The Science of Saving Lives

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At the Medical ICU in ChristianaCare’s Newark Campus, Dr. Michael Benninghoff and his staff are collaborating with medical experts around the world in response to the spread of the coronavirus

Last Thursday (April 16), the U.S. reported the largest COVID-19 fatality rate within a 24-hour period—4,591 deaths.

During the same time, the country saw the first public protests challenging stay-at-home orders in seven states.

As Delaware residents weigh the financial realities of a massive economic downturn against the ongoing advice of scientists and medical professionals in the fight to save lives, the Out & About staff thought it prudent to continue our COVID-19 response series by conducting a phone interview on April 17 with Dr. Michael Benninghoff, of Christiana Hospital in Newark, part of ChristianaCare.

“This is an international pandemic,” Benninghoff says early in the conversation, describing the disease and the efforts to combat it as “unprecedented in the medical community.”

Dr. Michael Benninghoff

Benninghoff joined ChristianaCare in 2008 and currently serves as the Medical Director of the Intensive Care Unit at Christiana Hospital. He has been practicing medicine professionally for more than 15 years and is board-certified in critical care medicine, internal medicine and pulmonary disease.

Benninghoff’s thoughts flow quickly and almost relentlessly; yet, simultaneously, his comments are sensitive and insightful, perhaps signs of a man whose years of medical training and reliance on accurate observations have been put to the ultimate test.

His words also convey a sense of gratefulness, to his staff—whom he refers to as “frontline heroes”—and to supportive citizens, who have helped mitigate the intensity and tragedy that began to unfold in Delaware in early March.

“I really want to make sure that we have a real dedicated shout out to the nurses, the respiratory therapists and the physicians, who are caring for our patients on the front line,” Benninghoff says. “That’s important.”

“I also want to take an opportunity if you can to truly thank the community,” the doctor adds. “We appreciate all the donations that we’ve received from the community in the form of simple things like lunch, which goes a long way when we’re facing a pandemic.”

Here’s what Dr. Benninghoff had to say about collaborating with doctors from around the world to combat the COVID-19 disease; observing local health protocols vs. reopening businesses; and the need for regional medical communities to work together to share resources.

O&A: Is there any indication that we’re making progress here, combating the disease in Delaware?

Benninghoff:  We have had decent outcomes from a standpoint of [treating] the most critically-ill patients.

We will need to be diligent and continue to follow the governor’s orders as far as social distancing, good hand-hygiene and common-sense social practices. We think that there’s still a potential for a surge. We haven’t observed a flattening out of acute admissions yet, so we still have a ways to go.

I do believe that COVID-19 will be something that sticks around for a while. It may not be in the surge form, but this very well may change the way people practice social distancing.

I suspect this will change the way we care for patients in hospitals, and how patients in the outpatient space or in primary care offices are tested and treated.

Like any virus, there’s sometimes a tsunami of reemergence after an initial phase of acute illness until herd immunity or vaccination can catch up. I think that herd immunity is only proven by tests—antibody tests—which, along with a vaccine to prevent COVID-19, may take some time to come to fruition.

O&A: Addressing the COVID-19 virus has been a challenge to communities across the country. ChristianaCare responded quickly to the crisis by as early as March 13, conducting free drive through testing at the Wilmington Riverfront. In what other ways has ChristianaCare responded to help address the situation?

Benninghoff:  Given the fact that this is an international pandemic, prior to the actual admission of our first patient, we have been meeting and preparing for any surge of COVID patients for admission from our community.

We worked under infection prevention diligently to set up testing guidelines, treatment guidelines, respiratory care guidelines, and PPE [personal protective equipment] guidelines.

So I believe that we were prepared well before we even were faced with our first admission. And good preparation in a time of uncertainty is the key to minimize anxiety and fear… with reports [coming in at the time] from Europe and China and the West Coast of the United States highlighting the infectious nature of this virus, [which] compared to the flu, [is] much more infectious and probably more deadly.

When you’re faced with that kind of news, everyone has a super heightened sense of awareness regarding the importance of good PPE and adequate resources.

We had the opportunity to plan with executive leadership, clinical leadership, organizational leadership from the get-go. We were ready.

