I’m seeing promising ventilator death data

Dr. Lee says ICU patients still face tough recoveries

This is the ninth conversation between Dr. Jarone Lee, a frontline critical care and emergency physician at Massachusetts General Hospital and associate professor at Harvard Medical School, and Dr. Paul Hattis, an associate professor at the Tufts University Medical School who participates in CommonWealth’s Health or Consequences Codcast. Find links for past conversations at the end of the story.

PAUL HATTIS: Last week we talked about the rather disheartening short-term, published data out of New York City about the experience of COVID-19 patients on vents. Anything to share from the MGH experience to date?

JARONE LEE: Just this last week, MGH with Beth Israel Deaconess published initial results of the first 66 COVID-19 patients admitted to both hospitals who were on ventilators. The mortality rate of this small and early cohort shows significant differences with the reported New York City outcome data. In our study of outcomes, there was a mortality rate of 16.7 percent amongst the patients that were admitted to the ICU, with over 75 percent of the patients discharged from the ICU alive—much better numbers than what was reported in the NYC study.

HATTIS: Wow, these are drastically different mortality numbers between Boston and New York. Are there any methodologic concerns with comparing these numbers?

LEE: Yes, this is a small dataset and represents an early experience, and the same caveats as noted last week apply here.  We should not compare the results between New York and Boston as this is not an apples to apples comparison. The reason is that the New York study excluded patients that did not have an outcome when the study closed and, as a result, had a very high and over-estimated mortality rate. Our study of patients here in Boston is the opposite. The researchers included all patients, including a few that are still in the ICUs. Also, our results were based on only an initial group of 66 patients across two hospitals in Boston, and over time now, the total of COVID-19 patients at our two hospitals has been in the hundreds. So, a fuller analysis in the future that includes the larger number of patients will likely show a higher overall mortality rate than what we found with this initial group.

HATTIS: Now that we are over the surge and many of the COVID-19 patients are recovering, are there concerns about longer-term health impacts on COVID-19 patients who have had long stays in intensive care units on ventilators?

LEE: Surviving critical illness from COVID-19 is just the beginning. In general, being so ill that a stay in the ICU is required has many lasting impacts on the body. We focus a lot on organs such as the lungs, heart, and kidneys. What is easy to forget about is that the brain is a very important organ as well that also gets injured during a critical illness, including if a patient is severely ill from COVID-19. In addition to direct, physical injury to the brain from COVID-19-related strokes, which can be devastating, we are also seeing COVID-19 patients with organic brain dysfunction that occurs without structural injury to the brain. For example, our ICU patients are regularly confused to the point where they will be very agitated and aggressive toward our clinical staff—name-calling and even some violent outbursts. A regular thing we do in the ICU is that we reassure family members that their loved one will sometimes act differently and unlike their normal selves. Assuming the patient survives, this typically gets better and patients often have no memory of their very confused behavior and outbursts—something that we understand, and do not take it personally or see it as aspects of our patents’ character.

Unfortunately, this brain dysfunction can last well past our patient’s ICU and hospital stay, with many patients experiencing symptoms lasting up to a year. Symptoms typically include memory loss, difficulty concentrating, and other forms of cognitive dysfunction. As you can imagine, this makes it difficult to not only do basic things like balancing your checkbook, but also in trying to go back to work. This can impact about half of patients that survive their ICU stay. My suspicion is that survivors of critical illness with COVID-19 will have similar challenges.

HATTIS: Besides this brain dysfunction, what other challenges exists for COVID-19 patients as they recover?

LEE: In addition to brain dysfunction, most of our patients are extremely weak after discharge from the ICU. Despite us doing what we can to maintain our patient’s nutritional needs and muscle mass, ICU patients tend to be physically deconditioned, sometimes so severely that they cannot do normal daily activities such as feeding and toileting themselves.  We regularly see patients that cannot even sit up by themselves. The road to regaining this strength is long and hard.

