Grandmother Rocket, the virus and the love of a family that exceeded 4000 kilometers away

More than 800 patients, like Toro, were still connected to respirators. Many doctors in severely affected hospitals have been concerned that a significant number of critically ill COVID-19 patients have entered a sort of “unknown dimension,” a state in which their lungs do not improve.

“What will we do with those people? Where will they go? Will they get better? ”Asked Mangala Narasimhan, Northwell Regional Director of Intensive Care. Given the limited understanding of the new disease, doctors disagree about how to care for patients who may survive long-term treatment, but could suffer from chronic illness or serious and long-lasting medical problems.

Three days before Rendón arrived at the hospital, several family members joined what a doctor, Eric P. Gottesman, director of the ICU, described as a call to discuss “goals of care.” Toro was sedated and in no pain, Gottesman assured them. However, after being connected to a respirator for two weeks, she said, they had trouble applying mechanical ventilation and taking out the gases that the body evacuates.

The doctor listed the efforts he and his colleagues had made: various medications, an experimental treatment, and rearranging Toro to help improve his oxygen levels. “Still,” he said, “we have not been able to improve his lungs.” They were very stiff, he added, “like an old sponge that won’t work anymore.”

If Toro recovers, Gottesman warned, “he will need a lot of help and will probably never be what he was before. Then she added: “We have to discuss what we will do from now on and what she would want.”

A pillar of your family

On the return trip to Colombia in late February, Toro stayed in a rented house with almost two dozen more family members now living in the United States. They went to walk to the hill, they attended a baby shower and they visited the grave of Toro’s older son, who died two years ago.

Toro, Rendón and Matías, their 18-month-old son, returned to New York on March 8. Soon after, Matías had symptoms such as runny nose and diarrhea. The following week, Toro felt bad, lost his appetite, and felt tired from what he believed to be a persistent cold. Cleaning the apartment with chlorine, Rendón commented that he could not smell or taste the salmon he had cooked, common symptoms of the coronavirus.

For Toro, with seven children and more than a dozen grandchildren, being sick was unusual. She was taking medication for high blood pressure, a fast heartbeat, and hypothyroidism, but she was stable.

Exercising with a set of weights, he traveled to Colombia several times last year and went swimming in the Florida Keys. She had a lot of energy, hurried up the stairs to reach her third-floor apartment in Queens, and prepared food so quickly that they called her Grandma Rocket.

He grew up in poverty in Colombia and cleaned houses and washed clothes to help his widowed mother raise her twelve brothers. Her luck changed when she married a vet, and the family had a large house where food abounded. However, her husband left and Toro opened a small farm produce store to support herself and her younger children. She then helped raise most of her grandchildren, including Rendón, whom she pampered by giving them treats from the store.

Almost a decade ago, Toro followed his oldest daughter, Martha Jaramillo, to Cape Coral, Florida. He helped care for Jaramillo’s mother-in-law, who suffers from dementia, until she was taken to an assisted living facility.

After that, Toro complained to Jaramillo: “I no longer have anyone who needs my help.” But later, Rendón’s pregnancy was a perfect opportunity to continue helping. Grandma went to the northern United States.

In Rendón’s small apartment in Queens, Toro’s bed and belongings were arranged behind a curtain in the living room. She cared for Matías while Rendón worked supervising accessories in an Oscar de la Renta warehouse and her husband removed lead paint in the New York subway. Toro fed the little boy, crawled on the floor with him, took him to the park and carried him to look out the window again and again and share his joy at seeing the light rail pass.

Three times a week he went around the corner to pray at the Lluvias de Gracia church. He liked to say that all his belongings fit in a suitcase, which allowed him to move easily with different relatives, they recalled. Money didn’t matter to him. “God first and everything else later,” he told his relatives.

Within days of his first symptoms appearing, Toro’s health worsened. She did not want to go to the hospital because she was afraid of getting the virus, family members said. However, Rendón, 32, and her husband, 48, insisted that she go and called her doctor, whose office was closed; They took her to an emergency unit, where they prescribed antibiotics; and then to the Jamaica Hospital Medical Center. They sent her home because she didn’t have a fever.

