The city has added more than 3,700 additional people who were presumed to have died of the coronavirus but had never tested positive.
New York City, already a world epicenter of the coronavirus outbreak, sharply increased its death toll by more than 3,700 victims on Tuesday, after officials said they were now including people who had never tested positive for the virus but were presumed to have died of it.
The new figures, released by the city’s Health Department, drove up the number of people killed in New York City to more than 10,000, and appeared to increase the overall United States death count by 17 percent to more than 26,000.
The numbers brought into clearer focus the staggering toll the virus has already taken on the largest city in the United States, where deserted streets are haunted by the near-constant howl of ambulance sirens. Far more people have died in New York City, on a per-capita basis, than in Italy — the hardest-hit country in Europe.
And in a city reeling from the overt danger posed by the virus, top health officials said they had identified another grim reality: The outbreak is likely to have also led indirectly to a spike in deaths of New Yorkers who may never have been infected.
Three thousand more people died in New York City between March 11 and April 13 than would have been expected during the same time period in an ordinary year, Dr. Oxiris Barbot, the commissioner of the city Health Department, said in an interview. While these so-called excess deaths were not explicitly linked to the virus, they might not have happened had the outbreak not occurred, in part because it overwhelmed the normal health care system.
What Doctors on the Front Lines Wish They’d Known a Month Ago. Ironclad emergency medical practices — about when to use ventilators, for example — have dissolved almost overnight.
Just about a month ago, people stricken with the new coronavirus started to arrive in unending ranks at hospitals in the New York metropolitan area, forming the white-hot center of the pandemic in the United States.
Now, doctors in the region have started sharing on medical grapevines what it has been like to re-engineer, on the fly, their health care systems, their practice of medicine, their personal lives.
Doctors, if you could go back in time, what would you tell yourselves in early March?
“What we thought we knew, we don’t know,” said Dr. Nile Cemalovic, an intensive care physician at Lincoln Medical Center in the Bronx.
Medicine routinely remakes itself, generation by generation. For the disease that drives this pandemic, certain ironclad emergency medical practices have dissolved almost overnight.
The biggest change: Instead of quickly sedating people who had shockingly low levels of oxygen and then putting them on mechanical ventilators, many doctors are now keeping patients conscious, having them roll over in bed, recline in chairs and continue to breathe on their own — with additional oxygen — for as long as possible.
The idea is to get them off their backs and thereby make more lung available. A number of doctors are even trying patients on a special massage mattress designed for pregnant women because it has cutouts that ease the load on the belly and chest.
ther doctors are rejiggering CPAP breathing machines, normally used to help people with sleep apnea, or they have hacked together valves and filters. For some critically ill patients, a ventilator may be the only real hope.
Then there is the space needed inside of buildings and people’s heads. In an instant, soaring atrium lobbies and cafeterias became hospital wards; rarely-used telemedicine technology has suddenly taken off, and doctors are holding virtual bedside conferences with scattered family members; physicians force themselves to peel away psychically and emotionally from fields of battle where the opponent never observes the cease-fire that the rest of society has entered.
“Never in my life have I had to ask a patient to get off the telephone because it was time to put in a breathing tube,” said Dr. Richard Levitan, who recently spent 10 days at Bellevue Hospital Center in Manhattan.
Why is this so odd? People who need breathing tubes, which connect to mechanical ventilators that assist or take over respiration, are rarely in any shape to be on the phone because the level of oxygen in their blood has declined precipitously.
If conscious, they are often incoherent and are about to be sedated so they do not gag on the tubes. It is a drastic step.
Yet many Covid-19 patients remain alert, even when their oxygen has sharply fallen, for reasons health care workers can only guess. (Another important signal about how sick the patients are from Covid-19 — the presence of inflammatory markers in the blood — is not available to physicians until laboratory work is done.)
Some patients, by taking oxygen and rolling onto their sides or on their bellies, have quickly returned to normal levels. The tactic is called proning.
Doctors at Montefiore Medical Center in the Bronx and Mount Sinai Medical Center in Manhattan have described it on Twitter; a flier is posted next to beds at Elmhurst Hospital Center in Queens as a guide for patients on how often to turn themselves.
At Lincoln Hospital in the Bronx, Dr. Nicholas Caputo followed 50 patients who arrived with low oxygen levels between 69 and 85 percent (95 is normal). After five minutes of proning, they had improved to a mean of 94 percent. Over the next 24 hours, nearly three-quarters were able to avoid intubation; 13 needed ventilators. Proning does not seem to work as well in older patients, a number of doctors said.
No one knows yet if this will be a lasting remedy, Dr. Caputo said, but if he could go back to early March, he would advise himself and others: “Don’t jump to intubation.”
The total number of people who are intubated is now increasing by 21 per day, down from about 300 at the end of March. The need for mechanical ventilators, while still urgent, has been less than the medical community anticipated a month ago.
One reason is that contrary to expectations, a number of doctors at New York hospitals believe intubation is helping fewer people with Covid-19 than other respiratory illnesses and that longer stays on the mechanical ventilators lead to other serious complications. The matter is far from settled.
“Intubated patients with Covid lung disease are doing very poorly, and while this may be the disease and not the mechanical ventilation, most of us believe that intubation is to be avoided until unequivocally required,” Dr. Strayer said.
This shift has lightened the load on nursing staffs and the rest of the hospital. “You put a tube into somebody,” Dr. Levitan said, “and the amount of work required not to kill that person goes up by a factor of 100,” creating a cascade that slows down laboratory results, X-rays and other care.
By committing all the resources of the hospital to highly complex care, mass mechanical ventilation of patients forms a medical Maginot line.
For heavier patients, Dr. Levitan advocates combining breathing support from a CPAP machine or regular oxygen with comfortable positioning on a pregnancy massage mattress. He had one shipped to the hotel where he was staying in New York and brought it to Bellevue.
The first patient to rest on it arrived with oxygen saturation in the 40s, breathing rapidly and with an abnormally fast heartbeat, he said. After the patient was given oxygen through a nasal cannula — clear plastic tubes that fit into the nostrils — Dr. Levitan helped her to lie face down on the massage table. The oxygen level in her blood climbed to the mid-90s, he said, her pulse slowed to under 100 and she was breathing at a more normal pace. “She slept for two hours,” he said.
His brothers are donating more mattresses. “We have to see how it pans out, but it makes a lot of sense,” Dr. Swaminathan said. “Obesity is clearly a critical risk factor.”
Dr. Josh Farkas, who specializes in pulmonary and critical care medicine at the University of Vermont, said the risks of proning were low. “This is a simple technique which is safe and fairly easy to do,” Dr. Farkas said. “I started doing this some years ago in occasional patients, but never imagined that it would become this widespread and useful.”