Christopher Yuen was so sure he’d be in and out of the emergency room quickly that he left his car in a no parking zone behind the hospital.
Nearly a month would pass, however, before he came out — a month in which coronavirus cases in New Jersey soared from 4,200 to nearly 100,000, and deaths increased from 62 to more than 5,000.
When he did exit, he was pushed in a wheelchair and clapped out by nurses and doctors celebrating his survival. He knew he was one of the lucky ones – only a fraction of patients with coronavirus recover after spending as long as he did on a ventilator.
The 32-year-old defied the odds in another way, too. When he got to his car, there wasn’t a single ticket on the windshield.
But for Chris, the journey back was just beginning.
At home, he leaned on his dragon-headed cane – the one he’d originally bought for fun – to climb the stairs to his second-floor apartment in River Edge. That was when the hard work – to regain muscle strength, lung capacity and mental equilibrium, all diminished during his long critical illness at Holy Name Medical Center — began.
In this, too, he’s been one of the lucky ones.
After leaving his gray Dodge Dart on a residential side street in Teaneck on the afternoon of March 25, Chris made his way to the triage tents outside Holy Name Medical Center’s emergency room. Those with symptoms of coronavirus were directed one way, and those with other emergencies were sent another. His path was obvious – he had a fever and difficulty breathing.
That day, New Jersey’s peak of coronavirus patients was still three weeks away. But at Holy Name, the wave crested early, just a few days behind New York City’s. It had already been 12 days since the triage tents were pitched and township residents had been told to stay home except for trips to get food and essentials.
Teaneck lay at the epicenter of the hottest coronavirus county in the second-hottest state; Holy Name was its hospital. More than 120 patients sought emergency care there that day, and half were admitted. No wonder the parking lot was full.
So much has changed since then, in our understanding of the symptoms of coronavirus and our ability to test for it. Chris’s account of his first hours at the hospital now seems almost quaint.
When his cough had started in mid-March, he thought it was a cold or allergies. He’d tried his family’s favored home remedy, a drink of boiled Coca-Cola with lemon, to no avail. He kept working from home. He went to the CVS MinuteClinic, which referred him to the hospital. There, the initial word was that he probably had the flu.
There were no quick tests. A nurse swirled a long, narrow swab around the back of his nasal cavity to check for coronavirus. The results wouldn’t come back for days.
He couldn’t pinpoint how he’d been exposed to the virus. Maybe he got it while riding the train to the city to date a girl he met online, he thought. He commuted by car to his job in Mahwah with Credit Saint, a credit repair company, and thought it unlikely he’d been exposed there.
Like most people Dr. Jose Gomez-Marquez saw in the ER those days, Chris had waited a week before seeking care. The ER was nearly overwhelmed. Staff gave him a wheelchair and a tank of oxygen. Then he waited 11 hours for a bed, even though the doctor assessed his disease as “fairly advanced.”
His condition quickly deteriorated.
On Friday, two days after his arrival, Chris’s oxygen levels plummeted. He was moved to an intensive care unit. Holy Name had converted a post-surgical recovery area into a second ICU and was getting a third ready, as it coped with the flood of severely ill patients.
Gomez-Marquez, a pulmonologist and critical care specialist, decided it was time to put Chris on a ventilator. He inserted a tube down Chris’s throat and into his windpipe, attaching it to a ventilator to force air into Chris’s lungs. As with most critical patients, it was impossible to synchronize the machine’s forceful pumping with the natural inhalations and expirations of Chris’s body, so he was sedated and paralyzed to keep him from bucking or pulling the tube out.
Ventilators were precious commodities in New Jersey in those days. At his daily press conference that Friday, Gov. Phil Murphy repeated an oft-voiced plea to the federal government to send 2,300.
Initially, Chris was prescribed Plaquenil, or hydroxychloroquine, the drug then touted by President Trump. It doesn’t appear to have affected the course of his disease.
