I had watched the evolution of this disease each day for almost two weeks. From admission, to degression over a period of days, and finally after a week of nights when BiPAP and high flow just weren’t cutting it and their saturations peaked in the 80’s despite every possible intervention. One of now countless COVID victims I’ve taken care of since July. It was my goal to keep them off the vent for just one more night, my last night on nights. An arbitrary goal for sure, as there wasn’t a person taking care of them over the last 2-3 days that didn’t know exactly where this was headed. It was just a matter of time. But I’d hoped it wouldn’t be on my time. Alas, here we were. A senior ICU resident, a respiratory therapist, the patient’s fantastic nurse, and me, a deliriously tired intern, all huddled over a petrified patient. A patient whose last conscious moments would be a team of faceless gowns and masks screaming over the deafening high flow of oxygen that there is a very real possibility that they would die on the ventilator they were about to elect for.
“If it will help me breathe.”
It was unmistakable, though barely audible, and the nurse recounted the words loud enough for a frightened daughter on speakerphone to hear. A daughter whose love and input was so cherished that prolonging the life of this tortured soul was a decision necessitating her input. There was agreement in the decision. We’d give it a shot. A trial of intubation. 10, maybe 14 days, and then we’d see. Just a little more time. One last college try and if it failed to improve their condition, then it would be the time. One last exchange of tearful “I love you’s” between a parent and child, and the call was over.
Now the work began. Immediately the nurse went to grab the sedatives and the respiratory therapist to grab the vent and call the on-call anesthesiologist. The ICU resident quizzed me on what I wanted for pain management, sedation, and vent settings. I blurted out some basic vent settings and guessed 4 times on the answer for sedation before being educated on the right choice. I carefully discarded my gown and mask and left the room. I dispensed two jets of hand sanitizer and scrubbed them dry before reaching into my pocket to answer mundane cross-cover pages. Yes, I can order Tylenol for Mrs. A. No, no morning labs for Mr. H. Sorry, Mrs. K is probably a surgery patient. Try paging them. I put my pager, that wretched bane of my existence and sleep, back in my pocket. Now in front of me was the anesthesiologist donning a gown and mask. “Is there anything I can do to help you?” I sheepishly asked as I hurriedly threw on PPE again. There was not. But this was still my patient, and I would be there for the intubation, which went off without a hitch. The anesthesiologist conveyed an enviable collectedness, even through her mask, a posture adopted only by someone who has done this 1000’s of times before. I went back to the workroom to put in orders and write the transfer note to the ICU. I managed to bungle that order set handedly (I haven’t done my ICU rotation yet) but received indispensable education by my astute senior shortly after. At least I remembered the chest x-ray.
It was close to midnight, and I needed to follow-up on some urine outputs and labs for one of the 30 or so patients I was covering. A far-cry from the 60 just a few days before. No electrolyte repletion for GI bleeder. Only 100mL out for heart failure dude – I’ll order a slug of Lasix. Ah yes, it’s time for that abdominal exam for Mr. bowel ileus. I floated up the elevators to introduce myself for the 2nd time that night to a man with an abdomen the size of a small tire. Passing gas, making stool, and no change from previous exam. “Good,” I thought. “I have no desire to drop an NG tube tonight.” I made my way back down to the ICU to check on our freshly intubated friend. The ICU resident appeared out of the workroom and without hesitation asked, “Want to put in a central line?” Without any knowledge of who or what for, I said “Hell yes,” and we walked back to our mutual COVID patient. Once more into their isolation room that, at this point, I’d been in at least a dozen times. More gowns, masks, and this time the addition of a surgical gown and gloves to prepare for a procedure. A procedure that involves jamming a catheter the thickness of a pencil into someone’s neck until it rests just outside the heart. I took the ultrasound probe to find the jugular vein, talking aloud the anatomical landmarks to my senior resident. Because of the ventilator, the screen vacillated between an absolutely perfect view of the large vein directly in the middle of the screen followed by immediate distortion of the image and me losing my 3-dimensional awareness completely. I cleaned and anesthetized the site. Taking the needle, I pressed it gently against the skin at the site of the probe to see exactly where I was, fighting the ventilator as I stabilized my right hand firmly on this patient’s face. After some readjustment I found my best opportunity to penetrate the vein and went for it. I pushed – quick and hard – and slowly my syringe gathered that dark red humor essential for life.
Success.
