Three weeks into the coronavirus blur, there are fewer patients in my ER, but they’re sicker and they do worse.
I was about to step out for an evening shift when I caught a small quiver in my wife’s lip as she was saying good-bye. This drew me up short. I could tell that she was worried about me; it occurred to me she had a point.
I’d had about a week off, and in that time my co-workers had begun seeing more and more COVID-19 patients. Now, it was my turn. I’d been distracted by my work adjusting the Emergency Department’s IT processes to cope with the new pandemic — and to the recent school and business closures. The degree to which the pandemic might affect me as a physician seeing patients in the ER hadn’t really sunk in.
It’s been a long three weeks since then; I wanted to jot some thoughts down.
When I head to the hospital, it’s the same old ER, with the same docs, nurses, PAs, techs, respiratory therapists, and secretaries. The work, though, the many familiar habits of patient care I’ve gotten to know these past eight years are utterly changed. The ER now is like a different specialty — on a different planet.
As a medical student, I was attracted to Emergency Medicine because of the variety. Every day, patients flooded in with anything from gunshot wounds to testicular pain to earwax. By law, we had to see them all, and did our best to help. Individual shifts could be stressful, or tedious, or depressing, but the next one was always different. That kept it fun.
Nowadays, nobody’s coming to the ER to have their ears rinsed out. Three weeks into the coronavirus blur, there are far fewer patients, but they’re sicker, and they do worse. My colleagues still laugh, smile, and crack the occasional joke, but we’re not having fun.
It caught up to me driving home from an early COVID-19 shift. I recalled how one of our techs, wordly as they come after twenty years in the ER, asked me out of the blue whether it was normal that she was having bouts of anxiety before her shifts now, when she’d had nothing like it before. I told her yes, that I suspected all of us were having those feelings. Certainly, I’d noticed a quiet strain pervading just about everything lately. But it was only in the car, tears welling in my eyes at some stoplight, that I was able to name the feeling we were all trying to work through.
I try not to dwell on it, but experiencing horror is fundamental to the practice of medicine. Whatever your specialty or role, you’ll occasionally see something truly awful, and that can’t help but affect you. Ideally, this helps develop the mental and emotional tools necessary to clinical work, though too much “badness” can also be traumatic. In my experience, this is a spectrum, not an either/or proposition.
Today, there’s badness everywhere we look: COVID-19 is a terrible disease. It attacks the lungs, the kidneys; patients can spiral down incredibly quickly. Those suffering with it are scared; it hurts to breathe, and no family can be there to comfort them. Those of us caring for them must do so covered by protective gear, so patients can barely see the human in front of them. Worst of all, until an effective treatment is found, we have little to offer other than supportive care.
Communication is a challenge. Several of our rooms have loud, whining fans to create negative pressure, keeping the room’s air from going out to the rest of the ER. My mask muffles my voice; the face shield causes harsh echoes; I have to shout to be heard over the fans. Ordinarily, the extra time spent interviewing patients who require interpreters (about three times as long due to the extra back and forth) is an opportunity for some brain rest as information flows less quickly. But standing in an enclosed room with a coughing, infected patient, I can’t help feeling exposed. One man in particular kept pulling his mask down to interrupt as the interpreter was relaying what I’d just said. I had to ask him to pull it back up; then I’d repeat my question or try to answer his. It happened again and again, until I was practically frantic to get out of there.
The virus that causes COVID-19 is dangerously contagious, but it needn’t infect patients to affect their health. When patients appear on our board that aren’t complaining of flulike symptoms, we all speculate what they might say to make us consider they might have COVID-19. Broken ankle? Funny story, they drive a shuttle bus and had sweats last night. Rectal bleeding? Just wait, and they’ll mention loss of smell…oh, and that nagging cough…
I saw a man in his forties whose chest pain and EKG were classic for a STEMI, a heart attack requiring an immediate procedure to restore blood flow to the heart. I called the cath lab and got: Does he have a fever? Any chance he’s COVID? It was all they wanted to know.
Another man, in his fifties, collapsed at home and came in pulseless. He had a history of cancer and hadn’t had viral symptoms; probably, he had a heart attack or a blood clot that lodged in his lungs. But to protect staff, we have to assume any code that comes in has COVID-19, and the precautions against infection significantly complicated the resuscitation, which was unsuccessful. The patient’s wife was utterly stunned by his death and kept asking how this could have happened, what she was going to do. I could only apologize; I didn’t know. I did my best, but still felt guilty for the stammering, shitty job I did trying to console her.
So, was it COVID-19? No one will ever know; with the pandemic raging, I couldn’t even request an autopsy.
“This sucks,” my wife pronounced as we regrouped one night, about a week into all this. It’s a synthesis I can’t improve on or contest. The ill and their families are suffering the most, but she shouldn’t have to worry about her husband being safe at work, nor should any friend or family of those in healthcare.
There are a few silver linings, though. I could start and end with my wife and kids — I’ve stopped pinching myself, because they’re definitely real, but it took years and I’m ridiculously lucky. Beyond that, supportive texts, calls, and emails from those I know have been warm, frequent, and deeply appreciated — even if I can’t answer right away. Any number of restaurants and other organizations and individuals have dropped meals and treats off at the ER; I wish I could thank them all. Others have donated PPE, whether bought or homemade — bring it all, we need it! On-shift, the customary, inter-specialty grumbling and sniping has vanished. Providers calling to send patients my way are checking first that I’m okay; I’m doing the same with the hospitalists and residents I page for admissions. Then there are the pictures and testimonials that have been shared by colleagues past and present. They aren’t just inspiring; they’re awe inspiring. All that compassion and competence and sheer will are just what is needed to help our patients fight this.
So…how’s that fight going? Massachusetts is a rich state, its medical institutions massive and iconic. The governor has encouraged, and most residents have taken, extreme and proactive measures to limit the disease’s spread. Still, we’ve been hit hard. If we’re lucky, we may just, just bring this disease to heel without the sort of healthcare collapse that would compound the tragedy, leaving many to die from otherwise treatable diseases. But we can’t trust to luck.
The first sci-fi book I ever read was called Armor. Far from a classic, it featured human soldiers in mechanized suits fighting masses of giant ants — with depressingly little success. That unpromising premise aside, I read it half a dozen times, and there’s one quote from the book that I still think of decades later: You are what you do…when it counts.
Now, more than ever, it counts. We can wash hands, wear masks, and most importantly stay home until this beast of a disease is under control. Whatever divides us, the practice of medicine makes clear that there is one characteristic, one feature or bug, that absolutely all of us share: mortality. I hope we can use that to support and be truly, obsessively human to each other in dark weeks to come. Then we can start to see past today’s horror, this icy chill engulfing our Spring. Here’s to brighter days ahead.