When I entered Mr. H's room, I saw him lying on his side with a plastic tube coming out of his mouth, motionless, eyes closed, with an odd twitching of his forehead. His ventilator and dialysis machine were humming. He'd been having odd neurological findings, maybe due to the virus invading his brain. We worry about this a lot in those who present with delirium, a global dysfunction of the brain that predicts COVID-19 may be doing something dangerous. "He's been staring at the wall all day and chasing a dog around the room that none of us can see," was a comment sent to our website this week from a concerned wife of another coronavirus patient. Mr. H was just lying there, with his scalp twitching, unaware of my presence.
As I was standing at the foot of his bed, something hit me that I'd rarely been conscious of in 25 years as an ICU physician: raw fear. I could sense an uncomfortable degree of fear in my head, heart and the pit of my stomach. Fear from general dread of a new deadly disease with so many unknowns. Fear of repeated exposures for my colleagues, who could become sick and die. And fear that the virus, which was invisibly present throughout the room, would infect my lungs, blood and brain despite my best efforts.
Fear can be healthy or unhealthy. This fear was unhealthy - like a barrier keeping me from the man I was there to try to help.
I began to wonder whether this fear is driving some of the striking deviations away from standard care that we are seeing for COVID-19 patients. These deviations are potentially dangerous for patients, and they are contributing to ventilator and bed shortages that are predicted to get worse. Such changes from standard guidelines include earlier intubations, deeper and lengthier sedation courses, prolonged immobilization. This leads to each patient occupying the ventilator and ICU room longer than usual, which contributes to resource shortages.
The illusion of control
When I trained in the 1990s, a culture of care in ICUs around the world had evolved in which we treated patients on ventilators with high doses of benzodiazepines and narcotics for a week or more so we could remain in total control of patients on life support.
It was only an illusion of control: We had unknowingly created an invisible engine of new disease that no one understood. After decades of doing this to people, we finally studied for long-term effects and found that it was very harmful to patients to keep them in this suspended state of animation. It led to profound harm from new diseases of the brain and body now called PICS, or the Post Intensive Care Syndrome. People suffering from PICS are unable to walk and think as they did before their ICU stay, and this can last for months, even years. Because of PICS-related physical and cognitive disabilities, they lose their jobs, get divorced because relationships break down, have memory deficits that mirror Alzheimer's disease, have depression and PTSD, become suicidal and come weekly to special clinics and support groups popping up around the country like the one at Vanderbilt University Medical Center run by two of my colleagues, Carla Sevin and Jim Jackson.
To help prevent these problems, investigators from around the world developed protocols, studied them and proved that programs called ICU Liberation and Thrive can lighten sedation, get people off ventilators faster and get them moving again sooner. A protocol called the A2F bundle has been implemented in the care of tens of thousands of people and shown to save lives, reduce hospitalization duration and send more people home rather than to rehabilitation hospitals and nursing homes.
Not in a hot spot, still terrified
I am not a physician in New York, New Orleans or Michigan. In Nashville, we have fewer than 2,000 confirmed cases so far. I cannot understand exactly what my colleagues in hot spots are going through. So I asked Robert Hyzy, a covid-team ICU director at the University of Michigan, what role fear is playing at the bedside of covid-19 patients.
"Doctors have a fear of exposing nurses and ourselves to the virus," he said. "This is driving a willingness to deviate from established practices. It is easier to induce a medical coma with propofol than to do what is right, turning off the sedation every day with A2Fs. Ultimately, it backfires because nurses end up getting more exposure because of longer patient stays."
I've never seen courage and dedication in a group of people like I have in our nurses and respiratory therapists. But there is fear, too.
Some physicians are recommending radically new approaches to COVID-19, said Hollis "Bud" O'Neal, ICU research director at Our Lady of the Lake Hospital in Baton Rouge, Louisiana. "All I know is that deviating from lifesaving approaches proven over 20 years will do more harm than good," he said. "For my patients, I'm sticking to what I know works."
It is a difficult situation: "I've never seen courage and dedication in a group of people like I have in our nurses and respiratory therapists. But there is fear, too." Perhaps it is the balance between fear and bravery that we must titrate to do our best for the patients we serve, the teams we lead and society at large.
