Linda Ohler, MSN, FAAN and Sapna Mehta, MD from New York University discuss the impact of COVID on patients and hospital staff in New York

00:04 Can I just test one more time? Can I hear you?

00:07 Yes. Can you hear me?

00:09 My name is Linda Ohler. Today is Monday, April 1, 2024. I would like to introduce you to Doctor Sapna Mehta, a transplant infectious disease physician at New York University in Manhattan. Doctor Mehta was probably one of the busiest clinicians in New York as Covid arrived in our city. Transplant patients already have a weakened immune system. With the medication they take to decrease the risk of rejection, that weakened immune system puts them at greater risk for infection. Keeping them safe during the pandemic was a major focus of our transplant teams, especially that of Doctor Mehta. Doctor Mehta, could you please start by describing the greatest challenges you experienced beginning in March of 2020?

01:04 Yes. Thanks. I think the most difficult aspect to the onset of the pandemic was dealing with a novel infection for which we also did not have readily available treatments. And it was a very unique situation, even for our multidisciplinary transplant team that is used to taking care of very critically ill patients who are often on the brink of life or death decision making situations prior to organ transplantation. Yet we were dealing with a new pathogen that made people sick very, very quickly, and we didn't have any treatments that we knew would work, and we had very little to offer from even the initial treatments that we thought might work based on information being shared from other parts of the world. And so that was the most difficult thing is trying to take care of people essentially without any tools that at our disposable. In those first months.

02:15 When you learned of cases in China and Washington state, did you have any discussions with your team or your department about what you might be able to do if it hit New York? I don't think we knew it was going to hit quite that fast and that hard. But did you have any discussions with your department at that particular time or the transplant team?

02:38 Yes, I did have discussions with our leadership team of transplant, as well as at the time, our transplant infectious disease team was a small team, but amongst ourselves and also the hospital leadership. So our chief hospital epidemiologists and that entire team who had been sharing what data was coming through the World Health Organization and other news forum in those early months of 2020. And we didn't know if it would reach us, but we realized pretty quickly we would need to prepare for that possibility and started to talk about how, you know, what we would need to do. And that really included developing a network of institutional leaders, again, our hospital epidemiologists, ourselves in terms of the transplant team, and also the transplant community across the country and also across the world.

03:47 At what point did you realize that the pandemic had arrived in New York?

03:53 Yes, I remember the first patient who was potential was suspected of potentially having Covid-19 Bellevue hospital. And my colleague, who was actually on call for the transplant team one weekend called me to see if I might be able to help round on the patients that day because she needed to go and address what was happening at Bellevue as the hospital epidemiologist for that hospital. And that's when I knew that even if that patient in particular didn't have Covid, that it was really probably a matter of time before we saw cases in New York again. The global connectedness of our world, and in particular New York.

04:42 How many infectious disease physicians are actually in your department?

04:48 Currently, we have five full time transplant infectious disease physicians.

04:53 But in the whole id department, how many are there?

04:56 Oh, gosh. We have a large division across four hospitals, two NYU Lingon hospitals that comprise our academic division, as well as Bellevue Hospital and the Manhattan Va. I would say there are over 45 faculty members who are clinical faculty members.

05:18 So were you communicating with any other infectious disease specialists at other transplant hospitals in New York?

05:25 Yes, I'm a part of a few communities and networks of transplant infectious disease physicians. One, of course, is the American Society of Transplantation Communications id community of practice and dialogue there, you know, began in terms of what were people seeing? And, of course, in the early days, there was not too much conversation. Certainly when we started to recognize cases were in New York, and it became very obvious quickly that New York was getting hit hard. You know, our. That that community, you know, was. Was very active. And I would also say our colleagues at the University of Washington in Seattle, really, even before things became apparent in New York, were certainly sharing their experience, really mobilizing. I commend them for what ultimately led to the large registry of national cases, from which we learned quite a bit about Covid-19 then I also am part of a network called the Northeast Transplant ID group. So that was really a lifeline throughout the pandemic and has been for other issues as well. Not just Covid, in terms of communicating, you know, in real time with one another about what we were seeing and.

