Perspective from Colorado and New York: We were all called to serve, and we ask that our communities join us
I initially wrote this blog post several months ago, in the Summer of 2020. It has been sitting in my drafts folder, waiting for me to tweak it into something more, but I am now publishing this. We are still called to come together to defeat the pandemic. So here it is…
Written in August, 2020.
When SARS-CoV2 hit our country, we were not prepared for the most challenging public health emergency in the past 100 years. It felt as if we had been attacked, by a potent enemy 120 nm in diameter. Faced with increasing numbers of patients presenting with this new disease, and soon seeing our overrun hospitals and increasing death count, the battlefield was drawn, and many — from frontline responders, healthcare workers, and researchers — responded to the call to serve. As we prepared for our surge in Colorado, many of us viewed the situation at our country’s initial epicenter in New York with the utmost respect and awe of our colleagues on the front lines, fearlessly battling this virus each and everyday. And some of us were given the opportunity to serve by traveling to New York City in an effort to bring relief to those who had had literally no days off, as well as learn from that experience to help prepare our centers for a potential Denver surge.
In this article I’m sharing a personal experiences with COVID, highlighting not only what we have experienced directly caring for patients with COVID, but the journey to get there and afterward. I hope this resonates with our colleagues reading this post, and even more so, I am sharing these experiences beyond the medical community as a call to action to our families and friends, neighbors, community members, elected officials and fellow citizens.
When I first became aware of SARS-CoV2, I was watching the news, witnessing what was happening in China, and preparing to go to Peru for an international meeting in my field of pulmonary hypertension. Little did I realize at the time that that meeting would be the last international medical conference I attended in 2020. When we returned from Peru, there were long lines in the airport, and extra questions about fever and symptoms, and whether we had been exposed to people who had traveled from Wuhan, China. We had no issues getting back into the country on February 3. The next month, I continued to watch the pandemic evolve and expand and in early March I attended my last local medical conference, just before all meetings and public spaces were shut down with a shelter-in-place order. At this point, life at our medical center changed drastically after that. We implemented screening protocols in the clinic, and until we had telehealth set up in our clinic, I postponed most of my routine in-person follow up visits with my pulmonary patients, choosing to check in by telephone and waiting for our telehealth to be set up for the time being. And as our cases here in Denver rose, and as I saw my colleagues on the front lines, both here and in other parts of the country, like my colleagues, I felt this call to contribute in some way.
Early in the pandemic (and unfortunately still in many areas today), one of the biggest issues was the shortage of personal protective equipment (PPE). I was struck how many frontline physicians were not adequately protected and at that point the CDC even said that when no N95 respirators or surgical facemasks are available, a face covering like a bandana was better than no PPE at all. Cloth masks soon became an obsession, so I partnered with our occupational medicine department, a biomedical engineer at our sister institution, and members of the local sewing community in a desperate search for the best, albeit imperfect, option. We researched and came up with our best design and launched a cloth mask campaign, collecting over 2000 cloth masks for nonclinical use. While cloth masks seemed contentious at first, by the time our campaign was in force, more data were coming out and recommendations evolved, recommending cloth masks to reduce transmission, especially asymptomatic spread.
Since coming to Denver, my call had been to build our center’s pulmonary hypertension program at our center, and in order to do that effectively, I had backed off on being a critical care physician spending days and nights in the ICU. When the pandemic hit, and I saw my colleagues around the country as well as here in Denver were stepping onto the frontlines, I felt that same call to serve again as a critical care physician. I was inspired by my colleagues who went from Denver to New York City, and so proud that National Jewish Health was sending doctors out each week for rotations to help and to learn, so I sought a way to sign up for clinical service. When my partner in pulmonary hypertension was the next to serve in New York City, I jumped at the opportunity to fill in for his ICU overnight shifts in Denver, and prayed that I would still have the skills to lead the overnight physician team.