I also want to mention that there are a lot of psychiatric impacts, too. We are finding patients with post-traumatic stress disorder after their ICU stay. Some experience symptoms of depression well after leaving the hospital. Beyond the patient, we should not forget about their families who can be greatly affected by these changes in their loved ones. Everything we know of COVID-19 currently and from taking care of critically ill patients tells us that surviving the ICU is only the beginning of a long and tough journey ahead for patients, families, and caregivers.

HATTIS: Sitting here with cases on the decline, what issues are holding your attention right now?

LEE: We are still very busy with COVID cases. Our entire team continues to work overtime. It does feel like a lull compared to a few weeks ago, but for me that only reinforces the need to continue all the public health measures that seem to be helping to reduce spread. The weather is getting nicer and we all have been stuck at home for almost two months. In many ways, this can be a dangerous time as we start feeling that need to relax. This disease is still in the community and affecting individuals every day. Just the other day, I took care of someone who has been social distancing for the entire time and has not physically left his house since this started. He wanted to be safe because he knew he was older and had risk factors for not doing well if he became infected with COVID-19. Unfortunately, he did acquire COVID-19 infection. We may never know whether he got it from young and healthy family members visiting or another source. He is now on a mechanical ventilator in our ICU. We also continue to see younger patients with no apparent risk factors who do poorly with COVID infection.

HATTIS: You told me earlier you are working clinically this week in the ICU at Newton-Wellesley Hospital. How are the system’s community hospitals experiencing COVID-19 as compared to MGH?

LEE: From an ICU-care perspective, they are really quite similar. If there is any differences to note, I’ve noticed that Newton-Wellesley is nimbler and more flexible compared to MGH. At Newton-Wellesley, they are able to adapt and iterate rapidly during the crisis. Coupled with the resources of our Mass. General Brigham enterprise that can be sent to assist them, Newton-Wellesley seems to have the best of both words – the agility of a smaller community hospital with the back-up resources ready if needed. For example, Newton-Wellesley needed additional dialysis machines, and was able to get them from other hospitals so patients didn’t need to be transferred.

HATTIS: All signs are that hospitalizations and ICU demand is down. What can you say is happening at MGH and across the Mass. General Brigham system?

LEE: The good news is that our hospitalizations and ICU needs continue to decrease both at MGH and across Mass. General Brigham. As of this morning, we have 348 patients who are COVID positive or suspected positive hospitalized and 119 ICU patients, down from around 420 inpatients and 140 ICU patients last week. We also are seeing more and more patients requiring medical care unrelated to COVID. Unfortunately, some of these cases are patients that have delayed their care too long because they were worried about contracting the virus in the hospital. We have seen multiple cases where patients have delayed care for vascular disease in their legs and now they need an amputation of the leg instead of potentially having the leg saved.

HATTIS: Anything to report on the home front?

LEE: This week I want to end on a different note. Instead of relating a story about my family, I want to remind everyone that this is Nurses Week. Typically, we have events in the hospital to show how much we love and value our nurses; unfortunately, because of social distancing, these events were all canceled. Please remember that our nurses are disproportionately affected by COVID-19 amongst our frontline staff, and so I want to honor their efforts as they bring their full selves, both physically and emotionally, to the patients they care for.

HATTIS: Dr. Lee and I both thought that readers of these conversations might have their own questions that they would like answered. Send them along to me at paul.hattis@tufts.edu.

 

 

Previous conversations with Dr. Lee:

The Codcast: A report from the frontlines at MGH

Q &A with MGH doc Jarone Lee: We’re seeing patients of all ages

Dr. Lee: Preparing for the surge

Dr. Lee: ICU units won’t beat this disease

Dr. Lee: At MGH patients don’t die alone

Surge still manageable for Dr. Lee

Meet the Author

Paul A. Hattis

Associate professor, Tufts University Medical School
Dr. Lee: We’re busy but in good shape

Dr. Lee says COVID-19 patient counts down