06:47 What we were trying to do at a different level. Linda and I were actually on the phone every Monday, Wednesday, and Friday with every hospital in New York. Transplant hospital in New York. There were 44 of us on Zoom every single Monday, Wednesday, and Friday for an hour and a half, talking about patient safety and staff safety. And what we were doing for the transplant patients, sounds like we were very fortunate to have those negative airflow rooms in our new hospital, so that was extremely helpful. And then having all these extra in the older hospital that we could put some patients in as well. So sounds like we did okay in that department. But it was really interesting to be able to see there was no competition at all among all of those hospitals in New York. Everybody was just there to do the same thing, patient safety and staff safety. We were looking at strategies each group was doing. So it sounds like you were doing that within the infectious disease community yet we were doing it within more of an administrative type portion of the epidemic.

07:59 Absolutely. I think around the world, you know, the physician community was just trying to communicate whatever they knew, whatever they were seeing, support one another, really virtually, you know, have as much of a meeting of the minds of, you know, what should, what can we do? What should we do? What should we not do also, which became apparent in terms of trying various therapies. And without that, this would have been such a different experience.

08:32 All elective surgeries were canceled at most hospitals in New York, and transplant surgeries were suspended for about six to eight weeks. We weren't doing any transplants. What other patient safeties, measures were being taken that you were aware of?

08:50 Well, we, outside of the hospital, we take care of a very large number of patients in the outpatient setting, and we had to completely pivot as our clinics closed for the first time. And while telemedicine had been around. And actually our lung transplant team had really been, had the most experience with telemedicine as they care for, had been caring for patients at a distance in other parts of New York. We really didn't have telemedicine integrated as a part of how we take care of patients. And that developed very quickly because we needed to take care of patients, and we couldn't just do it by the phone in terms of their ongoing care, their ongoing transplant medication adjustments. As an infectious disease physician, all the other infections did continue as well, particularly ones that our transplant patients experience, which are not necessarily just passed from person to person. So even when you're in lockdown or isolating, you can have reactivation of infections, which have nothing to do with whether you're around other people or not. And we needed to take care of people and safely, and certainly we couldn't bring them into the clinic. So that was a major endeavor, which is to implement telemedicine for outpatient care. And while that was in progress, we really developed and I'm very proud of all of the disciplines across our transplant team that developed a really rigorous phone and on call system to receive calls from patients, to monitor patients, find out how patients could get labs, and then, of course, keep patients safe in terms of where they could get testing for Covid, a triage system for when to direct people to the emergency room, balancing how full emergency rooms were. And at that time, at the peak of the pandemic in New York, a.

10:44 Lot of people were. A lot of our transplant team members were deployed to other areas because we weren't doing any transplants. How did you guys. I'm sorry, say, you guys, how did your team, your infectious disease team manage with. You couldn't do it with just one person on call. You must have had call almost every night.

11:09 That's right. So it was me and my colleague and that we basically, in the early days, divided the service, inpatient service, into people who had Covid and people who didn't, because we certainly were still taking care of people who were in the hospital for other reasons. And again, as we were still learning so much about transmission of the pathogen, we wanted to be as safe as possible. And we did this on many of our other inpatient transplant teams. For example, the inpatient kidney transplant team, where there would be typically one service with one attending out of precautions, we thought maybe we should have different care teams so that we don't accidentally transmit through, you know, going to see one patient and then the next hour a different patient who doesn't have Covid. Of course, we've since learned that's not necessary. But at the time, we wanted to be as cautious as possible because we didn't have information. And there was also a lot of conflicting information emerging, you know, around the world. And so we organize ourselves that way. But coming back to your main question for infectious disease, it was the two of us. So we were working every day in the hospital, and we alternated weekends in terms of who was seeing all of the patients in the hospital. So we could try to have every other weekend off or at least to be doing work like we did with you, reviewing cases and. And things that, you know, we're not face to face patient care, but developing our policies, our protocols, reviewing our cases, contributing them to the University of Washington registry. And we really tried to do that on the weekends. And, of course, you know, it was so difficult that everybody needs respite at some point. So that's really how we carried on from March until, you know, the beginning of June for transplant, infectious disease. And. And I would say that we also maintained, while many of our physicians and surgeons were deployed to various care units for Covid, we did maintain a core group from each organ team that continued all of the inpatient transplant care, and that would include at least one surgeon and many of the specialty physicians.

