PREVIEW
2019…. I was starting to feel the ‘burnout’ that is much talked and written about in physician blogs and communities. I was feeling sorry for myself without really knowing that I was feeling sorry for myself. And when say ‘myself’ I mean the broken system in which I was forced to be a ‘cog in the wheel’…..a hamster running on the hamster wheel in endless circles with no end in sight.
2020….. WHOA…. Can I go back to that hamster wheel ….it doesn’t seem so bad anymore!!!!
What a year this has been!
Need I say more??!!
I still remember how this all started…..how our world turned upside down.
It started out with a rumbling emanating from a place called Wuhan….in December 2019. I had never heard of Wuhan…or Hubei. The rumblings grew louder and LOUDER. There was a mysterious, deadly virus that had put the city in lockdown. As of January 30, 2020, there were almost 10,000 cases reported in over 20 countries.
We had heard of other viral illness causing havoc in the past …. SARS, Ebola, MERS, chikungunya. I read about them from afar, and memorized the clinical presentation, diagnostics and treatments for the many Board exams I have had to pass. MERS and Ebola brushed the USA with gentle strokes, a few cases reported in the media, but it was always far from ‘home’.
COVID-19….we finally had a name for this one! The WHO briefings were getting more and more serious and finally the word was spoken…. PANDEMIC on March 11th. Can I say WHOA again!!!
The first case of COVID-19 was reported in the USA on Jan 20, 2020. It was a 35-year-old male in Snohomish County, WA. That was not too far from home…. social media was ablaze with physician communities scrambling to keep up with the daily and sometimes hourly updates. I was scrambling to keep abreast of the information as best I could. The usual sources of information, reputable medical journals had nothing on this. Italy was being pulverized by the virus. The images and stories from the Italian hospitals were terrifying.
The first death from COVID-19 occurred on Feb 29, 2020. Then came the debacle at a long-term care facility in Kirkland, WA. The words ’community spread’ and ‘travel restrictions’ started being used frequently in the media. The death count rose, and we started seeing cases in neighboring hospitals. All the while the drumbeat that I kept hearing in my head became louder and louder.
March 22, 2020…that was an unforgettable day for me. I was working in the ICU and got a call about a COVID-19 patient who had been in the hospital for a few days and ‘was tiring out’ and needed intubation. My heartbeat rose about 20 points. My face felt flushed. I walked up to appropriate floor. I put on my PPE; my hospital had provided CAPRs, gowns, gloves, shoe covers – I was lucky. I took my time donning my ‘armor’, making sure that I was well protected from this invisible enemy. I evaluated the patient and agreed that intubation was the appropriate plan. I walked out of the room and doffed appropriately. I gathered the nurse, respiratory therapist and pharmacist, and we went about with the intubation. I don’t think I have even felt apprehension as I did for my first COVID-19 intubation. This was no ordinary intubation. There would be no ‘bagging’, the patient would have to be paralyzed and sedated to decrease the risk of aerosolization and it would have to be very quick. I was surprised at how ‘smoothly’ the procedure went. I am not sure what I expected – a giant visible viral ball to jump out at me when I looked at the vocal cords!!!…. but I walked out of the room intact and hopefully virus free??
I made sure to doff again. I made sure to wash my hands more carefully than I even had. I made sure to change my hospital scrubs immediately – something I have never done after an intubation. I could ‘feel’ the viral particles crawling all over me; or was it just my heightened state of apprehension and fear??
An hour later and I was finishing up my notes, I got another call. About another COVID-19 patient that needed intubation. This was not what I expected. To get called about 2 intubations in such a short time was pretty unusual. My heartbeat shot up another 20 points. The flush on my cheeks deepened. I evaluated the second patient and agreed that intubation was appropriate. This was starting to feel surreal ….. this was no virus I had ever encountered. It was indeed novel. It was invisible but the destruction it left in its path was frightening and I felt helpless.
I had my first preview of the next few weeks were going to be like….
CHANGED ROUTINES
I am a natural introvert. The practice of medicine is naturally extroverted. There is constant interaction with patients, family members, nurses, pharmacists’, respiratory therapists, MA’s, CRNA’s, housekeepers, the chaplain, the cafeteria staff, other physicians’, security guards, and so on and on. The hospital is a very social place. NOT so anymore. COVID-19 had changed the very landscape of the hospital environment.
