The Risks of Normalizing the Coronavirus
There are patterns and rhythms to life in a hospital’s emergency department. Many local clinics are closed on weekends, and many people don’t want to go to the hospital on their days off, and so Mondays tend to be busy; midafternoons are hectic, until things cool off, by eight or nine. Diseases also behave in recognizable ways. Chest pain radiating to the arm suggests a heart attack and, even as I talk with a patient, a sequence of diagnostic tests, medications, and specialists unspools in my head. Difficulty speaking and weakness on one side suggest stroke, and from the moment I learn about those symptoms I can see the entire course of treatment, from the medical workup to rehab, in my mind’s eye.
These days, perhaps because people are afraid to come to the hospital, we’re not seeing as many heart attacks or strokes. Instead, a new pattern runs through our days, persisting even though Boston is past the peak of the coronavirus pandemic’s first wave. In April, there were nearly four thousand patients hospitalized with covid-19 in Massachusetts, many of them in critical condition; now, there are around two thousand five hundred. The virus continues to circulate—there are still hundreds of new positive test results every day in the state—and patients continue to come in very sick. Over the radio, we still hear the familiar radio messages from ambulance crews: “Sixty-five-year-old male with fever, cough, and difficulty breathing,” they might say. “Requesting isolation precautions. E.T.A. five minutes.” On one particularly rough day earlier this month, my colleagues intubated at least one critically ill covid-19 patient every hour for much of their shift. The social-distancing regime may be beginning to lift, but Boston’s experience with the coronavirus is far from over.
Diagnostic tests for the virus still take hours or sometimes days to return results, and so we’ve become used to figuring out for ourselves which new patients have covid-19, relying on symptoms, blood tests, imaging, and intuition. In the E.R. where I work, two things happen simultaneously when a patient arrives. A team of nurses connects a variety of monitors—an inflatable cuff to measure blood pressure, nine electrode stickers to trace the heart’s rate and rhythm, and a small plastic box called an oximeter, clipped to a fingertip to measure oxygen levels. While this is happening, we are also observing. Does the patient appear attentive and alert, making good eye contact, or is he confused or in pain? Is he clammy? (Clamminess can herald serious illness: an old medical adage suggests that, if a patient is sweating, his doctor should be, too.) Most important, we watch what we call the work of breathing. Ten to twenty breaths per minute is normal, more than thirty is worrisome. A struggling patient might use his shoulder and neck muscles to breathe, or purse his lips. In the most severe cases, the skin between each rib sucks inward, or “retracts,” with each desperate breath.
All of this information contributes to what we call gestalt—a German word meaning pattern or shape, which refers to the total picture of how ill a patient is. Sometimes the gestalt comes into focus quickly. Medics bring in a woman with shortness of breath and, as she is transferred to a gurney, we notice that she is breathing rapidly, using her shoulders to do so, and that she appears clammy and inattentive. Numbers begin to appear on her monitor—heart rate elevated at a hundred and twenty beats per minute, blood pressure abnormally low, oxygen level of seventy per cent flashing red on the screen. “Febrile to one hundred and three Fahrenheit,” a nurse calls out. We see immediately that she is critically ill, probably from covid-19, and requires immediate attention.
For less critically ill patients with whom we are able to converse, the gestalt tends to reveal itself slowly, through a series of questions. We ask about symptoms and how they’ve evolved; we also ask about symptoms they haven’t had, to help exclude possibilities. A coronavirus infection, when it isn’t asymptomatic, is often mild at first, and covid-19 may make itself felt through minor symptoms that can evoke the common cold, the flu, or even allergies. And yet, while those familiar ailments primarily affect the nose, the throat, and the pharynx—together called the upper respiratory tract—the coronavirus seems to skip directly to the lower respiratory tract, multiplying in the lungs. A minority of covid-19 patients, therefore, report nasal congestion and sore throat; more experience lung-centric problems such as cough and shortness of breath. (As the pandemic has progressed, we’ve also learned to look out for other, stranger symptoms. Recently, I cared for a middle-aged mother of several children who came to the hospital complaining only of diarrhea and weakness; occasionally, the virus attacks the heart, and we were surprised to find that hers was failing. Other patients have described neurologic symptoms, such as impaired taste, headaches, or memory problems. Kidney failure has been reported, too.)
