Joshua Heisler MD
Montefiore Medical Center, Internal Medicine PGY3
April 5, 2020
The hardest part is not knowing. In training, one of the most frequent phrases I heard tossed around in med school and residency has been the importance of “decision making in uncertainty”. The general point being that, as physicians we cannot always wait for all the information before making decisions that are time sensitive. Sometimes it is necessary to weigh pre-test probabilities and decide on treatment prior to a formal diagnosis. Other times, like in a GI bleeder with an arrhythmia, there is no set answer, and I might have to plan with my patient based on perceived risks and benefits. You don’t always have all the information you would like, but more often than not, you have enough to make an educated decision, at least until this pandemic.
The uncertainty of how to treat this pandemic surrounds and suffocates me. We know that oxygen supplementation is beneficial, probably. I’ve treated nearly every patient I’ve admitted with hydroxychloroquine, relying on what seems to be at best, equivocal evidence. I attempt enrollment for each of my patients into clinical trials, hoping that might make a difference. From there it gets only murkier. Earlier this week I’ve been told that ‘dry lungs are happy lungs’ and so I tried to keep my patients from getting any IV fluids. Later in the week I read an article from a critical care doctor in the UK stating that physicians are being too aggressive in fluid restriction and causing worse outcomes due to kidney failure, and so I’ve liberalized the fluid I’m giving, if only a little. In order to predict which patients will do poorly I’ve been told at various points to trend CRP, or maybe it was IL-6. Nevermind, I’m sure ferritin is the marker to watch most closely. Everything is uncertain, and I feel lost.
Mr. W is in the room across from me right now. He was moved from a telemetry bed so I can no longer peek in to see his face or O2 sat and heart rate. His face is blocked by a portion of the wall, so when I try to look in all I see is a blanket covering his legs. I don’t know if my lack of knowledge has lead him to dying on a ventilator. What is certain is that he is a 77 year old man with mild hypertension and hypothyroidism, who had the misfortune of having a severe influenza pneumonia a month earlier. I know that when I met him he was receiving oxygen via face mask, and gradually needed more and more support, escalating to high-flow oxygen and then to BiPAP. When he decompensated with worsened pulmonary edema and a blood gas showing severe ARDS, I made the decision to give him lasix, even with his AKI, hoping that it would help dry his lungs. Hoping that dry lungs are happy lungs. I know he was enrolled in the Sirolumab trial, receiving his dose via small peripheral in his foot, after an hour of trying to get an IV in a dehydrated patient. I know that two days later he was intubated regardless, and by then, had developed renal failure. I know his wife is sitting at home, her quiet hope for recovery shattered by the afternoon phone call relaying his dire prognosis. I’m certain he will die soon, his blood pressures flagging, now only on a fentanyl drip to keep him calm while ventilated. This sort of knowing is small comfort sitting across from him with an empty feeling growing in my stomach.
I hope that tomorrow I will find an enlightening article, or that noon conference will share breakthrough, clear, data driven guidelines. I hope my patients will not be guinea pigs, that they won’t be practice for my next wave of admissions. Most of all, I hope for clarity.