Radiolab - Dispatch 5: Don't Stop Believin'

Episode Date: May 6, 2020

Covid-19 has put emergency room doctors on the frontlines treating an illness that is still perplexing and unknown. Jad tracks one ER doctor in NYC as the doctor puzzles through clues, doing research of his own, trying desperately to save patients' lives.  This episode was produced by Jad Abumrad and Suzie Lechtenberg. Support Radiolab today at Radiolab.org/donate.  

Wait, you're listening. Okay. All right. You're listening to Radio Lab. Radio Lab. From W. N. Y. C. See?

Yeah. Hey, I'm Chad Abumrod. This is Radio Lab Corona Dispatch 5. So I grew up in a lab. And, you know, what I mean is my mother was a researcher. I would go to her research lab every day after school. I'm very familiar with what a research place. place feels like. People are focused. It's very quiet. So it has been interesting to me to listen to the

voice memos you're about to hear because it is not the sound I'm used to. It's not the sound that I associate with research. We forget that throughout much of the history of science, science was done on the battlefield. There wasn't that sort of division between the research people over here and the patient people over there. It's all the same thing. And maybe in this moment, we've kind of gone back to that state a little bit.

So some of the stuff that you're going to hear in this dispatch might be a little hard to listen to. So this might not be the one to listen to with your kids, although we do have a feed called Radio Lab for Kids, which you should check out. But I wanted you to hear it to give you a sense of what science on the battlefield

actually sounds like now. What's up? Hey. Hey. Hey. Story really centers around this guy. Nice. Introduce yourself. Okay. My name's Veer Mitra. I know you because back in the day when you guys were on season three of Radio Lab, I emailed you because I heard an episode and I was like, this is the future.

Chad, I want to work with you guys. I majored in science and I have my own recording studio because at the time I was doing music, let me hang out with you guys. That's so crazy. Look what happened. You went on to do something much more useful. Not at all, no. I made the wrong choice, clearly. After Radio Lab, I went to med school,

ended up specializing in emergency medicine. I remember, too, you were a rock star for a minute, and then you went to med school? It's from Middlesex Community College in Edison. Bamboon shoots! There's that chapter. That little thing. You had just been our intern at that point.

Yeah, that was just, that was a crazy time. I always imagine you'd go back to that at some point. I know. All right, so you went to med school after that. Did you imagine you'd end up in an ER? When I first went to med school? Yeah. Not really.

It's kind of a weird specialty in that a lot of ways it's looked down on by the other specialties, which most people outside wouldn't kind of see. But it's a new specialty, relatively speaking. It started in, I think, like, 1970. And so it's kind of like this red-headed stepchild of medicine. Huh. Because the cool thing to do in medicine is to be a specialist. You know, an electrophysiologist that just focuses on the right atrium of the heart, and that's their specialty.

So going into one of the more primary specialties like emergency medicine isn't as sexy in some ways. Although I wonder if that'll change now. Right. Maybe. Okay. Okay, so one of the ways that I have been experiencing this pandemic, kind of as a voyeur, is through Avere. Avere works three or four shifts a week at an ER at a very busy Manhattan hospital. And after every shift, he would send me voice memos of just what he was thinking and experiencing. March 20th, 2020, just got into work to start a night shift.

Huh? I think so. The good news is the city looks pretty dead, but for sure there's just this underlying tension. New York is preparing for the worst. We're all kind of uncertain. You get a sense now there's a real inevitability about what comes next. Sometimes we make some jokes about who's going to tube us, but it's a little bit of gallows humor, I would say. The rate of increase in the number of cases, portends a total overwhelming of our hospital system.

I'm just curious, like, what were you thinking at that point when, like, people were saying, it's coming, it's coming, it's coming, it's going to be big, but it hadn't yet really hit yet. Trying to take myself back to that shift. I do remember just thinking, looking at patients, because already at that point, you know, we had seen several coming in. They looked like they had it, and so we isolated them, gowned up. Okay. Any belly pain?

I'm okaying in your chest. Any head shortness of breath? What else? But then I had a case where it was a patient just coming in with some random complaint, you know, blood in their urine or something. Just something completely random. So I'm doing my regular thing, you know, pressing on their belly, talking to them. And for whatever reason, they had to get admitted.

