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Two emergency physicians, based at two different hospitals in the New York metropolitan area, are logging their days for Slate. At the end of each shift, they write a response to three questions: What was today like? How did it compare with yesterday? And how do you feel? We have offered them anonymity so that they can write freely about their experiences. Dr. Kelly Keene and Dr. Lauren Serino are pseudonyms. Read Week 1 here.
Dr. Serino, April 1ER docs are superstitious. We don’t readily admit it, because we want to believe we’re rational scientists, but the pandemic has brought out all our little amulets and secret rituals. Today, for example, I have my lucky bodhi seed in my pocket, a gift from a good friend in med school. And while there might be disagreements about one portent or the other, we all agree on one: the nicer the patient, the greater the likelihood that something terrible is about to happen to them.
Mean patients don’t die. It might be the secret to immortality. Come in spitting and trying to beat the triage nurse with your cane, you’ll make it to 105. But this patient—a man in his early 60s with the medical history of a man in his 90s—was so sweet. When he came in, I was getting overwhelmed with the noise and the crowd and I must have seemed frazzled. He said: “I just have this little cough. There’s no rush, I see that you’re busy. You’re all doing a great job.”
But he is breathing at a rate of almost 40 a minute. His lips are a little blue. His lungs, of course, sound like white noise.
His family is in the waiting room and they can’t come in. They’re nice too. I tell them he’s very sick. He has emphysema and early kidney disease, and he had a heart attack a few months ago. His oxygen saturation is dropping, and even though he’s talking now, that’s not going to last long.
They ask, “Can we see him now?”
I tell them, no, it’s not allowed. It goes against every instinct to say this.
“Can we see him after?”
No.
“You’ll do everything?”
We coded another man this afternoon. We broke his ribs performing CPR that was never going to work. Everything is a violent request now. Sometimes it’s futile.
I’m honest. He’s a sick man. Once he goes on the vent, he probably won’t come off.
“He’s come off every time before,” his wife says. “He’s gone on vents a lot.”
I tell them it’s different. It’s not like before. Nothing is like before.
She says she knows. But she doesn’t really. I’m relieved that she gets a small respite from understanding right now, but I know the understanding will come. I’m not saving her any grief, just delaying it.
“You’ll do everything?” she asks again.
We do. His intubation is an easy one. Over in a few minutes without any complications. I wonder if I’ll answer her question differently soon. Or if I’ll get a choice to. We have a couple days of ventilators left in the city of New York. Every day the number goes down. Odds are he won’t make it. Odds are someone younger, healthier, with more reserve, just might.
There’s so much more to care than the vent. But if you need it and don’t have it, then there isn’t any more to do. Maybe a miracle drug will be approved. Maybe Oprah will show up with a truck full of medical equipment shouting: “You get a vent! And you get a vent! And you!”
The nice man has stayed on my mind all day. All night—it’s 3 a.m. now. I can’t shake him. Being a doctor doesn’t always get to be about fixing the problem. Sometimes it’s just about bearing witness. The virus makes it hard to breathe. Seeing what is happening to our patients and our colleagues and our home makes it hard to breathe too. We all need some extra air.
Dr. Serino, April 2I tell them it’s different. It’s not like before. Nothing is like before.
Colleagues from other states have been asking what I wish I’d known before we were inundated with COVID-19 and honestly, it’s less medical and much more systemic. So I spent the morning working out what I felt would have optimized our patient flow, minimized exposure, and streamlined our care had we known then what we know now. With the help of a friend, we turned the plan into a flowchart. I’m proud of it. I think it would be easy to implement and make a huge difference. I drink too much coffee and became convinced of it. I don’t know whom to share it with, though. I don’t know any administrators personally.
I sent a copy to the Department of Health email. I’m sharing it with everyone I can in case it’s useful. I like working on these kinds of organizational problems. Maybe it will save a doc who would have been infected. Maybe it’ll help more patients. Hope so.
The marks from my goggles and mask are now ulcers. They’re infected, red, and angry, and I’ll spare you the details. It won’t be healed in time for my next shift, which means I need to switch to a different pair so that the skin doesn’t open up further. My backup? Swimming goggles. Why not.
I feel off. Tired. My voice is a little scratchy tonight. I hate being so tuned in to every minor feeling in my body wondering if this is it. Did I get it?
