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Hellenic Medical Society President, Dr. Panagiotis Manolas: The pandemic from a doctor’s point of view
Dr. Panagiotis Manolas is a surgeon affiliated with Lenox Hill Hospital in New York, among others, and a founding partner of Surgical Specialists of Greater New York. He is a member of the Athens Medical Association, the Greek Medical Association, the International Union of Angiology, and president of the Hellenic Medical Society.
How have you functioned during the crisis?
Well, I have a leadership position at Lenox Hill Hospital so we had to organize administratively the appropriate response of the hospital to the crisis. First, we tried to empty the hospital from all the non-elective non-emergency operations to create capacity. But there was a big fear that the ventilators would not be adequate. So, by emptying all the operating rooms-Lenox Hill has, I think, the largest operating room unit in the city—we had close to sixty operating rooms with ventilators in them. And we expanded the intensive unit beds from 40 to 80, with the potential to go up to 120. The second thing, we restructured the whole hospital so that the surgeons were not exposed to coronavirus as much. There was a fear that the health care providers would get very sick, which happened—one-third of surgeons became infected with COVID-19.
Did you have a reduction of people coming in for regular elective surgery and people being brought in for things like heart attacks and strokes?
What happened to the patients who come in for elective surgery? Those we didn’t give appointments to: we rescheduled them for after May 15, to decongest the waiting area. Because, that’s where people would contract the virus. So, we maintained one or two people in our waiting area at Lenox Hill, which is very large, it’s close to 1000 square feet, we provided them with a mask and gloves when they came in. And primarily we saw patients who had cancer and are waiting to be operated on. Secondly, what happened to the people who had heart attacks and strokes? It is true, not only in our health care system, but throughout the United States, that visits for heart attacks and strokes has decreased, including visits for appendicitis. We don’t know what happened to these people. We will probably know three or four months from now. But they estimate that a large number of those people may have died at home, because they were afraid to go to the emergency room and contract the virus.
So there was a tragic toll in collateral damage?
It appears so. We don’t know. As you noticed, in the state statistics they actually increased the number of deaths attributed to COVID-19 by about 50 percent. In other words, whoever died and had no definite diagnosis for COVID-19 the past six weeks, I think a lot of those patients had heart attacks and they died at home. I could say that the patients that I operated on for appendicitis in the past six weeks were very neglected, advanced cases. In other words, the patients had pain for five-six days and perforation of the appendix and large abscesses in the abdomen. We usually don’t see such a high percentage of neglected cases in appendicitis.
Did your hospital reach or exceed capacity?
The hospital where I work, Lenox Hill Hospital, has approximately 420 beds, the capacity increased to close to 600 beds, using operating units and some common space to place beds. They reached the maximum coronavirus admissions of 408; we are now down to about 280. As you know, the admissions for coronavirus have decreased significantly in the past week, thank God for that.
Did you have all the PPEs that you needed?
Yes. We were never short of PPEs.
Because you had your own stock of supplies or you were otherwise supplied?
I think the Manhattan hospitals were hit much less than the hospitals in Queens and Brooklyn.
Well, Manhattan is a commuter borough. During the day, two and a half million people come into work. Once social distancing was imposed, these people were not commuting into Manhattan. In addition, they estimate that about 500,000 people from Manhattan left and went elsewhere. In Queens, though, there is social congestion: there are a lot of immigrants, and this created the early crisis: that’s why Elmhurst Hospital was the hardest hit hospital in New York City. Same thing with the Bronx hospitals, such as Jacoby and Albert Einstein: they had tremendous shortages with PPEs because of the enormous amount of admissions in a very short time span. One of our colleagues, Dr. Georgios Syros from Mt. Sinai, Queens, said Queens was hit very hard for several reasons. Number one, the two major airports of New York City are in Queens, and, second, there are communities with a large number of immigrants living in very close quarters. And it’s social inequality because these people are not mobile: they cannot leave, they are forced to live in very tight quarters. These are the people who were affected the most.
Any idea how the Greek community was affected by this?
The Greek community has the so-called older immigrants, who are here for many years and they are doing well and have jobs which gives them access to health care. And those people did not seem to be affected tremendously, like the new immigrants: the people who came after the Greek crisis around 2014-2015. These people are here mostly without a visa, with no access to health care, and they don’t enjoy social benefits, because they are undocumented: so. they don’t have health insurance, they don’t have unemployment, and they work on an hourly basis. These people were struck very hard and I believe that a lot of people from that community got very sick and were admitted to hospitals.
Which Greek communities might have been affected more throughout the country?