And later on, they spiked the fever, got tested, and were positive. positive. And that really threw me for a loop because I was like, oh my God, this is just everywhere. I just remember looking at every patient with just this suspicion. Okay, where is this patient sitting and how close to they to the other patient? And I just remember telling the charge and it's like, you know, let's just separate these patients if we can. When you should come back is if you start getting really short of breath, like you feel like you just sprinted on my. Okay. And, like you just fit sitting down. Like puffing and puffing like that.

If that starts to happen, it keeps happening getting worse. Come back here because then we need to check your oxygen level again to make sure you're getting enough. March 22nd, 2020. There are now more than 34,000 coronavirus cases in the United States. More than 400 Americans have died. I already knew I had my first COVID patient. She was an elderly lady. And she just came in for fever.

I just knew right then and there that she had it. You know, but I think it hit me the most because, She reminded me of my own grandparents. I was just talking with my friend, and she was telling me about her first COVID case. It made me think of mine. I don't think I'll ever forget it. It was a super nice guy, older guy, 80s,

brought in by his kid because he was having fevers, chills, cough, been short of breath, everything we'd been hearing about. We all kind of had a feeling that this was it. We gowned up, we wanted to be in the room, gave him a bunch of oxygen. And he seemed to be doing better. Spoke with the kid. You know, why don't you go home, get some rest, call in the morning. A couple hours later, he seemed to be getting worse. He's breathing more and more heavily hunched over, trying to catch

his breath. At that point, talked to him and made the decision to intubate him, put him on a ventilator. I'll never forget. He just kind of looked at me and said, looks like I'm going to be dying here. I said, no, you know, right now you're just working really hard to breathe. Let's let you rest, give you a bunch of oxygen. It's going to make you feel a lot better. He just kind of looked at me and said, all right, I was at the head of the bed, and I just kind of had my hands on his head. I told him to think of a nice place, a nice beach that he likes. I'm going to give him some meds to put him to sleep, and we put the tube in. He went up to the ICU. And yeah, a couple days later, he passed away. March 23rd, 2020. Hi, this is Dr. Mitro.

As expected, more cases. Everything's changing. Tensions are high today. March 26, 2020. All the ICUs are slagued. I almost wonder why some people are barely noticing. and other people are getting rather sick from it. Obviously, age has something to do with it, but it's more than that. Do me a favor. Take some sips of water. Sit that water. Take a sip of the water.

I know it's weird. Take a sip, take a sip. Drink that water. Okay, that's good. That's good. You're doing good, buddy. Regular patients have gone way down, and now it seems like we're seeing way more of these patients

than any other type. A good friend of mine, buddy from residency, he's got it right now. Six, seven days of having fevers, but he's doing okay. I would call again because it's just so busy here, but let me get your name and number so that we can have the team call you tomorrow. And are you the person to make medical decisions for him in case that he's not able to make them for himself? Okay. Now, if he needed to have every...

to have a breathing tube and be on a ventilator. Is that something that he'd want to happen? Yes. Okay. And then if his heart was to stop beating, we had to do chest compression, CPR and the life. Would he want that as well? Okay. Okay. And do everything. Okay. Like I said, right now, his oxygen's good, his blood pressure is good, his heart rate's good, but his labs are concerning. So I just want to give you a heads up that right now he's doing good, but we're going to obviously keep a very close eye on him because if things get worse, they could get worse pretty quickly. Back home after the shift today. Basically, it's just the new normal. The entire pod that I'm in has COVID.

That's it. That's the only diagnosis. I left a trash bag at the door, and I'm just going to put all my clothes in the trash bag and then, I guess, jump in the shower. Every night before you go to sleep, you say,

I got it, I got it. And then every morning, I got it. I definitely have it. And then you still haven't gotten it. As far as we know. Maybe you have, I don't know. It seems like it's constantly on your mind. What's it been like for you for these past two months?

It's just, it's a lot. It's hard to deal with, definitely. I feel bad for you because, yeah, because you're with me, you kind of become a high risk. No one wants to see me. Like, oh, you live with a doctor? Oh, stay away, please. Yeah. After I had quarantined myself for two weeks.

well, not quarantine. I mean, I wasn't sick, but after I isolated for two weeks, and I went to visit my parents, I miss my family so much, and they didn't want me around. And so that was that. April 6, 2020. Number of deaths are up once again, number of people we lost, number of New Yorkers, 4,758, which is up from 159, but which is, effectively flat for two days. The patient with abdominal pain is probably going to go over to blue because we're

running out of isolated bed. It's just crazy how there's no there's just no guidance like there's You mean to get an alcohol urine level? You know we're all out here just making our own decisions and kind of freeball in it really I mean, there's just so much we don't know. April 10th, 2020. I have never in my short career seen people spreading information amongst ER doctors

and ICU doctors literally by WhatsApp, texting each other images of charts that people have written kind of really just figuring it out as it goes, which is kind of incredible, because in medicine in general, we're very cautious. We'll sit in journal club meetings and debate whether we should give somebody 162 milligrams of aspirin or 325 milligrams of aspirin. We'll literally debate that for hours.

