Medical Examiner

What Can We Even Do to Treat This Thing?

It’s Week 3 in New York City ERs. The miracles are the patients who survive.

A kitchen with a box of Matzos on the table.
Photo illustration by Slate. Photos by Getty Images Plus and Amazon.

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 and Week 2 here.

Dr. Serino, April 7

I lied to my mom today. I told her I was cautious, but not worried, and that things would be fine. Things are what they are, and we will get through them, I said. She told me that she was constantly worried about me, and that it kept her up at night. So I repeated, “I’m fine. It will be fine. I’m low risk and I’m scrupulous about protecting myself at work. I don’t cut any corners.” She was silent as I went on about how we just have to be patient and careful. I was calm, verbally economical, slightly pedantic. So, not like me at all. ”I’m not worried,” I said again. And because she knows me, and knows that I am nothing if not worried—it’s my nature, my birthright—she knew I was lying.

My mom and I are close. The woman reads my mind. But she let me lie, because she needed to believe it too. The more I say it, the more I may start believing it myself. There was no way to keep up with the crushing anxiety of the first week, or the mounting dread of the second. But the strange acceptance that’s replacing both makes me nervous. If I become too accustomed to this new order, will I become complacent and slip up? If I really start to believe it will be fine, if I relax into thinking I will be fine—is that when I’ve jinxed myself? Magical thinking like this is intrusive. I don’t like it, but it’s like a gnat buzzing around my thoughts.

Every night before bed, my boyfriend reads Lord of the Rings to me, to quiet my mind. Books are my bibles. Stories have always been my dress rehearsal for life, a way to expand my emotional vocabulary. When I face something new, if I have experienced it in my imagination through reading, I feel somehow prepared. Or, at least, I feel like I can recognize some of the foreign ground I find myself standing on. Books remind me how to be in the world when I feel adrift. So it makes sense that I would turn to a tale that asks its characters to take on responsibilities they couldn’t ever possibly feel ready for right now. Early on, there is a scene between Gandalf the wizard and Frodo the hobbit, when Frodo discovers the true nature of the One Ring and realizes that a fight between good and evil is not in some distant future but must be dealt with now.

“I wish it need not have happened in my time,” said Frodo.

“So do I,” said Gandalf, “and so do all who live to see such times. But that is not for them to decide. All we have to decide is what to do with the time that is given us.”

I’m fine. It will be fine. Things are what they are, and we will get through them.

Dr. Serino, April 8

Nice guy is alive. I can’t believe it. I checked his chart twice. Not well, not extubated, but alive. I know that doesn’t mean he is going to stay that way. Even so.

Less great: Two more of my residents are sick. COVID, of course. Even without a test, we know. Their symptoms are familiar. My first impulse is to be frustrated. Didn’t I tell them to keep the mask on? Didn’t I say to wipe down the phone, or to not eat at work? I hate that impulse. It’s the same one that leads us to ask, “What were their underlying medical conditions?” when we hear about a young person dying. If someone was careless, that’s why they got sick. Therefore, if I am not careless, I won’t get sick. If someone had underlying conditions, that’s why they died. I don’t have that condition, so I won’t die. It’s comforting, maybe, to blame a victim. It gives a sense of control. But it’s not true.

My residents worked so hard to stay healthy. I know that. I wonder if I had gotten more PPE sooner, would that have made a difference? Maybe it really is just a matter of time till we all have it. Maybe it will be a different kind of relief once that’s happened.

It’s Passover tonight. About the most Jewish thing I could be doing is trying to get a plague to move past our home. I’m not religious, but I received a box of matzo from my college rabbi and the promise that he’s praying for all of us working in the hospital. I’ll take it. Being kept in someone’s thoughts feels powerful, even if no one but the thinker is listening. So I ate some unleavened bread and had some wine and toasted one Jew in particular: my grandmother, who survived the Holocaust and who never lacked an opinion. Whatever she did lack, it was not perspective. If she were still alive, I’d tell her about treating patients in a pandemic. I’d tell her about the dearth of PPE, the rapidly disappearing medical equipment, the colleagues getting sick. Then she would look at my face, scrunch hers in disapproval, and trace the ugly bruise marks left behind by my mask with her finger. She’d sigh and say in Yiddish, “Es felt mir vi a lokh in kop.” We need this like a hole in the head.

