Where to start this story that tells how Afonso was brought back to life after being connected to an ECMO for two weeks?
Technically called Extracorporeal Membrane Oxygenation, the ECMO intervenes when the functions of the heart or lungs are compromised, thus ensuring the artificial circulation and oxygenation of the blood. It is through this machine, connected to the patient through catheters, that this procedure is used when someone’s life is at risk.
It was Afonso who told me about the visit of death that peeked at him in his quiet corner in the Azores and put him to sleep, in an induced coma for three days. Little did Afonso know that it would be this near-death condition that would cause him to be urgently transported, in the President’s Falcon, to Santa Maria Hospital, where an entire medical team was waiting for him. The team included Nuno Gaibino, an internist and intensivist doctor and one of the big names of the Faculty of Medicine of the University of Lisbon.
Nuno Gaibino introduced me to Afonso Cruz, the smiling 30-year-old young man. This part of the story he couldn't tell me about. “They called us from Ponta Delgada Hospital and asked us to rescue a patient who, in three days, had deteriorated to such an extent that he needed to be immediately connected to the ECMO. He had already come from the Azores by Falcon to Lisbon, accompanied by a medical team”. Nuno Gaibino quickly shared the photographs of Afonso Cruz, now safe; that's how I saw Afonso on the day he left the hospital, and with a face of joy that could easily justify what doctor Nuno told me about him, “it's one of the many positive and inspirational cases for all of us”.
Afonso's version is only about before and after the coma. “The nurse from Ponta Delgada told me he needed to put me to sleep so I could be ventilated, but at the time I didn't even realize I was going to be connected to the ECMO. I was scared until then, but after everything was explained to me, I felt reassured. When I woke up I was in another hospital and I only saw faces covered up talking to me and who, calmly, repeated my name and placed me where I was”.
Those reading this now must not think that this story is intended to shock them. It may move those less used to cases of salvation from Covid-19, but even those who went through the experience are moved when remembering cases like this.
Afonso Cruz works and manages the family business in the real estate area, ensuring the financial part. Born on the island, he only left the Azorean capital to graduate in Lisbon, resuming the tranquillity of his land, which does not, for that reason, invite him to long walks through nature, despite admiring it a lot. Empathetic and in a very good mood, he says with a good sense of humour: "I'm glad I don’t practice sports, because it was a few extra kilos that helped me regain mobility after the coma". Having been fed only through a tube while ventilated, Afonso Cruz lost a lot of weight, yet he was strong enough for a quick recovery.
Protective with his family and in particular with the parents and grandparents, he thanks what he calls luck, having been the only one who was clinically ill, as he is one of the younger members of the family. He is equally grateful to have been infected at an early stage when no hospital was still experiencing the peak of the pandemic, and had all the space and time to receive him.
Until 26 March, when he was admitted directly to Intensive Care in Ponta Delgada, Afonso did not have an easy time. One notices that he is not the complaining type, but he feels that his symptoms he was regularly informing by telephone the local health authorities were played down. The days were slow and painful, 3 days with fever at 39 degrees Celsius, dry cough and extreme tiredness. It was clear to him that he was infected, the positive test proved it, he had the English variant. This was followed by the oximeter, which confirmed very low levels of oxygen in his lungs. Even struggling to speak and breathe, Afonso could not ask for direct help from his family, as it was mandatory that he was the one to call an ambulance. After two hours waiting for that single arrow of salvation, he had to walk down the ramp of his house and enter the ambulance on foot, “they were afraid to go through the gates of the house”, he explained.
In this quasi-psychological war scenario, the brothers only saw Afonso from afar, so as not to get infected. Even before knowing what was in store for him, Afonso only wanted to be connected to a ventilator. On 30 March, he was in an induced coma. He fell asleep in the Azores and woke up in Lisbon.
Initially after waking up from the coma, he had delusions, something normal as soon as one wakes up. He saw bugs and frogs around the room, but he knew deep inside that it wasn't a real scenario. He witnessed, however, more violent behaviour from other patients near him, harsher reactions from those who were absent from life longer. The sooner they are awake, the quicker the reaction. This reinforces the information that Nuno Gaibino had given. If the body was holding him back with fatigue and inertia, his mind was already sighing for victory and to return home and to normal life, mainly to be able to see Bowser, his 3-year-old dog who reacted very badly to his absence, running away from the farm where he was and going to Afonso's house, waiting for him to arrive.
The hospital's medical team tried to call Bowser, but Afonso thinks he never recognized him from a distance, despite having appeared on the phone one day while making video calls to the family.
His parents and siblings, who were trying to interact with an Afonso with tubes and who for two weeks could not speak, suffered, always at a distance, just by looking at him and listening to some noises that expressed his soul. Always trying to find a private space, just as safe, for family gatherings, Santa Maria gave his mother permission to come and spend a whole day with him. His mother brought the typical Azorean cheesecake pies that sweetened an exhausted but equally grateful team.
While he was ventilated, Afonso was fed with a saline solution. Unable to speak, due to intubation, he communicated through gestures and caught people’s eyes trying to decode whose eyes came each morning. He trained his brow a lot, he tells me laughing, and when he needed something he would lightly tap the bed so they could see him. The truth is that the teams guessed his needs before he tried to express himself. One of the things he was asking was for him to be turned over, for the secretions to be removed from his nose, or even to ensure the most basic physiological needs. Protein yoghurts followed, to start helping the body to function and rebuild muscle.
After 3 days in a coma, 10 days without speaking, 15 days connected to the ECMO and 16 days hospitalized in Lisbon, Afonso returned to the Azores on a commercial plane, accompanied by a medical team from Ponta Delgada, almost recovered, but still on a stretcher for not having the strength to stand up alone.
