|NARRATIVE MEDICINE SYMPOSIUM ON COVID-19: INDIVIDUAL CONTRIBUTIONS
|Year : 2020 | Volume
| Issue : 2 | Page : 142-144
COVID-19: Coming to terms with the absurd
Emerson Floyd, Manish Garg
Departments of Emergency Medicine, Weill Cornell Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
|Date of Submission||29-Apr-2020|
|Date of Acceptance||16-May-2020|
|Date of Web Publication||29-Jun-2020|
Dr. Emerson Floyd
630 West 170th Street, Apartment 3H, New York, NY 10032
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Floyd E, Garg M. COVID-19: Coming to terms with the absurd. Int J Acad Med 2020;6:142-4
March 30th New York 2020 COVID everywhere, invisible.
| Denial|| |
I suspected it was overhyped. I wasn't totally dismissive, but I was still wrong. We sat in the neuro intensive care unit (ICU) on my birthday, March 3, when I heard about the first case, a man from Westchester in our hospital. “We've all probably been exposed,” I said. Many of us went on to develop some annoying but not debilitating stomach symptoms over the subsequent week, some a runny nose. We figured it was “a little GI bug” in the unit. Who knows what it was? Over the rest of my time on the neuro ICU, my feelings remained the same. But, the NBA was getting shutdown because some asymptomatic players tested positive. Hmm… “We've all probably been exposed.” But, we're young and healthy. We'll follow the emerging personal protective equipment (PPE) regulations because it is the right thing to do, to keep from spreading this to those who might develop symptoms: the old, the sick, and the immunocompromised. At least it is not Ebola. The reports from Italy of a health-care system beginning to break down. these are anecdotal. Denial. Keep working.
| Anger|| |
I'm angry that my licensing exam date was canceled – I have no idea when I'm going to take it now – and then, I feel guilty about being angry because I still have a job and I'm in such a good shape compared to the millions of Americans who have now lost their jobs and are facing what appears to be, if an uncertain medical catastrophe, a certain economic one.
I'm never going to be intubated, I tell myself. High-flow O2, that's it. It is not death in particular that most doctors fear. It is a certain kind of death. An intubated death. Sedated into a loss of personality. Or a loss of an apparent one, trapped inside, the vital organs outsourced to bedside machines. Half man, half machine. But, it won't come to that anyway. I've probably been exposed.
| Bargaining|| |
Things worsen. Case numbers balloon. Atul Gawande writes, and we all read per usual. He reinforces some of my hopes and assumptions. For instance, that this bug is transmitted via droplet and contact, that by practicing good hand hygiene and changing a regular mask, I am reasonably protected from transmission. He also deflates some of my hopes, suggesting that “asymptomatic carriers are less common than feared,” citing data from Wuhan.
”Maybe it's the terrible particulate pollution in Wuhan. It's in Milan as well,” I guess hopefully to some of the family members. “Maybe there's a genetic trait in Italy that increases susceptibility to a morbid course. And their population is quite advanced in age as well.” The news from Italy is no longer dismissible. Their health-care system is falling apart. Vents are being rationed. Maybe the number of new cases is starting to taper off.
| Fear|| |
It hit me when I saw the projections. Internal memo, around the middle of the month. 250% increase in volume every other day for the next 3 weeks. Little sleep that night. I ride the shuttle girding myself for bedlam on arrival. Most hospital entrances are closed with a still, eerie quiet. Order is preserved, for now. Other hospitals and boroughs are not so lucky. Hospitals who offered free testing had people queuing shoulder to shoulder around the block in the mornings. If the patients didn't have it when they got in line they would have it when they got out.
It is a mysterious bug, COVID-19. The more we see of it, the less we can predict. It barely sickens some before it kills. Precipitously. Randomly. A patient sent to the non-COVID-19 area of the emergency department (ED) with abdominal pain and diarrhea desaturates and requires intubation. No cough, no fever. Positive COVID-19 when the test returns. Patients in their 20s, 30s, and 40s walking into the ED and collapsing without warning.
