Helpless

It’s been almost a year that I’ve been here, learning how to be an ER doctor. I love my work. I love the action and the drama and I still love the fact that people come to me oftentimes having the worst day of their lives, and even if I can’t always fix it, sometimes, just being the calm voice in the eye of the storm is enough to get them to the next step.

Sometimes, though, I can’t help.

I was at our sister institution downtown, the large tertiary care medical center in the heart of the city on my last block. I saw a woman while I was there who came in for nausea and vomiting. She only spoke French, and she was from somewhere in Africa. She was quiet and withdrawn, and quietly spoke through the translator about her history, making very little eye contact. The more we spoke, the more concerned I became that she was being trafficked. She couldn’t tell me how long she had been in the US. She didn’t know what condoms were. She lived with her “friend,” a man named Sam.

I asked her if she had any children, and when the interpreter translated my question, the woman actually looked at me for the first time. Her whole face brightened. Life shone out of her like a quietly burning star that had just burst through her heavy curtain of fear.

Yes, she told me, five of them. They live with my auntie back in Africa.

And how old are they? I asked her.

Her face sank again. She shrunk once more into her blanket of icy fear and indifference. I don’t know.

She didn’t know how old her children were, because she wasn’t allowed to speak to them, and because she had no idea how long she had been in the US.

I contacted the SANE nurse (Sexual Assault Nurse Examiner) and she confirmed that this was a woman who had been seen multiple times in the past, who had been forced to have abortions, who had been seen for STD’s, and who always became afraid and withdrawn when asked if she was safe at home. The SANE nurse, whose job extends far beyond mere evidence collection and coaxing frightened, hurting women out of their shells and onto the first steps on the path of healing, informed me that this woman was terrified for the safety of her children back in Africa. Despite multiple offers to protect her children, to extract them, to carry them beyond the influence of this woman’s captors, she continued to refuse, unable to see how it could be possible to escape the life she was now entrenched in, convinced that this was her lot, the sacrifice she made to ensure they lived a better life.

I felt so helpless that day.

I choked back my own tears as the portable ultrasound machine showed the tiny flicker of a living heartbeat, the source of her vomiting, a 9-week baby growing quietly in the recesses of her body, unaware of the violence that led to his conception, and blissfully ignorant of what would likely befall him, and had befallen at least four of his brothers and sisters before him, conceived and slaughtered by that self-same violence.

I printed every resource about human trafficking and refugee rights in the US that I could find in French and gave them to her.

I don’t know if she can read.

I wrote my note in her medical record, coldly detached from my words, and then slipped from my seat, walked to the staff restroom, and vomited.

The next week, I returned to my home hospital, and started the first of four weeks in the ICU. One of my first mornings there, a man came in with Covid. We are seeing more of them as restrictions lift, before the population is fully vaccinated. He shouldn’t have been there. He was in his fifties, and he was in pretty decent physical condition. He works in public service, and he should have been eligible for a vaccination months ago. He was a little overweight and took meds for hypertension, but he wasn’t a smoker or a diabetic and he wasn’t out of shape….

There was no reason to explain why this illness hit him so hard.

But it did.

He showed up in the ICU breathing so hard that it was choking him. We poured oxygen into him with a firehose. We strapped a mask to his face and blew it into his lungs at the highest power we could muster, and when he cried out with fear and fright, we shot him up with drugs to make him too high to care…..and still, he fought for air, screaming against the mask shoving air into his face at hundreds of miles per hour.

For three days he fought for air, shaking and trembling, while we went about the business of medicine, turning him on his belly to ease his work of breathing, medication for anxiety and nausea, measuring fluid balance and electrolytes and discussing nutrition and kidney function and the minutiae of cardiac activity.

The photo on the right is from the day he was admitted. On the left is from when I intubated him. Basically: dark is air, dark is good. White is bad.

Just after lunch on his fourth day on the unit, things changed.

He’d been laying on his belly, and with the valium and the sedatives, he was doing ok for a while. But that day, something just got to him. He sat up and started to retch. He screamed and choked and flailed until he ripped out the lines in his arms that were feeding him his steady stream of fluids and sedatives, spraying the entire room with saline and precedex and fentanyl and he started to vomit into his mask, the lifeline to the precious oxygen he so desperately needed. It took three people to hold him down and press the mask into his face while I got a new line in his arm and my attending ran into the room, hairnet askew and clutching in one hand the small red tackle box that is our final, most despised weapon in our fight against the lung disease caused by Covid.

The RSI box.

Early investigations said that only 20% of people who get intubated for Covid ever survive to get the tube pulled out. Recent data suggests that was more reflective of early numbers, when we thought it was better to intubate early, that Covid pneumonia acted like other forms of acute respiratory distress syndrome.

