We REALLY need to discuss goals of care with all patients admitted with COVID-19

Asa critical care medicine specialist, I am used to seeing the sickest of the sick. I am used to seeing patients with respiratory failure. I am used to seeing patients in shock. I am used to seeing patients gasping for air, with dangerously low oxygen levels. I am used to seeing patients in kidney failure. Never, however, have I seen patients as sick as those with COVID-19.
Frightening Hypoxemia (low oxygen levels)

https://bitcointalk.org/index.php?topic=5291884.msg55797401
https://www.deviantart.com/afiya777/journal/LIVESTREAM-Dundalk-vs-Arsenal-Live-Stream-863675001
https://www.deviantart.com/afiya777/journal/FREE-Dundalk-vs-Arsenal-Live-Stream-Free-863675727
https://www.deviantart.com/afiya777/journal/STREAMING-Dundalk-vs-Arsenal-Live-Stream-Free-863675549
https://www.deviantart.com/afiya777/journal/FREE-Dundalk-vs-Arsenal-Live-Stream-Free-863675735
https://www.deviantart.com/afiya777/journal/LIVESTREAM-Dundalk-vs-Arsenal-Live-Stream-863675738
https://www.deviantart.com/afiya777/journal/live-Dundalk-vs-Arsenal-Live-Stream-863675742
https://www.deviantart.com/afiya777/journal/LIVESTREAM-Dundalk-vs-Arsenal-Live-Stream-863675744
https://www.deviantart.com/afiya777/journal/FREE-Dundalk-vs-Arsenal-Live-Stream-Free-202-863675747
https://www.deviantart.com/afiya777/journal/STrEaMs-reddit-Dundalk-vs-Arsenal-Live-Stream-863675749
https://www.deviantart.com/afiya777/journal/Reddit-Streams-Dundalk-vs-Arsenal-live-stream-863675751
https://latingrammya2020.medium.com/live-celtic-vs-lille-livestream-uefa-europa-league-free-on-3ca391d3f225
https://latingrammya2020.medium.com/live-celtic-vs-lille-livestream-uefa-europa-league-free-e532123b16e7
https://latingrammya2020.medium.com/live-celtic-vs-lille-livestream-uefa-europa-league-free-on-hd-865768344881
https://uefaeuropalivetv.medium.com/live-dundalk-vs-arsenal-livestream-uefa-europa-league-free-on-759d5bac1d7a
https://uefaeuropalivetv.medium.com/newcastle-dundalk-vs-arsenal-live-uefa-europa-league-stream-4k-26e301bd29bf
https://uefaeuropalivetv.medium.com/live-dundalk-vs-arsenal-livestream-uefa-europa-league-free-on-d40732e7ebb8
https://tottenhamhotspurvsantwerplive.medium.com/total-sportek-tottenham-hotspur-vs-antwerp-live-free-by-reddit-official-streams-64bec64988b0
https://tottenhamhotspurvsantwerplive.medium.com/live-tottenham-hotspur-vs-antwerp-livestream-uefa-europa-league-free-on-c9d944cf0138
https://tottenhamhotspurvsantwerplive.medium.com/live-tottenham-hotspur-vs-antwerp-livestream-uefa-europa-league-free-on-1dbb4a673010
https://www.deviantart.com/afiya777/journal/OFFICIAL-FREE-Arsenal-vs-Dundalk-Live-Stream-863680156
https://www.deviantart.com/afiya777/journal/FREE-Arsenal-vs-Dundalk-Live-Stream-Free-2020-863680158
https://www.deviantart.com/afiya777/journal/STrEaMs-reddit-Arsenal-vs-Dundalk-Live-Stream-863680160
https://www.deviantart.com/afiya777/journal/live-Arsenal-vs-Dundalk-Live-Stream-863680163
https://bitcointalk.org/index.php?topic=5283339.msg55797441
https://www.deviantart.com/afiya777/journal/LIVESTREAM-Dundalk-vs-Arsenal-Live-Stream-863675001
https://www.deviantart.com/afiya777/journal/FREE-Dundalk-vs-Arsenal-Live-Stream-Free-863675727
https://www.deviantart.com/afiya777/journal/STREAMING-Dundalk-vs-Arsenal-Live-Stream-Free-863675549
https://www.deviantart.com/afiya777/journal/FREE-Dundalk-vs-Arsenal-Live-Stream-Free-863675735
https://www.deviantart.com/afiya777/journal/LIVESTREAM-Dundalk-vs-Arsenal-Live-Stream-863675738
https://www.deviantart.com/afiya777/journal/live-Dundalk-vs-Arsenal-Live-Stream-863675742
https://www.deviantart.com/afiya777/journal/LIVESTREAM-Dundalk-vs-Arsenal-Live-Stream-863675744
https://www.deviantart.com/afiya777/journal/FREE-Dundalk-vs-Arsenal-Live-Stream-Free-202-863675747
https://www.deviantart.com/afiya777/journal/STrEaMs-reddit-Dundalk-vs-Arsenal-Live-Stream-863675749
https://www.deviantart.com/afiya777/journal/Reddit-Streams-Dundalk-vs-Arsenal-live-stream-863675751
https://latingrammya2020.medium.com/live-celtic-vs-lille-livestream-uefa-europa-league-free-on-3ca391d3f225
https://latingrammya2020.medium.com/live-celtic-vs-lille-livestream-uefa-europa-league-free-e532123b16e7
https://latingrammya2020.medium.com/live-celtic-vs-lille-livestream-uefa-europa-league-free-on-hd-865768344881
https://uefaeuropalivetv.medium.com/live-dundalk-vs-arsenal-livestream-uefa-europa-league-free-on-759d5bac1d7a
https://uefaeuropalivetv.medium.com/newcastle-dundalk-vs-arsenal-live-uefa-europa-league-stream-4k-26e301bd29bf
https://uefaeuropalivetv.medium.com/live-dundalk-vs-arsenal-livestream-uefa-europa-league-free-on-d40732e7ebb8
https://tottenhamhotspurvsantwerplive.medium.com/total-sportek-tottenham-hotspur-vs-antwerp-live-free-by-reddit-official-streams-64bec64988b0
https://tottenhamhotspurvsantwerplive.medium.com/live-tottenham-hotspur-vs-antwerp-livestream-uefa-europa-league-free-on-c9d944cf0138

