One Doc’s Acute Respiratory Distress Syndrome story

Monday 6th April 2020

An update on our household’s scare with COVID-19

Friday 2nd April, 3pm- I had still not heard from occupational health about the COVID-19 status of my flatmate. To recap, we had now been in self-isolation for a little over two days. No news was good news. We could assume our friend was negative for coronavirus and we could continue on with our lives. I had never been so relieved to be able to go back to work. I ventured into work for the evening shift, a welcome break from the stress of isolation. The weekend was however a difficult affair.

Free-fall

Saturday morning went without complication. We had only ten of our own surgical patients and the remainder of the 20 ward patients were now respiratory patients, including two potentially COVID-positive patients. We had our own resident respiratory team to manage these patients. I enquired about the bed situation in the hospital from our nurse in charge – 230 empty beds in the hospital. Nearly a third of the 900 hospital beds free. “It is never this empty, not even at Christmas…”, noted the charge nurse, in reference to the seasonal reduction in hospital work around the holidays. This truly is the quiet before the storm. It seems people are staying away from hospitals in fear of contracting the virus, perhaps?

After an extended lunch break, my senior colleague and I arrived back onto the ward slightly sleepy from the post-meal slump. We were greeted by a worried nurse. Never a good sign. She let us know about a patient who she was worried about as they had reduced blood oxygen saturations. I grabbed my stethoscope and headed to see the patient, unaware of the free-fall that this story would take over the next day.

As I entered the four-bedded bay I saw the patient. They were receiving oxygen via two nasal prongs, delivered at 4 litres per minute. This was not an abnormal situation given that they had recently had part of their lung removed for a cancerous lesion. However, they were also connected to continuous monitoring via a blood-oxygen saturation probe and a blood pressure cuff. This was the first sign that something was abnormal. Patients are not routinely attached to continuous monitoring unless seriously unwell.

I quickened my stride to reach the patient. I took a short history which outlined increasing shortness of breath over the day. I noted from the observation charts that the patient’s oxygen requirement had increased from 3 litres/minute to 4 litres/minute and a single mild temperature of 37.8C. Despite the increased oxygen delivery, the patient’s blood oxygen saturations were dangerously low at around 88%. Normally patients without lung disease should have saturations above 94%. Whilst 88% saturations did not present an immediate threat to life these numbers were not reassuring. I ramped up the oxygen to 5 litres/minute and began my examination of the patient.

Apart from the patient’s obvious shortness of breath and some extra fluid to be heard with the stethoscope in both bases of the lungs, the patient examined otherwise normally. The combination of the increasing shortness of breath, increased oxygen requirement, fever and crackly lungs suggested that the patient had developed a pneumonia. I ensured the patient was stable before going to order the patient a chest x-ray and grabbing equipment to take bloods and insert a cannula.

When I arrived back to the patient, they were visibly struggling to cough up mucus. I suggested to the nurses to give a nebuliser, a solution which is propelled via oxygen to the patient’s airways and helps soften respiratory secretions. This would help the patient to cough up mucus and breathe a little easier.

The nurses began the nebuliser therapy as I cannulated the patient and took some bloods. As I was finishing taking bloods the radiographers arrived with the portable chest x-ray machine. They quickly snapped a picture. I was shocked by the image. The chest x-ray showed significant fluid overload and infective changes in the left lung. The diagnosis of pneumonia was looking more accurate and worrying. In quick consultation with my seniors we decided to put the patient on strong intravenous antibiotics and further escalate the oxygen delivering to the patient. One of my colleagues also suggested that we should swab the patient for COVID-19. I was unsure how useful this would be as it looked to be a post-operative pneumonia, which was not uncommon. But I obliged and called up the consultant who was designated to be on-call for advice on COVID-19. The consultant agreed that a post-operative pneumonia was more likely than COVID-19 but gave the go ahead for our staff to carry out the COVID testing.

With the patient now improving on higher volumes of oxygen and the start of stronger antibiotics for a suspected pneumonia, the medical team decided to leave the patient to settle for a while. As the patient was being tested for COVID, we had to assume that the patient had been infected with COVID-19. They were moved out of the four-bedded bay into an isolated side room and the staff were made to wear a mask, apron and gloves upon entering the room.

A few hours passed and we had heard little about the patient. I was sitting in the doctors’ room filling out paperwork when a worried nurse hurried into the office to inform me that the patient was unwell again. I jogged to the patient’s room and glanced into the room through the glass window. The patient was saturating at 80% on high flow oxygen despite our earlier medical treatment. It took me about five seconds to conclude that I could not, and did not want to, treat this patient alone. I ran to grab my senior colleague before running back to the patient’s room and getting the personal protective equipment on.

As I entered the room I could tell the patient was very unwell. Their oxygen saturations were very poor and their respiratory rate and heart rate were elevated. We opted for a 15 litre/minute oxygen mask, used for acute emergencies. My colleague took over the management of the patient whilst I called for further senior support. We decided that we needed to call the critical care team, who run high dependency units and intensive care units to manage this patient. We were simply at the limits for our ability to monitor and treat this patient on the ward.

I called the patient’s consultant, who was at home, to inform them about the patient’s dire situation. He was exceptionally worried about the patient’s rapid decline to an acute respiratory emergency within six hours. I too was very worried. I have rarely seen a pneumonia come on so quickly and with such ferocity before.

I arrived back to work weary on Sunday morning with the events of the previous evening still firmly etched into my mind. I was extremely concerned for the patient. I discovered that the patient had been admitted to the high dependency unit for continuous positive airway pressure ventilation. This is a type of ventilation which forces air into the lungs at high pressures and is useful when there is an excess of fluid accumulating in the lungs causing widespread dysfunction. However, the ability to ventilate the patient effectively was limited given that the patient had recently undergone lung surgery. The high pressures generated by the machine were at risk of tearing the internal stitches holding closed the larger airways, and potentially causing a catastrophic situation. I became increasingly concerned for the patient.

Throughout the day I continued to check up on the patient’s online notes. However, I also became increasingly concerned for my own health. On early Saturday afternoon, when I had first gone to see the patient I had treated the patient with a nebuliser. I did this whilst in prolonged, close exposure to the patient as I put a drip in and took bloods from the patient. The issue is that a nebuliser is a potentially aerosol generating procedure. Aerosol generating procedures are considered high risk for spraying infected respiratory droplets into the air. For obvious reasons, this is considered extremely dangerous for transmitting infection to healthcare staff in COVID-19 patients. Given my close proximity to the patient as they underwent their nebuliser treatment I was, and continue to be, somewhat concerned for my health.

The patient was put into a medically-induced coma, intubated and mechanically ventilated in the early afternoon on Sunday, just 24 hours after I had first been asked to see the patient. I am still unsure of the patient’s COVID-19 status. The tests are still in progress. Acute respiratory distress syndrome (ARDS) was the explanation from the intensive care doctors. ARDS is the terminal event in COVID-19 infection, but also in other respiratory infections. The cause of the patient’s ARDS is yet to be determined but coronavirus is high on the list of causative agents.

I was struck by the rapid decline of the patient. If this patient’s illness was due to COVID-19 it is a terrifying picture, truly. This was one patient’s story with ARDS, and one doctor’s experience of it. I can only imagine the terrors experienced by doctors around the world who are dealing with entire wards of patients with ARDS, simultaneously deteriorating in the same manner due to COVID-19. This is the reality of the situation.

That should terrify us. It scares the hell out of me.

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