Into the abyss

Not infrequently, as I sit in the intensive care unit (ICU) pondering a dilemma, my mind wanders to thoughts of my family and friends. It has been happening less this year, in the COVID-19 world that has thrust itself upon me, as thoughts compete for nanoseconds in my racing mind.

LJ will be 2 years old in April, at which point he will have spent half of his life in various degrees of lockdown. He is pale blonde, like Heather and I were at his age, with a gregarious attitude and a love for Ned and Otis, the Jack Russell and Mastiff who spend their lives guarding his.

Heather is 2 years younger than me and, like any big brother, I am fiercely protective of her. Occasionally on Facebook I'll laugh when Heather posts selfies of her belly, now 8 months pregnant with LJ's soon-to-be little brother. Her giant belly protruding from her petite figure seems cartoonish. Yet despite measuring only 5 feet 2 inches, I know she can kick her big brother's ass; her penchant for weight-lifting and a sporty lifestyle see to that.

It's probably a more apt expectation, then, that Heather would one day have to defend me, but a big brother's pride is mighty powerful. I don't often think of Heather when I'm working in the emergency department or ICU, where I, like many doctors in the world, have been spending an awful lot of time recently. But then I met K440, who I'll call Emelia.

Monday. Emelia is admitted to our COVID ICU, where I am assigned for the week as the senior trainee. As the ICU fellow, it is my job to oversee care of our 14 patients. I have taken care of about 50 COVID patients since the pandemic began in March, but Emelia is different. For one, she is my age, 35. Second, she's pregnant. For most clinicians who aren't specialised in obstetrics, pregnant patients are a little scary. Questions pop up almost instantaneously; can she lay on her belly? Can she receive dexamethasone? Can she receive convalescent plasma, remdesivir, or a host of other things we routinely offer critically ill COVID patients? A series of phone calls occupies the rest of the day. One of the residents asks how many weeks along she is, with a tone of voice that conveys the answer is somehow relevant.

Tuesday. Emelia looks the same as yesterday, “chilling on high-flow”, as the night team tells me at 7:00 am. On rounds, we discuss intubation thresholds in COVID patients, a moving target whose pendulum has swung far to one side then back again and is now settling somewhere at its equilibrium. We know COVID patients who are intubated have poor outcomes. If they survive, they remain unwell for months. We look at various data points, but ultimately it is her easy chest movements that have me declare she will likely make it through the night without needing mechanical ventilation.

Wednesday. Emelia looks the same as yesterday. The nurse reports various desaturations. Any movements, even eating, drop her saturations into the 80s. Patience, I urge; this happens to all COVID patients. I quiz the residents. “The Pregnant Airway” is the title of book chapters and lunchtime PowerPoint talks which dictate lists of many considerations when taking control of the most precious piece of real estate in the human body. We agree it is not yet time to pull the trigger on intubation. “Let's give it another day”, I announce.

Thursday. Mike is one of those respiratory therapists who is always right. He has been around a while, and we all know his expertise is not to be dismissed. It is his first day meeting Emelia, and after looking at her oxygen needs he thinks I am crazy when on rounds I say: “Emelia looks the same as yesterday. Let's give it another day.” But Mike's facial expressions make me doubt myself; I stare at her breathing, wondering if I have made the right call. I go home that night and call Heather, and we chat about nothing really, and after 2 minutes, we hang up.

Friday. There is a tiredness hovering over the team as we round for which sleep will not help. We are accumulating COVID patients, and the curves printed daily in the newspaper make us certain we will accumulate more. We arrive outside K440 and peer through the window. “She looks the same”, says one resident. “I dunno, she seems a bit despondent”, says another. This is how we assess her; 10 feet away, a pane of glass separating clean air from danger, opinions based on mental images of the week gone by. Mike's position hasn't budged and I feel like I can hear his internal monologue through his judging eyes. 5 days of high-flow nasal cannula, which both Mike and the nurse remind me is at “the max”. I start to flip-flop, but my attending reassures me. As a compromise, we scan her for a pulmonary embolism. No clot. “She looks the same today. We wait.”

Day 6. It's 6:43 am and I am walking around the unit, catching night nurses and their pearls before they head home to sleep. I peer through the glass of K440, and see Emelia. She looks terrible. Like always. No, wait. She looks worse than terrible. I stare at her, subtle, subconscious clues coalescing in my mind. Mike walks over, tells me today is the day, which is the same thing he told me yesterday, and the day before. But this time he is right; I know so because she knows so, too. She told her nurse she wanted to be intubated even before her blood gases came back from the lab showing oxygen levels as low as they have ever been, low enough that I wonder how much oxygen is getting to the placenta and baby.

I ask myself what I would do if K440 were occupied by Heather. I reach for my phone and call for help.

Two doctors, two nurses, a respiratory therapist. That is what it takes to intubate a COVID patient. We slowly dress for war, plastic gowns that act as droplet armour, helmets with fans to make us bullet-proof to the airborne shrapnel spewing from infected lungs.

Next comes the highest-stake thing doctors like me do at work. We inject a paralytic agent, depriving Emelia of a normally automatic, yet essential, bodily function: diaphragm movement. I've entered a moral contract to replace the air-flowing role of her diaphragm with some artificial means instead. If I fail, she will asphyxiate.

The squeaky beep-beep-beep of the saturation monitor descends into a dull bomp-bomp-bomp, the cockpit equivalent of “PULL UP—TERRAIN”. I struggle to navigate the endotracheal tube through her small oropharynx and before I can even use my own larynx to issue a command for assistance to my colleague, a bougie is thrust in front of my foggy helmet.

I see Heather's epiglottis. Emelia's arytenoids. Ubiquitous anatomical waypoints. I wiggle my blade into the back of her vallecula and lift, revealing my prized target. I stare into the abyss between the two vocal chords, pass the bougie, thinking only of little LJ anticipating a sibling as the tactile sensation of heavenly tracheal rings reminds me to breathe.

Emelia was extubated after being on a ventilator for 7 days. She was eventually weaned off oxygen and discharged from hospital with a normal obstetrical ultrasound.

Blair is an award-winning journalist, scientist, and emergency physician at St Michael's Hospital in Toronto, ON, Canada. He is currently completing a critical care fellowship at Stanford University, Palo Alto, CA, USA.

© 2021 Blair Bigham