open letter: #COVID19 trenches, WMC

Please read the following letter from Tufik Assad, MD

I wanted to share a message to everyone from the “COVID trenches”. For those who don’t know me, I’m an intensivist and Director of the Critical Care Unit at Williamson Medical Center. We’re now several months into this pandemic, the defining moment in most of our professional careers. Williamson Medical Center tested the first positive COVID patient in the state of Tennessee on March 3rd, and we’ve all learned so much over the past five months. Our hospital, and the entire state of Tennessee, is very much in the second wave of illness from COVID. We saw an initial surge of patients several months ago, followed by very few COVID patients seen at our facility during the month of June. Many of us, myself included, were lulled into a false sense of confidence that the worst was behind us. I can’t tell you how many times I’ve been humbled by this virus.

Our second wave has been much worse than our first. Our inpatient COVID census has consistently hovered between 20-25 patients for the past month (twice as many as our peak in April), with nearly half of those patients on any given day in our ICU. We have had more patients on the ventilator this week (5) than we did during our previous peak (3). And unlike the first surge, our overall hospital census is much higher as patients no longer fear coming to the ER and our surgical operation has returned closer to normal.

For those who are not directly involved in the care of these patients, I can hardly describe how laborious the entire process is. Every staff member who comes into contact with a COVID positive or suspected patient, even for the smallest reason, has to carefully don and doff PPE. Every diagnostic test, from phlebotomy to imaging studies to echocardiograms, is carefully considered in order to minimize unnecessary staff exposure. Every day, including weekends, a group of hospitalists, pulmonologists, ID physicians, and pharmacists carefully discuss the care of every COVID positive patient in the hospital. Multiple times a week representatives from the hospital staff and administration discuss the ongoing challenges of operating our hospital during this pandemic. 

It’s no surprise that our most challenging patients are the critically ill ones. High flow nasal cannula has allowed us to avoid intubating many patients, but mechanical ventilation is required for the sickest patients. Once intubated, patients are often not liberated from the ventilator for 2-3 weeks. Most patients are heavily sedated, and oftentimes paralyzed, in order to tolerate the ventilator. Many develop severe delirium, secondary infections, shock, and renal failure as a result of their illness. We have recently seen good results from prone positioning, a labor-intensive ventilator technique where patients are placed on their stomach in order to improve their oxygenation. Many of our patients have pulled through their critical illness, but several have not. The most challenging aspect of this pandemic for me is guiding a patient, and their family, through the dying process through the sterility of PPE, without the ability to hold their hands, without friends and family at their side.

Despite these challenges, I continue to be impressed and proud of so many colleagues at Williamson Medical Center. I was working this past weekend as 4 out of our 5 ventilated patients were getting proned by the nursing staff one morning. All 4 of the COVID ICU’s nurses and 1 respiratory therapist marched down the hall for over 1 hour carefully rotating every patient, protecting their endotracheal tube, gastric tube, central lines, arterial lines, and foley catheters from dislodgement, meticulously cleaning the patients and protecting their skin from breakdown.  In order to minimize going into and out of COVID rooms we have extended our IV tubing so that the IV pumps are located outside of patient rooms, so another nurse from across the hall came down to titrate all the vasopressor and sedative drips while it seemed every pump was beeping for one reason or another. And maybe most impressively, no one seemed upset by the hard job they were doing. 

From the bottom of my heart, I want to thank everyone who works at our hospital. For those who care for COVID patients, and for those who don’t. For those involved in patient care, and for those who work behind the scenes. For those who have been furloughed, or seen their hours reduced. For surgeons who haven’t been able to operate as they’ve been trained. For the fact that, despite this being a GLOBAL pandemic, affecting every aspect of our lives, you have all chosen to continue the hard but fulfilling task of caring for patients. All of us have made these sacrifices for a common goal: so that our hospital can continue to care for ALL patients, with and without COVID.  I don’t know when this pandemic will be over, but I know we’re going to get through it together. Thanks for all you do.

Tufik Assad, MD, MSCI

Pulmonary and Critical Care Physician, Williamson Medical Group         

Director, Critical Care Unit, Williamson Medical Center