by Chaya Milikowsky
Printed in The Jewish Press on 20 Iyyar 5780 – May 13, 2020
They don’t believe me when I say they need to be intubated, and soon. Their blood oxygen levels are dropping to dangerous levels in spite of maximum non-invasive support, and yet they often feel okay. They are scared of being intubated and ask if we can avoid it, what they can do to push it off.
I am scared for them too. I don’t want to tell them that this conversation may very well be the last conversation they will ever have. I don’t want them to push off intubation because then they will certainly die.
If we have a bit of time and they have a bit of breath, I tell them to call their loved ones. Let their family hear their voices a bit. If it’s not the last time they will ever do so, it will be the last time for weeks since Covid patients have been requiring longer bouts of intubation than those with other pathologies. They won’t hear, touch, or see a loved one for a long time.
“Will I die?” my patient asks me. I cannot tell him the truth – that more than half of Covid patients who develop this extent of respiratory failure die. “Not on my watch,” I promise him. “Not while I’m here.” That’s the best I can offer him. I won’t let him die tonight.
We call the anesthesiologists to intubate and they meticulously prepare everything outside the room. They can’t forget to bring any item with them because there will be no time to degown or go through the pantomimes of communicating with those outside the airborne-protected room. At the same time, they mustn’t bring excess supplies because everything that enters the contaminated room gets thrown out if unused.
It’s during the intubation process that my decision to have the patient intubated is confirmed correct. If I was second-guessing the decision, I no longer do so now. These patients have no respiratory reserve. Their oxygen levels drop dramatically and often take a long, heart-stopping time to respond to full ventilatory support. I now wonder whether we should have intubated much earlier.
Though they are on the ventilator, we are not out of the woods. Blood pressure is dropping and I need to insert a central line. The nurse inserts a nasogastric tube and a foley catheter. We order restraints so that all important lines and tubes remain where they should be. Can’t have them coming out when it takes us so long to go in.
Every time a patient needs something, it’s a process. Mask on, face shield on, gown on, gloves on. Check and recheck for a good N95 seal. And if we realize too late that we need something, it’s a song and dance communication game.
Bang on the glass door and get someone’s attention. Scribble our request on the handheld whiteboards and hope those outside can find one to respond in kind. You can’t hear our shouts with the doors shut tightly and the massive air filters running loudly, and you can’t read our lips covered with masks. Rapid scribbles and pantomime have become the communication methods of choice.
The filter noise and the full body protective equipment make it difficult to communicate with the patients as well. We all look the same, save for our eyes. We shout to get our words heard. Patients are scared, which makes it even harder for them to comprehend the words they barely hear.
It’s difficult enough for those patients who are not intubated. For those patients who are intubated and deeply sedated, dramatically weakened and deconditioned, it’s even harder. There’s no family at the bedside to understand a subtle look or hand squeeze. The nurses struggle with their desire to nurture and comfort a patient with the law of self-preservation that says get out of the room as soon as you can. You have a spouse and children at home; you can’t get them sick and you can’t die on them.
And besides, you will be of no help to any patient if you become sick. And then there are your other patients as well, with oxygen levels dropping, blood pressure fickle, and meds to be given. But this patient needs you now.
As a nurse practitioner, I am not in the room nearly as often as the bedside nurses. It makes me feel relieved – and also guilty. Sure, I get my time when we intubate, when a patient is decompensating, when I need to perform a procedure, to pronounce a death.
But it’s less direct patient contact than it used to be, and I feel guilty. I don’t go into the room during every shift like I used to. I peer through the glass wall, and that will have to be enough. There is so much guilt everywhere now. We are doing all we can, but are we doing enough?
We must protect ourselves so that we can continue to care for others, but have we neglected the basics of human touch and healing? When I do go in, I can’t help but apologize to the patients. To the deeply-sedated patients, and to the dead bodies. I am so sorry. As I touch their shoulders, I am so, so sorry.
But it’s not just guilt and sadness. There is also an incredible feeling of camaraderie, of innovation, of we-are-in-this-together and we-will-come-out-stronger. Our core ICU staff – nurses, doctors, nurse practitioners, physician’s assistants, respiratory therapists – have been bolstered and supported by additional hospital players who have joined our ranks and support us at every turn.
Anesthesiologists are ever present and check in often. They offer to insert invasive lines and find out who is on our “watch list.” PACU nurses, travel nurses, cath lab nurses, and floor nurses have all taken shifts in our ICU to help where we are hurting. Management checks in on us to make sure we are okay.
Our intensive care doctors have become champions of the patients, getting them into clinical trials and learning about and instituting new protocols from newly-generated evidence. People outside the hospital are sending in food daily; I cannot eat it, but I’m comforted by the outpouring of love and support.
And our ICU team has become incredibly innovative, changing practices to improve ease of care. Our ventilators have been dismantled so that while the “body” of the vent is near the patient, the “brain” remains outside the room for easy access.
We’ve done the same with IV machines and meds; we can hang and titrate medications from outside the room, with long thin tubing lines snaking under and around doors to deliver medications to patients. It truly is an honor and a privilege to work with a team that is so focused on supporting the staff and caring for our patients.
We have become invested in our patients, and we will never forget a single one. To this end, our unit has begun painting a Covid mural with a large tree set against bare ground and sky. Every time we lose a patient, the nurse paints a star in the sky. And when we successfully send one of ours home, we celebrate by painting a flower on the ground.
“Be a flower, not a star” has become our new mantra. “Be a flower,” we whisper to our patients. But if you become a star, we will memorialize you just the same. My dream is a ground lush with flowers, and the sky dark and starless.
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Chaya Milikowsky is a nurse practitioner in a community hospital in Maryland.