Tag Archives: ICU medicine

The Cost of Service: Doctors, Nurses, First Responders, and other Medical Personnel During the novel Coronavirus 19 Pandemic


Friends of Padre Steve’s World,

I’ve served in ERs and ICUs during pandemics, but none as bad as this one. Likewise, I have seen far too many people die, I lost count somewhere after 700, but can still remember many of the dead, their families, and those who tried to save them like it happened yesterday. Many of the cases I dealt with were violent deaths, others from people who were in the words of ICU doctors and nurses, medical disaster areas because they had so many things wrong with them that you could treat one disease or organ, but have more organ failures. In the Medical ICU this is called multiple system organ failure. I have been with people who died with loving families and friends with them, others who died alone, and still others, especially dying AIDS patients die and being condemned to hell by family members who then used the opportunity to separate the patient from his lover and best friends.

I have also seen those who survived their illnesses or injuries, but never fully recovered after long periods on ventilators to keep them breathing and huge concoctions of drugs and procedures to give them a chance to survive.

As a part of the treatment team I was often the go between from the physicians to the patients family members, providing ministry, even as I shuttled information between them with the goal of trying to help the patient survive. Sometimes all treatments were futile and I would help prepare the patients or the families for the end. Even as I write this the memories, images, and even sounds of these encounters of life between life and death.

Even without the scourge of a pandemic, ERs and ICUs in inner city medical and trauma centers, tend to resemble combat zones. Surges of critical patients flooding ERs followed by brief lulls, that are then followed by more surges. In between surges housekeeping crews clean the blood, fluids, gauze, wrappings from needles, intubation kits, chest tubes, masks and gloves, as doctors transcribe their notes, nurses and techs restock the rooms, and others either prep and transport the patient to the operating room, appropriate ICU, or ward. If the patient didn’t survive, following time for the family or friends to say goodbyes, the staff preserves the body, leaving in it the intubation tube, chest tube, catheters, and any other invasive treatments, place it in a body bag, and transport to the morgue. If the person was known to be infected by HIV or H1N1, or the SARS, MERS, or Ebola outbreaks when I was working in a hospital, more protective measures are taken.

 

Unlike television where miraculously people are pulled from the jaws of death, it doesn’t always happen, especially if the patient is being coded when they arrive in the ER aboard an ambulance, or their heart and breathing stops requiring the ER team to begin the Code, which unlike on television is a rather violent attempt to save the patient’s life. Cardiac compressions begin, the patient is incubated, lines of saline IV fluids are placed and set to maximum flow to keep the blood pressure up, if need cardiac stimulants such as atrophiere are administered, sometimes directly into the heart.  If the injury is due to trauma, or perhaps an Abdominal Aortic Aneurysm, the patient’s chest may need to be cracked. If this happens happens in the ER it is a truly ghastly sight, as the instrument used to separate the ribs looks like the bones of some dinosaur, and unless the trauma surgeons, surgery resident, or ER physician manages to repair the damage and get the heart started the patient dies. Only about one in a hundred survive the procedure under those conditions.

In the  ICUs of various types, Medical, Cardiac, Trauma/Surgery, Cardio-Thoracic, Neurosurgery, Burn, Pediatric, and Neo-Natal there can be chaos as well, but in normal times it is more controlled than in the ER, but despite the best efforts not everyone who gets to the ICU gets out. No matter how caring the staff, the ICU is a clinical and cold setting. In every room or bay there are ventilators, monitors, specialized beds, pneumatic heated blankets sometimes known as Bear Huggers”, crash carts. Available in a fully equipped ICU are dialysis machines, portable X-Rays, and even CAT Scans, under the direction of the ICU attending physician, physician specialists of various types, residents, and physicians. Most of the nurses are Critical Care RNs or have have attained the status of Nurse Practitioners. The techs that work in the ICUs are the best. Likewise there are Clinical Social Workers, Discharge Planners, Unit Clerks, and often Chaplains, like me.

 

In my last full time fully equipped ICU I took the time to learn about what our physicians, techs, and nurses did. I asked questions about how to read cardiac monitors, understand the importance of blood oxygen levels, know when a patient was going into an abnormal heart rhythm, or who was dropping their blood pressure, or de-sating. I still have a copy of the ICU book. One of our ICU attending physicians asked why I didn’t go to medical school, and I had to admit that because of my wretched high school advanced mathematics experience was that it would probably take me at least three years to catch up on the math, algebra, and calculus needed just to get into medical school, and that after the poverty of seminary that Judy would never consent to it. He understood.

