'Like a War Zone': One Nephrologist's COVID-19 Experience

Marlene Busko

March 29, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

This past January, cases of COVID-19 spiked in Orange County, California, leaving hospitals scrambling to obtain enough continuous renal replacement therapy (CRRT) and dialysis machines.

"Nearly half of our regular hospital beds had been converted into ICU beds, and we had 50 extra medical-surgical beds in a mobile field hospital in our parking lot," said Kam Kalantar-Zadeh, MD, MPH, chief of nephrology at the University of California Irvine Medical Center, Orange, California.

"There were days I was literally crying because I didn't know how to deliver care to ever increasing AKI [acute kidney injury] and COVID-19-infected dialysis patients and how to ration care and dialysis and make life-and-death decisions," he said.

Medscape spoke with Kalantar-Zadeh about his experience. This interview has been edited for length and clarity.

Medscape: When did the second surge start at your hospital, and how did it compare with the first? Was your hospital prepared?

Kam Kalantar-Zadeh, MD, MPH: The first wave of COVID-19 patients in Southern California occurred in July 2020 and was relatively minor, unlike the second wave that started gradually in late December. It got worse and worse. Every day we had more patients than the day before.

To their credit, hospital administrators had anticipated the second surge, and within days, they had installed an outdoor tent-based mobile field hospital in the parking area, converted some medical wards in the main hospital into critical care units, and transformed ambulatory clinics into medical wards.

Roughly how many patients with COVID-19 needed to be intubated? How many developed AKI and needed CRRT?

At the peak of the surge, patients with COVID-19 were only admitted if they needed to be intubated.

Roughly 20% to 35% of patients with COVID needed endotracheal intubation and mechanical ventilation.

About a quarter of patients with COVID-19 who were intubated and mechanically ventilated developed AKI and needed dialysis.

Most of the patients with AKI had hemodynamic instability [low blood pressure related to the heart's weakened ability to pump blood] and needed slow CRRT, as opposed to conventional hemodialysis.

We usually do up to three to five CRRT procedures per day for patients who require this slow, continuous dialysis, but then the need grew until we needed three times as many machines at the peak of the surge.

Meanwhile, all other hospitals in Los Angeles and Orange County had the same increasing need, so we couldn't just borrow machines. We had to get them from Las Vegas and cities in Northern California. By the time we ordered and received them, the need had increased even further.

It was a precarious situation, where we couldn't see the light at the end of the tunnel. But, very fortunately, we just managed to obtain enough CRRT machines as we needed them.

What would happen when a patient who was receiving hemodialysis developed COVID-19 and arrived at the emergency department?

Many patients who usually received dialysis at outpatient clinics three times a week contracted COVID-19 and needed to be admitted, intubated, and given CRRT.

However, other dialysis patients who developed COVID-19 and were febrile and coughing with shortness of breath when they came to the emergency department did not need to be intubated. I had to tell them, "There is nothing we can do. You don't need to be intubated. If you were admitted, you would be the lowest priority, and your dialysis would be delayed."

Fortunately, many dialysis centers gradually created special isolation units for the 10% to 20% of hemodialysis patients who tested positive for COVID-19, and they were able to absorb these patients. This initiative alleviated the burden on Los Angeles and Orange County hospitals.

Did hospital staff develop COVID-19?

We were short-staffed because more than 200 healthcare workers who otherwise would have worked in the hospital — including the dialysis unit — were COVID-positive. Some dialysis nurses were even intubated.

It was the same at every hospital in Los Angeles and Orange County. When I talked to colleagues, people were stressed and crying.

On the other hand, we were all in this together, and there was great teamwork from the pulmonologists, cardiologists, nurses, technicians, and support staff. We all worked very hard. It was the holidays, and people interrupted their vacations to come back to help.

Did you ever need to ration care?

We struggled every day with the following scenario: patients A and B both urgently need CRRT to survive, but we only have one machine available.

Yet almost every time, either another patient would die, or a patient's family member would come and say, "We decided our dad just wants to have comfort care, no dialysis."

You can imagine what a stressful situation it was for me and every other doctor and healthcare provider. These were our day-to-day lives for 25 days. It's not an exaggeration to say it was essentially like working in a war zone for 3 to 4 weeks.

We had to make decisions based on priorities. The most important decision was, "Who really needs to be admitted? Who needs to be dialyzed more than another patient?"

Although we ran out of many options, we managed to barely make it.

How did this affect your mental health?

I would go home after seeing things that I had never seen before in my life. I would sit down and stare without doing anything. You think about the things you have seen and not being able to do everything you [want to] do, but still you managed to treat patients that day. You wonder what's going to happen the next day and how it's getting worse.

But you can't feel burnt out and just suddenly give way because everything depends on you.

There were days and moments when I would sit in a corner and cry because I didn't think I could help tomorrow. Tomorrow we were not going to have enough machines. Tomorrow I would have to let somebody die. And then tomorrow would come, and we would manage to find the care that let the patient survive.

Going to the emergency department — sending patients who were less sick home or finding a COVID-19 isolation dialysis clinic for them so they won't occupy the bed of somebody who needs to be intubated and receive CRRT — added to the stress. It was like a nightmare.

How did the surge end? Do you anticipate a third surge, possibly related to new variants of the virus?

Around January 20, there was one day where we suddenly had fewer patients. And then the numbers started to go down and there was less requirement for dialysis.

If the peak number of COVID-19 patients reached 250, we are now at less than 25 at any given time.

We are hoping that with the mass vaccinations in Southern California, we will not see another surge like the last one, although a new variant might appear for which the current vaccines may not be protective.

In any case, we have learned a lot and are more prepared.

Kalantar-Zadeh has received commercial honoraria and/or support from Abbott, AbbVie, Akebia, Alexion, Amgen, Ardelyx, AstraZeneca, Aveo, Chugai, DaVita, Fresenius, Genentech, Haymarket Media, Hospira, Kabi, Keryx, Novartis, Pfizer, Relypsa, Resverlogix, Sandoz, Sanofi, Shire, Vifor, UpToDate, and ZS-Pharma.

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