Louisiana is currently the state with the third-highest Covid-19 infection rate per capita in the U.S. As of this morning, March 25, they have nearly 1,400 cases, with about half concentrated in New Orleans and 46 fatalities.
Just two weeks ago, millions of residents here were still out celebrating during Mardi Gras. Respiratory therapists at a New Orleans hospital were joking among themselves that they wished they could catch the coronavirus to take a paid sick leave.
In the ICU of the hospital, these respiratory doctors are meticulously adjusting each ventilator setting for their patients.
They have very few patients, mostly older individuals with asthma or chronic lung illnesses. Several times a day, the doctor will visit each patient, ensuring their oxygen tubes are placed neatly on their noses.
Until the wave of Covid-19 hit…
Lizzie Presser, a reporter for the non-profit investigative journalism outlet ProPublica, interviewed a respiratory therapist in New Orleans to find out what happened next.
The anonymous doctor stated he was truly shocked. Starting last week, he had to put ventilators on the most severely ill Covid-19 patients. Many were relatively young and healthy, with no significant underlying conditions, yet they were still knocked down by the virus.
These patients were gasping for air, struggling to grasp each breath. Pink, blood-tinged fluid was flowing from their ventilators. No doctor was still wishing to catch the virus for a day off.
The entire ICU at the hospital was overwhelmed. Ventilators were running low, as were medical protective equipment supplies. The respiratory doctors here no longer had the time to adjust each ventilator setting for each patient. They had to work as fast as possible to limit the time spent in the rooms.
Each shift now lasted 12 hours, yet there was still a shortage of doctors. Here’s what the anonymous respiratory therapist in New Orleans recounted to Lizzie Presser over the phone:
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When I read the daily news about Covid-19, I knew this disease would be very bad. But because we deal with the flu every year, I thought: Well, it probably won’t be worse than the flu.
It wasn’t until I saw Covid-19 patients being brought into the hospital that my perspective on this disease completely changed: Covid-19 is much scarier than the flu.
I received new patients over 40 years old, and I was genuinely shocked. They looked relatively healthy, with no significant medical history, yet they were struck down by the disease, as if they had just been hit by a truck.
Covid-19 knocks down completely healthy individuals. They were new patients admitted to the hospital, often only needing minimal support with a breathing mask and some oxygen. Yet suddenly, they could stop breathing at any moment, their bodies became utterly helpless and unable to inhale even a little anymore.
We have a monitoring unit in the hospital that receives patients who have tested positive or are suspected of being positive – these are patients who have been in contact with other positive patients.
Every four hours, we check the vital signs at each bed. Some patients are connected to continuous heart rate monitors, and we see their heart rates suddenly spike and drop. Some healthcare workers enter the room and notice patients are struggling to breathe or are no longer alert.
This seems to happen with many Covid-19 patients: They suddenly lose alertness or experience respiratory failure.
It’s called acute respiratory distress syndrome (ARDS) when the lungs are filled with fluid. This condition is revealed on X-ray: The entire lungs essentially appear white due to fluid overload. Patients with ARDS struggle to absorb oxygen. They have an extremely high mortality rate, around 40%. The treatment is to put the patient on a ventilator, creating additional pressure to help oxygen enter the blood.
Typically, ARDS is a gradually progressive condition over time, with the lungs becoming inflamed bit by bit. But with this virus, it seems to happen overnight.
While still healthy, your lungs are made up of small balloons. Like a tree shaped by its leaves, the lungs are made up of air sacs called alveoli.
When you inhale, all those small air sacs inflate, and they have many capillaries in the septa, which are small blood vessels. Oxygen is absorbed from the air in the lungs into those capillaries to be transported through the bloodstream throughout the body.
Normally with ARDS, the lungs become inflamed. It’s like inflammation anywhere in the body: If you burn your arm, the surrounding skin will turn red due to the extra blood flow to that area. The body sends extra nutrients to the inflamed area to heal it.
The problem is, when this happens in your lungs, excess fluid and blood start to flood in. The virus can damage the cells in the walls of the alveoli, causing fluid to leak into the lungs. A telltale sign of ARDS on X-ray is called “ground-glass opacity”, resembling the frosted glass bathroom windows designed to obscure visibility inside.
