100% FiO2 and no where to go
To recap:
67 year old male
from South Western Sydney
T2DM and HTN, CKD
otherwise living independently at home with his wife, retired.
three or so adult children, now with grandchildren.
unvaccinated.
covid positive and is documented to be under the care of public health, trying to care for himself at home. Amn Sp02 was provided.
In his home, lives his younger son and out in the granny flat is the older son and his family.
Slowly, one by one, they all contracted covid.
His wife also scored an admission however, got better and went home shortly before he required admission.
As he was admitted initially to another sister hospital to MICH, which uses powerchart for their notes I've been reading about his stay firstly on the wards, and then ICU.
He was transferred here because when they intubated, they punctured the trachea and thought he would need cardiothoracics input with regards to that. He had subcut emphysema at the time but that's since been resolved. This is likely why on oral care he's always had blood in his oral cavity.
He was heavily sedated to tollerate ventilation and with FiO2 best at 65% he just got worse and worse despite more and more support.
Increasing ventilatory support until there is no more we can change
FiO2 now at 100% his Sp02 is 85%
supine.
Paralysed.
Wasn't febrile but now is becoming so.
His family are lovely so I find this very sad. They say they've read about other people who took 3 months to get better (he's only really been sick since Dec) and that they've had family members on home oxygen living for 10 years.
100% FiO2 via the ETT is a massive mountain away from home O2. Home O2 would be at best 28% low flow, no pressure, natural airway.
I don't think his brain can tolerate CO2 of 68mmHg to 100mmHg ( I kid you not, yesterday it went up to 100, and yes that's an arterial blood gas) - normal btw is 35-45
and not only that his pH is now 7.25 - for maximal therapy he could get put on dialysis to clear the pH but we're still stuck with nowhere to go ventilation wise.
His family inquired about a lung transplant and he's simply too sick to survive.
ECMO has been off the cards since day one.
Last night he deteriorated and they tried to phone his wife but she didn't pick up.
Today, his son phoned. The team was still rounding in the amber/covid section. So I did my best to sort of indicate things were terrible.
The son said he wasn't sure he'd be allowed in today or which.
But as far as I knew the team wants to extubate today - which means, certain heaven in <1 min.
I don't know how the exemptions run and the rules, and what's happening in the unit. It's currently hybrid, half amber, 2 ecmo for I don't know why, 1 covid and my guy.
Likely to become full covid by the end of the week at which point, I have no idea where I will be going. Perhaps Cardiac or neuro ICU. Perhaps elsewhere. Perhaps, I'll take mat leave early. I don't mind I've made it to 35 weeks- it would only be cutting things short by 2 weeks and a bit.
Suppposedly theres a girl whose about 3-4 months working in covid ICU currently. I wouldn't cope with all that PPE - not at 4 months and not now - plus, you can't yawn. the moment you yawn, the mask is breeched. That's probably the hardest think I find about all the PPE (other than the heat) is the inability to yawn. Oh, and drink water.
I know where bed 23 will be going.
It's sad but I know the family don't really understand how bad he is. I don't think they realise that, even if we kept going there is only one ending. The choice is today, or perhaps next week.
How long can your brain and organs tolerate untreatable CO2 and pH of those numbers... I'm not certain.
So at 19:20 I gave the wife and one daughter a 5 min warning that they'd be closing the unit for covid - and at 19:25 I ushered their very polite but teary faces out of ICU. Only to return and the unit be fully covid. I had to wear the cap and face sheild as though I'd worked with covid all day (although I hadn't - but the unit was fast filling up all day bedspace by bedspace 1 at a time 27, 26, 25 etc. Two ex-covids remain in the corner in 28 and 29 and of course, my dude Mr 23.
Update on Mr 23. At 23:00 he had a cardiac arrest and died on the ventilator at 100% FiO2 and no reduction in ventilatory support.
noradrenaline had been weaned to 8ml/hr. Due to covid, his family were not afforded the opportunity to be at his bedside should they have wished to have been. That being said, it seemed via the observation chart to have been rather quick so should they have not been there anyway, he likely would have passed without family there.