In the lungs, the tiny air sacs called alveoli get damaged or filled with debris as the infection spreads. The result is pneumonia—an inflammatory response to the damage. In the eighteenth century, doctors detected it using a technique called percussion: tap a finger smartly against the chest, and afflicted lungs sound dull, while healthy ones are drum-like and resonant. Today, we use X-rays. Plugged alveoli attenuate the rays, and so appear on film as white patches. It’s easy to recognize the lacy white streaks of covid-19 pneumonia reaching, cobweb-like, through the lower fields of both lungs. Sometimes this signature appears unexpectedly, in an X-ray ordered for a dislocated shoulder, say, or after a car accident. Occasionally, a chain around a patient’s neck appears on the film, fastened to a wedding band or crucifix—a reminder that each image represents more than just another case of covid-19.
The coronavirus may seem like an equal-opportunity threat, afflicting prime ministers as well as bus drivers. But the truth is that it’s especially vicious when it spreads within marginalized populations. Last month, in Louisiana, African-Americans accounted for seventy per cent of the deaths caused by covid-19, more than twice their share of that state’s population; in Chicago, the risk of dying of covid-19 if you’re black is six times the risk if you’re white. Similar trends have been reported in the Carolinas, Nevada, Connecticut, Wisconsin, and New York. In Boston, our Hispanic population has borne the brunt of the disease: at Massachusetts General Hospital, Hispanics have comprised as much as forty per cent of covid-19 inpatients. (Normally, they account for about nine per cent over all.) And so, in addition to asking our patients about their most recent symptoms, we take note of their chronic health problems, their ethnicities, and the circumstances in which they live. Only one in five African-Americans have jobs that allow them to work remotely; crowded housing arrangements increase exposure and transmission; minorities have long suffered from inadequate access to health care, and carry a higher burden of chronic illness as a result. We’ve grown used to the diagnostic patterns that accompany covid-19—they’re as familiar to us now as the ones that attend heart attacks and strokes—but these social patterns, which have also always been there, now stand out with disturbing vividness.
Once the diagnosis is made, treatment also follows a predictable path. At first, we provide oxygen—just a few litres per minute for mild cases, delivered by nasal cannula. Sicker patients may require a special mask called a non-rebreather, which delivers higher concentrations of oxygen: these measures are usually sufficient to stabilize them, at least momentarily, while we wait for blood work to come in. (covid-19 produces a distinct pattern of abnormalities in the blood, characterized by high inflammatory markers and a low number of lymphocytes, a kind of white blood cell.) In some patients, however, the disease has progressed to a more deadly phase: acute respiratory distress syndrome, or ards, an overexuberant inflammatory response, triggered by the infection, that causes grievous collateral damage to already foundering lungs. In chest X-rays of people with ARDS*, the lungs are so damaged that they take on the appearance of densely frosted glass. These patients sometimes breathe as though they were running a marathon, because they can’t get enough oxygen. They can’t keep up the effort indefinitely. Some estimates suggest that as many as ten or twenty per cent of covid-19 patients who are ill enough to need hospitalization reach this point. For them, the next step is intubation, a procedure in which a plastic tube is introduced into the trachea and connected to a ventilator.
Ancient physicians understood that control of the airway could be critical. Egyptian papyri and the Rigveda describe tracheotomy, a procedure to open the trachea by cutting through the neck; Alexander the Great is said to have saved a suffocating soldier this way, using the tip of his dagger. The Roman physician Galen observed that a hollow reed passed between the vocal cords, which sit above the trachea, could be used to ventilate the lungs of a dog. A Spanish opera singer became the first person to perform laryngoscopy, or inspection of the vocal cords, in 1854, using a system of small mirrors. By the turn of the twentieth century, better tools had evolved, so precise that physicians could not just see the cords but safely guide an endotracheal tube through them.
As I stand at the head of a patient’s bed, preparing for intubation, I hold in my hand a descendent of those early tools. Called a laryngoscope, it consists of a cylindrical handle connected to a curved, dull metal blade. The blade is about fifteen centimetres long, and resembles a miniature scythe. The latest models have a camera embedded in the tip, connected by fibre-optic cable to a video screen. As our nurses draw up syringes of sedative and paralytic medications, I have a moment to consider the invisible marauder attacking the patient in front of me, and laying waste whole families and communities in my city, and to entire countries and continents. It hangs over everything in this patient’s room, millions upon millions of pieces of it, like a fine dust. It is on me, and I am grateful for my P.P.E.
“Ready?” the nurse controlling the I.V. asks, his voice muffled by an N95 respirator.
“Go,” I say, and he pushes a bolus of sedative to render the patient unconscious.
“Etomidate is in,” he says, chasing it with a paralytic medication, to relax the muscles of the patient’s airway. “Rocuronium is in.”