https://www.game.tv/tournaments/TOTAL-SPORTEK...-Arsenal-vs-Dundalka-Live-Free-10-December-2020--2e29ff0c3e694d82b5ed3772eedd0469

https://www.game.tv/tournaments/WATCH-Arsenal-vs-Dundalka-live-Stream-free-Reddit-online-TV--ab412d77ffdb4cb6ba1d2770824ac05e

https://www.game.tv/tournaments/StreamSwatchArsenal-vs-Dundalka-Live-Stream-Reddit--dc10440110a942eb882c046c4f6a62e2

https://www.game.tv/tournaments/WatchLive-Arsenal-vs-Dundalka-Live-Stream-Free-Game-HD--aaa043ca71b340f6bfead160b49bf124

https://www.game.tv/tournaments/streaming-live---Arsenal-vs-Dundalka-Live-Free-10-Dec-2020--eb663ebc7c0b412f837d9c8f2d69c506

https://www.game.tv/tournaments/Watch-Arsenal-vs-Dundalka-Live-Stream-Free101220--c63fe1ade9444c8d9707cbfe895cd291

https://www.game.tv/tournaments/Watch-Arsenal-vs-Dundalka-Live-Streaming-free--UEFA-Live-Stream--2d7b5518bc99459b8f7ad60b6c74fdc7
https://www.game.tv/tournaments/LiveSlavia-Praha---Leverkusen-Online-%C5%BEiv%C3%BD-prenos-2020--e16193e9a4064eccaed6ddb4796891fd

https://www.game.tv/tournaments/StReAmS.Slavia-Praha---Leverkusen-%C5%BDive-Online-Live-10-DEC-2020--846de84b51c64b6191f39071740fb718

https://www.game.tv/tournaments/ONLINE-Slavia-Praha---Leverkusen-%C5%BDIVe-Tv-%C5%BEiv%C3%BD-prenos--f0eed35ad6c24bab8577ccc489ae2d4a

https://www.game.tv/tournaments/Sky-SportsSlavia-Praha---Leverkusen-%C5%BDIVe-Tv-%C5%BEiv%C3%BD-prenos--5a5635abcff042c0888ab2304e202c4d

https://www.game.tv/tournaments/ONLINE-Slavia-Praha---Leverkusen-Evropsk%C3%A1-liga-UEFA-2020-LIVE-Slavia-Praha---Leverkusen-live--6685632ec12142d093ce413858d9dd8f

https://www.game.tv/tournaments/LiveSlavia-Praha---Leverkusen-Online-%C5%BEiv%C3%BD-prenos-Evropsk%C3%A1-liga-UEFA-2020--9461f531794f4b6cb814d04b9c738c24