Dr. Serino, April 9

I lied to more patients today. Honestly, I lie to a lot of patients. Every shift.

“It’s going to be OK,” I said yet again, while my gloved hand squeezed her gloved hand. I am trying to reintroduce brief, protected, touch. “It will be OK.”

It might not actually be a lie. If they’re being intubated, there’s about a 20 percent chance that a flipped coin may land on the side of truth. The odds are well over 50 percent if they’re just on nasal cannula oxygen. Sure, we’re limiting my predictions to a 24-hour period. At any rate, I don’t really know. They must know I can’t be sure. As much as patients want certainty from their doctors (how long do I have, will I live, will this hurt, what do we do?) the one big truth in medicine is this: You will never get certainty. We don’t have any. We’re great gamblers but terrible psychics. The closest thing I have to a crystal ball is the glass marble hanging from my keychain.

Emergency medicine is about playing the odds. Do you seem safe enough to go home? Would I bet my license that you won’t decompensate if I don’t admit you? Did the last 50 people I treated with your condition and general level of health do well on outpatient therapy instead of coming in?

Recently we also have to ask: Do we have beds available? Are there enough oxygen tanks? Could you make it through one more day at home?

We’re trying to answer the questions as best we can, even when the answers keep changing and the questions themselves may be all wrong. COVID, I have learned, is a trickster. The way it manifests so differently and in a myriad of ways. It’s slippery. I sometimes get upset with myself for being so interested in something that is so destructive. It feels like a betrayal when I stop feeling fear or worry and get intellectually excited by COVID-19.

I know that’s counterproductive, to blame myself. Fascination is what opens the way to solutions in medicine. So I try to quiet that self-flagellating chatter for a few minutes every day. I meditate a lot. Lately I’ve been focused on the idea of impermanence. Nothing is forever. There is no stasis in life. If so, maybe things aren’t good or bad, they are just happening or not and it isn’t my job to assign a value judgment. My job is to support the side of life, to offer comfort. Maybe things won’t be fine, like I tried to convince myself the other day. But maybe I’m not lying after all: It will be OK, even if things aren’t fine. That’s what I’ll tell everybody, most of all myself—it will have to be OK.

Dr. Serino, April 10

Today we discussed the number of ventilators in the hospital. It’s grim mathematics. We talked about how many vents we anticipated needing and how many had become available.

Available.

Want to know how they become available? It isn’t because the patient was extubated and is now at home, healthy, with their family.

And it isn’t because we got a new shipment.

Dr. Serino, April 11

I woke up from another nightmare this morning. They’re evolving. Now, instead of being crushed in a sea of dying patients, none of whom I can save—really subtle, subconscious—I’m dreaming that as I leave my shift, I’m kidnapped and forced into being a test subject for coronavirus treatments. I’ve always been a very vivid dreamer, but I feel physical pain in these, which isn’t something I’ve experienced in a dream since I was a kid. In all of them I’m receiving a blood transfusion, and a tight collar—presumably some kind of respiratory device—is clamped around my neck. I’ve been reading and thinking a lot about the vascular aspects of COVID-19 and have been looking into these fascinating pressurized hood devices that we might be able to use in lieu of intubation, so it doesn’t take Jung to figure out where the imagery is coming from. But to feel it? To be completely helpless and not wake up—even the few times I realized I was dreaming—is surreal. It only further intensifies the mounting sense of the uncanny. It is not my preferred way to experience empathy.

One of the stranger parts about being in the epicenter of a pandemic that is gathering strength at different rates around the country is the sense that you’re in a different timeline. We’re in the future. Kansas is probably two weeks behind us. I can have conversations with five different ER docs and know what they will say based solely on their geographic coordinates. Being the first—having what these days goes as expertise on a subject we still know so little about—means that now, I talk to doctors outside NYC discussing their first intubations, their observations as the cases start to trickle in, and think: We’ve done that, we did that too, didn’t they hear us say not to do this or that? But saying it and seeing it are different things. I want to be clear about all our missteps and the ways that a lack of preparedness snowballed into so many deaths. I want to be learned from.