On March 19, he started having it. “I feel very weak, Mommy,” she said to her granddaughter.

The following afternoon, Rendón and her husband drove the grandmother to North Shore University Hospital, across the Queens border. Valencia’s 16-year-old daughter tried to meet with Toro, who only spoke Spanish, to translate, but she was not allowed to enter the emergency room. The three waited in the parking lot from five in the afternoon until almost four in the morning, keeping in touch with Toro by phone.

She was admitted to the hospital and her family learned that she had tested positive for a coronavirus on March 22. However, during a call, she told her granddaughter that she didn’t think she was infected. “I believe that God is not going to allow that virus to reach me, but people are covered to look at me,” he said.

As of that week, North Shore was flooded with patients with coronavirus. Across New York, hospitals had a terrifying spike in cases and doctors were distraught as they tried to cure a disease without a cure they did not understand.

Doctors ordered a CT scan of Toro’s chest, and the results were consistent with pneumonia caused by COVID-19, according to the report, including scattered misty patches that looked like frosted glass.

Urgent conversations

To the best of his family’s knowledge, or as shown by a review of his medical history by one of his doctors, Toro was not asked what alternatives he preferred if his condition worsened. The family had not spoken of the decisions that might have to be made later, according to several family members, because at first they believed that he would recover.

In fact, at first Toro said he was starting to feel better. Soon, however, she sounded increasingly tired and out of breath on the phone. She told Jaramillo, the daughter who lives in Florida, that she was hungry but could not communicate with staff members due to the language barrier; they brought her food, but she was too weak to feed. He then required an oxygen mask, making it difficult for him to speak on the phone, and an x-ray showed that the pneumonia was getting worse.

At home, Matías leaned out the curtain in the living room, looking for his great-grandmother. “Uela Uuela,‘ uela, ‘uela”, he called her, meaning “grandmother”, the way he always greeted her.

On April 2, nearly two weeks after arriving at the hospital, Toro’s oxygen levels dropped to 85 percent — typically around 90 percent — and he had a harder time breathing, according to records. Doctors Gottesman reviewed. The medical team turned her upside down, a technique known as prone that sometimes improves oxygen levels in people with COVID-19. However, her blood levels dropped further, to 75 percent, and then to 60, so they turned her on her back.

An anesthesiologist placed a breathing tube in her airway and transferred her to the intensive care unit. Doctors believed he had developed an acute respiratory distress syndrome, or ARDS, and had reached a serious stage, Gottesman said.

Her family members had noted that Spanish-speaking Rendón was overwhelmed by the doctors’ calls and annoyed that he couldn’t visit her. “We feel powerless because we want to be with her right now,” Rendón said later.

So her aunt, Jaramillo, was in charge of decision making after consulting her brothers. Esteban, her husband, who speaks English, coordinated the calls between her and the alternate medical team that cared for Toro and often helped interpret for the family.

Three days after Toro arrived at the ICU, a resident doctor explained to his relatives that he had had a poor evolution and that his ventilation status had worsened. After the call, an order not to resuscitate was placed on his record. However, Martha Jaramillo was not yet ready to start what the doctor called palliative care.

Esteban Jaramillo, an instructor with the Reserve Junior Officer Training Corps, was frustrated by what appeared to be a lack of clarity in calls with doctors. What was palliative care? She learned that this involved turning off the respirator and having a family member visit her to say goodbye. How much time do you normally give someone connected to a respirator to get better? He remembered being told two weeks.

The most important thing was to know how likely her mother-in-law was to improve. A doctor told him that he was not even sure that Toro could survive that night. Due to that fear, Esteban Jaramillo quickly organized a group video call with a pastor, the family and Toro to say goodbye to her.

Rendón sat down with his grandmother’s worn out Bible and watched Toro from his laptop; medicated and asleep, she breathed rhythmically with a tube in her mouth. Relatives took turns praying and talking to Toro. With tears in their eyes, they told her how much they loved her.

At the end of the nearly hour-long call on April 6, the family thanked Elisa Vicari, the social worker who had connected them, who was wearing two face masks, a face mask, and goggles. Not all social workers were comfortable entering the rooms of coronavirus patients. But Vicari, 33, came on his days off to help family members say goodbye by video call, moments that happened almost daily in those days.

