As of this writing, the crisis is still ongoing, patients are still dying, families are still suffering. But objectively this has all decreased. Now, I feel more emotionally capable of handling some of the things I am seeing. But at the outset of working in the COVID ICU I saw and experienced things that will stay with me for the rest of my life.
As an aside, what we as ENT residents are doing at Elmhurst is pretty unique and I am proud to be counted among the residents who are working hard in a new and frightening setting with less training and oversight than we are accustomed to. A group of us have volunteered to run an entire COVID ICU at Elmhurst. During the rapid rise in critically ill patients there became a dire need for more ICU beds at the hospital. Overflow ICU's were created in random areas--pre-operative rooms and recovery bays. But they needed staffing, and importantly for the patients, consistent staffing. We answered the call by providing 24h resident coverage of the ICU even though this is well outside of our training. We are outside of our comfort zone, managing critically ill and sometimes actively dying patients. But we are here, and that's what counts.
When this ICU started, we actually had no home. We had a small section of the "Fast Track" unit within the Emergency department (this is the area of the ED where patients usually go for minor problems like small cuts, minor broken bones, etc.). Now it was a COVID disaster site. On my first morning, after waiting on line for my N95 mask that was to last for my entire shift (these are supposed to be one per patient, but not complaining as we thankfully have enough at all), I walked into the unit. This was one of the peak death days in the city. I was not surprised to hear that.
As I entered the unit it honestly felt like a thick wave of death hit my face. We had a small 6 bed section of a unit where there were maybe 30 patients. Alarms were blaring, including the hospital oxygen alarms as the room was not made to deliver that much O2 at once. I was sweating profusely through my multiple layers of masks and protective gear. I couldn't hear a thing. My mask, supposed to create a tight seal on my face, definitely wasn't working as I was fogging up my face shield and couldn't see anything either. I didn't know how I was going to make it.
I took over care of a few of these patients. A couple were intubated, one was still awake on CPAP (a form on non-invasive ventilation). I had no idea what I was doing. As an intern I did a rotation in an ICU, but there was so much oversight and no significant responsibility was placed on my shoulders. Once getting through that experience I never thought I would have to face it again. Now, lives were literally in my hands and I felt ill-equipped but had no other choice but to try.
About 1 hour into this, a patient was wheeled into the unit and someone asked our attending if we could take them. I saw my attending confused, but accepted the patient. They had a sheet with some blood on it over their head. I asked my co-resident if that was a dead patient. He said that it couldn't be. He was wrong.
During the peak of this pandemic at Elmhurst patients were dying at such a fast rate in the ED that the morgue couldn't keep up. There were freezers to store the bodies outside the ED but even those got filled up. In these scenarios, as I learned, we would have to house the dead body until someone could come pick it up. There was already another dead body in the middle of the floor elsewhere in the Fast Track.
They wheeled and boarded the dead patient next to my wide-awake patient on CPAP. I don't know if he knew, I never asked him. But if he did, I cannot imagine what he was thinking. And given the patient on the other side of him died only minutes later, he must have been terrified. That patient is now decompensated and intubated. I pray for his recovery.
One of my other patients, very ill to begin with and with a poor prognosis, began to code (i.e. his heart stopped) suddenly. I ran over to help. Up until this point I had been part of two other codes. One as a 4th year medical student in the Elmhurst ED (largely as an observer) and one as a 2nd year ENT resident. The latter was a big ordeal, lasting 45 minutes, in the OR, as I performed endless rounds of chest compressions. That patient died. Up until this pandemic, that was the death I had seen. I didn't really think I would see much more as an ENT. Codes in general are dramatic events, with multiple people involved, pushing medications, performing chest compressions, shocking patients. But this was something else. Because of COVID, the associated incredibly poor prognosis, and the risk of exposure to/disease contraction in healthcare workers and other patients from the activities involved in CPR, we have entered a weird ethical situation where we essentially will often not perform CPR even if the patient does not have a "Do not resuscitate" order in place. Instead we have often defaulted to "medically coding" patients--i.e. not performing chest compressions, but instead giving medicines and shocking only. Quite honestly, this is paying lip service. These measures will not bring the patient back.
