A Blog by Jonathan Low


Aug 9, 2020

The $1.9 Million Covid Patient: What Happens After Weeks In the ICU

Covid is causing extended patient stays in what was already the most expensive area of hospital care. And there are, as yet, no signs of the healthcare system's ability to moderate that level of service, or cost, punishing families, insurers and institutions. JL

Melanie Weeks reports in the Wall Street Journal:

Many of the most severe Covid-19 patients often are hospitalized for weeks rather than the few days typically spent by an intensive-care patient. That translates into fewer available beds as more Covid-19 patients arrive. One study of Covid-19 patients found half of those in ICUs remained for at least 10 days. Before the pandemic, the median patient remained in intensive care for two to three days.“Critical care is one of the most costly services a hospital provides. It’s a huge problem at the family level but a pretty substantial cost element for the health-care system also.”
Josephine Mazzara watched her husband disappear into a Manhattan emergency room, unable to follow and uncertain when she would see him again.
Once inside, doctors quickly diagnosed Salvatore Mazzara with Covid-19. Soon, the 48-year-old’s lungs, kidneys and heart would give out. Doctors tried experimental drugs and tested other therapies in an effort to keep him alive. He was put on a ventilator and when its prolonged use posed a danger, they delivered oxygen directly through a hole cut in Mr. Mazzara’s throat.
He survived. But he didn’t leave the hospital for six weeks.
Covid-19 has proven a surprising disease, with some patients experiencing few or even no symptoms, and others succumbing to a deadly assault on organs, circulation and the immune system. Some, like Mr. Mazzara, hover in lengthy limbo in intensive care, often for weeks, among the sickest in the hospital and some of the most difficult to treat.
“We all know what to do almost all of the time,” said Robert Hiensch, one critical-care doctor who cared for Mr. Mazzara. “All of a sudden, you’re faced with hundreds and hundreds of patients where you’re all just learning on the fly.”