But we know better now, and we know that intubation actually damages a person’s chances of recovery, and so we save it for the absolute final moments.

My attending handed me the tube, and asked me if I wanted a direct blade or video.

I’m far more comfortable with direct, a curved, lighted instrument called a tongue blade designed to lift the tongue and jaw out of your way and give you a good look at the vocal cords so you can thread a plastic hose past the voicebox and secure it just above the carina, the place where the trachea divides into right and left mainstem bronchi. This ensures you are blowing all your air directly into the lungs, no tongue, no throat tissue, no possible way to accidentally suck food or liquid or vomit into the airway and get in the way of that precious oxygen.

I’ve done this much more often, and I prefer the direct approach, positioning the head and neck just so, it gives you far more control over the tube and the airway, and in my past lives in medicine, I certainly never had anything fancier than a lighted tongue blade to work with.

Video laryngoscopy, or the glidescope, is a fiberoptic cable attached to the tongue blade, and hooked to a screen, so everyone can see what you’re doing. You don’t have to position the head and neck, but it requires a little more fiddling with the tube, which you operate more like a joystick, and less like a pencil or paintbrush.

But this guy was tanking. He’d ripped his mask off not two minutes before, and already the oxygen in his tissues had dropped by more than ten percent.

We wrested the mask back onto him. He started to thrash again, his muscles sucking up what precious little oxygen he had. We had to work fast.

“Video.” I stated. I knew I wouldn’t have time to reposition, I knew I wouldn’t get him at the correct height, and I knew I would really only have one shot at securing this airway.

More people started to pour into the room, the complement of people responding to his distress, but had been held up outside the room donning their N95 masks and face shields and the gowns that not only protect us, but the rest of our patients from breathing in any residual virus particles that might have otherwise been left on our clothes when we left the room.

I stood calmly at the head of the bed, checking my suction and my video. I attached a syringe to my tube, to inflate the balloon that would hold it in place once it passed the vocal cords.

It took six people to wrestle him back to the bed, as he fought, delirious, for air. His head landed on the bed in front of me. I touched his face and spoke to him, nonsense words, as my nurses and techs fought to hold him supine on the bed.

I unclipped the harness that held the mask tightly to his face, and as the seal broke with a hiss, we could finally hear what he was screaming.

“Help me!” he cried. “Help me!”

I looked him in the eyes, upside down, as I stood at the head of his bed, and I said, “I’m going to help you.”

He focused on me for just a moment, and I think he even recognized me. “Doc,” he forced out, “don’t let me die.”

I just stared at him.

He fell gently back on the bed, as if he was in slow motion, and his eyes glazed over.

“GO!” hollered my attending.

I realized that his paralytic had been given, and that this was my chance to intubate him, and that while he was paralyzed and not breathing, his oxygen saturations were falling fast.

It was a perfect tube. The view was a grade one, a textbook image of proper anatomy. The tube went in smooth and soft, and we pulled the stylet and I attached the valve bag and watched his chest rise when I squeezed it.

We strapped the tube to his face so that it wouldn’t go anywhere, and I wiped the tears from his cheeks….even though he was asleep, and would never know.

Live. I whispered. I did my part. It’s your turn, asshole.

I left his room, stripped off my gown, my cap, my goggles, my gloves. I washed my hands…..twice. I threw my mask in the garbage, certain that it was saturated with particles as I had thrust my face into the hail of droplets as he struggled for the breath of life.

I sat at my computer to write my procedure note, a dry account to the tune of “50 mg of propofol were used for induction. A glidescope was used to visualize the cords with a grade one view. The endotracheal tube was advanced into the airway and was visualized passing through the cords. Colorimetry verified position and bilateral breath sounds were auscultated.”

I left my desk.

I wandered aimlessly into the hallways of the hospital, until I found a corner that wasn’t often used, and I collapsed in the corner and wept.

And then I returned to my desk. I called his children, and told them, in a calm, quiet voice that wasn’t my own, that his respiratory status had deteriorated, and in order to give his body a rest, we had paralyzed him and put a tube in his airway.

And then I went on with my work. I helped a woman who had drunk so much water that she diluted her cellular salt balance and had a seizure while she was driving. Her son, an army private who had driven up from North Carolina, sat and listened and explained things to her patiently. When he was out of the room filling out paperwork, she called me a heartless bitch under her breath when I refused to let her drink any more water.

I sat in a room with a man and his brother and explained that he had pneumonia and his liver was failing, and that even if everything we did went perfectly, he still probably wouldn’t live long enough to treat his cancer. I told him that it was time to choose how he wanted to die, because it was no longer a matter of when.

I love my work.

Because when a person comes in having the worst day of their life, sometimes, I can be the eye of the storm.