My Virtual Reading Room

Written by a critical care physician.

These chest x-rays were taken 8 hours apart. On a relatively young, healthy, tough as nails veteran. When I assessed him in the ED initially, he looked great, sitting up in his bed, talking in full sentences. Texting on his phone. In the ICU, we refer to that as the ‘cellphone sign’. I thought to myself that he could probably be admitted to the ward as a COVID-19 rule out. Then I saw his admission CXR and told my charge and lead RT that I wanted him in the ICU in the next ten minutes and that we need to intubate him. I told him what was going on, he looked at me in disbelief when I told him that he was very sick and needed to be intubated. “ I feel fine doc, I just have the flu”. By the time i finished the cumbersome ritual of getting my PPE and PAPR on, his sats were in the high 80’s on a non rebreather mask. I knew we had no time. I intubated him immediately, the familiar change in tone on the monitor of dropping sats to the low 80s, then 70s, then 60s before recovery. He had zero reserve. Eight hours later, he was maxed out on conventional ventilator settings and I couldn’t get his sats above 85%. Now on APRV, inhaled nitric oxide with plans to begin proning, I’m still in disbelief with how quickly he deteriorated.

As a pulmonary and critical care fellow at a busy academic center in a large metropolis, I’m used to seeing critically ill patients. ECMO, transplant, PH, ILD, MCDs, high risk OB are things that I have become intimately familiar with. We deal with the sickest of the sick and my team does it very well. Death is an ever present companion for us. Yet, COVID-19 is unlike anything we’ve ever come across. Therapies such as plaquenil/azithromycin (flawed study), Kaletra (negative study), Actemra, Remdesivir do not have strong data (as yet). Steroids likely make these patients worse based off data extrapolated from the MERS/SARS cohorts. As of now, all we can do is provide supportive intensive care and try to mitigate the cytokine storm. Oh I forgot to mention that a large amount of patients seem to be dying from sudden cardiac death/acute cardiogenic shock, presumably secondary to viral myocarditis.

It doesn’t just affect the elderly. It affects everyone. Young people are dying too. It breaks my heart to see the casual attitude of society towards this pandemic while my colleagues and I work day after day without respite. I consider myself lucky to work with some of the most talented and bravest physicians, nurses, RTs and ancillary staff that I have ever met. We all know and accept the risk that comes with this job. I am cognizant that I will likely get COVID-19 during the next few months. I also know that my mortality risk is relatively low. This is a risk I fully accept. Many of my colleagues have a higher risk. They have demonstrated an unwavering commitment to the job regardless. We don’t want sympathy. We don’t want thoughts and prayers. We don’t want you to change your profile picture in solidarity with us. What we want is appropriate and adequate PPE. We want ventilators. We want for every citizen to do their part to flatten the curve. We want mass screenings. We want to be able to test patients based off of our years of training and clinical judgment. Not because some suits in admin decided that these patients didn’t meet some vague criteria decided upon by folks who have no idea what it’s like to be in the trenches. There are no high risk or low risk patients anymore, everyone should be presumed COVID-19 positive. We want for the government on a federal and state level to do their damn job and stop bickering and heed our warnings before there is nothing left to bicker over. Worst case scenario for the US puts us at 2.2 million deaths based off current scientific models (notwithstanding those who will indirectly die as hospitals are unable to care for the usual slew of chronic medical conditions). By the end of June, for every available critical care bed, there will be roughly 15 COVID-19 patients in need of one. Make no mistake, this is the greatest challenge the world has seen since WW2. The worst is yet to come.