This story appeared in the July/August 2020 issue as "The Learning Curve." Subscribe to Discover magazine for more stories like this.
We were flying blind.
The red alerts flashed from Wuhan to Lombardy to Seattle, yet the first COVID-19 cases in early March in New York City prompted an official reaction that suggested the virus had traveled by asteroid, not by human daisy chain. None of the patients in our emergency department had traveled to China or been around someone diagnosed with COVID-19. There was no clamor to broaden testing, no rush to rethink the model of contagion, no clarion to immediately shut down.
Reality hit in stages, like a plane lurching through air pockets.
First lurch: Coming onto a shift in mid-March, a colleague informed me, “Yesterday we had a middle-aged guy. Looked pretty good, decent oxygen saturation of 96 percent, then a few hours later, crumped [rapidly declined]. Crash intubation. Then another. The Italians warned us people look good, until they don’t.”
“Jesus,” I thought. “It’s on.”
Oxygen saturation — detected with a pulse oximeter (or “pulse ox”) on the finger — is the measure of oxygenated hemoglobin. The normal range is typically between 97 and 100 percent. The Italians discovered those oxygen levels can dictate life and death: COVID-19, unique among viruses, can slam it down to 70, 60 or even 50 percent. A pulse ox level above 95 percent, though, was supposed to be good news.
Our first case, and now we can’t even trust the initial pulse ox level?
Second lurch: My own first case. The ED tracker flashes: A patient in her 30s has a very rapid pulse. Chief complaint: fever and contact with a COVID patient. I hope someone else will pick her up. Someone not 63 years old and male with triple the risk of dying from this damn virus. Everyone else is tied up, though, so I click on the screen to sign myself up.
I shuffle to her isolation room. Mincingly, I don an N95 mask, cap, gown, gloves, surgical mask with face shield, and shoe covers.
I slide back the glass door. She sits on the stretcher against the far wall.
“How do you feel?”
“Achy. Some fever,” she responds.
“How’s your breathing?” The overhead monitor registers oxygen saturation at 95 percent. The danger zone starts below 90.
“Not too bad,” she answers, and my stomach unclenches.
I ask her to face away, and then barely touch with the stethoscope. Lung sounds will prove mostly useless in COVID patients: They tell you nothing the O2 saturation hasn’t already. But I still need to test her for COVID. The swab up the nose can aerosolize the virus to spread on air currents, potentially infecting others. How do you ask a nurse to take a risk you won’t? I come clean.
“I’m 63,” I tell Laura, trying not to sound pleading. “You?”
“Forty,” she answers. “Of course I’ll get the swab.”
Ah, nurses.
Two liters of saline settle my patient’s pulse. We admit her. Better the next day, she is speedily discharged.
The tsunami hits that same week. Everyone has COVID. Amid the swarm, we cling to three guideposts:
1) Follow the pulse ox. 2) Avoid aerosolization. 3) Intubate early and often.
The initial protocol was to keep the oxygen saturation above 90 percent with nasal oxygen. Per the Italians, if the patient needed more than 5 liters of oxygen per minute, you intubated. We avoided techniques like high-flow nasal oxygen and CPAP machines that deliver positive air pressure by mask because they aerosolize.
None of us put much faith in fad remedies like hydroxychloroquine. COVID is about lung mechanics, not magic bullets.
Third lurch: With each shift, you hear about colleagues around the city falling ill. We’ve all ramped up personal protection equipment (PPE) to include N95s and goggles all the time, but this virus is devious. Male and 63 is a bad thing to be.
I can’t help it. Each “NOTIFICATION” that blares on the overhead PA trips a jackhammer in my chest. It heralds another critical patient, and with them the scramble to don extra PPE. My fear breaks cover like a panicked game bird. It helps that courage is all around.
The paramedics and EMTs pull the critical and the dying out of tiny apartments. They intubate, and pound on chests. It feels disrespectful to quickly stop CPR on the pulseless patients they’ve brought in. But more resuscitation spews more virus. The critical patients who do make it to the ICU will be kept silent — intubated and sedated — and alone.
Nurses rival the medics. Doctors write orders and perform big-ticket procedures; it’s the nurses who insert IVs, draw blood, adjust oxygen dials, change soiled garments and turn patients incessantly. This is a nurses’ disease. In total minutes at patients’ bedsides, the difference between nurses and doctors isn’t even close.
By week two, the guideposts have moved. We’re starting to take the virus’ measure:
1) Follow the pulse ox: We now know there are “happy hypoxics” you can keep out of the hospital if you equip them with a home pulse oximeter, keep daily tabs on them with telemedicine and, as needed, arm them with portable oxygen machines.
2) Avoid aerosolization: Actually, do what’s best for the patient. High-flow oxygen and CPAP machines keep some patients off ventilators. Build hoods and tents to contain the aerosolization.
3) Intubate early and often: Or maybe not. Combine high-flow oxygen with position change. You can bump patients with lower O2 saturation just by rolling some of them onto their stomachs. Keep them turning.
This evil thing will be with us for too long. Even as we get smarter and bend that all-important curve, the virus will keep pulling more tricks. Now we are seeing late complications like heart failure, cardiac arrhythmia, kidney shutdown and strokes. There will be more.
One thing is crystal clear: Flying blind was inexcusable. We had the tools — big data, instant communication, lab capacity — to do this right. This must be the last pandemic.
Tony Dajer has been an emergency room physician for 28 years in New York City and is a frequent contributor to Discover.
