Except for Paul
The doctors wanted his wife to plan a funeral. I told her, “Let’s wait.”
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It was the height of one of the first waves of COVID, November 2020. Before the vaccine was available and nurses were still heroes. Patients weren’t yet demanding to be treated with horse dewormer, and no one had suggested drinking bleach as a cure.
Paul had taken off his mask to eat lunch with a colleague. A week later, he was sick. After the outside hospital had thrown the kitchen sink at him (convalescent plasma, Remdesivir, proning) to no avail, he was transferred to us and cannulated for VV-ECMO.
In truth, Paul had no business surviving.
When a patient is so critical that even a ventilator can’t keep them alive, ECMO is the last-ditch effort. It involves inserting garden hose–sized tubes into major veins, routing blood outside the body, through an oxygenator, and back in — completely bypassing the lungs. It’s the end of the line on the “we’ll do everything” train. Mortality hovers around 50%.
A week before Christmas, after being on ECMO for around 40 days, he had made very little meaningful improvement. COVID had settled deep in his lungs and made them stiff and fibrotic, and every time we tried to decrease his massive amounts of sedation, he would crash.
It was around this time when the fellow waltzed in and told Paul’s wife that he was going to die.
“He will never breathe on his own without the ventilator,” she said, with a robust conviction that made me raise an eyebrow. “You should start to think about making arrangements.”
With a few solemn nods and an offer of a box of scratchy hospital Kleenex, the fellow left.
I stayed.
To this day, I’m not sure what caused me to completely contradict a doctor who had just delivered a devastating bit of news to a family member.
Our 15-bed COVID unit was packed with critically ill patients, dying left and right with no rhyme or reason.
Nothing should have prompted me to say what I said to Paul’s wife.
“Let’s give it a few more days and see what happens.”
It was time for me to get meticulous.
Paul was sedated on an insane amount of IV drips — ketamine, Dilaudid, and midazolam. Over the next three days, I painstakingly weaned down all his meds while asking the team to keep his ECMO support the same.
One thing at a time.
Slow and steady.
At the end of the third day, his son came to say goodbye.
“Dad, I love you. Thank you for being such a good person, such a good dad.”
I stared blankly at the fluorescent computer screen outside the room under the guise of charting, blinking furiously to keep tears from spilling from my eyes.
Glancing furtively around the pod, I saw that each of my coworkers looked stricken and hollowed out, listening to this young man sob for his father, who had been marked as a lost cause.
His son left.
Since only one visitor was allowed per patient per day, Paul’s second son came the next day. Once again, I braced myself for the tears and the whispered goodbyes.
They didn’t come.
With his son at the bedside, Paul opened his eyes and mouthed, “I love you,” before closing them again.
His oxygen saturation held at 92%.
Over the coming weeks, Paul’s condition continued to improve.
No longer did he need to be deeply sedated to maintain his oxygenation.
He was able to participate in physical therapy and spent time sitting in the chair. Eventually, he was able to go for walks on ECMO.
Slowly, his lungs got better.
Finally, after defying all odds and spending over 70 days on ECMO, he was decannulated — able to maintain his oxygenation with the help of the ventilator and his tracheostomy.
Paul went home after a 110-day stay in the hospital.
By then, the trach was gone, and he only needed a little bit of oxygen in his nose.
To this day, we stay in touch, as you would if someone considered you one of their “guardian angels.” Yet despite the otherworldly title I earned, I continue to be flummoxed by his case, his trajectory, his survival, and my role in it.
I am one of the most cynical, pessimistic people I know.
I refuse to give patients or families false hope.
I try not to look to the future at all — especially if the patient is utilizing advanced mechanical circulatory support measures, as Paul was.
Why did I contradict a doctor who had drawn the line in the sand between life and death?
Why did I give a wife hope after she had been told to contact a funeral home?
After she had picked out a suit for her husband to be buried in?
Some might cite “nurses’ intuition” and feel good about that explanation.
These are also the people who freak out if you say the unit seems “quiet” today.
I don’t believe in either of those things.
Nobody had nurses’ intuition during COVID.
Nobody knew what the hell was going on.
Nothing made sense.
Everyone died.
There was nothing you could do about it.
Except for Paul.
Paul lived.
