What does severe COVID really look like?

One of the most irritating things for any medic who has actually looked after severely unwell COVID patients is hearing “It’s just like flu.”

While statistically this is completely untrue (COVID is three times as infectious and 5–10 times as deadly), clinically this isn’t true either. Having worked for six months in a COVID ICU I’ve probably seen over a hundred patients with life-threatening COVID-19, so I thought I’d try to paint what this novel disease really looks like in its most extreme form, and why it’s not like flu at all.

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At its height we had to quadruple our ICU size, and every bed was occupied by patients with the disease; severe COVID. Our patient mix was absolutely typical; mostly men, average age of 50, including 1 or 2 patients in their twenties or thirties. Most patients were from Asian or Afro-Caribbean ethnic backgrounds and many more were frontline key workers, especially healthcare workers, than would be expected in the general population.

ICU is all about the details. When we discuss a patient we talk about them systematically from head to toe, using the handy mnemonic ABCDE.

A is for airway and B is for breathing. COVID-19 is primarily a respiratory disease, and the hardest place severe disease hits is the lungs. In severe illness inflammation in the lungs fills the air spaces with fluid, meaning moving oxygen in and carbon dioxide out gets more and more difficult. Later the lungs start to stiffen, slowly ossifying the lungs from elegant, spongey balloons of flesh, into immobile rocks, which makes it much harder to then get air in and out. The chest x-ray turns from two clear black airspaces to a solid white like bone. We call this appearance a “white-out”. Just as a severe blizzard blinds you in endless snow, the disease in the lungs becomes so bad we become unable to “see” the problem clearly at all.

So how do we help? Normally when we breath, we flatten our diaphragms and expand our rib cages, which in turn expands the volume of our chest. This creates a negative pressure which draws air into the lungs. The natural elasticity of the chest muscles then recoils and pushes the air back again, exchanging fresh oxygen for old CO2. It’s a marvellously efficient system.

When someone is struggling to breath all of our interventions do the total opposite of natural respiration- rather than sucking air from the outside, we blow air at high pressure in. We use devices ranging from tubes up your nose, to face masks, to whole “hoods” that encapsulate your head in a bubble of pressure, to mechanical ventilation, where you are sedated and paralysed, a tube is passed directly into your windpipe (intubation) and then attached to a sophisticated machine that pumps air in and out for you; a ventilator.

During COVID most patients in ICU would be mechanically ventilated, often with a tube inserted into their neck (tracheostomy) rather than down their throat for longer term (weeks to months) ventilation.

C is for circulation, which means the systems that control the volume and delivery of blood from the heart to the tissues and back. In COVID many patients initially come in ragingly unwell with very high markers of inflammation. This causes blood vessels to dilate and the blood pressure to drop dangerously low, to the point vital organs like the brain and gut stop getting enough blood to function and get injured. This is sepsis. To counteract this we need to give blood pumping medication and fluid. We do this through big tubes inserted into the neck or the groin veins, while all the time watching for rhythm and other heart problems that occur commonly in COVID as well.

For the very sickest patients, where we can’t even blow enough oxygen into their lungs to keep them alive, we can try to get more oxygen directly into their blood through a special machine called extra corporeal membrane oxygenation (ECMO). This is an even larger tube that takes blood out from a large vein, adds oxygen through a special bypass machine, and then returns the blood back to the body again, essentially an artificial pair of lungs and extra heart. Our youngest and sickest patients were only saved after several weeks on this, without which they would’ve died instantly.

The other big problem with COVID is blood clots. It makes your blood very sticky in some patients and we don’t really understand why. This leads to clotting in veins, in legs and sometimes in other places, such as the brain and the lungs. One of the clinical markers of COVID is a very high level of something called D-Dimer, which is a marker of blood clotting and also inflammation, so high it would often surpass the labs ability to count at all.

Lastly, similar to autoimmune diseases, COVID has a particular affinity for damaging the kidneys, with many patients going into kidney failure as well. This requires another machine to filter the blood of dangerous toxins that would otherwise build up, leading again to fluid overload, dangerous heart rhythms or death.

D is for disability

Here we assess all of the impact of COVID and ICU is having on the brain. We look for levels of consciousness, and try to lighten the sedation in patients we plan to wake up. The eventual goal of every ICU patient is to not be in the ICU anymore, which means slowly weaning all of the interventions, inch by inch and day by day, until weeks or months later they can survive on their own again. Delirium in those that wake up is very common as well, a confusional state caused as much by COVID as the ICU itself, which again we have to slowly walk back to normality.

E is for everything else:

We check the bowels, scour the skin for sores or signs of clots, review the medicines and fluids chart and then write it all up.

If you were to go to a Covid ICU right now it would look something like this. The medical team universally clad in full PPE consisting of scrubs, gloves, a visor and a respirator mask, either disposable or increasingly permanent industrial versions. We even experimented with a scuba mask.

Each patients bedside will look very similar; a dedicated nurse, a ventilator machine, an array of monitoring screens, another array of various drug pumps which will include drugs to paralyse and sedate, antibiotics and any other drugs or fluids. Next to the bedside might be a kidney filter or sometimes the part-jet-engine, part-percolator-looking device that is the ECMO circuit. Managing all the various tubes, any one of which becoming displaced could be life-threatening, is a major task in its own right.

Which brings me on to treatment, of which there remains very little, even now. Steroids, and a procedure called “proning”, where the patient is turned from lying on their back to lying on their front, remain the only proven useful remedies for COVID. As you can imagine, turning a 80kg man, completely flaccid and asleep, with ten vital lines and tubes, is no small feat. It takes 7 people minimum.

All of the other medications we’ve heard so much about in the last year haven’t really panned out, with a few exceptions. What these patients really need is time; to support them through the very worst of the virus and out the other side alive, which is often weeks or even months.

And it doesn’t end there. Patients hospitalised with COVID have a 1 in 3 chance of being readmitted to hospital within three months after discharge, and a 1 in 10 chance of dying, 8 times higher than those of patients discharged from hospital for other conditions. ITU carries its own long-term damage to recover from. The road is very long and difficult, fraught with peril even after the initial illness.

Contrary to what so many sceptics profess online, anyone who’s actually looked after patients with COVID will tell you they are quite easy to spot. The clinical pattern is quite striking; a low white cell count of a specific type called lymphocytes, a very high marker of inflammation called CRP, and a sky high D-Dimer. The x-ray and CT pictures are particularly unique. The confirmatory PCR test result is only a part of that, and we certainly had patients with COVID testing initially negative and then positive afterwards, and vice versa.

Thanks to many of above the life-saving interventions, about half of ICU patients with severe COVID will survive. Through a combination of factors it was even better than that where I was working, but that wasn’t the case everywhere. As you can see COVID requires ALOT of healthcare resources to save lives, and when those resources reach their limit, even more lives are lost.

In adults the risk of death from COVID is around 5x higher than that of flu, and in the elderly 25x that.

Personally, it’s not a disease I would wish to catch at 34, a disease that can cause severe and long-term damage even in young people, and one that is very much not at all like flu. So regardless of what happens where you are over the next few months, keep informed, be careful and stay safe.

Dr Dominic Pimenta is a UK-based physician, author and researcher. His book about working in COVID ICU during the first wave in the UK is out now “Duty of Care”, with all sales royalties going to the charity he co-founded, the Healthcare Workers’ Foundation, supporting the welfare and wellbeing of healthcare workers in the UK through the pandemic and long into the future.