COVID-19, Top Stories

An ICU Doctor Reports From the Frontline

I had been out of clinical medicine for a couple of years but felt a calling to return to the intensive care unit (ICU) to help my local area in London cope with the additional burden presented by this pandemic. Like everyone, I had read that the National Health Service (NHS) needed a dramatic increase in capacity to save lives—beds, ventilators, and staff. I was a little scared. Would there be enough Personal Protective Equipment (PPE)? Would my new colleagues accept me? Would I survive, or become another face on the news of a frontline staff member who had succumbed to the virus? I felt a little deflated when I contacted four local London hospitals to offer my help, my time, possibly my good health, only to have my emails either not replied to or batted around various HR departments. Hospital administrators struggled to process a volunteer who was an ex-intensive care doctor with 11 years’ experience. Classic NHS, I thought. The national institution that all we Brits know: at times loved, at times hated, full of wonderful people, but not always well-run. This was part of the reason I had left my UK clinical work to become a doctor in the global pharmaceutical industry.

I cycled up to the hospital on an unseasonally warm day before the Easter weekend. My first day back. What immediately struck me was that the corridors of the old Victorian hospital were empty. Where was everybody? Where was the pandemic? There seemed to be no patients, no staff, no one about at all. Had this all been media hype? I expected the hospital to be a hive of bustle. The front line. This was where the rubber met the road of tackling COVID-19, I thought.

I was right, but not in the way I expected. COVID-19 had generated huge amounts of demand in the ICU and acute ward but the rest of the hospital had effectively shut down. Hundreds of patients had been discharged from their hospital beds in anticipation of the pandemic. Patients were now not presenting to hospital for routine medical issues. Heart attacks, serious infections, strokes—where were these patients? Perhaps, tragically, they were following too closely the UK government’s advice to “Stay Home. Protect the NHS. Save Lives.” Effective, clear messaging: the Prime Minister Boris Johnson and his chief advisor Dominic Cummings are renowned for it. So effective that even our four-year-old repeats it. Will more patients lose their lives for this reason than the lives saved from the lockdown? We know from early Italian reports that their cardiac centres had not had the throughput they usually experience during the COVID-19 peak. Heart attack patients had been staying home. Perhaps it was not communicated clearly enough that people should still seek medical attention if they feel they need it: COVID-19 does not mean suffer in silence.

After a short local induction, I was back on the front line. Very quickly I got a clear picture of the situation. The ICU, which usually had capacity for 10 ventilated patients, had nearly 30 ventilated patients following the requisition of adjacent clinical wards. Theatres and theatre recovery had also been shut down for normal business and were being used as an extension of the ICU. They were stretched, but just about coping, I thought. Doctors and nurses from all around the hospital had been redeployed to the ICU.

All the patients on the ICU were COVID-19 patients, all having followed a very similar clinical trajectory: a period of fevers and feeling unwell followed by worsening breathlessness. The unlucky few, after a period of oxygen therapy on the ward, would become too tired to maintain the additional breathing requirements of COVID-19 to maintain normal oxygen levels in the blood. For these patients, doctors would be required to make a decision—would they benefit from being sedated, intubated, and having their breathing performed by a ventilator on the ICU? This is not such an easy decision. If a patient is selected for this type of medical intervention when they are too frail, they would likely be consigned to a prolonged, uncomfortable, and undignified death in the intensive care unit. Surviving critical illness requires a degree of fitness and conditioning—for patients who don’t have this, intensive care therapy can be unnecessarily distressing and ultimately futile. It is thus crucial that the right patients are chosen for the ICU.

In addition, doctors must consider the challenging, but very real situation of stewarding limited capacity in the face of additional demand: giving an ICU bed to someone today who may not benefit, but who will restrict access for a patient tomorrow that might. These situations are perpetually challenging and put two of the fundamental principles of medical ethics at odds: autonomy and distributive justice. For example, a clinician must uphold the wishes and rights of the individual, while also making sure that the broader population can access the same treatment if they need it. In an ideal world this would not be a problem as we would have unlimited medical resources. But reality, particularly in the NHS, which immediately prior to COVID-19 had one of the lowest numbers of ICU beds per capita in the developed world, dictates that rationing decisions must be made. This is even more acute when demand is as high as it is in the COVID-19 crisis.

Much has been made in the British media of the need for additional ventilators. Mechanical ventilation was invented in the 1920s during the polio pandemic. The ‘Iron Lung’ was a machine that supported the work of breathing to patients who were unable to breathe for themselves via an iron cylinder that contained a polio patient’s body, but not their head. Cyclical negative and positive air pressure in the cylinder generated a gradient to suck air into, and then force air out of, a patient’s lungs. Ventilators are now much more advanced, driving air in and out of a patient’s diseased lungs via a plastic tube that is inserted through the vocal cords into the trachea.

This technological advancement is crucial, as the damage COVID-19 can do to a patient’s lungs is considerable. The lungs of these patients become infiltrated with fluid and scar tissue, limiting the normal function of gaseous exchange while becoming very stiff. As a consequence, many of these patients require ventilators to generate high inflation pressures to fill the lungs modestly. To further manage this problem COVID-19 teams are using a strategy of routinely “proning” patients, a practice used commonly in the ICU I am working in, as well as in others. Proning patients, or turning them on their front, can help redirect oxygen to healthier parts of the lungs and give damaged areas a chance to rest and recover. This is a therapeutic strategy well known to ICU doctors but infrequently used and certainly not deployed on the scale that it is being used now. Proning patients carries risks: It requires a team of seven people to turn the patient, taking great care not to pull out or dislodge any lines or tubes that are providing life-sustaining treatments. Humans are not used to lying face down for 16 hours and thus great care must be taken to protect the body from pressure injuries to the face and other parts of the body.

