This is a master class in caring for critically ill COVID-19 patients given by a nurse practitioner at the top of her craft, critical care clinical specialist Barbara McLean.
Learn more about Barbara’s work here. Thanks to Edwards Lifesciences for making this educational episode possible! Full transcript below, links to audio podcast version here.
The free “Edwards Clinical Education” App may be downloaded at the Apple AppStore, Google Play Store, or the Microsoft Store.
To access Edwards Clinical Education (ECE) materials please click here.
Check out the Edwards Lifesciences Clinical Education YouTube channel here.
Hey everybody, it’s Dr. Z. Welcome to the ZDoggMD Show. Okay today is a very important episode. We are going to teach frontline doctors, nurses, medical students, respiratory therapists, anyone who’s touching patients that are suffering from COVID-19 during this pandemic. We have an amazing educator with us today and this show is made possible by our friends at Edwards Lifesciences, they are the leader in hemodynamic monitoring. Why does that matter? Because in the settings that we’re taking care of COVID-19 patients, monitoring their hemodynamics is crucial for many, many reasons which we’re gonna talk about. But really this show is not about them, this show is about how do we take care of these patients in an ICU setting? Particularly for people who maybe haven’t been in an ICU for a while, or are still learning about COVID-19. Now the guest we have today is Barbara McLean. She is a critical care clinical nurse specialist and nurse practitioner, and she is practicing on the front lines in the number one trauma center in Atlanta, Georgia. She is a nationwide renowned clinical educator and has taught nurses, and doctors, and everybody about ICU care for a long career that is really more than I can get into. And I’ll try to put in the description, she has graciously, she just got off service where she’s been busting her butt, taking care of our sickest patients and training with her team there at the center, and is taking the time today to actually teach us what they’ve learned on the front lines. And this is gonna be invaluable you guys. Barbara, welcome to the show.
– Thank you so much Zubin. I’m so glad to be here, and I’m so happy to see all of you.
– You know, I gotta say this, you look so good for just coming off service.
– Lipstick does wonders for these old faces, I can tell you, thank you so much. And thank you for having me, because I hope that I can share something of value. But before I start, I just would like to say thank you to everyone, to all of our teams everywhere who are working tirelessly against this dark enemy that is so unpredictable, and that takes different turns, and has put incredible challenges in our way. Because in our practice, what we’re trying to do in general, with all of our patients, both patients under investigation, or on the medical surgical floors, or stepped down, and the persons under investigation, or positive patients who are in the ICU, we try to limit access into the room. Now I’m at a large academic center, and part of being at an academic center is that many people want to come and learn from each patient experience. And generally that’s an exceptional thing, but in our care for these patients, we have two issues that we have to consider. One is that you really have to limit exposure of all persons to patients who are PUIs or positive patients, and secondly, as we all know, we have to conserve our resources. And so a big change in our practice, and I’m sure in yours as well, is profoundly limiting the in and out. Now what that means is there’s reduced learning available for residents, and last week ACGME actually gave approval for residents to care for patients who are PUIs, or COVID-19, from now on I’m gonna say PUI, that will cover the whole aspect. So we now allow residents in our room. We didn’t do that before because we were concerned that that would be considered a forcible utilization of presence, but ACGME and all of our hospitals have agreed that residents can be in the room. We have APPs, we have our attendings, and fellows, et cetera, and traditionally, the team piles in the room. So now it’s very limited. We’ve limited our access to one attending physician and one other partner, either an APP, a fellow, or a resident per day. And in the beginning, the attending had to be in the room, and that was really only in the first week. After that, it was impossible for attendings to see every patient, so then higher level residents came to the room, and higher level residents are managing the patients. And now we see, and our APPs have always been able to manage patients, but now we’re seeing even lower level residents, and I know in some states, I heard today, not where I am, but I heard that some of the medical schools are graduating their students early in order to propel them towards the front line. Now they won’t be practicing as physicians, but they will be able to provide a tremendous amount of assistance in many, many ways.
– And that makes perfect sense because the need for bodies on the front line is so acute right now. What have you been seeing when patients present now? How are you triaging them and how are you thinking about that? Because you’re seeing a lot of volume, and you can teach us a lot about that.
