Portal de Periódicos da CAPES

First Person

2020; Lippincott Williams & Wilkins; Volume: 42; Issue: 9 Linguagem: Inglês

10.1097/01.eem.0000697760.72917.b1

1552-3624

Mark Mosley,

COVID-19 and healthcare impacts

June 28COVID-19, EP: Dr. Mosley in PPE.FigureI am caring for a patient with back pain and a headache. She has a mask. I have a mask. (We weren't routinely wearing shields yet.) I foam in and out. She had been checked for COVID-19 by the hospitalist—negative using the COVID-19 historical screening form—so I do not use PPE. She is obese, and has COPD, diabetes, hypertension, and no regular doctor. I decide to observe her for a borderline hypoxia of 88% with normal labs and workup but no oxygen at home. June 29 A nurse says, “Do you remember that woman we took care of with the COPD? She tested positive.” I smile. “Wow. No kidding.” (This was when a diagnosis of COVID-19 was still exciting, before it exploded in our city.) June 30 Our department is jam-packed with 24 admits waiting to go upstairs and 20 patients in the waiting room. We are severely short-staffed because of the “furlough of heroes,” including all of our scribes, “to try to make up for economic losses.” (Our parent company received only $800 million from the federal government.) I see 90 percent of my patients in the waiting room. At 2 a.m., my upper back is aching, and I have a mild headache. I am convinced it is from maniacal one-finger typing of my own charts. By 4 a.m., I have a touch of a sore throat, and my chest starts to feel tight, like it wants to wheeze. “I can't be sick!” (But I know that Iam.) I work till 5:30 a.m. from a separate physician room, and I let my midlevel know that I am sick and will be checking in to get tested at 6 a.m. when my relief comes—unless I am hypoxic. She says, “Hey, let's check your oxygen; there is a portable one right there.” We walk over, hook me up, and it takes quite a while to pick up my clamped-down cold fingers. It is at 73...74...75...77, and now the monitor looks like it is picking up, and the reading stays at 77. My heart rate is 97 bpm. We both furrow our eyebrows and press down our lips. We don't say much except, “Hmm.” My midlevel is encouraging. “You're going to be fine,” she says. She bolts to get a room set up and talk to x-ray for a stat chest. I start gathering all my stuff in preparation for hospital admission, and walk briskly out to my car to get my insurance card. My chest x-ray is normal. My pulse ox is 100%. My heart rate is 67 bpm. All I can figure is maybe we switched the heart rate with the pulse ox on the portable. That seems improbable. I don't really know, but it is weird. My bald head is dripping, and my scrub top is soaked with sweat. I am an autonomic mess. I have no fever, no hypoxia, normal chest, normal labs, no cough. Ironically, my chief complaints are back pain and headache, just like my patient two days ago. I do my own swab. It isn't that bad. At least it is better than almost any shift over the past few weeks. I have a good friend who works in the lab, and my wife texts me and suggests I ask him to run a rapid test. By serendipity, he shows up unannounced in the ED and is standing right next to me when her text came in! Our hospital does not do rapid testing for outpatients, even for physicians who work there, even for those in the ED. The July 4 weekend is coming, so I won't know my results until July 7 or 8. Luckily, my dear friend says that I should let him see what he can do, and three hours and four phone calls later, he talks to the employee health director (my phone calls had gone to voice mail). He finds my swab, which was lost, lying in the ED (providential for me because it would have already gone to the state lab if it had been sent to the lab). I go straight from the ED to isolation. I try to plot out with my indefatigable wife how we are going to navigate all of the chess pieces of our family life with the board being shaken up. Later that night, I hear a knock. My wife leaves me food outside my door, like in a prison movie. July 1 Late this afternoon, employee health calls me: “Dr. Mosley, your test is positive.” I am the first in our emergency medicine group to test positive for COVID-19. I feel fine. No more ache in my back than after a day of yard work or a racquetball game. The odds of this being much ado about nothing is good. Let's hope so. But I want to elevate this moment. I don't want to seem self-important, but I want it to be a positive communal educational experience for my group. Unfortunately, the odds are high that a few of you reading this may get COVID-19 soon. I am now officially Coronavirus Recipient Attending Physician #1 (what an acronym!), and I want to leave you my roadmap. July 2 I have yet to hear anything from the health department. Tomorrow is the Friday before the Independence Day holiday, and I wonder if they are even open. I wonder how they will be able to get hold of my close contacts before next week, especially all the sick patients I sat next to in a crowded waiting room. The person who called me with my positive result said someone would be contacting me. She had added, “If you have any questions, give us a call.” I had no idea what to ask in that moment. And I knew they wouldn't know how to answer my questions because last week I was the guy who thought he could answer the questions. To some degree, it all hinges on the county health department contacting me. (The health department never did any outreach to me or to any of my contacts.) Then it strikes me like the vibrating sound of a massive iron gothic bell: “I am on my own.” But in that same moment, I think, “How fortunate am I?” I am the one percent who literally has everything to help me survive this medically and financially. How in the world are our ED patients going to manage this? I set out my medication strategy. I decide that ibuprofen is not a true risk and take 