COVID19 continues in 2022- a disruptive NY perspective

 As we wish everyone Happy New Year in 2022, the year has not really started off happy for many in the NY area( or most of the United States and the world).  Omicron variant is flourishing over mankind. 

In March 2020, I had witnessed one of the most horrific moments of my career and life as we all saw death and sobering misery in NYC. But at the same time, human kind and all health care had a mission and calling to somehow combat this virus.

2 years later now Jan 2022, we are back in a similar situation. I was on service in early Dec 2021 and life was "covid" normal with mostly non covid admissions and a good mix of interesting nephrology consult cases. Conferences were hybrid and we were doing relatively ok.

Fast forward 3 weeks, and life has changed again. More COVID19 patients in the hospital, some sick, some not. More PPE again.. cafeterias restricting folks on eating, visiting not allowed, people scared again to talk to each other. This time around, there is less fear but more fatigue. This time around, there is sickness but not fear of death. There is more disruption. Disruption everywhere...

This wave is different. I call it the wave of disruption. More nurses, PA, NP, physicians are out and coverage and planning for coverage is challenging. Luckily most have mild symptoms and are returning to work. This wave is causing more cancellations due to disruptions and not due to fear. This wave is causing more delay in health care due to personnel out due to mild covid symptoms or a positive PCR than sickness. 

This wave is different as there are more incidental PCR positive findings in both inpatient and outpatient world and we are testing so frequently. The patient who comes in for a fall and femur fracture by chance is found to have PCR + in the ER.  This wave is not the SOB, DOE coming in with oxygen requirements for acute COVID. Don't get me wrong, there are some who are coming in with that as well.

This wave is different, it's the wave of " We know COVID treatment better". We know steroids and remdesivir work and avoid intubation if not necessary and we are doing it.. We are doing an amazing job discharging patients and keeping death rates low.. This wave is more disruptive and harm will happen due to shortened and shrinking staff in health care.

This wave is different as there is minimal to no AKI. There is less lung involvement and hence less AKI ( perhaps). Early treatment maybe making a difference. Most of this wave is going to be outpatient phone calls from dialysis units, transplant patients turning positive and what do we do... Most of the phone calls I am receiving are from patients turning positive either because they tested for a trip or have mild symptoms. This will overwhelm the outpatient practices.  Virtual visits are back to decrease the disruption again.. This wave will cause dialysis patient placement issues. Cohorts and special units may be possible in 2020 and 2021 but this wave, omicron is everywhere-- perhaps cohort the non COVID ones maybe a better option.

Phone calls from patients, friends, co-workers and family members are constantly telling me- I am positive.  Omicron seems inescapable. This variant is everywhere.. NY is again an epicenter for this wave and leading the front in the US( not a proud moment). And this is despite our vaccination rates. 

While, this Jan 2022 seems gloom and doom, we have achieved so much in the last 2 years.
Vaccination in record time for almost all age groups, preventing severe cases and death; RCTs showing how some medications and therapies work well such as steroids and perhaps in some cases remdesivir.  We have learnt Acute PD again, we have learnt to juggle immunosuppression for GNs and transplant patients. We have learnt to transplant in a pandemic. We have learnt to multi task and do hospitalist work again. Despite the anger and distress in the world, we have learnt to become more human again and help each other more.

While I am not a trained immunologist, I am hoping that Omicron stays mild and takes over Delta and Delta won't have any human hosts left and this would be a silver lining and perhaps an end to the pandemic. With so many people infected ( despite vaccination), endemic status maybe in sight..

Let's hope that 2022 is the year of mankind and not the virus!

Perspective: Innovation during COVID-19

As our health system and NY and parts of US keeping getting hit with COVID-19, it is hard not to notice innovation happening rapidly.  Our health system is now cared for over 9,000 COVID inpatients and several doctors and nurses redeployed to help in this mission. What an heroic effort.

What has evolved as a result of pressured needed timely treatments?

1. Shortage of ventilators- use of CPAP machines
2. Offices closed -fastest adaption of Tele medicine in history of mankind. 
3. Shortage of health care workers- All physicians doing a transitional prelim year model- just amazing to see
4. Shortage of CRRT machines- resolving to use of acute PD in certain areas, some using prolonged intermittent renal replacement therapy)
5. QTc monitoring on the screen- so impressed!
6. Fastest trial designs and rapid approvals of treatment is unprecedented for treatment of this deadly virus.
7. Several health startup companies have risen and are trying to use their ways to help combat this virus. See this article in health transformer.