For this patient, me, a nurse, and eventually an ED attending came to bedside to run this code. We gave 2 rounds of epinephrine, performed a cardiac ultrasound showing no heart movement and called the time of death 3 minutes later. No one around us knew this was happening. Too many other patients needed help. It was as if something as innocuous as our patient coughing happened. No one took a second glance. This was commonplace. The unceremonious death, without family, without effort. We were too overwhelmed to make it a big deal. We had to keep going.
That was all before lunch. I had empanadas.
In the afternoon, we were given the kindness of being told our newly formed unit would be leaving the ED and setting up shop in a pre-operative ambulatory surgery unit on a different floor. The logistics of setting that up and getting patients transferred there was difficult but a breath of fresh air in comparison to the earlier portion of that day. That room though would become a place of so much further death. Usually I would go into this room to interview and consent patients before surgery. After this pandemic is done, when things go back to "normal" I honestly don't know if I will be able to set foot in that room to do the same.
Over the next number of days I learned an incredible amount of intensive care. I had a crash course in an ICU fellowship--limited attending oversight, working with locum tenens nurses and doctors from around the country. Most of us had never been ICU trained. But all of us were trying.
But what I learned most was about how useless I was. I felt like everything I was doing was futile. Worse, I felt like I was hurting patients with my inexperience. More died despite our efforts. On one day we had two patients who died and received the same time of death. We coded one, chest compressions, epinephrine, the whole rigamarole. We actually called it, unhooked monitors, and walked away--10 minutes later some sort of Lazarus effect happened (maybe a delayed reaction to epinephrine) where a pulse was felt when removing lines. We hooked up back the monitors and a heartbeat was seen. Then the patient next to him mucous plugged their endotracheal tube. We removed it, reintubated quickly, but it was too late. She was in respiratory arrest. As a DNR patient we did not perform CPR. As this was happening, I looked over to our first patient--his heart had completely stopped again. Both patients were soon declared dead, simultaneously. For those not in medicine--this is NOT normal.
I called families to tell them their loved ones died. I videochatted them so they could say their goodbyes--sometimes when the patient was still alive, and in one instance, after they died. Holding that phone up to the dead body, and watching each child and spouse say their final words and holding each other while they cried, will stick with me forever.
I cannot do much. I can't save these people, definitely not with my skills alone. But what I learned in that first week is that I could provide closure for families. The worst part of this is that people are dying alone--no loved ones around them. In many instances these people are dropped off to the emergency department by the families (who cannot come in themselves) and are never seen again. To die like that is a punishment these people do not deserve. We called families daily to provide updates and began to videochat so our families could at least see and say prayers and thoughts with their loved ones. Even when I didn't speak the same language as the families I was calling, I could feel the appreciation. Giving families this was probably the only thing that kept me going during these initial days.
At the end of the week, to be frank, I lost it. I was watching a Disney movie with my daughter (Coco--a tale of a Mexican boy who travels to the land of the dead to visit his family...how appropriate). There is a scene where the father sings a song to his baby daughter "Remember Me", about how he hopes she will know how much he loves her even when he cannot be there. At that moment, holding my daughter in my arms, I began to weep. At that point the floodgates opened and I couldn't stop for the next 45 minutes as all of the images from the initial days of this experience, in the height of the COVID death peak, entered my brain. As embarrassing as it is to say that, I really needed it to happen. Holding that inside would not have allowed me to continue working.
It's hard to paint a complete picture of what happened during the peak of this pandemic. I will say that things have gotten better. I have also become more used to death. This paints a morbid picture, but for those with loved ones who may be ill, please understand that everywhere is different. Working in the ICU at the "epicenter of the epicenter" is different than in other places, and other levels of acuity of care. Things are bad but people are recovering and I can honestly say we are turning a corner.
My advice: We don't know what will happen. This seems to affect everyone, young, old, sick, healthy. Don't take chances. So hold tight. Keep fighting, keep social distancing so we can keep people alive. And don't leave things unsaid. Check in on people. Tell your family and friends you love them.
We will get through this.
