Medical ICU Hospital of
the University of Pennsylvania
This is the fourth installment of our new series, Flattened By the Curve, which features the voices of doctors, nurses, healthcare workers, and others on the front lines against COVID-19. For information on how to submit, click here.
We learned very quickly, with gnawing dread, that this virus made people sick — something more sinister than the lung injuries we knew so well. This was a sickness that struck like wildfire and smoldered longer than we first let ourselves believe. We exchanged breathless accounts of patients who walked in with a slight cough or fever, scarcely appearing ill, who within hours were fighting for their lives on a ventilator. One senior physician dubbed it “fulminant respiratory collapse.”
“Fulminant” is from the Latin fulminare — “to strike with lightning.”
For a patient on a ventilator, from the moment the breathing tube is in place, our eyes bend toward the day when it can be removed. We carefully dial back sedatives: the patient needs a high enough dose to be comfortable, but any excess means drugs building up hour by hour, a deeper and often delirious sleep. We back down the efforts of the ventilator itself where we can, letting the patient do more and more of the work, exercising their fragile lungs back to order. It is a cautious labor to create a controlled environment, one in which the patient can once again take strong, healthy breaths and soon — we hope — be able to come off the ventilator entirely.
In the ICU, hope is a rare thing jealously guarded, but extubation — the removal of the breathing tube — is a moment when the sun breaks through the clouds. After days or weeks of dependence on this machine, someone has come all the way up that difficult road, back to the waking world, and is once again ready to breathe the free air under their own power.
But now that ray of hope is too often fleeting.
The first patient to be extubated checked all the boxes: awake, breathing above and beyond the ventilator, strong and ready. The tube came out, and their lungs kept pace. The wall monitor showed a merry blue graph of oxygen readings, all exactly as they should be. We smiled.
But something was not right. Within a few hours, those lungs struggled. Breaths became ragged and hurried, and the oxygen graph turned sour. Far from being beaten, the virus had merely shown us the eye of its hurricane, and now the wind was picking back up. By evening, the breathing tube was back in place.
The second patient made it on their own for twelve hours. The third, a marathon, 24 hours. It was not enough to achieve escape velocity. The lungs could not keep up the fight, and the tube went back in. Each time, we watched with downcast eyes as one sad event became a grim trend, and we tried not to think in terms of inevitability.
If a routine extubation is a moment of celebration, an extubation for someone fighting this virus feels more like setting a kettle onto the stove. Watched or unwatched, you listen for the unmistakable sound — a high fluttering whistle of steam, a string of shrill alarms on the monitor — of things boiling over.
Justin Claire is a Pulmonary/Critical Care Physician Assistant in Philadelphia, PA. He misses Sixers basketball and believes that Angelo’s Pizza makes the best sandwiches in town. When he’s not at the hospital he likes to play the piano and garden, and he’s hoping it warms up soon so he can get his tomato plants in the ground.