Book Review: One Hundred Prayers: God's answer to prayer in a COVID ICU

By Anthony Eckshar MD

One Hundred Prayers: God's answer to prayer in a Covid ICU
amazon.com

The book is a very moving and spell-binding collection of the encounters between patients and physicians during the worst of the COVID-19 epidemic and Dr. Eckshar’s prayers for each of them. A devout person can read this as a prayer devotional; however, it is much more - an authentic account of what doctors and nurses go through working in the ICU. This book might help encourage people who are searching for faith, especially those who face severe illnesses in themselves or a loved one. It may also encourage doctors, nurses and other healthcare workers who might have been burned out working during the pandemic. Its main message is that faith, compassion, and the scientific method must co-exist. It is also a great review of the history of COVID pandemic from the trenches of patient care in the ICU. For nonmedical people it  should provide a clue to how doctors and nurses think. Hopefully, this book will lift everyone up and instill deep admiration and respect for the ICU doctors and nurses, and perhaps teach you a little something about faith.

Richard A. Robbins MD

Editor, SWJPCCS

Cite as: Robbins RA. Book Review: One Hundred Prayers: God's answer to prayer in a Covid ICU. Sodsuthwest J Pulm Crit Care Sleep. 2023;27(1):14. doi: https://doi.org/10.13175/swjpccs032-23 PDF

Medical School Faculty Have Been Propping Up Academic Medical Centers, But Now Its Squeezing Their Education and Research Bottom Lines

One of my former fellows emailed me an article from Stat+ titled “Hospitals Have Been Financially Propping Up Medical Schools, But Now It’s Squeezing Their Bottom Lines”. The article reports that hospitals have been financially supporting medical schools and are feeling their bottom line squeezed (1). An example cited is the purchase of the University of Arizona Medical Center in Tucson by Banner Health and an agreement by Banner to help both of Arizona’s financially struggling medical schools. Financial statements show that Banner has dedicated roughly $2 billion to the schools and a faculty medical group it bought as part of the 2015 deal. Banner is blaming these expenses for shrinking its operating margin from 5% before the deal to 1% today (1). The businessmen who purchased the academic medical centers initially embraced these mergers but now are facing the financial reality of managing a medical school (1). It seems likely that there will be increasing friction between hospitals and their affiliated medical schools competing for funds. These editorial points out the other side of coin, i.e., that the medical schools are financially shoring up academic medical centers.

Count me as one who is not overly sympathetic to businessmen in charge of academic medical centers. They now collect the pro fees from physicians, paying themselves first. Banner is a good example where the CEO made in excess of $25 million in 2017 compared to the average $155,212 earned by physicians (2). This means the CEO earned more in 2 days than the average physician earned in a year or about $164 for every $1 earned by a physician. As medical education has become more expensive, medical schools now find themselves increasingly reliant on the money they get from their faculty seeing patients and less able to count on other revenue sources, like federal research funding or tuition (Figure 1).

Figure 1. Source of medical school income (1). Click here to view Figure 1 in a new enlarged window.

Furthermore, many physicians, especially pulmonary and critical care physicians, worked above and beyond during the COVID-19 pandemic (3). The pandemic’s resulting disruptions affected academic and educational pursuits such as research productivity, access to mentoring, professional development and networking and personal wellness (3). These disruptions were compounded for faculty at high COVID-19–volume medical centers where clinical responsibilities were necessarily prioritized. Many recognize that it is important to prepare for a postpandemic accelerated burnout syndrome that disproportionately affects early-career physician-scientists at high-volume centers. However, rewards for service have largely been unfulfilled (3).

One quick comment on the validity of hospital ledgers. Physicians are usually shown the finances that businessmen want them to see. The accounting can be prepared to justify further physicians sacrifice of even more time and money. Hospitals tend to see the money generated by physicians, nurses and other healthcare providers as “their” money (1). They see a revenue stream going to a medical school as robbing them of “their” profit and want to know what they get for it (1).

All the above stems from the “hyperfinancialization” of medicine and applying a corporate structure to institutions which should be not-for-profit other than in name only. It is hard to pinpoint an inflection point in medicine, the point in which the direction changed and the mission changed. Maybe it is because in reality the inflection point is not a point but a large blotch, a series of smaller dots in coalesce into a bigger stain brought on by greed. I worry that the core of medicine has been forever damaged; that the doctor patient bond has been replaced with institute/provider - patient service. This model has proven to be more costly, less rewarding and associated with higher burnout. Yet, we continue to move forward with this model. Mergers between community-based physicians and hospitals which are supposed to bridge the gap between evidenced-based care and practice-based care has only served to devalue the intangibles in medicine further, always looking for what can be standardized and more importantly… billable. A corporate structure with a board, CEO, and a variety of vice presidents and other corporate titles has not served the public well. Physicians make less, administrators make more and hospital services have declined or not improved (4). One needs to only look at outcomes such as life expectancy and costs as a percent of GNP (gross National product) to recognize there is a problem (5).