I think that is what set us up for success. We’ve achieved some good outcomes for some of our patients who no longer need intensive care, for instance. That always goes a long way to boost our morale when you see some good outcomes.

O&A: When you talk [about] some of the wins you’ve hadthe positive outcomesand how that affects morale, what can you [say] about the morale of the staff? Like you said, this is unprecedented and it’s a challenge, and people on the frontlines are experiencing things [about which] the rest of us really have no idea. What can you say about morale and the rising to the challenge?

Benninghoff:  I’m proud of the way our Medical Intensive Care Unit nurses and respiratory therapists have pulled together to support each other and provide care to the sickest patients, perhaps, in the state of Delaware.

This is obviously a stressful situation in our unit. But we all have the same goal, which is to ultimately have patients reunite with their families.

O&A: You say you haven’t seen a flattening of the curve in terms of acute admissions, yet. Have you seen any positive results so far from the social distancing protocols currently in place?

Benninghoff:  If you look at the way that the social distancing is working—we use the University of Washington model for predicting peak use of resources that’s driven largely by testing and hospitalization—we think that we see some sense of stability, in that the number of admissions and the number of ventilators needed on a daily basis has been the same for the last week or so.

We have a wonderful dashboard here at ChristianaCare that highlights positive tests, medical admissions, ICU admissions, ventilator use and discharges. We gauge that for the entire pandemic. We also gauge it on a 24-hour basis.

We believe we’ve seen some stability, but it’s very busy. COVID-19 has filled in number of units here that were normal medical units for normal medical problems. So although this is a significant change in the way we practice, and where we put patients, we still have some stability in that there aren’t dramatic spikes in the number of ICU admissions.

Now, we’ve had a lot of ICU admissions, but the number of admissions for COVID hasn’t risen dramatically from week to week.

O&A: If you look at some of the charts, like the Johns Hopkins’ chart [predicting] what would happen if we had not done anything, it’s really an exponential rate. The numbers look like they would have doubled almost every week, and that hasn’t happened.

Benninghoff:  Yes, and here’s the bottom line: We’re on the front lines and we’ll be here with the nurses and therapists and until this crisis ends, but we do still need the community’s help. If citizens stay at home, we don’t see that doubling surge and, therefore, resources remain intact for the cases that we do need to treat.

And I think that you made that point that the social distancing has worked. We know that because we’re stable and these patients are stable—sick, very ill, with a tremendous burden of illness—but we have resources to care for them.

If the citizens had not heeded the warning of the governor and did not practice social distancing, then we would have experienced a significant surge in patient volume. We’re able to manage, from a resource standpoint, because people are doing what’s best for  population health.

O&A: In the media at large, there seems to be a lot of misunderstanding still about the virus. And, in general, there’s still a lot more that we can learn about it. Based on your experiences, in what ways do you see this virus different from other viruses like the flu, and perhaps other pandemic-related viruses like SARS, swine flu and the Ebola virus?

Benninghoff:  The easiest distinction to make is Ebola versus the others, because Ebola was a blood-borne pathogen.

This is different than the flu in that it’s more infectious and, because there’s an asymptomatic carrier period before you get symptoms for two-to-five days, the actual exposure to the population at-large is what makes this so much more different than the flu—that coupled with the fact that the case fatality rate seems higher.

Particularly in patients with comorbidities, like diabetes or high blood pressure, the case fatality ratio is higher, regardless of decades of life. That makes it a lot different.

So, you have then the fact that there’s an asymptomatic carrier period, the fact that it’s probably more infectious, and we know that the case fatality ratio is higher in patients based on comorbidities, and simple comorbidities like diabetes and high blood pressure.

In that sense, what we do is we learn from the existing evidence. We learned from the other cohorts in China, in Europe, on the West Coast, and in New York, and we derive our treatment guidelines based on the existing evidence and based on what’s been successful [according to our] other cohorts, and we rapidly apply that in quick pivots.

We meet with our pharmacotherapy and respiratory care teams twice a week to vet the most up-to-date evidence-based guidance per the other cohorts. So, we take what they’re doing and what’s working for them, and we rapidly redeploy those actions if the evidence supports it here on our own patients.

