I am a critical care physician and the medical director for the Providence Sacred Heart and Holy Family ICUs. In this capacity, I help manage about two-thirds of the critical care beds in Spokane. We’ve been caring for COVID-19 patients since the earliest days of the pandemic when we accepted some of the minimally symptomatic patients from the Diamond Princess cruise ship. Today this seems almost quaint as these patients were basically well and would never be hospitalized now. Since the start of the pandemic, I have cared for dozens of COVID-19 patients, most of whom have ultimately died because once you get sick enough to need critical care from COVID-19, the outcomes are poor.
I’ll be working in the Sacred Heart ICU the last two weeks of December and will witness firsthand the consequences of people’s Thanksgiving decisions, and I need to share what this will look like. I can speak to this with a high degree of confidence because the course of COVID-19 is relatively predictable.
First, we will try to support this surge of coronavirus patients without resorting to mechanical ventilation, but inevitably many of these patients will fail this approach. We will have a series of heart-wrenching conversations with the patients and their families in the days leading up to this. Some patients will decide not to go on the ventilator as they fail and they will die. The rest will go on a ventilator. I will intubate some of them myself; my partners will intubate the others. I will then watch our team do everything possible to keep them alive. We will treat them with dexamethasone, remdesivir, prone positioning, paralysis and antibiotics for weeks. A few of the younger patients will make it off the ventilator. Most of them will be profoundly weak and face a long recovery.
Young people do better than the elderly simply because they can better tolerate two or three weeks of critical care in a way that the elderly just can’t.
Unfortunately, most of the patients who need the ventilator will not survive and after a few weeks, probably around Christmas, they will start to succumb. We will have to have lots of difficult and painful discussions with their families over the phone because COVID-19 patients can’t have visitors.
Our palliative care team will help us with these conversations because we don’t have the time for all of them, and each of these conversations takes away a little bit of your soul and you can only give away so much of your soul each day. Our nurses will use Zoom and FaceTime so families can see their loved ones sedated and intubated.
Finally, we will decide to transition to comfort care and remove the ventilator. At this point, two visitors will be allowed to come see the patient, if they are not also COVID-positive or too afraid to come to the hospital. I’ll watch the visitors struggle to put on the same PPE that we put on dozens of times a day. The family will stand around the bed crying and watching their loved ones struggle to breathe as our nurses make them comfortable and dignified as they die. This will be repeated several times a day as our team labors to provide an avalanche of patients with the highest quality and most compassionate care possible.
All of this happens against the backdrop of our own lives which are, of course, impacted by COVID-19 just like everyone else’s. My college sons will quarantine in our basement and wear masks when they come home. My wife can’t visit her recently widowed mother in Canada because the border is closed. One nurse’s baby shower is now a “drive-by” event. Another nurse’s son is missing all the events of his senior year of high school. Everyone’s kids are home-schooling. A respiratory therapist worries about bringing COVID-19 to his child with congenital heart disease.
And yet, every day we come to work and care for these patients.
The U.S. has had more than 250,000 COVID-19 deaths; this is more than the entire population of Spokane. A recent study showed that our pandemic response is the worst on the planet.
This means that about half of the patients that we’ve watched die didn’t have to die.
I challenge anyone to explain why I shouldn’t be viscerally angry about this.
The University of Washington Institute for Health Metrics and Evaluation model predicts that our state will exceed our ICU bed capacity in December.
I won’t reiterate what people need to do to prevent the spread of coronavirus over Thanksgiving because everyone knows exactly what this is.
On behalf of my partners, our nurses, our respiratory therapists, and all our team members, I implore you to do your part to protect yourself, your loved ones, your community and us during the upcoming holidays.
Stephen Malkoski, M.D./Ph.D., Medical Director for Critical Care, Providence Sacred Heart & Holy Family Hospitals, Spokane, and Sound Physicians Critical Care
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