But few things have happened and I have seen it here as well
1. Less red tape with administration- fasted hiring approval I have seen to get someone on board- perhaps we should NOT go back to the old ways
2. Better and more meaningful meetings to get the job done
3. More modesty and acceptance of our strengths and flaws

Perspective: COVID-19: from the Trenches in NY on leadership, clinical care, teaching and research

In the last 3 weeks, our health system has been in the forefront of the entire COVID-19 pandemic in NYC. What I have learnt about leadership, medicine and nephrology is exponential in the last 3 weeks.

As soon as the cases started to rise, our department of medicine chairman started daily calls via Meetings that combined all department chairs, health system experts and division chairs to align the mission at stake. I cannot say how important this call is on setting the stage and the mood as a leader. It is important that all are on the same page and doing this with charisma and ease without panic. I was truly amazed at that. 

In nephrology, we quickly adapted a similar strategy on updated our fellows, faculty, staff on a twice a week basis on similar issues in nephrology.

Some of the issues in Nephrology that the world should consider:

1.       Deploy as many nephrologists in the inpatient setting (your volume will be increasing significantly).  I have not seen volume of AKI at this fold in years in practice.

2.       Re-deploy your fellows/trainees mostly inpatient and few for outpatient dialysis units.

3.       Remember, the other place where you will need help is outpatient dialysis units- beef up your medical directors and get help to them early as they will be 100% occupied- making schedule changes, creating extra shifts for PUIs and extra units/shifts for COVID-19 patients.

4.       Before you deploy to internal medicine help, help might be needed within nephrology itself- as we are in the front line as ESRD docs, inpatient volume increasing and transplant docs as patients with COVID and organ transplants also increase.

5.       Increasing supplies early on and not waiting till you hit peak- ordering more CRRT machines, fluids, cartridges is going to be key.. don’t wait

6.       Back up nursing and making sure you have a good balance between HD and ICU nursing and not stressing both with either HD orders and or CRRT orders.

7.       Anticoagulation might be extremely important in CRRT or citrate protocol( if possible) as clotting is not uncommon in this disease.

8.       Creating a simple but important criteria for need for dialysis in really sick patients and value of RRT in such cases

9.       Implementing and orchestrating (with a division champion) on tele medicine outpatient visits. This can help you fight the COVID fight by keeping your CKD/transplant patients out of the hospital. This is a very critical and important piece.

10.   Making all conferences tele for now but still doing them- education should NOT stop as we are still in the process of teaching along with caring for patients.

11.   Deploying some research strength to learning about COVID in this critical time and sharing information as quickly as possible to the world to allow for ongoing coordinate care.

12.   Separate inpatient and outpatient rounding docs every 2 weeks ( not to mix them) and give the inpatient docs a break.

13.   We also implemented more on call weekend docs for renal help and in addition, added a tele attending on call to help de burden calls on weekends.

14.   Rotation of clerical staff in the office to limit the number of folks in the office ( minimize exposure helps)

15.   Implementing dialysis tele health also helps (but should not replace seeing our ESRD patients). This might be best for our PD and home HD patients.

16.   Can’t stress enough is constant communication—with colleagues, fellows, nurses, staff about any changes. It eases the anxiety and plans for a smoother over a bumpy ride of this long winded ride we are in.

17.   While are in forced implementation of certain tactics due to COVID, perhaps some good tactics should be adopted for long term patient care as we overcome this pandemic. 

18.   The most important part- checking in your nurses, faculty and fellows – creating a group on WhatsApp or any app to share fun pics, old jokes and fun times together as a division. We are all in this together.. Let’s get over this hump…

Perspective of a Nephrologist amidst COVID-19 crisis in New York 2020

Just a month ago, I was on call at North Shore University Hospital in Manhasset and covering a census of >50 patients. It was a great mix of cases from AL amyloidosis, Anca vasculitis, Anti GBM, cardio renal syndromes, check pt inhibitor induced AIN, and several onconephrology electrolyte disorders.  In addition, our center had also just done their first heart-kidney transplant recently and it was an amazing feeling.

Fast forward, a month later, I am on call again and I sense a  census >60 and over 80% of those cases are COVID-19+ with either AKI or ESRD.  What just happened here????

As the pandemic knocked the doors of NY, the hospital I have worked for 10 years now had turned into a different place. In the last 3 weeks, all surgeries were cancelled, all non elective admissions postponed... outpatient clinics slowing down.. and what do I see now..

I walk in and I can't recognize people. The make up and gel that people used to have is replaced by N95s and surgical masks. Nice suits,dresses all gone and replaced by scrubs and surgical gowns.

