My Covid Diaries
Friends,
Things are worse off here than I thought. Initially I thought maybe the Long Island hospitals wouldn't be as bad off and I guess that's true but this hospital (an underfunded, publicly supported academic medical center) has been severely impacted. I have a feeling this place was always under-resourced but it is quite glaring now.
The surgical ICU, trauma ICU, cardiac ICU, pediatric ICU, and rehab units have all been converted to adult medical ICUs dealing with covid patients, majority intubated. I thought I'd get a little orientation, new badge, parking, maybe even a half-day learning the computer systems but instead was put straight onto the unit to lead rounds at 7 am. We ran all day. I am supervising a team of 5 interns, 3 residents and a critical care fellow in caring for 16-20 of these patients. They have all been working 100+ hour weeks. Medical students (all students actually) have been banned.
Since March 15th, this team has had only one patient extubated. Hospital-wide, 5 died yesterday. We've lost 2 today. I've lost count of the overhead 'Code Blue' or 'Stat Anesthesia' pages that indicate a crash since I arrived this morning but they are constant. I think other area hospitals are doing a little better (see resource comment above) in terms of extubating people.
Our team is still looking after the very first covid patient diagnosed on Long Island. He's still here, intubated since 3/11 and rather sick. There are constant shortages of critical supplies and medications but they have largely been able to adapt and improvise. The biggest shortage is personal, either because they are sick or have quit. Morale is low. Today, there were four RNs caring for our 16 patients (usual ICU ratio it 1:2 or even 1:1 for very sick patients). Apparently only 2 respiratory therapists came to work in the entire hospital today. I've yet to see one of them. They desperately need help so it makes me feel good about the decision to come up, if only for a month. Everyone is hopeful this is the peak.
Needless to say, the place is primarily run by the residents who have continued to consistently show up. They are doing just about any and everything. Foleys, blood draws, medications administration, and vent management. When an iv pump runs dry, it is strange to see the resident run to get it going again. There is just very little nursing support because they are stretched thinner than I've ever seen. They have the toughest job of all and can hardly chart they are so busy keeping everyone alive. So far, we have enough ventilators for everyone (Currently 64 intubated patients and 70 ventilators). But that includes every 'ventilator' they can find, including anesthesia and portable tranfer machines run as ventilators. The sicker patients get the proper machines - if you're still oxygenating OK you get by with the anesthesia machine. It's weird to see anesthesia machines all lined up in a row and connected to patients without an anesthesiologist watching each one individually.
Adventures aren't just happening at the hospital. Last night at 3 am my neighbor called EMS and I heard clear voices outside my window. An older man was breathlessly complaining of fever, chills and cough. The paramedics had him come outside (they didn't want to enter his house) and took his vitals and a brief history. Because his O2 sats were ok, they told him to stay home. Simple as that. Overwhelmed hospitals are reserved for sicker people. Earlier that night, around one, someone repeatedly try to break into my apartment - wait, did I drive to New York or Rio? Needless to say I didn't get much sleep last night and today was insanely busy.
Time for bed with the sincere hope that the demented homeless lady trying random codes on my front and back door locks doesn't come back again. It's been an insane start. My team is amazing and inspiring. They are working tirelessly and selflessly to help however they can, a truly Herculean effort. It's an honor to be here among them.
Jordan
Friends,
We lost John M today. He was the one of three deaths our service had in the last 24 hours, a very tough day. John was also the first patient diagnosed with coronavirus here. That was a distant 4 weeks ago. He spent his last 3 weeks on the ventilator. Things were briefly looking better for him and we were hopeful to get the breathing tube out this week. But Tuesday his liver abruptly failed and things quickly spiraled.
Covid fever can be intense, like nothing I've ever seen. 106, 107 degrees, for hours at a time, despite continuous tylenol, cooling blankets, ice packs around the body and cold saline irrigation running through the bladder. When the body fights a virus, the white blood cells release cytokines, tiny proteins that send different signals to the cells that orchestrate the immune response. In this case, they signal to increase blood flow, to release killing chemicals, to turn on response genes and to recruit more white cells. They are the switches used to activate the body's response to foreign invasion, aka inflammation.