All that being said I treasure my time with those physicians, nurses, techs, and EMT and Paramedic first responders, many of whom are now in the front lines fighting COVID-19. When I read about what is happening in ERs and ICUs in major urban areas, when I see the horrors of what these men and women are experiencing my heart goes out to them. They are being confronted in real life with what one could only imagine in the most terrifying Science Fiction, or Horror story. Take a combat zone and add a pandemic which not only infects and kills those brought to hospital, but those risking their lives to treat them. As of two weeks ago some 9,000 health care workers have been infected and about 30 have died as a result of COVID-19. That doesn’t count those who have committed suicide because of the impossible conditions they work under and the impossible choices that they have to make, of who lives and who dies, and which of their staff has to go back into the battle even if they are unready. The cases of PTSD, Moral Injury, and other psychological conditions that will afflict these heroes will rise to exponential level. Others will commit suicide, and even more will abandon the medial profession because the spiritual and psychological toll is simply too high. These are not weak people, but people whose humanity is being assaulted by their inability to save those committed to their care, and fear that they will make a mistake that will get them, their patients, friends, or families killed because they didn’t have the correct PPE or got infected during an intubation, or during CPR.

Sadly, while for the moment the first wave seems to have crested. But without adequate testing, tracking of cases, and eventually effective treatments, and a vaccine, COVID-19 will keep coming back. Each time it does it will harvest those foolish enough to tempt fate, or God, whatever works for them, and put others in harms way. Personally, I don’t want to see those I know fighting for the lives of others die because of the arrogance and stupidity of others who think that getting a haircut, their nails done, going to a fitness center, or going to a dine in restaurant or movie trumps the right to life of others. Anyone who thinks that their right to do what they want for enjoyment which endangers the lives of others is nothing more than a sociopath, incapable of empathy. Sadly, evil, is the lack of empathy.

As for me, I know all too well the consequences to others when people decide that their need for fun and to do what they want to do when they want to do it trumps the right to life of others, including those who are putting their lives on the line every day to fight a pand

Until tomorrow,

Peace,

Padre Steve+

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Filed under ER's and Trauma, ethics, healthcare, mental health, News and current events, suicide

Coronavirus and the Unthinkable: The Coming Need for Combat Mass Casually Triage

Friends of Padre Steve’s World,

We live in a vastly different world than we lived in just a few weeks ago. The President persists in repeating the mantra that nobody saw the novel Coronavirus coming, when in fact there were such creditable reports coming from China that even the Texas based H.E.B. Grocery chain began to prepare for it in January. The interesting fact is that we’re simply paying attention to unclassified, publicly available reports about it, and not the classified information being provided to the President by U.S. Intelligence agencies in January and February; information the President either paid no attention to or willingly ignored. Thus, unlike the people of H.E.B., the Federal government made no preparations for the coming pandemic. No wonder he persists in saying that no one saw it coming, it lets him off the hook, a victim of his own willful ignorance.

Because of this civilian hospitals are without enough room, ICU beds, isolation rooms, effective medications, respiratory ventilators, and Personal Protective Equipment, all known by the acronym PPE. Part of this is because we run a profit based medical system. ICUs are very expensive to maintain, if a hospital maintains a large surge capacity, it loses money.

They are not your general purpose hospital rooms; the really well equipped ones have  individual rooms, often equipped with negative pressure so infections cannot get into the rest of the ICU from being infected when the door is opened. they have to be staffed by highly trained physicians: Since most people in ICUs are dependent on some form of respiratory support, the Attending Physicians are usually Pulmonologists, or to put it simply, doctors who deal with the complexities of the human respiratory system. Depending on the patient they work with Cardiologists who deal with the heart, Neuro-surgeons, and Neurologists, who deal with the Brain and Central Nervous System; Cardio-thoracic surgeons, Gastroenterologists, Cancer Specialists, Rheumatologists, Renal Specialists, Trauma Surgeons, Burn Specialists, ENTs, Entomologists, Virologists, Radiologists, and host of other speciality disciplines. The nurses are not your ordinary nurses. They are RNs with certifications in critical care, cardiology. Neurology, and like the doctors a host of other disciplines, many have Masters and Doctorates, and nurses generally are assigned to work with one or two patients, where on a general medical or surgical ward that ratio might be one for every seven or eight patients. Then there are the respiratory therapist who run and maintain the ventilators and other breathing machines, the X-Ray techs, the phlebotomists, the lab techs, as well as LPNs, Nurse’s Aides, and Medical techs, and unit clerks who do the unglamorous work in the ICU. In really well equipped Medical Centers there are portable X-Rays, CT scanners, and Dialysis machines in the ICU. This doesn’t count the highly complex ICU beds, Cardiac monitors, IV pumps, and so much else to make them work. Let’s not mention the Chaplains, Social Workers and others who work with the patients, families, and treatment team in caring for each patient. I have spent a number of years as an ICU chaplain in major medical centers that are also teaching hospitals. I have seen my fair share of suffering and death, as well as the heroics of ICU staff members.

