If Decatur residents could witness what he sees every day inside Decatur Morgan Hospital, Dr. James Boyle suspects they would all be wearing masks in public and social distancing.
“People say, ‘This is overblown; it’s just like the flu.’ But it’s not like the flu,” said Boyle, a pulmonologist and medical director of the intensive care and critical care units at Decatur Morgan Hospital. He is overseeing the treatment of about 20 patients with confirmed cases of COVID-19 and another 20 “persons under investigation” who are awaiting test results. “It’s 10 times worse than the flu. It’s not the same. It’s much worse, and we’re dealing with lots more.”
Boyle said three people had died of COVID-19 at Decatur Morgan Hospital as of Friday, and four were on ventilators — a last-ditch step he only takes when patients are not responding to other treatments. No COVID-19 patients have successfully been removed from ventilators, although he said he expects the patients now on them to recover.
According to Alabama Department of Public Health data, two Morgan County residents have died of COVID-19, and no residents of Lawrence or Limestone counties have died of the disease. Assistant State Health Officer Dr. Karen Landers on Friday said the discrepancy between the hospital's death count and the ADPH numbers could be explained if the Decatur Morgan Hospital deaths involved people residing outside the three counties, or it could be due to ADPH delays in confirming a death was caused by COVID-19.
“While the process is as expedient as possible, there can be periodic delays due to obtaining medical records or other information,” Landers said.
The only drug that’s shown significant benefit in treating the new coronavirus, remdesivir, was not available in Alabama on Thursday or Friday.
Landers said ADPH exhausted its supply of remdesivir Thursday, but expects to receive more this week.
Boyle said remdesivir is most effective when administered early. His daily routine, until the state ran out, was to evaluate each of his confirmed COVID-19 patients and to score the unconfirmed cases to determine if they were likely to have the disease. He used that information to issue a request for the appropriate number of remdesivir doses, which are administered through a five-day course of injections, sometimes followed by another five days.
“We’ve got a few doses left, and we hope it will get us through,” Boyle said. “In my estimation, that’s the treatment of choice. I believe that remdesivir helps early on, so we try to get that to people as soon as we can when they come to the hospital.”
It's a bad time to be without the drug. ADPH reported 39 new cases of COVID-19 in Morgan County on Friday and 37 on Saturday. Of the 553 cases in the county, more than half have been reported in the last two weeks. Morgan County has more confirmed COVID-19 cases than Madison County, despite having one-third the population. Statewide, 888 new cases were reported Saturday, the highest daily count since testing began. It was the third consecutive day of record highs.
ADPH typically distributes remdesivir to hospitals the day after they request it — and not by FedEx.
“The vast majority of remdesevir is delivered to hospitals by couriers from the Attorney General's Office,” Landers said. “The attorney general has graciously allowed ADPH to utilize the AG investigative staff to provide this most needed service.”
Boyle said the first phase of COVID-19 is similar to influenza.
“With this COVID-19 virus you do have that first phase of illness just like the flu, where you have the fevers and the chills and the body aches. As that starts to go down, we have to deal with something called the cytokine storm. As the virus is going away, now your immune system is kicking in,” he said.
The immune response can be deadly.
“Influenza is a virus that predominantly affects the lungs. But COVID-19 is a systemic virus. It affects every single organ. We’re seeing effects to the brain; we’re seeing effects on the heart and in the gut; we’re seeing kidney failure,” he said.
Another unique symptom of COVID-19 is that it causes abnormal blood clotting, or coagulopathy.
“For the coagulation part, we’re using blood thinners. As (coagulation increases) we’re using more and more of the blood thinner to see if we can keep the people from getting clots and strokes and things associated with this virus,” he said.
Boyle does not use steroids during the viral stage of the disease because it suppresses the immune system, but he uses steroids and other immunosuppressants during the cytokine storm.
“The cytokine storm is a lot like the rheumatoid diseases, like rheumatoid arthritis and other inflammatory diseases where your immune system is really what we’re fighting at this point. We’re starting to fight an immune system that’s gone out of whack,” he said.
While shortness of breath is considered a classic symptom of COVID-19, Boyle said it’s not always present, and it does not correlate with the dangerously low blood-oxygen levels — called hypoxemia — he sees in some patients.
A person with healthy lungs typically has a blood-oxygen level over 95%. “We get a little nervous when it’s less than 90, a little more nervous when you’re less than 85. … If I can’t get you above 80%, you’re probably not going to survive.”
The problem is that people infected with the coronavirus may be hypoxemic without knowing it.
“What we see is these people coming in and they may be a little disoriented or maybe a little bit sick. They may be talking and they won’t say they’re short of breath, but their oxygen level will be 60%.
