Health UPSTATE
Coronavirus special edition connecting you to health and medical expertise
COVID-19 home care Advice to help kids & teens 3 quick, nutritious meals The calming magic of deep breathing Ventilation research How survivors might help
From the experts at
Spring 2020
WE ’RE in THis TOgETHER
Responding to the request for PPE
Mantosh Dewan, MD Interim President Upstate Medical University
Robert Corona, DO, MBA CEO Upstate University Hospital
Nancy Page, MS, RN, NEA-BC Chief Nursing Officer Upstate University Hospital
Amy Tucker, MD Chief Medical Officer Upstate University Hospital
Research scientists at Upstate Medical University donated supplies from their labs to be used by frontline hospital staff. In a request to scientists, Vice President for Research David Amberg, PhD, asked those working in the labs to use social distancing instead of gloves, masks and gowns. “We ask that you lend all PPE (personal protective equipment), you have to University Hospital so our frontline health care workers remain protected from infection.”
Lawrence Chin, MD Dean, College of Medicine Upstate Medical University
We are in this together
For members of the community who wish to donate PPE, please email: CovidDonations@upstate.edu
Telehealth options for patients
e are inspired by the way the Upstate
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Medical University family has responded
to the crisis. Our deepest thanks go to all
those at the front lines of patient care who are doing everything possible for our patients. As a result of the people who serve here, our clinical system is a resilient one—and one that is constantly examining the innovations and ideas that have emerged to fight COVID-19. As a public trust, our mission has never been more vital: to improve the health of the communities we serve through education, research and patient care. We also thank every person in the community who is practicing physical distancing and staying at home. By doing so you will help all the hospitals in the region to protect our most precious resource: those who have dedicated themselves to preserving your health.
Health UPSTATE UPSTATE
On THE COvER Nurse Scott Jessie, director of nursing for emergency services.
connecting you to health and medical expertise
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Health UPSTATE
Coronavirus special edition connecting you to health and medical expertise
COVID-19 home care Advice to help kids & teens 3 quick nutritious meals The calming magic of deep breathing Ventilation research How survivors might help
From the experts at
Spring 2020
Many Upstate University Hospital clinics are now offering telehealth visits via secure video and phone lines, so patients can see their providers safely and privately from their homes. Outpatient clinics postponed nonurgent visits to prepare for an increase in patients needing critical care and to reduce person-to-person contact. Current patients may contact their Upstate doctor’s office for options; new patients can call Upstate Connect at 315-464-8668 or 800-464-8668. In addition to remote options, some practices, including Urology, 315-464-1500, and Orthopedics, 315-464-8600, are extending hours to accommodate urgent visits for patients who might otherwise seek care in the emergency department. Upstate Health magazine is a community outreach service of Upstate Medical University in Syracuse, N.Y. Upstate is an academic medical center with four colleges (Medicine, Nursing, Health Professions and Graduate Studies); a robust research enterprise and an extensive clinical health care system that includes Upstate University Hospital, Upstate Community Hospital, the Upstate Cancer Center and the Upstate Golisano Children’s Hospital. Part of the State University of New York, Upstate is Onondaga County’s largest employer.
Although some drives have been canceled, blood donation centers are in urgent need of donations. Redcrossblood.org has a calendar and sign-up instructions. 2
U P STAT E H E A LT H l C O RO N AV I RU S S P EC I A L E D I T I O N l spring 2020 l upstate.edu
Health
C OnT E nT s
UPSTATE
spring 2020
PaTiEnT CaRE How a hospital prepares Explaining the spread Caring for someone with COVID-19 at home Special concerns for seniors Reflections from the front lines Coping tips for the long haul
page 4 page 8 page 10 page 11 page 12 page 13
FROm OUR ExPERTs Urgent options: Lung physiologist works to provide ventilator alternatives Experimenting with the blood of recovered patients Why you need to breathe deeply What you need to know about handwashing Advice for helping children and teens The benefits of solo exercise Eating well while sheltering in place Becoming a respiratory therapist
page 14
page 15 page 16 page 17 page 17 page 18 page 20 page 21
in OUR COmmUniTy How students have stepped up Raising spirits
page 22 page 23
sCiEnCE is aRT is sCiEnCE Coronavirus up close
back cover
UPsTaTE HEalTH EXECUTIVE EDITOR
Leah Caldwell Assistant Vice President, Marketing & University Communications
EDITOR-IN-CHIEF Amber Smith 315-464-4822 or smithamb@upstate.edu WRITERS
DESIGNER
Leah Caldwell, Prateek Harne, Jim Howe, Susan Keeter, Emily Kulkus, Charles McChesney Amber Smith Susan Keeter
IMMEDIATE RESPONSE: Restrictions to reduce possible exposure to COVID-19 change quickly. On March 16, Upstate University Hospital implemented a “no visitor” policy in response to the first two confirmed cases of COVID-19 in Onondaga County. By March 29, 146 confirmed cases and one death were reported in Onondaga County. PHOTO BY SUSAN KAHN
Visit us online at www.upstate.edu or phone us at 315-464-4836. For corrections, suggestions and submissions, contact Amber Smith at smithamb@upstate.edu addiTiOnal COPiEs: 315-464-4836
Upstate Health offices are located at 250 Harrison St., Syracuse, NY 13202
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The first thing that happened at Upstate — long before the first COVID-19 patient was identified in Central New York — was the establishment of an Incident Command. This group of approximately 75 individuals has a conference call twice each day. Led by Stephen Thomas, MD, chief of infectious disease, each call covers all aspects of operations, patient care and safety, logistics, communications and materials management across the entire medical university during the crisis. Here, a screen shot shows participants as they gather online for the morning call. PHOTO BY KATHLEEN FROIO
Crisis control A hospital responds to a pandemic
i
BY AMBER SMITH
t felt like the world turned upside down. So many changes, so suddenly, so surreal.
Medical classes moved online. Research laboratories shut down. Fever checks. Face masks. Toilet paper shortages. Rationing of pasta and butter and sugar. Elective surgeries postponed. Almost no hospital visitors allowed. Daily briefings by the governor and an order that all but essential businesses must close. Employees
who could work from home began to do so. Upstate University Hospital’s daily operations were turned over to an “incident command” structure reserved for major disasters. While the coronavirus tore through civilization, many in health care continued caring for the sick, feeling more like continued on page 5
COVID-19 is the name of the respiratory illness caused by the novel coronavirus identified in December from an outbreak in Wuhan, China. 4
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PaTi EnT CaRE
Upstate University Hospital CEO Robert Corona, DO, (center) and Stephen Thomas, MD, chief of infectious diseases, (right) share their COVID-19 expertise with Dan Cummings, NewsChannel 9 anchor.