CT ICU, NS ICU, SICU, CCU and transplant ICU - are now all medical ICU beds.
ER is overflowing with COVID-19 patients.
ICU has vented patients from ages 31-83y of age, both males and females.
CRRT machines being deployed at almost every floor.
Surgical floors converted to medical COVID-19 floors. Only 4-5 floors remain as non COVID floors in the hospital...
Hallways are empty, cafe empty since no family is allowed....

This transformation -- just in 3 weeks.  What a change.. Shock is an understatement.
What is more clear was the fear and anxiety in the eyes of the providers. People I used to see always joking around, making Trump Jokes, and laughing and smiling -- you could now sense fear in their voice.

Fatigue was evident in the nurses and ICU docs... but they were not giving up.
Renal consultations came every hour and it was all COVID-19 intubated patient in AKI, needing CRRT.  It was pre renal, ATN, AIN, who knows-- we were just trying to save whoever we could...
The fellow and I scared to enter rooms, no time to even take a bathroom break and not sure how to even eat at the cafeteria.

Sadness, fear and anxiety was evident everywhere....1/3 of admitted COVID-19 patients end up in ICU, staying longer and longer stays ( 2 weeks) on a ventilator.. and what happens after that.. renal failure, cardiac failure.

But....what also was evident and most inspiring to me was...

Never before seen- working together of teams of residents and attendings ever imagined.
One of the covid-19 ICUS was headed by a surgical intensivists, vascular surgery attending, medicine residents, and pulmonary team helping out-- what amazing team work..
Then comes the NSICU, another converted COVID-19 unit- intensivists out of their comfort zone providing amazing medical ICU care to these COVID patients.
Finally, pediatric ICU docs coming to help the adult ICU patients- working hand in hand with pulmonary fellows, medical residents, neurology residents... amazing amazing!!

Kudos to the hospital management, CEO, CMOs, and department chairs to get this together in 2 weeks and creating this team work environment.
While the hospital is now a COVID-19 hospital and increasing number of ICU beds, everyone has stepped up outside their comfort zone and created history at our institution.

There are some wins-some patients coming extubated and many getting discharged.. While we may loose many, we are also saving many lives.. Kudos to our ER, hospital medicine and ICU staff and amazing nurses and health care providers...
Consults have become real, people are not calling "non needed' consults
Note writing has been minimized... and communication has improved.

While there is fear in everyone's eyes, we also sensed and felt a sense of pride to battle this war with our invisible enemy...

One of my Nephrology friends said it perfectly  "This is literally a battle zone which we are dealing with. Quite honestly, for the most part could exhilarating.  You are living history. Nothing has prepared us for this. Soak it in.... Hopefully, 40 years from now, you will be telling your grandkids how you served on the front lines of the great 2020 pandemic.  You may never again have the opportunity to be involved in something more meaningful again."

Perspective: Double Standards in Medicine

In a cold march morning in 2021 a big city urban “academic” hospital, the “consult” phone rings. A Nephrology attending answers “ Renal consult, can I help you?”.  The “Hospitalist” on the other end says, “ Yes, I have a creatinine of 1.5mg/dl, AKI, please see.”.  The Nephrologist replies, “ Yes, we shall, please send me details of the location and will take care of it.”  The Hospitalist says, “ thank you, and please don’t ask you fellow to see, I want an “Attending only” consult.  The Nephrology attending politely agrees.  He nods to the “renal fellow” next to him and says, “ Don’t worry, this one is for me only”. The Hospitalist continues “One more thing, I am done for the day, it’s 4PM, can you call the consult recommendations to my resident in house, thanks!” and hangs up.

Not too long ago, we trained as residents and fellows to see patients and get the “ nuts and bolts” of medicine and the field you were choosing. You wanted to see more patients to get the experience; perhaps not all of us but most of us wanted to get the “full and complete “ experience.  Attendings saw patients with us and we learnt from their clinical wisdom. While fellows/residents were work horses, most academic centers had educational missions as well to counterbalance the workload. Things have changed in the last decade. The above conversation reflects some of those changes.