But the lack of ventilators hasn’t been as much of a concern as many expected. Hospitals can access a lot of ventilators across ICUs and operating theatres, plus simpler ventilators for transporting patients or providing non-invasive breathing support on the wards. More profound shortfalls in capacity during the crisis appear to be manifesting in two forms. The first is ICU nurses, who are simultaneously caring for two or three patients when they would normally only be looking after one. ICU nurses are some of the true heroes of this pandemic.

The second shortage is dialysis machines. These machines are used for patients who experience kidney failure. COVID-19 can trigger an inflammatory process, or ‘cytokine storm’, seven to 10 days into the infection. This can lead to kidney failure—both kidneys cease to perform their usual function of cleaning the blood and eliminating waste products via the urine. As a consequence, many COVID-19 patients require dialysis support, but there are profound shortages of these machines given the additional demand. Dialysis machines are therefore being rotated around COVID-19 patients who require them, rather than being used continuously until the kidneys recover, which is normal practice. This means patients with COVID-19 requiring dialysis are having to endure periods of time where they are not dialysed. Whether this will affect outcomes for these patients has yet to be seen. For patients who become critically ill with COVID-19, the challenges are very great—multiple organs are failing simultaneously requiring many therapies, both pharmacological and mechanical. This produces a complex illness where it is sometimes difficult to work out whether a particularly intervention has helped or harmed a patient.

Most heart-breakingly, families of these seriously ill patients are not allowed to the bedsides of their loved ones to prevent further spread of the virus. As a result, doctors give daily updates to the families regarding the clinical situation by telephone. I have felt the anticipation down the line immediately after I lead with, “Hi this is George, one of the ICU doctors. Can I update you about how your dad is getting on?” Families must wonder if this is the phone call they most dread. Sometimes it is. Our unit is able to provide video calls to families so they can see their loved ones in their final moments, before the machines are turned off, and the patient is allowed to pass away peacefully without the machines and monitors and their accompanying noises. These calls are heart-wrenching, as you might expect. Many of the victims are young—in their 40s or 50s. The doctors and nurses, in full PPE, emotionally hold the hands of these patients as the heart makes its final beat. The commitment and compassion of these frontline staff is overwhelming.

What next? Will there be a second peak if lockdown restrictions are eased in the coming months? What will happen when lockdown ends? Will the clinical trials yield an effective therapy or vaccine? This illness is like no other medics have experienced—we are learning on the hoof. How many will die? How many clinical staff will die? Time will tell, but one thing we have learnt is that there is no shortage of humanity on the wards and ICUs of the UK and beyond.

 

George Godfrey is an ICU doctor at a London hospital.

Feature image: Douris, Lebanon, 7 April 2020. Frontline staff on COVID Ward A at Dar Al Amal University Hospital’s novel coronavirus treatment facility. They are currently caring for five patients, two in the ICU. Elizabeth Fitt/Alamy Live News

Comments

  1. Great article. Clearly shows the dilemma faced by Public Health Professionals in walking the fine line between clear simple messaging and the need for more detailed and in depth information. Above all, a vacuum can created a demand for more information, which the market will always fill, especially when people have time on their hands, sitting at home. Unfortunately the advice that rushes in to fill the information void, isn’t always the most reliable. One innovation could be a central website with FAQ’s and a more in depth flow chart of questions, very similar to the fault logging previously used by phone companies and call centres to diagnose problems over the phone.

    But when the dust settles and the inevitable round of inquiries begins, I hope we can show the self-discipline to avoid the usual partisan bickering, reputation damage and blame game- because the insights that can be gained from such processes can be incredibly valuable moving forward. A key piece of analysis should focus on the different reactions of different types and scales of bureaucracies- without being critical, or blaming the civil service, are there ways that we can encourage bureaucracies to drop the love of process and systems, and develop the innovative and entrepreneurial approaches used so successfully in some countries- to abandon clearly delineated lines of authority and accountability, for the sake of expediency in a crisis.

    How best to harness the technocratic class, and encourage the too many Chiefs, to role up their sleeves and become Indians. I wonder whether the usual governing by committee approach and British insistence on endless meetings to fill days, hasn’t led to an institutional paralysis, when deprived of this option. The authority to issue anything other than person-to-person emails will likely need to be severely restricted in future, given that it’s likely that many have found themselves buried under white noise.

    In the final analysis, we will likely find that culture has played a huge role, in the behaviour of the virus during the pandemic. The Italians probably presented us with a worst case scenario early on, given their propensity for contact and public affection. Meanwhile, the Swedes with their reserved standoffishness and tendency to follow informed instruction, have been able to run a far more liberal response. In Britain and America, international hubs have been worst hit, and the huge degree of cultural and sub-cultural variety, has meant the most diverse areas have been worst hit, with the virus using variability of culture to vector…

  2. I will be interested to see - later on - if their national resilience to the virus becomes better than, less than, or the same as Sweden’s.

  3. This is a valuable picture, and is something that a lot of people are probably not seeing. Anyone who doesn’t live in a dense city isn’t seeing the threat the way this doctor is.

