I can’t speak from my experiences working in a major teaching hospital. As they say, been there, done that. But really why would the experience of being in a teaching hospital be so interesting? The COVID patients are already on vents or waiting to see if they’ll need to be on a vent before the day is through. They are all complaining of fever, hacking cough and shortness of breath. Their clinicians have no medicines to make them better, so they all wait, patient and clinician alike for something to happen. Life or death, so written by God in the great book at the end of Yom Kippur.
I work in a different kind of Emergency Room. I am the rear guard. I am the doctor wearing goggles, two masks and a thin, blue plastic gown that rips if I take a deep breath or make a sudden move. My days on the front line, cracking the chests, intubating the heart failure, coding the drug addicted are over. This was supposed to be my long easy slide into retirement. Instead it ended with me putting my life in danger in the service of a pandemic. This, will be my last rodeo.
Very few patients nowadays show up to the ER. In the pre-COVID time my night shifts would have had 30 to 40 patients lined up to see the doctor. My cases ran from the sublime to the ridiculous. This one has chest pain, that one an asthma attack. Here is a baby with a snot nose, there a grandpa with anxiety because his daughter doesn’t visit him. This is the cast of characters all night long. Most of them are here in my ER because they had nothing to do and the ER staff all have friendly faces.
It is different now in the time of COVID. Gone are the chest pains, the stubbed toes and the ladies with false labor. Most of the children have cleared out along with their relatives. I now see only five to ten patients on a night shift, almost all have symptoms of COVID, occasionally they are sick but they are definitely all scared to death.
Like the patients in the teaching hospital they have the same cough, the same fever and the same aches. The difference unbeknownst to them, but to the fear of the clinician is if they are very sick our ability to save them is only a fraction of that at the teaching hospital. We don’t have the equipment or personnel the big places do. It makes a difference, but then again, we are here in their neighborhood and they know us well.
COVID, as anyone who has recently seen the news, fake or otherwise, knows it is a disease of respiration. For most of my patients, oxygen is able to be transferred from the lung to the blood. Oxygen which feeds the cells needs to be at a certain level or bodily systems collapse and the patient dies. So, I check the data collected by the nurse. I need to see how fast the patient is breathing and what percentage of oxygen is in their blood. If it is low, how low? Next, does the patient have a fever? I have seen patients who have no fever and are oxygenating well but still will be diagnosed with COVID. The bet I have to make is whether the patient is well enough to go home or will this be the patient who crashes and dies? This part of the assessment I can do without fear for my personal safety. I read this data from a computer screen in our safety zone. The protocols for safety next determine whether the patient is placed in the hot (sick) or cold (relatively healthy) zone.
If the patient is in the hot zone I now have to go through the laborious process of Personal Protective Equipment or PPE. Being heavy and arthritic I steel myself for the discomfort of donning layers of plastic, cotton and nylon. For those of you old enough to remember the movie, “In the Shoes of the Fisherman,” I am reminded of the scene where Anthony Quinn is first elected Pope and has to be dressed by his assistants into the vestments appropriate to his office. I similarly have to don the new vestments of my office, by myself. To see a patient pre-COVID, I would swing my stethoscope over my neck and pop into an exam cubical. The new reality is to don a plastic gown, gloves, cap, two masks and goggles and trudge over to a room. The doctor is now an actor from “It Came From Outer Space” or so it seems to the patients, because they can’t really tell if there is a human under all that PPE. The patient is unsure of the doctor because when facial expressions are hidden how can you tell if the doctor cares?
The exam is almost cursory because the vital signs tell most of the story. There are two pieces of information that tells me the probable future course of the patient. What do the lungs sound like and what other diseases does the patient have?
We have learned from Doctor Oz and Doctor Fauci that patients with co-morbidities do not do well with the COVID virus. If we add older age, their chance of dying increases astronomically. When I hear the patient tell me they have asthma, diabetes or heart disease I know, no matter how the patient looks, I must be conservative towards admission. Patients like this deteriorate in minutes and intubation at my place is done rarely and has a danger in itself. Better to get a 911 ambulance to send them to a teaching hospital as a “just in case.” But this is Boston and it is 2:39 in the morning. Ambulances can take three to four hours to show up. If the patient crashes will I be able to stabilize the situation? Another gray hair under my cap appears.
Last, but should be first, the lung sounds. Crackly, rice crispy sounds when I listen with my stethoscope means there is a pneumonia and in this case probably a COVID pneumonia. An X-ray tells me if the pneumonia is in one or both lungs. I call my findings fluffy bilateral infiltrates making it sound like a friendly bunny. In reality it is a rabid rabbit. This finding is what keeps the lung from supplying the body with oxygen and causing death. If it is COVID, treatment so far is to get the oxygen levels up … somehow. As I sweat under my gown, gloves and goggles made foggy by my breath, I wonder if this is the patient I’ll have to intubate, mostly by myself with minimal help and a good chance of failure or can I put the patient on his or her stomach with an oxygen mask and pray the ambulance gets here in time. These are the times I wish I had retired early or taken an easier road like being a lawyer. Lawyers make money from ending calamity. I have to do my best to make sure the calamity never starts.
In any case I wonder what happened to the easy times when it was stubbed toes, runny noses and the occasional chest pain.
Dr. Irv Danesh writes from Marblehead.