Yvette O'Brien hasn’t used a stethoscope to listen to the sound of a patient's heartbeat or lungs in months.
‘“There are things that have been so routine to us for years," said the intensive care doctor at St Vincent’s Hospital in Melbourne. "Coronavirus has meant we have had to completely adapt and change our medical practices really quickly."
St Vincent’s Hospital intensive care doctor Yvette O’Brien.Credit:Justin McManus
A trusty stethoscope, for example, could easily become contaminated with coronavirus so Dr O'Brien uses an ultrasound, x-ray or blood tests instead to examine the inner workings of a patient’s chest.
Such measures are necessary when wrestling with a mysterious and insidious virus that at times appears to defy human biology.
For the past five months, long-established medical practices have been re-engineered on the fly. Doctors, nurses and physiotherapists have quickly learned the peculiar and life-saving medical practice of flipping a COVID-19 patient onto their belly.
Known as proning, the technique can help those in severe respiratory distress by relieving the effects of gravity and opening up new regions of lung tissue for air. It can be the difference between life and death.
While it has been known in medical circles for years, it is now routine practice.
A hallmark of COVID-19 has been the speed with which some patients crash. Infected patients with extraordinarily low blood-oxygen levels, enough to cause unconsciousness or even death, have been observed conversing clearly without appearing extremely ill. The phenomenon is known as “silent hypoxia” or “happy hypoxia" and has perplexed even the most seasoned doctors.
"I have certainly seen it and I’ve heard similar reports from colleagues," Austin Hospital director of intensive care Dr Stephen Warrillow said. "There may be something about COVID where oxygen levels fall and they kind of feel okay and they can even look okay and they suddenly hit a wall."
Austin Hospital director of intensive care Dr Stephen Warrillow, in one of the hospital’s wards earlier this year.Credit:Justin McManus
Doctors historically sedated people with very low levels of oxygen, quickly hooking them up to mechanical ventilators. But now, many are keeping COVID-19 patients conscious for as long as possible and having them roll over in bed, continuing to breathe on their own with oxygen support.
There are also notable differences with coronavirus when compared to other viruses that invade the lungs such as swine flu. COVID-19 patients often become sickest seven to 10 days after testing positive.
“There seems to be this pattern where they may have a second, later deterioration," Dr O'Brien said.
Patients have appeared to be recovering from the virus only to be taken off a ventilator and then deteriorate quickly again a few days later.
“Everything about the way we nurse has changed,” Royal Melbourne Hospital intensive care nurse Annette Dlugogorski said. “We used to have all the staff gathered together in a room with a patient, but now, we might have one nurse in there speaking to a doctor with a team on loudspeaker on the phone outside the room.”
Annette Dlugogorski and a colleague care for a patient in Royal Melbourne Hospital’s intensive care unit. Credit:Joe Armao
As Australian doctors and nurses watched their colleagues in faraway lands grapple with the unusual virus in January, they have had to learn as they went. Ms Dlugogorski spent days in simulation training learning how to safely put on and remove full protective equipment.
Then, there was a sense we had dodged a bullet in April, before a second, more deadly surge of infections.
Staff in the intensive care units across Australia have learnt to sweat beneath pale blue isolation gowns, masks and face shields that dig into their skin as they check vitals, hovering inches away from the airways of coronavirus patients.
Hospitals with empty waiting rooms and bedsides have become the new normal.
But it is the absence of family in the intensive care units that doctors and nurses struggle with most; the calmness that comes with having a loved one by a patient’s bedside or feeling their touch. The way their presence can slow down the heart rate of a distressed patient.
“You can learn so much about the patient from their family,” said Ms Dlugogorski. "It's really hard seeing a family member saying goodbye to a dying patient and not be able to give them a hug. Whenever I think about it, it makes me really sad."
Royal Melbourne Hospital intensive care nurse Annette Dlugogorski.Credit:Joe Armao
When Ms Dlugogorski calls families to update them, sometimes she puts the phone on loudspeaker so their loved one can hear their voices. Other times, she quietly reassures patients with messages from their family.
“If it was my loved one, that’s what I would want for them,” she said.
Unless death is imminent, families are not allowed to visit. Gut-wrenching decisions are made over which two people should witness their loved one’s final living moments.
"It is heartbreaking," Western Health intensive care doctor James Douglas said. "Hard conversations with families are made even more challenging."
Intensive care doctor James Douglas at the ICU ward at Western Health’s Sunshine Hospital.Credit:Penny Stephens
It was late in the evening during his shift at Sunshine Hospital early this year, when an elderly man gasping for breath with a fever walked in. Chest x-rays revealed shadows on his lungs.
“I remember thinking this is probably it,” Dr Douglas said. “It's been incredible to see how quickly research is being done and new treatments are coming out."
But in between the sheer exhaustion, the seemingly endless cycle of hard shifts of caring for our sickest in the toughest of times, there are stark moments of beauty when the ordinary becomes the magical. There are the days a coronavirus patient sits up in bed for the first time, or a group of nurses and doctors clapping and cheering as another patient takes their first step in weeks.
It can be hearing a patient’s voice for the first time as they are weaned off a tracheostomy tube inserted into their throat to help them swallow.
“At the start, they can’t speak or they don’t have their voice back yet," Dr Douglas said. "But as they get better and their lungs slowly improve, you can deflate the little balloon in it and suddenly they can speak again. Seeing their eyes widen and the smile on their face when they hear their own voice is incredibly special."
Without a vaccine or cure, Melbourne hospitals are trialling the promising antiviral drug remdesivir with preliminary evidence suggesting it can hasten the recovery of hospitalised COVID-19 patients by interrupting the virus’ ability to replicate.
Doctors are also administering anti-inflammatory drug dexamethasone which seems to reduce the chances of dying if you're in hospital.
Each week, Western Health runs a medical journal group where doctors analyse the latest coronavirus studies emerging globally and tweak their treatments.
“We now know the people who are more at risk,” Dr Douglas said. “Men seem to get sicker and need ICU care more than women. Elderly people seem to preferentially be hit along with those with underlying health problems like heart disease and obesity."
Dr Douglas has also cared for young, healthy patients and men in their 40s, like him.
“We are very lucky in Australia that we have incredibly good healthcare system,” Dr Douglas said. “At Western Health, we are seeing some of the highest caseloads of anywhere. The fact we have still been able to do one nurse per critically ill COVID patient and we haven’t expanded our ICU into triple or quadruple numbers has meant that we can give the same model of care more that we normally do.”
More than 2000 healthcare workers have become infected with COVID-19 since the pandemic began. Some have been left fighting for life and fears are growing that many are being infected in their workplaces.
“It something that causes a lot of anxiety,” Dr Douglas said. "It is always in the back of your mind. You’re in this uniquely horrible, yet incredibly privileged situation of actually being able to help people during a very, very difficult time.”
ICU nurse Steph Lord treats a coronavirus patient at The Austin hospital, one of the many facilities to undergo expansions in preparation for a surge in patients.Credit:Justin McManus
Recovery for coronavirus patients is gruelling. For every day spent in intensive care, a patient will likely spend a week in a recovery ward. For those who experience organ failure, the prognosis declines sharply. If a patient is sick enough to need dialysis mortality rates hover at 50 percent.
As the rates of new infections plummet across Melbourne for the first time in weeks, promising signs are on the horizon. On Friday, just one coronavirus patient was in The Austin's intensive care unit.
"That would be broadly speaking indicative of what's happening across the city as the numbers are going down," Dr Warrillow said. "We have been sitting at between 40 and 50 patients in intensive care across the state, but that will hopefully drop down to the 30s and then the 20s in the coming weeks."
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