In normal times there are just enough ICU units and beds to treat those that require them, as well as all the equipment and personnel to keep them going. But many smaller hospitals lack this capacity, they are dependent on major medical centers, and local specialists and practices to supply what they need. The fact is that this pandemic has revealed just how unprepared we were for it.

This places doctors in a terrible conundrum. These physicians, nurses, and techs are devoted to saving lives, and most of the time the work heroically to saves the lives of men and women with multiple morbidity factors, or what some of us called “medical disaster areas,” because they were so sick that even heroics could not keep them alive. Statistically most Americans will spend a month or more of their final year alive in an ICU, when palliative care would be more human. ICUs are incredible, but too many people, influenced by television medical dramas believe that they are miracle centers, when they are not. As modern Americans we have forgotten the lessons of our ancestors, we no longer value life enough to make our dying loved ones comfortable, surround them with love, remember their lives, and let them to tell their stories and say goodbye. Instead we try to keep people alive without considering the pain and suffering that the treatments of their maladies cause  them, We have institutionalized death, and made very caring strangers responsible for the deaths of our loved ones, in sterile, mechanical, and unfamiliar places. I have seen too many of these deaths and remember so many of them. That my friends is just in normal times. These are not normal times.

Since we failed to prepare for it in the eight or so weeks that we had a chance to prepare for it, the novel Coronavirus, or COVID-19, has infected over 600,000 people worldwide and killed over 30,000, is now straining even the most prepared healthcare systems to the brink. Despite the quality of our care, our government, medical systems, businesses, and population were completely unprepared for this, except for those like H.E.B. and me who began to follow it early.

This pandemic is in the process of making providers have to upend normal triage. In normal times we treat the sickest and most likely to die first, those serious but not in a life and death battle second, and those healthiest and likely to survive their injuries or infections last. I remember on one horrible night back in 1994 at Parkland Memorial Hospital in Dallas, our ICUs we’re slammed and I was the on call chaplain for the entire 900 bed hospital. All six trauma bays were full, with people suffering gunshot wounds, burns, and injuries from motor vehicle crashes. The same was tru in our Medical ER where all three critical rooms were occupied, with two in the process of full code from contaminated crack cocaine overdoses. As I made my rounds in the ER, preparing myself to be with doctors as they got ready to tell family members that their loved ones were dead, a young man, on an overflow bed, being monitored every 20-30 minutes, with a flesh wound cause by a small caliber weapon in his thigh pulled me aside. He pleaded with me. “You’re the Chaplain, I’ve been shot, get me treated!” I told the young man, “I’ll be glad to do so if you want me to tell the doctors that are trying to keep people from dying that you need to be seen before the man with the gunshot wound in the head that just died, or the woman with massive crush injuries from a car crash who is trying to die, or the man with 70% of his body burned Who is unlikely to live, or any of the others we are trying to keep from dying, for you? You are stable and being monitored, you’ll get treated and walk out of here by tomorrow. So who do you choose?”  The young man was stunned by my bluntness. He then stammered out, “someone just died and others might?” I nodded my head and said, ”what do you want me to tell the doctors?” My words must have struck a nerve and revealed that he still had a conscience. He replied, “No sir, help them and pray for me, I’m sorry.” I said, “getting shot isn’t normal,  and it is scary, but I will pray for you and these doctors will take care of you.” He simply thanked me and grasped my hand. I said a brief prayer for him and moved on in a night that would have me deal with eight deaths, and doing my best to care for the dead, their loved ones, and our staff.

In the Coronavirus era, the young man might be treated first and the dying placed on an overflow bed in the ER. This is not about choosing what life matters more, but the hard fact that no matter how hard we try we cannot save the lives of some people regardless of how many resources we employ.

