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Story #1

by First, Last Name

Covid-19 can affect many organs but the main reason for the patients coming to the ICU is because of its effects on the breathing system. When the breathing system fails, we put the patients on a breathing machine that improves oxygenation by both providing a high concentration of oxygen and also by keeping their lungs open, using a very high pressure called PEEP (Positive End Expiratory Pressure). This high pressure feels more or less like driving at 70 mph, then rolling down the window and sticking the head out the window with the mouth open. This feels extremely uncomfortable but is lifesaving. Almost all patients in this situation require very high doses of intravenous sedatives to tolerate the breathing machine. Following well established protocols, we attempt to suspend the sedatives on a daily basis as part of the routine care. However, it is frequently not possible because some patients become unstable, causing an accumulation of sedatives in their system. We encounter many survivors of the Covid-19 who end up with varying degrees of cognitive dysfunction after their breathing issues resolve. Although the adverse effects of the sedatives are considered a major culprit of brain dysfunction in the survivors of Covid-19, other factors are also well established. To name a few, low oxygen and low blood pressure before arriving at the emergency room, as well as Covid-19 encephalitis (inflammation and infection of the brain by Covid-19 virus) and stroke.

 

I was walking by a patient room at the beginning of my weeklong ICU rotation. The patient was three weeks into his ICU stay with severe Covid-19 pneumonia, had a tracheostomy tube (a breathing tube in front of the neck for long-term need for breathing machine) and was completely off of sedatives for 5 days. I noticed the patient was constantly staring at the ceiling when laying on his back. During my daily examinations, he was not following commands and was unresponsive. By the end of the week my patient still showed no signs of improvement in his neurological function. On my way out of the ICU, I looked at what he was staring at, and it was something that I had never paid close attention to in my entire career: the ceiling. I thought to myself with sadness, this is most likely what he will be looking at for the foreseeable future. Even though there is a chance that his cognition may somewhat improve over weeks or months, he will likely not go back to his baseline. The impact of Covid-19 pandemic is mainly reported as the number of confirmed cases and deaths by “Johns Hopkins Coronavirus Resource Center”, being widely used as one of the main resources by the general public and health care systems. Working in the ICU and long-term care facilities as part of my job has taught me that there is so much more under-recognized devastation that is caused by this pandemic.

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Three Second Backward Tie

by First, Last Name

“Donning and doffing” is what we call the putting on and taking off of personal protective gear: gowns, gloves, masks, face shields, etc. It is a necessary but cumbersome procedure. Personal protective gear significantly reduces the spread of Covid-19 to other patients and staff but makes for extra work and difficult communication. This is especially true for the nursing and respiratory staff who enter and exit a patient’s room many times a day.

 

Nurses are the experts of donning and doffing. One day, I was reviewing electronic health records in the ICU when a ventilator, keeping one of our very sick Covid-19 patients alive, accidentally disconnected. Our respiratory therapist was in another room caring for another patient. Before I had time to even find my equipment, let alone assemble it according to the protocol, one of our ICU nurses donned her gear and rushed into the room to reconnect the patient’s breathing tube to the ventilator just in time to prevent a certain cardiac arrest. Our ICU nurses’ compassionate care is no secret to me but what took me by surprise was that it took her less than three seconds to put her gown on and tie it behind her back – something that is only possible if it’s done dozens of times a day. Nurses and respiratory therapists are key members of the critical care delivery team. They defend and protect, more than anyone else, the thin line between life and death.

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