From the front line

By: Aliphatic
3/26/2020 2:36 AM

I have here an account from a resident working at a hospital in NYC, this is a repost from another community I am a part of. This physician has given us his permission to share this information with the rest of the internet.

Please be aware, this may be disturbing and reader discretion is advised.

Day 3.

Code Blue right off the bat at 7:35. COVID in the ICU, transferred an hour earlier from another maxed hospital. From the chart: 67F with DM2, CAD, HTN. 5 days of cough and body aches, a little short of breath. She was seen by an ED physician just after midnight two days ago. Within 8 hours she had crashed and required intubation. Multifocal pneumonia with positive COVID. Officially admitted to that ICU 24 hours later. Transferred to our ICU 24 hours after that, and 1 hour later her Discharge Note for the Expired Patient was written.

She marks the first COVID patient I’ve seen die.

The anxiety I felt a couple days ago isn’t so bad now. It’s clear there was no avoiding this mass casualty event. Now there’s just work to do.

The thing about intubating a COVID case is it’s a high risk droplet bomb going off around the guys and gals most needed right now: intensivists, anesthesiologists and those badass ICU nurses who are all needed to tube people whose lungs are filling up with fluid. Hospitalists might be able to pick up the slack, but they haven’t the same muscle memory.

So as I’m watching this woman die in her closed glass box of an ICU room, a grizzled doctor with the swagger of an old intensivist says to no one in particular, “Is that a confirmed positive? Not going anywhere NEAR there!”

A nurse over to my left says, “We shouldn’t have to Code cases like this.” And it’s not with the same tone as “This is pointless,” it’s “This puts us in danger for nothing.” I stay out of the room, the extra manpower of one extra resident won’t be worth the PPE for chest compressions. But my chief resident is in there.

He’s a good guy; hope he doesn’t get sick.

(As I write this, I get a call that one of my patients has died. Non-COVID, was in denial about her metastatic cancer, COPD, CHF progressively worse shortness of breath but still wanted to be intubated. She got her wish and died within an hour or two still.)

Then a Rapid Response at 7:56. Then a Rapid Response at 8:01. Then a Rapid Response at 10:30. That last one was for the patient I just mentioned who passed, we put her on BIPAP and loaded her up with Lasix. Then a Rapid Response again at 12:30, again for my patient, watched the intubation occur. There was a minor discussion of where to put her, since the ICU and CCU were full. We’re in the process of transitioning the SICU into another ventilator bay.

Lunch arrives sometime after 13:00. Here’s one silver lining to all this: the community has gone out of its way to shower us with food. My lunches and dinners (residents know to always raid the hospitalists’ office and grab a plate before heading home to crash) have been Mediterranean chicken kebobs on Sunday, chicken piccata on Monday, and pizza today. It genuinely raises moral.

Another Rapid as I’m talking to some other residents and wolfing down a slice. Most of these Rapids have been for non-COVID cases. The ones that are about COVID cases turn into intubation events.

I was wrong yesterday when I predicted we’d become a majority COVID case hospital in 2 days. We crossed the 51% threshold today.

I was naïve when I thought I could volunteer for the resident-run COVID wing so that one less of my fellow residents would be put at risk. We’re all at risk. So now we have 3 residents and an outpatient attending looking over 10 confirmed COVID cases.

My census of 13 today has 5 confirmed and 1 suspected COVID patients. I wish we could make these cases voluntary, but all we can do now is limit exposure and spread out the cases somewhat.

I get a call that our 87 year old COVID patient is desatting on 6L supplemental O2 via nasal canula. So we put her on a non-rebreather. I get a call that she’s desatting down to the mid-80s when talking in long sentences despite the 100% oxygen she’s receiving via mask. The nurse is spooked, and the current plan is to do a Full Code should she tank. So the patient and I get to have The Talk.