I learned these hard facts as a Medical Service Corps Officer in Germany at the height of the Cold War. In a NBC (Nuclear, Biological, Chemical) mass casualty event, or even an overwhelming conventional mass casualty event the triage of casualties is upended. In normal times we try to treat the most seriously injured or ill first. But in an environment where the ill or injured are infected by a biological agent that we cannot treat, or a chemical agent that will kill them anyway, or enough radiation exposure to kill them, or we are completely overwhelmed with casualties, we provide palliative care to the dying or most likely to die while minimizing their pain and suffering. instead we concentrate on saving the lives of those who have the best chance of living. As long as we have the resources and personnel we aggressively try to save the lives of people infected by Coronavirus, but if we don’t we need to issue “do not resuscitate“ or DNR orders in order to protect medical providers and to ensure that we save the maximum number of people regardless of their status in society.

In a combat environment, which I hate to say we are now in, a soldier with an otherwise treatable wound who has been exposed to a biological or chemical agent, is given palliative care. Likewise, you cannot run a full code on a person infected with Coronavirus because you risk infecting the treatment team, and other patients in the adjoining beds. That may sound heartless, but it is the most humane course of action. At the rate of expansion of COVID 19, more and more doctors and hospitals will be forced to make this choice.  Chaplains and nurses can care for the dying, so long as they use appropriate personal protective equipment in order to not become infected and pose a risk to others. No one likes this, but if resources and personnel cannot handle the numbers of those infected, then such measures are necessary, and I do not say this lightly. I have been through two pandemics, and combat. I value all life, but there are times when care has to be rationed. That is something I know from history, as well as my education and training. Every life might be sacred, but you cannot save everyone, and whether we like it or not, everybody dies.

That is what we are rapidly approaching now. In the past two days the number of deaths from novel Coronavirus-19 have doubled from 1,000 to 2,000. Since 8 March we have gone from 516 confirmed cases and 21 deaths to 123,750 infections and 2,227 deaths. That my friends is in 20 days. The rate of infection is increasing exponentially as the nation, led by a President who will not lead or take responsibility for his actions and that of his administration, desperately tries to contain it. The state governors who speak out asking for help for their citizens are demonized by the President and his cult like followers.  This isn’t about politics, it is about life and preserving it.

Mark my words, with a week hospitals in many major urban centers, and the understaffed, underfunded, hospitals throughout America’s Red State heartland will be having to make these terrible decisions about who lives and who dies. Sadly, the trail of guilt can be traced not just to Trump and his administration, but to leaders in both political parties, who refused to speak the truth when it was most needed.

I refuse to be one of them. I will speak truth to those in power as long as I can and provide my pastoral care to those who most need it, and I will not reject anyone, Christians, other believers, or those who struggle with belief or reject the entire concept of a Supreme Being. For me all that matters is that they are flesh and blood human beings in need of empathy and care, regardless of their beliefs.

So, that being said, I wish you peace, health, and the blessing of not having to make such decisions, unless you have to speak for a loved one who cannot speak for themselves.

We are in a war against an unseen enemy as well as others who want to destroy us. More often than not the President sides with those who want to destroy all of us regardless of party, race, religion, or ideology. Like it or not we are now dealing with a combat situation and  everything we knew before is  obsolete.

I have been preaching this for years, but because I deal with combat induced PTSD and other issues I have been sidelined by the Navy Chaplain Corps. But I won’t stop preaching to truth to power and caring for everyone in my care. Twenty-four years ago when I was ordained as a Priest in my former church, the Archdeacon made a prophecy that like Saint Stephen I would accept martyrdom joyfully.

Mind you, I am not one to take such utterances literally, and want to live as long and and happily as I can. Nor do I seek martyrdom be abuse I believe that God, whoever he or she may be is not a fan of such actions. That being said,  I want everyone I know to live through this and produce antibodies in their blood cells that will help others live. Likewise I will speak as long as I live against political, business, financial, military, or religious leaders who would use this crisis to consolidate and expand their powers at the expense of all over us, regardless of our race, ethnicity, religion, political or ideological beliefs may be.

But I am tired, so until tomorrow, please be careful out there.

Peace,

Padre Steve+

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Filed under Coronavirus, culture, Diseases Epidemics and Pandemics, ER's and Trauma, ethics, faith, History, laws and legislation, leadership, Military, News and current events, Political Commentary