Here’s a guest blog from a friend and colleague who practices Undersea and Hyperbaric Medicine and is also a Critical Care physician. I believe that she should remain anonymous for now. However, I was inspired by the emails and texts she has sent me and thought you would be, too. She’s sending me messages off the cuff – they are “raw” and not edited by her. However, I think that is best. She uses a lot of abbreviations and when I thought it was useful, I explained them in brackets. One day at the right time, I will tell you who she is and we can all thank her properly for her courage and commitment. Here are her COVID-19 Diaries – uncensored.
Critical Care Doctors Succumbing
Another one of our critical care docs has fallen ill. It is gut wrenching. Looking at your colleagues when they’re healthy and sharing conversation with you feels like a line of defense. When they fall ill, it’s like you inch closer to becoming a victim, too. So I stepped in to relieve a fatigued colleague and help out. The ICU volume has doubled. 22 patients on vents.
Font Line Clinical Pearls – blood clots, pneumothorax, renal failure – and a rethink on steroids:
- What we’re seeing now is crp’s [C-reactive protein, CF] trending down but d-dimers trending up. Is this a delayed inflammatory phase that’s pro-coagulant?
- We’re catching more DVT’s [deep venous thrombosis, CF] and PE’s [pulmonary emboli, CF], so our threshold for empirically treating PE’s is lower.
- We’re avoiding CTA’s [CT angiograms, CF] so as not to cause renal injury.
- We’re seeing a very protracted course on mechanical ventilation. I worry the patients will be “pulmonary cripples” if or when they’re liberated from the ventilator. Not to mention, the paralytics we have to use may leave them with a myopathy that will take months to recover, long after I am no longer even involved in their care.
- We’re seeing [pulmonary] barotrauma now [meaning, pneumothorax – collapsed lungs, CF]. Why all of a sudden? Are we more bold with taking them to peeps [positive end expiratory pressures, CF] of 24? Or is this two plus weeks into illness and the lungs are getting stiff from high peeps and FiO2 [inspired oxygen levels, CF]?
- We’re seeing more renal failure now.
- Anecdotally, two patients who have needed steroids for other reasons have seemed to do better on the ventilators. That matches the Chinese data, but Europe and the US tend to be anti- steroids for ARDS [Adult Respiratory Distress Syndrome, CF].
We continue question and do our best to minimize harm and maximize safety. The volume of sick patients is increasing, but the discharges of the less sick patients is increasing as well. So on non-icu floors there’s some hope.
The OCD Approach to Personal Protection
I find that I deal best with my anxiety by converting it into OCD [obsessive compulsive disorder, CF]. I Purell before I put gloves on. Then gown up. I already have my n95 respirator, goggles, face shield and hair bonnet on. I Purell the stethoscope and let it dry while I look at the patient and feel their abdomen, check their skin. Then listen to lungs, heart, abdomen. I Purell the stethoscope again. Peel my gloves off into the trash, Purell, remove my gown, purell, open the door, exit, Purell, remove my face shield – peroxide wipe, Purell my hands again.
I’ve been reusing my N95, going on week 2 now, however, the bruises and sores on my face reassure me that I’m getting a good seal and nothing is getting through that sucker. I also find that I’m mouth breathing in the mask because the work of breathing in that thing is more that nose breathing can handle.
On rounds today, one of my residents had a dry cough. I wanted to ask her if she’s OK, but also didn’t want to draw attention to it. I would feel bad if someone asked me about my cough – and of course it’s allergies!
Thank you for the food! It is much appreciated!
We are seeing so many nice things from the community. Today a whole cart of burgers fries and shakes came to the ICU. And the Girl Scouts sent us cookies! However, I’ve gone back to eating lunches brought from home, or the next set of covid diaries will be my 600 pound life.
Addendum – just as I was posting this new blog by our Front Line Doc, Dr. Barry Creighton sent me a link to this fascinating article which is interesting to consider in light of her new post. Thank you! CEF