Thursday, January 6, 2022

How CoVid Ravages the Body

If they put you in one of these beds, chances are, you won't leave alive.  But by the time you are put in this roto-bed, odds are, you would be in a coma and won't realize what is happening.

This article was posted on Facebook and Reddit, from an ICE nurse.  It is interesting in that it describes how CoVid ravages the body and how you can feel "OK" one day and within a few weeks be quite dead.  Here is the article.  I think it is worthwhile reposting:

I'm not sure if I can convey, in words, what it feels like to take care of a dead man walking.

Just another day in the ICU. He was around 70 years old. A pretty active guy, one of those relatively stubborn and fiercely independent people who didn't typically go to the doctor unless their arm had been ripped off. He had come to the hospital a couple of days ago with a cough, fever, and a little trouble breathing. Unsurprisingly, he had COVID-19. It turns out that his saturation percentage of arterial capillary oxygen (SpO2) was around 60% when he hit the doors of the emergency department.

Off onto a rabbit trail physiology lesson for a minute: in our blood, there is a protein called hemoglobin. Each single hemoglobin protein is capable of carrying 4 oxygen molecules at a time. If they are carrying 4, then they are "saturated" with oxygen. The hemoglobin molecules pick up oxygen molecules in the lungs, carry them to the body's tissues, drop them off, and then return back to the lungs to grab more oxygen. The body tissues need this oxygen in order to stay alive. The oxygen saturation number, or SpO2, measures what percent of the hemoglobin molecules that are flowing past the sensor are saturated with 4 molecules of oxygen. Normal SpO2 is 94-99%. If the saturation is less than that, some of the tissues cannot get enough oxygen to stay alive, and are forced to start essentially eating themselves. One of the classic signs of significant COVID-19 illness is having a SpO2 level that is alarmingly low, with only moderate symptoms.

Back to the patient: let's call him "Bob." When I walked on the floor of ICU to get report that morning, Bob had been transferred there a few hours before because they couldn't keep his SpO2 above 88% on the regular nursing floor in spite of increasing his oxygen supply dramatically.

The night shift nurse described how Bob was taking off his oxygen to scratch his nose, and taking off his SpO2 sensor because it was irritating his finger. She kept reminding him to put his high flow nasal cannula back into his nose, and had to replace the oxygen sensor several times. She finally had a frank and confrontational conversation with him.

"Do you want to die tonight?" "No, of course not!"

"Stop removing your oxygen. Stop removing your oxygen sensor. If you take those off and fall asleep, and I can't see what's going on, I'm going to walk into this room and find you dead tonight. You need both of them. You have to stop it!"

This seemed to finally get through to him, and, when I took over his care, he was a rather subdued and cooperative patient. "Scared straight" might be one way to describe it. I introduced myself to him, and asked how he was doing.

"I know I'm sick, but I feel fine!" he insisted. "I don't really feel that bad! I just get a little winded when I try to do too much. I'm gonna be fine."

I could see the frustration in Bob's eyes. Why was he stuck in the hospital, when he felt relatively okay? Why did he have to come to the ICU and get bothered more often? Why did he have to have all this stuff connected to him? He was used to being totally independent and going about his morning routine. And he didn't quite believe that all of this fuss was necessary. I took a couple of minutes to try to describe what was happening to him.

"Regular air floating around us right now is 21% oxygen. We just breathe it in and out, and it normally has no problem getting down to our fingertips, where the oxygen sensor is measuring how much oxygen is in your blood. That measurement is usually 94-99%. The reason that you are in ICU is that we are pumping air that is 100% oxygen into your nose at 60 liters a minute, the maximum rate that we can use with a high flow nasal cannula. Even with that extraordinary amount of oxygen flowing into your lungs, your sensor is only reading 88% IF you hold still and don't do anything. The problem is between your nose and that oxygen sensor, and that problem is your lungs."

"When your body is infected with other viruses, your immune system has already seen similar viruses, so once it figures out that you are infected, it can grab the virus pretty quick and attack it. With covid-19, your body has never seen anything like it before. So it was able to go deep into your lungs and hijack your cells, turning each cell into a virus producing factory and killing it. But, since your immune system has never seen it before, it takes a bit longer for it to recognize that there is an infection, and then it takes your immune system a while to figure out how to grab ahold of all of the virus floating around and stop it from killing more cells. The question is this: 'IF your immune system finally figures out how to do this, how much damage has already been done?'"

