I’m an information nerd.
Instead of toilet paper, my own personal way of feeling in-control during a pandemic is reading-up on the Enemy. Not just how we beat it (washing hands, staying home, etc), but how we can save the lives of our most vulnerable in the unfortunate event they get infected with COVID-19.
By now most of us have read about the math of COVID-19’s exponential spread, based on what they experienced in China and Italy. We know if we can keep the coming ER explosion from becoming Advanced Triage (where Doctors have to choose which patients to save, due to lack of supplies) we can save lives. In the same vein, perhaps the best incentive to make us stay home is understanding the struggle Doctors will have saving COVID-19 victims in severe respiratory stress in the coming weeks.
So what follows here is an explicit description of how COVID-19 kills vs just how our doctors can save the lives of COVID-19 victims near death. I am not a doctor, but in reading up on exactly how the Enemy kills, I learned a lot of details that most people may not know (for instance, COVID-19 deaths are not usually due to Pneumonia only). In understanding the tough situation American doctors face in the coming weeks, it helps me feel a little better and makes it clear: we must do social distancing NOW.
Here follows the story of a fictional 68 year-old who just contracted the virus, two days ago. TRIGGER WARNING: this may be upsetting for some people to read (our patient survives), please feel free close this page now if you find any of this upsetting. Or jump to the end, where I tell you how we can all save lives in the US during this month of March.
Day 1–5 (as long as 10 days) an at-risk person with high blood pressure and Type 2 diabetes goes out to eat at a local restaurant around March 12th. He contracts the virus. This person may have almost no symptoms, for as long as 10 days. He is fairly active before becoming sick, and contagious long before symptoms kick in. Then…as we all know: fever, chills, soreness. A dry-cough. The symptoms can come on very rapidly, and be fierce. They can even be moderate, yet still create complications as the days go on. Our patient goes to the doctor’s office, and tests negative for the Flu. His doctor informs him that he cannot administer a COVID-19 test without approval from the county Health Department. He advises our patient to return home, quarantine, and fight the virus. Our patient stops at CVS to get his antibioitics Rx, Gatorade, and Robitussin to settle-in.
Days 5–14 (or 10–14) — somewhere in late March the fever is still present, up to 103F average. Our patient has been keeping fluids up, despite nausea. Some at-risk victims may even beat the fever at this point, but they are now left with difficult, labored breathing. This virus may even be knocked-back, almost beat, by their immune response. Yet try as they might to drink Gatorade or water and get better, these patients can become dehydrated as their stressed immune system fails to cycle away from inflammation. Especially in the lungs. Our patient is frustrated, the Robitussin isn’t helping with the cough, and he wonders why he is so dizzy and feeling like he cannot get enough air. Even as his body valiantly reduces virus levels, fighting the virus off has left our patient’s lungs very inflamed.
Days 14–18. Getting out of a chair feels like 2 flights of stairs. For those with diabetes or high blood pressure, dizziness and near-falls are counteracted by the victim staying in bed. Victims may experience passing-out, and be in and out of conciousness at this point. Breathing is wheezing, and labored.
Days 18 onward — extreme reduced lung function as ARDS is underway. ARDS = Acute Respiratory Distress Syndrome. ARDS can happen with or without Pneumonia. ER visit and hospitalization often begins here. At this time, the patient is NOT yet in an ICU bed, but likely needs to be within a day or two if they are to be saved. Let me say that again: With COVID-19 it is NOT always Pneumonia that puts at-risk patients onto ventilators after 2–3 weeks, nevertheless these patients often will need an ICU bed if they are to be saved.
For our patient it is now April 2020, and people in our patient’s community and region did not socially-distance themselves until late March. Area hospitals are now overwhelmed, staff have been working 18 hour shifts, and ICU beds are full with all ventilators occupied. The patient, in and out of consciousness, sees double-parked beds outside of private examination rooms in the ER. He hears the sounds of caustic dry-coughing, breathing sounds much like his own, and urgent conversations between doctors and nurses. An Emergency Physician Triages our flagging patient, and must hold him from immediate ICU. He admits the patient and makes a phone call placing his name and two others at the top of a list for ICU consideration, every 24 hours.
The patient is transferred with another ER patient to a floor of the hospital normally reserved for advanced-care and geriatrics, but due to overwhelm has been transformed to overflow. Rooms designed for single-patient care have two patients per-room. IV fluids and anti-viral meds are immediately delivered, along with oxygen. O2 and breathing are monitored closely every hour. Here the patient is still concious, but with labored and weak breathing. Our 68 year-old patient will fight hard for 12-24 hours in this room, prior to ICU. Adult family visitors are allowed one-at-a-time, in a gown, gloves, and mask and only after having their temperature checked.
The millions of alveoli in a persons lungs become more inflamed at this point, and our patient’s lungs are now unable to efficiently move gaseous O2 into the tiny capillaries in his lungs. Inflammatory lung edema has been well-underway, and the Attending Physician orders fluid-management and immediate transfer to ICU as soon as it is available. The at-risk patient’s BP has gone up, and they are flagging further. The Attending knows what is coming, if the patient doesn’t get moved soon.
On another floor, a 77 year-old patient has just died after one week in ICU. A room and ventilator will become available. They are sanitized and our patient is immediately transferred to ICU. Now mostly-unconscious, the patient’s BP is lower but breathing is extremely weak and shallow, and O2 levels are dropping rapidly. The patient’s organs are begging for more oxygen, and the lungs are failing to deliver.
Just 3 weeks after contracting COVID-19, our Patient is now in an ICU near-death, in the fight of his life. The life-saving ventilator is ready, and miraculously an ECMO machine has also become available (though ECMO is for people <40 years-old, a younger man with ARDS just arrived next-door who may get it). Our patient’s luck has now turned, and he has a tired but fantastic team ready to save his life.
