Since late June, New Hampshire has had an uninterrupted climb in COVID-19 cases and hospitalizations. For unclear reasons, the cases numbers and grim events at our hospital --our region--have been level. A steady number of admissions and discharges each day keep the numbers around a dozen severe cases each day. But that correlates to one intubation of an individual with COVID-19 each week and one death of an individual with COVID-19 each week. During some weeks, unfortunately, these latter two events happen to the same person. Last week, the scale of the tragedy of the COVID-19 pandemic increased.
Monday a lady died after 9 days on a ventilator. Ominous COVID toes appeared over the weekend—toes reddened and darkened. Late in the afternoon her oxygenation dropped despite all the support of the ventilator. It could have been a pulmonary embolism despite the full anticoagulation. But what to do was murky when blood rose from the breathing tube; at first it was pink streaks then came frank blood. Over the subsequent hours, the trials to reverse things with suctioning and bag mask ventilation became less effective. Just after six pm, her blood pressure softened. She was too unstable to transport to the radiology suite for EKOS for a pulmonary embolism and a transfer to Dartmouth or Boston for ECMO was impossible. When her blood pressure fell further on three vasopressors and her oxygen hovered at 79% on the ventilator, her husband asked us to stop the life support. By then, iv sites bled and her urine looked like chianti. She died minutes after stopping the adrenaline and noradrenaline.
To die so far into an ICU course feels like a failure. It always should and does. However, Covid has shortened the lifespan of self-recrimination. In 2020, we learned the majority of patients critically ill with COVID died this way. That was when folks showed up three weeks into symptoms, not ten days. That was before the use of dexamethasone, Remdesivir, and appropriate anticoagulation. even with these therapies and more we lose most patients on ventilators with renal failure. And, fatal multiple organ failure emerges over hours, too quickly for some to receive dialysis or appropriate transfer.
For this patient like many others, It was the end of a struggle that evolved over the prior three to four weeks after an exposure which is all too often a sick family member. The illness timeline for the majority of patients is familiar now: 3-4 days of incubation after exposure, non specific constitutional symptoms arrive-fatigue, weakness, fever, chills, nausea, and maybe alterations in taste and smell that worsen over a day or two and then can disappear. Many attribute the day or two of feeling well to a cold and then go about their business.
Thereafter, 3-5 days after onset, after a day of feeling well again, people can begin to feel shortness of breath and/or an incessant cough. For a minority of others, what follows is 7-10 days of diarrhea and vomiting along with sweats and chills. No wonder lung injury goes unnoticed-- Silent hypoxemia. Many patients follow this timeline --summarized by the CDC-- which leads to acute respiratory distress syndrome (ARDS) around 8–12 days from onset of illness, intubation for many at day 9. It is also the beginning of the phase of illness given the name hyperinflammatory phase. Some just keep getting worse and enter critical COVID-19 infection.
Anyone with COVID who needs oxygen meets the definition of a severe COVID-19 infection. Anyone with COVID who needs oxygen has a strong likelihood of becoming worse before they get better. These are patients needing to be admitted for oxygen, monitoring, and ‘self-proning---asking patients sleep and lie on their stomachs for most hours of the day. As mentioned we treat everyone with dexamethasone, Remdesivir, and anticoagulation. We look for findings able to predict who escalates to critical care in the ICU. No marker is reliable.
About half worsen over seven to fourteen days needing at most four to six liters per minute delivered by nasal cannula. The other 25% have.a robust hyper-inflammatory response and need assistance by 100% by non-rebreather mask or high flow nasal cannula (high flow). A high flow device is capable of delivering humidified air 40-60 liters per minute. It keeps the lungs open without drying the nasal passages. Several days or weeks can pass at these levels of flow before a slow recovery begins. So to answer a question posed by a patient several months ago who took from the news the impression that all patients admitted died. Most admitted patients do not die. Most do not get to a level of critical illness.
Tuesday morning. The man I expected to be sent home from the ER on Monday afternoon is still there but now with need for 100% non-rebreather overnight. He is transitioned to a high flow system and further coached about the importance of prone positioning. Meanwhile, a 98 year old lady weeks ago with both Influenza and COVID did not die. In her delirium, she required relatively low levels of oxygen flow of 4-6 liters/minute for two weeks, was not good about remaining prone, then cleared enough to watch the Patriots (she knew Tom Brady was not the quarter back; I did not know of the change.) She would later return to the nursing home requiring 2 l/m of oxygen after discharge.
Since the release of Tocilzumab in April and even before Baricitinib was released this month, those on 100% non-rebreather mask or high flow nasal cannula have been given one of these biologic agents as a fourth drug. These are what we call ‘monoclonal therapies’—because it is a protein, synthesized in culture, monoclonal agents are also called ‘biologics’-- for admitted COVID patients. I should mention these two can be confused with a trio of outpatient monoclonal therapies also available. More on that later.
