No One Screams on a Breathing Machine

In ICUs that are typically alive with the hum of care and visitation, it is the silence and emptiness that are most alarming.
COVID ICU staff work on a ventilated patient
Lakshman Swamy

It's just past 4 a.m. in the COVID ICU. If you were here, you might be surprised at how quiet it is, at how few people you see. You might think it's not so bad here. How could this be a crisis?

BMC ICU hallway during COVID

That is not an accurate reflection of what's happening here. Our patients with COVID-19 are in single rooms behind glass doors on ventilators. In the ED, you might hear people screaming, sobbing, laughing. Patients with COVID in the ICU aren't doing any of that.

They just breathe.

We help them. Quietly.


The ICU is all about meticulous control. We don't thrive in chaos; in fact, our top priority is to suppress it. Disorganization and critical illness don't go well together. Instead, we watch, we control, we support. That's how we save lives. Slowly. A nudge here, a tweak there.

BMC ICU hospital room during COVID

Months ago, the ICU was full of life. Not all patients were on the vent. Some were in the halls working with physical therapy. Dozens of services from dietary to renal chatted at the nursing station. Families crowded rooms and joined rounds. It was ALIVE.

I miss it. We all do. It's all different now. There are no families, so the large rooms and wide hallways seem empty. Day or night, we limit staff exposure and conduct many consults virtually. We are all staying away from each other.

The silence, the emptiness — that is what's alarming.

BMC hallways with gurney during COVID

The waiting rooms had family in them at all hours of the night. Now, we've expanded our services for COVID so much that we've turned the family meeting rooms into more work rooms.

BMC waiting room

A frustrated colleague told me, "I hate this damn virus!" Months ago, I would have hugged her. But sympathy at six feet just isn't the same.

Before, when a patient died, we were there for each other. We knew it hurt. You saw the pain painted on your friend's face. Now, the mask is a barrier that keeps you out... and keeps me in. We disperse.

BMC physician wearing surgical mask

When you hear the analogies to a battle, know that this isn't a war movie. It isn't a rush of action or brave sacrifice or heroic last stands. But it is trauma. So much trauma — to lungs, to hearts. To families and communities. And yes, to us. We are not bold heroes of war... But we are bearing witness. In silence. Believe me, this is not a film you want to watch. No one screams on a breathing machine, but you hear it echo somewhere inside anyway.

Stay home. The storm is real.

This essay original appeared on Twitter. Follow Swamy @laxswamy.

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Lakshman Swamy, MD, MBA

Lakshman Swamy is a pulmonary and critical care medicine fellow at Boston Medical Center and VA Boston. He is interested in addressing the delivery of care and working environments to reduce burnout and improve patient outcomes.