‘Lucky’ NJ patient survives 20 days on a ventilator
Christopher Yuen was so sure he’d be in and out of the emergency room quickly that he left his car in a no parking zone behind the hospital.
Nearly a month would pass before he came out – a month in which coronavirus cases in New Jersey soared from 4,200 to nearly 100,000, and deaths increased from 62 to more than 5,000.
When he did exit, he was pushed in a wheelchair and applauded by nurses and doctors celebrating his survival. He knew he was one of the lucky ones – only a fraction of patients with coronavirus recover after spending as long as he did on a ventilator.
The 32-year-old defied the odds in another way. When he got to his car, there wasn’t a single ticket on the windshield.
At home, he leaned on his dragon-headed cane – the one he’d originally bought for fun – to climb the stairs to his second-floor apartment in River Edge. That was when the hard work – to regain muscle strength, lung capacity and mental equilibrium, all diminished during his long critical illness at Holy Name Medical Center – began.
The hospital
After leaving his gray Dodge Dart on a residential side street in Teaneck on March 25, Yuen made his way to the triage tents outside Holy Name Medical Center’s emergency room. Those with symptoms of coronavirus were directed one way, and those with other emergencies were sent another. His path was obvious – he had a fever and difficulty breathing.
More than 120 patients sought emergency care there that day, and half were admitted.
When Yuen’s cough started in mid-March, he thought it was a cold or allergies. He went to the CVS MinuteClinic, which referred him to the hospital. There, the initial word was that he probably had the flu.
There were no quick tests. A nurse swirled a long, narrow swab around the back of his nasal cavity to check for the coronavirus. The results wouldn’t come back for days.
He couldn’t pinpoint how he’d been
exposed to the virus. Maybe he got it while riding the train to the city to date a girl he met online, he thought. He commuted by car to his job with Credit Saint, a credit repair company, and thought it unlikely he’d been exposed there.
Like most people Dr. Jose Gomez-Marquez saw in the ER, Yuen had waited a week before seeking care. The ER was nearly overwhelmed. Staff gave him a wheelchair and a tank of oxygen. Then he waited 11 hours for a bed, even though the doctor assessed his disease as “fairly advanced.”
His condition quickly deteriorated. Friday, two days after his arrival, Yuen’s oxygen levels plummeted. He was moved to an intensive care unit. Holy Name had converted a post-surgical recovery area into a second ICU and was getting a third ready as it coped with the flood of severely ill patients.
Gomez-Marquez, a pulmonologist and critical care specialist, decided to put Yuen on a ventilator. He inserted a tube down Yuen’s throat into his windpipe, attaching it to a ventilator to force air into Yuen’s lungs. As with most critical patients, it was impossible to synchronize the machine’s forceful pumping with the natural inhalations and expirations of Yuen’s body, so he was sedated and paralyzed to keep him from bucking or pulling the tube out.
Ventilators were precious commodities in New Jersey. At his daily news conference that Friday, Gov. Phil Murphy repeated an oft-voiced plea to the federal government to send 2,300.
Yuen was prescribed Plaquenil, or hydroxychloroquine, the drug touted by President Donald Trump. It didn’t appear to affect the course of his disease.
He remembers few details of his stay, except for waves of fever dreams.
Day followed night, each indistinguishable from the next.
Nurses came and went on 12-hour shifts. They monitored his blood pressure and oxygen level, checked the lines carrying medication and nourishment, rolled him from his back to his chest and back again.
Doctors tried treating him with Kevzara, a medication that blocks a type of cytokine, the cells responsible for the acute immune response that leads to critical illness in some COVID-19 patients.
The drug is prescribed for some rheumatoid arthritis patients. Its off-label use at Holy Name on ventilated COVID-19 patients was part of a larger study.
Yuen’s mother, Susan, was told this didn’t work when doctors called to ask her for permission to put him on another trial.
Next, doctors gave Yuen remdesivir, the experimental antiviral drug that showed modest benefits in COVID-19 patients.
Yuen was given a 10-day course of the drug. Again, Susan Yuen was told it didn’t work.
Yuen had a bacterial infection – pneumonia – on top of his viral infection. The prognosis was not good.
“The last conversation I had with the doctor, the drugs didn’t seem to work,” she recalled. “The pneumonia had spread, but they had given him some antibiotics. Then his oxygen level went down. That was it.”
A mother waits
Two of Susan Yuen’s three sons were sick with the virus, and she was in Vancouver, Washington, 2,900 miles away.
Christopher was in critical condition at Holy Name, and Nicholas, his 27year-old brother, was fighting the virus alone at the River Edge apartment he shared with Christopher.
