I finished last week feeling good. The number of COVID cases were increasing but my patients were doing well. Well as in they were requiring High Flow oxygen at high levels but they weren't intubated and one was even downgraded from the ICU. At the beginning of this week we reached our highest peak since the first wave but we've been at this for months so that really didn't phase me. I mean by now we should know what we are doing right? RIGHT?!
That patient who left the ICU is at home now on regular oxygen at 2 liters. It's patients like that who give me a glimmer of hope as I went into this week in the ICU. We shifted my unit into an Official COVID Unit. How fun?! Anyways, all the patients started out Monday looking the same as the guy who is home now. But we forget that the patients who come into the hospital are usually VERY sick. They couldn't tolerate being at home, they couldn't breathe and they needed our help so they get admitted. They take their chance on the regular wards floors but as their oxygen requirements increase they need closer monitoring so they get upgraded to us in the ICU. So we get these patients and naturally as human beings we hope for the best but by the end of this week every single one of them turned for the worst. They all got intubated and who knows if they will ever get off the vent.
One patient in particular, let's call him Patient A was doing so well! The patient completed the standard course of Remdesivir, antibiotics and was on steroids. Everyday I'd come by and he was either eating, sitting in his chair watching tv or laughing on Facetime with his family. The x-ray from day to day did show some fibrosis which would be a chronic issue he would have to deal with but this happens to many covid patients and the acute problem which was the multifocal pneumonia was improving. Until it wasn't. The next day his X-ray and clinical status was a complete 180. At this point he was proning the entire day and stopping to catch his breath between sentences. His lungs on the x-ray were gone so, I had to have the talk that day and find out if and when we have to intubate would he want to undergo that? I stood with him at bedside and had to explain to him that, "despite everything we've been doing his lungs are getting worse and we may have to intubate him." "If we intubate you we will attach you to a ventilator." He asked with his voice cracking, "For how long?" "I don't know", I answered. The patient began crying and in between catching his breath stated, "O-kay, I will talk to my wife and then we will call you ... with our... decision". I said, "Okay, please take your time." But, I couldn't support him, I couldn't touch my patient or sit by his bedside like I normally would. I couldn't show too much emotion because my emotions were gone.
The next day the x-ray continues to worsen and the decision to make for oneself is not an easy one. If I say no, I die but if I say yes then I may be committed to a ventilator for the rest of my life. Tough decision to make for oneself especially when you are extremely sick and there's no family next to you to help support you.
On this day, it wasn't a matter of if he would get intubated but when. I still had some hope at this time comparing this patient to one of my success stories last week but with everything else going on it was very hard to do that.
I was dealing with other patients who were going through similar situations. One was a young woman with cancer and somewhere during her chemotherapy she got infected with Covid. Let's call her patient B. Her husband came to the hospital to talk about her current status and her code status. Having that conversation regarding a 31 year old is unbearable. I mean this person is three years older than me. The husband cried and said, "I have a six year old and a ten year old at home." I felt for him, I really did but again I couldn't show any emotion because I started the day sad, then angry and by this point I was stoic. To make it through this day without losing my shit that's what I had to do. We walked him over to the bedside. And he stood through the glass watching his wife lying there. Intubated. Sedated.
We got through half the day. At this point, Patient A was ready to give me his decision. I had a new patient in the ED (Patient C) so I was going to see them and then come back up to Patient A. Patient C was another COVID who was getting increasingly confused and needed intubation. Meanwhile, the son for Patient D wanted to talk about his mom. Now Patient D, even got her plasma treatment 2 days prior and she was now having increasing work of breathing at 40 breaths per minute so the son wanted to know what being intubated would mean before she tires herself out. I was on the phone with him while walking to Patient C's room and as I'm in the ED with Patient C the nurse for Patient A calls me and says, "his oxygen saturation is in the 60s and we need to talk to him now about his code status!" I said, "I'm on my way!" By the time, I change out of patient C and get a new mask, I'm walking into a room where the nurse is getting emergent code status from the wife, the patient is getting restless catching his breath on a non-rebreather, coughing and gasping for air. Patient A says, "I can't breathe." The attending is saying, "Lay back." But he can't lay back because he is suffocating. We grab the glidescope administer meds and just like that Patient A is intubated.
Soon after the chest x ray shows Patient A developed subcutaneous emphysema. It's not looking good. By now the unit is quiet even though it is the time for shift change. Patient A hit the entire unit on an emotional rollercoaster. Why? Because we thought he was going to get better. Man were we wrong. When patients come in you can sometimes make an educated guess about which route they will be heading towards. We don't say it out loud of course but we think about it. We are humans that's just what we do, we look at each patient objectively but this one, this one was supposed to be different.
That one glimmer of hope I mentioned from last week was gone this week. On my last day before my much needed break every single patient got intubated and when the family asks, "How long will this be for?" I have no response because we don't know if they will ever get off the ventilator. Who can answer that question? When we don't know anything. It can be one day, few days, three weeks or forever. Everything we do just buys time in the hope that people will heal themselves and during that time we're not only emotionally drained but scared for not just our patients health but our own!
Walking in and out of these rooms my own paranoia sets in about my well-being and my families well-being. Will we make it out of this? Or will we be in the same position? Every day is a fine line between doing your job and taking care of yourself. And every day is Exhausting. So when people ask me if this is real? I say, I don't know if it is but you better hope you don't end up in this position in order to find out.
This week was a whirlwind. And as the day comes to a close my attending (who has the most nonchalant attitude about everything) and I were standing by patient A's room. He said, "It's so sad". I look over and see the nurse lingering at Patient A who is lying there, intubated in a newly quiet room. The attending continues, "A few days ago Patient A wrote our names down on a piece of paper. Today, we saw that same paper with our names by his bedside. He kept that paper". As he said, those words tears filled up my eyes. But, I'm too strong to shed one. The nurse says, "This was the patient who was supposed to leave the ICU." We stood there a moment longer, said our goodbyes, I signed out my patients, thankful that there was no added bonus of a code blue before I exit the building. I got in my car and those tears that filled up my eyes finally began to flow down my face. As the day came to a close, my emotions came back to me.
If that won't make you bitter. I don't know what will. Wear a mask, wash your hands and try to keep that glimmer of hope even when it seems as if there is none.