Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

COVID-19 April 7, 2020 update

AMA Chief Experience Officer Todd Unger speaks with Omar Maniya, MD, MBA, an emergency resident physician on updates regarding COVID-19 including what it's like being on the frontline of the COVID-19 pandemic in the city of New York.

Learn more at the AMA COVID-19 resource center.

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Unger: Hello, this is the American Medical Association's COVID-19 update.

Today we have a special guest, Dr. Omar Maniya, who is currently working in the epicenter of the COVID-19 crisis in New York City. He's an emergency medicine resident physician on the front lines and the immediate past president of the Emergency Medicine Resident Association and the former student representative to the Board of Trustees of the American Medical Association. I'm Todd Unger, AMA's chief experience officer in Chicago.

First Dr. Maniya, I want to thank you for being here today with us. I know you're working really hard, and I can't imagine the tolls your days must be taking on you. We appreciate you taking the time here. Why don't you start by telling me a little bit about how life is going for you right now?

Dr. Maniya: Thanks, Todd. Well, since the last time we met, I have shaved my beard and kept my corona ‘stache so that my N95 and my PPE fits nicely. And I just finished up a string of five nights, so forgive me if I'm a little too honest.

Unger: Well, I appreciate that. You said you haven't slept in quite some time, and this is the only thing standing between you and that sleep. So I appreciate you doing that right now, and I'm glad to see you still have your sense of humor.

Dr. Maniya: Of course, I mean, this is important, sharing the stories. I think New York is, in some ways, a look into the future because what's happening here, where we're about to crest in our peak as the data shows and my experience says, that experience is going to happen all over the country. And so hopefully the rest of the country will be more prepared than we were.

In New York City, man, it has been crazy. Our ED usually sees 200 patients a day. We're now seeing maybe 400 patients a day, and 90%, 95% of them, anecdotally, are coronavirus patients. And, wow, are these patients sick.

I mean, yes you have your group of patients who is the worried well who're coming in for testing. Luckily testing sites have finally been set up, and so they can go elsewhere for that. But the result of that is the ones coming to the hospital and ones coming to the ED are really, really sick.

I mean I have never seen oxygen levels, O2 stats of 30%, 40%, 50% regularly every few minutes coming into triage, and that's what's happening. And these patients are so sick that you put them on a CPAP mask or you put them on a non-rebreather. And you take it off to give them a sip of water, and boom, their oxygen tanks again. And they're really sensitive.

Now just to give you a picture, I'll tell you about last night's shift, so in one part of our ER we have space for 15 patients. But it's a parking lot of stretchers now, and we squeeze in 85.

Unger: Wow.

Dr. Maniya: There's so many patients there, we can't even find places to stick new stretchers.

In a different part of our ER, the part I was working last night, we've turned into an ICU because our ICU volume has gone up by 10x. And so, basically, it's a glorified hallway, and we got 26 patients just stacked side by side by side. All of them are intubated or about to be intubated, and you're just running around trying to keep people alive. It's pretty intense.

Unger: The PPE shortages that have plagued nearly all of America at this point, are you still seeing those in action where you are?

Dr. Maniya: Luckily, no, not right now. I think that's probably because of a lot of the news coverage, a lot of donations that have been happening, but I think PPE is just part of the problem, right?

PPE talks only about what I have on my body, but protecting healthcare workers, I would argue, we need to take a much broader definition. And so a lot of the space challenges and supply challenges we have, those things affect our health and wellbeing just as much as the N95 on my face.

So I'll give you an example: Whenever you intubate a patient, and you put them on a breathing mask, if they don't have a filter, you're taking air directly from the depths of their lungs and just spewing it out into the air. And we're having shortages on those viral filters. And there isn't any hard data on this, but that's probably pretty high up there in importance with having an N95 mask.

Space is another issue. If you could have a single room with negative pressure, you can dramatically decrease, theoretically, the amount of virus that's in the air, but when you're putting 26 people in a hallway all intubated, some of them spewing virus into the air, does an N95 really matter at that point? I don't know. Certainly doesn't feel that safe.

Unger: So how are you navigating this emotionally from your own wellbeing standpoint every day in the trenches? Or for you it sounds like it's been every night, overnight. What is this like for you?

Dr. Maniya: It's intense. In a certain way, it's exciting because I went into emergency medicine because I love this. I love the opportunity to really change people's lives by doing a few quick things in the emergency department and changing the trajectory of their disease, and so that's been exciting intellectually and educationally. But man, it's just grueling. It's never-ending. You feel like you're not even—

I was talking to my attending last night, and we were joking we're playing whack-a-mole with sick patients. And later we talked about it as it's like the Titanic sinking, and there's a leak in the hall and we're trying to plug it with our fingers. Yeah, we're stopping a couple drops, but the whole ship is sinking.

Unger: I saw the news today that New York cases, or at least the deaths, had at least for two days held at about 600. Is that something you're feeling? That's a very high level as Governor Cuomo pointed out for a peak, so still a big area of concern.

