A dispatch from the front lines - revisited

Note from Tom 1/28/22: On June 27, 2020, I published two emails that had been sent to me by Jude Gamel; I reproduce the post in full below. Jude remains a reader of this blog, and a recent conversation with him made me go back and read this post – and realize how powerful and relevant it is. I think you’ll agree. 

Note from Tom 1/27/20: Jude Gamel, a recently retired critical care nurse who lives in Kentucky, started corresponding with me a few weeks ago about this blog. We hadn’t discussed his own experiences (and those of his former colleagues, whom he keeps in touch with regularly) treating Covid-19 patients previously. But yesterday, he was inspired by that morning’s post, which focused entirely on deaths from Covid-19, to describe, in two emails, what “successful” outcomes are – i.e. when the patient survives. In many cases, the patient might well wonder whether the physical, emotional and financial toll on them were actually better than dying. And there’s also a huge physical and emotional toll on the health care workers. His account is gripping.

Jude’s first email
I just finished reading you post for today. I would like to add or at least to comment on something that too often gets lost or goes missing in conversations about Covid-19 and I think it is particularly relevant to what we see happening now: there are some outcomes that are almost as bad as dying and Covid-19 is a perfect example. Let me see if I can articulate this properly in order to make this clear.

Take for instance ICU beds. Most patients admitted to an ICU are admitted because they require specialized care and monitoring that cannot be done on another unit or floor. It is usually just to get a patient through a critical point. A clear example of this is a patient recovering from Open Heart Surgery. They generally spend 24-48 hours in a Cardiovascular Intensive Care Unit and are then discharged to a Step-Down Unit and then home or to a re-hab facility for recovery (roughly 7-10 days). A patient who has a Myocardial Infarction (Heart Attack) goes to a Catheterization Lab and gets stented and spends, again, 24 hours or so in an ICU (if even that). Now more complicated situations like Sepsis, Diabetic Ketoacidosis, COPD Exacerbation or a bevy of other diseases both chronic and acute result in longer stays but rarely more than 5 - 7 days. Now remember (I know this should be self evident) once a patient is admitted to an ICU bed you cannot admit another patient to that bed until that patient is discharged or dies (a celestial discharge).

Critically ill Covid-19 patients occupy ICU beds for WEEKS and require incredible resources to keep them alive. This is a drag on the system and the morale of physicians, nurses, respiratory therapists and ancillary staff. The care these patients require and the steps healthcare workers must take to protect themselves are incomprehensible to the average person. If you have not done it or experienced it you just do not know. Once these patients are finally well enough to be discharged from the ICU they spend weeks on Step-Down Units or Floors and then spend even more time in Re-hab. The costs incurred by their families are insurmountable; only the very richest in our society can manage even with gold-plated health insurance policies! This is why I say ‘worse than death.’ Many of those we ’save’ would have foregone the saving if they knew what it would do to their family’s financial future and after all the suffering they endure. It is sad. And Trump and his Republican allies want to do away with the ACA in a Pandemic! You cannot make this stuff up!

Well, Tom, I could go on but the point I am trying to make is that we need to make distinctions about this disease that talking about Infection and Mortality just do not get at. Covid-19 is a devastating disease and you do not want to become infected. Yes, most cases are mild (thankfully) and some people may not even know they were infected. But new research is now indicating that even Asymptomatic people may have unrecognized sequelae from the disease whose after effects may not be known for years.

Jude’s second email

Let me give you more of a flavor of what I am talking about. Critically ill Covid-19 patients require 24/7 one on one nursing care. If they are on a ventilator they require frequent ’suctioning’ of their breathing tube, if their kidneys have shut down they are on bedside dialysis (CRRT…Continuous Renal Replacement Therapy), they require turning side to side every 2 hours minimum to prevent skin breakdown, they are on multiple vasoactive IV medications running through continuous pumps, they have a feeding tube threaded through their nose into their small bowel and are receiving nutrition via the tube, they have large bore IV lines in their neck, the feedings lead to diarrhea so you are constantly dealing with loose stool until you put a containment device in their rectum…it goes on and on, so I am sure you get the picture. Now, remember in order for the nurse managing this patient to protect themselves they are wearing an N-95 mask or a helmet like CAPR device, they are wearing a plastic gown, they have a face shield on, they have booties on their shoes, the rooms are hot, they cannot leave the room sometimes for hours and when they do they are soaked in sweat head to toe and they do this for 12-14 hours day in and day out.

Now, if this patient is on ECMO (Extracorporeal Membrane Oxygenation) [think of it as ‘bedside’ cardiopulmonary bypass], then they require two on one nursing care!