Many, including myself, remain skeptical of the intrusion of business interests into medical education. The oversight of academic medical centers provided by organizations such as the Accreditation Council for Graduate Medical Education (ACGME) that protects the public’s interests remain inadequate. Presently only a written statement must be provided every 5 years that “documents the Sponsoring Institution’s commitment to education by providing the necessary financial support for administrative, educational, and clinical resources, including personnel.” This is to be reviewed, dated, and signed by the designated institutional official (DIO), a representative of the Sponsoring Institution’s senior administration, and a representative of the Governing Body (6). It seems unlikely that review every 5 years by a DIO and other officials employed and dependent on medical center support is likely sufficient.

To provide oversight I recommend that a system be developed to hold medical center administrators accountable for decisions that lead to a decline in efficiency at both in the medical center and their affiliated medical schools (4). If they are in charge of medical care as they seem to think they are, then deficiencies need to be laid at their feet - the same for medical education and research. After all they now credential the healthcare providers and any deficiencies would seem to have resulted from a poor work environment or  poor administrative judgment in credentialing. It is time that administrators are held to the same standard. Physicians are required to have continued medical education, board certifications, etc. for credentialling. Present hospital systems where a board elects its own members with the nomination and blessing by the hospital CEO need to end. The chief of staff should be elected by the hospital staff and the majority of members of a hospital board need to be independent of the CEO and knowledgeable about the practice of medicine at that medical center (7). If administrators are not acting in a manner that promotes the doctor patient bond, increases the access to care, promoting cost containment in a transparent manner, and promote physician well-being, then it is time for them to go. 

Richard A. Robbins MD

Editor, SWJPCCS

References

1. Bannow T. Hospitals have been financially propping up medical schools, but now it’s squeezing their bottom lines. Stat+. April 14, 2022. Available at: https://www.statnews.com/2022/04/14/hospitals-medical-schools-financial-relationship-tension-squeezing-bottom-line/ (requires subscription).
2. Robbins RA. CEO compensation-one reason healthcare costs so much. Southwest J Pulm Crit Care. 2019;19(2):76-8. [CrossRef]
3. Kliment CR, Barbash IJ, Brenner JS, Chandra D, Courtright K, Gauthier MC, Robinson KM, Scheunemann LP, Shah FA, Christie JD, Morris A. COVID-19 and the Early-Career Physician-Scientist. Fostering Resilience beyond the Pandemic. ATS Sch. 2020 Oct 23;2(1):19-28. [CrossRef] [PubMed]
4. Jeurissen PPT, Kruse FM, Busse R, Himmelstein DU, Mossialos E, Woolhandler S. For-Profit Hospitals Have Thrived Because of Generous Public Reimbursement Schemes, Not Greater Efficiency: A Multi-Country Case Study. Int J Health Serv. 2021 Jan;51(1):67-89. [CrossRef] [PubMed]
5. Cohen J. Dismal U.S. Life Expectancy Trend Reflects Disconnect Between Dollars Spent On Healthcare And Value Produced. Forbes. Nov 1, 2020. Available at: https://www.forbes.com/sites/joshuacohen/2020/11/01/dismal-us-life-expectancy-trend-reflects-disconnect-between-dollars-spent-on-healthcare-and-value-produced/?sh=3657f353847e (accessed 5/2/22).
6. Accreditation Council for Graduate Medical Education. Institutional Requirements. Available at: https://www.acgme.org/globalassets/pfassets/programrequirements/800_institutionalrequirements2022.pdf (accessed 5/2/22).
7. Robbins RA. Time for a Change in Hospital Governance. Southwest J Pulm Crit Care Sleep. 2022;24(3):43-5. [CrossRef]

Cite as: Robbins RA. Medical School Faculty Have Been Propping Up Academic Medical Centers, But Now Its Squeezing Their Education and Research Bottom Lines. Southwest J Pulm Crit Care Sleep. 2022;24(5):78-80. doi: https://doi.org/10.13175/swjpccs023-22 PDF

Protecting the Public’s Health-Except in Tennessee

State regulatory boards that regulate professionals such as doctors, nurses, psychologists, etc. are often appointed by politicians and headed by lawyers. Under this category has been most Medical Boards and their parent organization the Federation of State Medical Boards. Although they claim to be protecting the public, they seem more concerned with identifying “disruptive” physicians and blacklisting them through the National Practitioner Data Bank (1). However, in July the Federation issued a warning to physicians against propagating COVID-19 vaccine misinformation and disinformation citing a "dramatic increase" by physicians (2). The statement gave some hope that the Federation was striving to maintain some degree of professional standards by saying that spreading disinformation to the public was dangerous because physicians enjoy a high degree of public credibility.