– One of the things that I think is quite important is that I actually kind of inundated myself into my system as I saw that we were receiving patients. Our infectious disease team was doing a remarkable job of educating how to put your clothes on, we call that Don, D with an on, and now you take your PPE off, that’s called Doff, Off with a D, but oftentimes it was occurring during times that nurses couldn’t get away, and it was not occurring in off shifts. So we actually made a commitment to be at every change of shift to educate all staff, nurses, physicians, RTs, everyone, to educate all staff on how to wear their PPE, and most importantly, how to take it off in a very specialized way so there’s no possibility of contamination. And in that, I would like to say that one of the things that I believe in as a clinical specialist, as a bedside nurse, and as a human being, that I would never ask somebody to do something that I won’t do. So I have spent a lot of time in the rooms of patients who are COVID positive, in patients who have just arrested, in patients starting them on CRRT, in patients where we know that perhaps they are not going to survive, where we know they’re not going to survive because we know when that happens, and we’re quite clear about it. And with my hospital, we have a no visitation edict for any COVID patients, or any patients under investigation. So very fortunately I work with just such incredible people and someone offered their phone, my phone doesn’t work in the hospital unfortunately, but they gave me their phone and I put it in a biohazard bag, dressed, went in the room, called my patient’s daughter, spoke to her, she already knew that this was a dire situation, spoke to her, held the phone to his ear, took it off speaker, held the phone to his ear, and waited for them to have their conversation. We actually were getting ready to manually prone him and he was very unstable so we were not certain if proning was going to actually cause his death. But actually when we first turned him up on his side, he increased his saturation, when we put him prone, his saturation was beautiful. But unfortunately he did not survive the night. And this is one of the big struggles, I think, for us at the bedside, and I know it’s a little different than the question that you’ve asked. But I wanna make sure that we appreciate the struggle for us at the bedside is really, not only this overwhelming requirement for providing excellent care in a very difficult situation, but it’s also the moral and ethical loss that we’re, all of us at the front line, all of us are experiencing every day, sometimes every hour. And when I think of my colleagues in New York City who have had such a significant increase in death, that understanding this and seeing this tragedy unfold over, and over, and over again, and in rapid succession, is very difficult. And then we feel so saddened by the fact that our families can’t say goodbye to the person that they love. So we’re trying to make sure that we’re taking a phone in so the family can at least speak to our patients. And many of them, of course, are on paralytics with sedation, analgesia, they’re intubated on a ventilator, they’re not responsive. But it’s an important way to facilitate for families to say their last goodbye. And sometimes for families to say that they’re sorry for something that happened to relieve themselves of that. But I’m gonna tell you that patients deteriorate very quickly.
– This is something that everybody in leadership in this country needs to hear, how this is going down, because you know, you can look at what’s happening in Italy, you can look at what’s happened in China, you can look at what’s happening in Spain, it doesn’t mean anything to Americans unless they see it happening in their own hospitals with their own front line staff. If I ask a question about triage and you tell me that answer, that tells me what your experience right now actually is. Your experience is people are dying alone in their rooms, talking through a bag on a phone, in a biohazard bag. That’s the reality of this epidemic on the ground. And until we get a handle on we have to control it, people should never be in the hospital in the first place, but now we’re where we are. So the question is Barbara, in your experience, because you’re seeing patient after patient with this, how, when they come in, you were mentioning they rapidly decompensate. Does this happen over days, hours, minutes? What are you seeing happen? And what’s happening with their hemodynamics and how you’re monitoring them?
– So you’ve asked a lot of great questions and I’m gonna try to answer as succinctly as I can. As you can imagine, because I’m in the depths of this now, it’s very emotional, and it may make it difficult for me to just be succinct. So I appreciate you keeping me on task very much. I would just say unfortunately there’s not a predictable model. We have patients that come in and four hours after they’re in the emergency room, having just gotten tested, they die. We have other patients that come in who actually have come in as something else who then become PUIs, who then have symptoms, and PUIs, I’m sorry if I didn’t explain, persons under investigation. So we’re assuming that they have COVID until proven otherwise. And then they blossom, and they do that pretty quickly. So the typical model that we hear about that’s the epidemiologic model, and it’s an academic model, not really a clinical model, is that you have symptoms, and then around the fifth to seventh day you deteriorate. Now that may be true, because patients may be outside of the hospital before they come, and they’re not coming until their symptoms are very significant. I think many people are afraid to come to the hospital right now because they know what’s happening. And so they may be delayed in coming to the hospital. But what we’re seeing is typically if you come in and you’re already critically ill, you deteriorate very quickly in the ICU, and that would be the majority of our patients.
– And so–
– And that could be six hours, it could be 12 hours, it could be 20 hours, but typically not too much longer than that. And sometimes our patients were PUIs, have a preliminary negative, and we get the second opinion, that’s from the CDC. So we send our tests on to the CDC. So it may be six, to seven, to eight days before we have an absolute confirmation.
– And are you mostly seeing, and by the way thank you Barbara for sharing this, I know it’s so hard on the front lines, and I can just feel it. Are you mostly seeing older patients that are decompensating quickly, or are you also seeing youngers?
– Okay, so I’m not an infectious disease specialist, nor am I an epidemiologist, but I would say that we are seeing across an age range. We, thank God, have not had anybody very, very young, but to me, people who are young are in their 40s, in their 60s. We have had some older patients, of course, and they cave comorbidities, they’re more frail, they’re not able to sustain themselves. But we’ve also had an 81 year old woman who survived. So I feel like at this moment in my real life experience, I don’t have enough longitudinal access and data to actually say there’s an absolute predictable model. I don’t feel there’s a predictable model. I think that every one of us has to be aware that this virus knows no boundaries, it does not discriminate based on gender, or race, or age. It has no control, and it is a profound virus that’s very virulent, and that takes over quite quickly.
