Inside the Covid ward. By Jane Smith, a junior doctor in England.

I try to talk to the man, but it’s difficult for him to hear me through my mask and the noise of all of the CPAP oxygen machines. He tells me that he’s tired of fighting, and that he wants to be left alone.

Through my mask I try to explain that he has been getting better, and that we wouldn’t have a place for him on the high dependency unit (HDU) unless we thought he had a good chance of survival. He tells me that I don’t understand what it’s like, desperately struggling to breathe, which is true. This goes on for around 10 minutes. Eventually, I have to take his request seriously. Perhaps it isn’t illogical for him to want to die peacefully.

In order for me to allow him to make this decision, I have to be sure that he understands the risks, so I ask him to explain to me what he expects will happen if he takes off his mask and doesn’t put it back on. He says he doesn’t know. I tell him that he has to understand that he will die and that he needs to say those words to me if that is what he really wants. Eventually we compromise; he will put his mask on for another hour, then phone his wife and tell me his decision. This man is 61. …

B Bay:

I am allocated B Bay, in which there are five patients. My patients are mostly men, ranging from their early 30s to their 60s. This is younger than normal on HDU because — as I explained to the man — we only have beds for people with a fighting chance. …

I then put on my PPE (FFP3 mask, hairnet, long-sleeved gown, gloves, visor) and enter the bay to examine the patients. …

The patients don’t ask many questions, mostly because they need to spend all of their energy breathing. I try to work out if one of my patients isn’t answering my questions because she is delirious, because she doesn’t speak English, or because she is depressed. I work out that it is probably the latter; her notes say that her husband died just before New Year, from Covid. I try to remember every patient as an individual, since I can’t bring the notes into the bay to write as I go, but each crackly chest I listen to blurs into one. …

Phoning relatives:

I now have to update relatives over the phone, since they are unable to visit. I always put this part off; I almost never have good news to deliver. Hearing people cry on the other end of the phone, knowing that I am bringing them news of the worst day of their lives, is heartbreaking. There is nothing positive that can be made from the words “your father is currently on the maximum support we can offer, and we are not sure if he is going to survive today”. …

Prone:

We try to have our patients prone (lying on their fronts) since this opens up their lungs at the back and improves their oxygen levels. The patients hate proning, since the masks dig into their faces, their backs hurt and their arms go numb, and we do not have massage table-style beds with holes for their faces. …

Good bye:

We have several patients who are not “fit” for ICU in the current climate. Before Covid, they most likely would have been given a chance, but not now. When we think that these patients have suffered enough, and are unlikely to ever recover, we start talking about making them comfortable. It’s partly that we need the beds for patients with a better chance, and partly that we feel it is cruel to keep these people suffering when their chances of survival are slim. It’s difficult to work out which of those is your true motivation.

The most distressing part of their struggle is the air hunger. You can spot these patients easily, as they grasp the masks to their faces with both hands and gasp visibly for air.

Once we decide to palliate someone, we give them morphine to reduce their respiratory drive, and ease this feeling. We give them benzodiazepines to lower their anxiety, antiemetics to stop them from feeling nauseous, and other medications to prevent them from needing to cough. We then take off their masks.

It is important that these medications are given before their masks are removed, otherwise they will die terrified and gasping. This decision is made for about two or three patients each day on my ward, out of 20 or so. …

Once a patient is deemed to be dying, they are allowed one family member to see them for 15 minutes. The patient won’t be able to see their loved one’s face, since they will be wearing full PPE. Because the family member only has one shot at visiting, we need to accurately guess the patient’s time of death so that we can call them to come in. Sometimes we get this wrong, and the family never gets to see them. But all of the patients who die do so alone. There is nobody to hold their hand. Nobody to comfort them. Nobody to tell them they love them.

Imagine doing that every day. Or imagine being a patient.

What a dreadful story. Be sure to take some ivermectin or HCQ preventatively, and keep up your levels of vitamins A and D, and zinc.

hat-tip Stephen Neil