Reckoning. 2 months with COVID19

I’ve just finished an overnight shift with an AM meeting added for good measure. 7 PM to 10 AM. If you have ever done this it is a strange set of sensations. Nervous energy? A paradox of physical and mental exhaustion coupled with a confusing mix of biochemistry – the melatonin is off, the cortisol is ramping up, the ghrelin up – and evolutionary forces that are pushing you to wake up and face the day.

When I’m not at the school of medicine, I am in my community working in a mixed medical and surgical ICU. In addition to the primary ICU my group manages a progressive care unit (PCU)/intermediary care unit (IMCU)/Step-down unit.  Typically. Typically,  there are ED residents, attending physician, APPs. COVID has changed what we do in almost every aspect. We officially started testing for the SARS CoV2 virus on 3/15. This is my 2 month retrospective account. Nothing is typical.

The Logistics.

Currently we are running 2 ICUs – COVID ICU, non-COVID ICU. That is 35 beds. We have now taken over part of the cardiac unit to allow this to serve as a “COVID step-down. 3 units, same small group. The COVID-ICU is filled with critically ill, mostly intubated or heated hi-flow nasal cannula acute hypoxemic respiratory failure patients. The non-COVID ICU is filed with the rest. Our length of stay has, I suspect, tripled. Our number of intubated/ventilated patients has tripled. If it weren’t for the heroic actions of our colleagues in anesthesia, surgery, cardiology – essentially serving as our very talented and capable ICU fellows 24/7 we couldn’t sustain this pace. They volunteered. They are placing themselves and their families in harms way in the service of our patients. I will never forget this act of selflessness. The silos are down, and we will emerge a better institution and a better health system because of it.

The Day to day.

It is still weird to not have visitors. Now, some background. It isn’t absolute, but it is never good when I call the CNO, the ICU nurse manager and security and let them that the family for bed 2 needs permission to visit because their loved one isn’t going to survive this monster of a viral infection

The medicine.

I published “1 month with COVID19” here. I suspect there will be a month 2 post at some point, but honestly I have achieved some stability with the clinical aspects of COVID19 with the exception of 1. See, the pathophysiology, for reasons I cannot explain, seems to progress in a very stepwise fashion from a worsening perspective, but a more linear fashion in recovery. The worsening is steeper than the “better-ing”.

In fact, anecdotal observation is for those patients who did not survive, the events that lead to their terminal deterioration happen quite abruptly, typically within 24 hours. The progression seems to be a fever spike followed by significant increased in ventilatory needs. I suspect it is from this increased metabolic load from the fever. At the same time, oxygenation and ventilation become much more challenging. This precipitates a vicious cycle of worsening mixed metabolic and respiratory acidosis associated with hypotension. The worsening acidosis gets to the point of depressed myocardial function and catecholamine resistant shock leading to cardiovascular collapse.

I have seen this happen to patients who have received IL-6 agents and not. Who were on broad spectrum antibiotics and not. Who were on systemic anticoagulation and not. Who received tPA (thinking could this be massive PE) and not. I feel helpless to stop it.

The world.

No not with Marco Werman but it is great.

We are stir crazy. We are Americans. We are free – free to roam, free to have opinions, free to be free. I have been exploring a lot of philosophy. When Things Fall Apart is my current read.

I also happened to stumble across this:

A man in a boat began to bore a hole under his seat. His fellow passengers protested. ‘What concern is it of yours?’ he responded, ‘I am making a hole under my seat, not yours.’ They replied, ‘That is so, but when the water enters and the boat sinks, we too will drown.’

–Rabbi Shimon Bar Yochai, Leviticus Rabbah 4:6

I am not sure there is a better allegory for our current situation then this. Humans have a tremendous capacity for understanding and empathy, however we always try to seek the “correct” answer. What if there isn’t a correct answer? This moral dilemma, currently in the modern zeitgeist with regard to AI has befuddled humanity likely since we started evaluating the consequences of our decisions as our frontal cortex evolved and we were able to engage in “executive planning”.

We have a risk continuum that is unknowable at the moment because our understanding of the SARS CoV2 virus is limited. If you are a visual person, it looks like this:


We can keep everyone safe(r) and home, but people will suffer economic consequences and business owners will suffer. We can make it a free for all, and can end up, like Wisconsin Governor Tony Evers said, “the Wild West”, businesses might be ok though I question how many people will partake in this restored freedom.

Clearly somewhere in the middle is the best option. If you are operating on the premise that:

  1. There is no effective therapy (remdesivir shortening hospital is *an* important endpoint and important to hospitals and the public health infrastructure but it isn’t necessary the most important patient centered endpoint)
  2. There is no vaccine.
  3. A majority of people worldwide are immuno-naive.
  4. There is likely more circulating virus in the community than when the lockdown was started.

The risk of too early opening is we turn into NYC. My ICUs are running at 200%+ capacity on the lockdown. People aren’t leaving the hospital fast. The ICUs and EDs will be rapidly overrun (~3-4 weeks in, maybe). Where does that get us? I’m not sure, but under that scenario I fear the death toll will mount and we will be back to lockdown.

There is no easy answer and we humans have this tendency to be susceptible to the Ostrich Effect. I think for some protesters there is a bit of an ostrich effect. However for others there are genuine concerns. I simply wish they would express their motives more transparency, we will not judge. Simply say, I’m afriad. I’m afraid I can’t pay my bills, or have food, or be secure, or enjoy my life. I’m afraid I can’t see an easy way out of this pandemic. I wish they would use these words instead of bravado, and sexism, and misogyny and racism covering oneself in flags and personal liberty. We are all on this boat together.

More later. Be safe. Get some sun. Hug a puppy or a kitty. Be nice to each other, we are all struggling in our own ways.