It made no difference where Susan was. “I couldn’t have gone to see him anyway,” she said of Christopher.
For almost a week, she said, she didn’t hear from anyone at the hospital. She waited. She prayed. She cried. And she kept her cellphone on in case the hospital – or Nicholas – called. While Nicholas was sick from the same virus as his brother, his parents were so preoccupied with keeping him out of the hospital, “it took our minds off Chris.”
Nicholas’ symptoms ran the gamut – chills, fever, lightheadedness, insomnia, hallucinations, shakes, diarrhea – for five days. One night, he was afraid to go to sleep because he feared he would die and no one would find him. Susan stayed on the line with him for hours. “I’m retired,” she thought, “I can sleep later.”
Nicholas pulled through.
There was no news about his brother. “It was torture,” Susan recalled. “Sheer torture.”
Maybe no news was good news, she told herself. A relative offered to book
three hotel rooms in New Jersey in case the family had to head east to plan a funeral.
“That’s how close it was, how scary it was,” she said.
For six days, Christopher was unresponsive – sedated and paralyzed. The machine breathed for him.
The team in critical care didn’t lose hope. Yuen was just 32. “We worked really hard on him,” said Gomez-Marquez, the critical care doctor. “We kind of made him a project.”
Then, some progress. The antibiotic the medical team had chosen worked against the pneumonia. The doctor lowered the ventilator pressure. Yuen’s oxygen level held steady.
The medical team decided to turn off the ventilator to see if Yuen could breathe on his own for a few minutes. He could.
For the young nurse on the night shift in the ICU caring for Yuen, this was a turning point. He was a few years older than she was and had been healthy before the virus. It gave her “a glimmer of hope,” Jacqueline Strasser said, “faith that what we were doing helped.”
She called Yuen’s parents to see if they wanted to FaceTime with her patient. Susan Yuen wasn’t sure if this meant a final opportunity to say goodbye or a chance to offer words of encouragement.
Either way, she jumped at the chance.
When the image came into focus on her cellphone, there was Christopher – the tube down his throat, his eyes closed. But at least she could look at him. Strasser said he was sedated, but he could hear. The nurse put the iPad close to his ear, so he could listen to his parents’ voices. Later, Yuen said he dreamed they had visited.
It was April 12 – Susan Yuen’s birthday. Easter Sunday.
“Divine timing,” she said. Christopher Yuen had been in the hospital for 19 days.
The next day, the ICU team turned off the ventilator and carefully pulled the tube from his throat.
Doctors learned with experience that the ventilator could be harmful for some patients. In consultation with the nursing team, Gomez-Marquez said, he weaned Yuen earlier than was typical. Yuen’s oxygen needs were met with a nasal cannula, a narrow tube with prongs into his nostrils, that carried high-flow oxygen.
At 5:30 a.m. two days later, Susan Yuen’s phone rang. Christopher’s name popped up on the caller ID. His voice was low and raspy.
“We went from the lowest low to the highest high in one week,” his mother said.
What worked? “There’s no magic drugs,” Gomez-Marquez said. “I don’t have an answer for you.”
One patient in five, on average, survived more than 14 days on a ventilator with a coronavirus infection. Yuen had been on the vent 20 days.
His recovery was just beginning.
Rehabilitation
Though the main goals of rehab are to rebuild muscle strength and lung capacity, some side effects of the extended periods critically ill patients spend in ICUs are seldom discussed. These include delirium, confusion and longterm cognitive impairment.
Over the past decade, critical care specialists have focused on how to recognize and prevent “ICU psychosis” and “post-ICU syndrome.”
The sheer number of patients, the concerns about contagion, the redeployment of non-critical-care specialists to ICUs and the absence of visitors to anchor patients in time and place have all contributed to the disorientation.
“The ICU is a special place,” Gomez-Marquez said. “The brain isn’t used to that environment. The lights are always on, the nurses and doctors are always yelling, and the alarms are always going off.”
It’s too soon to tell what COVID-19 ICU survivors such as Yuen will experience, but there are a lot of them.
At the pandemic’s peak in mid-April, 1,705 patients in New Jersey ICUs relied on ventilators to breathe. As of June 4, there were 406 – a reduction that was a result of “flattening the curve” of the pandemic, as well as doctors’ evolving understanding of how to treat critically ill COVID-19 patients. These patients have stayed on ventilators a long time – usually two weeks or more, compared with the pre-pandemic norm of seven to 10 days for pneumonia.
About 75% of all ICU patients suffer delirium – mental confusion and memory loss – during their ICU stays, according to a study published in the New England Journal of Medicine in 2013. A year after their stay, one in four of these patients still showed evidence of cognitive impairment equivalent to mild Alzheimer’s disease.
