Liz understands what it is to live a drawn out existence, and she knows this is not a life.
Since the beginning of the omicron surge in the Bay Area, Liz has been leaving the apartment early, before her husband and mother-in-law are up. She tells them that since the hospital has been at capacity, her shifts have been extended, but in reality, she sits in her car for half an hour collecting herself. She is never disturbed here.
At the beginning of the pandemic, her husband Daniel declared the carport a “dirty space” and marked the ground off with hazard tape. Back then, whenever Liz returned home from work, he made her strip in the storage shed, hose herself off, and soak her feet in a bucket of disinfectant. He observed her making a beeline to the shower, then wiped the door handles and who knew what else. At first, Liz told herself such measures might be considered reasonable, but one time, bone-weary from a 30-hour shift, she walked straight into the house, and Daniel pushed her away with a broom, calling her contaminated. Liz never told him how that made her feel, but she made an anonymous call to the HOA the next day. After they sent an email to the complex about appropriate uses of storage areas, he backed off. But since then, she has come to appreciate this “dirty space” for its privacy.
Even though she does little with this time, it is a luxury. At work she dons her professional guise, and she feels the pressure to appear put-together and perfect. After all, if she compares her life to those of her patients, she knows she has no grounds for complaint. But when she returns home, her husband and mother-in-law descend in tandem. Last week, Liz found them poring over her journal of basal body temperatures, and they did not even act sheepish. The carport is her refuge. Occasionally she calls friends from residency or medical school, but hearing about their lives often makes her unable to talk of her own. Even when she calls her therapist from this space, she avoids vulnerability, afraid of feeling too emotional before seeing Daniel. So now, she just sits until her phone alarm buzzes. Then she opens the glove compartment, takes a pill, and leaves for the hospital.
Liz likes to walk through Pod C on her way to sign-out to get an idea of the census. Today, all the rooms are full, and about a third of the patients are prone. In report, the litany blends together. Fifty-two-year-old man, diabetic, got it at Thanksgiving, on 80% high flow; 23-year-old man, unvaccinated, threw a COVID party, admitted with the pediatric version with inflammation of his heart; 70-year-old woman, intubated, paralyzed; 38-year-old, brought in from a COVID hotel with a brain bleed from using meth he got from contactless drop-off. Here, everyone looks up.“Apparently, that’s a thing,” the overnight intensivist says.
In the early pandemic, sign-out was much more extensive, which mirrored the extended time Liz could spend with her patients. She remembers the first patient who died from the disease, nearly two years ago. Visitors were not allowed then, but she cajoled the hospital supervisor to let the patient’s son come to the bedside. At that time N95s were scarce, even at hospitals, but Liz sent a requisition down to central supply. The COVID command center replied with a query—she’d already picked one up for the day—but she told them she sat on it by accident and needed another. After half an hour of back-and-forth, a capsule shot through the pneumatic tube system with one neatly packaged teal N95 in a zip-lock bag. She still remembers the son’s shaking hands as he put it on.
The first patient she visits is Angel. Angel has been on a mechanical ventilator for a month, and all the staff know that she will die in the hospital. A few weeks earlier, Liz had broached the idea of a tracheostomy with Angel’s husband Tom, but Angel’s lungs plateaued in a gray zone: working well enough to keep her alive, but not well enough to risk a surgery. The CT scan looks like crushed honeycomb. She will not get better.
Every day during rounds, the charge nurse asks Liz when the next goals-of-care conversation will be. Liz hates the euphemism because it’s so transparent to her what the hospital expects its doctors to accomplish. In the last few family meetings, Liz has stopped talking about a tracheostomy. Instead, she has tried saying what she needs to say in all the ways she knows how, but still she cannot get the answer she wants from Tom.
Technically, Angel is off isolation, but Liz still puts on her protective gear. She clips a respirator battery to her waist, next to her personal pager, the ICU pager, the airway pager, and her cell phone. Then she undoes the drawstring of her scrubs and retightens them. She steps into a white bunny suit, pulls on shoe covers, and starts the fan of her powered air respirator. How familiar it feels now, donning PPE. She remembers the first time she had to wear the getup; she put the bunny suit on backwards and couldn’t reach behind her to unzip it after she was done. She thinks of all the failed first dates she had before Daniel, returning to her apartment alone and struggling the same way to take her dress off.
“Hi Tom,” she says as she slides the glass door open and feels a whoosh of air suck into the room. When he motions to get up, she waves for him to relax.
Tom rubs lotion onto Angel’s feet. He does this every morning, rolling each toe between his thumb and forefinger, tracing circles along each interspace and over each knuckle. Sometimes Liz feels as though she is intruding.
