The Gaspasser
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I could be the last person some of these patients ever see, or the last voice they hear. A lot of people will never come off the ventilator. That’s the reality of this virus. I force myself to think about that for a few seconds each time I walk into the ICU to do an intubation.
This is my entire job now. Airways. Coronavirus airways. I’m working 14 hours a night and six nights a week. When patients aren’t getting enough oxygen, I place a tube down their airway so we can put them on a vent. It buys their body time to fight the virus. It’s also probably the most dangerous procedure a doctor can do when it comes to personal exposure. I’m getting within a few inches of the patient’s face. I’m leaning in toward the mouth, placing my fingers on the gums, opening up the airway. All it takes is a cough. A gag. If anything goes badly, you can have a room full of virus.So, there’s a possibility I get sick. Maybe a probability. I don’t know. I have my own underlying condition when it comes to this virus, but I try not to dwell on that.
Up until a few weeks ago, I was the anesthesiologist people would see when they were having babies. I’d do five to seven deliveries a day, mostly C-sections and epidurals. We’re a large state hospital at University of Illinois-Chicago, and we end up doing a bunch of high-risk deliveries. You’re trained to be the calmest person in the room. They teach us: “Don’t just rely on medication to calm a person. Use your voice, your eye contact, your whole demeanor.” We give people positive ideas and positive expectations. It sounds corny, but it works.
Our team had a meeting on March 16th to figure out a staffing plan, once it was clear where this was going. Chicago’s becoming a hot spot now. Our ICU is almost full with covid patients. The pediatric ICU has been cleared out to handle overflow. The wave is just starting, and we need to limit our exposure or we’re going to run out of staff. Everyone basically agreed we should dedicate one person to covid intubations during the day and another at night, and I started thinking: I’m 33 years old. I don’t have any kids at home. I don’t live with older relatives. About an hour after the meeting, I emailed my supervisor. “I’m happy to do this. It should be me.”
Now my pager goes off throughout the night. Nine o’clock, midnight, 2, then again at 3:30. Most of the time I do several airways in a shift. By next week or the week after that, they’re saying it could be 10.
It’s a common procedure. Intubations are routine for us, at least most of the time. You can be in and out of the airway in 10 or 15 seconds if everything goes right. But when you’re dealing with a patient who isn’t getting enough oxygen — which is everyone at this point — every second becomes crucial. As soon as I get the page in my call room, I grab my backpack of medications and my duffle bag of protective gear and run for the stairs. There isn’t time to wait for the elevator. I go two floors up to ICU and get into my protective gear outside the room: mask, face shield, hood, secondary hood, personal air filter, gown, two sets of sanitized gloves. I tape everything together, because a few times the gown has risen up and exposed my wrists. There are so many opportunities to contaminate yourself. I monitor my heart rate, and it goes from like 58 to 130 by the time I get into the ICU. I’m stressed and rushed and hot inside the protective gear. I’m trying not to show it.I’ve been shocked sometimes when I walk in and see the patients. Most of the ones I’ve intubated are young — 30s, 40s, 50s. These are people who walked into the ER because they were coughing a day or two ago, or sometimes hours ago. By the time I come into the room, they are in severe respiratory distress. Their oxygen level might be 70 or 80 percent instead of 100, which is alarming. They are taking 40 breaths a minute when they should be taking 12 or 14. They have no oxygen reserves. They are pale and exhausted. It puts them in a mental fog, and sometimes they don’t hear me when I introduce myself. Some are panicky and gasping. Others are mumbling or incoherent. Last week, one patient was crying and asking to use my phone so they could call family and say goodbye, but their oxygen levels were dropping, and we didn’t have time, and I couldn’t risk bringing my phone in and contaminating it with virus, and the whole thing was impossible. I kept apologizing. I just —. I don’t know. I have to find a way to hold it together in order to do this job. I tear up sometimes, and if I do, it can fog up my face shield.
The first thing I do is pull up a stool and get right down to their level at the bed. Most of the time, the look in their eyes is fear. But sometimes, honestly, it is relief, like, “Thank God. I can’t do this anymore.” They don’t have the energy to be hysterical.
I put an oxygen mask on the patient and give 100 percent oxygen for a few minutes. You want to tank them up, because they won’t be able to breathe on their own. Next I give medication to put them to sleep. We’re trained to touch the eyelashes a bit to make sure they’re down. Then I give a muscle relaxer and take a look down the airway for the vocal cords. With this virus, I see significant upper airway swelling, tongue swelling, lots of secretion. When I start to put the tube in, that gives an opportunity for the virus to release into the air. The patient’s airway is wide open at that point — no mask or anything. People can cough when the tube goes in toward the trachea, a deep, forceful cough. My mask and hood can get covered in fluid. Usually it’s tiny droplets. Aerosolized virus can float around. You’re basically right next to the nuclear reactor. I go in confident and fast, because if you miss on the first try, you have to do it again, and then you’re bringing out a ton more virus.
Once I’m done, sometimes I’ll go back to the call room and do squats or lunges. I try to keep my lungs strong. It’s hard not to think about, because I’ve had bad asthma since I was a kid.