Therefore, when assessing a patient with a Covid infection it is paramount to establish the first day any symptoms began and separately the first day of shortness of breath (dyspnea) and cough. A sense of progression and severity can then be assessed. While mild dyspnea is common, worsening dyspnea is ominous.
Tuesday afternoon, a thirty year-old failed high flow and was put on positive pressure to add pressure to each breath as a help with work of breathing. When the work of breathing demands opening wet, heavy lungs and it takes effort to exhale through airways clogged and in spasm, this is insurmountable work. This is critical illness unsustainable for anyone, young or old. No one can pant 24/7 for two to three weeks. Also, everyone this sick has also been knocked down for the previous week or two. About a third on high flow with COVID become critically ill like this.
Positive pressure— also known as noninvasive ventilation— is a more robust and intricate version of the more familiar CPAP which opens the airway and lungs to treat sleep apnea. Unfortunately, Bipap can only be used to keep folks off the ventilator for about 2-5 days. That is the usual point of diminishing returns when one of two things happen, 1) the cheeks and crest of the nose are squeezed and rubbed raw by the mask and straps. Or, 2) the COVID-19 lung injury gets so bad the patients cannot take a momentary break. The sat monitor is low and lips are ashen before they can take a bite to eat or sip of water.
Therefore the mainstay for the critically ill is ventilatory support. As mentioned, It is now about one third of those on high flow who end up needing a ventilator to live. With the delta variant, that is double the portion of high flow patients who go onto the ventilator. Doubled to about one in three.
Also that afternoon, another patient, a woman in her forties, failed bipap and was put on a ventilator. With that second intubation in a day, every one of our ventilators were in use for the first time since the January 2021 peak. Indeed, all the patients in the Icu had Covid, those not on high levels of ventilator support were on high flow and needed close observation and encouragement to self-prone to stay above 90% oxygen.
Wednesday morning. Without an ICU available, the OR began to reschedule surgeries. Noon on Wednesday, with more patients in the ER with COVID and hypoxemia, the census ‘tipped the beans:’ The majority of patients on the census had covid. There was no room on the Covid unit to accommodate two of the three ERhold patients. We moved another individual off isolation after 14 days of symptoms to created an isolation room for one ERhold patient on 6 l/m nasal cannula. That person had been boarding in the ER for the second day.
When the ER is this full like this we move admitted patients into an annex to the main ER meant for urgent carte, evaluating chest pain, and monitoring observation patients. To use the ‘Fast Track’ or Clinical Decision Unit (CDU) area for floor patients is care foreign to patient and caregiver alike—Not only does the label ‘Fast track” not do justice, adding the adjective ‘fast’ really is a lie. With that discomfort among the staff, the annex has more than one fitting new name: ‘Purgatory’--‘Limbo.’ -- The CDU (Cannot Discharge Unit). ‘Surgistan’ or ‘Coronastan.’
Filled hospitals and emergency rooms in New Hampshire will be a fixture for the foreseeable future. Less than 40,000 people have been vaccinated in NH since the start of June. This is a two percent change -- 52% to 54% of the population--in vaccine status over an interval of six months. This leaves about 700,000 unvaccinated people vulnerable, susceptible. They can live free to be infected by a killer virus. I will pause now to let you play with the state motto.
Thursday. A nurse found a packet of Ivermectin stuffed in the toe of a patient’s boot. Wow. No longer do we find, coke, pot or oxycontin. De-wormer is the new contraband. One of several DIY remedies. Vitamin C, Vitamin D, hydroxychloroquine, Apple Cider Vinegar, zinc, Vick’s vapor rub. Anything but the vaccine. ‘Natural immunity’ is better, longer lasting.’ “The golden ticket” of natural immunity. “Go out and get covid to avoid getting covid.” ‘They did not test the vaccine enough.’ “My religion exemption is based on the use of fetal tissue to develop the vaccine.”
Most patients I talk to aren’t ardent anti-vaxx; they just think the chance of contracting COVID-19 is low. They discount the threat of COVID-19 one way or another. “I’m healthy. My immune system is strong.” I have yet to meet someone thinking there is a ‘GPS chip’ in the syringe. Yes, this is silly thinking. To Discount the value of the vaccine.
Indeed, the vast majority admitted during this surge have not been vaccinated. The state of New Hampshire is not stratifying patients this way. My estimate is that one in nine patients admitted have been vaccinated. So, far only three havre gotten to the unit. one vaccinated person with a chemotherapy regimen was intubated. One thing I am running into are people who had gotten sick with COVID and when I ask for them to get the vaccine, they have the notion they are immune.---henceforth and forevermore they will be powerfully immune. Wherever do they get that idea?
I say to people there is ‘no trouble the vaccine can bring you, that the virus won’t ten to hundred times more often.’ But, I sense that is too long a sentence, too focussed on the down sides of the immunization. So lately I just say to folks they are ‘going to get the vaccine or they are going virus.’ The choice is theirs. It is resignation because the notion goes only so far with individuals who believe the illness is ‘just another flu virus,’ or ‘no worse than the flu,’ or “I never get the flu, so no need to get the flu vaccine or the covid vaccine.”
