Essential

Nine months ago, I lost my sense of smell. Its comeback has been egh... I'm probably at like five percent. A couple things -peppermint, gin- smell noxious. Relatively easy to cut out, I now have a tooothpaste collection that pre-smell loss would've made me hurl... I'm working on a whiskey-based apple cider drink served hot.

There were certain days and weeks that this new reality of mine felt life altering. I have drafts of prior posts to prove it (they go: "this feels life altering"). I also have drafts of prior posts that prove that smell used to be a very important sense for me (they go: "those smells though, on this walk home, they're what really got me. Those memory inducing smells.").

But most days and weeks, it's obvious what actually altered, shook, and changed me... changed us... this year. What’s heavy, as we steer unsteadily towards the next phase of this all. My... our... long haul symptoms are the grief, the memory, of those we left behind.

This past Tuesday, actually, I woke from sleep panicked. The day before I realized a patient list I'd created on my hospital’s electronic medical record system to collect the names of the patients I treated with COVID was gone. I’d called it aCOVID, so that it showed up atop my other lists. And suddenly it was no longer, probably accidentally deleted as I clumsily navigated the newest update to EPIC. 

Why was losing this registry, this access to names and medical record numbers and notes and vital signs, causing heartache.. a recycle of the emotions I’d felt when so many patients on this list had passed away. That’s rhetorical, I know why. 

At work I went through my pent up papers and found the hard copies. Every morning at work I print a list of the patients I’m responsible for each day, and use it like a note pad. As I remembered, as my panic quelled en route to work, I’d kept the Lists from those cold April days. I’m looking at one now. 

Looking back at me, on creased yet crisp paper, are the names that lived and didn’t. In blue ballpoint pen, next to each name, I scribbled oxygen requirements, oxygen saturations, and respiratory rates. Some examples, which some will decode like it was yesterday: “NRB + NC.. low 90s”, “NRB + prone.. 92%, RR 38”. Other notes too, “coughing less”, “desatting when talking”, “discuss with son + wife”. A lot of family phone numbers. Not a lot of To dos. Because there wasn’t a lot to do.... no helpful labs, no helpful medications. 

Looking back at me, on this softly creased yet crisp white paper, Printed by Rebecca Lazarus on 4/19/20 9:12 AM, are the names that lived and didn’t. 

There’s Mr. and Mrs. A, a couple in their late 60s. He was slightly sicker than she was, but they both did great and survived. She was a teacher, and I remember talking to their daughter on the phone as the pair rallied towards their discharge date. It was a public hospital triumph that the 2 shared a hospital room. 

There’s Mr. C, who only spoke Cantonese. And Mr. N, who only spoke Mandarin. I swear I remember standing at their bedsides like it was yesterday. Mr. C was a little better on my 4/14 list but tired, hungry by 4/19. I remember his tall thermoses of soup. His family couldn't come to his room, nor even the floor. But if they left items like this in the lobby they'd be brought up and to the bedside. I remember Mr. C was stoic, proud, and fighting. He really was tired. You're entering the chart of Mr. C, who passed away on 4/28/2020.

Mr. N was younger. He shared a 4-bedded room which was OK because his 3 roommates all had COVID too. He had the window bed on the left; a southeast view taken up by the Harlem River drive curving East. Mr. N's hypoxia made him anxious, jumpy almost. Every day on the phone his family would ask me to give him fluids. He's asking for them, they'd say, he thinks they'll make him better. So eventually I gave him the smallest of boluses, cautious to not overcrowd his already failing lungs. Slightly better I wrote on 4/15. Even more stunning to think about now- that I treated this virus with salt water. You're entering the chart of Mr. N, who passed away on 4/23/2020.

I'm trying right now, as I lie longways on the couch in my warmly lit apartment. Full from dinner. The Brooklyn Nets are on mute... I'm trying to imagine what in the world this must have felt like for these patients. I close my eyes as they did as they took these fast and shallow breaths. As they panicked, some solemnly and some with more animation. To have felt so helpless. So out of control. So out of breath. 

There's Mr. J; with a cross out through his name. Because he was very old and weak and died before I even met him. There's Mr. R who dutifully would lie on his stomach when I told him he had to, because any other way his oxygen level dipped. Because his life depended on it. There's Mr. T whose sister-in-law worked in the emergency room and came to check on him most days. He was always breathing fast but was relatively young and otherwise healthy and survived. There was Mrs. M whose daughter I FaceTimed at the bedside. And then again once out of the room to comfort her as she broke down across the line.

