A Trip to Bryce Canyon in the Midst of the Corona Virus

Time to get out of the house....

Gather up a few belongings, two friends and head out the door...

Final Reflections About a Month in New York

Hello All,

I wanted to share some final thoughts and one more experience from my brief time in New York. I’ve been home for two weeks and am feeling very fortunate to have made it through a 2-week quarantine without symptoms (plus a negative test!)

It’s wonderful to be home. It’s a magical time in Virginia- warm, green, lush. Being home is at times surreal, so unlike from my life up there, a world away. We don’t have much Covid in Virginia, which is only because social distancing is working. Last night, I did my first shift back in the Richmond ICU. There were a handful of covid patients. While I was comfortable with the management and quite familiar with the disease, it brought back a flood of difficult emotions. I had 25 of my patients die in New York, one more than I saw discharged from the unit. That experience, not surprisingly, left me with difficulty sleeping. I have tough dreams and frequently relive difficult moments, though less and less each day.

I think about patients like Oscar, a 45-year old painter and father from Queens. He was admitted to our unit for worsening fever and breathing problems after 2 days on the regular floor of the hospital. When we met, his oxygen saturations were mid-70's (Normal 94-100%) on a non-rebreather mask blasting 20 liters of oxygen/minute. Despite breathing rapidly, he was surprisingly calm, thumbing through his phone.

This isn't unusual with Covid pneumonia. Patients commonly present with remarkably low oxygen saturations — numbers seemingly incompatible with life. Although breathing fast, they have minimal apparent distress, despite terrible looking chest X-rays. Though this was the case with Oscar, it was clear from his breathing rate and low numbers that he was running out of reserves. He was starting a dramatic cytokine storm.

I asked him if there was anyone he wanted to call. He greeted the question with apparent suspicion and I realized we had failed to explain the full extent of what was going on. Regretfully, things often get so hurried we forget to humanize and contextualize what is surely a very lonely, terrifying and confusing time for patients. 

I pulled up a chair next to his bed to talk about where he was clinically and where he was likely headed. We talked about what a ventilator does and why we use them. I explained there was a very good chance he'd need one. Once that happened, he wouldn't be able to talk or communicate with anyone for days or weeks, maybe longer. It is physically impossible to talk with a breathing tube in your airway. It holds your vocal cords open and pins down the tongue. Further, intubated patients are usually heavily sedated, unable to otherwise interact. I told him a number of patients don’t survive the ventilator, but it would be his best hope for recovery.  

He thanked me for my time and affirmed that he wanted intubation, if needed. He said he would call his wife and his cousin, who had been admitted the night before with covid and was three floors above us.

Two hours later we intubated him. He couldn't get nearly enough oxygen otherwise. Despite this, over the next two days his condition worsened. He needed very high pressures (PEEP) to keep his oxygen saturations above even 85%. The strain to his organs from the combination of the severe oxygen deficit and circulating cytokines was starting to impact his brain, liver and kidneys. 

On his third night in the ICU, the elevated ventilator pressures needed to keep him alive blew a hole in his right lung. Untreated, it is a rapidly fatal condition (a tension pneumothorax). A quick-thinking resident understood what was happening and immediately relieved the condition with a long, decompressing needle to the chest. Surgeons were urgently called and they placed a tube in his chest under the armpit to help keep the lung inflated.  With the chest tube secure, he stabilized some, began to storm less and even showed signs of improvement with his kidney/liver function. His fever broke.

But there was a problem lurking, apart from the obvious Covid. The original hole in his lung didn't heal. (Usually such holes mend naturally after the chest tube is placed). His grew steadily over the next 48 hours. Little noticed at first, he required more and more oxygen to be pushed through the ventilator to fill his lungs (a bronchoplueral fistula). By day three of the chest tube, it had become impossible to drive enough air into his lungs. 

With oxygen saturations around 75%, any additional gas volume we gave simply ran through the ever-larger hole in his lung and out the chest tube. In a pre-covid era this problem might have been corrected with a surgery to close the fistula but that was decidedly off the table now. Open lung surgery on an critically-ill covid patient was very high risk, for the patient and the staff. The only way to save his life would be to isolate that injured lung and allow it to heal without pressure from the ventilator. This meant directing the breathing tube in the left main bronchus to only ventilate on the left side. 