    One thing that they’re not mentioning, which might be worth mentioning, is why the rest of the hospital is virtually shut down. Hospitals are great vectors for transmitting diseases, because you don’t come there unless you work there or are sick, or maybe are related to someone who is. What this means is that any patient who comes into a hospital with something else has a risk of catching covid-19 on top of it, and so shutting down as many other functions as possible helps keep people from catching it and ending up in the ICU. Yes, it does suck for other diseases and treatments than the pandemic in question, and this is one of the side effects that we may have to think about in terms of how we solve for future pandemics.

    One of the things that I have kept saying is that, as more and more of us pack into cities, particularly extremely dense cities like New York City and London, and as our globalization grows, we become far more vulnerable to pandemic. Diseases which might travel slowly or be much more mild now can travel quickly across the world, with our response lagging behind. This can produce major societal changes that we may need to think about and think through as we make them.

    This is not just a tale of our times, this has always been a problem. For example, we can see this with cholera in England. English cholera used to be fairly mild, although it could be a serious problem. However, when strains arrived from India that were much more virulent and lethal, cholera became a huge problem. In fact, arsenic poisoning was so similar to the symptoms of this more lethal strain of Cholera that it was hard to tell the difference, and spurred the development of chemical tests for arsenic and the burgeoning science of forensics. This also drove societal changes, like the understanding of how sewers work and why they need to be built, and things like putting your outflow from your sewers downstream of your sewer intake. It helped move germ Theory along, not because we knew the germs, but because we now knew that diseases could be waterborne. Struggling against cholera helped define many of the cities of the world, as is was not just London that felt its sting. Nowadays, we have sewers and sewage treatment and the threat of Cholera is minimized as long as those are working well, though certain natural disasters have brought it back, as was the case in Haiti. Societal changes around access to clean drinking water, building water purification plants, sourcing clean water, dealing with bacteria, all of these are changes derived from our understanding of water-borne diseases like cholera.

    We now have a similar issue with diseases like covid-19. We are more vulnerable to them due to the tight packing of our society and our globalization, so what societal changes are we going to see as a response to help mitigate the danger and get out ahead of these diseases when they arise?

  4. Sobering piece by dr Godfrey In the UK and US people are terrified to go to the hospital for any reason. Our hospitals in New York with the exception of the Covid areas are empty. Heart attacks, strokes, and serious infections are not being treated. The question has always been, is the cure worse than the virus. In the US in 2018, the total deaths from suicides and drug overdoses were 130,000 Does anyone think that number will not be 200,000 or more this year?

  5. George Godfrey and ICU colleagues all over the world NEED TO READ THE PAUL MARIK PROTOCOL https://www.evms.edu/covid-19/medical_information_resources/ AND THE PROTOCOL OF THE FRONT LINE COVID-19 CRITICAL CARE WORKING GROUP https://covid19criticalcare.com IMMEDIATELY.

    No apologies for ALL CAPS. Many of your patients are dying due to your ignorance of the best way of treating ICU patients in general and COVID-19 patients in particular.

    This article makes no mention of these protocols, which involve early intervention with IV vitamin C, B1 and corticosteroids. Most COVID-19 patients survive when these protocols are followed. Mechanical ventilation is generally avoided.

    Most ICUs around the world have not adopted these procedures. It is commonplace to read of many patients being ventilated and 50% of them dying, for instance: https://www.abc.net.au/news/health/2020-05-04/recovering-after-coronavirus-treatment-intensive-care-ventilator/12200084 .

    Health administrators and reasonably well educated people all over the world need to read these Protocols too. IF everyone who became seriously ill could be treated in this way, the death toll would be vastly lower and there would be no justification for the deadly (uncounted medical harm and death), socially and economically disastrous lockdowns.

    The trouble is that even if all hospitals adopted these procedures, and there were no other approaches to handling this new coronavirus, we would still need economically and socially crippling restrictions for years to limit the spread of the virus to a level where all those who needed hospital care could get it. Even this would severely reduce the capacity of hospitals to cope with other forms of ill-health, which they generally struggle to do in the best of times.

    These restrictions would require very limited international travel and would be economically crippling for almost every country. Eventually, when 90% of the population had become infected AND IF this gave most people a pretty good chance of not getting it again for the next few years (which seems like a reasonable expectation, on average) then restrictions could be reduced, and international travel could be allowed again from all countries which had a similar rate of immunity.

    There will probably be NO VACCINE. Anyone who thinks a vaccine is coming this year or next hasn’t read the reasearch. Maybe one will be developed, found to be generally effective and free of side effects after several years work - but attempts so far at developing a vaccine for SARS have failed. One trial was abandoned after the antibodies raised by the vaccine caused an actual infection to become much worse: Is antibody-dependent enhancement playing a role in COVID-19 pathogenesis? Negro Francesco Swiss Med Wkly. 2020;150:w20249
    https://smw.ch/article/doi/smw.2020.20249 .

    EVERYONE needs to read the following research articles (not yet peer reviewed) which show, beyond a shadow of doubt, that low vitamin D levels cause serious harm and death for COVID-19 patients and people with adequate levels have few, if any symptoms.

