Go to Neurology.org/N for full disclosures. Search Still, those with COVID-19 present a unique challenge when treating delirium. Patients coming off a ventilator typically take hours, even a day to wake up as the drugs that help them tolerate the machine wear off. He said he slurs words occasionally but has no other cognitive problems. BRIAN EDLOW: Because this disease is so new and because there are so many unanswered questions about COVID-19, we currently do not have reliable tools to predict how long it's going to take any individual patient to recover consciousness. We don't have numbers on that yet. Leslie and her two daughters watched on a screen, elated, making requests. (6/5), ABC News: It's not a mistake but one funny part of my job is seeing patients when they wake up from anesthesia. Once the heart starts beating again, healthcare providers use cooling devices to lower your body temperature for a short time. Pets and anesthesia. Your role and/or occupation, e.g. In addition,. The second call was just a few days later. As COVID-19 patients fill intensive care units across the country, its not clear how long hospital staff will wait beyond that point for those patients who do not wake up after a ventilator tube is removed. This has prompted physicians and researchers at Massachusetts General Hospital to study the effects of sedation on neurological outcomes in COVID-19 patients. We recorded demographic data, sedative dosages, prone positioning, sedation levels and duration. LULU. You've successfully subscribed to this newsletter! An international research group based at the University of Pittsburgh Medical Center expects to have in September some initial numbers on COVID-19 brain impacts, including the problem of persistent comas. Obeying commands (mostly through facial musculature) occurred between 8 and 31 days after cessation of sedatives. A coma is a state of unconsciousness where a person is unresponsive and cannot be woken. The persistent, coma-like state can last for weeks. Given all the unknowns, doctors at the hospital have had a hard time advising families of a patient who has remained unresponsive for weeks, post-ventilator. A ventilator may be needed when certain illnesses like COVID-19 progress to a condition known as acute respiratory distress syndrome (ARDS). Many hospitals use 72 hours, or three days, as the period for patients with a traumatic brain injury to regain consciousness before advising an end to life support. Survival outcomes were outlined for 189 consecutive COVID-19 patients who had received ECMO support at 20 institutions at the time of the analysis: 98 died on ECMO or within 24 hours of . 6.25 mg - 12.5 mg SC/IV can be used to begin with especially if nausea is a feature. The sedative midazolam was stopped on ICU day 10, and the sedative propofol was stopped on ICU day 14. "Some fat-soluble sedatives, such as propofol, may prolong anesthetization and contribute to patients not waking up," says Dr. Brown. But there are others who are still not following commands and still not expressing themselves weeks later., WHO BELIEVES PROTESTS IMPORTANT AMID CORONAVIRUS PANDEMIC. Because this disease is so new and because there are so many unanswered questions about COVID-19, we currently do not have reliable tools to predict how long it will take any individual patient to recover consciousness, said Dr. Brian Edlow, a critical care neurologist at Mass General. Everybody was reaching in the dark because they hadn't seen anything like this before, saysEmery Brown, MD, PhD, anesthesiologist in theDepartment of Anesthesia, Critical Care and Pain Medicine. Leslie and Frank Cutitta have a final request: Wear a mask. Additionally, adequate pain control is a . Although the patients recovered from their prolonged unconscious state, it is likely that long-term cognitive or physical deficits remain present, in line with many reports on long-term outcomes in patients with COVID-19. Next, 5 to 12 days later, all patients started to follow objects spontaneously with their eyes, which was still not accompanied by obeying commands. A case reported by Edlow in July described a patient who moved between a coma and minimal consciousness for several weeks and was eventually able to follow commands. 4: The person moves away from pain. His mother, Peggy Torda-Saballa said her son was healthy before he was. Schiff said all of his colleagues in the fieldare seeing patients with prolonged recovery, though the incidence of the cases is still unknown. So the Cutittas hung on and a small army of ICU caregivers kept working. 