Mantosh Dewan, MD, interim president of Upstate Medical University, prepares for one of his videotaped updates about COVID-19 issues to Upstate’s more than 9,000 employees. PHOTO BY WILLIAM MUELLER
PHOTO COURTESY OF NEWSCHANNEL 9
Crisis control
continued from page 4
they were reporting for duty in a war against a microscopic villain. Others were isolated at home, watching grimly as the Johns Hopkins University global coronavirus map turned redder as more cases of COVID-19 were reported on every continent except Antarctica, and as federal health officials predicted maybe 200,000 Americans could die. Just like in the movie “Contagion,” this virus got its start in a bustling Asian city some 7,500 miles from Syracuse. Infectious disease experts at Upstate were aware of the novel coronavirus and the respiratory syndrome it causes. It was similar in some ways to the SARS outbreak in 2002, and the MERS outbreak in 2012, both respiratory illnesses caused by other types of coronaviruses. After the first case of COVID-19 was diagnosed in the United States in January, Stephen Thomas, MD, Upstate’s chief of infectious disease, said what’s still true today: “We don’t know more than we do know. It’s an evolving story.” Common symptoms of fever, cough and achiness are well-known, but there is no proven treatment. This disease is more infectious than seasonal influenza, and deadlier. (See page 8.) Scientists, including some at Upstate, are developing tests for the virus and for the antibodies that would indicate a person had recovered. (See back cover.) Others are working on a vaccine. And others are involved in ventilator research (see page 14) and efforts to treat those infected (see page 15).
At Upstate, some 75 hospital leaders gather twice a day – virtually – in “incident command” meetings so that everyone’s aware of issues related to the coronavirus pandemic: how many beds are available, the supply of masks and other personal protective equipment (PPE), staffing issues, requests from county or state emergency management officials and more. With incident command in place, the twice-daily meetings launched March 16, the same day the first case of COVID-19 was confirmed in a patient in Onondaga County. “Decisions are made, data is updated. We execute,” explains Robert Corona, DO, chief executive officer. “It’s pivoting, and making impactful decisions hour by hour.” Someone during each meeting summarizes important information from the World Health Organization, the Centers for Disease Control and Prevention, the state Department of Health, scientific literature and other health organizations. “We put all of that in context,” Thomas says. “Our policies are first to protect Upstate staff and second to conserve PPE. Protecting our staff is our priority. Period. Full stop.” The leaders explore how best to care for infected patients. Dean of Upstate’s College of Medicine Lawrence Chin, MD, coordinated a 90-minute conference call between Upstate experts and Chinese doctors in Wuhan — the first COVID-19 battlefield — to learn from their experiences. continued on page 6
Frequently disinfect high-touch surfaces, including tables, doorknobs, light switches, countertops, handles, phones, keyboards, toilets, faucets and sinks, to help reduce the spread of the virus.
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Crisis control
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Upstate nurse Julia Burns greeted a patient at the coronavirus testing site at the Upstate Specialty Services at Harrison Center. To minimize contact, gowned and masked staff took nasal swabs in the parking lot, so patients did not have to leave their vehicles. The swabs were tested for dozens of respiratory illnesses in the pathology lab at Upstate. If those were negative, the swabs were sent to Albany for coronavirus testing. PHOTO BY SUSAN KEETER
“We thought it would be really helpful to have the perspective and experience of doctors that have been dealing with this the longest,” Chin explained to Syracuse.com. Neurology resident physician Husitha Vanguru, MBBS, crosses Almond Street to report for duty at Upstate University Hospital. PHOTO BY SUSAN KAHN
They discussed a variety of topics, including early identification of patients, chest imaging, drug use, hormone therapy, immune adjustment, plasma exchange and treatment using a machine called ECMO, extracorporeal membrane oxygenation, which adds oxygen, removes carbon dioxide and recirculates a patient’s blood. Mental health concerns have also been addressed. Upstate interim President Mantosh Dewan, MD, asked the chief of psychiatry to talk in a webinar to all Upstate employees about healthy ways to cope. (See page 13.) When Governor Andrew Cuomo ordered all hospitals in New York to be ready to expand capacity by 50 percent, Corona says his team came up with a plan to obtain beds and staffing to increase by 77 percent. Some private rooms would be doubled up, and some other rooms in the hospital would be converted for patient continued on page 7
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The body’s white blood cells produce proteins called antibodies to fight an infection, and they remain in the bloodstream long after the infection clears. So, an antibody test could reveal those who have survived COVID-19. U P STAT E H E A LT H l C O RO N AV I RU S S P EC I A L E D I T I O N l spring 2020 l upstate.edu
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Crisis control
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care. He said nearby hotels were prepared to help as well, providing lodging for health care workers or patients. The incident command team also works through ways to minimize the hospital services that are nonessential, for the time being, and how to keep essential services operating. Because, even as the crisis unfolds, heart attack patients are still revived, people injured in car crashes are still put back together, babies are still born. u
This may save you a trip to the doctor Technicians at Upstate and Microsoft together built an online assessment tool, known as a chatbot, to answer questions about the coronavirus. It is offered in English and Spanish. The chatbot asks users about their symptoms and travel history. Based on responses, the chatbot assesses the person’s risk of having COVID-19 and offers a variety of next steps. A major benefit of the assessment tool is its ability to quickly assist people without requiring a visit to a doctor’s office or emergency department. “Hospitals are carefully managing capacity issues and need to be available to those who are ill and need treatment,” says Upstate University Hospital Chief Executive Officer Robert Corona, DO. “While users may ultimately need to be in contact with a physician, we can help them make that determination without having them show up at an office when it may not be necessary.” Further enhancements to the assessment tool are expected to be rolled out that will allow Upstate to follow up with those individuals who were recommended for testing using bar-code technology. The concept for the patient-tracking element of the assessment tool is based on work Corona and Sam Carello, director of biomedical informatics, undertook during 9/11 to manage an anticipated surge of patients to be transferred to Syracuse from New York City. The objective of the system is to triage and track patients, which have now been shown by South Korea and other countries to be an important tool in managing the spread of the virus.
