It’s not supposed to happen like this (June 21, 2020)


 

Hospital Update (Joe Dang – IronMen):

It’s not supposed to happen like this. A month ago, our hospitalized COVID patient census was in decline. The models all predicted that the summer heat and humidity would adversely affect the transmission of the virus leading to a decline in new cases or perhaps even lead to a disappearance of the infection for several months. The models were all very wrong. They didn’t take into account human nature. People are behaving like the disease is gone. They act as if no one is getting very sick or dying anymore of COVID. Some think that only elderly people get sick and die of COVID. They are gravely mistaken.

When I go into a store, I don’t see people wearing masks. There is a significant community spread of the virus in Houston. I don’t blame just the George Floyd related protests. I don’t think people will listen to the government if they try to shut down life again. People are tired of being isolated and don’t trust the government whose projections were all wrong. People aren’t afraid of the virus anymore. At least, they don’t seem to act afraid anymore. They meet and walk shoulder to shoulder like the world before COVID.

The Memorial Hermann Hospital system COVID census comprised of more than ten hospitals has doubled since last month and continues to rise throughout the greater Houston area, including my local hospital Memorial Hermann Southwest which serves a low-income population of seniors and immigrants mostly from south of the Texas border and Asia. Despite sending patients home daily– sometimes with oxygen tanks—many more come into the hospital emergency room gasping for air.

A few months ago, COVID ravaged the Houston nursing homes and skilled nursing facilities killing many elderly people. Now, we still see elderly people who live at home with their younger children, but most of our patients are working-age ranging from 20 to 60 years olds. The non-COVID hospital patients are back with their wide variety of illnesses. It makes for a crowded hospital these days which one would think would be economically advantageous. However, caring for COVID is expensive. Patients are delaying more profitable elective surgeries and procedures that hospitals need for financial security. As a result, Memorial Hermann has cut salaries and retirement benefits with job layoffs looming just around the corner. Hospital employee morale seems low and people are tired of the extra work with diminished financial rewards and increased risk of getting sick. But the COVID patients keep coming.

Three months after the initial widespread outbreak of COVID in the US, we certainly have more tools and diagnostic tests available. Tests for COVID are readily available with fast turnaround times and personal protective equipment does not seem to be in shortage. Today, I was able to retrieve the same reused and sterilized N95 mask I wore last month that I had labeled with my name. At least I know who put the sweat stains present on the recycled, sterilized mask. We can thank China and its hoarding of Personal Protective Equipment for turning an inexpensive, designed to be the disposable lifesaving tool that used to cost less than one dollar into a precious commodity that needs to be cleaned and recycled until it disintegrates.

We now have a new antiviral drug called Remdesivir, which has been shown to help clear the virus. A few days ago, a British study confirmed that giving steroids to patients with COVID needing oxygen improved survival—steroid use to treat advanced COIVD disease has been a widespread universal practice for months. Now that many people have had the infection, the survivors are donating convalescent plasma which contains antibodies to fight the infection in newly infected patients receiving their generous donation. I wish I could say all these changes are helping to improve survival. It has not.

The mortality of this disease has not changed significantly in the Memorial Hermann System in the last three months. Roughly, one out of every ten patients who are hospitalized does not leave alive. It’s not just the elderly that are dying. Many young, working-age adults who should have decades to live have died of COVID. I have reviewed the charts of every person who died of COVID at my hospital looking for information that could help future patients—unfortunately, it’s quite many. I can parrot the phrase I heard New York Governor Andrew Cuomo stay months ago. Everything that could have been done to save these patients was done. They still died.

Most of the patients who died in the past few weeks have received all available treatments including steroids, convalescent plasma, and Remdesivir. They died free of detectable virus. Convalescent plasma and Remdesivir work well at eliminating the virus. Unfortunately, with advanced stages of COVID illness, an immune response called the cytokine storm develops destroying the lungs and other vital tissues creating a point of no return. Cytokines should be helpful. They act as messengers for the immune system to wake it up to destroy foreign invaders like harmful bacteria and viruses. Unfortunately, in advanced stages of this disease, the cytokines act like artillery spotters that call in airstrikes of napalm and cluster bombs on the friendly base (our lungs) which has been infiltrated by the virus. The medical and scientific community has yet to discover an effective way to dampen the cytokine storm leads to the eventual death of many patients with advanced disease.

Critics of government policies to mitigate the spread of the virus say that over eighty percent of the deaths from COVID in the US have occurred in seniors who did not have long to live. The facts are that 99 percent of patients who die of COVID have one or more significant medical condition such as immunosuppression, hypertension, diabetes, obesity, and coronary artery disease. They are labeled “underlying conditions”.

Since when did being a little heavy or having elevated blood pressure or even an elevated sugar level result in a death sentence! Peering into a crowd of Americans over the age of 40, it may be a little difficult to spot the thin people without any chronic medical conditions.

At my hospital, the mortality rate of COVID in adults aged 40-65 is nearly the same as the mortality rate of older seniors. Perhaps this phenomenon is related to the predominance of patients with Hispanic, African American, and Asian ancestry. It may be related to a deficiency of vitamin D, which is well known to play a vital role in immunity found in people with dark skin.

