04-April-2020
The Full COVID-19 Experience:
COVID-19 patients are very different and many require invasive ventilation, probably the most important initial reason is severe respiratory distress.
The worst symptom these folks are experiencing is severe respiratory distress.
They are extremely hard at work, struggling for their next breath. They
also are likely to be only semi-conscious at best, because not enough oxygen
is getting to the brain. And they can deteriorate from feeling like they
have a bad flu to this state extremely rapidly, in 1-2 hours.
Try to imagine what
it would feel like to go underwater and hold your breath for four
minutes. At the moment when you absolutely have to get a breath, you
are forcibly held underwater and cannot come up for air. Now add in
incoherence. You are literally drowning. You are physically struggling
with all your might for your next breath. Your instinct will be rip off
the oxygen mask. Someone will forcibly hold the oxygen mask on your
face to keep you from ripping it off. There will be a physical
struggle.
Emergency intubations are violent, dramatic, dirty
events. There is a very real possibility of you generating large amounts
of spray, exposing the healthcare team to large amounts of virus.
Everyone is getting hosed with highly concentrated, infectious liquid.
You will be restrained. You will be sedated. Otherwise; you will just lapse
into a coma. In the case of COVID-19, this is all made worse by an extremely
high fever ... 103F+ and extreme tiredness. Your poor body is working so
hard fighting the virus. Your immune system is on overdrive and it may
start a cytokine storm (overreaction) where your immune system begins to
attack you. You are gasping for your next breath. You will eventually be
too tired to keep fighting.
... So tired that the flapper valve at
the top of your airway can no longer protect your airway from stomach
acid. As your esophageal muscles relax, stomach acid will slosh
upwards, into the airway and into your lungs. You will begin to
literally drown in your own stomach acid.
Given this colorful new understanding of invasive ventilation:
...
An endotracheal tube (ET) will be inserted into your airway. It has an
inflatable bladder that wraps around the last third of the tube. Once
inflated, it then creates a seal to protect the lungs from stomach acid.
This
is already going on hundreds of times everyday. It will become even
more frequent in the next few weeks. It is so hard to imagine the scale
of the mass suffering. Your chances of surviving ventilation depend a
lot on your age, your sex and your prior medical history. Patients under
50 seem to have about a 75% chance of surviving ventilation. Seniors
with pre-existing conditions have a 10% chance of surviving ventilation.
These
events are 180 degrees against my training and instincts as a physician
... to standby and do nothing as someone perishes in front of me in an
emergency. It is so very different than watching a cancer patient slowly
decline and pass gently at the end of a long struggle.
This is
wartime tent medicine. There are too few resources right now. The
medical teams face extreme personal hazard. Performing a resuscitation
on someone who has basically no chance of surviving, but meanwhile will
consume precious resources that might be better used to save someone
else, is my nightmarish ethical dilemma of standing there and watching
the person die. This is happening now. A thousand+ times just today.
The emotional toll on the medical teams is probably unimaginable for you.
Healthcare workers have been living this hell for weeks. Witnessing it
changes us.
It will get worse and it will last months. Many
healthcare workers will need serious psychotherapy to emotionally cope
with the endless horrors that we witness everyday.
Jamie L. MacDougall, MD, FAAD
Clinical Professor of Medicine and Dermatology
Keck+USC School of Medicine