Dr. Maniya: Yeah, I think that's reflected in my experience as well on the ground. Our new arrivals have plummeted, and so it seems like we're peaking. And now it seems like the big challenge is the backlog of patients and trying to provide good care for them.

Everyone talks about coronavirus and providing supportive care because there's no magic treatment. Supportive care, well supportive care is really hard. Supportive care is a week or two or three on event where you have to turn the patients yourself, you have to breathe for them, you have to feed them, you have to check their electrolytes, you have to do all of those things, and that takes a lot of manpower. That's really time intensive.

And what's interesting to me is that in many ways our healthcare system was really broken to begin with and just barely squeaking by. And so you throw this stress on it, and it blows up. I think the AMA did a study a couple years ago where they found that only 27%, so only a quarter of a physician's time was actually patient care. The rest was administrative burdens.

And so when we talk about things like bed shortages or physician shortages or other staffing shortages, the numbers look a lot worse when you consider that only a quarter of a doctor's time are they actually even providing care, especially the type of time intensive care that this virus demands.

Unger: Yes, those kinds of burdens, I know we were working to confront them on the fastest route possible. Hopefully you're seeing some of the effects of that on your end. Let me ask you, I know you been recently married, and what happens when you go home? Are you afraid of that, and how's your wife taking it?

Dr. Maniya: I had rules placed upon me for good reason. I take all my stuff off outside and take a shower to try to minimize contamination, but even given all of that, four weeks ago, a couple of weeks into the crisis, I got coronavirus. And I was real sick for three days, quarantined for a week, and about a week later, despite all of our social and physical distancing techniques, my wife got sick too.

Luckily, we're both fine, and we recovered well. We had a little home pulse oximeter where we were checking our pulse oxes, make sure they were in the mid to high 90s, but that just shows how contagious this disease is. I mean you can wipe down all the surfaces, you can try to stay six feet apart, but that doesn't guarantee you're not going to get it. I really think that people need to take this as seriously as possible because, man, this thing is bad.

Unger: Yeah, are you surprised that there are still some states out there that are not using shelter in place orders or allowing still groups to congregate and things like that?

Dr. Maniya: That blows my mind. I don't understand how. What I love about New York is Governor Cuomo came out very aggressive and very early in both the social distancing but also in the regulatory relief documentation, malpractice and licensure and scope of practice.

And so we have, like, ophthalmologists, neurosurgeons, dermatologists, podiatrists, dentists helping out in the ED and the ICUs in the hospital, and without all of those people, it would be so much worse. And that's a good example of regulatory relief helping us out.

But I do not understand how states and cities, how a couple across the country, still have not taken this as seriously as they need to because everything you're doing now is affecting you two or three weeks from now.

Unger: Yeah.

Dr. Maniya: And so making a decision based on your data today just makes no sense. You have to—

Unger: What kind of advice would you have for your fellow residents in different parts of the country? Maybe haven't experienced, obviously, what you have over the past several weeks. What kinds of advice would you give them to prepare themselves?

Dr. Maniya: So I think there's two levels. There's things you can do to prepare, and then there's things you can do to help your program or hospital prepare.

On a personal level, I wish I had really, really familiarized myself with supplies, and it doesn't sound that exciting. No one goes to residency to play Legos, but that's what I'm doing all day.

We're using seven or eight different vents. Each has different tubing, each has different masks, and the little connector thingies don't fade into the others. And then you're scrambling around looking for Lego pieces, these little connectors that fit in, and Googling user manuals. And it would be much better to do that two weeks ago than today. So really familiarizing yourself with your supplies I think can go a long way to making your day go by easier.

On a program or more institutional level, one thing that's been great, where I'm at, is they've been very open to feedback, and they've recognized that, "Hey, we're not going to get this right the first time. Give us feedback, and let's just keep rapid iterating."

And there's not enough of that in healthcare. Historically, as you know, medicine has been probably the least innovative industry in the world, particularly American healthcare. And so this is an opportunity to change that and to improve that. And so I think I've seen a lot of residents and medical students start PPE drives and been really successful, raised $50,000, $60,000, $100,000, and that's great. But now let's apply that to things like the flow in the hospital, to other supply shortages because it's kind of like a domino effect in PPE. I think, from what I'm seeing, was just the first domino of no shortage.

Unger: Dr. Maniya, I cannot tell you how grateful we are that you took the time out of what is a very, very intense day to talk with us and share your experience with our audience. You are a hero in my book, and I'm really proud of you. I'm really grateful for the work that you and all of your colleagues are out there doing, so thanks for spending time with us.

That's it for today's COVID-19 update. I want to thank you, Dr. Maniya, again.

Everyone, we'll be back with another segment tomorrow. In the meantime, if you have any questions about COVID-19 please use the AMA resource center at ama-assn.org/covid-19.

Thanks for joining us.

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