Published April 30, 2020
David Holmes was supposed to be in Sierra Leone this month on a global health trip with UB medical students. But when the trip was cancelled because of the pandemic, he decided to fill out an application to volunteer to care for COVID-19 patients in New York City.
Holmes is a clinical associate professor of family medicine and director of global health education in the Jacobs School of Medicine and Biomedical Sciences at UB, and a physician with UBMD Family Medicine. For decades, he has led medical missions of UB students and practitioners all over the world. This month, his lifelong commitment to providing holistic, patient-centered care took him not to a remote village in an underdeveloped country, but rather to Woodhull Hospital in downtown Brooklyn, a designated COVID-19 facility.
Holmes is not unique among UB faculty-physicians: Hundreds of faculty and medical residents are working on the front lines of the pandemic, caring for COVID-19 patients in Buffalo hospitals.
“I know I speak for our entire community in expressing deep gratitude to our dedicated health care workers and our UB faculty physicians and medical residents who are providing care to our community’s most vulnerable members during this pandemic,” said Michael E. Cain, vice president for health sciences and dean of the Jacobs School.
More than 500 faculty physicians and more than 700 medical residents from the Jacobs School provide care to patients in UB’s affiliated teaching hospitals throughout Western New York. Many are treating COVID-19 patients in the region.
Upon his arrival in New York in April, Holmes was struck by the quietness. “The city is a peaceful place to be right now,” he told UBNow. “Unlike the streets, however, the hospitals are not peaceful.”
Because it was designated a COVID-19 hospital, Woodhull had transferred many of its non-COVID-19 patients to other hospitals. When Holmes arrived April 13, about 200 of the hospital’s 240 beds were filled with COVID-19 patients, with about 70 on ventilators.
Woodhull normally has two intensive care units (ICU), but it turned three additional medical floors into ICUs with ventilators to meet the need. In addition, Holmes said, many patients, including those on ventilators, were backed up in the ER, requiring the ER to have a medicine service and a mini-ICU until beds opened up on the floors.
Holmes said the hospital was lucky to get old, but functional ventilators from the Federal Emergency Management Administration, but, he explained, COVID-19 also can cause kidney failure, so many patients required dialysis. Unfortunately, there weren’t enough dialysis machines. A tragic consequence, Holmes said, is that some patients died simply because they couldn’t get dialysis in time.
“The hospital has had an ‘all-hands-on-deck’ response to the crisis,” he said. “Ambulatory clinics are closed and outpatient physicians, subspecialists and surgeons are now working as general medicine hospitalists. Volunteer physicians from various specialties have been working as hospitalists to help meet the need.”
Normally, the hospital has five in-patient medicine teams, but there were 13 when Holmes was there. All medicine residents were pulled from electives to help out on the in-patient services. Residents from other specialties, including pediatrics and oral and maxillofacial surgery, were assigned to in-patient medicine teams. Temp agencies also sent mid-level practitioners and nurses to help with the crisis.
“A few weeks ago, at the peak of the COVID crisis, there were about 40 patients dying each day in this hospital,” Holmes said. “Then it went down to 20, and lately there have been about 10 patient deaths a day, so it seems things are getting better, but we still have a long way to go.” Normally, pre-COVID, he said about 15 patients die each month in the hospital.
Once a COVID-19 patient is intubated and placed on a ventilator, it’s very difficult for them to get off the ventilator and breathe on their own again, Holmes observed.
“Therefore, doctors do everything they can with high-flow oxygen to avoid using the vent,” he said. “However, eventually, it gets to the point where many patients will die from respiratory failure if they don’t go on the vent, so we’re between a rock and a hard place.
“But some patients do manage to get off the vent and start breathing on their own, and when they do, it’s a celebration. At Woodhull, whenever a patient was weaned off the vent, they played rock music throughout the hospital. Hearing that music would always bring a smile to my face.”
The hospital had sufficient personal protective equipment (PPE) and vents, but other critical supplies were lacking, such as tubing for high-flow oxygen, medications, catheters and central line kits that are badly needed in the ICUs.
At first, most COVID-19 patients were given hydroxychloroquine, the antimalarial drug that’s also used to treat some autoimmune diseases. Holmes was told by the hospital’s full-time attending physicians that they gave this medicine because it was standard of care, even though most didn’t think it did much good. By the time he left the hospital, some research had confirmed that it wasn’t effective treatment for COVID-19 and may be doing harm by increasing the risk of cardiac arrhythmias, so hydroxycholoroquine is being used much less often now.
