Mr. X had been on a ventilator for more than three weeks when he died for the first time, the second time, the third time, and the fourth and final time. Each time he died, his heart stopped beating. Each time we performed chest compressions, gave him eleventh-hour medications, and resuscitated him, until the final time. None of it would have happened if Mr. X had not been infected with SARS-CoV-2, the coronavirus that causes COVID-19.
While Mr. X was my patient for only a few days, the truth is that there have been tens of thousands like him across the United States over the past three months, men and women who have died of the coronavirus—more than 85,000 as of this writing. Despite our communal response to COVID-19, I fear there may still be tens of thousands yet to come if not more. For that reason, it is important the story of Mr. X and his death be told. He was a unique person with a singular life, but in terms of dying from the coronavirus, he could have been you, me, or anyone.
He was not a young man, but he was not especially old either. He was in his 70s, the same age as my parents. He had an irregular heart beat for which he took blood thinners and an immune condition for which he took a low dose of daily steroid. Like 1 in 10 of the U.S. population, he had diabetes. Long ago he suffered a mild stroke.
Upon his death, he had already been treated in the ICU with antibiotics for bacterial pneumonia three times. A few days earlier, he had a heart attack on account of the stresses critical illness was placing on his body. This was despite already being on high-dose steroids to boost his insufficient adrenal glands in coping with that stress.
When he came into the emergency department three weeks earlier, he had only been sick for less than a day with nausea, vomiting, diarrhea, and a cough. Six hours later he was gasping for air, intubated with a tube down his throat, and put on a breathing machine like nearly 11 percent of people with COVID-19 in hospitals. Tragically roughly half those intubated people end up dying of acute respiratory distress syndrome, lungs that are so critically damaged by COVID-19 that they cease being able to deliver oxygen into the blood. This was the fate of Mr. X.
For days after his admission into the hospital, Mr. X was also in septic shock. His blood pressure was dangerously low and supported with medication delivered through an intravenous tube placed into the jugular vein in the right side of his neck. Its tip ended in the big vein that fed the right side of his heart, allowing for medication to instantaneously mix into the blood.
Despite all this, there were moments of hope. At some point, Mr. X no longer required medication to maintain his blood pressure. The level of oxygen needed through his breathing tube decreased. His support was weaned. But in this lull, multiple tests of whether Mr. X had the strength to come off his ventilator ended in failure, with hope always lying in trying again the next day.
But after steadily improving over weeks, he quickly began to worsen over a single day. The first time his heart stopped was at noon that day. His blood pressure plummeted, and his heart rate dropped. Everyone in the ICU was at the ready when his pulse disappeared and CPR was started. Six minutes and two doses of epinephrine later, his pulse returned. He was alive again.
Forty minute later, Mr. X died a second time. A “CODE BLUE” was announced over the hospital speakers. Three minutes later, there was a pulse. An emergency ultrasound showed strain in his right heart indirectly pointing toward a massive blood clot in the lungs despite his blood thinner; he received an urgent clot-busting infusion twice.
Then, 20 minutes later, his pulse disappeared a third time as Mr. X’s heart went into ventricular fibrillation, a twitchy, shockable rhythm. In five minutes, he received two shocks at 200 joules each and his pulse returned. But the situation was dire with blood tests showing such profound abnormalities that we all knew we were no longer extending Mr. X’s life insomuch as prolonging his death.
We spoke to his family throughout Mr. X’s ordeal. We all agreed not to start compressions if his heart stopped a fourth time. In three weeks, they were never able to visit him in the hospital. But as his medical team, we called them every day with updates.
Mr. X died an hour after we decided not to start compressions again, at 3:38 p.m. A nurse held his left hand while a doctor held his right hand as his heartbeat gradually slowed before it disappeared forever. His family received their last phone call from the doctor with the sadly expected news.
Mr. X died after being infected with SARS-CoV-2, the coronavirus that causes COVID-19. The story of his death is his, but I worry there will be many more to come, with stories that start to feel familiar.
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Update, May 18, 2020: Due to an editing error, an incomplete version of this story was originally published. The additional paragraphs have been added.