“I’m just going to do a quick exam,” Liz says. But there is nothing to examine. She had stopped bringing her stethoscope in weeks ago, and now, she just looks into her patient’s face. Angel has grown stubble over the last week, and Liz runs her fingers over it. A couple weeks ago, when the medical team discovered clots in both Angel’s legs, they stopped her estrogen, and when her potassium started climbing, they stopped the spironolactone that was blocking her testosterone. Angel’s fake eyelashes came off when they taped her eyes shut so they could position her face down; her makeup had rubbed off onto the BIPAP mask she wore the days before she was intubated.
To Liz, who remembers Angel in the Emergency Department putting on blush and staring in her compact, this person seems so different. But when she glances back and sees Tom undoing his wife’s compression stockings and massaging lotion onto his wife’s calves, she wonders if she is the only one who thinks this.
“I’m sorry the hospital won’t let you bring in a razor,” she says. Tom had shaved Angel’s face every morning before the staff noticed and stopped him.
“That’s alright, she’s still my baby.”
Liz can’t help but think of her husband. She hates how Daniel calls her “babe” all the time, but she has never told him, chalking it up as one of those frustrating things she complains to her girlfriends about but never acts on.
“Did you think more on what we talked about yesterday?”
“Yes,” Tom says.
“She’s not really making urine. Her kidney numbers are worse.”
“I know.”
“I think we’re at the end of what medicine can do for her,” Liz says. She looks away from Tom, back at Angel. “I’m so sorry.” She takes Angel’s hands, noticing new nail polish. “We’ve done everything we can for her.” She forces herself to turn back to Tom. “We don’t have anything left to offer.”
“I know.”
“And sometimes, for some patients, when they’re at this point, well, some families say, enough is enough, and it’s time to stop putting her body through all of this.”
“I know.”
Liz feels her chest tighten. She knows she should wait, remembering a rotation in hospice medicine as a student where her mentor told her silence is the palliative care physician’s scalpel. But the fan of her respirator fills her ears with static.
Liz says, “Or, I could put in a dialysis catheter. It could buy her some time. It would be a big line though. I’d have to put it in her groin. And it wouldn’t fix her lungs.”
Tom nods. Liz isn’t sure if he’s decided on the procedure or not, but she thinks this is the path of least resistance. She knows this about herself, that she avoids direct confrontation when the right choice isn’t clear. When she had to pick her residency, she defaulted into internal medicine because she didn’t find the perfect specialty. When Daniel asked if his mother could visit for a few months, she acquiesced even though she worried she would be miserable. Here, she considers steering Tom away from dialysis, but she thinks it’s easier just to go ahead with it.
She flags down one of the nurses passing by. With the powered air respirator, no one outside the room can hear her, and after she fails at miming dialysis catheter, she finds a whiteboard marker and writes it out on the glass door. Ever since the beginning of the pandemic, everyone has gotten much better at mirror-writing.
The nurse gives a thumbs up, and asks, “Do you want anything else?”
Liz shakes her head. Over the last two years, Liz’s desires have all been external. She wants her mother-in-law to move out, wants Daniel to hug her, wants her friends to stop posting pictures of their babies on social media. But what does she want for herself? How has this pandemic stripped her of her agency, made her helpless even as she is one of the few people who can help in this catastrophe? She wants very much to be selfish, but isn’t sure how.
Liz feels her utility belt vibrate, and she decides to doff her getup and leave the room while they get her supplies. By the time she steps out, Tom has reattached the compression stockings and begun massaging Angel’s thighs.
Liz checks her three pagers, but it’s her phone that’s buzzing with texts.The dialysis catheter is stuck. Liz tries forcing it, but feels the skin buckle and the catheter kink. Warm blood pools in the pockets of the drape.
Hey babe.
Mom’s getting scared of this omicron thing, so I think she’ll prob stay longer.
I just canceled her flight. But full refund yay traveler insurance.
Liz ducks into a supply closet to call Daniel. “I’m worried about omicron too,” she says. “The numbers are up.”
“So it’s okay if she stays longer?”
“I don’t like having her in the house.”
“But she’s my mom. You’re not asking me to kick her out, are you?”
“You know how she feels about me. How she treats me. She can’t stand me,” Liz says.
“She couldn’t stand any of my previous girlfriends either,” Daniel says. “She doesn’t mean anything by it. It’s fine.”
“It’s not fine. And I’m your wife, not your girlfriend. You always take her side.”
“I’m not taking any side. I’m just saying, with this surge, she has to stay.”
“You could at least get her vaccinated.” Liz says.
“You know she’s not going to.” Daniel says.