He would later remember few details of his stay, except for waves of fever dreams.
Day followed night, each indistinguishable from the next.
Nurses came and went on 12-hour shifts. They monitored his blood pressure and oxygen level, checked the lines carrying medication and nourishment, rolled him from his back to his chest and back again.
Machines beeped. Alarms sounded.
Doctors tried treating him with Kevzara, a medication that blocks a type of cytokine, the cells responsible for the acute immune response that leads to critical illness in some COVID-19 patients. They hoped it might ease the stiffening of his lungs, which hampered the exchange of gases – oxygen and carbon dioxide – through the lungs’ tiny air sacs, or alveoli.
The drug, made by Regeneron, is prescribed for some rheumatoid arthritis patients. Its off-label use at Holy Name on ventilated COVID-19 patients was part of a larger study.
Chris’s mother, Susan Yuen, was told this didn’t work when doctors called to ask her for permission to put him on another trial.
Next, doctors gave Chris remdesivir, the experimental anti-viral drug by Gilead that was later shown to have modest benefit in COVID-19 patients. Remdesivir interferes with replication of the virus. (Two preliminary studies published in April showed it shortened the time that moderate or severely ill COVID patients spend in the hospital.)
Chris was given a 10-day course of the drug. Again, Susan Yuen was told it didn’t work.
Chris also had a bacterial infection – pneumonia – on top of his viral infection. It has worsened, his mother learned. The prognosis was not good.
“The last conversation I had with the doctor, the drugs didn’t seem to work,” she would recall. “The pneumonia had spread, but they had given him some antibiotics. Then his oxygen level went down. That was it.”
Susan Yuen doesn’t usually sleep with her cellphone on beside her bed. During the coronavirus crisis, though, everything changed.
Two of her three sons were sick with the virus, and she was in Vancouver, Washington, 2,900 miles away.
Chris was in critical condition at Holy Name, and Nicholas, his 27-year-old brother, was fighting the virus alone at the River Edge apartment he shared with Chris.
It made no difference where Susan was, though. “I couldn’t have gone to see him anyway,” she said of Chris.
While she waited, she recalled how Debbie Reynolds had died within a day of her daughter Carrie Fisher’s death, a phenomenon she now understood.
For almost a week, she would later say, she didn’t hear from anyone at the hospital.
So she waited. She prayed. She cried.
And she kept the phone on in case the hospital – or Nicholas – called. With Nicholas sick from the same virus as his brother, his parents were so preoccupied with keeping him out of the hospital, “it took our minds off Chris.”
Nicholas’s symptoms ran the gamut – chills, fever, lightheadedness, insomnia, hallucinations, shakes, diarrhea – for five days. One night, he was afraid to go to sleep because he feared he would die and no one would find him. Susan stayed on the line with him for hours. “I’m retired,” she thought, “I can sleep later.”
Nicholas pulled through.
There was no news, however, about his brother.
“It was torture,” Susan later recalled. “Sheer torture.”
Maybe no news was good news, she told herself. But a relative offered to book three hotel rooms in New Jersey, in case the family had to head east to plan a funeral.
“That’s how close it was, how scary it was,” she would later say.
For six days, Chris was unresponsive – sedated and paralyzed. The machine breathed for him.
The team in critical care didn’t lose hope, though. He was just 32. “We worked really hard on him,” said Gomez-Marquez, the critical care doctor. “We kind of made him a project.”
Then, some progress. The antibiotic they had chosen worked against the pneumonia. The doctor lowered the ventilator pressure. Chris’s oxygen level held steady.
The medical team decided to turn off the ventilator to see if Chris could breathe on his own for a few minutes.
For the young nurse on the night shift in the ICU caring for Chris, this was a turning point. He was just a few years older than she was, and had been healthy before the virus. It gave her “a glimmer of hope,” said Jacqueline Strasser, “faith that what we were doing helped.”