Nurse Dominique Luckey heads to work at Upstate University Hospital. PHOTO BY SUSAN KAHN
In the first week that the chatbot was operational, Corona reports 33,542 unique users. Find the chatbot at upstate.edu/covid The New York State Department of Health offers a COVID-19 hotline at 888-364-3065. u Report continued on page 8
Human coronaviruses were first identified in the 1960s. Four cause mild illnesses known as the common cold. Three are known to cause more severe disease: the 2002 outbreak of SARS (severe acute respiratory syndrome), the 2012 outbreak of MERS (Middle East respiratory syndrome) and the current outbreak.
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Crisis control
Two new things This crisis prompts hospital to think of new ways to do things: l
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“Virtual Visits” allow patients who are in the hospital or the emergency department to download an app on their cellphone that allows them to communicate with their health care professional in the hospital, without that person having to enter the patient’s room. “This diminishes the exposure of our frontline providers,” explains Robert Corona, DO, chief executive officer. Nurses devised a way to monitor some infected patients who are on intravenous medication without entering the patient’s room, chief nursing officer Nancy Page says. By using extension tubing, they can place the IV pole in the hall outside of the patient’s room, so they can reduce the number of times they enter the room to monitor and make adjustments.
continued from page 7
Bryttnaye Karker from outpatient surgery takes the temperature of anyone who enters the Upstate Golisano Children’s Hospital. PHOTO BY MAISHA BROWN
it’s not the flu Coronavirus appears to be spreading more quickly and infecting more people than influenza does, with a higher percentage of those infected requiring intensive medical care, and with a higher death rate. As of early April, adults age 35 and older who become sick with COVID-19 had a 1 in 5 probability of ending up in a hospital. That’s according to a pair of epidemiologists from Syracuse University who are also affiliate faculty members at Upstate. Brittany Kmush, PhD, specializes in infectious disease epidemiology, and David Larsen, PhD, is an environmental epidemiologist. They study the way infectious diseases spread and how to control or reduce that spread. So how did this pandemic begin? (A pandemic, by the way, is the outbreak of a disease over a large geographic area.) “This is what is called a zoonotic event,” says Larsen. “You have a pathogen (something that causes a disease) that is circulating in an animal system, and it makes a mutation or a leap into a human system. Human-to-human transmission is happening now. All the science suggests that this happened at a seafood market in the city of Wuhan, in the Hubei province of China, in late November, early December.” The first case of COVID-19 in America was reported Jan. 21 in Washington state. Several of the people who got sick there were tied to a traveler who returned to Seattle from a trip to Wuhan. At the end of February, 70 people became infected from one person who attended a medical conference near Boston. New York’s first continued on page 9
Coronaviruses are a large family of viruses. Some cause illness in people. Others only infect animals. Rarely, animal coronaviruses have emerged to infect people. This is believed to have happened with the virus that causes COVID-19. U P STAT E H E A LT H l C O RO N AV I RU S S P EC I A L E D I T I O N l spring 2020 l upstate.edu
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Subrat Kamal, MD, crosses Almond Street to head to work at Upstate University Hospital. PHOTO BY SUSAN KAHN
Resources Upstate resources If you believe you have been exposed, visit upstate.edu/covid for an online assessment tool that will help you determine your next step. Upstate health care technician Kimberly White wipes down equipment before and after it is used. Careful cleaning of all surfaces and shared spaces goes on day and night. PHOTO BY SUSAN KEETER
confirmed case, on March 1, was in a woman who returned from Iran. Epidemiologists have a term — R-naught — for the average number of people a sick person is likely to infect. For influenza, it’s about 1.2, says Stephen Thomas, MD, a professor of medicine and microbiology and immunology, and the chief of infectious disease at Upstate. COVID-19 appears to be at least 2 and maybe up to 4. “What that means is, one person could infect two people, and each of those people could then infect two people.” This helps explain the upward trajectory we see on charts of the rate of infection in various cities. The time from exposure until a
person starts showing symptoms – known as the incubation period – is likely from five to seven days, Kmush says, but self-isolation times have typically been 14 days, to be safe. “This virus is more deadly than the flu,” she says, explaining that one or two of every 1,000 people who get influenza may die. With COVID-19 infections, 20 to 30 of every 1,000 people who are infected may die. That’s known as a case fatality rate. Larsen adds that COVID-19 also has a high rate of required intensive care. “About 20 percent of people who get the virus are requiring intensive care, critical care because they can’t breathe.” u
Find a collection of Upstategenerated COVID-19 news at www.upstate.edu/covidnews A variety of medical experts from Upstate offer education and advice about the coronavirus via podcast. Visit upstate.edu/healthlinkonair
new york state resources For emotional support related to COVID-19, calls are answered between 8 a.m. and 10 p.m. at 844-863-9314 For general questions about COVID-19 infection, call 888-364-3065
Federal resources The Centers for Disease Control and Prevention compiles coronavirus information at coronavirus.gov The National Institutes of Health compiles research related to the coronavirus at nih.gov/coronavirus
Even at an accelerated pace with human volunteers, officials at the National Institutes of Health estimate the first phase of COVID-19 vaccine development will take 14 months.
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Advice for caring for someone who has COVID-19 BY AMBER SMITH
ith no specific treatment for COVID-19,
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people who are sick at home may be com-
forted with supportive care measures.
That means get plenty of rest. Stay hydrated with plenty of fluids. Consider honey, vitamin C and a pain reliever that can help reduce a fever: acetaminophen, ibuprofen or aspirin. “All of those measures we would use for treatment of colds and mild respiratory tract infections apply to this, as well,” says Jana Shaw, MD, a pediatric infectious disease specialist at Upstate. She says it’s important for those who are ill to isolate themselves as much as possible from housemates. Use a separate bathroom, exercise diligent hand hygiene, cover coughs. The majority of people who become infected with the new coronavirus will experience mild symptoms, so mild they may not realize they are sick. That’s why medical experts have told us to stay home and keep 6 feet away from others.
