There are patterns and rhythms to life in a hospital’s emergency department. Many local clinics are closed on weekends, and many people don’t want to go to the hospital on their days off, and so Mondays tend to be busy; midafternoons are hectic, until things cool off, by eight or nine. Diseases also behave in recognizable ways. Chest pain radiating to the arm suggests a heart attack and, even as I talk with a patient, a sequence of diagnostic tests, medications, and specialists unspools in my head. Difficulty speaking and weakness on one side suggest stroke, and from the moment I learn about those symptoms I can see the entire course of treatment, from the medical workup to rehab, in my mind’s eye.
These days, perhaps because people are afraid to come to the hospital, we’re not seeing as many heart attacks or strokes. Instead, a new pattern runs through our days, persisting even though Boston is past the peak of the coronavirus pandemic’s first wave. In April, there were nearly four thousand patients hospitalized with COVID-19 in Massachusetts, many of them in critical condition; now, there are around two thousand five hundred. The virus continues to circulate—there are still hundreds of new positive test results every day in the state—and patients continue to come in very sick. Over the radio, we still hear the familiar radio messages from ambulance crews: “Sixty-five-year-old male with fever, cough, and difficulty breathing,” they might say. “Requesting isolation precautions. E.T.A. five minutes.” On one particularly rough day earlier this month, my colleagues intubated at least one critically ill COVID-19 patient every hour for much of their shift. The social-distancing regime may be beginning to lift, but Boston’s experience with the coronavirus is far from over.
Diagnostic tests for the virus still take hours or sometimes days to return results, and so we’ve become used to figuring out for ourselves which new patients have COVID-19, relying on symptoms, blood tests, imaging, and intuition. In the E.R. where I work, two things happen simultaneously when a patient arrives. A team of nurses connects a variety of monitors—an inflatable cuff to measure blood pressure, nine electrode stickers to trace the heart’s rate and rhythm, and a small plastic box called an oximeter, clipped to a fingertip to measure oxygen levels. While this is happening, we are also observing. Does the patient appear attentive and alert, making good eye contact, or is he confused or in pain? Is he clammy? (Clamminess can herald serious illness: an old medical adage suggests that, if a patient is sweating, his doctor should be, too.) Most important, we watch what we call the work of breathing. Ten to twenty breaths per minute is normal, more than thirty is worrisome. A struggling patient might use his shoulder and neck muscles to breathe, or purse his lips. In the most severe cases, the skin between each rib sucks inward, or “retracts,” with each desperate breath.
All of this information contributes to what we call gestalt—a German word meaning pattern or shape, which refers to the total picture of how ill a patient is. Sometimes the gestalt comes into focus quickly. Medics bring in a woman with shortness of breath and, as she is transferred to a gurney, we notice that she is breathing rapidly, using her shoulders to do so, and that she appears clammy and inattentive. Numbers begin to appear on her monitor—heart rate elevated at a hundred and twenty beats per minute, blood pressure abnormally low, oxygen level of seventy per cent flashing red on the screen. “Febrile to one hundred and three Fahrenheit,” a nurse calls out. We see immediately that she is critically ill, probably from COVID-19, and requires immediate attention.
For less critically ill patients with whom we are able to converse, the gestalt tends to reveal itself slowly, through a series of questions. We ask about symptoms and how they’ve evolved; we also ask about symptoms they haven’t had, to help exclude possibilities. A coronavirus infection, when it isn’t asymptomatic, is often mild at first, and COVID-19 may make itself felt through minor symptoms that can evoke the common cold, the flu, or even allergies. And yet, while those familiar ailments primarily affect the nose, the throat, and the pharynx—together called the upper respiratory tract—the coronavirus seems to skip directly to the lower respiratory tract, multiplying in the lungs. A minority of COVID-19 patients, therefore, report nasal congestion and sore throat; more experience lung-centric problems such as cough and shortness of breath. (As the pandemic has progressed, we’ve also learned to look out for other, stranger symptoms. Recently, I cared for a middle-aged mother of several children who came to the hospital complaining only of diarrhea and weakness; occasionally, the virus attacks the heart, and we were surprised to find that hers was failing. Other patients have described neurologic symptoms, such as impaired taste, headaches, or memory problems. Kidney failure has been reported, too.)
In the lungs, the tiny air sacs called alveoli get damaged or filled with debris as the infection spreads. The result is pneumonia—an inflammatory response to the damage. In the eighteenth century, doctors detected it using a technique called percussion: tap a finger smartly against the chest, and afflicted lungs sound dull, while healthy ones are drum-like and resonant. Today, we use X-rays. Plugged alveoli attenuate the rays, and so appear on film as white patches. It’s easy to recognize the lacy white streaks of COVID-19 pneumonia reaching, cobweb-like, through the lower fields of both lungs. Sometimes this signature appears unexpectedly, in an X-ray ordered for a dislocated shoulder, say, or after a car accident. Occasionally, a chain around a patient’s neck appears on the film, fastened to a wedding band or crucifix—a reminder that each image represents more than just another case of COVID-19.
The coronavirus may seem like an equal-opportunity threat, afflicting prime ministers as well as bus drivers. But the truth is that it’s especially vicious when it spreads within marginalized populations. Last month, in Louisiana, African-Americans accounted for seventy per cent of the deaths caused by COVID-19, more than twice their share of that state’s population; in Chicago, the risk of dying of COVID-19 if you’re black is six times the risk if you’re white. Similar trends have been reported in the Carolinas, Nevada, Connecticut, Wisconsin, and New York. In Boston, our Hispanic population has borne the brunt of the disease: at Massachusetts General Hospital, Hispanics have comprised as much as forty per cent of COVID-19 inpatients. (Normally, they account for about nine per cent over all.) And so, in addition to asking our patients about their most recent symptoms, we take note of their chronic health problems, their ethnicities, and the circumstances in which they live. Only one in five African-Americans have jobs that allow them to work remotely; crowded housing arrangements increase exposure and transmission; minorities have long suffered from inadequate access to health care, and carry a higher burden of chronic illness as a result. We’ve grown used to the diagnostic patterns that accompany COVID-19—they’re as familiar to us now as the ones that attend heart attacks and strokes—but these social patterns, which have also always been there, now stand out with disturbing vividness.