13:21 Describe any research that was started to study the effects of the medications. I know you were doing some research, too, and that must have been very difficult with all of your other things to balance during that, to get this research going. Tell me a little bit about that.

13:39 Sure. So, in the beginning, we really tried to describe our cases, because we really did not know whether immunocompromised patients would have more severe illness from Covid-19 the same. Or there was also the hypothesis that perhaps less, because they're immunosuppressed, and if this is a really inflammatory disease, maybe you can't mount that kind of inflammatory response, so maybe you won't get as sick. These are all the hypotheses as the pandemic started. And so in the beginning, we tried to describe our cases through case reports to really just get information out there for, again, people who. And I think people did benefit from some of those early case series before much of the rest of the United States had a surge in their cases, such as the south and the Midwest, which certainly did occur in subsequent months. In terms of therapies. You know, I think we knew very early on that we don't know what works, and we're not going to find out what works unless we do this in a rigorous manner. And that typically involves multicenter studies. So NYU, as an institution, mobilized very quickly to spearhead or participate in various important trials, including evaluating remdesivir and antiviral, that we continue to use to this day to treat Covid as well as monoclonal antibodies. We even had a really novel study where one of our highly astute and skilled kidney transplant surgeons developed with an agent that actually had been initially developed as part of antibody mediated rejection treatment. But through understanding the mechanism of action, had a potential role to treat Covid early and prevent the severe Covid-19 that, you know, also led to a lot of deaths. And that all started at NYU, and it was a 24 hours, seven, you know, operation. So it was a lot of. It was effort from a lot of team members, and different team members were leads on different studies. And we. But again, we tried to prioritize participating in multicenter studies where we knew that's where we would be able to contribute and learn the most in regards to treatment and outcomes.

16:14 Well, that's a lot of data to collect. So how did you do that? It seems that we had some medical students maybe working with us, too.

16:22 We did. And you were such an integral part of that as well. And, you know, it was all hands on deck. So we had many faculty, house staff, trainees. So that's residents and fellows who wanted to help, who are interested. Medical students who were very proactive and enthusiastic because their entire medical school experience, it also pivoted, and they, they were really instrumental in helping review cases. Have our organized database. You know, we wanted to ensure integrity of data. So we had a system of not just data entry, but also, you know, review of the data by a different person to make sure that the data collection is accurate. Because I think one thing we know is when people are very busy and in a type of crisis situation, you know, we, we need all the eyes and ears to ensure that, you know, there, there are not errors.

17:18 One of the things we were collecting that I thought was really interesting, in addition to all the inflammatory labs and data that we were collecting along those lines, the medical lab, I thought it was really interesting that we were also collecting zip codes and that you could see pockets of the high incidence of COVID in areas of Brooklyn and Bronx. And it was really interesting to see all of that.

17:48 Yes, it was.

17:54 Let's see. Next question is, NYU School of Medicine and School of Nursing graduated seniors a few weeks early to help out in the hospitals. Did any of these students work with you?

18:08 Excuse me. Let me just get a glass of water. Excuse me.

18:16 Sure.

18:25 No, not directly on our transplant service, but I know that they were working throughout the medicine floors and also, I believe, in some areas of the ICU as part of taking care of patients with COVID And so I certainly saw them behind PPE, but they were not directly on our transplant teams.

18:48 What did you do to maintain and care for your own mental health during this time? Because you were really stretched?

