A couple of days ago I intubated my first critically ill patient with probable COVID (the test takes 5 days to return, so we never know in the moment).
I should preface what I write next:
- Many talented people have taken on unbelievably time-consuming, entirely voluntary roles in order to ensure a robust response. My institution has risen to the occasion. Rather than step away and wait for the state or county to fix someone else's problem, we have collectively stepped up to develop our solution to our problem.
- The ED has been a beacon in a time of chaos - I could not be prouder of the docs, nurses, techs and secretaries who risk their health daily to care for their neighbors.
- One of our intensive care docs spent time in a previous life as a member of the CDC's Epidemic Intelligence Service - we have bright folks in those starring roles.
- The time I spent getting my MPH was spent disproportionately preparing for humanitarian crises and disaster relief - this is ostensibly the moment my training has prepared me for.
Despite these encouraging factors, the experience left me demoralized on a number of different levels.
A male a few years older than me had been seen days earlier with fever and cough and a normal chest x-ray and labs at the time (he did not meet criteria to test for COVID then, and it would not have changed management one iota). He now returned with low oxygen levels and a bilateral pneumonia on chest x-ray.
I had time to discuss his case with the on call intensivist. We both agreed on early intubation.
The patient was lucid, and I explained what I planned to do. He was afraid but understood this was the best course of action. Like so many patients before him, he was quick to entrust his life to us.
(The shrapnel of a life in medicine rains down to cause collateral damage at home to your spouse and kids. Then someone you just met trusts you with his life, leaving you conflicted about leaving medicine altogether.)
At the prompting of a wise and considerate nurse, I went out to inform the patient's wife of our plan. She was waiting in isolation in her car. Her reaction was tearful, appreciative, concerned. Because her husband was in the designated "hot zone" of the ER, she understood we could not allow her to be near him.
Thankfully she did not lash out at the messenger - this happens often. If our safety isn't at risk enough from the disease, it's placed at risk from angry family members of the person we are trying to save. Joseph Heller would have made a great emergency physician.
Separation of patients from those who love them is one of the most damning features of this disease. It mandates that a social species isolate, in some cases to die alone.
Many of us on the front lines risk transmitting the illness to our families during the asymptomatic period because the staying apart is too awful to consider. One colleague had a trailer parked in front of her house and plans to live there, alone, to avoid bringing the illness to her family for as long as it takes. This would break my heart in increments.
Technically, the intubation was not difficult. Before entering the room, I explained to the deliberately restricted personnel who would be inside exactly how it was going to go down - we choreographed it like a ballet, each person set to hit their mark at the appropriate time.
We blocked out precisely which piece of equipment would fit in what area of the room - our two negative pressure rooms are notoriously small, so we coordinated our large cast for performance in the small theater we had.
We talked through each step in sequence - planning ahead which drugs, tubes, machines, connectors and contingency equipment needed to enter the room to minimize how often the door was opened.
We ensured everyone had properly donned PPE - we had supplies, at least that day.
It went off exactly as planned - no suction or bagging of the patient, video laryngoscope showed tube passing through the cords, attached immediately to the ventilator using a viral filter. As oxygen levels increased, sphincter tone decreased.
Afterward, I asked everyone in the room to choose a buddy to double-check their doffing technique - no room for sloppiness here - and had them watch as I removed part of my contaminated PPE in the room. See one, do one.
The patient remains intubated in the ICU as I write this. COVID patients can require up to a couple of weeks on a vent. I read his daily consultant progress notes feeling more deeply invested in his outcome than I have for any patient in a long time.
The day before, I'd been part of a call to help create an algorithm for deciding how to allocate ventilators when demand exceeds supply. In addition to the burden of caring for a surge of patients, I fully expect that ER docs will be having end-of-life discussions with patients who are not prepared to die, for whom there are no ventilators, the likes of which we have not experienced in our careers.
My colleagues at every level have been incredible. Our community has been dropping off leftover N95 masks from drywall jobs and food for our staff. Friends are sending texts and emails and phone calls full of encouragement, appreciation and concern.
But I can't shake the sinking sense that this was the first raindrop before the tempest arrives.
Click here for a preview of what may lie ahead, but be warned - it's not an easy listen.
Postscript: My patient was eventually extubated. He has a long road ahead, but I am deeply grateful for the positive outcome so far.