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.

Methodically, I instructed the coordination of transferring James onto our infusion pump as to not interrupt his sedation. He was then placed on our cardiac monitor, blood pressure cuff, and pulse oxemiter. We placed the defibrillator pads on his chest. I had already input the settings on the vent and was waiting until the last minute to move him over so that we didn’t run out of oxygen on our jump tank. I verified my settings with the respiratory therapist to make sure everything was in order. We had double and triple checked our oxygen supply to ensure our tanks were full, but that didn’t stop me from checking again right before we moved James to our gurney.

Despite my best efforts to organize, the wires and tubing tangled like spaghetti across James’ belly, but it was about as good as it was going to get. We moved the gurney next to the bed and grabbed the edge of the hospital sheet James was laying on. Between all six of us we counted… one… two…three… and heaved his body from the hospital bed to our gurney.

James began to sweat again and started biting the tube as we arranged him securely on the stretcher. Propofol is a great sedation drug for the hospital. It knocks a patient out quickly and can be monitored easily on a patient that is stagnant. Unfortunately, propofol starts to metabolize and wear off rapidly whenever a patient is moved – transferring to the gurney or bumping down the highway in an ambulance, for example. But once James was still again, he stopped biting the tube and the respiratory therapist and I transferred him from her ventilator to mine.

The vent alarmed immediately, as it always does, and I silenced the screeching. James coughed through the tube. High Pressure, it read, meaning there was a blockage somewhere between the vent and the patient. This was not uncommon. It sometimes took a breath or two for the patient to become adjusted to the travel vent and being moved, but we ensured there were no kinks or blockages, and that the tube was still secured and in the correct placement. After a few seconds, James calmed down and the vent proceeded to breathe for him without incident.

Another alarm sounded, this time from my cardiac monitor. James’ oxygen saturation was at 75%. Since he was receiving 100% oxygen through the vent, this number was alarmingly low. We switched the pulse ox to his forehead, hoping that since the blood flow to his fingers was poor, that it was a bad reading.

It wasn’t a bad reading. James’ oxygen still read low.

I retrieved the hospital pulse ox and read the numbers on their monitor: 83%. The difference in the monitor readings was unnerving, but the respiratory therapist assisted me in attempting to gain a better reading from my monitor. Our efforts hadn’t yielded any better results. James was sweating profusely again and the pulse ox wouldn’t stick to his damp skin.

“He’s becoming more unstable with everything we do.” I said to no one in particular. I looked up at Harley and shook my head, “I still don’t think this is right.”

The nurse looked over at me and said, “I’ll go get Dr. Ansari.”

She returned a minute later with Dr. Ansari in tow. He appeared much more sympathetic at this point, but it masked the irritation I knew he was holding back.

I explained the decline in oxygen saturation and the difference between the hospital reading and my monitor. “So I don’t know what you want me to do, Doc. Do you want me to assume the whole way down that my monitor is reading incorrectly? I’m at a loss here.”

Dr. Ansari paused and studied the monitors and his shoulders fell. “I mean, the only thing we can do for him is get him to an ICU.”

I had my answer. We were alone in this.

“What the hell is going on in here? You’ve been here for over an hour!” A tall bearded nurse yelled from outside of the room. “I’ve got a patient in the waiting room who needs a bed and is about to code!”

“Well, I’ve got an unstable patient that might code en route and then I have to turn around and end up right back here,” I spat back.

He scoffed and threw up his arms. “Aren’t you a paramedic? Don’t you know CPR?”

“DID HE JUST FUCKING SAY THAT TO ME?” I said rather loudly across my crews, the nurses, techs, and Dr. Ansari. “I’d rather not be doing CPR at 75 miles an hour BY MYSELF in the back of the ambulance.” I turned back to what I was doing. “He can wait. This is the only patient I care about at the moment. He has a whole hospital to help him. This is not our fault and I’m not leaving until I’ve got this patient ready for transport.”

The nurse rolled his eyes and stomped away. That was the last straw. I was done. I was not going to be bullied anymore tonight. My concern was for James and his well-being. I had not doddled. I had not allowed messing around. Every action taken up until this point was in James’ best interest and I would be damned if I was going to be rushed.

It only took a few more minutes to create an action plan, secure the final straps and unkink any tubes before we pushed James out of the hospital on the gurney. We loaded him into the ambulance and I switched his oxygen from our small tank to the large one. Harley jumped in the back and sat on the bench while I took the airway seat at James’ head. Elise had sent Erik, an EMT, as promised so that I could have Harley with me in the back. We were planning for the worst and hoping for the best.