    Mark Alipio in the Philippines: Vitamin D Supplementation Could Possibly Improve Clinical Outcomes of Patients Infected with Coronavirus-2019 (COVID-2019) https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3571484 .:

    Of hospitalised patients with > 30ng/ml 25OHD (D3 is converted in the liver to 25OHD, the form of vitamin D needed by the immune system and which is measured in blood tests) 47 of 55 had mild symptoms (without pneumonia). 4 had ordinary symptoms (CT confirmed pneumonia with fever and respiratory symptoms), 2 had severe (hypoxia and respiratory distress) and 2 had critical symptoms (respiratory failure).

    Of the 157 patients with 30ng/ml or less 25OHD, 2 had mild symptoms, 55 ordinary, 54 severe and 46 critical.

    A similar trend is found in death rates: Patterns of COVID-19 Mortality and Vitamin D: An Indonesian Study Prabowo Raharusun et al.
    https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3585561 .

    4.2% of hospitalised patients with > 30ng/ml 25OHD died. The death rate for those with 20 to 30ng/ml was 49.1% and for those with < 20ng/ml, 46.7%.

    Within the total infected population, the death rate of those with > 30ng/ml 25ODH would be vastly less than 4.2%, since this is 4.2% of the few who were sick enough to go to hospital.

    Normal weight people taking 4000IU vitamin D3 a day (0.1mg, so a gram lasts for 27 years) will, on average have 25OHD levels of about 47ng/ml, which is about the same as those of African hunter gatherers. (Please see my page http://aminotheory.com/cv19/ for all the references, charts and links to further research.)

    In one study, white women in the USA were almost all below 30ng/ml without supplementation, and 2,500IU D3 a day brought all but 16% of them above this.

    In a recent study COVID-19 outbreak at a large homeless shelter in Boston: Implications for universal testing Travis P. Baggett et al.
    https://www.medrxiv.org/content/10.1101/2020.04.12.20059618v1 . 36% of 408 homeless people with PCR positive for COVID-19, meaning they were currently or had recently been infected. Their average age was 53.1. They had no serious symptoms, and a remarkably low incidence of minor symptoms: 7.5% cough, 1.4% shortness of breath and 0.7% fever. These rates hardly differed from those of the other homeless people whotested negative, average age 50.8.

    These homeless people were generally younger than the older people who are most often killed by their body’s dysregulated immune response to COVID-19, and they probably get more exercise. (Smoking is a wildcard - there is a suggestion that nicotine is protective. https://www.qeios.com/read/WPP19W.3 ) I guess homeless people rarely take vitamin supplements, but they spend more time outdoors and so probably higher vitamin D levels than the majority of the population, who get little UVB sunlight, and who likewise do not take vitamin D supplements.

    If we could get everyone’s 25OHD levels, on average, to 40ng/ml, only a small fraction of the population would have levels below 30ng/ml. (Almost everyone in modern societies who does not supplement has such low levels, and some have half or less). Then the death toll would be vastly reduced.

    Unfortunately, it would takes many months of increased production at existing factories, and building new factories, to achieve this. Vitamin D3 is made by mercury vapour lamps UV irradiating an alcohol solution of chloresterol derived from wool fat. Most of the work is in refining it. Most factories are in China and India. The ex-factory price is USD$2500 per kilogram. At this rate, 4000IU a day costs 9 US cents a year.

    6 months supply at 4000IU a day is 18.3mg, so a kilogram would cover 54,000 people for long enough to let the coronavirus spread to most of the population, by which time new D3 factories could be operational. To cover all the adults in the USA - say 324 million people - we would need 6 tonnes of D3 for 6 months. I doubt if such quantities exist in stock - except perhaps for less refined D3 made for animal feed. Even if it did, India and China need it for their own people.

    Boron is not officially recognised as a nutrient for humans, despite decades of research showing it reduces some ill-effects of low vitamin D and that (like vitamin D) it aids immune system regulation and reduces the overly-aggressive inflammatory response (cytokine storm) which is what kills COVID-19 patients. It has numerous other roles in bone health, wound healing etc.

    Boron is readily available as technical grade borax - and is sitting on supermarket shelves in the laundry department at about $10 a kilogram. Most people only get about 1mg boron in their diet. The replete level is somewhere between 6 and 12mg. 6mg a day, requires 50mg borax, in water solution.

    There are no randomised controlled trials concerning boron and COVID-19. We don’t need them since we desperately need to reduce the whole population’s proclivity to immune system dysregulation, and the level above which ill effects might occur is 20mg/day.

    6 months of 6mg boron a day requires 9 grams of borax. I think it is highly likely we can find this in supermarkets and warehouses in most Western nations. Borax is a naturally occurring salt of boron, sodium and oxygen. It is refined at the mine sites in California and Turkey.

    The neglect of the nutrients vitamin D, boron, omega 3 fatty acids, potassium and vitamin C has lead to a global chronic inflammatory disorder disaster, driving cancer, neurodegneration, bone weakness, arthritis, asthma, IBD, Crohn’s disease etc.

    There have long been very strong reasons for supplementing all these nutrients - but most people, doctors included, haven’t read the research or have been unreasonably resistant to the arguments for supplementation. COVID-19 makes D3 and/or boron supplementation much more urgent, because until we fix the nutritional deficiencies which render many people’s immune system both weak in its antiviral response, and destructive in its overly inflammatory response in the later stages of the disease, COVID-19 will kill millions of people.

    No antiviral drug can stop the virus spreading. A vaccine is probably a fantasy. We will need to adapt to this virus being part of life forever. The virus will spread, and can only be slowed by unsustainable lockdowns.

