Life in an intensive-care unit
There will be no sit-down rounds before seeing the COVID patients today. As I enter the Medical Intensive Care Unit (MICU), a COVID patient is crashing and needs to be intubated. The halls that had previously been filled with families visiting their loved ones and greeting the nurses and doctors are now crowded with the empty “COVID suits” that health-care workers must put on before they visit COVID patients. The ghostly silhouettes of these strange outfits remind us of what we are fighting. I quickly put on my gear: hospital-issued scrubs, a hazmat suit, two sets of gloves, an N95 mask, goggles, a face shield, and a cap. Equipment that used to be readily available is now rationed to me only upon request.
But this first patient needs to be intubated, so I switch to my powered air-purifying respiratory unit—a helmet connected to a machine that supplies purified air—hoping it will work today and not fog up on me. Someone looks me over to make sure I’m as protected as I can be before I go into the patient’s room.
Meds, bougie, endotracheal tube, C-Mac, oral airway, oxygen-saturation level on the monitor. The intubation is successful, but the dread persists: Will this COVID patient survive? There are moments when this all feels like pantomime. We do what we are supposed to do, walk the stage, say our lines. But the reality is that, even if we hit our marks, many of our patients will not survive. I have COVID fatigue.
I spend the next two hours stabilizing the patient, hoping that everything we do will give him a better chance of living till the next day. I prepare for more procedures with another sterile layer to protect the patient, a third set of gloves on top of the two I was already wearing. I squeeze my fingers to help with circulation before I start my procedures. Sweat runs down my back from the layers of PPE, the hazmat suit, and the warmth of the room. My goggles and PAPR keep fogging up as I try not to stick myself with the needle.
I work in the Medical Intensive Care Center at the University Medical Center in Lubbock, Texas. The death rate in this part of the state is among the highest in the nation. To date, Lubbock County, whose total population is just over 310,000, has had more than 42,900 cases of COVID-19 and more than 570 deaths. I have been caring for critically ill COVID-19 patients since last March.
Since I’m already gowned up, I continue doing my in-person rounds. The team waits
outside the room to notify me of overnight changes, phone updates, or alarming labs
before I enter a patient’s room. (I will go over each individual patient’s data again
later this evening on my own, in the quiet of my office.) Every time I finish with
a patient and exit his or her room, one of my staff sprays me down with an antiviral
solution. I gently scold the nurse to wear her goggles before she sprays me down—the
staff know my feelings about how important it is for them to protect themselves. Then
I move on to the next room. I enter each room with a heavy heart. I have to be careful
not to pull the IVs running across the room, the ventilator cord connected to the
control panel outside, the hoses from the dialysis machine to the patient: it would
spell disaster if any of these became disconnected. A game of MICU Twister, with high
stakes. Finally, I make my way to the patient. Some patients are upright, some on
their stomachs; almost all have an endotracheal tube coming out of their mouths. Most
are sedated, some paralyzed. I touch, I examine, I talk to them. Can they hear me?
I open the doors and shout questions at the nurses because they can’t hear me through
my mask and the door of a negative-pressure room. Then I close the door again and
continue assessing the patient.
I am worn down by witnessing so much suffering and death every day—many times a day.
I make my rounds with the MICU iPad so that I can FaceTime family members and let them know the latest about the status of their loved ones. “Nothing new to report.” “Kidney function is worse—we need to do dialysis.” “Their condition has not changed in days.” “They are worse. You should come up for a family meeting.” Or: “I would like to get palliative care on board.”
I miss being able to talk with my patients. Those who can speak utter only a few words before having to pause and cough violently, or before the alarm bells go off because their oxygen saturation level has dropped precipitously. When they can, they ask questions. “Am I going to make it?” “Am I doing better?” “When can I go home?” I miss making small talk; sharing little jokes with patients about their lives and loved ones; meeting family members in person and getting a glimpse of their lives. I miss telling patients, “You’re gonna be OK.” Because you cannot do that with COVID. With COVID, even if you recover and go home, you are not the same person who arrived at the hospital. And you never know when you’ll have to come back, or what you’ll come back with. Even if they’ve made it out, I may meet my patients again because of continued shortness of breath, exhaustion, memory loss, or a whole host of other post-COVID problems.
I have COVID fatigue. I cannot erase the memories of patients dying. I cannot forget the moment when my ten-year-old child sat with me at night and asked, “Are you going to die?” I told her, honestly, I would do my best not to; I didn’t know what else to say. These days I am often at a loss for words. (I was never at a loss for words before.) I cannot forget how it felt to wear an N95 mask around the house in the early days of uncertainty about PPE rations, and gently push my kids away to keep them from hugging me, pretending I was a duck with my duckbill mask so as not to frighten them. I cannot forget the devastation of standing outside my parents’ house, waving at them to say hello and to check on them. I feel pangs of gratitude when nonmedical people tell me they’re doing their part by staying home, wearing their masks (over both mouth and nose!), or by pleading for the welfare of health-care workers.
I am worn down by witnessing so much suffering and death every day—many times a day. When I ask my nurses “How are you?”, they answer with heartfelt confessions of sadness, anxiety, depression, short-temperedness. And even without hearing it, I can see that the light has gone out in their eyes. They text me the day’s death count and their secret confessions that they went home and cried for hours in the bathtub so that their family wouldn’t see their pain. They share with me their frustration, their hopelessness. They write to me: “We sweat our butts off putting PPE on and off all day and no matter what we do to save these people, most of them die.” “This is not what we went into nursing to do. We became nurses to help save lives and to show compassion.” “I feel like a ping-pong ball...just helpless at the end of the day. People do not understand the emotional and physical stress we go through every day.” We reassure one another that this too shall pass, but I can’t help asking myself: At what cost—to ourselves and to our families? We all have COVID fatigue.
Another press conference. Another letter. Another plea. Another visit. Another talk. Another treatment. Another scolding. “Wear your masks. Cover your nose and mouth. Social distance.” “It’s not about you.” We watched, we wrote, we spoke.
My head lies heavy on my pillow. I close my eyes and see flashes of light underneath my eyelids, reminding me I’ve spent too much time staring at a phone screen, searching for answers, for new treatments, looking again and again at patient charts and imaging, hoping another answer will suddenly emerge. My dreams become another set of rounds. “What can I do? Did I try such and such? What if I tried that?” Then I wake up and it all starts again.
Ebtesam Attaya Islam, M.D., Ph.D., is an assistant professor at Texas Tech University Health Sciences Center and a pulmonary/critical-care physician. She works in the Medical Intensive Care Center at the University Medical Center in Lubbock, Texas.
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