As the ambulance pulled away from the bay with the lights flashing and the sirens echoing off the surrounding buildings, Harley and I exchanged a look.

“We got this,” he assured me. “YOU got this. Whatever happens, he’s lucky you’re here.”

I took a deep breath, and with a newfound restored confidence I decided that we were going to get through this one way or another.

….

James was doing his best, and Harley and I could see he was holding on. We continued to talk to James as if he could hear us. The last sensation to leave is your hearing. I wanted him to know everything that was going on.

“We got you James, you’re doing great, buddy.”

Around 20 minutes into the transport, James’ blood pressures were skyrocketing again, and he was drenched in sweat. The vent began to screech High Pressure. James was fighting us. The sedation was wearing off as we were rattling around down the road. I adjusted the settings on the infusion pump to administer a slightly higher dose of propofol over a selected period. It seemed to do the trick. James settled back into a quiet sleep and the alarms stopped for a minute. I asked Harley to run another blood pressure after the bolus of propofol I administered had completed.

80/30.

The propofol had tanked James’ blood pressure, but after checking for a pulse and finding a strong bounding under my fingers, I knew we were still doing okay. This was a known possible side effect of propofol and one I knew I needed to monitor closely. Harley spiked a bag of normal saline and I attached the tubing to one of James’ other IV’s in case his pressures didn’t stabilize on their own. We continued to run blood pressures every 5 minutes, and we watched the numbers rise higher and higher while his pulse ox remained too low. He was already receiving the maximum amount of oxygen the vent could provide. I adjusted the settings on the vent in an attempt to make it more effective: higher respiration rate, longer breath time. It would have to be enough, though I continued to adjust as needed.

We continued to tell James that we were taking good care of him and that we promised we would do our best.

I leaned up front and told Erik that he was doing a good job, to continue to drive safely, and that we were still doing okay in the back. I knew from my EMT days the stress of driving lights and sirens for a long distance and not knowing what was going on with my partner in the back. He was in it with us.

Peaking at the GPS I took a deep breath. 45 minutes until we reach the hospital. James’ pressures continued to rise. I knew what would come next. The vent and the cardiac monitor would alarm. The sweating, the fidgeting, the biting the tube – the sedation was wearing off again. I bolused another dose of propofol – a smaller dose than previously as not to bring down his blood pressure so low again – and I felt James relax. I felt for a pulse which was still present, but I took note of the distention in his neck veins.

“JVD,” Harley noted. I nodded. Jugular Vein Distention. A sign of major stress on the heart. There was nothing I could do for him here. James needed a doctor. He needed an ICU. He needed to not be jostled around on the freeway. Erik was driving as smoothly as the ambulance would allow, but due to the worn out shocks and the unavoidable potholes, there was nothing more he could do.

I bowed my head and prayed that we would make it to the ICU.

We pulled into the bay of the hospital and began detaching oxygen hose from the ambulance and reattaching it to the gurney jump tank. Harley handed Erik a spare oxygen tank as a backup. We walked with purpose down the halls – left, right, left, left again – until we reached the elevator. For the first time in my career I was thankful for a middle of the night transfer because the elevators were empty and James didn’t have that kind of time to wait.

Wheeling James into the ICU floor, I took note of the full rooms. Two patients in each ICU room. Every last one of them intubated. The steady beeping of the cardiac monitors harmonized above their heads.

A flock of ICU nurses and techs met us in front of James’ room. They pulled the hospital bed out into the hallway to transfer him. The room was much too crowded with James’ new roommate already lying in the second bed. I relayed my report to the ICU team and the physician as my monitor, vent, and pump were removed and replaced with the hospital’s equipment. The process took less than two minutes and James was wheeled back into his room, sedated, medicated, and breathing by way of their vent. He looked peaceful for the first time in the last 4 hours that I’d seen him.

As we walked outside and I let the air hit my face, I heaved a deep breath. My entire body unclenched. I felt a soreness in my muscles I hadn’t noticed before.

Harley held an After Action Report for us as we decompressed outside in the bay. We discussed what we did well, what we would have changed, and what was utterly and completely out of our control. But the biggest statement he stressed:

James had made it the whole ride. Alive.

I would never know what happened to James. I try not to dwell on the ‘what ifs’. What if he never made it back to his family? What if he was permanently ventilator dependent for the rest of his life? How long would the rest of his life even be? I gave myself time to sit with these questions before realizing there was no point. We had done all we could do. He was in a higher level of care.

James had been given his best chance.