What is wrong with the above conversation? What has bought us to this stage or might get us to this stage? Why is it “okay” for the “team” calling the consult to have trainees see their patients and “consult” team has to be “attending only”?  While a fellow might have less experience, their vision is not tunneled and they might bring an amazing differential diagnosis to the forefront.  While the fellow might be seeing many patients, seeing more patients might make them more efficient and learn to prioritize. There is lot of learning even when the volume of patients is high.  Is it the fear of “patient satisfaction” or is it a fear of “litigation”?  Not really sure.  I have heard it’s “communication” and many subspecialty fellows “don’t want to see more patients.”  Is that really true? Maybe once in a while, we all get tired and want to “go home”.  But we most of us went into medicine to “see patients” and provide optimal patient care.  I can say proudly that sometimes my patients ask “ Where is the fellow?, you are alone today? We miss the fellow..”  You form a team and a “team” always brings more to patient care than a “single person”. 

In addition, “consult” team cannot ask any questions. “ Yes sir, I shall see the patient”. Questions are asked to see the urgency of situation, to assess workup and to get a sense of what can be done quickly before we get there. “Asking questions on the phone” does not equate “avoiding” a consult. A good consultant will ask pertinent 1-2 questions and see the patient.  “Fellows” ask too many questions.. perhaps they are avoiding the consult.  Fellows ask questions to learn about the patient- it’s simple. Most fellows are nervous and want to make sure that when they present to their “attending”, they have a complete story.  Unfortunately, this is sometimes mistaken as “ avoiding consults”.  How quickly many attendings forget—“ I was once a trainee and did the same!”.

In the era of corporate medicine, where “academia” is blending with “private practice”, there is soon going to be no difference.  “Pan-consultemia” will drive these consults that will increase medical costs even more.   “Attending only” services are good to help off load the fellows burden in many academic centers and creating such services is an excellent idea for that reason.  When a surgical team calls a “attending only renal consult” and I don’t even get to speak to an “attending” on the other end-let alone a fellow or resident- it boggles my mind.

Double standards in medicine!

Perspective: Broken Medicine

Here is a question for you:

A 55 y old male with HTN is here for follow up.  He has no other medical problems.  Medications include losartan, metoprolol, amlodipine, and HCTZ.  Blood pressure is 160/100 mm HG.  What is the next best step for his blood pressure control?

A.      Dietary history

B.      Check Renin/Aldosterone levels

C.      Check secondary workup

D.      Make sure the patient is taking all medications properly

E.       Obtain a 24 hour ABPM

Any of the above or all of the above would be good choices and one can start with either one. Here are the real world choices…

A.      Obtain Renal consult

B.      Obtain Endocrine consult

C.      Obtain Cardiology consult

Here is where the fragmentation begins. Why does this happen?

Here are the top reasons in my opinion

Not enough time to think
Inertia to think
Patient satisfaction( I want a HTN specialist)
Training not adequate
Trainers were not master clinicians and hence they believed in panconsultemia as well

Once consults are obtained: - more confusion as cardiology and nephrology don’t agree on drug choices. Endocrine wants more tests. Now more accidental findings…. And it continues. 

Welcome to medicine in 22^st century.
Let’s please stop this madness!!

Perspective: How an Ultrasound machine has changed my practice?

My new instrument in the last 2 years has been the ultrasound probe.  It adds tremendous value to my physical exam. Residents in our program have traditionally been learning ultrasound skills as part of examining the patient: especially in the ICU.  Lungs look wet, kidneys look ok, bladder is full and IVC is plump.. We have now gotten information that can really make the care of the patient really swift. Official ultrasounds are still obtained but a quick and important organ examination can save lives and critical time..

Besides, I now feel that as nephrologists, this might be an important skill that we need to develop and gain acceptance too.  A patient calls and says he cannot urinate and he is having pain and he has known CKD. You see him but you are concerned about potential distal obstruction:- A quick bladder sonogram in the office can reveal the obstruction or distended bladder with urine and rather than an ER visit, you can promptly send this patient to the Urologist for foley insertion and home.

A dialysis patient tends not usually gain weight ( maybe 1kg between treatments) , comes in slightly short of breath. A lung ultrasound done by you reveal B lines and in multiple views suggesting fluid overload.  This allows you to take off 2kg today and patient feels better.  Alternatively, you would have done that anyway but also perhaps exposed the patient to an X-ray that might have not been necessary. 

My practice has changed with this revelation. Training our faculty and fellows in this important skill- sonogram of the bladder and kidney and lung US and IVC for volume status is important. In the era of declining interest in nephrology, perhaps this skill might shed some excitement in the field of nephrology.   Lung US compares favorably to CT scan for detection for pulmonary edema and might be better than CXR.

The Emory course on sonogram might be the excellent course. What I envision is more of a short burst of courses that can really help us use this in clinical practice like we use our stethoscope, and not focus on using it for billing/coding etc. purposes.  Let’s save lives by making a difference in our patients in a fast paced manner , avoid ER visits and giving them a more comprehensive care in the Nephrology clinic.