“She’s still going to her mah-jong games and line dancing, it’s really not safe.”
“I can’t control my mom.”
“But why is it okay that she does these things? She could bring it home. And what if I’m pregnant, and she gives it to me and the baby?”
“You’re being dramatic. Relax, babe, it’ll be fine. If you want her to stop going out, you should just tell her yourself.”
“Are you making me do this because you’re scared to? Fine. I will make her get the vaccine. And stop seeing her friends.” Liz feels her hands shake, but she thinks this is the right decision. She wants to stand up for herself.
“Babe, you are feeling and acting paranoid again. Let’s not go overboard. We’ll talk about it when you get home. It’s fine.”
“No, it’s not fine.” Liz suppresses the desire to crush the phone in her hand. “Do you know what I was just doing minutes before you texted?”
“What?” Daniel asks.
“I was literally intubating an unvaccinated COVID patient.” Liz talks faster and faster. “This patient refused the vaccine because she thought it was a scheme to collect her DNA. Then she caught COVID from her kids who probably go to school with a bunch of other anti-vaxxers. I’m not being paranoid. Don’t tell me how I feel.”
“Were you wearing all the protective gear? I don’t want you coming home if you were exposed.”
“You’re not listening to me. My patient might die because she didn’t get vaccinated. And you keep defending your mom just because she’s afraid of shots. Do you know what I did when I intubated this patient?” Liz cracks open the door, looks down the hallway, and then closes it again. “When I pushed the propofol, I whispered to her, ‘When you wake up, you’ll get the vaccine. When you wake up, you’ll get the vaccine.’”
Daniel starts laughing. “Oh, come on.”
Liz says, “If hypnosis works, I’ll take it. Please, Daniel, talk to your mom. If I do it, she’s going to hate me even more. She might actually listen to you.”
Daniel says, “Well, maybe we can wait until after the holidays. With this surge, I don’t want her going out to get the shot.”
Liz clenches her teeth. “You know what else? The radio was on the holiday music station in that patient’s room, and after I intubated her, I told the nurses they should play the song, ‘Last Christmas.’ Because this is probably her last one.”
The line was silent for a while. “Kinda harsh, you think? I mean, that patient could have been my mom.”
By the time Liz returns to the room, Tom is kneading Angel’s shoulders and humming Christmas carols. With her PPE, Liz can’t touch her face, so she turns away, blinking back tears. She pulls the curtains to give them privacy.“Angel loved this time of year,” Tom says. “While you were out, the nurse brought some things in for you.” He gestures at a dialysis kit and gloves. “Can I stay in the room?” he asks.
Liz has the answer on the tip of her tongue.
“Please,” Tom says, “she would want me to stay. If it were okay with you.”
Liz acquiesces. In the end, they arrange themselves in a strange jigsaw. Tom sits behind a curtain, pulled so that he can’t see the procedure but can reach around to hold Angel’s hand. Liz paints Angel’s groin with antiseptic and squares it off with a sterile drape that covers the patient from her face to her toes. The three cannot see each other yet they remain connected, as if in a confessional.
“So what’s your story, doctor?” Tom says.
“What do you mean?” Liz asks.
“You married? Kids?”
“We don’t have kids yet.” This is how she answers the annoyingly frequent question, and she braces herself for the optimistic wishes that usually follow.
But Tom says something else. “Are you feeling unsure about it?”
Liz sorts through the needles, syringes, and catheters in the kit. In her peripheral vision, she sees Tom grasp Angel’s hand tightly and notices a tremor. She thinks she hears his voice waver as well. In all her visits in the past few weeks, this is the first time she recognizes vulnerability. Even in their talks about Angel’s prognosis and complications, Tom projected such a strong front. But now, with the curtains to the room drawn, in the intimacy of this procedure, she feels invited into a different space.
Liz surprises herself, saying, “I guess I’m a little unsure. It’s always the default, you know, to have kids, and we were trying. But it kept not happening. And then the pandemic hit.”
“How do you think the pandemic changed things?” Tom asks.
Liz scans Angel’s groin with the ultrasound probe, trying to identify the vein and artery. “Well, he’s really afraid of COVID, and I do, you know, this job, and it doesn’t even make sense because he invited his unvaccinated mom to live with us.” With a smooth thrust, she advances the needle into the vessel and slides a guidewire into the vein. “But I guess, even before that, the pandemic made it hard for us to connect. I was exposed early on, and it spooked him. He stopped hugging me, stopped touching me. We couldn’t get tested then, so we slept in different beds and ate at different times. Except when we were trying to get pregnant.”
“He avoided you otherwise?” Tom asks.