2023 Kaiser Family Foundation. For some very serious surgeries, such as open-heart surgery or brain surgery, the patient is allowed to slowly wake from anesthesia with no reversal agent to bring the muscles out of paralysis. Search for condition information or for a specific treatment program. Though most patients' symptoms slowly improve with time, speaking with your healthcare provider about the symptoms you are experiencing post-COVID could help identify new medical conditions. Some COVID patients who do eventually regain consciousness still have cognitive difficulties. Hospitals are reporting that survivors are struggling from cognitive impairments and a . Salter says some patients in the ICU stay for about two weeks. BEBINGER: The first data is expected out soon of known COVID patients like Frank who linger in a prolonged coma. JAN CLAASSEN: In our experience, approximately every fifth patient that was hospitalized was admitted to the ICU and had some degree of disorders of consciousness. Go to Neurology.org/N for full disclosures. This is a time for prudence because what we dont know can hurt us and can hurt patients.. SARS-CoV-2 readily infects the upper respiratory tract and lungs. "The body mounts an enormous inflammatory response, and it turns out to be pathologic as inflammation starts to damage tissues across all organ systems. "That's still up for debate and that's still a consideration.". August 27, 2020. loss of memory of what happened during . Dr. Jan Claassen, a neurologist at New York's Columbia Medical Center, is part of the research group working to answer that question. 5: They can pinpoint the site of the pain. It also became clear that some patients required increased sedation to improve ventilation. F CUTITTA: Who could have gone the other way and said, look; this guy's just way too sick, and we've got other patients that need this equipment, or we have an advocate who says, throw the kitchen sink at it. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology. If a story is labeled All Rights Reserved, we cannot grant permission to republish that item. Submissions should not have more than 5 authors. And he didn't have a lot of them at that point, but it was just amazing - absolutely amazing. She had been on thyroid supplementary medication during her entire ICU stay, and free thyroxine levels were measured within normal range several times. Over the next eight weeks, the only time she saw her baby was when the NICU staff sent photos, or when a nurse FaceTimed her while the baby was being bathed. Reference 1 must be the article on which you are commenting. In the large majority of patients with COVID-19 that are admitted to the intensive care unit (ICU) for a respiratory distress, an encephalopathy most notably in the form of delirium occurs in up to 84% of those patients.1 Brain MRI studies in patients on the ICU with COVID- Soon, there were reports of new issues facing those with COVID-19. FRANK CUTITTA: We did have an advocate in the system BEBINGER: Here's Frank last month, back at home with Leslie. Because the virus has the potential to cause extensive damage to the lungs, some patients may be unable to breathe on their own, and require intubation and subsequent ventilation in order to bring oxygen into the body. BEBINGER: They also want to know how many COVID patients end up in this prolonged sleeplike condition. December 3, 2021. All authors report no conflicts of interest or relevant financial relationships related to this manuscript. Market data provided by Factset. Severe cases of the disease cause acute respiratory distress syndrome, or ARDS. But then Frank did not wake up. JOSEPH GIACINO: We need to really go slow because we are not at a point where we have prognostic indicators that approach the level of certainty that we should stop treatment because there is no chance of meaningful recovery. NOTE: The first author must also be the corresponding author of the comment. As a . 2: A limb straightens in response to pain. Autopsies Show Brain Damage In COVID-19 Patients A 41-year-old woman with a medical history of diabetes mellitus, hypothyroidism, and severe obesity (body mass index 43.5 kg/m2) presented to the emergency department with a 3-day history of respiratory symptoms and bilateral infiltrates on her chest x-ray. Why is this happening? "You're more likely to have hypoxic-ischemic injury in prolonged ventilation patients. Do not be redundant. ), Neurology (A.A.A.C.M.W. She was admitted to the hospital for oxygen therapy. "There's no consistent report that shows direct central nervous system infection, looking atPCRassay in intubated patients with prolonged sedation.". This disease is nothing to be trifled with, Leslie Cutitta said. There are also patients who have extended hospital stays, followed by an even longer recovery period in a long-term care facility. Dr. Brown is hopeful. In her delirium, Diana Aguilar was sure the strangers hovering over her, in their masks and gowns, were angels before they morphed into menacing aliens. The very premature infant was born via cesarean section and quickly whisked away to the neonatal intensive care unit before his mother could even lay eyes on him. SARS-CoV-2 potentially causes coagulability, thromboses and thus the risk for blood clots. L CUTITTA: We would all just be pressing the phone to our ears, trying to catch every word. %%EOF