I’m an emergency doctor working in Manhattan at two NewYork-Presbyterian hospitals. I celebrated my 40th birthday during the peak of COVID-19 at a time when more than 150 patients were coming through our doors every day, more than 2,300 were already admitted, and more than 700 were in intensive care units system-wide. Things wouldn’t start to level off until the following week. I spent the night before my birthday in the thick of the fight, one in a string of long night shifts that now blend together in a haze of sickness and suffering that has left me exhausted and unsure how long we could keep this up.
Along with all the birthday wishes came many questions about how I was faring and what I’d been seeing on the ground. When you are so entrenched in the battle, it is easy to forget that most people never get a glimpse of what we are seeing every day. To help bridge that divide, I am sharing my journal entries from the past few weeks. Stay in. Stay safe. Stay healthy.
The eyes stay with you. In peacetime, most of those we intubate are chronically ill, or profoundly confused, or unconscious and unaware of the world around them. COVID-19 has changed the equation. Most of my patients now remain awake and alert until the end. These days, the ER is permeated with frank conversations about death and dying and what a chance to live entails. It is a hard thing to tell a healthy and functional person who felt fine and well six days ago that they may be dead in a day or two and humbly ask how aggressive they want us to be. A chance to live comes with the risk of pain and dependence on life support. The alternative is the guarantee of an imminent but peaceful death. I have never had more harrowing, more brutally honest, more meaningful, more exhausting conversations in my life. Complete strangers open up to you in profound ways during such times, and you can only hope both your expertise and your humanity serve them well.
For those I intubate, those who choose intubation, I often find myself having a final stare. After all the words are spoken, the decisions made, the medications drawn, the bed positioned, and the tubes and drips and ventilators readied, there is a final stare. It is a stare of intention. It is a moment of humanity. It is a shared space, a hallowed space, the final moment of someone’s awareness, possibly forever. It is a space where fear and hope mingle, where autonomy fades into trust, uncertainty into acceptance, and all the patient has left is placed firmly in your gloved hands. It’s brief, and you’re busy, and time is essential, but you find a few seconds to share this breath. That stare lasts a moment. That stare lasts a lifetime. And the eyes stay with you.
I am asleep before a long night shift. I awake to the sound of cheers and yells. To hooting and hollering. To the clanging of cowbells and the banging of drums. They yell and shout and scream to honor us. They shout from rooftops and ground floors and all the windows and balconies in between. It wakes me up. I am scared shitless. I think the building is on fire. I run around panicked and confused for several minutes. Why do the fire sirens sound like drums and cowbells? Do I even have a fire escape?? WTF is going on?? Oh. Ohhhhhhh. OK. I get it now. My heart is still racing, but now I’m grinning. Thanks. I feel grateful...mostly.
“Oxygen rounds” is a new term we have become all too familiar with. I have a hospital full of medications — antibiotics and antivirals and sedatives and vasopressors and steroids and opiates. But the only truly effective medicine we have is oxygen. We blow it at high flow rates into people’s mouths and nostrils, a crutch to help the lungs that are struggling and staggering. And it’s in shorter supply than I’d like. It flows forever from spigots on the walls, but we have many times more patients than spigots and even fewer rooms, so an ever-increasing number of patients on stretchers line hallways, farther and farther from the spigots on the walls.
We place portable tanks next to stretchers, but the tanks run out and we can’t refill them fast enough. Once per hour, sometimes twice, I walk the halls, hunting for gauges that are approaching empty and hoping the cabinet holds a replacement. Invariably I find empty ones and hope it hasn’t been empty long. Invariably someone is turning blue. It’s no one’s fault. It’s everyone’s fault. It’s COVID’s fault. And there just aren’t enough eyes and hands to keep up. I mutter a promise to check three times in the next hour. I pull a stepladder from the utility closet and string plastic connector lines from end to end to end, threading them from wall spigots through corrugated ceiling tiles to drop down above patients’ heads in the hallway so they aren’t reliant on a tank. It’s hard to tell which knob goes to whom, but at least it doesn’t run out. It’s a strange time when a stepladder becomes a more useful tool than a stethoscope.