https://www.game.tv/tournaments/ONLINESlavia-Praha---Leverkusen-%C5%BDiv%C3%BD-prenos-%C5%BEiv%C3%A9-Evropsk%C3%A1-liga-UEFA-2020-LIVE-ONLINE-10.10.2020--9035222622714ad1b345948e8e555825

https://www.game.tv/tournaments/prenos-TvSlavia-Praha---Leverkusen-sledujte-online-prenos-na%C5%BEivo-Kvalifikace-Ligy-mistr%C5%AF-UEFA-10122020--1a4ff055e0ad44f193d7ad9d24602059

https://www.game.tv/tournaments/ONLINE-Slavia-Praha---Leverkusen-%C5%BDiv%C3%BD-prenos-%C5%BEiv%C3%A9-Kvalifikace-Ligy-mistr%C5%AF-UEFA-10.12.2020--b88b471364be42728b4d3a25a79cf81d

https://www.game.tv/tournaments/On-DirectStreaming-Slavia-Praha---Leverkusen-En-Direct-10-DEC-2020--a18dc501af444893aca328d059d45b3c

https://www.game.tv/tournaments/LIVE-Slavia-Praha---Leverkusen-o-live-Online-%C5%BDiv%C3%BD-prenos-Evropsk%C3%A1-liga-UEFA-2020-Online--65901fdc5f6d4bd78d3eab149e36dc43

https://www.game.tv/tournaments/Online-Tv-Slavia-Praha---Leverkusen-%C5%BDiv%C3%BD-prenos-Online-Evropsk%C3%A1-liga-UEFA-2020--137e1d5db3fd444c8b2d1855f16915f8

https://www.game.tv/tournaments/STREAMING-Slavia-Praha---Leverkusen-liveStream-Kvalifikace-Ligy-mistr%C5%AF-UEFA--31db374301bf4659996c8a0103c5a207
https://www.game.tv/tournaments/LIVEArsenal-vs-Dundalk-Live-Stream--b9a6d232fc674924acb22739a80161f2
https://www.game.tv/tournaments/LiveArsenal-vs-Dundalk-Live-Stream---TOTAL-SPORTEK--a9edb5f1b15c4fea9bc4fce2f8b6503a
https://www.game.tv/tournaments/LiveArsenal-vs-Dundalk-Live-Stream-Reddit-Free--8ef4ed446b1a4042913f5668e8dd3ad8
https://www.game.tv/tournaments/LIVESTREAMArsenal-vs-Dundalk-Live-Stream--8130a383e4cf45aaa8ccdf4219707782
https://www.game.tv/tournaments/STREAMING-Arsenal-vs-Dundalk-Live-Stream-Free--17a43d26bea745aea875cb62e2c207b6
https://www.game.tv/tournaments/StReamSLiVe-Arsenal-vs-Dundalk-Live-Stream--4470ed6607ba451882f86a106cbd4665
https://www.game.tv/tournaments/LIVE-Arsenal-vs-Dundalk-Live-Stream-Reddit-Free--6c24ae782843423084d03dc34d6ba8fd
https://www.game.tv/tournaments/STREAMREDDIT”“-Arsenal-vs-Dundalk-live”-liVe-StreaMs.-reddit--3f58e28a3f2c4e928dad59362e85114f
https://www.game.tv/tournaments/TOTALSPORTEK”Arsenal-vs-Dundalk”-lIVE-fREE-bY-rEdDiT-OfficialStreams--45be10f799a941b2ae01f11ba0a3b5b5
https://www.game.tv/tournaments/MATCHTHREAD'-Arsenal-vs-Dundalk-live-LIve-StreaMs-reddit.--b1ef25bcadb54553b8a600b41d5def08
https://www.game.tv/tournaments/LIVEArsenal-vs-Dundalk-Live-Stream--b9a6d232fc674924acb22739a80161f2
https://www.game.tv/tournaments/LiveArsenal-vs-Dundalk-Live-Stream---TOTAL-SPORTEK--a9edb5f1b15c4fea9bc4fce2f8b6503a
https://www.game.tv/tournaments/LiveArsenal-vs-Dundalk-Live-Stream-Reddit-Free--8ef4ed446b1a4042913f5668e8dd3ad8
https://www.game.tv/tournaments/LIVESTREAMArsenal-vs-Dundalk-Live-Stream--8130a383e4cf45aaa8ccdf4219707782
https://www.game.tv/tournaments/STREAMING-Arsenal-vs-Dundalk-Live-Stream-Free--17a43d26bea745aea875cb62e2c207b6
https://www.game.tv/tournaments/StReamSLiVe-Arsenal-vs-Dundalk-Live-Stream--4470ed6607ba451882f86a106cbd4665
https://www.game.tv/tournaments/LIVE-Arsenal-vs-Dundalk-Live-Stream-Reddit-Free--6c24ae782843423084d03dc34d6ba8fd
https://www.game.tv/tournaments/STREAMREDDIT”“-Arsenal-vs-Dundalk-live”-liVe-StreaMs.-reddit--3f58e28a3f2c4e928dad59362e85114f
https://www.game.tv/tournaments/TOTALSPORTEK”Arsenal-vs-Dundalk”-lIVE-fREE-bY-rEdDiT-OfficialStreams--45be10f799a941b2ae01f11ba0a3b5b5
https://www.game.tv/tournaments/MATCHTHREAD'-Arsenal-vs-Dundalk-live-LIve-StreaMs-reddit.--b1ef25bcadb54553b8a600b41d5def08