We wait thirty seconds while the medications take effect, watching the patient’s breathing slow and then stop. From there, it’s a race between intubation and hypoxemia—a dearth of oxygen in the blood—which can precipitate cardiac arrest. Recently, I had a patient whose oxygen levels dropped from ninety-eight to eighteen per cent in the ninety seconds it took me to intubate him—a level I had never before seen in a living person. I kept my finger on his neck, feeling his pulse, so that if his heart stopped we could begin chest compressions immediately. I felt it slow and weaken, but continue, just barely.
With my patient now fully paralyzed and no longer breathing, I pry open his jaw with one hand and slide the laryngoscope blade gingerly over the tongue with the other, careful not to break any teeth. The base of the tongue leads to the epiglottis, a flap of tissue that protects the trachea. I nudge the tip of the laryngoscope just beyond the epiglottis into an anatomical cul-de-sac called the vallecula, and lever the blade up. This maneuver lifts the epiglottis and brings the vocal cords into view. They look like the anther and column of an orchid, and I thread the endotracheal tube through them and into the trachea. Then I pull the blade out, and the nurses secure the tube with cloth tape and connect it to a ventilator.
With any other disease, a successful intubation brings a sense of relief to the team. The patient is safe, for now. But covid-19 is different. For mysterious reasons, the medications we use to keep intubated patients asleep and comfortable can be far less effective. Just a few minutes after intubation, even though a powerful sedative called propofol is running through his I.V., my patient wakes up.
Endotracheal tubes are deeply uncomfortable: they can make patients who aren’t adequately sedated feel like they are choking. My patient gags and coughs, causing the ventilator to bark in alarm. He bites down on the tube, blocking the ventilator’s flow. He reaches to yank it out, and the nurse and I hold his arms while our pharmacist runs for more medication. We give him dose after dose of propofol, midazolam, and fentanyl without effect. We secure his hands to the bedframe with soft restraints for his safety. We max everything out.
“Try this,” our pharmacist says, thrusting a dose of an antipsychotic medication that we sometimes use for sedation through the open door. It’s a last-ditch effort, and it works. The man finally closes his eyes and descends into unconsciousness. We were lucky it wasn’t worse: recently, a friend of mine saw a patient who could not be adequately sedated bite completely through his tube, and had to re-intubate him. In a Detroit E.R., a patient woke up, dislodged his tube, and died before anyone noticed. Most covid-19 patients who require intubation aren’t this difficult to sedate, but scenes like these are playing out in emergency rooms everywhere, and hospitals are beginning to run low on sedative medications. What will happen if we run out?
With our patient finally sedated, we can turn our attention to the ventilator. Although its elemental functions—oxygenation and ventilation—are simple, it is an incredibly sophisticated machine. Our first task is straightforward: we dial up the mix of oxygen to meet our patient’s needs, all the way to pure oxygen if required. The second is more complex: we must adjust the mode or style of ventilation. As my colleague James Somers has written, patients can be exquisitely sensitive to the size of a ventilated breath, and to the pressure with which it is delivered. Too much pressure or volume can further damage already fragile lungs; too little can leave a patient struggling. Respiratory therapists, who are experts in ventilator management, help us carefully tune the settings to each patient. It’s a delicate balance between benefit and harm. Some doctors and engineers have proposed that, to avert ventilator shortages, multiple patients might be connected to a single ventilator. This might keep some people alive, but all nuance in tuning the machine would be lost. It’s possible that connecting multiple people to a single ventilator might result in all of them being lost rather than any of them being saved.
In the E.R., we do our best to find the optimal ventilator settings for each patient, but our primary focus is on getting them out of the emergency room and into an I.C.U. as quickly as possible. I step out of my patient’s room and lift a phone from its cradle on the wall. I call the triage physician to relay the salient points of the patient’s case and to request a bed in the “unit,” as the I.C.U. is often called.
“Sounds good,” she says. “I’ll speak to the nursing supervisors so we can open up a bed.”