But right now we're just trying different things out almost on a whim. So these WhatsApp groups you were telling me about where you're exchanging information with doctors in Italy and China. Yeah, and a lot from Washington also. Washington State, right. Their outbreak started, I don't know, what was it, a week or two before hours. So based on, because I find this part of it really interesting. So what were you hearing from them? I guess phase one was expecting things based on what they were seeing.

And at the time that was, okay, a virus comes to the back of your throat. It's flu-like, it's upper respiratory. It's like up here in your neck. A lot of people clear it. But if it gets worse, it progresses down to your lungs. It becomes lower tract. And that's when you start to see these pneumonias. And then if these pneumonia get bad, it becomes ARDS.

Acute respiratory distress syndrome. That was phase one. So that made perfect sense to me, you know. But then I think phase two was seeing things that didn't add up with that. We'll get into all of that after the break, when the battlefield science really begins. Thank you. Hi. Hi. My name is Madeline Dubois, and I'm calling from the Hamlet of Pooleville, New York.

Radio Lab is supported, in part, by the Alfred P. Sloan Foundation, enhancing public understanding of science and technology in the modern world. More information about Sloan at www.sloan.org. This is Radio Lab. I'm Chadabumrod. Okay, a viewer before the break was describing how in that moment when the ER was getting slammed and doctors were just trying to figure out what is going on, what is this new disease, what he and his colleagues

started doing was going on these massive WhatsApp groups and exchanging information with doctors in Italy and China It was sort of like this network of people with tin cans to their ears connected by giant strings. And he says what he was expecting to see in his ER, based on what they were telling him, were people coming in with respiratory infections, which started in their throats, and then moved down into the lungs and then got much worse. But instead, what he ended up seeing was just much stranger than that. The biggest thing that struck me is patient coming.

you measure their oxygen level with a pulse ox. And to take a step back, the pulse ox is that little thing you put on your finger with a laser light. It shines a laser through your finger and reads the color of your blood. And from that, it tells you your oxygen concentration. If normal is, you know, 97 to 100 percent, you know, we're seeing patients that are at 60, 70 percent routinely. Normally if someone's oxygen saturation is anything close to 70 percent, percent. They're not awake. They're out of it completely. They're grasping at anything trying to get oxygen. But these patients were seeing routinely that are looking at us, talking to us, they're wide

awake texting on their phone, and their oxygen saturations are at these super low levels. I remember you sent me a text message of somebody who had an oxygen saturation reading of like in the 50s, and they were on their phone. Exactly. That one got circulated around because we were all seeing the same thing. And it's like, you look at someone with a 54, that's a person that you're like, okay, ma'am, you're going to be taking a long nap, you know, you're going on a ventilator. And they may be like, well, can I just finish posting on Instagram first? You know, it's just so surreal. Okay. Can you tell me where you are right now? Okay, what year is it?

Can I get up here? Do you? Because the yellow top of interest. 2020. Okay. Thank you. This is a vire and a colleague working with a patient whose blood oxygen level had bottomed out at around 50, and yet the patient was sitting up talking to them.

All right. All doctors are coming up slowly. And clinically, she looks very well. Are you coughing? Divers? Try to take some deep breath. Big breath. Big breath.

Like that. Big one. Big one. There we go. Perfect, perfect. Just keep doing that for me. It's going to get your oxygen into you better, okay? Okay, so you're seeing all these patients where the numbers just seem like they should be in really bad shape, but they're not.

And at the same time, a pre-print paper came out, and again, this is a pre-print paper, so who knows what validity it will end up having. But in this paper coming out of China, they kind of found that one of the proteins made by this virus has the ability to attack hemoglobin. The paper basically argued that we've been thinking about COVID as a lung disease, but you know, the lungs are not the only part of the equation in terms of taking in oxygen. The lungs snatch the oxygen out of the air, but then they give it to the blood where you've got this little protein called hemoglobin. And then the hemoglobin's job is to grab that oxygen and then carry it in the blood

to the tissues where it ultimately needs to go. So the idea of this paper was, it could be that the virus is attacking the hemoglobin's. So maybe the problem is not the lungs so much as it could be a problem with the blood, which was super exciting to me because that's like, oh, well, we have all these arsenal of weapons that we could potentially deploy against the blood problem. All sorts of other treatments we can do. We can replace the hemoglobin. You could just get a blood transfusion.

