COVID-19 Changes Medical Practice, Maybe Forever
/Rounding in the ICU for 2 weeks taught me that a new risk calculus has emerged in the COVID-19 era.
I’m recording this after spending two weeks on the renal ICU service here at Yale in Connecticut. We are in the upswing of our COVID-19 surge.
I want to talk a bit about what I’ve learned and experienced in these two weeks, with the caveat that there is significant selection bias. Patients with COVID who end up needing renal on board are generally not doing very well – we’ve really been struggling to provide the best care possible.
So – some thoughts and observations. Obviously, due to privacy concerns I can’t give you specific patient information.
In two weeks, we had many deaths and one successful extubation. These patients take a LONG time to heal and prolonged ventilation, at least in those with renal failure, is the rule not the exception. By the way since I know people will ask, all of these patients received hydroxychloroquine – it is part of Yale’s, publicly accessible COVID-19 treatment algorithm.
Most of the patients had pre-existing conditions, but typically they weren’t severe – these were definitely NOT people who might have died anyway. We’re talking a pre-existing condition of a BMI of 35 for example. And several patients, including a couple of young ones, had no medical history at all.
It’s bizarre not seeing patients’ families. So much of what we do when patients are critically ill is facilitate a families’ understanding of where they are and what might happen next. Doing that by phone is strange and impersonal and really hard.
Managing volume status in COVID-19 is complicated. My bias has always been to try to dry people out as much as possible in the setting of ARDS but I’m not totally sure that’s the best thing here. In particular, a lot of these patients need high PEEP and that makes me worry that aggressive volume removal could lead to V/Q mismatch and worsening ventilation. The ICU docs have been invaluable guiding our assessments here.
Speaking of the ICU docs by the way. I have seen so much heroism these past two weeks. From the ICU doctors, the nurses, and the medical assistants who are in and out of those rooms all day. Thank you.
And can we please acknowledge our medical trainees – the residents and fellows – who are doing so much for these patients, truly on the front lines, and are getting paid about a quarter of what attending physicians are.
More than anything else, the thing that has stuck with me I’ve been calling “COVID calculus”. It’s this change in how we practice hospital medicine. It’s based on the fact that our decisions now aren’t simply trying to balance risk and benefit in our patients, but in our providers as well, in the whole hospital system really.
Simple example. If I don’t have prior kidney imaging on a patient, I usually get a renal ultrasound in the setting of AKI. Is it high-yield? No, but I do it to be complete – to see if they have hydronephrosis, how big the kidneys are, etc. Every once in a while it matters.
Now I have to stop and think. Is it worth exposing the ultrasound tech to the risk of going in the room? Will the machine be properly decontaminated? If the tech gets sick, is there someone to replace them? Is the benefit worth the risk?
This is happening all over. Last week, it was reported that New York City EMS is being instructed NOT to bring cardiac arrest patients to the ER unless they can get return of spontaneous circulation in the field. The risk of exposing ER workers to the virus is just too high.
This is echoed by hospital policies regarding CPR. Historically, we know that cardiac arrest that occurs in the hospital is associated with fairly poor outcomes – just 20% make it to discharge according to this seminal New England Journal Article.
We still resuscitate these patients though. But Covid calculus may change this – the risk of aerosolizing virus during CPR is high – and a lot of people need to be in the room to run a code. Some hospitals are modifying their DNR policies to mitigate this risk.
The insidious thing about COVID calculus is that it gets worse as the epidemic gets worse.
But it’s not all bad. One thing COVID calculus eliminates is low value care – and we’re learning quickly what that is. When this is all over, will I go back to ordering renal ultrasounds on everyone with AKI? Will we demand patients see us in the office for follow-up when it’s easier to do a telehealth visit?
Whatever the outcome, it seems clear that the world of 12 months from now will be unrecognizable compared to the world of 12 months ago. I hope you’re all safe and protected.
This commentary was first published on medscape.com.