Names, locations, and some events described in the below story may have been changed for privacy and legal reasons. The premise of the story is based on a true event. This story is about the intubation of a Covid-19 patient. This content can be triggering. Reader discretion is advised.

James was laying on the thin mattress of the ER bed, intubated, as reported. But he was far from stable. I noticed, above all else, that James was what we called “biting the tube.” When a patient is intubated, it is vital that he be completed sedated. James was a large man – probably over three hundred pounds. The nurse had told me in her report that there was a chance they underestimated his weight. James was being sedated with a medication infusion called propofol, also commonly referred to in our field as “milk of amnesia” because of its unique milky color and ability to put a person to sleep. The problem was that propofol was a weight-dosed medication. Under dosing a patient would prove less effective – and undoubtedly uncomfortable for the patient, if not painful.

Harley and I continued to assess James from head to toe. He was sweating profusely. His face was pale and his arms were mottled – a skin sign we look for when we suspect a patient is not perfusing well, meaning, poor blood circulation. James’ legs were the worst. More mottling but distinctly more pale and becoming purple at the toes and feet. James was shunting blood to his core, his body’s last ditch effort to keep his vital organs – brain, heart, lungs, liver, – circulating blood.

“I marked on his legs where I first saw the shunting and it’s moving above the line now,” Harley informed me, wielding the black Sharpie.

I glanced at the cardiac monitor beeping at the head of James’ bed. Blood pressure 203/110, heart rate 120, oxygen saturation 93%. James was compensating. Hard.

“He’s not stable for transport.” I whisper to Harley. “He is in pain, he’s not perfusing, the propofol isn’t working.” I shake my head. “If we take him he’s probably going to code in the back of the ambulance.”

The nurse slid open the glass door and entered. “I called for a couple other people to come help move him to your gurney,” she said. Behind her mask I could see the crinkle of her eyes. Ever since masks were mandated for Covid it could be hard to tell a person’s facial expressions. But some people’s smile radiates in their eyes.

“Hey, we’ve got some problems before we continue,” I started and I saw the crinkles smooth out. “He’s unstable. I can’t take him by ambulance that far. He’s going to code. I’ll be doing CPR in the back of the rig by myself, and we’re going to have to turn right back around to come back here.”

The nurse nodded. “Okay, I understand what you’re saying. What would you like me to do?”

I took a deep breath. “First if you could get him some fentanyl for pain and re-dose the propofol I think that is a start.”

She looked uncomfortable. “I’m not sure about the fentanyl…” The nurse glanced at James and then back to Harley and me. “I’ll…. go get Dr. Ansari.”

“Can we take a third rider? In case…?” Harley let the notion hang in the air between us as I pulled out my phone.

Sammy was at my side in a second. “I can go with you if you want.” I smiled at her. As much confidence as I had with my skills and knowledge of critial care, two medics with a newly intubated and unstable patient were far better than one.

“I’m going to message Elise.” I was already texting my supervisor.

This patient is unstable and cannot go by ground but also is too heavy to fly. I’m getting ready to talk to the RN. I typed out my findings to support my argument and walked out of the ER room to find Dr. Ansari and the nurse flipping through the paperwork.

I approached the doctor who greeted me warmly.

“Does he have a DNR?” I asked. I already knew the answer, but judging by how quickly this patient had deteriorated, and continued to do so, I wanted to be ready for all worse-case-scenarios.

Dr. Ansari raised one eyebrow with a condescending smirk and for a second I felt like I had just started speaking gibberish. “No?” He let out a low chuckle and slapped the paperwork on the counter, “Why would we intubate a patient with a DNR? How would that be beneficial.”

I raised both my eyebrows (partly because I can’t raise just one like he did) and folded my arms across my chest. “I am asking because there is a high possibility this patient will code during transport and I need to know what his wishes are.”

Dr. Ansari mimicked my gestures. “And why do you think he’s going to code?”

“His pressures are high, he’s not properly sedated and biting the tube, he’s diaphoretic and mottled head to toe. He’s showing signs of lack of perfusion and above all else he looks like he’s in pain.”

The doc threw up his hands and shrugged. “Well, he’s gotta go. We don’t have any open beds in ICU here. The next closest hospital doesn’t have any beds either. He’s gotta go somewhere.”

I involuntarily rolled my eyes. “Okay hang on, I need to call my supervisor.” I heard him scoff as I walked outside to call Elise.

She had already texted me back: Keep me updated.

I shivered as the cold air hit my face and I hit ‘call’. Elise picked up on the first ring and I relayed my findings, my interaction with Dr. Ansari, and my request to take Sammy as a second medic.

“I can give you another EMT, but I can’t spare another medic to go out-of-town tonight and the closest transport nurse is 2 hours away. I’m sorry.” I know she meant it, but that didn’t mean I wasn’t upset.

“I’m so irritated right now.” I felt the prickle in the back of my eyes. Don’tcrydon’tcrydon’tcry, I told myself, Keep it together. “I like to think of myself as a half-decent medic, but I’m an even better inter-facility medic. And I feel like if I say this patient is too unstable then that should carry some weight.”

Elise agreed with me. “But he has no other option, right? He needs to go. You’re his best solution to get him to a higher level of care. Keep me updated en route and if you need a flight crew or to divert to another location you have my full support. I will get you whatever you need.”

Another deep breath. I felt my voice shake as I told Elise that I would handle it and hung up.

Returning to James’ room I told the nurse that if she didn’t administer the fentanyl then I would do it in the ambulance. She adjusted the propofol dosage then administered a paralytic followed by a solution to my repeated requests for pain medication.

As I primed the infusion pump tubing for the propofol, Sammy was at my elbow. “Take me with you, you need a second medic.”

“Elise already told me she couldn’t spare you.” My eyes didn’t leave what my hands were working on. I heard the swish of the glass door open and the screech of the curtain as someone walked in the room.

Sammy put her hand on my arm, “Our staffing crisis isn’t your problem.”

I finally looked up, “Our staffing crisis isn’t my problem, but apparently the hospital’s staffing crisis is my problem.”

The big picture was that the whole world was facing a staffing crisis. EMS was not special in this situation. And contrary to what the public believes, sometimes beds are open in the hospital. The issue was that there were no staff to TREAT the patients in those beds. Years of healthcare worker abuse, mandatory overtime, and low wages were starting to prove too much for those in the field while managing crises during a pandemic where people were dying in rapid succession right in front of their eyes.

“Ahem.”

I looked back at what I was doing with the pump. I would not give Dr. Ansari the appearance that I was at all okay with this situation. He approached me with caution.

“I know this isn’t an ideal situation,” he started, “and you could be right and maybe he does code en route and you end up right back here. But it’s not about what could happen. It’s about giving him his best chance.”

I refused to look up and just nodded. Dr. Ansari informed me that he would order whatever medications I needed before transport, and I nodded again. With that he left me with my small team.

Harley’s voice was low, “Holly,” he said. “We got this.”

“Yup.” I still couldn’t look up. I knew if I looked my partner in the face that I would cry right then and there.