When I heard the words coming out of my mouth, volunteering for the COVID-19 team at my hospital, I wanted to give myself a good shake.
What am I getting into? This is not just a bad flu; this is very serious. Healthcare workers, young healthcare workers, are on the news getting sick and dying! But I am still a full-time practicing physician, and no stranger to hospital medicine, and since I've never married or had children, I have no family to endanger by bringing a sickness home. Mostly, however, I feel sucked in by the gravity of this moment in history. I don't know what's ahead, but I know I must go.
My hospital has organized "COVID teams," special groups of doctors and nurse practitioners who only see COVID patients – which, if nothing else, stops somebody going from infected to noninfected rooms. It also enables us to rapidly spread information about and stay consistent with the latest protocols, which are still constantly changing. I met my team by teleconference the Sunday before the Monday I was to start. Although some doctors were "locum tenens," traveling doctors for hire, most were people I was familiar with, including local infectious disease and pulmonary doctors. Everybody, however, was clearly under stress. Our chief of staff was on the line, and had just come down with a 102° temperature.
I graduated family practice residency in 1999, so this is not my first rodeo. Since then I have seen my colleagues tired, I've seen my colleagues stressed, but this is the first time I've ever seen my colleagues, including very seasoned colleagues, scared. That rattled me. It did not help when the news that night said we must prepare for the week ahead, my week ahead, to be another "Pearl Harbor or 9/11."
The thought that scared me the most, however, was not getting sick, but the idea of standing at a patient's bed and not having oxygen or a ventilator when I needed one. Watching somebody struggle to breathe is one of the most terrifying things you will ever see.
I drove to the hospital in the early gray morning and got my temperature scanned and went in. The hospital was working with essential staff, and masked people shuffled quietly through dimmed halls. There was a heaviness, a fear. I stood outside the door, ready to see my first COVID patient, and we didn't have any gowns. There were gowns in the hospital, but they had to come up from supply, and I could hear staff say, "I am not going in without a gown." Neither am I. It's not just a matter of self-preservation; if the helpers go down, who would be left to help? If we catch this, we will leave the hospital and spread it.
The gowns did come up, and I began my "donning procedure," with gloves, gown, my N95 mask (which I wear all day long), a surgical mask over my N95 so that I may continue to wear it all day, and a face shield, along with the surgical cap I am wearing. It is stifling. It is hard to see or be seen clearly. It is even harder to talk clearly, and heaven help you if the patient has hearing problems! The N95 itches, but you cannot touch the mask or your face. Are you paying attention to all this? Because as you get hurried or tired, you might forget to put a surgical mask over your N95, or to put on a face shield, or you may even rub your eyes. Perhaps more important will be the "doffing procedure,” which also must be done in specific order, because now you're actually handling contaminated articles.
The patients were alone in their rooms, no guests, including family, were allowed. Gray, gasping figures with fear in their eyes, which would follow me home that night, surrounded only by these indistinguishable masked, gowned, and gloved figures mumbling through our masks. I am careful to keep my face shield towards them; I ask them to roll over, away from me, and I listen to their lungs. But many of these patients are not, in fact, old – as I see with the flu. I have 20- and 30-year-olds on my ward, and most of the people vented in ICU are in their 40s and 50s – and I have never seen that in the worst flu years. Then you see that you are not far from these gray, gasping, terrified figures. One split in the seam, one chink in your armor, and the fever can slip in and you will be in that bed or on that vent.
By the end of my first day, I felt like I was going to liquefy. But I could not, because, as an ER surge warning was announced overhead, we were called to do more admissions that had come in from a nursing home. The COVID team structure had hurriedly been built over the prior few weeks, and who was to be where, doing exactly what, was still being worked out. Yet here we are, with this country's colossal health system, with hospitals and hospital systems, and I go to meetings regularly, where we talk about metrics and ICD-10 codes and modifiers and electronic health records and "meaningful use" – but nobody prepared for anything like this? No PPE could be stockpiled anywhere? No emergency funds to pay people's unemployment, or cover their medical insurance if they lose it from being out of work?
At the start of the second day, I had to drag myself out of bed with the question, "how can I make it through this?" But the answer came back, “the same way you always have, one day at a time and one moment at a time." The mountain will crack with the steady knock. You must try not to think too far ahead, and be in the now. Still, a floor nurse commented that we will all probably have some form of PTSD from this. That may be so. For me, in the past, when I've had stressful periods like now, it usually manifests as an inability to "stand down." If I get a moment to sit still, I have a constant and nagging feeling that there's something very important that must be done, but I'm forgetting. I am not. I must distract myself with something else. I have learned how to deal with that.