I think the New York community and the New Jersey community were affected the most.
Did you have any Greek patients affected by this?
Yes. We do know several of my patients and friends who actually died from the disease. Some Greeks, and non-Greeks. Our community had losses in the older population. Studies compiled in the American Medical Association Journal showed that the average age of the people hospitalized was 63 years of age. And at least the majority of them, close to 90 percent of them, had at least one co-morbidity, hypertension being the highest risk factor in about 58 percent of the patients, morbid obesity in 42 percent of the patients, and also diabetes: the most risk was in patients who had diabetes. They were more likely to be intubated and eventually die.
Most likely diabetics have a susceptibility to infections, but they also have more chances to have renal damage from serious infections. And that has been the experience with the coronavirus and subsequent bacterial infections. The virus itself does not cause the actual demise of the patient: the virus causes a tremendous inflammatory response that subsequently leads to lung infection and lung failure, leading to intubation and eventually death. So, the data published in the AMA Journal indicated that if you go into the hospital with the coronavirus you had a 20 percent chance to die. And if you become intubated you have an 80 percent chance to die. This is much higher than what we initially thought: initially we thought that half of the people would survive: it seems that only 12 percent of the people who become intubated actually survive.
Why is that?
This is the scary part of this disease. It has to do with people developing a condition called ARDS, which translates to Adult Respiratory Distress Syndrome, which is brought on by the inflammatory response to the viral infection and the subsequent super-infection with bacteria, not with viruses, with bacteria. Once you develop ARDS the mortality is very, very high in the general population, and more so with the virus because they found that the virus attaches to a certain receptor that we have in our cells that is called ACE2 receptor, and it causes the cell to open up so that the virus infuses its proteins inside the cell to replicate. By doing so, basically, it affects the cardio-respiratory system. That’s why people who are hypertensive are more susceptible, and develop heart failure, cardiac arrythmia, and this also causes the patient’s demise.
Do you have a choice of putting a patient on a ventilator or not?
For someone to go on the ventilator he must reach a point where they cannot breathe any longer. When Dr. George Liakeas got COVID-19 he was home, he was tired, he felt tightness in the chest for a few days, and then he got to the point when he could not breathe: he felt like he didn’t have enough oxygen. He took his oxygenation, it was very low, he got concerned, he took the ambulance and went to the emergency room at Presbyterian Hospital in Manhattan. After 24 hours, he became so tired fighting to get more oxygen and more air that he couldn’t breathe, anymore. His muscles became so weak that he couldn’t bring enough oxygen into his lungs and he actually asked to be intubated. And he remained intubated for eleven days. Now if someone remains intubated for five days the chances of survival are 16 percent. If he stays intubated over ten days, the chances of survival are six percent. We had thousands of people praying for George because he is such an amazing person and he is such a wonderful human being and Hellene and somehow he made it. It was a miracle. He made it and he is in amazing shape.
Do you know what the side effects of the disease will be? Some people had limbs amputated.
All infections can make our body have an increased tendency of blood clots. Same applies to coronavirus and the subsequent bacterial infections that contaminate our bodies once our immune system is broken, so to speak. So, one person had his leg amputated because of clots in the arteries that bring the blood supply to the foot. Other organs can also fail, like the kidneys, the lungs, the heart. The only positive, if possible, about the pandemic is that the estimate of 2.2 million deaths from coronavirus is not going to be realized, thank God. We do lose between 40 and 60 thousand people in this country to the flu. The difference with the coronavirus is though if we didn’t implement the social distancing we would have had millions more people contracting the virus, and thousands more dying from it, because it’s easier to contract, it takes between seven and 14 days to start giving symptoms to the host, so the host doesn’t know that he’s sick, and the host goes out and gives the virus to other people.
How did Greece do with the pandemic?
Greece did very well. They locked down very early. Probably the government was afraid the Greeks were not going to be obedient. Which was wrong, actually, because the Greeks behaved very well with this crisis and they took it very seriously. They had very few cases reported and very few deaths.
How many cases?
I think they had a couple of thousand cases and only 50-100 deaths. The good thing is that this was not the tourist period for Greece, so there were not a lot of people coming in and out of the country. That’s why the number if limited. But they got scared when they saw what happened to Italy, which is a very different situation, because Italy and Spain were bringing in close to 100,000 Chinese immigrants illegally every month, especially from the hotspots in China, to actually manufacture all these Italian brands in Italy. Greece doesn’t have industries like that, and though the refugee camps are densely populated, and Athens is a densely-populated city, Greece did very well.