Some, not all, corona-virus infected patients are sending copious amounts of these little proteins into circulation, creating a 'cytokine storm'. As storms go, it's intense-- despite being contained inside a little coat of skin. Externally, the signs of the internal disarray are the fever, very rapid heart rates and profuse sweating. The body's target is virus-infected cells but effect is felt generally. Healthy cells everywhere are hit with friendly fire. It is this cytokine storm that made the 1918 flu so deadly for young people whose strong immune systems made the storms more robust and fatal. And now the storms are back but, for unclear reasons, the age groups affected are different. It's disconcerting to see them start. You know it is ravaging tissues everywhere. We have three storming intensely right now, my guess is they will be dead soon. I don't know how to stop it. I hate this feeling. I hate this time.
We need better therapies. We need any therapy. Now, we have nothing. Just a handful of temporizing measures to buy time. Our last resort, the ventilator, simply buys time. Days, maybe weeks. It never treats what's actually wrong. Eleven times yesterday across the hospital, it failed to buy sufficient time.
Every single covid patient in the hospital is on hydroxychloroquine. If it is a miracle, game-changing drug like Mr. Trump says, someone needs to tell the patients. They keep dying.
It will be incredible to see the full brunt of modern scientific inquiry, technique and industry applied to this problem. Resources, time and energy will not be spared in the hunt for understanding, therapies and vaccines. I'm entirely confident this worldwide, concerted search will bear rich fruit on a timeline like we've never seen before. But for John and so many others, it won't be fast enough.
Jordan
Friends,
The ICUs here are lined up along one central hallway. The seven automatic, sliding doors into each individual unit have stopped working. They are now operated by hand but they get jammed in the tracks and never close completely. One won't move at all. So we are left with virus-filled air spilling out into the world. Living patients are wheeled through in a steady parade but seldom seem to exit back out. Things are broken, jammed in so many ways.
We had two more deaths overnight, both from the family mentioned on day two. Now only the father is with us. His 43 year-old son and 36 year-old daughter have gone. I hate for these missives to be constant downers, but it is a dark time in New York. It will get better. Already the hospital is seeing fewer new admissions. Social distancing is working.
In previous entries I've talked about the lack of supplies and the medications. Staff shortages continue to be a problem. We also face lack of will to help. The big IVs we place to infuse critical medications (central lines) can only be used for a week or two before they become an infection risk. Bacteria colonize the thin plastic tubes which then seed infections straight into the heart. After a time, we ask for help replacing these temporary lines with peripherally inserted central catheters (PICC), which can be used a bit longer term. Our requests often meet outright refusal. Orders for ultrasounds and echocardiograms are ignored.
Patients intubated long term do better with a trachestomy, placing the breathing circuit straight into the windpipe at the neck instead of through the mouth. Feeding tubes through the nose are best replaced with one placed surgically directing through the skin into the stomach. The surgeons won't do either for our patients. Too risky for them, they say.
It's entirely possible that this is the right decision. I don't know. I don't --I can't-- fault them. The risk to the providers could easily be greater than the potential improvement in outcome from these procedures and studies. After all, the patient who needed the tracheostomy on Monday was dead on Thursday. When one provider earlier refused our request for a PICC line, we asked another who helped immediately. That patient was dead 24 hours later. I don't know the right answer. I'm just glad some are choosing to help. I have to believe that things would be worse off if brave souls did not put their fears aside and come to aid those in critical need.
Of course the threat is real. We are all concerned about it, as are our families and friends. Nurses and doctors test positive here, every single day. Most will be fine. After 14 days of being symptom free, a good number are coming back to work. For those who fare worse, their sacrifice and love should always be remembered and held up as what makes humans so amazing and so wonderful. This is what makes me smile today.
Jordan
Friends,
All the employees are funneled though a single entrance in the back. The bricks and hallways along the way have been covered with messages of support, thanks and optimism. "Stay strong! Keep fighting! It's us against Corona! You got this!" On day one they seemed quaint or inadequate, perhaps even a tiny bit gauche. But now I look forward to the little messages of hope as we come through each morning, a gauntlet of affirmation. We need all the support we can get. It helps. It helps more everyday. I love that they constantly add to it, as more thoughts of love and support arrive.
We lost five people today, almost a third of our service. Sometimes, you can see the crash coming a mile away. The third death, Mr. H, had required increasingly large amounts of medications to keep his blood pressure up over the last 48 hours. His skin was mottled and gray. Even with the settings on his ventilator all the way up, he wasn't getting nearly enough oxygen. I didn't know him as a person, just a name followed by a dizzying array of numbers, xrays and trends. Yet, when he finally crashed, I felt so sad. Completely gutted and weak. It's profoundly demoralizing to be so impotent. To come up blank, again and again.
