DO NOT CROSS RED LINE UNLESS IN FULL PPE (PERSONAL PROTECTIVE EQUIPMENT)
We’re out of tie-back surgical caps, so I’m wearing a hairnet that makes me look like the dinner ladies from school. The straps of my respirator go over the top and I squeeze hard around my nose to create as tight a seal as possible. I’ll have another nosebleed later, and my slowly worsening pressure sore will hurt like hell – but it’s a lot better than the alternative.
Full length surgical gown on – L, because the XL’s have all gone. Two pairs of gloves follow, one under and one over the cuff of the gown. Visor – none left. Right, scuba style goggles – oh, all gone too. One pair of GCSE Biology eye-shields languishes in the box, trying not to look like the last kid to be picked in the P.E class line up.
Dr. Jones (my boss) dons his PPE next to me and notices our predicament. He looks me up and down appraisingly, under the guise of being my ‘buddy’ and ensuring there aren’t any gaps in my protection. He nods approvingly, unconcerned about the massive area of exposed skin between my hairline and lower nose, while reaching for the eye-shield himself.
“Your glasses should do the job, I’m not so lucky.” At least he has the good grace to look sheepish.
In theory, it shouldn’t matter. All our ICU COVID patients are intubated and on the ventilator, meaning the air flows from the machine down the tracheal tube into the lungs, and back again, in a closed circuit. Compared to the aerosol releasing atom-bomb of the intubation itself, there aren’t many aerosol generating procedures regularly done on the Unit – provided the ventilation circuit remains closed. Still, the fear and respect for the virus remains. By now we’ve all heard the stories of our colleagues (ear-nose-throat surgeons in particular) dying after exposure to high viral load.
I give Dr. Jones’s armour the once-over like a good squire, and together we cross the red line.
“How long at the crease for Bed 8?”
“Mrs. A is day 10 since intubation. Ventilation requirements have plateaued. PEEP of 10, FiO2 is still 50% on PRVC.” I pause for a moment. “Her kidneys are still hitting boundaries.” That gets a snort from the boss.
“What do you think about a tracheostomy for her?” Dr. Jones asks.
“She’d definitely benefit. With the tube directly accessing the front of the neck there’s less dead space to ventilate, so less work for the machine to do. It’s not as invasive as the ET tube is, so we could wean her sedation and start to wake her up without a massive autonomic reaction. The only challenge will be her anatomy – she’s got a short, chunky neck.” It’s an easy enough question, and Dr. Jones is satisfied.
“Agreed, let’s do it now. Could you hold the tube for me? Alex can have a go with the bronchoscope.”
Including the time to get all the equipment ready, it only takes 10 minutes for things to go wrong. For me, that is.
After cleaning thoroughly, we create a sterile field with a small drape over the front of Mrs. A’s neck. I take my position at the head of the bed, tightly gripping the endotracheal tube with my dominant hand. My left hand holds the plastic connector to the ventilator’s tubing, through which the life-saving gas exchange is funnelled. The small port that allows external access to the circuit remains closed under my thumb. Alex takes up a position to my left, fibre-optic bronchoscope in hand. On my signal, I flip the port open and he quickly inserts the camera before too much COVID air is vented out from Mrs. A’s lungs into the air.
Our eyes turn to the screen and we’re treated to a high definition visual of the inside of Mrs. A’s windpipe as he progresses down the ET tube. Or at least, that’s the idea. Instead all we see is an off-white mass of viscous viral secretions completely clogging the airway – a sign of incredibly infected lungs. Alex tries to change the angle, and liberally suction away the secretions but they’re so thick and voluminous that the camera is totally covered. Trying to surgically insert anything blindly into someone’s trachea isn’t the greatest idea outside of a total emergency, so we put the tracheostomy on pause while visuals are established.
Even Dr. Jones has a go on the bronchoscope, but he casts it away in frustration after a minute. Every time the bronchoscope is removed to clean the tip, and then re-inserted, the port is flipped open and Mrs. A’s lung output is vented directly into my face. My respirator should hopefully be giving me an airtight seal. I hold my breath each time anyway, cognizant that I’m still screwed.
“Give me an 8.0 ET tube please, I’m just going to re-intubate her.”
I hastily take my unprotected eyes and face and beat a retreat away from the ICU-level viral load droplet bomb. From around the corner I can hear the alarms blaring loudly for the few seconds Mrs. A is extubated and not being ventilated, as her oxygen saturations crash to incompatible-with-life levels. Fortunately, the intubation is smooth (Dr. Jones is very good, despite being a goggle thief), and we take up our previous spots.
The bronchoscope gives us a better view this time around – the secretions are still everywhere inside the windpipe, but Alex keeps the camera just inside the newly inserted pristine plastic ET tube. He suctions as much as he can and holds steady while Dr. Jones begins his incision just south of the Adam’s Apple. We see the pressure of his instrument on the trachea from the inside, confirming he’s in the right spot, and he pushes his introducer through the tissue and into place. The rest proceeds smoothly, one instrument sliding glossily over another through the ready-made channel until the brand-new tracheostomy airway is in-situ and allowing direct ventilation of the lungs, bypassing the mouth and larynx.
Everyone relaxes, and I make to remove the now unneeded endotracheal tube. Of course, at the very moment the tip is leaving Mrs. A’s mouth, and despite all the sedation she’s on, she gives an almighty cough.
I don’t even see the projectile blob of lung secretion, so fast did it travel, I just feel it splatter onto my face below my right eye. Everyone freezes, except sister Chloe who scrambles for an alcohol-wipe to thrust in my direction, and Dr. Jones who looks up from his suturing.
“See? Your glasses did the trick, imagine if that had gone into your eye. We’d be intubating you next!”
I hope colleagues will forgive me for the halls ringing with curses as I head for the nearest shower.
“How’s life your end?” I put my phone on speaker as I start the hunt for something edible in my fridge.
“About the same, we’ve not been as badly hit as you Londoners.” Muhammad is one of my best friends from medical school, and also works as an ICU doctor, out in Essex.
“You won’t believe what happened to me today during a tracheostomy…”
There’s a thoughtful pause after I’ve finished dramatically narrating my distinctly not-heroic tale.
“I hope you didn’t keep that set of PPE?”
“What, like a trophy? God no, all our PPE goes in the bin outside the Unit.”
“Oh, that’s good. We’re having to wash ours and reuse it.”
I almost cough on my Cheerio’s. “Are you joking? They’re single-use disposables”
“Bro, these are orders from the managers. Apparently you can wash them up to 3 times at 60 degrees. But how do you monitor how many times a gown has been washed? And what if someone does it at 40 degrees?” He chuckles to himself. I can hear his two small children playing together in the background.
“Do you trust them? The managers, I mean.”
“With my paycheque, sure. With my life, not a chance. But still, count yourself lucky – at least you had a decent respirator.”
“True, the guys on the wards don’t even have that. It’s like the Somme out there mate…”
Our conversation drifts back to familiar paths, reminiscing about halcyon days and making extravagant plans that will never come to fruition. The only change recently is how we say goodbye.
“I gotta feed the kids. Listen, don’t die.”
“No promises, but you too.”