The Clinical Observations of ABPS Diplomate Frank Nocilla, MD, During DMAT Deployments for COVID-19

Frank Nocilla, MDDMAT Teams (Disaster Medical Assistance Teams) have been called to respond to smaller hospitals along the U.S.-Mexico border that have been overwhelmed by the volume of patients infected by the COVID-19 virus and the degree of illness progression.

The COVID-19 virus has led to a large influx of Mexican-American and Mexican nationals in search of medical care for the infection. DMAT teams have been deployed to several hospitals to provide ICU/Critical Care and Medical teams to augment overtaxed staff members. As an internist and a disaster medicine specialist who is a DMAT team member, I was recently deployed on DMAT rotations for COVID-19 response. This article relates to my DMAT experiences and clinical observations at two hospitals, the El Regional Medical Center in El Centro, California, and the Val Verde Regional Medical Center in Del Rio, Texas.

First, I must commend these facilities’ physicians and nurses, as well as laboratory, respiratory therapy, and ancillary staff members for their commitment and the compassionate care they give to their patients. Both hospitals responded to increased demand for ICU and stepdown beds by quickly expanding their ICU capacity.

During my DMAT deployment at these facilities, prolonged (7-14 days) BiPap or high-flow oxygen support led to urgent intubations with sudden respiratory failure for several patients. One patient on BiPap for 14 days during intubation had a fibrous necrotic exudate covering the entire oropharynx occluding it. A hemostat was necessary to tear this fibrous mesh and remove it before intubation was possible. Another patient who was intubated for a protracted length of time unfortunately expired upon removal of the ET tube. Adherent to the lower end of the ET tube was 4 inches of necrotic lung tissue. These observations were confirmed by post mortem findings.

Patients with any respiratory complaint were put on a nebulized mixture of mucomyst and albuterol every six hours. Given the above observations involving prolonged BiPap or high flow oxygen, if there was no improvement in oxygen requirement in five days, or if there was any respiratory compromise at all, the patient was electively intubated and mechanically ventilated.

Given the marked decrease in lung compliance and fibrosis caused by the COVID-19, especially in the upper lobes, ventilator settings were well above the norm. Peak pressure requirements sometimes were over 60 mmHg and PEEP settings over 15! Patients with these high vent requirements were paralyzed to allow the ventilator to improve patients’ oxygenation and ventilation and decrease the Peak pressures, Tidal Volume, and PEEP.

In the initial stages of the COVID-19 pandemic, the World Health Organization did not recommend corticosteroids, and they were initially not prescribed.  However, in contradistinction to the WHO’s recommendation, high-dose corticosteroids were used for intubated patients, successfully reducing their Peak pressures and PEEP. The addition of Remdesivir to the high-dose corticosteroids provided additional benefit in severely ill patients. Current treatment with Tocilizumab has also proven beneficial in treating severely ill patients or preventing cytokine storm.

For patients with closed respiratory support system and mechanical ventilators, no additional filtering was done. In open systems, BiPap, high-flow oxygen, non-rebreather oxygen masks, or venti mask systems that allowed expired air into the environment, patients’ rooms were closed and patients were placed in a negative-pressure room if available and filters were placed on the exhalation ports of these systems. If patients were on nasal canula or high-flow oxygen and negative-pressure rooms were not available, patients were changed to venti masks with a filter on the exhalation port. If any patient on high-flow oxygen or BiPap did not maintain their oxygen saturation, they were selectively intubated as noted above.

Virtually all COVID-19 patients were proned. Morbidly obese patients were turned side to side; this was usually done on change of shift when there were extra hands to help. In proning intubated patients, a foam block was adapted to prevent kinks in the ventilatory circuit and ET tube.

Patients with HTN, chronic malnutrition, diabetes, COPD, CAD, CHF, or any disease state that lowered the immune system had a higher infective rate and poorer outcomes from COVID-19.

All patients were supplemented with total parenteral or peripheral parenteral nutrition with double the dose of multivitamins along with Vitamin D3 supplementation.  Azithromycin and initially hydroxychloroquine were used until a patient’s severity necessitated Remdesivir therapy.

Dr. Nocilla is board certified in internal medicine and disaster medicine with the American Board of Physician Specialties® (ABPS).

Save the Date
House of Delegates & Annual Scientific Meeting
Innovation & Overcoming Challenges
June 10-15, 2022
Patient Care Is Our Priority

Medical organizations throughout North America understand that our rigorous certification standards prove that ABPS Diplomates are capable of delivering the best patient care possible.

On October 18, 2007, President George W. Bush released Homeland Security Presidential Directive 21 (HSPD-21), calling on our nation, among other initiatives, to “collectively support and facilitate the establishment of a discipline of disaster health”. It is a great testament to the wisdom and foresight of the American Board of Physician Specialties that it immediately set to work and created, within the short span of only one year, an educational blueprint and set of certification examinations, both written and oral, for a new subspecialty of disaster medicine—and it is why I chose to be part this vital initiative and this wonderful organization. This is but one of the many innovative programs initiated by the American Board of Physician Specialties over the years, and why I am proud to support its work on behalf of our nation’s public health.

Art Cooper, MD
Disaster Medicine
When the American Board of Physician Specialties offered to host the American Board of Integrative Medicine, ABPS became a landmark organization working to move medicine into the twenty first century. Certifying physicians who have completed rigorous academic training in Integrative Medicine ensures that the field of Integrative Medicine will continue to develop academically, clinically, and professionally. The leadership of ABPS continues to impress me - they are diligent in constantly innovating to provide certifications for physicians who want to advance their careers and their areas of expertise. I am honored to be a part of this organization.

Ann Marie Chiasson, MD
Integrative Medicine
There are many ways board certification advances a physician career. ABPS Board examination verifies your accuracy, precision, and reflects your mastery of your residency training verifying your expertise. ABPS Board certification demonstrates your level of expertise beyond your practice experience, primary education degrees, and training which are necessary for insurance reimbursement and practice privilege requirements. Attaining your ABPS Board Certification will clarify your purpose, secure your practice growth, and expand into leadership positions. Board certification can serve as an indication of a physician’s commitment to medicine, beyond the minimal standards and competency of training, their measurement to quality of care, and attaining an award for excellence.

Chris Kunis MD
Internal Medicine
When I think historically, advancement in medicine and patient safety and care has been driven by the diversity of people and scientific thought. That’s what I found at the ABPS and more. For over 60 years that is just who we are. I found a physician certifying body that provides a choice and voice to all physicians ensuring that patients are always placed first.

Jerry Allison, MD
Emergency Medicine
When I decided to pursue a full time role as a physician executive it was important to me to obtain additional professional training, education and work experience. Board certification through the ABPS in Administrative Medicine is validation of my efforts and a demonstration of dedication to professional development. We need more physicians to become full time health care executives, knowing there is a board certification option in Administrative Medicine encourages physicians to take the leap from full time clinical practice to healthcare organizational leadership.

Richard Paula, MD
Administrative Medicine
The American Board of Physician Specialties has provided me with the opportunity to demonstrate mastery of internal medicine through board certification. As a hospitalist, board certification is an expected credential, and hospitals recognize the American Board of Physician Specialties (ABPS) as one of the three standard credentialling bodies for Internal Medicine. Additionally, the ABPS has helped me develop leadership skills as a Board member and Committee Chairperson. ABPS has also helped me sharpen critical thinking skills as a test question developer and reviewer. The Allopathic (MD) and Osteopathic (DO) physicians in the ABPS are lifelong learners and frequently pursue multiple board certifications. I enjoy the camaraderie of my peers in ABPS.

Loren Jay Chassels, DO
Internal Medicine