Clinical limbo and the end of the road
The intensive care unit is full during my latest shift. The slow drip drip drip of cases day by day has filled the unit.
The doctors have spent the past few weeks rebuffing soft and speculative referrals – professional relationships are surviving, even thriving despite the sometimes fraught conversations.
Many of the patients have now been on the unit for two or three weeks. Since these patients have developed respiratory problems two weeks after contracting COVID most of these poor folks are now effectively a month after they got infected. Most of the patients are surprisingly young – forties and fifties. They have a mix of co-morbidities, especially diabetes, smokers’ lung, obesity or kidney disease. After this long many of these patients are facing the end game.
About half the patients have managed to recover sufficiently to ‘earn’ a tracheostomy and be weaned off the ventilator. The damage to their lungs makes us all wonder if any will avoid being respiratory cripples. Despite this recovery, COVID is also leading to profound neurological dysfunction. Some patients are agitated and confused but for a significant proportion, the lights are on but no one is home. We wonder how families will react to their loved ones being different people.
Many patients are in a clinical limbo – not getting worse – but also not going forwards. The daily conversations with relatives are variations of the same theme trying to emphasise that in the big picture their relatives are critically unwell and that almost nothing can be read into the slight changes in oxygen or ventilation pressures. Relatives are clearly reading up on their medicine, clinging to every possible indication of improvement however unrealistic. Others are putting their faith in the divine – this is all God’s will.
Many of the patients are also on haemodialysis to replace kidneys which have failed. Now patients have not passed urine for weeks – each day makes it more and more unlikely that the kidneys will ever recover. Hence, in reality, these patients are clinically deteriorating, but this is hidden by the layers of medical intervention.
A few patients in this unit are now at the end of the road – changes are effectively like rearranging the deck chairs on the Titanic. Every day the ward round tries another attempt to reduce the level of support – usually resulting in a deterioration that leaves the later shift the work of reversing our changes. Today, another patient dies weeks into treatment – the oxygen level in their blood suddenly decreases – but with the patient already paralysed, on 100% oxygen and maximal pressure support there is nowhere else the clinical team can go.
The end is quick, quiet and peaceful and there is nothing else the team can do but to gown and glove to confirm life extinct.