TABLESPOONS OF AIR | Katherine Toler
The elastic of my N-95 snapped against the back of my head for what seemed the 100th time that shift. I was a cardiothoracic ICU nurse—trained to care for patients who’ve had their sternums opened and then wired shut. Patients who needed blood transfusions, had stunned myocardium, were on six different IV infusions. I wasn’t trained for this.
The COVID ICU had been retrofitted into the oldest wing of the hospital. Jagged squares were cut into the plexiglass windows to create makeshift negative pressure rooms. Huge HEPA filters rumbled constantly, their hoses dumping viral-laden air out to a city gone silent.
My patient, Paul, was admitted that November. During that time, pre-existing conditions were being accused of delivering death sentences. The only pre-existing condition Paul had was bad luck.
He'd taken off his mask to eat lunch with a colleague. A week later, he was sick. Lying on the floor with a fever of 103, breathing became impossible. His wife left him at the emergency room entrance and drove away; she had no other choice.
Alone in his hospital room, he ate grape popsicles while nurses increased his oxygen to 6 liters, then 10 liters, then 12 liters. His sons waited at home for updates. When they swapped the nasal cannula for a full-face mask and oxygen delivered at a fractional concentration of 100 percent, his breath came in sharp gasps, and it was impossible to eat any more popsicles.
Then the breathing tube went in and the vent was switched on.
Even that wasn’t enough. He was dying.
There was only one thing left to do.
Transfer him. Cannulate.
They told his wife he was a good candidate for “one last shot.”
“They can put him on ECMO.”
“ECMO? What’s ECMO?”
“It's his only chance.”
“Do it,” she said. They packaged him up and within hours the MedEvac helicopter was on the roof of our hospital. Paul’s wife had consented to veno-venous extracorporeal membrane oxygenation. Two garden hose-sized tubes inserted into major veins. Blood is pumped through mechanical circuitry outside the body to be oxygenated by an artificial lung.
Its only function is to buy the patient time. It’s not a cure or a treatment.
It is simply a stay of execution.
After cannulation, Paul lay motionless in bed, breathing tube down his throat, paralytics coursing through his veins, sedatives dialed to ungodly high levels.
Radiographically, healthy lung tissue shows up jet black on the chest film. Every day when the ICU team pulled up Paul’s x-ray, the result was the same: “completely whited out.”
A deep breath will inflate healthy lungs about 550 milliliters. A seasoned ICU nurse can hear what a good ventilator breath sounds like: a low hiss of compliant lung tissue. Paul’s vent made harsh, truncated clicks. The volumes it registered: 15, 25, 30mL—a tablespoon.
The ECMO continued to oxygenate and circulate, unbothered by the rest of the body’s dysfunction.
In the dizzying monotony of holding onto life by a thread, almost a thousand sets of vitals were charted while his unconscious body was shifted back-and-forth hundreds of times. 40 days elapsed—an eternity. He’d been given monoclonal antibodies, stress-dose steroids, expensive antivirals authorized for emergency use, plasma infusions from patients who survived, his body a receptacle for our experimental pharmacology.
Then, a week before Christmas, the fellow told Paul’s wife that time was up.
These discussions typically took place in the presence of the attending physician, the bedside nurse, and the family gathered stone-faced around a table in a tiny consult room. Instead, we were standing in Paul’s room, ears full of the ventilator’s useless soundtrack. His body was hidden beneath the sheets, shapeless, already a corpse in a shroud.
“He’s not going to survive."
Click.
“You’ll need to start making arrangements.”
Click.
“We can wait until after Christmas.”
Click.
I almost missed my cue to hand over the box of scratchy hospital Kleenex to his stricken wife. Paul had been given an expiration date. No questions. No hedging. It was definitive.
The fellow had an air of certainty that rattled me. I instinctively looked around for an attending to fill in the gaps, to sand the rough edges off her assessment. Her eyes were glassy, blinking furiously. She patted Paul’s wife on the shoulder and walked away before her tears fell.
I stood in the silence with one thought: How can she be sure?
And yet the rational part of me knew Paul had no business surviving.
With the fellow gone, his wife and I stepped into the hall, surrounded by six sliding glass doors, behind which six other patients were defying death on ECMO circuits.
I locked eyes with Paul’s wife and did something I’d never done before and haven’t done since. I directly contradicted a physician’s end-of-life assessment.
“I know things aren’t looking good, but I’m not giving up yet.”
***
I had four shifts to do what they said wasn’t possible. Wake Paul up. Wean all his sedation. Prove that he could be conscious without crashing.
The practice of medicine during COVID had become one part wild west, one part superstition, and two parts apathy. The residents and NPs had a list full of patients on fire. Many were reluctant to make changes, knowing anything could send an otherwise critically stable patient into an acute death spiral.
