My experience with COVID19 on the Navajo Nation

COVID19 has been a frightening disease. I work with the Navajo population in Kayenta, Arizona. We started to notice atypical pneumonia, and patients with respiratory distress in March. At first we were testing patients with the send-out PCR that took several days to result. It became apparent that COVID19 testing was redundant for the symptomatic patients we were seeing. Classic Xray/CT findings of multilobe ground glass opacities. LDH elevation from 700's to 1000's. Normal WBC count. Temperature 101, tachycardia and pulse ox 90-94% on room air. The pulse ox values quickly drop when the patient starts to move around. Patients who become hospitalized usually have the symptoms for 8 days before the shortness of breath becomes too much to tolerate. There were several cases early on that were primarily migraine-like headache, abdominal pain, and loose stool. These patients eventually progressed to COVID19 respiratory failure as well, but at first it was confusing and I didn't think they had the virus. I was suspicious because family members would be in neighboring ED rooms with the classic COVID19 findings.

I work ten 12 hour shifts in a row and then head home to spend time with family and catch up on exercise and yard work. When I returned in April for my block of shifts it was like a war zone. Every bed was taken by COVID19 patients, several intubated with others needing intubation. People were completely doned with PPE like a scene from a movie. When COVID19 started emerging abroad I thought, "oh this is just a bad influenza-like illness." I was skeptical. There is so much misinformation and fear mongering it's hard not to be numb to new emergencies. We have so many mass shootings and news of atrocities still occurring in places like Syria that it's hard to be emotionally invested. When I arrived here my perspective changed immediately. Whole families were decemated from the virus within weeks. I still wonder if the Native American population is more susceptible to this virus.

What terrifies me the most are those patients who present with rapid deterioration and fulminant pulmonary edema. These patients are nearly impossible to resuscitate if they come in too late, but they don't know it's too late. One day they are mildly short of breath, the next they are collapsing on the floor being coded. I've received several calls from ambulance crews who arrive on the scene of elderly COVID19 patients that suddenly became unresponsive. I pronounce them over the phone.

It's May 15th and we are still seeing cases. We are still intubating patients every day. We have flight teams moving in and out of the ED packaging patients for continued critical care in tertiary ICU's. I'm a lot more familiar with the illness now and have my processes streamlined. For me in a rural setting it's about recognizing who needs to be transferred to another hospital and who can go home with close follow up. It's very unpredictable when they are saturating in the low 90's on room air, but don't have respiratory distress.

Intubating patients with this disease is a paradigm shift from other diseases that cause respiratory failure. Although the recommendation is to try non-invasive measures like high-flow oxygen, CPAP, or BIPAP, it's really not an option in my setting. The receiving hospitals and flight crews don't want to take a chance with inflight, or in-ambulance decompensation and on top of that, these interventions aerosolize viral particles that can infect the people caring for the patient. So we intubate them earlier than we normally would. It's unusual to have a conversation with a patient about intubation, then they call their family, and then I come in and sedate and intubate. Normally there is not a lot of time for conversation.

I live in North Carolina and they recently started to open the state back up. NC now has the highest incidence of new cases compared to any other state. My family and I are staying home and social distancing for the time being. I don't see us returning to normal life until herd immunity can be confirmed reliably, or a safe vaccine is available.

All that being said, I love coming to work even more than normal. It's a challenge and we are truly making a difference. I feel closer to my patients and colleagues. We're all going to get through this one way or another and eventually will perseverate and bore our grandchildren about the COVID19 pandemic of 2020.