Image by Anh Nguyễn Duy from Pixabay

Coronavirus

What I Learned This Week Caring for Hospitalized Patients on the Covid-19 Unit

Fifty-eight encounters with patients suffering from the novel coronavirus must have taught me something, right?

As you probably know, the prevalence of the novel coronavirus has fluctuated by state and region across the US. Many areas that were hotspots initially eventually saw a decline in cases while locations that seemed to be spared at first saw a rise in numbers later. Where I work as a hospitalist physician in Billings, Montana fits this latter category. Billings is the most populous city in Montana which is sort of like being the fastest snail or tallest mite. Our state was quick to follow the trend of shelter in place orders initiated in March and saw relatively few cases until June. Hospitalizations picked up in July and actually reached their highest so far, at least for my hospital, in the first week of August.

While I have managed hospitalized patients with Covid-19 on a regular basis since March, it had been a few weeks since I was last assigned to our dedicated Covid-19 unit. So this past week ending on August 14th marked the period of time I cared for most patients suffering from Covid-19 in such a short timeframe.

With this story I hope to paint a picture for those who are curious to know more about the facts — the latest treatments and outcomes we are seeing — as well as the feelings — the general mood and environment on a hospital’s Covid unit. Keep in mind, I’m talking about one week in one hospital, and, of course, my experience doesn’t necessarily translate to what is seen in other facilities across the country. In addition, I have to be careful not to provide details that would allow individual patients to be identified. So, I apologize if parts of the story seem cryptic. First, let’s take a look at the data.

Demographics

• The average age was 57 with 63% being male.
• By race, 53% were White, 42% Native American, and 5% Latinx.
• The average body mass index (BMI) was 36 with an average of 45 for patients under age 60 (a BMI greater than 30 is considered obese).
• Five percent had a BMI of less than 18.5 which is considered underweight.
• None of the patients had a BMI in the normal range of 18.5 to 25.
• The majority of patients were hospitalized due to Covid-19. However, a few were hospitalized for other reasons but happened to test positive for the virus, SARS-CoV-2.

Patients with chronic disease

• High blood pressure: 63%
• Diabetes: 37%
• Chronic lung disease: 32%

Interventions

• To assist with breathing, all patients were provided with a device called an incentive spirometer designed to keep the small air passages in the lungs open.
• Patients were also encouraged to change positions regularly including lying face down in the prone position.
• Eighty-nine percent required some form of supplemental oxygen.
• About one-third of patients received oxygen delivered by a device called a high-flow nasal cannula.
• Another third required positive pressure ventilation with a facemask (either CPAP or BiPAP).

None of the patients on the floor this week needed to be intubated and started on mechanical ventilation, and as a result, none were transferred from the hospital floor to the ICU. A quick note on intubation:

Early in the pandemic, non-invasive methods of delivering oxygen that produce aerosols, like the high-flow cannula and positive pressure devices mentioned above, were discouraged in favor of jumping straight to intubation because of concerns related to a viral transmission. Now that we have more experience and better infection control protocols in place, this no longer happens.

I still read or hear comments sometimes about how intubation is associated with poor outcomes, and my response is, of course, it is! Intubation is essentially a last resort. By the time a patient is that ill from respiratory disease like Covid-19, the only choice a provider may have is to either watch a patient expire right there or intubate. Fortunately, the group of patients this week was spared of that need at least for the time being.

Medical treatment

• Eighty-four percent were treated with the steroid, dexamethasone, which has been shown to reduce the incidence of death in hospitalized patients receiving oxygen without mechanical ventilation from 26% to 23%. Patients on dexamethasone were also given a medication to suppress stomach acid since steroids can weaken the lining of the stomach increasing the risk of stomach ulcers and gastrointestinal bleeding particularly for patients on blood thinners (see below).
• Twenty-one percent received the anti-viral, remdesivir, which has been shown to reduce the average recovery time from 15 to 11 days. Remdesivir is thought to be more effective early in the course of Covid-19, it is expensive, and supply is limited.
• Forty-two percent received convalescent plasma as part of an ongoing research study.
• All of the patients received anticoagulation (i.e. blood thinners) either at a dose intended to prevent blood clots or at a higher dose designed to treat a blood clot.
• None of the patients this week were diagnosed with a blood clot. Even still, 16% received the higher treatment dose anticoagulation for at least a portion of their stay because the suspicion of a clot was high and they were too ill to undergo a CT scan to rule out a clot in the lungs at the time.
• Forty-seven percent received the diuretic, furosemide, also known as Lasix, in an attempt to remove excess fluid from the lungs.

Outcomes

• Fifty-three percent were discharged home.
• Twenty-one percent were able to move to a different floor of the hospital because they were far enough out from the start of their illness that they were no longer considered contagious. The majority of these patients had recovered fully from Covid-19 but remained hospitalized because of other medical or surgical issues.
• Thankfully, all of the patients this week have survived.

All the feels

To be honest, I’m not the best at this part, but I think it’s important to comment on the overall vibe at the hospital and the Covid unit. I was struck by how appreciative the patients are. They went out of their way to share with me about the positive experiences they were having with various members of the staff.

I did not get the sense that the staff feared for their safety. Our facility has an adequate supply of personal protective equipment including masks, gowns, face shields, goggles, and gloves. There is also an adequate number of negative pressure rooms. Our hospitalist group has made assignments in a way that minimizes exposure to providers who are older or at high risk for other reasons. Seeing the needs of other hospitals that were hit hard early on showed us how to prepare. It is the brave healthcare workers who experienced the brunt of the pandemic at its outset that we can thank for paving the way.

Despite a lot of positivity, there were also times that the grim reality of this deadly virus was front and center. I noticed that as infections started to progress, the patients’ numbers (e.g. their oxygen levels or other vital signs) often declined before they actually felt worse. I would see concerning numbers, check on a patient, and find them sitting up eating or watching television telling me they were doing well. This phenomenon has been described before as ‘happy hypoxia’. Then by the next day, or even over the next few hours, patients would develop more labored breathing, fatigue, and sometimes confusion.

I encountered those facing the fear of what might happen next, wondering if indeed they were going to need intubation and transfer to the ICU. I held discussions with patients and loved ones about their goals of care. It is essential that patients know their decisions are supported whether they want to continue fighting Covid-19 with every available intervention, pivot to a comfort-based approach, or something in-between. Trying to communicate in a manner that is reassuring, but also upfront and honest is no small task when speaking to a patient who feels like they’re drowning. Moreover, a loud machine connected to a large breathing tube in the nose or a facemask limits the ability of two people to connect and understand one another. This is when communication with other caretakers becomes even more important.

I was encouraged by the attentiveness the nursing staff and respiratory therapists showed to their patients as well as the insightful and timely ways they communicated with me particularly when important changes occurred. Managing a patient in the hospital involves a diverse team with a variety of skills including subspecialty physicians, dietitians, pharmacists, administrators, social workers, phlebotomists, lab and radiology technicians, other therapists, and staff from the kitchen and environmental services. Knowing that all these individuals are using their unique talents to bring about healing for a patient is especially uplifting in the midst of the pandemic.

I am most inspired by the bravery displayed by patients with Covid-19. Whether confronting difficult decisions, fighting exhaustion, or simply trying to navigate their way to the bathroom without tripping on a line or tube, these patients have earned my admiration and respect. It is a privilege to be their doctor.