“She’s here for shortness of breath,” the intern said. “She’s coughing, also.”
“Does she have a fever?” I asked.
“Not now,” the intern said, looking down at the chart. “But I’m waiting for the Spanish interpreter.”
“Should she be in the COVID unit?” I asked.
“I think she has heart failure,” she replied.
I knew the interpreter would be a while. I speak Spanish imperfectly.
“OK,” I said, “Let’s go talk to her.”
We’ve divided the emergency room here in Albuquerque by closing fire doors. One half is supposed to be clean. The other is contaminated by COVID-19.
Patients with coughs and fevers are sent to one side. Patients with everything else are sent to the other. We are trying to put those with COVID-19 in separate units, to protect both staff and uninfected patients from the virus. But many with COVID-19 do not have coughs and fevers, and many coughs and fevers are not caused by COVID-19. The distinctions between the clean and the contaminated, the safe and the unsafe, are only educated guesses. Without accurate testing, it is a hopeless task.
Standard tests for COVID-19 typically come back in 1–3 days, but rapid tests for COVID-19 exist that deliver results within minutes. If they were readily available, patients could be both tested and separated quickly.
We should have an abundance of these rapid tests by now. Instead, due to inexcusable national failures, we have only a handful to use each day. Most patients who need to be hospitalized cannot be tested quickly. As a result, patients with symptoms even vaguely suggestive of COVID-19 must be placed in contaminated units regardless of their true COVID status. They wait on those units until the slower tests come back. Many of them are elderly, and many have significant medical conditions that put them at much greater risk of severe illness and death from the virus.
Staff in the contaminated area of the ER wear full protective equipment—N95 masks and face shields and gowns. But staff in the clean area wear surgical masks alone, which offer far less protection. Six months into this pandemic, again due to inexcusable national failures, we still do not have enough N95 masks for everyone to wear all the time. The masks we do have are variable in quality and size. Some of them fit, and some of them do not. The hospital is doing its best to limit their use, because the supply remains uncertain, and no one has confidence that this will change.
You can look into the COVID unit through small windows in the fire doors and see masked, gowned figures. Their work seems mysterious, as if secret rites are being performed.
Even now, most of the time the figures sit and wait. There are still not that many cases in the city itself. For much of New Mexico, as in many places in the United States, Covid-19 remains eerily and dangerously abstract, even as the numbers insidiously rise. For the moment, the headlines are elsewhere, in Texas, and Arizona, and Florida. But we are not making progress against this virus. It is making progress against us, and the summer heat is not slowing it down.
The intensive care units two floors above us are full of patients on ventilators, tucked away like secrets. The patients arrive every day, from all over the state, one by one. Most, so far, have come from the Navajo Nation 150 miles to the west, where poverty, lack of running water, multigenerational families living closely together, and a host of other factors have contributed to one of the most tragic regional outbreaks in the United States.
The patient was in her early twenties, sitting up straight and breathing too fast. Her legs on the gurney were swollen and heavy with fluid. The oxygen mask on her face cleared with each gasp, and then clouded again with her breath. There was a suitcase in the corner of the room.
I struggled to understand her, as she spoke between breaths. She coughed, several times, and I stepped back closer to the door.
She said that she was traveling from Texas to California on the bus, that her breathing had gotten bad, and she knew it was her heart again.
I asked her what was wrong with her heart.
It’s weak, she said. It’s no good. I always take the medicine but it’s not helping.
I asked her how long she’d been coughing.
I always cough when my heart gets bad, she said.
So I asked her if she’d had a fever.
“No se,” she said. “Perro pienso que Si.”
I looked at the intern.
“We need to swab her,” I said. “She thinks she’s had a fever.”
Back at the doctor’s station, the intern pulled up the patient’s chest X-ray on the screen. Her lungs were full of fluid, white on the X-ray film.
“Should I give her some Lasix?” the intern asked, through her surgical mask. Lasix is a diuretic that has been used to treat heart failure for 60 years.
“Yes,” I said. “And we need the records from Texas.”
When the translator arrived, more details emerged. The patient had been sick for several years, and was getting worse. All of her care had been in Houston. But her brother, who lived in California with his family, had agreed to help her, and take her in. This was why she was on the bus. She had her medications with her, in her suitcase, meticulously arranged. The doctors in Houston had told her that her own body had attacked her heart.
The intern got on the phone, and started making calls.
“She has an autoimmune cardiomyopathy,” she said, triumphantly, an hour later, when the pages of records finally flowed out of the fax machine.
Later, the charge nurse came to me.
“If you think she has COVID, we have to move her to the other side,” she said.
“Can’t we keep her here?”
She sighed. “It’s the protocol,” she said. “Do you really think she has it?”
I had no answer. Altitude rises slowly on a bus from Texas to Albuquerque. The air grows thinner. People with heart failure who can breathe at sea level often cannot breathe at 5000 feet.
But COVID-19 is everywhere in Texas.
So we looked at each other.
“Let me think about it,” I said.
Choices like this are being made every day now, in every hospital in America, and they are impossible. You risk the many, or you expose the few. It is so easy to be wrong.
The intern called the cardiologists. She spoke on the phone for a while, back and forth, then turned to me.
“They agree that she needs to be admitted for heart failure,” she said. “But they want her on the COVID floor if she says she had a fever.”
I looked at the computer. There were only a few patients in the contaminated area of the ER, and there were open rooms. The rooms have glass doors, but they are not sealed. The virus undoubtedly is in the air some of the time.
I watched her from the doctor’s station for a little while. The diuretic was working, and her breathing had visibly eased. I knew that her heart wouldn’t keep her alive for much longer no matter what we did. Without a heart transplant, she had only a year or two left. Her frailty was so clear, and I knew the virus was very likely to kill her if she caught it.
“OK,” I said, finally, because I had no option. “But put her in the corner room, and keep the door closed.”
The corner room, in the COVID unit, was as far away from the other patients as possible. I consoled myself, slightly, with that knowledge.
A few minutes later, they wheeled her away down the hall, and through the doors into the unit. They swabbed her there, inserting the probe deep into her nose. The result would be back in a day or so.
Eventually, the cardiologists came down to the ER, and admitted her to the hospital. They didn’t enter the COVID unit or examine her, and they reviewed her EKG, her X-ray, her blood work, and her records from a distance. She lay there for hours, breathing contaminated air through an oxygen mask, until finally a bed opened on the ward upstairs for possible coronavirus patients, and she was gone.
A few days later, I looked her up on the computer. The cardiologists had increased her diuretic, and adjusted her blood pressure medication. Her breathing had improved, and she was discharged.
I thought of her on the bus, in the crowd, heading west again, trying to reach her brother, descending toward California, and I thought about incubation periods, and how vulnerable she was, and how, like so many stories, hers had already dissolved into the unknown, and the unspoken.
The swab was negative.
*Some details have been changed to protect the patient.
Frank Huyler is an emergency physician in Albuquerque, NM. His next book, White Hot Light: 25 Years in Emergency Medicine, will be published in August.