On the Frontlines: “These Patients are Alone”

An internal medicine doctor talks about Covid-19 diagnoses, treatments, and closed doors

Doctors treating coronavirus patients often have to check on them through closed doors /Courtesy: Francisco Àvia_Hospital Clínic de Barcelona

The battle against coronavirus rages on. There are more than 117,000 cases in New York City as of April 16. But social distancing and other preventative policies have helped slow down the spread of the virus, according to Gov. Andrew Cuomo. Hospitalizations in the state are on the decline and intensive care unit cases have also dropped in New York, said the governor.

Still, internal medicine doctors, like Dr. Francesco Laterza, are managing care for thousands of the sickest coronavirus patients after they have been admitted. Dr. Laterza, a New Jersey native who now works at Einstein Health in Philadelphia, talked to New York City Lens about what diagnosing, treating, and caring for COVID-19 patients is like during this pandemic.

What are some of the changes the hospital has made to treat COVID-19 patients?

From the very, very start, my program director was on the phone with people here, in Seattle, New York, LA, and asked what they were doing, asked them what worked, and what didn’t. He was planning from when [the virus] hit Seattle.

Essentially, keep [doctors] as healthy as possible.

In the beginning, a lot of residents were getting sick. So, whether it’s just a cold, we have to send them home. Typically, we just work through it. A year ago, if I had a cough, I just wore a surgical mask and went to work. Now we have to stay home and that is kind of stretching us thin.

What are the challenges you have faced as a doctor in this pandemic?

The number of patients we have is nothing like New York, we haven’t had that big surge of all patients all at once, even though we’re only two hours from New York.

What makes it difficult is almost every single person, 90 percent of [ICU patients] are on a ventilator, which we have never seen before. That’s what takes the time. That’s what makes it so complicated.

If people are so sick, we have to spend 30, 40 minutes on them trying to figure out what to do. I was taking care of eight ventilated patients, where you’re trying to make these decisions quickly. You have to be very vigilant and constantly there. I’ve taken care of eight before, but it’s more so the complexity.

The biggest change for sure was the separation, literally a wall between us. In the ICU, we try to keep the doors open so we can actually react faster. Now, it’s weird seeing so many closed doors. We try to minimize the amount of times we go in and out of the room to conserve PPE (personal protective equipment).

I’m looking at my patients through a window, instead of going up to them. I’m peeking through a window, kind of like squinting, to see what the rates are. If it’s  a routine in the morning, we send the most senior person into the room to minimize PPE. If they’re only getting sicker, then we go in. We don’t hesitate for that.

Can you take us through what is involved in diagnosing a COVID-19 patient?

To get a clue if someone is positive, we look at a chest x-ray.

This is not like the flu. Typically, pneumonia hits one specific lung or one part of the lung, not everywhere. There’s a little spot of white stuff that we see, it’s kind of like a circle. We call it a consolidation.

For coronavirus, that whiteness is not in one focal spot, it’s throughout the entire lung. So almost all of the lung can be taken up. And as the virus gets worse, more and more of the lung gets involved. When people get sicker and sicker, the inflammation worsens. Your lungs can’t work that well. And you don’t get oxygen.

We’ll see a patient who’s sitting on the floor breathing without any oxygen support, and then suddenly, they can’t breathe and we end up having to intubate them or put them on a ventilator.

What happens when someone doesn’t get enough oxygen?

Ideally, [the concentration of oxygen] would be the best above 96 percent. I’ve seen in the 80s, 70s, I’ve even seen 50 percent – that’s when their heart stops beating. If someone’s breathing very heavily, very rapidly, they’re going to get tired. And then the body is going to stop because you don’t have the energy and the muscle strength to breathe.

You need oxygen to live, to form energy in our body. If you don’t have energy, your body can’t have any proper metabolism and typical chemical reactions that happen to keep us alive – we can’t do.

Parts of our body will start shutting down, the acid levels in our body start to rise. And as the acid levels get higher, our proteins and our enzymes that live in our blood start to stop working, and that’s when everything goes downhill.

How are doctors treating COVID-19 patients?

For mild cases, essentially the ones who can still breathe, the majority of care is supportive. Just like we would treat any other viral illness. We provide oxygen, we keep their fevers controlled. Make sure they’re hydrated, they’re eating if they can control their nausea.

Severely ill patients are intubated on a ventilator in the ICU. We are trying to treat these patients similar to the way we treat very severe [acute respiratory distress syndrome] patients, but it’s not as successful as it was when we treat ARDS in the past. Patients are staying on the ventilator longer than we expect and longer than they have in the past.

If they can’t properly get oxygen, what happens is, we can go one of two ways. One would be we proceed toward something called ECMO (extracorporeal membrane oxygenation). You hook someone up to a machine that acts as a lung for them and it allows oxygen to be given to their body. Not everyone qualifies for it. It’s very, very intense and very stressful on the body, but it saves lives. If someone does not qualify for ECMO, we do our best to kind of manage them the way we are.

Do you use hydroxychloroquine to treat patients?

We do use hydroxychloroquine. We regulate it and we need a permission from our infectious disease specialist on whether these patients qualify for the use.

I can’t say for sure how much it works, the design of data on it – it seems to be doing a good job in some patients and for other patients it doesn’t.

The concern would be people who have mild symptoms are not that sick, so is it worth giving it to them? Every medication comes with a side effect that you have to weigh the pros and cons of before recommending it to someone.

I’ve mostly seen [hydroxychloroquine] used just in the sicker patients. Honestly, if you know the person or the patient is kind of moving in the wrong direction, how could it hurt if they’re already on the way to dying?

What are the signs a patient is getting worse?

Everyone’s different, but multi-organ failure is really the clue that patients are not getting better.

The downward spiral we see is that their blood pressure starts sinking and we have to keep adding more and more medications to keep the blood pressure up. The acid levels in their bodies start increasing, and when their kidneys start to fail, that is the big one. And a lot of some people even have heart attacks, some of them have heart failure, they get a blood clot.

It’s a lot of different things. That’s why this virus is so hard.

What’s the hardest part about this pandemic for you as a doctor?

We try to involve family as much as possible and we can’t do that here. It’s very hard to tell someone over the phone. your loved one is dying. These conversations about withdrawal of care, an end of life situations are always important and better in person than over the phone.

And the saddest part is that these patients are alone. So, families aren’t allowed to visit unless they’re about to die. And unfortunately,[in those instances] it’s through a window. They can’t actually go up to their mom or their dad or their son or daughter.

Patients are alone. They are intubated, they are sedated, and even if they wake up a bit, no one they know or recognize is around them. It’s a very distressing situation for them, for families, and it is heartbreaking for us to see.

For the ones who die, they’re not surrounded by the people they love.

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