4th in a series of emails from a physician treating COVID-19 patients near the Tyson processing plant.
N = 7 on Day 4
Day 4 and we have started treatments on 7 patients.
The day started poorly. At 8am I walked into the ICU, where 8 COVID-19 patients are intubated (in just a 24-36 hour period since the outbreak started). Our HBOT Patient 2 had just been intubated. A huge burst to a tired bubble, but that is the way the practice of medicine is. We keep learning what we can do better for the next patient. He is stable and we can only hope that HBOT stopped some of his cytokine storm and he will be one of the ventilator survivors!
I met with one of the hospital-based physicians. We have limited HBOT capacity – we have to decide who we will treat. We started with the list of the sickest. Patient #5 was “prone” (on his stomach) since data suggest this type of positioning helps them breathe. He was so short of breath he could barely speak. He was our first treatment for today. I am using the FACES sheet (normally used to rate pain) for patients to rate their difficulty breathing on a scale of 0-10. Patient #5 scored his difficulty breathing as a 10/10 (most difficult, CF) prior to treatment, but a 2/10 after HBOT. Honestly, I was shocked that HBOT improved it so much! Even Dr. X, who speaks Spanish and was translating, paused to double check when the patient said his post-HBOT score was 2/10.
COVID-19 patients pant. They don’t take breaths, they just barely move their chest, and do so rapidly. I am wondering if it is due to a pleuritic chest pain, but I digress. One of the things we are seeing fairly quickly after starting the HBOT treatment is a slower breathing rate and deeper breaths.
Our second treatment today was Patient #4 from yesterday. Prior to his treatment yesterday he was dropping his oxygen saturation down to the 70s whenever he moved. I was in the hallway with the wheelchair, waiting for a new tank of oxygen (rookie mistake we can’t afford to make is to run out of oxygen while transporting patients). I look up and the patient walked across his hospital room and came out in the hall and sat down in the wheelchair. I was shocked (and hugely concerned) because he didn’t even have his oxygen mask on. Yesterday he was at lethal levels of oxygen saturation when he so much as tried to talk. Now here he is walking around. I put the pulse ox on him and his saturation (after walking to the wheelchair) was 90%. He looked at the monitor, smiled and said, “Earlier I was 98%.”
Patient #6 was another patient admitted last night. Our first female. When I read the Wuhan data and they stated in the case report there was a patient with saturation of 67%, I said “There is no way that could be correct.” I went into her room to speak to her and saw her oxygen saturation was 68%. Yet, she was sitting there calmly with no apparent panic or concern. Many physicians have reported on how unbelievably low the oxygen saturation can be and patients may not be aware of it. I waited until the saturation improved a bit. I asked her to take some deep breaths. She clutched her chest and stopped, Indicating severe pain in her chest. After her treatment, her pulse ox stayed in the 90s for the whole trip back to her room and she could breathe deeply with great ease.
Can I Stay in There?
Patient #7 is immunosuppressed from taking organ transplant medications, but is otherwise the only patient not on supplemental oxygen. As soon as we pulled him out from his hyperbaric treatment, he said “can I stay in there? This is the best spot in the whole hospital.” While he said he didn’t have other symptoms, he admitted after hyperbaric treatment that his breathing was not normal prior.
Lastly for the day, we treated Patient #3 again. He was the sickest we have treated (other than the ICU patient), as he kept coughing which would drop his oxygen saturation to the 70s. He truly looked just miserable, and he actually was not happy with us after his treatment yesterday. But when I saw him this morning, explaining it would be late tonight that we could see him, he was complaining he couldn’t stay in the chamber too long. He said he had gotten anxious and didn’t like it. We made a deal we would do a shorter treatment (nothing like patients dictating their own protocols when you are trying to figure out which one is optimal!) By the time we could see him tonight, he was saying, “I might want to stay longer in the chamber.” After an hour, he said he was okay to keep going. He is actually quite funny. I commented that he had almost stopped coughing completely. He said “they gave me a Tylenol, that’s why.” Reminded me of my mother years ago who told me that Tylenol helped her sleep. Dumbest thing I ever did was tell Mom that Tylenol didn’t help her sleep.
After emailing everyone how great HBOT is working, it was tough to see it wasn’t enough for Patient #2. We did 5 treatments on patients who all got better with HBOT. We cannot use video for patient privacy, but it would be interesting to try to use audio to capture the “before HBOT” coughing vs. during HBOT – during HBOT the coughing just stops. During HBOT, they get a look of peace on their faces and many fall asleep, which is not typical for most HBOT patients. Patient start off not even being able to talk and then the day after HBOT, hop across the room because they are so ready to go down for a treatment. We have to find the appropriate ways to measure what we are seeing. We discussed trying to do an incentive spirometer measure. They can’t take their oxygen off long enough to even put their mouth on it, much less be able to blow, and then we would be waiting for 30 minutes, like I did for our first female patient, for her saturation to improve just so she was “safe” to transport.
We Need a Way to Measure the Relief on Their Faces
When I was a surgical resident, if a patient had an oxygen saturation in the 90s, we would have transported them on a stretcher with every possible monitor. In this pandemic, patients whose sats are in the 90’s are being put in a wheelchair and pushed across the street via a skybridge connecting two different parts of the hospital – with only a sat monitor. Ironically, all of these patients, after their HBOT, sit up in the wheelchair to look out the windows as we cross the bridge. I think they feel better and instead of just concentrating on their next breath, they can look around… because it is the first time they have been out of their room.
Except for the immunosuppressed patient who we treated because of his underlying condition, every one of the patients we treated with HBOT appeared to be headed to intubation. It will truly be interesting to see age-matched, disease-matched controls and their time course. But I think we need to think of some other parameters to measure. For tonight, a man walking across his room and hopping in the wheelchair ready for a hyperbaric treatment, who could speak only 3 words yesterday, is enough of a data point for me. It helps take away the sting of the patient we treated who was intubated today. A patient went from 10/10 breathing difficulty to 2/10. These are numbers we can track, but we don’t have a way to measure the relief in their faces when they get HBOT. We keep working until we get it right every time.