Volume 13 • Number 1 • Spring-Summer 2021

Alexander Gong

Mr. A

It’s 11PM on New Year’s Eve. The end of 2020, and onto 2021, a fresh start. A few nights prior, I went on Amazon and bought way too many gold, silver, and black balloons to decorate our resident call room. I even brought a helium tank to inflate the balloons, thinking it would be comical. I am on medicine consult nights, arguably the toughest rotation for third year medicine residents at our program. You cross cover three teams, admit patients, carry the CODE BLUE and RAPID REPSONSE pagers, and help triage which patients are priorities to receive ICU beds. In addition to you, there are five other medicine night float residents who admit patients in a rotation. On average, a night float resident will admit between five to seven patients a night, in addition to cross covering two teams of roughly sixteen patients each. Working nights is typically busy, but also it creates a sense of camaraderie amongst your coresidents with whom you can complain, express your frustration, talk through patient cases, and joke around when there is downtime. We usually order delivery for dinner so that we can all take a break before returning to our frenzied nights assessing patients at bedside, fielding hundreds of nursing calls, and rifling through our EMR piecing together lab values and vital signs. On a circular table that served as our call room dining area, I had laid out plastic champagne glasses next to a dozen bottles of Martinelli’s apple cider for the New Year’s Eve count down. The golden and black balloons were inflated, hugging the low hanging ceiling of the common space of our call room.

My VOIP rings. The digital screen of my VOIP reads “OPERATING ROOM.” It’s the nursing station of the PACU (post anesthesia care unit) which normally serves as an observation area where patients can be monitored after surgery. Just days ago, it was repurposed to become an area where PCU level patients could receive high flow nasal cannula oxygen. For the last two weeks or so, COVID numbers in Los Angeles County had been increasing at a staggering rate, some 20,000 new cases per day approaching 1 million cases to date, with nearly 8,000 hospitalizations. With our Emergency Department overwhelmed by the onslaught of COVID patients requiring admission for multifocal pneumonia and respiratory failure requiring high levels of supplemental O2, the opening of the PACU was hailed as a victory—ten to fifteen PCU level beds where we can provide high flow oxygen would help us all out so much.

I had only been to the PACU once the day before. Located on the fifth floor nearby the operating rooms, the PACU was located approximately 100 yards away from the inpatient tower—it felt like the length of a football field—down a long corridor which connected the inpatient to the outpatient tower. That intervening corridor housed the radiology department (CT scanners, XR, MRI), operating rooms, and then there was the PACU.

I rush down the corridor, frequently checking my pockets to make sure that my printed lists of patient information (medical record numbers, bed locations, names, and my scribbled notes), did not fall out and get lost (which often would happen when rushing to see a sick patient). A security guard, sitting behind a podium, wearing a black collared jacket with a patch reading “ALLIANT SECURITY,” greets me casually. I don PPE in a hurry, a bright green N95 mask made by 3M, which I fasten securely to my face, and a light blue surgical bonnet. I enter the PACU.

“I got called about OR 39, Mr. A!” I exclaim to the room, hoping to catch the attention of the nurse who had called. “Yes! Doctor, he is looking worse. I had him last night and he definitely is breathing a lot faster and looks more tired.” I don a disposable gown, face shield, and nitrile gloves and walk hurriedly to A’s bedside, which is located in a corner. I brush open the curtains. Mr. A is turned towards me, as he laid face down in prone position, the high flow nasal canula prongs stuffed in his nose and a non-rebreather mask resting awkwardly to the side of his face. He looks uncomfortable but doesn’t complain. I glance at the monitor behind him. HEART RATE 120, RESPIRATORY RATE 37, BLOOD PRESSURE 130/78, SPO2 88 percent.

I squat down near the head of the bed, my face no more than a foot away from his, separated, by my N95 mask and my plastic face shield. He glances at me from the side. I see him breathing heavily, speaking two to three words at a time. With the high flow oxygen machines humming in the background, I feel as if I am shouting through my N95 mask, my words sounding muffled: “WE ARE GIVING YOU THE MAXIMUM AMOUNT OF OXYGEN RIGHT NOW...BUT YOU’RE STILL NOT GETTING BETTER.” My Spanish has never been the best, but I have grown more comfortable in my three years working at County, where the majority of patients are Spanish-speaking. He nods deliberately. “Am I getting better?” he asks. I must have mispronounced the word “worse” in my attempts at Spanish. I shake my head with disappointment. “I’m really sorry that this is happening,” I look him straight in the eye. Our gazes lock, and the oxygen machines continue their humming.

