Editor’s Note: This report is based on conversations with Nurse T., who works in an ICU in a New York hospital that serves an impoverished Black and Hispanic community.
New York, NY – It is two hours into Nurse T.’s shift when one of her patients pulls out her endotracheal [breathing] tube. The woman’s oxygen saturation displayed on the overhead heart monitor has been dropping down into the 70’s, even though she is on 100% oxygen. But Nurse T. has been wrestling with another agitated patient and was unable to intervene.
Desperate to breathe, the patient had freed one of her hands from the cloth restraint and yanked out the tube. Cardiac arrest was imminent.
It is her third time. As Nurse T. yells for the doctors to come and re-tube the patient, she wonders how many self-extubations the patient can survive. The medical team hurriedly don their isolation PPE’s and rush into the cramped room, where they find the patient gasping open-mouthed, starving for air like a fish out of water.
With sedation in extremely short supply, the anesthesiologist, a tall, British gentleman with an accent that the nurses love to hear (they find it sexy) elects to administer a paralyzing agent. The paralytic immediately renders the patient limp and immobile, but inside, the woman is awake and terrified as her mouth is pulled open and the new tube is pushed down her trachea.
Nurse T. examines the old tube. It is clogged with solid blood clots. She shows them to the anesthesiologist and asks what is going on with the patient’s blood? He offers (in his lovely accent) a diagnosis that frightens even a veteran like Nurse T. “D-I-C.” Disseminated Intravascular Coagulation.
Leaving the patient’s room, Dr. S., the ICU attending, gathers her team around the sink. She is a short, heavy-set woman with dark, close-cropped hair and dark eyes that once were mischievous. As they wash their hands one at a time, Dr. S. asks, “Do you know what happens when you are bit by the Black Mamba snake?” The British doctor answers. “The toxin sets off the blood’s clotting mechanism. Clots form throughout the vascular tree. Death occurs within minutes.”
The attending physician confirms that the Covid-19 virus has an effect similar to the Black Mamba snake: it sets off the coagulation cascade inside the patient’s body. With all hands clean and dry, Dr. S. leads the group to a computer and shows them images of a clot in a carotid (neck) artery, captured by a sonogram, and another of multiple clots in a heart chamber. Everyone is dazed and in shock.
Nurse T. tells the attending that when she checked her patient’s urine output on her hourly assessment, she found blood clots in the urometer, she had to milk the foley tube to get the urine to flow.
The attending orders a blood “thinner” – a drug that interrupts the body’s clotting mechanism. It is normally given to patients with pulmonary emboli or phlebitis (clots in the leg). She isn’t confident that the drug will be effective, nobody understands how the virus disrupts the body’s clotting mechanisms. Nor does she know how it can disrupt the peripheral nervous system and suppress the sense of taste and smell, but it does. Still, she reflects, they are beginning to develop treatment strategies, hoping to lower the devastating mortality rate.
A moment later, the hospital operator calls out a Code Blue on the loudspeaker overhead. It is on one of the medical wards. At the moment the ICU has no empty beds to receive the coding patient, although a bed is likely to open up when another patient dies. Wearily, the attending sends the anesthesiologist and an intern out to the ward to assist with the code. She does not know where they will find a suitable critical care bed to receive the patient.
Timothy Sheard, RN (retired), worked in hospitals for over 40 years. He is an author of nine medical mystery novels and founder of Hard Ball Press, a social justice imprint.