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