The medical community is divided when it comes to treating #COVID19. Various debates/theories dominate #MedTwitter & #FOAMed. Im glad to see these discussions & our progress, however patients sometimes get caught in the middle….
@cameronks @srrezaie @emcrit @EMNerd @airwaycam
@cameronks @srrezaie @emcrit @EMNerd @airwaycam
This thread’s intention is to simply share observations & the experience of a #COVID19 patient code named “Halo” (yes consent received by mother) whose story might seem unique but sadly a common occurrence throughout many NYC hospitals
@sinaiem @jacobi_EM @LincolnEM @NYEmergency
@sinaiem @jacobi_EM @LincolnEM @NYEmergency
Halo, A mid 30 year old w/#COVID19 symptoms (Febrile/SOB) for a week presented to the ED & had this CXR👇
As ED physicians, the difficult decision of disposition has never haunted us more these days when they’re like Halo: alert, talking & do not appear clinically ill
@grepmeded
As ED physicians, the difficult decision of disposition has never haunted us more these days when they’re like Halo: alert, talking & do not appear clinically ill
@grepmeded
Saturations at room air were 95 & above until eventually dropping to 90, getting them a nasal cannula to start. The astute emergency physician ordered a CT scan (shown below) & felt it was best for Halo to be admitted for close monitoring & continued oxygen therapy
#COVIDFoam
#COVIDFoam
On the floors, despite saturating at a consistent 88%, tachypneic into 30s (& sometimes higher), Halo continued to report “being fine” on HFNC day after day. Still talking in full sentences & even asked not to have family contacted for fear of them worrying.
#COVIDFoam #FOAMed
#COVIDFoam #FOAMed
On hospital day 5, it was deemed on the floor that Halo was clinically worsening (my thoughts on that at the end) & the difficult decision was made to intubate, reassuring them they’d extubated quickly...
Post-Intubation CXR is below 👇
@grepmeded @DShadowgazer @WeAreCanadiEM
Post-Intubation CXR is below 👇
@grepmeded @DShadowgazer @WeAreCanadiEM
Halo was stable for 3 days on the ventilator. Having just finished reviewing their blood gases (see below), I was called to bedside for desaturations into the high 70s, HR into the 150s. ETT was suctioned & w/o a cuff leak. Then quickly started becoming hypotensive & bradycardic.
Halo then coded & we tried everything on them, Bicarb pushes + drip, Epi, Levophed, & CPR (all in PPE and despite the known poor outcome).
Unfortunately, Halo still died shortly after, never having been visited by their family….
Unfortunately, Halo still died shortly after, never having been visited by their family….
“Clinically worsening…”
There’s a strong argument made that Halo’s increased WOB & persistent tachypnea paired w/hypoxemia would have enventually led to a sudden crash/code which physiologically is understandable, yet…
There’s a strong argument made that Halo’s increased WOB & persistent tachypnea paired w/hypoxemia would have enventually led to a sudden crash/code which physiologically is understandable, yet…
Halo compared to MANY similar patients we're seeing in the ED was actually very well off, most would argue better than the majority. Sating high 80s, still able to speak full sentences, able to consent to & tolerate placement of a central +arterial line
@cameronks @Maimonides_EM
@cameronks @Maimonides_EM
The decision to intubate is extremely difficult & prior to #COVID19 it wasnt AS hard. There are patients who most certainly need it & then there's Halo who maybe didnt. Ive constantly heard…what would 1 more day on HFNC achieved or what else could have been done?
@FOAMpodcast
@FOAMpodcast
1 less ventilator/ICU day is an enormous win. Less invasive therapies (ie. HFNC, Nitric Oxide, Convalescent Plasma, etc) need to be considered 1st. Im NOT saying intubation killed Halo but fear of them suddenly crashing should not be driving this decision because…
At the end of the day, they still “crashed” suddenly and died….
Would their outcome have been any different without the tube, no one will know. We also wont know what impact those other interventions may have had if any
Neither will Halo or their mother…
#COVID19 #COVIDFoam
Would their outcome have been any different without the tube, no one will know. We also wont know what impact those other interventions may have had if any
Neither will Halo or their mother…
#COVID19 #COVIDFoam
In the end, we need to think about & approach #COVID19 patients differently. While waiting for evidence/RCTs, we need to accept this is unlike any disease weve seen & stop trying to put it into treatment boxes/protocols we are familiar with as it may cause more unnecessary deaths
