I am not an intensivist, a physician that works full-time in critical care units, aka ICUs. Although I’m a hospitalist, I don’t do much work at all in the ICU. Intensivists are usually pulmonologists although I think more recently there are fellowship programs that bypass typical pulmonology training and go straight to critical care.
Anyway, if this Coronavirus pandemic really takes off in my area, I may have to start impersonating an intensivist because there may not be enough to go around.
Local TV news last night mentioned that the Feds are re-opening a hospital in Phoenix that closed down last fall—Phoenix St Luke’s—to provide 340 ICU beds. I swear that’s what I heard—340 ICU beds. Where will they get the staff: intensivists, respiratory therapists, ICU nurses??? My hospital has 8–10 ICU beds. Sometimes a bed is available, but no nurse to staff it. So the bed is useless. Be aware that ICU nursing is a specialty; you can’t just take any nurse and throw him in there.
The video below will be unintelligible to you unless you are a hospital-based physician, respiratory therapist, or nurse. So move along. Dr Z interviews Philadelphia intensivist Dr Herbert Patrick, who’s had experience with critically ill COVID-19 patients.
A few of my personal notes, “just in case.” These may not be accurate because Dr Patrick’s voice recording was sub-optimal.
- his ICU patient are in “airborne isolation” negative pressure rooms
- since Dr Patrick didn’t want to shave his beard, he uses a PAPR (powered air-purifying respirator)
- some physicians are buying their own PAPRs for $1500-3000 (they are in short supply
- providers not using PAPRs are covering the N95 masks with a “paper mask” (a surgical mask, I assume)
- he advocates everyone in the hospital wear a surgical mask all the time (?)
- don’t assume shock is always due to virus; search for bacteria and you will find
- most COVID-19 ICU admits get an arterial line and central venous catheter, certainly if going on a vent
- proning (prone body position) is helpful: 4 hours prone, 4 hours on back or side, alternating every 4 hours
- Ventilators: Start with PEEP of 8. 100% O2 at first, as usual. Tidal volume depends on plateau pressures during inhalation (keep under 30 cm H2O). A “weanable” patient should have FIO2 down to 50% and PEEP around 8.
- permissive hypercapnia OK if needed; prevent or treat the associated acidosis with enteral bicitra via ore-gastric tube
- don’t use so much PEEP that you interfere with cardiac output
- if central venous O2 saturation is under 60-70, your PEEP may be impairing cardiac output, try to back off PEEP
- he mentions external cardiac output measurement devices, which I’m not familiar with
- the Impella device may help support cardiac output in selected cases; sounds like he prefers it over IAPB when available
Steve Parker, M.D.