The Talk is basically asking people if they want to receive (often futile) CPR that cracks their ribs as they die, or if they would prefer to be attached to machines when they die. But I don’t put it like that. I say things like “chest compressions” and “a plastic tube down your throat” but made it clear that if she were to be sedated for the intubation, she may never wake up. And despite our plans and treatments, her body is taking actions that will most likely (but we can never say guaranteed) going to end her life. Not today, but it’s a good time to put things in order.

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By: Aliphatic
3/26/2020 2:38 AM

The patient said her daughters want everything to be done for her, but she doesn’t want to be on machines when she dies. I said that was reasonable. She asked me what I would do, and what I would want for my mother.

I’m not proud of this next part.

I told the truth. I said that my mom and I have worked in medicine, and she would never want to be intubated if it was a long shot she’d ever recover. I told her I recently only rescinded my own Do Not Intubate order because were I to get COVID and need intubation, I’m a young, healthy guy who could survive it. But were I hit by a truck and braindead, I’d never want to be intubated. She said she’d call her daughter back and explain things.

I get a call later saying this very sharp 87 year old lady has signed the form declaring her Do Not Resuscitate / Do Not Intubate.

Intubation would have been the wrong choice here, I believe that. And I only told the truth (which I usually avoid by saying things like “it’s not for me to make you decide either way.”)
I helped the patient make her personal wishes count at the end of her life so she could die on her terms.

But, in the back of my head, I was also thinking I saved the nurses from having to witness a pointless and traumatic CPR and I saved one likely-inevitable ICU bed and a ventilator.



I don’t feel like writing anymore today.

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By: Aliphatic
3/26/2020 2:41 AM

They’re critically low on PPE and using trash bags for certain staff




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By: Aliphatic
3/26/2020 2:42 AM

Day 4

“The residents should run the Code Blues, they’re probably better trained than us.”

I’ll start off with what is good.

We’re becoming more adept at treating COVID cases. With a growing census of confirmed COVID positive patients (10 COVID positive in a census of 16 today), we’re getting a better sense of how this bastard virus behaves. There are the easy presentations: 40F w/ no significant PMH presenting w/ a 7 day hx of fever, dry cough, fatigue found to have bilateral ground glass infiltrates, elevated LFTs, lymphocytopenia and even ****ing hypokalemia on admission. Might as well not even swab to confirm. (But the ED will, oh yes, because now they’re swabbing everyone and costing us probably 30-40 PPE kits per admission while we wait the 24 hours for the COVID test to result.)

But then there was the subtle one: 73M w/ multiple comorbidities who was diagnosed with simple CHF exasperation and sepsis secondary to a UTI (positive UA and UCx) who was tubed on arrival to the ED, admitted straight to the ICU, found to be COVID negative 3/21. He is taken off the vent within 24 hours and discharged to the floors. Because he’s COVID negative you see. We treat him with antibiotics, work up his NSTEMI which he managed to throw in during his first day admitted and kind of take mild interest in his recurrent fevers. But he’s not coughing and is satting well. Yesterday, my team and I thought “This guy has a normal white count, elevated LFTs and recurrent fevers. Forget the last test, order a repeat COVID.” I do this several hours before speaking with the attending physician. During table rounds, he pointedly asked me if I was aware of the protocols the Command Center had put in place for repeat testing. I say no, as these protocols change every day. (Side note: N95s are now rated for indefinite use, not just 4 days. Hope we didn’t toss all those other ones away for no reason!) “Cancel the test, let’s get Infectious Disease on board and ask them their input.”

I put in for the ID consult, I “forget” to cancel the COVID repeat or inform the Command Center. Busy day as you saw from yesterday. Comes back positive. We know what this bastard virus looks like.

But we spent 2-3 days in his room without our N95s on.

We would have spent more in there had we not tested.

We’re still early, but we know how fast or how slow a case progresses. Our younger patients, the 41F and the 49M might get discharged to home quarantine as early as tomorrow! They’re not reliant on supplemental oxygen and haven’t had fevers for >24 hours. Our older patients aren’t as lucky. No one on our census so far has been intubated. The 73M whose COVID we caught late rapidly progressed to requiring supplemental oxygen and was transferred to the SICU as the last stop before ventilator land.

