Tammy Tavdy MD
Montefiore Medical Center, Internal Medicine PGY2
April 29, 2020
I never hesitated to run into a patient’s room in the “pre-COVID era.” I knew how to ease families into difficult goals of care discussions, and had time to think critically about ventilator settings and pressor adjustments. Now, it’s my safety and well-being that comes before a patient’s critically low blood pressure. I must safely don PPE before adjusting the drip rate and checking the pulse oximeter. I aggressively address goals of care with family members who cannot be there in person, and commit the ARDSnet protocol to a close memory so that oxygen adjustments become second-hand in nature. Most difficult of all, I have never been so cautious to be optimistic.
It was my first day on telemetry - a floor of COVID-19 positive patients who also required close cardiac monitoring. Historically, the patients on this service are medically complex - with multiple underlying comorbidities and new arrhythmias that require frequent face-to-face assessments. At this point, everyone on the floor is on hydroxychloroquine, and in many cases, at least one other QT prolonging agent. In fear of over-exposing myself and the nursing staff to the virus, I rely on my judgment of the telemetry monitors and am mindful of how many daily EKGs I am ordering, knowing however that an unstable arrhythmia could be the tipping point for any patient’s continued stability.
A new COVID-19 positive patient arrived on the floor. I do a quick eyeball of her in the stretcher, and become cautiously optimistic when noticing that she appears comfortable on room air. With a scan of her labs, I learned that she initially presented with hyperglycemia and in diabetic ketoacidosis. With anecdotal evidence that these two presenting factors contribute to morbidity and mortality in COVID, I worry that her gap may reopen at any point. “An insulin drip? Q1H fingersticks? I cannot possibly do that to her nurse.” In short, this would mean at least 12 gowns per shift for just one patient. Ideally, this patient should have been in the ICU, but she is not mechanically ventilated and is not in acute hypoxic respiratory failure; she is my responsibility now.
In the “pre-COVID era,” I relied on hospital-based protocols and peer-reviewed recommendations to wisely devise a plan of care for my patients. Today, I rely on cautious optimism, defined by a hope that I am doing my best to improve a patient’s prognosis, despite the boundaries and difficulties of frequent donning and doffing.