His primary nurse, also gowned up in PPE leans in at the foot of the bed so that she can hear our conversation. This is my very first time meeting Mr. A, but this is what I say next: “YOU ARE AT THE POINT WHERE OTHER DOCTORS AND NURSES ARE GOING TO START TALKING ABOUT INTUBATION AND BEING CONNECTED TO A VENTILATOR.” I look down at his hand, which is resting by his head on the bed. His hand looks worn, as through hard labor, its creases and fingernails darkened with soot. He’s been admitted here for days, I thought, but hasn’t had the chance to wash his hands, no one has offered, or he has not been able to get up because he’s encumbered by the oxygen machine. I rest my hand over his. I muster another, “I’m sorry.” “Do you understand?” He nods, still looking towards the head of the bed, in prone position with the dull roar of oxygen deafening the silence between us. He shrugs, “if that’s what I have to do, that’s what I have to do.” I confirm that he would like chest compressions and intubation if necessary, to which he says yes.

At that moment, I could not imagine what was going through Mr. A’s mind. This young doctor, who must be roughly the age of his children, who knows nothing of what it is like to be ill or dying, is saying in broken Spanish that he will need to go to the ICU within the next hour where he will likely have a breathing tube inserted because of COVID. And to that awful, terrifying news, news that would mean he may never have a conscious moment after tonight or speak with his loved ones again or return to the life he had, he softly affirms, “if that’s what I must do, I’ll do it.” His courage in that moment is extraordinary to me. He is so brave; I wish someone else could’ve witnessed that moment. But it’s just me. I stand from my crouched position by the head of the bed, and I turn to the nurse who was listening to our conversation, and who called my VOIP to alert me that he was sick in the first place. She eagerly began arranging for his family to call him. I saw him speaking with them with the plastic telephone connected to the bed. I look at the clock, it’s 11:45 PM.

I call Mr. A’s daughter. She speaks English. I describe what is happening and that because her father is working to breath and requiring the maximum amount of oxygen we can provide noninvasively, I tell her that he urgently needs to go to the ICU. I can hear the distress in her voice over the phone, and she confirms that Mr. A has told her that he would want to do everything to be able to live, including intubation and being connected to a ventilator. We hang up.

There is about 600 liters in a 2,000 PSI tank of oxygen. With the high flow nasal canula device, its maximum rate of O2 delivery is 60 liters per minute. Do the math, and an oxygen tank can last ten minutes. There was some back and forth between the ICU nurses accepting Mr. A, who were concerned that there wouldn’t be enough oxygen to transport him at this maximum rate of O2, and that when he arrived, his oxygen saturation would be dangerously low and his heart could stop. We called the anesthesiology team to intubate Mr. A in the PACU, but they decided that because he was still speaking coherently and to them resting comfortably, although tachypneic (breathing rapidly), it was safe to wait to intubate him. Now connected to a mobile monitor and Mr. A’s bed equipped with four O2 tanks, accompanied by a respiratory therapist, two nurses, and the anesthesiology attending, all gowned in PPE, sprinting, we push and hover closely to Mr. A’s bed as if it were a bobsled. Panting to breath within my N95 mask, I hear the staccato sounds of the cardiac monitor beeping and wheels gliding down the long, endless corridor that leads to the inpatient tower and the ICUs.

Mr. A was intubated shortly after by the ICU fellow. It’s 12:45 AM.

A week later, I am at home sitting at my desk in my apartment in Monterey Hills, a condominium community just ten minutes away from the medical center. My fiancé is cooking Shepherd’s Pie in the kitchen. For whatever reason, compulsively, I remotely log onto the EMR from my computer and scan the ICU team lists. Mr. A was one of several I had sent to the ICU for COVID during that week of nights, with the other night float residents each sending several as well. I search his name, and see that he died in the ICU just two days prior. I begin to cry. I read that his family came to see him in his last moments. I can only imagine that the most tragic and difficult part about all of this is that these people die alone, away from their families, in a strange place. I wipe my tears with the back of my hand, and then begin to type away about how I met Mr. A.

Alexander Gong is a current third year internal medicine resident on the front lines of the COVID surge in Los Angeles. This piece was previously published in the Keck School of Medicine Newsletter.