Berks County Medical Society Medical Record Summer 2020 - 21

Coronavirus Chronicles: Berks Responds

Fear and Loathing (but mostly Fear)
and Faith in the ICU
by Philip J. Wexler
Pulmonary Medicine and Critical Care

very day has a natural rhythm that we all hear as we dance
through our days. The rhythm is steady, familiar, pleasant
and calm. The ICU is no different. Although "intense"
there is a familiarity to the daily chaos that develops within the
intensivist and ICU team. The daily rhythm is soothing.
Covid-19 demolished that rhythm.
Covid-19 has been Elvis, the Beatles, Willie Nelson, the
Ramones, Michael Jackson, Prince, Nirvana and the Notorious
B.I.G. all rolled into one. A revolution, a sledgehammer, a train
wreck, a complete upending of any semblance of what we have
been used to. Our rhythm was uprooted. All sense of "normal" was
removed the moment the first patient with Covid-19 and severe
hypoxemic respiratory failure was admitted into the ICU. Normal
suddenly replaced by fear and unknown.
In the ICU, the intensivists pride themselves as being experts in
chaos. The ability to remain calm, caring yet focused and analytical,
grounded in the familiar tenets of modern critical care medicine
while a fellow human is facing the darkest of hours is the job
description. Projecting confidence without conceit is a must in the
ICU. With Covid-19, what we all knew (or thought we knew) was
suddenly questioned. No one was confident.
The usual rhythm and flow of rounding, family meetings,
procedures, and the typical ebb and flow of the day had been
replaced by fear and unknown. The fear was palpable. We were
now wearing 2 masks or a PAPR and face shields. Patients were
all being treated in negative pressure rooms. Fear and anxiety were
present every time we would sit down to type on the computer
keyboard. We were afraid to sit outside of a patient's room.
We found ourselves questioning the basics. This is new. This is
different. This is what we fear: the unknown. The lack of familiarity
led to an inability to have confidence in our approach. "Clearly,
this new process deserves a new response" became our new refrain.
The questions rapidly accumulated: How do you treat this rapid
decline? How do you approach this patient with a new disease that
we haven't seen before? Should I try an antimalarial drug? After all,
tens of patients in France did well. Should I add an antiviral? What
is the risk? the benefit? Will I get it? Will I bring it home to my
family?
As I pondered these questions while caring for the initial wave
of Covid-19/SARS/ARDS patients and donning my N95 with a
face shield, I ordered the ventilator bundle to ensure I minimized
the risk of Ventilator Associated Events per routine. I ordered low
tidal volumes. I made sure to order light sedation and perform daily
wakening. DVT prophylaxis, GI prophylaxis, glucose control...
check, check, check. I will place a line, sterile precautions, a timeout, confirmation of placement. This patient is still severely

hypoxemic, we will increase the PEEP and try prone positioning as
per standard protocol. Let's figure out how to remove the Foley to
minimize the risk of CAUTI.
Suddenly the unfamiliar was familiar again. Faith was put into
the basics; the tried and true; the tested and the confirmed.
We haven't solved the issue of best therapy for this rapidly
progressive viral pneumonia and cytokine storm. However, as with
many disease processes in the ICU, it is putting the COVID-19
patient out of harms' way while providing the time the body needs
to heal itself that informs the basics of treatments. Gaining time
for protected healing is an overriding theme that we adhere to
on a regular basis. Our core principles and fundamentals have
prepared us for this. The fear is still present. But we can find faith
and truth in the newly familiar. The fear is not overwhelming.
It is a fuel for questioning the next move, the next therapy. The
unknown has shown us all who we are, some of us innovators, early
adopters, skeptics and naysayers when it comes to new therapies
and concepts. But we are all bound by the basics, and it is the basics
that provide the best chance at recovery. The fear is healthy. It is
fear that will drive us to know more, to learn more, to question
more and to treat better. It will allow us to know our patients, this
disease, and ourselves better.
Now, approximately three months into the pandemic, a new
rhythm has arrived. It is again becoming familiar and recognizable.
I am used to breathing in my N95. I know which wipes I will use
to clean my visor so there won't be streaks. What we have learned
is that despite the challenges, the fear, and the unknowns, we in
the ICU will remain grounded in our faith in the core principle of
critical care medicine to do no harm while intervening to support
the healing process. We will use this core to accept the unknown
and allow this faith to overcome our fear.

SUMMER 2020

Berks County Medical Society Medical Record Summer 2020

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