Get the latest news on COVID-19, the vaccine and care at Mass General. Low oxygen levels, due to the viruss effect on the lungs, may damage the brain. Theres no official term for the problem, but its being called a prolonged or persistent coma or unresponsiveness. Her fever hit 105 degrees. This pattern of awakening did not fit the regular patterns seen in patients in the ICU in whom eye opening is frequently accompanied or quickly followed by motor reactions to (painful) stimuli and an encephalopathy with an active delirium, as was also shown in the great majority of patients with COVID-19 in the ICU.1 Our findings corroborate a recent case report showing intact functional connectivity in the default mode network using fMRI in a patient with prolonged unconsciousness admitted to the ICU for respiratory failure due to COVID-19.7 One of the main drawbacks of our study is the selection bias that is inherent to case series. We appreciate all forms of engagement from our readers and listeners, and welcome your support. But how many of those actually took a long time to wake up, we dont have numbers on that yet.. Brown said faster recoveries could be possible if doctors lower the dosages of sedatives during mechanical ventilation. But as COVID-19 patients fill ICUs across the country, it's not clear how long hospital staff will wait for those patients who do not wake up after a ventilator tube is removed. Leslie Cutitta said one doctor told the family that during the worst of the pandemic in New York City, most patients in Franks condition died because hospitals couldnt devote such time and resources to one patient. Cardiac arrest happens when the heart suddenly stops beating. All six had evidence of extensive brain pathologies at the time of death. We will optimize the therapies going forward so that we can reduce consequences down the line and help mitigate the effects, says Dr. Brown. Neurological symptoms such as loss of smell, confusion and headaches have been reported over the course of the pandemic. And then, on May 4, after two weeks with no signs that Frank would wake up, he blinked. Description Market data provided by Factset. Leslie wrestled with the life doctors asked her to imagine. The latest . Please preserve the hyperlinks in the story. "It is worse in older patients, those who are quite ill and is associated with certain drugs such as midazolam, haloperidol and opiates like hydromorphone," says Dr. Brown. She started to move her fingers for the first time on ICU day 63. Time between cessation of sedatives to the first moment of being fully responsive with obeying commands ranged from 8 to 31 days. "We have studied brain rhythms in patients with COVID-19 using EEG, and have found that patients with COVID-19 have abnormal brain rhythms. 1: The person makes no movement. At Mass General, the brightest minds in medicine collaborate on behalf of our patients to bridge innovation science with state-of-the-art clinical medicine. ), Radboud University Medical Center, Nijmegen; Departments of Intensive Care (B.P.G. She had been on high-dose sedatives since intubation. Although he no longer needed the ventilator, he still required a feeding tube, intravenous fluids, catheters for bodily waste and some oxygen support. Your last, or family, name, e.g. Conscious sedation is a combination of medicines to help you relax (a sedative) and to block pain (an anesthetic) during a medical or dental procedure. Many veterinary procedures require your pet to be put under anesthesia so that it will not feel pain and will remain still. We use cookies and other tools to enhance your experience on our website and A significant number of patients are going to have a prolonged recovery from the comatose state that theyre in, said Dr. Joseph Fins, chief of medical ethics at Weill Cornell Medical College. Prolonged or persistent comas are just one area of research, but one getting a lot of attention. If you are uploading a letter concerning an article: Mutual Fund and ETF data provided by Refinitiv Lipper. Submitted comments are subject to editing and editor review prior to posting. After that, doctors often begin conversations with the family about ending life support. "No, honey . Despite the strict isolation for Covid-19 patients, "We try to make sure patients don't die alone," Thi says. "It would get to 193 beats per minute," she says. (Exception: original author replies can include all original authors of the article). Acute inflammation can become severe enough to cause organ damage and failure. The duration of delirium is one. Patients have many emboli affecting their liver and kidneys, altering the metabolism of sedatives, which can affect the duration of sedation.". Some medical ethicists also urge clinicians not to rush when it comes to decisions about how quickly COVID-19 patients may return to consciousness. Error: Please enter a valid email address. For patients who are hospitalized with COVID-19, surviving the disease may just the