Welcome, Doctor Mike Hansen here and in this video I'm going to talk about some of the things that
I've learned while working in the covid ICU unit. so some intensive care units at various hospitals
throughout this country have designated units for covid 19 patients and as an intensive care doctor
myself I've been seeing a lot of covid patients and are designated to covid ICU it's one thing to
read about covid in the medical literature but to be actually seeing real patients with disease is
a whole nother experience altogether there are lots of things I've learned but for this video
I'm gonna focus on the top ten that stand out to me so starting at the bottom with number 10 is
I'm gonna talk about the signs and the symptoms so the most common symptoms that I'm seeing are
fever cough shortness of breath and body and muscle aches I haven't seen many patients with
other symptoms we often hear about such as loss of taste and smell or nausea and diarrhea I've
not seen any rashes related to Covid probably because I only see adult patients I will say
that even though confusion and delirium is very common in the intensive care unit in
general there does seem to be more of that with Covid so a lot of Covid 19 patients who require
hospitalization do have low vitamin D levels and this is consistent with what we're seeing
and a lot of the recent studies that have been coming out but of course correlation doesn't
necessarily mean causation so does it just so happen that a lot of patients who have moderate
or severe kovat happen to have low vitamin D levels maybe maybe not and does that mean that
we should give every hospitalized patient with covid big doses of vitamin D when they hit the
door maybe and does that mean people in general should supplement with vitamin D and what is the
ideal level of vitamin D for the population especially when it comes to covid should we
be targeting the current general recommendation for everyone irrespective of covid with a goal
of 20 MGS per ml or should we aim for a higher like 30 or perhaps 40 no one knows for sure the
answers to these questions but there are studies being done on this and as we speak there are three
randomized control trials for vitamin D in Covid I take a further deep dive into vitamin D and
some of my other videos on this channel so if you want you can check those out so number eight this
iris is very contagious one of my patients was in the hospital for unrelated reasons she actually
had sepsis due to infarct that gut meaning part of her intestine was not getting enough blood flow it
was so severe to the point that some of the tissue in her tessen had died off when this happens the
bacteria that live in the intestine could then invade the walls of the intestine and get into
the bloodstream this is bad news because these bacteria can then spread throughout the body and
this is known as sepsis so besides antibiotics this is treated with surgery where the dead gut
tissue is removed meaning part of the intestine is taken out and this is what happened with her
and she got better but after she initially got better she started having more difficulty with
her breathing her oxygen levels are dropping despite us giving her more and more oxygen so
we got a chest x-ray and later a cat scan of the chest which showed bilateral infiltrates meaning
areas of inflammation in both lungs and this is the pattern we typically see with Covid pneumonia
where it tends to go to the periphery of the lungs and also more so at the bottom of the
lungs so we tested her for covid and sure enough the PCR test came back positive unfortunately she
did not survive so how did she get covid no one really knows of course she got in the hospital
but there weren't any known healthcare workers who had Covid and she did not have any visitors
because of the visitor policy so it's a mystery as to how this stealthy virus was transmitted to
her which speaks to just how contagious the virus really is I've also seen entire families who live
under one roof all hospitalized so yeah pretty contagious and that leads me to number seven
which is because of the no visitor policy it sure is lonely for patients in the hospital and
it's incredibly hard for family members to not be with their loved ones especially when they may not
survive so as if dying is not bad enough some of them die alone which is obviously horrible
based on my experience it's hard to really get a gauge on the treatments that we give so for most
patients depending on individual circumstances we're giving remdesivir convalescent plasma
dexamethasone and even therapeutic doses of blood thinners so for the blood thinners meaning in
psycho agya Latian giving lovenox AKA enoxaparin if their kidney function is okay or alternatively
if their kidney function is not okay we give another blood thinner like heparin we still
don't know for sure who we should be treating with full doses of blood thinners because it's
usually not practical to try and diagnose blood clots and someone who's sick with covid in the
hospital there are various reasons for this one there's no single test that can definitively
diagnose clots in the body every test that looks for clots either with an ultrasound of the leg
or CT angiogram of the chest or a VQ scan of the lungs or CT scan of the brain looking for stroke
or a blood test checking the d-dimer all of these things can have false negatives not only that but