Jana Shaw, MD, gave an interview about the coronavirus for the radio show/podcast “HealthLink on Air.” PHOTO BY JIM HOWE
“Social distancing is the key to mitigate the transmission of this virus in a community,” Shaw says. “We currently have no other effective measures to stop the virus from circulating but to remove those susceptible – which is all of us.” This virus is such a challenge because so many people are infected without realizing they are sick. Even those who go on to develop symptoms may be spreading the disease for days before a cough or fever develops. Shaw says most people can let the virus run its course while they recover at home. But, if the cough worsens, or it becomes difficult to breathe, call your health care provider. If you do not have a primary care doctor or are uninsured, call the Upstate COVID-19 hotline at 315-464-3979. u
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The first case of infection in the United States was reported on Jan. 21; in New York City, March 1; and in Syracuse, March 16. Epidemiologists say the coronavirus seems to be spreading at least twice as fast as influenza. U P STAT E H E A LT H l C O RO N AV I RU S S P EC I A L E D I T I O N l spring 2020 l upstate.edu
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Looking out for seniors Geriatrics chief highlights special concerns BY AMBER SMITH
pstate’s chief of geriatrics,
“The assumption we all have to make is that everyone has the virus, even if they don’t have symptoms.”
Sharon Brangman, MD, has a
Brangman says seniors should not have guests over and should not babysit for grandchildren who are home from school. She suggests a single designated person interact with a senior who is housebound. That person can help with groceries or errands, limiting contact with others.
U
simple message for seniors dur-
ing the coronavirus pandemic: Stay home. “We want them to limit their contact with people who could potentially give them the virus,” she says. Even those individuals who don’t get around much are a concern, “because they may come in contact with adult children or grandchildren who have traveled. Sharon Brangman, MD PHOTO BY DREW OSUM
If no one can pick up prescriptions for you, Brangman suggests calling the pharmacy ahead of time and making plans to arrive early, when the store may have fewer people. “We don’t want older people waiting in long lines or being in crowded stores.” She notes several groceries and pharmacies offer early-morning hours meant for seniors only. As for seniors who live in nursing homes, Brangman points out that many nursing homes were proactive in restricting visitors, which protects the residents. This likely means loved ones have to get creative in how they maintain communication with their loved ones, those in nursing homes and those living alone. “Even though we are maintaining physical distance, we should try to double our efforts to call people and make sure we’re in contact with them and see if they have any needs we can help them meet,” Brangman says. What makes seniors more vulnerable to this virus? “After the age of 50 or so, our immune system starts to get a little weaker. And then as you get older, your immune system becomes even weaker,” she says. “When you add on other medical problems, that’s another stress on the body, so that when you get exposed to a virus — whether it’s the flu or something like coronavirus — that becomes a stress that can overwhelm your system.” Brangman says because of their vulnerability, seniors need to react quickly to the development of any unusual symptoms. Achiness, fever, runny nose or cough are symptoms that warrant a call to their primary care provider. u
Cancer patients are among those at high risk of serious illness from an infection because their immune systems are often weakened by cancer and its treatments. Most people who were treated for cancer in the past (especially if it was years ago) are likely to have normal immune function, but each person is different.
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Upstate’s Prateek Harne, MD, is interviewed by CNN anchor Anderson Cooper about his experience caring for the first person in Onondaga County to die of the coronavirus.
In scary times, humanity brings us together, pulls us through BY PRATEEK HARNE, MD
“i
am very scared,” my patient said, as my heart raced. She wasn’t the only one.
As I write this, the coronavirus pandemic has reached more than 800,000 cases worldwide, and the number is still rising.
I am a resident physician working at Upstate University Hospital in Syracuse. I was mentally prepared to see these cases in our hospital, but when I did — in the context of what we know about this virus so far — it left me changed. Doctors are trained to listen calmly and to understand and validate our patient’s anxiety. Through numerous encounters, we are equipped to handle these situations so that our patients feel acknowledged and relieved after we have had a conversation with them.
sobering experience Every now and then there comes an interaction that leaves an indelible impact. My first encounter with a COVID-19 positive patient is something I will never forget. She had been admitted three days earlier, and I was asked to evaluate her, as
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her oxygen requirements had dramatically increased. As I stood in her room, my heart was racing. I didn’t quite realize it in the moment, but I was scared. With a distinct heaviness in her breath, she told me how nice everyone has been to her in the hospital. I thanked her. After examining her, I told her that we would need to insert a tube into her airway for her to breathe better, and she replied by telling me she was very scared. I held her hand and told her it takes courage to do what she was doing. She asked me to call her husband, who was being quarantined at home after testing positive, and tell him that she loved him a lot. I did what she asked, and he asked me if I could tell her the same. continued on page 13
“It is OK to be afraid, but we are asking people to do their jobs,” Upstate infectious disease chief Steven Thomas, MD, told The Atlantic magazine. “When they do that, that’s what I think courage is.”
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In scary times
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Four days later, she passed away due to severe respiratory failure, despite maximal medical supportive therapy. Since then, every time I have entered the room of a patient with a potential COVID-19 infection I have felt scared — scared that I will infect other patients, my colleagues or my loved ones.
Ever onward Health care providers internalize or forget the emotional toll the job can take. We walk into work, smiling, calm and composed. We portray a version of ourselves that is undeterred by the uncertainty associated with this pandemic, even as we all know that we are scared. During these times, we find ourselves going back to something that makes us human. Something unrelated to this pandemic that threads us together. From singing songs in solidarity, to donating to hospitals, to offering help to health
care providers, to staying at home and maintaining social distance — all of this tells us that each one of us is doing our part. I find my salvation in writing. There is a lot to worry about amidst the increasing incidence, high transmissibility, non-conclusive treatment modalities, potential scarcity of personal protective equipment, crashing economy and unemployment that this world is facing — that you and I face. But if we take one day at a time and calmly focus on our role in this fight, then we might be able to see the light at the end of this tunnel. I am a soldier in this battle, I am fighting my piece, and I ask you to fight yours. Breathe and keep fighting. u Editor’s note A version of this essay, written by Prateek Harne, MD, first appeared on CNN.com
A marathon, not a sprint 4 tips from a psychiatrist e are familiar
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with acute stressful
events. Making a presentation in front of a bunch of people. Attending a funeral. The event happens, and the stress passes.
“This is a different kind of stress,” psychiatrist Thomas Schwartz, MD, interim chair of Upstate’s department of psychiatry and behavioral sciences,
says of the COVID-19 pandemic. “You have to have a long-haul mentality to manage this long-term stressful event.”
