Staring Death in the Face

Like a dreaded tsunami, the current COVID surge has flowed over our protective barriers and is flooding our hospitals with sick, debilitated patients who are literally struggling to take each and every breath. The emergency sirens have sounded, the call for help has been heard and it is all hands on deck in the hospital.  Last spring, I and a dozen of my colleagues agreed to help staff an expanded ICU to care for the expected demand.  We did some training shifts but the numbers receded and our services were not required-until now.  My hospital usually has capacity for 30 ICU patients.  We have now expanded to take 57 such patients.  Last week I did my first over night shifts in 25 years.  This week I am finishing three 12 hour day shifts. 

I am covering a unit with 10 patients.  Most of them have COVID and are on high flow oxygen delivery systems.  In the beginning of the pandemic all of such patients were put on ventilators.  It was feared that such oxygen systems would enhance the propagation of the virus.  We have since learned that it can safely be used if appropriate precautions are taken. This has greatly improved our ability to treat such patients as well as to safeguard the limited supply of ventilators.  Now if a patient has gotten severe enough to warrant mechanical ventilation, they are much more ill. Either their condition is too severe or they have lingered on these oxygen therapies for weeks and have now started to deteriorate. The grim reality is that if they require ventilation and survive they face an almost certainty of needing to be on it long term which requires a tracheostomy (a surgical hole in the neck to insert the breathing tube). They also will likely need to be in a ventilator specific nursing home till they can be weaned off of the machine. 

This last week, I have spent most of my hours having conversations with the patients and their families about this difficult reality.  Some have chosen to push forward with all we have to offer.  Others, often who are elderly or otherwise compromised, have decided that if their condition gets that bad, they would prefer that we focus on making them comfortable at the end of their life and to withhold life support.  Staring your mortality square in the face is hard. It is hard for the patient, it is hard for their families and it has been exhausting as their doctor.  The patients are tired.  They have been breathing thirty times a minute for weeks, as if they had just finished a sprint that never recovers.  The thought of being on life support for months is daunting.  Many families have a hard time grasping how ill their loved one is.  They see others in the community who are sick for a few days and recover just fine.  They are not allowed in the ICU and must gain all their knowledge from our phone calls. It is hard for them to truly see how sick their loved ones are. 

I have a passion for making sure that patients and families truly understand the ramifications of whatever decision is made.  There is a reason why almost all physicians chose to not be resuscitated and put on life support if the condition arises. We know that it is a horribly uncomfortable experience for the patient. Hollywood makes life support seem as if a simple tube is taped by the nose while the patient is able to talk, eat and carry on with life.  That is far from the truth.  Over the 72 hour span of working this week, I had the "death talk" over 10 times.  There were 3 individuals who chose to withhold life support that we made comfortable in their last hours, making sure that family was by their side. I had the heart wrenching experience of helping the family of one of my own patients to whom I had cared for over twenty years, make the decision to withdraw the ventilator as there was a certainty that he would never recover. In every case, the family was so gracious and kind.  As emotionally exhausting as it is to have these conversations, it is immensely rewarding as well.  I truly could not do it without my belief and faith in God and that they will live on in spirit. 

News of an effective vaccine is like a break in the clouds, the sun shining over our flooded land.  It provides hope that this kind of suffering and these kind of difficult conversations may not be needed, at least for this dreaded virus.  It will take time for the population to get sufficiently vaccinated to provide herd immunity.  May we heed the call of the sirens to head for safety, to continue to watch out for each other as we get vaccinated, mask up, stay apart and keep safe.