Too Late: Tales from the COVID ward

Rarely do I dream of death.

But one week ago, after my final shift on the COVID ward, I did.

*

I don’t believe that dreams are messages from ‘beyond,’ or portents of the future.  They’re not part of a supernatural cosmos.  I believe that they are the garbage disposal of the brain, a dumpster for our consciousness.  We fall asleep and our brain cleans house, clearing space in the cupboards and closets for another day of ceaseless, endless input.

There will, of course, be familiar elements in our dreams.  We’ll see things that we’ve experienced, or thoughts we’ve been processing, or activities we’ve been worrying about.  It’s all jumbled and bizarre, but it’s frequently based in reality.

So I suppose I should have been expecting it, considering my final night at work.

*

I couldn’t find her on the ICU patient roster.

I was caught up on my work, on my charting.  It was the deepest, darkest part of the night, and my patients were asleep, hooked up to oxygen cannulas and cardiac monitors and SpO2 wires. 

I had time to check on patients I had cared for previously, patients who were losing their battle against COVID, and had been moved from our med/surg/tele unit to stepdown, or even up to ICU.

But I couldn’t find her in the rosters.

I clicked through all four ICUs.  One was the cath lab, converted to an ICU after the regular ICUs overflowed with patients dependent on ventilators.  One was the PACU, jury-rigged in the same manner after the cath lab filled up.

Not there.

I knew what it meant, of course.  I knew.  But I wanted to see it in writing.  I wanted to know how.  And when.

So I sat back in my chair and fiddled with my pen and stared at the computer screen and tried to remember the spelling of her last name so I could type it into the search function, and thought about the night we coded her.

*

Three things had happened simultaneously.

First, the primary nurse had flagged me down.  “Can you help in room 51?  She’s worked her way down to the bottom of the bed.  We need to haul her up.  She keeps tearing her mask off, and she’s de-satting quickly.”

Second, the nursing assistant had come running out of 51, wide-eyed and talking rapidly.  “Something is wrong with her.  She won’t talk to me, won’t look at me.  Something is wrong!”

And finally, my phone rang.  “Hey, this is Greg up in tele.  I can’t reach the primary nurse for 51.  Their heart rate is reading 20.  Can you go check on them?”

I hung up the phone and called the hospital-wide rapid response before I even had my gear on.  We got geared up and into the room and she was flopped on her side with an arm hanging over the side of the bed.  She was a big girl, and it took three of us to drag her onto her back.  I remember thinking, she’s awfully grey, and I shoved my fingers against her neck and there wasn’t a pulse and I said “oh SHIT” and another nurse pulled the code lever on the call light.

And off we went.

*

We got her back.  Three rounds of CPR and epi for her PEA arrest.  I couldn’t believe it.  ED came up and intubated her without RSI (thus the famous “rocuronium” comment from my Facebook post a few weeks ago), and she rolled to the ICU, where she promptly coded again.  They resuscitated her a second time, and called her family.  They kept the tube in, hoping against hope, but they made her a DNR – No Compressions.

And she’d been there, hanging on, for ten more days.

*

I remembered her last name, typed it in, clicked on her chart.  The warning box I’d been expecting popped up.

“You are opening the chart of a deceased patient.  Do you wish to continue?”

Yes.

Yes, I do.

In the end, it was simple, and quiet.  Her heart had started to slow on ICU day 11, slower, and slower.  She lost her blood pressure.  And then, just as it had when she was our patient, her heart simply…..stopped.

And she was gone.

* * *

In my dream, I was dead. 

In and of itself, this might have been frightening, but I was old.  I mean, I was really old.

Also, my grandfather was there.  My mother’s father, a kind, gentle man who told us silly jokes and made us root beer floats and died more than ten years ago.

And there was a dog there, too.  A big german shepherd.  I’ve never owned a german shepherd, so I’m not sure why he showed up, but honestly, if we DO end up somewhere after we die, I’m going to be OK with it as long as there are dogs there.

And I was crying and upset, and my grandfather and the dog were comforting me, but I wasn’t upset because I was dead, per se.

I was upset because it was over Too Soon – much too soon! — and I had So Many Things Left To Do…

*

And then I woke up.

* * *

Later, on that final night working the COVID-19 ward, I got an admit from the ER at about 2am.  She’d been sick for eight days, was maxed out on the Vapotherm, 40L at 100% FiO2, and she couldn’t even talk without dropping her SpO2 into the 70s.  It took her many long, scary minutes to recover her sats into the 90s.

Her labs were terrible, her pulse was sitting in the high 90s, her fever was over 101.  She was exhausted and sick and out of breath, and despite it all she was funny and friendly and helpful to the best of her ability.

In age, medical history, and presentation, she was a carbon copy of the woman who had coded in room 51 twelve nights earlier.

I gave her tylenol for her fever, steroids for the inflammation, insulin for the blood sugar spike that inevitably followed the steroids, antibiotics for her bilateral pneumonia, and a blood thinner to try to ward off the future pulmonary embolism that was probably already forming in her legs, the one that might suddenly dislodge and shoot to her heart and put her into PEA arrest.

I hooked up all her monitoring wires, all the cables, adjusted the heavy tubing of Vapotherm cannula, and gave her a small cup of ice chips for her sore, dry throat.

“I’m going to get out of your space now and let you rest,” I said.  She’d been in the ED for fourteen hours before finally making it to our floor.

“Thank you for your help,” she said, and paused as I reached down to fiddle with one more wire.  My face was close to hers and she looked up suddenly and caught my eye, and said:

“Do you think I’m going to get better?”

And in that millisecond after the question, I re-lived every moment of ten weeks in New York, and five weeks in Texas, and all the charts closed with the electronic label “deceased” and thought to myself, you have every single co-morbidity that works in partnership with COVID to kill you and you got to us too late —

::too late, too late, too late, they got to us too late in Sierra Leone as well, and died in the ambulance, or died in the triage area, or died alone on a bloody mattress in the dark::

And I tore my brain away from my memories and back into the present moment, and I took her hand, held it through my glove and met her eyes behind my goggles, and although she couldn’t see it, I smiled at her from behind my N95 mask.

“Yes,” I said.  “I do.”

~ ~ ~