“There’s a term that’s going around with this pandemic. It’s called ‘happy hypoxemia,’ because people come in and appear to be OK, but they’re profoundly hypoxemic, to the point they can’t support their organ systems. That’s probably why some people get in trouble at home, because the normal signal that you’re in trouble — that you need to go to the hospital — is that you’re short of breath. This illness does not necessarily have that.”
Boyle said patients with a severe case of the flu are sometimes put on ventilators, basically to give their lungs time to heal. Those experiencing a cytokine storm, however, have a much worse prognosis.
“If you end up on a life support machine, it’s not a short course. You’re not on it for three days, not for five days. You’re likely to be on it for three weeks or longer. If the inflammatory response just continues, and we’ve seen this occur, those lungs just get progressively worse,” Boyle said.
COVID-19 patients are sedated before being put on a ventilator, and sometimes drugs are used to paralyze them.
“There are two reasons we paralyze you. One is you require less oxygen when we paralyze you. But the primary reason we do that is that we have to have maximum control over your breathing. If we don’t paralyze you then you will cough and you will try to breathe against the machine and you’ll generate really high pressure that will do more damage to your lungs. We’re trying to maximize our ability to oxygenate you, but sometimes even that is not enough,” he said.
He said one patient died after being on the ventilator 26 days. Another died after about 23 days on life support.
If the ventilator is not raising the blood-oxygen levels enough, Boyle and his team will flip the unconscious patients onto their belly, called “proning.”
“It sounds simple, but it’s not,” Boyle said. “We don’t typically have IV access to your backside. So you now have a tube in your windpipe. You’ve probably got a tube in your nose that’s going into your stomach. And then you probably have one or more lines either in your neck or below your clavicle or in your groin. And you’ve probably got a catheter in your bladder. When you flip people over, you definitely do not want to pull the tube out of the windpipe — that would be catastrophic.”
The procedure is risky enough that Boyle is always present when it’s done. He assigns a respiratory therapist to monitor the ventilator tube, and a separate nurse to monitor each IV line or tube. Other nurses will then slowly roll the patient over. To avoid causing ulcers on pressure points in the prone position, one of the patient’s arms is placed along his or her side and the other is folded over the head.
“I’ve been here since ’98 and I’ll employ that maneuver once or twice every couple of years. With this new virus that’s coming through, we are proning people pretty much every day,” he said.
He said it’s too early to know, but he expects it will turn out that those who survive severe cases of COVID-19 will have ongoing cognitive problems.
“I suspect they’re going to have cognitive issues related to this inflammatory process, because this inflammatory process is affecting every vessel, and the brain is a very vascular structure,” he said. “Those people with more severe disease will probably have some cognitive issues down the road, and I wouldn’t be surprised if they’re chronic.”
Boyle said he gets frustrated when he hears claims that the number of COVID-19 deaths are being inflated.
"You can do a separate article on things that irk the pulmonologist. One of the things I hear people say is, ‘We don’t believe the death numbers. They say they die from COVID so they can collect more money.’ I don’t believe the death numbers either. I think we’re missing some," he said.
One factor that leads to overlooked COVID-19 deaths, he said, is the coagulation caused by the disease.
"You’ve got people who have heart disease and they would have been alive for another five years, and they get COVID and they get a little bit of this coagulopathy, so they’re more likely to have a heart attack. You’re going to see them die in their sleep or something and not count it," Boyle said. "So I don’t believe the numbers either. I think the numbers are under-representing what’s actually happening in the community."
His experience on the front line of the fight against COVID-19 has Boyle mystified that people in Decatur are not being more cautious, particularly since asymptomatic and presymptomatic people can transmit the virus.
“I’m 100% convinced they are not taking it seriously enough,” he said, especially when he finds himself as one of the few people in a store wearing a mask. “In general, I would say we’re doing a terrible job. … Each exhalation, you’re just blowing that virus out. And anybody that walks by that cloud and inhales is going to have the virus.”
He said he’s treated COVID-19 patients ranging in age from 20 to 90. Some contracted the disease when singing at church, some have no idea where they caught it, and some got it from a family member.
“I think the older generation is in general trying to self-quarantine, but then they get it from the younger generation, which is a tragedy,” he said.
It's a tragedy he's trying to avoid.
“I am self-quarantined from my parents. If I see them, they sit on the porch and I sit in the yard. I don’t see them as much as I would like, mainly because I don’t want to live out that tragedy. I don’t want to take the virus and give it to my mom or my dad and they pass with that illness, and I carry that burden for the rest of my life.
"I have seen that tragedy in our little hospital. All the tragedies that you see play out on the big stage are playing out in this little community hospital.”