– You have all these patients coming in, how are you able to guide them to, is there a specialized unit? A way that we can keep them from the rest of the hospital, make sure that there isn’t nosocomial transmission, and then triage them? Are you using any techniques, or monitoring, or anything else to guide where you send them and that sort of thing?
– So I’m in a large, public, urban hospital. We see about 280,000 patients a year in our emergency department on a slow year. We have 150 adult intensive care beds. We’re charged at 900 beds. We right now are not operating at that level because we had some fiscal problems that took about 250 beds offline, which couldn’t have happened at a worse time because we need all those beds. We have a couple of trailers, we have tents. In the ECC there is a separated area for patients who are suspected patients, there’s a screening room and a nurse who does all the nasopharyngeal swabs and is evaluating that patient. And we have a beautiful screening tool, which asks particular questions, but of course, I wanna reiterate that I know that we hear that even the symptom profile is changing and it evolves. Initially it was shortness of breath, and chest pain, and a rapid heart rate, and a rapid respiratory rate, and a temperature. And now we have a wider range of symptoms and we know that patients are coming in with things that are more predictive of a gastroenteritis with nausea, vomiting, and diarrhea. So again, it’s very hard to triage based on that. If you come to my hospital and you are having moderate symptoms, you’ll be admitted to some specialized areas that are med surg areas or step down areas, and of course you’re kept in isolation. And we are very fortunate because we have one area in the hospital, actually has 28 negative pressure rooms because we deal with a culture of poverty, so tuberculosis has long been with us. And that’s been very helpful. But as the CDC tells us that the time we really need to be concerned about negative pressure, and aresolization, is during aresolizing procedures. So in general, we have not been able to put all of our patients into negative pressure rooms, nor are we doing that. But we do have a specific area. Initially with our first one or two ICU patients, they were in a generalized ICU, and now we have two cohorted units with 30 beds total. And we are making plans for our next evolution. Our triage is basic subjective evaluation and waiting for objective data, and like everyone, we wait for our tests. And one of the things that I talk about a lot in my practice is reminding everyone about patients, that we do do the tests in our own hospital, and if you confirm positive with our hospital test, you’re positive, no questions asked, you’re positive. And we treat everyone who is a PUI or COVID positive the same. We treat them all like they’re positive in terms of PPE and how we’re taking care of them. If you have a preliminary negative and we believe there’s an alternative diagnosis, that preliminary negative looms very large, and we assume that you are negative because there’s an alternative diagnosis. So you came in through the ED, you were short of breath, you had whiteout on your chest x-ray, you got Lasix, you made urine, your lungs look better, we feel we have an alternate diagnosis and this is likely not to be COVID. So that’s preliminary negative, alternative diagnosis, and agreement with our ID team and primary team that this not COVID. But then the other one is preliminary negative that there is no alternative diagnosis, that we’re looking at the ground blast view on your CT scan, we’re looking at your chest x-ray, and most importantly your refractory hypoxemia. So the tachypnea, which progresses very rapidly from nasal canula to non rebreather for us, nasal canula, non rebreather, intubation. And we try to avoid any emergent intubation, but when that happens and there’s no alternative diagnosis, even if you’re preliminary negative, we assume you’re positive. And I always say, we ask for a second opinion, and that second opinion is the robust testing done by CDC, which then adds another five days before we have your final diagnosis.
– Barbara, you guys are not doing CPAP and BiPAP because of potential for aresolizing and spread, and it feels like those guys need to be intubated anyways pretty soon?
– So our choice is not to do CPAP and BiPAP in the current state of affairs. So we are rich with a very large respiratory therapy department, respiratory therapists who are assigned to the ICU, 70 high-level, brand new 940 Puritan ventilators that have a broad capability for application, and then we have another 50 ventilators that are less robust. So we own many ventilators, but as the situation unfolds, again having so much respect and always wanting to say the respiratory therapists are really the heroes here.
– [Zubin] And how.
– Our therapy department has said, “Okay, we know we’re gonna need to use CPAP “and BiPAP ’cause we don’t have enough ventilators.” So they have actually found exhalation valves, and those exhalation valves, or exhalation filters, actually will capture the majority of the nebulized air, and therefore protecting persons in the room. So the respiratory therapists, I feel in my hospital, are multiple steps ahead of the game. They are always planning for what’s gonna come next. They’re as prepared as they can be, but we will shortly, I think, overrun our abilities.