Here are some interesting references !

http://www.criticalecho.com/content/tutorial-9-lung-ultrasound

http://www.ncbi.nlm.nih.gov/pubmed/25030008

http://www.ncbi.nlm.nih.gov/pubmed/23884727

http://www.ncbi.nlm.nih.gov/pubmed/16716814

Ethics in Dialysis practices

" You stole my patient when she was admitted to a hospital I don't go to". " How come all my dialysis patients are being taken away by the other group in town as they open a new unit?"

These are concerns and ethical issues that many nephrologists in practice face as competition arises between practicing groups. A recent CJASN article highlights many issues that we face ethically when such issues arise.  This paper is almost as close to a policy statement re such unethical practices that are business minded and not patient centered.
Key points that are discussed have to deal with how one group can refrain from soliciting other groups patients and keep their business interests aside while taking care of patients.

Tips suggested are:

1. Rescual ( don't get involved in care of the other group's patients)
2. Avoid soliciting
3. Full transparency to the patient if you have to get involved.
4. Avoid self referrals to one's unit or office
5. Provide a collegial environment( while competition is good, we all went into this profession for patient benefit)

Glad an article to this regard is published in nephrology. Its worth applauding the authors on a topic that is often faced by many of us in a competitive environment; and to highlight that such tactics that are often used are unethical and remove us far far away from our professional oath.

A resident's view

The renal elective in our institution has allowed now to have residents participate and see the side of nephrology that they might have never seen before- transplantation and peritoneal dialysis.  One of the residents penned her thoughts on her blog about the experience of seeing the transplantation side of nephrology.  Please check out this very well written commentary on her blog.

Patient Perspective: Give us the Choice by Kamal Shah

Give us the choice

Most people in India, when diagnosed with kidney failure are advised to get their fistula surgery done. Which is great in one way because the fistula, as we all know, is the gold standard when it comes to vascular access for hemodialysis.

However, I have often wondered why the PD catheter is not offered to the patient as an alternative to the fistula? Or a registration on the cadaver transplant list? Why is it almost always the fistula?

When I was diagnosed with kidney disease at the age of 22 in July 1997, I was given an AV shunt because my kidneys were expected to revive in a matter of weeks. Of course that never happened and I graduated to a fistula eventually - probably the first sign that my kidneys are not going to ‘jump back to life’! I got to know of PD only after my failed transplant, a good eighteen months after my initial diagnosis with kidney disease.

I have thought hard about why PD is not presented to patients as an initial option. In my case, it may not have made sense because of the perceived temporary nature of the condition. However, in a majority of other patients whose CKD is most definitely at stage 5 and he or she is going to need some form of RRT for the rest of his or life, PD is definitely an excellent option!

Then why this step-motherly treatment for this modality in India (and as I gather in many other parts of the world)?

One reason is patients themselves. I have talked to some patients about PD and find a reluctance to take care into their own hands. They are happy giving themselves up to the medical team and blame them for everything that is wrong with them. There is also the scare of infection. In India, very few patients on dialysis know about how rampant Hepatitis  C has become in dialysis units. With PD, yes, there is a risk of bacterial infection but the risk can be minimized if the patient is properly trained in aseptic techniques. With in-center hemodialysis, you are entirely at the mercy of the technicians and nurses. Hepatitis C is a very real danger due to their negligence.

Another reason could be nephrologists themselves. For some reason, nephrologists the world over have shied away from PD.

Another option that patients could be given is that of a transplant. Why wait even for a few months on dialysis? When the patient reaches Stage 5, start preparing for a transplant -  live related or cadaveric. Get everything in place and get a transplant as soon as necessary so that the patient does not need even a single session of dialysis.

These are all excellent options which the nephrologist must discuss with patients. All the options. Hemodialysis, Peritoneal Dialysis and a Transplant. The nephrologist (and possibly a trained counsellor) must explain all the three options well ahead of time and involve the patient and his or her family in the decision. Unlike today, when the nephrologist makes the decision for us.

It is my life. I want a say. Is this too much to ask?

By Kamal Shah

http://kamaldshah.com

http://dialysis.org.in

What Kamal is saying is not only true likely in India but in USA as well. This is an ongoing problem as more and more Younger Nephrologists don't feel well trained or comfortable in taking care of PD.  Meanwhile countries like Japan, have majority of their dialysis patients getting PD.  Economics or patient preferences- both might be a playing a role in this sad state of affairs.