It was starting to sink in, as physician assistants working in the surgical intensive care unit of a level one trauma center, we were going to be one of those healthcare providers on the front lines.

Our First Patients
On March 12, 2020, the hospital admitted its first patient, and soon the hospitalist service and the medical intensive care unit were focusing their efforts on managing COVID-19 patients. Initially, things were manageable. With the state-mandated shut-down of non-essential workers, it was thought that we may avert the surge New York City was experiencing. Eventually, as the case count continued to rise, our hospital’s incident command center was activated, elective surgeries were halted, and the local community was afraid to step near a hospital. As a result, the hospital census initially declined, but was later inundated with more and more patients who were infected with COVID-19.

Since most areas of the hospital were shut down, many colleagues were furloughed. Simultaneously, COVID-19 admissions were rising, which resulted in an environment never before experienced - a disproportionate distribution of work. There was no COPD exacerbation, no appendicitis, no pneumonia - just COVID-19. These critically ill patients, who were initially located in the medical ICU (our designated COVID-19 ICU), were flooding the surgical ICU, cardiac ICU, the pre-operative area, and postoperative areas. This was when involvement in managing these critically ill patients became real. Without hesitation, our team of eleven physician assistants and nurse practitioners started overseeing one of the critical care units to off-load some of the medical team’s responsibilities. Walking into the COVID-only ICU was daunting. Many thoughts circulated – to trust personal protective equipment? To trust the ability to properly don and doff PPE? What was the risk of contaminating ourselves, other colleagues, or even other patients? Reports were that front-line workers across the country were becoming infected, and some were even dying. Would this be a fate healthcare workers possibly faced? What made this so terrifying was that the enemy was invisible; we were fighting a war against something we could not see, hear, taste, smell, or identify. Moreover, we did not have ammunition to fight this war. The unknowns far outweighed the knowns with COVID-19.

Sicker than the Sick We Knew
After working in a 600-bed tertiary care hospital for 20 years as physician assistants, what sick is and how to treat sick was known. Well, these patients were sicker than the sick we knew. As a result of

the visitor restrictions, family were prohibited from entering the hospital, and many patients would pass away without family at their side. This did not happen on one occasion; this was becoming the new normal. Each of these critically ill patients required a tremendous number of resources and manpower. Initially, treatment included hydroxychloroquine (immunosuppressive and anti-parasite drug, typically used for malaria), but as new data became available, recommendations continued to change, and soon, we stopped using hydroxychloroquine. We then used Lopinavir/Ritnovir (HIV antiviral medication), then Remdesivir (broad-spectrum antiviral medication), then steroids, and then convalescent plasma (antibody-rich product from blood of people who had the disease caused by the virus). The treatments were everchanging; however, improvements were minimal. As you can imagine, patients were scared and lonely; at times, some of the most impactful care was spent at the patients’ bedside, holding their hand so they were not alone.

From a respiratory standpoint, the thought was to intubate early and avoid non-invasive ventilation and high-flow nasal cannula (HFNC) because of potential aerosol generation. However, with time, we realized that most patients who were intubated were never extubated, and as more data became available, there was a shift in practice to avoid intubation. Instead, treatment began to focus on noninvasive ventilation and HFNC. It was a type of respiratory failure that was uniquely different when compared to the acute respiratory distress syndrome (ARDS) previously seen. In addition, to avoid mechanical ventilation, these patients showed significant benefit from proning.

Proning has been the process of turning a patient with precise, safe motions from their back to their stomach which relieved the pressure of gravity and assisted with improving oxygenation (Penn Medicine Physician Blog, 2021). In the past, this was something rarely performed as it required the use of a specialty bed to secure the patient and prevent tube dislodgement. Without access to these beds, the alternative was something learned from our European colleagues, called the “Burrito” technique (Wiggermann et al., 2020). Working with physical therapy and occupational therapy colleagues, a proning team trained in this technique was created and responsible for successfully flipping many of the sickest patients. We also were worried about running out of ventilators. During this time, the media was fixated on this issue; however, everything was running low - including dialysis machines, dialysate solution for dialysis, IV pumps, and numerous medications.