The COVID-19 Diaries return, as we see how our guest blogger has truly been forever changed by the experience.

–Caroline

The Battle of the Mind

The past two weeks I have been on the pulmonary consult service. I went right into weekend call and the next week back to the ICU – that’s 12 tough days in a row without a break. The battle of the mind still persists. You work with COVID-19 patients and feel a sore throat or a cough, and you ask yourself, “Did I get COVID-19 this time?” But the symptoms go away. I’m not afraid anymore – I’m too tired to be afraid. I also have more faith in my PPE which, knock on wood, has kept me safe – at least I’ve been symptom free. My colleagues who caught COVID-19 are back now, and I ask them about their initial symptoms and if they know how they caught it. Almost all of them have said they don’t think they caught it from the patients. In the hospital setting, they think they caught it from their fellow healthcare workers. Afterall, we KNOW when a patient has COVID, or at least we assume they do and behave as if they do. But our colleagues who look fine? Early on, we took off our PPE in the staff rooms and in conference rooms. It seems likely the docs who got sick got it that way.

It’s Baffling

Transitioning back to the ICU was exhausting. The first four weeks (that I’ve blogged about), I had adrenaline. Now, no more adrenaline, just fatigue. The patients are still so hypoxic. They still baffle us. Is this one on two liters nasal cannula going to be ok? – Nope, three days later he got intubated. Is this patient on 6L nc (liters nasal cannula oxygen, CF) and 100% NRB (non-rebreather face mask, CF) going to get intubated and die? Nope, he got better after about two weeks. Why won’t this one who has been on double oxygen for four weeks not getting better? We can’t budge him off of his oxygen needs and he’s had every drug out there!

I extubated someone who was on the ventilator for three weeks. We all cheered! 48 hours later, we had to re-intubate him. Will he survive? Or does he fall in the 80% mortality range some have reported for intubated patients?

80% Oxygen Sat is the New 100%

My sickest patient this week was so hypoxic, and did so much better prone, we had to keep proning him almost immediately after putting him back into the supine position. While supine I quickly placed a dialysis catheter, hoping the nephrologist would be willing to attempt dialysis – despite him being on two vasopressors for low blood pressure. At one point his oxygen saturation was 62%. We had to prone him again after only being supine for 20 minutes, or he was going to die.

It is horrible having to watch someone die – their oxygen is so low it can’t sustain life, then the heart rate suddenly slows down – you know it’s going to stop and there isn’t a damn thing you can do about it. The respiratory therapist, nurse and I all began to do chest physiotherapy. We were beating on his back with cupped hands to try to open up lung and move secretions. Did we believe it would help? No. Was there anything else we could do? No. Finally after about forty minutes, his sats climbed back up to the mid 80’s. His heart rate picked back up again and he didn’t die. We said 80% is the new 100%. Not really – but it made us feel better to say it.

The Valkyrie Nephrologist

The nephrologist, a petite woman, showed up and agreed to attempt dialysis on my patient. Usually we don’t dialyze patients on vasopressors because they’re already so unstable, but she knew (like I knew) that he’d die without it. Then we met resistance with the dialysis company, because they don’t “do” dialysis on prone patients. The nephrologist sweetly and firmly asked to speak to one supervisor after another, working her way up the chain of command until she got the approval to dialyze my patient in the prone position on three vasopressors. Yet another “COVID-19 first” for our hospital. If I could replay her walking into the ICU – I’d hear the ride of the Valkyries playing in the background. I told her she was my angel – she told me it was her job. The heroism I’ve seen in my colleagues has been humbling. However, it’s especially poignant when the hero is a woman who is 5’3” and weighs maybe 120 lbs. I guess power can be manifested in many forms.

Ventilating Concrete

I woke up the next morning and checked my list to see if he was still alive. He was! And his metabolic derangements were somewhat corrected by the dialysis, but no fluid could be removed. He is now 16 Liters fluid overloaded. His chest X-ray is officially the worst chest X-ray I’ve ever seen. I took a de-identified photo of the chest X-ray and shared it with another pulmonary colleague – she said, “you’re trying to ventilate concrete.”

