She would arrive home at around 10.15 at night. In less than 10 hours, she was expected to repeat the same cycle, the following day….Life and death would continue a devilish dance all day, next day!
By Nazarul Islam
Last year, my daughter M, a graduate of FSU Medical College, began her Covid hospital shift at a North Carolina Hospital. On her first day…before she could even head to her allocated bay, a nurse was already asking for a doctor to help her. One of her patients won’t put on his mask and his oxygen levels were dropping. It would take M a few moments to get on her PPE before she could get to the Covid patient. She tried to talk to the man, but it was difficult for him to hear through the doctor’s mask and the noise of all of the CPAP oxygen machines. He tells Dr. M that he’s tired of fighting, and that he wants to be left alone.
Through her mask Dr. M tried to explain that he had been getting better, and that the medical team wouldn’t have a place for him on the high dependency unit (HDU) unless they thought he had a good chance of survival. The patient tried to tell the doc that he did not understand what it’s like, desperately struggling to breathe, which was true. This would go on for around 10 minutes. Eventually, M had to take his request seriously. Perhaps it wasn’t illogical for the Covid victim, to want to die peacefully.
In order for M to allow him to make this decision, She would have to be sure that he understood the risks, so M asked him to explain to her what he expected would happen if he took off his mask and did not put it back on. He said he didn’t know. M shared with him that he ‘has to understand’ that he will die and that he needs to say those words to her if that is what he really wants. Eventually both compromised; he will put his mask on for another hour, then phone his wife and tell M his decision. This man was 61.
Dr. M was allocated B-Bay, in which there were five patients, mostly men, ranging from their early 30s to their 60s. This was younger than normal on HDU because — as she explained to the man — they only have beds for people with a fighting chance. She would read their charts to update herself on what happened overnight.
Who had dropped their oxygen saturations? Who had needed their CPAP (Continuous Positive Airway Pressure) settings increasing? This came via a tight mask that went over the Covid patient’s face to help him breathe by forcing air into the lungs at high pressures, keeping the airways open. Dr. M is told that it feels like the patients are suffocating.
Oh, God….Who had crashed overnight and was now on the ICU (intensive care unit)? Who had died?
Again, M put on PPE (FFP3 mask, hairnet, long-sleeved gown, gloves and visor) and enter the bay to examine the patients. She had felt rather lucky to have had this level of protection — her colleagues outside of the HDU only have surgical masks, which offer little protection against an airborne virus.
The patients didn’t ask many questions, mostly because they needed to spend all of their energy breathing. M has tried to work out if one of the patients isn’t answering her questions because the patient is delirious, because she doesn’t speak English, or because she is depressed. M has worked out that it is probably the latter; her notes say that her husband died just before New Year, from Covid. She tried to remember every patient as an individual, since she couldn’t bring the notes into the bay to write as she went, but each crackly chest she listened to blurred into one. She summarized what she had found, for the consultant’s round, later in the morning.
By this point, the blood test results should be back. M had been wondering why one of her patients was deteriorating — requiring more oxygen and at higher pressure — and his blood results provide her with a likely answer: a blood clot on the lungs. He is too unwell to enter a CT scanner, which would confirm this theory, so M treats him as if he has one, with higher doses of blood thinners. M cornered the ICU doctor, who happened to be reviewing another patient on the ward at the same time, asking him to have a glance at her patient. He agrees that he will likely need an intensive care bed at some stage, but at the moment they simply don’t have one.
M had worried that her patient was going to end up with an emergency intubation, much more dangerous than a controlled one in ICU. She now had to update relatives over the phone, since they are unable to visit. M always put this part off; she almost never had good news to deliver. Hearing people cry on the other end of the phone, knowing that she was bringing them news of the worst day of their lives, was indeed heartbreaking.
There is nothing positive that can be made from the words “your father is currently on the maximum support we can offer, and we are not sure if he is going to survive today”. Seriously…M had felt like a bad doctor because — to put it bluntly — she was causing suffering rather than alleviating it. Why couldn’t she make them feel better?
They tried to have the patients prone (lying on their fronts) since this would open up their lungs at the back and improved their oxygen levels. The patients hated proning, since the masks would dig into their faces, their backs hurt and their arms go numb, and the facility did not have massage table-style beds with holes for their faces.
One of my patients had not managed to be prone at all. M spoke to his wife, who informed her that he was very claustrophobic, and that might be why he had been resistant. She told her that she had been pleading with him on the phone to try it, but hadn’t been able to persuade him. M asked her if there was anything that had helped him in the past with his claustrophobia and she says sometimes watching a film on the iPad. But M did not have the courage to tell her that he is nowhere near well enough to watch a film. She suggested a fan, so M arranged for one to be set up for the patient, and he managed to prone all day. That day, M had felt like a good doctor.
The RESCUE hospital had several patients who were not “fit” for ICU in the current climate. Before Covid, they most likely would have been given a chance, but not now. When the team thought that these patients had suffered enough, and were unlikely to ever recover, they would start talking about making them comfortable. It’s partly because they needed the beds for patients with a better chance, and partly because they felt it was cruel to keep these people suffering when their chances of survival were very slim. It was difficult to work out which of those was the doctors’ true motivation.
The most distressing part of their struggle was the air hunger. Doctors could spot these patients easily, as they grasped the masks to their faces with both hands and continued to gasp visibly for air.
Once they had decided to palliate someone, and give them morphine to reduce their respiratory drive, all this had eased this feeling. They also gave the benzodiazepines to lower their anxiety, anti-emetics to stop them from feeling nauseous, and other medications to prevent them from needing to cough. They had then taken off their masks.
It was important that these medications were given before their masks had been removed, otherwise they would die terrified and gasping. This decision was made for about two or three patients each day on M’s ward, out of 20 or so. However, this process did not always run smoothly. Sometimes these medications were prescribed but not given in a timely fashion, or at insufficient doses. With so many patients, they could not keep an eye on them all; to watch whether what they were doing, was actually working.
The practice had been that once a patient is deemed to be dying, they are allowed one family member to see them for 15 minutes. The patient won’t be able to see their loved one’s face, since they will be wearing full PPE. Because the family member only has one shot at visiting, they needed to accurately guess the patient’s time of death so that they could be called inside. Sometimes they would get this wrong, and the family never got to see the dying relatives. But all of the patients, who died, did so alone. There was nobody to hold their hand – Nobody to comfort them. Nobody to tell them they loved them.
Towards the end of one given day, two of Dr. M’s patients were deteriorating and destined for the ICU. Another doctor had an ICU candidate in her bay. They were all between 60 and 64 years old, none of them with significant comorbidities; all were working full time until coronavirus struck. They all now required 80% oxygen at high pressures, breathing at around 50 breaths per minute and tiring. There was only one ICU bed. M deliberately left hospital before the decision was made as to which of them will get the bed. She was sure that whoever didn’t get that was likely to deteriorate overnight.
M had paid for an Uber home, because at 9.30pm she could not face walking in the January dark to the bus station and spending over an hour getting back. She would arrive home at around 10.15 at night. In less than 10 hours, she was expected to repeat the same cycle, the following day….Life and death would continue a devilish dance all day, next day!
[author title=”Nazarul Islam ” image=”https://sindhcourier.com/wp-content/uploads/2021/05/Nazarul-Islam-2.png”]The Bengal-born writer Nazarul Islam is a senior educationist based in USA. He writes for Sindh Courier and the newspapers of Bangladesh, India and America. He is author of a recently published book ‘Chasing Hope’ – a compilation of his 119 articles.[/author]
