Clinical Notes from COVID service
Anecdotal experience from my initial stint on COVID service:
· The two most frustrating aspects of caring for COVID patients:
1. The relative inability to accurately predict who would do well and who would crash. Despite trending inflammatory markers, oxygen saturations, and days since symptom onset, it remained very difficult to predict which direction patients were headed. Some patients did very well that I anticipated crashing and others crashed that I thought were on the mend.
2. The lack of treatments / therapeutics to help folks beyond giving them oxygen. Everyone at NYU gets 5 days hydroxychloroquine/azithro and high dose zinc assuming qtc ok. As we all know, it’s unclear if this does anything. Beyond this, there are no additional therapies or treatments other than supportive care. Thus, it’s a very helpless feeling to watch someone’s oxygen needs increase and know there’s very little you can do to stop the deterioration. Very frustrating.
· I would start every note with days since symptom onset and hospital day. I found this helpful to give me a read on where someone may be in their course. Generally, those who are symptom day 10 or earlier were usually on the upswing and those on day 17 or longer of symptoms were generally on the downswing of their illness. I checked CRP, ferritin daily and checked d-dimer, ldh every other day. Some folks had AST/ALT elevations but labs were otherwise generally unremarkable. I found CRP and ferritin most helpful but neither correlated perfectly with disease severity. CRP’s on admission were generally ~100-150 and would peak between ~200-300 before starting to downtrend. Ferritins ranged from 600-2500.
· 2 patients had positive strep pneumo urine antigen and both had high white counts so there definitely can be superimposed bacterial processes in addition to COVID.
· Proning works even before someone gets intubated. Anyone who got to 5L NC or more we tried to get to lay on their stomach or at least their side. This helped oxygenation almost every time. Biggest challenge is patients dislike it and few could maintain for >30 minutes to an hour. But, for patients who were able to do it, it made a big difference.
· Clarifying code status early on in hospitalization is critical. The conversation is a real downer for the patient and family especially since family can’t be present but given how quickly some patients deteriorate it’s a must-have conversation early on.
· Most concerning was a patient who was initially admitted for COVID 2 wks ago, was in the hospital for 5 days on nasal cannula, improved to room air and was discharged home in good condition. Of note, her CRP on that initial admission never went higher than 60 before downtrending. She subsequently re-presented 5 days later in respiratory distress with markedly increased inflammatory markers (CRP ~250) and ultimately passed away. There was no evidence of another process going on such as PE, superimposed infection (though she got broad-spectrum antibiotics just in case), but was almost certainly COVID-related. She likely presented very early in her disease course and crashed in late part of week 2 in her illness. The concerning part is that I’m sending out many folks that looked like her on initial presentation who required some oxygen but recovered to only needing room air and sent them home. We don’t have the capacity to watch every patient in the hospital who may still be in the window for crash, so although unsettling, no choice but to send them home and hope their symptoms don’t return.
For ICU pearls, here is a twitter thread from the UK that seems to be consistent with other intensivists I’ve spoken with.
Hope that’s helpful and reach out with questions,
Harry