Our fixed-wing air ambulance was recently dispatched to Spain to bring 87-year-old John and his wife of 62 years, Rose, home to the United States. They'd traveled to Spain for their annual vacation long before “COVID-19” or “coronavirus” were household terms, but John had fallen early on in the trip and broken a hip. He'd spent four weeks in a local hospital and had his injured hip surgically repaired, and then was deemed “stable to fly home” by a physician. And so he'd been transported back to his hotel two days prior to our arrival. The crew deposited him in the bed, bid farewell to his wife, and left.
And now John was dying. He lay on the twin bed in his hotel room. His eyes were closed. His breathing was rapid and shallow. My partner and I stood, stunned into momentary silence. We had come straight to his hotel from the airport, and his condition was far worse than we had anticipated.
We'd left our equipment in the aircraft, as John's transport was planned for the following morning to allow time for our pilots to rest. John's respiratory rate was 60 with frequent pauses, his pulse weak, heart rate about 95 and irregular. He wouldn't open his eyes or respond to us verbally, but he fought us when we tried to move him. He was covered in feces.
George and I told Rose that he needed to be admitted to the hospital immediately, but Rose explained to us that the hospital wouldn't take him back. The COVID-19 crisis in Spain had accelerated since their arrival in the country and hospital resources were now being allocated for younger, healthier patients . . . patients with a better chance of survival.
She pleaded with us to help them.
But we weren't hopeful that we could save him.
We had a discussion with Rose about John's advance directive. Although she told us that he would not have wanted to be aggressively resuscitated, she begged us to do whatever was in our power to get them both back to New York, where her grown children were waiting. She understood that advanced measures would be required for any chance of a successful flight, and that putting John on a ventilator would be necessary.
George and I retrieved our equipment from the aircraft. We initiated an IV and gave John a liter of fluids. We inserted a Foley catheter, thoroughly cleaned him, and changed the linens. We hooked him up to our monitor and were not surprised to find a blood pressure of 70/40, an unreadable O2 saturation, and an EtCO2 of 18.
We called our medical director, an ED physician, and briefed him on the situation.
Never one to mince words, he told us, “Not even a fully staffed ICU can help this man at this point. . . . But do what you can. I doubt he'll live through the night.”
George told Rose to call if John's condition seemed to change, and we called her four times that night to check in.
The next morning, Rose told us that John had seemed more peaceful overnight. His heart rate was now in the 40-50 range. We couldn't get a blood pressure or an oxygen saturation level. We started a vasopressor and his vital signs improved. George intubated him, but then we lost his pulse. We initiated advanced cardiac life support and did everything we could, but he was gone.
A pandemic's peripheral victims. Our long-range transports require a measure of stability at the outset. I've certainly never tried to resuscitate someone in a hotel room in Spain.
Our efforts felt heartbreaking and unreal. To have felt this elderly man's ribs crack under the force of futile chest compressions while we pushed drugs that wouldn't help, to look at his face and know with certainty that he'd gone and that his death was the opposite of the peaceful end he should have had . . . the juxtaposition of John's intubated body in the bed with the green parrots that screeched and flew among the palms outside while waves crashed on the abandoned beach below. I've never felt so unsupported by local resources. I can only imagine how Rose must have felt.
We stayed for hours, assisting Rose as she met with a kind young mortician. We helped arrange the transport of John's remains, and we called her sons in New York. And then we flew Rose home with us. We left her with her sons at JFK airport, and there wasn't a dry eye among us.
I see John as a peripheral victim of COVID-19, collateral damage that I'm sure we will all see more of as resources are strained and standard supportive care is shortened or eschewed completely. John and Rose's case is one of those that will stay with me forever. Despite the futility of our care for him, Rose's perception of our efforts seemed to give her peace; she continually thanked us for being the only ones she felt really tried to help. Our support of Rose has been one of the only times during this crisis when I've felt I really helped someone. It feels ironic to me that the help wasn't for our intended patient. But supporting Rose may be one of the most important things I'll ever do as a nurse.