“It was awful. It was like trying to have a child was worth the risk of him being around me, but otherwise, he was too scared.” Liz makes a nick in the skin with a scalpel and begins dilating the soft tissue to get the pencil-thick dialysis catheter in. Blood wells, rolling down Angel’s inner thigh.
“But I didn’t get pregnant,” she says. “Finally, I saw a specialist up at UCSF. She ordered a procedure with some dye to look at my uterus and tubes, and Daniel, that’s my husband, he didn’t come. Because he was afraid of COVID. Even though they were allowing family members. He said I was a doctor, it was no big deal.” Liz’s hands shake. She has forgotten Angel is on an anticoagulant for blood clots, and now she struggles to push the dialysis catheter over the guidewire against a swell of blood.
“Does that mean you’re thinking IVF?”
“I haven’t decided,” Liz says. “It might be the next step, but I’m not sure.” She has never verbalized this, not to her infertility specialist or her therapist. Neither of them lets her entertain a world where she doesn’t, or can’t, have children. Or imagine a world where one might not want to.
“Those IVF injections are horrible,” Tom says. “Angel told me they mix the hormones in something super viscous, and you have to inject them in your butt.”
The dialysis catheter is stuck. Liz tries forcing it, but feels the skin buckle and the catheter kink. Warm blood pools in the pockets of the drape. She wonders to herself what Tom is talking about. How does he and his transgender wife know? Liz tries twisting the catheter to coax it toward the vessel. The visor of the powered air respirator distorts her depth perception, and she begins cursing under her breath.
Tom says, “Angel and I were thinking of starting a family. One of our college friends volunteered to be a surrogate. She was so excited for us. Angel gave her the injections. She’s a nurse, you know.”
Liz does not reply. She knows she won’t get the dialysis catheter in and should stop traumatizing the tissue, but she continues for another minute, fervently hoping more force will make it work. She doesn’t want to tell Tom she has failed. Her gloves are sticky with blood. Finally, she abandons the procedure, pulls the catheter out, and holds pressure.
Tom continues. “But when Angel got COVID and then got sick, we weren’t sure whether to keep going. We don’t have a lot of money, and well, it was like all our eggs were in our friend’s basket. So to speak.”
“So what happened?”
“Then Angel got intubated, and I got scared what I would do if…” Tom takes a breath. “We’d already used up our savings and put our friend through the egg process, and I needed to decide whether to go through with it. Angel wanted a kid so much. But I got scared.”
“What did you do?” Liz asks.
“Well, now I’m here. And our friend, you’ve probably seen her, she’s visited a few times. She’s not pregnant.”
“I’m sorry. I’m sorry about Angel too. Maybe that was the right decision.”
“I hope so. It was hard to feel like I was stopping the plan we had. But after Angel was intubated, I knew what that meant, and I knew I had to make a decision.”
“Thank you for telling me,” Liz says. With one hand, she continues holding pressure on the puncture site. She peels the glove off her other hand and reaches over the drape to touch Tom and Angel. The three of them remain silent for several minutes.
Tom asks, “Are you done with the dialysis catheter?”
“No. I’m sorry. I ran into bleeding, and I couldn’t get the catheter in. She’s on the heparin, remember, for the blood clots. I don’t think I can try again at this site.” Liz closes her eyes. “Maybe Angel wouldn’t want all of this. Maybe she would just want to be comfortable. Even if we know it’s the end of her life.” Liz waits, her hand cramping as she holds pressure. She can feel the pulsation of Angel’s femoral artery underneath her glove.
Tom remains silent, and Liz wonders if she should flag down a nurse to bring more supplies. But she has seen this before, many times. Angel may live another couple weeks, but dialysis will not save her, and she will dwindle away day after day. Liz understands what it is to live a drawn out existence, and she knows this is not a life. Not for Angel, and not for herself.
“Tom,” Liz says.
“What is it?”
“I think it’s time to stop.”
Liz pulls the drape back a little so that she can see her patient’s face. She squeezes Tom’s hand, still clasping Angel’s. During the weeks of goals-of-care conferences, she has wanted Tom to make decisions unpressured, but now she asserts herself.
“I think it’s time to stop.”
Tom says, “I know.”
No blood got onto her hands, but Liz stands in front of the sink outside Angel’s room washing them over and over. Although most of her sadness is for the marriage filled with love, some of it is for the one where love is absent. She thinks of Angel and Tom. She thinks of herself and Daniel. Liz decides to be selfish. She still has to put in comfort care orders for Angel, see 15 more patients in the ICU, and answer her chirping pager, but those things can wait. Ducking back into the supply closet to call her husband, she whispers, “Hell is murky.”
Header photo by sfam_photo, courtesy Shutterstock.