“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.