for each of these tests they all have their own risks for example with a CT angiogram not only are
you giving them the radiation from the cat scan but you're also given them contrast which means
they could potentially have an allergic reaction or they can also get some kidney damage from
that contrast never mind the potential spread of the virus when you move the patient to the
CT scanner so because of the incidence of blood clots and Covid patients who have severe disease
it's tough to be around 30 to 40 percent or so most ICU doctors including myself are opting to
just empirically treat all covid patients in the ICU with therapeutic doses of blood thinners now
the downside of course is the risk of bleeding so it's a judgment call at this point some doctors
also base their decision on how high the d-dimer level is but again we simply don't know at this
point if we should do that or not but we do see a lot of clots and patients I had one patient
who had severe covid to the point of requiring a ventilator it was also severe enough to the point
of causing our kidneys to shut down when we were doing dialysis on her the Machine kept clogging
up with blood clots and later on we were able to take out the breathing tube once her breathing
finally got better but something was off with her from neurologic standpoint now I really don't like
sending covid patients to the cat scan because then you risk spreading the virus throughout the
hospital but sometimes you have to do it and in this case I did I ended up biting the bullet and
sure enough she unfortunately had a stroke and as far as all the other treatments I mentioned
including convalescent plasma I can't really say one way or another if they're making a difference
if they are making a difference it's not obvious it's not like you give any of these treatments
and patients are all of a sudden magically better so that's why we always need scientific studies
in the form of a randomized controlled trials to really know if a treatment is working or not so
for number five I'm gonna go with testing I think testing is still a guessing game at this point one
of my patients who is in ICU for more than 20 days so he initially tested positive with the PCR test
and then we ended up retesting him about three weeks after that and he again tested positive
so does that mean he can still spread the virus to other people maybe or it just might be that
the PCR test is picking up the inactivated viral RNA and these viral remnants are causing the test
to be positive even though it's possible he's no longer shedding the virus all right number
four a lot of my Covid patients are obese or morbidly obese and here's the thing a lot of
people who are obese have obstructive sleep apnea and a lot of people who are obese especially if
they're morbidly obese have something called obesity hypoventilation syndrome which is a
fancy way of saying that they're not able to breathe off as much carbon dioxide as they
should because of their body habitus sometimes when an obese patient is in the hospital and
we suspect they have obstructive sleep apnea we give them a CPAP machine to use at night or if
they have obesity hyperventilation syndrome we give them a BiPAP machine which is essentially
the same thing as CPAP except instead of blowing air into the mouth and nose using one constant
pressure the BiPAP does two different pressures one at a higher pressure and then one at a lower
pressure so the higher one is for inhalation while the lower pressure is for exhalation in
fact that's what BiPAP means by level positive airway pressure well when someone is covid
positive that kind of throws a wrench into our plans because CPAP and BiPAP generate aerosols
in the room which means you can potentially have that virus being thrown around the room from the
CPAP or the BiPAP so that means the patient would have to be transferred to a negative airflow room
and negative airflow rooms are limited so they may not be available especially in times of a pandemic
that's what makes the surge in cases recently all the more cancer because more cases means
more hospitalizations which of course means less negative airflow rooms less ICU rooms available ok
number three on the list is mechanical ventilation so a couple things with this one it's still really
hard to know when or if we should intubate someone meaning put a breathing tube down someone's throat
some patients have very low oxygen levels while not necessarily being in respiratory distress
meaning they may not feel short of breath or have air hunger or they're not necessarily breathing
that fast and deep so the question becomes how low are we willing to let their oxygen levels go
before we decide on putting their breathing tube in so the decision to intubate is much easier
when someone is in respiratory distress once the patient is intubated the settings that we dial
in on the ventilator really have to be catered towards that patient and while this is true of
intubated patients in general this is even more so with Kovac because of the variability of their
lung disease meaning some patients might have more inflammation in ARDS compared to others
while other patients might have more blood clots and less inflammation so some patients might be
obese while others might not be obese there are really so many factors that go into how we manage