Many of the most severe Covid-19 patients often are hospitalized for weeks rather than the few days typically spent by an intensive-care patient. That translates into fewer available beds as more Covid-19 patients arrive and hospitals reopen to others in need of intensive care. In Texas, Florida and Arizona, hospitals reported rising numbers of Covid-19 patients in intensive care in July, forcing some to turn away ambulances and transfer patients hundreds of miles.
One early study of Covid-19 patients in California and Washington found half of those in ICUs remained for at least 10 days. Before the pandemic, the median patient remained in intensive care for two to three days, some studies show.
Mr. Mazzara remained in Mount Sinai Hospital for 44 days. He spent 23 of those days in intensive care.
Patients with lengthy intensive-care stays were a key driver of ICU expansions at Mount Sinai as cases in New York surged. The hospital expanded to 10 intensive-care units, from seven, which require more doctors and nurses, more technology to monitor patients and protect staff, and re-engineered ventilation to prevent the virus from circulating, said Roopa Kohli-Seth, director of the Institute for Critical Care Medicine at the hospital.
A significant surge in chronically critically ill patients risks added strain to budgets of public and private health insurers and households, said Jeremy Kahn, professor of critical care medicine and health policy at the University of Pittsburgh. Hospital costs for the so-called chronically critically ill—patients in the ICU for at least eight days, with certain other conditions—totaled an estimated $26 billion in 2009, Dr. Kahn and colleagues reported in 2015.
“Critical care is one of the most costly services a hospital provides,” said Shannon Carson, chief of the division of pulmonary and critical care medicine at the University of North Carolina School of Medicine. “It’s a huge problem at the family level but a pretty substantial cost element for the health-care system also.”
Bills submitted to the family’s insurance company for Mr. Mazzara’s care totaled about $1,881,500, according to statements reviewed by The Wall Street Journal. It includes about $867,000 in bills that the insurance company disputes. After subtracting discounts of the price negotiated by the insurer, bills so far total roughly $178,200. The amounts aren’t a final bill and could change. The Mazzaras’ share will be based on their insurance benefits.
The hospital system won’t directly bill patients for care, a Mount Sinai spokesman said. “Anyone, regardless of health insurance status, who requires treatment and care for Covid-19 can come to any hospital in the Mount Sinai Health System and receive the world-class medical treatment they deserve,” he said.
This account of his hospital stay is taken from interviews with Mr. Mazzara, Ms. Mazzara, their children, Gabriella, 18, and Salvatore Jr., 20, and staff and physicians at Mount Sinai.
The Mazzaras had initially hoped to avoid the hospital when Mr. Mazzara’s persistent cough grew worse. He began to suffer fever, aches and vomiting.
On April 3, Ms. Mazzara watched her husband tuck a card for the Catholic Saint Padre Pio into his pocket. Her anxiety soared. “You can’t really breathe, can you?” she asked.
The two had met as teenagers, when Salvatore went to an Italian bakery to buy bread and Josephine was behind the counter. They recently celebrated their 24th wedding anniversary.
On April 4, the couple raced from their home in the borough of Queens to the Mount Sinai Hospital emergency room in Manhattan.
Hospitals nationwide closed to all visitors to prevent spread of the virus. Before walking into the hospital alone, Mr. Mazzara told his wife: “I will see you soon.”
She was frightened. “Will I see him again?” Ms. Mazzara thought. “Can this be happening to my family?”
Doctors pumped air and oxygen into Mr. Mazzara’s lungs, but with little change to his gasping for breath. Mr. Mazzara was too sick to return home. Doctors admitted him.
He quickly was given hydroxychloroquine, an antimalarial medication that has emerged as a high-profile example of medical uncertainty in the pandemic.
Early reports from China and France suggested hydroxychloroquine helped improve Covid-19 symptoms. The Food and Drug Administration authorized the drug for emergency use. Demand by doctors and the public soared despite risk from side effects, while researchers pushed forward with more studies.
Mount Sinai eventually halted its use on April 24, based on studies that found little benefit and after the FDA warned of reports of serious heart-rhythm problems for Covid-19 patients who used HCQ, said Judy Aberg, the Icahn School of Medicine at Mount Sinai infectious diseases chief. The FDA revoked its emergency authorization, granted in late March, in mid-June.
His first three days in the hospital, Mr. Mazzara didn’t need intensive care. He had a chronic condition that could affect his lungs, but it wasn’t active, and he was healthy, said one doctor who cared for him. Mr. Mazzara texted his wife about their children, believing he would be home soon.
Then, on the evening of April 7, an alert for a patient in critical condition brought Dr. Hiensch to Mr. Mazzara’s bedside.
Dr. Hiensch stood before Mr. Mazzara, baffled by yet another a Covid-19 patient with dangerously low blood-oxygen levels who was alert and talking. Patients with such symptoms typically are confused and too distressed to speak.
To get more oxygen to Mr. Mazzara, Dr. Hiensch could place him on a ventilator, which forces air and oxygen into the lungs with more control than other breathing machines doctors already tried. But the machine isn’t without risks.
Doctors globally have struggled to decide how best to treat Covid-19 patients with injured lungs. Early reports of what worked were limited and conflicting, with doctors sharing experiences as the pandemic rapidly spread. Some said early use of ventilators prevented further harm to lungs; others urged more restraint in light of high death rates for Covid-19 patients placed on the machines, suggesting they aren’t as effective as for those with other illnesses.
Dr. Hiensch decided Mr. Mazzara’s blood-oxygen levels were too low to forgo ventilation. “His numbers were completely deranged,” he said.
