The burning embers

She was only in her 30s. She only had mild diabetes. She developed a cough, aches and fever about a week prior to when I saw her. Many of her coworkers had recently tested positive for COVID-19 and she tested positive as well. Gradually she noticed difficulty breathing prompting her to come to the hospital where she had low oxygen levels and was promptly admitted. She was not in long when she worsened further and was transferred to the ICU. When I saw here she was requiring a lot of oxygen and her lab work did not look good. We gave her all the standard treatments – decadron, remdesevir, convalescent plasma, and lovenox – and she stabilized for several days. She was still requiring high levels of oxygen and using CPAP at night but she was not getting worse. In fact there were some signs of improvement.

I have a clear memory of kneeling down next to her as she sat in the chair in her room. She was calm but I could see the fear behind her eyes. She was struggling to maintain control in the face of her situation. I had to nearly scream to be heard over the buzz of the negative pressure generator and my PAPR, “You’re stable and you’ll start getting better soon,” I told her. The minute I said it I could see the tension ease on her face and feel it ease in myself as well.

That was the last thing I said to her.

That night she stood up to use the commode and her oxygen dropped precipitously. This had happened before but she had always recovered in a few moments. This time she didn’t. She lost consciousness, her pulse slowed, and then her heart stopped beating. CPR was started and fortunately the team was able to resuscitate her quickly and placed her on a ventilator. Things got much more difficult from there. We induced a medical coma and paralyzed her to reduce her oxygen usage. We put her in a special bed that rotates her to keep her face down and improve blood flow in the lungs. We did everything possible with the ventilator to keep her oxygen up. She stabilized somewhat but if she was manipulated or turned on her back her oxygen would quickly drop to life threatening levels. We had nothing more we can do for her. Our only option was to transport her to a special center to hook her up to a heart lung bypass machine called ECMO.

It took an hour to get her set up for transport – a feat which she survived only because of the amazing skill and dedication of our nurses and techs. As I watched this all unfold the image of that moment when I told her she would get better soon played in a haunting loop in my memory. After she left her empty room was littered with discarded supplies, sheets, and blankets that testified to the chaos that ensued just a short time prior. We were left to move on to the next patient.

“How’s it going at the hospital? Are there a lot of COVID patients?” “Are you really busy?”. I was asked these questions that night. I had been asked them multiple times before but this time they seemed to weigh a bit heavier.

We are all struggling to get our brains around the pandemic

The motivation to know the situation in the hospital is quite understandable. We are all struggling to get our brains around the pandemic (an endeavor that may be doomed to futility). We have to somehow bridge the divide between what we see in the news and our personal experience. The news media’s business model always favors the sensational. Our personal experience often contains no direct personal experience with the virus but only with the reverberating waves of annoyance that it creates. Throw in misconceptions, political leanings, and a public education that often lacks in the sciences just for good measure and the situation quickly spirals beyond our grasp. When people ask me how things are going at the hospital they are looking for a personal connection to help them bridge the divide between the global and the personal, between meandering anxiety fueled by imagination and a reality that often justifies it. My answer is usually the same. It’s very busy, but it was very busy before COVID. It’s always busy. After all, it’s called the intensive care unit not the mellow care unit.

It’s important for people to understand that hospitals in America over the past several years have cut down on beds to cut costs. This means that, before the pandemic, most hospitals were usually full or close to it. We’re always busy. You can see, then, how hospitals can so quickly become overrun. They were full before hundreds of COVID patients hit their wards.

So too in our ICU. We usually are close to capacity under normal circumstances. For every transfer, discharge, or death, another patient is waiting to come and take the bed. When the numbers were high in the spring we were overflowing to other units and were beyond even our usual full unit. Fortunately, for the past several months we have not had many COVID-19 patients and have settle back to our baseline busy state.

While the numbers are down, the virus is certainly not gone.

While the numbers are down, the virus is certainly not gone. It regularly rears its ugly head to to let us know it is still around. That poor young lady was our most recent reminder of this.

COVID-19 is somewhat analogous to a forest fire. The fire is not out until it’s all the way out. If you have it 90% contained but that 10% is left to burn, the conflagration can return stronger than before. The same is true of a pandemic. As long as there are circulating cases and as long as people are vulnerable (it has been estimated that only 10% of the population has any level of immunity) there is plenty of wood to burn and the fire can burn stronger than before.

This has been seen in the global experience with the virus. Case rates go down but not to zero. If people the let their guard down too soon the cases come roaring back and the cycle starts all over again.

When the numbers are down its because of all the steps we are taking to keep them down. It’s analogous to airbags and seatbelts. For decades auto fatalities have been declining as safety measures have improved and become mandatory. Would you say that, since there are fewer motor vehicle deaths, we should stop wearing seat belts and requiring air bags? The same is true for COVID-19. The numbers are down because of the steps we are all taking to keep them down. We are all fighting this virus together. When we do these things businesses and schools stay open and the virus can stay contained. When we stop, it comes back.

In other words, buckle your safety belts. This ride is not over yet.