Diary of a Trauma Surgeon: 12 Days of Covid-19's Surge

Today is Wednesday, July 8th

and COVID is still happening in Los Angeles.

[eerie instrumental music starts]

[Annie] The medical ICU is full,

surgical ICU is full,

there is not a single ICU bed open in the hospital.

[eerie instrumental music]

It is Friday!

Today, it's Saturday.

Just another really hard day.

Holy crap, he comes back to life!

Heart starts beating, there's a real blood pressure,

I'm like, Fuuu...

An ICU nurse can only take care of one or two patients.

We are busy here, we are drowning.

You know, with California re-opening

and Los Angeles sort of getting back to regular life,

but the outbreak, you know,

being quite far from under control.

We've sort of gone back to regular modes

of functioning at the hospital, plus COVID.

I just sort of never really imagined

that it would happen in that way.

We're doing tons and tons of trauma,

July is a very busy month for traumas.

For example, I was on-call yesterday

and had a couple of gunshot patients come in,

who needed emergency surgery,

who happened to have COVID.

So community spread is very common and very prevalent.

There are tons of asymptomatic people coming to hospital

for other problems, who happen to have COVID.

So that's putting a strain on our system,

because we don't have the specific isolation beds

that we might need for such a patient.

I've been sort of surprised by that.

That's just not what I pictured.

The ER occasionally, here, will go on diversion,

except for the most critical of trauma cases.

And then, just the other night,

we finished two cases in the middle of the night,

one was a stab wound to the abdomen,

one was a gunshot wound through the arm

and through the belly.

And this gunshot wound guy had COVID,

and the other guy did not,

but neither had an ICU bed available.

So they had to just, sort of, park in the OR

for, like, six hours while they waited for a spot.

So, that's sort of what's going on these days.

Still got my mask.

Everybody's hanging in there.

[mellow guitar music]

Good morning.

It's Thursday, July 9th.

It is 5:50 in the morning,

and I'm coming into work.

COVID number's going up,

and if you look at the curve in Los Angeles,

we had, just like in the rest of the United States,

a big spike in April, which just began

to come down a little bit in May,

which sort of flattened, but never really went away,

and now numbers are going back up.

So the curve in Los Angeles looks

very similar to the curve in the rest of the United States.

With the big spike, a little bit of a flattening,

and then...up.

It is still Thursday, July 9th.

It is now 7:30 p.m.

I am here on my little porch,

in my little rocking camping chair.

And meanwhile, my phone is blowing up.

Trying to get me to move people out of ICU,

because the ED is so full of ICU patients

they have nowhere to go.

So they are trying to push current ICU patients

out, out, out, out, out!

As fast as possible.

You know, when the system stretches,

everybody suffers, not just COVID players.

I have a bunch of COVID patients

who are in the COVID unit

but have, primarily, trauma and surgical problems,

and I was asked to move them out of the ICU.

And I think it's too early,

because they still have ongoing issues

and we're, sort of, grasping at straws

as to which patients will be safest to move.

Good morning!

It is Friday, July 10th.

I got a text last night letting me know that

our hospital has reached capacity

for the number of patients who require dialysis.

So we have no more dialysis machines.

As you guys probably have heard by now,

COVID is not a respiratory illness.

What is actually is,

is a vascular illness.

The virus attacks the tiniest little

blood vessels in the body.

You know, there happens to be some of those in the lungs

but there also happens to be a lot of those in the kidneys.

So, many patients, when they get critically ill,

go into kidney failure.

It's gonna be a problem for our trauma patients.

We've been advised to transfer early,

if we have patients who we think are gonna need dialysis.

Which is crazy, like, where are we supposed to send them?

You know?

So, we'll see.

Happy Friday.

One sort of interesting thing that has happened

over the last couple of weeks,

is patients who initially tested negative for COVID

on the way in the door of the trauma bay

have become positive later in their hospital stay.

As they're literally rolling in the door,

somebody jabs a Q-tip in their nose

and sends it off to the lab.

We test every single patient

who gets admitted to the hospital.

Before they go out to rehab or something,

the rehab place will ask for another

confirmatory negative test,

and we'll send it, and it will be positive.

Some of those folks are asymptomatic,

but I have another patient who developed

fevers, a cough, and a funny-looking chest x-ray.

We actually, luckily, are not bursting at the seams

anymore in the ICU.

We do have beds available

but we are still on diversion,

meaning ambulances are still

not bringing us patients, except for trauma,

because we actually don't have

enough respiratory therapists.

In addition to needing physical space for patients,

we need enough staff.

An ICU nurse can only take care of one or two patients.

A respiratory therapist,

who is the person who runs the ventilators,

they can only have, I think it's five or six here.

So our hospital's not full,

but we still are not taking new patients for that reason.

