‘Second-week crash’ time of peril for some virus patients
During the first week she had COVID-19, Morgan Blue felt weak, with a severe backache and a fever. The symptoms did not alarm doctors at her local emergency department, however. They sent her home after she showed up at the hospital.
But on day 8, she abruptly felt like she was choking.
“That day, I suddenly couldn’t breathe,” said the 26-year-old customer service representative from Flint, Mich. An ambulance took her to the hospital, where she spent eight days, four of them in intensive care, before she recovered and was able to go home.
For people who suffer the most severe reactions to the novel coronavirus — and their caregivers — the second week of the disease can become a time of sudden peril and heightened concern, when some of those who seem stable or mending can suddenly become critically ill.
There is little consensus among doctors and experts about why days five through 10, or thereabouts, seem to be so dangerous for some people with COVID19, the disease caused by the virus. But everyone from critical care specialists to EMTs is aware of this frightening aspect of the disease.
“This second-week crash has certainly been well described, but 2 1/2 months in, why it happens we’re still not entirely sure,” said Ebbing Lautenbach, chief of the division of infectious diseases at the University of Pennsylvania’s Perelman School of Medicine.
Learning on the fly as they confront the new virus, clinicians speculated about the influence of an individual’s genes, the virus’s effect on lung tissue, overactive immune responses, blood clotting and even the impact of the ventilators used to save patients’ lives.
There is little, if any, current research to guide them.
“I’ve been thinking about this a lot,” said Naftali Kaminski, chief of pulmonary critical care and sleep medicine at the Yale School of Medicine, who studies the genomics of lung disease. “There’s an early stage of infection and the virus sits somewhere. You can almost look at the virus as a fifth column coming in, securing its stronghold and then slowly inducing more cells to let it in.
“Because of this lurking nature, your genetic makeup and pre-existing conditions will affect presentation of the disease,” he said.
Doctors say the overwhelming majority of COVID-19 cases do not require hospitalization. According to the Centers for Disease Control and Prevention, U.S. COVID-19 patients are currently hospitalized at a rate of 29.2 per 100,000 people, or just under 10% of the 1 million known cases so far. Of those, only a small percentage require intensive care or ventilators, and only some will experience a rapid downturn in their health.
But people with the coronavirus can crash before or after they are hospitalized. Doctors report seeing patients who wait too long to seek care, including those who do not feel the symptoms of plummeting oxygen levels, such as shortness of breath, until they are in crisis. No one is sure why. Many people’s lungs remain flexible for a while, allowing carbon dioxide out and forestalling the sensation they aren’t getting enough oxygen.
“The people who actually crash, they’ve actually been sick a while,” said Merceditas Villanueva, an associate professor of medicine at the Yale School of Medicine. “They’ve underestimated how sick they are, or they’ve just waited.”
The virus may be killing the cells that line the air sacs of the lungs, which keep them open and allow for the exchange of oxygen and carbon dioxide, said Russell G. Buhr, a pulmonary and critical care physician at Ronald Reagan UCLA Medical Center in Santa Monica, Calif.
At some point, the body simply can’t regenerate those cells as quickly as they die, he said, and a stable situation turns life-threatening. That may also help explain why COVID-19 patients can linger on ventilators for up to four weeks, much longer than in other respiratory diseases, he said.