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Thread: COVID and the hospitalization process.
Little housekeeping stuff: I am not speaking for a hospital or organization, just from my experience. I am a critical care nurse practitioner that has been working with COVID patient in critical care since March.
Little housekeeping stuff: I am not speaking for a hospital or organization, just from my experience. I am a critical care nurse practitioner that has been working with COVID patient in critical care since March.
1/: Covid as a novel (read: new) virus has unique characteristics. It's not that corona viruses are new, just this variant. These diseases emerge every so often, usually from areas where there's significant animal/human contact.
2/ Infection occurs via respiratory droplets, and is higher likelihood in tight spaces. Walking is safer than a bus, a bus is safer than an elevator ect.
/3 Once a person is infected, the symptoms won't occur for a few days. This is during a period called 'Viral replication', where the virus is reproducing in the body to a point where the body begins to mount an immunological response- usually fever, chills fatigue.
/4 As a side note, the use of temperature as a screening tool is good, but it almost certainly means the patient is in the viral shedding phase. There are studies that suggest that the characteristic loss of taste/smell is more sensitive as a self screening test.
/5 But it's not sensitive enough to base other decisions on apart from preventative isolation and rapid screening. Lancet article here. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32317-5/fulltext
/6 Once symptoms are determined to be present (Fever, myalgia, fatigue and anosmia) people are advised to contact their local HCP via phone. They will be screened for respiratory distress and if needed, advised to seek care at the ED. The ED will (or should be) advised beforehand
/7 Upon arrive in the ED, the rapid covid screen will be done along with the medical workup. RP-PCR is one of the common tests. This is a lab test where specific chunks of genetic protein are looked for with dye. If you think of it like how the fingerprint tech looks for the
/8 matching points in a print, and that's not far off.
Anyway, once the covid test is done (and hospital tests are fast- usually under an hour) the treatment pathway can begin.
Anyway, once the covid test is done (and hospital tests are fast- usually under an hour) the treatment pathway can begin.
/9 Simultaneously, the ED physician and team is evaluating the patient for signs of respiratory distress. This is where COVID gets tricky. Most people who are having problems breathing LOOK like they're having problems breathing. Increased work, subjective shortness of breath
/10 and low blood oxygen level.
A bit of a side bar on blood oxygenation. We look at something called an Arterial blood gas (ABG) to evaluate how well the lungs are oxygenating the blood; and by default the body. The ratio of O2 to CO2 and relative blood acid and alkali levels
A bit of a side bar on blood oxygenation. We look at something called an Arterial blood gas (ABG) to evaluate how well the lungs are oxygenating the blood; and by default the body. The ratio of O2 to CO2 and relative blood acid and alkali levels
/11 Can tell us a lot about lung function and how sick a person is getting. If the CO2 is high, it builds up in the blood, causing lactic acidosis. Acidemia (the states of an acidic blood) is extremely dangerous and can lead to death by disrupting normal cardiac function.
/12 This is what kills people when ANY interruption of blood flow happens- drowning, choking, ect. It's the buildup of CO2 and lack f new O2 that will end up in death. The body has about 3 minutes of reserve O2 in the blood. After that, there's reversible damage in the 4-6 min
/13 Mark, and irreversible damage (anoxic brain injury) and death between seven and ten minutes. Needless to say, time is of the essence to restore blood flow.
/14 Now that said, covid causes edema in the lung alveoli. For you non medical people, that's the bubble on the ends of your tracheobronchial tree that actually exchanges the O2/CO2. This edema impairs the exchange of the gasses, leading to increased blood CO2 and low O2
/15 For my ease, I'll be referring to the blood O2 as 'PaO2' and the CO2 as PaCO2' which are their medical terms-for brevity.
/16 Now, one of the interesting and clinically puzzling things about COVID was that people didn't LOOK too bad- even when their numbers told us that they were doing terrible. PaCO2 is usually between 35-45, and PAO2 needs tone greater than 70- in a healthy adult.
/17 We were seeing people come in with CO2 in the 55-60 range and PAO2 in the 55-60 range- obviously too high of CO2 and too low of PAO2. This by itself we see for time to time, and the answer is usually to treat reversable causes and intubate if needed.
/18 By reversible causes I mean, drug overdose, COPD exacerbation, asthma flare, whatever was causing them to not breathe- and if they STILL couldn't breathe we'd do it for them via intubation and mechanical ventilation.
/19 So, to get back on track- these patient would be presenting with numbers that *in our experience* told us they were in deep, deep trouble. Early on, we'd treat them like we would anyone else presenting like that. Early, aggressive intubation, and mech ventilation.
/20 But COVID patients don't always *look* like they're in trouble. They can be sitting up talking and interacting with PAO2/PCO2 numbers that would leave most people flat on their backs, and near death. It was extremely puzzling. We also noted that
/21 the people we intubated early didn't do well at all. In fact, the pressure required to preserve their oxygenation seemed to make the lungs worse- which requires more pressure and o2 and that made it worse and eventually they'd get what we call an 'iatrogenic lung injury'
/22 Basically, we beat the hell out of their lungs trying to save them. Now before anyone asks, yes, there's some guidance on this. There's a condition called 'Acute Respiratory Distress Syndrome. (ARDS). We see it all the time from a myriad of things.