For all this talk of "heroism," there really is nothing happening now that we healthcare workers don't do on a regular basis. We hold patients’ hands, we fight with their insurances, we stay up late worrying about them, or thinking "what am I missing?" We expose ourselves to multidrug resistant tuberculosis, hepatitis C, and HIV. No, I don't see anything we don't normally do, except suddenly, there's a lot more of it all at once, and it's everywhere, every day.
What I hate most about COVID-19 is how it separates us. Not just the patients, alone in their rooms, but their families. It is very difficult, especially when patients can't advocate for themselves, trying to discuss the patient's status and reassure the family. The families often have more than one member in the hospital, and maybe more than one hospital. I am updating them on the status of their father, but their mother is in the ICU and just got intubated or died, and the father doesn't know about that, and the family is afraid to say anything because they don't want him to get worse. Families are completely overwhelmed, and I become aware that I am going over the same ground with them again and again, as things don't sink in. But how can they? I take a breather, step back, and refocus, which is hard to do, since I only slept four hours last night and have not eaten or drank anything in 12 hours, and am so scrambled right now I have to make sure I am giving them the results on the right patient. There were 30 on my floor.
When a patient dies, the distant family is coping not just with the pain of loss, but with the thought that the patient died "alone," or thinking the family "abandoned" them. But over the years, I've come to believe that people don't really "die alone." I have seen many dying patients visited by loved ones who have previously passed on, and whether you believe in a great hereafter or think this is simply the process of dying neurons, this fact is well-documented, and I try to reassure people of that – though, as with most things these days, I often wonder how effective I am at it.
Not feeling effective can be overpowering. We really don't have, to date, any documented treatment or treatments for COVID-19. We have no "magic bullet." Modern medicine and society expect us to be great "fixers," and to fix things fast. Like Dr. House! But the only things I've seen work consistently with COVID-19, to date, have been oxygen therapy and time. While most people have been understanding, reassuring people is a different story, especially as patients go into the "cytokine storm" phase of the illness, when the body's immune system goes overboard and produces multisystemic inflammation that can damage the heart, lungs, liver, and kidneys. As a doctor, you are supposed to have all the answers, but I have seen 80-year-olds come through like champs and 30-year-olds end up on vents and 50-year-olds die, and I really don't know what tomorrow will hold for each patient, as we do the best we can. I look for complications, like asthma, that could be flaring things and need their own treatment, but I always feel at the mercy of this tide.
You read about doctors who commit suicide. I do not know them, yet I feel I do. I know they were truly dedicated and caring people who lost themselves to this darkness that says, “you are not enough." But I have found that the way to fight this is to rejoice in the little victories each day. No, you cannot wave a magic wand and fix everybody or save everybody or know all ends, but you can still help people and be there for your patients and their families. You can help them focus on the positive and provide comfort, even if it is only empathy, through the negative. Your words and actions can be medicine. You can hold their hand. You can arrange FaceTime visits with their families. You can arrange for them to stop by the ICU, on their way out of the hospital, to see family still there. You could try adjusting the oxygen or try different modalities like proning (flipping them on their bellies, opening airspace), and you keep them from going back on the vent! The little joys and victories, the patients you have seen get well, are the steady knock that cracks the mountain, and you will find the light and joy in this darkness.
I just did my second week in the hospital after two weeks off at the end of this month. Social distancing has been working, here in New Jersey, and admissions and patient census are down. We are out of crisis mode and everybody is breathing easier. We pray this trend continues. I know there are many people who think we should just reopen the economy and "take our chances." I think these people have never been slammed by admissions. I think these people have never been approached by a respiratory therapist asking them to prone a patient and buy three hours so a vent can become available. If they feel a certain percentage of loss of life is acceptable for the economy, I would like to ask them, which percentage of their friends and family they would like to sacrifice?
The fight against COVID-19 has been compared to a "war," but there has been some pushback against this analogy. Opening the economy must be done, but should be done by a process founded in surveillance and tracking – which, like PPE supplies and crisis team preparation, were not thought of until now. This is not like a shooting war, where we heroically charge the guns to bravely be slaughtered. This is a time when we need leadership with a plan. I do not want to be back in the call room hearing any more surge alerts. I, and many of my colleagues, have been staying especially away from our friends and family so we do not get them sick while we check our temperatures at home twice a day and watch and wait for any cough or symptom.
Nobody wants this to end more than us.