Scenes from the COVID battlefield

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I wake to a WhatsApp call. It is my aunt, who lives in India. “We are all worried about you,” she says. “All of us here are praying for you. Make sure that you stay safe.” Coincidentally, she is a nun, so I’ll take her prayers whenever I can get them. I promise her that I will stay safe, and then I get ready to enter the ER. I don my armor: my N95 mask, my eye protection, my surgical cap. I prepare for war.

As I open the electronic medical record, I smile as I look at the comments. We often place these in the charts of particular patients to keep the entire team aware of the next steps and final disposition. In a sea of high-risk COVID, rule out COVID, and likely COVID, one of the comments reads: “Yay! A non-COVID admission!”

It will be the last of the day.

As an emergency medicine resident in New York’s Westchester County, at the epicenter of the coronavirus outbreak, the last week has been exponential. Our emergency department has undergone extensive preparations, constructing outdoor tents to triage potential COVID-19 patients and sending home the ones that we can with instructions to self-quarantine. Initially, we had fewer total patients come to our emergency room. It was even, dare I say it, quiet. But we knew that the tsunami was coming.

And now it is here.

The night team has had a busy night, filled with patients who cannot breathe. They tell me that there is one patient we must keep an eye on. He is in his early 20s, Spanish speaking only, and in a sign that is quickly becoming classic for COVID-19, he is having increasing oxygen requirements. He is working harder and harder to breathe. It is becoming increasingly clear that this patient will require intubation and a ventilator. The sooner we do it, the better shot he will have to successfully make it through the procedure.

The patient is unaware of this reality, and it is our job to break the news, to answer all of his questions, and to gain his informed consent. In the department at this particular time, my high school AP Spanish is the best Spanish we have. It will have to do. I gown up, adjust my N95 mask, and pull my eye protection straight. “Usted necesita una machina para ayudar con respiracion, Necesitamos a intubarlo. Sabe que es intubar?”

The patient says that he understands. He asks how long he will need to be on the machine. I tell him that I do not know.

He confirms that he will call his mother and explain what is going on, but he asks me to explain to her as well. She asks me if everything is going to be OK. I tell her that I do not know.

We get anesthesia on board. No messing around with this young one, we are going to aggressively paralyze and sedate him with vecuronium, fentanyl, and midazolam to ensure that the machine completely takes over his breathing. The intubation takes less than 15 seconds. In that time, the patient’s oxygen levels drop from 91 percent to 72 percent. After some increasingly liberal use of additional paralyzing and sedating agents, the patient finally stabilizes.

Before another hour passes, another patient will be emergently intubated.

It feels increasingly futile to try and screen patients by the so-called classic symptoms of cough, shortness of breath, or fever. I have seen far too many patients who come in without a single respiratory complaint, only experiencing nausea and vomiting, diarrhea, or isolated abdominal pain, who we later find has the patchy lung findings that are a hallmark of this disease. In the past few days, we have gone from a handful of COVID-19 rule-outs to over 80 percent of our volume being presumed COVID-positive. We do not have time to wait for coronavirus testing in the emergency room, particularly when it typically takes days to result. At this point, we run an emergency room dedicated almost entirely to coronavirus patients. And increasingly, we are running an ICU.

The ICU attending drops by and tells us that the young patient who had been intubated earlier had worsened. His oxygen levels had dropped precipitously, despite the machine doing all the work for him. One of the things you can do for these critically ill patients is place them face down, or prone them, which helps improve oxygenation. The downside: This requires specialized equipment to perform effectively. Our facility does not have this equipment. So, he tells us, we stacked pillows. We built a makeshift ramp. And the oxygen saturation improved dramatically. As the ICU attending leaves, he casually remarks that he will go to HomeGoods on the way home and grab us more pillows.

We fight this war with whatever ammo we have. If we run out, we will forge more out of whatever we do have. We will make do, as best we can, for the sake of our patients.

At home, I ponder the latest information from podcasts such as EM:RAP and EMCrit, and I scrutinize the latest research. There is a five patient case series out of China, indicating that plasma from patients who have recovered from COVID-19 may help critically ill patients. Mount Sinai is starting up a trial soon and needs volunteers to donate. My fellow residents and I are in agreement: If and when we find out that we have developed the appropriate antibodies, we will be the first in line. Right after our shifts. During our increasingly rare free time, we will do our part. And when we are home, away from the chaos of this war, we will fight our guilt at abandoning our brethren at this critical time, even if it is just for a precious few hours.

Some soldiers say that they miss the battlefield. I have never understood that sentiment more than I do right now.

Time to sleep. I work in the morning.

Nishad A. Rahman is an emergency medicine resident.

Image credit: Shutterstock.com

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