Listen and subscribe/follow on , , and , so you don't miss the next episode. And if you like what you hear, a five-star rating goes a long way in helping us share the story side of medicine!
This story is from the Anamnesis episode called Winning in Medicine and starts at 2:47 in the podcast. It's from , a pulmonary and critical care physician at Johns Hopkins.
Following is a transcript of his remarks:
My name is Brian Garibaldi. I'm a pulmonary and critical care physician at Johns Hopkins. I have actually been here in Baltimore since 2000 when I came to Hopkins for medical school, and then I stayed on for internal medicine residency, pulmonary and critical care fellowship, and chief residency at Hopkins. I joined the faculty back in 2011 when I was doing basic science research on mouse models of lung injury and fibrosis.
Then actually I took a left turn and went to Malaysia to help run a Hopkins-affiliated medical school in Kuala Lumpur. After returning from that, I also became involved in highly infectious disease preparedness when I was asked to help set up a high-level isolation unit, or a biocontainment unit, back in 2014 to help our health system and state prepare for the possibility of taking care of patients with Ebola virus disease.
The First ICU of Many
When it became clear that COVID was coming to the U.S., our unit was the first to start getting ready, but also the first to activate for our first people under investigation and our first confirmed cases at Johns Hopkins.
I remember our first ICU-level patient. We had a few patients who had come in, who were doing reasonably well, but needed to be hospitalized. But our first ICU patient was transferred in from one of our affiliate hospitals where he had come to the ED short of breath and soon after had to be placed on a breathing machine. He was transferred to us, but he was awake still. He was on sedation medications, but he was awake and he was texting with his parents. Then he was texting with us [to communicate].
He was a young guy. He was almost the same age as I am. He was really sick.
I remember thinking this is still at a time where we didn't know much about this disease. We didn't understand who was at risk to become severely ill or to perhaps die from it. We didn't know how safe it was to take care of these patients, even with all of our special training and gear.
I mean, he is just incredibly fit. He would run marathons and triathlons. He looked like a bodybuilder and he was in the best shape of his life.
And he was texting with us -- and obviously we were texting about all the uncertainty and trying to figure out what were going to be the next steps -- he got even sicker and got to the point where he needed to be proned, as we talk about, put on his belly and needed to be heavily sedated and even paralyzed at times.
I just remember thinking, "Wow. If this can happen to him, oh my gosh, we're in for a really, really rough ride. I hope that we're all going to be safe."
Thankfully, he was our first patient who was on the breathing machine, but he was also our first patient who got off the breathing machine.
Our First Win
I have since talked with him. He is back to work. He is back in the gym. He tells me ... I haven't obviously seen him with his shirt off since I took care of him in the hospital, but he tells me he is back to even better shape than he was before COVID.
It was our first sense of ... it was our first win, really. The first ... He was in the hospital for many weeks. During that first wave of COVID back in March of 2020, we were accepting patients from all throughout our health system, but all across Maryland. That's where we were getting the sickest of the sick.
There were times in our ICU where every patient was proned and paralyzed on a breathing machine. It was an unbelievably stressful time and we really didn't understand the mechanics of COVID at that point. We didn't understand what it did to the lungs in terms of lung physiology and how to manage people appropriately on the ventilator.
When he got extubated and was actually able to be transferred to the floor, I mean that was just an amazing sense of, "All right, we've saved the first person from this. We can do some good here. We have a chance to do some good."
Our biocontainment unit had been training for years to be able to provide care for someone who had a highly infectious disease. Initially, that preparation started around viral hemorrhagic fevers, which we know are contact-transmitted. You can catch them by coming into contact with bodily fluids. But we also were preparing for airborne-transmitted diseases or respiratory droplet diseases like COVID because at the time we were worried about a reemergence of SARS back from the early 2000s.
From time to time, there were outbreaks of MERS, which was another coronavirus that is most commonly seen in the Middle East, but has occasionally gone to other countries and caused outbreaks. We had protocols in place for both viral hemorrhagic fevers, as well as respiratory pathogens.