My first two nights taking care of COVID patients were nights I will never forget. Never had the ICU been so full. There were 54 patients on service, and all but 8 patients (who were in a completely separate unit in the hospital), had COVID-19. As we did our evening rounds, we checked boxes on each patient: intubated, proned since 8AM, status post hydroxychloroquine (at the time still under investigation), no evidence of cytokine storm, etc. There were no family members present. It was just our ICU team in the hallway, the patient inside the room, and writing on the ICU glass windows indicating the status (intubated, time they were prone positioned, etc) as well as needs from the nurse working inside the room to people outside to fetch medications, or another liter of normal saline, for example.
We rounded on one man who had been in the unit for 3 weeks, and he had multiorgan system failure. It was expected he would die in the next 24–36 hours. There was no more we could do and as the inevitability of his outcome was near, his family had made the decision not to escalate care. Later that evening I was working on the computer working up an incoming patient coming to our other unit after having a cardiac arrest, when he passed away. We had a no visitor policy at that time because of the rising cases and already overwhelmed medical system, but after patients pass away, our hospital would allow one family member to come in to see him. For as long as I live, I will never forget his wife coming in sitting at his bedside and crying, saying “Levantate! (Get up!)” An hour later that night we intubated a patient with cardiomyopathy and heart failure who was declining, and prior to his being intubated we made sure he had talked to his family, because with COVID-19, it is possible that that might be the last time his family would hear his voice. After he was intubated, he went into V fib storm, and a long resuscitation ensued. I stood at the bedside with the code team, and resident and in-house anesthesiology attending (a part of our expanded surge capacity for lines and procedures during the pandemic), resuscitating this patient when a non-COVID patient arrested in the distant ICU. With the ICU team and anesthesiology attending continuing our code in the ICU, I headed to take care of the patient having the ST elevation MI in the other unit, as we worked as a team to keep these people alive. In my two call nights in the ICU we lost 2 patients to COVID-19, and what struck me the most was the sadness of patients dying without family there. This has been covered extensively by many in the media, but when you witness it, it is one of the most devastating moments you can imagine. While death in the ICU is always sad, and always tragic, this loss is even more profound without the closure that people can have when they are with their loved ones when they leave this world.
I also saw the challenges we face with patients outside the ICU, as one of my dear friends became sick with COVID-19. My colleague was young, previously extremely healthy (no hypertension, diabetes, metabolically healthy), and had been unknowingly exposed early by a patient in her clinic. She felt the immense fatigue, and then noticed hypoxemia and shortness of breath, improved by breathing by laying face down. She sequestered herself from her family, and worked to get through this. When the hypoxemia worsened, she went to the hospital and was admitted for a few days. When she was given enoxaparin shots and the team saw a sudden improvement, she was able to be discharged with normal, albeit low normal oxygen levels. Over the next few days her oxygen levels declined, especially at night, and she was prescribed home oxygen. Her course of improvement has been steady but slow, and it is still ongoing. Knowing someone personally who had gotten sick with SARS-CoV-2 only strengthened my desire to try to do something more.
After my two nights in the ICU in Denver, I submitted my name to our critical care medicine head, hoping that I might get called to serve with my colleagues in New York. I continued to take in all the information I could about managing patients with COVID-19. I would wake up, read articles, look to my colleagues on #MedTwitter for discussions on the latest published and pre-published work in this new disease, all in an effort to prepare myself for our surge, should it come, or to serve in New York City, should I get the chance. Then I got the call to serve in New York City as part of the last contingent from National Jewish Health to rotate through our sister Mount Sinai Institution, which led to more nights short on sleep and a lot of reading, taking in webinars, and talking to my colleagues who had traveled there before me. I felt honored to go, but also anxious that I would be know enough, make the right decisions, and be able to help my battle-worn colleagues.
We arrived in Manhattan, had our orientation, and soon were dispatched to our various hospitals. I was dispatched to Mount Sinai Queens, where I would take over the pulmonary consult service for the 4th floor and assist one of the step down units. The step down unit was a PACU converted to a negative pressure room by creating holes in windows with giant generators pulling the air outside the building. Outside of the room, we would gown up in the presence of an observer to make sure we used proper technique: Head covering, gown, gloves, shoe coverings, surgical mask over our N95 respirator (which we wore all day except when eating or drinking), and face shield. When you entered the room, it was a large room with 7 beds in one room and 2 beds in an attached room, all patients with confirmed positivity for SARS-CoV-2. Some were on high flow nasal cannula, others on BiPAP, and frequently, intubated on the ventilator for even a couple of days until the ICU bed opened up. I served that week alongside Dr. Cruz, a talented anesthesiologist from Florida whose sincere effort to these complex patients was obvious from day 1. She was in the unit full time managing these patients during the day, while I would handle consults there and on the floor.