His advice: l “Social
distancing means social isolation, which leads to depression,” so be proactive and follow the teens. Use social media to stay in touch with friends and family. Make phone calls. Use internet-based connections.
l Take
a break. Sit in your car to listen to your music. Scroll websites looking at antiques you don’t plan to buy. Whatever you do, Schwartz says, “don’t think about COVID-19 a couple times a day. You need a break, even if it’s five minutes.”
l You
can control some things: You can wash your hands properly, and you can practice physical distancing. Of course you can’t control everything. “Change what you can. Accept what you can’t,” he says.
l Don’t
judge yourself or others. Some people are stoic in the face of the pandemic. Others are completely frozen with fright or lonely. If you can help someone wash their hands correctly, do it in a kind way. If someone is really incapacitated, don’t judge them about being weak. Help them.
These are a few tips that have helped some others manage in chronic stressful situations. u
Experts do not know whether the spread of COVID-19 will decrease when the weather becomes warmer, but the World Health Organization says the virus is being transmitted in climates with hot and humid weather.
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FROm OUR ExPERTs
Gary Nieman conducts research on ventilation in his laboratory at Upstate University Hospital.
Urgent Options Lung physiologist explores how to help during a ventilator shortage BY AMBER SMITH
ow to help large numbers of
H
people with severe pneumonia during a pandemic had not
crossed Gary Nieman’s mind. Now it’s all he thinks about.
Nieman is a lung physiologist who has spent his career studying the origin, development and treatment of acute respiratory distress syndrome and ventilator-induced lung injury. He and his research partners have some projects that may help people with COVID-19:
Time-controlled adaptive ventilation (TCav) method is a way to protect the lungs from damage that a ventilator — a breathing machine — may cause. Nieman and his team describe this technique in the March issue of the journal Annals of Intensive Care, saying it “changes the current approach to mechanical ventilation,
from arbitrary to personalized and adaptive. The outcome of this approach is an open and stable lung with reduced regional strain and greater lung protection.” Nader Habashi, MD, the medical director of the critical care unit at the University of Maryland’s R. Adams Cowley Shock Trauma Center, developed the TCAV technique, and Nieman conducted extensive experiments in his laboratory at Upstate University Hospital to identify how well it works. This technique is likely to help patients come off ventilator support more quickly, Nieman says, thus freeing up the machine for other patients and avoiding ventilator shortages.
a chemically modified tetracycline medication that Nieman’s lab studied from 1999 to 2011 as a possible treatment for acute lung injury still holds promise. He says the research halted after some corporate changes. “It’s a unique drug with a lot of potential,” he says, describing the multiple anti-inflammatory properties that he believes would work well on COVID-19, which can be fatal when the body’s immune system overreacts in what is known as a cytokine storm. continued on page 15
The virus is known to spread from person to person through respiratory droplets produced when an infected person coughs or sneezes. 14
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FROm OUR ExPERTs
Urgent options
continued from page 14
Because previous work has shown this medication is safe for humans, Nieman is hopeful that it will be studied in patients who have COVID-19 in the near future.
Hand-held resuscitative equipment invented in the 1950s requires someone to squeeze each breath of air into the patient. Collaborating with researchers at Syracuse University, Nieman is testing a device that would take the place of a hand. It would connect to an oxygen source in a hospital room and function as a rescue ventilator if none were available.
desperate measures, to be used only as a last resort, include dual ventilation or hand-held ventilators, Nieman says. “We must have options available for the physicians if the number of patients with respiratory failure exceed the number of ventilators.” Connecting two patients to a single ventilator is a complex process. Habashi wrote protocols for how this can be done, based on experiments Nieman conducted at Upstate.
After tests demonstrate that it works, Nieman says the plan is for the device to be rapidly produced on 3-D printers at SU if needed. u
Recovered from COVID-19? You may be able to help others BY EMILY KULKUS
pstate Medical University is
keep all of their “good cells,” Endy says, and anecdotally, doctors are seeing only positive results from patients who are treated with convalescent plasma.
U
seeking patients who have recovered from COVID-19 for
an emergency clinical trial. The recovered patients would donate plasma, the liquid part of their blood, to help treat severely ill patients battling the disease.
The project is part of the National COVID-19 Convalescent Plasma Project, which the Food and Drug Administration has approved as an emergency investigational new drug (EIND). The theory is that people who have recovered from COVID-19 have developed antibodies against the disease. Those antibodies could then be given to a currently infected person to lessen the symptoms and speed recovery, says Timothy Endy, MD, professor and chair of microbiology and immunology at Upstate, and Stephen Thomas, MD, chief of infectious disease and leader of COVID-19 preparations at Upstate University Hospital. The pool of potential local volunteers for the project should grow as those diagnosed continue to recover, Endy says. More than 100 people called in the first day the project began. Plasma donation is safe for patients because they get to
“The scientific premise is sound that antibodies can reduce symptoms and hopefully the severity of COVID-19,” he says. “The unknown with this type of product is currently we don’t know how much antibody we’re actually getting from recovered patients. That’s a question that needs to be answered, and we’re hoping to do that.” Upstate’s participation in the treatment trial was sparked during a teleconference among doctors from Upstate and in Wuhan, China. Doctors in Wuhan said they saw improvements in the severity of COVID-19 symptoms in patients that received convalescent plasma. “If we can stop the progression of the disease from having to have someone go onto a ventilator by giving convalescent plasma, that would have a huge impact,” Endy says. “If we could reduce people’s hospital days by three days, that would be a huge impact, too.” Thomas says Upstate intends to be the regional resource for the project for any severely ill COVID-19 patients. He stresses that the donation and the transfusion of plasma is safe for the donor and the patient. Upstate is working with the American Red Cross to do the plasma collection. u HOW TO vOlUnTEER: If you are 18 years or older, have tested positive for COVID-19 and are now 14 days out from your last symptom, call Upstate Clinical Trials at 315-464-9869 to arrange a screening appointment.
