- Marion C. Bishop
Faces of Covid-19
Details about individual patients have been changed to protect their identities. Descriptions of Covid are exactly as I witnessed them.
I was still waking up at the beginning of an early-morning ER shift, when an ambulance page sounded over the radio in truncated medical jargon: “Elderly nursing home patient.” Static. “Difficulty breathing.” More static. “Poorly responsive. Full code.”
“Could it be Covid?” the charge nurse asked. “Maybe,” I responded. “Better get ready.” It was good that we did. When the patient arrived, she was in extremis—medical terminology for trying really hard to die. She had an oxygen saturation level of 72%—at my altitude anything greater than 90% is considered normal—a respiratory rate of nearly 60 breaths per minute, and a heart rate more than double that. “She wasn’t responsive at all when we got there,” one of the EMTs said through his mask. “But we put her on 15 liters,” he continued—gesturing to the oxygen tank the patient was tethered to—“and she perked up, a bit.” “Good job,” I said, finding it hard to imagine the patient looking much rougher than she did without already being dead. Then the Emergency Room sprang into action. Nurses started IV lines, respiratory therapists attached the patient to monitors and began asking me if we wanted to intubate, and X-ray techs stood outside the room, waiting to shoot a portable chest X-ray. “Do you know her name?” the registrar asked. “Not yet,” I responded, now fully awake. “But EMS brought these,” I said, and handed him a big stack of medical records while not taking my eyes off the patient. Her face strained against the work required to breathe, and her lips were blue. This is not a disease I ever want to have, I thought to myself, not for the first time since the pandemic started. In a hurry, my day had begun.
In the early days of the pandemic, I felt sure that the rural communities where I practice would see their own versions of the giant wave of Covid patients that filled New York City hospitals. Aggressive social-distancing and stay-at-home measures protected us from this, for a time. And it was easy—if you did not work in a hospital or have first-hand knowledge of someone who was ill—to minimize the disease and understand it as something that was happening far-away. But that was harder to do in the ER, where my colleagues and I had begun our own process of acquainted with Covid. Going to work sometimes felt like leaving one reality and entering another. In the outside world, some people were carrying on their lives as if the disease was a hoax—or at least an overblown worry. But in the Emergency Department, I was beginning to see patients who were genuinely, truly sick. It just took twelve weeks to get the same, on-the-ground, education regarding the disease that my Emergency Medicine colleagues in New York got in the first twelve days. Initially, the patients trickled in slowly, with many more worried-well folks requesting tests than people who were actually sick. But as March turned into April and then May, I learned to recognize the range of symptoms and presentations of this illness. Now in July, as state stay-at-home orders have lifted, and the numbers of people getting ill are increasing, my education is deepening and broadening at an equally fast rate. It took a while, for example, before I heard the Covid cough. It was the middle of the night when a patient in her twenties presented with an unrelenting cough. She had tested positive for Covid several days before and had been recovering at home when she developed hacking chest spasms that would not stop. I heard my Covid patient before I saw her. She had a rate of cough that matched the staccato pace of pertussis, but with a different tone. Pertussis, or “whooping cough,” is characterized by a series of sharp, staccato coughs that do not end. The patient coughs and coughs, long past the time they are out of air, then takes a huge breath that often sounds like a “whoop”—hence the name. “Oh, that’s the dry, Covid cough,” I thought to myself, hearing a new version of a cough so rapid it starves a patient for air. And this patient was sick. She would cough so long that her oxygen saturations would drop to the low 80s. Then the spasms would pause for just a second and she would gasp, pulling in more oxygen as fast as she could, before starting the whole process, again. I knew that if this cycle went on long enough, the patient would either wear out and not have the energy to continue breathing or die from lack of oxygen—or both. “Can’t you help her?” a family member urged, and we tried, but I was in a tough spot. The medications that are used most often to quiet coughs—narcotics—also decrease a patient’s desire to breathe. And with a disease-process like Covid—that already decreases a patient’s oxygen level and respiratory drive—this was not a side-effect I wanted my patient to have. I ended up splitting the difference. I put the patient on a low dose narcotic cough suppressant and oxygen at the same time. I also got lucky. The cough did not completely resolve but slowed enough that the patient’s oxygen levels steadied out and she could rest. This is not a disease I want to have, I thought again that night, as the nurses and I got the patient ready for admission to the hospital.
