What Could I Have Done Differently?

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This story is from the Anamnesis episode called At a Loss and starts at 25:30 on the podcast. It’s from Venus Oliva, DO, who works at a large teaching hospital in Philadelphia.

Following is a transcript of her remarks:

He Was Never in a Hospital Before

When COVID first hit Pennsylvania, I was in the ICU as a senior resident with an intern on my service. Our attendings rotate through three different hospitals, so you’re left alone a lot. Towards the end of my shift, I got a call from the emergency room for an admission that was a suspected COVID pneumonia in a 30-year-old male. I remember it was like 4:00 p.m. We were filled in the ICU.

It had already been quite a day with other cases, but I definitely didn’t want to leave the admission for the incoming hospitalist to have to deal with, so I went down, got the history from the emergency department attending, and gowned up, put on my N95, my mask, my shield, and went into the room that had yet to get a HEPA filter in.

The door was closed. The patient was there, I could see through the window, and Mom was at bedside. When I walked in, I discovered that he had a history of autism. He was high-functioning, but he had never been in a hospital before and was very, very tight with his mother. Entering the room, I stood next to the door to try and ease him.

The majority of the history was gathered from Mom and the patient just kind of stared at me. He had his nasal cannula on, so for the most part he was being cooperative, but he didn’t look great. He came in satting like mid to high 80s, popped up on nasal cannula, but he was already maxed out on nasal cannula so I knew he would have to move on to the next step.

She Didn’t Want to Leave Him Alone

I asked Mom how well he would do with an admission to the hospital and she asked whether she could stay because she didn’t think that he would fare well. Our policy was already that anyone who was a COVID-suspect couldn’t have any visitors or family members at bedside in the hospital upon admission. We were still letting visitors in the ED at that point.

When I walked out of the room and de-gowned and washed my hands, I went upstairs, presented the case to my attending and I called the nursing supervisor to kind of roll it by him to see if we could make an exception for this case. Of course, that was a no — which I can’t blame him because it’s policy — but I told my attending that this is going to be a difficult case.

He’s a young man with high-functioning autism, but with a lot of sensory difficulties. He has never been in hospital. He lives in a home with like six other roommates. I didn’t really know the extent of what they do on a day-to-day basis, but it sounds like he’s really tight with his mother, and really did not want to let her go. I had to, and she had to basically convince him to stay because we knew that he would decompensate outside of the hospital and it wouldn’t be good after that.

A Turn for the Worse

At the end of my shift, he rolled into my ICU bed. We had to clear something out, move some people around, rearrange the nursing ratios. It was already a mess in the ICU. We had already started talking about opening up a second unit and he held his own while he was there.

I kept him on nasal cannula. He kept complaining that he was hungry. Then he started pulling at his nasal cannula, so we struck a deal. I told him if he leaves the nasal cannula on and I can see that his O2 sats do okay for him to eat, and as long as he left it on while he ate, we’ll be okay.

I passed the case off to the hospitalist that night, kind of giving him the heads-up on keeping an eye on this kid. His ABG came back like right as we were discussing. There was no need for intubation at the time, but it wasn’t great. From what we had seen already, if this kid was COVID-positive, which we highly suspected based off of his CT chest and his symptoms, this wasn’t going to be a good outcome. I definitely like had my qualms and even as I’m recounting this story, like, my voice is shaky.

I came in the next morning. This kid looked terrible. His room was right in front of my computer desk, and he didn’t look good. He got a repeat ABG and honestly I can’t… I remember it wasn’t… it didn’t look great. It was slightly worse than before, but nothing that would make me panic initially to intervene right then and there. But I was told that he had to be moved up to high flow. He wasn’t cooperating with keeping oxygen on. He was very uncomfortable, this kid. He wasn’t grasping and taking direction very well, and he was starting to panic.

I went to the room and knocked on the glass to try and talk to him. I told him that he really does need to keep the oxygen on in order for everything to be okay and to get him out of the hospital quicker, and he just wasn’t having it.

I looked at his morning labs and his morning chest x-ray. Everything… his chest x-ray looked worse and clinically, he just didn’t look great. He started to desat, so the nursing staff started to come up to me, expressing concerns. We decided that we need to intubate this guy because he’s going to decompensate. It’s going to be worse. Everything is getting worse. He’s moving in a bad direction. He is not being cooperative with his oxygen. It’s a bad situation all the way around.

The nursing staff went in, the RT went in, my intern — who actually had the case that I was overseeing — went in, and automatically like this created a huge issue for him. Unfortunately, there were too many people in the room for his comfort. He started getting very rowdy, wouldn’t keep the oxygen on, and couldn’t keep a pulse ox on him. They lost IV access, had to sedate him, and it was just like a mess.