Proper handwashing is important, but if soap and water are not available, use an alcohol-based hand sanitizer with at least 60% alcohol. upstate.edu l spring 2020 l U P STAT E H E A LT H l C O RO N AV I RU S S P EC I A L E D I T I O N
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FRO m OUR ExPERTs
The benefits of deep breathing BY AMBER SMITH
f you’re feeling anxious
i
IN
— and who isn’t? — Upstate’s director of integrative medicine,
Kaushal Nanavati, MD, recommends taking a moment to breathe deeply. “Take a nice, deep inhaling breath, the longest inhale possible,” he coaches, “and take even longer to breathe out. Slowly, slowly, slowly.” Taking time to breathe slowly and deeply helps break your pattern of thinking. “As we start to get anxious, the emotions spiral. In our brain the prefrontal cortex that helps us with some of our logic doesn’t get a chance to get activated,” Nanavati describes. “When we take a deep breath and we calm ourselves down, that part of our brain can get engaged again. That helps us use reason and logic and be able to think about, ‘OK, in this situation, what is in my control?’
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“We have good science behind this. We know that with 10 minutes of nice, deep breathing,” Nanavati says: l Levels
of cortisol, the stress hormone, drop. This not only helps reduce stress, but can help prevent our immune system from weakening. Lower levels of cortisol are also helpful for blood sugar and inflammation in the body. Cortisol can also affect blood pressure.
l Levels
of the “fight or flight” hormone, adrenaline, drop, which helps reduce anxious feelings.
l Levels
of the hormone melatonin rise. This can help with sleep and in boosting the immune system.
l Levels
of the chemical serotonin rise. This can enhance our mood and help with gut motility.
l Levels
of the chemical messenger dopamine rise, increasing our sensation of pleasure.
Now, getting back to what is within our control. Nanavati points to proper handwashing and social distancing. He says those are two of the best steps we can take to reduce the ability of the virus to spread. Some anxiety over this uncertainty may be expected. Nanavati’s reminder: “This is not something to panic about. It’s something to be practical about.” u
Fever, cough and shortness of breath are the hallmark symptoms of COVID-19. Seek emergency care for these warning signs: trouble breathing, persistent chest pain or pressure, confusion or inability to arouse, or bluish lips or face. U P STAT E H E A LT H l C O RO N AV I RU S S P EC I A L E D I T I O N l spring 2020 l upstate.edu
PaTiOUR EnT ExPERTs CaRE FROm
Handwashing Answers to 5 important questions does it matter which kind of soap i use? Liquid soap is the best way to go, says Jarrod Bagatell, MD, a doctor of family medicine and the medical director for employee and student health at Upstate. With bar soap, the concern is that germs like moist environments and may gather on bar soap that has been sitting around for a bit.
sick, he or she certainly should be using a separate towel.
does touching the faucet or doorknob undo my handwashing efforts? Yes.
is it safe to use lotion?
The important thing is that you are washing with either soap for at least 20 seconds, Bagatell says. “That time allows me an opportunity to pause so that while I’m saying, ‘1 Mississippi, 2 Mississippi,’ in my head, I’m taking slow, deep breaths to allow myself to reset,” he says. “I actually look forward to that opportunity to pause and wash my hands and be mindful.”
is it important to dry my hands? Germs like to grow in damp environments. It’s important to thoroughly dry your hands. Paper towels are effective because after you use them, you throw them out. Cloth towels are fine for personal use. Just make sure they get washed every few days or so. If a person is
It’s OK to use your own personal lotion to keep your skin intact. I would advise against sharing other people’s lotion bottles.
How is all this handwashing helping? We are ultimately only as safe as our neighbor, or our coworker, keeps themselves safe. It is so important that we tend to our hand hygiene — and that those around us do the same thing, Bagatell says. It is the most important thing we can do to help mitigate the spread of this virus. u
Helping kids cope Child psychologist offers advice n a time of uncertainty, parents can help children
i
cope by being open and honest about their feelings –
first with themselves, then with their children.
Children will pick up on and mirror the feelings and actions of their parents, and if parents are anxious or upset, it’s likely the kids will be too, says child psychologist Wendy Evers Gordon, PhD, a professor of psychiatry and behavioral sciences at Upstate.
during the outbreak, she advises parents to l Limit
access to TV and other mass media. Unlimited screen time will increase anxiety, and after awhile, anxiety takes over our brain. Leave several hours to relax before bedtime and try not to watch news of the outbreak around smaller children.
l Remember
that physical distancing does not mean emotional
distancing. We all crave connections, so we should communicate with phone calls, texts, social media and letters, or perhaps talking through a glass door or window to someone. l Start
a dialogue with your child: What have they heard? What do they wonder about? This allows parents to correct any inaccurate information and answer questions in an age-appropriate way. l Establish
a routine as much as possible, especially to keep up a semblance of the school week. This means regular times for sleep, meals, schoolwork and some sort of physical activity. u
No evidence suggests dogs or cats can spread the virus, but Centers for Disease Control and Prevention experts suggest restricting contact with your pets if you are sick with COVID-19. upstate.edu l spring 2020 l U P STAT E H E A LT H l C O RO N AV I RU S S P EC I A L E D I T I O N
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FROm OUR ExPERTs
Lunges, going up and down stairs and using an exercise band are a few ways to keep fit while stuck at home, as Carol Sames, PhD, shows here. PHOTOS COURTESY OF CAROL SAMES
Exercise in isolation Keeping fit while confined to home BY JIM HOWE
xercise is even more important
much, or at all, to think about how to get some movement in their day.
during a pandemic, says Carol
Moderate activity means doing something where you can still carry on a conversation. If you can walk 20 or 30 minutes at a time, great, but if you can only walk for five or 10 minutes, break it up that way.
E
Sames, PhD, an exercise physiolo-
gist and director the Vitality Fitness Programs at Upstate. She says people can keep moving and keep fit while stuck at home. Here’s her advice: Be creative With a little creativity and flexibility, you can follow the current fitness guidelines for adults: 150 minutes per week of moderate activity, plus two or three sessions of strength training and some flexibility training. “Within those guidelines, any exercise is important,” Sames says. The exercise doesn’t have to be done all at once; it can be done a few minutes at a time throughout the day. She also encourages those who have not recently exercised
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If it is hard to get outdoors to walk, see what can be done indoors, such as going up and down a stairway. Even household tasks like cleaning out a closet can keep one moving. As the weather improves, yardwork could be added.
little or no equipment? no problem While gyms and fitness centers are closed, dust off that old stationary bicycle or other piece of exercise equipment you might have, and use that. You may also be able to clear out a space to exercise by shifting some furniture. A wide variety of exercise videos and articles can be found for free online. These range from heavy-duty aerobics sessions to exercises that can be done while seated. To get in strength training without a lot of equipment, look for body weight exercises. Push-ups, for example, can be done from a variety of positions, such as against a wall to make them easier. continued on page 19
People with severe COVID-19 infections may develop pneumonia in both lungs, organ failure, and their immune system may overreact in what is known as a cytokine storm. U P STAT E H E A LT H l C O RO N AV I RU S S P EC I A L E D I T I O N l spring 2020 l upstate.edu
FROm OUR ExPERTs
Exercise continued from page 18
Standard push-ups can be made more challenging by elevating the feet.