patients on the ventilator so it's pretty common we're really tinkering around with those vent
settings trying out different modes on their different settings so some patients do better
when they're prone and others not so much some patients need to be given a paralytic medication
in order to be synchronous with the ventilator while others don't need paralytics so it's not
one-size-fits-all with all these patients and some patients don't need the ventilator while
others might only need it for a couple days while others need it for weeks and when someone needs a
ventilator for a few weeks or longer that's when we need to do a tracheostomy meaning make a small
hole in neck to fit a smaller size breathing tube we do this because the original breathing tube
meaning the endotracheal tube can only be left in for so long before the risk of complications
from that really start to climb typically the arbitrary cutoff is two weeks but with covid
we're generally waiting for three weeks all right number two recovery so as an intensive care doctor
I see patients in the intensive care you but as a pulmonologist meaning a lung doctor I also see
patients in the pulmonary clinic so I'm able to follow patients who have not only had covid
and that ICU but then see how they do in their recovery in the pulmonary clinic afterwards I
had a young patient in his 40s who was not obese and who was otherwise healthy who was on the cusp
of requiring a breathing tube when he was in the hospital his cat scan showed the pneumonia in both
lungs ultimately he didn't require the breathing tube and he slowly got better but he needed to
be discharged home with supplemental oxygen and he's still not 100% back to normal and this is
now three months after he first got the virus thankfully he's alive but his lungs suffered a
lot of damage will his lung function fully recover I don't know only time will tell sometimes with ARDS
due to viral pneumonia there can be permanent damage but lots of times a damage from all the
inflammation there slowly gets better with time and something I forgot to mention is he actually
had something pretty unusual happened to him not that it's unheard of but it's pretty uncommon for
it to happen and that is he developed something called a new marrow seal as a result of having
pneumonia so what is a new Maddison it's a cyst in the lungs that develops after an infection and or
ARDS acute respiratory distress syndrome a cyst is a thin walled bubble if you will now in his
case it really formed between the upper and middle lobe of his right lung but because of the fluid
that we can see inside there was the possibility that this was an abscess and that's why we treated
him with an antibiotic especially because he was having pain in the right side of his chest
especially when he would take a deep breath the pain would actually become worse so this is known
as pleuritic chest pain oh and here's a fun fact for you did you know that the lungs themselves
don't have pain receptors however the lining of the lungs called the pleura do have pain receptors
so anything that disrupts the pleura can cause pain so this can include adjacent pneumonia in
the lungs and in this patients case it was the cysts and possibly abscess that was irritating
the pleura the lining of the lung and this was causing his chest pain but getting back to some
of my other patients who had severe covid some of them required nation for a few weeks and survived
and some of them required a tracheostomy while others did not so why some people have worse
disease and others still hasn't been sorted out yes we know that severe disease is more
likely with older age or other medical problems like diabetes high blood pressure obesity type
A blood but we don't know why is viral load part of the reason may be I'm sure genetics are a big
part of as well but we don't know what specific genes or genetic variations okay number one on
this list is unpredictability and variability of this virus and this disease so this virus
and this disease is just so unpredictable in so many ways who gets sick the variation of the
symptoms the variation and severity of disease the variability of timing where someone can be
relatively fine all of a sudden and then BOOM within hours they require a breathing tube how
some people get more inflammation while others get more clots how some people recover quicker than
others how some people have the disease but their test is negative meaning they have false negative
so we're all still learning about this virus and this disease in real time and there's a lot to
learn and hopefully we can get a vaccine for this that is both safe and effective and hopefully
enough people get the vaccine for herd immunity to take place but a vaccine itself is not a guarantee
especially because we don't know how long these coronavirus antibodies are protective and there
are more and more drugs being studied and some look more promising than others but only time
will tell with more randomized control trials but for now we have to social distance and use masks
because that's the only thing we have at this point and this virus isn't going away anytime
soon but anyway thanks for watching this video I have more videos on the way of course I think the
next one's going to be on convalescent plasma so check that out and I will see you in the next one