She called Chris’s parents to see if they wanted to FaceTime with her patient. Susan wasn’t sure if this meant a final opportunity to say good-bye or a chance to offer words of encouragement.
Either way, she jumped at the chance.
When the image came into focus on her cell phone, there he was: The tube down his throat, the eyes closed. But at least she could look at him. Strasser said they had just sedated him, but he could hear. She put the iPad close to his ear, so he could listen to his parents’ voices. Later, Chris would say he dreamed they had visited.
It was April 12 – Susan Yuen’s birthday. Easter Sunday.
“Divine timing,” she said.
Chris had been in the hospital for 19 days.
The next day, the ICU team turned off the ventilator and carefully pulled the tube from his throat.
Doctors were learning with experience that the ventilator could be harmful for some patients. In consultation with the nursing team, Gomez-Marquez said, he weaned Chris earlier than was typical. Chris’s oxygen needs were now met with a nasal cannula, or narrow tube with prongs into his nostrils, that carried high-flow oxygen.
At 5:30 a.m. two days later, Susan Yuen’s phone rang. Chris’s name popped up on the caller ID. His voice was low and raspy, but he was alive.
“We went from the lowest low to the highest high in one week,” his mother said.
What worked? “There’s no magic drugs,” Gomez-Marquez said. “I don’t have an answer for you.”
One patient in five, on average, survived more than 14 days on a ventilator with a coronavirus infection at that time. Chris had been on the vent 20 days.
Yet his recovery was just beginning.
While the main goals of rehab are to rebuild muscle strength and lung capacity, some side effects of the extended periods critically ill patients spend in ICUs are seldom discussed. These include delirium, confusion and long-term cognitive impairment.
Over the last decade, critical care specialists have focused how to recognize and prevent “ICU psychosis” and “post-ICU syndrome.” But the exigencies of the COVID pandemic have created what one expert calls “a delirium factory” in ICUs.
The sheer number of patients, the concerns about contagion, the redeployment of non-critical-care specialists to ICUs, and the absence of visitors to anchor patients in time and place have all contributed.
“The ICU is a special place,” said Gomez-Marquez, one of the physicians who cared for Chris. “The brain isn’t used to that environment. The lights are always on, the nurses and doctors are always yelling, and the alarms are always going off.”
It’s too soon to tell what COVID-19 ICU survivors such as Chris will experience going forward. But there will be a lot of them.
At the pandemic’s peak in mid-April, 1,705 patients in New Jersey ICUs relied on ventilators to breathe. As recently as June 4, there were 406 – a reduction that results from “flattening the curve” of the pandemic as well as doctors’ evolving understanding of how to treat critically ill COVID-19 patients. These patients have stayed on ventilators a long time – usually two weeks or more, in comparison to the pre-pandemic norm of seven to 10 days for pneumonia.
About 75% of all ICU patients suffer delirium – mental confusion and memory loss — during their ICU stays, according to a study published in the New England Journal of Medicine in 2013. A year after their stay, one in four of these patients still showed evidence of cognitive impairment equivalent to mild Alzheimer’s disease.
Chris was indeed confused when he woke up. There were times he couldn’t tell the difference between reality and dreams. He had frequent panic attacks.
Things that tethered his mind to reality were missing. He couldn’t look out a window. He didn’t know the day or the time. He had no idea how long he had been unconscious.
Chris and his brother Nicholas learned they each had hallucinated during their illnesses that the other had died.
The hospital transferred Chris from the ICU to a transition unit, but even that was over-stimulating, Gomez-Marquez said. So they quickly moved Chris to a regular medical-surgical floor and then, as soon as he was able, sent him home.
Those first few days at home, he sat on the futon in the living room, with a tower of celebratory balloons on one side and X-men posters on the wall, watching television or using his phone.
That’s where Veronica Victorero, the registered nurse from Holy Name’s home health care department, found him when she introduced herself and took a medical history the day after he left the hospital.
