Dispatch from the COVID front

Editor’s Note: Josh Abetti is a registered nurse and pastor of Concord Community Church in Concord, VT. He is temporarily working with COVID patients in a Bronx ICU.

Many people have asked me, "What's it like to work with COVID patients?" This is my attempt to answer that question from my limited experience. It’s long but I ask you to read the whole thing. In this post I attempt to share my observations and those of other coworkers. I’ve tried to restrain myself from making definitive conclusions because there is still so much about this disease we don’t understand. I’ve also written this from the perspective of a nurse.

Working in a COVID hotspot

The last several shifts I’ve been working on a COVID ICU with some of the sickest COVID patients in the hospital. We have 20+ COVID patients with 95% on ventilators. As my wife pointed out to me, “That’s more COVID patients on your 1 unit than all the hospitalized COVID patients in the state of VT!” Puts it in perspective. I’ve been told by the hospital and the nurses that this part of the Bronx was ground-zero for COVID in NYC. Not sure if that’s true but suffice it to say this has been a hotspot for COVID.

COVID’s effect on the lungs

This is a very sad and cruel disease. People who are walkie-talkie with healthy lungs suddenly enter the ER having difficulty breathing. Some go on the ventilator within minutes, others go on the ventilator in a couple days. I only work with the severe cases so I can’t speak to the prognosis of everyone with COVID. But yes, for reasons we don’t fully understand (yet), an extreme immune response—cytokine storm—overreacts to the virus and inflames/blocks/inhibits the ability of the lungs to exchange oxygen. That’s why we see people enter the ER with pulse ox saturations as low as 50%-70%. Your chronic COPDer would normally by unconscious by that point but not the COVID patient; they’re still walkie-talkie despite the low saturations. But of course they need supplemental oxygen and ventilation at that point.

Why we use ventilators

The saddest part of this disease is the struggle to breath. You watch these people struggle as they’re fighting for air. Their respiratory rate is in the 30’s-40’s, and this sets off a vicious cycle of panic and anxiety which also increases the respiratory rate. Oxygen helps, but it’s no good if the lung is non-compliant and is struggling to inflate and take in air. This is why they need the ventilator. The ventilator, through positive pressure, helps to inflate the lungs. But these lungs aren’t compliant. They often become inflamed, somewhat rigid, and swimming in secretions and fluid. If you overinflate them, you might cause a pneumothorax. It’s a delicate balance between pressure and what the lungs can tolerate in order to achieve oxygen exchange. This is why I’ve seen a lot of vents set at a high respiratory rate (30-35) with lower tidal volumes set at 400-500mLs.

The risks of ventilators

You can imagine, having a machine help inflate and deflate your lungs is not comfortable, which is why we put everyone on sedation. The goal is to get the patient to synchronize their breathing with the machine; we don’t want the patient to subconsciously fight the vent. The ventilator doesn’t heal the patient; it buys them time, time for the body to fight and overcome the virus and this immune response. But being on a ventilator comes with risks: pneumothoraxes, excess secretions, pneumonia. And as we’ve learned, the longer you’re on the ventilator, the more there is an increased risk of mortality. One last vent observation: Most are on a FI02 of 100% (very high) with sats usually ranging in the low 90’s to high 80s (not good).

Septic patients

These people are septic. Temperatures are as high as 103-106; many are on scheduled Tylenol. We’re applying ice packs often, sometimes putting cold water into the stomach through an OGT or NGT. Blood pressure is often labile—but most are hypotensive. Seems that most are tachycardic. Most are on 1-2 vassopressins and 2-3 types of sedation.

Blood clots

Blood clots are common, especially pulmonary emboli, which makes it even harder for an already respiratory compromised person to exchange oxygen. Everyone is on blood thinners.

Importance of proning patients

One thing we do is prone the patients which is normally done with a fancy bed called a RotoProne (and looks like something out of a Tom Cruise Mission Impossible movie), but we don’t have those nice beds. Instead, there are teams at my hospital, from the Army and Air Force, that literally flip patients over onto their belly, and leave them there for 16hrs, so that the posterior sides of their lungs can open up better. And usually it works! I’ve seen sats go from 82% to 100% after being proned.

Medical professionals contracting COVID

Many of the nurses who are employed by the hospital have gotten COVID. For most of them, their symptoms were mild, and they’re back at work. My hospital provides free COVID testing and antibody testing for nurses. I promised my wife I’m going get tested for both before I leave NYC.

Personal protective equipment

Because the risk of getting COVID is so high for the staff, we usually wear three layers of gowns, plus our masks, and goggles/face shields. We've had plenty of PPE.

Limiting contact with patients

We try to limit how frequently we go into patient rooms while still providing optimal care. One reason nurses enter a room a lot is to attend to all the IV drips. Most hospitals have created access ports between the hallway and patient room so that IV pumps can remain in the hallway. The IV lines are extended and funneled through the ports and connected to the patient. It has worked very well.

Experimental treatments

Most of our patients are on IV Zithromax, famotidine, and some are receiving Remdesivir as part of a clinical trial. Again, from my limited perspective, it’s too early to tell if these treatments are therapeutic but hopefully they will be.

Deaths

Yes, some of my patients have died. Studies show that 60-70% of COVID patients on vents will die. This is a very discouraging statistic. Hopefully with an increased understanding of the disease process and effective therapies, we will be able to bring that number down. Some say we need to treat people earlier so they never end up on a vent. I would be all for that, but I’m not sure yet what that treatment would be. Maybe oxygen? I think it boils down to how each person’s body responds (or overresponds) to the presence of this virus. Also, pretty much all my patients have other comorbidities that put them at risk, such as heart disease, diabetes, obesity, immune diseases or chronic infections/illnesses. But this disease has killed young people and people without comorbidities, although that is less common. I haven’t had any young patients yet, but nurses have told me stories of people in their 30s and 40s succumbing to COVID.

Recoveries

But I have also seen COVID patients comes off the vent and breathe on their own. When that happens, the whole unit cheers and they play “Here Comes the Sun” on the loud speaker.

My hope in Christ

Lastly, I get asked all the time, “How are you doing?” And my answer varies. When I’m working 3-4 shifts in a row, I’m in the zone doing my job. I feel fine. I feel well-supported, we have plenty of PPE, my coworkers are great, we get free food, and we even laugh while on break. On my days off, however, it can be sad and depressing. I think of my patients who aren’t improving, I think of how I miss my family, but I also think of the resurrection a lot.

Jesus once told Martha, after her brother Lazarus died, “I AM the resurrection and the life.” Honestly, I can’t type those words without crying. I sometimes dream of hanging a medicine called “Resurrection” and letting it run into my patient’s veins and watching them get out of their bed and run into the arms of their family. But then I remind myself, “There is no drug called resurrection. Even better: It’s a person; it’s Jesus! And he will raise His people from the grave, whether they’re buried in Hart Island or the Concord cemetery.”

The resurrection of Christ gives me hope. Death, though present and real, will one day lose all its victory and all its sting. Death will be no more and life will reign. Until then, let’s fight death to the best of our abilities with our minds and hands AND, more decisively, by believing and proclaiming this Good News that Jesus is the resurrection and the life.

Come, Lord Jesus, Come!