Tales from the front

I learned a lot from a two week tour of duty in the COVID-19 unit. First is the unpredictability of this disease.

Details will be obscured so that no patients can be identified. Pronouns will be “they”, “them”, or “the patient”. I am not a doctor, but I play one on TV. A few numbers will make things make more sense. “Oxygen saturation” or “SpO2” is the amount of oxygen in the blood expressed as a percentage, with 100% being the ideal state in healthy lungs. Over 90% is generally not a problem. “FiO2” is the percentage of oxygen in the air being supplied to a patient. Air is about 21% oxygen. 100% FiO2 means pure oxygen. The flow rate of oxygen is measure in liters per minute. Home oxygen concentrators can supply about 5 liters per minute (some up to 10). Normal resting heart rate is around 75. Normal respiratory rate is about 12-20 breaths per minute. There will be a quiz later.

In my world, I am asked to make a discharge recommendation the first time I see someone. (Can they go home? Do they need to go to rehab? Do they need extra help?) If I think they can go home I am to “clear” them for discharge home when I think they are safe to go home.

One patient looked great when the Physical Therapist saw them. She told me she had cleared them to go home and I didn’t need to see them. She thought they might leave that day. The next day the nurse called to say they looked worse, and could we see them? On day 3, they could sit up at the edge of the bed (with two of us helping) long enough to eat a snack. Two days later they were dead.

Another patient was up independently in their room; able to wash, dress, go to the bathroom independently . Two days later, they were on 50 liters per minute of supplemental oxygen (at 50% FiO2), with a respiratory rate of 35, heart rate of 115, and oxygen saturation of 82% – at rest. What happens next, I don’t know. I have a prediction. I will not speak it here.

A third was cleared by another therapist and I was asked to monitor them (look at the medical record each day, see if there were any significant changes that might require our intervention). I decided to go see the patient when I read that they might go home soon. SpO2 was 90+% on 6 liters of O2. Getting up from a chair and standing for 1 minute caused the patient to feel the need to sit down. Half a minute after sitting, SpO2 dipped to 75%. Flow rate had to be increased from 6 to 15 liters/minute and it took 15 minutes of rest to recover and get back to over 90%. I rescinded the “cleared for discharge home” designation. They went home the next day.

Another patient looked great the first day. I cleared them for discharge home. The next day they were placed on a mechanical ventilator – a machine to breathe for them. After extubation (removal of the breathing tube down their throat, removal of the ventilator), the nurse and I helped them to a chair. They were on 6 liters per minute of O2 via nasal cannula. Up in the chair we added 15 liters more via a non-rebreather (a mask with bag attached that looks sorta like what you see on an airplane) in order to keep their saturation level acceptable. Two more days and they are making a great recovery on 3 liters/minute while up in a chair.

This virus also messes with your blood clotting system. A person came in with COVID-19 and a blood clot (thrombus) in the leg. Part of it broke off and settled in the lungs (an embolus), where it became immediately life-threatening. The treatment for this is a heparin drip (a steady release of an anti-clotting agent into the bloodstream). This resulted in bleeding into the muscles of the butt/torso (a hematoma). Now we had a dilemma – stop the heparin to stop the bleeding so they don’t bleed to death, or continue the heparin to break up the clot in the lungs so they don’t suffocate? That’s why doctors make the big bucks, not me. While this person was afraid to get out of bed, then afraid to walk to the bathroom, ultimately they recovered and went home.

That’s only five people – half a day’s work -but you get the idea. So what did I learn? I can’t make a reliable prediction from seeing someone once. I’ve come to write “To be determined” for my discharge recommendation on the first day, and revise it daily. While it is important to be up and moving if possible to help recruit healthy lung tissue, we need to monitor vital signs closely and adjust our expectations minute by minute. One patient talked with their child and the child said they were taking it, not “one day at a time” like AA, but “one hour at a time.”

Usually I scribble quick notes to myself as I go, then transcribe that into the electronic medical record (EMR) when I leave the room. Since every patient on this unit is in isolation, I can’t bring a pen and paper in the room and take it back out, so I memorize all of these numbers and try to write them as soon as I leave the room. After seeing 8 or more patients, I shower, change clothes, and write all of the notes into the EMR at once.

Each patient is isolated from each other patient and the entire unit is isolated from the rest of the hospital (meaning doors are closed unless someone is passing through them – all automatic door openers are disabled – and the unit is negatively pressurized so air does not escape). We wear hospital-issued scrubs (usually reserved for operating room personnel). For each patient we don fresh gowns and gloves that we remove before we leave the room. We disinfect our face shield and hands before we enter a room and when we leave it. We disinfect our hands and the keyboard before and after touching computers. If in doubt, we disinfect our hands before and after touching anything. As such, everything takes longer than usual. The nurses use a PAPR (Powered Air Purifying Respirator – sort of above-water SCUBA). They remove and disinfect it after every patient. Our N95 mask (formerly used once, with one patient, and discarded) is to be used for 7 days. (Image from workersafety.3M.com)

The caseload is going up. The hospital is full. A month ago it was full of non-COVID patients. Now the COVID units are filling up. A newly-remodeled unit will open soon. I suspect it will be diverted from its planned use to being a COVID-19 unit. Elective surgeries are being postponed again (as they were last spring). A 500 bed field hospital has been opened on the State Fairgrounds. A lawsuit has just resulted in an injunction against the Governor’s order limiting crowd sizes. At least the mask order was upheld (different suit, different county). So you can go into a crowded bar and take off your mask to drink, but you need to keep it on to shop for groceries. And of course, everyone in bars stays 6 feet apart, no one talks loudly, and everyone controls all bodily secretions (“say it, don’t spray it”).

I know our president still thinks it is no big deal. Among the things I wish for him, is that he could follow me for a day – change in and out of isolation gear 8-10 times, run from room to room, and then remember what you did 8-10 different times to write it all down later. Mostly I want him to see the people who aren’t him, who didn’t recover and get back to work in a few days; watch them struggle to breathe, to get out of bed, to do the things we take for granted every day. I want him to see that not everyone has a personal team of doctors and nurses who have only a single patient to care for. I want death to not be an abstraction.