I Got This One Wrong
I got this one wrong. I know that now. I thought this wouldn’t hit us… It wouldn’t be that bad... It’s all overblown… Social media hysteria in it’s worst form. I was wrong.
In the first week, we saw a handful of the worried well, just like everybody else. Typical cough and cold symptoms, but nothing too bad. They got tested (while we still had a test to do) and were discharged home with instructions to self-quarantine for two weeks. Tylenol, ibuprofen, chicken noodle soup.
But then I saw my first really sick COVID-19 patient. A young (early 40’s) male who had recently returned home from West Africa, where his family still lives. He initially had a couple days of just feeling run down. Then he developed high fevers and muscle aches. He thought he would ride it out at home with his roommate, who had similar symptoms. But then he felt as if he couldn’t breathe. That’s when he called 911. We had the heads up from EMS, so everybody was prepared. We had PAPR (powered air-purifying respirators) with gowns and gloves. He arrived and moved himself from the EMS gurney onto ours. He told me his name and briefly what was going on. He was awake. Alert. Not well-appearing, but certainly not awful. His story was concerning enough that we were fairly sure he had COVID-19. We started our work up and the nurse drew labs and swabbed him for testing. Flu negative. Leukocytosis with lymphopenia. Slightly elevated LFTs. A single view CXR was done and it’s images sealed the diagnosis. Bilateral dense infiltrates.
As he was in the ED, we had started the conversation on where he would go. We did have ICU capabilities at this hospital (Level III trauma center located in a small mountain town), but this patient may be too sick for us. His work of breathing was beginning to worsen and I could tell he was tiring out. The decision was made to intubate and transfer down to our bigger Level I facility. Critical care was notified and we began getting things ready for intubation. I told him the plan. I said we would give him some medication to make him sleepy and would place a tube to help him breath. He would be asleep and wouldn’t feel a thing. It’s hard to hear much while wearing PAPR, but I could hear what he said to me at that moment. He looked up and in a thick West-African accent, asked me if he was going to wake up. I put my hand on his shoulder and told him he was going to be just fine. I hoped I was reassuring. Not only for him, but for myself as well.
His oxygen saturation was high 80’s despite having 15L oxygen via a non-rebreather facemask. He was given RSI meds and video laryngoscopy was performed. The procedure itself was not terribly difficult, but his oxygen saturation dropped precipitously. The tube was in place and balloon up within 20 seconds, but his O2 sats were now in the 30’s. This man, who had arrived awake and alert 2 hours previously was now dying. We bagged him up with a PEEP valve attached to a BVM, but could only get saturations in the mid-80’s. He was placed on the vent and settings were adjusted, but he was quickly requiring 20 of PEEP and high FIO2. Initial PaO2 was low 40’s. Initial imaging showed what appeared to be dense infiltrates, but there was some concern that the right lung had an effusion. CT imaging was ordered, but quickly denied. Our hospital had one CT scanner and using it for a COVID-19 patient would mean two hours down for a deep clean. This hospital served five large ski areas and on any given day, there is often a line for CT due to trauma. Taking the only CT off line for two hours was not an option. Ultrasound was attempted, but sadly I couldn’t truly differentiate effusion from infiltrate. To attempt better oxygenation, I placed a chest tube in the right side hoping to get fluid out. This was to little avail. No fluid. No improved oxygenation. Pt was redosed with a paralytic and RT continued to adjust vent settings. The ICU at our large center one hour down the road was now out of the question. He needed ECMO (extracorporeal membrane oxygenation). He was accepted at a facility 2.5 hours away that had ECMO capabilities. We did our best to optimize his vent and sedation and sent him down.
The following day, his roommate came into the ED. Also in his 40’s with no past medical history. He was made aware of his friend’s condition and thought he should be evaluated, as he was feeling worse. Same symptoms. Roughly same vitals. Nearly identical CXR. Surely the same diagnosis- COVID-19. Thankfully, he did not deteriorate quite as quickly. He was admitted to the ICU, but did require intubation two days later. He was also transferred, but ultimately did not require ECMO. His roommate (now two weeks out from his initial ED presentation) remains intubated, sedated and on ECMO. He is prone with optimal vent settings, but still worsens.
This disease is not only for the frail and elderly. It will claim the lives of young and healthy people. I got it wrong initially, but am now fully aware of it’s potential. Our mountain town has since closed all ski resorts. There is a mandated stay at home order in place. We are social distancing in attempts to prevent complete collapse. My hope is that it will work, but only time will tell.
Share your " I Got This One Wrong” story in the comments section below.
Subscribe to the blog by entering your email in the subscription box below. Don't rely on Facebook to get notifications for new posts. We only email when a new post is published. No spam. If you are reading this on your phone, just keep scrolling down to get to the Subscribe box.
Give us some love by sharing the blog. Forward the blog to people you think would like it. Post the blog on social media. Like and Follow our Facebook Page. Follow us on Twitter. Follow us on Instagram
Erik’s bio is below. Keep scrolling.
Dr Erik Adler
Emergency Medicine Doctor. Trained in Colorado. Hobbies include snowboarding, mountain biking, camping, and hanging out with his wife, daughter, and two dogs.