Back on the early morning shift with the elderly patient, I was trying to sort out whether or not to intubate her. In the first weeks of the pandemic, the recommendation had been to intubate everyone with low oxygen levels. But more recent research has suggested that high-flow oxygen—often at rates exceeding 50 liters per minute—can be more beneficial for some patients than intubation. Using high-flow oxygen spares the patient the invasive procedure of intubation but is riskier to medical staff because of the aerosolization of millions of virus particles that are scattered around the room through the garden hose-like force that is high-flow O2. That morning I decided to give it a try. “Let’s see if it works,” I said to the respiratory therapist, “even if is just a temporizing measure. But we should also get ready to intubate.” Intubating in the time of Covid is a complicated process. Because of the proximity to the patient’s face that intubation requires, it is also the time that a physician is at the most direct risk for exposure to coronavirus. All kinds of things have been recommended and invented in past months to help minimize this risk. But nothing can change the fact that it is a one-on-one procedure, performed face-to-face with another human being. Even before Covid, intubation would sometimes make me consider my own death—especially if the patient was close to my own age. But questions about death that were theoretical in the past have become literal in the present—and not just because Covid is a disease that most of us will eventually get. Rather, it is that in our coronavirus-filled world, intubation is not just a procedure that could save a patient’s life, but one that may also threaten mine. Mulling this over, I turned to the patient. Her wishes mattered, too. By that time her oxygen saturations had risen to nearly 85%, and she could talk to me using one or two words at a time. But her respiratory rate was still rapid, and I worried that, before long, she would tire out. “Would you want to be intubated?” I asked her, “to have us make you sleepy, put a tube down your throat, and hook you up to a machine to breathe for you?” I continued, giving my best, easy-to-understand summary of what intubation meant through whirring machines and the wind-tunnel of oxygen filling the air. “Yes,” she said, with a resolute look that showed me she had understood every word. “I don’t want.” She paused and took some breaths. “To die.”
In the past few months, I have learned that there are many faces of Covid—the asymptomatic patient, the happy hypoxemic, the moderately sick individual, the person who is just-about-to-die. Research suggests there are other presentations, as well: patients who come to the ER with stroke-like symptoms caused by Covid, and children with a complicated multi-organ system syndrome, that mimics, but is also unlike any other disease we have seen. None of these are illnesses I want to have. They also are not just the flu. And in recent weeks, as stay-at-home restrictions have been lifted, I have added a new category: the surprise Covid patient. This is an asymptomatic patient who comes to the ER for another purpose—usually a trauma. A chest X-ray or CT scan is done, looking for injury, and instead reveals the kind of pneumonia that Covid causes. Usually this patient—who is young and healthy enough to be out participating in whatever event led to the trauma—is completely surprised. Most of these patients will also likely recover and be fine. But there is a series of emotion that crosses their faces—often rapidly, and usually in the same sequence—that remain with me long after the patients leave the ER. The first is shock that they have been caught by a disease they thought they could elude. The second is some combination of anger and fear, as they understand themselves to be powerless over a disease process that has already begun. Then, when their thoughts turn from themselves to the people they love—and remember everyone they have inadvertently exposed in previous days—concern and regret washes over them and stays.
In our new pandemic-filled world, it is hard for some people to believe that this disease is real, or if it is real, to believe it is anything to worry about, or something that could happen to them. Other folks can’t believe that this first group of people does not believe. Politicians and the press have made much of this divide, and the way it plays out in public policy, and all over social media, every day. But I actually have compassion for all of us in the middle of this mess—and more than politics, I think it is lack of knowledge and imagination that causes some of the trouble. It is difficult to wrap one’s brain around something we have never seen before, and that did not even exist in our world until six months ago. It is also easier to blame others, or to deny the gravity of the illness, than it is to comprehend all the ways an unseen pathogen with a funny name is disrupting and changing our lives. So sometimes, especially after a really hard shift, I wish that the doubters and believers alike, could see what I see, could know what I know. If I could give them a tour of the hospital, I think to myself, if they could stand at my side as we look together at faces of Covid, maybe we would all conclude this is not a disease any of us want. Or want to pass on.
