The sheets on my patient’s gurney in the emergency department were sodden with sweat. “That’s nothing,” he said when I pointed it out. “My clothes have been drenched for days.”
Droplets beaded his face. Sitting on the side of the bed, speaking in halting sentences to fit in breaths, he told me he knew he'd been exposed to someone with the novel coronavirus the week before, when he travelled to a few cities in Europe. He got back to the United States just before the government prohibited incoming flights, and he thought half the people on the plane were coughing and sick.
Only in his 50s, the biggest medical problem he'd faced until then was high cholesterol. Our conversation was only two days ago. Now, he is intubated in the ICU.
That was the end of a week on the coronavirus service at a large metropolitan hospital. My first day on the coronavirus service, last Thursday, was kind of slow. I’d never seen the emergency room so empty. When my cousin asked how things were going, I wrote back, “Seems like the calm before the storm.”
I just didn’t know how quickly the storm would hit.
By Sunday, I had a full service, about half with people waiting for coronavirus tests — we were getting results in about 12 to 18 hours, done in batches, coming in twice a day — and the other half with people who tested positive. Most people with the virus were OK, with moderate symptoms like cough and fevers, and only two required oxygen to help them breathe.
By Tuesday, most were Covid-19 positive, with a number of patients needing oxygen. I spent much of the day seeing new patients in the emergency room — each sicker than the last — and in discussions with the ICU about which patients would likely need a higher level of care. Two of the patients I saw earlier in the week had already been sent there.
Checking in on Thursday, I learned that five patients I took care of were now in the intensive care unit requiring ventilators to breathe. Two had severe respiratory failure.
It wasn’t all bad news: another was getting better, had left the ICU and would likely leave the hospital soon. But I was surprised at just how quickly the situation had changed from calm to intense, both in terms of number of patients and how quickly people needed help to breathe.
We're practicing familiar medicine but all the hospital staff are stepping up their game still more — from the environmental teams who quickly clean the rooms to make space for more patients, to the intensive care unit teams who rapidly respond as some patients need more oxygen.
But the numbers are quickly ramping up, with more and more presumed cases every day. At this rate, the concern that the health system will be overwhelmed is very real – and likely to happen fast if we stay on the path of about a 33% rise in infections per day.
Thankfully, most patients have few, if any, symptoms. There’s no need to see your doctor if you only have a cough or a fever, though it’s worth checking in (by phone!) with a doctor if you have shortness of breath in addition to the fever and dry cough. Some patients even have a mild pneumonia that resolves in a couple days.
But like my patient who was recently in Europe, the few patients with severe shortness of breath requiring oxygen develop a type of “acute respiratory distress syndrome” or ARDS. We do not fully understand ARDS, but it seems caused when the immune system goes haywire, pushing fluid into the lungs and making it difficult to get enough oxygen.
Doctors have a lot of experience treating ARDS with ICU care and ventilator treatment, and in most cases, after a few days or weeks, a patient gets better and can breathe on their own again. But when people die of Covid-19, it seems to be those who had ARDS and complications.
So please let me add my voice to those asking you to practice social distancing even if you feel fine. My Covid-19 patients told me of the dinner parties and art fairs that they attended in the few days before they got their symptoms.
Of course, it isn’t clear whether they got the virus or spread it to others at those events. But with our limited testing, we can’t be sure who has it and who does not. So please don’t be like the spring breakers partying in Florida and saying no virus would stop them.
For example, my sister texted me if she should keep going to the gym. I wrote back “Had a patient today – very likely Covid-positive – who ran the [city] marathon. How many people who ran that marathon are at your gym?”
“No idea,” she wrote back. “But I think that’s your point." (Grimace emoji)
David Scales is an internal medicine hospitalist at New-York Presbyterian Hospital, formerly an Instructor at Harvard Medical School and on staff at Cambridge Health Alliance.