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, Week 2 here, Week 3 here, Week 4 here, and Week 5 here.
Dr. Keene, May 1
Today, I learned that a colleague died by suicide. Dr. Lorna Breen, a beloved emergency medicine physician and medical director of the ED at New York–Presbyterian Allen Hospital, succumbed to self-inflicted injuries at a hospital in Virginia after surviving COVID-19 and attempting to return back to work on the front lines. It is devastating news for many, and it certainly hits home. The mental, emotional, and physical toll of COVID is extreme. I see how it’s affected my colleagues, from residents to nurses to techs to EMTs—no one is spared. The feeling of helplessness when one is not able to save lives is a fairly unfamiliar one to many health care workers.
We in New York, being an early major peak of COVID cases in the United States, had been stumbling blind and trying to learn from our mistakes, trying to learn from Italy. As a doctor, I feel so helpless when there is no treatment I can offer, no miracle drug to target the disease. So as a system, we threw azithromycin and hydroxychloroquine at the patients, without any strong scientific evidence that those drugs would help. Now, we have added remdesivir, tocilizumab, vitamin C, Pepcid, etc. Nobody knows for sure if any of those are helping. Normally, it takes months to years for a drug to pass through trials and be ultimately approved by the FDA for use. All that seems to have gone out the window as everyone desperately scrambles for something, anything, we can do to potentially treat COVID. I understand the feeling of desperation, that sense of helplessness and frustration that there’s not more we can do as health care workers. “Desperate times call for desperate measures,” we have thrown caution to the wind, and any treatment is better than nothing, right? But is it? All medications have side effects, and there is still so much we don’t understand about this disease. As I worry about the medications we’re trying, I worry about the vaccines that are being trialed. How stringently has the safety profile been checked? What downstream consequences will we be seeing because we are being less cautious about potential negative effects?
Hour after hour, day after day, we see bodies being lined up on ventilators and know that only 20 percent will survive. We provide iPads to patients to communicate with their families while we as strangers hold their hands, we make heartbreaking and devastating phone calls to break bad news to loved ones. … The traumatic impact of COVID on health care workers is tremendous. I worry about the well-being of all my colleagues, and I am concerned that there will be a significant surge of PTSD in front-line workers. I am also apprehensive that many might not seek out care—”doctors make the worst patients,” as the saying goes.
I am endlessly thankful for the wonderful support system I have. But I know that not all are so lucky. There has been a noticeable increase in the number of patients coming into the emergency department with mental health complaints. In the last shift, I had at least one patient every hour who came in complaining of depression, anxiety, etc., and requesting a voluntary psychiatric admission because they cannot cope at home anymore. Our mental health system is far from ideal. Now, with an increasing exacerbation of mental illness (likely secondary to anxiety about COVID in addition to the stress of “solitary confinement” in quarantine), how will our system handle it?
Dr. Keene, May 2
A podiatry consultant walks up to my computer station carrying a plastic container with a bloody stub inside. I look at him with an eyebrow raised. “Oh, yeah, I took off a toe while I was evaluating the patient’s foot. It was basically dead and falling off anyhow, and the whole foot is beyond saving—the wounds track into his bone and there are no appreciable pulses. He’ll need at least a below-the-knee amputation, but he’s not a good surgical candidate, so I’m not sure if vascular surgery will offer much. Maybe he should get a palliative care consult instead.”
The patient he’s talking about is an eightysomething gentleman who came in complaining of worsening foot wounds since a surgery two months prior. The wounds have been nonhealing and progressively worsening. He has diffuse vascular disease and is a diabetic, meaning he has poor circulation and poor wound healing. At this point, however, the situation of his infection and his poor circulation seems to have reached the point of no return.
Shortly after evaluating the above described gentleman, two more cases of severe soft tissue infections present to the emergency department. Both were festering wounds that have worsened over the past couple weeks. Both ended up being necrotizing fasciitis, a severe infection that leads to death of parts of the body’s soft tissue. One of the two patients agreed to emergency amputation and went to the operating room. The other refused despite the fact that it is life-threatening. Usually, this is an uncommon diagnosis. I wonder, is this severe infection a result of delayed presentation for medical care?
The emergency department volume has been drastically lower than usual over the past two weeks. Many of us were concerned that meant certain patients were avoiding hospitals despite having serious medical issues. In the past few days, the number of patients have been creeping back up. Many of these patients present with medical complaints that should been seen days or even weeks ago, such as these cases of worsening infections or cases of abdominal pain that end up being perforated appendicitis or diverticulitis with abscess. All cases that would have been much easier to treat if the patients had presented earlier, before developing complications. I feel terrible that these patients, who hid at home because they were scared to go into the hospital, will now have a much more complicated hospital course. It’s also tragic that for some of these delayed presentations, they end up with irreparable damage, sometimes even leading to demise. I do hope that the slowly increasing number of patients mean that more are finally seeking care. Perhaps the decreasing number of COVID cases will encourage more to seek the care they need.
Dr. Keene, May 3
Complacency. It seems to me that the public is lulled into complacency. Over this past week, more and more people seem to be out and about with less and less distance between them. Yes, it’s true that the numbers of new cases, hospitalizations, and deaths have been decreasing in New York. But there is a false sense of security spreading. Decreasing numbers is certainly encouraging, but that does not mean there is no risk.
In the past several days, I have seen more people bustling about on the streets than on any normal day pre-COVID pandemic. People standing in hordes around street corners, people jogging past crowds with no masks on. All of this is bound to lead to more new cases. Perhaps people are becoming desensitized. Day in and day out, the news has been focused on COVID for months. As the media highlights the good news, people seem to forget about the bodies that are still piling up in the makeshift morgue trucks. Some New Yorkers are beginning to treat this COVID quarantine time now almost as a “staycation.” The weather is becoming nicer, and people are becoming more relaxed about staying in and quarantining. Frankly, I’m angry when I see these people, laughing and enjoying themselves out in the open. I am resentful that while myself and other health care workers are risking our lives at work, staying away from our loved ones, these people are sunbathing on the beach and laying out in Central Park. I am also frustrated that these people are acting so selfishly, endangering others around them. COVID isn’t only killing people via respiratory troubles and low oxygenation. Now, we are seeing more and more patients come in with sequelae of clots after their COVID infections—young people coming in with strokes and ischemic limbs and pulmonary embolism because their bodies throwing clots into their blood vessels.
In a way, I understand why people are coming out of their shelters. New Yorkers have diligently quarantined for over six weeks. There is only so much confinement one’s psyche can endure without having significant effects. We have seen a peak and now a decline in numbers. I think it is quite reasonable to start a controlled reopening of society. But the reopening must be well-planned. There must be adequate testing and contact tracing capabilities. There must be an orderly, logical, stepwise progression of how and when and what to reopen. Yet I have heard no solid plans. I am aware of no convincing preparations. What has our government done to ensure a controlled, safer reopening? Despite now months of dealing with COVID, hospitals still do not have enough PPE for staff. How are we to deal with another wave of COVID, another peak in society?