400 mg as needed for muscle aches and headache. I use half a tablet of Lortab 5.0 at night as the myalgias become increasingly intense. The achiness is not painful, but it grabs my attention and does not let go. You definitely need something at night to help you relax. I use prednisone 40 mg each morning for five days based upon no good data at that time (because I am a doctor, and we do stupid things when it's us). I am fearful if I end up being transported to the hospital that they will check my white count. I will have to confess that I self-prescribed steroids. And then, by God, they will have to put me in four-point restraints if they call a sepsis alert. I drink lots of caffeine, thinking of it as a derivative of theophylline, but mainly because I like coffee. I did not consider hydroxychloroquine, azithromycin, Tamiflu, vitamin D, or any medication endorsed by the president or Dr. Oz. July 3 The CDC website states that “time is of the essence to immediately identify and interview all close contacts,” which it defines by spending 15 minutes with someone, being closer than six feet, or within the 48 hours before your first symptoms. This is day three of my symptoms. No calls from the health department. My wife has left them three messages. Few of us even know the definition of a close contact. But what about the people you saw within 48 hours of your first symptoms who you talked to for five minutes? Or those who you hugged once? They don't meet the definition to require a 14-day quarantine. But what do we do for them, those who I will call emotional contacts? Telling someone who is afraid not to worry about it is simply not productive. Fear is primitive, a precognitive physiological response that is difficult to override with cognition. When I first saw that my oxygen saturation was 77%, I was not thinking fear. I used the same mind that I use when I walk into a code—all business. But my adrenal gland had already gotten the message before I even thought about what was happening. I became profusely diaphoretic just at the idea of hypoxia and intubation, something I had not even fully comprehended, and it ended up being false information! Powerful. What do you say to all of your emotional contacts who are also carrying around a pair of adrenal grenades? What about the many nurses, techs, APPs, and physicians who I worked with Sunday, Monday, and Tuesday? What do you say to your 10-year-old daughter who asks if you are going to get sicker and be put on a ventilator? Or wonders if she, her brothers, sisters, and mommy are going to get sick now? (Luckily, none of my co-workers or anyone in my family got sick.) Everyone will choose to handle this somewhat differently, but I think we begin by empathetically validating their reality: “Yes, this is frightening.” Then we normalize the emotion: “Yes, this would freak out just about any normal person.” And then we communalize the response: “We are in this together, and we can do this together.” Embrace their fear, and then embrace them with hope. Here comes the night again. I haven't had a fever. (And I question the quixotic idea of checking every asymptomatic person walking into an arena with the wave of a Walmart thermometer. We would be smarter passing out black licorice: If you don't spit it out, you need to be tested.) I have had very little cough, just some mild tightness of my chest. Clearly, it would be far worse had I not taken the prednisone! My sore throat is gone. No GI symptoms. The myalgias continue hammering. And no loss of taste, but starting this morning and all day long, I've been feeling a bizarre buzzing of my entire tongue and lips. It is not painful, but it is as intense as an electric toothbrush. It would be a little funny if I weren't worried about stroking out some primitive tract of my brain. July 4 It is a bad night. It is the myalgias, the tightening serpentine akathisia of the back and neck muscles. Luckily, no headache, fever, or photophobia, but the aches are deep and savage, which make me wildly restless. I up my bedtime dose of Lortab to 5.0. By 2 a.m., I am tossing fitfully. By 3 a.m., I am out of bed. I can't sleep, so I take another Lortab and ibuprofen, and then a hot shower waiting for the meds to kick in. Now my brain fog is dense from the steamy shower or the Lortab or the illness. The electric toothbrush sign is still buzzing in my mouth. I stand in a hot shower, and I think I am alone in a deserted house. It begins to storm. Occasional firecrackers are still exploding outside the window, like an opening scene from “The Twilight Zone” ... or the shower scene from “Psycho.” I never make it back to bed, but I feel better as the sun comes up. But the 3 a.m. shower while spinning on Lortab on the Fourth of July was a surreal out-of-body experience, like listening to a Nirvana album while on a ketamine drip. It is inevitable, even if you are reassured by the numbers (I was), that you think about death with this illness in a way you don't with other illnesses. Growing up in Oklahoma, there are huge black crows, evil birds that are scared of nothing. Anyone my age who grew up watching Alfred Hitchcock's “The Birds” would understand, even though it would come off as a bad comedy today. At 3 a.m., somewhat delirious in a shower, this Oklahoma boy experienced the presence of death like a huge black crow. It perches close enough that you can't ignore it. It cocks its head with eyes like black beans and blinks just enough for you to get nervous. It doesn't shoo. It acts as if it has just as much right to be there as you do. And it just sits there, quietly blinking. Death did that last night. I wasn't scared. I didn't like it, but it probably wasn't going to attack me. But it was there, black eyes blinking. My better self, when awake and not having an Alice-in-Wonderland experience, says 2,786,059 people have had this at this point. (Total cases were 4.6 