And here is how they will do it.
Two doctors confer and two Repiratory Care physicians stop by. A PA and two ICU nurses enter the room. They speak loudly with the patient, waking him and informing him they are going to place him on a machine to help him breathe, and it will save his life. The patient’s ribs and diaphragm are sore at this point, from the labored breathing of these past few days. He wholeheartedly agrees, giving the doctors and staff a weak thumbs-up.
The doctor’s discuss the care plan ahead. The patient overhears them. They sound confident. The doctors know: with the ARDS, it’s really bad. When the edema begins, and if Pneumonia is present, it can feel like drowning. Not enough oxygen gets to your organs. Organ failure follows. Without a ventilator or other interventions like ECMO — organ failure will lead to death.
“Not Today”, whispers the Attending Physician and gives a thumbs-up to our patient. They are going to fight with three ventilator modalities developed in the wake of SARS in 2004. These three modalities will save our patient:
Once on the Ventilator, doctors will work to heal the patient’s lungs by keeping continuous pressure in the lungs while using a low tidal volume. This reduces the inflammation in the alveoli, but requires vigilant monitoring of O2 and CO2 levels.
Low tidal volume ventilation is very uncomfortable for the patient, and most patients resist the tidal “breathing” — so the doctors will need to give our patient a carefully-administered medicine to paralyze his breathing effort: the ventilator must be in charge of all breathing, for the time-being.
Next the doctors will place the patient into a prone (laying down) position for 18 hours a day.
A patient receiving prone and Low Tidal Volume ventilation
Together, the above 3 treatments while on the ventilator give our patient the best chance at survival. Our heroic doctors today are using new knowledge, advanced-technology, and intensive-care to save vulnerable patients like this in Italy. And it is how they will do it in America, if we can mitigate the coming spike in patients and avoid hospital overwhelm.
It is now day 5 in ICU for our patient and, unlike the room’s last unfortunate occupant, our patient is improving and responding well to treatment. He has been sleeping a lot, but while he sleeps his body continues the fight. Now less-inflamed, his inmmune system already dealt the final blow to COVID-19. He is now virus-free and no longer contagious. His fever is well-managed, and the IV antibiotics cut short any severe pneumonia….but he still requires ventilation for at least another two days while his lungs heal.
Day 6 passes and the patient is now laying on his back, and when he is awake he writes on a notepad to the nurses…..”glad not on stomach anymore...” was the last thing he wrote today before sleep. The Third Modality (laying prone) is becoming less freuqent now as the fluid-management is working and the edema and inflammation in his lungs decline.
By day 7, the paralysis medicines are reduced significantly because the tidal volume on the ventilator is now raised. The patient is still uncomfortable, but he will no longer need breathing-paralysis soon: he is working in-tandem with the ventilator now. They are a team. Our patient is thankful. Healing. His body O2 levels yesterday were between 79% and 81%, and today they are approaching 85%. He now is awake 6 hours a day and watching the news and nodding and writing on his notepad. He tells his wife and daughter he loves them in a FaceTime chat. He misses his family and, thanks to the tired Hospital staff, he will see them again soon.
Day 9 the new Attending Physician walks in, introduces himself, and tells the patient he will soon come off of the ventilator. He is a young doctor who looks a little less tired than the other ICU doctors. Our patient’s O2 levels are now 92%. Coming off the ventilator will be “fun” the doctor says, because he will get a solid meal and only get stronger. Our patient gives the doctor an emphatic thumbs-up. The doctor also says they got the test-results back, and it was indeed positive. Coronavirus is what put him here. Our patient smiles and rolls his eyes, “sure wish they had the ability to test last month...” he thinks to himself.
It is now Day 12 and nearly a month after our patient contracted COVID-19, and he will be discharged. He has lost 15 pounds, but feels strong and happy to be alive. In a last act at the hospital, he donates some blood to help with the hospital’s supply of plasma containing COVID-19 antibodies. It’s the least he can do for those who saved his life. They still have a long battle ahead of them. It may last until July for this hospital, but a vaccine is on the horizon for December 2020.
This will be the story of many poeple in the coming weeks. How many? That depends on us! And for those getting ventilator treatments and the above interventions, they might have to live with the following complications the rest of their lives: retinal apoptosis (reduces vision), reduced lung function (possibly permanent), and kidney or other organ-damage.
Because of the limited testing the US started, it is very likely we are in for tens of thousands of these kinds of patients in April. Community-spread has been underway for weeks now in the US, and so we are already in that feared uptick range of people needing emergency medical interventions against ARDS and other complications.
COVID-19 will be downright deadly for some people by next month, but our amazing doctors will save lives. But if the numbers of advanced-stage and at-risk COVID-19 patients explode, our hospitals may be overwhelmed. They may not have enough ventilators or ECMO machines for those doctors, to save lives. So WE must help those doctors NOW. We can help our medical professionals have all they need, by doing all we can NOW to protect as many vulnerable as we can: by social distancing and staying home.
Let me say that again: WE can HELP doctors have enough ventilators! And all we have to do, is remain distant from others and stay at home as much as we can. Distance ourselves from people at work, at the store, and anywhere else we have to go. Refrain from going out in crowded places, and be cautious. It’s just for a little while.
I have an 89 year-old mother who turns 90 on April 5th. Her skilled-nursing facility is in total lockdown right now. I want her safe. I want all of our vulnerable safe. So even if you aren’t sure social distancing will save lives, maybe do it anyway. Do it for my Mom, and our elderly everywhere. Practice social distancing this week, and next week.
Doing this will save lives.
Together, we can arm our doctors and medical professionals with the best possible tool to beat COVID-19 in the US: time.