“Hey is that the ICU outreach on-call? It’s Jenny, one of the respiratory ward doctors,” you begin.
You tell me about Alan, a fairly independent 62 year old gentleman with a BMI of 29. He unfortunately smoked in his youth, and has COPD – although his exercise tolerance is still apparently half a mile. Other than that, he’s got an enlarged prostate and Crohn’s disease. His main issues are the COVID that’s been rampaging through his lungs for the last 10 days, resulting in his increasing need for oxygen; and the negligible amount of urine he’s produced today.
You tell me that you called my ICU colleague yesterday to discuss Alan, and you were advised to increase the pressure of the air being pushed into his lungs with the CPAP machine, the percentage of oxygen in the air being delivered, and to turn him onto his front. Despite that, you say, his saturations are continuing to drop. His latest arterial blood gas shows a blood oxygen level of 7.3, and a pH of 7.15. His blood is becoming acidic because of increasing carbon dioxide levels.
You think you’ve reached the limit for what you can do for Alan on the ward, and you’d really like me to consider accepting him for transfer for ICU for intubation and invasive ventilation.
We meet in the doctor’s office on your ward. Scattered coffee cups and half eaten food cover the spots on the worktops where I’d normally perch. You don’t offer me a seat, but that’s ok – I’d rather not dally in this windowless cage of growing weariness.
I ask a few more questions about Alan which you dutifully answer. I pretend not to notice the hope in your voice. We’ve been facing this pandemic for weeks already, you should know by now that even ICU isn’t salvation for you or your patients. Maybe we were before this, and we will be again one day… but right now our ivory tower is just another losing battleground, no matter how big our guns are.
You walk me to side room 3, and tell me you’ll be in the office when I’ve finished if I need anything else. The unspoken implication is clear – ‘please save this one’.
I take a breath of my own exhaled carbon dioxide, recycled thanks to my respirator, and enter.
“They said they’d call you. That you could help me get better.”
“Well, they wanted to know if there was anything more I could add that might help you.”
He’s breathing fast, and covered in sweat. His chest is moving in a see-saw pattern, belly splinting the diaphragm and stopping his lungs from expanding well. His heart rate is fast, and barely supporting a crap blood pressure. His eyes are unfocused, and he seems agitated – tugging at the mask. His catheter bag is empty. Hypercarbia, tiring, two-organ failure on the fast track towards more.
I take his clammy hand in my gloved one.
“I’m afraid that the things I could offer are very extreme. In your case, they’d be more likely to kill you than help you get better.”
“Does that mean…am I going to die?”
The silence always feels like it lasts an eternity, but it’s never more than one second.
“Yes. I’m so sorry.”
We talk for a bit longer, although he doesn’t say much. Privately I wonder if he feels each breath differently now, knowing he doesn’t have many left. I tell him that my colleagues will be able to give him medication that will make him comfortable. I promise they’ll be able to help him speak to his family. He thanks me for my time, and I thank him for his. I squeeze his hand in goodbye, because he doesn’t have the strength to squeeze mine.
You’ve been biting your lip. Didn’t you used to smile a lot more? I suppose things are different in your world – you’re able to discharge people home daily after you fix them, and you’re uncomfortable with the really sick ones. You want me to wave my magic wand and help you out, but COVID has made us both muggles. Actually, if you’re a muggle, I’m at least a squib.
I can tell you’re putting on a brave face as I give you the update – you nod along sagely with the merest frown. But we both know you’re going to cry at some point later – Jonny would have you in the ‘wetty’ column within 5 minutes. I don’t blame you though, maybe I’d do the same if I wasn’t so emotionally blunted. As long as you’re not one of those types that does it on the job, when there’s work to be done, we’re good.
After I’ve left, you start the syringe drivers that identify an end-of-life patient heading towards a hopefully more dignified death. Morphine to reduce the pain and work of breathing; Glycopyrronium to help dry out the viscous, airway blocking secretions; Haloperidol to overcome the intractable, relentless nausea; Midazolam to take care of the constant agitation.
Over the next twenty-four hours, Alan feels his breathing ease a little, and he drifts closer to sleep.
His eyes close. They don’t open again.
“Hey is that the ICU outreach on-call? It’s Jenny, one of the ward doctors,” you begin flatly.
You tell me about Nisha, a normally independent 53F with a BMI of 24, and a PMH of hypertension and type 2 diabetes. She’s day 10 post onset of symptoms, with a chest x-ray that shows bilateral infiltrative changes up to the apices. The rest of the story could be a pre-recorded message, i’ve heard it so many times from so many people. Worsening oxygenation and ventilation, tiring, blah blah. Yes, i’ll come and see her.
I can’t help but ask why you’ve scrawled your name on your respirator with whiteboard marker. Isn’t that what name-badges are for? You explain resignedly that on the wards, there aren’t enough – so you’re all re-using the same one for the whole shift. I do my best to look sympathetic, while subtly moving my arm to cover the two fresh respirators in my scrub pocket. If you notice, you don’t say anything.
The only thing that bothers me as I walk into the patient’s room is that you don’t sound hopeful anymore.
[She’s the right shape to be a winner / She’s too co-morbid / She’s only got single-organ failure / I’ve seen her X-Ray, she’s got hardly any lung left / Her gases aren’t bad, I really think she’s worth a shot, boss.]
“Will it hurt?”
“No, we’ll put you to sleep first. You won’t feel a thing. Once you’ve been intubated, we can connect you to the ventilator and help your breathing a lot more.”
“But you said there’s a chance I won’t wake up?”
“I can’t lie to you Nisha. You’re very sick. There’s a chance that even on ICU you won’t recover. But we’ll do our very best, no matter what.”
“If I don’t let you do this, I’ll die, won’t I doctor?”
“Yes, I’m afraid that’s very likely.”
“Is there time for me to call my husband? I’m sorry, I’m just really scared. I’ve got so many things…”
“Take your time, I’ll be here for as long as you need.”
Intubation kit. Rescue airway kit. Emergency surgical airway kit. Propofol and Ketamine for induction of anaesthesia, Rocuronium to paralyse. Metaraminol to support a crashing blood pressure. Everything’s ready.
I’ll have to remove her CPAP mask to get access to her oropharynx, to visualise the vocal cords and site the endotracheal tube. As soon as the mask is off, her oxygen levels will start to drop. Better still, as soon as the paralytic agent takes effect she won’t even be able to breathe on her own, so her oxygen levels will tank. The icing on the cake is that the very act of intubating someone causes a profound systemic shock. Combine that with crashing oxygen levels in an already unstable patient, and you’re on the fast train to cardiac arrest. In short, the moment the intubation process starts, success versus failure is measured in single-digit seconds.
I visualise the step-by-step movements my hands will have to make. My heart finally starts beating a little faster. I savour the rush of adrenaline. Retrospectively, I wonder at how broken I must be to only feel alive when someone else is at death’s door.
The anaesthetic drugs go in. My hands start moving.
Her eyes close.
16 days later they open again.