The theories being circulated by one person or another regarding the pathophysiology of the severe hypoxia we're seeing in the COVID-19 patient population (ie the reasons the virus causes such horrible lung disease) are numerous.
And the suggestions for management, including pharmacologic, procedurally, and ventilatory, are numerous as well.
Some say this disease process is similar to ARDS but not exactly the same. Some say it is nothing like ARDS. There are theories that alterations in the heme moiety on our red blood cells leads to altered O2 affinity that may contribute to the severe hypoxia. There are components of cytokine storm. There are likely micro-embolic events injuring the vasculature with a DIC-like picture. Some demonstrate multi-organ involvement, including myocarditis, liver injury, and kidney failure.
Some of the sickest, and only those who qualify, will be placed on V-V extracorporeal membrane oxygenation (ECMO), where deoxygenated blood from the patient is removed from a large vein, cleared of CO2, infused with oxygen, and then re-infused into the patient. It essentially functions as an external lung in those patients whose lung function is severely compromised.
And to add to all of this suckiness, there is evidence for neurologic involvement, where the virus attacks oligodendrocytes and glial cells, resulting in an acute disseminated encephalomyelopathy and demyelination, and also of a multifocal necrotizing encephalopathy, sometimes hemorrhagic. The clinical picture keeps getting grimmer.
There are patients who were previously healthy and are now fighting for their lives. We have patients with multiple co-morbidities who are showing improvement. And everything in-between. Though to be completely frank, the old and/or sick are still the most likely to deteriorate and pass. But all groups have individuals who can die, and do, very quickly and unexpectedly.
Apologies for all the medical jargon and not explaining everything in simpler terms. But the point is to demonstrate there is absolutely nothing simple about this disease.
Whenever we think we are beginning to understand the disease, we discover something new that totally confuses us once again. This disease manifests itself so differently from person to person, that it's seemingly impossible to get a good handle on this disease.
This disease is unlike anything we have ever encountered. So all we can do is trust our training, experience, and extensive medical knowledge, and hope that is enough to help navigate these human beings through their disease process until we get a better handle on this insanity.
On a different note, I'm sure many of you have seen Mayor de Blasio calling for a national "medical" draft, stating this crisis is no different than war. I don't disagree with the comparison.
BUT the comparison should end there.
Healthcare workers around the city do not have adequate PPE. I personally have friends at other institutions who I worry about, some of whom I've even told they should relocate to another hospital where they can be adequately protected.
Unfortunately, the resources keep getting scarcer, and many locations keep getting SCARIER by the day. So if de Blasio wants a medical draft, he sure as hell better GUARANTEE adequate PPE for everyone. Because the infantry is not looking to run into a firing squad unprotected.
Yes, we do need more physicians, nurses, respiratory therapists, etc. Especially here in NYC. But we also need to be able to put all of them in positions where they can succeed and perform safely and competently.
Dermatologists and ophthalmologists are being asked to staff emergency departments and ICUs. Yes, they have medical knowledge. But no, this is not their area of expertise.
Hospitals can vary in equipment, protocols, treatment modalities, amongst other things. It takes time to get acclimated to a new environment, especially when it is an environment that is completely foreign. That acclimation is essential to provide safe patient care and to keep our healthcare workers safe.
We are not machines. You cannot just expect to plug us in and press "START" and function perfectly. Especially when you're jerry-rigging us to perform a function we were not originally designed for.
There are many of us who have been reallocated to areas of need within our own hospitals, and even then there is a transition period. For some like me, the transition was not too difficult. But many have been relocated to services where they have never had any experience at all. I even had a friend who considered resigning because she felt she may not be able to perform her job safely. So even for those familiar with an institution, it can be a bumpy transition.
We need help. But we also need to not panic and figure out how to get that help to where it is needed, and to create working environments that are as safe as can be during these very unsafe times.
We want to help others because so many are dying. But we could be in danger of adding ourselves to the numbers of those dying, as some already have, if we continue to proceed recklessly.
And on that somewhat of a downer note, I'm going to stop writing for tonight. I know these are stressful times. But please, do your best to ease your mind and sleep and dream of better times ahead.
Just believe. Because those times will come.