    Vitamin D3 is well known and would probably fix the problem - but it can’t be obtained in the quantities we need. Boron is readily available, and the laundry borax is probably just fine. My wife and I use it. Our 6kg cat’s feline tooth resorption resolved once we started him on 0.6mg boron from borax. However, labs should test common borax brands for purity before my proposal proceeds.

    Before all this can happen, most people and ideally most doctors will need to recognise that they have been wrong to think that humanity can get by with modern diets without supplements. We need supplements for our bodies to function properly. We wouldn’t tolerate contaminated fuel for our cars, AA batteries which were only 1.3 volts, or pet food which lacked all necessary nutrients.

    History will record that all this trouble - and most of the sepsis, chronic disease, Alzheimer’s, Parkinson’s etc. - results from inadequate nutrition. Hopefully we will fix this within months, rather than years. When we do, the benefits to humanity will be at least as profound as arose from another successful challenge to accepted assumptions, in which which some doctors spent decades resisting research which showed the the importance of hand-washing.

  6. Call me a skeptic, but I wish I had $100 for every supplement that has been touted as the “next game changer” for health, only to fall on the scrap heap of good ideas with no data.

    We do randomized controlled trials specifically to sort out promising mechanistic theory vs actual benefit. When I was training, it was practically considered malpractice to not have a post-menopausal women on hormone replacement therapy. After an adequately powered trial was finally completed, “Oh wait, scratch that, you may want to rethink HRT in post-menopausal women. It doesn’t improve cardiovascular outcomes like we just KNEW it would, and there is an increased risk of thromboembolic events”.

    Vitamin D levels are low in cardiac patients. There is a good mechanistic theory for raising Vitamin D levels to reduce cardiac risk. Well, a meta-analysis of 83,000 patients published last year revealed NO cardiac benefit to Vitamin D supplementation.

    Vitamin E: The CHAOS trial over 20 years ago had everyone in a dither that Vitamin E was going to be the next great thing for patients with coronary artery disease. As a resident, it became part of our discharge protocol for all patients admitted coronary events to go home on Vitamin E. 15 years and 6 randomized controlled trials later, the conclusion: Vitamin E supplementation has no benefit in CAD patients, and there is a non-statistical trend for harm (probably due to the fact that Vitamin E causes monocytes to increase expression of tissue factor).

    Vitamin B6 and B12 could be of benefit in lung cancer? Actually, no, supplementation raised the risk of lung cancer, particularly in male smokers. Ditto for Vitamin A supplementation.

    Honestly, I could go on for a quite a while listing just those supplements that have failed in my field of cardiovascular medicine. I am not dismissing the notion that certain supplements may be potentially beneficial in certain clinical situations, but it must be tested. The situation is far more complex than understanding the biologic functions of an element, making the observation that a deficiency of the element is seen in association with specific disease states, and then concluding that supplementation will be beneficial. I only wish it were that simple.

  7. Well, I go for this notion too. I’m not a biologist, but I tried to read articles on flu that were written before the whole Covid-19 panic. From what I gathered , a flu will generally attenuate (weaken). Also, while most people regard the idea of herd immunity as suicide, it actually isn’t a bad strategy against Covid-19. Vaccines are awesome. They’re the reason why polio and smallpox don’t trouble us anymore. But the idea of vaccine against Covid-19 is semi-pointless. Most say a vaccine is about 18 months away and that’s an optimistic figure because, really, how can you guarantee the development of a vaccine? So while herd immunity would be an insane strategy against something like malaria, because we can’t develop a natural immunity to it, we obviously can develop a natural immunity against Covid-19. At least 80% of people who get it survive it without a dent. The number of people under 20 who’ve died from it is very small (I think five), and so unlike influenza it is not very fatal to children. One should protect the high-risk groups, such as the elderly, from the coronavirus, but you can allow the rest of society to function normally. If you want masks, provide masks, that’s fine, but the lockdown, to me at least, is abject stupidity. I think the chances of this being recorded as humanity’s dumbest “hour” far exceed its chances of it being our second “finest hour”.

  8. Another quick point, for those who think anyone who talks about the economy is putting money ahead of lives: the economy is lives. There are no health services without an economy, there is no food supply chain.

  9. Sure, I get what you’re saying. That if since it is highly contagious, it could potentially afford to be more lethal, and it wants the “sweet spot” between lethality and contagion. My point is still the same though. It has mutated, but it hasn’t become more dangerous. We know who it’s more likely to kill: the elderly and those with respiratory illnesses or immune deficiencies. For the rest, the risk is minimal. This is not say it’s
    zero, but many people survive it without medical treatment. The same is not true of typhoid or TB or malaria or any number of illnesses I could mention. Those all demand serious medical intervention. If you break a leg, you put the leg in a cast, not the whole body. Protect the high risk groups. Encourage masks, hygiene etc. but keep things moving along. Remember that “keep calm and carry on” slogan that was so popular for a stretch? It seems we prefer: “stay hysterical and cower.” Also, I just don’t think you can really wall off the virus. For example, prisons are probably crammed with Covid-19 cases.

  10. I guess I’ll start by stating that I’m not sure why labeling someone “a high school biology teacher” would somehow equate to an insult in your world. I can honestly say that my high school biology teacher had a tremendous influence on my decision to go into medicine. The man was an intellectual giant, and I admired him a great deal. In fact, he recently died at age 93, and despite the fact that I hadn’t spoken to him in over 30 years, I felt compelled to write a letter to his family expressing my gratitude toward their father. I guess you hit a sore spot with me using high school teacher as a disparaging term.