“It’s just a little bit of what these families need,” Vicari said later. “You can hear the pain and sadness in their voices.”

Gottesman and his colleagues continued treatments that they believed could help Toro. They had tried chloroquine, the antimalarial drug, as well as anakinra, which is generally prescribed to treat rheumatoid arthritis. Doctors inserted a camera tube into her airway twice, without success, to see if there were any blockages that could explain why it was so difficult to oxygenate her.

Then they brought in the hospice team, which specialized in comfort and end-of-life issues. One of his doctors spoke to the family the day they had the video call to “help them with difficult decision-making,” said a note in their history.

Toro’s disease only affected his lungs – “all other parts of his body worked,” Gottesman said later. Her lungs were not improving.

‘One last hope’

On April 16, ten days later, Gottesman and Vicari met in an intensive care unit office for the “care goals” video call with the Toro family.

As they were preparing for the call, Gottesman said to a journalist, “I will give you one last hope.” He had subjected Toro to three days of high-dose steroid treatment to try to help his lungs. If that didn’t work, he and his colleagues agreed, they should disconnect the respirator. “If it goes well, it will be magnificent. But if not, we will also help her in the final stage. ”

He said he was not planning to come up with an option that could continue Toro’s life support but not restore his health, because his lungs likely had significant scarring. “She was an active, vivacious woman before this,” Vicari said. “I don’t know how much that would agree with their values.”

The option he was referring to was a tracheostomy. With a surgical opening in the neck, a ventilator can be placed on patients who need long-term or indefinite use, allowing the uncomfortable breathing tube to be removed from the patient’s mouth and throat.

That makes it easier to decrease sedation and try to wake patients up, though it can be difficult for those with the type of lung damage like Toro seemed to have, Gottesman said. He added that patients do better when they are kept sedated and still to allow the ventilator to work for them. North Shore, he said, had performed relatively few of those procedures on coronavirus patients.

Intensive care specialists differ in their approaches to COVID-19 ventilator patients, and have been debating what is most effective. “Across the city, there are many discrepancies about tracheostomies and what to do,” says Narasimhan of Northwell.

In some hospitals, doctors perform the procedures frequently, often less than two weeks after a patient receives a ventilator, believing that they can shorten the stay in the intensive care unit and improve the chances of recovery. “I think it’s better care,” said Roopa Kohli-Seth, director of the Critical Care Institute at Mt. Sinai.

Narasimhan noted that finding a place in a long-term care facility was difficult at best. Within the Northwell system, he said, there were discussions about creating his own long-term care facility, just as certain areas of his hospitals have been converted to intensive care units in recent weeks.

The hospital did not consider Toro to be a candidate for another treatment, such as using a heart-lung machine that allows those organs to rest. The resource-intensive therapy – extracorporeal membrane oxygenation (OMEC or ECMO) – was scarce and reserved for younger patients, the hospital had decided, Gottesman said later. It was unlikely that it would help heal his lungs, he added.

Finally, the call began, and Toro’s family members in the United States and Colombia joined. “We are living in a difficult situation,” Gottesman told them. “No matter what happens, she will no longer be an independent woman.”

Vicari asked if Toro had told them what his wishes were, and Toro’s youngest daughter answered, her voice breaking as she spoke with the help of an interpreter.

“Once she told me that she wanted to fall asleep and that her little heart would go out,” said Andrea Rendón, adding that her mother had told her: “I want to die before being a burden on you and to see me in a bed sick. “

Jaramillo, Rendón’s older sister, added that her mother had had a similar conversation with her and said that she had asked the Lord not to leave her in a bed suffering for a long time.

The doctor and the social worker turned to see each other and nodded. “It sounds like Carmen and the rest of the family are very spiritual and have a lot of faith in God,” Gottesman said.

