The author of “COVID Diaries” reflects on the one year anniversary of the pandemic at her institution. All I can say is, wow — you need to read this. Giants walk among us, but some of them are disguised as ordinary people.
–Caroline
This Time Last Year
One year ago my hospital admitted the first COVID-19 patient to the medical floors. I had already been tracking the Wuhan virus in the news, knowing it was more important that the impeachment proceedings that were leading in the news at the time. I was preparing for a weekend on call. I had been bumped up in the rotation because my colleague who was supposed to be on call had succumbed to the respiratory virus that we were now calling COVID-19. At the time we didn’t know exactly how lethal COVID would be, and there was a lot of fear. Yesterday, a dear nurse friend stopped me in the hall to remind me of a conversation we had had almost exactly a year ago, and which I had forgotten – it was a moment of raw honesty as we stood in the hallway leading to the ICU. That day, she felt compelled to find me on the Friday afternoon (COVID hit us) – to pray with me. We held hands and began to weep, because the fear and the uncertainty hit us. In some ways, it felt like we were saying goodbye to one another. Departments were shutting down and staff were being deployed to other areas. I barely recall this moment, because I was already strategizing in my mind how to fight this unknown and invisible enemy.
I do recall one of my final decisions before being left as the sole intensivist on call that weekend. I was chasing down my section chief to make sure that there were enough dialysis catheters on stock. I had studied SARS (Severe Acute Respiratory Syndrome), which was also a coronavirus. I knew what happened to those patients. They often developed Acute Respiratory Distress Syndrome (ARDS) – leading to multi-organ failure. During my fellowship I had been trained to place dialysis catheters, so it was a procedure I was comfortable doing. I remember that my questions about the availability of these catheters were treated almost as an imposition, in part because the other intensivists weren’t comfortable placing them — but I didn’t care. I wanted the equipment I needed to help my patients, knowing they’d be needing full life support.
Realizing I wasn’t getting what I wanted from my own colleagues, I turned to the radiology department. At my hospital, the interventional radiologists usually place these catheters, but they required patients to be transported to radiology for the procedure – a risky journey for someone who is critically ill (not to mention possibly contagious). I happen to like this doctor very much– he’s jolly and laughs at all of my jokes. But I made him nervous when I told him the scale of multi-organ failure I was anticipating. He brought me to the stock room and we decided we only had three catheters in the entire hospital that would work for my situation / skill set. He also revealed that the employee who ordered the supplies was retiring in 4 hours. I told him to triple the par levels of the dialysis catheters. There was a sense of urgency (and institutions were already hoarding). We were trying to get supplies before they ran out and before other hospitals caught on that they’d need them, too. I also felt a need to protect my colleagues. There are 8 Pulmonary / Critical Care doctors at my institution, and only 2 Interventional Radiologists. Conservation of skills and resources is important, and moving critically ill patients out of the ICU for procedures is risky and unnecessary if I can do the procedure at the bedside. Once we had secured the catheters, I returned to the ICU to “tuck in” the patients who were already there and assess the census. The pandemic was still on the horizon but hadn’t hit yet. I drove home.
So it Begins…
I believe 3 patients got intubated that night after I went home. I couldn’t sleep well. I woke up at 3 AM. That was the beginning of a routine that would continue nightly for the next 6 months – restless sleeping and 3 AM wake-ups. I checked my list of patients before driving in to the hospital on Saturday morning and saw the number of COVID patients had tripled overnight. I began formulating a speech in my mind – just some ideas, nothing solid. As I drove, I began to pray for the right words to say to the staff. It was just going to be me, the ICU nurses and some really inexperienced house-staff.
When I walked into the ICU that sunny morning, there was a low-grade buzz of energy. There was definitely an underlying sense of fear and a need for direction in the of face huge unknowns. The house staff began to gather around me – as they usually do to check the patient lists and prepare for rounds. The nurses were just to the side of the nurses’ station also waiting – for something to happen. This is what I told them:
“You were created for this very moment in time. If you went into medicine to help people, to save lives, this is your moment. This is what you trained for. We are no longer going to practice the type of bullshit medicine that you’re accustomed to at this hospital — we are going to practice real critical care medicine. There will be a tube in every orifice, because these patients will need it and we will need it to take care of them. They will need central lines, a-lines, foleys, NG tubes, rectal tubes etc. We will prone them. We know how to do this. We know evidence-based medicine, we know critical care medicine, and we will help these patients together.”
