NELLIS AIR FORCE BASE, Nev. -- In the late winter months of 2020, while the COVID virus was surging throughout the United States, I was working as an active duty physician assistant (PA) at the Nellis Air Force Base family health clinic. With only one year of clinical experience, I was just beginning to hone my craft.
I had previously volunteered to be on a COVID disaster response team, and I had a hunch that I would be supporting a mission after reading headlines in the news. The call came in early January, and in a few short days, our response team arrived in Los Angeles, Calif.
At the time, I had no true idea that the next month and a half was going to be one of the most difficult and challenging experiences of my life, testing my intellect, mental health, and spirituality, and leaving me hopeful that the world would never again experience a pandemic such as this again.
I was only one of two advanced practice providers tasked to our designated hospital. The other PA had previously been tasked for a similar mission during the initial COVID surge in early 2020. She made it clear when we met that this wave the patients were sicker, and the mission seemed much more difficult.
We had both been reading local news reports that the ICUs had been at 100% capacity and were overflowing, but we were still unclear what our part in this would look like. When our team, a mix of medics, nurses and PAs, arrived at the hospital, we were greeted by a grateful, yet exhausted, nursing staff.
The reality of what we had walked into became obvious when we received the tour of the hospital. I asked one of the nurses how many people were actually dying and was shown a freezer truck full of the deceased and told another would come the next day as the morgues could not accommodate all the bodies.
The broad scope of our training as PAs allowed us to integrate with the hospital medical team quickly. We were each assigned a supervising internist to oversee us, who inquired about our background, consisting of primarily outpatient care with very limited inpatient experience.
The internists appeared tired and overworked. For the past few months, they had gone without any days off, missed holidays and sacrificed countless time away from family. This, along with the sheer amount of death they were handling daily, had worn on them. They decided we would be best utilized by managing high-flow COVID patients, which would allow them to devote more time to the more critical intubated patients.
In medicine, we have tools to help patients breathe. We start by delivering oxygen (O2) by nasal cannula/mask, then progress to a CPAP/BiPAP. If these fail, we typically move to a bag valve, and, finally, intubation.
The conundrum of this pandemic is caring for patients who ultimately meet the criteria for intubation, but knowing from the literature that when a patient is intubated, especially individuals with multiple comorbidities (i.e. elderly, obese, diabetic), the outcome tends to be poor, and potentially worse than if they weren’t intubated.
One of the most difficult parts of this work was trying to explain to patients and family members the low rate of survival. But, many would fixate on the slim chance of hope and request to remain full code, ultimately requiring intubation.
During my time there, I personally only saw one patient extubated who survived.
I was constantly reminded of the complexity of this disease throughout my time at the civilian hospital. One of the first patients I was assigned was the perfect example of this.
The patient was in his late 60s with diabetes and a long history of smoking. When I first met him he was cycling between a HiFlo nasal cannula and a non-rebreather (NRB), requiring a CPAP to keep his O2 saturation in the 80s.
Every day, we discussed whether or not to intubate this patient, but we saw intubated patients pass every day, only to see newly intubated patients take their place. This patient initially decided to be do not resuscitate (DNR/do not intubate (DNI). However, he slowly deteriorated to the point his mental/medical decision-making capabilities were no longer intact.
We discussed the next best steps with the family, who were not able to see him in person, and despite our recommendation for comfort care, reversed his DNR. The patient’s condition worsened, degrading to a codable dysrhythmia, likely secondary to his chronic lack of O2.
Instead of passing away more comfortably in a controlled setting, he received six rounds of CPR before dying. When the patient’s family was informed, they were distraught and angry at the hospital staff, convinced there was more that could have been done.
Similar scenarios occurred multiple times every day. And it wasn’t only the patient’s family questioning whether the right decisions were being made. This constant uncertainty of the unknown stretched and distorted our beliefs in science, medical decision-making and spirituality.
I relied heavily on the quick teaching by internists over us of what the standard of care was for these COVID patients. They had been dealing with this disease for nearly nine months and were still unsure as to what could be done to save the most lives.
Unfortunately, so many people had been infected and in critical condition that the hospital was no longer able to accommodate patients appropriately. So many required critical care services and high quantities of O2 that every unit in the hospital had been outfitted with a negative pressure outflow, which connected to windows with plastic curtains/seals separating the rooms and units from non-COVID areas.
This reminded me of a scene out of an apocalypse movie, where the character walks into the hospital every day, masks up with an N-95 and dons PPE before entering every COVID unit.