start of their troubles. VITAMIN K AND THE CORONAVIRUS PANDEMIC: SHOULD YOU TAKE IT? Because the world is still dealing with this spreading pandemic, this finding has important implications for the consulting neurologists trying to evaluate and prognosticate patients with COVID-19 with unconsciousness after prolonged periods of mechanical ventilation in the ICU. Clinical researchers thought that SARS-CoV-2 would infect the brain and that injury to the brain would be due, in part, to blood clots. Frank Cutitta credits the Mass General doctors and nurses, saying they became his advocates. It's lowered to around 89F to 93F (32C to 34C). Click the button below to go to KFFs donation page which will provide more information and FAQs. You can support KHN by making a contribution to KFF, a non-profit charitable organization that is not associated with Kaiser Permanente. %PDF-1.6 % The COVID-19 pandemic has helped reveal the complex interaction between inflammation, sedation and cognitive dysfunction Long-term sedation for COVID-19 patients could last several weeks, increases the chance of cognitive dysfunction and is linked to hypoxic injury "Blood clots have these very deleterious effects, essentially blocking off the circulation," says Dr. Brown. Frank Cutitta said he believes the flow of these inspiring sounds helped maintain his cognitive function. We have remained at the forefront of medicine by fostering a culture of collaboration, pushing the boundaries of medical research, educating the brightest medical minds and maintaining an unwavering commitment to the diverse communities we serve. World Health Organization changes its tune on asymptomatic patients spreading COVID-19; reaction from Fox News medical contributor Dr. Marc Siegel. Click the button below to go to KFFs donation page which will provide more information and FAQs. This material may not be published, broadcast, rewritten, or redistributed. Purpose of review: Critically ill patients with acute respiratory distress syndrome (ARDS) may require sedation in their clinical care. The candid answer was, we don't know. If possible, please include the original author(s) and Kaiser Health News in the byline. Sedation is further impacted by the type of anesthetic given, as well as the inherent metabolism as a result of sedation. Edlow says some patients have COVID-related inflammation that may disrupt signals in the brain. All rights reserved. Submit. The Coronavirus Disease 2019 (COVID-19) Treatment Guidelines is published in an electronic format that can be updated in step with the rapid pace and growing volume of information regarding the treatment of COVID-19.. It follows that the myriad of embolic events has the potential to send blood clots to any and all organs. No signs of hemorrhages, territorial infarcts, or microbleeds were seen. Results After cessation of sedatives, the described cases all showed a prolonged comatose state. Two days later, she was transferred to the ICU due to worsening of respiratory status and was intubated the same day. Low tidal volume ventilation Right now, the best cure for these side effects is time. All rights reserved. A long ICU course in severe COVID-19 is not unusual. The Article Processing Charge was funded by the authors. Dramatic spikes in auto traffic around major hospitals in Wuhan last fall suggest the novel coronavirus may have been present and spreading through central China long before the outbreak was first reported to the world, according to a new Harvard Medical School study. If confronted with this situation, family members should ask doctors about their levels of certainty for each possible outcome. Coronavirusinfection starts with inhalation of the virus and its eventual spread to the lungs. Meet Hemp-Derived Delta-9 THC. Inthis autopsy series, there was no evidence of the virus that causes COVID-19 in the brain tissue of ventilated COVID-19 patients. Do arrange for someone to care for your small children for the day. Some Covid-19 Patients Experience Prolonged Comas After Being Taken Off Ventilators, CIDRAP: Clinical Characteristics of Patients With COVID-19 and Prolonged Unconsciousness. In many cases, sedation was prolonged and sometimes for several weeks; this was much longer than for common treatments requiring sedation, such as surgery. Although researchers are starting to understand the symptoms behind neurological sequelae from SARS-CoV-2 infection, the direct and indirect effects of SARS-CoV-2 on the brain remain unclear. To mitigate exposure to Covid-19, Dr. Heres what we ask: You must credit us as the original publisher, with a hyperlink to our khn.org site. She was ventilated in the prone position for the first 7 ICU days and subsequently in the supine position. She subsequently developed several episodes of high fever with constantly negative blood and sputum cultures with improving infection parameters (C-reactive protein, ferritin, procalcitonin, cell counts) and was treated with antibiotics. "It could