When Dr. Gerald Pierone’s office spoke by phone with a patient in his concierge practice complaining of respiratory symptoms, staff booked a follow-up for her this past Monday morning.
Florida had uncovered its first two COVID-19 patients two weeks earlier. But the visit caught Pierone off guard. As he stepped into the exam room, he quickly realized she could be contagious and left to grab protective gear.
Turns out she was. Last Thursday, the swab he took showed positive for COVID-19. Pierone, an infectious disease specialist who has worked with thousands of HIV/AIDS patients for more than three decades, is now self-isolating with his family.
Until that moment, Indian River County appeared blissfully coronavirus-free – enough that just as the patient was getting sicker and sicker, the Vero Beach Art Club was going forward with its huge Under the Oaks art festival, planning for 50,000 people – until the city’s police chief shut it down after the first day.
The drumbeat of cases across Florida signaled a march of the virus from the north, the west and most alarmingly from the south, where the novel coronavirus had a fierce grip on Broward County. With that hotspot 100 plus miles away, Indian River seemed safely insulated by covid-free counties; only the following day would Brevard County to the north declare its first positive.
Over the course of three days, Pierone would learn three of his patients were positive. The drummer was serenading at Pierone’s office door.
Trained in infectious diseases at Mt. Sinai in New York, Pierone continues in that specialty at the HIV/AIDS clinic he founded in the 1990s. It is now part of Whole Family Health, a low-cost clinic not far from his concierge and facial rejuvenation clinic.
At the opposite spectrum of that practice, Whole Family serves 6,000 people who pay on a sliding fee scale – and sometimes, not at all. Like the virus invading Vero, Pierone’s reach doesn’t distinguish between rich and poor.
Today he worries about how to swab Whole Family patients who walk or ride up on bicycles, unable to afford a car. “They can’t get tested at the hospital’s drive-through,” he said. “We’ve decided to suit up and swab them in our parking lot.”
Sad as that is, he also has to worry about his more affluent patients, able to travel anywhere they like, including destinations now at the crux of the pandemic.
He watched as John’s Island, an affluent island enclave of some 1,200 homes, was roused to the fact that its gates couldn’t keep out covid. Though a robocall from the Indian River Shores chief of police went out the first week in March urging residents to wash their hands and cover their coughs, the wake-up call, as Pierone calls it, came on March 12, the day Sen. Lindsey Graham put himself in quarantine.
Graham had given a talk at John’s Island, then gone to a party at Mar-a-lago. There, he had contact with a Brazilian government official who later tested positive for covid. Graham has since tested negative.
“Virtually all of those clubs started reacting, right in those several days,” Pierone said. “A lot of the clubs really started dissuading family from coming down. When kids and grandkids come down, they could bring the disease in. They’ll handle it fine, but their grandmother will not handle it fine.”
Seamlessly Pierone segues to a sadder group of elders, the 450 or so people in nursing homes around the county. Visitors have been all but banned there as well as at assisted living facilities since March 14, with limited visitation allowed only in end-of-life cases.
Pierone said he even knows of a hospice nurse being turned away. “He was deemed non-essential,” he said. “Nursing homes are kind of the wild card. If any nursing home gets a positive patient, that’s a disaster.”
At the governor’s behest, random residents of senior living facilities are going to be swabbed to try to uncover any asymptomatic infection. To ease their isolation, Pierone suggests delegating a staff person to visit patients with a laptop or other device to let them communicate by Facetime with family. “That’s one of the saddest things in Italy. These people are dying alone.”
As the number of positive cases swells in Vero, and likely will continue to grow now that drive-through testing is taking place seven days a week at Cleveland Clinic Indian River, a local COVID-19 task force is meeting regularly, increasingly joining in by teleconference. Last week, Dr. Greg Rosencrance, president of the hospital, told the Hospital District that emergency department volumes were down slightly; good news, he said.
“We monitor our PPE (protective personal equipment) supplies twice daily,” Rosencrance told the Hospital District board last Thursday. “We know our supplies and we’re OK at the moment. But we need to conserve those supplies. Every unnecessary visit to the hospital, we burn our supplies, so that’s another reason to stay home.”
He said fever over 100.4 degrees and a cough warrant a call to a physician, or evaluation through an appointment at the drive-through testing site outside the hospital.
If Vero is coming to the COVID-19 onslaught just as cases are piling up at Cleveland Clinic’s south Florida site, things would likely have been worse had the pandemic hit a couple of years ago.
Prior to Cleveland Clinic taking over the hospital in January 2019, Indian River was an independent hospital, a rare breed in health care today. As such, it would have had to rely only on itself for thinking the unthinkable – a pandemic! – and stockpiling extra equipment or nailing down sources in the event of shortages.
Now though, supplies like protective gowns and masks are shared within the Cleveland Clinic Florida system, which includes three more hospitals on the Treasure Coast – two in Stuart and one in Port St. Lucie. In addition, Cleveland Clinic Florida owns medical practices in Palm Beach County where at last check corona virus cases were six times greater than in Indian River County. And the system’s flagship hospital, Cleveland Clinic Weston, is in Broward County, with the second highest number of cases in the state.
Could coming late to the pandemic mean supplies are expended before Vero’s need ramps up? Will they be able to be restocked if Vero’s numbers soar in the days ahead? Complaints are already pouring in nationwide about shortages of not only test kits, but masks, gowns, ventilators and respirators. Will Vero’s curve flatten to delay need until sources for such equipment are developed?
Impossible to say. But there is an ethical way to handle things, Pierone says. It is one that Rosencrance echoed in last week’s meeting.
“If for example Broward gets overwhelmed and five people need ventilators, and we’re not using them in Indian River County, you put those on a van to Broward,” said Pierone. “That would be a proper response to me. If you were corona czar, that’s what you would do, is transfer resources.