Covid. I want to hate it, to blame it and to curse it. But's it's inanimate and unfeeling, A random, self-replicating packet of genetic material that is constitutively without intent or design. There is no malice to fault, no scheme to denounce. We have only its' devastation to behold. I made the silly mistake of crying today. It came right after our third code in less than three hours. I can't do that again. It just fills your N95 respirator with itchy, wet snot with no good way to clean it out without breaking down your PPE. That's dangerous and resource consuming - so I lived with it. Like so many things in an ICU, it's gross...but what can you do?
I'm proud of my team. Proud of their steadfastness and willingness to jump in. Codes, always a somber affair, have a new, added dash of terror. When patients lose their pulse, we go through the usual procedures-- which always start with chest compressions. It's a last-ditch effort to reverse things but it has become very risky for the personal involved-- you have to physically touch the patient and pump hard on their chest, 100 times a minute. These efforts indubitably aerosolize large amounts of virus widely and in concentrated form -- aimed straight at those doing the compressions. Yet, they keep jumping in to do it. Over and over again.
The doom will pass. There are signs things are looking better in terms of ER visits and hospitalizations. Headlines say we are at a peak here in NY. Surely, for each patient here there are hundreds, if not thousands, that have been infected and are recovering nicely. As terrible as this is, it is manageable. We never ran out of ventilators. The doctors and staff so far have (largely) avoided major illness. Everyone, inside and outside of the hospital, is collectively doing so much to slow this down.
And on schedule, the world is erupting with fragrant blooms and tender spring life. Bright-eyed babies are being born, somewhere, every moment when we lose a patient. We will inevitably renew as we have always done- relying on persistence, thoughtfulness and love.
Along the entrance gauntlet of encouragement, someone has posted the famous Mr. Rogers quote, "When I was a boy and I would see scary things in the news my mother would say to me, ‘Look for the helpers. You will always find people who are helping.’” I'm going to leave things with Fred and his quote for a while. I need to think about other things when I'm home. Tomorrow on my drive, I'm not going to think about what to say in an email and instead focus on cataloging the Latin names of all the plants I spot in bloom. Then I'll focus my brief evening on learning about those I couldn't name. Maybe down the road I'll send an update or two. Until then stay strong, enjoy spring.
I love you,
Jordan
Hello friends,
Just a quick update so you all know I am okay. Things are moving along in NY. First off, here's the important update: Acer rubrum had finished it's early spring flowering and has begun to set fruit. Magnolia × soulangeana is putting on it's amazing annual show, peaking here 2 weeks behind their Virginia siblings. Narcissus are everywhere and the early tulips are popping. Cercis blooms have still not erupted but Prunus and Pyrus are at peak bloom. So, all proceeding apace. The beautiful renewal of spring has come despite the human world seeming to fall to pieces.
Personally, I'm feeling good, staying rested and fed. Yesterday, I drove out through the Hamptons and saw beautiful Montauk. You will all be reassured - I can confirm the NY billionaires appear safely tucked away in the 9 million dollar oceanside mansions with their Bentley SUVs parked out front, intact and shiny as ever. The daily deliveries of french wine, spanish cheeses and fresh toasted paninis does not appear to have stopped as all the high-end charcuterie have signs announcing home delivery, phew.
Back on earth, hospitalizations have clearly peaked, as have new intubations. Nursing and clinical staff levels are approaching par. There remains intermittent, critical shortage of supplies. As one missing item becomes available, others run short. Monday, we ran out of non-sterile gloves and called for more. Central supply said that's all we get until tomorrow. So everyone got a pair of sterile gloves to last the rest of their shift. Wasteful but better than nothing. No one should have to work in a covid ICU without gloves. There is a lot of make-shift protective gear being used. Everyone is wearing a different kind of N95. Masks are from hardware stores, ski googles from the garage and hair nets from salons are commonplace. People use whatever they can find.
Someone told me about a room where they have PPE set aside for doctors. I went down to ask if they have any hairnets. It was just one guy sitting behind a table covered in reusable cloth gowns. Not surprisingly, that's the one item we've never run low on. There's always plenty of wrinkled, tiny yellow gowns. (See -Farley, Chris "Fat guy in a Little Coat") I asked if he ever gets anything else and he just shook his head slowly, with a mournful look. "But we have plenty of these gowns if you want one!" (Many of you have offered to send things up, which I appreciate greatly. Thank you. For now, I am okay. I reuse my personal PPE on a rotation, after letting it rest for five days).
