I’m starting to see rays of light pierce through the clouds like it does after a bad storm passes by. Maybe we have actually achieved the goal of “flattening of the curve,” which is what we hoped would be the reward for shutting down the entire world. The ICU staff decided to pick a theme song to play when we discharge a COVID-19 patient. The winning song, which we now play for every COVID-19 discharge is… “Here Comes the Sun” by the Beatles. The voting process was fun, and provided an uplifting antidote to the usual hospital COVID-19 email updates which daily announce in red text: N95 running low, surgical gowns running low, fentanyl drips running low.
But, that ray of hope just disappeared behind a cloud – because now there’s an uptick in the census.
What We Are Learning
- Less pressure, more oxygen: Initially, chest X-rays and PF ratios (PaO2/FiO2) were consistent with ARDS [Adult Respiratory Distress Syndrom]. But maybe the lungs aren’t as stiff as we thought and the high PEEPS [positive end expiratory pressures] from the old ARDSNET protocols may not have helped these patients. Now we’re using lower PEEP, higher FiO2 [Oxygen percentage] protocols and are getting patients off the ventilators sooner.
- Slower to intubate: We started with intubate early, now it’s intubate as a last resort. It turns out that some patients linger on 100% Oxygen, non-rebreather face masks for days – and while some do require intubation, some get better.
- Faster to anticoagulate: At first we didn’t know what to do with the inflammatory markers (and maybe we still don’t), but we’ve seen a lot of embolic events [clots in the blood stream] and they’ve correlated with rising d-dimers, so we’re anticoagulating patients sooner and moving from prophylactic to full dose much more quickly. We’re also recommending that patients be sent home on anticoagulation for anywhere from 2 weeks to 3 months.
- Less wild about the new drug cocktail: Do the drugs work? Have no idea. At first I thought, if I get COVID-19 then I want Plaquenil/Zithromax and Kaletra. But now… not so sure. We’ve had a huge number of people on these drugs develop prolongations in their QT interval that are frightening. Pancreatitis and other drug interactions also occur. That combination of “anti-COVID-19 drugs” interacts with everything.
- Wild about Prone Positioning: It works. We even tell patients who aren’t intubated to sleep on their stomachs.
- This physiology is NOT in the book: Many patients are hypoxemic down into the 80%’s range and yet their heart rates are only in the 70’s. Patients who are that hypoxemic should have a rapid heart rate. This makes no sense.
- Et tu, kidneys? Why are the kidneys failing? It acts like acute tubular necrosis. Some of them progress to needing renal dialysis while some recover. Is it the hypoxemia and high PEEP that results in low mean arterial pressure that damages the kidneys, or is it the drugs?
- The symptoms of COVID-19 are… any and everything. My perspective is colored by seeing only the sickest of the sick. However, my primary care colleagues are seeing COVID-19 symptoms as minor as headache and sinus pressure for a few days. Some have cough and fever for two weeks. Some are hypoxic but trying to hang in there at home. Then you have the ICU world – which is a house on fire. Incredible spectrum of presentation.
How Do We Get Back to Where We Once Belonged?
How do we do re-entry? How do we return to “normal” when this is all said and done? Will there be a second or third wave as we relax restrictions and infect those who didn’t get infected in the first wave? Do we do a deep decontamination of the entire hospital, once the last COVID-19 patient leaves?
In my mind, I am trying to plan the “After-COVID” party which I hope will happen this summer. Are we gathered around the campfire sharing lockdown stories, sipping wine out of a Yeti cup, our lives back to normal? My daughter would say that Yeti cups are “bougie” (bourgeois). She envies other kids who, “actually get to hug their moms every day.” She gets frustrated that I go to work early in the morning and come home late at night and that I’m not there to do art projects with her. But I asked her, “Who would you want to take care of you if you were sick?” She generously acknowledges if she were sick, she’d want me as her doctor. So, I promised her that one day when this is over, we will have an entirely “bougie” day: I’ll take her to a coffee house and I’ll drink overpriced coffee and she can have unicorn hot chocolate. Then we will go get a mani-pedi, and after that, go shopping for something that sparkles obnoxiously. Then, to make sure we have done bougie right, I’ll take her to lunch at a local French café because the French invented the bourgeoisie – that affluent class insulated from the realities of life. Except, of course, we aren’t. We are in the battle, and our lives afterwards won’t be the same. But will make it through this, and I am walking through the ICU humming,
“Here comes the sun little darlin’ here comes the sun and I say, it’s alright….”