BOSTON — Behind a closed door, an elderly man hopes a test will show that he no longer has an active coronavirus infection so that he can return home to his wife of six decades. Until then, he gazes out the window where he can see the trees. Sometimes his mind wanders to the lurid, delirious nightmares of the intensive care unit. He tries to distract himself with poetry.
Down the hall, a younger man works to get stronger so that he too can get back to his family. He feels better, he tells me, but he is so bored, and the Covid cough still bothers him, along with a burning in his hand — likely a nerve injury from the days spent lying on his chest when he was intubated. His face bears the scars of that lifesaving maneuver, blackened ulcers on his cheeks, nose and forehead. He too looks out the window. Waiting.
This is life for the growing number of patients who have survived severe Covid-19 but have not yet recovered. As a critical-care doctor, I could easily avoid seeing this part of the story; it would be almost preferable to think that the removal of a breathing tube or a long-awaited discharge from the I.C.U. is the victorious end to the narrative. But that is not the case. Even as hospitals continue to care for the surge of critically ill patients, it is time to prepare for what comes after.
In a way, it’s strange that Covid-19 survivors must recover in places that look a bit like nursing homes, the very facilities that have been ravaged by this virus. In my own hospital’s intensive care units, we have too often cared for patients transferred from nursing homes, coronavirus-positive and dying. It is little surprise, then, that many skilled nursing facilities refuse to take coronavirus patients after hospital discharge — even when these patients are their own long-term residents. Until they have cleared the virus, these survivors are unable to go home again.
Which is why, in recent weeks, dedicated Covid-19 “post-acute care facilities” have sprung up throughout the country. Here in Boston, I recently started a rotation as the pulmonary consultant at a long-term acute care hospital that has shifted to care for recovering Covid sufferers. While some of our patients are nursing home residents, many are younger and previously healthy, debilitated now after days to weeks of deep sedation and mechanical ventilation. They need to learn to walk again. To dress themselves. We have more than 50 admissions already and a waiting list that is pages long.
At the same time, we are still caring for those without Covid too, transplant recipients and cancer patients, frail and vulnerable. To limit exposure, the Covid patients do not leave their rooms. And as in the acute care hospital, families cannot visit. Physical exams are kept to a minimum and most encounters take place via iPad.
On one recent afternoon, I sat at the central nurses’ station with a headset on while my patient, just a few paces away down the hall, talked to me through the iPad next to his bed. The machine was at an odd angle, it was nearly impossible to look at him head-on, and behind me the alarms blared and I could barely hear, but when I tried to sign off he asked me please not to go. An adult man with his hospital gown askew, socks halfway off, asking me to keep talking just a bit longer.
I told him how it was finally getting warmer outside and agreed that there really is never anything on television during the day. I did not hang up until a physical therapist in full personal protective equipment entered. It was time for his daily session in the room. The rehab gym down the hall remains empty.
At least we know how to track and treat the physical consequences of our patients’ prolonged I.C.U. stays. These outcomes are visible. More insidious are the potential psychiatric and cognitive dysfunction that some former I.C.U. patients describe — anxiety and depression; hyperarousal and flashbacks to delirium-induced hallucinations that are characteristic of post-traumatic stress; poor planning skills and forgetfulness that might make it hard to remember medications or appointments.
These are far trickier to screen for and to treat. Of course, it is early still, and we do not yet know the burden of these outcomes in our Covid-19 survivors. But given their protracted critical-care stays and the persistent isolation that so many of them endure, these issues will be widespread.
At our hospital, before the coronavirus, we built a clinic for I.C.U. survivors. There, I worked with another critical-care doctor, a psychiatrist and a social worker to screen our patients for common post-I.C.U. problems and to offer them referrals.
Patients asked us to fill in missing details: What happened to me? How long was I on the vent? This scar, what was it from? On a few occasions, we even accompanied patients back to the intensive care unit. I remember how their expressions would shift, fear fading into relief, as they realized that this was just a place that they could now enter by choice and then leave again.
We do not have rigorous studies to tell us that these clinics help our patients. And it will be hard to set them up now, with so many of us critical-care doctors still doing the work of keeping our patients alive, keeping ourselves safe. I do not pretend to have the answers here. But we owe it to our survivors to try.
We have come to recognize that for many patients with coronavirus, the disease follows a characteristic pattern. For them, there is an initial constellation of symptoms — fever and cough — followed by a period of improvement and then a catastrophic decline. A disease with two waves. I think of us now, as a nation, at the end of our own first wave. We breathe a bit easier. Perhaps we will be OK, after all.
But the second wave is coming — not of death this time, but of survival.
That afternoon at the long-term care hospital, I was startled in the middle of writing my notes by an unintelligible announcement on the overhead. I turned to one of the respiratory therapists. “A Covid patient is being discharged,” he explained. “Want to go see?”
We rushed down the stairs to join the group that had already gathered, all of us in scrubs and masks, waiting. Someone turned the music on and “Here Comes the Sun” filled the small lobby. Behind me, the patient’s two adult sons radiated excitement. When they last saw their father, he could not breathe.
I watched as the elevator doors opened and a nurse emerged, pushing a small man in a wheelchair. He scanned the crowd, spotted his sons and gave us all this proud little wave, like royalty. I clapped as loud as I could for him, mouthing the song’s refrain, “It’s all right,” behind my mask, not knowing what this virus would leave him with or what kind of life he would re-enter, but hoping the words were true.
Daniela J. Lamas is a critical-care doctor at Brigham and Women’s Hospital.
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