COVID-19 Series: Interview with Prof. Brody treating patients on NYC's front line

Prof. Abraham A. Brody, Associate Professor, Nursing & Medicine & Associate Director, Hartford Institute for Geriatric Nursing

 

“It is amazing how everyone has pitched in, come together, and done their best to help each other and our patients.”

 

How are you serving and caring for patients in hospital during the pandemic?

 

 

When the geriatrics section of the NYU Department of Medicine, where I am associated faculty, was tasked with serving as the hospitalist service at NYU Langone Orthopedic Hospital, I was redeployed as a nurse practitioner. This is a completely different role for me, serving in a primary management role versus as a geriatric and palliative care consultant at NYU Langone Health. I'm no longer the outside voice coming in to take a fresh view. I’m on the frontline, ensuring effective day-to-day management and responding to physiologic changes.

As part of our inpatient medicine team, I'm instituting changes to the plan of care. Instead of facilitating difficult goals-of-care conversations with the primary team, I am largely handing this responsibility solo. Even more so because I'm working on nights, when there are fewer staff, as my wife is also a clinician on the frontline and one of us has to be watching our kids.

What is not different, however, is that we are all working as a team. Almost everyone is playing a different role than normal and handling it with grace and professionalism. The cleaning and engineering staff, patient care technicians, nurses, rehab therapists, respiratory therapists, physicians, clerical staff, administrators, and otherwise. It is amazing how everyone has pitched in, come together, and done their best to help each other and our patients.

 

What made you decide to take that on?

 

 

There was a need, plain and simple, and we all have to chip in. This was where the most help was needed, and I don't have any underlying health conditions that would put me at higher risk.

 

How is this virus different from other viruses and flus you’ve seen in clinical settings?

 

 

There are four major differences between COVID-19 and other viruses and flus we have seen in the past. First, it is so much more readily spread, with no vaccine, and only treatments of unknown efficacy. That means we have limited avenues, other than containment and supportive interventions, such as intubation, inhalers and fever reduction.

The second difference is the populations that it is harming the most. We are already starting to see from what little data we have that in this country black and brown people are being disproportionately infected and having worse outcomes. We are also seeing that men are far worse off than women, with almost 3:2 hospitalization, ICU, and mortality rates. Unlike with most other viruses where thousands of children die each year, COVID-19 does not affect most children in any substantial sort of way. On the other hand, we are finding that older adults have reported rates of mortality approaching 50–90% if they are in the ICU and slightly lower if hospitalized, particularly among the oldest old.

Third, fever does not seem to be the leading indicator if patients are healing or not, it is oxygenation requirements. We have to be very watchful when someone's oxygen saturation goes down and need for supplemental oxygen goes up and be ready to hit the panic button much earlier than we normally would.

Fourth, of those that do recover, because many need long hospitalizations, they are debilitated as they regain their lung function. The question then becomes, where do they get rehab? Many subacute rehab facilities require two COVID-19 negative tests before receiving a patient so they rightly do not spread the disease within the frail nursing home population, so it is hard to discharge these individuals. They can spend weeks in a "limbo" sort of state where they are healthy enough not to fully need acute care anymore yet not able to go to rehab.

 

 

What is the role of the nurse in this pandemic?

 

 

There is no “single role” of the nurse in this pandemic. Nurses, just like in other times, take on many roles. In this case we have our ER and ICU nurses providing care to the hardest-hit patients, often in very trying conditions. Our med-surg nurses have to monitor patients who are very labile and one minute may look fine and the next are not. We have also seen other nurses within our healthcare system take on different roles from their typical ones, from being drafted into ER/ICU/Med-Surg settings to becoming outpatient COVID+ testers to telehealth screeners. .

Also included are all of the public health nurses out there serving as disease detectives and spread reducers — and all of our nursing home, home health, and hospice nurses, who have had to add a completely different element to their workflow, one which they have not been prepared for and may not have the protective equipment to do without endangering themselves. Finally, we still need our nurse educators to educate so we can bring more nurses into the workforce, as many of our talented NYU Meyers faculty continue to do. .

There are so many ways for nurses to help, whether on the frontline or in a supportive role. We need nurses in all these places to help advocate for our patients and the health system, to be on TV, in the newspapers, and on social media advocating for safe and effective care and caregiving, given their front row view of what is going on.

 

Do any experiences or stories with COVID-19 stand out so far?

 

 

Even in a short period of time there have been so many experiences in helping patients in their healing, making difficult decisions about clinical care, and supporting each other in a truly unparalleled time in recent history. What stands out for me the most, as a geriatric and palliative care NP by training, is how we, in the thick of an emergent issue, automatically do the default all-curative measures that may not be in the patient's goals or interest.

I had a patient recently who came back with a concerning lab value for cardiac damage and potential heart attack, and my rapid response muscle memory from way back when I was a bedside nurse (last time was in 2005, no less) kicked in. Assessing, ordering labs, an ABG, EKG, and all the other care that comes with a potential cardiac event pathway. But about five minutes in, I stepped back. This patient already had “do not resuscitate/do not intubate” (DNR/DNI) orders, but the rest of their care goals had not been fully established. I called the healthcare proxy who had already been discussing with their family what they should do in this type of case, and they had an answer. Their loved one had always said that if they did not have the ability to be independent (which this patient was unlikely to achieve, given the complicated nature of their stay), they would not want a wheelchair or bedbound life. Therefore, we pulled back and implemented a comfort care pathway.

Within an hour the patient looked much more comfortable and we were able to peacefully care for her symptoms without extensive additional, potentially uncomfortable workup and procedures. If we had continued down the cardiac event pathway, the patient could have ended up with a lot of aggressive care, short of intubation, which would not have been congruent with her goals. Instead, she died peacefully and compassionately in inpatient hospice.

In the end, we were meeting the patient and family wishes and supporting a seriously ill individual at the end of their life to have their care match their goals. Sometimes patient goals are around maximal curative treatment, and it is important to honor that just as it is important to honor when it is somewhere in between or fully comfort care, but the most important is to match those goals with the care we provide.