First of all, almost all of these patients present with such frighteningly low oxygen levels. I am also a lung specialist, and I am accustomed to seeing patients with low oxygen levels. Normal oxygen levels are anything above 90%, and I have seen patients come with levels as low as the 70s. Rarely, however, do I see patients presenting to our hospital with oxygen levels in the 50s and even lower. What’s more perplexing, sometimes these patients have oxygen levels that low and have absolutely no symptoms. I have never seen that before in my career as either a lung or critical care specialist.
Frighteningly Quick Deterioration
Secondly, when these patients with COVID-19 crash, they crash very quickly and crash very hard. Each patient is a ticking time-bomb, and they could be doing fine for several hours, and then — suddenly — they are gasping for air with plummeting oxygen levels and a plummeting blood pressure. One patient — a sweet woman in her 60s — was holding her own for several days. She was still very sick, but she was holding her own. All of the sudden, she became severely short of breath and was gasping for air. Despite getting multiple interventions, including going on a ventilator, she suffered cardiac arrest and died. We were all devastated.
As a critical care specialist, I am used to seeing the sickest of the sick. Never, however, have I seen patients as sick as those with COVID-19
What I’ve Learned Taking Care Of These Patients
This disease is unlike anything we have ever seen. COVID-19 has confounded critical care specialists the world over. It has upended decades of critical care gospel, and it has left very smart clinicians, scientists, researchers and regular bedside doctors — like me — scratching their heads. Each patient acts differently to the virus, and we need to treat each patient differently. What works for one, may not work for another, and this is different than what we have been used to. This is ultimately a good thing, and it will make all of us better clinicians in the end.
Not every patient needs a ventilator right away. Early on, clinicians taking care patients with COVID-19 were recommending “early intubation,” which means placing patients on a ventilator if conventional oxygen treatment did not work. They were not wrong. At the same time, we have learned that some patients can avoid going on a ventilator if we can treat them with high amounts of oxygen with high flow rates. We have had great success using this treatment modality in keeping multiple patients from requiring a ventilator. In addition, we have found that, if patients can lie on their stomach themselves, this has helped many of them avoid having to go on a ventilator. A lot of research is being conducted on this treatment, but we have found good success with it in our patients. While a ventilator can be life-saving, and I would not hesitate to use it on any patient who can’t breathe, it can also damage the lungs, and it is important to try everything in our arsenal first before we place someone on a ventilator. Indeed, multiple guidelines have now come out saying the same thing.
We need to aggressively correct any dehydration. It has long been a teaching that the patients with the severe lung disease called ARDS, or Acute Respiratory Distress Syndrome, need to get as little fluids as possible. This is appropriate, because too much fluid in the body can cause the lungs to fill up with fluids and make the respiratory failure worse. At the same time, patients with COVID-19 typically come into the hospital and ICU very dehydrated. They have had fevers for several days, which causes dehydration itself, and they are not really eating and drinking (because they are sick). So, if we do not give them fluids, we are setting them up for kidney failure. As a result, we have been more liberal with fluids — all while not giving too much — and we have been very successful in preventing kidney failure.
We REALLY need to discuss goals of care with all patients admitted with COVID-19. This disease can kill. It can leave you needing a ventilator for a very long time, if not forever. Do you want this? Yes, of course, we try to “do everything” for all of our patients. The thing is, “doing everything” may not be consistent with someone’s wishes and values. Do you want to live the rest of your days on a ventilator? Do you want to die on a ventilator? Do you want to die with the team pounding on your chest? Whatever the answers are to those important questions need to be communicated to the doctors taking care of patients with COVID, BEFORE they go into respiratory failure. Having me, as a critical care medicine specialist, ask these questions is too late. It needs to be done sooner.
Like I said, I have never seen anything like this before in my career. This pandemic will have long-standing consequences on the medical profession, hospitals, the healthcare system, and society at large. I pray they are not all negative, and that — when this is all over…some day — we will all be better and stronger than we were before.
The opinions expressed in this blog are my own, and they do not reflect those of my employer or the institutions with which I am affiliated.