O&A: So, it sounds like this challenge has really necessitated a lot of collaboration throughout the country and internationally. How much of your time is talking to doctors from other areas?

Benninghoff:  We have a group that meets every morning at 8 a.m. with all the medical directors for all the intensive-care units plus the emergency department. Then in the afternoons, we do staff modeling, as well, with the same group to ensure that we have appropriate resources. But in that group, all the medical directors are also on various list-serves and blogs.

Then we actually reach out to colleagues and the other regions of the country and the world by virtue of webinars, so that we can learn what they’re up to as far as treatment regimens, and testing regimens, and how they’re using PPE.

So, it’s been unprecedented in the medical community internationally—[that] because of the fear and the unknown of what this virus can do—[there has been an] unprecedented level of communication and sharing.

Simple sharing of treatment guidelines and sharing of treatment algorithms have been widespread. I’ve talked to people that have been practicing for 30 years, and they’ve never seen this level of engagement internationally, by virtue of electronic communication. Digital communication and social media have been quite helpful.

O&A: That’s an interesting point. If this had happened, perhaps in the ‘70s or ‘80s, we might have been looking at something completely different and much more horrificin the sense that the electronic communication has allowed us to engage a lot more with different communities and share information.

Benninghoff:  Absolutely. We watch webinars from China in the evenings at home. They start 8:30 p.m. and are put on by a local university in Philadelphia. And there’s a lot of collaboration.

I’ve been fortunate enough to watch three of these webinars now. And we’ve directly learned from what the [medical experts] over there and China have used and dealt with in terms of the patient’s phenotype and the clinical experience. And we’ve definitely benefited.

And in the ‘70s, God forbid, but I think the mortality rate would have been a lot higher because they could not share information [as well]. And they would have to do what China did and learn the hard way. China had a high mortality rate on ventilators. For instance, China’s mortality rate exceeded 60- or 70-percent early on because there was no prior group that had to deal with it. So, China learned from themselves, and we learned from China the best way to approach life support in the COVID-19 era.

O&A: Is there a strong indication that this virus derived from the Chinese wet markets in Wuhan? Do you think that’s pretty definitive? Or are we still investigating that?

Benninghoff:  I think the [initial] incident case was probably in Wuhan. They have molecular signatures, I believe, with some of these viral cases, the initial incident cases. So, I believe a lot of these signatures point to Wuhan. I do feel like we do know that. The CDC, I think, has acknowledged that as well. But I don’t know which hospital or which lab isolated it first.

O&A: We are located just 150 miles or so from New York City, which is the epicenter of the pandemic right now in the U.S. How does that impact Delaware?

Benninghoff:  I just read a great paper from MIT, by an economics professor [that] trace[s] a lot of the New York City spread of the virus to the subway system. So, I think it’s important that we acknowledge the risk in the big cities may be tied to mass public transit.

We don’t necessarily have that in Delaware. That being said, we’re close to Philadelphia, we’re not that far from New York.

We keep our guard up. We’re prepared in the event that we get a secondary surge. It’s related to displaced patients. And we’ve had a few patients who are not from Delaware end up in our hospital here, in our health system, and we’re prepared to care for those patients. Just like we’re preparing for our citizens.

O&A: What advice can you give our readers? Moving forward, if it seems like things are improving, how do we get back to normal or when do we get back to normal? There’s a lot of talk right now of people wanting to reopen. What advice could you give our readers?

Benninghoff:  We have to keep planning for what could happen in the days and the weeks ahead. We have adequate PPE, but I think the best thing to do is to continue [social distancing]…until we get evidence. Let the scientists use that evidence to recommend any kind of lifting of current policies regarding social distancing…

I think that we let the science dictate when it’s safe, when we truly see cases and infectivity go down in the community.

We still have positive tests—hundreds of them a day in the community—which leads me to believe that people are still quite infectious. The worst-case scenario would be we rest on the fact that we’re stable from a research standpoint, and [then] they lift social distancing, but we get another surge that we can’t handle.

The bottom line is we need to continue to let the evidence base and the science dictate any decision-making from a political standpoint.

Our job is, as you know—physicians, nurses, respiratory therapists—is just to continue to provide the best evidence-based care we can.

So, what do you think? Please comment below.