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Improvisation and medical mysteries in the COVID-19 ICU

A fierce and unpredictable illness keeps doctors and nurses searching for solutions — without the help of time-tested science

Boston Medical Center staff peered through the glass as a team performed a tracheostomy on a COVID-19 patient on the ICU floor of Boston Medical Center.
Boston Medical Center staff peered through the glass as a team performed a tracheostomy on a COVID-19 patient on the ICU floor of Boston Medical Center.Erin Clark/Globe Staff//File

The nurses and doctors who work in intensive care are schooled in mass casualties, skilled at rescuing the sickest patients, and accustomed to relying on the findings of time-tested medical science.

But nothing in their experience compares to COVID-19.

The frightening way that patients take a sudden turn for the worse. The sorrowful need to keep sick people alone in their rooms, to prevent disease spread. The mysterious blood clots clogging IV lines. The sheer volume of patients, and how terribly ill they are.

Nurses are finding themselves improvising in new roles and doctors are learning on the fly, tapping any source they can find.

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Including social media. Dr. Michael Ieong, director of Boston Medical Center’s medical ICU, found helpful advice on preparing for the surge, not in a medical journal but in a Twitter thread from a Seattle doctor.

With no time to wait for the results of clinical trials, he said, doctors are talking to each other as never before, across the boundaries of nations, states, and institutions.

“A lot of it was word of mouth, which is like heresy in evidence-based medicine,” Ieong said.

Small unpublished studies and anecdotes shared over the phone are guiding critical decisions such as when to put a patient on a ventilator or whether to start blood thinner.

“We had to adapt very quickly based on experiences happening in Europe,” said Dr. Anthony F. Massaro, director of the medical intensive care unit at Brigham and Women’s Hospital. “We’ve had to do a lot of learning and coping in real time.”

Nurse anesthetist Chelsea Hough (left) and Dr. Robert J. Canelli, an anesthesiologist, donned personal protective equipment as they prepared to perform a tracheostomy on a COVID-19 patient at Boston Medical Center.
Nurse anesthetist Chelsea Hough (left) and Dr. Robert J. Canelli, an anesthesiologist, donned personal protective equipment as they prepared to perform a tracheostomy on a COVID-19 patient at Boston Medical Center. Erin Clark/Globe Staff

Jessica Coughlan, a cardiac nurse at Tufts Medical Center now redeployed to the hospital’s ICU, has been startled by how COVID-19 patients can get so sick so fast. “I feel like I’m always holding my breath when I’m at work,” she said.

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Rachel Fishman, a critical care nurse at Boston Medical Center, used to see a patient with severe respiratory failure once every few months. Today, all the patients in her COVID-only ICU are that bad off. “The sickest are now everyday care,” she said.

It’s too soon to tell whether that care is succeeding. No one can fairly calculate the survival rate of COVID-19 patients in Massachusetts ICUs — because most of them are still there, relying on ventilators. One study of COVID-19 patients in New York, drawing primarily on data from March, found that a quarter of those requiring mechanical ventilation had died, but 72 percent were still in the hospital, their futures unknown.

Several ICU chiefs in the Boston area said it looks like as many as 75 to 80 percent are surviving so far.

And only a small proportion of those infected with coronavirus need to enter an ICU. It’s estimated that 80 percent suffer mild symptoms or none at all. Of those who get sick, roughly a quarter — 5 percent of the total — need hospitalization, and about a third of hospitalized people end up in intensive care, almost always relying on ventilators to breathe for them.

Respiratory therapists Mandi Britt (left) and Jaymee Moniz conferred through the glass doors of a COVID-19 patient's room during a procedure at Boston Medical Center. Only those with protective gear can enter the patient's room.
Respiratory therapists Mandi Britt (left) and Jaymee Moniz conferred through the glass doors of a COVID-19 patient's room during a procedure at Boston Medical Center. Only those with protective gear can enter the patient's room. Erin Clark/Globe Staff

But although ICU patients make up a tiny percentage of all those infected, with an illness so widespread, they are overflowing the ICUs, forcing hospitals to repurpose other units. At the peak on April 26, there were 1,089 people in intensive-care beds throughout Massachusetts; that number had tapered down to 922 by May 5.