My advice to any adult trying to avoid getting sick or dying from COVID is to take vitamin D supplements, get adequate sleep and exercise, and to optimize all chronic medical conditions like diabetes and hypertension. Losing excess weight is more important today than ever before in the last hundred years of human history.

My hospital is scrambling to create new negative pressure rooms to handle the new burden of COVID patients. There is evidence that ventilators can cause lung injury and lead to poor outcomes in advanced COVID disease. Doctors try to maximize non-invasive oxygen delivery systems like Vapotherm or high flow oxygen systems.  Vapotherm causes the virus to aerosolize in a room increasing the risk to those taking care of critically COVID patients… thus negative pressure rooms are our new precious resource.

Yesterday, we ran out of negative pressure rooms temporarily. I still get chills down my spine when I remember hearing the poor man lying in bed on his belly with a nonrebreather mask crying, “someone please help me, I can’t breathe!”. I rarely raise my voice or lose my temper, but I was probably a little harsh to charge nurse and the critical care specialist demanding a negative pressure room so I could start this patient on Vapotherm. “Place two patients in negative pressure rooms if you need too. This man is suffocating on the medical floor. He needs vapotherm soon, or you will have to intubate him on the floor exposing everyone to risk!”

Naturally, taking care of COVID patients at my hospital is not something I look forward to doing. Sometimes I have difficulty connecting with these patients whose lives are less fortunate than mine. Most don’t speak English. We communicate through an interpreter using speakerphone or video conferencing through a tiny IPAD. As you can imagine, it’s very difficult to hear my voice muffled by an N95 mask, and interpreting gestures and body language is nearly impossible through the layers of protective gear.

Last month ago I took care of a very sick COVID patient in his forties who spent over a month on the ventilator in the intensive care unit. He was an alcoholic with diabetes who looked like he didn’t take very good care of himself. He looked like a drunk I have seen countless times before in my medical career passed out from intoxication. However, unlike most alcoholics that act normal when they sobered up, he remained confused, deranged, and combative.

During most of his hospital stay, he was in restraints, heavily medicated and sedated due to his agitated and uncooperative behavior. I assumed his care when he left the ICU. He was so weak that he could barely form words with his lips. One of his clever nurses discovered that if she gave him commands in Spanish he would obey her so we discontinued the restraints. I weaned him off his sedating and antipsychotic medications and made an extra effort to try to speak to him through a video conferenced interpreter in Spanish.

Finally, one day he had the strength to tell me that he wanted to eat. He had been fed through a nasogastric feeding tube in his nose for six weeks and all he wanted was to taste food again.

After a long weekend of waiting, the speech therapist finally cleared him so he could eat. The next day he was watching Spanish television. I heard him talking to his wife on his cellphone telling her he was grateful to be alive and willing to change his life. He told me he worked as a painter. Like many painters I have met, he suffered from alcoholism to curb his boredom … or maybe painting is one occupation that is compatible with life as a heavy alcoholic. In the span of a week, my deranged patient who seemed like a lost cause transformed into a remorseful, suffering human being right before my eyes. After a two-month stay, he was finally discharged with home oxygen. I don’t know how he could even stand up after lying in a bed for more than six weeks.

I can imagine with some different choices that I have made in my life that I could have ended up like this patient. Perhaps he reminded me of myself nearly twenty years ago when I was a medical resident in training. I woke up in the hospital with a broken shoulder after a motorcycle accident with no memory to this day of the prior past week I had spent critically ill in the hospital with a traumatic head injury. I don’t even remember the expensive Lifeflight helicopter ambulance that brought me to Memorial Hermann. When my parents who lived in Tennessee came to see me in the hospital, I didn’t recognize them at first. I told the hospital staff that I was a Jedi knight…that I suffered from renal failure and prostate cancer…at least that is what the doctors wrote in the medical chart. Even months after my accident, I was not certain that I could still be a doctor. I wondered if I had suffered permanent brain damage that would limit my career that hand not even started.

A few years of soul searching trying to understand my own brush with death and numerous other circumstances in my life including taking care of hundreds of cancer patients at MD Anderson and the short illness and death of my father from brain cancer led me to understand that Christ saved me for a great purpose on this earth. Thanking Jesus and asking for his forgiveness healed my broken heart and changed my life forever.

In closing, I want you. Brothers and Sisters. to take care of yourself.  The virus is still present causing havoc and destruction in Houston. We have to return to work and earn a living, but we don’t need to take risks that will spread the virus. Fortunately, it seems to spare children from the worse of suffering but it can have devastating effects on adults of any age.  Your children need you. Please don’t become complacent thinking the virus will never impact your life. Wash your hands frequently before touching your face, keep your distance from others, and wear your masks at all times when you are inside buildings and enclosed spaces. Depending on the ventilation, airborne presence of active virus droplets has been detected hours after an infected person leaves a room. Probably, the only safe place to socialize is outdoors where ultraviolet light destroys the virus in seconds and the wind blows respiratory virus-laden particles away.

Pray for a vaccine. Pray for God to weaken the virus. Pray for people to set aside political, racial, and ethnic differences to help one another in this difficult time of great suffering and social turmoil. The virus does not seem to care one bit who it maims or kills.

 

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