I was used to walking into the hospital at any odd hour of the day or night. I was always met with friendly staff greeters, other medical personnel trying to get to work on time, clocking in and out, a quick greeting, a stop at Starbucks for a ‘pick me up’ before shift.
Now I walk into a deserted hospital entrance. There are 3-4 nurses behind a desk, all in masks, so I may not recognize them, scanning my badge to make sure I am allowed to enter. I have been turned away and had to sprint back to the parking lot a few times when I have forgotten my badge in the car. My hospital scrubs are not validation enough. If you are a visitor you can’t just walk in; you need a temperature check, a mask, and special permission to be the one allocated visitor per day per patient.
My rounding routine has changed as well. I make my way into the office. Previously we would get ‘sign-out’ from the outgoing physician in the ICU; in the ‘thick of things’. Now we do ‘sign-out’ in the office. Less ‘germy’. I will then wipe down all the visible surfaces, desk, keyboard, mouse, chair, door handles, light switches, in the office with Sani wipes. I then make my way into the designated COVID UNIT. I will get my daily supply of PPE, my N-95 mask, my bouffant hat, my shoe covers, my surgical mask with shield. I carefully donn my ‘armor’ and start seeing patients.
I am a remnant of the ‘good old days’ – I like paper and pen and always had a paper list of my patients on hand, to make notes for myself as I went along with rounds. NOT so anymore. I no longer wear my lab coat; I wear hospital issued scrubs; I no longer carry a stethoscope since each patient in isolation has their own dedicated stethoscope that does not leave the room; I don’t take notes since I don’t want to carry anything in and out of patient rooms anymore. I rarely stop at random computers to place orders or to peruse labs and X-rays. I don’t like to touch any surface that I have not sanitized. In between patients I am careful sanitize or change my PPE so as not to cross contaminate other patients.
Rounding on patients is a surreal experience nowadays. Pts are always alone in their rooms with doors shut. There are no family members in the room. They are usually intubated and sedated and can’t talk to me. There may be one RN in the room, donned to the hilt in PPE, which makes talking hard since it’s hard to hear through layers of masks, hats, CAPRs etc. The silence is almost deafening.
Some patients are lucky to not be not a ventilator. These patients are usually on high flow nasal oxygen, which delivers oxygen more efficiently than a regular nasal canula. These patients are awake and can talk to me, but they don’t have much to say since they usually don’t feel very good. Sometimes they are talking to loved ones on Facetime and I get to see and talk to their loved ones. Seeing patients loved one gives me a different perspective on these patients – a glimpse of who they were prior to COVID-19.
I have had a few patients talk to their loved ones on Facetime just prior to intubating them. That is a ‘new trend’…we never did this prior to COVID – 19. Loved ones would either be at bedside already, or patients were too sick to Facetime with loved ones prior to intubation.
Then the intubation is done. And it’s quiet again….
COVID UNIT
THE COVID UNIT is a new term. I had not learned about this in medical school. I had not seen these in the hospitals I trained in. I had never heard the term ‘COVID’ untill very recently. It stands for Corona virus infectious disease. It was a ‘catchy’ term coined to make this virus more pronounceable (is that even a word).
Since this virus is so contagious, the new normal is trying to contain the virus as much as possible. This included a dedicated ‘unit’ in the hospital where patients with the virus are housed, usually in negative pressure rooms which clean out the air several times an hour. There is a dedicated team of doctors and nurses that takes care of these patients so as not to cross contaminate other patients. To enter these units, one needs to donn PPE and then doff that contaminated PPE prior to exiting.
No family is allowed in this unit, so these units are eerily quiet. One may not see the usual hustle and bustle in the units since the staff tend to stay in patient rooms and avoid coming in and out of the rooms unless needed to prevent the contamination that may come from doffing and donning PPE.
The staff appear different as well. The RNs usually dress in brightly colored scrubs, the doctors in more sober colored scrubs or business casual attire, and a lab coat. It was easy to tell them apart. Now everyone is dressed in scrubs, most are hospital issued, the only pop of color is the scrub caps that is the new trend adopted by all to protect the ‘fomites; from latching on to their hair. Lab coats are a relic of the past. CAPRs and N95s are the norm along with surgical masks for all.
These units are intimidating. In their silence, in their empty hallways, in the rare sighting of staff dressed to the hilt in lifesaving PPE. The air is thick with the smell of SANI-wipes and uncertainty.