Oh, and I forgot to mention, the patient is a 5 ft 5 in woman who weighs 275 lbs or a 6 ft 5 in man who weighs 350 lbs. Their girth extends side to side in the bed and requires at least two sometimes 3 or 4 people to turn them…and, God forbid you are ‘proning’ the patient; that might require 6 or 7 people.

Now, imagine doing that for the foreseeable future. It is grinding, overwhelming work that will take you to your knees. That is what is coming to the nurses at hospitals in FL, TX, AZ.

For these patients, well in order to keep them comfortable some of them require continuous Neuromuscular Blockade (chemical paralysis), continuous pain and sedation medications for weeks. Some of them do not wake up for days when you try to wean them from the ventilator. The neuromuscular blockade leads to something called ‘critical illness polyneuropathy’ which means they initially have little motor movement or strength and take a long time to just sit up much less raise their arms to feed themselves or walk.

And then you have the bills…

So, yes, I do believe there are some things worse than dying. When we put all of this in that box that says ‘Infected’ or ‘Recovered’ or ‘Died’ this is the type of thing you are talking about. 

Covid-19 is a horrid disease and you want to do everything you can to avoid it because you do not know if you have that chink in armor that lets it take you down. 

New cases jumped from 41,000 to 49,000 yesterday. Given that there were four days in mid-June during which new cases were under 25,000, this is a stunning increase. Unfortunately, this probably isn’t the end of it. My biggest question is when and how much it will increase the deaths numbers. Yesterday, the 7-day average of new deaths jumped to 5%, and that didn’t change today. But if we have more deaths numbers soon that come anywhere near 2,500 (yesterday’s level), then it’s inevitable deaths will increase at an even greater rate soon. This is something to watch closely.

The numbers

These numbers are updated every day, based on reported US Covid-19 deaths the day before (taken from the Worldometers.info site, where I’ve been getting my numbers all along). No other variables go into the projected numbers – they are all projections based on yesterday’s 7-day rate of increase in total Covid-19 deaths, which was 5%.

Note that the “accuracy” of the projected numbers diminishes greatly after 3-4 weeks. This is because, up until 3-4 weeks, deaths could in theory be predicted very accurately, if one knew the real number of cases. In other words, the people who are going to die in the next 3-4 weeks of Covid-19 are already sick with the disease, even though they may not know it yet. But this means that the trend in deaths should be some indicator of the level of infection 3-4 weeks previous.

However, once we get beyond 3-4 weeks, deaths become more and more dependent on policies and practices that are put in place – or removed, as is more the case nowadays - after today (as well as other factors like the widespread availability of an effective treatment, if not a real “cure”). Yet I still think there’s value in just trending out the current rate of increase in deaths, since it gives some indication of what will happen in the near term if there are no significant intervening changes.

Week ending	Deaths reported during week/month	Avg. deaths per day during week/month	Deaths as percentage of previous month’s
March 7	18	3
March 14	38	5
March 21	244	35
March 28	1,928	275
Month of March	4,058	131
April 4	6,225	889
April 11	12,126	1,732
April 18	18,434	2,633
April 25	15,251	2,179
Month of April	59,812	1,994	1,474%
May 2	13,183	1,883
May 9	12,592	1,799
May 16	10,073	1,439
May 23	8,570	1,224
May 30	6,874	982
Month of May	42,327	1,365	71%
June 6	6,544	935
June 13	5,427	775
June 20	4,457	637
June 27	6,272	896
Month of June	23,626	788	56%
July 4	6,594	942
July 11	6,933	990
July 18	7,290	1,041
July 25	7,664	1.095
Month of July	34,191	1,103	145%
Total March – July	164,015

Red = projected numbers

 I. Total deaths

Total US deaths as of yesterday: 127,649

Increase in deaths since previous day: 864

Yesterday’s 7-day rate of increase in total deaths: 5% (This number is used to project deaths in the table above; it was 5% yesterday. There is a 7-day cycle in the reported deaths numbers, caused by lack of reporting over the weekends from closed state offices. So this is the only reliable indicator of a trend in deaths, not the three-day percent increase I used to focus on, and certainly not the one-day percent increase, which mainly reflects where we are in the 7-day cycle).

II. Total reported cases

Total US reported cases: 2,504,676

Increase in reported cases since previous day: 49,010

Percent increase in reported cases since yesterday: 2%

Percent increase in reported cases since 7 days previous: 11%

III. Deaths as a percentage of closed cases so far in the US:

Total Recoveries in US as of yesterday: 1,068,768

Total Deaths as of yesterday: 127,649

Deaths so far as percentage of closed cases (=deaths + recoveries): 11% (vs. 11% yesterday)

For a discussion of what this number means – and why it’s so important – see this post. 

I would love to hear any comments or questions you have on this post. Drop me an email at tom@tomalrich.com