I am a critical care physician. I am at the frontlines of this pandemic, in a state of “war” against an unseen enemy that has brought unimaginable destruction in its path.

I arrive at work at 7 a.m. for my shift. I am in a state of hypervigilance. It is a chilly fall day, but in my hospital issue scrubs, I feel warm. I am ready for what is to come.

I print out the list of twenty-three patients I am to care for today. All of them are housed in the COVID ICU. I don my N95, taking care to mold the edges around my nose and cheekbones, testing for a good seal. I put on my face shield and start rounds.

Ms. A is a middle-aged woman on high flow oxygen. She has to take short pauses between words to catch her breath. Her oxygen level falls to 84 percent, and I coach her to take deep breaths. It takes her five minutes to recover. She has been in the ICU for 5 days, and I see no improvement. I predict that she will need intubation.

Next, I enter Mr. B’s room. He’s sixty-two years old. He has been in the ICU for over 40 days. He was intubated early in his hospital stay. His lungs have permanent scarring, and he will never breathe on his own. His daughters had made posters for his hospital room. The man in these posters is smiling and having the time of his life. On the other hand, Mr. B is at the end of his life, waiting for his family to remove the ventilator, which serves only to prolong his suffering.

Mr. C is a fifty-year-old Hispanic male. He has been in the ICU for three weeks on high flow oxygen, finally needing intubation. We had chatted about his vacation to Mexico before the illness. His family had all recovered, and he was eager to go back home. He was eventually weaned off life support and discharged home. I was glad he got his wish.

My next patient is Mr. D, a black, diabetic, hypertensive man who is fifty-five. He has been in the ICU for two weeks. He has been reluctant about ventilatory support. Today he is lethargic. I obtain permission from him to talk to his wife. She consents to intubating her husband, since she is his surrogate decision-maker. My new intubation routine involves covering patients with a clear plastic drape to limit droplets’ aerosolization during this highly aerosol-generating procedure. Mr. D develops kidney failure and needs dialysis. His lungs show no signs of recovery, and like Mr. C, we are waiting for his wife to make the unspeakable decision to take him off life support.

Ms. E is a petite Asian woman who is in her sixties. She contracted COVID-19 through her college-going sons’ girlfriend. She is on high flow oxygen in a state of “happy hypoxia.” She is ill but not in distress. I think she will recover.

Mr. F is in his seventies. He has been in the hospital for three weeks and improving. He had gone into cardiac arrest overnight and was actively dying. His wife had been informed. We allow family visitation (in full PPE) when patients are at the end-of-life. Mr. F can hold on until his wife arrived.

I move on to Mr. G, who is in his forties. He is a diabetic, Hispanic farmworker. He had been in the ICU for three weeks on high flow oxygen. There had been no change in his condition. He is motivated and self-prone to improve his lung aeration.

Mr. H lifts my spirits after this exhausting morning. He is 30 years old. He had come through the ER yesterday. He had been defibrillated seven times. His EKG showed a myocardial infarction (STEMI). The cardiologist had elected to treat him with thrombolytics. It was a good call. He was tired but awake, off the ventilator, eager to go home. He had been diagnosed with COVID-19 a week ago and had woken up yesterday morning with chest pains. He had developed blood clots in his coronary artery due to   COVID-19 causing the cardiac arrest.

Mr. I is seventy-one years old. He has been in the ICU for over two months. He has a tracheostomy. He is very weak and delirious. We are awaiting placement at a long-term care facility to continue to rehab and possibly wean off the ventilator.

Next, I arrive in Mr. Ks room; his heart rate is 150 beats per minute, and his blood pressure is 80/30. He is crashing. He had tested positive for COVID-19, diabetic ketoacidosis, and had a STEMI. The cardiologist found significant coronary blockages. As a consequence, he was in heart failure and taking a turn for the worse. He lost pulses, and we started CPR. This went on for 20 minutes. I called his mother over the phone. She asked me what to do – should she come in? I informed her that if she visited and contracted COVID, her chances of survival were not favorable. She decided not to visit. She made him a DNR. She asked me to call her if he passed. I made that call 20 minutes later.

It’s 11 a.m. I walk to the cubby in the corner of the unit that serves as a physician charting area. I need a few minutes to regroup and inadvertently shed a tear. I don’t want this moment of weakness, emotion, and possibly my own humanity to be witnessed. In four hours, I have lost two patients.

Rizwana Khan is a pulmonary and critical care physician and can be reached at DrKhanMDOnCall.

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