Dr. Terrence Coulter is medical director for critical care at CoxHealth, and he's on the frontline of the COVID-19 pandemic, treating the sickest patients.
The 52-year-old has three subspecialty board certifications: Pulmonary medicine, critical care medicine and sleep medicine. He followed in the footsteps of his father who was also a physician.
"And growing up I'd seen his enjoyment and satisfaction of his job, the challenges he faced, the joy he had of helping patients feel better and just kind of contributing to the communities," said Coulter.
Dr. Coulter began treating COVID-19 patients at Cox in March.
"Of course, early on, most of the patients were unknowns as far as what we call a person under investigation. And the incidence was so low that we had a few trickle in in March. But then, of course, as this wave slowly hit us and ebbed up and down, the numbers have markedly increased to the point now where we've had close to 2,000 admissions to Cox with COVID patients, and unfortunately have acquired a lot of experience over the last several months now as the numbers and incidents is markedly increased."
Could you have imagined when you first set out in medicine that you would one day be treating patients in a pandemic like this one?
"No, I mean, we read about it, you know, in school, and you learn about the various pandemics through history but never thought we would be thrown in the midst of one and fighting our way through this."
Describe what you see when you enter the COVID unit at Cox. I know it must be heartbreaking to see, you know, all the people that are so sick.
"Yes. Specifically in our 51-bed COVID unit, what we call the tower. After you don your PPE and put on your masks and gloves and gowns and head gear and Ice shields, it's like you're walking onto the moon. You're stepping into a different environment as you pass through the doors as they open, and you just see the whirl of activity, what I call orchestrated chaos, the way everybody synergistically works in there to take care of the patients. And, unfortunately, the way it's set up, it's just rows of beds. And, you know, you've seen those pictures. So, you can just look down the row and see the patients laying in the beds, you know, all on life support receiving treatments and therapies. And it is exasperating when you first walk in thinking of the unsurmountable task that you have in front of you to go down those rows and assess and manage those patients. But you just start at the first bed and keep on walking down. And again, with the help of the staff, the nurses, the respiratory therapists, the pharmacists that are in there, you just focus on the patients and get it done."
I'd like you to talk about what COVID-19 does to a person. Tell me about the condition of the patients you treat from those with the mildest symptoms to those with the worst.
"Well, we see those with the worst. Those are the ones that end up in the intensive care unit and on ventilator support or breathing machines. And COVID primarily attacks the lungs, to put it simply. It’s the primary organ involved in the infection of COVID--pneumonitis or pneumonia, as we say, which leads to significant inflammation. And as the lungs fill up with these inflammatory cells, it's hard to get the oxygen from the air into the blood. So they become very hypoxemic or low on oxygen. In order to assist them, we give them supplemental oxygen via the small nasal cannula. Sometimes we step it up to what's called high flow oxygen or it's high flow of high percentage of oxygen trying to keep those levels up. Other times we'll have to go to what's called non-invasive ventilation, where it's simply a mask strapped to the face that's blowing the air in with high levels of oxygen. And lastly, if they fail at that, it's the intubation process where you have to put an endotracheal tube, in through their trachea, and then they're on full life support via the ventilator."
Are you hoping that that their lungs are going to recover? How often does that happen once they're on a ventilator?
