COVID-19 plans are admirable, but be prepared to change course
Former President Dwight D. Eisenhower, supreme commander of the Allied forces during World War II, has been quoted as saying, “In battle, plans are worthless, but planning is indispensable.”
No one could have been prepared in early January for the battle about to be waged against the COVID-19 virus. Our preparations in what would eventually become hard-hit Michigan were timely as a practice, as an acute care facility and for our outpatient dialysis units, but we had never been battle tested to the extremes posed by this infection.
We had to improvise, modify and innovate in ways we have never before done. Suddenly telemedicine became the norm. Fit testing for N95 masks were updated promptly on a large scale. Re-education of donning and doffing personal protective equipment (PPE) was communicated through previously untested channels. We had the tools, we just were never forced to use them to this extent and the consequences being so great of getting it wrong.
COVID-19 hits hard in the ICU
The reasons behind our Great Lake State becoming an early hotspot for COVID-19 are many and still not yet fully explainable. The entire southeastern Michigan region became hard hit with devastating rates of illness never before seen by caregivers and community leaders alike. Our acute care hospital had to double the number of adult ICU beds during a 48-hour period while limited supplies of PPE forced modifications of utilization techniques by the hour.
In our just completed analysis of a cohort of 200 patients with COVID-19/person under investigation admitted to our institution who developed respiratory failure, rising creatinine or preexisting kidney disease was a single variable identified as leading to respiratory failure independent of race. The impact on mortality is still being sorted out at this time.
Blessings to our staff who worked mandatory overtime and canceled paid time off out of sheer dedication to the overwhelming number of critically ill patients who presented or deteriorated on the medical wards.
It is no surprise we failed our “health disparities stress test” as coined by William Owen, MD, in his JAMA article published April 15. In Michigan, 14% of the population is African American, yet they account for 33% of diagnosed COVID-19 patients and 40% of the deaths due to the disease.
In spite of a community-wide surge that lasted from March 15 and peaked on April 10, there were few places to turn to transfer the huge volume of patients. Unit by unit was transformed into caring for a single disease state, the novel coronavirus infection. Appreciation goes out to Alan Kliger, MD, and the Nephrologists Transforming Dialysis Safety for the production and distribution of webinars in a timely fashion to prepare our providers and trainees to make safe and appropriate decisions based on delivering the highest quality care on behalf of the greatest good for our patients – this at a time when there just were not enough hours in a given day to deliver a typical dialysis prescription to the entire cohort of patients.
Nursing staff worked long hours into every night putting themselves at risk for infection and delivering treatments to an overwhelming incidence of AKI that occurred in conjunction with the disease.
Fight against AKI
We estimate 40% to 50% of the patients infected with COVID-19 developed AKI and a third of those required supportive therapy. Continuous renal replacement therapy was used frequently in limited timeframes with high dialysate volumes among multiple patients until shortages forced a return to usual dialysate volumes. Although the data are yet to be released, my suspicion is our outpatient dialysis providers aggressively protected our extremely high-risk ESRD patients through early masking and isolation procedures in the outpatient units. We know we were not perfect and mourn the loss of loved ones, friends, neighbors and patients.
By the grace of God and the dedication of countless nursing staff, residents, fellows and internal medicine faculty and subspecialists, we have seen a plateauing of our COVID-19 cases to date. We remain cautiously optimistic that through physical distancing and more rigorous testing we can avoid any future surges as previously experienced in our community, but there is more to learn. We will be forever changed by the COVID-19 pandemic and hopefully a lot wiser in the end.
Ending with another quote from the famous Allied general and 34th president of the United States: “There is nothing wrong with America that faith, love of freedom, intelligence and the energy of her citizens cannot cure.”
- Owen W, et al. JAMA 2020;doi:10.1001/jama.2020.6547.
- For more information:
- Keith Bellovich, DO, is with St. Clair Nephrology PC in Roseville, Michigan. He is also a Nephrology News & Issues Editorial Advisory Board Member.
Disclosure: Bellovich reports no relevant financial disclosures.