"By the time you came into the hospital, there was already enough viral damage in your lungs that your SpO2 was around 60%. So, that means that there were already enough dead lung cells that the oxygen couldn't get from the air into your blood. We are giving you all the stuff we can to help encourage your immune system, but ultimately we don't know how this is going to turn out. Even once the virus is stopped, your body is now dealing with lungs that have a lot of dead cells in them. So it may take weeks before your lungs start recovering, if they even can."

Bob was really listening. I could see a flicker of recognition in his eyes. A brief glimpse at his own mortality. "God, I wish I had gotten vaccinated," he said, shaking his head. This was replaced quickly by stubborn determination, and he asked for help getting set up to eat breakfast. I moved his oxygen supply and monitor cables around so that he could stand up and walk to the chair. He seemed purposeful and resilient, relishing the fact that he required only help with the equipment. His SpO2 dropped to 83% when walking, but it came back up with a few minutes of coached breathing, and he started eating.

I checked on Bob throughout the morning. His SpO2 hovered right at 86-89%, barely acceptable. A little while after his breakfast was done, he needed to use the toilet. After this, he sat back down in the chair. The exertion of this simple morning routine proved to be more than he could handle. Bob's SpO2 fell to 85% and wouldn't come up any higher, even with coached breathing. We added another oxygen mask at its maximum flow of 100% oxygen at 15 liters per minute on top of his high flow nasal cannula that was already at maximum flow. This got us back up to a SpO2 of 88%.

"Bob, if your SpO2 drops down into the danger zone and doesn't come up, would you be okay with us sedating you and putting a breathing tube into your lungs so that we can force more oxygen into your blood with a ventilator? Or do you not want that?"

"Well, I really don't want that, no. But if that's what we have to do, I'm okay with that."

"Right, we'll keep doing everything we can to keep you stable and safe without doing that."

I helped get Bob back into bed so he could rest. He remained strong and relatively independent, and still didn't really feel that sick, just "a little bit winded from walking." His SpO2 hovered at 88-90% with the additional oxygen mask, quasi stable for the moment.

Bob put on his call light an hour or so later. When I looked in the window, he excitedly waved me into his room. I put the plastic gown, gloves, N-95 mask, and goggles on again, and entered his room. "Look, look at this!" Bob announced, proudly waving his incentive spirometer in my general direction. An incentive spirometer is a device that measures how big of a breath you can take. We encourage patients with lung infections to use it, because it helps inflate their lungs all the way, and helps the most oxygen get into their blood. "I got it all the way up to 101 using this!" I was a little confused at what he meant, so i asked him to show me. Bob began taking really deep breaths using the incentive spirometer and was able to hit the maximum inhalation measurement of 2500mL of air over and over again. I watched his SpO2 on the monitor drop from 88% to 85% to 80% to 75% as he took 5-6 of these breaths. He turned and looked triumphantly at me, his eyes sparkling a bit with hope. "See! It's all the way up to 99%!!" I cocked my head and looked at the monitor, and then realized the confusion. "Oh, that's your heart rate. Your oxygen is 78%. When you are using the incentive spirometer, you are breathing through your mouth instead of your nose where the nasal cannula is, so it drops pretty quickly. Which is why your heart rate goes up. Does that make sense?"

The hope faded from his eyes and was replaced with a flicker of terror. A dark haunting shadow of dread combined with fear. It didn't matter how hard he tried. It didn't matter how deeply or rapidly he breathed. It didn't matter how much oxygen we shoved into his nose. It didn't matter how badly he wanted to get better. The oxygen simply was not getting from his lungs into his bloodstream. The viral army was still winning this battle. Stoic resilience followed the terror, and Bob nodded to me that he understood, and put the mask back in place over the nasal cannula.

Bob barely picked at his lunch. He was watching the monitor like a hawk now, and would hold the extra oxygen mask up to his face between every bite. Eating food was now a secondary priority to him, he just wanted to keep his oxygen levels up. He looked discouraged, so I offered to pray with him if that would be helpful. He gratefully accepted.