The Tennessee Board of Medical Examiners followed the Federation’s lead by issuing a verbatim restatement warning that physicians who spread false information about COVID-19 vaccinations risk suspension or revocation of their medical license. Under repeated threats by Rep. John Ragan, R-Oak Ridge, co-chair of the State of Tennessee’s Joint Government Operations Committee, the warning was removed on December 7. 

Figure 1. Representative John Ragan.

Rep. Ragan insisted board members do not have the authority to create a new disciplinary offense without the approval of the lawmakers on his committee. He threatened to dissolve the board and appoint all new members if it did not immediately take it down and the Tennessee board succumbed to Rep. Ragan.

Across the country, state medical licensing boards are struggling to balance the politics and public interest with how to respond to scientifically baseless public statements about COVID-19 by some physicians. The Federation says the statements are increasing public confusion, political conflict, preventable illnesses and deaths (3). There have been only a small number of disciplinary actions by medical boards against physicians for spreading false COVID-19 information. Critics say the boards have been weak in responding to these dangerous violations of medical standards. For example, Dr. Lee Merritt, an orthopedic surgeon, from my home state of Nebraska has appeared on talk shows and in lecture halls to spread false information about COVID-19 (4).

Figure 2. Dr. Lee Merritt

Among her claims: that the SARS-CoV2 virus is a genetically engineered bioweapon (the U.S. intelligence community says it is not) and that vaccination dramatically increases the risk of death from COVID (data show the opposite). The entire pandemic, she says in public lectures, is a vast global conspiracy to exert social control. Yet, in October, she was able to renew her medical license in the state of Nebraska. Documents obtained through a public records request by NPR showed it took just a few clicks: 12 yes-or-no questions answered online allowed her to extend her license for another year.

Physician ethics have also been under assault in medical schools. Several medical schools recently founded by healthcare organizations seem overly concerned that their graduates might object to some COVID-19 statements on a scientific basis (5). Through these new medical schools, business interests hope to indoctrinate medical graduates on how to serve the public any way a healthcare administrator tells them. Even a healthcare organization as lofty as the American College of Physicians now has their ethics statement written by a lawyer (6).

These, as well as other examples, demonstrate that as we lose control of the ethics of our profession, we lose control of our profession. Assuming the physicians reading this editorial are against the dissemination of false information, what can we do? One example, came from Houston, Texas where Dr. Mary Bowden, who posted "harmful" and "dangerous misinformation" about Covid-19 and its treatments on social media, had her medical staff privileges suspended. She subsequently resigned from Houston Methodist (7).

We as physicians should work through our medical staffs over these issues. Hopefully, we will not try to repress legitimate concerns from physicians expressing objections to hospital or medical staff policies through appropriate channels. However, if the medical staff chooses to proceed over those objections, each physician can use their conscience to refuse to work with physicians disseminating misinformation. We are one medical family and what hurts one of us, hurts us all.  