We were trying to keep a limited number of people in the room to reduce exposure and exposure time. People still had to get set up, establish access again, get the medications pooled, and restrain him to keep him in the bed so we could actually do all of this and get it accomplished. It was very difficult to try and get directions through masks and through glass windows. Everybody basically had to scream at each other in order to get any directions across. The patient, with his sensory difficulties, is making it much more difficult. Finally, after several minutes and a lot of frustration on either side, we were able to intubate him.

Later that day, his COVID test came back positive, which was not a shock. He was decompensating. We threw everything at him that we knew we could at the time, including hydroxychloroquine. ID was on every single case in the ICU. My ICU rotation ended and he was still in the ICU.

I remember talking to his mom and calling her to tell her that he is COVID-positive and everybody that has had contact with him needs to be aware and to quarantine, and monitor for symptoms, and gave them ER-presentation precautions. I called the home that he was at and let them know as well.

I discussed the COVID status with Mom and she started crying on the phone. It was very difficult to see somebody that was so young with a history like this. It’s somebody who couldn’t advocate for themselves and couldn’t even quite understand what was going on. I think that’s what made it more difficult for me, is you have a young kid that just doesn’t get it. He doesn’t understand what’s going on, the gravity of the situation, and how many people I have already seen die from what he has.

Even the milder cases that came through and people who were able to cooperate and didn’t need intubation, as long as they kept the oxygen on and we were proning them, and they understood that they had to do their part to help with pulmonary physical therapy, they had a shot at overcoming this and at least getting out of the hospital and regaining some function. This kid didn’t get that, so it made it that much more difficult for the team and his prognosis much poorer.

What Could I Have Done Differently?

I ended up leaving my rotation and following the case outside. He ended up dying, which haunted me for months afterwards, just thinking about the case and what I could have done differently. In talking to like my attendings, there was nothing that we could have done differently. Oh my gosh, sorry.

We threw everything that we knew at him, adjusted, troubleshooted any of the vent, we adjusted for ARDS protocol, we threw all the medications that we knew at the time to try and combat what he was going through, on the phone with family every single day giving them updates and asking them how far they wanted us to go and what was going on, just like every other case.

I think this case just really hit me hard because of his medical history and his inability to advocate for himself. It really gets to you as a physician, feeling helpless. All these cases made me feel completely incompetent, even though I had attendings telling me, “You did everything. There is nothing else that we can throw at this. We don’t know enough about the virus and what it’s doing. We know a limited amount and we’re working off of that, and every day is evolving in knowledge.”

That entire month, from Day 1, my first case that walked through… or, well, didn’t walk through, rolled through in the ICU intubated… we pulled 14-hour days in the ICU. I’d come back and would just immediately hop on the computer and start researching what was out, again, and what was new on the forefront of COVID treatments, on Facebook with our physician groups. “What have you guys seen in the hospital? What are you doing? What are you trying? What’s working? What’s not working? What are people doing in other countries?”

This is a very interesting dynamic I have never been through. Granted, I’m only four years into actually practicing medicine as a resident, but contacting, reading blogs from physicians in other countries who experienced this before us, and seeing what they’ve done, it was a little crazy because it just felt so chaotic, although it was nice to see that there was a form of collaboration.

It did reassure me to know that we’re doing what everybody else is doing. Some things we were doing that were a little more novel, but it is scary as a physician too, after all your years of training, to see that something can still hit medicine and affect the population to the gravity of like not knowing how to combat it. I think that’s a lot of the frustration on the physician point of view with the general population. They don’t see what we see. We see a lot of death and destruction and how bad this disease is.

My very first patient was a 50-year-old firefighter. I’ve had a 40-year-old mother of four, a single mother of four, on a ventilator who couldn’t control her lungs and it just takes people, and aggressively and without any remorse. It doesn’t care who you are or what you are. I mean, it’s just nuts, and obviously to see how it impacts us as physicians.

PTSD Is Real

This was in February of this year and I am now recounting in December, and I still get teary-eyed. I had nightmares for months afterwards, just anxiety, like picturing the cases in my head, running through them. I couldn’t sleep, so the PTSD is definitely real for a lot of the frontline workers.

It’s a little difficult for me to open up to any of my colleagues, but I finally did and discovered that I’m not the only one. Everybody else is kind of going through the same thing. There is some solidarity in that.

But it’s nerve-wracking because these are places that we walk into on rotations all the time. You have to walk into every room prepared for the worst, but with the knowledge of what you’ve learned in the past and what’s been effective, and kind of cleaning the slate for yourself, honestly.

It is a little nerve-wracking to walk into an ICU again, especially the same ICU, knowing what we’ve gone through before. But our faith is in science and with a vaccine starting to roll out I’m really hoping that we have something to look forward to, to get back to some sort of normalcy.

Other stories from the At a Loss episode include “Growing Close Then Saying Goodbye” and “A Broken System Killed My Young Patient”

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