From our clinical team, there is the usual parade of successes and failures. We had another extubation this morning. A 41 year old, previous healthy man, who had been intubated since 4/6. His kidneys have failed and he will likely need long-term dialysis but he is breathing on his own, awake and alert. And no deaths for three straight days!. (Well, not really... two people died on our service yesterday but I was off so...)
Today we started our first trials of convalescent serum. People who have fully recovered from Covid-19 have donated serum that we will now give to those who are sick. The hope is that the antibodies present will slow or stop the disease. The first patient in the hospital to receive it is one of ours, a 43 year old male intubated since 4/10. We are very hopeful it will change the course of things. I'll let you know. Thank you so much for your well-wishes and for keeping in touch. I love you,
Jordan
Friends,
I wanted to share some final thoughts and one more experience from my brief time in New York. I’ve been home for two weeks and am feeling very fortunate to have made it through a 2-week quarantine without symptoms (plus a negative test!)
It’s wonderful to be home. It’s a magical time in Virginia- warm, green, lush. Being home is at times surreal, so unlike from my life up there, a world away. We don’t have much Covid yet in Virginia, which is only because social distancing is working. Last night, I did my first shift back in the Richmond ICU. There were a handful of covid patients. While I was comfortable with the management and quite familiar with the disease, it brought back a flood of difficult emotions. I had 25 of my patients die in New York, one more than I saw discharged from the unit. That experience, not surprisingly, left me with difficulty sleeping. I have tough dreams and frequently relive difficult moments, though less and less each day.
I think about patients like Oscar, a 45-year old painter and father from Queens. He was admitted to our unit for worsening fever and breathing problems after 2 days on the regular floor of the hospital. When we met, his oxygen saturations were mid-70's (Normal 94-100%) on a non-rebreather mask blasting 20 liters of oxygen/minute. Despite breathing rapidly, he was surprisingly calm, thumbing through his phone.
This isn't unusual with Covid pneumonia. Patients commonly present with remarkably low oxygen saturations — numbers seemingly incompatible with life. Although breathing fast, they have minimal apparent distress, despite terrible looking chest X-rays. Though this was the case with Oscar, it was clear from his breathing rate and low numbers that he was running out of reserves. He was starting a dramatic cytokine storm.
I asked him if there was anyone he wanted to call. He greeted the question with apparent suspicion and I realized we had failed to explain the full extent of what was going on. Regretfully, things often get so hurried we forget to humanize and contextualize what is surely a very lonely, terrifying and confusing time for patients.
I pulled up a chair next to his bed to talk about where he was clinically and where he was likely headed. We talked about what a ventilator does and why we use them. I explained there was a very good chance he'd need one. Once that happened, he wouldn't be able to talk or communicate with anyone for days or weeks, maybe longer. It is physically impossible to talk with a breathing tube in your airway. It holds your vocal cords open and pins down the tongue. Further, intubated patients are usually heavily sedated, unable to otherwise interact. I told him a number of patients don’t survive the ventilator, but it would be his best hope for recovery.
He thanked me for my time and affirmed that he wanted intubation, if needed. He said he would call his wife and his cousin, who had been admitted the night before with covid and was three floors above us.
Two hours later we intubated him. He couldn't get nearly enough oxygen otherwise. Despite this, over the next two days his condition worsened. He needed very high pressures (PEEP) to keep his oxygen saturations above even 85%. The strain to his organs from the combination of the severe oxygen deficit and circulating cytokines was starting to impact his brain, liver and kidneys.
On his third night in the ICU, the elevated ventilator pressures needed to keep him alive blew a hole in his right lung. Untreated, it is a rapidly fatal condition (a tension pneumothorax). A quick-thinking resident understood what was happening and immediately relieved the condition with a long, decompressing needle to the chest. Surgeons were urgently called and they placed a tube in his chest under the armpit to help keep the lung inflated. With the chest tube secure, he stabilized some, began to storm less and even showed signs of improvement with his kidney/liver function. His fever broke.
But there was a problem lurking, apart from the obvious Covid. The original hole in his lung didn't heal. (Usually such holes mend naturally after the chest tube is placed). His grew steadily over the next 48 hours. Little noticed at first, he required more and more oxygen to be pushed through the ventilator to fill his lungs (a bronchoplueral fistula). By day three of the chest tube, it had become impossible to drive enough air into his lungs.