Richard A. Robbins, MD                                  

Editor, SWJPCC

References

1. Robbins RA. The disruptive administrator: tread with care. Southwest J Pulm Crit Care. 2016:13(2):71-9. doi: http://dx.doi.org/10.13175/swjpcc049-16.
2. Federation of State Medical Boards. FSMB: Spreading Covid-19 Vaccine Misinformation May Put Medical License at Risk. Available at: https://www.fsmb.org/advocacy/news-releases/fsmb-spreading-covid-19-vaccine-misinformation-may-put-medical-license-at-risk/ (accessed 12/13/21).
3. Sawyer N, E Bloomgarden E, Cooper M, Nichols T, Hickie C. Opinion: State medical boards should punish doctors who spread false information about covid and vaccines. The Washington Post. September 21, 2021. Available at: https://www.washingtonpost.com/opinions/2021/09/21/state-medical-boards-should-punish-doctors-who-spread-false-information-about-covid-vaccines/ (accessed 12/13/21).
4. Brumfiel G. A doctor spread COVID misinformation and renewed her license with a mouse click. Heard on All Things Considered. November 4, 2021. Available at: https://www.npr.org/sections/health-shots/2021/11/04/1051873608/a-doctor-spread-covid-misinformation-and-renewed-her-license-with-a-mouse-click (accessed 12/13/21).
5. Shireman R. For-Profit Medical Schools, Once Banished, Are Sneaking Back. The Century Foundation. March 20, 2020. Available at: https://tcf.org/content/commentary/for-profit-medical-schools-once-banished-are-sneaking-back-onto-public-university-campuses/ (accessed 12/13/21).
6. Sulmasy LS, Bledsoe TA; ACP Ethics, Professionalism and Human Rights Committee. American College of Physicians Ethics Manual: Seventh Edition. Ann Intern Med. 2019 Jan 15;170(2_Suppl):S1-S32. [CrossRef] [PubMed]
7. Watts A, Elassar A. Texas doctor suspended for spreading 'misinformation' about Covid-19 submits resignation letter. November 16, 2021. Available at: https://www.cnn.com/2021/11/13/us/houston-doctor-suspended-covid-19/index.html (accessed 12/13/21).

Cite as: Robbins RA. Protecting the Public’s Health-Except in Tennessee. Southwest J Pulm Crit Care. 2021;23(6):162-4. doi: https://doi.org/10.13175/swjpcc067-21 PDF 

Combating Morale Injury Caused by the COVID-19 Pandemic

Healthcare burnout is on the rise during the great COVID-19 pandemic. Healthcare burnout is emotional exhaustion, cynicism and depersonalization, reduced professional efficacy and personal accomplishment caused by work-related stress. Numerous factors cause healthcare burnout: long work hours, lack of respect, difficult patients, feeling of helplessness, lack of healthcare worker safety and leadership seemingly disconnected from the universal goal of all healthcare workers—saving people’s lives. Morale injury occurs when hands are tied from giving each and every patient the very best care, he/she deserves. Healthcare workers experience disappointment from doing a great job when saving lives. Hearing negative feedback about inconsequential small details and lack of praise for their great deeds can understandably lead to depression, anxiety and fear about the future. In order to combat negative feelings built up over time, it is important to fight back with positive feelings. This requires active positive thinking and not negative thoughts that can consume you. Throughout the day and night all kinds of thoughts flow through our mind. This cannot be controlled but you can counter negative thoughts by thinking of positive thoughts. There are things to be grateful for everyday in life: 1) life itself; 2) family; 3) purpose; 4) belonging to something greater than yourself; 5) the weather; and 6) all of the boundless opportunities that lay ahead. According to Gautama Buddha (1),

“to enjoy good health, to bring true happiness to one’s family, to bring peace to all, one must first discipline and control one’s own mind. If a man can control his mind, he can find the way to Enlightenment, and all wisdom and virtue will naturally come to him”.

Healthcare workers expend so much of their time and energy helping others, they themselves can end up in a void. Therefore, it is important that healthcare workers set aside a time for rejuvenation. (I personally find exercise as a great way to recover and let my mind clear after a long day in the hospital). Anything that gives you joy will suffice such as listening to music, singing, reading, laughing, playing with your children or having a funny conversation with your friends and family. Even something as simple as smiling at a stranger walking by and saying good morning will not only make you feel better, but it will also make the other person feel better. I say hello to everyone I pass in the hospital hallway and it makes me feel good.

It is always life or death in the intensive care unit (ICU). Working as an Intensivist, I am exposed to extraordinary situations every day. Thus, prior to walking into the ICU, I make it a point to think of something positive and smile because once those doors open up all Hell can break lose. Lack of personal protective equipment (PPE) because of the COVID-19 pandemic and staff isolation has demoralized everyone. I try my best to provide some encouragement in this very high mortality setting. It is important to let the staff know about those patients that survived so they know they are truly making a difference and see there is light at the end of the tunnel (2).

