Measles, Influenza, Covid: Tales from the Crypt

 

Of all the people Mad Dog has seen die, and there were scores of them who died when he was training, one stands out from the rest. 

It's not entirely clear why, but likely has something to do with her youth and the unexpected nature of her course of illness.

Mad Dog had seen people die with great regularity at the Memorial Sloan Kettering Hospital for Cancer and Allied Diseases, but they had cancer and were expected to die and when they did, some of them welcomed death.

This woman was 21 years old and brought to the emergency room by her boyfriend. The ER resident called Mad Dog down saying, "She just looks...dusky."

The admission game in the ER is that the ER resident has to justify why he thinks a patient is sick enough to require admission because the intern getting that patient is going to be working for hours no matter how sick or not sick the patient may be, and the intern wants to be convinced the case justifies all that effort. 

But in this case, the ER resident was not calling an intern, he was calling Mad Dog, who by then was a senior resident, and it was Mad Dog's job to decide if the patient was sick enough to warrant a precious ICU bed. In those days even a big city hospital like The New York Hospital only had 12 intensive care unit beds, and those were on the Cardiac Care Unit and were, theoretically reserved for people with heart attacks, usually men in their 50's, but here the resident was pitching admitting this 21 year old woman to the CCU, and she had no heart problems. 

What she had was "dusky." Even in the fluorescent lights of the Emergency Room, you could see it. Dusky means sort of gray/blue. 

Mad Dog's job was to look at her and say either yes or no. If it was no, she'd go the ward, where each nurse had a dozen patients and more at night, and this was just before midnight. 

She was lethargic, but awake, not comatose, and the ER resident had done blood gases and her oxygen level was 60, which had to be a mistake.  Arterial blood oxygen was 90-98% not 60. This was in the days before those little finger gizmos which show you your oxygen saturation--to know the arterial oxygen level you had to stick an artery--usually we used the radial artery in the wrist and then plop the syringe in an ice cup and press on the wrist for 15 uninterrupted minutes. Sometimes, if you missed the artery you hit the vein next door and Mad Dog thought the ER resident had inadvertently sent off venous blood.

This being night time, there was no nurse to do the compression, so Mad Dog did all that and then ran the cup up to the lab on the 9th floor. By the time he got back to the ER, breathless and wondering what his own blood oxygen level might be, the lab tech was on the phone with the results: 60, again. And Mad Dog knew for sure that was an arterial blood--the syringe had pumped up a centimeter with each heart beat, just the way it should have. 

So Mad Dog wheeled her gurney up the the CCU where the intern and resident were nowhere to be seen, busy with other crises and Mad Dog remained with her for a while. She just got bluer and bluer and more and more obtunded and before we even had a chance to put her on a respirator, she arrested (cardiac arrest) and died right in front of us, the nurse and Mad Dog. 

It was flu season, so the hospital was packed, every bed occupied, some patients on beds in hallways, and when the autopsy results came back we understood why she never stood a chance: Her lungs were the consistency of liver. Normally lungs are sponge like, pretty fluffy and light and moist, but these lungs were thick and heavy and maroon, and there was no way air would come into contact with the delicate blood vessels carrying the red blood cells which were supposed to pick up oxygen across the delicate alveolar vascular spaces. 

The influenza test was positive. 

She had died of influenza.

Mad Dog presented her case to a half dozen conferences, asking everyone what he could have done differently. He knew he should have intubated her--put her on a respirator in the ER, but that was difficult and had its own risks and would have delayed getting her to the CCU. But beyond that, Mad Dog was looking for answers from the graybeards, the guys who had tricks up their sleeves, who had seen everything and done everything.

 But as he gave the story, he saw the flash of recognition in all the older doctors' faces: They had all seen patients die of influenza.

"This is what influenza does," they would say, shaking their heads. "It just does that." 

Not to everyone, influenza does that, but to a high enough percentage that more people and more soldiers died of influenza in 1918 Europe than died from bombs and bullets on the battlefield.

When COVID hit New York City, Mad Dog's son was doing his residency at Mt. Sinai. They had long refrigerated 18 wheel rigs parked outside the hospital on Fifth Avenue--to receive the bodies. The hospital morgue was overflowing. He had to strip down in the hallway outside his apartment and put  his scrubs and mask in a black plastic garbage bag, and walk straight to the shower before seeing his wife and baby. 

Given the death rate of COVID, early on in that pandemic in 2020,  about 3-4 million Americans were projected to die from that virus. In that first year only 1 million died, once the vaccine became available. "Only" a million died. Death statistics are endlessly arguable, but it's pretty clear the vaccine saved lives, and not just the lives of people at the far end of their lives, but little kids, twenty-somethings, all through the age ranges.

Watching "Gone with the Wind" in a movie theater Mad Dog was struck by the audience reaction when Scarlett O'Hara gets the letter which announces that her husband had died, not in combat, but from measles, in camp. 

The audience laughed.

Mad Dog knew why they laughed. Scarlett's husband was a well meaning nerd, a half man, not virile or a warrior and it seemed perfect that he would die of a child's disease, to which no strong man would succumb.

But, of course, measles took the lives of thousands of soldiers in their camps, men who had never been vaccinated or even exposed to measles because they lived isolated on farms. 

But, of course, to that 1974 audience, living in New York City, in an age of universal vaccination, these folks had never seen measles, nor heard much about it. Measles seemed to these 20th century New Yorkers a ridiculous thing to die from.

When you think about it, in the 21st century, it still is a ridiculous thing to die from. But watching someone die from measles does not seem ridiculous. It is bleak, maddening, agonizing.

And we will see more of that now. Because of just a few men, our President and his chosen new vaccine expert, RFKJR. Neither should ever be forgiven that. 

Diptheria has just claimed several victims. Influenza will always claim victims, but fewer if enough people get vaccinated. COVID is less likely now to claim the young, but it will still claim some unvaccinated. And measles now is doing its terrible work again.

Measles does that. It just kills people with a pneumonia. That X Ray at the top of this blog post is a measles pneumonia.