What's it like to be in the emergency department in one of the places hit hardest by COVID-19?, an emergency physician and military veteran in New York City, shares his journal.
March 20
Tough night last night. Intubated a young woman with a history of smoking, who decompensated very fast. There are so many COVID cases in New York City. Please stay in the house for as long as it takes to make this virus stop spreading. The lives of millions of asthmatics, diabetics, smokers, cancer patients and elderly depend on you. At this rate of intubations we're going to run out of ventilators.
Shoutout to my nurses that held it down last night!
March 21
Another night, another intubation for respiratory distress. This time it was an older woman with COVID and multifocal pneumonia.
We only have so many of these isolation rooms in the photo to place patients in order to protect us for high-risk procedures such as intubation, where aerosolization of the virus occurs. The fewest people needed are in the room, usually a senior resident (me), brave nurse (Garleny Olivari), and brave respiratory tech to hook the patient up to the ventilator afterward. Others look on through the glass doors, while we perform critical care. Of course, we would like the personal protective equipment China has but at the moment this is the hand we are dealt.
Once the patient goes up to the ICU, the room is decontaminated by our environmental services team (unsung heroes). The camaraderie in the emergency room is akin to my experience in Iraq as a medic. We laugh, tell jokes and vent about lack of personal protective equipment. Paramedics tell us their stories in the field and correlate that to our experience in the emergency dept. All of us have families that are very concerned about our exposure and we all want to get home safe and through this. In reality, we know that it is a matter of time before we are all infected, but hope that there is not a cumulative effect of the virus due to being exposed to it 12 hours a day, as almost everyone is infected. Till then we continue to provide the best patient care possible.
New York City is now the epicenter of the coronavirus outbreak and major disaster area in the United States with 4,408 cases.
Well, time to get rest for my night shift in 8 hours -- a good friend said that helps with your immune system. I would hate to get a fever and a cough.
March 22
6,211 cases in New York City.
Last night was insane; high volume and high acuity. Sick patients lie on stretchers hooked up to cardiac monitors that beep endlessly throughout the night. At one point I just stood at the nursing station and looked around. I guess this is what the pandemic will look like. There were at least 80 positive coronavirus patients in all 4 bays that required admission. Their age ranged from 20-90s, but each age group was represented equally. I've never seen so many people with pneumonia with rapid progressions. I try to discharge the younger patients with pneumonia, but when I walked them and check vital signs, their oxygen drops down to 85% and heart rate increases to the 140s. They are so fragile. A few of these patients were otherwise healthy, yet still stricken with pneumonia. A lot of patients had to be intubated for respiratory distress -- they crash so quickly.
I'm really happy with the way leadership has responded to the crisis. Last night they deployed an anesthesia intubation team to help us with the vast amount of people being intubated and placed on ventilators. I intubated the prior two nights, so it was great to have others help because aside from coronavirus patients, we still manage other emergencies such as strokes, brain bleeds, seizures, heart attacks, appendicitis, GI bleeds, etc.
There are still a lot of people that come to the emergency room and want coronavirus testing, but we cannot test everyone, because there are not a lot of tests. The coronavirus test is limited for patients being admitted because patients have to be cohorted with patients that have or don't have coronavirus. Our main criteria for admission are shortness of breath and hypoxia, which have to be monitored closely.
What is shortness of breath? Imagine running full speed on a treadmill at an incline of 8 then stopping immediately and trying to speak to someone. That is what respiratory distress from coronavirus does to you. Patients cannot breathe at a rate of 40 times per minute for too long before they tire out.
Young patients usually do well on supplemental oxygen, but a portion of them desaturate on the floor and ultimately end up intubated.
March 24
12,305 cases in New York City and 98 deaths.
"If I get corona, I get corona."
Many of you have seen the video on CBS showing young kids on spring break, oblivious to the reality of the coronavirus, only caring about themselves. While it's true that they might not die from coronavirus, that doesn't mean they will not be hospitalized in critical condition with a severe pneumonia.
In New York City, the coronavirus continues to infect citizens at an alarming rate and we are seeing more and more patients in their 20s and 30s with multifocal pneumonias unable to walk 10 steps without becoming short of breath. I don't know about you, but I consider people between the ages of 20-30 years old to be young. It's shocking to see these patients so deconditioned by the virus.
During my off-time, I follow up on patients that I've admitted from the previous days to see how they are doing. Were they discharged? Did they decompensate? Or did they pass away?