“It’s almost a wartime footing,” he said. “If you’re exhibiting leadership, you would change resources around. It’s another thing, if hospitals here don’t have patients, for doctors to send them up to Indian River and put them in ICU here. It’s another strategy that may occur, but is there going to be resistance to that, like, keep your patients to yourself? There probably will be. But in general, we’re in a crisis situation. I’m worried too.”
“If there’s an outbreak across part of Florida, it will be throughout all of Florida,” Rosencrance told the District Board. “I think we will not be transferring patients between facilities. We have adequate bed space. There’s no plan to do that at this time. Though what I say today may change.”
The likelihood of that seemed to diminish last week as the state opened its first field hospital in Broward, able to house 250 COVID-19 patients.
Rosencrance said Indian River has an “adequate supply” of ventilators and has acquired more through a supply chain. A shortage of ventilators forces medical staff into a heart-breaking dilemma of diverting them to patients more likely to survive, even though they would keep a weaker patient alive.
“The advantage of being in a less affected place is you get additional time for social distancing to occur,” said Pierone. “In New York and Seattle, it’s crazy out of control, and obviously the cat’s out of the bag. They’re going to have a lot of morbidity and mortality and they’re not going to be able to fix that now.
“We haven’t reached that stage. Our ability to shut down clubs and restaurants buys us time with the medical system. We’ll have less strain on our healthcare system. That’s the major benefit – we get a little extra time.”
And while Cleveland Clinic was able to begin drive-through testing for COVID-19 over the weekend using kits supplied privately, clinics like Whole Family and Treasure Coast Community Health were struggling to get adequate testing supplies.
At week’s end, Whole Family had received only five specimen collection kits. Treasure Coast Community Health, an even larger community health clinic, was given 15 kits to be divided among three locations.
Also possible in an evolving situation is that patients could be juggled between the three hospitals serving Indian River County: Cleveland Clinic Indian River, Lawnwood Regional in Fort Pierce, which has a 12-bed freestanding ER in south Vero, and Sebastian River Medical Center.
Pierone says that’s where information sharing comes in. “If all of a sudden we go from zero to 10 (inpatient) cases, we get on the phone and say, ‘Sebastian, can you take them?’ That’s shared resources.”
Cleveland Clinic Indian River has 286 critical care beds with 14 intensive care beds. Sebastian River Medical Center, with 121 acute care beds with 16 in the ICU, has a new wing under construction that was supposed to open in February; it completed its 80 percent inspection by the state at the end of January, but no new opening date has been announced. Repeated queries remain unanswered, though a spokesperson has commented on COVID-19 preparations.
The new wing would add 24 beds in the current phase, and another 24 in a future buildout of the third floor. Another older wing within the main hospital is typically underutilized and could be pressed into service, as could the 33 additional beds in a rehab center within the hospital, since a federal executive order was issued to ban elective surgeries like hip replacements that could be delayed without putting the patient’s health at risk or “contribute to the worsening of a serious or life-threatening medical condition.”
Whether that ban will be applied broadly has become a matter of controversy in some areas, since those procedures contribute significantly to a hospital’s revenue.
“Our interpretation of this order is that the ultimate authority still rests with the medical decision making of individual physicians,” said Darren Grubb, a spokesman for Steward Health, Sebastian River’s parent company.
Steward claims to be the first in the nation to create a COVID-19-only hospital in Massachusetts and says it intends to do the same in other regions. Florida is a possibility, though converting the hospitals in Melbourne and Rockledge rather than Sebastian might serve a greater need should there be a spike in Brevard, with its larger total population.
Over the weekend, Gov. Ron DeSantis announced he supported a strategy to free up hospital beds by moving less critically ill patients into a stand-alone building that would serve as a transitional care facility until the patient is no longer contagious.
As of Monday, the CDC’s website was still suggesting people prepare a room at home for a family member who falls ill. But DeSantis wants local entities to begin scouting for buildings that could serve as dorms for patients who tested positive or showed symptoms of the disease but were not seriously ill. That would spare them from isolating at home and potentially infecting family members or roommates. It would also save on PPE by cohorting patients in one facility.
In New York City, student housing at NYU was vacated specifically to take in COVID-19 patients. Will Indian River County health officials at some point consider, say, the dorms at Dodgertown? The motel Riverside Theatre built near the airport to house actors? The Life for Youth Camp or FlightSafety dorms?
“No one’s talking about that yet,” Pierone said last week. He says, generally, he’s looking to Cleveland Clinic for leadership.
But Pierone can envision resistance to that strategy, an attitude of “keep your patients to yourself.” “You know, there probably will be. I’m worried too. We’re in a crisis situation.”
Both Pierone and Rosencrance hailed the VNA for lending its mobile unit to the hospital’s emergency department so that symptomatic patients would not enter the building without first being seen. And the VNA has announced it is capable of sending nurses to homes where COVID-19 patients are isolated or recovering.
With luck, the VNA won’t be sending a nurse to check on Pierone. Just as he was getting pounded with positives for his patients, he himself began to feel symptoms – “night sweats, profound fatigue, muscle/joint pain, and oddly, hearing loss” (like being on a plane). He has not had a fever and has only “a minimal cough” – two of the three sentinel symptoms of COVID-19.
“I did develop symptoms over the weekend but not sure if it is reflective of a viral infection (or my own neurosis about a viral infection),” he said.
A test is pending from Friday, he said. He collected another sample Monday morning. “The multiple-day delay in getting test results is frustrating for everyone impacted by this,” he wrote in an email. “In my case I would like to send my patients definitive information on my status to hopefully reassure them.”
“All fine so far,” he added.