Back in the ER, the high-flow oxygen seems to have worked—at least for the moment. The patient’s oxygen saturation has risen to 90%, her respiratory rate has slowed, and she can speak in short sentences. She asks to make a phone call to her husband, who was still sleeping at home, when the nursing home sent her to the ER in an ambulance with lights and sirens. The patient’s chest X-Ray shows a near complete whiteout: opacification of the lung on the right side to her clavicle, and on the left to her axilla, or armpit. This means that almost the entire volume of both lungs is full of fluid. I cannot believe she has enough functioning alveoli—the workhorse cell of the lungs—left to exchange oxygen for carbon dioxide. Looking at her X-ray, I know that her prognosis is grim. I hope she will continue to improve and avoid intubation. But if she does not, I am glad our ER interventions have bought her at least one last chance to speak with her husband. The community hospital where I work does not have ICU capacity, so patients like this one get transferred to neighboring hospitals that are Covid centers. I explain this process to the patient, and then again, over the phone, to her husband. The patient looks scared. She has good reason to be. The nurses and I feel for her, and through the whirring noise, blowing O2, and PPE, do our best to comfort her.
There is a cliché among physicians that an ER doctor is “jack of all trades, master of none.” Another cliché is that Emergency Medicine is not really a specialty, but just a giant triage service for the rest of the hospital. The real doctoring, this line of thinking argues, happens outside of the Emergency Department, on medical wards, and in ICUs and operating theaters. Some of this may be true. But as the specialty that is charged with taking care of any patient, at any time, with any illness, ER doctors become experts not in the nuances and long-term complications of every disease or trauma, but on the very specific ways each of them can kill you. Motor vehicle accidents, gunshot wounds, heart attacks, strokes, respiratory failure? I am your girl. I know the exact mechanism that is trying to end your life and the interventions necessary to walk you back from death’s door. Eventually, you may need a trauma surgeon or cardiologist or a long ICU stay. But that moment just before death—from whatever pathway got you there—is an ER doctor’s bailiwick. In fact, until coronavirus came along, it was hard for me to imagine there was not a road to death I had not already traveled, on behalf of patients, many times. But within days Covid humbled me. It also scared me just a little. And it showed me a whole new passageway to death—and the rugged terrain approaching it—that I had never seen, before.
While I waited for the ambulance to come pick up my patient for transfer to the other hospital, I stood outside her negative pressure room—watching her through my glasses, face shield and a window cut into the door. The nurses had arranged for her to have a FaceTime conversation with her husband on an iPad or iPhone. I could not see the screen, and I could not hear what she was saying, but watched her face, tired as it was, respond to the things her husband was telling her. I wondered who she was, beyond the stack of medical records I had handed the clerk, and the name I had just learned. I wondered if she had children, and if they knew where their mother was, right now. I watched her forehead wrinkle and relax. I saw her lips purse and then open in response to whatever her husband was saying, and the effort required to continue the conversation while also struggling to breathe. I wanted to breathe for her, to put my arm around her, and to smooth the wrinkles off her forehead in the same way I would comfort a child.
After my ER shifts, I have an elaborate routine for leaving the hospital. I shower there and wear clean scrubs home. Encountering my own face in the rear-view mirror of the car sometimes feels like being startled by a stranger. I can wash the germs and sweat off my body and out of my hair, but the indentations from wearing PPE for an entire shift stay on my face for hours. So does the worry and fatigue. After I park the car in the garage, I change clothes, again, stripping completely naked, and wrap myself in a terrycloth robe I keep hanging in the garage for just that purpose. My shoes go on a high storage shelf my kids can’t reach, and my scrubs go into a Trader Joes bag next to them—I’ll use it to carry the dirty scrubs back to the hospital next time I return. Then I run through the backyard, into a back door, and straight into the bathroom for a second shower. Two showers might not be necessary, but it makes me feel like there is something I can control. My children know not to touch or come close to me until this decontamination process is done. A couple mornings ago, after a long night-shift, my five-year-old son caught me barefoot just outside the garage door. He quickly took a few steps back, remembering the six-to-eight-foot buffer I had taught him. “Hi, Mom,” he said, and then reached his arms out wide—like he was holding a giant balloon—before crossing them in front of his body and wrapping them around his own chest, hugging himself tight. I did the same thing back. I was proud of him for remembering to stay away from me, and the sweetness of the gesture warmed my heart. But even as he smiled at me, I broke just a little, inside. The sleep-softened grin of my bed-headed son, social-distancing from his own mom, was another face of Covid I never imagined I would have to see.