During my time as a medical student it was rare for a week to go by without some doctor telling me to, “listen to the patient”. They were right. Whether it’s on a mountainside or in the confines of the ITU, listening has often lead to the right diagnosis and perhaps more importantly, told me whether the treatment plan was working. This was certainly the case recently when a patient with Covid-19 was admitted to our critical care unit in the first few days of the pandemic…
The call came from the ED registrar shortly after the start of a night shift. The story was already becoming a familiar one – an obese man in his mid 60’s had presented with a week’s history of fever and respiratory symptoms that had recently taken a turn for the worse. Findings included a low lymphocyte count, characteristic x-ray changes and an oxygen saturation in the 70’s. But there was something else. Sounding somewhat exasperated, my colleague paused and finished by saying, “and the patient refuses to turn onto his back”.
Along I went to the ED and found a group of frustrated nursing staff trying to turn the patient over. It was clear from the muffled cries from behind the oxygen mask that this wasn’t going well and so I encouraged them to stop. I knelt down and asked the patient why he was resisting. “I feel better like this” came the reply. When pushed further he said that his breathing was easier, that he felt a lot more “clear headed” and there was no “bloody” way he was going to turn onto his back!
Looking at him it slowly dawned on me that there might be a physiological explanation for his reluctance to lie on his back.
COVID-19 Pneumonia. Of those patients with COVID-19 who require hospitalisation approximately 70% have an abnormal x-ray on admission. Findings are most often seen after 10-12 days of illness. Ground glass appearance is normally bilateral, peripheral and inferior. Pleural effusions are rare.
On his back the weight of the heart and abdominal contents were squashing the areas of lung around the spinal cord and great vessels. These parts of the lung receive a large blood supply and can be crucial if oxygen is going to be taken from the lungs and transported around the body. In Covid-19 this may be even more important as much of the lung may be badly damaged. Results from the patients CT scan confirmed this, showing that the only healthy areas of lung were those posterior parts that opened up when in the prone position.
In one simple maneouvre the patient had allowed a small amount of healthy lung tissue to work to the best of its ability and significantly increase the amount of oxygen entering his body.
Over the next week, the patient spent most of the time wearing a CPAP hood. This not only gave him the high concentrations of oxygen that he needed but also provided the positive airway pressure necessary to open up his damaged airways. As the patient improved he started to spend less time on his front. Noone told him what to do, he just did what felt right. Thankfully, this patient-led approach meant that he was saved from mechanical ventilation and discharged home a few days later.
By listening to patients like this I’ve recognized the value of proning in the treatment of Covid-19. So have many others. As one of our nursing staff so memorably put it,
"Face down ass up
That’s the way the sats go up!"
More on the "link" between COVID-19 and mountain medicine can be found here.