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
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