JSt0rm
Lifer
- Sep 5, 2000
- 27,399
- 3,947
- 126
Day 3.
Code Blue right off the bat at 7:35. COVID in the ICU, transferred an hour earlier from another maxed hospital. From the chart: 67F with DM2, CAD, HTN. 5 days of cough and body aches, a little short of breath. She was seen by an ED physician just after midnight two days ago. Within 8 hours she had crashed and required intubation. Multifocal pneumonia with positive COVID. Officially admitted to that ICU 24 hours later. Transferred to our ICU 24 hours after that, and 1 hour later her Discharge Note for the Expired Patient was written.
She marks the first COVID patient I’ve seen die.
The anxiety I felt a couple days ago isn’t so bad now. It’s clear there was no avoiding this mass casualty event. Now there’s just work to do.
The thing about intubating a COVID case is it’s a high risk droplet bomb going off around the guys and gals most needed right now: intensivists, anesthesiologists and those badass ICU nurses who are all needed to tube people whose lungs are filling up with fluid. Hospitalists might be able to pick up the slack, but they haven’t the same muscle memory.
So as I’m watching this woman die in her closed glass box of an ICU room, a grizzled doctor with the swagger of an old intensivist says to no one in particular, “Is that a confirmed positive? Not going anywhere NEAR there!”
A nurse over to my left says, “We shouldn’t have to Code cases like this.” And it’s not with the same tone as “This is pointless,” it’s “This puts us in danger for nothing.” I stay out of the room, the extra manpower of one extra resident won’t be worth the PPE for chest compressions. But my chief resident is in there.
He’s a good guy; hope he doesn’t get sick.
(As I write this, I get a call that one of my patients has died. Non-COVID, was in denial about her metastatic cancer, COPD, CHF progressively worse shortness of breath but still wanted to be intubated. She got her wish and died within an hour or two still.)
Then a Rapid Response at 7:56. Then a Rapid Response at 8:01. Then a Rapid Response at 10:30. That last one was for the patient I just mentioned who passed, we put her on BIPAP and loaded her up with Lasix. Then a Rapid Response again at 12:30, again for my patient, watched the intubation occur. There was a minor discussion of where to put her, since the ICU and CCU were full. We’re in the process of transitioning the SICU into another ventilator bay.
Lunch arrives sometime after 13:00. Here’s one silver lining to all this: the community has gone out of its way to shower us with food. My lunches and dinners (residents know to always raid the hospitalists’ office and grab a plate before heading home to crash) have been Mediterranean chicken kebobs on Sunday, chicken piccata on Monday, and pizza today. It genuinely raises moral.
Another Rapid as I’m talking to some other residents and wolfing down a slice. Most of these Rapids have been for non-COVID cases. The ones that are about COVID cases turn into intubation events.
I was wrong yesterday when I predicted we’d become a majority COVID case hospital in 2 days. We crossed the 51% threshold today.
I was naïve when I thought I could volunteer for the resident-run COVID wing so that one less of my fellow residents would be put at risk. We’re all at risk. So now we have 3 residents and an outpatient attending looking over 10 confirmed COVID cases.
My census of 13 today has 5 confirmed and 1 suspected COVID patients. I wish we could make these cases voluntary, but all we can do now is limit exposure and spread out the cases somewhat.
I get a call that our 87 year old COVID patient is desatting on 6L supplemental O2 via nasal canula. So we put her on a non-rebreather. I get a call that she’s desatting down to the mid-80s when talking in long sentences despite the 100% oxygen she’s receiving via mask. The nurse is spooked, and the current plan is to do a Full Code should she tank. So the patient and I get to have The Talk.
The Talk is basically asking people if they want to receive (often futile) CPR that cracks their ribs as they die, or if they would prefer to be attached to machines when they die. But I don’t put it like that. I say things like “chest compressions” and “a plastic tube down your throat” but made it clear that if she were to be sedated for the intubation, she may never wake up. And despite our plans and treatments, her body is taking actions that will most likely (but we can never say guaranteed) going to end her life. Not today, but it’s a good time to put things in order.
The patient said her daughters want everything to be done for her, but she doesn’t want to be on machines when she dies. I said that was reasonable. She asked me what I would do, and what I would want for my mother.
I’m not proud of this next part.
I told the truth. I said that my mom and I have worked in medicine, and she would never want to be intubated if it was a long shot she’d ever recover. I told her I recently only rescinded my own Do Not Intubate order because were I to get COVID and need intubation, I’m a young, healthy guy who could survive it. But were I hit by a truck and braindead, I’d never want to be intubated. She said she’d call her daughter back and explain things.
I get a call later saying this very sharp 87 year old lady has signed the form declaring her Do Not Resuscitate / Do Not Intubate.
Intubation would have been the wrong choice here, I believe that. And I only told the truth (which I usually avoid by saying things like “it’s not for me to make you decide either way.”)
I helped the patient make her personal wishes count at the end of her life so she could die on her terms.
But, in the back of my head, I was also thinking I saved the nurses from having to witness a pointless and traumatic CPR and I saved one likely-inevitable ICU bed and a ventilator.