The doctor proposed to end the three-day steroid treatment. If it didn’t work, as he suspected, he said, “I think we should do what I think is medically correct and it also seems to be Carmen’s wishes and what the rest of the family would want. That is to say, remove the respirator but make sure that he does not feel pain, that he is very comfortable and that most likely he dies quickly but calmly and calmly. “

Jaramillo’s voice broke when he asked: “Isn’t there anything else that can be done for her?”

Gottesman replied, “We have tried everything possible.”

Another daughter asked how oxygen dependent her mother would be if she survived.

“If he does, he probably needs oxygen,” Gottesman said. “She couldn’t breathe well on her own. If he can walk, which would have to be seen because of all the time he has been in bed, he would need a lot of rehabilitation. And if he can walk, his lungs would not allow him to walk much because he would be short of breath and basically have a lung disability. ”

That night at home Gottesman kept thinking about his patient, he later recalled, wondering what else could be done. The 56-year-old doctor had dedicated his career to treating lung diseases and providing critical care, in part because his father, a doctor, had died young of a blood clot in his lungs after surviving after being hit by a car.

Gottesman knew of a new study to test whether survivors’ blood plasma, which contains antibodies that fight the virus, could help people fight the disease. The next day, he asked if the family would be interested in Toro participating.

“We will do whatever it takes to try to save his life,” Jaramillo told the doctor, after consulting with his wife. “Whatever”.

That night, the family gathered for the daily online prayer session, using the Zoom app. The theme was victory. Rendón joined from his kitchen table in New York, praying and singing in a low voice, wiping away tears, and occasionally laughed as relatives shared memories. Her husband sat next to her with his arm behind the back of his chair.

Family members read passages about David and Goliath and gave testimonies. A woman said she had seen on the news about an older man discharged from a hospital after his battle with the virus. “All the nurses and doctors applauded,” said Luz Arce, a niece. “There was music and there was joy.”

“Can you imagine us going for it and being able to bring it to us?” Rendón whispered to her husband. She read to her family the Epistle of Santiago: “Blessed is the man who endures temptation, because when he has resisted the test he will receive the crown of life that God has promised to those who love him.”

The following afternoon, on a Saturday, Gottesman informed the Jaramillos that the steroids had not worked. After arguing, he and his colleagues had decided not to use the blood serum treatment, thinking it would not change things.

“Nothing works,” Gottesman later recalled telling them. “We should talk about when we want to take the tube out.” The family accepted what seemed inevitable, although there was no formal decision.

Finally, Rendón would be allowed to be next to his grandmother’s bed. “You were the soldier, strong for all of us,” a relative would tell him.

‘Open your eyes’

That Sunday, April 19, Gottesman took Eliana Marcela Rendón and her husband to the intensive care unit. “It will scare a little,” he warned. “They’re all hooked up to respirators in this area.”

They took Rendón and her husband to the hallway window of her grandmother’s room. “The most noble and humble person I have ever met is you,” he said, speaking through the glass. “Open your eyes, my queen. Open your eyes”.

The medical team blocked the window and disconnected the respirator while Rendón and her husband were helped to put on hospital suits. They prepared religious music in Spanish on a tablet to help Toro “have a smoother transition,” said a staff member.

The social worker, Vicari, made a call through Zoom to other relatives and entered the room with Eliana Marcela Rendón, her husband, Dr. Gottesman and a nurse.

Toro was breathing, but was unconscious, after receiving morphine, a sedative, and the anesthetic medicine ketamine. Gottesman had not planned on giving her oxygen with a mask or a nasal tube because she was sedated and did not think she needed it to be comfortable. However, the granddaughter asked for it, believing that it would help keep her alive.

A chorus of voices sounded from the speakers of the tablet to greet her and told her how beautiful she was, in addition to thanking her and expressing her love.

Rendón begged God for his grandmother to live, even if that meant taking care of her with a respirator. He spoke to Toro and reminded him of how happy he was that spring came to take Matías to enjoy it. “The flowers are coming out,” he said. “Get up, spring is here.”

With his face mask on, Rendón leaned down and kissed his grandmother on the forehead. Then he stroked her face and arms and took her hands. He walked to the other end of the bed, removed the sheets, and kissed her feet.

As the voices began to pray, Toro’s breathing slowed and, after almost an hour, it stopped.