There were so so so many more. On my aCOVID list. In my hospital. In our city. And the list goes on and on.

It's silly, but there's evidence to support olfactory training for post-viral smell loss. It's done via essential oils, and at this point I've amassed dozens. I can actually smell them, they're pungently concentrated, but it feels good, so they're scattered between my work office and bedside table. 

Last week, in a sign that we're heading towards normal, but that normal in the healthcare world can still be sad, a patient of mine admitted to begin cancer treatment was experiencing horrible post-chemotherapy nausea. Though none of our anti-nausea meds were working, she seemed to be comforted by sniffing alcohol swabs. Yo tengo otra aromas, I sputtered. Peppermint? She asked. 

I raced to my office and back to her room, with my small vial in tow. And in that brief moment, for that small shard of time, amidst the chaos and sadness and tears and memories racing through my mind, it felt like I was right where I was supposed to be, doing exactly what I was supposed to be doing, passing on this essential oil, to someone who needed it more. 

Waking up from a nightmare

I've been having frequent nightmares, since this all began. I've heard I'm not alone. The common themes in mine are loss, and being lost. Just this past week I was on an overnight road trip to nowhere, in the driver's seat of a car I didn't know how to drive. Family members got sick. Patient's passed. Michael -who in the true world has barely left my side- was with me no longer. From these alternate and inferior faux realities I awaken in my dark city apartment breathing rapidly; to gain composure I sit on the side of my bed, planting my feet into the actual, cool ground. 

As is a dreams tendency, shortly after awakening the details of these parallel lands already start to disintegrate. What's left over is how these nightmares made me feel: scared, anxious, unsafe. I'm glad to wake up.

This past week I've been off, but last week at work I led a team which consisted of a melting pot of providers: interns from other departments, physician assistants from other states, and the youngest of MDs who had shed their medical student skins just the week prior, graduating early to assist on the front line.

On my last shift on service, this crew and I walked down a hallway and marveled at a string of empty patient rooms. Doors wide open, lights off, beds empty. Like a collective conscious we processed the strangeness of the sight: over the previous month our public hospital had repurposed unit after unit, room after room, to accommodate a swelling number of patients. As dramatically as the census crescendoed, as last week progressed the plateau in the number of patients was palpable, and on my last day these abandoned rooms, like clam-less shells or abandoned Incan cities, represented the statistics our hospital system, city, and state were reporting: coronavirus admissions had finally slowed.

But something else struck me, walking down that hallway; a thought that followed me home from work that day, and has stayed with me since. Like an Instagram filter that blurs a photo's edges... like my nightmares shortly after I wake up... those weeks -those fever pitch weeks of late March and early April- were already beginning to feel not just like a memory, but a dissolving dream. 

As I process the out of body experience of what recently transpired -and of course is still unfolding- there are some lessons I do not want to forget. As a reminder for my future self, I've decided to jot them down. 

I have never been so present, so undistracted and un-rushed, at my patients' bedsides. With no competing priorities -research, meetings, after work obligations, and even my cell phone, which pre-PPE was accessible in my pocket- my morning rounds unfurl into the afternoon. Spending longer at the bedside -and surprisingly without the aid of stethoscopes, nor as many labs and imaging studies- I see my patients as clearly as I ever have. 

I have never relied so heavily on my ability to comfort the sick in front of me. With no antibiotics or treatments, keeping a patient calm, quelling some anxiety, really feels like an integral element of providing supportive care.

I have never had to serve as such a bridge between my patients and their families. Unable to be at their loved ones' sides themselves, through daily phone calls, often via a phone translator service, I spent my afternoons patiently updating petrified wives and children. I am actually Ms. Li's sister, the Mandarin interpreter translated one afternoon. Ms. Li, the patient's wife, is too scared to talk directly on the phone. But she is right next to me.

These connections have affected me profoundly. Knowing my role in this web of sorrow, this entanglement of uncertainty, is in part what gets me through.

Shifting to the care team. Amidst the fast pace and stress of hospital life, the relationships between primary teams and consultants, between physicians with a common goal but uncommon expertise, can become a little heated. I've been touched by how physicians, previously on all different career paths and daily schedules, have come together to care for our patients with bravery and gentleness. When this is all over and our paths diverge again, hopefully this shared experience will still bind us.

Outside of work and outside, I've learned some things too. I've reaffirmed that New York City, with its landscape and people, its sounds and sights, is the most special of cities. As the oblivious pink cherry trees blossomed and the first migrant birds settled in Central Park, friends and I swap photos of colorful spring flowers. The lack of crowds, traffic, and the empty store windows make the magnificent architecture, moldings, and facades stand out.  