With oxygen saturations around 75%, any additional gas volume we gave simply ran through the ever-larger hole in his lung and out the chest tube. In a non-covid patient this problem might have been corrected with a surgery to close the fistula but that was decidedly off the table now. Open lung surgery on an critically-ill covid patient was very high risk, for the patient and the staff. The only way to save his life would be to isolate that injured lung and allow it to heal without pressure from the ventilator. This meant directing the breathing tube in the left main bronchus to only ventilate on the left side.
Lung isolation is rarely performed in most ICUs because the conditions requiring it are so unusual. Fortunately, it is done more frequently in the OR to facilitate lung surgery and I'd had a decent amount of training with it during residency. To perform the procedure, we would need to do bronchoscopy.
Bronchoscopy, placing a thin camera through the mouth and into the lungs, had been specifically banned by the hospital the month prior because it aerosolizes huge amounts of virus. To ensure compliance with the new edict, the hospital had hidden away all the required equipment in central supply on the first floor.
I didn't know what to do. Urgent bronchoscopy was possible (and available with some hassle) and was clearly his only chance at survival. But was it worth the added risk to our staff? I sort of wished I hadn’t gotten to know him a little as a person. It would have been easier to say it wasn’t worth it. We were just starting rounds, the whole team was assembled and waiting.
The risk was not just academic. At this point, 32 of the hospital's doctors (mostly residents) had been infected with coronavirus. An anesthesia attending had required ECMO (similar to the heart-lung bypass) at an outside hospital to stay alive. (This option wasn’t available at our facility for Oscar and he was too sick to transport to another spot that had it). On our floor, 12 nurses had already tested positive. Hospital-wide, three employees were dead from work-related exposure to covid-19.
I decided to do it. If we were going to save his life, it had to happen now. First step was to get permission from the chief of pulmonary medicine and on-call hospital administrator. A few quick calls later, the equipment was released and the fellow and I made preparations for what would be the fellow’s first attempt at a left mainstem intubation. He performed deftly as I supervised and the procedure went quickly, without complications. Almost immediately, we were able to improve his ventilation. Over the next few hours, his oxygenation also improved some. But his left lung (the one without the hole) was still ravaged from Covid and, by itself, proved insufficient to capture enough oxygen. He died 12 hours later.
Was it worth it? He was already so sick, the odds of success were low. I don’t know how to answer that question. Each day in the ICU is filled with an endless stream of difficult choices, tough decisions about therapies, procedures-- all balancing the pros, cons, best known evidence with a patients' individual circumstances and available resources. Medical practice is often more colored by recent experience, personal biases and institutional culture than clear guidelines and obvious formulas. I can only say, with full confidence, that as a whole our efforts to keep Oscar alive were worth it. He and his family deserved the chance to halt the horrible disease he had unwittingly acquired. By that same token, I know my trip to New York was worth it. They desperately needed help and I was trained and able to provide it. So I’m glad I went, I’m even happier to be home.
I truly appreciate everyone's support, especially my family. I’m thankful my work partners at home covered me and made my absence at the surgery center workable. Thank you to all for the messages of support, care packages and thoughts. My lovely girlfriend sent cheerful boxes filled with chocolate, useful items and messages of love every week. When I got home to start quarantine my house was spotless. The pet and plants were healthy, happy and well-cared for. Thanks to Kristi and Bobby, the fridge and pantry were stuffed with homemade, ready to eat meals, fresh fruit, vegetables and healthy snacks.
I guess it’s now time for many of us to ease back into regular life, though I'm scared about the human cost of reopening. I’m a living testament that with good hygiene and basic precautions, you can navigate safely through a world filled with covid and avoid symptomatic infection. Yet, I’m shocked to see how cavalier people can be about this virus. I guess until it affects more of them personally it will remain too remote to be real.
Finally - a little PSA. Please, please wear a mask if you go out in public. All indications say that this is nearly always spread by aerosolized droplets. One either breathes them in directly (most commonly) or picks them up off a surface with the hand that then touches the face.
It's very clear that people can spread the virus for days without knowing they are infected. If you are unknowingly infected, you will shed way less virus for others to catch if you have a mask on. The idea that ‘My body, My choice’ around mask wearing is ridiculous. It’s like saying, ‘My car, My choice’ then driving around drunk. Don’t do it. Any one of us could have this thing at anytime. Don’t spread it around.
With love,
Jordan
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