The best physician leaders are making sure nurses know we will proactively help with feeding, cleaning patients and changing their beds. We must never ask them to do something we will not do ourselves.
All of us in gloves, scrubs and N95s have grappled with a degree of fear in our roles at the bedside even before covid-19: Fear of missing the diagnosis. Fear of a botched procedure causing a lung to pop or leading to life-threatening bleeding. Fear of being completely misunderstood by our patients or by their families. And yes, fear of getting sick from a patient with tuberculosis or a highly drug-resistant bacterial infection.
But rarely, if ever, is the fear as palpable as it is with COVID-19. Darin Portnoy, a physician with covid teams at Montefiore in the Bronx, who was also the past president of Doctors Without Borders USA (Mdecins Sans Frontires, or MSF), told me: "What I'm seeing in the Bronx is eerily similar to Ebola in West Africa." He was in Monrovia, Liberia, with MSF in 2014. "Both diseases have had confusing and dissonant public health messaging at the start, growing levels of community mistrust, and patients separated from their families when they seek care. Patients see us dressed in unfamiliar and threatening gear and they struggle to hear our muffled voices through masks. They sense our uncertainty when we can't tell them exactly what to expect with their illness, and we have no cure to offer. At death in both diseases, families are unable to be with patients at their bedside or come together to mourn their death later."
Not stay the same
A period of sedation and paralysis in the hospital today is not the problem; the problem is not trying to stop them tomorrow. We say to ourselves, "Let's keep sedation going today because she's stable and unchanged." But unchanged is death. People in the ICU should get better, not stay the same.
Keeping sedation going should immediately trigger fear of PICS. But my colleagues say it does not. Hyzy told me "that fear is drowned out by fatigue and bleeding noses from N95s." Elisabeth Riviello, an ICU doctor at Beth Israel/Harvard in Boston, explained, "The risk of PICS is less dramatic, and further away, so we give in to immediate fears and keep people sedated too long."
Of course, the best way to avoid a ventilator shortage and PICS altogether is to remove unnecessary intubations in the first place, which is what others treating covid-19 are already starting to do. Taking a person who is perfectly conscious, but with low oxygen saturations, and asking them to hang up the phone they are talking on so we can put them on life support early just because they are infected with the coronavirus is not supported by evidence.
Fear - on top of the overwhelming volume, high acuity of covid-19 patients and the need to repetitively don personal protective equipment, or PPE - also keeps us from entering rooms very often to care for the patients' existential needs. "We keep our visits brief," Portnoy said. "Our rounds are compressed, and we limit the human touch we so commonly use when seeing our patients, focusing only on the essential physical exam. We can't adequately address patients' fears of isolation or the evolving threats of delirious hallucinations."
Last week, a Vanderbilt resident came to me and said: "Dr. Ely, I'm afraid I'm not being a real doctor because of COVID-19. I came on service yesterday and took care of a patient admitted the day before. I didn't go in the room in order to save PPE. I just held his hand today for the first time as I pronounced him dead."
At the bedside with Mr. H, I bent down to hold his puffy hands and listened to crackles throughout his lungs. I found little consolation in his normal heart sounds, because he could not wake up: He was deeply sedated, full of the effects of milky propofol running through his veins and into his brain. But his oxygen needs had stabilized.
A lightbulb went on in my brain that fear had turned off. I remembered what I should do next - the best antidote to fear: talk to my patient. I bent down near his ears, regaining my standard practice of talking to comatose patients in case they can hear me. "Mr. H, I am Dr. Ely, and we are here to take care of you. We are not going anywhere, and we will not leave you. We just spoke to your daughter, and she wants you to know she loves you so much. It's time to wake you up now. We need to see if you can breathe on your own and listen to your daughter through our iPad." He did not move. I stood back up and began the tedious process of safely leaving the room and removing my PPE, to reduce the chances that my time with him would spread a life-threatening viral infection to me, a team member or my family.
Ely is the co-director of the Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center at Vanderbilt University and the Nashville Veteran's Administration Hospital.