18:57 Yes. You know, I think that it was difficult, and I think in the beginning also, you know, you just have worry, and we all had worry about ourselves, too, and our families. I'm also a mom, so two sons who were pretty young at the time, and, you know, just worried about my spouse and my kids and, you know, whether I was putting them at risk coming home. And it was challenging to live in the city when the schools closed and the playgrounds and the parks closed, and, you know, how to take care of your kids and keep them healthy as well. You know what? My. My spouse was invaluable, valuable support, you know, during that time. But it was stressful for both of us, I think, you know, the support of other physician colleagues around the country and around the world really helps. And I can give you an example. One of the things that was hardest in the early weeks is that you're taking care of patients all day long, yet you need to scour all of the influx of information which was coming on very unconventional platforms. We never looked to Facebook, for example, to find information about, you know, how to take care of patients. But from a small town in Italy, that's where one of the first hospitalist reports, reports of, you know, the severity of this illness in large numbers was posted, was on a Facebook post. And. And so, you know, as you're going through your work day taking care of patients in front of you, you had to find a way to read what was emerging around the world and process it and then discuss it with other colleagues to see what is actually good information versus not really substantiated. I actually have an infectious disease friend who works in Sydney, and she takes care of transplant patients there. We train together at NYU. And, you know, one of the things we did early on, because we have the flip flop time zones, is that anything that before I would go to bed, anything that I kind of learned as high level, you know, news and information or studies, I would email to her so that when she was starting her day, she benefited from, you know, that without having to re scour the information, and she would do the same at the end of her day. And again, we trust one another in terms of knowledge base. And it was. It's just a small example of how, you know, your friends and colleagues in your area of work were just a huge network. And part of that was also checking in on one another. And, you know, all of my physician friends, whether in New York or outside of New York, stayed connected. And those messages and those sort of words of support and reaching out to one another, even if it was just text messages, really helped. And then, you know, I think prioritizing sleep, I think the New York City community was incredible in terms of providing food delivery to the hospitals and the places we were working for physicians and nurses. And then really, you know, an important part was just when you were able to get a day off, you know, to get outside and be with your loved ones. And that's what I tried to do.

22:24 You did? I'm glad to hear that. I didn't think you ever took time off. So I'm really glad to hear that you did, because that was very stressful period of time, especially for you.

22:35 I will say that one thing that was amazing is I love to ride my bike and to ride your bike through New York City during some of those weeks where you could literally ride down an avenue, they were empty streets, really had an exhilarating feeling that was relaxation.

22:52 Any thoughts of how we can better manage disinformation? That became rampant, it seems, about vaccines and Covid, have you had any thoughts about that?

23:04 I think that, yes, I think there's a lot that we still need to learn from that. And I'm really happy to see that in the last year or two, there's really been some very proactive reflection about what things could have been done differently. And I know the infectious disease community worldwide is continuing that dialogue. I attended the european infectious disease meeting, which is called ecmid, last spring, about a year ago, and those discussions were part of plenary sessions. And I think they're very important because one of the things that is so challenging in a crisis situation is how to keep unnecessary panic while helping people prepare for what is a very urgent situation and requires such drastic change in, you know, our way of living, in our behavior. And something that was highly recommended in the beginning was to be black or white to people because the gray zones and the nuances were too confusing for people. So you needed to just say, like, stay this far apart, wear your mask in these situations. You know, Covid spreads through this, but not this way, and just keep it very black and white. But I think what happened over the subsequent months and years is that as we learn more about the virus and those absolute black and white points, you know, change because of what we learned about the virus, the, the public lost confidence in those initial public health messages that were given. And I think there's a role for saying we don't know, and a little bit more of explanation of why this is chosen based on what we know right now. And I think that there was some of that, but I think we could have done more around that, and then we would have had perhaps less backlash later as we retreated from certain measures that we thought were critical in the beginning but actually were not that important or maybe were important when cases were at a certain level, theres a certain degree of transmission or before there had been really exposures in the community or vaccine related immunity. And I think its hard to know how to do that well. But I think thats an area we need to reflect on more and more. And practice sort of our language in terms of how do you communicate scientific and medical information to people who may not be professionals in that area, but can still understand, you know, the basics of what's coming behind that message. And so we need to find the right language rather than keeping it too simple and too black and white, when we know that in a month we may need to pivot and change based on new information or a change in the number of cases in the community.

26:26 Along those same lines, what lessons did we learn that we are going to apply to future issues? I mean, New York has been hit with Hurricane Sandy, and NYU especially had to evacuate because the East river decided to come into the building. And then we also had 911. Now we have the pandemic, and we were the epicenter for that. What would we do differently if this came along? It seems like we learned a lot from this. There were a lot of positive, better understanding of all of this, as you were explaining.

