Dispatch from Seattle v7: My uncle starts 4th week intubated from COVID

 

Dispatch is new column on life from inside the Seattle-area experience of COVID-19. It’s meant to offer insights into what other regions of the country can plan to experience as the wave of COVID rolls into their community.

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Just over a month ago, my uncle accompanied my aunt on a trip to Seattle. They live in large city by Alaska’s standards; more of a small town by standards in the Lower 48.

A few times a year for the last thirty years or so, my uncle would accompany my aunt from their home in Alaska to regular treatments at Virginia Mason in Seattle for an auto-immune disorder she has been living with over the years.

He was always a big hearted caregiver to my aunt, and worked to make these trips as smooth for her as possible.

They didn’t reach out to us on this trip for a visit. They made a relatively quick turn back home, skipping out on any tourist traps that they had long since had their fill of. They landed safe and sound back home in Alaska on March 10th.

This is a story of my uncle’s journey through becoming COVID+. It’s an effort to share the subtle details of a loved one dealing with the acute nature of the disease. It hopes to show both the humanity and the suffering, the hope around small details and the implications for dealing with a new normal for us all.

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On March 11th, my uncle developed a cough with a low-grade fever. He was an active grandparent, and so he had his grandkids over for a sleep over with grandpa and grandma on the 13th. This was the same day Washington’s governor first imposed an order to close schools from COVID.

On the 19th, my uncle visited my cousin’s home. He was noticeably confused and disoriented. He was an active presence in the family; the cough was a noticeable presence with my uncle.

On March 21st, the night of my aunt and uncle’s 50th wedding anniversary, my uncle was admitted to his local hospital, becoming Alaska’s first hospitalization from the disease. He tested positive for COVID on Monday.

By Tuesday night, my 71-year old uncle was intubated, and put into a medically-induced coma.

While at his local hospital, the family physician was struggling to know how best to help him. He told my family that he canceled a day of patient appointments to learn as much as he could about the disease. The doctor said he felt out of his depth, and was candid about his limitations.

The local hospital said they only had two ICU beds, and that now my uncle was taking up 50% of their capacity. There was an implication that they didn’t want a COVID+ patient in the ICU, for a range of reasons, I’d suppose. It was a different kind of candor about limitations than that from the physician. The hospital’s approach left a somewhat more bitter taste.

The physician suggested, however, that perhaps a better alternative for my uncle would be to be medically evacuated to Seattle. The community, he said, had been dealing with the disease and had developed more experience. He confirmed that Virginia Mason had a bed and a team available to him. The medical advice was that my uncle would be stable through the flight and that it would give him a better chance once he arrived at Virginia Mason.

Before the flight, he was on about 50% oxygen, and the fever was held at bay for as long as 12 hours at a time. The Alaska hospital said they measured success, in part, by the absense of any significant organ failure.

Upon arrival, my uncle was on 100% oxygen, later moved to 90%. The fever would come and go.

As he got settled into Virginia Mason, it was clear immediately that the level of care was multiple levels more sophisticated. The bedside manner and empathy on the part of the institution was also as different as night is to day.

One of the first calls my cousin received was from a palliative care physician. Rather than signal a near-end, the physician said his job was to advocate for the patient, “to humanize him for everyone else” taking care of him.

The palliative care physician underscored how weak my uncle would be if he made it out. He’d have weeks – “probably even months” – in a rehab facility or skilled nursing facility. He would no longer be an adequate care giver for my aunt.

The care team at VM was careful to rotate my uncle from side to side, and from back to front, in order to re-align the fluid in his lungs from one side to another. Apparently, there is more lung tissue near the back of the body. So, by moving him to a prone position, fluid accumulating in his lungs would move to the front of his chest. This would allow more oxygenation of his blood.

While on his stomach, they were able to move the oxygen back down to 70%. He could only remain on his stomach, however for about 16 hours a day before he needed to be moved back. His oxygen levels fluctated over the hours in the ICU from 50% to 100%.

 

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One nurse was assigned to my uncle so that he could be in one on one isolation with my uncle all day. This is smart. It limits the rate of infection in the hospital, and gives the patient as much attention as is needed throughout the day. The nurse would provide updates to my family’s point of contact.

Physicians would call regularly, as well. In addition to the palliative care doctor, a resident would also phone as would an infectious disease specialist.

Together, the care team explained what they thought worked and what they didn’t know. They explained that they were about three weeks into this wave. So, they had learned a few things, but were still finding their way.

For example, they had come to believe that providing mild paralytics to eliminate body movement saved energy to focus on healing.

They didn’t believe that many of the untested alternatives floating around were quite yet worth the risk, meaning they could exacerbate collapse rather than forestall it.

They learned that COVID is a disease that teases you with two good steps forward before it delivers one tough step back.

They came to find out how few resources exist upon discharge. Patients who went into an ICU three weeks ahead of him, and onto ventilators, are only now coming out of the system. The long term care community is just starting to come to terms with their step in the process. They are getting patients from hospitals whether they are quite ready for them or not.

One promising tool is “convalescent plasma,” or plasma taken from COVID survivors. The idea is to infuse that plasma back into patients struggling with COVID in the hopes of supporting an immune system response.

On March 29th, my uncle entered into a “cytokine storm.” This is an event the coronavirus triggers where the immune system begnis to overdeploy, attacking the body rather than the disease. His lungs began to fail.

However, his fever had also abated. No secondary infections were present.

Yesterday, March 30th, his lungs stopped taking oxygen for unknown reasons. It likely led to brain asphyxia, meaning even if he recovered, there might be some brain damage. My cousin, my aunt, and family and friends were told to prepare. He would not likely make it through the night.

A new tube was inserted, stabilizing his breathing, and returning his oxygen saturation levels to appropriate levels.

A few days later, a new report that white blood cell counts were rising suggested that perhaps a secondary infection was forming. This is a common side effect of intubation, the hospital said. They had had my uncle on anti-biotics for just this reason.

Creatinine levels began to spike, suggesting that perhaps kidney function was struggling. Urine flow was diminished. A new catheter hoped to help address that, and so far that appears to be the case.

A few days into April, my uncle’s lung collapsed. Air was leaking into his chest cavity, depressing the level of O2 saturation. The physicians did what they could to stabilize the lungs, being careful to apply the right balance of pressure of airflow into my uncle to not damage the situation.

This disease creates a significant mucous response while intubated, apparently. The mucous can become a blockage to air flow. Typically, since the patient can’t cough, the care team tries to suction out the mucous. However, that began to show diminished efficacy, the physician said.

 

 

The care team replaced the tube again, as a result, pulling out a significant “mucous plug.” His oxygen saturation rose as a result.

My uncle now rests at between 50-70% on the ventilator. The care team has withdrawn paralytics. He doesn’t seem to be fighting the ventilator. The doctor said “there is some improvement” in his condition.

Today, is the last day of week three on a ventilator as a result of COVID. There is no clear end in sight for my uncle.

Somewhere between 3% and 20% of patients who go on a ventilator as a result of COVID will come off.

If my uncle makes it off the ventilator, he may have suffered brain damage. as a result of four hours of low oxygen saturation. His lungs will be very damaged. Life will certainly not be the same.