An Open Letter to the Public on the Coronavirus, from an ICU Nurse (Page 30)

I’m writing this in the hopes that this will cut through some of the noise. As nurses, I feel it is our role to educate the public, especially in times like this. What I’m about to say is not intended to scare you or make you panic. It’s to help you understand the gravity of the issue that faces us, and to keep you well-informed. In fact, my hope is that, instead of fear and panic, you feel more knowledgeable than you did before reading this. And with that knowledge, my hope is that you will act responsibly, effectively, and with caution. This is especially for people who tune out the news, know others that aren’t taking this seriously, or believe that we are over-reacting. I can assure you, we aren’t.

With each passing day, more and more people are becoming infected, with known infections doubling every few days. Estimates from infectious disease experts have said to assume that there may be 10–50 times as many cases than what’s confirmed, which would put a rough estimate of between 100,000 – 500,000 people in the United States that have it and are either symptomatic, known or presumed infections, or show no symptoms. Because of not having enough tests, the state of Minnesota issued this statement:

“Coronavirus/COVID-19 has reached the point of community spread in Minnesota, meaning that we are finding the virus in people with no known exposure risk for contracting the virus. Given the increasing commonness of coronavirus in the community we are no longer testing patients who are not critically ill.

For everyone else who has a cough or fever, you should assume you are infected with the coronavirus. Accordingly, you should self-quarantine for fourteen days from the first day your symptoms started. You should call if you have increasing shortness of breath, wheezing or sustained fever above 101.5. If you are significantly short of breath or experience chest pain you should call 911 or report to the nearest emergency department for urgent evaluation.”

The reason that this is so serious is because no one on the planet has any natural immunity to this virus, we have no vaccine, we are not sure how to most effectively treat it yet, and all treatments are experimental and supportive. News media is vague, stating that some cases might be really bad and require people to be admitted into the intensive care unit. But they aren’t really explaining to the public just how bad this can be for a patient that requires intensive care. They’ve already covered the implications of socializing and not washing your hands and being diligent. I don’t need to get into that, other than to say that it would overwhelm our hospital systems, and we would not have enough hospital beds (both ICU and non-ICU) for all the patients that need them. We also would not have all of the machines and equipment to adequately provide care for those patients that need them in order to live, let alone enough personal protective equipment to keep our staff adequately protected in the ways that we need to.

In effect, two things will happen: people will die due to a lack of resources within our health system, or people will die because we have to triage cases based on disaster relief criteria and determine who lives and who dies. As far as inadequate supplies to protect hospital staff, if we don’t have that, and our healthcare teams are becoming infected, then we are transmitting that virus to others; and, being sick ourselves, we would be unable to take care of the people that need us. This further exacerbates the issue of our limited resources. This is what’s happening in Italy right now, as hundreds are dying every day due to a lack of resources and due to healthcare providers having to make the decision of who gets treated and who doesn’t. All trends suggest that this has a very high possibility of happening here, too. As a healthcare provider, this is never a situation I want us to be in. And, if we take this seriously, we don’t have to be.

I want to describe what it means when someone becomes critically ill and requires admission into an ICU because of the coronavirus. The coronavirus is a respiratory infection that causes a viral pneumonia. Keep in mind, this is a viral pneumonia that your immune system does not know how to fight and that we have no drugs to give you that are proven to work. What is happening in these severe cases is that this viral pneumonia is causing a buildup of mucus and fluid in the lungs, partly due to how the immune system tries to fight a respiratory infection. This leads to the sensation of feeling short of breath, because your lungs, filled with excess mucous and fluid, are not able to adequately put oxygen into your blood, causing your blood oxygen saturation to drop. From here, a few things can happen. Without any treatment, your respiratory symptoms could worsen, your blood oxygen saturation could continue to drop, your respiratory system could fail, and then your other vital organs would not get the oxygen they need to survive. This would ultimately lead to a cardiac arrest because the cells in your heart need oxygen to function, and with them starved of what they need, they become strained, leading to a heart rhythm that is not compatible with life. You lose a pulse and subsequently, consciousness. With no intervention, death results.