– Yeah, and that’s what I’m hearing around the country. And a question then is, once folks are intubated and they’re on one of those scarce ventilators, how are you finding, in your experience now ’cause this is very much in your specialty wheelhouse, how are you monitoring them hemodynamically? Are there certain parameters that you look for that would allow you to tune their management better? Particularly in the setting of this ARDS, blossoming ARDS, and the sense and reports that we’re getting of myopathy, heart failure progressing very rapidly. What are you doing form that standpoint?
– So I really appreciate that question. So our goal is for any critically ill patient who’s in the ICU to have both a central venous catheter, and obviously that’s very helpful because they to a one, have required vasopressor therapy, and secondarily to have an arterial line. Now I happen to be a very big fan of arterial-based cardiac output. So we’re using arterial-based cardiac output, which I really appreciate, because it reflects left ventricular ejection, and basically will trend along, not absolutely, but trend along with ejection fraction that you would be able to evaluate if you were doing an echocardiogram. In general, we try to avoid any non-essential testing. So unless an echocardiogram is gonna make a profound difference in your therapy and diagnosis, we wanna look at our stroke volumes. And we look at stroke volume and we manipulate that with volume, as I’m sure you know that one of the issues is volume overloading in these patients is very deleterious because they have very profound capillary leak and a lot of interstitial edema, so we really try hard not to volume overload. And when you trend your stroke volumes, so for me, the way I always practice is, the correlation of CVP to stroke volume and being sure that whatever I’m giving my patient improves their stroke volume without significantly impacting their myocardial ischemia or their myocardial oxygen demand. I think it is really important to appreciate that in a trajectory that actually has a lot of similarities to sepsis, we see that many of these patients develop profound cardiomyopathy and heart failure, and those that improve and survive, we know from reports, and from our own experience, that they regain, to some level, their cardiac function. Perhaps not in the immediate time, to their ejection fraction that they had prior to their illness, and many times of course, we don’t know that. So again, we actually don’t take patients anywhere except to higher level or lower level of care. We don’t take them to CT or MRI unless it is absolutely vital to have that information. And so in general, we never do that. We do occasionally do echocardiograms because our patients aren’t behaving the way that we predict. But I think the other thing that I would be remiss if I didn’t mention, and this might be a lot for listeners.
– No, no, keep going, this is great. This is exactly the kind of thing that is gonna help people on the front lines, yeah.
– So I think the other thing that’s really important is recognizing that because our patients have such severe refractory hypoxemia, we quickly climb our ladder. So whatever ladder you’re using, if your ARDS ladder with FIO2 and PEEP, you’re using Berlin, which of course is also FIO2 and PEEP, what we typically see is our standard patient is somewhere between 14 and 24 PEEP. And with that also requiring 60 to 100% FIO2 in order to promote oxygenation. So one of the things I do think is quite important, and this is my particular area of interest, is creating a burden with your ventilator, creating a burden for the right heart, which is almost insurmountable for the right heart to overcome. So one of the things that I’m talking about a lot, and a lot of my providers, and we have discussions together, we can stand, even if we’re outside the room looking in, because all of our vents, our pumps, our CRT, and our bedside monitor are all turned to face our windows so we can look at data all the time, and talk about the data. Look at the labs, talk to the person in the room about their assessment, understanding their urine, understanding their urine output and correlating all that together at once. It is also vitally important to consider that we can induce a primary right heart failure with our mechanism of ventilatory support. So in order to deal with that on the front line as we’re manipulating this, we also have to give particular attention to the right ventricle and remind ourselves that in our normal situation the right ventricle is a very weak muscle, it does not provide a lot of tension, it doesn’t mobilize volume that effectively. It’s really a volume conduit, not a work pump. And now we put a huge burden, we all know that the right ventricle is very susceptible to increasing pulmonary resistance, which we have now applied with our PEEP to our pulmonary vasculature, which is now very compressed. So we are very frequently, and in fact I would say in almost all cases, applying inotrope, inodilation, or inhaled pulmonary vascular dilation, Flolan or Fil–
– So this is actually something you’re seeing on the ground more than you would in other cases of ARDS? Or do you think it’s a typical ARDS pattern where you have to have high PEEP, high FIO2s, you’re putting stress on the right heart, and you’re having to take these countermeasures?