/23 There's a ton of research on it, and it's well understood. We have protocols and everything. If you haven't, check them out. (And the Surviving Sepsis Campaign, too- but that's an entire other topic)
http://www.ardsnet.org
http://www.ardsnet.org
/24 So it was apparent pretty early that using the ARDSnet protocols wasn't working- so we did what we had to. Our anesthesia and Pulm Crit attendings threw the book at these people and nothing much seemed to work. It became apparent that some of these people were going to die.
/25 No mater what we did. So we did everything we could think of, and then some. This is where you hear weird stuff like jet ventilation, oscillator ventilation (which sort of worked) pronation (which worked but only if they stayed face down) and off label drug use.
/26 When it came to decision points, there were four primary levels of decision making.
FIRST: First is their primary doc- Is this real, and are they sick enough to send to the ER. Every person sent to the ER needs to be considered- Are they sick enough to use the ED resources
FIRST: First is their primary doc- Is this real, and are they sick enough to send to the ER. Every person sent to the ER needs to be considered- Are they sick enough to use the ED resources
And if they AREN'T sick, will they GET sick there? The Primary Care guys and gals don't get nearly enough love and props for what they've done in this. They're the true tip of the spear on this.
/27 The second is the ED. Are they positive or show enough symptoms to be admitted? If yes, to what level of care? Reasonably, the ED doc needed tosses if the patient A) needed hospitalization or could be sent home and B) if they DID need hospitalization, at what level?
/28, (And by what level I mean general care of critical care.
Generally the decision is made if the physician makes the determination that the patient is unstable or LIKELY TO BECOME unstable, then they need an ICU bed. That said, ICU beds were mighty tight, so patients ended up
Generally the decision is made if the physician makes the determination that the patient is unstable or LIKELY TO BECOME unstable, then they need an ICU bed. That said, ICU beds were mighty tight, so patients ended up
/29 on the wards, and often deteoriated and ended up transferring into the ICU. (We call it 'crashing'..very dramatic, I know).
/30 In academic med centers like mine, the team on the ward is usually a junior internal medicine resident, an NP or senior resident and an attending. The attending would oversee sometimes up to 20 patients and 5-7 providers under him.
/31 I don't know by how much, but their loads increased dramatically, and often the residents had to make decisions that PGY1-s usually don't. Transfer to unit or not? This treatment or that? Hold him and watch or call for help? The PGY 1-2's of last year stepped up and deserve
/32 every accolade they're given. They really stood in the breach and bought us back in the ICU valuable time to do what we needed to do. If you know a 1st or second year resident, shake their hand. They did a hell of a job.
/33 So, back to the patients. Once they were admitted to the floor, we'd usually see them do one of two things: They'd do ok with some careful fluids and supplemental oxygen, and get out in a week or so; OR they'd crash within 24 hours and end up in the unit.
/34 This is the fourth level of decision making. We'd get these people in distress. Oxygen wasn't working, low pressure airway support they could do on the wards wasn't working. (That's CPAP and BIPAP)
/35 Often,they'd arrive to the ICU behind the ball. Low PO2, high CO2 and we didn't have a ton of choice, and they'd end up intubated. Occasionally, and when we understood things better, we'd get them early enough to try some of the alternatives that came up- Helmet CPAP-for one.
/36 As the pandemic went on, we got better at feeling out who needed tubed and who we could push through with airway pressure devices and didn't need a tube. I remember a very tense few nights taking care of a friends mother, and praying to god that could make it
/37 through the night without intubating her, because ifI had, she probably wasn't going to survive. (We pulled it off somehow- she ended up doing ok.) There were a lot of tough decisions and moments I everwon't forget from this time in my life. Decisions I'll always thing about.
38/ Back to the story. So once we figured out that using aggressive steroids seemed to prevent the rampant inflammation and that late intubation/permissive hypercapnea was better and improved the survival rate, the number of people who made with through sever covid improved
B39/ y August/September, the mortality fell to close nowhere it is now and has held relatively steady.
/40 The purpose thread of this is to give a look behind the curtain as it were. Not every young person who gets it does ok- as a military college of mine can attest, and not every older person dies, as my patients can attest.
/41 It is an extremely dangerous bug, and was new enough that our typical treatments didn't work. The influx of patients put tremendous strain on our health system, and our providers (including myself).
/42 However, the American medical system is more resilient and has more flexibility in it than most suspect, and our healthcare workers stood in the breach and held the line-saving millions of lives.
/43 There will be long term effects on those us who were there, including psychological casualties..myself included. I ended up having to take a knee. I hate admitting it, but that's what officers and leaders do- we lead by example.
/44 I got in trouble by trying to punch through. Don't. Know the signs, and if you need total a knee and drink some water as we say in the Army, do. You may inspire someone else to do the same. Someone will pick up the flag and carry it forward. They always do.
/45 Anyway; as always I'm here to answer questions or discuss the overall processes of care of covid patients. Hope you found this thread informative, and take care of yourselves, your family and your team.
Salty, out.
Salty, out.