I exchanged the syringe for a guide wire, then the needle for a dilator. My senior handed me the scalpel and I used the mortally sharp blade to incise the skin just enough to advance the dilator. A rather violent push and turn motion, necessary for the procedure, extruded yet more blood such that a thin film of coagulating blood painted my fingertips. All to be expected. The final exchange of the dilator for the catheter, followed by removal of the guidewire concluded my participation. I left to put in more orders and my senior finished the sutures (I was always terrible at throwing stitches). Slowly I’m learning. Each day I’m practicing. And nearly every interaction with patients is a suspension of reality and the gravity of what it means to practice medicine. At least I remembered to order the chest xray (again).
I wrote something somewhat similar to this around this time last year. Medical journals have these submissions that aren’t research or case reports, but reflections on medicine that involve personal experiences of doctors and lessons learned treating patients. I wrote about an experience I’d had as a 4th year med student and submitted to a few journals without success. Suffice to say my writing style is…verbose compared to other submissions, and besides being melodramatic in prose (but a completely accurate description of events) it was probably just poor writing. But I’ve included it below:
I was midway through a shift in the emergency department during my ultrasound rotation, two weeks away from a much-needed winter break. I waited for my patient suffering from back pain to return from a CT scan so I could perform a bedside echocardiogram. In the interim I refreshed my cardiac anatomy, but my attention strayed to the open electronic health record tab of our most recent patient. COVID-19 positive, worsening shortness of breath, and chest x-ray demonstrating diffuse, bilateral opacities. I scanned their problem list, developing a gestalt of their health and mentally checked off each comorbidity portending poor outcomes for a virus now resurging. My seasoned 3rd year emergency medicine resident prognosticated a succinct yet ominous disposition.
“They’re not going to make it out of this hospital.” I followed her gaze to the room behind me and saw a tortured soul fighting for air as the respiratory therapist increased the oxygen via high flow nasal canula. I stared blankly for a moment, yet quickly my attention was averted. I caught a glimpse of my patient returning from CT. My resident was busy finishing notes, but our attending physician also noticed their return. He looked at me while pointing to the ultrasound machine.
“Ready?” He barely finished the word before darting toward the patient’s room. I’d quickly realized this was the only pace at which emergency medicine physicians worked. I eagerly rose from my chair and responded. “Let’s do it!”
My attending provided guidance as I felt the prominent rib contours through the ultrasound probe pressed against my patient’s frail frame. A textbook view of the heart appeared on screen, just as my attending was urgently called out of the room. I continued the procedure, awed by my patient’s abnormally large heart, with such poor contractility it bordered on asystole. As I finished up, I thanked my patient for the learning opportunity yet fumbled briefly having forgotten their name. This rare uncouth moment represented a sharp deviation from what is normally my penchant for quickly building authentic rapport with patients. Leaving the room, I recalled past evaluations by residents and staff that corroborated my intrinsic investment into patients’ lives. But immediately after closing the door, a cacophony of different colored scrubs in another patient’s room broke my internal reassurance. An all too familiar scene of organized chaos I recognized as a code.
Two medics, whom I’d worked with before medical school as an EMT, arrived with a patient in cardiac arrest. COVID-19 precautions barred students from assisting in these, so I watched from afar and reminisced with my former co-workers. Moments later, a nurse scurried from a small opening in the sliding door to hand the crew their LUCAS device. We exchanged farewells and as they departed, I heard the echoes of alarm tones emanating from their radios, followed by their dispatcher’s voice. She begrudgingly addressed the crew, provided them a street address, and gave them their next call: “Code 3 – cardiac arrest.”
My focus shifted back to the resuscitation. A fellow classmate and I talked as we gazed helplessly at the ongoing entropy beyond the plexiglass. We discussed potential etiologies of this patient’s stopped heart, as well as prudent investigations and treatments. When our view inside the room was obscured, our conversation detoured to life updates, postponed holiday plans, and the fraction of anatomy current first-year medical students had learned compared to our class. “They didn’t learn any of the pterygoid fossa?!” I exclaimed in disbelief.
“Can we get another amp of bicarb?” Another nurse exclaimed from behind a small opening in the door. I peered through this fleeting aperture to get a closer view of the turbulent exercise of restarting a heart I’d participated in countless times before.
The resuscitation was momentarily successful – a thready, tenuous, slowed heartbeat restored. My attending remained outside the room to console the family over the phone, tenderly informing them of the situation and the grim prognosis. Silence followed, then muted sobs from the other line. They’d made the decision to act in accordance with the patient’s newly discovered “Do Not Resuscitate” order. Barred from the hospital given COVID-19 precautions, the family listened over speakerphone while the hospital chaplain gave the patient’s last rites. A final ventricular depolarization flashed on the monitor before deafening stillness. There would be no compressions this time.