– I would tell you that if there was even one microcapsule of silver inside this dark cloud, I think it has changed the way people look at practice. It’s changed the way we are practicing. We’re trying to bundle our care. So instead of doing labs 14 times a day, we’re trying to do them once or twice. And I think that it’s changed the way that people understand mechanical ventilation and the right heart, because we’re moving so quickly and so aggressively. Right now our number one mechanism is high PEEP and pressure control, but we have the capability, we do airway pressure release ventilation, which for those of you don’t know, is a continuous high airway pressure, which pops open your alveoli, and then reduction very rapidly, and then return to the high. So we don’t allow time for the alveoli to collapse, but what we do is produce a methodology for CO2 to rapidly move up and out of the airway. So unlike regular pressure control inverse ventilation, APRV applies that mean pressure strategy to pop open the lung, but it allows time for an active removal of CO2. So we will apply APRV, we have to be very careful in this situation. And in general, for APRV to work, your patient must be able to breathe on their own across their high time, because that’s what moves the CO2 up into the airway. So most of these patients actually, they’re so tachypneic, honestly they’re just suffering so much. They’re so tachypneic we have to paralyze them. We normally don’t paralyze our patients, but typically these patients who are really descending, they really do require paralytic, sedation, and analgesia because otherwise we’re not able to help them ventilate appropriately. So APRV works best in the scenario where a patient can breathe spontaneously across high time and high pressure. And even, there was some discussion, and I think that’s probably a discussion being had at major centers around the United States, about considering high frequency oscillation, and of course ECMO.
– ECMO too, have you guys done a lot of ECMO there?
– We are not an ECMO center currently.
– Right, and let me ask, you obviously are running permissive hypercapnia in these situations, so you’re less concerned about the CO2, or are you not?
– Well the patients frequently have a combined respiratory metabolic acidosis, so we actually are limiting permissive hypercapnia more than we would traditionally do, because the profound acidosis, if it’s combined, it creates a scenario that we can’t recuperate you from.
– Right, and it probably is depressing myocardial function as well. So another question I had relating to that is, if you’re looking at right ventricular issues, what proxy measurements are you using to actually determine right ventricular function? Teach me about this, ’cause it’s been a minute since I’ve thought about this.
– So of course what I would tell you is the number one way to actually evaluate right heart function, and there’s really only one absolute way, and that’s the PA catheter. So again, we’re being very cautious about that, we haven’t really moved to that model. We might move to that model because I think it would give us excellent information and help us in our therapeutic interventions. And we have PA catheters that give us the capability to look at right heart ejection fraction, right ventricular and diastolic volume, and those are the super spaceship PA catheters. But even a simple PA catheter with just PA pressure measurements. Not really using my PA catheter for cardiac output, but using my PA catheter to really look at those pulmonary hypertensive states that can be induced, and recognizing that as you’re trying to open the lung, you must open the vessels, and you must provide the right ventricle with support. So in the most limited of situation, I basically use a Frank-Starling model, and some of you might remember, Frank-Starling works on a model that on the horizontal axis is your filling pressure, and on the vertical axis is your stroke volume. And as you give a patient volume, and you see that their CVP goes up aggressively but their stroke volume does not, what that generally is telling you is loss of right ventricular compliance. In the best scenario that we have, because we want to place central catheters and we want to place A lines for these patients, our best scenario is a modified Frank-Starling curve where we actually give volume and watch the stroke volume go up and the CVP goes up mildly to moderately, but the stroke volume goes up. But if we give you volume and your CVP goes up but your stroke volume does not go up, in this way we can consider that it is probably reflective of right ventricular disfunction in this way. And if we correlate that with just understanding the basic lung model, air pressure’s greater than blood pressure, blood pressure and air pressure match, and blood pressure is greater than air pressure, that’s called the West model. In a modified West model, what we’re saying is we’re using 22 of PEEP, we’re using high opening pressures of 30 centimeters water pressure, we’ve now made our whole lung a big air lung with very little profusion. And you have to support the right heart to mobilize that blood flow through the pulmonary vault. So I think in a step-wise fashion, what we see, and just to give you this step-wise, is a patient comes in, he might go to the medical surgical floor, he’s a PUI, he’s on nasal canula. And today one of my colleagues on the med surg floor said to me, “We’re not used to five, six, seven “liters of flow from a nasal canula. “We never give more than three.” But we start them and we move them up to five, six, seven, and then we give a non rebreather, and we see that the patient has refractory hypoxemia. At that moment, there really does need to be a unified decision that the patient is not responsive, and elective intubation should be performed so that it’s not everyone in chaos, everyone in emergency, hard to control people coming in and out of the room. And that’s really important, we really try to control who’s coming in and out of the rooms. In our most recent code we had a fellow, a third year resident, a respiratory therapist, a nurse, and another nurse, and then someone outside the room ready to go in the room who is donned in all the protective equipment, ready to enter the room to continue compressions. And that way, the person who comes off compressions has to rotate out of the room because they’re hot, and they’re exhausted, and it’s the work that we do at the bedside here, I want everyone to appreciate and understand, it’s so much harder than our regular work even with the most acute patient, because with our face shield, or our goggles, our mask, our mask cover, our gown, our gloves, and sometimes two gloves, and very physical labor, you almost are suffocating and you are sweating so profusely. The work is so much more difficult, and this is simple PPE. I’m not even talking about people who have hazmat level suits and a PAPR. The PAPR gives some circulated air, but those suits are still oppressive. And it’s almost extraordinary to think that nurses and doctors can provide care for a 12 hour shift in this model. It’s really, really difficult.