On the other hand, some of the critically ill patients were given plasma donations from recovered COVID-19 patients, and in some of them it seemed to make a difference in helping wean them of the ventilator. But here, too, Holmes noted, it isn’t entirely clear that the plasma antibodies are what’s making the difference. “The jury is still out on this one,” he said.
Proning, where patients with respiratory distress and hypoxia are placed on their stomachs, rather than their backs, to help improve oxygenation, seemed to make a positive difference, he said.
During his 11-day volunteer stint at Woodhull, Holmes cared for approximately 30 COVID-19 patients.
He treated a 77-year-old woman with Parkinson’s dementia, whose husband, her caregiver, was hospitalized with COVID-19. She also tested positive but was asymptomatic. She was going to be placed in a nursing home until her husband recovered; however, as Holmes noted, “there is no guarantee.”
One of the hardest parts about treating COVID-19, Holmes said, was the no-visitor policy. “The no-visitor policy is understandable and needed, but I still feel badly that so many people are seriously ill and can’t be visited by family or friends. Too often, when people bring their loved one to the ER, that’s the last time they ever see them alive. During the day, when I had time, I would try to check in on a few patients whom I had seen in the ER to see how they’re doing and just listen to what they wanted to talk about.
“One patient I saw in the ER was a woman in her 60s with a beautiful Caribbean accent. At home, she felt weak, had a cough and was short of breath. Her children, who live out of town, tried calling several times. She didn’t answer because she didn’t have the energy. When they couldn’t reach her, they called the police, who checked on her. They called the ambulance. Not surprisingly, her COVID test came back positive.”
Once transferred to a medical floor, she was no longer under Holmes’ care, but he made social visits almost every day.
“There wasn’t much I could do about the COVID. She was on oxygen and receiving good medical care. However, I wondered if just by listening to her and encouraging her, I could help alleviate some of her anxiety. Here are some of the things she shared with me: She has six kids (five girls and one boy) and several grandkids. She’s been married for over 40 years. When I asked her what was the secret to marriage, she said, ‘We fight. We wake up. We patch up … and then we fight again, and wake up and patch up and on it goes.’
“When I asked her what helps her cope, she said, ‘Talking with you. We all need to talk to someone.’ At the end of one visit, I asked her if she wanted to pray and she did. We prayed to cast all her burdens upon the Lord, including coronavirus, and that God would take care of her and help her to overcome this illness.
“She told me about how, as a child, she really wanted to be a nurse but her family struggled financially and could not afford nursing school. Eventually, she became a certified nurse’s aide. However, now at age 64, she’s talking about maybe trying to go to nursing school to fulfill her childhood dream. She had good things to say about the nurses at Woodhull and how well they cared for her. I think they may have inspired her and re-ignited her desire to become a nurse.”
Little by little, Holmes saw that her condition began to improve, and her oxygen requirement went down from 15 liters per minute to just 2 liters per minute.
“During our last visit together, she gave me a colorful $50 bill from her home country as a gift worth a few cents in U.S. dollars,” he said. “On the bill she wrote ‘To My Dr. God. bless u. Keep up the good work.’ And she signed her name to it. That was a very special gift. I’m sure it was full of coronavirus, so I had to be careful about handling it, but I greatly appreciated it and her kindness.”
Looking back on his shifts at Woodhull, Holmes recalled a recurring frustration. “I wish I knew how to manage vents and care for critically ill patients because that was what was needed most there. Hopefully, more pulmonologists and critical care specialists will come help out at Woodhull and the many other hospitals that desperately need the same kind of help. The needs are so great and I feel that anything I do is just a drop in the bucket,” he said.
“However, I’m learning to be content, knowing that we may have different types of training and skill sets, but we all have a part to play. If everyone is putting their drop in the bucket, then soon it will be full and the need will be met.
“During my time at Woodhull, I’ve learned a lot about COVID management. I’ve also learned how incredible the doctors and other staff at this hospital are – the ones who are here full time and have been working so hard for so long to keep patients alive. Some have gotten sick with COVID themselves and a couple have died.
“Yet, those who are able keep coming to work and keep persevering with a positive attitude and genuine concern for the well-being of their patients and each other,” he said.
“These are amazing people. It is a privilege to have been able to work with them and learn from them.”