“I have seen things you people would not believe…. All those moments will be lost in time, like tears in rain.” Blade Runner
Mardi Gras in 2020 was special. Our little family celebrated together without a worry in the world. The celebrations fell late in February and were marked by beautiful sunny days. Strange to think that the period of excess is meant to signify the beginning of fasting during the ensuing 40 days of Lent leading to Easter. We were happy. By all appearances, Les bons temps fleurissent!
Upon return to my post in the emergency room, everything changed. “Did you hear?” No, I said. “What news?“ “Do you remember that patient that you admitted last week?” Shit… what went wrong? Which patient? Did I do something wrong? “ Which patient?” “ The one you admitted after deplaning at the airport?”
The week prior to Mardi Gras, early to mid February, marked the first rumors of a deadly novel virus arising in Wuhan, China (suddenly all Americans knew where this city could be found thanks to google maps). Along the Gulf Coast, that horizon seemed far off and at a safe distance, but we were preparing. I had gone to a hardware store and purchased an N95 mask and face shield usually used for such applications as sanding and plaster work to keep dust out of the lungs and eyes. I purchased several extra filters in preparation for whatever may come. Normally, I would use the blue 3M N95 masks provided by the hospital, but in those weeks, mysteriously, there were none to be found. Usually, the masks were bountiful on respiratory carts in the emergency room. I later learned that the masks had been requisitioned by administration in order to prevent pilfering so that they would not go missing. Presumably, the disease-preventing masks might be taken by staff members in a panic. Regardless, there were none to be found.
I had been working in Medical 2, a shift that started midday at 10am, so I was fresh. I walked into a room and was greeted by an extremely gregarious middle-aged couple. Where was my mask? In the world of medicine we always say that nice is a bad prognostic factor. And here were two of the nicest people that I had the pleasure of taking care of in the recent past. The chart said shortness of breath. So I began asking the basic questions affiliated with dyspnea or shortness of breath. “I just returned from the holy land via Heathrow and Atlanta before landing in Gulfport.” “ I returned home but after 20 minutes I couldn’t breathe, so I came to the emergency room.” Of course, he had just got off a long plane ride developing shortness of breath and dyspnea on exertion. Textbook, I thought. One of the most common causes of pulmonary emboli is long plane flights during which inactivity and long periods of sitting still result in blood clot formation in the legs. These DVTs (or deep venous thromboses) may ultimately be thrown to the lungs.
I returned to my seat to further review the chart and put in orders. As I perused his vital signs, I noted that he was febrile (the patient had a fever). Well, this changes everything. In my mind, I suddenly developed a grave concern that this could be that strange, new viral illness being mentioned in the news. But this would be a medical zebra, better to focus on the more likely diagnosis of a pulmonary embolism given his prolonged air travel.
But he had mentioned traveling through Heathrow Airport. This is one of the most busy international airports in the world. Surely he may have encountered tourists traveling from China. He didn’t look that sick. He’s my age and without any risk factors. So I ordered Labs that would cover either pneumonia or pulmonary embolism. This included blood cultures and I decided to get a portable chest x-ray as well as a CT of the chest. I went back and talked with him to clarify the history of his current illness. Where is my damn mask?
Ma sacre toux! “ Well, I left Gulfport toward the end of January. I spent a little under two weeks photographing the holy land.“ He hadn’t felt ill until landing in Atlanta. During the plane ride from Atlanta to Gulfport, he became progressively more short of breath. Once he got home, the inability to breathe became intolerable. He had his wife drive him to the hospital because he felt so bad. He didn’t notice a fever, but he was sweating profusely. “ Had he encountered anyone from China,” I asked. “ It’s possible in the airport, but I’m not sure.”
I returned to my cubicle. Where is that damn mask? Hah, I left the N95 mask that I had purchased specifically for this case in my car. It was still in the grocery bag.
I immediately put the room on lockdown, specifically no one was to enter without an N95 mask. In the emergency room, our job is to presume the worst first and rule out the deadliest possibilities. For example, if someone presents complaining of chest pain, an EKG is obtained to ensure that the patient is not having a myocardial infarction (aka heart attack).
Well, it is possible that he has Covid. During his travels, he may have come in contact with an infected individual traveling through the airport. He was short of breath with O2 saturation in the low 80s improving with supplemental oxygen. He did have fever.
Just then the chest x-ray results popped up on the computer. I reviewed the film myself and noted that he had infiltrates bilaterally. The radiologist read the x-ray as bilateral pneumonia. A voice in my head began to scream, “This is Covid! This is Covid!”
I called our lab and stated that I wanted to get a Covid test done on this patient as soon as possible. No. “You have to download a form from the CDC.” I did as the voice on the other end of the phone requested. Several criteria have to be met before testing to be done by the CDC: has the patient been to Wuhan China? Well no. According to the CDC requirements, in this case Covid testing is not applicable. What!?!
The patient returned from the CAT scan. He looked worse than when he first came in. Several hours had elapsed and I had given him antibiotics to cover for pneumonia. The CT revealed bilateral infiltrates of a ground glass nature. In the coming months, this would be the telling sign of Covid pneumonia. There was no evidence of blood clots, excluding the diagnosis of pulmonary embolism. I hurriedly called the hospitalist to have the patient admitted.
“ He died!” He had only been admitted for two days before this outcome.
I never entered a room without wearing that mask for the next two years.
J