“I think, very important, the young people and people of good health, and groups of people, just are not strongly affected.”Donald J. Trump, March 2020
The line was delivered with the characteristic pomp and swagger of a man completely confident that whatsoever he says is the Truth – regardless of how many people say it’s complete bollocks. In a way, it acted like a witch’s curse, and the universe seemed to do everything in its power to prove him completely wrong. Not that he’d care anyway, the orange buffoon.
“We’re still learning about this disease every day. But you’re young, and you don’t have any other health issues. That means you’ve got a good chance, okay?”
Mr. K nods, clutching the CPAP mask to his face as if it was his tether to the world of the living. Which, in fairness, it is – just a quickly fraying one.
He’s a 32 (yes, thirty-two) year old gentleman of Middle Eastern ethnicity with nil past medical history that presents to A&E complaining of worsening cough, fever and all the tick boxes for this COVID thing. The chaps downstairs are surprised, he needs a fair bit of oxygen to get his saturations to respectable levels, and that’s unusual for a young man. After all, Trump says this virus isn’t really an issue unless you’re old.
But there are always outliers, and he’s admitted to the ward for some supportive treatment and monitoring that’ll help him get over the worst of the virus before discharge. His admission isn’t so unthinkable really, he’s got a big belly and it’s splinting his diaphragm – the big muscle that contributes to our breathing.
The ward doctors frown because he’s just not improving, despite continually increasing oxygen via the non-rebreathe mask. But he’s young, and he’s a big man, so maybe he just needs some extra pressure to keep the airways open alongside the oxygen. They move him into a side room and connect him to the Continuous Positive Airway Pressure (CPAP) machine. Now the exhaust port is venting out COVID-laced exhaled air, but that’s okay because Trump said he’ll be fine, and the room can be deep cleaned after discharge.
Only he doesn’t get much better, and the ward doctors are at the limit for what they can confidently do for him, so they call ICU for an opinion.
My opinion is that this gentleman is an outlier – just like the centenarians running marathons. The virus has started buffeting the hospital with ever increasing tidal waves of its hostages – men and women, typically a half-century in age and older, with a smattering of 40-year olds. It stands to reason we’d have a case like this.
[You thought you knew the enemy]
I stop by the doctor’s office on the ward for a quick biscuit and a quicker catchup while all the formalities of transfer are sorted out. My medical colleagues ask me about Mr. K’s chances, but confidence is the colour of my painting, and I joke that we’ll fix him up and send him back soon enough.
I speak to his wife, and his niece who works as a doctor in another London hospital. I reassure them that while he’s very unwell, we’ll just be giving him some extra help with his breathing on ICU. We’re hopeful that he’ll do well, I tell them.
He’s scared, but I hold his hand while he speaks to his family, and while the tears come and go. I sit by his side while he reads from his holy book, and by the time my consultant is injecting the anaesthetic medication to put him to sleep, he seems less scared.
The intubation is tricky, his obesity doing its best to hide the larynx from me – but Dr. Adams applies some cricoid pressure and a second later I’m in. I manually ventilate his lungs until the alarms stop blaring, and he settles in lockstep with my heart rate.
As we wheel Mr. K onto the Unit, some of the ICU staff are surprised how young our newest admission is – but that’s okay, because we’ve only lost so far, and maybe now we’ll have a win.
He survives, for another twelve days.
In all my dreams before my helpless sight,
He plunges at me, guttering, choking, drowning.
If you could hear, at every jolt, the blood
Come gargling from the froth-corrupted lungs…
“Cardiac Arrest, A&E Resus”
Observing the renaissance painting of the crash team awaiting battle is always fascinating. There’s the grizzled A&E consultant confidently standing arms-crossed at the foot of the bed, our general that will lead the team in whatever comes through the door. His subordinates for the next however-many-minutes are a few A&E doctors and nurses, looking anywhere between terrified, excited, and overly sleep deprived. Completing the picture are myself at the head of the bed, and the medical registrar, who had come along for a lark; she’d be the team leader if the arrest call was anywhere other than here or the ICU.
A consistent dull thudding becomes more and more audible until the doors to resus slam open, and the paramedics are upon us. Their charge is a very young-looking woman, made to look even more diminutive by the immense LUCAS machine strapped to her front, consistently delivering chest compressions. I reflexively take over the bag-valve mask from one of the paramedics and start ventilating the lungs, while the team jolts into action. One, two, three on my count and she’s transferred from the ambulance trolley onto the resus bed – the mechanical thudding of artificial heart beats never ceasing.
“Nice and quiet for handover please,” the consultant barks.
“This is Susan, a twenty-two-year-old COVID positive female. She’s been self-isolating for a week, and was spotted on the ground in her garden by a neighbour who dialled 999.” The big bearded paramedic’s voice is muffled by his respirator, but he efficiently gives us the summary of what we’re dealing with.
“She had a pulse on arrival, but had reduced consciousness with best GCS of 8 so we did a scoop and run. She arrested en-route, CPR in progress for approx. 4 minutes. She has venous access in the left ACF.”
Every cardiac arrest has the potential to be utter chaos, but our conductor wrestles that into simple algorithmic order. The LUCAS provides the bass track as all of us immediately work in synchrony to bring this dead woman back to life.
2 minutes of CPR. Check the rhythm. Shock if appropriate. Repeat the cycle if she’s still dead. Have Adrenaline and Amiodarone at the ready. It’s simple really – the rest is just attempting to figure out and fix whatever caused the heart to stop.
“She had reduced GCS, and she looks a bit blue. Can we have a definitive airway please.”
That’s my cue from the conductor. My heartbeat builds up for the crescendo of another emergency intubation.
Squeeze the bag valve, pump as much oxygen into the lungs as possible to buy myself precious seconds.
Remove the mask, open the mouth and insert the laryngoscope to visualise the larynx.
All I see is blood.
My hand shoots out and grabs the wide-bore suction without needing to look.
Evacuate the blood, and more, and more, until – there! I see a flash of white as the vocal cords are revealed.
But the view disappears, more blood – definitely from the airway. I don’t have time; I have to do this semi-blind.
“Give me the bougie, hold this suction exactly here. Boss, I’ve got massive pulmonary haemorrhage up here.”
[Did you think you were in control?]
The blood keeps filling my view faster than the suction can remove it, propelled by the constant pressure on the chest.
Plastic guidewire down, down, there’s resistance but I can’t see what; withdraw slightly and visualise the destination I saw for a fraction of a second. Go again, smoothly.
The blood lessens for a moment revealing my guidewire perfectly placed through the cords.
“I need the biggest tube you have. What’s that, an 8.5? Fine.”
Slide the endotracheal tube over the guidewire, down, push, guidewire out. I start to reach for the oxygen while my colleague moves to inflate the tube cuff-
-a gout of blood pours from the end of the tracheal tube, and another.
[Remember your failure]
We keep playing, down the algorithm again, and again. I don’t know how long for, until-
“Thank you everyone, let’s stop here.”
There’s no final, mournful note. Just silence.
The next day came the 28 year old tennis coach, and the 35 year old chef, and the 26 year old healthcare assistant, and the 18 year old student, and the 38 year old single mother and the 33 year old solicitor and the 19 year old scaffolder and the 39 year old programmer, and the…
“I think, very important, the young people and people of good health, and groups of people, just are not strongly affected.”