27:06 Well, I think we've really learned how to temporarily take care of patients at a distance, which can help any sort of natural disaster or, God forbid, another pandemic. And we really didn't have that in the way that we have now. We always hope it's only for the short term, because even now it's not ideal for all forms of care. But it's certainly in a crisis situation, you can at least stay connected to patients, see them, visualize them, deliver care, and that includes how not just seeing your provider, but how labs can get drawn at home for a period of time. These things are not cost effective to do, you know, forever or every day for every patient. But again, how to deploy those kinds of services to keep people safe, to keep people from dying, is really important. And that's an important part of the medical care delivery that I think we've learned from the pandemic in the United States.

28:08 We had to submit a playbook for the next pandemic or next emergency that ever hit. So we had to submit that to the Department of Health at the end of all of this, which I thought was interesting, and they were involved in a lot of our calls working with us. So that was interesting. Anything that I didn't ask you that you would like to share about this experience?

28:35 You know, I just think that what was very challenging for the entire healthcare community, whatever part of really working in a hospital or a clinic that a team member may be a part of, was that it went on for much longer than we expected, certainly in New York City. I won't speak to all parts of the world, but it went on much longer than expected, and healthcare workers really didn't have a reprieve for quite some time. It was very difficult to take any time off, even once the surge, as we refer to it in New York City, was over, because then you finally were able to have patients return for other care, which was behind, and that was a very large volume of care. We also had, you know, a fair number of people who left the healthcare workforce. Anytime someone developed Covid and was a healthcare worker, you had a required isolation period. So the ability for people to take time off, to take care of themselves or their loved ones became very difficult. And I also think for their own mental health. And I think that we can't underestimate the effect of that on even the most resilient of people and most experienced of professionals. And I also just want to say that I cannot imagine what it was like for the mental health professionals in our country during this time, because they were invaluable and in such high demand and certainly didn't have respite, and probably still to this day, don't have, and we don't, in this country, have enough mental health professionals as it is, much less for a situation like this. And they were certainly on 24/7 in their discipline. And I think that that's really important to know about the experience in the US.

30:29 It was interesting that as we were talking the 14 different hospitals, we found that almost each one of us had set up a room where people could go in and, you know, on a break and just go in and talk to a mental health person that was set up in almost every one of the hospitals someplace so that nurses or doctors could just go in and just kind of have a cup of tea or just talk for a few minutes about kind of unwinding. And another thing that I have found interesting, and this is a little bit on a personal level, is my grandson was a yemenite high school senior during this, and he was going to go to college and study engineering, but this changed his whole way of thinking. He's now working on his master's in public health, plans to get a PhD in public health, and plans to be the head of the CDC. So, wow, that's great. That's his goal. But I just think it's interesting how it impacted on high school kids. I thought that was very fascinating, that he changed everything after this happened and decided to go into public health.

31:46 Yeah, I can only imagine. And it's so nice to hear things like that in terms of how it influenced people on their decision career wise. I think some of us worry that people would see what they saw in the news and say, like, wow, I really don't want to be a part of that. And we need a continued talent and minds coming into healthcare. And as it is, you know, we don't have as large of a workforce as we should for our population in this country. And I think people saw on tv at least, and on social media, situations of distress in healthcare, in hospitals around the country. And I wondered at times, does that inspire young people want to go into this now? Actually, everyone actually knows what an infectious disease physician is. I know parties have to explain what I do because everyone has seen Tony Fauci and knows that that's a specialty, and that could perhaps inspire people to go into this field they didn't know about. But I did also wonder if just what they saw could also deter people from wanting to go into a profession where you might find yourself in that kind of situation. So I'm really glad to hear that. About your.

33:07 And the schools of nursing have been. We've had to turn students away at several universities because we didn't have enough faculty for all the people that found this to be something they wanted to do, you know, and hearing about it. So that was, I thought, very positive, too. So I was pleased to hear that.

33:27 That's great.

33:29 Is there anything else you'd like to add before we close? I really appreciate your taking the time to do this today.

33:36 No, thank you. It's so nice to see you because, you know, you are a huge part of my pandemic experience, and, you know, were an important part of our planning in those early stages and getting through the months of the pandemic. And, you know, you brought up research, and we couldn't have done a lot of what we were able to accomplish without your participation and work in it.

34:01 I was deployed to infectious disease. I even asked for it. So thank you so much. I really appreciate this. I will let you know when this is available to see. Okay, thank you. Thank you. Hi to all my colleagues.

34:18 I will thank you.