Oh, interesting. So that's when I started doing some of those experiments. April 10th, 2020. Total lives lost, 7,844. Well, the lactate is clearing. I've been running experiments. So, yeah, you want to do the A-A gradient? To see if this might be true.

The way that I was thinking of, and it turns out a lot of other ER doctors were thinking of, I don't think I invented this, is to test something called an ABG. which stands for arterial blood gas. An APG test is where the doctor draws a little bit of blood from the wrist and looks at dissolved oxygen in the blood. The thought was, if this were a hemoglobin blood issue, this test would allow him to know that. Yeah.

So you know how people were talking about this being a hemoglobinopathy? Yeah. In that maybe the hemoglobin is poisoned and it's not so much a lung issue. But the fact that the P.A.O.2 is low. It kind of goes against that, you know what I mean? Unfortunately, by testing the patients that I've been having over the past couple of days, what I've found is the hemoglobin probably isn't the main problem. It probably is the problem.

There's a problem with the lung, which is what we know. Which I guess now brings me just back to square one. I don't know. I was hoping for something more exciting than that. Meanwhile, April 11th, 2020. Total number of lives lost, 8,627. In the ER you have stark contrast. There is the COVID pod, which is overrun,

and then there is the non-COVID pod. Which is just empty. It's so surreal. I'm not used to it sounding this quiet unless it's like four in the morning on Super Bowl Sunday. I don't know where all the appendicitis has gone. I don't know where the strokes are. Nobody has chest pain.

Nobody has stomach pain. What's happening with those people right now? They're probably having heart attacks at home, waiting it out, because they don't want to be exposed to sick people. This is something that we're seeing in ERs across the country, by the way. Non-COVID-related patients coming in has dipped by as much as 50%. April 15th, 2020. I did an experiment on myself today to see how the PPE. what we're doing is wearing a respirator and then wearing a surgical mask on top of that.

It's pretty hard to breathe in there, so I tried an experiment today to see what my pulse ox was and what my CO2 level was. Structed of VBG, and one was PCO2, 58, and the other one was 62. So, you know, with breathing, we're trying to do two things that are both very important and somewhat unrelated to each other. One is get oxygen in and the others get carbon dioxide out. So when I checked my oxygen levels, it wasn't really affected by the respirator and the surgical mask. I was at like 99% either way. When I checked my CO2 levels, though, normally I'm probably somewhere around 40, 45. With all that on for an hour, I checked after wearing it for an hour.

I was up to 59 on my CO2. Which are numbers that in a regular context I'd actually really worry about. Yeah. Like they're really retaining. Which means I'm retaining carbon dioxide. I was 59. I really want to know you were 59. So I wouldn't know what I am in the middle of the night.

Because I'm also wondering for our upregulating air hemoglobin. I want to check my buy card to see if I'm like compensated. Oh, they were. Their pH was normal. Yep, pH was normal. We need to publish this. Yes. April 16th, 2020.

600 people died yesterday from the disease. Today I took a quick trip up to the ICU. The ICU is where. where people who have to be put on ventilators go. It was hard to see all the patients because we have them all in isolated rooms, but I was walking by, looking at their vent settings. I think one thing that really struck me is the amount of hair that I saw. I spent months working in the ICU as a resident.

You just get used to seeing IV drips, pumps, ventilator equipment, big bed and gray hair on it. And I'm walking through this ICU and like jet black hair, brown hair, blonde hair. That really struck me. I mean, I wish people could see that. I guess I'm used to processing the sadness of the ICU in terms of people at the end of their life who've lived a good life. And I always concoct some story in my mind of how they've lived this fulfilling life. And, you know, their family is going to feel sad, but they're going to feel sad. but they're going to feel like,

okay, this is a sad but inevitable chapter, a final chapter. But with these patients, these aren't people who, they're not at that chapter. Their families are not going to feel closure when they die. Their kids still need a dad, you know. It's just scary. April 21st, 2020. So, exploring a number,

