It doesn’t take long in the practice of medicine, indeed in the training for the practice of medicine, to learn humility. To understand our limits in our understanding of a disease process, in our abilities to heal patients, and in our own importance in the grand scheme of things.
Yet as physicians and as experts we are socialised to exude an aura of authoritarianism in the medical decision-making process as it applies to our various specialties.
Life is a long lesson in humility
J.M. Barrie
COVID-19 has made some of us uncertain as we care for our patients. We have become anxious. We feel less than as we watch people infected with SARS-CoV-2 get ravaged by it. We know that we are not incompetent but somehow COVID-19 has left us feeling impotent.
The other day, a hospitalist friend broke down in tears after just pronouncing the third death of the morning due to COVID-19 while bracing themselves for that phone call to the family. In providing comfort, I had to remember that now more than ever we have to support each other through the many struggles this pandemic is putting us through.
One of the great responsibilities in doctoring is alleviating suffering. That hasn’t changed. But the novelty of COVID-19 means we all are limited in our fund of knowledge. While there are tons of literature coming out in the past few months it has been difficult to weed through each to decide which contains the best data to inform clinical decision making. The rapid dissemination of data and protocols shared by various hospitals has been impressive. It helps to calm the mind to know that one is not alone in our individual institutions. We are all rising to the challenge to learn while taking care of our patients. Still, we yearn for the randomized control trials which hopefully will provide data that will support the evidence-based approach we prize in the practice of medicine.
COVID-19 is indeed a terrible illness. That we leave our patients to manage without their families for support and we leave said families feeling hopeless at home to grieve without a chance of in-person closure is enough trauma as it is.
The grace of humility is a precious gift.
Sir William osler
I have yet to be convinced that any particular medication is making a difference. Almost every patient is getting hydroxychloroquine with or without azithromycin off-label per adopted protocols and it doesn’t seem to be making a difference. The remdesivir compassionate use report essentially tell me it works for some, but for whom, that I am not sure. Plasma antibody therapy, in theory, sounds exciting, but will it be effective in practice?
We may not have a cure for COVID-19. Yet, it is humility that drives us in the continuous pursuit of knowledge.
I think back to just over six weeks ago. How much our world has changed. Before the practice of universal masking on hospital grounds. Before the closure of the hospital to family and friends of patients and any other visitors. Before the sequential conversion of medical-surgical floors to COVID-19 units. We are up to five now. Before the cancellation of elective surgical operations and other procedures. Before having no choice but to attempt to keep one’s medical practice afloat through the use of telemedicine.
I remember in the very beginning before even our very first COVID-19 patient seeing for the first time the hairless faces of male colleagues, faces selflessly shaved bare in anticipation of fit-testing for N-95 masks so as to protect self, patients, and family. We were enervated. We could do this.
But then the slow realities. The patients were not going to present all neatly tied up as COVID-19 infected. No, if we were to not expose ourselves, we would have to be super-vigilant. How far have we come in about a month where now it doesn’t even matter if the patient presents as a motor vehicle accident, best to make sure they don’t have COVID-19 in addition.
We, physicians, are but humans. That first time donning the personal protective equipment (PPE), gown, gloves, N-95, face-shield, wondering if this was enough when photos of healthcare workers in China and Italy show them in multiple levels of head-to-toe spacesuit protection. Then doffing making sure not to contaminate self in the process. Wiping down face shields or PAPRs with bleach-wipes, storing masks both surgical and N-95 in brown paper bags, wondering what sense our reuse of PPE makes when any other day these would go promptly into the trash since they are designed for single-use purposes after all.
Slowly coming to the realization that if we come anywhere close to the numbers of COVID-19 patients elsewhere in the world we would not feel safe. Overnight it seemed all physicians had transformed into wearing scrubs. Not hospital-supplied scrubs mind you but personally procured scrubs. I wonder how much FIGS has profited in the past month or so.
When I finished medical residency in 2007 I was so happy to never have to experience an over-night shift in the hospital ever again and to never have to be in scrubs. Yet, here I am. Do I now need to go dig up my Marino and re-learn ventilator management as well? Watch videos on how to intubate a patient or place a central line as a refresher? Yes, I re-certified for Internal Medicine in 2017, but how would I fare if I had to respond to a surge redeployment as a hospitalist or worse yet an intensivist. Would surge redeployment be covered by medical malpractice insurance?
After one week of taking care of COVID-19 patients, I had had enough. I could tell my fellow colleagues felt the same. And this was just the beginning.
The impending sense of doom. The constant worry of contaminating oneself or suffering a different breach in the use of PPE. Being keenly aware of one’s own health and mortality. Trying not to become a patient as we take care of patients. Discovering meditation apps like Calm and Headspace, the latter which is free now to healthcare workers. Being committed to daily exercise like never before.