I admitted four of my colleagues today. Four of them. They had the usual symptoms: a week or so of cough and chills, fever and body aches, fatigue and loss of smell. They stayed at home and took Tylenol and sipped chicken soup and wondered which patient they had gotten it from. They stayed inside and washed their hands and waited to feel better. But better never came. The cough worsened, they had trouble walking around their home without getting winded, and they knew all too well what that meant — so they came, each of them, not knowing the others were doing the same. I’m in a room with four chairs housing four colleagues with oxygen flowing into their four noses. I’m used to seeing strangers — people I care about because they’re human, but strangers still. With them, I can maintain a detached distance. This is different.
These are my friends and colleagues. These are the people I suit up with and go to battle beside. This is my team. I’ve had harrowing experiences beside them for years. They keep me sane and effective and capable. Together we’ve saved lives and lost lives and everything in between. But now they are on the other side of the curtain. Their coughs hurt my ears more, their fear becomes my fear. I check on them to the point of harassment, can’t help it, can’t fix it. I can’t cure them, can only support. Can only stand beside them and hope. They try to reassure me, a strange role reversal that belies their strength. I well up with a deep respect. I well up with tears. The front line really feels like the front today.
The makers are my favorite people this week. Several days ago, I intubated without a face shield. It was 3 a.m. and we had run out. There were simply more intubations than face shields, and we had burned through the stash. But a patient came in and was suffocating in their own lungs and needed a breathing tube — so they got one, and they got one from me, and I did not have the proper armor. Today, I stand in a room with hundreds and hundreds of face shields. They are pulled hot off the 3D printers like newspapers off a press. They are arranged on tables by volunteers who add elastic bands and snap together visors to complete the ensemble. In the background, the gentle hum of a dozen printers working around the clock is an echo of the thousands of engineers and designers, tailors and manufacturers, cooks and delivery workers and writers all contributing to the cause. Each shield is a person protected. Each volunteer is a soldier in the fight. I feel less alone.
Oxygen means something different in this new reality. In peacetime, an oxygen level below 95% is bad. An oxygen level below 95% for someone wearing a non-rebreather face mask is terrifying. That’s a no-brainer. That gets fixed quickly or they get intubated. But everything is different now. We hang face masks of oxygen on people with 85–90% saturations for days. They are on the edge of the cliff with one foot dangling, and there they stay. Will they inevitably fall off? Are we helping or merely delaying? No one knows. Ventilators are in short supply, ICU beds are full, and ICU docs are tired. We’re all tired. So we temporize, hoping a few will sneak by and not get intubated, hoping someone doesn’t fall off the cliff when we aren’t looking. The monitors don’t help. They are all beeping and blaring all the time from every direction, the background music of a pandemic. They only tell us what we know: Everyone is sick. Only our eyes and experience can help us now. I take another lap around the ER to check the cliff edges.
I’m baking a mask tonight. My single-use N95 has been on my face for days. The backs of my ears are raw from its straps rubbing, and my nostrils are filled with the scent of the fibers mixed with my coffee-flavored breath. My mask bakes and bakes in my oven, 70 degrees Celsius for 30 minutes every night, sterilizing it and killing any viral hitchhikers that attached themselves today. I wish I could do the same for someone’s lungs. It comes out warm and toasty and clean. It comes out safe. I set it on the windowsill to cool, like an apple pie from easier days. Worst dessert ever.
