In my 7 days on one of our (now 12!) non ICU #COVID19 units, I admitted 58 patients for COVID rule out, of whom 50 tested positive. Two died (DNR), 2 went to hospice, and 5 went to the ICU. That is… not my typical gen med service week. Following, some clinical observations.
My experience perfectly matched published reports. Procal universally low. Ferritin, CRP, d-dimer elevated. Lymphopenia prominent. Patchy infiltrates on CXR. Diarrhea common. So, I want to share some other things I haven’t seen talked about as much.
1st, I was shocked by the persistence of fevers. My patients had fevers every day, often all day, often >39, for days on end, not especially Tylenol responsive. And they had all had several days fevers before admission.
2nd, the fevers did not seem particularly related to outcome. In fact most of my ICU transfers did not have persistent fever. They did, however, make patients miserable.
3rd, this is not your usual sepsis picture. NONE of my patients, even the deaths/ICUs, developed meaningful AKI or liver failure (most had trivial transaminitis). There is no multiorgan failure. Just respiratory failure (I know reported later cardiac; I didn’t see those).
4th I did have a bunch of mild troponin elevations, but mostly demand ischemia. No EKGs c/w myocarditis. Suspect too late a complication for me to see.
5rd, as noted by others, just about all of my patients had had symptoms for 7-10 days before needing admit for O2. This posed a conundrum for the few who were admitted with <5d sx (all on RA) – keep to await nadir? Can’t afford the beds. Had to discharge with warning.
6th, I found CRP and ferritin often to move in opposite directions (usually CRP ↘️while ferritin still ↗️; CRP leading indicator?). This was confusing. Moreover, I had patients with ferritin >3,000 who did well and others with <800 who struggled. So, not universally helpful.
7th, as noted by others, these patients deteriorate fast. Really fast. I started calling ICU for any patient who went from RA to 6L in <24 hours; nearly all wound up at least on 100% NRB or high flow if not intubation.
8th I kept underestimating their exertional hypoxia. Learned my lesson when I transferred one pt to lower acuity floor and he had a syncopal event getting from wheelchair to new bed. Walked all patients with pulse ox prior to d/c.
9th On the topic of syncope, I admitted 3-4 COVID+ patients with presenting complaint of syncope (2 with head lacs), all early in course, with orthostatic hypotension without significant antecedent fevers. Could COVID be having some effect on autonomic system?
10th Our standard protocol right now is azithro/hydroxychloroquine/zinc but I have little faith in efficacy. For the patients I really worried about (fast O2 requirement rise, high inflammatory markers) I gave tocilizumab off label. Clinical trial of sarilumab starting this week.
11th Proning is now standard in our ICU and I tried hard to get my sicker patients to do it too to head off intubation. This is much harder than it sounds. Most patients couldn’t get into position on their own, found it uncomfortable (back pain), refused.
12th Most of my patients didn’t eat anything. Partly lack of taste/smell, partly misery with fever, partly hypoxia with exertion, partly lack of visitors/staff in room to encourage and help. Several asked me for soft diet to reduce effort of chewing. Must attend to nutrition.
13th Lastly, one of the biggest concerns for non-critically ill patients was persistent painful cough. Most had paroxysmal dry, wheezy coughing spasms, often precipitating desaturations. Tried cough syrup, albuterol MDI with spacer (avoiding nebs), codeine, with little effect.
