It’s been years since it’s been clear

Dr. Nick Werne is tired.

Covid-19 driven by the Delta variant and the unvaccinated has overwhelmed the staff of the hospitalist team at Memorial Hospital and Health Care Center.

Werne’s normal schedule, what he calls civilized, is seven 12-hour days on, followed by seven days off. These past few weeks, he and the other doctors and staff have been coming in on their off time to help with the Covid-19 patients as well as the normal patient load.

Werne’s job as part of the hospitalist team is to care for any patient admitted to the hospital.

“I take care of people that are too sick to go home,” the Jasper native stated simply.

In essence, when you see that two-dimensional graph showing the number of Covid-19 patients admitted to the hospital, Werne and the other doctors, nurses, and staff on Memorial’s hospitalist team are the ones on the ground meeting their needs daily.

Usually, as he mentioned, his job is civilized. He’s able to spend time with his four children and be at home regularly.

But not right now. Since August the number of hospitalized Covid-19 cases has steadily risen. The last week of August seemed like every call he was getting from the emergency room was another Covid-19 patient with low oxygen levels.

He described last week as a complete disaster as the hospitalist team worked hard to help the many patients being admitted with Covid-19. So many required ventilators, Werne said the hospital had to rent them.

This is in comparison to early February when the cases seemed to drop precipitously as the vaccine became more and more available and the country still had mask requirements and social gathering restrictions.

“It’s frustrating because I’d say 90 percent of patients when asked if they are vaccinated, the answer is no,” Werne said about the stream of patients there now.

As of Monday, Memorial had 28 patients with Covid-19 in the hospital, 25 unvaccinated. There are 13 in the ICU of which 12 are unvaccinated and none of the seven patients on ventilators are vaccinated.

This vaccine hesitancy is taking up beds in the hospital and causing issues around the country for other patients needing care. Fortunately, Werne has not had any instance in which the local Covid cases have impacted care for anyone else coming to the hospital.

“We don’t have people sitting in our emergency department waiting on beds,” he said. “But in a lot of places, it is affecting care.”

However, he has had issues transferring local patients to other facilities for care because of those facilities’ patient loads and staffing issues from Covid. This has especially impacted dialysis patients.

When a Covid patient sees Werne, their care plan shifts to doing whatever is necessary to prolong their life long enough to recover. “At my point of care, I don’t end up talking about it (vaccination) because that ship has sailed. They’ve already got pulmonary lung involvement from the Coronavirus,” he said.

To understand what Werne does and his frustration with this disease, it helps to understand why he is a doctor. He enjoys helping patients; that seems intrinsic to most medical professionals. But Werne is driven by the investigative aspect of determining the source of a patient’s ailment and then fixing it.

“I like the science of it and I like the puzzle,” Werne said.

Finding out what is wrong is the base he builds from to help a patient.

Covid-19 has made that hard from the beginning. Testing positive for the virus doesn’t give clear answers on how to treat a patient. As doctors resort to using whatever treatments and tools they have available, those don’t always work and complications from Covid-19 make things harder to overcome.

“This has just been such a unique situation professionally,” Werne, who has been practicing since 2004, said.

“At the beginning of the pandemic, nobody knew how to treat this,” he said. “People were just trying stuff.”

Early on it was thought that the sooner patients could be put on a ventilator the greater their chances for recovery. That stance has changed over the genesis of the pandemic.

Being on a ventilator is devastating to the human body. Most people are unconscious and some require being paralyzed. The propensity for complications rises the longer a person is on a ventilator.

Covid-19 causes blood clots. Additionally, blood clots are a concern for immobile patients on ventilators. Bedsores and skin infections can occur. Muscles weaken; including those that allow a patient to breathe.

Even if everything goes perfectly with someone on a ventilator, the length of time Covid-19 patients are on the vent requires long periods of recovery and additional care when they come off. They won’t be returning to normal life for a while.

A lot of times we are like, ‘hey, we’ve got this thing that might help you.’

And Covid-19 causes complications for individuals while they are on a ventilator. The virus creates inflammation in the lung walls causing them to harden and no longer passively open and close; the process necessary to oxygenate the blood being pumped through. So, a ventilator takes over that action pressurizing the lungs by forcing air into them.

There have been cases in which the pressure required to get the lungs to inflate is so high it causes tears in the lung walls. Subsequently, air leaks into the patient’s body causing more issues.

When the lungs become too damaged to be inflated, patients are put on an ECMO (extracorporeal membrane oxygenation) machine. The ECMO machine pumps the blood outside the body through an artificial lung to be oxygenated.

Now, doctors try to keep patients off of the ventilator if at all possible. But that is proving to be somewhat of a crapshoot with this new virus.

To do so, doctors are throwing anything and everything they have available (with FDA approval) at the disease, all the while, weighing the well-being of their patients against the potential outcome of the Covid-19.

They’ve used the plasma treatments that were making the news last year. There are steroids like dexamethasone that have helped open patients’ lungs up but come with a risk of increased susceptibility to other infections.

