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Battling COVID-19 Perspective from the ICU
Battling COVID-19
perspective from the ICU
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What is my perspective of the COVID 19 pandemic as viewed as an ICU physician? That is easy. I am tired of it. We all are tired of it. I am tired of the way COVID causes suffering of our patients and their families. I am tired of the ways it effects our personal lives and our community. I am tired of the effect it has on our local businesses, schools and churches. I hate COVID 19. This article is written more out of fatigue and emotion than the regurgitation of known scientific data, although the medical facts presented are true.
I’ll have to admit, in January when the coronavirus was first reported in China, I didn’t think much about it. I was still worried about our current flu season in Arkansas. When COVID found its way on to cruise ships I watched with interest. When COVID overran the Italian medical system in March I began to worry. When New York City was the epicenter for the infection in our country I watched the daily news with horror. Finally, the virus made its way to Arkansas, first arriving in Pine Bluff via Mardi Gras from New Orleans. By then, we knew the statistics and predictions of coronavirus. 60 to 80% of the population could become infected. 20% of infected patients would require hospitalization. 20% of the patients admitted to the hospital would need ICU care. 20% of those admitted to the ICU would require mechanical ventilation. Doing the math, if 10% of those infected required hospitalization in Jonesboro, with a population of 77,000, then approximately 9,000 of them would require hospitalization and of them 360 patients would ultimately require mechanical ventilation, quickly over running our hospitals’ capacity to care for patients (not including area patients from out of town communities).
We began preparing. Did we have enough ICU beds? No. The hospital looked for ways to expand our ICU capacity. Did we have enough ventilators? No. Did we have enough endotracheal intubation tubes? Maybe. We watched YouTube videos on how to mechanically ventilate multiple patients on one ventilator. Did we have enough protection equipment and would it protect us? I didn’t know. We received generous donations of face masks and N-95 masks from the public. We watched physicians from Italy explain how they treated their COVID patients and how sometimes decided who would receive care and who would not due to lack of hospital capacity. We learned from New York’s medical care during their crisis.
As I waited to care for my first COVID patient to arrive, I was nervous. Would I get infected? Would I bring the virus home to my wife? Would the personal protection equipment keep me safe? Would our medical community be over run? I was impressed with the ICU nurses and respiratory therapist and the other hospital staff as they didn’t hesitate to provide care for these patients. They were placing their own health at risk to care for others. They were true heroes. I gained emotional strength from their dedicated care and determination. They were a light of hope during this dark pandemic.
Fortunately, the predicted numbers did not happen. As everyone practiced social distancing, the infection rate was slowed. A lot of those infected were not, or only mildly, symptomatic. Maybe we had dodged a bullet. This gave our hospital time to prepare. It allowed time to accumulate adequate protective gear and testing equipment for our staff and patients. It allowed the pharmacy time to stock up on various antiviral medications. It allowed our hospital time to increase our number of negative pressure rooms to safely isolate larger number of infected patients. It allowed the staff to become accustom to wearing protective equipment and treating isolated patients. As the COVID cases began to trickle in, they were sick, but not THAT sick. They required higher amounts of oxygen, but they got better.
Over time, the number of cases began to increase. The severity of illness increased. Some patients were requiring 2-3 weeks of hospitalization to recover. Some patients required mechanical ventilation. After several months of no mortality we had our first death. Then more deaths. Unpredictably, despite risk factors, some patients would improve; some patients would not improve despite all available therapy.
We saw COVID spread into nursing homes and prison systems. We began having multiple prisoners admitted to our ICU and hospital. We watched them struggle through their illness alone, except for the guard outside the door. I remember our first nursing home patient admitted with COVID required mechanical ventilation, not expected to survived, but did. Unfortunately, others did not.
As COVID spread through out the southeast region we began taking admissions from as far away as Mississippi and south Arkansas because we had the closest ICU bed available to treat their patients. Their regional ICU beds had been over run. We watched the northwest Arkansas numbers increase. We watched our local numbers increase.
COVID “surges” moved around the state. We saw the wearing of face mask mandated. With the mandate, the cases were reduced again, but then with the starting of schools and colleges the numbers began to increase again.
We are now 7 months into this pandemic. As of the writing of this article, we are caring for an average of 10 to 14 COVID patients daily in a 36 bed ICU. The other beds are filled with critically ill patients that do not have COVID. As the case number and severity of illness increases, we find ourselves being able to spend less time with each patient in order to care for all the patients admitted to the ICU.
We have learned much about this virus during this short period of time, but there is still much to learn. There is no proven treatment or cure for this infection. Treatment recommendations have been confusing (to the public and to the physicians). Initially steroids were to be avoided, now it is recommended. Hydroxychloroquine was to be used, then avoided. Anti-coagulation was recommended, then not recommended, then maybe recommended. We have learned to pronounce the words “Remdesivir” and “tocilizumab”. We have become familiar with the terms “cytokine and bradykinin storms”. Some studies show POSSIBLE benefit with certain medications to improve outcome and lessen the severity of illness, but they are still considered experimental. There is no definitive treatment for COVID infection other than supportive care. You either get better or you don’t. Fortunately most get better, but it is heartbreaking when some do not. By far the best treatment is prevention. It has been shown without a doubt, that wearing a face mask and social distancing helps prevent infection spread and ultimately saves lives. It has been devastating to watch families say their last goodbyes to their loved ones over the phone or seeing families watch their dying family members at a distance through a window, unable to be by their side. It is emotionally and spiritually draining. It has been disheartening to see some choosing not to wear a mask in public claiming “personal rights”. Personal rights end where the rights of those at risk begin. Wearing a mask is the one thing that CAN help save lives. It is everyone’s responsibility to protect those that are vulnerable. It has been discouraging seeing some people and even some political leaders not support a face mask mandate.
There is hope, though. A vaccine is coming that will hopefully provide protection against this virus and allow us to return to a somewhat normal life. Until then, we will continue to treat patients with a combination of medications, including steroids, anti-viral therapy, anti-inflammatory therapy, anti-coagulation therapy and convalescent plasma, and with love, respect and prayer. The ICU nurses, respiratory therapy and staff will continue to provide courageous and selfless care to their patients and their families, under stressful and sometimes overwhelming situations. The hospital leadership and medical community will continue to provide up to date care for this pandemic.
Remember, until there is an available vaccine, wear a mask and social distance. Get a flu vaccine and save a life. Stay safe. Love one another. There is light at the end of the tunnel.
