It’s 6 a.m. I’m still in bed, and my eyes are barely open. I reach for my phone. I check my email. Last night’s sign-out -- the transfer of patient information between caregivers as one shift ends and another begins -- just arrived. I scan the names, looking for one in particular.
I admitted you just hours before, just a few days into your symptoms. You got sicker fast. I remember you insisted to every clinician before me that intubation wasn’t within your wishes. I wasn’t so sure.
You were in your 50s, no major health issues. Didn’t like doctors or the health care system. I recognized the fear. I walked into your room. I knew how this would go -- nothing new. I introduced myself: “I’ll be the senior ICU doctor taking care of you. Is it OK if I examine you?”
In situations like this, I start with the exam. There isn’t much to discover, but few things convey how much we care as the amount of time and attention we devote with our hands and stethoscope. I spent longer than usual. There was work to be done here. I was laying the foundation.
Next, I describe the findings. Slowly. Then I make some guesses. They stopped being guesses long ago. “You probably feel OK right now, just really wiped out. Not short of breath at all. That oxygen in your nose is pretty intense. Your back starting to get sore from this bed yet?
“They keep freaking out about your numbers, right? How far do you think you can walk? The bathroom? What would happen if you tried to go to the bathroom right now?”
I explain how we try to make the most out of the lung that isn’t sick. Giving you oxygen is one part of that. Reducing how much oxygen the body needs is another. I talk about bed rest, bedpans, catheters, spending time on your belly. I avoid talking about what happens if that isn’t enough.
“I know you’re scared. This is more frightening by the moment. You’ve heard the stories. What are you worried about?” You mention your kids. Your dog. Almost always you talk about someone who depends on you. You don’t talk about intubation. Neither do I.
I take your hand. “I want you to know something. You’re in good hands. We are here for you. Whatever happens. It doesn’t matter what happened before. We are here for you.” The response is palpable. Your hand tightens on mine.
You know that I get it. How real it is. How bad it is. “I want to tell you this, right now. This can get bad. I hope it doesn’t. But it might. If it does, we are here for you. We will do whatever we can, whatever we need to do to get you back to Miles. You’re in the right place.”
The high-flow oxygen is blasting. I’m almost screaming through the N95 and face shield. I’m staring into your eyes. You nod. “You know what that means. In an emergency -- only in an emergency, only to save your life -- we will do anything needed. Including putting in a breathing tube.”
Your face tightens. A stiff nod. I pause. An opportunity for you to say something. But I know why you won’t, because you haven’t heard it like this before. It makes a lot of sense for many people to say they don’t want a breathing tube or CPR or other “heroic measures.” But you aren’t thinking about any of those reasons. You’re terrified because of what you’ve heard about breathing tubes and COVID. You thought the breathing tube would kill you, just like so many others have told me they thought they’d get COVID from the vaccine. Now you’re realizing it isn’t like that at all. The machines are there to save you -- to breathe when you can no longer breathe on your own. I continue. “One of three things will happen, and I have no idea which one. First, you might just get better quickly. I so hope that’s what happens for you. But it may not.
“You might also stay like this for days or weeks. Sore. Tired. Weak. Uncomfortable. But some of those people get better just like that, so every day you spend like this is a win, too.
“Or -- you might get worse. Bad enough that you need the ventilator. Bad enough that you need more. I hope that doesn’t happen to you, but if it does we will be here with you every single minute. You are not alone. I’m going to call Miles now.”
I called Miles. That was a tough conversation. It was important. I learned more about what mattered to you. And before I left, I did dozens of other small things to make it safer, to make it better. Medications to help with nausea and anxiety and pain, if it came. Blood thinners to reduce the risk of a clot while you’re in the ICU. I ordered the other COVID therapies like steroids, protein shakes for whatever extra nutrition we could get into you, and blood labs scheduled for the next morning. I made sure “vaccination after recovery” was on your plan as a follow-up item after discharge, and I made sure your code status was clear: Full code. Do everything possible to keep you alive.
Back in my bed. I keep scrolling through the sign-out. I find what I’m looking for. Your oxygen saturation dropped around 2 a.m. You were confused and agitated. They intubated you. Almost immediately your heart stopped and you arrested. They performed CPR for 35 minutes. You were gone.
I put my phone away. It’s time to go back to work.
Several weeks have passed since this patient died. Miles is a pseudonym to protect the family’s privacy, but the truth is there are so many patients with stories like this. We have a 75% two-shot vaccination rate in Massachusetts. Since the start of 2022, about 65 more people have died of COVID-19 in my state, bringing our total to nearly 21,000. That’s just a fraction of the 850,000 deaths in the United States since the start of the pandemic.
Lakshman Swamy is a pulmonary and critical care physician at Cambridge Health Alliance and an instructor in medicine at Harvard Medical School. He created Critical Care: The Game, a crowdfunded cooperative card game that helps the public learn about the intensive care unit.
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