As soon as I heard that someone from our residency needed to be transferred to the COVID floor, I knew it would have to be me. Based on our rotation schedule, I was the most reasonable choice. I volunteered before I had time to think about what this really would mean. Am I risking my health or my family’s health? Now I will be squarely in the middle of a dangerous pandemic caring for only COVID-positive patients or ruling out patients. I am young and healthy, and my partner is too. The likelihood that she or I get seriously sick is small, but how would I feel if she ended up on a ventilator because I brought home COVID-19? I have to push past my fears because this is a national emergency. Didn’t I become a doctor to help people?
On orientation day one we met from our living rooms, talking over Zoom about logistics of rounding followed by watching table rounds. Pediatrics, neuro, and ENT have also supplied a resident. I become overwhelmed with what I am about to walk into. These patients do not just have COVID-19: they also have other complex medical conditions that I have not encountered since medical school. I also learned that because we are limiting PPE, time spent in the room by any health care professional should be very limited and visitors are not allowed even if the patient is dying. This means the only real human interactions the COVID-19 patients will have are in the few times medical staff go into their room. My heart is heavy thinking of how lonely and scared these people must feel. I can’t imagine going through such an uncertain illness without the comfort of my loved ones.
Orientation day two was spent shadowing. Walking into the work room, it was chaos. The systems for how patients get moved on and off the COVID floor was constantly in flux. We were at capacity and needed to move out all confirmed negative patients. There was a tense discussion on logistics to conserve PPE. I rounded with the current intern. Our first patient was dying and COVID positive. We donned our PPE and went into the room. He was barely responsive, taking intermittent agonal breaths. This man will die in this room completely alone. Our next patient was COVID positive, asymptomatic and only admitted because he did not have secure housing. After we told him that he had COVID, he begged us to keep him admitted so he didn’t have to sleep on the streets because no shelter would take him if he was COVID positive. This is an issue that keeps coming up: patients unable to self-isolate even if asymptomatic end up staying for one to two weeks due to inability to safely discharge. There has to be a better option when resources are so limited. I finished my orientation and had to walk through labor and delivery to get to my call room. Immediately upon walking onto the unit, I was accosted about why I was there. I explained that I had cleared it with infectious disease, but later I was notified not to come on the unit and that I need to use a different call room while I am working on the COVID floor. The obstetrics and gynecology department is my work family and, with social distancing and isolation, a huge source of strength and support. My rational brain gets their fear, but I still felt ostracized and alone.
COVID ward day one started with the expansion from two to four teams. I had only two patients, so I could ease into the role of a medicine resident. Both were stable and on the recovery phase of their COVID course. I rounded on them over the phone and my attending did their physical exam to conserve PPE. All the new systems were overwhelming, new ways of handing off patients, different paging norms and COVID patients that require very specific care plans. I spent most of the morning learning all the nuances. Later, I accepted a COVID-positive transfer from the ICU. She had come in the day before with worsening shortness of breath. In the emergency room she had been desaturating on three to four liters of supplemental nasal cannula oxygen. All night long she was on the verge of intubation, but somehow she improved and by early afternoon she was on room air ready to come to our floor. Just doing a physical exam is no easy task. It starts by going to the supply room and getting a battery pack for powered air purifying respirator that you strap around your waist. You plug your mask in and place it over your head and face. The respirator is positive pressure, extremely loud, and sounds like a wind tunnel (Figure 1). You then put on your gown and gloves making sure to hand sanitize between each step. You look and sound a little like an astronaut (Figure 2). Listening to heart and lungs is almost impossible with the whooshing of air in your ears. It’s ironic that the most important exam is almost impossible with the safest form of PPE. Next, you do all the things the nurses ordinarily do to prevent them from having to come into the room after you and use up more PPE. So I stayed with my patient for another 30 minutes to walk her to the restroom, help her clean up, and get her resituated into her bed. Now it’s time to doff my PPE, which takes about 10 minutes if you are efficient. I ended up spending 20 minutes with the nurse reminding me of each step.
