Residency Diaries Series #13: Grieving (COVID Part V)

It feels strange to read these “old” entries from the earlier days of the pandemic. They are similar what we are going through now, with COVID cases surging once again in NYC. We are somewhat better prepared this time around, with our dexamethasone, high flow nasal canula, and honestly a bit of immunity to seeing (previously) shockingly low pulse oximeter numbers.

But the hospitals are getting full again and it’s getting really tiring again.

When hospitals get full, the emergency department is directly affected. Patients do not care if the hospital is full. They do not stop coming to the ED. We do not close our doors.

Personally, as a 3rd year resident taking care of all critically ill patients, a full hospital means that all my SDU (step-down unit- somewhere in between regular floor and ICU) and ICU patients are staying in the ED for longer. These are sick patients that should not be under extended care of our ED nurses, as wonderful as they are, who have no actual cap on how many patients they take on at a time. (*as a reference, in a normal ICU setting, nurses typically have a 2:1 patient to nurse ratio. On a busy day in the ED it can be as many as 10+ patients/nurse and they could all be very sick)

And more importantly, they should NOT be left in the care of a brain fried 3rd year EM resident running to new notifications every 20 minutes: Sepsis NOTE! Stroke Code! STEMI alert! Hypoxic notification! Hypoxic AND Septic note! Hey doc, can you come check this out? Can you update my sister in law? She’s a pharmacist…and so on and so forth.

Today I had to dose 2nd and 3rd doses of antibiotics for my multiple admitted SDU patients. I repeated their labs because they had been in the ED so long. I wrote for maintenance fluids. These are all the things I rarely, if ever, had to do prior to the pandemic.

Patients on the BiPaP machine, patients with actual bacteria in their blood, patients getting their 2nd and 3rd units of blood… all stayed over 24 hours in the emergency room waiting for a team assignment (for the inpatient team to take over their care) followed by a bed assignment (to physically leave the ED). One of the patients decompensated and ended up on BiPAP. One pulled out his NG tube and had to get it re-inserted. One requested an unnecessary MRI. Most, including myself, were unhappy about being in the ED for so long.

Anyway… it sounds like a lot of complaining. And I suppose I am. It probably doesn’t help that I just came off of a brutal 12-hour shift without meals or breaks— which honestly isn’t too out of the ordinary even before pandemic times. There is clearly a systemic issue on multiple levels that I just feel too tired to figure out. Here is an entry about times worse than today and being on survival mode.

6/3/2020 Wednesday 11:38pm

 I’ve been thinking a little bit about grief. We’ve had a lot to grieve lately, individually and as a community/country. We grieved, or have been grieving, things as trivial as not being able to go out on a Friday night for drinks with friends to heavy stuff like loss of lives, losing multiple family members, the deeply ingrained societal injustice and racism. Here are things that I have personally grieved over the past few months. 

 Losing patients. It’s never easy to have someone die in front of you. I still remember losing my first hospice patient when I was a hospice volunteer (pre-med). I remember thinking that it was my first “patient” death and it felt strange to acknowledge that as someone going into medicine, it was going to be the first of many. Most deaths that occur in the ED are not surprises. Most people who die in the ED come to the hospital already dead (CPR ongoing) or already very sick and at the end of life or severely injured. Our time with the dying patient is very short and so is our time with their family members.

I’ve had the opportunity to spend most of my COVID times in the ICU. In the ICU, things are a little different. You spend time with the patients, day in and day out. You speak to the family members everyday about how they are doing-- maybe with some guarded optimism and options. Sometimes, the entire purpose of the phone call is to have the difficult discussion about goals of care.

When I started in the Neuro ICU in mid-April, I was surprised to find that one of the patients I had admitted in late March (prior to my two week vacation) was in that ICU, intubated (*He was in the neuro ICU because we were running out of ICU beds and basically ALL ICUs were COVID ICUs). This was a young patient in his late 30s with no medical problems. He wasn’t yet intubated when I first saw him in the ED. He had walked in, short of breath and tachypneic to respiratory rate of 40s. He needed a lot of supplemental oxygen but settled out with the oxygen saturation in the mid-90s with 15L of nonrebreather mask. If he needed any more support he would have had to be intubated. I watched him all night, terrified that he was going to drop his oxygen saturation and require intubation.

I had heard about patients dying in the remote hallways of the ED because they decompensated or because their oxygen tanks ran out (wall oxygen ports are limited). I kept asking if he was feeling tired from breathing so fast. You can’t maintain the respiratory rate of mid-30s to 40s for too long before you “tire out.” But he was young and I wanted to save him the intubation if possible. I checked on him constantly. The anxiety and fear I remember from the early COVID days was this exact feeling. Feeling like someone was going to die if I didn’t check in frequently enough. I left the shift in the morning after having secured a spot for him in the step-down unit-- not quite an ICU bed but one with closer monitoring than on a regular floor.

The next shift I found out that the next ED attending ended up intubating him that morning. I’m not sure if he tired out from breathing so fast or maybe he dropped his oxygen saturation. Maybe it was going to be impossible to keep checking on him to make sure he was okay with the influx of sick patients we were getting. He was already very obviously sick and maybe it was the wiser decision to give him a definitive airway.

On my first day on the neuro ICU over two weeks later, I was surprised to find his name on the patient list. I was even more surprised to hear that he is one of the sicker ones and that he may not make it. During my entire month in the neuro ICU, he never woke up. We were never able to wean any of his ventilator settings (you “wean” the vent then hopefully extubate the patient). He kept getting pneumothoraces from being on the ventilator and required multiple chest tubes.

But he was so healthy and young before- I held out hope that he would somehow make it despite the rest of the team saying he was probably going to die. When I came into work for my last shift at the neuro ICU, I heard from the overnight PA that he had died overnight. In what world does this make sense? I probably had COVID in late March during my vacation when I lost my sense of taste. He got COVID in a less “risky” situation compared to me. His boss had been sick. I think he worked at a flower shop or something like that. How is it that I came out totally fine with not even a fever but this man who is only 7 years older than me died? How is a family supposed to make sense of that? 

In the same ICU, I held a FaceTime call with a recently passed woman’s body so that her family can say goodbye. By the time the family was all gathered (virtually) and ready for the call, I had been standing in all my PPE in the isolation room with the body, unzipped from the plastic bag for over 20 minutes. I tried to cover up the body bag with a blanket. No one wants to see their loved one’s body in a plastic bag. I tried to make it look as peaceful and clean as possible but it was hard with the endotracheal tube still sticking out from her mouth (I was told we could not remove it until the autopsy). I could not believe the situation I was in. I never expected that we would ever be in a situation where the family cannot see their loved ones as they near death. As I waited for the family representative to call me, I felt hot and uneasy. PPE was suffocating. I had other living patients who I had to keep from dying. I felt guilty for feeling that way but it was the truth. Then again, what good can we do in this fight other than comfort family members and help with closure as our patients slowly, helplessly die in front of us?