Dr. Serino, April 3There’s another refrigerated truck outside the hospital. It doesn’t feel as startling as the first. It feels inevitable, now. Of course there would be two. The fancy ones have shelving so that the bodies don’t have to be piled on top of each other.
Inside, I don’t know if the death rate is going up or down—we don’t feel averages in the ER. A little more than we can handle feels the same as a lot more than we can handle. We’re getting into a rhythm, though: For every five admissions, there are three on nasal oxygen, one on a noninvasive oxygen source, and one who gets intubated. For every admission, there are five discharges, one of whom will make you so uncomfortable you check their chart three times after you get home to see if they’ve already bounced back to the ER. If you were unlucky you’d see the EMR warning: “You are opening the chart of a deceased patient. Do you want to continue?” That hasn’t happened for me. Yet. Luckily, I’m distracted by physical discomfort. Water sounds so good by Hour 8 of a shift. But there’s another four hours to go and I can’t have water until I’m somewhere safe to take my mask off. Safe is in my own car.
My decontamination process has gotten longer. Everything is bleached now. Everything. Even my keys. All my scrubs have changed color in the wash. I’m paranoid about bringing COVID into my home. It’s a tiny apartment and I don’t live alone. I’m afraid of being a vector. We have a plan for if and when I get sick, but I know that’s not really enough. Even so, I try to isolate—to the couch, my desk, and the Murphy bed in the living room. I can’t worry about any of those things having the virus on them. I have to be able to drop the constant diligence sometimes. Rubbing my eyes when they itch, while I sit on my couch reading, is about the height of pleasure these days. That, and those mini Cadbury eggs. Decadence!
Outside, the sun is still shining, the weather is crisp, and runners are bouncing across the East River Park. The water glitters and the skyline looks so perfect it might be digital. Everyone seems rosy-cheeked and healthy. Things seem not just normal, but bursting with spring.
I close my eyes to feel the air on my face but I still see the bodies in the trucks. I can’t unsee the bodies in the trucks. The people out here don’t see them. I’d have a hard time believing it if I hadn’t seen it myself—the day is so beautiful, the weather so nice. I feel like I’m living on two sides of a mirror. We contain things so well behind the ambulance bay doors; sometimes I think we shouldn’t. Maybe people should see just a little. Just enough to let their imagination wander. Just enough to keep them diligent and angry at how things are turning out.
Dr. Serino, April 4I learned today that a resident—barely older than me, with three little kids—is dead. I heard rumors of a resident death in N.Y., but it’s not confirmed. I’m getting frustrated with the war metaphors: disease as battle, references to docs are warriors, health care workers as the front lines. You know whom they put on the front lines? Infantry. And what is the infantry? Bodies for slaughter. Maybe I’m bothered by the metaphor because it’s apt. We’re not the officers. We’re bodies running around trying to keep other bodies alive.
This morning I felt thrilled for a while: The PPE acquisition efforts resulted in 500 more masks on my doorstep. 10 boxes of gloves. 200 hair covers. Guys from the glazier union are going to try to make plexiglass intubation boxes for us. I made three drop-offs and will do more tomorrow evening. Supplies that will hopefully help keep people from being on the growing list of health care casualties. A friend who donated to the GoFundMe that supplied this batch of masks asked me why we can find masks when some hospitals and the government can’t.
Why weren’t we ready? We knew a pandemic was coming eventually. I wish we’d realized eventually would be now.
I feel relieved I have supplies to share. A couple of pool noodles in a tsunami still help you float.
Dr. Keene, April 5I’m tossing and turning, unable to nap before my overnight shift. Sleeping has never been my forte, but it is so much worse now—just restless and filled with dreams about COVID. Dragging my exhausted self to work, I’m greeted by the sight of multiple patients intubated or on non-rebreather masks. Overhead, more “rapid responses” and “code blues” are announced through the PA system. I take a deep breath and brace myself for another night.
Sleeping has never been my forte, but it is so much worse now—just restless and filled with dreams about COVID.
As now expected, many of the patients present are in varying degrees of hypoxia (low oxygen), likely due to COVID. Interspersed between these hypoxic patients, there are a few other medical emergencies. One patient is in intermittent ventricular tachycardia, repeatedly needing defibrillation. One patient presenting with a headache turned out to be having a significant intracranial hemorrhage. Another patient comes in with status epilepticus, a dangerous condition in which seizures follow one another without recovery of consciousness in between. Yet another with perforated bowel, a surgical emergency. Each of these is stressful, but it is almost refreshing to see medical emergencies now that are not respiratory-related. My night team of nurses and techs and medical assistants is incredible, and I’m grateful to work with each person. The emergency medicine residents have all really stepped up to this time of crisis, meeting the challenges head-on bravely and without complaint. I am so proud of them, even as I worry about them.