As we began to get more information about what was happening with COVID from other health systems -- both internationally, but also in California and New York who were hit harder than us earlier on -- we modified our personal protective equipment to make sure that we had the appropriate respiratory protection, but also to make sure that we were going to have enough in terms of having gowns and gloves, and being able to keep everybody safe. We were pretty confident that we had the right protocols in place. We were fortunate enough that our institution has just a fantastic supply chain and operational command and emergency preparedness teams who were able to make sure that we always had protective gear to keep us and our staff safe.
What we did shortly after we activated for the first patients is we recognized that we would only be able to take care of the first round of patients and very soon after that the entire hospital would have to step in and start taking care of more patients. Our teams helped to organize training sessions for hundreds of healthcare workers across our hospital and health system.
We helped design a safety officer training program so that each unit that took care of a COVID patient would have someone who could help frontline providers get into their gear and then get safely out of their gear, decontaminate their gear to keep everyone else safe. Then we also worked to try to disseminate what we were learning, both in terms of the clinical care, but also in terms of potential research questions with our health system, but also with our regional and national partners.
There were people in the healthcare environment who did get COVID, but our hospital did contact tracing and kind of looking into where potentially people could have gotten sick. By and large, we don't think people were getting sick from their actual direct care activities. We think in the rare incidences where there was a healthcare worker or a staff member who did get COVID, it was much more likely that it was actually happening in the community.
Our team took care of the first 3 weeks or so of patients and thankfully we were all safe and none of us got sick. I think that sends a really important message to the rest of the hospital that, "Hey, you guys can do this. We can all do this. We can do it safely. We have to be careful. We have to use protocols. We have to make sure we have the right gear. But if we follow those protocols and trust in our training, and trust in each other, we can do this safely."
It's not very often that you encounter a disease that no one has ever seen before. There are rare diseases. There are descriptions of very uncommon occurrences that maybe you will encounter during your career, but it's very rare that as a healthcare worker you're going to take care of a patient who has a disease that's never been seen before.
I remember that there was obviously concern and everyone was worried about safety issues appropriately. There also was this sense of excitement about, we were doing important work, but I think there was also this immense sense of responsibility that we really had to pay attention because no one has seen these patients before. If we pay close enough attention, we might pick up on something that will make a difference for the person in front of us, but that can also make a difference for other providers who are going to take care for the thousands more who were yet to come. That really led to a concerted effort on the part of the institution, but also our team, to try and learn as much as we could from the patients we saw.
That's really where our patient registry came from. That's where our desire to use our Precision Medicine Analytics Platform (PMAP) to try to input all the data from the COVID patients we've seen at Johns Hopkins, to then feed back something that would be meaningful and useful to frontline providers at Hopkins, but also at other hospitals.
I think we've been successful doing that. We've been able to learn about the factors that underlie risk of severe disease or death. We've created a prediction model that's currently running in our electronic health record to help providers not just make decisions about patients they are seeing, but also to talk to families and patients themselves about what might happen to make sure that we're engaging them in discussions about their goals and their preferences.
We have learned about the real-world effectiveness of therapeutics such as remdesivir and tocilizumab because, by and large, the population that we've seen has had a lot of underrepresented minorities that were not present in the clinical trials. I think those findings have been important and have informed care.
I was actually attending in one of our bio mode intensive care units. This was a unit that traditionally had not been an intensive care unit, but became an intensive care unit for COVID patients who require ICU-level care.
This is early October. It was a Friday morning. I had just gotten done with morning rounds on our COVID patients and I had stepped out of the unit just to get a glass of water and maybe use the restroom. I got a call from our dean, who asked me if I would be willing to go down to Washington, D.C. to help out with the care of the president.
I think in that moment I realized this was really ... the reason I was being asked was because of all the work that our team had been doing for COVID and that our hospital had been doing for COVID, but also the years of work that our team had put in to try to prepare for these types of high-consequence pathogens. It was a huge honor to be asked and it was a huge honor to be able to go down to the White House and also work with the team at Walter Reed and the White House medical unit to provide care for the president when he was ill.
Check out other stories from the Winning in Medicine episode, including "Breaking Down Patients' Barriers" and "A Victory for Cancer Prevention."
Want to share your story? Read the Anamnesis Storyteller Tip Sheet and when you're ready, apply here!