Hey, everyone.

It is Monday, July 13th.

It's 8:00 p.m., just got home and showered.

Just another really hard day.

We just had this young girl in her thirties

just die of a massive, overwhelming,

soft tissue infection of the arm.

There was nothing we could do,

and it went from zero to 90 in, like,

just a couple of hours.

She was impacted by the COVID outbreak

'cause her family couldn't really be with her

in her last moments.

And that's unfair.

And so much of this is unfair.

One aspect that people probably

have heard about in the press

is the disproportionate effect that

the COVID pandemic is having on patients of color.

You know, in Los Angeles county it's something like

a third of the population is Hispanic,

but they represent 70% of all hospitalized patients.

There's a lot of reasons,

and some of them include the fact that

most of those people are working front-line jobs,

where they can't work from home,

and they are the people that are keeping the economy going.

Working in deliveries, working in the restaurants,

working in the service industry.

These folks are not able to self-isolate

and protect themselves.

In Los Angeles county,

two percent of all in-patient admissions for COVID

have been white people.

Which is, obviously, vastly underrepresented

of how many white people there are in Los Angeles county.

So...

That's unfair.

Right?

And decisions and policies that open the economy too early

are racist policies, because they will have

a disproportionate effect on the health

and life of people of color.

Our government has just, kind of, wished this virus away,

and it's still here, and we're opening.

And, actually, today Los Angeles...

And California, Governor Newsom said that

we're taking a step back in opening.

So I'm proud of that policy,

people are at their wits' end at the hospital.

So that's where we are today.

Hey, everyone.

Today is Tuesday, it's two o'clock in the afternoon.

We had our quality improvement meeting today,

in which we go over our numbers for the trauma center.

Our volume, our outcomes, our mortality, that sort of thing.

Our overall trauma numbers were much lower,

but our overall penetrating numbers were much higher.

Usually, our percentage of penetrating trauma

is somewhere around 20%.

But for the months of April and May,

it was significantly higher, and more like 25%.

It's, you know, hard to know if that's

a blip in the statistics,

or if that's a real phenomenon,

that more people were shooting and stabbing each other,

despite the overall drop in trauma volumes.

It's July 15th, Wednesday, 7:30 p.m.

The news today is that the federal government

has decided that the hospitals

and local public health authorities

should now be reporting their COVID data

to a centralized database run by the White House,

and not to the CDC.

This is concerning because of

transparency issues, and data-sharing issues,

and accountability issues, and privacy issues.

I wanna take care of patients,

and operate on sick people,

and do my job, and do it well.

We are busy here, we are drowning.

We are stressed out.

It is incredibly frustrating

to be, pardon my French, balls deep in taking care

of a lot of sick patients, and have the government types

not be able to deal with this effectively.

I'm just like, Guys, figure this out!

Today is Thursday, July 16th.

And there's been two situations in this last week

that have been sort of, like,

Hmm, that's kind of interesting.

One is a lady who has a really terrible,

and difficult, and complex abdominal wall hernia.

And normally, between operations, we would be

removing the breathing tube and putting it back in.

Just for surgery.

But because she has COVID,

and reintubating and extubating is just

such a massive exposure for the doctor who's intubating,

the anesthesiologist who's intubating,

the nurse and the respiratory therapist

who would be extubating,

this lady who otherwise would be awake and walkie-talkie,

just with this abdominal problem,

has been intubated this entire time.

And then, another patient that's been sort of

different because she has COVID,

is this lady that we admitted overnight.

She's a young lady,

who was witnessed to be assaulted by three different people.

She was getting kicked, and punched,

and all these other things.

She has this massive fever.

So, is that from an intestinal perforation

that we don't know about,

or is that from her COVID?

All other things being equal,

she probably would have earned herself

an abdominal operation to go in and check on things.

But right now we're just chalking that fever up to COVID.

So we'll have to see,

she's sort of a mystery at the moment,

so we'll follow her closely and see

sort of how she plays out.

And we are being asked to recycle our N95s.

PPE seems adequate here,

but next to every COVID or negative pressure room

there is a bin to recycle the N95s.

It's Friday, July 17th.

6:10 in the morning, I slept in a little bit.

I got a bunch of frantic text messages

from the on-call trauma team last night,

'cause there was not a single ICU bed in the entire house,

and they needed me to move somebody.

And we had to pick and choose.

These are people who, under normal circumstances,

would probably take another day or two

of observation in the intensive care unit.

But, you know, with the crunch for beds

we had to sort of boot them out a day early.

So, I think they'll be fine,

but it was just...

It was a very surreal conversation

that I was having last night, so...

I just realized that, on this day,

two weeks from now,

I will be walking out of the doors of this hospital

for the last time.