As Friedrich Nietzsche said, “that which does not kill us, makes us stronger” (1). That saying can be true for some but not all. You have to have a particular mindset in order to learn from these terrible situations and rise above like a phoenix from the ashes. “These life experiences have been called ‘crucibles’, severe test or trial that is unplanned, intense and often traumatic” (3). Unfortunately, not all of us can handle such diversity and may develop post-traumatic stress from such life experiences and never recover. That is why it is important to try and look at such profound life altering events as lessons. There is always something to be learned from every situation. Even negative events can be turned into positive experiences that build on a person’s character. For example, immediately after a COVID-19 surge descended on one hospital I was working at, I immediately learned to question the reliability of the estimated oxygen saturation measured by pulse oximetry (SpO₂) and to intubate as quickly and as safely as I could in order to avoid exposing staff to the SARS-CoV-2 virus as well as preventing cardiac arrest during intubation of those critically ill patients. It was a Sunday, the day before Doctor’s day 2020 in America when all of a sudden, the flood gates opened from the wards and literally five patients within minutes all required immediate intubation because all of them had critical oxygen levels despite maximal high-flow therapy. One after another the patients arrived in succession into the ICU and I went from bed-to-bed intubating all of them. This kicked off many months of treating very high numbers of critically ill patients two to three times the volume I was used to treating. Instead of being overwhelmed by the pressure, I focused on each patient and discovered the best treatment options all the while making sure that I did not add to the depressing morale by complaining about how difficult the working conditions were in order to keep the ICU team motivated. As Winston Churchill repeated during the daily bombardment of England by the Germans in WWII—keep calm and carry on (4).

I had never seen the need for so many arterial blood gas draws (ABG) and neither had the laboratory staff. One evening around midnight I needed around 20 ABGs. Instead of shrinking from the challenge, two laboratory technicians stepped up and brought the machine that processes the ABGs to the ICU and enthusiastically ran all of the tests. This made a huge difference in patients’ outcomes because what I was seeing was a big discrepancy between the continuous patient SpO₂ monitoring and the actual partial pressure oxygen (PaO₂). The true measurement of PaO₂ derived from the ABG helped confirm my suspicion that many patients were actually hypoxic despite having normal readings on the pulse oximeter, allowing me to adjust the ventilator appropriately and preventing death. I praised the laboratory workers in person and let their supervisors know what a terrific job had been done. They never complained despite being understaffed (some of their colleagues quit and never showed up for work that day). The lesson I learned from all of that was that as long as I kept pushing myself, I could save those patients despite the large volume and lack of supplies which gave me a great feeling of accomplishment. I then travelled to other hospitals facing similar situations and was able to continue this way for over a year.

Now I realize that not everyone can handle the pressure that follows a crucible event. I, myself, struggle as well and I have to remind myself to carry on and stay positive, which is not always an easy task. I definitely have not mastered this strategy yet, but I am trying. Marcus Aurelius said “you have the power over your mind – not (on) outside events. Realize this, and you will find strength” (1). Throughout our lives we will encounter hardships but as we get through one and then the other encounter, we realize that we can handle it. Know that the next life event is just another challenge. From the 2^nd century BCE Epicurus reminds us that “a person will never be happy if they are anxious about what they do not have” (1). Use that incredible focus and discipline you summoned from deep within during decades of study to train your mind into thinking positively. “Our life is shaped by our mind; we become what we think. Joy follows a pure thought like a shadow that never leaves,” Gautama Buddha (1). Remain altruistic and continue to take care of those in need and you will live a happy and joyous life.

Evan D. Schmitz, MD

La Jolla, CA USA

References

1. Robledo, IC. 365 Quotes to Live Your Life By. Powerful, Inspiring, & Life-Changing Words of Wisdom to Brighten Up Your Days. Published by I. C. Robledo, 2019.
2. https://www.goodreads.com/quotes/521459-there-is-a-light-at-the-end-of-everytunnel#:~:text=Quotes%20%3E%20Quotable%20Quote,%E2%80%9CThere%20is%20a%20light%20at%20the%20end%20of%20every%20tunnel,to%20be%20longer%20than%20others.%E2%80%9D
3. Warren G. Bennis and Robert J. Thomas. Crucibles of Leadership. 2002. Harvard Business Review.
4. https://london.ac.uk/about-us/history-university-london/story-behind-keep-calm-and-carry.

Cite as: Schmitz ED. Combating Morale Injury Caused by the COVID-19 Pandemic. Southwest J Pulm Crit Care. 2021;22(5):106-8. doi: https://doi.org/10.13175/swjpcc015-21 PDF

Clinical Care of COVID-19 Patients in a Front-line ICU

Robert A. Raschke MD

Tyler J. Glenn MD

Kim I. Josen MD

HonorHealth Scottsdale Osborn Medical Center

Scottsdale, AZ USA

These are some clinical observations made after over the past 10 months, working in a busy COVID-19 ICU unit in Scottsdale, AZ. The opinions expressed here are those of the private practice authors.

Overview of triage and rounding on large numbers of COVID-19 patients in the ICU service. Our approach to bedside care of our ICU service has required abbreviation for the sake of efficiency in the face of more than a doubling of our census. Our approach to rounding is opinion-based. We’ve been forced to evolve our triage and rounding systems in order to survive.