I updated his son by phone. He was the same age as me. I told him the same thing I tell all of the families in this situation. I told him that we have to take it a day at a time. That we were now riding the covid train, and we weren't sure where it was going to end up. That sometimes the lungs can't recover. Sometimes it takes weeks for the lungs to recover. And sometimes people get better surprisingly quickly. That, with covid-19, I've seen 90 year old ladies leave the hospital on just a little bit of oxygen. And I've seen 30 year old men with no medical history never make it out of ICU. That each day is precious, and we should just grab ahold of that day and live it. That, if his dad got any worse, the next step was a ventilator. And that he should come visit if he could. Just be with him as he rides the train.

I finished my shift that afternoon, and gave report to the next nurse. Just another covid-19 report. They are all so similar: "Bob is here with covid-19 pneumonia, he was 60% SpO2 in the ER and was admitted 2 days ago to telemetry on high flow nasal cannula. He was transferred to ICU last night due to increasing oxygen demand. He is alert and oriented, lungs are clear but diminished, he is maxxed out on oxygen, dry hacking cough, up with assistance with equipment, everything else is relatively normal. He didn't understand how serious this was until this morning, but I think he's starting to get it."

I walked back to the locker room and showered before changing clothes and walking out to my car. The little flicker of terror in Bob's eyes haunted me a bit. For a brief second he knew what we already knew: Bob was a dead man. Maybe, just maybe, he could be the rare miracle that survives this level of illness. But that was really unlikely. What was actually going to happen is that Bob would end up intubated and on the ventilator. He would require maximum ventilator support, eventually requiring chemical paralyzation to maximize lung compliance, because even that wouldn't work. Bob would need to be pronated onto his stomach for 16 hours a day, requiring either a roto-prone bed that looks like a medieval torture device, or a team of 6 nurses and 2 respiratory therapists, to flip him twice a day. Eventually, after a week of this, his family would realize that this was futile and ask that we stop. The lung damage was done. The train was already down the tracks. He was a dead man walking. And for a half of a second, he knew it, too.

I visited Bob 2 days later. He was now on continuous AVARS, which is a pressure mask strapped to the face to provide maximum lung inflation and oxygen exchange without intubation. Even on that, his SpO2 hovered around 87%. I could see his dry parched lips behind the clear mask, and Bob asked if he could have some water in a muffled voice. I knew that, at this stage of the game, removing that pressure mask even for 30 seconds might take 30 minutes of recovery, so I told him that I would have to ask his nurse for the day. I told him to stay strong and take it a day at a time, an hour at a time. I wished him well, and fist bumped him before I left him to sit there and wait. Nothing to do but wait.

I ripped off my plastic gown and tossed it in the trash as I walked out of the room. I kind of slam dunked it into the wastebasket in frustrated despair. Yup, he was a dead man. This train was going to stop at the morgue.

I checked on Bob 2 days later. But I didn't talk to him. I actually couldn't, because he was sedated, and on the ventilator. I wanted to talk to the son again, to tell him how much I was sorry that this had happened, to tell him that his pain and grief was normal, to tell him to prepare to say goodbye. But I wasn't involved in the situation anymore, so I didn't want to cause any unnecessary communication issues.

A couple of days later, I saw the rotoprone bed in the room, as his limp comatose body was being flipped twice a day to recruit every single scrap of his lungs possible in order to keep him alive. I winced as I pictured the pressure ulcers that were probably forming on his face in spite of all of the precautions that we take. Just a matter of time until the train reached its destination.

A couple of days later, he was gone. I saw the rotoprone bed parked outside of the ICU, cleaned and ready for the next patient. Ready to take the next one on a ride.

I live for the little moments. Yes, I want them all to recover and walk out of the hospital. But I just try to connect with their humanity. To let them know that they matter. That their life is precious and meaningful. That every moment of waking breathing sentient awareness is a miraculous gift from God. Those little moments when I make eye contact with them, and mutual love/respect somehow gets transmitted between us fill me with purpose and energy.

But the moments when I see the dark fear in their eyes? When they experience the flash of hopeless terror? When they know, deep down, that they are a dead man walking? And I know that I can't fix it? And that it was largely preventable? It hurts at the soul level.