Medical Grand Rounds Focuses on COVID-19 Pandemic

The Department of Internal Medicine Medical Grand Rounds returned after a six-week hiatus to focus on the COVID-19 pandemic.

The April 23, 2020 Medical Grand Rounds entitled, “COVID-19 Clinical Management at Yale: What We’ve Learned So Far,” was presented by Merceditas Villanueva, MD; Maricar Malinis, MD; and Mayanka Tickoo, MD.

Vice Chair for Education & Academic Affairs and Clinical Chief for Infectious Diseases Vincent Quagliarello, MD, said, “These are unprecedented times. Times of unique adaptation, cooperation and resilience that we are witnessing amongst the uncertainty of the COVID epidemic and caring for patients with a disease that is a moving target. We felt it was important to give a Medical Grand Rounds to our group in that vein.”

Villanueva started with the natural history of the disease, epidemiology, clinical presentation, and testing of COVID-19. She was involved in the first diagnostic case at Yale New Haven Hospital (YNHH) and ‘cannot believe how much our world has changed in six short weeks.’

Malinis highlighted treatment options and the treatment algorithm, which has been frequently revised “based on the most up-to-date clinical data, local clinical experience, and expert opinion.” Currently, there is no FDA-approved treatment of the disease. She also reviewed the rationale for the different interventions and current active clinical trials at Yale School of Medicine.

Tickoo presented management of critically ill COVID-19 patients in the intensive care unit (ICU). She discussed respiratory support modalities, mechanical ventilation, the use of ECMO, and surge strategies such as vent splitting.

At the conclusion, there was a 10-minute question and answer session featuring Lynn Tanoue, MD, MBA; Richard Martinello, MD; Mark Russi, MD; and Marie Landry, MD.

Hannah Oakland, MD; Jonathan M. Siner, MD; Alfred Lee, MD, PhD; Charles Dela Cruz, MD, PhD; Elaine C. Fajardo, MD; and Margaret Pisani, MD, MPH presented at the April 30, 2020 Medical Grand Rounds “Critical Care in COVID-19 Patients.”

Oakland presented a case of a 33-year old man, that was ‘extraordinary, but has become commonplace in the MICU.’

Dela Cruz discussed critical illness from the coronavirus pneumonia standpoint, as compared to SARS in 2003 and MERS in 2012. He reviewed data from Wuhan, China; Lombardy, Italy; and Seattle, U.S.A. He highlighted the potential long term healthcare complications in individuals recovering from COVID-19 and highlighted the ongoing research efforts saying, “When evidence is missing for care, provide care in a way that generates evidence.”

Siner’s talk was on acute respiratory distress syndrome (ARDS), outside of and during a pandemic, such as COVID-19. He reviewed the treatment for ARDS and highlighted that COVID-19 induced ARDS extent based on what is known now should be treated like other forms of ARDS. The focus should be on ‘low tidal ventilation, prone positioning, and use of PEEP judiciously.’

Lee reviewed COVID-associated coagulopathy (CAS), which is characterized by very unique features such as high d-dimer and fibrinogen levels. He shared data from a study completed at YNHH using MICU and non-MICU patients where they looked at hemostatic markers to determine if the patients had disseminated intravascular coagulation (DIC) and concluded that while there was an increased tendency for coagulation in these patients, it was not DIC.

Fajardo explained the concern for potential ventilator shortage during the surge in COVID-19 critically ill patients in Connecticut. She explained the principle behind expanding ventilator capacity, as well as the limitations using ventilators not designed for critical care in patients with ARDS. She has also described two Yale solutions: the Vent Multiplexor and PReVentS, that both allow the ventilation of two patients using one ventilator, while still individualizing the ventilation.

Pisani wrapped up the presentation with her talk on the impact of the disease on the management of the critically ill patient. She discussed how staffing changes were implemented in the MICU to best prepare for the COVID-19 surge and acknowledged the many physicians that volunteered to help the MUCU teams carry load. She explained the use of the ABCDEF bundle and how and why COVID has altered care and finished by highlighting the importance of the long-term effects of critical illness on health.

Naftali Kaminski, MD, Boehringer-Ingelheim Endowed Professor of Internal Medicine and chief of pulmonary, critical care, and sleep medicine, concluded by thanking all the participants.

“Leaving your comfort zone is no easy task in normal times. But to be able to do it in the face of stress, uncertainty and even potential personal risk is simply nothing short of heroic.”

A short question and answer session was held at the conclusion of the talk.

Did you miss Medical Grand Rounds? Yale-affiliated faculty and staff can watch these Grand Rounds on the website at Medical Grand Rounds Videos.