So here we are now: How do we get out of this?
The only way to get out of this is the so-called testing, and probably continue with social distancing, and being careful to reopen the markets over the next three to four months; insist that people protect themselves with masks, gloves and glasses, contrary what the CDC advised us in the beginning, which was very callous. We have to protect ourselves any way we can in the next few months. And point of service testing where we can actually test someone and have the results within 15-20 minutes.
But you need millions and millions of test kits?
The commercial laboratories do have that ability now and they have the ability to do serological tests, which are much more specific and advanced than doing swabs on the nose, because nasal swabs have a 30 percent false negative rate. In other words, the test might show negative but there is a 30 percent chance that you are positive and the protein was not detected. Whereas serological tests from a blood test have a more accurate response to the virus. Because then you can find the people who got infected in the past and they have antibodies. And those people can go back to work and they don’t need to self-isolate.
When do you think we would have enough tests to do that?
We have enough tests right now to test about a million people a week in this country. But, as you now, the laboratories can expand this capacity enormously, because this is a business and if they know they are going to make money from this they can make many more tests available. Everything has to do basically with the ability to finance this expansion. There are laboratories in New York City, several, where we send samples to them now and get results within a day or two.
Are we close to that capacity now?
We are close to that capacity, the thing is, right now there are certain guidelines where you have to have symptoms, or you have to have an indication that you have the disease in the past 6-8 weeks to get and be tested, otherwise you are wasting resources for nothing. You can’t be tested just out of curiosity that you had the virus. They estimate that about five percent of Americans had the virus, 85 percent of them had no symptoms whatsoever, about five percent had mild symptoms, and the rest of them had serious symptoms. So, 95 percent of the population is not immune, and with the isolation we have right now, it’s not helping our immune system to get acquainted with the coronavirus. Having said that, who is crazy enough to go and expose themselves to the virus intentionally?
Will it get complicated because every state seems to be following its own guidelines?
It will be complicated because you cannot close the borders of each state. I don’t know if you were aware, but there were instances of people with New York plates being turned away by the police in Connecticut. To the point that there was discrimination based on where you live. Even if some states have very few cases, if people start visiting from other states you may have a second resurgence of cases.
Will there be a second resurgence in the fall?
Dr. Fauci, like all the people who work for the federal government, are trying to keep this country safe. So, he has to warn the population that there might be a new coronavirus strain that might come in September along with the flu and then we can have another similar disaster. The reality is that nobody knows. People have to get vaccinated for the flu so that at least we have the majority of the population not susceptible to severe bouts of flu. Then we will have to worry about the coronavirus only. Now the Chinese came out, and if you believe them, they said they identified more mutations of the COVID-19. In other words, the virus, because it’s a relatively small virus, has more ability to change and mutate. If that is true, even if a vaccine comes out, it will not be equipped to protect us in 2021. This is the scariest part.
Another important thing, if this restarts, hopefully it won’t restart in China, because people have lost their trust in China. There is as study from Southampton University in England, an epidemiological study, very well structured, that showed that China had the first event, the first victim on November 17 and they were aware that it was human-to human-transmission as early as the first week of December. But they did not notify the WHO until three weeks later. So, the English study said that had China notified the WHO a week before, we would have had 55 percent fewer victims and less deaths. And if they had notified the WHO the first week of December, there would be 95 percent fewer deaths. This is stunning. That means that the WHO has the ability to contain most of those pandemics, but we have to identify and notify the world as early as possible so that the first hot spot can be contained before it radiates out. This unfortunately did not happen because the WHO, not to politicize it, until the middle of January they did not issue any warnings. And until February 10, I think, they even criticized America for closing the border. A lot of things fell through the cracks. This could have been avoided 100 percent had people been more responsible.
How has your routine changed since the pandemic?
Well, one thing, I used to work 80-100 hours a week: now I am trying to do some work educating people, many, many members of our Hellenic Medical Society do that, free to all the media, both here and in Greece, to try to increase awareness and educate people so that they replace the fear with hope and maybe self-discipline.
How many members in the Society?
We have at this point approximately 550 members, and there are three thousand Greek American physicians in the Tri-State area who are one way or another engaged with the Society, participate in the events, but are not necessarily paying members. We are in every hospital in the Tri-State area. We have an excellent representation across all specialties.
This is a New York organization built and established by George Papanicolaou, as you know, was a professor at New York Hospital and Cornell University, and who saved the lives of millions and millions of women with the development of the Pap test. So, George Papanicolaou established the society in 1916 and since that time we’re going strong: we’re the largest medical society outside Greece.