The Pandemic-Era Emergency Dep’t: Weirder, Wilder & Emptier Than Ever (Medium). Matt Bivens, MD.
Image: uncredited
[ed. A gripping and graphic account of how clinical treatment decisions unfold in real time. Appreciation for how hard our health community is working to figure out this complicated virus.]
A lot of attention has focused recently on “rationing limited ventilators.” We weren’t there this particular early morning in Massachusetts. But a ventilator is a brutal therapy. Even young, healthy patients find themselves profoundly deconditioned after a few days lying in a bed sedated and perhaps paralyzed, with the machine doing the breathing. The lungs aren’t used to being inflated actively; they are used to being tenderly tugged open by the expanding chest and dropping diaphragm, which gently draws air in; with a ventilator, the air is forced in, the lungs are forced open from the inside, so they expand and smush up against the inside of the torso, lifting the dead weight of the chest wall out, and forcing the diaphragm down. It’s debatable whether the modern ventilator is always an improvement over the Iron Lung, the big tank used for patients with polio paralysis in the 1930s — in those the patient’s head would stick out the top, like a volunteer at a magic show about to be sawed in half, and the Iron Lung would create negative pressure gradients inside, to suck outward the torso and draw in the air. (...)
A lot of attention has focused recently on “rationing limited ventilators.” We weren’t there this particular early morning in Massachusetts. But a ventilator is a brutal therapy. Even young, healthy patients find themselves profoundly deconditioned after a few days lying in a bed sedated and perhaps paralyzed, with the machine doing the breathing. The lungs aren’t used to being inflated actively; they are used to being tenderly tugged open by the expanding chest and dropping diaphragm, which gently draws air in; with a ventilator, the air is forced in, the lungs are forced open from the inside, so they expand and smush up against the inside of the torso, lifting the dead weight of the chest wall out, and forcing the diaphragm down. It’s debatable whether the modern ventilator is always an improvement over the Iron Lung, the big tank used for patients with polio paralysis in the 1930s — in those the patient’s head would stick out the top, like a volunteer at a magic show about to be sawed in half, and the Iron Lung would create negative pressure gradients inside, to suck outward the torso and draw in the air. (...)
COVID-19 is a viral pneumonia — and medicine calls pneumonia “the Old Man’s Friend” for a reason. It can be a quiet, relatively easy way to slip away — maybe after some hours or a day or two of low-key final interactions with loved ones. The alternative could well involve ending all human contact now — the last person you interact with being me, a doctor in a space suit hood, right before the medications put you under. This is so highly likely in the COVID-19 era — when literature suggests few people put on ventilators actually make it off of them — that we recently put a computer tablet into the emergency department, specifically to allow patients to interact with loved ones by video a final time before going under onto the vent.
I didn’t want my patient to die today, and I always want to respect family and patient wishes. But I also didn’t think a ventilator was in his interests — especially if it could be avoided. I thought about that left lung whiteout on chest Xray. If it was mostly pneumonia, that’d be terrible; but if enough of it was just pleural effusion, I could do a semi-emergent thoracentesis — stick a needle into the back of his chest, drain the fluid from around his lungs. It’d be challenging; he’d need to sit up and preferably follow commands, and since he also happened to be on blood-thinning medications, the procedure would come with increased bleeding risks. But if it worked, and a large amount of fluid could be drained off, it might stabilize his slipping oxygenation; he might be able to avoid the ventilator.
I didn’t want my patient to die today, and I always want to respect family and patient wishes. But I also didn’t think a ventilator was in his interests — especially if it could be avoided. I thought about that left lung whiteout on chest Xray. If it was mostly pneumonia, that’d be terrible; but if enough of it was just pleural effusion, I could do a semi-emergent thoracentesis — stick a needle into the back of his chest, drain the fluid from around his lungs. It’d be challenging; he’d need to sit up and preferably follow commands, and since he also happened to be on blood-thinning medications, the procedure would come with increased bleeding risks. But if it worked, and a large amount of fluid could be drained off, it might stabilize his slipping oxygenation; he might be able to avoid the ventilator.