Don’t get me wrong: almost every day, I review the charts of patients I’ve recently cared for; I am in disbelief and heartbroken to see how many have taken turns for the worse. These patients and their families, certainly, remain seared into my memory. 

I know many have faced tragedy and trauma that they'll never be able to completely wake up from. But as time passes, I know what will most stick with me, with us, is how this experience made us feel. I look forward to taking some select lessons with me as well. I look forward to better dreams ahead. 

I still can't smell them, but beauty on the UES

When the sadness catches up to me

The NYC cabbie insisted I not pay for my yellow taxi ride to work and that gesture carried me, until lunch. I ate free chicken and rice and leafy greens from a hip local restaurant and that meal held me over, until a mid afternoon break. I sat in the work room with colleagues turned friends and briefly we laughed and swapped stories, and those conversations absorbed me, until I got home. I Facetimed Michael and my family and ate more mini cupcakes that a dear family friend had sent over and that all made me smile, until the calls ended and the lights were out and my apartment was dark and quiet and then... then there was nothing left to carry me. And the images and realities of the day caught up and I cried. Not because I'm sensitive or because I'm an easy cryer,  both of which I am. But because this is sad. Relentlessly, devastatingly sad. 

I've been off the last 2 days or so, but prior to that I worked 7 shifts over a 7 day period. A combination of days and nights. The only saving grace was that I didn't have a core group of patients of my own- instead filling a role in which I responded to emergencies, as we say in the industry I helped to put out fires. And thus as I raced from room to room, from breathless patient to breathless patient, I barely knew the names and ages let alone the stories of those whose bedsides I rushed to stand beside. Sure, as I donned my PPE, quickly but diligently lowering my face shield and tying the belt of my gown, someone would call out the patient's co-morbid hypertension or kidney disease, their duration of symptoms and the progression of their oxygen requirement. But I would know nothing, nothing, about their spouses and children and hobbies and livelihoods.

You know even pre-COVID, frankly, we often didn't know a lot about our patients, or as much as we wish we did. Illness can be a magnificent equalizer, and once a patient is admitted to the hospital and dressed in a hospital gown, once they haven't had the opportunity to brush their hair or polish their nails, keep up with the news or express themselves lucidly due to their sickness, an element of their identity is stripped. But we'd get through our days because we kept an eye on the small amount we did know about our patient's pre-hospital selves. We put all of our effort into getting them back to that self.

How do we usually know, what our patients are like, pre-hospitalization? Sometimes through pictures, often through stories. But most telling, often we would see how spouses and children and siblings and friends, vigilant at our patients' bedsides, would look at them. We'd see our patients through the eyes of those who loved them, and often that would tell us all we needed to know. 

So I guess it's pretty telling: the aspects of my patients' lives that used to keep me going, I am now scared to realize. This is how helpless we feel.

We're not used to laying our patients on their stomachs, a posture found to help with breathing. Between this and the oxygen masks our patients are invariably wearing, it's hard to have a face-to-face conversation, or to look into our patient's eyes. When we do more often than not we hear and see fear.

We're not used to every patient having virtually the same exact problem. I responded to an emergency in a room on our seventh floor the other day, and like a deja vu I recalled taking the same path the week prior, addressing the same acute problem (low oxygen, or hypoxia) in the same room (7W 37B), due to the same illness (COVID-19). That prior patient, now passed away.

We're not used to our patients not getting better, to not having treatment. Usually when our patients have pneumonia, we give them antibiotics and they heal. Now, more often than not, we stand helplessly by as our patients just get worse. On my shift the other night I watched as a middle aged man, who had spoken to me in complete sentences days prior, was now only stringing a few words together between each struggling breath. His oxygen level was falling and he emergently required intubation; I stood by as a pair of anesthesiologists took over the room. Suddenly, under the influence of sedation analgesia and the direct flow of oxygen into his lungs, the patient was now still and quiet. Had I just heard his last words, ever? 

I can't stop thinking about a patient of mine who was already hospitalized prior to the outbreak, one of very few that we weren't able to discharge prior to what feels like all hell broke loose. This patient and I both developed fevers 3 Mondays ago, on the same day. We both almost certainly contracted the coronavirus within the hospital walls. While I recovered, this patient's pneumonia progressed, his kidneys failed. I am heartbroken that this patient has now passed. This patient whose faded and creased black and white family photos I had seen. This patient whose personality, will, and livelihood I had gotten to know. I trust you, Doc, he'd say when over the last few months I'd titrate his meds.

