safe and fairly easy to do,” Dr. Farkas said. “I started doing this some years ago in occasional patients, but never imagined that it would become this widespread and useful.”

This was rebuilding the engine on a car going 100 miles per hour.

“I wouldn’t be surprised if in a couple of weeks someone around the country comes up with better way to do this,” Dr. Swaminathan said.

The medical community is in desperate need of research but there is no time to wait. “Everyone’s got an observation,” Dr. Strayer said. “Everyone’s got an opinion. It’s not very useful. What matters is science and we don’t have any yet.”

After shifts filled entirely with the stress of uncertainty, doctors use their own maps to hunt down peace at day’s end.

“I live alone,” said Dr. Strayer. “That turns out to be a huge advantage for me and my own well-being.”

Dr. Swaminathan said he goes through a decontamination ritual before driving home to his wife and children. “We decided moving out was not an option,” he said. They keep him sane. He has Zoom sessions with friends who work outside of medicine. And there were surprises.

“Someone tweeted the English National Ballet musicians, doing a Zoom session playing Tchaikovsky’s ‘Swan Lake,’” he said. “I listened to it. I noticed my whole body relaxed.”


An earlier version of this article imprecisely described the number of new intubations per day. As of Tuesday, the total number was increasing by 21 per day. There were not, in total, 21 new intubations a day.

Jim Dwyer joined The Times in 2001. He was the winner of the 1995 Pulitzer Prize for commentary and a co-recipient of the 1992 Pulitzer for breaking news. He is also the author or co-author of six books. @jimdwyernyt

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