These days, three weeks after leaving the hospital, and despite maintaining respiratory and muscle physiotherapy, the oxygen levels in his lungs seem to be normal, which makes him celebrate life through a regular walk from home to work.
A crude description follows, insofar as it is positive and a glimmer of hope for so many who, seeing life giving a hand to death, follow one of two paths: wanting to live, or giving up. I asked Afonso Cruz everything about human fear, which we normally not mention. But Afonso gave space, and I limited myself to being guided by him and inspired by him.
May I ask you to describe exactly what it feels like to wake up connected to a ventilator?
Afonso Cruz: Ventilation is very uncomfortable. We have tubes down the throat and the mouth never completely closes, it's dry. I could only sleep for one to two hours a day, because everything bothered me a lot. I remember that when they took the ventilation out I felt like I passed out from lack of sleep. I remember that my first instinct was to check my cell phone, but I couldn't, I was exhausted. I just wanted to sleep.
The ECMO is connected to the human body through catheters that transport blood and oxygenate it, returning it to the body. Described like that it's impressive, but how does it feel?
Afonso Cruz: There were two catheters, one closer to the shoulder (points to himself), here near the neck, the other in my leg. This machine is a scientific marvel that replaces the heart and lungs for several days. (He sounds relieved). The catheters could only be felt if I changed position, then they shook, it felt like a snake going up my leg (he smiles). But nothing to bother about. The only time I felt a lot of willpower was needed was while I was on ventilation. And even after the tubes were removed, all that oxygen, with the mask, is so much and so strong that it dries your nose and it hurts. But then a nurse always comes with an ointment to help us and avoid the wounds, it's always a salvation. (He laughs). But you know what? While I was on the ECMO, the process was very positive every day, because a doctor always came and said to me: "Afonso, today you are even better!". In other words, every day I made progress, which meant that my oxygen was gradually reduced and I was less dependent.
Please explain how the body looks like after two weeks being static and ventilated.
Afonso Cruz: We almost couldn't move, because we lost practically all the muscle mass. The only thing they can do for us is to put us on our side, but those are brief moments. The first exercise I did, a week and a half after becoming conscious, was to sit up in bed. After lying down for so long, if we try to get up, we fall to the ground. It's impossible, because there's no muscle to take it. But it is important to say that even while I was unconscious, physiotherapists came to exercise my legs and arms. Then, when I managed to stay upright, they moved on to a new stage, we walked a little, then spent afternoons sitting in the chair and no longer in bed.
This is a totally intimate question and I dare to ask it because people wonder about their basic capacities when in bed. How do you live the basic routines, how to deal with your own physiological needs?
Afonso Cruz: We become babies. They bathe us, turn us over. While we are totally bedridden, we have diapers and even when we are unconscious, I found out that our bowels work, did you know that? Even in a coma, we have laxatives so that the bowel is never too still. But you know that while I was ventilated, my intestines didn't need to work, they only came back when I left the saline and started eating.
Does this process of regression of our inner independence mess up your head?
Afonso Cruz: Yes and no... (he thinks for a while) In normal situations it could mess up my head, yes, but in this case, it didn’t. Do you know why? Because there's a whole team supporting us, taking care of everything. Of course the body gave up somehow, just look at the muscle loss, and that makes us babies again, but we accept this care and see it positively. It's impossible to feel alone or ashamed, because they are amazing teams. Santa Maria must be good anywhere in the world, how is it possible for me to have done so well in such a short time! (Laughs) I've been more stressed out since I've been working than while I was at that Hospital.
I was very lucky, there were only two patients in intensive care at that time, even in that I was lucky. In the middle of this serious situation, I was lucky.
Your positive attitude towards your ordeal is amazing…
Afonso Cruz: Indeed, I have a positive attitude. The things that socially made me feel more uncomfortable, nowadays pass me by. Now I look and say, "There, the world is imperfect." But I play things down. You see, about 1 million Portuguese have been infected, others were hospitalized, a few were in a coma like me. But to have escaped all this means I am incredibly lucky, how can I not be positive about it?
How has your life changed since you left hospital? How is your locomotion?
Afonso Cruz: When I’m doing my walks I feel the same person, can you believe it? I believe so. I know that post-Covid recovery can be very complicated, it depends on the person, especially if the person did a lot of sport and was very active before. But I wasn't an athlete, nor a sportsman. (laughs) I like to walk, but I'm not into big running. I wasn’t like that at all, and I'm not now. It's okay like that! I only feel that my breath changes if I have to go up a slope, the steepness takes my breath away, but I always ask myself, "Was it like this before Covid, or not?"
On several occasions, Afonso gave me the idea that he misses Santa Maria Hospital and the medical teams that took care of him and saved him. There is almost an impulse-driven desire in him to come and visit them.
He knows, however, that to meet those teams that saved him, they will need to identify themselves. He asks them to tell him a story to remember who helped him. The teams from intensive care showed only their eyes and bits of hair and that's why Afonso created an image of these people, without knowing if they corresponded to the right look. When on the way out he met some of the people of the team less covered by the PPE (personal protection equipment), he was amazed they had such different faces and much more hair. There were exceptions, he has always recognized his doctor Nuno Gaibino, "he always showed such enthusiasm when he came, it was impossible not to notice it was him".
One of the things he most values nowadays is having a complete bathroom, with a shower, or being able to do his most private routines alone, a luxury of civilized countries, he tells me with tremendous pride.
During the hardest times, he received so many messages via WhatsApp that he “felt like a public figure”. There were hundreds of messages looking for news about his situation. Afonso laughs and all the time, in the same proportion, he plays things down a lot. He feels very grateful, because despite all the "bad luck", luck was his guide almost every day. He ends our virtual meeting by saying "I'm here thanks to all of you, I can't thank you enough".