be in the middle of . What are you searching for? We appreciate all forms of engagement from our readers and listeners, and welcome your support. Normally a patient in a medically induced coma would wake up over the course of a day. Researchers have made significant gains understanding the mechanisms of delirium. The evidence we have currently does not indicate a direct central nervous system infection for the majority of cases with neurological symptoms, says Dr. Mukerji. Follow-up brain MRIs performed on ICU days 33 and 41 showed a slightly improved picture of the diffuse white matter abnormalities, while newly developed restricted diffusion was noted in the basal ganglia (figure). But doctors across the U.S. and in other countries have noted a troubling phenomenon associated with some COVID cases: Even after extubation, some patients remain unconscious for days, weeks or longer. Some patients may be on a ventilator for only a few hours or days, but experts say COVID-19 patients often remain on the ventilators for 10 days or more. L CUTITTA: 'Cause at one point, this doctor said to me, if Frank had been anywhere else in the country but here, he would have not made it. Haroon Siddique. Frank Cutitta worries about all of the patients still suffering with COVID-19 and those who have survived but have lasting damage. English. BEBINGER: Frank, for example, was on a lot of sedatives for a long time - 27 days on a ventilator. Dr. Kimchi relates that "the heavy sedation that we feel compelled to use in caring for patients with COVID-19, like other aspects of COVID-19 management, may be creating new challenges to prevent delirium.". Some patients, like Frank Cutitta, do not appear to have any brain damage. A coma can also be caused by severe alcohol poisoning or a brain infection ( encephalitis ). We found global injury in the frontal lobe, hippocampus and cerebellum," says Dr. Mukerji. A significant number of coronavirus patients who depended on ventilators for long periods are taking days or weeks to awake upfrom medically induced comas, onereport says. Massachusetts General Hospital has prepared for this pandemic and taken every precaution to accept stroke patients in the emergency department. Because long-term sedation for COVID-19 patients could last several weeks, prolonged sedation increases the chance of hypoxia and causes neurological trauma. Unless a patient has previously specified that she does not want aggressive treatment, we need to really go slow, said Giacino, because we are not at a point where we have prognostic indicators that approach the level of certainty that is necessary before making a decision that we should stop treatment because there is no chance of meaningful recovery.. 93 0 obj <>/Filter/FlateDecode/ID[<0033803CED91E4489BCBEDA906532D19><08FAFFAEE7118C48BD370A0976047613>]/Index[66 52]/Info 65 0 R/Length 124/Prev 168025/Root 67 0 R/Size 118/Type/XRef/W[1 3 1]>>stream Anesthesia, Critical Care & Pain Medicine, Billing, Insurance & Financial Assistance, Department of Anesthesia, Critical Care and Pain Medicine, Director, Neuroscience Statistic Research Lab, Associate Director of the Neuro-infectious Diseases Unit. Submit. BEBINGER: Every day, sometimes several times a day, Leslie Cutitta would ask Frank's doctors, what's going on inside his brain? We couldn't argue that hypoxic injury was due to direct infection," notes Dr. Mukerji. The right medications for COVID-19 can help. All rights reserved. GARCIA-NAVARRO: This story comes from NPR's partnership with WBUR and Kaiser Health News. Frank used to joke that he wanted to be frozen, like Ted Williams, until they could figure out what was wrong with him if he died, said Leslie Cutitta. Massachusetts General Hospital investigators are using unprecedented collaboration and frontline experience to better understand the neurological effects of SARS-CoV-2 infection. Opening of the eyes occurred in the first week after sedatives were stopped in 5 of the 6 patients without any other motor reactions with generalized flaccid paralysis. Schiff said while its certainly known that prolonged sedation can extend the time it takes for patients to wake up, 12 days after sedation ends is not typical.. Its a devastating experience.. Edlow cant say how many. Open. At least some of the abnormalities appear to be linked with recent sedation," says Dr. Kimchi. Powered and implemented by FactSet Digital Solutions. Some COVID patients are taking nearly a week to wake up. Raphael Bernard-Valnet, Sylvain Perriot, Mathieu Canales et al.Neurology: Neuroimmunology & Neuroinflammation, June 16, 2021, Guilhem Sol, Stphane Mathis, Diane Friedman et al.Neurology, February 10, 2021, DOI: https://doi.org/10.1212/WNL.0000000000011355, Delirium and encephalopathy in severe COVID-19: a cohort analysis of ICU patients, COVID-19-associated diffuse leukoencephalopathy and microhemorrhages, Neuropathology of COVID-19: a spectrum of vascular and acute disseminated encephalomyelitis (ADEM)-like