My friends, it starts.
More and more patients present to emergency departments across the country with viral respiratory syndromes, and now that testing is ramping up, confirmed cases double about every 2.5 days in the US, and deaths about every 3, consistent with the worst international experience. Coronavirus pneumonia patients can crash quickly, requiring ventilator support within a day or two of getting admitted to the hospital.
Hospital ventilators are increasingly occupied by patients who will require them for weeks, not days like with typical pneumonia patients. We don’t have enough ventilators for this rapidly increasing and prolonged need. And these patients remain infectious for the duration of their illness—care teams’ exposure risk escalates with each patient admitted to the unit. Places like Yale and Vanderbilt have already created overflow wards to care for the flood of patients that New York is already seeing.
Doctors and nurses across the country lack the most basic personal protective equipment (PPE). Medical teams in China, Italy, and Iran wear hazmat suits like we saw during the Ebola outbreak in 2014. In the US, we don’t even have enough masks and gowns. We face a raging wildfire armed with squirt guns. Our PPE will run out in days unless supplies are replenished now. My colleagues and I are on the phone with our dentists, contractors, and even our patients themselves, looking for N95 masks, disposable gloves and the like. This in the country that thinks it’s the best at everything.
I wrote last weekend about my friends on the ‘front lines’, my emergency, hospitalist, and intensivist colleagues. They are the most qualified to care for the sickest patients. Their exposure risk is the highest. In China and Italy, and now in the US, these physicians are the ones falling critically ill and dying. New grads have already been recruited to stem the tide in Italy. Retired physicians have returned to bays and wards in New York.
My primary care colleagues and I have been asked whether we will volunteer to work in these high risk areas, for which we have neither the training nor the expertise anymore. I have not managed ventilated patients in almost 20 years.
If I am called up, I will answer. But I’m scared.
Both of my kids have asthma. Though children appear largely spared from coronavirus death, hundreds of children were admitted with severe disease in China. And my kids’ risk is likely higher than many of their peers’ because my husband and I are both physicians. We work at different hospitals. So each of us has a wide and unique exposure circle, both of which we bring home to overlap on our kids every day we see patients. By the time I’m needed in the high intensity care areas, the situation will be truly catastrophic, and the risk to my family and me will be even greater. Hubs and I have already agreed that should that happen, we should probably not live at home. He and I will try to avoid having to answer that call at the same time.
There will be much more death and suffering before this ends. And the end is still very far off.
You can help.
I leave you with a personal story that I read tonight. God bless Dr. Gilman.
https://www.facebook.com/plugins/post.php?href=https%3A%2F%2Fwww.facebook.com%2Fcleavon.gilman%2Fposts%2F10157045636977393&width=500“>From Dr. Cleavon Gilman, emergency physician in New York City, March 20, 2020:
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 virus 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 pneumonias with rapid progressions. I try to discharge the younger patients with pneumonias, but when I walked them and check vital signs, their oxygen drops down to 85% and heartrate 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 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.
I was fortunate to spend the night with our ED director Dr. Betty Chang, and residents Taylor Walsh and Marc Tarsillo (pictured below). Till next time.