We’re getting better as a team of residents. We’re all more than a little scared. I’ve talked to my favorite resident / current carpool buddy / best second-in-command about my anxiety about this situation. How the adrenaline kicks in when I’m on the floors and makes me feel less afraid and more focused. The crash after work is awful and the anxiety kicking back in takes a drink or two to knock down, but **** it, I’m better at my work when I’m not terrified.

Oh and the food remains the best part of the day. Thank you, local places that sent great sandwiches for lunch and Greek for dinner. Makes the rest of this easier to write about.
Now on to what’s not good.

The hospital is now greater than 2/3rds COVID cases. The ratio of ventilators for COVID patients to non-COVID patients is 7:1.

We’re maxed out on the capacity of our Intensivists, intensivist PAs, and Anesthesiologists. The sprawl of the traditional ICU has taken over essentially anything that used to be elevated care and we’re still scrambling for beds. A handful of Internal and Family Med Hospitalists are being recruited to act as lieutenant Intensivists overseeing the ventilated. I mean lieutenant in its original definition: "substitute,” “deputy," literally "place holder." They report to the Intensivists directly.

At lunch today, it was declared that due to the sheer number of Rapid Responses and Codes, and due to the overwhelming census of the Greater ICU, Residents responding to Rapid Responses are not expected to get any Intensivist backup.

I’m no stranger to Rapid Responses. You hear the call over the PA and are given a floor, you rush upstairs and enter a room blind with someone either choking, or unconscious, or bleeding, or seizing, or with a heart rate incompatible with life. You remain calm, you ask the patient questions while asking the nurses to give a summary of the patient’s medical background, current admission issues, latest changes, vitals, labs, imaging. Scary, but doable.

During the meeting, the Medical Director said the Hospitalists would be asked to run Code Blues. The Hospitalists balked.

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By: Aliphatic
3/26/2020 2:45 AM

See, Intensivists ran every single Code Blue in the hospital before now. One Hospitalist said, “We haven’t run a Code since residency! The residents should run the Code Blues, they’re probably better trained than us.” The room of a couple dozen full-blown-attending Hospitalists nodded in agreement. I was the only resident there, too stunned to speak up. No final decision was made.

I know the timing of Epi pushes and ACLS algorithms enough that a couple days’ review would cement it pretty well. But the actual pressure of making the call for a defibrillation or a push of atropine or adenosine is so beyond what I’m prepared for.

CPR is a violent, ugly thing with a fatality rate that is 100% for COVID patients with lungs too full of fluid for their heart pumping to matter. Even if I were to run everything perfectly, the person is still going to die. Let alone if I **** up and make the wrong decision.

I’ve come to terms with the idea that I’m going to see COVID patients die under my care a whole ****ing lot.

I don’t want to be forced to watch them die under my care from three feet away while I make a series of life or death decisions that are guaranteed to be utterly pointless.

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By: Md.Chas
3/26/2020 6:55 AM

Was this post really necessary? I just lost a lot of respect for you.

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By: Robert
3/26/2020 8:34 AM

Believe most of us know by now that COVID19 can be deadly. Not sure we needed the graphic narrative that you posted. Thumbs down

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By: redray
3/26/2020 12:57 PM

Believe most of us know by now that COVID19 can be deadly. Not sure we needed the graphic narrative that you posted. Thumbs down

Robert


After reading many of the posts on many different topics on this board maybe the graphic narrative will help some folks understand. Sometimes words work, sometimes pictures work, sometimes force works and sometimes it takes a loved one dying in order to convince people. Everyone has their own learning curve.

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By: Robert
3/26/2020 1:49 PM

Believe most of us know by now that COVID19 can be deadly. Not sure we needed the graphic narrative that you posted. Thumbs down

Robert


After reading many of the posts on many different topics on this board maybe the graphic narrative will help some folks understand. Sometimes words work, sometimes pictures work, sometimes force works and sometimes it takes a loved one dying in order to convince people. Everyone has their own learning curve.

redray


Maybe, but find it hard to believe it hasn't hit home with most everyone. Of course there always will ne naysayers, but even that post wasn't going to change their minds. I suppose I was surprised that on a board like this one that the "front line" story was posted rather than being just linked. I dunno, maybe just spoke out of turn and will delete my comment.