"Well, we've learned--early on the theory was to intubate early, give them support and let the lungs heal on their own. We've learned that that probably wasn't the best approach, and it's best to forego intubation as long as we can because once they get intubated, it gets to be a bit more challenging to manage these patients. We know the outcomes are much worse. There was a large study published last month looking at 56,000 patients that were placed on the ventilator with COVID infection. And the mortality rates, the death rates, were disappointingly high. And, to put it simply, if you're age zero to 50 and you got intubated, you had about a 50 percent chance of dying. And then the next decade, from 50 to 60 years of age, you had about a 60 percent chance of dying. In the next decade from 60 to 70, you had a 70 percent chance of dying, on up. So, we've learned to better manage these patients in lieu of intubation, but if it comes to it, then we still have to provide them that support, because on the flip side, say you've got a 70-year-old who has a 70 percent chance of dying on the ventilator, well, there's 30 percent chance that they could survive. And it's hard to predict who will do well and who won't do well. And this is what have been the most challenging things in this disease process, is to figure out who's going to be at higher risk. We know there are certain risk factors, obesity probably being one of the biggest, high blood pressure, heart disease, diabetes, age, of course, immunosuppression patients who are on medicines that can suppress their immune system, chronic liver disease. So, we know there are certain risk factors that will increase that chance of dying when they get COVID and get to that point where they're on a ventilator and life support. But we've had some that have survived, fortunately, and have come off and indeed gotten back to somewhat of a normal baseline. But, beyond that, it's just so hard to predict when somebody first rolls through those doors how they're going to do. And we continue full support with everything we have to try to get them to turn around. And that's why the unfortunately, the death, you know, count continues to rise because so many people still succumb to this no matter what we do, despite our advances and despite our better understanding of the disease process and how to manage it."
Yeah, there's only so much you can do, and as a physician who is tasked with healing, it has to be really frustrating to only be able to do so much.
"And it's more frustrating because, you know, it's been said an ounce of prevention’s worth a pound of cure. And so much of this can be mitigated by simple adherence to what's been recommended as far as masking, social distancing, washing your hands, limiting exposure to larger groups of people or those that may be at risk. We're spending so much time, efforts at the back end of this, treating it when we need to be spending more effort and time preventing it. And it's by some very simple measures. A 50 cent facemask is a lot less expensive than a $3,000 course of Remdesivr or a $50,000 four day hospital stay or a million dollar stay for a month in the intensive care unit on life support. You just have to put in perspective."
What would you say to those who just refuse to wear a mask or take steps to prevent spreading this disease?
"It's disappointing because ...you do it more so for the other people you're around and for the people you live with and for those that you love as much as you do it for yourself. It's almost analogous to patients who continue to smoke. It's their choice. And we still have to deal with the consequences of the choices they make. But smoking doesn't have as much of a direct impact on others around them as COVID does in the spread of the disease and simply not adhering to something so simple. It’s noninvasive, it doesn't hurt, and it's an easy intervention that can be done to help prevent the spread of this disease."
Let's talk more about what you do. What is a typical workday look like for you?
"Well, again, in the COVID unit, we all usually come in around --we usually do 12 hour shifts starting from 6:00 a.m., get into what's called the donning area, where we don all our PPE, go into the COVID unit and again start rounding on patients, assessing them, doing physical exams, any interventions or procedures that need to be done, speak with the nurses at bedside, speak with the respiratory therapist there, get in touch with the pharmacist as far as any adjustments in medications or changes that we make. And it takes a while to get through that process in that unit. And it's very physically tasking. Usually we come out just dripping in sweat because it's just so hot under all the gear and everything. We step off into our doffing area where we take everything off in a methodical manner just so that we don't contaminate ourselves or any of the environments around us. Step out and we start doing our charting, our notations, that we have to do on the computer for the medical record. And then we start calling families. We spend a good portion of the rest of the day trying to get hold and talk to families. And of course, families have many questions. And many of those questions are hard to answer. You know, a lot of it's predictive questions. And we just kind of share with them what we've done with that patient and what the plan is, but more so the families are just reaching out to have contact with the patient because they're not allowed to be in those units. So, again, these patients are isolated. Nurses do the same thing. They'll call into the units and the nurses will get on the phone. And if the patient is able to talk, hold the phone up to them. Sometimes if they're awake and alert, we’ll try to use FaceTime or some video calling to contact and connect with the family. But it's just very emotionally draining by the end of the day, when you've gone through 20, 30 patients and families and updating them and just trying to convey what's going on and what you're doing. It's--by the end of the day, again, you’re physically and emotionally drained."