– Can I ask a difficult question? Because what you’re saying sounds, it’s an ordeal, it’s hard, it’s hard on the staff. The question is, is it helping the patient? So in other words, if someone is coding, secondary to a COVID-related disfunction, if they’re coding, what are the likelihoods that CPR and full resuscitative efforts are gonna lead to a meaningful recovery here in your experience so far?
– So I love this question, and I’m gonna talk with you philosophically, and not absolutely. So we have had two patients who responded to resuscitation, we don’t know yet if they’re gonna have a meaningful recovery. We don’t know that they’re gonna recover. They returned their spontaneous circulation, we were able to wean their vasopressors, we’ve been able to wean the FIO2 and the PEEP, but we don’t know neurologically what their recovery will be, and we’re not doing a brain blood flow, and we’re not doing EEG in the room, because we’re limiting tests. So I can’t give you that, that’s the longitudinal data I can’t tell you. I do think that all of us are considering limited resuscitation, which is what we’re doing. We’re doing a limited resuscitation. So we had a round of epi, a round of CPR, another round of epi, and another round of CPR, and then we have to have a discussion, should we continue? And I think most hospitals, if they’re capable, are doing limited CPR. And then of course you know that many other places are considering that we’re not gonna do any CPR on COVID patients, and those are probably hospitals that have a lot more experience with a failure to resuscitate. In many of our patients, we know that when we do something that might be strenuous physiologically, like proning, which can be very helpful for the patient, but may also put an extraordinary strain on them, particularly if they have some abdominal excursion of volume and now you put them down on their abdomen and you compress their vasculature. And understanding that we also are very aware that we are entertaining a DNR status, I think all of us in the world, not just my hospital, but all of us in the world, are entertaining DNR status much sooner than we would normally, because one of the beauties of being at an academic center is, we never give up. We try so hard, we try so hard to save your loved one. And we are still doing that. But we have found this enemy to be so unpredictable and so profoundly altering that even with all of our knowledge and tools, we are having a hard time overcoming it. And I think that at this moment, I’m very grateful because at this moment, in my hospital, we are not facing the idea of splitting ventilators between patients. Not yet, we’re not facing that. God willing we won’t, but I think that if we look at all our other models, we probably will. And again, I think about what the hardship of this is to come together, and it won’t be one person’s decision, and we can’t ever have that be one. We have a group, and we have our palliative care group, we have our attending physicians, we have the bedside nurse, our pharmacist, our therapists come together to discuss, should we, can we, will we, and how much will we do? And I think that’s really, really important because I think historically, that ethical burden has been placed on the shoulders of physicians who make that decision not rarely, but not five times a day. I think making a decision five times a day that you’re not going to be able to proceed is disastrously soul destroying. And so I think we have to be sure, in all of our institutions, that this is a plan, and that many people are in that plan and that they agree to the plan, because I think we have to have it be in census that we choose not to resuscitate, or that we choose to end resuscitation after one round, or after two rounds. And we are not doing resuscitation like we normally do. It’s quite interesting if I were to share with you that, again being in an academic center, when there’s a life-ending event, we call it the code blue, when there’s a code blue, hundreds of people come running, and many of them come into the room, even though they may or may not be doing things, and we have to ask them to leave the room, step outside, watch through the windows. But now, we have to be very careful, because everyone who goes in the room has to be dressed, everybody in that room has to have a designated role, and the treatment team should make that decision every day. And that’s a decision that the treatment team in discussion should make every day, if there’s a code, what are we going to do? Are we going to allow gentle passing? And I think another lesson for us, which is not an easy lesson for us in America, but our other colleagues around the world, this is a lesson we can learn from them, that in our life that we’ve always perceived that death is our enemy. But here I think a peaceful death is our friend, and that’s something that we are learning, that the violence of CPR in this untenable situation is tragedy upon tragedy. And so I think we’re learning about good death, and we’re very grateful for our palliative care teams that are helping us, and also giving us a lot of staff support.
– I’m with you 1000% on that. And this has been a personal crusade of mine actually, throughout the show. And again, it’s hard to go back to management after talking about that, because it’s so important, but I wanna go back to what you said about double ventilating. So people are talking about that now. Barbara, can you explain to me the mechanics of how that would work, sharing a ventilator among two patients? What would be the parameters where you would even be able to make that work? And how technically would you do it?
