Day 11
“…unless it’s ’visibly soiled.’ Like we could
see Corona.”
I’ve been known to flirt with the LD50 of caffeine, but this morning I’m slipping it some tongue.
I’m status post two pieces of 100mg caffeine gum and a cup of coffee by 6:30AM. I hit 70 on the back roads heading towards the hospital in the minutes just after sunrise. There are practically no other cars around. My AirPods stream Andrew W.K.’s “Ready to Die.” A tasteless choice, sure, but it fits the energy of the day so far.
The 73M with multiple comorbidities who developed an NSTEMI, and who tested positive for COVID 4 days after testing negative has steadily been declining in the SICU. He’s refusing his medications despite his seasoned ICU nurse using the full spectrum of asking, demanding, and sternly admonishing him on his nonadherence. She even broke out the fake tears, she told me. She doesn’t do that for everyone. But no dice.
More importantly he’s doing poorly on a nonrebreather (NRB). If he takes the mask off, his sats drop to the 70s, a value you might guess correctly to be incompatible with life. He’s a little altered and he’s been put on dilaudid and a wrist restraint. Just the one, a CVA left the left arm safely useless.
One of the interns asks me what the plan was for our patient here.
“Palliative has a Goals of Care meeting with his family today. Our only plan is to keep him alive long enough for them to sign the DNI/DNR.”
I can blame the caffeine, I can justify it by saying his prognosis was
dire and it’s reasonable to think we did all we could, but I scare myself a little with how low my empathy’s dimmer switch is set.
But I don’t know how else to deal with this. The recommended treatment guidelines changed, yet again. Azithromycin is now actively
counter-indicted for COVID patients. We take him off it. Steroids, which as of yesterday were counter-indicated for COVID are now the standard of treatment for all patients on NRB. We start him on Solu-Medrol 1.5mg/kg divided BID. For all the good that will do.
He’s also well past the 5 days of Plaquenil / hydroxychloroquine. You know, that drug that was supposed to solve this whole crisis?
We all remember that right? I’ve got photographic proof we used to believe it would work.
Take a look at the March 17th (or Day -5, if you’d like)
National Enquirer cover:
CORONAVIRUS
CURES
FINALLY
FOUND!
Warning! Surgical masks SPREAD INFECTION!
Take a look at
every single intubated patient’s medical orders and you’ll see they either completed or are on Plaquenil and azithromycin.
And people
still think we have any handle on this other than jamming tubes down throats and waiting.
No one will believe the history of this thing when it’s over.
The patient passed that afternoon.
His daughters had signed a DNI/DNR right before.
…
I’m reminded of an intro Stephen King wrote for one of his books, where he writes about fear:
"The shape is there, and most of us come to realize what it is sooner or later: it is the shape of a body under a sheet. All our fears add up to one great fear, all our fears are part of that great fear - an arm, a leg, a finger, an ear. We're afraid of the body under the sheet. It's our body.
…
And [the writer] takes your hand and he enfolds it in his own and he takes you into the room and he puts your hands on the shape under the sheet… and he tells you to touch it here… here… and here…"
A quarter million Americans (
at least) are going to become bodies under sheets in the span of one or two months. And we’re talking about returning to work and a “miracle” ending to this in nine days.
Wake up and feel the corpses.
(PS: Yes, I owe Stephen King a royalty check given how much I crib his writing style.)
Day 12
“I will continue using military metaphors. We are at war with this virus.”
The greetings this morning were grim.
“Stay safe” has become the
aloha of intra-Resident conversations. I heard that twice before reaching the front doors of the hospital by 6:50AM.
“How was the night?” is the standard greeting to the two Residents just finishing their 12 hour Night Float shift. These are the two young MDs left to put out fires across half the hospital’s two hundred or so non-ICU beds.
“We had the longest Code ever. Took an hour. We went through maybe 20 epi’s.”
Epinephrine is only given to people with either pulseless electrical activity or those who are asystolic – flatliners. (Once again, Hollywood has lied to you. You don’t put the paddles on anyone with a monitor next to them going
BEEEEEEEEEEEEEP.) The ACLS guidelines say you push epi every 3-5 minutes.
The
Ok, We Tried alarm should have gone off about 3-4 epi’s in. Not 20.
“Was it a young guy?” “No, It was John.”
I curse a little louder than I mean to. I walk out of the room and wash my hands even though I’m sure I hadn’t touched anything.
John is-
was a nurse at my hospital. He
was maybe in his early 50s. Every Resident loved him because he was tough and always fought for his patients. He was a nice guy and a pleasure to work with. But he was fierce. He’d seek us out during Rounds, stare us down and make sure we put in orders for his patients ASAP. We all respected him.