Our hospital uses the Abbott ID-Now® rapid point-of -are test for screening all COVID-19-asymptomatic patients admitted to our hospital, but due to its low sensitivity in hospitalized patients (1). We do not trust it to rule-out COVID-19 in patients with pneumonia being admitted to the ICU and also order an in-house PCR for such patients prior to, or upon ICU admission. We are cautious about transferring COVID-19 patients out of the ICU on bilevel positive airway pressure (BiPAP) or high-flow nasal cannula since many such patients have deteriorated and bounced-back to the unit within the subsequent week.

We try to see as many of our COVID-19 ICU patients (who are practically all our patients) sequentially, without interruption if possible, leaving our masks and gowns on continuously and moving quickly from room to room, changing only gloves between patients unless a bacterial pathogen that requires contact isolation has been identified. Little/no helpful information can be gleaned by entering the room of patient who is proned in a rotoprone bed. Such patients may only be supined for brief periods, sometimes in the middle of night shift; and discussion with the nurses regarding their physical exam findings during supine positioning is high yield. Auscultation of COVID-19 patients using isolation stethoscopes is seldom of value. Palpation of the neck/trunk for crepitus, neurological examination (especially in patients emerging from heavy sedation and/or supined after prolonged proning), and assessment of fluid status are high yield. We keep track of how many days the patient has received mechanical ventilation, the cumulative fluid balance (which sometimes gets very positive), and signs and lab values possibly related to complications of COVID-19 discussed below. The duration of antibiotics and sedation medications needs constant monitoring to avoid overuse. We do not routinely follow serial INR, ferritin, CRP, or D-dimer, since these do not affect patient management. We sometimes use BNP and procalcitonin to trigger further cardiac or infectious disease evaluations respectively. We do not treat isolated elevated procalcitonin with antibiotics, nor do we treat isolated d-dimer with therapeutic dose anticoagulation.

We have been conservative in our treatment of COVID-19, relying primarily on dexamethasone and usual evidence-based critical care practice. Over the course of the outbreak, our conservative approach has been validated; various hyped but off-label therapies (hydroxychloroquine, antirheumatic therapies, universal therapeutic anticoagulation) have failed to show benefit and possibly caused harm when subjected to evidence-based scrutiny (2,3). Benefits of remdesivir in patients with advanced respiratory failure seem unclear/minimal (4). Most of our patients present to the ICU in the second or third week of illness, already having developed IgG antibodies and therefore unlikely to benefit from convalescent serum or monoclonal antibodies.

Clinical course and management of respiratory failure. Many patients remain awake and able to tolerate spontaneous ventilation with non-invasive ventilation and/or high-flow nasal canula oxygen delivering high FiO2, for as long as two weeks before they either recover or require endotracheal intubation. Before the current outbreak, it was unusual to manage severely hypoxemic patients without intubation and mechanical ventilation. For COVID-19, it seems to be the norm, with intubation delayed until the last possible moment, as it is unclear that mechanical ventilation with its attendant complications (immobility, sedation, invasive support apparatus) offer any definite benefit. Once intubated, many patients seem to transition abruptly to refractory hypoxemia and hypercarbia, which previously would have made them candidates for Extracorporeal membrane oxygenation (ECMO) transfer. In one recent case, we requested ECMO evaluation for a patient prior to intubation, anticipating that he would deteriorate badly immediately thereafter. The consultant requested intubation before ECMO evaluation, and indeed, once intubated, the patient immediately became too unstable for uncannulated transfer. In general, the numbers of patients fulfilling historical criteria for ECMO consideration have greatly overwhelmed ECMO capacity.

We have tried several approaches to invasive mechanical ventilation, but each has drawbacks. Our primary mode of ventilation, pressure-regulated volume control, has sometimes resulted in high plateau and driving pressures as respiratory system compliance worsens. We’ve used pressure control ventilation in some patients to limit driving pressure, but this has led to unrecognized worsening of respiratory acidosis in some. We have managed several episodes of cardiac arrest due to uncontrolled combined respiratory and metabolic acidosis in COVID-19 patients being treated with permissive hypercapnia ventilation who subsequently developed acute renal failure. We are now trying airway pressure-release ventilation (APRV) as an optional approach in which we try to avoid proning and heavily sedating the patient, but aim for Richmond Agitation-Sedation Scale (RASS) of -1 to -2 and allow maintenance of spontaneous respiratory efforts by the patient during “T high”. It is not clear whether any of these approaches results in better clinical outcomes.

