Medical Examiner

Bracing for the Coronavirus in an Empty ER

In this emergency department, our caseload isn’t doubling. But not much else is happening either.

A nurse in PPE preparing to enter the room of a patient being tested for coronavirus.
Matthew Paré puts on personal protective equipment at Maine Medical Center in Portland, Maine, on March 11. Brianna Soukup/Portland Press Herald via Getty Images

When I work an overnight shift in the ER, my body temperature always drops around 4 a.m., an oddity I thought I’d gotten used to. These days, though, it’s taken on a sinister quality—the slightest chill could be the harbinger of a coronavirus-induced fever. I cough into my mask and hope it’s just my allergies. Unlike ER doctors in New York and New Orleans, we have the time to indulge in hypochondria, because things are slow here in central Virginia, at least right now. COVID is here with us, but weeks go by and our case numbers don’t double. Most people I test don’t have it. But I keep testing, because the ways that people come in with COVID vary so greatly. Passed out on a front porch. Pain in the abdomen. Conjunctivitis. Confused and drove into a tree.

We keep reading the gut-wrenching news from other cities and telling ourselves we are lucky, so far. But there’s a unique horror in sitting back and watching the rest of the world struggle and not knowing if we will be next. We see COVID in our ER just enough to be afraid but not enough to be familiar with its myriad presentations. I’ve been doing this job for more than a decade, long enough to know that I’m good enough at it; I’m not good at the coronavirus. Everyone who I think has it doesn’t. I test and test, and I’m wrong over and over again. And then there are the surprises. The patient I signed out who I thought was having a psychotic episode decompensates hours after I leave my shift and ends up on a ventilator: COVID. I go over her case in my mind again and again, searching for clues that I missed. And I wonder if I will ever trust my clinical judgment again.

The slowness is difficult. Everywhere in the country, the regular patients, the bread and butter of emergency medicine—heart attacks, appendicitis, alcoholic pancreatitis, drug overdoses—are not coming to the hospital. We are not used to sitting around with nothing to do; it’s even harder to do that when we know that just a six-hour drive from us, ER hallways are full of COVID patients, and we realize these might be the good times for us. Are we supposed to enjoy them? We don’t know if people are dying quietly at home, or if it turns out they just don’t need modern medicine after all. We feel purposeless as we wait for non-COVID patients that aren’t coming in the short term and terrified as we wait for COVID patients who we know are coming in the future. We worry that just when things seem to be under control, restrictions will be lifted, and our numbers will spike. At the same time, we worry that restrictions won’t be lifted, and patients will die at home of treatable conditions.

I try to remind myself that things could be worse. I am glad this disease affects children less (I have two of my own, and I see pediatric patients); I am relieved it doesn’t cause encephalitis, a horrible brain infection; we are unlikely to be as affected as New York, sparsely populated as we are. But as the pandemic changes not only what my job is but who I am, it becomes increasingly harder each day to think of anything with positivity. There’s new bad news all the time. A child dies in Detroit … from COVID encephalitis.

Each week a different doctor friend talks about how they are afraid they will get it and die.  There are many professions in which death is a legitimate fear, but for most physicians, it hasn’t been until now. I’m a manic dreamer at the best of times, but now I find scenes from my life, mostly my childhood, popping up in my brain, unbidden, even in my waking hours. Perhaps this is my life flashing before my eyes in slow motion. I tell myself our case numbers are so low my risk is negligible. But then I wonder: As we continue to see few patients who really have it, will we begin to let our guard down? Will I bleach-wipe less diligently, forget not to touch my face, wear my work shoes home by accident? And what is the long-term cost of all this hypervigilance in a field where making quick decisions is essential?

I decide I won’t be much good to anyone else in a constant state of anxiety, so I make a phone appointment with a friend’s therapist. But I find myself editing what I tell him. I don’t want to make things worse for him, by coming to him as an “expert” (as if anyone can be an expert in this strange disease) with my fears. Besides, isn’t anxiety the only rational response to this? I’ve said as much to a patient having a panic attack over the state of the world.

The most difficult questions come from my residents. I’m their boss and their mentor. They, not yet full-fledged doctors, are both brave and understandably afraid. They hear about their counterparts across the country struggling, seeing patients without PPE. Fake and real news about resident deaths abounds, to the point where I, and other program directors, have to investigate every report before it causes hysteria. One of the residents has family in Hubei province, so while we have only been anxious for a few weeks, she’s been anxious for months. One day an email from the hospital says we only have five days of N95s left. We don’t know what the backup plan is. I spend hours responding to questions by text that I can’t answer. I don’t know how to manage the residents’ anxiety on top of my own. Finally, on the advice of a friend, I email them and honestly say that I don’t know what we are going to do but that I hope the institution will come through for us. It does. We now have more than 200 days of N95s.

In person, my residents are nonchalant. We joke and laugh at work. When they have real concerns, they tend to ask me in writing—by text, over email. My own concern is what will become of their education. Residency is an apprenticeship. They learn by doing, but we are not doing much of anything. I haven’t reduced a fracture, sutured a laceration, or diagnosed a heart attack in weeks. In the absence of treatment, we turn to preventive care. It’s not really emergency medicine, but some colleagues and I start looking at food insecurity screenings we can administer in the ER, to direct people in dire financial straits to community food resources. It makes me feel better, but how will I teach my residents the common causes of respiratory distress, of chest pain, of diarrhea, so they can practice emergency medicine when we are past the era of COVID? And will they lose faith in a system they have only just joined, whose holes and cracks and failures are being pointed out in the most glaring of ways? Will they lose faith in their educators, whose clinical acumen is worthless in the face of this new disease? Some of them will be spending the better part of their three-year training program in masks and goggles. It’s not what they signed up for. It’s not what any of us signed up for.

But it kind of is. I don’t want to be a hero. I do want to fight. We love emergency medicine because of the chaos. Many of us chose it because we love walking into a mess and leaving slightly less of a mess, eight to 12 hours later. We are used to dealing with the unexpected. Now, it’s waiting for the expected that stymies us. We are used to inhabiting a world where it’s always the worst day of someone’s life. But those are stochastic events, and it’s easier to help patients when your own life is on a firm footing. I don’t even have that to offer these days, now that we are all living in a common hell.

I tell a construction worker we will test him for the coronavirus before sending him home. He looks at me and says sadly, “I just want all of this to go away.” I can only reply that I do too, and then we stay in silence for a moment, looking at each other, realizing neither of us has any other words of comfort to offer.

On particularly difficult days, when I come home, I wash my hair with the same shampoo I used when I was in high school. One of the effects of wearing a mask all day is that the senses of smell and taste are intensified. As the sweet fragrance of my youth wafts around with the steam in the shower, I feel 16 again, when my biggest worries were about a boy and a hole in the ozone layer, and I thought I would grow up to change the world. For a moment, I am optimistic that maybe a glimmer of that hopeful person might make it through this to the other side.