…
I don’t feel like writing anymore today.
Code Blue right off the bat at 7:35. COVID in the ICU, transferred an hour earlier from another maxed hospital. From the chart: 67F with DM2, CAD, HTN. 5 days of cough and body aches, a little short of breath. She was seen by an ED physician just after midnight two days ago. Within 8 hours she had crashed and required intubation. Multifocal pneumonia with positive COVID. Officially admitted to that ICU 24 hours later. Transferred to our ICU 24 hours after that, and 1 hour later her Discharge Note for the Expired Patient was written.
She marks the first COVID patient I’ve seen die.
The anxiety I felt a couple days ago isn’t so bad now. It’s clear there was no avoiding this mass casualty event. Now there’s just work to do.
The thing about intubating a COVID case is it’s a high risk droplet bomb going off around the guys and gals most needed right now: intensivists, anesthesiologists and those badass ICU nurses who are all needed to tube people whose lungs are filling up with fluid. Hospitalists might be able to pick up the slack, but they haven’t the same muscle memory.
So as I’m watching this woman die in her closed glass box of an ICU room, a grizzled doctor with the swagger of an old intensivist says to no one in particular, “Is that a confirmed positive? Not going anywhere NEAR there!”
A nurse over to my left says, “We shouldn’t have to Code cases like this.” And it’s not with the same tone as “This is pointless,” it’s “This puts us in danger for nothing.” I stay out of the room, the extra manpower of one extra resident won’t be worth the PPE for chest compressions. But my chief resident is in there.
He’s a good guy; hope he doesn’t get sick.
(As I write this, I get a call that one of my patients has died. Non-COVID, was in denial about her metastatic cancer, COPD, CHF progressively worse shortness of breath but still wanted to be intubated. She got her wish and died within an hour or two still.)
Then a Rapid Response at 7:56. Then a Rapid Response at 8:01. Then a Rapid Response at 10:30. That last one was for the patient I just mentioned who passed, we put her on BIPAP and loaded her up with Lasix. Then a Rapid Response again at 12:30, again for my patient, watched the intubation occur. There was a minor discussion of where to put her, since the ICU and CCU were full. We’re in the process of transitioning the SICU into another ventilator bay.
Lunch arrives sometime after 13:00. Here’s one silver lining to all this: the community has gone out of its way to shower us with food. My lunches and dinners (residents know to always raid the hospitalists’ office and grab a plate before heading home to crash) have been Mediterranean chicken kebobs on Sunday, chicken piccata on Monday, and pizza today. It genuinely raises moral.
Another Rapid as I’m talking to some other residents and wolfing down a slice. Most of these Rapids have been for non-COVID cases. The ones that are about COVID cases turn into intubation events.
I was wrong yesterday when I predicted we’d become a majority COVID case hospital in 2 days. We crossed the 51% threshold today.
I was naïve when I thought I could volunteer for the resident-run COVID wing so that one less of my fellow residents would be put at risk. We’re all at risk. So now we have 3 residents and an outpatient attending looking over 10 confirmed COVID cases.
My census of 13 today has 5 confirmed and 1 suspected COVID patients. I wish we could make these cases voluntary, but all we can do now is limit exposure and spread out the cases somewhat.
I get a call that our 87 year old COVID patient is desatting on 6L supplemental O2 via nasal canula. So we put her on a non-rebreather. I get a call that she’s desatting down to the mid-80s when talking in long sentences despite the 100% oxygen she’s receiving via mask. The nurse is spooked, and the current plan is to do a Full Code should she tank. So the patient and I get to have The Talk.
The Talk is basically asking people if they want to receive (often futile) CPR that cracks their ribs as they die, or if they would prefer to be attached to machines when they die. But I don’t put it like that. I say things like “chest compressions” and “a plastic tube down your throat” but made it clear that if she were to be sedated for the intubation, she may never wake up. And despite our plans and treatments, her body is taking actions that will most likely (but we can never say guaranteed) going to end her life. Not today, but it’s a good time to put things in order.
The patient said her daughters want everything to be done for her, but she doesn’t want to be on machines when she dies. I said that was reasonable. She asked me what I would do, and what I would want for my mother.
I’m not proud of this next part.
I told the truth. I said that my mom and I have worked in medicine, and she would never want to be intubated if it was a long shot she’d ever recover. I told her I recently only rescinded my own Do Not Intubate order because were I to get COVID and need intubation, I’m a young, healthy guy who could survive it. But were I hit by a truck and braindead, I’d never want to be intubated. She said she’d call her daughter back and explain things.
I get a call later saying this very sharp 87 year old lady has signed the form declaring her Do Not Resuscitate / Do Not Intubate.
Intubation would have been the wrong choice here, I believe that. And I only told the truth (which I usually avoid by saying things like “it’s not for me to make you decide either way.”)
I helped the patient make her personal wishes count at the end of her life so she could die on her terms.
But, in the back of my head, I was also thinking I saved the nurses from having to witness a pointless and traumatic CPR and I saved one likely-inevitable ICU bed and a ventilator.
…
I don’t feel like writing anymore today.
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