Similarly, many nurses didn’t want to change a thing. The saying “if it's not broke don’t fix it” was heartily applied, except everyone was broke and we just didn’t know how to fix it. Most contented themselves with doing the bare minimum, hoping orders from the team wouldn’t incite the wrath of the vent or the ECMO circuit screaming its string of alarm-based obscenities.
But I just couldn’t turn, water, and feed Paul until an arbitrary date came and went. I had to try.
I appealed to the NP in charge of Paul’s care. “Can we try to wean his sedation without making any ECMO changes? Only do one thing at a time?”
She gave me the most indifferent greenlight: “Sure, go for it.”
I had my permission and a job to do.
No playing candy crush. No scrolling Instagram. My eyes roved from his vitals to his ECMO circuit, watching. I drank my coffee standing in front of his closed door, staring at the monitor. Forgot to take lunch, not that there was anyone free to watch for me anyway.
Come down on the ketamine first: 300 milligrams, 200, 100, 50, off.
Dilaudid next. Even slower.
I held my breath—he held his sats.
My fixation on Paul’s life seeped into interactions with my coworkers. Before I relinquished control to the night shift nurse, I made sure they understood the plan: “Keep him stable. I’ll be back in the morning.”
“Sounds good,” the night nurse shrugged. Less work for her.
The next morning, I took off the last sedative—Midazolam. Each lowered titration allowed for more neuronal activity, more consciousness to leak in.
Please, God, don’t let me mess this up. He seems like such a nice guy. Please don’t let this one die.
For the fifth time that shift I glanced at the crooked photo of his German Shepard, taped to the wall next to Paul’s bed and remembered his wife’s words, “Willie, doesn’t know what to do without him.”
I hyperfixated on the ebb and flow of the cyan waveform that represented his oxygen level. The pleth had to be perfect at all times. No question marks, no artifact. The infrared light glowed red on his index finger, transmitting the assurance that everything was going to be okay. It had to be okay.
At the end of the third day, his eldest son came to say goodbye. His family was still under the impression that this was it. The young man entered the ICU alone. Only one visitor allowed per patient per day. I mumbled niceties and handed him the box of Kleenex, closed the curtain. Tried to ignore the ache in my chest.
“Hey, Dad, it’s me. I just wanted to thank you for being such a good person, such a good dad.” He choked back a strangled sob, the kind you wouldn’t want anyone else to hear.
I tapped the keyboard unnecessarily hard.
Vaccines were still weeks away, yet each shift inoculated us with a microdose of resignation to COVID’s effects. For months I had maintained a steady state of numbness. I wanted my weighted blanket of detachment back. I heard a sniff behind me. When I turned to look, another nurse was using her mask to dab her eyes.
The entire nurses’ station was filled with tears and hollowed-out faces.
I gave myself permission to stop trying to stop it. I pressed my forehead into the cool Formica of the desk and kept it there.
When it felt safe to lift my head, I saw the eldest had gone.
I had one last shift with Paul.
That day it was Paul’s younger son who had come to visit. I steeled myself for the tears. Again I held out the box of Kleenex, the gesture now feeling insultingly empty, and looked away.
The goodbyes never came.
The sedation had been completely off for eight hours. Paul hadn’t moved. Everything was still grey until I heard, “Dad? Can you hear me? I love you.”
Paul opened his eyes, mouthed “I love you, too” before closing them again.
The cyan waveform broadcast its verdict—oxygen saturation 92%.
***
Over the coming weeks, Paul continued to improve. He maintained his oxygenation without deep sedation. He sat up in a chair. He participated in physical therapy.
Tablespoons of air turned to cups, then liters. Jet-black streaks wove their way through the sea of white.
Slowly, his lungs got better.
After borrowing 70 days from a machine, he was liberated from its never-ending humming.
***
Before his discharge, I visited Paul on the stepdown floor. His room was littered with evidence of a prolonged hospital stay. A wall of cards and photos hung with Scotch tape, a massive bundle of half-deflated mylar balloons with “You Can Do It!” and “Get Well Soon!” floating ghost-like in a corner.
I stood awkwardly, uncertain how to act in an area of the hospital where death didn’t seem imminent. “Do you remember me?”
He broke into a wide grin, and I saw his eyes were no longer full of that drugged, far-away ICU haze. He was bright, awake, alive.
“Of course I do.”
It was the first time I’d ever heard his voice. During the months I intermittently cared for him, he'd always had a breathing tube in his mouth, or a trach in his neck, attached to a ventilator that kept him mute. I’d spent shifts during his recovery working to read his lips, understand his gestures, or reading notes scrawled in Sharpie.
Now he could speak.
Katherine Toler is a critical care nurse based in St. Louis, Missouri. Toler writes about the intersections of grief, medicine and moral ambiguity in clinical spaces. Her work has appeared in Raw Lit, Please See Me and is forthcoming in Survive & Thrive: A Journal of Narrative Medicine and American Journal of Nursing: Reflections. She is currently working on a collection of essays.