Mr. Mazzara asked to call his wife. “If it has to be done, it has to be done,” she told her husband, wishing she could be there to hold his hand.
Once on a ventilator and heavily sedated, Mr. Mazzara needed the heightened monitoring of the ICU.
On his first day in intensive care, doctors ordered a new prescription: the experimental drug remdesivir. Doctors enrolled Mr. Mazzara in a study of the drug.
On the third day, Mr. Mazzara’s kidneys began to fail, a poorly understood complication of Covid-19. The kidneys prevent remdesivir from accumulating in the body. He was forced to leave the study.
Early results for remdesivir from a National Institutes of Health study show promise. It didn’t appear to help those most critically ill like Mr. Mazzara, however.
With such limited options, doctors could only try to help their Covid-19 patients outlast the virus as the body’s immune system fights the infection. For Mount Sinai critical-care doctor Sanam Ahmed, who also treated Mr. Mazzara, days became nonstop work to adjust medications and ventilator settings to give patients the best chance of recovery.
“We felt happy walking out the door as long as nobody died and we did our best to help,” she said.
For the first 10 days in intensive care, doctors treated Mr. Mazzara’s kidneys with drugs and helped his lungs with “proning,” which involves rolling a patient on his side or stomach. He remained sedated.
Unable to visit, Ms. Mazzara called the hospital at least twice daily. A doctor called her every afternoon. Mr. Mazzara’s kidneys slowly improved without dialysis; his lungs made incremental progress.
Then his heart stopped.
The pause was brief, but Mr. Mazzara’s heart muscle then began to quiver, known as atrial fibrillation. Critical patients commonly develop the heart issue, a response to stress, said Adel Bassily-Marcus, a critical-care doctor who treated Mr. Mazzara.
Doctors stopped the twitching with electrical shock.
Mr. Mazzara approached two weeks on a ventilator, a duration doctors consider to be long. His lungs continued to make halting improvement, but he still needed mechanical help breathing.
An anxious Ms. Mazzara organized food to be delivered to the hospital for staff. Family and her employer, the Dominican Academy, a Catholic girls’ school, brought meals of sausage and peppers, pizza and pasta.
At home, she slept on the couch and struggled to eat. Family brought groceries and called and texted their support. But risk of spreading the virus made it impossible for them to visit her.
She spoke often to a photo of her husband. “I know you can hear me,” she said. “You have to come home.”
His doctors considered the risks of prolonged ventilation. Use of heavy sedatives to make patients comfortable with a tube down their throat also puts them at risk of neurological complications, such as delirium or coma.
An alternative allows doctors to wean patients from sedation. It involves connecting the ventilator to a hole cut into the windpipe, a procedure called a tracheostomy. Doctors typically don’t do it for patients who would soon be off a ventilator. Mr. Mazzara’s doctors decided nonetheless he would benefit.
First he had to show improvement. The air-oxygen mix forced into his lungs by the ventilator needed to be 60% oxygen, down from 100%. His family waited days for him to reach the mark, checking the number on each call to the hospital. His daughter, Gabriella, chanted the magic number ahead of one call. The news came: He was at 60%. “We all screamed and cheered,” the 18-year-old said.
Doctors performed the tracheostomy. They gave Mr. Mazzara fewer sedatives and weaned him from the ventilator. They nudged him with questions and prompts to wake up.
He didn’t respond. Days passed. Doctors struggled to rouse Mr. Mazzara from a hazy state. Visits still weren’t allowed.
As they worked to keep Mr. Mazzara alive, the hospital emptied one floor to create a new ICU and did the same for two other wards. Demand for skilled nurses stretched the hospital’s workforce. Nurses who typically care for no more than two patients took on a third, with help from other medical staff who took on some of the nurses’ work.
Dr. Ahmed focused on changes to Mr. Mazzara’s drug regimen in an effort to wake him. She finally broke through. She asked him to squeeze her hand and wiggle his toes. He did.
Ms. Mazzara called the hospital on the last day of April. “He finally answered me,” a nurse told her. Elated, she asked to speak with her husband and was connected by video. “Keep fighting,” she told him. Mr. Mazzara recalls his wife’s words as part of a vivid dream, he said.
Speaking to her husband on the screen, for the first time in 23 days, was frightening, Ms. Mazzara said. His eyes were wide open and scared, she said.
Mr. Mazzara soon left the ICU for a floor where staff worked to wean patients off oxygen support.
A week after leaving the ICU, Mr. Mazzara was again able to breathe on his own, after 34 days.
Dr. Ahmed soon visited him, telling everything that had happened in the past month. He was amazed. The physician noticed he hadn’t eaten lunch. The hospital food wasn’t great, he explained. He longed for pasta. Dr. Ahmed cooked penne with arrabiata sauce that night and bought it for him the next day.
He started physical therapy to begin rebuilding his strength. The following week, doctors removed the tracheostomy tube. He called home often, chatting by video with his children, who panned the camera to the family dog, Luna. He asked his wife to leave the phone on, so he could hear activity in the house.
He was ready to leave, having been seen more than 350 times by doctors, nurses, nutritionists, social workers, chaplains and respiratory, occupational and physical therapists during his stay.
On May 18, Mr. Mazzara left the hospital, after six weeks. Outside, a crowd of family cheered as a hospital employee wheeled a waving Mr. Mazzara from the hospital. Health-care workers streamed out after him, clapping.
Doctors sent him home with blood thinners, a precaution being prescribed for Covid-19 patients. That has raised another mystery.
Doctors believe inflammation brought on by coronavirus can cause blood clots that contribute to strokes and pulmonary embolisms. They see benefits from the drug but are uncertain how long it may be required.
“We don’t know when to stop it,” Dr. Bassily-Marcus said.


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