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By: hatterasnc
3/26/2020 3:33 PM

This sensationalized "story" serves no purpose but to alarm and cause fear. There is no attribution to it. It might as well be made up. If true, it should be via a link to allow folks to make up their mind. Take it down.

...And I never respected you anyway... Big grin

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By: Aliphatic
3/26/2020 9:26 PM

Day 5

“If you’re going to stroll around here, you’re going to need full PPE”

“Usually takes about 20 minutes, then everyone’s arms get tired”

If this hospital is at war, it’s ceding territory at an alarming rate.

Here’s the layout of the field: we’ve got medsurg wings on the cardinal points of the compass (except 2SW for some reason) in a somewhat random pattern from first floor to fifth: 1N, 2S, 2SW, 3N, 3E, 5E, 5S. The ICU, CCU, CICU, and SICU are floating around the periphery of the 3rd floor.

By the time I started Day 1, 2SW and 5E were already on lockdown and designated as COVID territory. My team alone had a total of two pending and one confirmed COVID cases.

By Day 2, the CICU became a conflict zone and joined 2S and 5E. 5 COVIDS or pendings.

By Day 3, my team had pending tests in 5S as well. 6 COVIDs or pendings.

By Day 4, the 5th and 2nd floors were entirely given over to COVID. 3E still had some non-COVID evacuees waiting to be transferred to the last bastions of 1N and 3N. Everything ending with -CU is overrun by this point.

It’s Day 5. My census stands at 15, of which 9 are COVID positive. There’s talk of clearing out 1N sooner or later even.

The hospital is fairing less well: of the 170 or so inpatients (not counting the 25 or so Greater ICU COVID positive people on vents), 100 are COVID positive, and a third more have pending tests.



So those are the numbers. Actually walking the halls puts the change from Day 1 to Day 5 in starker contrast.

The amount of PPE used per nurse or CNA has steadily increased. On any floor (except the Last Bastion wings), if you squint your eyes all you can see is uniform green paper scrubs with blue hairnets and and blue paper booties and blue paper masks +/- an N95 underneath. If you look further down the hall you’ll see a spray of yellow as one of them gowns up to enter a patient’s room. (The nurses have been using Sharpies to write their names on the paper gowns so people can tell each other apart.)

Maybe you’ll spot a Resident in a long white coat rush by.

And by every single door on wheeled tables usually topped with hospital food are boxes and boxes of blue gloves and yellow gowns. Might be my imagination, but the boxes of face masks are disconcertingly not as ubiquitous.

The Greater ICU is less colorful. Just window after window of people on vents. Walk the whole length of it and count maybe one person who’s conscious. Most don’t look like our usual ICU clientele of the cachectic elderly. These are mostly men (my imagination?) ranging from their 50-70s.

I made the mistake of asking who the youngest intubated COVID patient on the unit was.

Younger than me.

So we finish at the ED. It’s not chaotic like a Saturday night. Sure there are a few beds in the hallways, but that’s nothing new. I walked the length of it too. Some people on oxygen here and there, wider variety of ages.

Lots of people getting gowned up to enter rooms though. And I know we’re supposed to take them off at the door of the patient’s room, why are people walking around-

“HEY! If you’re going to stroll around here, you’re going to need full PPE. With an N95 on!”

The ED is now considered COVID home territory.



I don’t feel like a soldier. I don’t feel brave for showing up to my job. I most certainly don’t feel like a hero.

I feel like the tide came in way too fast and everything around me is starting to go underwater.

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By: Aliphatic
3/26/2020 9:29 PM

Well, this doctor took his earlier journal entries and put them on reddit and it absolutely blew up with attention.

He’s got major news outlets looking for interviews.

You’ll likely see him on the television in the coming days.

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