another hypothesis, again, coming back to the same problem that coronavirus is thought to infect the respiratory tract and the lungs, but we're seeing findings that are beyond that and can't be explained just by the lungs. One of the things he says that's been puzzling is just a crazy array of symptoms he's seeing in people with COVID. There's the usual cough, fever, breathing issues, but you also have people reporting neurological issues. Some people, including a few folks that I work with, lost their sense of taste and smell for a while. Others are reporting skin issues on their fingers and toes. Migraines. Trying to understand

what's going on and more importantly what to do about it. So one hypothesis that has been kind of floating around and I've been thinking about and a lot of people have been thinking about is this idea of a coagulopathy. He says the idea started again on a what's that. group. I first heard about it from Washington. It may have gone back even to Italy or China. I'm not sure. Doctor in one of these groups says, hey, I'm seeing these weird lab values in my COVID patients, not sure what it means. Avir and his colleagues start to investigate and ultimately notice that COVID patients often seem to have very high levels of this one enzyme in their blood. It's an enzyme that's often associated with clotting. If someone's making clots and breaking down clots

and just going through that clotting process, so that kind of brought up this theory. of could it be that this virus is somehow inducing little clots all over the body? Thousands and thousands of these microclots that might be jamming up the highways and preventing the oxygen in the blood from getting where it needs to go. And it also could potentially explain why we're seeing heart damage because the blood's supposed to go to the heart is getting clotted before it can get there. Same thing with the brain. And as a matter of fact, we see problems with the kidneys.

We're seeing problems with every end organ. Maybe it's not a problem with the organ. problem with the blood supply that should be getting to the organ. This might, emphasis on the word might, explain why there are so many different symptoms to this disease. So in our hospital, the hematology department kind of sat down with this data and came up with an algorithm for us to use in the ER and on the floor in the ICU, which is to basically try putting these patients on blood thinners.

So let's go. So you want to give her, so let's do lovin. weight-based dosing. So that's what I've been doing. That's what we've been doing for the past. She's not on any blood thinners already, right? This week, you know, when a patient comes in, COVID-positive, and they need to be admitted, we're putting them on blood thinners.

And is that where you are right now? I mean, it's May 5th. We're talking for the last time before this goes out. Is that still what you're doing? Yes. For us, it's been a unique experience. All right, I want to ask you about one last moment in your voice memos. This is, I think it's at a point at which in the arc of this whole pandemic so far that, like,

the volume of patients is finally leveling off. And you're talking to these two residents who are there to help. And then there is this announcement over the intercom. Can you just, do you remember that moment? Can you just describe what that was? Basically, the CMO of our hospital, basically, the CMO of our hospital, comes on the intercom and says, I just want to thank you guys for everything you're doing,

what you're doing is working. 340 patients from COVID disease as a discharged vaccine to a tumor away. We discharged this many people today. You know, just kind of a pep talk over this really shitty intercom. And then they play... What's the only are? I'm so scared.

I know. I don't. I don't. I have to say that's the sweet. It's got myself. It's tough of God. Thank you. Have a great thing.

Be safe. I have to say that is the sweetest thing I've ever heard in my life. It's so sweet. And now what they're doing is every time they extubate someone, take someone off a ventilator. They play, Here Comes the Sun by the Beatles.

It was really moving to hear that. Yeah. Huge, huge thank you. Huge, huge thanks to Avere for sharing his thoughts and experiences with me and to all those people on the front lines working to help people and to help us understand what we're up against. What you heard were Aver's personal thoughts, they don't represent his institution, and all the science we talked about is tentative.

We're still a long way from understanding the true shape of this disease. Props to Susie Lechtenberg for helping me produce this episode. I'm Chad Abumrad. Thank you for listening. More stuff coming at you very soon. Science Reporting on Radio Lab is supported in part by Science Sandbox, a Simon's Foundation initiative dedicated to engaging everyone with the process of science. This is Aaron Scornia calling from Jefferson City, Missouri.

Radio Lab is created by Jad Appamrod with Robert Krollwitch, and produced by Soren Wheeler. Diane Keith is our director of sound design. Susie Leckinberg is our executive producer. Our staff includes Simon Adler, Becca Bressler, Rachel Cusick, David Gevel, Duttle Hobte, Tracy Hunt, Matt Kielty, Annie McEwan, Ladif Nasser, Sarah Kari, Ariane Wach, Pat Walters, and Molly Webster, with help from Shima Olaiye, W. Harry Fortuna, Sarah Sandbox, Melissa O'Donnell, Tad Davis, and Russell Gregg.

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