As regular readers know, I have worked as a paramedic in New York City for over 25 years. Covid was the hardest challenge of my career, by far. It was the challenge of the century to our healthcare system (and our society). Controversy rages around Governor Cuomo’s management. Actually, I wish it were. Controversy is conspicuously quiet in many media circles, and is being eclipsed by his sophomoric sexual conduct.
Early on, in our pandemic management, it was clear to me we were not using an approach based on objective, evolutionary medicine. For the sake of blog brevity, I will confine this point only to cardiac arrest resuscitation.
Getting some necessary science out of the way: we have a solid chance of restoring to acceptable brain function someone who goes into cardiac arrest from some things, but not most. As I teach my students: most of the things that will put a person into cardiac arrest are by definition deadly. In an arrest, we must try to fix that deadly thing, WHILE also trying to fix the cardiac arrest. In a non-Covid cardiac arrest, we are able to resuscitate around 6% of patients. Restoring someone in cardiac arrest from trauma is a true rarity. Resuscitating a patient who died from Covid could not be done, according to the largest study done on it.
Yet we had so many cardiac arrests from nursing homes (I had two in a row, one day), that I actually asked our senior doctor if there might have been some perverse agenda (a scientist, he didn’t want to speculate). The nursing home medical directors (all physicians) know the stark facts of cardiac arrest just as well as we do. They knew, as well as everyone in medicine (or who doesn’t live in a hermit cave), that the healthcare system’s decisive battle for survival was in “flattening the curve,” which meant trying to mitigate the flow of patients to the EDs, so our rationed resources would not be overwhelmed by too many sick patients at once. I took many, many risks to my career doing my best to put this goal into practice. We knew we would get those patients eventually, but we wanted them spread out, to buy time. Trust me to say that our system was very close to complete failure. Failure would have been what happened in Italy, when they had to move old patients off ventilators to provide them for their young ones. Yet the nursing homes staff would not allow patients to expire, despite the insurmountable odds of our being able to help them.
It seems we have evidence of that perverse agenda: the Governor had an incentive to hide the nursing home mortality, with the result that it was nearly 50% higher than we thought it was. “We thought” is also highly relevant to his negligence: all clinicians managing the pandemic relied on the State’s data. Altering it is the equivalent of telling submarine hunters there are 50% fewer U-boats in wartime. As I wrote in the Gamestop vigilantes piece, the perception of corruption is just as important as the corruption itself. Another corrupt conflict of interests involves Cuomo’s acceptance of campaign contributions from the nursing homes while granting them immunity from Covid liability.
All the perverse agendas makes Cuomo’s dismissal of “what difference does it make,” (where patients die) fatally fatuous. Before the news of the nursing home perverse agendas emerged, the argument was merely fatuous: if you were told your loved one died in the desert, your assumptions would be different than if you were told they died in an ICU. And the assumptions would be different again, if we learned of excessive mortality because of political decisions no clinician would make. If our justice system is not completely corrupted, the difference will be between disgrace and criminality: If Rick Schneider can be indicted for the Flint water crisis, surely we have precedent enough for a criminal case against Cuomo (assuming the facts remain as they seem).
About those decisions: the doctors of the Medical Advisory Committee of the City of New York, who oversee all EMS operations, everything we paramedics do, must bow to the decisions of the Governor. Irrespective of how right they are, of how experienced they are, or how wrong they knew the Governor was. This pedantic point was endlessly hammered by the media in criticism of President Trumps’ competency in managing the pandemic (and rightly so). The sea of ink spilled in covering how President Trump could not find advisors he could work with because of his volatility (again, rightly so), contrasts amazingly with the media failure to report on the same problem with Cuomo during the nursing home scandal. We should have had an alarm about Cuomo’s judgement when a procession of clinician advisors resigned. Where do alarms come from, but from the media? Here we have another conflict of interest, with the media touting Cuomo as the country’s savior against the Bad Orange Man, and awarding him an Emmy. Add his brother anchoring the entity most likely to sound that alarm.
Which brings us to killing me: there are no medical procedures that spread Covid like an attempt at a resuscitation. CPR and mechanical ventilation (artificial breathing) of any type creates clouds of Covid. Unnecessary CPR definitely mattered to me, and it definitely mattered to a patient who might otherwise have needed a hospital bed. And it mattered very much to a patient holed up at home with a serious illness, trying to stay out of the healthcare system, out of civic duty, doing what they were told by the Governor. If there was a perverse agenda in making it look like patients were dying in the hospital, rather than in the nursing homes, where they passed on matters a great deal.
To protect myself, in my decontamination procedures, I had to acquire the equivalent of OCD. I messed up my iPhone by drowning it constantly in disinfectant. Clinicians in the United States saw how many clinicians in Italy fell, and they are at the top of the heroes’ pantheon for buying us the time we needed to get our own procedures ready. Which worked. Few of us got the disease, thank God. But the nursing home decision, incomprehensible as it was at the time (the subject of a future piece) might have undone anyone caring for that patient.
My hope is that justice to all the unnecessary, unbearable loss is upheld. But I’m not holding my breath.
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I just thank the Good Lord Above that I live in a sane state. Gov. DeSantis has actually done a good job.