Provided you get to an emergency room when you feel short of breath, it doesn’t progress as far as I just described, and you require intensive care, then what you would need are a couple of things: oxygen, and depending on the severity, your treatment team might try BiPAP (a type of therapy similar to a CPAP machine) to help increase your oxygen levels, or, they might proceed to intubation and mechanical ventilation (putting a breathing tube through your mouth and into your lungs, and hooking you up to a machine called a ventilator that supports your respiratory system). The reason they do this is because when your lungs are unable to keep up to meet your body’s demands, you go into respiratory failure, which is a condition in which your blood does not have enough oxygen and you start to retain carbon dioxide.

From here, treatment is predominantly supportive. Adjustments are made to the ventilator to fix the imbalance of oxygen and carbon dioxide in the blood. But here’s the thing: this virus can be so severe, that even on maximum support from the ventilator, this isn’t guaranteed to fix the problem. In fact, your condition can worsen. Due to your body trying to fight this virus, and due to the nature of the virus itself, severe widespread inflammation occurs in the lungs, and fluid continues to build up within them. The lungs aren’t able to fill up with enough air, which means that they can’t get enough oxygen to the rest of your body, depriving your other organs from getting the oxygen they need to function. This condition is known as acute respiratory distress syndrome (ARDS). ARDS typically occurs in people who are critically ill and who have had some type of lung injury or infection. Additionally, this can damage the lung tissues, which leads to bleeding in the lungs, and long term, can cause scarring of the lungs themselves. Many people that have this condition don’t survive, and the risk of death increases with age and severity of illness, which partly explains why the mortality rate of the coronavirus is higher in older populations. The thing is, the infection is becoming this severe in patients who are younger, who have no prior health history or conditions that would make this infection worse, and they are dying.

What’s more, is that this widespread inflammation and oxygen deprivation can start to affect other vital organs, leading to lasting or even permanent damage. While many may think that this is something that would only happen in an older patient, or in patients with health conditions that would make this viral infection worse, reports are showing that these cases are rapidly progressing from infection, to respiratory failure, and then to ARDS, at times with these other complications, even in younger, otherwise healthy people with no medical history.

As a last-ditch effort, these patients can be placed on another form of life support called ECMO. This is a machine that removes blood from the body, takes out the carbon dioxide, fills it with oxygen, and then returns it to the body, bypassing the lungs and allowing them to heal while still making sure that the rest of the body gets the oxygen it needs. Patients who receive ECMO as a treatment are extremely sick, and based on current statistics related to ECMO outcomes, only about half of those that go through all of this will survive from their admission to the hospital until discharge. Notice I say “survive”. That does not even bring into consideration any complications that may occur as a result of their hospital course or those treatments. Many patients that get this sick often times develop various degrees of liver, heart, or kidney failure, and then must manage them as chronic conditions.

As a therapy, ECMO is extremely complex, and requires highly-trained and experienced staff to be able to manage those patients. Not only that, but not every hospital has physicians, nurses, and technicians that are trained to take care of them and manage the ECMO circuits. In the twin cities metro where I work, there are only two hospitals that offer this treatment, and to my knowledge, my hospital system only has 12 ECMO machines total. The next locations that have them in the upper midwest are located at the Mayo Clinic in Rochester, Minnesota, the University of Iowa in Iowa City, and then some hospitals in Chicago, Kansas City, and St. Louis, I believe. And while we have machines and equipment that can help to support and sustain life while your body tries to fight off the coronavirus, many are not that lucky. That is, provided we have enough of the equipment we need to help you. If too many people become critically ill in too short of a time frame, then our health system fails, and we can’t give these treatments to everyone who needs them.

If we are in the midst of an outbreak, and our hospitals are flooded with patients that require intensive care units, mechanical ventilation, or ECMO (if it’s available), then we can’t help you, regardless of who you are, how young you are, or how healthy you are. We would have to ration these treatment options to people that we decide would benefit most from them, and exclude those that we feel would benefit the least. Another thing to note is that this does not even consider patients who present to our hospitals for reasons other than a coronavirus infection, that would require these interventions and treatments, such as cardiac arrests, heart attacks, trauma-related injuries, or in patients requiring surgery. Without the proper resources, these non-COVID patients can potentially die.

