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Paramedics rush a patient to an emergency room in Boston, where the intensity of covid-19
has surprised even the most experienced doctors.
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The system is coping, but the intensity of COVID-19 has surprised even experienced doctors.
As the coronavirus spreads in all fifty states, it’s becoming clear that not all places are experiencing the pandemic the same way. Dense urban areas, such as New York and New Orleans, have been hit hardest; less dense cities, like Seattle, and cities that enforced social distancing earlier, like San Francisco, have seen their numbers rise more gradually. Demographics may play a role: the prevalence of diabetes in New Orleans is more than double that in King County, Washington, where Seattle is situated. Other chronic problems that seem to make covid-19 more dangerous, such as high blood pressure, are also unevenly distributed.
We don’t yet know what will happen in Boston, where I live. At the beginning of last week, I reported to work at my hospital’s E.R. expecting the worst; sure enough, we were inundated with sick patients by noon. Some were brought in by the usual car accidents and heart attacks, but many others, judging by their symptoms and X-rays, seemed to have covid-19. After my shift ended, I thought the floodgates had opened. But then, on Tuesday, the emergency department slowed. Although there were spikes in covid admissions throughout the week, the momentum never held. We started wondering whether social distancing might have slowed the spread of the virus. For now, Boston remains one of the cities that hasn’t yet seen an overwhelming surge in covid cases.
That’s not to say that the caseload isn’t increasing. The number of deaths from covid-19 in Massachusetts has doubled every two or three days since March 21st. When incoming ambulance crews call in on the radio, their reports are always the same: “Fever, cough, difficulty breathing. Requesting isolation precautions.” So far, we’ve been able to handle the volume of covid patients; everyone who has needed a ventilator and an I.C.U. bed has gotten one. But the hospital is steadily filling up. The patients we already have don’t seem to be getting better quickly enough to free beds and ventilators for the new arrivals.
This disease is different from what we typically see, and its severity has unsettled even our most experienced doctors. One man arrived and had to be intubated immediately; his blood-oxygen level, thirty-eight per cent, was the lowest any of us had ever seen. (Greater than ninety-five per cent is normal; eighty per cent is alarming.) We have seen other patients with levels in the sixties or seventies. Another patient’s levels plummeted to below twenty per cent in the few seconds it took us to connect him to a ventilator. Not long ago, one of our physicians started wearing a new fitness tracker that purports to measure stress levels; when it recognizes high stress, it vibrates and displays messages, like “Relax” and “Take a break.” During a recent shift, it buzzed almost continuously.
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N95 respirators staged for decontamination in the Battelle Critical Care Decontamination System
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Our supply of personal protective equipment, or P.P.E., appears to be holding. Judicious rationing is helping our stockpiles last longer, and the hospital is investigating whether radiation or ultraviolet light could be used to sterilize N95 respirators and other equipment after it’s been used. I’ve been disinfecting my plastic face shield by cleaning it with bleach wipes. The ambulance crews seem to be in worse shape. I’ve seen medics wearing non-medical respirators, probably purchased at Home Depot or donated; others have no masks at all. One crew transported a patient who was breathing with the help of a cpap machine—a device often used by those with sleep apnea, which delivers breathing support through a tight-fitting mask. Because air sometimes leaks around the mask, the machine can become a leaf blower full of virus if the patient is infected. The medics transporting him had no P.P.E. “We haven’t received any instructions or guidance from our bosses,” they told me. Another medic I know said that transporting a covid patient was “so much worse than a bad trauma,” during which blood can splatter all over the back of an ambulance. “With a trauma, at least you can see where the blood is,” he said. “With the virus, you can’t see it at all.”
The virus has changed how we think, feel, and interact. My colleagues and I all seem to be paying more attention to our own bodies. We wonder if our headaches are a symptom of covid or just allergies, or if we’re starting to develop sore throats. Recently, I noticed that I now grip door handles with just two or three fingers. With everyone wearing masks, it’s become more difficult to pick up on emotions and moods. As compensation, I’ve registered, for the first time, the eye colors of people with whom I’ve worked for years.
I find it hard not to feel superstitious. There’s a playground near my house, now closed with a padlock and chains. The magnolias and forsythia planted there have taken advantage of the mild weather and are now sprouting buds. The forsythia in particular have seemed portentous: their blazing yellow flowers are a symbol of spring; in Chinese herbal medicine, they’re a tonic for fever, sore throat, and cough. Last week, it was snowing as I left the hospital. I caught myself worrying about the forsythia, and wondering what lies ahead.In the last few days, palliative-care doctors, who specialize in well-being and decision-making at the end of a patient’s life, have started joining us in the E.R. Before the sickest patients are intubated, the specialists, wearing full P.P.E., enter their rooms to discuss the options. Because it can take more than a day for results from a covid test to arrive, patients may find themselves contemplating intubation without knowing for sure that they have the coronavirus. If they have it, the prognosis can be grim; if they turn out to be suffering from some non-covid disease—ordinary pneumonia, or heart failure—they may be more likely to recover. Some patients choose not to be intubated. Others decide that they want to move forward, but determine in advance that, if their covid tests come back positive, they will undergo a terminal extubation in the I.C.U. Some conclude, courageously, that they’d rather free up the ventilator for other, younger patients—a form of self-triage.
If our patient load increases, we may not be able to leave these decisions entirely to patients and their families. Earlier this month, on Twitter, an Italian physician reported that at his overwhelmed hospital patients older than sixty-five or with serious medical problems were no longer being considered for I.C.U. beds or ventilators. A document published recently by the Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care notes that age limits may become necessary “as a way to provide extremely scarce resources to those who have the highest likelihood of survival.” Reports out of New York suggest that hospitals there are dangerously close to this scenario already. At Columbia University’s Irving Medical Center, operating rooms that have been converted into I.C.U.s are already filling up with intubated patients—including the first pair to share a single ventilator. A friend of mine in New York told me that one of her co-workers intubated seventeen people in a single overnight shift; arriving at one bedside, she was aghast to find that the patient was one of her colleagues.