COVID ward day two began with an admission. He was a homeless patient with a chronic cough well known to our COVID service. He’s been admitted twice for “rule out COVID.” He’s never had fevers or chest X-ray changes, but he knows that if he gets a COVID swab he has to be observed until the test results come back because he does not have a safe space where he can self-isolate. So he gets admitted, gets warm meals and a nice private room, and 24 hours later when his test results come back he gets discharged. He will most likely test negative, be discharged, and return in a day or two. I really can’t fault him, if it were me, I might do the same thing. But I can’t help feeling frustrated by the amount of resources and time this takes up. Because now he requires PPE. Our precious PPE. Yet no one wants to risk not admitting him. He has all the risk factors and exposure to contract COVID and could get seriously sick. If we had unlimited resources, if I didn’t get an email daily about how we need to conserve PPE I would not be frustrated. I am saddened by how frustrated I am. I feel the pressure this pandemic is placing on our medical system and I am not alone. The stress is affecting clinical judgement. In the time of COVID it feels like everyone has forgotten that other diseases exist. We had an admission overnight for neutropenic fever and no work up was done. She was severely neutropenic and instead of doing an extensive work up, it seemed to me the thought process was this: fever? yes; COVID? probably. She ended up testing negative. It’s incredibly easy to narrow your focus and forget that the world that existed before COVID still exists. People with heart failure still have heart failure in a pandemic. And our broken health care system and limited resources for undomiciled people still exists.
COVID ward day three starts with my daily check of the ICU census, mostly in the hopes that patients get better and can be transferred to us. This has happened a few times, but never to a patient that was intubated. We have yet to have a patient be successfully extubated. It’s scary. Many of the patients have preexisting conditions who end up being extubated but not all of them. Some are completely healthy. I am 31 years old, healthy, with no preexisting conditions and even though I know I fit into the low risk category for mortality from COVID, I can’t stop thinking I am not that different than some of our sickest ICU patients. What if I got sick? I could end up in that ICU, intubated on multiple pressors. When you’re paralyzed and intubated you are powerless. It’s unnerving to think about having such little control. I would be completely vulnerable and exposed, to my colleagues and my friends. My thoughts spiral when I am reading these ICU notes. This disease creeps up on people. One patient’s family could not be convinced that their loved one was near death. In reading the palliative care note, the mother just kept saying the hypoxia is just from obstructive sleep apnea. It’s almost impossible to grasp how rapidly people’s lung function changes with this disease. They are fine until they are not fine. Both of my patients today were relatively stable. I think all of us on the COVID units are just waiting for it to get really bad. For the surge to hit. It’s an eerie feeling waiting for a disaster. I have this uneasy feeling with my COVID-positive patients too: even when they are stable, I am just waiting for them to get worse.
By COVID ward day four I realize I have never done so much sitting in residency. In obstetrics and gynecology, we are hustling around trying to get everything done. You are lucky when you have time to sit and finish a note without being interrupted. But this is a different life. We come in each morning and review our patients’ charts (sitting), then do table rounds (sitting) with the resident team, then we do table rounds again (sitting) with the attending. Then we get up, examine our patients and then return to the work room to write our notes (sitting). After our morning notes are complete, we make family phone calls and call consults and look for new results (sitting). I got so desperate for some physical activity, I went and ran eight flights of stairs. So why do we have two residents sitting just waiting for admissions on the COVID floor? Shouldn’t we be limiting in-hospital personnel to only what’s needed? What is eerie about this pandemic is everyone bracing for it to get as bad as Italy and New York. But no one can predict if we are going to be overwhelmed tomorrow or not at all. So we keep sitting and waiting for admissions. Toward the end of my shift I admitted a healthy 34-year-old with COVID. She is one of us: she works at our hospital. She was breathing room air, not tachypneic, mostly just very anxious, probably because she has seen what COVID does to people. When I went to examine her, she looked terrified. In my full PPE, I told her we would take really good care of her and we would do everything we could to help her get well. She had no risk factors. She was healthy.