I’ve been on two hours of sleep and can barely keep my eyes open as I head home from work, feeling like a zombie, both emotionally and physically drained. Several packages are waiting for me when I arrive home. As I open boxes filled with masks, brownies, coffee, and positive messages, tears well up in my eyes. I feel so lucky and blessed to be surrounded (from a distance) by such wonderful, giving, thoughtful people. It is so encouraging to know that there are so many people who will come together in support and solidarity in times of crisis.
Dr. Serino, April 5Today I had a real day off. In the morning, I made a cup of pour-over coffee in the Chemex I bought myself as a social distancing present. Amazon delivered it in two days—which was a surprise, because I thought it was prioritizing medical supplies and necessities. Then again, I am supplying medical care, and it is necessary I have caffeine, or my brain doesn’t work.
I learn something new about myself: I can’t make coffee. All attempts were disgusting. Somehow even worse once I added milk. I drank it anyway—both cups, actually—because I have a problem. I also told myself I wouldn’t look at the internet. I made it to 12:30 p.m. Believe me when I tell you this is a coup.
There’s a sense of quietude on the street today. During my walk I was less diligent about dodging people on the street. On Third Avenue, a man comes around the far corner with a boombox playing funk. He catches me nodding my head. “All this open space makes the music flow,” he says. He spins. I spin. We have a little appropriately distanced dance party. The city, even in crisis, provides these gifts that have always made it feel like home. It’s good to be reminded how much you love the thing you’re fighting for.
I’m struggling with guilt tonight. Why? Because I relaxed, only spent two hours updating myself on new COVID material, cooked a meal, and then ate it. And I had the audacity to enjoy it. I didn’t even have my usual stomachache until I remembered I was idly nibbling while people were still crowding the ERs, and my colleagues were getting crushed and definitely not getting dinner, and there was so much work to do. I try to remember that giving myself a break will make me more useful, but it feels like justification. You don’t save anyone by torturing yourself. Sure, but it always feels like you can do more.
Positives: My infection is clearing up and the tickle in my throat has disappeared.
Dr. Serino, April 6I took 50 telemedicine calls today. I kept all but one out of the ER. The rest I talked through home care and called in some relevant prescriptions. I also spent the better part of an hour talking down a woman having a panic attack. Her uncle had died downstairs from her, this morning, of COVID. A few hours later, she started having mild COVID symptoms and called me. We breathed together for 10 full minutes. That’s not a normal call length, but it wasn’t a normal call. Anyway, normal in regard to anything hasn’t really settled yet. So I kept telling her it would be OK, despite the evidence to the contrary lying on the couch downstairs. I worry it was condescending. I should have said her health would probably be OK. Statistically, that’s still true, despite the mounting body count. As for other aspects of her life, OK is going to be highly relative.
Still, it was nice taking the time to breathe with her. To sit quietly and listen while she cried. To hear her say, “I’m so afraid, I’ve never been this afraid,” and tell her, honestly, that I’m afraid too—and maybe she could be afraid sitting by the window for a moment, with it open, with the sun on her face, taking more deep breaths with me over the phone.
Yes, I love the adrenaline surge that comes from intubating a crazy trauma or shocking a heart back into rhythm. I’m a good doctor. But plenty of my colleagues are smarter, more efficient, and more experienced than I am. The extra something I bring to my practice is that I’m good at making people feel seen, even if I only have a few minutes at their bedside. Patients come to us on what is often the worst day of their lives. I can hold a hand and have a tough conversation after meeting them a few hours before. I can be frank with families. I can sit calmly in the presence of death and not flinch away. That’s my skill. And that’s what, more than anything, COVID has taken away from me as a doctor.
The layers of PPE, the enforced isolation from family, the phone calls, the lack of touch. I hope patients know that we are trying distance ourselves from the disease, not from them. Unfortunately, in practice, the distinction is semantic. I wonder how we can make them feel cared for, even as we rightfully prioritize actions that keep more people alive. I know we are being coldly efficient, and I know they cannot see or hear us clearly under the masks and goggles and shields. I worry about my patients feeling as though they are alone.
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