Lung isolation is rarely performed in most ICUs because the conditions requiring it are so unusual. Fortunately, it is done more frequently in the OR to facilitate lung surgery and I'd had a decent amount of training with it during residency. To perform the procedure, we would need to do bronchoscopy.

Bronchoscopy, placing a thin camera through the mouth and into the lungs, had been specifically banned by the hospital the month prior because it aerosolizes huge amounts of virus. To ensure compliance with the new edict, the hospital had hidden away all the required equipment in central supply on the first floor.

I didn't know what to do. Urgent bronchoscopy was possible (and available with some hassle) and was clearly his only chance at survival. But was it worth the added risk to our staff? I sort of wished I hadn’t gotten to know him a little as a person. It would have been easier to say it wasn’t worth it. We were just starting rounds, the whole team was assembled and waiting. 

The risk was not just academic. At this point, 32 of the hospital's doctors (mostly residents) had been infected with coronavirus. An anesthesia attending had required ECMO (similar to the heart-lung bypass) at an outside hospital to stay alive. (This option wasn’t available at our facility for Oscar and he was too sick to transport to another spot that had it). On our floor, 12 nurses had already tested positive. Hospital-wide, three employees were dead from it.

I decided to do it. If we were going to save his life, it had to happen now. First step was to get permission from the chief of pulmonary medicine and on-call hospital administrator. A few quick calls later, the equipment was released and the fellow and I made preparations for what would be the fellow’s first attempt at a left mainstem intubation. He performed deftly as I supervised and the procedure went quickly, without complications. Almost immediately, we were able to improve his ventilation. Over the next few hours, his oxygenation also improved some. But his left lung (the one without the hole) was still ravaged from Covid and, by itself, proved insufficient to capture enough oxygen. He died 12 hours later.

Was it worth it? He was already so sick, the odds of success were low. I don’t know how to answer that question. Each day in the ICU is filled with an endless stream of difficult choices, tough decisions about therapies, procedures-- all balancing the pros, cons, best known evidence with a patients' individual circumstances and available resources. Medical practice is often more colored by recent experience, personal biases and institutional culture than clear guidelines and obvious formulas. I can only say, with full confidence, that as a whole our efforts to keep Oscar alive were worth it. He and his family deserved the chance to halt the horrible disease he had unwittingly acquired. By that same token, I know my trip to New York was worth it. They desperately needed help and I was trained and able to provide it. So I’m glad I went, I’m even happier to be home.

I truly appreciate everyone's support, especially my family. I’m thankful my work partners at home covered me and made my absence at the surgery center workable. Thank you to all for the messages of support, care packages and thoughts. My lovely girlfriend sent cheerful boxes filled with chocolate, useful items and messages of love every week. When I got home to start quarantine my house was spotless. The pet and plants were healthy, happy and well-cared for. Thanks to Kristi and Bobby, the fridge and pantry were stuffed with homemade, ready to eat meals, fresh fruit, vegetables and healthy snacks. 

I guess it’s now time for many of us to ease back into regular life, though I'm scared about the human cost of reopening. I’m a living testament that with good hygiene and basic precautions, you can navigate safely through a world filled with covid and avoid symptomatic infection. Yet, I’m shocked to see how cavalier people can be about this virus. I guess until it affects more of them personally it will remain too remote to be real. 

Finally - a little PSA. Please, please wear a mask if you go out in public. All indications say that this is nearly always spread by aerosolized droplets. One either breathes them in directly (most commonly) or picks them up off a surface with the hand that then touches the face. 

It's very clear that people can spread the virus for days without knowing they are infected. If you are unknowingly infected, you will shed way less virus for others to catch if you have a mask on. The idea that ‘My body, My choice’ around mask wearing is ridiculous. It’s like saying, ‘My car, My choice’ then driving around drunk. Don’t do it. Any one of us could have this thing at anytime. Don’t spread it around.

With love,

Jordan

Looking Back...

Eli with the bubble stuff Brent made at Thanksgiving.. Can you believe that giant bubble?  So fun.

From FB of four years ago.

Too funny not to save.