That has to have such a big toll on you guys. I mean, you're dealing with something where, you know, normally family can come in and be with their loved ones, but you guys are it. You're there for the patients when their family members can't be. So what is that like?
"Well, again, you can hear it on both ends. When the patients are able to communicate to you, they long for their family to be there. When you're on the phone with the family, they long to be there with the patient. So many times you feel like an emotional medium where you’re just passing those emotions through the communication from the patient to the family and from the family to the patient. When it comes to end of life issues or times where we're withdrawing support from a patient, we do move the patients to a different unit, part of the hospital where the family can come in and be with them to have some final moments during that transition. But, unfortunately, some patients, you know, succumb and die before we can even get that set up. You know, if they die quickly and urgently, if they have a situation where they go to immediate cardiac arrest or respiratory arrest and we can't get them back, and it's unfortunate. But again, we try to provide them as much compassion, you know, as we can as we're being there on behalf of the family that can't be there."
How do you deal with the emotional and physical toll that your job takes on you?
"Well, that's a good question. Everybody, I think, deals with it in different ways. You just try to process what you can--learn from what happened that day, be grateful for being able to walk out of there, being thankful for what you've been able to do as far as helping others. Go home, get some sleep, eat something and get up and do it again the next day."
How worried are you about contracting the coronavirus?
"At first we were all very concerned, those that work in the COVID ICU, because, again, these are the sickest of the patients. These are the patients that are most likely going to have a significant exposure due to the fact that they're, again, most likely the highly contagious one due to that level of severity of their illness and the fact that we are participating in what are called aerosol generating procedures, meaning we do intubations or breathing treatments. Some of the procedures we do, you're at greatest risk because the patients are coughing. You’re up in their face. That's how it's transmitted. So early on, everybody was very worried and concerned about our potential for contracting the virus. But, surprisingly, or maybe not so surprisingly, within my group of eight physicians, none of us have contracted this despite having hundreds of patients and hundreds of procedures. Likewise, many of the nurses, as best we can tell, did not contract it while at work--the patients in our ICUs. I think that goes back to the strict adherence to wearing our mask, our gloves, our gowns, sticking to the policy and procedure of keeping everybody safe. So, I now state being deep in that COVID ICU amongst the sickest patients is where I feel the safest in the city. I'm terrified of walking into Walmart because I don't know who has this, but standing there in the unit, I know who has it in and I'm protected from it."
That's an interesting observation for sure. Do you share a living space with other people?
"Yes."
How concerned are you about taking the virus home, and what precautions do you take?
"Well, again, yes, that that's a real concern, bringing it home to others in the household. And the precautions, again, are what we do at work. And I feel safe and confident when I'm leaving work. I have had minimal to no risk of any significant exposure. Again, when we get home, as most health care workers do, you just take off your scrubs, you jump in the shower, you clean up, and then you go on with your life as you do at home."
Do you have kids still living at home?
"Yes."
What do they think about you working in the COVID-19 unit?
"They don't really think much of it. It's just another day at work as far as they're concerned. You know, prior to this...I worked in, you know, did ICU. It's just a different challenge, a different disease process. So, again, I think they're aware. And proud, I think, of the work that's being done by all of us that work in the hospitals, front line workers."
Are there any patients who particularly stand out in your memory? Can you tell me about any of them?
