Intubating COVID Patients in the ICU

What it is like intubating a COVID patient?

Successful COVID intubations require preparation, intelligence, and meticulous attention to detail. These situations have A LOT of synergy: the patients quickly decompensate, are highly infectious, and only the minimum number of people should be in the room.

The SARS-CoV-2 viral pneumonia (infection of the lungs) can cause acute respiratory distress syndrome (ARDS), a constellation of symptoms related to severe lung inflammation. ARDS is also seen in severe pancreatitis, bacterial pneumonia, and rarely influenza. These patients have very little physiologic reserve- meaning they quickly decompensate without aggressive oxygen and ventilatory support.

When I intubate a COVID patient I have to remove their respiratory support devices, such as oxygen masks or high flow nasal cannula, in order to place a breathing tube. The amount of oxygen in their blood falls precipitously. If I don’t get the tube in quickly I will create a very dangerous situation for the patient, myself, and everyone around me.

In emergencies people often lose their cool then make poor decisions. I protect everyone when I can keep the situation calm, linear, and simple. I bring everything I could possibly need into the room because I don’t want additional physicians, nurses, or respiratory therapists exposing themselves to a highly infectious possibly lethal disease. In highly complex situations simplicity and planning are your only hope.

I have to identify all possible emergencies then be able to rescue myself if anything bad happens. Some COVID patients are quite old and sick- one of mine last week had a non-functioning left lung and heart failure! I think of this as buying insurance for myself. I want to be covered in every circumstance I can think of. Sometimes this means I will place an arterial line or additional IVs before intubation. In the world of anesthesia preparation is everything. Once a dangerous situation occurs you have already lost. The greatest victory is that which requires no battle.

Intubating these patients is quite unnerving. After medications are given I use a laryngoscope to visualize the vocal cords. Only my PAPR shield, a few millimeters of plastic, separates me from the virus. It feels like I’m looking down the barrel of a gun. Additionally it is very hard to communicate outside of the room- if something goes wrong it is highly unlikely I will get the help I need before the patient decompensates.

The process starts with me learning everything about the patient, choosing my drugs, and rescue strategies; then donning proper PPE, making sure the nurse and respiratory therapist understand the plan. In the room the ventilator is prepared, drugs are prepared, additional lines are placed if appropriate, then it’s go time! The actual intubation, when all goes well, takes about 15 seconds. Overall it takes about 45 minutes from start to finish, longer if lines are placed.

After the intubation I take off my PPE in a specific manner, clean my equipment with anti-viral disinfectant, then change my scrubs. If i’m in the room for an extended period of time I will also shower. I don’t want to spread COVID in the hospital.

Anesthesiology can be a cruel teacher- there are no participation trophies, only a small margin between life and death. So far I have not caused any emergencies during my COVID intubations…but I can’t help but feel like a turkey awaiting Thanksgiving. Statistics affect everyone. Anesthesiologists say better lucky than good.

Anesthesiology is high-stakes, open-ended chess game: we can’t fully know our opponent, don’t have defined rules, and losing is not an option. We play every day in operating rooms and ICUs. Our profession is more of an art than a science- there is no “correct” way to intubate a COVID patient or do an OR case because every patient is unique. We don’t think in terms of populations because in our world only unique situations exist. Additionally our actions are not reversible- once a drug is pushed it can’t be taken back, once a dangerous situation occurs we have to deal with it, and if we are unable to deal with the complications of our decisions our patients can die within minutes.

My 45 minute COVID intubation was a chess match against uncertainty, fate, and Death itself. The 15 seconds of routine were my game-ending move. Checkmate.

Published by Nabil

Nabil Othman, MD is an anesthesiology resident physician at Cedars Sinai Medical Center in Los Angeles, CA. As a Michigan native he advocates calling carbonated, sugary beverages "pop". When he is not an indentured servant in the hospital he enjoys CrossFit, telling everyone he meets about CrossFit, and attempting dangerous hikes in Hawaii with his college roommates.

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