I was getting hungry as we neared shift change, and anxious to get home. I refreshed my patient’s chart from earlier and opened their CT scan images. I challenged myself to read the imaging before the radiologist’s report. But the pathology was clear even to my novice eyes. The vertebrae in my patient’s spine were peppered with a half dozen or so small, lucent circles representing erosion of bone. As if pierced maliciously by a hole puncher. The etiology of their back pain was clear. I reviewed the rest of their chart.
“Mets,” I said quietly, to no one. Metastatic cancer.
“I called medicine and palliative care,” my resident exclaimed to our attending as they discussed my patient before sign-out. I admired her astonishing efficiency, having already finished her note from the code. This patient, too, was likely not going to leave the hospital.
My stomach growled.
The oncoming night resident appeared at the workstation to relieve us, and I practiced delivering sign-out on my sole patient. I approached a nurse who’d helped me earlier in the shift with placing IVs to say thank you before heading home. My walk back to the workstation led me past our patient suffering COVID-19 pneumonia. Their battle for oxygen grew more intense as the respiratory therapist traded the nasal canula for BiPAP.
Another growl from my belly. I found my resident and expressed gratitude for her teaching, solicited feedback, and we parted ways. I hazily remembered the mental map back to my car as midnight passed. I drove straight home – immediately falling asleep and forgetting to eat altogether. I was awoken peacefully by a late-rising December sun hours later. Feeling refreshed with sleep, coffee, and finally a meal, I began a process I’d routinized since starting clinical rotations that proved crucial to sustaining my humanity in medicine: Writing, reflecting, and learning from the previous shift.
As I began typing, however, the gravity of each encounter began weighing on my conscience. My refreshed energy quickly abated, supplanted by a gnawing grief as I recapitulated the suffering I’d borne witness to. My seeming indifference to this pain, then necessary to focus on my learning and catalyzed by hunger and fatigue, gave way to overwhelming guilt. I recoiled from the keyboard. My eyes closed. My thoughts quieted. I opened up space – to feel. A space to focus on that painful, yet necessary, expression of sorrow unconsciously triaged until now. I surrendered to those emotions, shedding tears concordant with suffering heretofore left unattended. The suffering of three patients and families whose mortality was now palpable. Undeniable. Eventually, my catharsis and tears rescinded, having rehydrated the clearly desiccated but still fertile soil that sprouts the compassion and empathy from which my motivation to practice medicine harbors its roots. I finished my reflections, sobered and revitalized, ready to carry my replenished soul to my next shift.
Now, over halfway through intern year, I’m reminded again that the practice of medicine involves ignoring, or even making light of entirely, solemnity. I recently made a friendly challenge with one of my clinic patients. They doubted their ability to live much longer, so I wagered if I kept them alive from their metastatic cancer long enough to graduate residency that we’d share homemade chocolate cake at our last clinic appointment – we both smiled. I sang Pavarotti with one patient to increase the negative pressure in their chest so I could safely remove a central line in their neck, to the amusement of my nurse and med student. Just two of countless examples of the necessary diminution of morbidity and mortality in medicine, obfuscating the gravity physicians and patients face. But that gravity exists, always, no matter how much it’s shuttered, ignored, repressed. Perhaps each clinician’s scales are calibrated to measure that gravity with more or less weight, but I believe it pulls on each of us, nonetheless. I’m intensely melodramatic so my scale is acutely sensitive. But I think that gives me an opportunity to be uninhibited in my connection with patients and families. Certainly, humanity is tabled when learning or performing procedures is the objective at that moment. Compartmentalization is a necessary component in this field. But my natural predilection is for empathy, not callousness. To be as willing to hold the hand of the grieving and dying as I am to hold a catheter or a breathing tube. To be equally proficient in lines, vents, procedures, and patient management as well as being earnest in my investment in patient well-being. To be unmatched in that part of medicine that’s practiced at the bedside, emulating the physician you’d want to have if it were you about to make what’s likely the last decision of your life. That’s my practice. That’s how I intend to practice.
But as a budding pulm/crit doc, I do really, really love procedures, too.
All-in-all, I still can’t believe they let me do this shit. I fucking love it. 🙂
‘Til next time my friends – much love!