I’ve heard four different versions of the the virus being released intentionally. The story loses legitimacy because we are asked to believe China infected the world by people who are the same people opposed to any action to protect us from a supposed attack.. In Guiliani’s case, it is delivered as a boastful pick-up line lacking urgency when he voices it. If this were an uncontrolled forest fire, let alone an invasion, we would give up so much more to fight it.
All this misguided thinking motivated me to look up the notorious northern India study for Ivermectin taken in the first five days with doxycycline. There was a claim of benefit. Not only was this never repeated in a worm endemic region or elsewhere, I learn that the paper was retracted. “They are giving this in India. And people survive” Actually the Indian government removed the drug from the covid guideline along with hydroxycjhloroquine in late September.
The vaccine survived peer review and a real-world trial; Ivermectin did not survive either of those.
By Thursday afternoon the two ERhold patients from Wednesday found rooms but I hear of two new ERhold patients with COVID are waiting now. Upon arrival to see the two assigned to me the ER attending informs me of a third patient with COVID needing admission. She is comfortable, free of chronic medical illness, and was vaccinated in April. She was able to maintain oxygen at 94% on room air and ten days into symptoms, I make the argument she is on the recovery side of the illness. We send her home with a plan to watch the pulse oximeter reading and return if she gets to 90% for three hours. That is not from any guideline— there is no advice about when to return—but is a prudent threshold for someone monitoring their oxygen. A finger pulse oximeter is available in most drug stores and costs there 30-50 dollars. They are all pretty good. I have even seen Fit-bit devices and apple watches capable of measuring oxygen saturation.
Anyone able to maintain oxygen at or over 94% has a mild or moderate case and is sent home with request to seek out a pulse oximeter and to return if oxygen drifts down below 94%. Or is it 92% or is it 90%. This is a gray area. We have not settled down to a consensus about who gets admitted and when people should return. We compound the confusion by failing to have a consensus how long we mean by sustained ‘low’ oxygen and whether this is at rest or with exertion. One thing is clear, in ER patients with COVID-19, a 3% reduction in pulse oximeter reading upon walking is cause for concern. Do not discharge at or below 94% without plan for monitoring oxygen at home.
Friday. I’m in the office. It has been not a normal clinic for the last twenty months. Fewer referrals. Lot’s of cancellations. So, we do video-visits when the hospital census surges. Before I sit down at the monitor, though, we get a call from an emphysema patient. She has COVID and her oxygen is good. I had mentioned monoclonal therapy to her last week but she lost the website I gave her. Us practitioners fail to mention monoclonal therapy is available in small quantities for those with covid-19 infection who are at high risk of progression but still have mild or moderate symptoms. So, monoclonal antibody treatment should be given as soon as possible after diagnosis. Administration within 10 days of symptom onset is possible, but the biologic treatment is best taken within seven days of symptom onset.
For reasons unclear to me, many folks who refuse vaccination are perfectly okay with the monoclonal therapies. The molecule is an engineered —a genetically engineered signaling protein—of an antibody you hope a vaccine would elicit. It is far from any natural immunity. Maybe it has to do with the monoclonal keeping TFG and his cabinet out of the hospital. One more double standard bestowed on TFG.
In New Hampshire, casirivimab-imdevimab (either as four subcutaneous injections or a one hour infusion) or now bamlanivimab-etesevimab combinations (infusion only) are available through ConvenientMD. As far as I know Sotrovimab is not available. These drugs cannot be scaled up as well as the vaccines; so, they will remain in short supply. It says something important about the virulence of the Delta and other variants that as a single agent Bamlanivimab is ineffective. ‘Bam’ alone was revoked on April 16, but returns(ed) in the combination cocktail with etesevimab.
Saturday. The lady we sent home Thursday returned. Her oxygen saturation was 75% at home. She felt a bit more short of breath these past two days. Unfortunately, it was only Saturday morning she could check her oxygen level. The pulse oximeter shared among her family was misplaced for two days.
Is COVID in full gallop? Is it the cold weather driving us indoors? Is it the exposure of Halloween? Fewer numbers a t the stores wear masks now. A new variant is even possible. Whatever the cause, it is the un-vaccinated who are most vulnerable. Among the many reasons to write this diary down is a request we keep inviting people to consider the vaccine. I see a large minority (or maybe half ) of those unvaccinated and ill and hospitalized with COVID-19 later get the vaccine. Some are stuck with the failed notion of natural immunity being ‘better and longer lasting.’ No, no, no. Through the next 2-3 years we will all be exposed at some point ,more than once. Everyone needs to anticipate exposure to covid-19 and getting a vaccine and subsequent booster would reduce the risk of infection, illness, and spread.