– So I have not experienced dual patients on one ventilator in my career, and I’ve had a long career, and I’ve been in lots and lots of disasters, and very hazardous conditions. I haven’t experienced it before, but I think quite simply, we can appreciate that we have actually done dual lung ventilation in the same patient actually having a split tube that is promoting a different volume and pressure in each lung. And so I think no one loves the idea of providing two patients ventilatory support from one ventilator, but we have a very good model for this as a precedent because we do have that ability to do dual lung ventilation. And it really is splitting the flow between the two patients. And remember that the inhalation never crosses with the exhalation. The exhalation’s completely separate, so there’s no passing of contaminant, which I think is something that the public certainly could be worried about. And I think that’s really important for us to appreciate and achieve. And we have to think in scarcity of resource that will have to consider this, to be able to split ventilators between patients. And again, I think especially you should be thinking about that. If you don’t already have a model for dual lung ventilation, to have that model in preparation. Have your therapists in preparation to consider that this might become a possibility in your setting.
– And that’s super helpful, because it’s nothing I’ve ever encountered, so it’s interesting that we’re talking about it, that we’ve gotten to that point. One thing I wanted to make sure I asked you about too is, so in your typically ICU patient, they’re prone, ventilated, what are the minimum lines that you would have in them for monitoring? Because we wanna make sure we minimize any sort of procedures that aren’t necessary, like you said, this new paradigm of testing infrequently. Heaven forbid, I’ve been talking about that for years, it’s like, why are we constantly drawing blood off the A line and sending it for no reason? And our lab colleagues are scratching their head at why we’re doing Q1 hour calciums. And so, the question is, what’s the bare-minimum monitoring lines that you’re placing in these patients that you’ve found has been enough to manage them?
– Our group of providers have made the decision that if you are in the ICU intubated on a ventilator, you will receive a central line and an A line. Period. So I would advise that for all ICU patients because even though your patient may be looking good this hour, the possibility for rapid deterioration and requirement for very aggressive vasoactive drips, it looms very large, and you need to be prepared for that and you wanna have a central line for that.
– So it’s so rapid that if you’re not watching those pressures, if you’re not looking at it, it’s gonna catch you unawares. That’s the feeling I’ve gotten from frontline ICU folks around the country. Is that true?
– I think that the decline is more rapid than what we traditionally see. It’s not like you had a pressure of 120 and now it’s 40, you will have a slide down, but it’s a fairly rapid slide down. And again, one of the things to remind ourselves about is that within the time of JCH, and CMS, and as you may not be aware, this rigid control of nurses, and saying nurses can’t practice outside of their domain, and they have to have an order for every time they go up on the vasopressors. This is impossible.
– That’s crazy, yeah.
– You have to have trust in your team. Your nurse must trust you, you must trust your nurse. Your nurse has to have the ability to be empowered to respond in the moment to the patient, and that of course is one of the things that we look at is really trying to make sure that our nurses are well prepared, that they feel well supported, that they’re supported by the system, that they’re supported by the law, that they’re supported by the government. So let me tell you that most nurses I know, all they care about is that patient. They are not thinkin’ about their license, they’re not thinkin’ about what the rules are, they are looking at someone’s pressure drop, and they’re gonna titrate up. Now I always urge caution with that, because when we titrate too rapidly to pressure, we now also put a burden on the left heart as we vasoconstrict the patient. So I always wanna be cautious, and always for me, the number one thing in my mind is always, I want to titrate your vasopressors to improve your driving profusion pressure, particularly to maintain your kidney, to maintain your cerebral flow, and your cardiac flow, but never to the deficit of your stroke volume. So as we titrate up on our vasopressors, if our stroke volume starts to decline, what we’ve done is we’ve increased your pressure but we’ve reduced your flow. We’ve reduced your volume, we put extraordinary work on your myocardium, and that’s particularly the left heart, but we also have put extraordinary work on your right heart. That seems to me to be a recipe for disaster. So I urge everyone to appreciate that you need some continuous methodology with these patients, to really experience beyond blood pressure what’s actually happening in the cardiac state as you are titrating up vasopressors, as you add inotropes, and of course, if we really wanted to see what the right heart is doing, we need a PA catheter, but we can correlate our CVP to stroke volume, not using CVP as a volume number, using CVP as a compliance measure. So what we’re looking at when we’re giving volume, and we’re adding people, we’re adding people, we’re giving volume, is that our CVP increases extraordinarily, but our stroke volume has decreased. And now our patient becomes more acidotic, which means they’re now refractory to their vasopressors and vasopressors go up, they don’t respond, we’re having now catecholamine toxicity. It’s an incredible cycle in a downward spiral.
– Barbara, you know it’s rare where I do an interview where I am exhausted just even by experiencing by proxy, and I mean this in a way that it’s so intense what you, and your colleagues, and everyone on the front line right now are having to do for these patients, heroically taking care of these patients, looking at everything from the science of this, to the physiology of it, the parameters of measurement, and hemodynamics, and making sure the PEEP, and the CVP, and the stroke volume, and everything, and thinking about all that intellectually. And then like you said, I’m gonna quote you specifically, “The soul sucking” horror of having to have five code conversations in a day, of having to decide how we’re gonna allocate resources we don’t have, about how we’re gonna work with limited PPE, or how we’re gonna do a code in a full PAPR hazmat suit when five minutes of compressions and you’re covered in sweat, and do that for 12 hours, maybe longer when they ask us to work longer, because we don’t go home when our patients are sick because that’s what we do. And seeing that everybody on the front lines is stepping up in a way that, gosh, if only our politicians, and our administrators, and our leaders would step up like that, maybe we’d have a world, right? Instead it all falls on the backs of people who will never say no, who they can push, and push, and push, and push until we break because that’s what we do. And that’s what I see in you Barbara. Again, I am so honored to even be in your presence, that you’re there doing this, and that you’re able to take the time out of this to teach us, it means so much to me, and it means so much to the audience. So thank you.