I’m reminded of a wonderful demotivational poster I received as a present in college, the kind that makes fun of all those office wall garnishes showing photos of high-fiving mountain climbers with captions reminding you that you can ascend higher if you don’t climb alone. But the poster I had showed a picture of the Titanic, already half-sunk into the ocean, with the caption: It could be that your life is meant to serve only as a warning to others.

There are days when I feel like all I’ve done is pressed a few buttons on the respirator to see if changing the settings will help and flipped patients onto their stomachs like hypoxic sausages in an attempt to see if proning will improve their oxygenation, while watching the death count reach 800 yet again. On those days, I think: Well, this is the definition of insanity, doing the same thing over and over and hoping we get a better result. But we have no choice until someone comes up with a better idea.

I hope people are paying attention. I hope that the constant stream of observations we make, though some are barely scientifically tenable, are helping to forward the conversation. That’s been a positive. The global medical community has rallied. We are talking to one another, we are asking questions, we are not afraid to be foolish. I can’t tell you how big a deal this is among doctors. We’re less scared to say something that may be wrong, or seem stupid, now. We’re being more compassionate when something turns out to be incorrect. Most of it turns out to be incorrect. We’re describing our experience of COVID the best we can. We’re blind men all trying to identify the elephant by describing the part under our hand.

So even though it’s frustrating that the recommendations keep changing, I also find it heartening. It means we are willing to be flexible. To change course quickly. Time is not on our side, believe me. The future New York City is living in is not so distant for the rest of America. We already know how it’s going to turn out in other regions, we already know who is going to be making the same social and medical decisions next. In the end, we are more than just a doctor to the patient in front of us. We can help treat patients we will never even see if we further the real work by being part of the conversation. If we are quiet, we are sitting out of the fight. So we have to do something foreign to most of us: We must be journalists. Only in telling the stories of our patients’ medical courses, of treatment outcomes, of the way we manage the flow of cases, can we help reach a happier ending somewhere else. The ending to New York’s story should have the highest body count in the country. If it does, we’re not just good doctors; we’re good editors. Every writer knows your first draft is terrible. It teaches you what not to include in the next version. So, OK, we are serving as a first draft. Maybe some of our purpose is to serve as a warning to others. Maybe that’s OK.

Dr. Keene, April 13

A physician’s assistant approaches me as I’m wiping down my station at the start of another shift: “Remember that patient we had a few weeks ago? The one who you instructed to call his wife before we induced a coma and intubated him?”

Yes, I do vividly remember him. I remember struggling with the decision of whether to put him on the ventilator, because he was still able to maintain his airway enough to breathe—but he was also breathing at 50 breaths a minute and tiring out. A fiftysomething-year-old male who was relatively healthy, tiring out just breathing. I remember explaining the process of medically inducing a coma, inserting a plastic tube down his throat, and hooking him up to a ventilator machine to help his breathing. I remember telling him to call his wife as he would not be able to speak to her afterward, and she would not be able to visit him in the hospital. I also remember thinking he was relatively healthy otherwise and might recover eventually.

I nod and look at my PA expectantly. “Well, he didn’t make it—he died from COVID-related myocarditis.”

My heart sinks. I immediately think of his last phone call to his wife and wonder what he had said to her, if he had told her everything he wanted to say if he knew it was going to be their last conversation.

The overall ER volume is actually noticeably lower compared with the usual. The optimistic part of me hopes this means that maybe—just maybe—we have seen the peak in new cases and are turning the corner. But the other part of me wonders where all the other non-COVID patients are. Where are the usual chest pain and abdominal pain patients, the congestive heart failure and asthma exacerbation patients? Are these patients staying home even when they should be seeing a doctor? Are patients dying at home because of delays in seeking medical attention? I don’t have any answers—does anyone, really?