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Hospitals have coped with catastrophe before. The Boston Marathon bombing brought a sudden influx of severely injured patients. But that was a one-time event, with a clear endpoint. The COVID-19 pandemic persists week after week, its course and duration unknown.

And with COVID-19, caregiving has to happen amid the harsh imperatives of infection control: no visitors, as few people in the room as possible, and always with protective gear.

Despite the hubbub in the ICU, the people who work there feel the absence of patients’ family members, normally a mainstay of care. With visits relegated to occasional FaceTime sessions, the patients are solitary even in their last days.

“That’s not how we generally practice. We include the families in everything,” said Jill Robertson, charge nurse in the Boston Medical Center ICU. It takes a toll on caregivers to see patients so alone, and to care for them alone.

Nurses are used to rushing into a patient’s room whenever needed, multiple times a day. Now, they must pause and mindfully pull on a gown, two sets of gloves, two masks, and a face shield. They need to plan ahead, to accomplish all necessary tasks in a single visit, to conserve the protective gear.

Nurse Kate Hartley (left) and Dr. Jacqueline Wulu waited for additional supplies before performing a tracheostomy on a COVID-19 patient in a Boston Medical Center ICU. To minimize the risk of coronavirus exposure, the team kept the doors closed and used a radio to communicate with those outside the room.
Nurse Kate Hartley (left) and Dr. Jacqueline Wulu waited for additional supplies before performing a tracheostomy on a COVID-19 patient in a Boston Medical Center ICU. To minimize the risk of coronavirus exposure, the team kept the doors closed and used a radio to communicate with those outside the room.Erin Clark/Globe Staff

If they need a medicine or piece of equipment, they’ll scribble on a paper towel and hold it up to the glass. At Tufts, the nurses use baby monitors to talk with each other. Those peering in from outside the room have resorted to binoculars to read the monitors.

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On a recent afternoon at Boston Medical Center’s medical ICU, another innovation was put to use for only the third time: a plexiglass cube intended to block viral particles from patients during procedures. Designed by a BMC nurse, who was inspired by the work of a Taiwanese doctor, the box goes over the patient’s head, with two holes for the doctor’s hands to reach in.

The patient equipped with this “aerosol box” was a man in his 30s who had been on the ventilator for three weeks. That’s a long time, but doctors still had hope for him. To spare him the irritation of a tube down his throat and make it easier to wean him off the ventilator, they performed a tracheostomy, cutting a hole in his neck for the breathing tube.

It’s a procedure that doctors have feared would spread the virus, but an experiment with a mannequin “coughing” fluorescent dye suggested the plexiglass might protect them. Boston Medical Center is now using the aerosol box for all tracheostomies.

With only experimental drugs available to treat COVID-19, the goal is to keep people alive until their bodies fend off the virus and start to heal. For the sickest COVID-19 patients, that fight goes on for an extraordinarily long time, two to three weeks or more.

Many are suffering not just from the virus’s assault but from their own body’s overreaction, the “cytokine storm” that occurs when the immune system kicks into overdrive and attacks healthy tissues. This happens with other infections, but it appears to be particularly abrupt and intense with COVID-19.

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Dr. Samuel Belok, a pulmonary fellow, checked on a recently admitted COVID-19 patient in a Boston Medical Center ICU.
Dr. Samuel Belok, a pulmonary fellow, checked on a recently admitted COVID-19 patient in a Boston Medical Center ICU.Erin Clark/Globe Staff

“It’s much more common with this virus than with other viruses,” said Dr. Nicholas S. Hill, chief of the pulmonary, critical care, and sleep division at Tufts Medical Center. “As a consequence they’re spending more time on mechanical ventilation, more time in the hospital.”