Performing a simple physical exam and communicating with a patient was extremely difficult, and multiple loud devices such as negative pressure pumps, combined with the muffling of masks and language barriers all served as yet another obstacle to overcome.
Additionally, the inability for patients to see emotion through facial expression added a layer of misery and defeat that exacerbated the already profound moment of the final moments of the patient’s life.
One of the strongest individuals I have ever had the honor to meet was a patient in a similar situation to the previous patient, requiring HiFlo nasal cannula with NRB mask maxed out O2 delivery and a CPAP. This patient decided it was best to be DNR/DNI and chose to fight the virus head-on.
When I rounded on this patient and asked how he was doing he always replied, “Bien, I’m bien.”
Despite his shortness of breath and the limitations of his thick accented Spanish, he always had a way of expressing his determination to fight.
One morning, I quickly noticed his O2 was in the 60s, so I ran to the head nurse to help translate and discuss the severity of the situation with the patient and that our recommendation would be for him to be placed back on CPAP/BiPAP as he was not oxygenating well.
He acknowledged he understood, but he no longer wished to push for more care. He continuously assured me he was “bien” as he struggled to breathe through the mask, even declining pain medication.
We attempted to have the nursing staff set up a video call to his family, but he unfortunately passed too quickly. I think about this man a lot and the strength and courage he possessed, he wanted to fight to the very end and see his family and friends again. He was willing to fight through the struggle of suffocation knowing the risks of the alternative.
He both inspires me and reminds me no matter how strong a person’s mind is there is also a limitation to how far the human body can be pushed.
I suspect what ultimately led to this patient’s death was a common occurrence for hospitalized COVID patients, throwing blood clots to develop a pulmonary embolism. Virchow's triad, immobility causing circulatory stasis and hypercoagulability secondary to infection and inflammation.
Almost every admitted COVID patient has gone through multiple courses of antibiotics for pneumonia/sepsis, chronic corticosteroids/albuterol inhaler treatments, anticoagulant therapies, received variations Ofretro/antivirals, Ivermectin, convalescent plasma, and a whole host of other piloted therapies. Also, there was significant risk in taking patients off wall O2 for CT, limiting imaging options.
Another patient I cared for was a 67-year-old obese female with diabetes that had been in the hospital for about three weeks and was full code.
She was overall improving until the night she was found to be unconscious and desaturating by nursing staff. I discussed my concern for a clot with my supervising physician, who agreed with my recommendation for a bedside transthoracic ultrasound, which showed a large right ventricle thrombus.
We weighed the risky options of surgical thrombectomy vs TPA, but ultimately decided on therapeutic anticoagulation as it seemed to be the best option for her survival.
The next morning, she was found unresponsive, not breathing, but with a pulse. I quickly called the code team, as I was unsure if she had changed to DNR/no code or not.
The floor team assembled and wasted no time breathing for the patient with a bag valve mask.
The floor nurse shouted to the code team that she recently changed to DNR/no code, and in a blink of an eye I felt her pulse vanish and watched her blood pressure decrease from 90s/60s to nothing.
Just like that, she had passed on. The staff around had looked at me and asked me if I was going to call time of death, as I realized I was the only provider present. This was a new situation for me, and flooded with adrenaline and surreality, I pronounced her dead, informed my supervising physician and the medicine team, and then continued with my rounds.
But, not all cases were completely morbid. I had success stories, as well. A patient hospitalized with COVID-induced Guillain Barre Syndrome who left the hospital by wheelchair and will require a lengthy road to recovery, but miraculously survived. Also, a 20-year-old with undiagnosed diabetes who developed multi-organ failure and a pneumothorax and trached who left the hospital for subacute care.
In what seemed like a flash of time, but had only been about a month, the overflow of patients decreased. For whatever reason, infection rates requiring critical care measures improved and our medical team was thanked for our service/help and returned to our home stations.
Since I've returned home to my family and Monday through Friday clinic, I find myself reflecting on this experience.
At the time, it was difficult to process the entirety of the situation, an almost primal instinct kicks in – to try and save as many lives as possible.
I sometimes think about if we could have made more of a difference if our aid arrived just one month sooner. How many lives could we have potentially saved?
I think about all the hardship these medical professionals endured during this past year. They are all truly heroes.
I find comfort in knowing that we did all that we could, but it has been a bitter pill to swallow that we could not save everyone. Medical professionals get into this line of work to help others, not have that ability taken away.
This opportunity may have been a once-in-a-lifetime event, certainly an atypical experience for a new family practice PA, but something I whole heartedly hope never occurs again.
My deepest and most severe condolences go out to all family, friends and loved ones that have been affected by COVID-19 in some way.