This disease is appalling. I fear my patients, my colleagues, my family and my health. Don’t stop trying to ‘smooth the curve’.
I am ICU physician in Honolulu, Hawaii, and my wife is apulaisvaltion epidemiologist. She cares for public health and I do clinical medicine. Needless to say, he hasn’t had a day off in the last six weeks. But now the coronavirus has entered the intensive care unit.
The transition from controlling the disease to treating the infected one by one is opening the eyes and breaking the heart. What do you do when there are far more sick patients than you can treat?
This pandemic is like no other one of us has ever experienced. On a personal level, I only need to limit the use of masks to one – all day. In the past, I would have used the mask only on certain patients and would have changed it every time I went to the new patient room, just to be careful. Similarly, if I wear a face shield, I must wipe it down and reuse as much as possible.
When treating COVID-19 patients, I move to the hospital scrubs upon my arrival at the hospital. Before I leave, I change these scrubs, shower and wipe my glass, phone, shoes, stethoscope and work bag wipes in the hope that I will not accidentally bring home the disease and expose my children (4 years and 4 years) 6 who would probably be okay) or my wife’s parents (who are over 70 and certainly would not).
The risks that keep us awake at night
Everyone in the front line is afraid of coughing when they are fearing; and whenever we feel a little scratched throat or sneeze, we think, “Is this? Have I finally got this? Have I distributed it to my patients or other health professionals or my family? Does that mean I have to stay home for the next two weeks when I need it most? “
This angst keeps me (and many others) at night.
We fear the disease itself, both for ourselves and our loved ones. I have taken care of hundreds of patients suffering from respiratory difficulties, such as we see COVID-19. If patients are conscious, they may feel drowned and force them to breathe with minimal air. This almost always involves inducing coma and sometimes using medication to chemically paralyze. They demand a breathing tube that is painful and uncomfortable and stops them from speaking.
At COVID-19, we have found that patients’ stomach turning is particularly effective, so once or twice a day a group of nurses, respiratory therapists and doctors find ways to turn these coma patients back and forth. We feed patients through oral or nasal tubes and infuse drugs to optimize the support of all organs of the patient’s body.
It is an honor to treat critically ill patients, but it is also appalling. What if we make a mistake that costs someone their lives or causes irreparable damage? Can we prevent them from dying, and at what point do we recognize that, despite our best efforts, we are losing the battle? Marking the skill of caring for these patients means that we have a responsibility to do our best, but also to realize that our best may not be good enough. This can be difficult to swallow the pill.
We are also concerned about how we will cope with the wave of critically ill COVID-19 patients we are expecting. According to one model, the number of patients expected to be ill exceeds the number of hospital beds in Hawaii between April 20 and May 10. This would have devastating consequences.
Hospitals must ensure that they have adequate personal protective equipment to ensure the safety of staff; according to most accounts we have about two weeks worth of supplies. In addition, we can clear the entire supply of respiratory equipment in Hawaii, and many of them are unlikely to arrive in several weeks.
Preparing for Limited Resources
Hospitals are also considering the role of every healthcare provider. This means that outpatient first aid nurses can be recruited to work in the hospital, and physicians who usually treat non-critically ill hospital patients (nurses) are needed in the ICU.
Intensivists (like myself) are usually heavily involved in all aspects of ICU COVID patient care, including performing procedures, managing respiratory equipment, and talking to families. However, every hospital has a limited number of ICU doctors, and it is simply impossible to be one of them in each bed all the time. Ironically, I may have the least contact with patients, as the responsibility is leading dozens of critically ill nurses.
Finally, hospitals need to develop protocols to rationalize their limited resources. If there are 10 patients who need a ventilator at a time and there are only five ventilators available, there must be a sensible process to literally decide who lives and who dies. I can assure you, no doctor will ever want to face this decision, but we may have no choice.
Perhaps the worst part of preparing for the next few weeks is simply that this is a brand new illness. We have extensive experience in treating patients with acute respiratory failure, but COVID-19 seems to have a number of unique features: It is more serious, lasts longer, is unpredictable, can affect the heart, and most importantly, not a cure.
The virus is still spreading and my wife is still working seven days a week. But now it’s my turn to be shocked. I’m scared of my patients, my colleagues, my family and for my physical and mental health. Do not relax in your efforts to “smooth the curve”. They give us the best chance of treating every sick person.
Philip A. Verhoef is a physician and associate professor of intensive care at the John A. Burns School of Medicine, Honolulu, University of Hawaii. Follow her on Twitter: @DrPhilipVerhoef