Reflections on the Battle of Covid-19
by Jan Schlain
From the July, 2020 issue
"One of the indoor track-and-field stadiums was going to be a hospital," Valerie Vaughn recalls. "I remember walking through and just imagining it with people laying down on cots on it, and just being scared to death."
Michigan Medicine passed a milestone in June when a day passed with no new Covid-19 admissions. But back in March and April, a third of the beds at University Hospital were filled with pandemic patients. Detroit's hospitals were overwhelmed, and there were fears that Ann Arbor's hospitals might follow.
Vaughn was there. According to the U-M's Institute for Healthcare Policy's website, she "helped create a new kind of hospital team focused on caring for patients with COVID-19, learned how to provide an intensive level of care for the sickest among them, trained hundreds of physicians in how to do the same, and created free online learning tools for physicians nationwide."
In June, after Michigan's statewide lockdown "flattened the curve" of new infections, she reflected on her months on the frontline.
Talking by phone one evening in mid June, Vaughn explained how she and her colleagues "opened up an entire unit dedicated to care for Covid patients who needed ICU care plus built additional ICU space in our surgical waiting room preoperative area ... We normally have about 100 ICU beds, and we went up to 250 during the height of the pandemic."
Before Covid-19, Laraine Washer, medical director of infection control and an epidemiologist, was "taking care of patients with infections of various sorts, and instituting policies to prevent infections in patients.
"But this [Covid] is a whole new scale," Washer says. "We've had pandemic plans in place for a long time," but they "had to be quickly changed and broadened for this epidemic."
With Covid, Vaughn explains, "there's this period of time between when you get it and when you express symptoms. That's the asymptomatic period that everyone worries about, because you're contagious but not yet symptomatic.
"Then there's this period that
can last anywhere from five to fourteen days, of having symptoms, and [it] feels somewhat like a bad flu. In some people [it] can be very mild. But the most common symptoms during that time period are cough, fever and shortness of breath.
"Then, for reasons we don't know, some people then get better, and there are no issues. Other people, as their immune systems fights off the virus ... [it] goes overboard.
"That's when you see people who have been starting to get better, or were not doing great but not doing badly for days, and then suddenly get worse. Their fevers start getting really high, and they start getting incredibly short of breath ... you measure their oxygen, and it's very dangerously low, and you get a chest X-ray or a chest CT of their lungs, and their lungs look riddled with inflammation."
That's the cytokine storm. Cytokine cells "signal that there's an inflammatory response going on in the body," Washer explains. Patients often "have very high spiky fevers ... We can see low blood pressure. We can see acute kidney injury," sometimes caused by blood clots--which also can damage the lungs.
With Covid, clotting "was way more common than anything I've ever seen" in other infections, Vaughn says. It's what put a lot of patients in the ICU. Often, "we were giving them anticoagulation drugs even if they didn't have clots to try to prevent them from getting them."
Some patients got Remdesivir, an antiviral drug, as part of a clinical trial. In another trial, patients suffering cytokine storms got an "Interleukin fix inhibitor," Vaughn says, "to basically stop their immune system for a little bit."
They don't have data that ties the risk of clots, or of the immune system going haywire, to age. But they do know, Vaughn says, "that if you were on a ventilator, your mortality was much higher; if you were older, your mortality was much higher."
According to the Washtenaw County Health Department, none of the 106 county residents who died from Covid-19 by mid June were under forty, and only one was under fifty. More than half were over eighty.
"I think there are a couple of things that makes this disease so devastating to older people," says Washer. "One, is that we are all naive to this virus. None of us have been exposed or have any immunity." Covid is also more dangerous "for those who have comorbid infections or diseases, like diabetes, or heart disease or lung disease, and those are more common in older adults."
The immune system itself becomes less effective with age, Washer adds. And lastly, "a large number of the older adults who have been impacted by Covid have lived in congregant settings like nursing homes ... and their risk of exposure in those settings has been high."
Elderly patients aren't just more likely to die of Covid, Vaughn says. "There are so many ways being older makes it more difficult to survive ... with a good quality of life."
"We might be able to save your body," Vaughn says. But after weeks in the ICU in an induced coma, you're likely to lose some brain function. "Maybe you're not the same person you were before," she says. "Maybe you can't ever get up and walk or take care of yourself."
That's why, she says, it's essential to talk about advance directives. "If you don't want to be in that place where you're dependent on someone else for going to the bathroom or getting out of bed, then maybe we say we only provide medical care up to a certain point, and after that focus on comfort and making sure that you don't suffer. We let the body's natural dying process go through."
She had a lot of those talks. "I actually think it's one of my most important jobs as a doctor," Vaughn says. "Because if we put someone on a ventilator and keep their body alive for two months, and at the end of it they don't remember who their loved ones are, they never leave a nursing home again, that's not a success story.
"What I can do as a doctor is help provide context and then listen to people. Maybe they have certain religious beliefs that say that x, y, and z need to happen or maybe they really want to survive to know their child graduated."
Others already had thought these questions through with their primary care doctor and their family and provided advance directives.
Vaughn recalls "many beautiful situations" where "instead of dying on a breathing machine, their family actually came in, we put them in PPE and gowns and masks and all of that, and [they] got to be there while their family member was still lucid. It's a much better way often of saying goodbye than dying on a machine."
"I never understood people who enlisted in the Army, saw horrible things, and then the second they got back home, reenlisted, and went back," Vaughn says. "It just never made sense to me--until this."
She cites "the camaraderie of the people you're working with, who are also amazing, and also doing the best that they can; the patients; and the families, who are just amazing. Even when you'd be telling them that their loved ones were dying, [they] would tell you 'thank you' at the end of the phone call."
Sometimes there were thanks from strangers, too. "Coming out of work every day and seeing the notes painted on the ground for us, seeing the signs in people's yards, it really meant a lot," Vaughn says.
"The bad news is we all think there will be another wave," she adds. "None of us know what that will look like. And anybody who says that they know is probably misjudging their knowledge."
Washer says her "hope is that this very near-time experience with this disease will make it very real to people and really make it more likely that a larger number of people will embrace vaccination."
But whatever happens, they've learned a tremendous amount about how to handle a pandemic. If "we have to expand our ICUs again, we'll be better equipped," Vaughn says. "I think the community will hopefully be responsive and aggressively social distancing again the next time around.
"That's my optimism. I think we're all better prepared than we were the first time."
[Originally published in July, 2020.]
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