    Now, in regard to your post, I think you would be surprised to learn that I agree with you on a number of issues. The “panic porn” peddled by national media outlets has been shameful. Perhaps it helps their ratings and/or political agenda, but whatever the reason, it has been excessive. In my opinion, the lockdowns have served their purpose, and there is no reason to continue them at this time. I also agree that numerous people have died out of fear of COVID. Heart attack volumes across the country (and in Europe) were down 30-40%. In our hospital’s emergency department, heart failure exacerbations, COPD exacerbations, drug overdoses…all down by more than 50%. People stayed home out of fear, and many died at home as a result.

    And, finally, yes, I am certain I have had to debunk the notion that this is “just another flu” over 100 times. I hear that argument daily for friends, family, and people in my community. I have now cared for critically ill patients in the hospital for a total of 27 flu seasons, and one COVID season, and as someone who has seen both up close and personal, I marvel at those who tell me I’m wrong. I gain nothing by making false claims about COVID. All I’m telling you is that it is not the flu. It is worse. You state that heart failure patients are dying of heart failure “with COVID, not because of COVID”. That may be the case in some patients, but from what I have witnessed, patients who have been stable with their cardiac condition for years arrive in the hospital with viral symptoms, hypoxia, and can go into the crapper in the blink of an eye. These are not patients who were hanging on to life by a thread at home due to their heart failure, and then happen to have a positive COVID nasopharyngeal swab as they die of their heart failure. The same can be said for the other comorbid conditions you listed. Our median age for ventilated COVID patients was 56, and I assure you that many of them were not chronically ill at home before acquiring COVID. Yes, they may have had diabetes or HTN, but they were stable prior to COVID, not acutely declining.

    I was unaware of any perverse incentive to label patients as COVID in order to receive higher reimbursement. I’m a bit skeptical as we have been judicious in our testing based on the patient’s presentation. We have not tested for COVID unless we had a suspicion for COVID. If there was some corrupt scheme to increase billing for COVID status, wouldn’t you expect widespread testing for everyone admitted to the hospital? That hasn’t been the case, at least not where I practice.

    Finally, don’t take my word for it. If you have found reports of a single ICU physician (not some urgent care hack in California), but an actual pulmonary/critical physician who has gone on record stating that COVID is nothing more than a seasonal flu, please attach and send my way. I have been in communication with dozens of hospital based physicians across the country. They come in all stripes and political persuasions, and not one of them would agree with your position.

  11. I’m really nothing special as a source. I’m an interventional cardiologist whose second home has been a large teaching hospital for the last 25-30 years. I’m simply reporting what I see first hand, as well as second hand reports from friends and colleagues around the country. I can tell you that none of my peer group has anything to gain by spreading misinformation about this pandemic. Our hospital recently furloughed staff for two months, my pay has been cut by 30%, and all perks have been eliminated, including funding of our retirement accounts. If anything, I would benefit by the narrative that this is only the flu and there is no reason to treat it any differently. When I’m not on hospital rounding weeks, all of my clinic has been remote visits, so this has provided me with more time to read Quillette, and comment on those topics where I actually have some first-hand knowledge.

    You and michaeltoo are both correct that the media has been irresponsible, and many of michael’s points have been valid, or at least partially valid. The media has misled the public on the point of social distancing. The goal of avoiding a surge that overwhelms local hospital systems has been achieved (and hopefully we don’t see that with subsequent waves), but now the goal seems to have shifted to preventing future infections/deaths from SARS-CoV-2, and that is simply is not realistic. The flattening of the curve was never intended to do that, despite the media’s cries to the contrary. As I mentioned in a prior post, I fall into the camp that believes the only way we are getting past this is with population-based immunity, which means a tremendous number of infections, and likely up to a quarter million deaths (far more than anything we see with flu). It will be a slow burn, the media and public will lose interest in the count, but somehow I think the panic button will be hit again as we approach the next election. I have no particular expertise in vaccines, but I’m doubtful we will ever get an effective vaccine (still waiting for the HIV vaccine I was promised we would see as a med student in 1993), and even if we do, I have to think it is months to years off and will be “too little, too late”. This virus moves like wildfire, and I would be surprised if 50-60% of the population hasn’t been infected by the time a vaccine arrives.

    On a final note, the comparison to seasonal flu does make me a bit crazy. Look what happened in Milan, Madrid, and NYC. We don’t see that every year with seasonal flu. If Milan lost 150 physicians to the flu every year, they wouldn’t have any physicians left! Perhaps this is what seasonal flu would look like if introduced into a population with no immunity, but this is not comparable to modern conceptions of seasonal flu.

  12. Oh damn, you got me, I might as well admit it. I’ve been making all of it up. I haven’t actually seen patients go on ECMO due to COVID, nor have I seen patients die of COVID, alone without family at their side. All of the footage from Italy was clearly fabricated. And, of course, the only healthcare workers who are dying are those who are “90 year-old dentists and retired general physicians”. The sad news I received about a former colleague dying in Milan is also part of the disinformation campaign. I’m sure he is enjoying a glass of wine overlooking Lake Como as I write this. And, of course, I’m sure the poorly researched list I have attached below is all fiction. Peruse the list. You will see the occasional octogenarian or nonagenarian, but amazing how many you will see aged 30-65.