Another 24 hours pass, proning, dialyzing, managing drips. DRIPS – my patient had NINE pumps going at once. Bicarbonate, levofed, vasopressin, pheynylephrine, zosyn, vanco, heparin, fentanyl, versed, rocuronium, famotidine. Some of the drugs “piggyback” onto other drugs, so it was nine pumps and 11 drugs to keep him alive. I had to take a photo of the IV pole.

Finally, despite full life support and ventilating concrete lungs, my patient was “ok”. I’d maxed out what I could do with my resources at my hospital, and it was time to try for the second time to transfer him to our tertiary care university hospital where he could get inhaled Nitric Oxide (a pulmonary vasodilator) and other forms of renal replacement therapy (dialysis). First he had to demonstrate “stability” in the supine position, as the ambulance can’t transfer the patient in the prone position. We flipped him over – I was present, because it had become a life-threatening event every time we did it for this patient. Once he was flipped over, the ventilator was giving him 70ml breaths. His sats dropped to 40%. The respiratory therapist had to bag him back up to the 80’s. Once he hit 85% we decided to put him back on the vent again, slightly higher settings than what he’d been on while prone. Didn’t work. There was something wrong between the end of his endotracheal tube and the ventilator. We changed out the vent circuit (tubes that connect the patient to the machine). Didn’t work. We’re still bagging him, sats are in the 90’s now. Changed out the ventilator, hooked the patient back up again. Still crappy volumes, and he lost his oxygen sats again. So I called for a different respiratory therapist. I looked at the ambu bag and decided, if they’re bagging him with 700cc breaths roughly with peep, and I can hear breath sounds, we have to some version of that via the ventilator. I told the new therapist to crank the machine up to an inspiratory pressure of 40 and a peep of 20. Mind you the maximum pressure you should EVER ventilate a patient with is 30 – this patient was getting effectively a pressure of 60. But he was going to die. She nervously did what I asked, while I kept auscultating his chest and reminded everyone that we’re ventilating concrete. Finally, with an inspiratory pressure of 34 and peep of 20, we were getting decent volumes and oxygenation. I made the call to transfer the patient – the ambulance had to make sure first that their ventilator could deliver the kind of pressures that my ventilator was delivering – it could. All systems go.

I left his bedside to get caught up on notes and eat a little lunch. Then I heard overhead – “CODE BLUE – adult intensive care unit, CODE BLUE.” They say it three times. I ran out of my office without my mask, ran back to get it and ran to the ICU saying “Dear God, please not my patient.” It was the patient next door to mine. Incidentally, he received some CPR and got intubated and survived. My patient was still “stable.” Thank you God.

Higher Level of Care, Maybe…

When the critical care ambulance team arrived to pick up my patient, they were all wearing space suits complete with helmets. They have to. Can you imagine the rig hitting a pothole and the patient popping off of the ventilator and spraying viruses all over the inside of the cabin? They were so good at what they do, it was like watching a special forces team come in and acquire an asset. They untangled the spaghetti IV tubing and drugs, re-hung them on their poles and pumps. Then they clamped the patient’s breathing tube so as not to lose the pressure in the lung (thus preventing deflation) and switched my patient to their ventilator to make sure he tolerated a different machine – which he did – and shifted him over safely with 9 drips, an arterial line, a dialysis catheter, an internal jugular line and ventilator tubing onto the tiny transport stretcher. Off they went.

The patient’s nurse and I felt a little empty when he left. There’s this sense of loss and relief. This patient had consumed every minute of our lives for the past three days, and now there was an empty ICU room. He made it safely we heard. University hospitals naturally think they can do better medicine than small hospitals. So they tried to change his ventilator settings and he did not do well – so back he went to the vent settings I had him on again – not ideal, but the best we could do given the circumstances.

COVID-19 Has Changed Me

As I write this, I have not been in the ICU for 48 hours and will take a few days off next week. I will re-enter a less adrenaline-pumping time for a while. Wrapping up the week, I felt I barely made it to Friday evening – I was exhausted. My arms are sore from pounding patients’ backs to open up airways. I came home, did my usual decon routine, showering in the basement before greeting my family. Even with the sound of water running and surrounded by my things at home, I can still hear the ventilator alarms, the IV pumps running boluses of medications into my patients. I can hear these sounds so audibly, I have to turn my head to see if there’s a source behind me. I wake up in the middle of the night – managing ventilator settings. COVID has changed our lives – COVID-19 has changed me.

Caroline Fife, M.D.

Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos

The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.