Dr. Serino, April 13

I’m a guinea pig! It’s not a dream this time. I’ve been accepted to be part of a study out of the University of Minnesota exploring hydroxychloroquine as a preexposure prophylactic medication in high-risk health care workers. One arm of the study will receive a vitamin, one arm receives 400 mg of hydroxychloroquine to take once a week, and the last arm gets 400 mg of hydroxychloroquine to take twice a week. These are the doses we use for anti-malarial purposes. They have a reasonable safety track record, I don’t have any medical history that would keep me from participating, and apart from the possibility of an upset stomach and some very rare side effects, there is no reason not to take part. Other than taking the medications, nothing else changes. I can keep using my PPE at work the same way I have been doing, but now I’ll add a couple of pills and report on my COVID status. The more of us who participate, the better the data will be. Yes, sure, I’m dreaming of challenge trials for vaccines, which are not being performed. Yes, I want the variolation studies that could help us understand if very low doses of exposure really do result in milder forms of disease. Until then? Hydroxychloroquine is a huge unknown. There are some theories on the possible mechanism of actions. But we don’t actually know if it’s broadly useful as a treatment. We don’t know if it’s a good preventive at these doses. We don’t know if it’s a good preventive at any dose, actually. So, this is how we help figure that out. The research nerd in me is thrilled—I’ve always wanted to be a point in a dataset.

The study is only three months. That’s short for research, and for me personally, three months usually flies by much too quickly, but as I sat thinking about it today, it started to feel like a crushing length of time. The constant vigilance—at work, in the grocery store (where the man who coughed briefly next to the celery makes the space feel almost more threatening than work, where I’m nearly hermetically sealed against COVID), in the lobby of my own apartment—takes up such a big part of my mind. I feel exhausted by it. What else might I be thinking about if half my mental energy wasn’t taken up by a constant-infection prevention checklist? I want to feel like less of a vector. Less like a viral landmine waiting to explode on my partner if he gets too close.

I was jealous of a colleague tonight who was diagnosed last week with COVID. He was mildly ill for two days and is back to work already. Being on the other side of it, having the antibodies—he must feel bulletproof. He must feel free. Then I think of another colleague who spent three weeks on a ventilator. Whatever else my brain might be thinking of will have to wait. The sooner we have more research, the shorter that time might be.

Dr. Serino, April 14

Nice Man continues to live. There is nothing in his favor to explain this. In the time he’s been in the ICU, I’ve watched as younger, healthier patients are overcome by COVID in the course of hours. It’s reminiscent of time-lapse videos of fungi consuming the body of a fallen field mouse. Tubes and wires, wrapping and reaching like mycelium, seem to self-propagate. There’s something about being on a ventilator that makes a person shrink. Perhaps it’s just scale, or a fast-moving physical atrophy. But it happens with such rapidity that it seems to be an energetic construct. A literal withering of the spirit. It is palpable the moment you step into a room. There’s an overwhelming sense of reaching out for, and just missing, the string on a balloon that is floating away. Somehow, though, the nice man remains tethered.

I’m not on shift today, but I have remote access to charts and I check Nice Man’s every day. Sometimes more. We all have a particular horse in this race. Every doc has that one patient we cling to as our emotional compass. They alone determine the direction we spin. Oftentimes, it’s the patient we connected with most—the one we had the chance to speak with and learn a few details about before they were intubated, who remind us of our best friend, our dad, our partner. Or maybe it’s the patient to whose viral load we were most exposed. While our whole job is riskier than normal now, there are some exposures that worry in our pockets like a stone.

The phrase often quoted is, “There are no emergencies in a pandemic.” When the alarms sound, you need to adjust your PPE and think, not simply react. But it’s difficult to overcome the impulse to jump in when the light in the eyes of the patient just looking at you snuffs out. Caution makes absolute sense as a thought experiment: affix your own oxygen mask before helping the person next to you. Don’t rush into a cloud of contagion semiprepared, with your poorly sealed goggles atop a 3-day-old N95 mask, even if that’s all you have. Remember you’re no use to other patients if you’re ill, and even less use once you’re dead.

But ingrained impulses are hard to overcome. And delaying a resuscitation, knowing that every moment without oxygen is just a greater cumulative hypoxic brain injury? We are frequently well-intentioned fools, confusing courage with folly.

Only saving their life justifies the risk. We’re trying to figure out when we can really save the lives. So, we watch. When the chart is filled with nursing notes and improving oxygen saturations, we feel like we can breathe ourselves. We feel like we might be able to help. For a moment, the needle points in the direction of relief. That’s as close to hope as I’ll allow.

For more on the COVID-19 pandemic, listen to today’s What Next.

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