Deep Breathing

One recent evening, just before I was about to leave my apartment and start my shift as a cardiologist in the Elmhurst Hospital Cardiac Care Unit, my phone rang. Since my wife and our baby daughter moved out to the suburbs a month ago to protect themselves from possible Covid infection, there is nobody around to answer it but me. It rang and rang. Finally, I got up. 

It was my father, calling to tell me that my grandmother, 96 years old, who recently tested positive for Covid at her nursing home, had taken a turn for the worse.    

The zoom link to her nursing home reveals a PPE-clad nursing aide hovering over my grandmother. “She hasn’t said much for the past day or two,” the aide says. Despite wearing a mask, faceshield, and body suit, the aide’s look is unmistakable to me. She knows what’s about to come. “Is there anything you want to say to her?”

My grandmother is taking irregular, raggedy breaths. Her body is slightly arched, and her chin juts straight up into the air. The aide holds the iPad to my grandma’s face. Her eyes are scrunched closed, and her shoulders heave up and down. Her bony hands, which would always grasp mine with a cold and familiar smoothness, lie motionless at her side. 

“…I love you, Grandma,” I say. “I’m thinking about you. I love you.” 

She doesn’t move. 

COVID patients are different from my normal cardiology patients.  I went into cardiology because I like fixing problems. Blocked arteries can be stented. Damaged heart valves replaced. With COVID, the sickest patients don’t seem get better. This isn’t for lack of trying – we just don’t understand this disease well. We’ve tried proning, experimental drug therapies, convalescent plasma, steroids, and advanced ventilator settings. It doesn’t seem to make any difference. Progression to acute respiratory distress syndrome – a hyperinflammatory state resulting in the destruction of lung tissue and respiratory failure – is nearly always fatal. 

Later, at the hospital, I head to the fellows room, and put on my own PPE: blue tearaway scrubs, cap, faceshield, N95, booties. Everyone does it differently. Some have helmets being fed oxygen through hoses, some have goggles, some wear white bodysuits with hoods. There’s none of the small talk so common to hospital life. Everyone walks the halls quickly and quietly. 

I head to the CCU. It has become a Covid unit with every patient on a ventilator. Next to me is a worker from nutrition services with his meal cart. Normally, he would be transporting trays of food. His cart now holds stacks of cartons containing milky, tan liquid. Tube feeds for all of the intubated patients. Dinner for my unit. 

I walk room to room with my residents, adjusting vent settings and drips, rounding and taking stock. We break patients down into organ systems, for completeness. Neuro, heart, lungs, renal, GI, ID, heme, endo. We go up on this med, down on that one. We send streams of labs. We call consultants, order imaging, and debate the best next move. That there is an underlying sense of futility for most patients goes unsaid.

You can almost feel patients’ humanity slipping away, minute by minute, forced breath by forced breath. They lie in sepulchral stillness from sedation and paralytics. After weeks of intubation, their skin becomes puffy, waterlogged, and taut, with decubitus skin ulcers and arms a deep shade of purple from repeated blood draws. Plastic IV tubing snakes from their frail bodies to pumps in the hallway. With visitors barred from the hospital, and the patients under deep sedation, each room is conspicuously silent, except for the high-pitched whooshing of mechanical ventilation. 

Squeee, hisssssss. Squeee, hisssssss. Squeee, hissssss.

A patient on a ventilator is technically breathing, but it’s all backwards. They are having breathing done to them. 

We breathe by lowering our diaphragms, which creates a negative space which air rushes in to fill. When we raise them again, the air is gently shepherded out. But a mechanical ventilator forces air in at much higher pressures than normal, and after waiting for gas exchange, sucks it back out again. 

Breathing, normally so mindless that we forget we are constantly doing it, is a complex, precise sequence that is poorly imitated by mechanical ventilation. The sustained high pressure of ventilation can cause a pneumothorax, or the collapse of lung tissue from air in between the chest wall and the lung. The endotracheal tube is often a source of infection and can lead to aspiration pneumonia. Airway secretions must be suctioned. Acid-base balance can be significantly altered. 

If patients are not adequately sedated, they buck and fight against the ventilator, causing alarms to blare. Their chests heave disconcertingly up and down, and air can build up dangerously in their lungs. It’s as if on some level, the body is fighting against the profaning of its most sacred function.

Squeee, hisssssss. Squeee, hisssssss. Squeee, hissssss.

Everyone is doing a little worse than they were the day before. Mr. Sanchez had a large cuff leak on his endotracheal tube, and had to be re-intubated, and since then his oxygen requirements have been much higher. Mrs. Arredondo was fighting the ventilator too much, and had to be medically paralyzed. Mr. Khan, thirty-four, nearly coded during the day after having his right lung collapse from the sustained barotrauma of prolonged ventilation. He needed an emergent chest tube to re-inflate the lung. He’s also being medically paralyzed to ensure ventilator synchrony. My unit is sick. Hemoglobins down, arterial blood gases with falling pH, urine outputs decreasing. Human decompensation, neatly documented.

We have to place a dialysis line on Mrs. Garcia, whose urine output had fallen to nothing and whose potassium was quickly rising. We speak with her family on the phone to get consent. They are grateful and appreciative. “Anything you need to do to keep her alive,” they say. “And thank you doctors, we are praying for you. Thanks to god for you.” We’ve been calling them daily for three weeks. Their stoicism and grace defies comprehension. I don’t feel like I’m doing anything to actually change her outcome. 

We don’t deserve this praise. 

Finally, the shift ends. I sign out the patients and head back home. 

I make some soup, and eat it on the couch. My daughter’s playmat sits unused in the corner. Her favorite stuffed animal, a purple rabbit, lies in a dramatic, almost comical, posture, stretched out in the corner. 

I turn on an iPhone app for guided meditation, meant to help relax. It instructs me to take deep breaths. I feel my chest expand all the way out, full of air.  But I can’t quiet my thoughts. My head is full of facts. The feeling of the lungs full of air derives from the filling of six hundred million tiny alveoli, two-tenths-of-a-micron thin, that comprise our lung tissue. What use is this info? I miss my girls. Will my daughter still remember me? When will it be safe for me to hold her again?

I pass out, and wake up to several missed calls from my dad. 

He says my grandma passed away during the shift. 

When he hangs up, I want to take some deep breaths to calm down, but it’s not working. I want more time with Grandma. I miss her elegant voice already. What I’d give for her to clasp my hands one more time, for one more “you’re wondahful!”

The app is… ludicrous. My breaths are unsteady, irregular. My tears make the pillow wet.

Still, the doctor in me feels relief that her passing was short and painless.  Indeed, my grandma was never on a ventilator. She was DNR. And after what I’ve seen at work, I’m strangely relieved. 

I think about the young patients I have in the CCU, about Mr. Khan and his failing lungs. We have to ventilate, to give everything to save him…right? It’s obvious. It’s what I’d want for myself… I think. Or maybe not. I’m scared for Mr. Khan. I hope that if we can’t save him, we can at least make him comfortable. In the context of multi-organ failure, besides sedating him heavily, I’m not exactly sure what that means.

I spend the next day talking about arrangements for a virtual funeral for my grandmother. Then, the following evening, the routine repeats. I’m back wrapped up in PPE, back in the ward, facing a new list of impossible problems.

Slowly, painfully, the week ends, and I rotate off service. But I can’t stop thinking about Mr. Khan. I log in remotely and check the patient list.

Remarkably, he’s still hanging in there.