Lunges and calf raises can be done alone or using simple equipment such as a chair, stability ball or stretchy exercise band.
Take it easy to start
Flexibility is often lost in the ankles and neck area, so try tracing the letters of the alphabet with each ankle while seated, and moving one’s head from one side to the other, ear to shoulder and chin to chest. If you happen to be sick while at home, you probably will just want to rest. But if you are only mildly ill and can get up and move around, try something as simple as rearranging a drawer and add more activities as your condition permits.
For those who might want to start a new, heavy-duty routine, such as running, Sames cautions that suddenly going out and running can leave you very sore. She suggests a routine of walking for two minutes, then running for one minute, for awhile, gradually increasing the amount of time you run, to accustom your body. And be sure you have adequate footwear. People should remember that “I didn’t get out of shape in a day or a week or a month, so I want to start slowly, so I can continue to be active,” she advises, adding that people tend to stick to more gradual programs of exercise. u
Instructor Linda Goodrich, left, leads an Upstate Oasis online class in Tai Chi for Arthritis. The series was organized with 100 Black Men of Syracuse Inc.
All together for tai chi In February, Upstate Oasis and 100 Black Men of Syracuse Inc. teamed up to offer Tai Chi for Arthritis, exercise classes that feature slow, joint-safe movements and breathing to improve strength, mobility, balance and concentration. A month into classes, COVID-19 public health mandates stopped in-person gatherings. Tai chi instructor Linda Goodrich offered to continue classes online, so participants could exercise at home. The program is paid for by the Onondaga County Department of Adult and Long Term Care. For more information on classes, go to upstate.edu/livinghealthy. u
The coronavirus is more infectious than influenza. Each person with the flu may infect one other person. Each person with COVID-19 is likely to infect three others. upstate.edu l spring 2020 l U P STAT E H E A LT H l C O RO N AV I RU S S P EC I A L E D I T I O N
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FROm OUR ExPERTs
Eating right when you’re staying in BY JIM HOWE
T
hese are trying times. Even when you’re safe
at home, you can still maintain nutrition.
Juliann Mellen, a registered dietitian nutritionist at Upstate, advises that as much as your circumstances and available ingredients allow: l Keep
up a regular meal schedule.
l Try
for healthy snacks with at least two food groups, such as whole-grain bread or crackers with peanut butter or cheese. Try to include a protein, vegetable and whole grain in your meals.
l Be
flexible when food you would like isn’t available. Try eggs, beans or tuna if you have no meat. No rice? Try grains such as quinoa or farro instead. Be willing to make do with what you can get.
l Occasional
sweets or less nutritional foods are OK, but don’t overdo them.
Pasta and sauce
Chili
Cook a box of pasta, any size or shape, according to the box instructions, adding a bit of salt to the cooking water. In a separate pan, sauté a protein in olive oil for a few minutes till golden brown — this could be lentils or crumbled tempeh, a soy product, or a ground meat (turkey has less fat than beef), seasoned to taste with salt, pepper or maybe some paprika or cayenne pepper. Add a jar of pasta sauce and whatever vegetables you have and let the mixture simmer, stirring as needed to prevent burning. Serve the cooked pasta with the sauce mixture.
In a large pot, sauté in olive oil a chopped onion and garlic with whatever vegetables you have. Add protein, such as ground meat or tempeh and cook until the vegetables are soft and the protein is browned. Add 3 cans of drained beans, such as 1 can of pinto beans and 2 cans of black beans, a large can (28 ounces) of diced tomatoes with the juice, and 2 cups of chicken broth, vegetable broth or water, plus whatever seasoning you like, such as salt and pepper, oregano, cumin or taco seasoning. Bring to a boil, then let simmer for a while to come together, adding a little lemon juice or vinegar for a bit of a kick.
Natalie Antosh, a fourth-year medical student at Upstate, offers some simple, adaptable meals you can prepare using commonly available ingredients. Her interest in nutrition helped create a nutrition class offered to medical students at Upstate. Each of these meals serves 4 to 6. You can stretch the number of servings by adding more vegetables or water, as needed. And, if you are using frozen ingredients, thaw before cooking.
COOKING WITHOUT RECIPES lentil soup In a large pot, sauté in olive oil a chopped onion and garlic with whatever vegetables you have, chopped small, until soft. Add 4 cups of broth or water and a cup of brown or green lentils, then boil with the vegetables. If you have diced tomatoes, add those, including the juice. Season to taste with salt and pepper and whatever spices you have on hand, such as cumin or curry powder. Cook until lentils are done. If you have a grain like barley, rice or quinoa, cook that separately and serve the soup over it in bowls. u
Older adults and people of any age who have serious underlying medical conditions may be at higher risk for more serious complications from COVID-19. 20
U P STAT E H E A LT H l C O RO N AV I RU S S P EC I A L E D I T I O N l spring 2020 l upstate.edu
in OUR C Omm Uni Ty
High-demand career Becoming a respiratory therapist BY CHARLES McCHESNEY
heir place on the front
How a ventilator works
T
A mechanical ventilator is a life support machine that helps people breathe when they are not able to breathe on their own. It may also be called a breathing machine.