Our use of prone positioning has increased dramatically. Self-proning of awake patients receiving non-invasive mechanical ventilation or high-flow nasal canula oxygen has allowed some to survive episodes of severe oxygen desaturation and avoid intubation. We have extensively utilized proning in mechanically ventilated patients with PaO2/FiO2 <150. Several of our patients experienced cardiopulmonary arrest when briefly supined resulting in several fatalities. Consequently, we have learned to placed US-guided internal jugular central venous catheters and chest tubes in patients in proned and semi-proned positions. We have noted that at some point, prone positioning needs to be abandoned if the patient is ever going to recover, even if their PaO2/FiO2 ratio falls upon supine positioning. In such patients, supine positioning allows reduction of heavy sedation and resumption/improvement of spontaneous breathing efforts that may allow ventilator weaning to slowly proceed.

Complications of COVID-19 in the ICU. We have seen more barotrauma than previously described, some occurring during non-invasive ventilation prior to endotracheal intubation (5). Point of care chest ultrasonography has been instrumental in several cases in which anterior pneumothoraces were not clearly apparent on chest radiography, except perhaps as a deep sulcus sign, and also to rapidly rule-out pneumothorax as a cause of acute cardiopulmonary decompensation.

Hypotension requiring intravenous vasopressors is common (6). In many cases, it seems due to sepsis and sedation with propofol and/or dexmedetomidine. We have occasionally seen acute or chronic cardiomyopathy, but not as often as noted early in the pandemic (7). We have repeatedly diagnosed relative adrenal insufficiency later in the hospital course –after dexamethasone has been discontinued. Such patients commonly received etomidate during intubation which could possibly be contributory.

Bacterial co-infections are uncommon at presentation, consistent with published meta-analysis (8), and we do not routinely give antibiotics to all patients with COVID-19 pneumonia up front. Later in the course of mechanical ventilation, many patients experience recurrent fever, leukocytosis, elevated procalcitonin and/or worsening pulmonary status prompting endotracheal secretion and blood cultures and empirical antibiotics. We have commonly isolated a wide variety of potential bacterial pathogens from the respiratory secretions of such patients including methicillin-sensitive Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus aureus (MRSA), gram negative rods, some multi-drug resistant. We recently isolated carbapenem-resistant Enterobacter. It is uncertain whether these represent true cases of secondary pneumonia.

Coagulopathy related to COVID-19 is complex and increased risk of thrombosis and bleeding seem apparent (9). We administer enhanced prophylactic-dose anticoagulation to all our patients (typically 40mg enoxaparin every 12 hours in patients without morbid obesity or renal failure), but do not treat elevated d-dimers with therapeutic anticoagulation in the absence of documented venous thromboembolism (4). A minority of our patients have had documented venous thromboemboli prior to ICU admission and a few have had acute myocardial infarctions and strokes. We try to get CT angiography of the chest and doppler ultrasound of the lower extremities on all patients requiring mechanical ventilation. Bedside ultrasonography demonstrating acute right heart failure has been helpful in a few cases in which pulmonary emboli were suspected but the patient too unstable for CT angio or VQ scan. Three of our patients experienced CNS hemorrhages, two of which were fatal. Gastrointestinal bleeding is not uncommon.

Acute renal failure is common and complicates permissive hypercarbia, sometimes necessitating high dose bicarbonate infusions (6). Circuit thrombosis during dialysis is common, perhaps a manifestation of COVID-19 coagulopathy, and sometime necessitating therapeutic anticoagulation.

End of life issues. It is our impression that the mortality in intubated patients is higher this winter than it was previously in the pandemic. This might be because patients are receiving more aggressive therapy earlier in the course of illness, and often are only intubated after failing a prolonged course of non-invasive mechanical ventilation. Perhaps this selects treatment-unresponsive patients for intubation. Prognostication seems very difficult. We treated an 89-year patient with severe comorbidities who rapidly recovered after a 4-day course of mechanical ventilation and a 28-year-old previously healthy man who died despite receiving veno-venous ECMO. We have not found clinical scoring systems such as

Sequential Organ Failure Assessment (SOFA) to be helpful in prognosis, since many patients have isolated severe single organ dysfunction at the time of ICU admission, and therefore have similar SOFA scores – mostly comprised of points given for severe respiratory failure. Old-fashioned bedside common sense and family discussion still seem the best approach to determining code status. It is logistically difficult/impossible to safely administer CPR to some patients who are proned, especially those that are morbidly obese. We have told families that we are instituting limited code status (no CPR, no ACLS) in such situations, subsequently discussing resumption of full code status if/when the patient recovers enough to tolerate resumption of supine positioning.