It is not the flu. It doesn't just weaken us and make us prone to bacterial pneumonia that we can treat with antibiotics. We have little but pressurized oxygen to offer. And, it spares no one. It barely causes symptoms in some unknown proportion of us. It sickens many of us with an ever-expanding repertoire of symptoms – from cough and fatigue to diarrhea and anosmia. And in some of us, it seems to make the immune system go berserk, destroying our own lungs, flooding them with fluid and debris, so that all we can do is try to keep the lungs open and dry and inflated so that some surface remains for gas exchange until the body either heals or does not.
| Facing the Absurd|| |
I reflected on my medical school interviews on the way home. A physician sits across from me. “Why do you want to go to medical school” the interviewer would ask? To do work with a clear purpose that society needs.
250% increase in volume every other day for 3 weeks. I don't have to do the math to know what this means. It means that, in about 2 weeks, we confront the emergence of the absurd, the erosion of purpose. It means no ventilators to offer the sickest patients. It means there's nowhere to sit a patient who needs noninvasive oxygen. It means that my strokes, my STEMIs, my aortic dissections, my bread and butter emergencies will have nowhere to go and no one to take them. It means showing up with only one thing to offer: false hope, a false assurance of medical care that I myself would have no confidence of receiving at that point.
We are not there yet, but we are getting there. Tension in the air. Intubations left and right. Frantically dialing family members' numbers to have goals of care conversations, trying to save the ventilators we have for the patients who might benefit from them. Trying to keep up with the volume while trying to remain mindful of personal protective practices – don't touch that now! Double glove. Put the outer mask on now so I don't forget as soon as a crashing patient comes in. Hang the pulse oximeter on the outside of the gown along with the penlight, so you remember to wipe it down before you put it back in your pocket. Keeping up with PPE is mentally exhausting, but I'm thankful to have it available. If it failed, now would be the time to get sick, before viral absurdity yields medical futility.
| Acceptance|| |
If the projections are true, we'll never make enough ventilators in time. The rest of the country is getting too sick for their ventilators to get shunted over here. But, someone at Rice is working on a little robot that will squeeze a bag. I don't know how we'd measure tidal volumes or peak pressures, but at least we could provide some positive end-expiratory pressure, helping the oxygen we provide get into the blood and keep the patient alive.
My friends and family worry about me, and I try to reassure them while reinforcing the need to wash hands and social distance. “Don't come to the hospital unless you're short of breath and try to get a pulse oximeter if you don't have one.” I agree when they tell me I'm fortunate to be on the front lines, having a chance to help, to do something other than sit helplessly at home.
I don't tell them that I fear there will be less and less for me to do or offer. I still have hope. That the projections are inaccurate. That little robots won't be squeezing bags in convention centers. That split ventilators won't be sustaining four patients at once. That blocked coronary arteries will keep getting popped open in the cath lab. That we will begin to be tested for COVID-19 antibodies and we will know if we have been exposed, thus knowing that we didn't roll snake eyes in this plague's dice of death. That we will not only survive but become stronger. That this, too, will pass. That we might look back upon the absurd wake of this virus and say some things, and some of us, got better.
| Looking Back, Looking Forward|| |
My hopes came true; the projections did not. Before we ran out of ventilators, patients stopped coming unless critically ill.
This bug, still everywhere, remains as mysterious as ever. Intubated patients aren't doing well. But I've seen patients on the verge of intubation improve once flipped onto their stomach. “Small victories” I say to an ICU attending. “No,” she replies. “huge ones.”
The end's not in sight. In the ED, we're waiting for the second wave to rise as society restarts. The volume is starting to pick back up.
Work with a clear purpose that society needs. Purpose hasn't changed, not for me at least. But, what does society need? Hope? Crowds cheer for us from their apartment windows as I recall an old attending's remark. “Hospitals are modern cathedrals.” I think I'm starting to understand what he meant.
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Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
The authors of this manuscript declare that this scholarly work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network (http://www.equator-network.org). Within the broader context of narrative medicine, this article discusses individual stories and patient encounters as integral aspects of the lived experience of health and illness.