Updated on: May 7, 2020

One Patient’s Story

Original story posted on: May 1, 2020

A healthcare administrator who returned to the ICU amid the coronavirus epidemic had a memorable patient to care for – with a little help from an app.

When I was a child, there was a show on TV called The Naked City. At the conclusion of each show, a baritone voice recited the same lines, each week: “there are 8 million stories in the Naked City. This has been one of them.”

Well, Lewes, Del. is a smallish “Naked City,” and it has its stories, too.

Last week, as a recently resurrected ICU physician from an administrative afterlife, I found myself at the bedside of a very scared and very hypoxic woman I had just admitted from the ER two hours earlier. I was talking to an interpreter app on my cell phone, and the voice generated by the app was in turn talking to my patient. I asked the app to explain that we needed to sedate her and then put a breathing tube down her throat to keep her alive.

She asked only one question: “will I see my children again?”

Simplifying all the pathophysiologic vagaries of COVID-19 respiratory failure into a single word, I said “yes.”

The interpretation app then answered, “it is okay to do.”

For the last week, I lived with the possibility that my “yes” was a lie. The ICU team proned her, kept her plateau pressure low, monitored her QTc,  worried about her p/f ratio, went through their mental rolodex of ventilator modes, debated about the benefits and harms of hydroxychloroquine and methylprednisolone, and, then, finally, asked if they could extubate her. Again, the answer was “yes.”

And it all worked, better than anyone’s fervent hopes. The endotracheal tube was out and she was sitting up on nasal oxygen – a woman transformed. Resurrected, like me.

I went back into her room after her extubation in a gown, hat, googles, eye-visor, N-95 mask, and gloves. I brought my phone to again do the talking for me, and I asked it to say, “you did very well.” The patient responded in a raspy whisper.

The app said she said, “I talked to my children.” I took her hand with my double-gloved hand and gently squeezed it. She squeezed back a little.

She had spent six days on a ventilator, cared for by several physicians, many nurses, many RTs, many lab techs, many pharmacists, several chaplains, many PAs and NPs, many others, and by several cell-phone interpreters. The very caring staff would sometimes attempt to FaceTime with her family to coincide with her daily sedation. It may have made her smile, but it made no memories in her mind, which was washed clean around the clock with IV midazolam, fentanyl, and ketamine. Her last memory before going under was the app reassuring her that she would see her children again. The cell phone had said “yes,” too.

I really don’t know how many stories there are in Lewes, Del., but I do know that we now have many more stories than we used to have.

This has been one of them.

Michael A. Salvatore, MD, FACP

Dr. Michael Salvatore was a pulmonary medicine/critical care physician for 35 years. Since 2012 he has been the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. After earning his MD at the University of Arizona, he trained in internal medicine and PULM/CCM at Duke University. Dr. Salvatore is a member of the RACmonitor editorial board.

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