lines caring for those with COVID-19 has brought a
greater awareness of respiratory therapists. With specialized training in caring for those with issues with their hearts and lungs,
Students in a clinical skills lab at Upstate
respiratory therapists are counted on to help COVID-19 patients with the disease’s severe acute respiratory symptoms. That can include administering oxygen and medicine or setting up and monitoring ventilators, should patients need assistance with breathing. US News & World Report included respiratory therapy among the top 20 in-demand health care career options in 2019. The magazine said the median national salary for them was $60,280 in 2018. Upstate Medical University’s Bachelor of Science in Respiratory Therapy is offered through the College of Health Professions. Students with aptitude in math and science can complete two years of intense, specialized training that includes clinical work in the medical field. “When they graduate, respiratory therapists are prepared to work with patients, from newborns to the elderly,” said Michele Pedicone, assistant professor of respiratory therapy. For more information on the respiratory therapy program at Upstate Medical University, visit upstate.edu/respiratory or email admiss@upstate.edu u
The ventilator connects to the patient through a tube placed into the windpipe. It blows a high concentration of oxygen into the lungs and helps the body get rid of carbon dioxide through the lungs. Ventilators help ease the work of breathing, so that a person does not feel so out of breath. They can provide what is called positive end expiratory pressure, to hold the lungs open, so air sacs do not collapse. And, the tube in the windpipe makes it easier to remove mucus if the patient has a cough. Most patients who need support from a ventilator because of a severe illness are cared for in a hospital’s intensive care unit. The ventilator itself does not cause pain, but some people dislike the feeling of having a tube in their mouth or nose. They cannot talk because the tube passes between the vocal cords in the windpipe. They also cannot eat by mouth with the tube in place. People on ventilators may receive sedatives to help them feel more comfortable. SOURCE: AMERICAN THORACIC SOCIETY
COVID-19 is deadlier than influenza. Of 1,000 people who get the flu, 1 or 2 die. Of 1,000 people who get COVID-19, the case fatality rate may be as low as 10 per 1,000 in communities with good access to advanced medical care or as high as 100 deaths per 1,000 in countries without.
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in OUR C Omm Uni Ty
Stepping up Upstate students volunteer to help BY CHARLES McCHESNEY
pstate Medical University students are pitching
U
in to help, using what they have learned, to
Luke Slate, a third-year medical student from Buffalo, gave blood at a drive that saw many students volunteer. PHOTOS BY CHARLES MCCHESNEY
assist in the battle against COVID-19.
Among the volunteers are first-year medical student Katherine Forsythe (pictured at right), who has helped organize an emergency blood drive, third-year medical student Stephanie Cortes, who has volunteered for shifts answering calls from people worried about whether they should get tested for the disease, and MD/Master of Public Health student Gary Shmorgon, who has helped survey hospital emergency departments around the state to find out how others were handling the crisis. Well over 100 Upstate students have stepped up to assist, says first-year medical student Julie Erlich, who helped launch a student volunteer effort to provide assistance to frontline medical staff.
U.S. Army’s 23rd Infantry Regiment in 1917 in Syracuse.
In fact, she explains, they had more volunteers willing to walk pets, shop for groceries or run errands than they had requests for help. Another group is working on expanding the chatbot under guidance from Public Health faculty. “Everyone is trying to find ways to help,” says Cortes. u
PHOTO FROM THE LIBRARY OF CONGRESS
The 1918 pandemic The coronavirus pandemic echoes the influenza pandemic of 1918. The first cases in Syracuse of what was called the Spanish flu were diagnosed among the military, including the thousands of soldiers living at the New York State Fairgrounds in Camp Syracuse, a temporary Army training center during World War I. Syracuse underwent similar
22
limitations then to stem the spread of the disease, such as banning public gatherings and closing theaters and churches. Sick residents were asked to stay at home, and the public was urged to sneeze or cough into handkerchiefs. The Spanish flu eventually killed 675,000 Americans and an estimated 20 million to 50 million people around the world. u
The best way to prevent illness is to avoid exposure. That's why leaders have directed people to stay home during this crisis, which in turn reduces demand on the health care system.
U P STAT E H E A LT H l C O RO N AV I RU S S P EC I A L E D I T I O N l spring 2020 l upstate.edu
in OUR C OmmUniTy
Raising spirits Throughout Upstate Medical University and Central New York, people are finding ways to support those who work on the front lines in the battle against the coronavirus. Clockwise from top left: “Upstate Proud” caps — modeled by internal medicine resident Parth Sampat, MD — are distributed to staff; child-life specialists and hospital administrators post inspirational messages throughout the hospital (pictured: Catherine Disalto reading “As you head home after a long day, thank you”); community member Nancy Shepard of Fayetteville sews face masks to donate to the hospital; and patients make cards to express their appreciation for staff. Instructions for making and donating masks can be found at www.upstate.edu/masks u
CARE FOR THE CAREGIVERS In response to the crisis caused by the coronavirus outbreak, a new fund has been established by the Upstate Foundation to provide assistance to Upstate staff with unmet needs, such as child care, elder care and food. Donations can be made online at www.upstatefoundation.org/CareforCaregiver Or by sending check or money order payable to the Upstate Foundation, to: The Upstate Foundation, Inc. 750 E. Adams St. CAB326 Syracuse, NY 13210 Please reference fund #47681
Thank you. Impacting patient care, education, research and community health and well-being through charitable giving.
Foundation
The incubation period — the time from exposure to when a person develops symptoms — is thought to be 5 to 7 days for COVID-19, although health experts have advised 14-day quarantines to be safe. People are infectious before they experience symptoms.
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Non Profit Org. US Postage
PAID 750 East Adams Street l Syracuse, NY 13210
Permit No 110 Syracuse, NY
SCIENCE IS ART IS SCIENCE
Hearts & Minds Together
WE’RE IN THIS TOGETHER.
A large group of clinical and basic scientists at Upstate is engaged in several activities related to the COVID-19 pandemic. These include efforts to: • Improve testing related to negative or inconclusive results. • Precisely quantify the viral levels in patients as their disease progresses. • Improve the care and therapies for COVID-19 patients. • Determine factors that influence resistance to the disease or recovery.
20.092 0420 42.5Mcanfieldsk
• Identify social, biological and ecological factors that affect the rates of the disease in Central New York. This summer, a lab at Upstate will become operational that will allow additional research to be safely conducted on COVID-19.
This image of the novel coronavirus that causes COVID-19 was produced in February on an electron microscope at the National Institute of Allergy and Infectious Disease’s Rocky Mountain Laboratories in Montana, using a sample from a patient in the United States. Spikes on the surface of coronaviruses give the virus family its name. Corona is Latin for “crown.” u IMAGE OF CORONAVIRUS COURTESY OF THE NATIONAL INSTITUTES OF HEALTH NIAID
