Case 41: The White Walkers

MAY 7, 2020: SCROLL TO BOTTOM FOR UPDATE IN BOLD

I never could get into HBO’s Game of Thrones. Occasionally, though, I hear plot-lines from the popular show and I’m tempted to give it one more chance. On one side of The Wall, I’m told, an army of barbarians called the Wildlings threatens to attack human-kind. While the Night Watch prepares for the Wildlings’ imminent assault, they ignore the danger of the dreaded White Walkers and are blind-sided.

In one week, it will be May. It’s been a month since my patient Nick*, the previously healthy lawyer, was placed on a ventilator for COVID-induced respiratory distress. Back then, it was projected that we’d have sixty ventilated patients in our hospital by the end of April. Fortunately, we’re nowhere near there. We’re down to six COVID-positives in the ICU. Five have died over the last month, and six have recovered after an ICU admission. As the public practices social distancing, the curve seems to be flattening, for now.

It’s just after five on Sunday afternoon when I call the ER. While things are usually quiet on Saturdays, the department typically picks up as the weekend comes to a close. In normal times, my shift would start around around six, I’d see twenty to thirty patients, and then head home just after one am. Things have been different for the last month, though, and I’m surprised when Dr. Jimishin* tells me that there are patients to be seen – that there’s work to do. Since the arrival of the virus, the ER has been as barren as the offices and storefronts that surround it. Our average daily ER volume – over three hundred patients a day – has been cut in half.

When I arrive to the hospital around six, only one patient is waiting to be seen. “Sorry,” my colleague says. “There was a brief rush, and now we’re just waiting for patients to register.” I see a couple of patients in my first hour, and then catch up on paper-work and buy socks online.

Just after 10 pm, I see Lincoln Reacher, a retired bus driver in his mid-fifties*. Like all of our patients, he’s been given a mask. I’m wearing one too, along with a face shield. My hands are clean and my stethoscope has been wiped with bleach. I’m not worried about getting COVID from my patient, and he shouldn’t be worried about getting it from me. Lincoln has been sick for almost three weeks. He looks unwell. His temperature is thirty-nine degrees, his heart rate is one-twenty, and he’s almost gasping for air. But that isn’t what’s most striking about his presentation. A child could take one look at a Lincoln and know that something is very wrong.

His fever started on April 1st, and was coupled with a sore throat two days later. On April 9th, his symptoms worsened. He developed body aches, weakness, a cough and a loss of appetite. By the 14th, he developed a fine pinpoint-rash on his torso, and although his wife insisted he go to the hospital, he refused. Instead, he called his family doctor. Like Nick, who’d called his family doctor two days before his ICU admission, Lincoln was prescribed the antibiotic Azithromycin over the phone. After four days of taking antibiotics, he felt his symptoms were improving. But on the fifth and final day, his weakness became profound, and his shortness of breath, severe. The next day, he could barely stand, and finally, after his wife insisted, he called an ambulance. After listening to his story, I auscultate Lincoln’s heart and then ask him to sit up so I can listen to his lungs. I’m relieved that I don’t hear them – the dreaded COVID-crackles at the base of each lung. “Is the rash still there?” I ask him. “I don’t see anything on your chest or back.”

“No,” he says, huffing for air. “It cleared up a few days ago.”

He lets go of the rails and sighs as his back falls against the stretcher’s mattress. I palpate his abdomen. It’s soft, and a little tender throughout. His bowels have been moving well, and he hasn’t vomited, but he’s been nauseated for days. Before I can ask, he answers the question I’ve had since I first saw him. “In case you’re wondering why I didn’t come in earlier, it was because of absolute fear.”

“Just one more question,” I say. “When you called your family doctor on the fourteenth, did you tell her that your skin and eyes were yellow.”

“No,” he says. “I didn’t.”

His jaundice is so marked, he’s practically orange. He doesn’t drink alcohol and has never had any issues with his liver. His complexion is so unnatural, it’s as if there’s a yellow spotlight overhead. “Was your skin yellow when you called your doctor?”

“I’m not sure,” he says, “but it’s possible.”

Days later, I’ll ask his wife the same question. “I don’t know,” she’ll say. “I’m visually impaired and I can’t see color.” More importantly, though, it’s a question his family doctor won’t be able to answer either. There are significant limitations and risks to a clinical assessment during which a doctor can’t see or touch their patient.

Over the last month, I’ve seen many patients like Lincoln – patients who stay home and hope their symptoms will resolve, too terrified to come to the ER. Some are scared that they’ll get COVID, while others are afraid they’ll pass it on to others.

A few days earlier, a colleague handed over a middle-aged man who was waiting on blood-test results. When he was ready for reassessment, I told him that everything looked okay. “Thanks,” he said. “But before I go, can you look at something for me? It happened a couple of days ago, but I was too scared to come to the ER.” He slowly pulled away his mask and uncovered his upper lip. It was split wide open, the exposed edges having already scabbed over. “I don’t know if there’s anything you can do for it now,” he said. “It’s already been a couple of days.”

“No,” I said. “The edges are already healing. It’ll be like pinching your fingers together and hoping that they’ll stick.” I studied the scabbed edges. It was the worst unattended laceration I’d seen in twenty years of practice. “We can’t leave it like this. If you’re okay with it, I’ll freeze it, re-open the edges with a scalpel and then suture it back together.” I led him through an empty hallway to a procedure room. “It might take an hour or so, but really, I don’t have anyone else to see right now, so we have plenty of time.”

The headline of an April 18th Globe and Mail article sounds dramatic, but it’s true: Doctors worry people are dying as they avoid ERs due to coronavirus fears.

A few days before the split-lip, I saw an athletic forty-year old who ran five miles several times a week. But just around the time COVID hit, he returned from a vacation and found that he couldn’t complete his usual route. As days passed, his shortness of breath worsened. Soon, he couldn’t run at all – he could barely walk. It wasn’t until he collapsed at home that he came in by ambulance. He had chest pain, severe shortness of breath and a swollen leg. A CT scan showed blood clots in his lungs so extensive, that only the top of his right lung was getting blood-flow.

An hour after seeing Lincoln, only a few of his test results are back. It’s eleven o’clock now, and the overnight doctor is here. There are only two patients to be seen, so I tell him about Lincoln and pack my things. Over the course of the evening, I’ve seen only thirteen patients – about half of what I’d normally see.

As Dr. Alan Drummond said in the Globe and Mail, “a pandemic doesn’t stop heart attacks, strokes, serious falls and seizures, yet many people who would normally visit a doctor to check what could be serious symptoms are choosing not to seek help.” On my way home, I think about Game of Thrones. Just because the Wildlings are suddenly threatening, it doesn’t mean the White Walkers are going to let up.

Four days after his admission, Mr. Reacher’s condition is worsening. A biopsy shows drug-induced liver failure, likely secondary to the drug he’d been prescribed over the phone. Specialists decide that Lincoln likely had an infectious illness with onset around the first of April, and that the antibiotic (coupled with the illness) thrust him into liver failure. His case is discussed with a liver-transplant team at a downtown hospital, and he’s accepted for transfer pending a CT scan of his brain. He’s developed confusion, likely secondary to liver failure, but the accepting physician wants to ensure that he hasn’t developed intracranial bleeding as liver dysfunction can impair blood clotting. During the scan, however, Mr. Reacher suffers a cardiac arrest. And although he’s resuscitated and transferred to the ICU, he suffers a second cardiac arrest a day later, and unfortunately, doesn’t survive.

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*identifying details changed

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