So, what's with the out of service for an open hole?  This totally made me laugh the day I drove thru.

Few Days of Fun and Excitement....

The world still seems to be in a hunkered-down mode, BUT, people are getting angry and antsy.

In the midst of all this, we did a few things.

We had our first Thursday of the month meal, but instead of eating out, we went to Mike and Loretta Allam's.  It was delightful to just sit around their fire pit by the pool.

In this picture are Loni, Allen, Mike, Wilda Watts, Nick Watts, Donna and Stan Conder,

Unfortunately Loretta is staking the picture, so is not in it.

ON Wednesday, we went for a great ride and saw some of Southern Utah's lovely land:

We bought a couple of porch swing seats:

And went to a new way to do bridal showers: Curb-side stuff:

Miles entered a talent show via computer.....It was awesome...go, Miles!

And lastly, Allen got stung, bit, whatever it was....

Quite a week even tho, we are still hunkered down!  HA HA

TIME OUT...for Laughter....

DEAR Drs. Rose and Fisher:

Your files recently came across my desk here at the Ima A. Fraud Clinic for Rehabilitating Exercise Freaks.

It appears that the two of you are sisters.  It also appears that you are both trying to achieve immortality by exercising.

If my files are correct, in the LAST YEAR ALONE, both of you have suffered FOUR injuries (two Each) due to the careless neglect of your body at rest.

Kristi was running in St George, Utah ONE YEAR AGO and suffered a debilitating ankle or leg injury.  It was very painful and required something to get her well.  Then, just recently, she was on her bike, which tipped over, causing her to break a finger, which was excruciatingly painful and required surgery and two pins.  Even though she had both of these very painful injuries, she was a required to go back to work and try to: a.  Stand on an aching ankle/foot and B.  try to perform anesthesiology with a broken finger; both very painful.  Both involving extremities which are essential to work.

Jenni ONE YEAR AGO was riding a bike (do you sisters see a theme here with bikes?) and crashed into a pile of tar?  Who does not see tar on a road ahead?  This accident also caused Kristi to crash into her, but thankfully, at that time, Kristi was already in pain from her ankle/foot, and didn’t seem to notice any other additional pain from falling over her sister.  Then, recently, Jenni was doing something quite simple, such as yoga, when she pulled a muscle and is having constant pain coursing through her body since then.  Again, even with these injuries, she, like her sister has been required to return to work.  Only this time, she had to wear a face mask, so no one could see her writhing in pain constantly.

We, here at the Clinic for Rehabilitating Exercise Freaks are VERY CONCERNED about you two sisters.  There does seem to be a dangerous pattern forming here.

As in:, neither of you was inured while putting on lipstick, reading a book while lounging on the couch, or even painting (a hobby which it seems you both have recently taken up!)

Our clinic is devoted to helping people JUST LIKE YOU.  

We have classes in the following:  

stationary biking with no pedals or arm movement….you sit on a bike seat and look at a screen moving along a safe road.  Safety straps provided

YOGA and the many different postures of corpse pose; both back and front body postures.  Help getting up and down is provided free of extra charge.

HOW to Correctly Lie on a Couch to read a GOOD BOOK:  this is our number one class here at the clinic; too many people do not know how to lie across a couch correctly.  Tea and crumpets are offered with this course at no additional charge.

We hope that both of you will consider attending courses at our clinic.  YOUR LONG-TERM HEALTH is our Number one priority!  (Aside from the money we get, of course!)

You two are the perfect candidates for our program.  It is relaxed, no pressure, and you will meet many people, who once were just LIKE YOU, and have reformed totally.  Once in awhile, people will relapse, of course, but when they stub their toe, or get a hangnail, they come running back to our clinic for help once again.

My credentials are impeccable.  I have been a couch potato now for over sixty five years, and the only injury I have ever sustained is I broke a tooth while eating pizza in Arizona at a cafe that had been frequented by Prince Harry; but that is a story of another time, albeit, it is true.

I send my warm regards (it’s almost 100 degrees here!) and a strong wish that both you wonderful sisters can find, peace, joy, and no more broken bones, digits, fractures, aches, pains, etc.

Yours, most sincerely and with a desire for your bu$ine$$:

IMA A. FRAUD

Doctor of couch potatoing