Thoughts and Reflections of Dr. Hesham A. Hassaballa: Critical Care specialist, physician leader and author.
Asa critical care medicine specialist, I am used to seeing the sickest of the sick. I am used to seeing patients with respiratory failure. I am used to seeing patients in shock. I am used to seeing patients gasping for air, with dangerously low oxygen levels. I am used to seeing patients in kidney failure. Never, however, have I seen patients as sick as those with COVID-19.
Frightening Hypoxemia (low oxygen levels)
First of all, almost all of these patients present with such frighteningly low oxygen levels. I am also a lung specialist, and I am accustomed to seeing patients with low oxygen levels. Normal oxygen levels are anything above 90%, and I have seen patients come with levels as low as the 70s. Rarely, however, do I see patients presenting to our hospital with oxygen levels in the 50s and even lower. What’s more perplexing, sometimes these patients have oxygen levels that low and have absolutely no symptoms. I have never seen that before in my career as either a lung or critical care specialist.
Frighteningly Quick Deterioration
Secondly, when these patients with COVID-19 crash, they crash very quickly and crash very hard. Each patient is a ticking time-bomb, and they could be doing fine for several hours, and then — suddenly — they are gasping for air with plummeting oxygen levels and a plummeting blood pressure. One patient — a sweet woman in her 60s — was holding her own for several days. She was still very sick, but she was holding her own. All of the sudden, she became severely short of breath and was gasping for air. Despite getting multiple interventions, including going on a ventilator, she suffered cardiac arrest and died. We were all devastated.
As a critical care specialist, I am used to seeing the sickest of the sick. Never, however, have I seen patients as sick as those with COVID-19
What I’ve Learned Taking Care Of These Patients
This disease is unlike anything we have ever seen. COVID-19 has confounded critical care specialists the world over. It has upended decades of critical care gospel, and it has left very smart clinicians, scientists, researchers and regular bedside doctors — like me — scratching their heads. Each patient acts differently to the virus, and we need to treat each patient differently. What works for one, may not work for another, and this is different than what we have been used to. This is ultimately a good thing, and it will make all of us better clinicians in the end.
Not every patient needs a ventilator right away. Early on, clinicians taking care patients with COVID-19 were recommending “early intubation,” which means placing patients on a ventilator if conventional oxygen treatment did not work. They were not wrong. At the same time, we have learned that some patients can avoid going on a ventilator if we can treat them with high amounts of oxygen with high flow rates. We have had great success using this treatment modality in keeping multiple patients from requiring a ventilator. In addition, we have found that, if patients can lie on their stomach themselves, this has helped many of them avoid having to go on a ventilator. A lot of research is being conducted on this treatment, but we have found good success with it in our patients. While a ventilator can be life-saving, and I would not hesitate to use it on any patient who can’t breathe, it can also damage the lungs, and it is important to try everything in our arsenal first before we place someone on a ventilator. Indeed, multiple guidelines have now come out saying the same thing.
We need to aggressively correct any dehydration. It has long been a teaching that the patients with the severe lung disease called ARDS, or Acute Respiratory Distress Syndrome, need to get as little fluids as possible. This is appropriate, because too much fluid in the body can cause the lungs to fill up with fluids and make the respiratory failure worse. At the same time, patients with COVID-19 typically come into the hospital and ICU very dehydrated. They have had fevers for several days, which causes dehydration itself, and they are not really eating and drinking (because they are sick). So, if we do not give them fluids, we are setting them up for kidney failure. As a result, we have been more liberal with fluids — all while not giving too much — and we have been very successful in preventing kidney failure.
We REALLY need to discuss goals of care with all patients admitted with COVID-19. This disease can kill. It can leave you needing a ventilator for a very long time, if not forever. Do you want this? Yes, of course, we try to “do everything” for all of our patients. The thing is, “doing everything” may not be consistent with someone’s wishes and values. Do you want to live the rest of your days on a ventilator? Do you want to die on a ventilator? Do you want to die with the team pounding on your chest? Whatever the answers are to those important questions need to be communicated to the doctors taking care of patients with COVID, BEFORE they go into respiratory failure. Having me, as a critical care medicine specialist, ask these questions is too late. It needs to be done sooner.
Like I said, I have never seen anything like this before in my career. This pandemic will have long-standing consequences on the medical profession, hospitals, the healthcare system, and society at large. I pray they are not all negative, and that — when this is all over…some day — we will all be better and stronger than we were before.