And then I walk away, knowing that I probably won’t see this patient again. Before covid-19, I would sometimes go to the wards upstairs to visit a patient I’d cared for in the E.R. Those brief moments of human connection were deeply valuable to me, and, I think, to the patient. But such a visit today would risk spreading the virus, and so I move on. Someone else has arrived with fever and difficulty breathing, and may also need to be intubated; one of my colleagues is already preparing the equipment. I monitor the patient’s work of breathing from the doorway. Next door, I check in on a patient with a surgical emergency. As I step back into the hallway, my pager goes off with critical results from radiology. Then an ambulance crew calls in over the radio: they’re five minutes out with another patient in respiratory distress. In the emergency department, we’re constantly thinking about where patients are headed. We’re always trying to move them along—to admission or discharge, the I.C.U or the operating room. We need to make room for the new arrivals, even as we evaluate, stabilize, diagnose, and treat the patients already under our care. On the busiest days, it’s like juggling with pins that are human lives; drop one, and somebody could die. It’s easy to get swept up in the flow—to forget that we are in the midst of a historic pandemic, responding to a novel and highly communicable disease for which there is no cure, living through circumstances never before seen in our lifetimes.
The concept of intensive care in medicine is no older than my father, and was born from a medical crisis that began in 1952, the year of his birth. A devastating viral illness called poliomyelitis, which causes paralysis and respiratory failure, was ravaging the children of Copenhagen; at the height of the epidemic, as many as fifty were admitted to the city’s hospitals each day, many unable to breathe on their own. Modern ventilators had not yet been invented, and intubation wasn’t yet standard. External devices, such as the iron lung, were in short supply. An anesthesiologist named Bjørn Ibsen improvised by having tracheostomies performed on the children, inserting plastic tubes through incisions in their necks. He recruited two hundred and fifty medical students to breathe for them in shifts, squeezing rubber oxygen reservoirs by hand. The mortality rate was cut in half.
The children required around-the-clock monitoring, and a much higher level of care compared to typical patients. Ibsen set up a special unit for them in a converted nursing classroom at Copenhagen Municipal Hospital; it’s now recognized as one of the world’s first I.C.U.s. Grouping these patients together facilitated close observation, as did higher nurse-to-patient ratios. By the nineteen-seventies, such units were becoming standard in European and American hospitals. Today, I.C.U.s are filled with the latest medical technology, but the basic principles are the same as in Ibsen’s day: the aim is to carry the body through an emergency, so that healing might have a chance to proceed.
On arrival in the I.C.U., seven floors above our E.R., my intubated patient is greeted by a phalanx of nurses in full P.P.E. They shimmy him over from gurney to bed, careful not to tangle the many I.V. lines, tubes, and wires that are attached to his body. They switch him over to the I.C.U.’s ventilator, monitors, and infusion pumps; a large screen above his bed boots up, displaying his vital signs. Situated in the bed, surrounded by machines, he resembles a lone astronaut in a small cockpit.
The patterns that emerge in the I.C.U. unfold on a different timescale than the ones in the E.R. Downstairs, where I work, things happen quickly; upstairs, critical illnesses often evolve over the course of days or weeks. Tasks that the body usually accomplishes with ease, such as maintaining a normal blood pressure, become complex and highly elaborate when doctors take over: a team of nurses, pharmacists, physicians, and respiratory therapists holds rounds on its patients every day, examining them, reviewing new information from blood tests and X-rays, adjusting ventilator settings, antibiotics, diuretics, and blood pressure medications. Meanwhile, the team is looking for any hint about how or whether a patient might recover. Some covid-19 patients steadily deteriorate, their organ systems failing one after another despite maximal treatment. Others show steady progress, with clearing chest X-rays and decreasing dependence on their ventilators. Some oscillate, improving one day but worsening the next, a pattern which seems to be common for covid-19. Still others plateau, neither worsening nor improving, adrift on a sea of intensive care.
Ultimately, the ventilator is not a cure for covid-19; the machine can only provide support while doctors monitor and hope for improvement. In this way, the pandemic evokes the era before antibiotics, when no treatments existed for bacterial pneumonia and physicians could do little more than wait at a patient’s bedside for the “crisis”—the moment which heralded whether recovery might be at hand. At the crescendo of symptoms, one doctor wrote, in 1892, a patient might suddenly shift from “a state of extreme hazard and distress to one of safety.” Doctors today are marshalling extraordinary resources for their patients with covid-19. Even so, whether patients will pull through is often out of our hands; in a very real sense, they are alone in the fight.
Isolation and aloneness have emerged as familiar motifs in the covid-19 pattern. Owing to restricted visitation policies, patients are physically alone during their hospital stays; family members are unable to sit with their loved ones as they convalesce or hold their hands as they die. Not long ago, a nurse at one of the hospitals where I work brought a patient in a wheelchair down to an elevated, glass pedestrian bridge; the patient’s family stood on the street below, waving. We’ve been authorized to use our personal cell phones to record patients’ last words, or their wishes before intubation. Recently a friend of mine used his phone to send a final video of a dying woman to her family, before the team withdrew life support.
