/I’m an NHS consultant anaesthetist. I see the terror in my Covid patients’ eyes | Coronavirus | The Guardian

I’m an NHS consultant anaesthetist. I see the terror in my Covid patients’ eyes | Coronavirus | The Guardian

I’m not ready,” the patient implores me through her CPAP [continuous positive airway pressure] hood. She’s breathing at more than triple her normal rate and I’ve been asked to intubate her as she’s deteriorating, despite three days in intensive care. She is 42 years old.

There’s terror in her eyes. A tear runs down her cheek. She’s looking at the patient opposite who is in an induced coma, intubated and ventilated, and isn’t doing well.

The noise of 30-litres-a-minute of oxygen in her CPAP hood makes communication almost impossible. She repeats, “I’m not ready”, and raises trembling hands.

But her oxygen saturation is only at 84%, when it should be close to 100%, and she’s becoming exhausted and agitated. She tries to rip off her hood. “I need to phone my family,” she gasps. I nod and say OK, almost shouting to be heard over the noise of the alarms.

I’m wearing clawingly claustrophobic PPE for this aerosol-generating procedure: an FFP3 respirator face mask, face visor, gown and double gloves. I’m starting to sweat, and realise that, due to her obesity, it is likely to be a difficult intubation.

The patient tries to talk to her family on FaceTime. She is extremely breathless and looks like she is dry drowning in thin air. Tears pour down her face. I hear someone on the phone crying and saying “I love you”.

I take off the mask and pre-oxygenate her with 100% oxygen by tightly applying a Waters breathing circuit to her face. I gently put my hand on her shoulder. “We’re all here to help you. Everything is going to be OK. We’re now giving you some medicine to help you relax. Let us look after you.”

The anaesthetic trainee injects 100mg of ketamine, 100mcg of fentanyl and 100mg of rocuronium intravenously in rapid succession “Everything will be OK,” I repeat. Almost immediately her oxygen saturations start falling. The tone of the oximeter becomes sickeningly low.

We need to allow 60 seconds for full paralysis. “Sats are 60%,” says the operating department practitioner [ODP]. Forty-five seconds, and I can’t wait any longer. I take a big breath. I thrust the video laryngoscope blade into her mouth and over the back of her tongue and immediately see a swollen and haemorrhagic oropharynx. I go deeper, until I can finally see the larynx and the vocal cords. There is Covid pus bubbling through the larynx.

I immediately insert the endotracheal tube [ETT]) with a metal stylet. The ODP removes the stylet and I insert the tube through the vocal cords and further down the trachea. I clamp the ETT tube, and we connect it to the ventilator and confirm we see an end-tidal carbon dioxide trace on the monitor. The oxygen saturations are unrecordable, the patient’s lips are dark blue.

The pulse oximeter tone finally rises and the oxygen saturation ever so slowly rises from the abyss. I look up at the team and meet their wide dilated eyes through our visors. I breathe a deep sigh of relief. All the monitoring alarms are screaming but I don’t hear them. I look across the bay and see another terrified patient, on CPAP, staring straight back at me.

Three hours later, we are asked to intubate this patient. She bursts into tears, saying: “I’ve got children at home. I can’t go on a ventilator. I’m not ready. I can’t die.” She is 35 years old. I kneel down and hold her hand. I explain again that we are here to help her with her breathing. As she FaceTimes her children, we urgently get our equipment and drugs ready. Her young children are crying. I must look really scary to them. I can see them but can’t communicate with them at all, even as their mum is becoming increasingly hypoxic and agitated. “I love you, I love you, I love you… ” she says, until she finally presses “end” on the screen with her shaking fingers.

She is struggling and will become more acidotic and distressed if we don’t take over her ventilation soon.

While we are pre-oxygenating her, I take off her CPAP hood and lean closer. “We’re here to look after you. Everything will be OK.” I stop talking because I think I might cry. I worry she is dying. I hold her hand. She squeezes it and I squeeze hers back.

I look across the bay at the patient from earlier. I think about her family at home. I think about this patient’s family at home. I think about my family at home. “Sats are 75%… ” Thirty seconds. “Sats are 60%… ” Forty seconds. My attention snaps back to the airway, which I need to rapidly secure first time. No time to think. No second chances. We are ready.

After many subsequent emergency intensive care Covid intubations, I think back to my first two patients almost daily. I can still see the terror in their eyes.

Almost 50% of Covid patients intubated after failed CPAP have not survived, despite the most intensive of care. I decided not to find out what happened to my first two patients. I can still feel a hand holding mine tightly with desperate hope. Was I the last person ever to speak to them? The thought is too painful.