My experience there was only 8 days, but in that 8 days I experienced intensity, triumphs and the lows of COVID-19 experience. Everyday I would wake up at 5AM and read the latest journal articles, trying to understand this disease. I would walk with my colleague to work and we would discuss the latest data and hypotheses. We would occasionally text our other Denver colleagues at other hospitals in New York, asking what they thought about certain questions or difficult cases. At the end of the day we’d get dinner on the way back to the hotel, go our separate ways, and go through the decontamination procedure in each of our rooms. My ritual: take off shoes and all clothing at the door, put it in the laundry bag, wash hands, take off N95 mask, wash hands, shower, PJs, and eat dinner and watch the news. Download articles I would want to read the next morning, and go to sleep.
The triumphs came when we would hear the song on the loudspeaker, “Just breathe” when patients were extubated and “Here comes the sun,” for every patient who was discharged from the hospital. Although I was not there long enough to see the people I was caring for extubated or discharged, it brought hope that with continued efforts this may happen for them. Many of the patients I cared for were Spanish-speaking, and without family or friends at the bedside, the biggest way I contributed was being able to help them communicate even with my less-than-great Spanish. Each day after we rounded, the most important duty was to call and update the patients’ families. Not being able to see or talk to their family members easily (with most on high flow oxygen or BiPAP), it was crucial to update them on how they were doing. Most days Dr. Cruz called them as she was in charge of the unit, but on her days off I had the opportunity to do this myself.
I literally have journal pages full of patient stories from my experience that week, but the one that stands out most is that of Mr. G. I inherited him from my colleague who had been taking care of him during her week there the week prior. Mr. G. was a lovely and kind young man in his 30s with history of type 1 diabetes, but otherwise healthy and fit. He had contracted COVID-19 and was on the floor for weeks on high flow nasal cannula in a prone position. When I came at the beginning of the week he started requiring 100% non rebreather on top of his high flow nasal cannula, an attempt to keep him above 90% and from requiring intubation. As the week progressed, his sats continued to drift below 90%. He was hemodynamically stable, already on therapeutic dose anticoagulation, and we put him in Trendelenberg, proned, and added another course of steroids to see if this would help given his sats continued to drop into the 80s. On my last day there, he looked more tired, and we just could not get him back out of the low 80s. We transferred him to our step down unit for closer monitoring, and I made phone calls to find a potential clinical trial or possible ECMO solution at a sister hospital. I spoke with his brother and made the patient did as well. There was no available trial, and he proceeded toward intubation. After that he only became sicker. Having spent days at his bedside on the floor and now in the step down unit, it felt like a huge defeat. During my brief week, I had 4 patients progress to the point of intubation and transfer to the ICU, and we lost 2 others right in our step down unit.
When it came to the end of my mere week in New York City, I felt guilty about leaving. We had only spent 8 days there, and although the landscape was improving since the initial onslaught in March, the fight continued. I wanted to stay, to continue the fight with my New York colleagues. The weight was heavy, but not as heavy, I realized as those fighting COVID-19 and perhaps their own struggles with battle fatigue. We flew back to Denver to a local airport, and I found my car had been broken into while I was away. A very kind man who ran the company in whose parking lot we had parked was beyond apologetic and took care of cleaning the glass and repairing my driver’s side window. As we sat there talking to one another, wearing our masks, I was so appreciative of how he jumped on his company’s pandemic response early. In his small business, his number one priority was to protect his employees. He had instituted cleaning policies from the start, and implemented masks and air circulation in the shop. It was the least he could do, he explained, and part of his duty in this pandemic. I was grateful to hear this, and reassured, especially after having seen people die, despite our best efforts, from this terrible virus.