THE PATIENTS
COVID-19 is also called nCOV-SARs2. The novel virus causes a novel illness. I have treated patients with pneumonia, respiratory failure, ARDS (acute respiratory distress syndrome). I have seen new-ish viruses before like H1N1. But this is different, truly novel.
The patients with COVID-19 in the ICU follow 2 patterns. These patients were very ill. They came into the hospital with respiratory difficulty and progressed very rapidly, within hours or a day or two to respiratory failure needing intubation and mechanical ventilation. These patients for the most part were able to communicate with us till that point. They just get more and more fatigued and if nothing were done, they would ‘tire out’ and have respiratory arrest. These patients were able to call their families and talk to them one last time prior to being placed on the ventilator. There were always tearful farewells. I would attempt to reassure patients and their families that the goal of this treatment was to buy time for the immune system to recover and the lungs to heal. I would see myself in the Facetime camera and think – geeze – this picture of me dressed full on in a ‘space suit’ could not be reassuring to anyone – but this suit was what prevented me from being on the other side of that suit. It was what allowed me to take care of my patients.
Once intubated, these patients followed a predictable course. They would remain on the ventilator for 10-20 days. This was much longer than the usually coarse in ‘regular’ pneumonias. They were usually well sedated so they could tolerate the therapy that most of them needed, which involved laying them on their belly for up to 16 hrs. a day. This therapy was called ‘prone positioning’. This helped the lungs aerate and oxygenate the blood. This cycle of intubation, prone positioning, with strong sedatives to facilitate patient tolerance of these therapies would go on for weeks. A vast majority of patients would go through the ‘cytokine storm’ where they would have high fevers, some would develop kidney failure needing dialysis, some liver failure. A lucky few would turn the corner. The fevers would subside, the oxygen needs decrease, the kidneys would recover. Some of these patients would come off the ventilator and have another few weeks of learning to breath, swallow, talk, walk and eventually be discharged home but with significant debility. A fair number of patients would succumb to the dreaded cytokine storm and they would be another obituary in the local papers.
A few patients surprised us all. They spent 30 even 40 days in the ventilator without any seeing hope of recovery. These few patients would plug along, would need a tracheotomy and eventually be discharged to a long-term acute care facility where they would an even longer road to recovery.
The patient demographics is what was most surprising. My youngest patient was 30 years old. A seemingly healthy patient who presented with apparently deadly complications of his virus but just as rapidly improved with supportive care. My oldest patient was in their ninth decade. It was impossible to predict who would survive and who would succumb…..
THE END OR NOT?
It’s been a few months since our world changed. Is this the end of the storm or is this our new normal? I suspect the latter. We have a handful pf patients that are COVID-19 positive in the hospital. Even fewer are in the ICU with severe respiratory and other organ failure. Does that mean the virus is losing potency, or that social distancing and other extreme measures have worked? I suspect the later.
We are still doing virtual or telephone visits at the clinic. I am apprehensive about seeing patients in clinic in person. The hospital is a controlled environment where mask wearing is enforced, and I have access to N-95 and face shields and CAPR masks if needed. The clinic is less controlled. Patients are screened for symptoms via phone call the day prior to their visit and then at the door. But some patients have been asymptomatic, and some have been less than honest in their desperation to be seen. Are surgical masks adequate protection in an examination room where I may be with a patient for 40 minutes?
These are fears that I never expected to face. As introverted as I am, I enjoy the face to face time with patients and their families. I ask them about their personal lives with free reign since I need to know their family and social history. There are so many personal details that are shared with me on a first visit. I carry this information with me in a small cubby hole reserved in my brain for each individual patient. I go back to the cubby hole to retrieve this personal information which allows me to connect better with patients when I see them next. These little details help me view patients as the multidimensional humans that they are, rather than a man struggling to breath because of decades of self-inflicted lung damage from smoking, or the grandma found in a drunken stupor on the porch and landed in the hospital for a few days to detox. These patients though struggling with illness and addiction have interesting lives and loved ones waiting for them at home. I hear their pride when they talk about the family they have created, kids, grandkids and great grandkids. I hear about spouses that are deceased and the struggle and loss experienced in their absence. Some succumb to the depression and loneliness and some find another partner. Some tell me about their hobbies, their love for pickle ball, restoring cars, their dahlia or rose garden. I have missed these stories and these connections…..
Just thinking about this past life not so long ago has made me emotional. I am looking forward to seeing my patients…..
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