Yuen was confused when he woke up. There were times he couldn’t tell the difference between reality and dreams. He had frequent panic attacks.
Things that tethered his mind to reality were missing. He couldn’t look out a window. He didn’t know the day or the time. He had no idea how long he had been unconscious.
Yuen and his brother Nicholas learned they each had hallucinated during their illnesses that the other had died.
The hospital transferred Yuen from the ICU to a transition unit, but even that was overstimulating, Gomez-Marquez said. Yuen was moved to a regular medical-surgical floor, then, as soon as he was able, sent home.
Those first few days at home, he sat on a futon in his living room, with a tower of celebratory balloons on one side and X-men posters on the wall, watching television or using his phone.
That’s where Veronica Victorero, a registered nurse from Holy Name’s home health care department, found him when she introduced herself and took a medical history the day after he left the hospital.
“Before this, I’d have to run at least 4 miles before I broke a sweat or started to feel winded,” Yuen told her. Now climbing the stairs to his apartment left him winded.
At least 10 times a day, he breathed through a spirometer, a device respiratory therapists use to train patients to take slow, deep inhalations to expand their lungs – similar to retraining outof-shape muscles. He measured his oxygen levels with a pulse oximeter and took his temperature and blood pressure with devices supplied by the hospital to monitor his vital signs remotely.
He was an early enrollee in the hospital’s Post-Acute COVID Exercise and Rehabilitation, or PACER, program, so a physical therapist visited to teach him exercises to strengthen his legs and regain the energy he’d lost.
“Our expectation and goal is to get him back to what he was before – and beyond,” said Jason Kavountzis, the hospital’s director of rehabilitation services.
Even patients who are inactive and in bed for as little as 72 hours lose muscle mass, Kavountzis said – imagine how much more that occurs in COVID-19 patients.
Yuen’s voice – essential to a job that entails speaking on the telephone eight hours a day – was weak, and his throat was sore. That was partly attributable to the intubation and partly to his reduced lung capacity.
His primary care doctor, Eli Djebiyan, wasn’t worried. She suggested he return to work July 1.
On the road to recovery
In mid-May, Victorero pulled into the parking lot of a two-story brick apartment building in River Edge. It was 10 a.m., her second patient visit of the day.
She donned gloves and pulled a blue disposable gown over her head, pushing her arms through its sleeves. She added a second pair of gloves, eye goggles and a surgical mask on top of the N95 mask she already wore. The only equipment she carried was her stethoscope.
This was the last of six visits with Yuen, who had been discharged from Holy Name a little more than three weeks earlier.
His improvement was dramatic. On her first visit, he’d barely risen from a seated position on the bed. This time, he easily came downstairs to open the door and lead her back up. She cheered this progress.
Victorero loves the closeness that visiting a patient at home affords. The pandemic has taken a heavy toll – on her patients and herself.
One of those patients, recovering from the virus, grieved over the loss of her mother to COVID-19 because she didn’t have a chance to say goodbye. Another was asked to decide whether to discontinue life support for his wife, who was dying from the virus, on the day Victorero visited.
“Sometimes we do a lot of listening,” she said. “We cry a little bit, because we’re human beings. This whole process is hard. We’re mentally exhausted. But we have to be strong.”
She stood in the living room, facing Yuen on his futon. “How are you doing, Christopher?” she asked.
He was doing well, he said, so well that he wanted to be evaluated to see whether he could donate plasma. The antibody-rich blood plasma of recovered coronavirus patients is being studied as a potential treatment for patients with the virus.
He inhaled on the spirometer for her – perfect. He showed her the 98% reading on his pulse oximeter – perfect. His blood pressure was a little high, she said, “maybe because you just went up the stairs.”
She went over his medications, most of which were no longer needed. The anxiety, pain in his throat and upset stomach had all abated.
A quick listen to his lungs – “beautiful!” – then the summation: Keep using the spirometer. Wear a mask, wash your hands and practice social distancing. Eat less salty food, and drink plenty of water.
“You are one of the lucky ones,” she told him. “Slowly, you’ll go back to your normal life. Enjoy life.”
He rose and went to his desk. “I have something for you,” he said, handing her a wrapped box of chocolates.
The day before, he had walked to the drug store and back home without getting out of breath.
He spoke with his mother every day. “It’s taken a while,” Susan Yuen said. “But he’s on the right track – physically getting stronger and emotionally and mentally getting back to normal.”
Soon, he hopes, he’ll get on a plane and go visit his mother across the country.