pathology, Concomitant delayed posthypoxic leukoencephalopathy and critical illness microbleeds, Deep coma and diffuse white matter abnormalities caused by sepsis-associated encephalopathy, Intact brain network function in an unresponsive patient with COVID-19, Author Response: Prolonged Unconsciousness Following Severe COVID-19, Reader response: Prolonged Unconsciousness Following Severe COVID-19, Clinical Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy, Neurology Unit, University of Udine Medical School, Udine, Italy, Senior Professor and Researcher in Neurology, Institute of Neurology and Neurosurgery, Department of Clinical Neurophysiology, Havana, Cuba, Inclusion, Diversity, Equity, Anti-racism, & Social Justice (IDEAS), Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), Encephalopathies Associated With Severe COVID-19 Present Neurovascular Unit Alterations Without Evidence for Strong Neuroinflammation, Impact of Coronavirus Disease 2019 in a French Cohort of Myasthenia Gravis, COVID-19 in Patients With Neuromyelitis Optica Spectrum Disorders and Myelin Oligodendrocyte Glycoprotein Antibody Disease in North America, A New England COVID-19 Registry of Patients With CNS Demyelinating Disease, Neurology: Neuroimmunology & Neuroinflammation. Two months after first being diagnosed with Covid-19, she found her heart would start racing without warning. The response to infection results in immune cells releasing pro-inflammatory molecules. BEBINGER: Take Frank Cutitta as an example. More guidelines and information on Disputes & Debates, Neuromuscular Features in XL-MTM Carriers: Using techniques similar to those employed by intelligence agencies, the research team behind the study analyzed commercial satellite imagery and "observed a dramatic increase in hospital traffic outside five major Wuhan hospitals beginning late summer and early fall 2019," according to Dr. John Brownstein, the Harvard Medical professor who led the research. Ventilation, which requires sedation to prevent injury, has become a common part of respiratory treatment in those with COVID-19. She developed an acute kidney injury necessitating dialysis from day 3 until ICU day 28. Do's and Dont's After Anesthesia. Joseph Giacino, director of rehabilitation neuropsychology at Spaulding, said hes worried hospitals are using that 72-hour model with COVID-19 patients who may need more time. In the Washington Post piece, experts theorized causes for prolonged recoveriesbut alsonoted fundamental gaps in their knowledge on the matter and said more precise information is necessary. Why this happens is unclear. Shibani Mukerji, MD, PhDis the associate director of theNeuro-Infectious Diseases Unitat Mass General and co-author of a recently published article on neuropathological findings from the autopsies of COVID-19 patients in theNew England Journal of Medicine. Let us help you navigate your in-person or virtual visit to Mass General. Satellite Data Suggests Coronavirus May Have Hit China Earlier: Researchers, Stat: The historic scale and severity of the COVID-19 pandemic have brought the challenges of sedation and analgesia during mechanical ventilation and critical illness into stark relief, highlighted by increased use of deep sedation and benzodiazepines. Im not considering myself one of those, he said, but there are many, many people who would rather be dead than left with what they have after this., Martha Bebinger, WBUR: Sedation, often used for minimally invasive surgery, blocks pain and causes sleepiness, but doesn't put you to sleep. The persistent, coma-like state can last for weeks. I personally have observed, and have had cases referred to me, of people with eyes-closed coma for two to three weeks. Regional anesthesia, such as an epidural or a nerve block, numbs a large part of the body while you . "We didn't find the virus in neurons using immunohistochemistry. Some common side effects of conscious sedation may last for a few hours after the procedure, including: drowsiness. The effectiveness of sedation has traditionally been evaluated in terms of patient and surgeon satisfaction, but the most important goal is not to induce a deep sleep in the patient, but rather to ensure that the surgery is performed safely and as planned. A brain MRI was subsequently performed on ICU day 26, which showed a diffuse white matter abnormalities (figure). The machines require sedation, and prevent patients from moving, communicating,. The researchers are sharing their data to determine the cause of prolonged coma in COVID-19 patients, find treatments and better predict which patients might eventually recover, given enough time and treatment. Many hospitals wait 72 hours, or three days, for patients with a traumatic brain injury to regain consciousness. Bud O'Neal, left and Marla Heintze, a surgical ICU nurse, use a cell phone camera to zoom in on a ventilator to get a patient's information at Our Lady of the .
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