Recently, JAK2 inhibitors have shown some promise — these are a class of rheumatoid arthritis medicines that have received emergency use criteria for use in hospitals to treat Covid. These immunomodulators are designed to reduce the overactive immune response in the lungs. “These have received emergency authorization for people with really, really severe Covid who have ended up in the ICU,” Werne said.

There is Remdesivir, an antiviral that also received emergency use criteria for use to treat Covid.

The problem is that none of these are necessarily proven to work.

“A lot of times we are like “hey, we’ve got this thing that might help you,’” Werne said.

Remdesivir, the antiviral, is an easy choice for Werne as it doesn’t have a lot of side effects. “We’ve used that a ton,” he explained. “I feel pretty good about that medicine. I don’t know if it helps people out, but I have not seen it cause harm.”

Reread the last sentence in that quote.

That is the essence of fighting Covid-19 in a hospital setting, according to Werne.

“This might help you but at least it probably won’t hurt you,” he reiterated.

He’s familiar with hydroxychloroquine, it’s been around for a long time. For him, that is a reason to be concerned about using it. Some of these older medications have interactions with new medications that can have serious consequences.

Does anyone ever go to the doctor for a Z-PAK? “It’s such great branding by them,” Werne admitted adding it is the single best treatment for pneumonia for people not in the hospital.

“There is no debate about that, right,” Werne laughed sardonically.

They have been using it to treat Covid as well. It may have some immune-modulating properties and it is anti-microbial. “But that is one of those ‘maybe it helps’,” Werne said.

However, Zithromax (Z-Pak) has a side effect that can be exacerbated by Covid and hydroxychloroquine. It causes the QT wave in the heart to prolongate (lengthen). Hydroxychloroquine can have the same side effect. The two combined can create a longer QT wave and if your heart tries to beat during that wave, it can send you into an arrhythmia called Torsades de pointes. “It is a lethal arrhythmia,” Werne said. “Like within minutes.”

A lot of people are shocked when you tell them they might not get better.

Werne admits it doesn’t happen often, but it can. These are things doctors have to consider treating all patients, not just those with Covid-19.

As Covid patients fill the rooms at the hospital, Werne is faced with a lot of difficult conversations. When asked about recovery by a patient, Werne has to be honest.

“You’ve got someone on 10 liters of oxygen and they are asking if they are going to get better,” Werne illustrated. “I don’t know. Maybe not.”

“A lot of people are shocked when you tell them they might not get better,” he added. “They look at you like you are crazy.”

Those hard moments with the added uncertainty regarding Covid-19 treatments cements his stance on masks.

“The masks are nice, because, as opposed to the other treatments that I’ve talked about, I am one hundred percent sure that masks aren’t going to hurt anyone,” Werne said.

The first studies regarding the effectiveness of masks in preventing droplet infections were published based on research into the spread of tuberculosis.

“You don’t hear about tuberculosis anymore,” Werne added. “If someone had tuberculosis, you bet people would be wearing masks.”

“Even if you think they don’t work that well, if they prevent like one case of Covid, then they’ve done their job, right.”

Werne is human, just like all of these medical workers, and it is emotionally difficult. “We give a lot of bad news at the hospital,” he said. “I am doing okay with this part but I am really good at compartmentalizing these things.”

What happens when all the compartments are filled?

He isn’t sure how to overcome the wariness to the Covid-19 vaccines but knows the majority of his patients fighting Covid in the hospital right now have landed in the unvaccinated camp.

“There’s something that exists in the hospital world called ‘leaving against medical advice,'” Werne said.

This is when a patient has been advised they are too sick to leave the hospital, but against the doctor’s recommendation, decides to leave.

He views people choosing to not get vaccinated in a similar way to these patients that leave against his advice. “I’m sorry. We gave you the tools and you decided not to use them,” he said.

Admittedly, this disease has taken its toll on the nurses, respiratory techs, doctors, and staff but they are completely devoted to saving lives. It’s why they are working so hard even as they face patients refusing the lifeline the vaccine offers them.

Werne has seen his fair share of deaths. He hasn’t had a single patient come off of a ventilator.

“Little darling, it seems like years since it’s been clear”

The Beatles ‘Here Comes the Sun’

However, there have been those moments when someone recovers from Covid-19.

The tired nurses, techs, staff, and doctors rally to line the hall as these patients are wheeled out to go home. They clap and cheer to the Beatles singing “Here Comes the Sun.” George Harrison’s lyrics reverberate in the sterile atmosphere. A moment of cheer as Delta rages on everywhere.

“Little darling, it seems like years since it’s been clear.” A bittersweet lyric from Harrison in the harsh reality of these past few weeks and many months of the pandemic.

“It is hard when you know that it is so preventable,” Werne said about the patients that may not be going home.

He’s working again today even though it is his day off.

“I am heading back to see if we can get a couple of people off of the vents,” he said. “It would be a pretty big win for us.”