"Yeah, there are several. Certainly, earlier on--there is a good friend of the family who was pretty much close to my age that contracted the virus. This was early in the course. So we didn't know much as to what was going on and how to manage these patients. And he ended up on the ventilator for about three weeks. And many times during that course, there were concerns that I did not think he would survive this. And there were instances where I would not think he would survive an event where we had to do some emergent interventions. But nonetheless, you know, with the support provided and the team that was involved, he was able to recover, get back home. And, having seen him in follow up, you know, fully back to his baseline from a pulmonary standpoint, no limitations or restrictions on his pulmonary function. His oxygenation is back to normal. He's back to working out on a regular basis and just a total full recovery as opposed to the concerns we had early on. Conversely, there are other patients who we've had the same hope and fight and struggle with that did succumb to the virus, to the consequences of the inflammation. And, you know, you get close to the family because, again, like I said, you're kind of like an emotional medium between the patient and the family talking to them every day. They share stories with you. You just really get pulled into the knowing that patient more than they are a person simply laying in that bed. You get to know them as a person, not just physiologically. And it hurts. You know, when you walk into the unit and the nurses all have red, puffy eyes, you know that we've lost one or several, you know, that night before or that day because they all get attached to the patients and the families."
Is there any rhyme or reason or pattern or anything that you guys have learned about this illness?"
Simply the fact that there is no rhyme or reason to it or pattern. Like I said, it's hard to predict who's going to do well, who's not going to do well. But we know once they get to a point where they've been on support for at least two or three weeks, that's going to be a much more prolonged course and a less likely chance of any significant, meaningful recovery as far as liberation off the ventilator and getting back to any baseline as to how they were before. The lungs just get so damaged, diseased, scarred and fibrotic in the end due to all the inflammation if it persists and smolders for so long. So, again, it's just hard to identify and predict who's going to do well, who's not going to do well."
I'm wondering, too, what age range are you seeing in your unit?
"Well, I mean, we're seeing patients in their 20s up into their 80s and 90s. Of course, most of them are on the older end of the spectrum. But what's disturbing is that we are seeing patients in their 20s and 30s and 40s ending up in our unit on life support, some surviving, some not surviving."
Coulter said, while the friend who recovered from COVID-19 after being on a ventilator is back to doing things he did before the illness, COVID-19 can have long-term impacts. Those are referred to as post-acute COVID syndrome symptoms.
"Which is more neurologic issues. They have neuropathies, they have the brain fog, the COVID brain fog, as they call it. So, some more long term neurologic symptoms that persist. The loss of taste and smell, you know, have been reported to last six to nine months. Of course, you know, this is as long as we've known the disease process. You know, some recover, some are still having the absence of taste and smell. So, yeah, there are prolonged effects of this infection and virus beyond just the pulmonary effect, which is what we predominantly see in the hospital."
One day, hopefully, when this is all passed us and you look back on this time, I mean, how will this stand out, looking at your career as a whole?
"Well, I think it's taught us not to take things for granted, not to just ride along with the status quo and to always be prepared because this hit us rather quickly. We had the fortune of administration recognizing this, allowing us to acquire the PPE needed to protect the staff quickly building the 51 bed ICU for COVID patients so that we can take care of our community and just committing to what it takes to survive and get through this this pandemic. I think, you know, we'll learn many lessons from this, both good and bad, such that if this ever happens again or I should say when it happens again, we will be better prepared and ready to tackle it again."
Do you consider yourself a hero? A lot of people are calling health care workers and other front line workers to heroes, and I can see why.
"I don't consider myself a hero. You know, this is what we signed up to do. It’s what we went to medical school and training for just to help people. And it's our calling is to deal with this during a pandemic. It’s what we do. And I think it's the same as all the other physicians involved, the nurses, the respiratory therapists. It's just kind of what they're calling is. I consider those staff in the COVID units, nurses, respiratory therapist, I consider them superheroes for what they have to put through the duration. And again, like I said, the emotional stress and in the physical demands, I mean, it's just above and beyond what they ever signed up for."
As someone who works directly with COVID-19 patients, what would you like the public to know? What are some things that we haven't talked about that you would really like people out there listening to know?
"Again, the biggest thing is just to adhere to the requests for basic masking. You know, so much of this can be prevented or mitigated by some simple measures. And it's not taking away individual freedoms or rights. It's not political. It's just something--if you want to do it for yourself, do it for your fellow man, woman, family, friends. It's just that simple."
