COVID

What happens when you’re hospitalized for COVID-19

"I’m very concerned about the rising cases we’re seeing because they’re affecting patients who would otherwise have been protected if they were vaccinated."

An intubated patient inside a negative pressure room in the Covid-19 intensive care unit (ICU) at Freeman Hospital West in Joplin, Missouri, U.S., on Tuesday, Aug. 3, 2021. Hospitals in states where Covid-19 cases are once again surging are beginning to feel the strain in their emergency departments and intensive care units. Angus Mordant / Bloomberg

Hint: it’s not pretty.

Though vaccinations have already – and will likely continue to – lower the risk of hospitalization and serious illness from COVID-19, the number of Massachusetts residents in the hospital continues to increase.

Over the weekend, the number of hospitalized COVID-19 patients jumped from 467 to 530 – with 155 being fully vaccinated. The number of patients in the ICU increased from 108 to 139, and intubated patients from 49 to 68.

MORE ON COVID

Compared to Massachusetts’s pre-vaccine surges, the numbers remain relatively low. At the height of the first surge, on April 21, 2020, there were 3,965 patients hospitalized for COVID-19. In January 2021, the second surge peaked at 2,428 hospitalized on Jan. 4. 

Advertisement:

The state does seem to be approaching spring 2021 levels of patients needing hospitalization, ICU care, and intubation. On April 6, 755 people were hospitalized, 179 were in the ICU, and 105 were intubated. However, far fewer people were vaccinated then; 1,530,080 people were vaccinated on April 6, compared to 4,456,559 on Aug. 23.

The delta variant has led to increased transmission, and some individuals remain unvaccinated and at a higher risk of serious COVID illness. Two COVID care providers at Massachusetts General Hospital, Dr. Kathryn Hibbert, a pulmonologist and medical director of the ICU, and Laura Lux, a registered nurse working in the ICU, said most cases they’ve been seeing are among unvaccinated people, and more and more are among younger people.

According to state data, in the last two weeks the highest number of hospitalizations has been among 50 to 69-year-olds, but the highest rate of hospitalization is among those over 80-years-old.

Lux and Hibbert staunchly support vaccination.

“I’m very concerned about the rising cases we’re seeing because they’re affecting patients who would otherwise have been protected if they were vaccinated,” Hibbert said. “It’s incredibly sad and tragic to see people critically ill and dying of a disease that would have been prevented by a vaccine that is readily available.”

Advertisement:

Like it can be for any serious illness, hospitalization for COVID-19 can be traumatic. Lux and Hibbert told Boston.com what hospitalization for the disease usually looks like. 

How it begins

Dr. Kathryn Hibbert, a pulmonologist and medical director of MGH’s ICU, said patients who seek hospital care often can’t catch their breath and have low oxygen levels, so are placed on continuous oxygen and given some medications to help their symptoms. Sometimes that’s enough, but patients who can’t safely maintain their oxygen levels will go to the ICU

“We have lots of ways to provide oxygen to patients, sometimes at very high flow rates,” she said. “Sometimes we bring patients to the ICU as they worsen and they don’t ultimately need intubation, but most patients who come to the ICU end up getting intubated.”

Laura Lux, a registered nurse working in the ICU, confirmed this. She said some have been feeling unwell for a while at home, and not wanting to come into the hospital, so the severity can be high.

“By the time they get to us in the ICU, there has been so much damage to the lung already that the patients tend to deteriorate quickly,” she said. “Their lungs are already scarred, there’s so much fluid in their lungs already, that they need IC level of care, and it just happens so rapidly.”

EMS physician and researcher Nick Asselin demonstrates emergency endotracheal intubation on a training mannequin on September 23, 2019, in Providence, Rhode Island. Here, he is seen using a laryngoscope and an endotracheal tube. – (Kayana Szymczak for ProPublica)

The breathing machine

Sometimes patients start recovering with medication and a little extra oxygen, but if a patient can’t support their own breathing, and isn’t getting enough oxygen, intubation is the next measure. Hibbert described how it goes:

Advertisement:

“A big team comes to the bedside; we provide sedation through an IV and we paralyze all the muscles in their body…and using a tool that helps us look down their throat, we put a tube through their vocal chords into their lungs and connect them to a breathing machine. Once they’re connected, we choose settings on the ventilator to try to protect their lungs and we continue to give them lots of sedation…because the way we protect their lungs on the ventilator can feel very uncomfortable if you’re awake.”

After that, patients are consistently evaluated through vitals and chest X-rays. When providers think they’re starting to improve, Hibbert said, they conduct a spontaneous breathing test, or SBT, which can be pretty uncomfortable.

“We wake the patient up enough that they are able to breathe, and then we change the settings on the ventilators so the ventilator isn’t providing any support to do the work of breathing, it’s only providing some oxygen, and then we see if the patient is able to take big enough breaths on their own,” she said.

After that, it can go a couple ways. If a patient eventually passes an SBT, the breathing tube is removed and they breathe on their own. These patients still face a long road to recovery: they usually need intensive inpatient physical therapy, and often swallowing therapy, as well as time to regain their strength. 

Advertisement:

“We have a lot of technology to support people and keep them alive, but the experience of being in the ICU can be very difficult, it can be very confusing to patients and it can be uncomfortable,” Hibbert said. “We do use medication to try to keep patients comfortable and help them sleep through part of the experience, but we know that patients who have been critically ill in the ICU sometimes have PTSD…and there are particular sensations, like being really short of breath, that are really scary and uncomfortable.”

Some patients never regain their ability to breathe independently. Depending on disease severity and other medical conditions, a tracheostomy is an option for some, Hibbert said. A tracheostomy is a surgical procedure that connects a breathing tube to the lungs through an incision in the neck and windpipe. Some live with this permanently, bed-ridden, and some may only have to spend their nights connected to a machine.

The worst outcome

Since the start of the pandemic, 17,809 Massachusetts residents have died of COVID-19. Though the death rate has significantly dropped since vaccines became widely available, people are still dying. As of Aug. 19, 84 people had died during the month. 

Hibbert said that when patients come into the ICU and need to be intubated, providers often see the body start to shut down in other ways. 

“Their kidneys may fail, or their heart may not work as well, we see their body overall not working as well,” she said. “There are times when patients are not showing signs of improvement and there are other signs their body is under tremendous stress and starting to shut down that we have to share with families that their loved one is dying.”

Advertisement:

Lux said nurses have seen this so many times, that the progression of COVID-19 severity is all too familiar now. 

“We already know once they start escalating in their oxygen requirements, it’s getting to the point now we think we have to intubate,” she said. “If the patient is awake enough, then we’re like, ‘let’s try to get a Zoom so they can call their families to let them know what’s happening,’ and for some patients, what we experienced frequently, it was the last time they got to see their family.”

Hibbert said patients can die a number of ways in the ICU. 

“Sometimes their heart stops and we do CPR and they die regardless,” she said. “Sometimes it becomes clear we’re not going to help them get back to the life they were living before, and from their prior wishes, that they would not want to be kept alive on machines. So, we take the breathing tube out and give them medication to make them comfortable and allow them to die peacefully in the ICU.”

Lux said it’s gutting for nurses to witness, especially since a vaccination is available now.

“It’s so hard for us to think about people that don’t want to get the vaccine or don’t believe in it,” she said. “We saw so much death and dying and so many families suffering that we don’t want to have to go through that again.”

Conversation

This discussion has ended. Please join elsewhere on Boston.com