All hands were on deck today. Elective surgeries have been canceled, and the surgeons and anesthesiologists and neurologists and orthopedists and urologists and rehab specialists and pediatricians have been deputized as ER and ICU docs. Attending urologists and shoulder surgeons are rounding with ICU teams, adjusting ventilators, and drawing blood gases. Pediatricians are seeing adult patients and monitoring oxygen levels. Outpatient docs are working in tents in front of the ER to decompress the volume. General surgeons are going from room to room to room, putting in central IV lines and arterial lines on our sickest patients. Anesthesiologists are running in to intubate. It remains busy. It remains overrun with sickness and suffering. But today we have more help. Today we have reinforcements. Today we feel like one big army devoted to one fight. Today it feels like maybe, just maybe, we can keep up.
Today I’m a palliative care doc. This man is not doing well. This man needs intubation to survive. He’s 67 and only speaks Spanish. He’s healthy. He’s dying. His oxygen is very low. His respiratory rate is very high. He’s getting tired. He’s suffocating in his own body. He needs to be intubated. He doesn’t want to be intubated. He doesn’t want to be on a machine. We ask if we can help call his family to say goodbye. He looks at us, puzzled, somehow still not fully understanding. “Se está muriendo, señor. Es el fin.” This is the end.
He gets it. He’s stoic despite the tears. He’s strong. If this disease attacked character instead of lungs, he would have a fighting chance. We set up a video call with his family. He says goodbye. They say they love him in a dozen different ways. He touches the screen. A digital handhold in a pandemic age. We make him comfortable. He’s still drowning, but he can’t feel it. He says thank you before his eyes close. I can’t help but wonder if he would have survived had he been intubated. The odds say no. The sense of defeat within me screams maybe. I try to remind myself this is what he wanted, that this is for the best. I quickly forget.
I give out more juice and blankets than I ever have. In peacetime, the ER is busy, always busy — but most people are not dying. Very few are dying, and even fewer are acutely and actively dying. The scourge of COVID-19 has rewritten those rules. Everyone in the ER tonight is too sick to go home. Many are dying. Many will never leave the hospital. Many will never have a meal or a juice box again. In peacetime, I often can’t be bothered to bring someone juice. It’s not a priority. Tonight, anyone asking gets juice. Even those not asking get juice. Often it’s the only comfort I can provide — a small ease of suffering, a brief distraction from the fear. It may be the last juice they ever drink. Some nights, it’s the best medicine I have.
We had a patient tonight who impaled her hand with a crochet needle. Right through her hand. Simple stuff for us. Easy to take care of. Three of us ran over. Two more than were necessary. An orthopedist playing ICU doc was walking by. He ran over. He was excited. We were all excited. This was not COVID-19; this was something we could fix. We did it together, eight hands to do the job of two. We removed the needle, held it up like a trophy, washed it off, and gave it back. Our patient smiled, said thank you, and went home in one piece. It was the best we’d felt in days.
My colleagues are tired. The patients keep coming. The ER is wall-to-wall misery and mayhem. Only five people died on me today. Only five. But everyone there is dying to varying degrees and at various rates. The ER is a cross section of the disease: The well who will stay well. The well who will come back much worse. The sick who are stable. The sick who are crashing. It’s all around us. It keeps coming in through the front door. It keeps coming in through the ambulance bay. And my colleagues are tired. We give oxygen. Everyone staying gets oxygen. Needs oxygen. We try antibiotics. We try antivirals. We try hydroxychloroquine. This week we use steroids. This week we limit IV fluids. This week we give blood thinners. Does anything work? Are we saving anyone, or just supporting them as they go along a path predetermined by the virus coursing through their insides? Is the inevitable inevitable? Some days, we just feel like spectators, front-row observers going through the necessary scenes of a play whose final act has already been written. So much death. So much dying. And my colleagues are tired. We’re all tired.
And yet, somehow, for some reason, I find there’s no place I’d rather be.
I leave the ER, the sun has come up, and I walk around enjoying its warm tendrils. It’s quiet. Stores are shuttered, streets are empty, and sidewalks are bare. It seems peaceful. It’s an illusion. But I appreciate it. Time to go home. Time to recharge. Tired won’t last forever. COVID-19 won’t last forever. And there is still plenty of fight in us. ●