White coats have essentially disappeared in the hospital. One less potential fomite. Rings. Gone. Watches. Gone. Phone into a Ziploc bag. Stethoscope? What is there to gain from a chest examination of a COVID-19 patient except for the increased risk of infection of self? If we have limited access to PPE is it not the right thing to limit the number of people who use them? To that point, if I am a consultant, what is there to be gained from entering an isolation room? Could I not just speak to the patient using their bedside phone? Examine them from the window of their door?
For those brave enough, changing into street clothes in the hospital parking lot before driving home to family. For others, driving home in our scrubs to strip naked in the garage and dash for the shower before greeting any of our family at home. For others still, renting a separate apartment so there’s no chance of becoming a vector of transmission of SARS-CoV-2 to our loved ones sheltering in place at home.
Wondering if today is the day we have become infected with SARS-CoV-2. Hoping that if we are unfortunate indeed to have COVID-19, we would be one of the lucky mild cases, ill for a bit, but soon to make a quick recovery.
Yet to be sure, it’s time to review the estate planning documents. Do I have enough disability insurance? What about life insurance? Perhaps I should update my beneficiaries. Do I have an Advance Directive? A will? A trust? Does my next of kin know that if I end up intubated for weeks at a time I need them to pluck my whiskers? That I want the TV station turned on to the ambient sound of waves crashing on the shore and absolutely not to any news channel? That I need three to four blankets on me at least? If I were to die, would my family know how to access all my accounts? Must leave directions and a list of passwords.
But wait, if I were to get sick enough to need hospitalization, would I want to go to the nearest hospital, or should I ensure that I make the trek, somehow, to my hospital, where people know me, where perhaps someone would go the extra mile to get me access to an experimental therapy if I am deteriorating? Asking myself if I’m willing to have a tracheostomy placed if needed?
It’s been about a month now. Every day brings us more COVID-19 patients. When we are not taking care of COVID-19 patients, we are reading COVID-19 literature and tweets, listening to COVID-19 podcasts, writing COVID-19 protocols, trying to avoid COVID-19 political media, and dreaming COVID-19 dreams.
Lately, some days are worse than others in terms of the ever-increasing numbers of new cases. Some of us are convinced that surely by now we have been infected and that by the grace of God we have all been asymptomatic. Or maybe that tension headache from the exhaustion of constant vigilance, or that seasonal allergy cough, or that chlorhexidine mouth rinse for a dental infection that altered our tastebuds are all proof that we are suffering from COVID-19 right this minute. Physicians, yes we are. Hypochondriac none-the-less to be sure, unfortunately.
We are fed up with this our new normal. Waiting for the surge. The frustration of knowing that when some of our patients deteriorate there’s not a lot we would be able to do, except to attempt to alleviate their suffering, while watching, wishing we had a magic pill to offer. Wondering how much longer we can keep ourselves mentally and emotionally intact. The strain of it all.
It is appalling that physicians and nurses are turning to the use of garbage bags for gowns in the United States of America. It is equally dreadful that the CDC guidance for PPE includes the use of bandanas in the absence of actual protective masks. If we fall ill or die from COVID-19 because of our profession, to what purpose? I read about physicians being fired for raising alarm over the lack of PPEs, of hospital systems placing gag orders on their healthcare workers, of residents being put into unfair and unsafe positions. I realise that to the healthcare system we physicians are expendable. But that’s the thing. We are not expendable. It’s up to each of us, therefore, to make sure we are well protected. For ourselves. For our loved ones. For our families. Fear? We all have it. I am not trying to be a hero. No. I just want to stay alive. I’m sure my colleagues feel the same. Yet despite our fear, we show up.
We are showing up. It remains unconscionable that we be in a position to crowd-source our own PPE or to re-use the one mask we were assigned a month ago but here we are. Showing up. Putting on our brave faces. Trying to leave our fear and frustration at the door. Signing up for extra hours at no additional pay, some of us unlucky enough to work harder for less pay as our hospitals say they feel the crunch of the lockdown. We are now both healthcare providers to our patients as well as their new family, holding their hands so they do not die alone.
Humility. We have to believe we are strong. Yet we have to stay smart to stay safe. Stay focused. Take it one day at a time. Try not to take the despair of the patients home now more than ever. Try to engage in relaxation activities. Turn off the news so we are not faced with reports of people who are not social distancing, people who sooner or later will be patients in our COVID-19 units, or faced with the political opinions that don’t mesh with scientific principles and medical common sense.
Now more than ever, we physicians are expected to exude that aura of authoritarianism. So we must quell the fear we carry to be able to show our patients and staff who rely on us the face of a physician in control. We must reach out to one another showing love and compassion for we are in these trenches together. For me, I have realised that I need to make time to reach out to my extended family across the globe because they are scared too, for themselves yes, but unfortunately for me in my profession as an infectious disease physician, trying to reassure them that I am okay, indeed I am okay.
Take therefore no thought for the morrow: for the morrow shall take thought for the things of itself. Sufficient unto the day is the evil thereof.
Matthew 6:34 KJV
Beautifully written, my friend. Praying for your safety and strength.