My trip to New York was a week that changed me. It changed how I view medicine. It gave me a new sense of purpose, highlighted the incredible need to communicate with patients’ families, and brought a sense of urgency to doing something more in this fight. I had shared some stories, and mostly positive stories (no patient information) on social media so people knew what it was like living this experience for a week. I felt the support and prayers of my friends back home and around the country who left kind words on those posts. I actually felt the sense that we were in this together.
A new challenge: Misinformation
However, after we returned to Denver, we were quarantined for one week to recover lost sleep, and make sure we tested negative for SARS-CoV-2 prior to returning to clinic. In that week off I slept, read, reflected, and recovered. From the posts I had seen on Facebook when I was in New York and even back at home, I believed that I would come back to an American community dedicated to doing their part to social distance, slow the spread, and help defeat this virus. However, the truth is that while we were no longer in the heat of the pandemic, we all found we faced a new battle, the battle against misinformation.
When people are faced with societal challenges like the pandemic, that have a lot of questions and little answers, especially at the beginning, unfortunately conspiracy theorists thrive. We saw videos go viral like the Bakersfield doctors’ video, debunked by many and condemned by the American Academy of Emergency Medicine and American College of Emergency Physicians, as well as the Plandemic movie, debunked by Science. In July we again saw “America’s Frontline Doctors” in white coats on the Capitol steps, misrepresenting existing knowledge about SARS-CoV-2 treatment and prevention, again jeopardizing public health. I saw these videos and other anti-mask and anti-social distancing posts shared by friends on Facebook, people I knew from high school or my former life in Pittsburgh, and each day I would interject my opinion in their feed, as a pulmonologist who has seen people with the disease, only to have more vehement perpetuation of these dangerous conspiracy theories and misinformation. What they don’t see as they spread this misinformation, is that it is like a knife stabbing the heart of those who are working hard to defeat this virus. Perpetuating misinformation as a “Facebook scientist” is not only ignorant, but actually cruel, even if those who do this do not see that. In large part, I fault the miscommunications from our country’s highest executive and the echochamber of right wing media: Response to this pandemic starts at the top. Because the lack of a unified response following the evolving science, and despite what we now know from voice recordings about how our president expressed he knew about the virus behind closed doors, his lack of setting and example by following the science, wearing a face mask in public, as well as his expressed beliefs in unproven therapies as well as that the virus would some day “just go away” minimizing the pandemic, he and his echo chamber influenced some people’s perception and response, and contributed to unnecessary infections and deaths. I engaged in fighting back until it became exhausting, as I realized that I was being manipulated by Facebook’s algorithms to keep me engaged on the platform by interjecting these conspiracy supporters every so many posts, just to capitalize on my most precious asset: my attention and time.
Because Facebook is not factchecking or disallowing political ads, and because it is not doing enough to fight the battle against misinformation (against bad actors from both within and outside our country), I have mostly left this platform. Admittedly, this is a continued internal conflict, because while I see my friends and community on this platform, and feel the need to help put counter the misinformation to help fight COVID-19, I don’t have enough energy in my day to allow it to be dissipated by a platform whose ultimate motive is that of profit over democracy. Perhaps we need to continue the positive and factual information on Facebook to counteract the false narratives, but with Facebook the odds are not in our favor.
With this pandemic, the most disheartening aspect of all of it, is that we were all called to serve. Some of us on the front lines, and others as a part of society to do what we can to all defeat the virus, from protecting ourselves and or friends and neighbors. Seeing people embrace non-science, unfortunately even from our president, who continues to minimize this pandemic as well as the over 200,000 lives it has taken, and betray their own inability to respond to the call is beyond a slap in the face to those who are doing their best to care for our ill brothers and sisters, or those who are doing their best. It is as if we were sent off to war, but people back at home chose to contribute nothing, and just go about their daily lives to maintain normalcy. If each and every American asked themselves what they could to to stop the spread, protect themselves and their neighbors, and then did that, we would be in a different place today. It is not too late to do this, but in order to do so, each of us must answer this call.
What will you do? Will you help answer the call?