Few COVID-19 patients hospitalized
Only a small percentage of coronavirus patients ever see the inside of an ICU. Most are treated and sent home to mend. Yet those who are hospitalized tend to need round-the-clock care. Usually, clinicians place them on supplemental oxygen, which is supplied through a face mask or a tube inserted into the nose. If the patient continues to deteriorate, they consider a ventilator. This involves inserting a breathing tube through the patient’s mouth and into the airway, then attaching the tube to the mechanical ventilator.
“Part of the problem was that these patients didn’t look as bad as they should with the extremely low oxygen levels they were showing,” Lorenzo said, making it hard to know when a more invasive procedure was needed. “We are still learning how the virus affects the lungs, just how diffuse the inflammation is and how it affects the transfer of oxygen. It really just creeps up on people.”
“We were all worried about the risk of aerosolizing infectious particles,” Lorenzo said, explaining how if the ventilation tubes aren’t secured properly, air from the patient’s lungs can spew across the ICU room. But best practices early on appeared to be to ventilate earlier rather than later. The risk of death appeared too high without ventilation. So the team came up with a plan for how to conduct the procedure with as little risk of infection as possible, Lorenzo said. An airway team of a dozen or so clinicians was made available 24/7 to perform the procedure whenever necessary. The goal was to keep the number of workers in the ICU to a minimum, which usually meant only an anesthesiologist, respiratory therapist and registered nurse. Those three would get in and out of the room as quickly as possible, while still providing the best care.
“The physicians wrote the orders to guide us and to make sure everyone is safe, but in the end we had to go in the room,” said Free, the respiratory therapist. “I was worried at first about whether I was doing everything right — if I’d followed the video on how to don and doff the personal protective equipment correctly. Or if anyone else even knew how to make sure I did.”
Once in the room, Free, joined by a nurse and physician, would insert the breathing tube while suctioning out secretions, then attach it to the ventilator, making sure the patient was comfortable and all the connections were tight enough to prevent air leaks. The respiratory therapists also occasionally performed tracheotomies for those patients who were still deteriorating on breathing tubes, making an incision in the neck to insert the tube directly into the windpipe.
“The hardest part for us was at the bedside,” Free said. “You go in and see these patients in their most vulnerable state, really struggling to breathe, but right next door the same situation is happening. You try to keep them as comfortable and safe as possible. Then you have to just do your job, move on. I’d go home at night and talk about it with my wife. She’s a critical care nurse and could understand.”
As weeks passed, the team learned that they could defer intubating some patients by providing oxygen via other means. They also found that patients could, in fact, stay on ventilators for weeks, even months, and still recover. Following the standard procedures designed for ARDS patients seemed to work well. As quickly as they could, the ICU team developed its own best practices guidelines.
During those first months, they carefully recorded what they learned in a document now available online. It has been used as an information source by other Bay Area hospitals. And while it will continue to change, the team hopes what they’ve learned can add to the global knowledge base about the new virus.
“We are still learning,” Rogers said. “We’ve seen enough patients to learn a lot from them, but there’s no way to say these will always be the best treatments. Thankfully, we now know three months later that most people who get COVID will get well. Even those intubated for weeks and weeks we saw walk out of the hospital. It was amazing.”
Stanford never saw the surge it planned for; perhaps early stay-at-home orders in the San Francisco Bay Area helped reduce infections. Maybe the fact that the Bay Area is not as densely populated as places like New York helped. At its peak, the ICU cared for about 25 patients, far fewer than the 80 planned for. That helped keep enough supplies of protective equipment on hand to ensure frontline workers were safe from the virus. So far, survival rates of COVID-19 patients in the ICU remain high, at 80%. But the future is far from clear.
“Not having family members at the bedside is really hard,” Lorenzo said. “That element of having a loved one next to you, a friendly voice — it’s really missed. We do communicate with families over tablets. I call my coronavirus families every day to give them the best update I can. Some patients get better, but some don’t. I do my best to advocate for them. ”
As the number of COVID-19 patients in the ICU has decreased, the team is now back to meeting just once a week. They continue to share what they learn as new studies are published, and some conduct their own clinical trials.
“We learn from our mistakes,” Lorenzo said. “We refine our practices, try to make them a little bit more efficient. We rest. We take care of ourselves and our loved ones. We realize now that this is probably not going to be a peak, but a trickle of patients for a long time to come.”