– Thank you, you’re so very kind, and I really appreciate that. But I think it’s important to see that what I really do is I’m representing all of us, all of us healthcare workers who are really just striving to do the best that we can do. I apply a lot of science, but I really, really don’t wanna forget a couple of things. First of all, our patients come in, they go to the ward, they look good, then they deteriorate and they deteriorate rapidly, and we move them quickly to a higher level of care. And we’re going through the hallway, and the fear and panic of our staff in relationship to this, can I help them survive? How do I make sure that mom knows that he’s in the ICU? And how do I go home tonight and protect my family? Because these are all really important things for us to discuss. And then as we move to the ICU and the ICU is closed, and we’re not allowing any visitors in our hospital, and how we continue to work scientifically and struggle. For us right now, we’re doing very well with our ventilators, we’re using every ventilator we have, every ventilator we have is in use. But also, just appreciating again that the humanity of this situation, of appreciating that we are at the forefront, not only as scientists, and providers, and purveyors of wisdom and knowledge, but that we are seeing every one of these patients as members of our own family. More than we’ve ever done before, because we all feel that our families are at risk. And I think what’s the most important thing for all of our leaders and our administrators to understand is that the single most important reason that staff feel panicked is because they don’t know what your decisions are. They need to have daily information. They need to understand why you have this reduction in PPE, not just that you do, you only get one mask a day, but why that is. We need to relay that information. You cannot believe how much comfort there is in that understanding. And then I’m going to say that I have this small team, and I would like to mention them, my small team are nurses that worked with me on hazardous infectious disease, their names, David Garner, Lauren Skinner, and Michael Henderson. David, Lauren, Michael, and I, since that first day, February 28th, we actually put together a team where we’d come in, one of us comes in and rounds every morning and every night at the change of shift. Now these are nurses who have already worked a 12 hour shift under extreme difficulty who then go to all the areas where we have patients, our PUI patients, and we train nurses and other persons, doctors, therapists, whoever’s there on appropriate donning and doffing to help protect them. We answer a lot of questions, and we give a lot of support. We’ve done that every single day since February 28th, and we have not missed a shift, we have not missed a day, this team of four. And our education department is getting ready to come online to now take that over, because now that we have so many patients in so many areas, it often takes us five to six hours, and that’s beyond our normal work day. So I wanna say, they represent everyone, this is, everyone is giving something up. Some of us are giving up what we believe is our safety. We are putting this together every day at the bedside, and lastly I wanna say that in my most recent days, what I’ve also done is after I’ve done a don doff, I just offer a prayer. It’s not a religious prayer, it’s a prayer of unity and love. And just caring about each other. And you cannot believe what a difference that makes on a daily basis to be able to say we’re here, three feet apart, we are virtually holding each other’s hands, and we say a prayer. And it’s a prayer of the heart, it’s not a standard prayer, it’s a prayer of the heart, and asking for the strength to get through our day, and for our patients, and our knowledge, and our wisdom, and to be able to apply that, and to appreciate each other, and to understand that we’re all human, and that we are struggling. And I’m struggling way less than others because I’m in a hospital that’s paid a lot of attention to the staff. My hospital has paid a lot of attention to the staff, they have engaged a psychiatrist to go and talk with the staff, there’s so much that my institution is doing for my staff. I love where I work. I’m in love with where I work right now because they are really paying attention, and that’s the lesson I wanna give to all.
– Barbara I am in awe of you. I’m in awe of your contributions to all of us on this, and over the years, and currently. And everybody out here should be supporting folks like you on the front lines, and we’re gonna do our best to make as much noise about this as we can and get your word out. Thank you so much for being with us. Get some rest, stay safe. Guys, Z Pack, do me a favor, please share this video. Leave your comments, leave your wisdom. There are resources we’ll link to. This is all hands on deck. It’s a group effort, we’re learning from each other as we go against a foe that is just absolutely merciless and doesn’t care about us, and so we have to care about us together. And I wanna thank Edwards Lifesciences for making this show possible, for helping us educate, giving us the resources to do that during this difficult time when face-to-face education is much harder. So what we’re doing, Barbara, will hopefully help some people. And thank you again, and stay safe.
– Thank you so much Zubin.
– And we out, peace.
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