The thing is, this might never happen to you even if you get the coronavirus. If you follow published statistics, the chances of this happening to you are much lower than the chances that it will. For most, it won’t happen at all. But being young and healthy does not make you invincible. Even if it doesn’t happen to you, it’s highly possible that you could transmit the coronavirus to someone else, most likely your loved ones or people you come into contact with, and this could happen to them.

Current estimates suggest that about 1 out of every 5 people from the ages of 20–44, one fifth to one third of patients ages 45–60, and 30–70% of patients older than 75 will require hospitalization. Using what data I could find from various news sources, if we take 40–70% of the American population (the range estimated to get the coronavirus), and multiply that by the range that’s estimated to require hospitalization (between 20–70% for all age groups, with an average of 40%), then that means anywhere between 26 to 161 million people will need to be hospitalized in the United States, with an inner average range between 52-92 million people, assuming the total population of the United States to be around 329 million. However, there are less than 100,000 ICU beds in the entire country. The number of ventilators in this country is similar to that of the number of ICU beds.

Taking this math further, if the mortality rate stays between 1.8 and 3.4 percent, then it’s estimated that anywhere from 2.3 million to 7.8 million people in the United States alone could die from the coronavirus. Again, I’m telling you all of this, not to instill fear or panic, but to give you the knowledge I have, so that you can understand how serious this can be. All of this is why “flattening the curve” is so important. Doing so reduces the speed at which people become infected, and by slowing down that infection rate, it allows our health systems to more effectively provide care to the people that need us, especially those that find themselves in life-threatening situations.

I entered into this profession because I love people. I love to help others, take care of the sick, and give them the tools they need to take care of themselves, and right now, we need you to help us. We have a chance to reduce the impact that this will have on communities across the country, but we have to take this seriously, and we have to act collectively. Our healthcare systems can’t handle a sudden, massive spike in coronavirus cases. So, please, practice extreme social distancing. Only go out when you absolutely have to, and stay away from others. I know it’s difficult and radically different from what we are used to, but a virus, in order to survive, needs a host. If a virus can’t continue to infect others by being transmitted from one person to the next, then the virus dies. Social distancing is the best way for us to achieve this.

Be diligent in washing your hands. Sanitize frequently touched surfaces and objects, particularly if you do not live alone. Stay away from open public spaces. Only order delivery or curb-side pick-up. It will literally save the lives of people you will never even meet, and will help your healthcare teams be able to better serve you and your communities by keeping infection rates at a level we can manage.

Lastly, do not lose faith. I know right now that’s a very hard thing to do, as we struggle with social isolation, job loss, economic insecurity, political division, and with things happening in the world right now that are very scary and seemingly unprecedented. The future will present itself with many challenges for us to face, but the American people are resilient. We can’t overcome these challenges by ourselves. We can if we work together, and we must, regardless of our political affiliation, religious beliefs, gender identities, sexual orientations, race, or anything else that may set us apart. It is my firm conviction that we can and we will get through this.

To my colleagues in every setting, the physicians, nurses, pharmacists, respiratory therapists, occupational and physical therapists, as well as all ancillary staff, both locally and across the country, thank you for everything you are doing to help protect us and protect the public. To my colleagues in the ICU, those I work alongside both within my health system and within the twin cities metro, and those who have trained me and given me the knowledge to be the nurse I am today, I am proud to be facing these challenges with you. It’s up to us to do what we can to safeguard our public health, and to mitigate this crisis.

–  Joseph Stimac, RN-BSN, CCRN Member, Minnesota Nurses Association

Sources: news articles from the New York Times, Washington Post, USA Today, LA Times, The Hill, and the American College of Cardiology.

All views and opinions expressed in this letter are my own, and do not necessarily reflect the views or opinions of my employer.