Psychosocial issues. Incredible emotional injury is being experienced by patients’ families. Several of our patients come from families in which two or three primary relatives have already died from COVID-19. We called one patient’s wife to inform her that her husband had narrowly survived a prolonged arrest secondary to pneumothorax, interrupting her during her son’s funeral, who had died from COVID-19 pneumonia the previous week. Eventually, that family suffered the death of three primary relatives from COVID-19 over the course of three weeks.

We have tried to use cellular technology to help mitigate restricted family visitation, but it seems a poor substitute. Our nurses have had some patients make cell phone video messages to their loved ones before intubation – sometimes the last memory their families will ever have of them. We have held our cellphones by the ears of COVID-19 patients as they are dying so that their loved ones can say goodbye. It was heart-wrenching to hear a husband of 42 years sobbing uncontrollably over the phone, telling his dying wife that he loved her, and how much he’s going to miss her as we prepared to remove her endotracheal tube to let her die.

The nurses, respiratory techs and physicians have shown incredible bravery and self-sacrifice and outward morale is good. But all are suffering severe vicarious injuries the full effect of which may not be apparent for years to come. Much of the human connection previously so important to ICU practice has been lost – few of the patients can interact, and the families are generally not allowed to visit. We simply don’t have the time anymore to call them as often as we would like, and it’s unusual to call them with good news. We should plan for a future increase in PTSD and burn-out among healthcare providers.

We are grateful to have received my COVID-19 vaccination, and I was sincerely astounded by the organizational excellence of the vaccination event implemented by HonorHealth here in Phoenix. They did a very good job that will serve our entire vaccine-willing population in the coming months.

References

1. Basu A, Zinger T, Inglima K, Woo KM, Atie O, Yurasits L, See B, Aguero-Rosenfeld ME. Performance of Abbott ID Now COVID-19 Rapid Nucleic Acid Amplification Test Using Nasopharyngeal Swabs Transported in Viral Transport Media and Dry Nasal Swabs in a New York City Academic Institution. J Clin Microbiol. 2020 Jul 23;58(8):e01136-20. [CrossRef] [PubMed]
2. WHO Solidarity Trial Consortium, Pan H, Peto R, Henao-Restrepo AM, et al. Repurposed Antiviral Drugs for Covid-19 - Interim WHO Solidarity Trial Results. N Engl J Med. 2020 Dec 2:NEJMoa2023184. [CrossRef] [PubMed]
3. Salama C, Han J, Yau L, et al. Tocilizumab in Patients Hospitalized with COVID-19 Pneumonia. N Engl J Med. 2020 Dec 17. [CrossRef] [PubMed]
4. American Society of Hematology. COVID-19 Resources: COVID-19 and VTE/Anticoagulation: Frequently asked questions. Version 5.1 (last updated December 24, 2020). Available at: https://www.hematology.org/covid-19/covid-19-and-vte-anticoagulation (accessed 1/3/21).
5. Botta M, Tsonas AM, Pillay J, et al., PRoVENT-COVID Collaborative Group. Ventilation management and clinical outcomes in invasively ventilated patients with COVID-19 (PRoVENT-COVID): a national, multicentre, observational cohort study. Lancet Respir Med. 2020 Oct 23:S2213-2600(20)30459-8. [CrossRef] [PubMed]
6. Cummings MJ, Baldwin MR, Abrams D, et al. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. Lancet. 2020 Jun 6;395(10239):1763-1770. [CrossRef] [PubMed]
7. Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, Lee M. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA. 2020 Apr 28;323(16):1612-1614. [CrossRef] [PubMed]
8. Langford BJ, So M, Raybardhan S, Leung V, Westwood D, MacFadden DR, Soucy JR, Daneman N. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clin Microbiol Infect. 2020 Dec;26(12):1622-1629. [CrossRef] [PubMed]
9. Helms J, Tacquard C, Severac F, et al., CRICS TRIGGERSEP Group (Clinical Research in Intensive Care and Sepsis Trial Group for Global Evaluation and Research in Sepsis). High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020 Jun;46(6):1089-1098. [CrossRef] [PubMed]
10. Hayek SS, Brenner SK, Azam TU, et al. In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study. BMJ. 2020 Sep 30;371:m3513. [CrossRef] [PubMed]

Cite as: Raschke RA, Glenn TJ, Josen KI. Clinical Care of COVID-19 Patients in a Front-line ICU. Southwest J Pulm Crit Care. 2021;22(1):11-15. doi: https://doi.org/10.13175/swjpcc070-20 PDF