One awfully sad thing I've seen in this pandemic is guilt. An older man with metastatic cancer has been isolating himself. However, his son, worried about him, convinces him to allow a visit. The son brings his children - the patient's grandchildren - because they haven't seen him for over six months. This is complicated by the fact that the man's metastatic cancer gives him a survival prognosis of less than a year. His children and grandchildren may not be able to see him before the pandemic is over.

Several days after the visit, the man develops high fevers, shortness of breath, and cough. His oncologist by televisit sends him to the emergency department and he is diagnosed with COVID. Over the ensuing week he rapidly worsens. When he was diagnosed with metastatic cancer, he had discussed what he would want at the end of his life. He did not want to die on a ventilator. Eventually, his oxygen worsened to the point that we could not sustain him. He said that he was ready to move on.

The death, while tragic, is a common occurrence in this pandemic. We did what we could for him medically, and when we reached the limit of what we could offer, we tried to give him a painless, dignity-affirming end of life. But I was most affected by my conversations with the son. They were by phone because unfortunately, he tested positive for COVID as well. And as you may imagine, his sense of guilt was overwhelming. I struggled with what to tell him. 

What is it like to grapple with the guilt of Oedipus? How do we make decisions when each branch could lead to regret? Can we afford not to visit family dying of cancer? Can we live with ourselves if we think we might have hastened their death? Could this be happening around the country, around the world? It's easy to brush off consequences of our actions if they are far away and unknown, but how devastating it is to realize they are so close to home.

Our composition of COVID patients has changed a bit. We have begun seeing patients who require intensive care for other diseases but incidentally test positive for COVID. A few months ago, all patients with COVID in the ICU had respiratory failure from coronavirus, but now we have patients with heart attacks, strokes, diabetic crises, and other typical intensive care illnesses who also have COVID (since we test virtually everyone who presents to the hospital). What does this mean? I think it contributes to the finding that there is a community reservoir of asymptomatic people with COVID; these patients who tested positive would not have otherwise presented to the hospital. It also reveals the heterogeneity of COVID infections.

A young woman who is self-isolating because she knows she has COVID decides to pass the time by taking some hallucinogens. Unfortunately, she has a bad fall leading to brain bleeding; she is brought in by paramedics, intubated, and admitted to the intensive care unit. As we treat her brain bleeding, we notice that despite being COVID positive and having an abnormal chest X-ray, her oxygen needs are minimal. This seems consistent with the finding that COVID's effects on the lungs vary by age.

A young diabetic who gets COVID feels miserable, is unable to take his medications, and cannot eat or drink. He goes into diabetic ketoacidosis, his sugars eight times normal, his body unable to maintain its acid-base balance. He is admitted to the intensive care unit overnight. He doesn't require any supplemental oxygen, and he is discharged home several days later. Even mild COVID that doesn't cause significant alterations in oxygen can trigger other medical comorbidities that stress our hospital system. Although coronavirus in these patients may not require advanced oxygen therapies, it does limit which rooms these patients go to, nursing ratios, and use of personal protective equipment. With the high prevalence of coronavirus in our communities, we will have to remain cognizant of our resources and limitations. As this pandemic unfolds, we will have to be nimble in our hospital operations to handle the changing landscape of healthcare.