Days of Peril and Promise

By Dr. Jeffrey Rediger

In five days, our hospital has gone from two medical COVID-19 units to every unit except one having a high proportion of patients who are either COVID-19 test pending or already positive. Our day surgery center is now a second ICU, and my friend, the Chief of Infectious Diseases and medical director of the ICU, said he has never felt so helpless. He goes from ventilator to ventilator, unable to get the numbers up so that people can begin breathing on their own and recover.

Daily hospital life at this point is a bit like working in a ghost town. This is ironic, since the beds are full. Patients must remain in their room behind closed doors, and staff who enter gown, goggle, mask, and glove up, standing across the room from the patient and speaking with a voice muffled by the mask, remaining in the room only briefly. When outside the room, communication with other staff remains restricted; talking is simply more difficult with masks. In contrast to the ceaseless noise and activity, the controlled chaos that normally characterizes hospital life, quiet now dominates. Nurses stations are hushed, sometimes empty. The spaces are small, so physical distancing requires that only one or two can be present at a time.

It’s incredibly isolating for patients. And although the responses vary across a wide continuum for doctors, nurses, and other clinicians, you can feel the anxiety. Many are managing their fear of becoming ill themselves or unknowingly passing COVID-19 to a family member. Many also worry about their own immune-compromised conditions, or about exposing family members when they return home.

My 90-year-old COVID-19 positive patient this week gasped wide-eyed between breaths, “I’m terrified I’m going to die. Please don’t leave me alone.” With breathing already difficult, panic further restricted her ability to get a breath. Her door had to remain closed at all times. Her family was not allowed to visit. Staff could only remain in the room briefly because so many other patients also needed to be seen. As if all this wasn’t enough, she also had a mild delirium secondary to hypoxia. Upon entering the room, we stood at a distance, looking like aliens from outer space and speaking in muffled tones. If I’ve ever seen a breeding ground for fear and paranoia, this is it.

The medication I provided for her anxiety visibly relaxed her enough that she could breathe more easily. But I could also hear the anxiety in her husband’s voice when I called him. Although I considered writing an order for him to visit in spite of the policy against it, I didn’t because he can’t afford to become ill himself. We spoke about him remaining in touch as much as possible but she was too weak to answer so the phone calls mostly went unanswered.

When I clicked open the consult list last night to see who needs to be seen, the word at the top of her file was blunt: “expired.” She died during the night. I had more patients than I could possibly see, and only later realized that I needed to check in with her husband and see how he’s doing. Of course, he’s devastated.

Other patients don’t have COVID-19 but still suffer unintended consequences. I saw an 84-year-old gentleman a few nights ago. Normally a stalwart, sturdy chap, he was scheduled for a hip replacement last week but received a call informing him that because of the pandemic his surgeon isn’t free until June. He has avascular necrosis of the hip joint and can’t walk. Even shifting slightly in bed causes such debilitating pain that he grits his teeth, trying not to scream. He has lost 30 pounds in recent weeks, bemoaning that “The pain takes my appetite away.” For someone his age to not walk until he’s post-op sometime in June – that worries me and almost certainly will dramatically shorten the trajectory of his remaining life. I will see him tomorrow and ask if emergency surgery can be scheduled, but there was no discussion of that in the notes.

These are also days of unexpected promise.

In spite of so much suffering, the overwhelming reality is that so many staff are just simply devoted to alleviating suffering wherever they can. The ones who I believe deserve special credit are those who do aerosolizing procedures such as the intubations or breathing treatments that cannot be done without droplets spraying everywhere; and also the nurses, who go from bedside to bedside all day long, most frequently exposed. Their level of selfless dedication is humbling and inspiring.

As staff, we are coming to know each other in new ways, at new levels. We are all focused on the singular goals of taking care of our patients and ourselves as safely as possible. We are also changing our systems and ways of caring for patients faster than we ever imagined possible. We are transforming what we do by meeting multiple times each day and by texting, emailing, and tele-conferencing on weekends and evenings, letting each other into our lives and homes to a degree that is historically unparalleled.

And then there’s the exponential shifts in technology-deployment that are occurring as we rapidly move into telemedicine, communicating with patients remotely, whether they are in a hospital bed or at home. This was forced upon us by a crisis last week. One of our docs who is 74 years old and has an immune-compromised husband was dismayed to walk into her office one morning last week and find four or five staff sitting there without masks. She promptly resigned, giving her 90- day notice but asking for it to be immediately effective. Facilitated by the unprecedented single-mindedness of all the regulatory and reimbursement forces that shape and structure modern western medicine, the program was able to be reborn as a telemedicine program within two days, leaving doctors, social workers and others able to interact with their patients in a way that felt much safer for all. 

Across the board, regulatory bodies, insurance companies, licensing authorities, and both public and private research institutions are loosening restrictions that traditionally have made it difficult or impossible for medicine to keep up with technological changes and democratizing forces occurring in the larger culture. Many of these changes will remain, and we will finally be able to say with more justification that medicine is entering the digital age. Just as in the recession of 2008, when Uber, Airbnb, WhatsApp, and many other revolutionary business models helped transform our economy and contributed to a later economic boon, we will see the same again as we recognize and capitalize once again on the opportunities for a whole new level of sharing, connection, and democratization[i], this time hopefully in medicine and science as well.

As Charles Eisenstein points out, corona means “crown.” The underlying idea driving democratization around the world, and now in medicine, is a slowly growing respect for the underlying goodness and latent capacities of each individual human being. Let’s takeaway from this crisis a commitment, stronger than ever, to crown each individual with life, love, and dignity.

Jeffrey Rediger, MD, MDiv, is on the faculty of Harvard Medical School, the Medical Director of McLean SE Adult Psychiatry and Community Affairs at McLean Hospital, and the Chief of Behavioral Medicine at Good Samaritan Medical Center. He is also the author of CURED: THE LIFE-CHANGING SCIENCE OF SPONTANEOUS HEALING