I knew he was on a vent as of the night before with settings that looked, well,
dire, but it’s still a shock.
The night team leaves. I start mindlessly updating the cheat sheet summary of our 16 patients. I’m on autopilot at this point. 13 are COVID cases. COVID cases are, unfortunately, very easy to manage. You put in orders for medications that you’re pretty sure don’t work, you note how bad their oxygen saturation is on nasal cannula (NC) or nonrebreather (NRB), and you gown up and see the worst cases / people you think might need to be intubated in the near future.
The first Rapid Response comes at 7:40AM. I reach the door (of course it’s a COVID room, that’s all we have left) and realize I left my N95 at home. I’m not entering that room. I flippantly tell the interns to assess the situation and head to pick up a new mask at the Command Center.
The nice nursing admin lady hands me a paper bag with a new N95. She tells me to sign for it in the binder just outside the door. Despite my autopilot brain, I joke, “Oh we’re on the honor system? You know I’m just going to sign ‘John Smith’ in the binder right?” She laughs and says it’s ok I left my N95 at home.
I take my mask and sign John Smith in the binder.
Just because I’m in shock doesn’t mean I can pass up a joke like that.
I head back up to the Rapid. I get a debrief that this was narrow complex ventricular tachycardia in the 200s. They pushed metoprolol (wrong decision) and adenosine (right decision). I go talk to the very bright and hardworking intern on my team. I explain that in situations like this where the patient is otherwise hemodynamically stable, metoprolol isn’t going to do enough to slow the heart rate. You’ve got to reset the circuit breaker. I asked who the attending was in the room.
There was no attending. The intern had to make the call.
I left my interns to the wolves when I walked off in a huff to go get a new mask.
My autopilot brain goes over how shitty I am of a senior Resident.
When YOU were an intern, at least your seniors never walked away from a Rapid.
As I walk back to the call room to barricade myself behind a door for an hour or so, I come upon a nurses meeting where the news of John’s passing was being announced. I honestly don’t remember a single word of it. I do remember the occasional sobs coming from these amazing women.
Then there’s a Rapid and a COVID is intubated.
Table Rounds.
Then there’s a Rapid and a COVID is intubated.
I’m getting good at assessing whether or not a hypoxic COVID patient will get tubed and if we have time to get them upstairs before they crash.
Go me.
…
“The world breaks everyone and afterward many are strong at the broken places.”
I worry that some of my fellow Residents will break in the near-future.
It wouldn’t be a big break, just a small one that makes you sob on the way to work and dread every new day. For what it’s worst, so long as no one gets sick, I don’t think I’ll break. A few of us are close though.
It‘s the Night Float’s birthday today. Which means she technically coded John for 60 minutes on her birthday in the pre-dawn hours. When she tells me this, we tell social distancing to go fuck itself and hug for a while. I offer to take her shift and work a 24, but she declines.
The possibility, the
comfort of breaking feels like it’s hiding just over the horizon waiting for us.
It’s what follows that Hemmingway quote which worries me.
“But those that will not break it kills. It kills the very good and the very gentle and the very brave impartially. If you are none of these you can be sure it will kill you too but there will be no special hurry.”
John never broke.
He was good, and gentle and brave. And he was killed.
Day 13
“Where do you want dad to die? Paralyzed on a ventilator or not?”
Quiet day. Got time to take stock of everything.
The hospital is housing somewhere around 250 patients including the regular floors and the Empire of the ICU, >90% positive COVID. My team’s census for tomorrow is 100% COVID. There’s talk about transferring the few remaining COVID-negatives to the USNS Comfort.
Oh, and yesterday some moron tried to crash a train into the USNC Mercy on the West coast. Because we’re dumb, panicky animals.
45 COVID cases on vents with a dozen or so vents available. A little over 60 people currently on nonrebreathers.
We're still 5 days from peak hospitalizations and 6 days from peak fatalities per day.
Personally, I think I’m holding up as well as I can. Writing has helped. Occasionally get some exercise in. Plan on going for a long walk tonight.
I’ve got 6 more days of scheduled inpatient care left. Two weeks of vacation after that. I’m thinking about signing up to do COVID swabbing since it pays well and I’d go nuts if I weren’t doing something.
I still hate the idea of treating this as a war, but I’m thinking about volunteering to be “redeployed” to another hospital elsewhere in the States once New York gets past this. The rest of the country is only a week or so behind. New fronts are opening up. I’m pretty well experienced in managing COVID cases at this point.
…
Feels like I’m living in the time between a flash of lightning and the roll of thunder.
www.jpost.com
eot
and the MSM.
www.foxnews.com