I use an inhaler twice a day. I’m very in tune with my breathing, and whenever I’m getting sick, the first symptom is I start wheezing. My whole family was like, “Why are you volunteering for this? What are you doing?” My dad and brother got a bunch of tools and built a Plexiglas intubation box based on a model out of Taiwan. It sits above the patient’s face, like a shield to reduce your exposure. I haven’t been able to use it yet, but they’re worried. They’re trying to protect me.
Last week, I called to tell them about my end-of-life wishes. Then I emailed them, just in case. I said, “If I have to be intubated, I’m fine with that. But if I’m going through liver and kidney failure, and if I’m cognitively impaired at that point, and if you can tell my body is failing and I’m not going to get back to being who I am …” Well. It was a hard conversation. But I know how this virus can go.
Each night I try to do rounds with the doctors in the ICU to check on the patients I’ve intubated. They’re not allowed to have family or visitors. I’m not a religious person, but I do like to stand there for a minute outside the room and think about them and what they’re going through. I try to think about something positive — a positive expectation. Mostly they’re unconscious on the vent, but each day for an hour or two they get what we call a sedation holiday, which means we bring down their medications so we can check on their baseline level of consciousness and see how they’re doing on their own. In other words, for a little while, they might wake up.
They can’t talk with the tube in, but I have seen a few patients before write messages on a piece of paper. “Vent?” Or: “Surgery?” Or: “How much longer?”
Usually, before this, patients would be on a vent for three to five days. Now we’re seeing 14 to 21. Most of these people have acute respiratory distress syndrome. There’s inflammation, scar tissue, and fluid building up in the lungs, so oxygen can’t diffuse easily. No matter how much oxygen you give them, it can’t get through. It’s never enough. Organs are very sensitive to low oxygen. First comes kidney failure, then liver failure, and then brain tissue becomes compromised. Immune systems stop working. There’s a look most people get, called mottling, where the skin turns red and patchy when you only have a few hours left. We have a few at that point. Some have been converted to “do not resuscitate.”
In between intubations, I’ll sit in my call room and watch the monitors. I can see all of the patients’ vitals and check on how they’re doing. We’ve had some successes. A younger patient came off the vent earlier this week and just got sent home. The staff at this hospital is amazing. Even so, it usually goes the other way. I’m looking at the monitor right now, and there’s one patient who isn’t going to make it through the night. Three others are tipping toward the edge.It’s a powerless feeling, watching someone die. The oxygen level drops, the heart rate drops, the blood pressure drops. These patients are dying on the ventilator, and sometimes when they take away the body, the tube is still in the airway.
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I stay in touch with a lot of the people with whom I used to work. All of my former partners have new jobs in at least 4 local hospitals, and they're doing well - or at least they were.
I've also been in frequent contact with our former "anesthesia tech." I think I've mentioned her before.
Two weeks ago, she posted this about the University of Chicago, where she works now:
I have no idea how many ORs the U of C has, but if it's anything like where I used to work, I'd guess that it's north of 50. Add to that the number of "off-site" anesthetics being given (endoscopy, MRI, etc), and I'd guess that they have about 75 "anesthetizing locations."
Today, they have 7 cases.
Seven.
Anyhow, we stay in touch. Last week, on the 31st, I asked her how things are:
I'm doing good. We have 80 covid pts. Only a dozen on vents. Several dozen have already been discharged. It's going ok.
Then I asked: "Any word from Large Suburban Hospital how John and Bob are doing?
John is on the covid team.... Senior attendings with most intubations. He figured he and Bob have done more than these people.
I can't imagine.
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Large study of vent survivors over age 65
https://medicalxpress.com/news/2010-12-older-survivors-mechanical-ventilation-significant.html
Things to think about with the advance directives if you are looking for something to do.
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@Loki said in The Gaspasser:
https://medicalxpress.com/news/2010-12-older-survivors-mechanical-ventilation-significant.html
Yes. Not surprising at all, and it sort of tracks with the mortality, over time, of something like a hip fracture. Older people don't do well.
I didn't get into the weeds of this, because I'd love to see what the reasons for ventilation were: pneumonia? Post-surgical support? Heart attack? Those are, presumably short-term issues that get resolved within days, perhaps a week. But with this disease we're seeing much longer need for ventilation and the primary problem is pulmonary and untreatable. That's a recipe for disaster.
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wow. Interesting article and discussion. Thanks for sharing!!
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The answer (if this is going to be the dance and not the hammer) is more focus on treatment earlier in the process. All those people being sent home after being diagnosed and being told to take otc cold medicines until it gets so bad that it’s basically too late. By the time you get to the Vent, the horse has already left the barn so to speak.
Me/rry/Christmas
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@LuFins-Dad That's exactly right.
Also, okay, let's pretend we're on the other side of the curve. New case percentage is nominal. They're talking about relaxing the lockdown and having people go back to work.
Are we going to be in a position where we're going to be able to see the next outbreak coming far enough in advance that we can shut down soon enough to not cause hospital saturation? I very much doubt that.
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@Aqua-Letifer said in The Gaspasser:
Are we going to be in a position where we're going to be able to see the next outbreak coming far enough in advance that we can shut down soon enough to not cause hospital saturation? I very much doubt that.
We should be able to take a shot at calculating the answer to that question now.
Hopefully that is part of the plan used to turn the world back on.
