Interventional neuroradiology in the time of plague: New York City, Spring 2020

What's true of all the evils in the world is true of plague as well. It helps men to rise above themselves.—Dr. Bernard Rieux, Albert Camus, The Plague (La Peste). ¹

The drumbeat of impending crisis began in January—marked first by the nervous retelling of ambiguous news from distant places—then rising to a nagging expectation as first-hand accounts from close friends in Italy raised the alarm. We did not have long to wait.

Orders! … When what's needed is imagination.—Jean Tarrou, Albert Camus, The Plague. ¹

Early March proceeded as if through the “fog of inevitable conflict” as indeterminate resignation devolved quickly into hapless efforts to address a fast-changing chaotic situation. Restrictions, policies, directives on every level—from hospital, city, state, and federal agencies—changed with maddening rapidity. Fraught with uncertain availability of essential supplies: surgical masks, gloves, gowns, medicines, as well as the more sophisticated personal protective equipment—N95s and ventilators, each hospital undertook its own preparations, leading to unfortunate disparities in material, staffing, or funds to procure additional critical equipment and medication. These issues would play out on a world stage over subsequent months—inciting political and medical disputes over innumerable issues: supply chains, governmental and organizational responsibilities, the availability, hazards, and effectiveness of various treatments. ²

Why, that's not difficult! Plague is here and we’ve got to make a stand, that's obvious.—M. Grand, Albert Camus, The Plague. ¹

Initially, at New York University (NYU), we divided the neurointerventional service into two fully staffed independent groups—nurse practitioner, fellow, and attending—planning to rotate the groups on a weekly basis, with the off-group having no hospital duties, thus, it was hoped, reducing the probability of pan-group exposure to the virus. For a variety of reasons, this scheme did not work, as multiple staff members were either reassigned or volunteered for direct medical duties on the ever-proliferating COVID-19 units.

By early April, New York City was the COVID-19 capital of the world. The largest public hospital system—Health and Hospitals Corporation (HHC), responsible for the care of the indigent, uninsured, and undocumented individuals—faced indescribable pressures. Our group staffed the INR services at its flagship hospital—Bellevue—a transfer destination for much of HHC’s cerebrovascular disease. Despite critical shortages, Bellevue continued to function as a neurovascular transfer center throughout the crisis. That we were able to continue INR coverage there with a skeleton crew was, in truth, possible principally because of the collapse in our overall neurovascular case volume. Much has been written about ischemic and hemorrhagic stroke during COVID-19,^3,4 and needs not to be repeated. Less has been said about the role of INR services in the context of an infectious disease pandemic. For us, it was a limited role indeed. Despite important coverage of COVID-related neurovascular complications in the academic and lay press, as well as various online media—neurovascular issues (certainly neurovascular issues which might have benefited from our interventions) were dwarfed by the overwhelming non-neurologic medical burdens thrust upon the hospital system by the pandemic. Moreover, the majority of COVID patients requiring our interventions were compromised by multiple co-morbidities, central among them, a quite serious pulmonary disease; and, in the end, we snatched precious few from their fate. By the end of March, our usual INR volume of 115–125 cases per month had dropped to 63, by the end of April—39.

It may seem a ridiculous idea, but the only way to fight the plague is with common decency.

What do you mean by common decency?

…Doing my job.—exchange between Dr. Rieux and M. Rambert, Albert Camus, The Plague.

By early April, COVID-19 admissions to NYU Langone and Bellevue each had reached 1000 patients/week. The combination of reduced INR volumes and increasing demand for medical staff provided us (including nurse practitioners) the opportunity to volunteer for duties on the subacute medical floors and intensive care units—nearly all of which had been converted to COVID-care by this time. The routine involved rotations of 4 days on, 3 days off, serving as medical interns under the guidance of pulmonologists and critical care intensivists. The experience was humbling—as much as gratifying and educational—serving up a mélange of human experience: suffering, compassion, erudition, and bravery—further connecting each of us to the camaraderie and ideals of our early medical training. Despite the interruption to our routine, we endeavored to maintain academic focus on INR-related issues associated with coronavirus severe acute respiratory syndrome-2 (SARS-2) infection.^3,4 Maksim Shapiro, always mindful of our roles in education and examining our specialty, spearheaded the launch of an online version of our anatomic-interventional neuroradiology (INR) course (BANANA), relabeled: BANANAZ—which in collaboration with Kittipong Srivatanakul—became a Tuesday fixture through early August. BANANAZ provided an international Zoom venue for anatomic review and spirited discussion of case presentations. It continues as a monthly event.

Once the epidemic was diagnosed, the patient had to be evacuated forthwith. Then indeed began “abstraction” and a tussle with the family, who knew they would not see the sick man again until he was dead or cured.—Narrator, Albert Camus, The Plague (1).

A tragic, yet necessary feature of the pandemic was the enforced hospital policy barring family visitation of the sick.^5,6 This had the untoward effect of separating patients from their loved ones and disrupting the flow of information between families and health care providers,^7,8 contributing to the stress of the unknown, and resulting in nursing stations being inundated by calls from family members concerned with the welfare and progress of their hospitalized relatives. Here the institution excelled. Launched by one of the medical attendants afflicted in the early stages of the crisis by coronavirus SARS-2, this irrepressible lady aided by medical students and many radiologists, sidelined by the closure of outpatient imaging sites, initiated a program called FamilyConnect in which volunteers, after rounding by teleconference each morning with providers of an assigned unit, would take charge of calling each patient's family with daily updates—and further arranging videoconference visits between patients and family members at timely intervals. For the families of those most critically affected, the hours speaking with a FamilyConnect volunteer provided the only link to their loved ones—sometimes for months during the long hospitalizations.

All he had gained was to have known the plague and to remember it, to have known friendship and to remember it, to have known affection and to have one day to remember it. All that a man could win in the game of plague and life was knowledge and memory.—Narrator, Albert Camus, The Plague. ¹

By the end of July, with the crisis in New York City abating, we drifted back to earlier habits dictated by our recovering elective practice. What remained of the previous months’ work—the physical and emotional intensity, the successes and losses, the patients, their families, our colleagues—is inscribed for posterity in the record of what had had to be done.