It’s not only covid-19 patients who are suffering from this isolation. Not long ago, an elderly woman came into the E.R.; she had lost her footing and fallen, striking her head and suffering a catastrophic brain injury. We could only make her comfortable. I stood outside her room in the E.R., watching her heart rate slowly wind down. Later, a colleague called her husband to tell him that she had died. “Do you have any friends or family that can be with you tonight?” he asked.
“No,” the husband said. “I’m alone.”
In the evenings, at dinner, my fiancée usually asks me how my day has been. As she passes the salad, I might tell her about a man in cardiac arrest whom we couldn’t save, or about a young woman I diagnosed with cancer, or about a covid-19 patient I intubated who probably won’t make it out of the hospital. Earlier this year, I told her about an elderly man who was brought in with some of the worst gangrene I’ve ever seen. Much of his right leg was dead, and the infection was almost certainly going to be fatal. As we raced to stabilize him, he kept asking for a slice of orange. It was only over dinner, as I told my fiancée about the case, that I realized that a slice of orange might have meant more to him than anything else we were doing.
Moments like that have made me think about normalcy—where we see it, how we feel it, how we maintain that feeling. When the word “normal” was first incorporated into English, in the seventeenth century, it meant something like “in conformity with a rule”; in Latin, the word “normalis” can refer to something that’s been built at right angles, using a carpenter’s square. At work, cardiac arrests, cancer, and gangrene are normal for me. I approach them as though with a carpenter’s square; I understand their rules and patterns. This is partly adaptive. To function, doctors must make the unimaginable manageable. And yet normalization can obscure things. While I was caring for the man with gangrene, I was so focussed on the normal, repetitive aspects of his care (antibiotics and a surgical evaluation) that it didn’t occur to me to slip out to the cafeteria. But what could be more normal than to want such a simple pleasure—the taste of a slice of orange—as you lay dying?
A few days ago, as we gowned up in P.P.E. to see a new patient, a colleague turned to me. “I guess this is our new normal, huh?” she asked. Meanwhile, Anthropologie and Old Navy have débuted their own lines of cloth masks. Outside the grocery store, I look for the duct-taped hash marks on the pavement that separate the entry line into six-foot increments; at work, elbow bumps have replaced handshakes. I’m a front-line doctor, and despite what I do—or perhaps because of it—the daily death statistics have almost come to seem normal, too: casualty reports from a familiar war.
It’s possible to become used to the life-or-death stakes of severe covid-19. For those who are able to make daily progress in the I.C.U., doctors dial down ventilator settings; when a patient becomes able to breathe on her own, the tube is taken out. Sometimes patients aren’t ready after all, and re-intubation is necessary, but, many other times, nurses in the I.C.U. text colleagues in the E.R. to give us the good news that a patient has been extubated and is doing well. Those texts lift the mood of the whole emergency department. The next steps are transfer to a regular medical floor for further monitoring and convalescence, then discharge. Every day, on my way into work, I see a few more of these patients in the lobby of the hospital, waiting in wheelchairs for a lift back into the world.
Other patients continue to deteriorate, or perhaps just plateau with no sign of improvement, and so the I.C.U. team and family members must make a difficult decision about when to transition to end-of-life care. There used to be a designated room for those conversations, adjacent to the unit, but now they take place on the telephone, or through Zoom or FaceTime. Once it’s agreed that further treatment is likely to be futile, the team shifts to comfort measures. Dialysis machines are powered down; I.V. pumps are disconnected; the vitals monitor is turned off, and its colored numbers disappear. Alarms go quiet, and the room falls silent. Morphine is given to ease pain and air hunger. Other medications decrease respiratory secretions, so that breathing can be as unencumbered as possible. Finally, the tube is removed, as delicately as possible, and the patient takes his or her last breaths.
If this is our new normal, I worry. What do we lose if we allow ourselves to become numb? In the early days of the pandemic, I was nervous but excited to be caring for the first critical cases of covid-19; now these cases can feel typical, common, part of a pattern, in conformity with a rule. I send labs, I order X-rays, I intubate. Over the Memorial Day weekend, more than three thousand new deaths due to covid-19 were reported across the country, each one a mother, a husband, a brother, a neighbor, a deacon, a teacher—a whole galaxy of human life wrecked by a dangerous plague that’s on the loose and against which we have tools to use, if only our government would give them to us. To normalize this is to invite complacency, and complacency, as much as the virus itself, ought to be our enemy.
(Author’s bio: By Clayton Dalton)
(Copied from The New Yorker)
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