The lungs appear this way because the fluid shows up white on X-ray, so the patients’ lungs look like a layer of cloudy white glass, or sometimes entirely white due to having too much fluid instead of air.
Patients infected with the coronavirus in our facility, once they have to use a ventilator, most need to be set at the highest level we can manage. About 90% oxygen and PEEP (positive end-expiratory pressure) level 16 help keep the lungs fully inflated.
This number has reached nearly the highest I have ever seen. Having to set the ventilator at that level means we are running out of options.
In my experience, only drowning patients have such severe respiratory distress – as they have a bunch of dirty water in their lungs. Or another case is people who have inhaled corrosive gases.
The acute onset seen in Covid-19 patients is hard to explain. I have never seen a microorganism or an infectious disease cause lung damage this quickly. That truly shocked me.
The first blow that made me realize the difference with Covid-19 was when my first patient progressed to severe illness. Almost, I had to cry out, “Oh my God, this is clearly not the flu.” Just look at this relatively young guy gasping for air, the pink fluid dripping from his ventilator and mouth.
The ventilator was supposed to help the patient breathe, but he was still gasping, mouth moving, writhing and struggling. We had to restrain him. All other coronavirus patients, we also had to restrain.
They were breathing rapidly, truly fighting for every breath. When your mind is drowning in shortness of breath and delirium from fever, you don’t know when and if someone is trying to help you, so you will try to pull the ventilator out because you feel it’s choking you, but the truth is, you are drowning.
Previously, when encountering an infected patient, I would see normal-colored secretions that could be reasonably explained. They were green or yellow. But with Covid-19 patients experiencing acute respiratory distress, they had a lot of pink secretions, as they were full of blood cells leaking from the vessels into the airways.
Essentially, they were drowning in blood and fluid because their lungs were flooded with them. This is why every time we approach the bedside, we continuously need to suction the secretions out.
Before all this happened, we were joking among ourselves. The jokes were very crude, saying that if we exposed ourselves to the virus, then tested positive, we would be compensated.
We all joked: I want to catch the coronavirus because then I would get paid leave.
But then when I witnessed what happened to this patient, I seemed to cry out once again: Oh my God, I don’t want to catch this virus and I don’t want anyone I know to catch this virus.
Since last week, I have been working at a very intense pace. At first, I saw it as a new experience. But as time went on, it became a serious issue. Initially, my hospital only received one to two patients, but then it rose to 10 and then 20.
Each day, the workload kept increasing. We had more patients and many patients were getting worse. When everything started, we all had tons of equipment, tons of medical supplies. But as more patients came in, everything gradually ran low.
The hospital had to impose limits. At first, we tried to use one mask for each patient. But then the new directive was: You have one mask for the active patient, another mask for the rest. And now the directive is: You only have one mask left.
I work shifts that last 12 hours. Right now, we are operating four times the number of ventilators than normal. We have a large patient volume, and it’s difficult to find enough people to fill all the shifts.
The ratio of caregivers has decreased, and you can no longer spend much time with each patient. You cannot even stop to meticulously set the ventilator parameters, as you do not have much time when visiting each room.
We are trying to minimize ventilator assignments to as few patients as possible. Because you wouldn’t want any patient to be on a ventilator longer than they need. Your risk of death increases every day you are on a ventilator.
At that point, a high-pressure air stream is being pushed into the lungs, and it may burst those small balloons inside. They can be ruptured. Air can destroy the alveoli. Even if you survive ARDS, while some damage may heal, there will be long-term consequences in the lungs.
Your lungs may be filled with scar tissue. ARDS can lead to cognitive decline. Some people lose muscle mass, and they take a long time to recover after finishing their ventilator treatment.
There is a very real possibility right now that we could run out of ICU beds at any time. And when that happens, who knows what will happen to patients needing intubation and ventilation.
Will they die because we don’t have enough equipment to keep them alive? What will happen if this outbreak lasts for months, will there be dozens of patients dying because we have no ventilators for them?
I hope it won’t come to that, but if you only have one ventilator and there are two patients, you will have to allocate the ventilator to the one with a higher chance of survival. And I fear we have reached that point. I have heard that this has happened in Italy.
Source: ProPublica