million at press time, and will be higher still by the time you read this.) Get over it, I tell myself. But the reality is that very few of us change meaningful behaviors until it becomes a personal crisis. The only way for any of us to get it without really getting it is through shared experience, like a story. This is one reason I write. July 5 At 2 a.m. almost every night, the virus turns into a werewolf. It is like clockwork. The daytime is not too bad. But in the hours of the moon, you can hear the beast breathing. This is not just a variant of everything is worse at night. This is a completely different creature. I am told in the Harry Potter series that Death Eaters take on multiple forms. This virus is so mysterious that it too seems to shapeshift. The first few evenings, it was just the writhing muscular aches that came out. Those have mostly dissipated. Then there were the two days of the buzzing electric toothbrush mouth. Weirdest thing ever, but no loss of taste or smell, like some comedic curse of an alien from the galaxy of Orthodontia. Yesterday was my best day. I was cresting the hill of my 10-day isolation. And then in the evening, Lord Viraldemort came back. This time he was fatigue, but saying “I am so tired” does not do this justice. I have never experienced a weakness and fatigue this profound. This will make absolutely no sense, but you are too weak to sleep. Your brain is chained to the monster of your body, and you just lie there, brain-desert tired. My mind jumps for a moment, enough for me to consider, “Is this the happy hypoxia?” Is this the dawning of the cytokine storm?” I have a pulse oximeter and I need to make sure my sats are not in the 70s, but I am too weak to get up to check it! (I am not kidding.) I lie in bed and want to lift my head to start to get up, but it is too heavy. And I am too tired. I am submerged in lassitude. It's not something I've experienced before. Finally, by afternoon, I feel better. I have been reading about this fatigue in others' stories, but I assumed I knew what it was. I also assumed that my fitness would be good enough protection against the dark arts of the Rona. But we need a new word that transcends something as mundane as tired or fatigued. I am calling it coronuscruciatus, the spell of Lord Viraldemort. July 6 It is day 6 since I found out I had COVID-19. It's judgment day, the day (range: 6-10) when those with COVID-19 can take a turn for the worse and exhibit an inflammatory cascade that leads to a condition like acute respiratory distress syndrome. The boogie man of day 6 has been labeled cytokine storm. You need to know that this is more of a literary metaphor than a substantiated pathologic entity. For skeptics, it may be an intentional misdirection for drug makers of monoclonal antibodies (Tocilizumab) to sell their drug by inhibiting interleukin 6 as the advertised key cytokine. Cytokine storm is just the next iPhone of sepsis but even more mythological. Interleukin 6 is above normal in SARS-CoV2 but not dramatically. And the clinical outcomes for patients with severe SARS CoV-2 who have low IL-6 are just as bad. IL-6 may just be an innocent bystander that reflects inflammation in some people, but it is a poor measure and certainly not the cause. There are many inflammatory mediators and hyperactive immune responses apart from interleukin 6—interferons, other interleukins, tumor necrosis factor, chemokines, etc.—and they too suffer from not distinguishing cause from correlation, just sexy CRPs. This bizarre virus is going to teach us something brand new about hemoglobin and the endothelium. It has already created things we have never witnessed, like happy hypoxia, COVID toe, and a viral hypercoagulable state, to say nothing of the loss of smell and taste (and the newly described electric toothbrush sign). July 7 (Final Entry) No storm. I go for a walk in the morning sunlight, looking at trees, a little boy on a lawn, a dog being walked, and a man taking out his garbage. I am crying now. I don't even know why. I just walk without regard to time or distance. My walk into the morning light is worship. Each step a prayer of thankfulness, a breathing in of the ordinary. I have never felt so much freedom to love. I am not sure how long it will last, but I will end my conversation with “I love you” before leaving for my shift. This had been my first pilgrimage of illness. I would never dare compare it with someone who has cancer, cardiomyopathy, or any serious chronic disease, but my experience of thinking about my own mortality might be similar. Dostoevsky wrote in Crime and Punishment, “A healthy man is always an earthly, material man...but as soon as he falls ill, then the possibility of another world makes itself known to him at once; and as the illness worsens, his relations with this world become ever closer.” We are held captive by so many strange and even evil forces beyond our current control. We must admit fear in the midst of our dark situation and then embrace hope. We must write and speak to each other of the freedom that love brings. We must immerse ourselves in the baptism of the ordinary. We must hold onto the memory of home and thankfulness. And, hopefully with grace, we come to know that our story is someone else's story. The journalist Steven Joel Sotloff was held in captivity and executed by ISIS in 2014, but he smuggled this note out to his family a few months before: “Do what makes you happy. Be where you are happy. Love and respect each other. Don't fight over nonsense. Hug each other every day. Eat dinner together. Live your life to the fullest and pray to be happy. Stay positive and patient. Everyone has two lives; the 2nd one begins when you realize you have only one.” Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website, www.EM-News.com. Comments? Write to us at [email protected]. Dr. Mosleyis an emergency physician in Wichita, KS.