I will finish my year of critical care fellowship,

and that will complete 10 years of medical training.

And I'll be done.

So, two more days running in the ICU,

then a few trauma calls in the last two weeks,

and I am out of here!

Our center is also participating

in a couple of clinical trials for COVID,

which is pretty exciting.

One trial that we're involved in

is looking at mesenchymal stem cells,

which are just stem cells naturally found in the body

that have the potential to become

anti-inflammatory type cells.

Doctor Baudisch is coming around,

and keeping tabs in all the patients,

collecting various data points

and seeing whether it's helping.

Good morning!

It's Saturday, July 18th.

I'm heading into the hospital

for my last day ever rounding the ICU at county.

The fellowship has 12 days left in it,

so one more day rounding the unit

and then four 24-hour trauma calls in 11 days.

That doesn't sound like that much, but that's a lot.

But it's good.

It'll be good.

It's a good strong way to finish this year.

Okay, well, it's Saturday, July 18th.

I'm finished rounding.

The overnight trauma team was very busy,

we have many new patients, many very sick new patients.

And a lot of them have COVID.

So just another day at the office.

Because our hospital is cohorting the COVID patients

and so strict about that,

meaning the COVID patients can only go to certain units,

a lot of our trauma patients

are ending up in the medical ICU.

These medical ICU nurses are now being asked

to take care of trauma patients

with hemorrhaged, you know,

ridiculous amount of blood volume,

or have bad head injuries.

It's not, sort of, in their wheelhouse

the way it's in the wheelhouse of the nurses up on five.

You know, it just takes a little bit more communication,

it takes a little bit more patience,

it's for the greater good of the hospital,

and the staff, and the patients,

that we sort of cohort all these

COVID positive folks together.

So we just have to, kind of,

do what we have to do and adapt, in that sense.

It's July 20th, it's 9:20 p.m.

Little bit past halfway done

with this 24-hour trauma shift.

I would say these last 12 days have been

sort of, less of a whirlwind than

the first surge of COVID back in March and April.

When LA was still shut down,

all we could do was focus on taking care of COVID patients,

and that's what we were doing.

But now, since LA is open, and we have this second surge,

we are just doing a little bit of both at the same time.

Operating on a COVID patient is, like, real slow.

Everything that usually takes a long time

takes 10 times longer.

From anesthesia getting all set up

with their very special space helmets,

to intubating safely and clearing out the room

for 30 minutes with negative pressure.

It's been so up and down, and a rollercoaster,

and nothing surprises me anymore.

Like, my life four weeks ago was really different

from my life four weeks before that,

was different from my life four weeks before that.

So when there's new policies, or new developments,

or new steps we have to take,

or new interesting twists on

the way COVID and trauma can mix up,

it's made me more dynamic,

and it's made our nurses more dynamic,

and our staff more dynamic.

You just have to roll with the punches,

'cause the punches are non-stop.

It's been crazy.

But we're used to it.

We're used to crazy around here.

It's what we do, we specialize in crazy.

Oh my good Lord.

So now I'm finishing my 24-hour shift.

Last night was, like, one of the craziest nights

I've ever had here.

One of these young kids, 28 years old,

he was very unstable, very sick.

Meanwhile, while that's going on,

I get the trauma page that a gunshot wound is coming in.

So, run downstairs to see that.

It's a lady who got shot through the arm,

into the right upper quadrant,

and it went sort of all the way across her abdomen

and caused a bunch of trouble.

And the pager was off again.

It's a stab wound to the chest.

So, there's a two-centimeter little laceration

in the front of the heart.

So I said, Okay.

So I put a little stitch in that.

And holy crap, he comes back to life!

Heart starts beating, there's a real blood pressure,

I'm like, Fuu...

Meanwhile, my other team is working on this gunshot wound,

who obviously also has COVID, of course.

My stab wound guy did not.

Luckily, everybody was wearing their spacesuits

and their special masks,

because, like I said before,

we treat everybody when they're coming in

like they do have COVID.

And, you know, thank God we do,

because 50% of our patients last night had COVID.

So yeah, I'm pretty jazzed right now, pretty amped up.

Thank God everyone this morning is doing much better

than they were last night.

So, all in all, a very positive but very busy night.

I have full faith in the staff that remains here

to keep doing what they do,

which is work really hard and care really deeply,

and take care of each other,

and take care of patients.

We really should never forget,

a lot of people in the world have lost family members.

Their moms, and their dads, and their kids,

and their brothers, and their sisters.

That sort of puts everything to a little bit of perspective.

And a little bit of inconvenience here and there,

or a little bit of a need for ingenuity and adaptability,

I think that's just a small price to pay.

So, I think that's it for me.

I'm signing off, it's been great talking to you guys

and sort of keeping this time as a little time capsule.

All right, peace out!