“Before this, I’d have to run at least four miles before I broke a sweat or started to feel winded,” Chris told her. Now climbing the stairs to his apartment left him winded.
At least 10 times a day, he breathed through a spirometer, a device respiratory therapists use to train patients to take slow, deep inhalations to expand their lungs – similar to retraining out-of-shape muscles. He measured his oxygen levels with a pulse oximeter, and took his temperature and blood pressure with devices supplied by the hospital to monitor his vital signs remotely.
He was an early enrollee in the hospital’s Post-Acute COVID Exercise and Rehabilitation, or PACER, program, so a physical therapist visited to teach him exercises to strengthen his legs and regain the energy he’d lost.
“Our expectation and goal is to get him back to what he was before – and beyond,” said Jason Kavountzis, the hospital’s director of rehabilitation services.
But the weakness was real.
Even patients who are inactive and in bed for as little as 72 hours lose muscle mass, Kavountzis said – imagine how much more that occurs with COVID-19 patients.
Chris’s voice – essential to a job that entails speaking on the telephone eight hours a day – was weak, and his throat was sore. That was partly due to the intubation and partly to his reduced lung capacity.
His primary care doctor, Eli Djebiyan, wasn’t worried, though. She suggested he return to work July 1.
In mid-May, Veronica Victorero, the home health nurse, pulled into the parking lot of a two-story brick apartment building in River Edge. It was 10 a.m., her second patient visit of the day.
She donned gloves and pulled a blue disposable gown over her head, pushing her arms through its sleeves. Then she added a second pair of gloves, eye goggles, and a surgical mask on top of the N95 mask she already wore. The only equipment she carried was her stethoscope.
This was the last of six visits with Chris, who had been discharged from Holy Name a little more than three weeks earlier.
His improvement was dramatic. On her first visit, he’d barely risen from a seated position on the bed. This time, he easily came downstairs to open the door and lead her back up. She cheered this progress.
Victorero loves the closeness that visiting a patient at home affords, but admits that the pandemic has taken a heavy toll – on her patients and herself.
One of those patients, recovering from the virus, grieves over the loss of her mother to COVID-19 because she didn’t have a chance to say good-bye. Another had been asked to decide whether to discontinue life support for his wife, who was dying from the virus, on the day Victorero visited.
“Sometimes we do a lot of listening,” she said. “We cry a little bit, because we’re human beings. This whole process is hard. We’re mentally exhausted. But we have to be strong.”
Today she stood in the living room, facing Chris on his futon. “How are you doing, Christopher?” she asked.
He was doing well, he said, so well that he wanted to be evaluated to see if he could donate plasma. The antibody-rich blood plasma of recovered coronavirus patients is being studied as a potential treatment for patients with the virus.
He inhaled on the spirometer for her – perfect. He showed her the 98 percent reading on his pulse oximeter – perfect. His blood pressure was a little high, she said, “maybe because you just went up the stairs.”
She went over his medications, most of which were no longer needed. The anxiety, pain in his throat, and upset stomach had all abated.
A quick listen to his lungs – “beautiful!” – and then the summation. Keep using the spirometer. Wear a mask, wash your hands and practice social distancing. Eat less salty food and drink plenty of water.
“You are one of the lucky ones,” she told him. “Slowly you’ll go back to your normal life. Enjoy life.”
He rose and went to his desk. “I have something for you,” he said, and handed her a wrapped box of chocolates.
The day before, he had walked to the drug store and walked home again. He hadn’t gotten out of breath.
He spoke with his mother every day. “It’s taken a while,” Susan Yuen said. “But he’s on the right track – physically getting stronger, and emotionally and mentally getting back to normal.”
Soon, he hopes, he’ll get on a plane and go visit her across the country.
Lindy Washburn is a senior healthcare reporter for NorthJersey.com.
Email: email@example.com Twitter: @lindywa