My externship experience has continued to evolve and shape me in many ways. Being in the ICU, as I have said over and over again, is a life-changing experience for me nearly every single shift. I love every heart-wrenching moment on 6A, and despite the emotional toll I feel, I’d not trade one moment for anything else.
An experience that I have both honorably and sadly taken great part in is COVID-19. My unit, Medical ICU, has once again (after last year and the onset of COVID) become the dedicated ICU for COVID + patients in need of critical care.
In one vein, all COVID ICU patients are the same. They report to the ER with dyspnea after classic symptoms usually occurring for 7-10 days before breathing became difficult enough to cause alarm. They are then found to have low oxygen saturation, usually in the 80’s at that point, and are put on a nasal cannula at 2-6 liters, pending their needs to reach at least 90%. They are typically placed on a floor, where their oxygen requirements increase, eventually reaching Airvo which is a high-flow humidified nasal cannula for patients that can breathe spontaneously. This is also the last stop of oxygen assistance that allows patients to eat and drink on their own safely. Once they reach 60 liters of oxygen, their requirements exceed what Airvo can provide, and they are placed on bi-pap. This is a high-flow, pressurized mask that forces air into the lungs of a patient, covering their entire mouth and nose. At first, patients are able to swap out for Airvo for meals and drinks. Eventually, even 1 minute on Airvo alone causes dangerous desaturation, causing them to be bi-pap dependent. At this time, they are usually either given an NG or OG tube to supplement nutrition and IV fluids become continuous. They continue to evolve, and as their bi-pap oxygen needs become maxed out, they are sent to us.
It is at this critical point where; you meet a patient. Whom, while exhausted and hungry for oxygen, are still awake. They are still able to talk to you, however taxed, grasp your hand. Smile at you. Tell you about their spouse, their kids, their grandkids, their dreams, their goals. Their individual, unique, beautiful lives as humans on this journey through space and time with the rest of us. This is where all COVID ICU patients are dichotomously NOT the same. You see each of them as the brilliant unique flame in this universe that they are.
Then, we intubate them.
They have one last phone call. We have to tell them their chances of coming off of the ventilator, ever, are small. We have to tell them this might be the last time they ever speak to their family members and loved ones. We have to tell them it is now or never, they make this decision, or they will not survive, even if their chances of survival after choosing mechanical ventilation are small. We have to tell them that it is greater than certain death without it. I have watched and listened to so many patients saying goodbye to their crying families, unable to say everything they wanted to or needed to, because of the huge force of air being blown into their lungs from the bi-pap machine. I’ve watched their noses turn blue and their fingers turn black as they wave goodbye in tears. As soon as this happens, things move forward quickly.
A sedative, Etomidate, is pushed. The patient becomes somnolent and unconscious, within a few seconds. Rocuronium (or Succinylcholine, pending their medical histories, as they have opposing neuromuscular blocking mechanisms) are then pushed, which paralyzes every muscle in their body. All respiratory drive is lost, and their breathing is 1000% the responsibility of the team intubating them. They are then intubated and in rapid succession I personally place a foley, NG, and 2-3 IVs because of the 8-12 drips they will need while intubated, with varying compatibilities. Eventually, over days, the ventilator becomes maxed out, and their saturations are still falling. Nearly everyone develops an acute kidney injury (AKI) because of the clotting cascade influence of COVID-19, and we then set up CRRT (continuous renal replacement therapy) which is essentially bedside dialysis. I have become very adept at these machines, which is both fortunate and unfortunate. I have come to learn that once this occurs, or becomes necessary, survival is nearly impossible. I visit the morgue 2 or 3 times per shift. I hold the hands of patients while they take their last, horrible, exhausted breaths. I watch nurses and doctors exhaust themselves doing everything humanly possible knowing it is statistically fruitless, but fighting just as hard, just the same.
I have seen one successful extubation. A woman was on the vent for 31 days. She had a white-out CXR and eventually, over time, she was able to have her forced inspiratory oxygen (FiO2) reduced, her pressure to force her alveoli open (PEEP) reduced, to where we could wake her up and trial oxygen requirement reduction. She succeeded, with flying colors, despite several comorbidities (which I should add – this surge, our patients are nearly all between 20 and 50 years old, many with NO comorbidities at all), and was extubated. When orienting her, all of us ready to celebrate, we told her she was in ICU from COVID-19 and had been on the vent x number of days, and was successful enough to have her tube removed, and would likely recover and go home, how rare and beautiful this was for us and most importantly for her. She kept shaking her head no, which perplexed us. Once she could finally say some words, she told us, “Covid isn’t real. You did this to me.”
I was a special sort of sad that day. I hope for more success stories, I hope for better education for the public, I hope for higher vaccination rates, I hope for misinformation to decline with numbers of active cases.
I hope for many things.
Story by: Christina, BSN student