The Other Side of the Mask

I don’t know what it’s like on the other side of the mask.

Not the cloth mask, which I now wear every day, as habitually as my socks. I mean the plastic bipap mask, which provides the highest level of ventilation COVID patients can receive, short of intubation.

That mask.

When COVID first started, in the spring of 2020, our hospital used to intubate patients sooner rather than later. When patients’ oxygen requirements exceeded a certain amount, they’d be sent to the intensive-care unit for intubation.

This was around when I was graduating medical school. I didn’t start my internship training until July of 2020, by which time the medical community had gained more experience with the novel coronavirus.

We now know that COVID patients do better when not intubated early. We also know that steroids offer some benefit, so we start steroids as soon as a patient shows signs of low oxygen levels. In my hospital, we can give patients supplemental oxygen via nasal tube. When their oxygen requirement exceeds 60 liters per minute, we place them on the bipap mask.

The bipap mask gives patients both oxygen under pressure to help them breathe. Loud and unsightly, it’s strapped onto the head with Velcro bands and covers a patient’s nose and mouth. Patients cannot eat or drink while wearing it, and when they talk, it’s difficult to make out their words.

Needing a bipap mask used to mean a trip to the ICU. But amid the pandemic’s second wave, the numbers of patients increased so dramatically that we had to keep even the sickest patients out of the ICU unless intubation was absolutely unavoidable.

Many COVID patients never require any supplemental oxygen. Of those who do, some get better with steroids. Some get better with higher doses of steroids. And some complete an entire course of high-dose steroids and still keep worsening. Their chest X-rays go from showing clear lung fields to showing “whiteout”—their lungs are so full of fluid and inflammation that no air is visible inside them.

Many of these last patients end up on bipap. At that point, treating them with steroids feels like waving at the ocean. Nothing we can do will keep the tide from swelling and the waves from crashing.

If patients don’t improve on bipap, we have no choice but to intubate them. We know that; the patients know that.

And once they’re intubated, the survival rate decreases significantly. We care providers know that; I honestly don’t know how many patients do.

That’s why I say that I don’t know what it’s like on the other side of the mask.

But I can imagine.

I’ve looked into too many eyes wet with tears of fatigue, pain, loneliness and fear. These patients have spent weeks isolated in their hospital rooms, seeing no one other than their medical staff. They are exhausted from fighting this illness. The sedatives we give them while intubating them must feel like a welcome reprieve from the effort of breathing. But once sedated, they’ll likely never wake up.

The bipap mask terrifies me.

That is because I know what it’s like to call a family when their loved one is about to be intubated.

“You should try to FaceTime,” I always say, because they’ll probably never see each other again.

I know what it’s like to call a family to provide a daily update. Our mentors teach us that in our calls, we need to emphasize how critically ill these patients are, and how slim their chances of recovery.

“Don’t say anything to this family that could open a door to something hopeful,” one attending physician told me. “They have to understand that he’s going to die.”

I know what it’s like to tell someone’s wife that her husband is breathing so poorly on the ventilator that we can no longer oxygenate him safely through his lungs.

“We will connect him to an extracorporeal membrane oxygenation (ECMO) machine that puts oxygen into his blood, because his lungs cannot do that right now.”

I also know what it’s like to call a fifty-year-old man’s twenty-one-year-old daughter and say, “Your father is on maximum ventilator settings, but his oxygen levels are still low. He is unfortunately not a candidate for ECMO because of his kidney failure. I’m afraid he’s not going to survive this.”

I know a lot of things, but I don’t know enough to cure these patients.

No one does.

As I write these words, it has been seventeen months since the pandemic started. We’ve made incredible advances in medical knowledge—including a very effective vaccine. In January of 2021, my hospital felt like a morgue. By May, we’d started to see some relief. The number of COVID patients was decreasing. My colleagues and I felt safer eating lunch around each other. We started to see a loosening of strict guidelines in restaurants and public places. All of this was thanks to the vaccine.

Still, the story is far from over. The coronavirus is evolving rapidly, creating new versions of itself such as the delta variant, which is sweeping through our population and greatly increasing the number of COVID cases and hospitalizations.

It turns out that the vast majority of patients who are hospitalized did not receive the vaccine. This gives me hope: The vaccine is effective. We have to keep working to vaccinate as many people as possible to establish herd immunity. This will allow us to protect even those among us who are not eligible for the vaccine.

But our work is far from over. In the hospitals, we continue to treat COVID patients with a limited number of resources. In the community, we have to keep educating patients on the need to get vaccinated.

I hope that one day I’ll look back on my intern year and feel amazed at how far we’ve come since then. I hope that we’ll be able to vaccinate every eligible person to protect our society from this unforgiving disease. I hope that a drug will be discovered that can save even the worst-stricken patients. I hope that future interns won’t have to make as many helpless, heartbreaking calls as my classmates and I have made to COVID patients’ family members.

Of course, none of this will change the fate of the more than three million people who have died of COVID worldwide. This won’t erase the pain of their loved ones. Death is difficult to process at any age, but I’ll never forget how many young children lost their parents to this virus. I hope that everyone who has suffered loss can find love and healing.

Finally, I hope that those who died had a moment, at least one moment, of peace on the other side of the mask.