I was taking care of a young woman the other day, otherwise healthy who was stricken by a pneumonia. On shift, I periodically scan the emergency room track board for patients with unstable vital signs. I saw this young woman in her 30s with the chief complaint of fever and a cough. "What brings you to the emergency room?" I asked. She replied, "I've had a fever and a cough for a week." All patients with coronavirus must be walked! Vital signs don't lie. She took 10 steps, before she began desaturating to the 80s prompting her to stop, tripod in the hallway and catch her breath. On follow-up a day later, I saw that she decompensated on the floor and needed to be placed on non-invasive ventilation (NIV) to help her breathe. NIV is like sticking your head out of the car window while driving and taking a deep breath -- the machine helps push air into the lungs. This healthy woman is now in critical condition. It's great that she came to the emergency room when she developed shortness of breath while walking. It's shocking how quickly these patients decompensate over 24 hours. You can even see the changes in their chest x-rays showing patchy opacities everywhere! It's as if they are drowning. (see below)
The coronavirus doesn't care if you're young or old. Younger people likely have better outcomes because they have more pulmonary reserve -- meaning they can compensate for lack of oxygen longer than an older person with lung disease. But to say that young adults are not affected by coronavirus is not true.
Of the young patients requiring admission to the hospital, a portion of them have underlying asthma, which before the coronavirus pandemic was easily treated with nebulizers and steroids. Nebulizers are great because they deliver medication directly to the lungs by a mist, which opens the airway making it easier to breathe. However, nebulizers in patients with coronavirus are really dangerous for healthcare workers, because they create aerosol particles that carry the coronavirus deep into the lungs of healthcare providers, causing pneumonia. As a result, nebulizers are only given in negative pressure rooms, which prevent the virus from being released to other parts of the hospital. It would be great if we had 20-30 negative pressure rooms in the emergency department, but the fact is that we only have a handful.
To address this problem, leadership has worked tirelessly to decompress the emergency room, thereby freeing up our negative pressure rooms for patients that need nebulizers, non-invasive ventilation and ventilators. When a patient becomes hypoxic we first place the patient on nasal cannula. If this is unsuccessful then we try a non-rebreather mask. Patients requiring non-rebreather masks are on their way to getting intubated and placed on a ventilator. Sometimes we can buy time by placing patients on NIV.
12 days ago the COVID-19 Critical Care Group was formed by one of my colleagues, Kabir Rezvankhoo. This group connected doctors from all over the world. Importantly, doctors on the frontlines of the pandemic in Italy, such as Dr. Federica Stella, shared critical information with us about the 5 types of patients they've seen with coronavirus. It was so well written and accurate that I wanted to share it with you.
The 5 Types of COVID-19 Patients
Type 1: Fever +/- respiratory symptoms, negative chest x-ray, no hypoxia at on blood gas (commonly hypocapnic). If no desaturation during the walk test then can be safely discharged home. A large majority of patients fall into this category.
Type 2: Fever and hypoxia OR fever and positive x-ray. These patients MUST be admitted because they can deteriorate very fast.
Type 3: Fever AND hypoxia AND positive x-ray. Usually spO2 >90% can be obtained with high flow oxygen. They need hospitalization in areas with continuous monitoring and NIV.
Type 4: "Early" acute respiratory distress syndrome (ARDS). Patient needs NIV to obtain acceptable levels of oxygen saturation.
Type 5: ARDS. The typical patient is a male, between 35 and 70 years old, pO2 between 30 and 45 at arterial blood gas analysis. If lung US shows only a wet lung can be treated at the beginning with NIV, if lung US shows reduced lung sliding and/or multiple subpleural areas of consolidation early endotracheal intubation is mandatory. They are easy to vent and need high PEEP (usually 15) to obtain acceptable sat levels.
Each day the number of patients in respiratory distress requiring intubation increases, while the number of patients hospitalized on ventilators remains the same. Areas of the hospital are being repurposed to increase hospital beds and decompress the emergency room.
When I was deployed to Iraq with Alpha Surgical Company, I was part of the Shock and Stabilization Team. We received incoming casualties from the battlefield and performed life-saving measures before quickly shipping them out to Baghdad, Germany, and ultimately the United States.
The emergency room in NYC is functioning in much the same way. Unstable patients in respiratory distress are quickly stabilized, then seen by an ICU triage resident, slotted for an ICU bed, then whisked away -- opening negative pressure rooms for the next critical patient requiring intubation.
Every day is different, we never get too high or too low. I'm fortunate to work alongside world-renowned colleagues such as Dr. Craig Spencer, who was New York City's first Ebola patient in 2015.
It's been really great to have everyone's support through this pandemic. In my spare time, I rhyme about medical topics and about the coronavirus, supported by Adam Rosh. Help me spread the word. We need to keep the type 1 patients (fever, sore throat) out of the emergency department, because the surge is underway.