    What an effort health care workers are making to propagate the myth of this virus.

  13. Yes, EU policies have not helped Italy and Spain. My relatives in Italy believe COVID will be the final straw for Italians, and this may well start the process for their own “Brexit”.

    SARS-CoV-2 enters cells via the ACE2 receptor, and this receptor is prominent on vascular endothelium, renal endothelium, and interestingly the testes (? whether this partially explains the disproportionately high death rate in males). The consensus at this time is that use of ACE-I and ARB medications does not increase the risk of more severe illness with SARS-CoV-2, and research continues as to whether it may be protective.

    Vitamin D deficiency may play a role disease severity in some patients, but it is not simply a matter of supplementing these patients with Vitamin D.

    Finally, Dr. Erickson strikes me as a hack. I watched ~15 minutes of his video, and concluded he was something of a moron: #1 He is an emergency room physician who owns a few urgent cares, yet repeatedly states he has extensive study over his career in microbiology and epidemiology. If he does, he is the only one of his kind. To be honest, I’m doubtful he could pass a high school level exam on the differences, and interplay, between innate and adaptive immunity. #2 He undermines his rich pedigree in microbiology/epidemiology within the first few minutes by making an unacceptable error. He takes the percent of positive COVID tests in sick patients and extrapolates that out to the entire population. “In New York state, 39% of patients tested were positive for COVID, that means 39% percent of the population has been exposed”. Hey, Einstein, no it doesn’t. In the first several weeks of this pandemic, you couldn’t get a test unless you were acutely ill, or a close contact of someone who tested positive. You can’t look at the positive rate in that population, and then extrapolate to the population at large. That is called “selection bias”, and I would assume a self professed expert in microbiology and epidemiology would be familiar with that term. Honestly, so stupid and inexcusable, and I have to admit I stopped watching a couple minutes later. Perhaps he redeemed himself later in the video, but I doubt it.

  14. Yes, breathnumber, you are quite correct. I have been a bit overwhelmed with anxiety and you are so insightful in picking up on my “seeming distress” from my post. You have to forgive me: I chose a field conducive to my panic and anxiety…those are just the characteristics one needs to handle heart attacks, shock, and cardiac arrest on a daily basis. We interventional cardiologists are quite a hysterical bunch, just can’t seem to handle pressure very well.

    And…your little role play betrays the fact that you have no idea what the hell you are talking about. Not worth discussing further.

    Sad to sign off on Quillette for a while. I start a 10 day stretch in the hospital this morning where I’m sure to have spastic colon every time an emergency arises. If only I could have your nerves of steel.

  15. An interesting perspective from a nurse(cousin) on the frontline in Illinois

    Hi everyone. I haven’t said a whole lot about novel Coronavirus and COVID-19 here, but I’d like to share my experience last night and today (I’ve been reassigned from my day shift office job to night shift in one of the system’s ICUs. We’ve been extremely busy with COVID patients):

    Wake up about 5PM, not feeling entirely rested. I’m no longer a night-shifter, you see. But there are very sick people, and much like Liam Neeson in “Taken”, I have a particular set of skills. So I get up, and put on street clothes. The hospital lets us wear OR scrubs (since we’re not doing elective procedures at this time anyway), and some people wearing scrubs in public have been harrassed. My amazingly supportive boyfriend has dinner and a lunch ready for me, and we eat dinner together before I leave for the night. I also take the lunch he made because although the community has been generous in donating food for us, even on night shift, I have food allergies and must be careful.

    I then drive the 30 minutes to work. I moved earlier this month to be closer to work. But the reassignment is not to the hospital nearest me. I’m needed at the further hospital. Luckily, there isnt typically much traffic these days. But I still need to get on the tollway and pay for more gas.

    I get to work, and have to submit to a screening before being allowed fully into the building. I answer questions about whether I’ve had any symptoms of COVID or if anyone in my household is ill, have my temperature checked, sanitize my hands, and don a surgical mask. This mask will be my best friend for the next 12 hours or so, as I’ll need to wear it whenever I’m not wearing an N95 mask.

    I go to the locker room and change into hospital-issue scrubs. I make sure my compression socks are in place, my shoelaces are double-knotted, and my hair is all tucked into my scrub cap. I know it’s going to be a busy shift, because they always are. I grab my things, clock in, and sign out the reusable P100 mask that I was fit-tested for. I double check that the filters are clicked in appropriately, as this sometimes gets missed in the sanitation process. I’ve had a filter fall off the mask while I was putting it on before.

    I present for report and learn about my patients. Both are COVID positive, and neither are doing well. One only speaks a language other than English, and the other is so weak from trying to breathe that we cannot understand what is said through the BiPAP mask. I sit to try to organize my thoughts when the BiPAP alarms. It takes me a moment to get into the room, as I have to appropriately don all of my PPE: a gown, my P100 mask, my eye protection, and 2 pairs of gloves (because putting new gloves on sweaty, sanitized hands is a task I’ve yet to accomplish). My patient is no longer on the BiPAP mask, and is not doing well: oxygen saturation in the low 80s, heart rate 120s and climbing, and blood pressure 180s/90s. I get the mask back on the patient, and am able to knock on the room door for attention. One of my coworkers comes over, and I’m able to yell to them, through both the room door and my mask, my request for supplies and help.