COVID-19 causes damage diffusely throughout the lungs, until the tiny air sacs can no longer transfer enough oxygen into the bloodstream. But unlike with typical respiratory distress, the lungs don’t stiffen even as blood-oxygen levels plummet. As a result, people can look deceptively well despite needing high levels of oxygen, and then can suddenly get worse.

So, in one of the biggest challenges in COVID-19 care, doctors walk a tightrope in deciding when to put a patient on a ventilator, a risky, invasive procedure involving placing a tube down the throat. Patients on ventilators are kept in a medically induced coma that can have lasting effects.

“We’re trying everything we can to prevent them from getting intubated,” Ieong said.

At first, they provide oxygen through a mask or helmet. They ask the patients to turn on their bellies for a few hours, so that gravity can pull the blood toward the better-aerated parts of the lung. Called “proning,” this process has been proved to help patients already on the ventilator; with COVID-19, doctors are finding out whether it can help them avoid the ventilator altogether. They have also experimented with inhaled nitric oxide, to dilate the blood vessels.

Anesthesiologist Robert J. Canelli began the intricate process of removing his personal protective equipment after leaving a patient's room at Boston Medical Center.
Anesthesiologist Robert J. Canelli began the intricate process of removing his personal protective equipment after leaving a patient's room at Boston Medical Center.Erin Clark/Globe Staff

But if oxygen is inadequate and doctors wait too long, the patient could crash and require an emergency intubation, an especially risky proposition, made even more dangerous by the delays needed for staff to don protective equipment.

Doctors are noticing another peculiarity with COVID-19: a propensity for blood clots to clog up intravenous lines. They’re finding unusually high blood levels of a protein that indicates clot formation, and small clots sometimes appear in the lungs or legs. These clots, some speculate, may contribute to organ damage or even cause strokes. So they’re experimenting with higher doses of the anticoagulant medications than are typically given in the ICU.

Dr. Kathryn Hibbert, medical director of the Massachusetts General Hospital ICU, cautioned it’s not clear that COVID-19 is all that different from other severe respiratory infections, which also involve cytokine storms and clotting risk.

To Hibbert, the biggest difference is the sheer volume of patients so sick they need ventilators. When so many patients are severely ill, rare complications of severe illness may be seen more often. “We don’t know yet how much of what we’re seeing is truly unique to COVID,” she said. Only large studies will tease out the answer, Hibbert said.

With a typical lung infection, Ieong said, doctors can tell within three or four days whether a patient is likely to recover. With COVID-19, patients linger on the ventilator for days on end, their future uncertain. Still, many of those seemingly hopeless cases eventually rally.

“We’ve been extremely surprised about how resilient patients are,” said Dr. Craig M. Lilly, vice chairman of critical-care operations at UMass Memorial Medical Center.

But nurse Jeanne Hanlon knows she’s seeing more deaths in a short period of time than she can remember in 30 years working in the Boston Medical Center ICU. She cries every day. “We used to be able to go in, take care of somebody, and they’d get better,” she said.

Kellie Smith, associate chief nursing officer for critical care, was recently looking at a photo of the ICU staff wearing their protective gear, taken just as COVID-19 cases were starting to come in. She remarked, “Wow, you can tell this is in the beginning because you don’t see all those sad eyes and all the tired faces.”

But it’s not all grief and exhaustion. Caregivers thrill to the challenge of doing new things and working every day at the top of their skills.

“There’s a real kind of esprit de corps among us,” Ieong said.

Hanlon, who knew at age 4 that she would become a nurse, has felt compelled to give her all to the COVID-19 effort, signing up for extra shifts.

“I was born to be a nurse,” she said, “and I want to be there.”



Felice J. Freyer can be reached at felice.freyer@globe.com. Follow her on Twitter @felicejfreyer