She should not have been this sick, though it had been a hard life. Years of alcoholism left her with a cirrhotic liver, but it did not seem fair for her to be in the end stages this young. She had stopped drinking, reconnected with her family, and made peace with her daughters. And now she was bleeding into her lungs.
The decision to intubate a patient should not be taken lightly. There are obvious indications for which the procedure should not be delayed, like if a patient has stopped breathing on their own, or for a surgery during which they will be put under anesthesia. There are some more nuanced situations, however. Sometimes we decide to intubate a patient because we are concerned about the direction their clinical course is going. It may be safer and easier to do so before someone gets sicker and they need the procedure in a critical situation. This patient was on the border, so we talked through it together.
Before we intubated her, she smiled at me. She thanked me for taking care of her. She seemed happy that we were doing the “safe thing”. It was the last time she ever spoke.
Two years later I was called to the trauma bay to prepare for a burn victim being brought in from a terrible house fire. Burns are terrifying to an emergency physician, as patients can inhale high-temperature smoke that leads to injuries we cannot see. These patients may not appear to have difficulty breathing, but we will often intubate them if there is concern for smoke inhalation, as the damage to their airways can lead to rapid swelling that would make later intubation near-impossible.
She was burned so badly that she couldn’t feel pain. She was burned all over including her face. She likely had burns in her throat. I set up to intubate.
During the COVID-19 pandemic we took precautions to protect ourselves before intubations, as the procedure could lead to virus particles being aerosolized. As I put on my mask and face shield, I explained to her why we should place a breathing tube.
When I was done explaining, she smiled at me. Then she got a concerned look at my protective equipment. “Doctor,” she said, “you do not have to worry. I know I do not have the coronavirus. You will be safe.” She smiled, and never spoke again.
Our culture places heavy emphasis on people’s last words. The hangman asks the outlaw if he has anything to say before the trapdoor opens. The heroine is held by her partner as she succumbs to the fatal blow, with one final expression of love. The patriarch sighs calmly and looks at his loving family, before saying his last goodbye. In medicine, we seldom know when people’s words are their last. As a provider trained to intubate, I have had the privilege of hearing several people’s final words, though neither of us knew it at the time. My patient with cirrhosis died in a week, never awake enough to speak with her family, her daughters. My patient with burns was sent in a helicopter to a specialized burn center, where she died within a day. She didn’t have coronavirus.
Life is not like a movie; very few people know that their last words are final before they say them. Your last words may not be heard. They may be foolish or cruel. They can be grateful and full of hope, removed from the fact that you will never wake up again. They can be full of concern for the young doctor trying to take care of you, full of generous spirit, full of compassion even when your body is spent. We don’t get to choose when our last words will be, but we always can choose what we say.
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Keep Scrolling down for Dr. Garrett’s Bio
Alexander Garrett MD
Alex Garrett is a PGY-4 Emergency Medicine resident at the Harbor-UCLA Medical Center in Los Angeles. He is originally from Maine but moved to California for his education. He is a proud graduate of Stanford University, and he received his MD from the David Geffen School of Medicine at UCLA. He is deeply interested in medical education and social emergency medicine