Written 9/15/20
“Squeeze my hand, honey.”
Carl cannot stop repeating his plaintive mantra, even though Peggy is still unresponsive. He continues his vigil at her bedside in the ICU. It is a lonely watch, especially because the person he loves most in the world is right next to him, yet seems infinitely far away. Peggy has now been ill for twenty five days. What she has experienced during this ordeal is difficult to imagine. Her family has endured long periods of boredom and exhaustion, punctuated by episodes of horror, when some fresh complication jolted them unexpectedly. There have been plenty of jolts.
Sitting at her bedside, Carl cannot help but roll through the trials in his mind. There was the low blood pressure (shock) that left her barely clinging to life. Next, kidney failure necessitated dialysis. Soon after that, a blood clot required blood thinners.
Then, as a result of the blood thinners (as a complication of the treatment for a complication!), she abruptly decompensated from massive intestinal bleeding. That was a week ago. Carl was in the room for that incident, the most touch-and-go moment of all. Peggy’s bed suddenly filled with dark blood, pouring from her rectum. Her blood pressure plummeted, and she took on a color so ghostly and a look so deathly that the vision will haunt Carl forever.
But the tide has turned since that low point. Her kidney function has improved, and Peggy has not required dialysis for four days now. Blood counts are normalizing. Lung numbers are trending in the right direction. The blood pressure has stabilized, too. Many of the tubes have been removed.
One constant, though, is the ventilator. Despite her improving oxygen levels, Peggy has not been able to breathe on her own. She required a tracheostomy last week in the anticipation of a long road ahead, if she should survive at all. But most discouraging is the fact that although Peggy’s sedating medications were tapered and discontinued three days ago, she has not awakened.
The Course of COVID-19
We don’t yet know what proportion of people who are infected with SARS-CoV-2 actually develop symptoms. The latest data suggest that perhaps forty percent of cases are asymptomatic.
Of those with COVID who do actually get sick with symptoms, eighty out of 100 will recover relatively uneventfully. Their illness will last a few days to several weeks and range from something like a minor cold to a miserable case of the flu. I don’t want to minimize their suffering. Losing one’s sense of taste and smell, having a fever for weeks, or coughing for a month are life-dominating experiences.
But life-threatening is another thing altogether. Peggy endured a typical COVID-19 illness of fever and cough for a week and a half. Then, when most would be recovering from the illness, the bottom dropped out. She falls into that unfortunate twenty percent. For them, there is a more severe stage of the illness, typically involving pneumonia and sometimes progressive failure of other organs (such as kidneys, liver, brain, or heart), shock, blood clots, and bleeding problems. This advanced stage of COVID-19 will prove fatal in 1 to 2 of the original 100 patients.
Paradoxically some patients with this advanced disease do not have high loads of virus. In fact viral levels in the body begin to fall five days after the onset of symptoms and sometimes are not even detectable in this severe stage of the illness (as is the case with Peggy). That is because this rarer, critical phase is characterized less by direct damage from the virus, and more by an over-activation of the immune system. In the most extreme cases, something known as “cytokine storm” ensues. This cytokine storm is what has swept away Peggy in a tempest of inflammation.
What are cytokines? They are not made by the virus. They are normal substances made by your own body and they seem to be responsible for many of the most severe manifestations of COVID-19. Cytokines are the chemical language of the immune system.
Military Intelligence
Communication is paramount in a military conflict. Armies use messengers, written orders, smoke signals, flares, and radio transmissions to coordinate their efforts. In the heat of battle, officers bark orders to the troops, and radio chatter flies up and down the lines of command with frantic calls for air support, artillery fire, and troop deployment.
Things are not much different at the microscopic level. This is a strange concept – cells within your body communicating with one another – especially when you consider that you are completely oblivious to it all! The cells of the immune system can communicate by directly touching one another via receptors on their surfaces. These interactions convey basic information, like “I am on your side,” (the way a uniform identifies which “side” a soldier is fighting for), or “Sir, would you take a look at this?” or “Follow me,” or “Attack!”
But infections can occur anywhere in the body. This renders direct touch of limited usefulness. No modern army could coordinate troops over a large area merely by face-to-face orders. Similarly, the theater of war in our bodies is far too encompassing for direct cellular interactions to suffice. To mobilize the immune system against a systemic infection, cells must talk to one another in distant parts of the body. How can a tiny, single cell send such a relatively long-range message?
Armies communicate over long distances by radio. By comparison the cytokines are like the radio signals of your inner army. These complex molecules are released by cells into the blood stream, where other immune cells sniff them like blood hounds and decode their messages. There are numerous cytokines, each sending a signal to a different kind of cell with a particular message. The system is extremely complex and fine-tuned.
For every “Charge” there is also a “Retreat.” For every “Attack,” there must also be a “Stand down.” “Fire,” must be counterbalanced with “Hold your fire.” At least it should be. But that is the problem in some COVID infections. The sickest of COVID-19 patients like Peggy, are battling not only a novel virus, but also an over-activated immune system that seems to run rampant and actually contributes to the overall illness.
Sometimes in COVID-19 infections, the enemy is not just the virus. It is us. What can be done about that?