My Virtual Reading Room

Written by a critical care physician.

These chest x-rays were taken 8 hours apart. On a relatively young, healthy, tough as nails veteran. When I assessed him in the ED initially, he looked great, sitting up in his bed, talking in full sentences. Texting on his phone. In the ICU, we refer to that as the ‘cellphone sign’. I thought to myself that he could probably be admitted to the ward as a COVID-19 rule out. Then I saw his admission CXR and told my charge and lead RT that I wanted him in the ICU in the next ten minutes and that we need to intubate him. I told him what was going on, he looked at me in disbelief when I told him that he was very sick and needed to be intubated. “ I feel fine doc, I just have the flu”. By the time i finished the cumbersome ritual of getting my PPE and PAPR on, his sats were in the high 80’s on a non rebreather mask. I knew we had no time. I intubated him immediately, the familiar change in tone on the monitor of dropping sats to the low 80s, then 70s, then 60s before recovery. He had zero reserve. Eight hours later, he was maxed out on conventional ventilator settings and I couldn’t get his sats above 85%. Now on APRV, inhaled nitric oxide with plans to begin proning, I’m still in disbelief with how quickly he deteriorated.