First of all, almost all of these patients present with such frighteningly low oxygen levels. I am also a lung specialist, and I am accustomed to seeing patients with low oxygen levels. Normal oxygen levels are anything above 90%, and I have seen patients come with levels as low as the 70s. Rarely, however, do I see patients presenting to our hospital with oxygen levels in the 50s and even lower. What’s more perplexing, sometimes these patients have oxygen levels that low and have absolutely no symptoms. I have never seen that before in my career as either a lung or critical care specialist.
Frighteningly Quick Deterioration
Secondly, when these patients with COVID-19 crash, they crash very quickly and crash very hard. Each patient is a ticking time-bomb, and they could be doing fine for several hours, and then — suddenly — they are gasping for air with plummeting oxygen levels and a plummeting blood pressure. One patient — a sweet woman in her 60s — was holding her own for several days. She was still very sick, but she was holding her own. All of the sudden, she became severely short of breath and was gasping for air. Despite getting multiple interventions, including going on a ventilator, she suffered cardiac arrest and died. We were all devastated.
As a critical care specialist, I am used to seeing the sickest of the sick. Never, however, have I seen patients as sick as those with COVID-19
What I’ve Learned Taking Care Of These Patients
This disease is unlike anything we have ever seen. COVID-19 has confounded critical care specialists the world over. It has upended decades of critical care gospel, and it has left very smart clinicians, scientists, researchers and regular bedside doctors — like me — scratching their heads. Each patient acts differently to the virus, and we need to treat each patient differently. What works for one, may not work for another, and this is different than what we have been used to. This is ultimately a good thing, and it will make all of us better clinicians in the end.
Not every patient needs a ventilator right away. Early on, clinicians taking care patients with COVID-19 were recommending “early intubation,” which means placing patients on a ventilator if conventional oxygen treatment did not work. They were not wrong. At the same time, we have learned that some patients can avoid going on a ventilator if we can treat them with high amounts of oxygen with high flow rates. We have had great success using this treatment modality in keeping multiple patients from requiring a ventilator. In addition, we have found that, if patients can lie on their stomach themselves, this has helped many of them avoid having to go on a ventilator. A lot of research is being conducted on this treatment, but we have found good success with it in our patients. While a ventilator can be life-saving, and I would not hesitate to use it on any patient who can’t breathe, it can also damage the lungs, and it is important to try everything in our arsenal first before we place someone on a ventilator. Indeed, multiple guidelines have now come out saying the same thing.
We need to aggressively correct any dehydration. It has long been a teaching that the patients with the severe lung disease called ARDS, or Acute Respiratory Distress Syndrome, need to get as little fluids as possible. This is appropriate, because too much fluid in the body can cause the lungs to fill up with fluids and make the respiratory failure worse. At the same time, patients with COVID-19 typically come into the hospital and ICU very dehydrated. They have had fevers for several days, which causes dehydration itself, and they are not really eating and drinking (because they are sick). So, if we do not give them fluids, we are setting them up for kidney failure. As a result, we have been more liberal with fluids — all while not giving too much — and we have been very successful in preventing kidney failure.
We REALLY need to discuss goals of care with all patients admitted with COVID-19. This disease can kill. It can leave you needing a ventilator for a very long time, if not forever. Do you want this? Yes, of course, we try to “do everything” for all of our patients. The thing is, “doing everything” may not be consistent with someone’s wishes and values. Do you want to live the rest of your days on a ventilator? Do you want to die on a ventilator? Do you want to die with the team pounding on your chest? Whatever the answers are to those important questions need to be communicated to the doctors taking care of patients with COVID, BEFORE they go into respiratory failure. Having me, as a critical care medicine specialist, ask these questions is too late. It needs to be done sooner.
Like I said, I have never seen anything like this before in my career. This pandemic will have long-standing consequences on the medical profession, hospitals, the healthcare system, and society at large. I pray they are not all negative, and that — when this is all over…some day — we will all be better and stronger than we were before.
The opinions expressed in this blog are my own, and they do not reflect those of my employer or the institutions with which I am affiliated.

--

Get the Medium app

A button that says 'Download on the App Store', and if clicked it will lead you to the iOS App store
A button that says 'Get it on, Google Play', and if clicked it will lead you to the Google Play store