On COVID ward day five I learned that she got much worse in the evening and started struggling to breathe. She was transferred to the ICU and emergently intubated. In this illness, intubation feels like a death sentence. I know that’s not entirely true, but we have only had one person live through extubation and he is still really sick. Did this patient know that? When they told her they were going to intubate her was she thinking she may never breathe on her own again? She is like so many people who are working with COVID patients: young and healthy. I have been almost ritually telling myself that I would be fine if I got sick, it would be mild if anything. But seeing this patient’s rapid decline got me scared. I started anxiously taking deep breaths just to reassure myself that I wasn’t sick. I did not think I had COVID but this patient’s story made me question my confidence in my health. No one can know who will get really sick or who will die.
On COVID ward day six I have a lot of people reaching out to me to ask how I am doing and what working on a COVID floor is like. I struggle to talk to them about it honestly. I don’t think they really want to hear that it is scary or that people I didn’t expect are getting seriously ill, people like them. My sister texts me every day to see how I am doing, but I don’t tell her about the times I force myself to take deep breaths for reassurance, or about the patient who looked just like me who is now intubated and proned. Working on the COVID unit I have seen people get better which is reassuring. But they aren’t the patients I keep thinking about. The other ICU transfer yesterday was an 86-year-old with many health issues, but full cognitive capacity to make his medical decisions. He desired full code. His hypoxia got progressively worse and intubation seemed imminent. With his many medical problems he would most likely not survive CPR and if intubated would not survive extubation. We readdressed code status with him, explaining what full code would mean for him and again he wanted everything done. When we transferred him to the ICU, the attending intensivist again asked him about code status and again he confirmed full code. What is going to happen if and when we get low on ventilators? It seems crazy to intubate someone who will never survive extubation, especially if tasked with having to choose between them and a young healthy person with COVID. I cannot imagine having to make that choice or explain that choice to the family of the person who didn’t get intubated.
COVID ward day seven begins with a patient who has been on our service for over a week. He initially presented to the emergency department because he wanted a shower. He was screened for COVID symptoms because he endorsed a chronic cough which bought him a swab. He tested positive and because he is homeless and there are currently no shelters accepting COVID-positive patients he will have to stay admitted for at least fourteen days. He has yet to have any symptoms of COVID and every day he asks to be discharged. There are two reasons why he stays. We cannot discharge homeless patients who are COVID positive unless we have placement for them or they retest negative. He has been retested twice and is still positive. He is also paraplegic, so he physically cannot leave against medical advice without our assistance. We would have to put him in his wheelchair and assist him out of the hospital which the nurses and attendings do not feel comfortable doing since he is COVID positive and would return to crowded streets or homeless shelters and possibly expose people. I am struggling with the ethics of this. I see why people are uncomfortable discharging this patient. He is a public health risk but keeping someone with full capacity in the hospital against their will still feels wrong. When does protecting the public override an individual’s rights? Today I convinced him to stay by bringing him a coffee from Dunkin Donuts.
Every day I go to the COVID ICUs to get updates. So far I have transferred five patients and all are still very sick. Walking through the ICUs and seeing bed after bed of proned patients on ventilators is unnerving. We currently have five ICUs full of COVID patients, with almost as many patients as all of the wards. Even our pediatric ICU is now being used as an adult COVID ICU. Most of our operating rooms are empty, with equipment draped and silently waiting to serve as additional overflow. Nurses from all over the hospital are being pulled to work in the COVID floors, just like us doctors. Everyone is masked, all of the time. There are no more in-person meetings. This experience is not at all what I expected in residency, but it has taught me that the resiliency of my fellow health care workers is truly astonishing. We are all pushing ourselves to function effectively in unfamiliar positions, on new teams, and against a disease that none of us had ever heard of. It’s hazardous and frightening and no one knows how or when this will end.
Tomorrow I start my second week. I hope that I’m still ok at the end of it.
Abby Schultz, MD is a resident in the Department of Obstetrics and Gynecology at Tufts Medical Center in Boston, MA.
Disclaimer: The thoughts and opinions in the Frontline Voices initiative reflect experiences of individual ACOG members and do not represent official organizational opinions of ACOG.