I then turned to the senior resident and said, “Get the program director and chief resident on speaker phone now.” They did – and I said, “I need a dedicated ICU team, our infectious diseases doctor needs a dedicated resident, I need the residents who are on vacation to come back to the hospital and be my central line team. Talk to the hospitalists and figure out what your floor and ED admitting situation looks like and fix it.” I then called the respiratory supervisor and said, “I need a dedicated respiratory therapist who will round with me in the ICU and we as a team will round at the bedside on every ICU patient with their assigned nurse so that the plan is cohesive.” Mind you this is how most ICU’s run, but was a total overhaul for my hospital. I then told the residents that their job was to do whatever the ICU nurses asked of them. I knew that the patients would need sedatives, restraints and other orders and I didn’t want the ICU nurses to have their “hands tied” because they were waiting on physician orders from doctor’s they couldn’t reach.
Then we began to round on the patients, going from bed to bed. The residents had not been held to a strict formal presentation style that is typical for ICU — they were all over the place in their thought processes. I had to edit them constantly – but they could sense the gravity of the situation and by the third patient, their presentation style had tightened up. We were taking care of the sickest patients we’d ever seen while trying to innovate the delivery of care to minimize staff exposure to the virus. A nurse’s instinct to protect her patient is so strong. At one point a patient awoke slightly from sedation and the nurse ran into the room without donning Personal Protective Equipment (PPE) to prevent the patient from extubating himself. It was at that point we put restraints on every intubated patient and began sedating heavily. We all had a sick gut feeling when we saw her expose herself. One of the lessons learned on the front line was to protect yourself first – or you’d succumb to the virus and not be around to take care of patients for a couple of weeks. The ICU charge nurse and I realized that ideas were flying fast, and that she and I were making many decisions simultaneously. Together we filled a paper front and back with our ideas, and about 85% of them were identical. We got extension sets for IVs and put the poles outside of the rooms, we turned the ventilators so the screens were toward the doors, we would write the latest Arterial Blood Gas (ABG) results and ventilator settings on the glass doors. I began using the large glass doors to each ICU pod as my chalkboard – drawing lung physiology sketches and giving everyone a crash course in critical care medicine. Everyone at every level had to become proficient within days — we did not have the luxury of learning at a leisurely pace.
We went from 3 intubated patients to 9 intubated patients in 3 days. By Sunday afternoon that first weekend there were 25 hypoxemic, non-intubated patients with respiratory failure. Much of the rest of that first weekend is a blur. I came home that night and entered my house through the garage, disrobing and wiping down the whole way, then took my temperature, followed by a hot shower to decontaminate – and quarantined myself in the basement away from my husband and children. In fact, the basement became my home.
Remembering
Yesterday we held a moment of silence in the lobby of the hospital, remembering the beginning of the pandemic, one year ago. It stirred up memories and emotions I had suppressed. I’m not sure I’m ready to unpack those feelings yet — it is exhausting to do so. The weather is nice and the days are getting longer. Right now we are in the low double digits for COVID hospital inpatients. I want to pretend things are normalizing and just have a nice weekend. But in a sense I need to mark this anniversary too, as it has been a year since my life — all of our lives — changed forever. I never could have predicted that the decision to pursue a fellowship in critical care medicine or that the strange timing of the call schedule would position me to be the first intensivist on call for COVID Wave One. It had a massive impact on my life.
Yesterday after the moment of silence, my dear friend, wound care nurse, prayer warrior, and closest friend and I looked at one another and wept. How little did we know that our little prayer in the hallway and our fears for one another’s safety in the face of uncertainty would mark the beginning of it all. How little did we know the way in which we would be changed one year later. COVID is a crucible, it consumes the dross from the raw material, its impact destroys, strengthens, and scars.
What Would I Tell Myself, if I Could Talk to Me Before COVID?
I would have told myself not to sweat the little stuff. You will be OK. Pray as much as you can and when you can’t, your friends will pray for you. Love with abandon and hug with impunity because soon you won’t be able to hug everyone. Share food and drinks and spoons and salsa – because soon you will not be able to share food. Buy stock in March in anything!!! Invest in skin care because you’ll never wear makeup again.
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