    Despite my coworker’s best efforts, the patient continues to decompensate. We call our specialized COVID intubation team. They get to the unit, get geared up, and get to the bedside. It’s obvious to everyone this patient is not doing well and needs to be intubated and placed on the ventilator. This is done, several pairs of hands on deck: myself, the physician, a nurse anesthetist, 2 respiratory therapists, and my amazing tech for the shift. I have 2 nurses outside the room, running supplies and titrating drips on the IV pumps outside the room. We get it done, though the patient decompensates further before all is said and done: heart rate to 160s, oxygen saturation in the 40s.

    I’m unable to leave the room for approximately 2 hours afterward. We’re barely 1 hour into the shift. Ventilator settings are titrated, medications are given, sedation is titrated, and the patient is still fighting the ventilator. We finally get everything settled, and I’m able to doff my PPE. I need to clean the eye protection and mask, because I’ll use them again. I realize I’ve sweat through my scrub top, so I go change. When I get back, my patient’s blood pressure is 70/40. Time to back off the sedation. The blood pressure improves slightly, but now the oxygen saturation is decreasing because the patient is no longer well-sedated and is fighting against the ventilator. The rest of the shift is a never ending battle between a blood pressure that will supply blood to end organs (kidneys, brain, etc), and an oxygen saturation greater than 85%. I titrated sedation, gave IV pushes of medication, gave IV fluids, and just sat and tried to reassure the patient. None of it allowed me to get the patient both a good blood pressure and a good oxygen saturation at the same time.

    My other patient was on the maximum flow of oxygen for the device they were using. The next step, should their oxygen saturation drop, would be more invasive help like a breathing tube and ventilator. Thankfully, this patient seemed to enjoy sleeping on their stomach (proned), and their saturation did well overnight. Of course, laying on your stomach all the time comes with its own complications, and the patient vomited in the middle of one of my other patient’s more significant downtrends. I’m thankful for helpful coworkers who helped that patient clean up, and administered the anti-nausea medication in my place.

    This doesn’t count the 5 phone calls to physicians, 1 call to pharmacy, countless updates to the charge nurse, and attempting to document it all. I also need to draw labs, calculate intake and output, pass medication, and be sure things are ready for the oncoming shift. I also needed to do some research about my patient to be sure the 2 liters of fluid I had given weren’t about to cause flash pulmonary edema because the patient’s heart was too weak to handle the fluid.

    Its finally shift change, and I’m able to hand off care of my 2 patients. Now that someone else is in charge, I can finally sit and be sure everything is documented appropriately. I finish that and clock out at about 8am. Place my P100 mask for cleaning, and place my ID, eye protection, pens, and cell phone into the UV box for sanitizing. Go back to the locker room to change into my street clothes, and head out to drive the 30 minutes home, scream-singing to my favorite band along the way to stay awake.

    I get home and dont sit on any furniture, I dont hug or kiss my boyfriend, do not pass go, do not collect $200. I head straight to the bathroom, put my “hospital clothes” straight into the washer (on hot), and head straight to the shower. I scrub off all the germs (I hope) and try to feel normal again. Then I can hug and kiss my boyfriend, give the cats some scritches, and hopefully make it into bed before falling asleep.

    I consider myself fortunate: I have ICU experience and was able to “volunteer” to go to the ICU. The people I’ve met there have been wonderfully helpful and kind, and I’ve been able to pass on some knowledge and help myself. We also have PPE. The P100 masks are available to us, and while we’re reusing gowns, eye protection, and masks, it’s not nearly to the degree I’ve heard of in other areas. While the supply chain situation is difficult, I feel like the hospital I’m in has been making the best effort to get their staff the things we need. If anyone has an in for the PDI Sani-wipes though, feel free to hook a girl up :stuck_out_tongue_winking_eye:.

    I have an amazingly supportive boyfriend, friends, and family. People have been checking in and wishing well. I have a job and am getting paid. In the time of a crisis like this, I’m incredibly fortunate (and will do whatever I can to help, should you be running on hard times). What I’m currently struggling with is how to strike a balance between keeping people safe and loosening restrictions so people can get back to providing for themselves and their families.

    I’ll tell you, honest to God, it is absolutely horrible to watch young, healthy people die of this disease. And we’ve seen it. We’ve also seen 80-something year old patients recover. I have zero problems running for 12 straight hours and doing whatever I can to save a patient. The problem is how little knowledge we have about this virus and the disease it causes. It’s too unpredictable to have any kind of working management of it. Yet, people need to work and provide for themselves and their families. I completely understand that, and am bothered by the fact that so many are struggling.

    I’m saying I dont have the answers. I’m not convinced anyone does. But please understand that while healthcare providers might be vocal about wanting to continue shelter-in-place orders, it has nothing to do with wanting to cripple the economy or feeling like this is the “only” way to go about keeping the curve flatter. It’s about not wanting to see another person die of this awful disease, young and healthy or old and infirm. But we don’t know how to stop it yet, other than keeping people away from one another.

    People are touting “herd immunity” and how more people need to be infected to achieve immunity. The biggest 2 problems are 1) we dont know if having the virus offers the host any immunity, and 2) if it does, how long that immunity lasts. Trying to achieve herd immunity before more is known about this virus will wind up with many more sick or dead.

    So please, I beg of you. Be patient. Be careful, wash your hands, and dont touch your face. And if you’ve fallen on hard times, please reach out. If I cant help, maybe we can find you some resources that can.

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