It strikes me that as our medicine and ICU services expand, as we utilize every nook and cranny of the hospital to care for more patients, the same thing is playing out at the hospital across the street. As well as at hospitals across the city, state, country and world. The moment my pager is quiet, indicating no acute emergencies, someone else's pager on the Westside or uptown or across the river is going off, someone is gasping for breath, someone is saying their last words.

I could not be doing this without the outpouring of love from my family, friends, colleagues, and community. Everyone's love is, unquestionably, getting me through each day. And it's helping me get though the moments the heartache catches up to me, too. But recognizing the sheer and total sadness of this situation is part of the process. I think it's ok to let the tears carry us as well.

This is just for now

My thighs ached like wet rags being rung out. The chills took hold.  My sense of smell dissolved. And the shortness of breath... the shortness of breath was unmistakable.

Count the respiratory rate. I instruct medical students, new interns. That's the vital sign you want to pay the most attention to.

I counted mine, last week, when I was sick. Like a systolic murmur it crescendoed to a peak on days 4 and 5, before normalizing again shortly thereafter. It was strange to be tachypnic -to be breathing fast- when I was walking to the bathroom, pouring myself some juice, simply lying still in bed. It was hard to ignore.

But with rest (and with time) it slowed. And with Tylenol (and 45 minutes of time) the chills and the aches and the sensation that my head was heavy and light all at once would cease. And during those moments of feeling better, I found myself looking -quite literally- to the past, as well as -a little more abstractly- to the future.

This, all of this, is just for now.

How to be so sure? While sick, I did a lot of scrolling through the photos on my phone, through thousands of squares of color and light. At those depicting medical school and residency, I stopped short.

In scrubs and long white coats. On night shifts and short calls. In clinic and the ICU. Each photo served as a launching pad, jogging memories of the moments seconds minutes hours that led up to the pose, as well as those that followed. I know we all have these images in our minds, and saved to our camera rolls. Of those days we worked relentlessly hard but yet found time to smile, to put our arms around each other, to be -without trying- care free.

There's a photo of me as an intern on night float, with a stack of patient lists in one hand and a birthday card in the other, because the clock struck midnight on my 28th birthday while I was on call.  There's a photo of an East River sunrise through smudged window glass and plastic blinds, signifying day break on another overnight ICU shift.

There are photos of the hospital decorated for Christmas. My friends and I gathering in the hospital garden. Of white boards with lesson plans I didn't want to forget. There are close ups of unusual CT and X-ray findings. Screenshots of Duke's criteria. Stethoscope selfies.

All these moments came, and went. As well as so many more that though not captured with a click nor easily recalled in photo-like detail, have still managed to invisibly contribute to who we are today.

Our emotions are defining this moment. Our actions and roles keep us present, bound to this phase in our careers and our lives. But it's been helpful for me to know this is not how it always was, nor how it always will be. 

This... this is most definitely just for now. And soon? Soon we will be close again, care free, with our arms around each other. Perhaps the future doesn't feel so abstract after all.

Pink sliver is the sun rising on a long call ICU shift

Luck in the time of corona

Like an obsession I check my hospital's electronic medical record app on my phone. Like a compulsion, the numbers keep rising. The names I know ricochet back and forth: their room numbers flip from those I know to be on the regular floor to ICU-capable beds, some back and forth and back again. Is this for real?

I felt that about my symptoms, too, that began last Monday. It's cold in here, right? I asked Michael, as we were falling asleep. Hours later I was up for the night with a feverish feeling, chills, and muscle aches. I trecked -ok I live in a studio apartment so in reality I walked the 10 feet- to my couch and tried to fall asleep there. I am achy and feel hot and cold, I texted one of my best friends, as well as my dad. I don't know what to do. Up hours later still feeling unwell, I emailed my department's directors. I'll probably be okay by the morning, but in case I'm not, I'm not sure if I should come to work. 

Michael and I have nicknamed it community covid, I think we like the alliteration. And though my swab has yet to result as the days creep forward it has become more and more clear that even if my symptoms may be slightly amplified by anxiety, even if I think this can't be for real, I'm checking all the boxes that make this disease process very likely. Muscle aches, fatigue, slight shortness of breath, joint pain, diarrhea, dry cough. All mild, but I have to say I've never quite felt like this before. I can't do half a jumping jack, I told my mom. Stop trying to do jumping jacks, she replied.

I am fine, though- because I am young and healthy. I am fine, though- because I speak English and understand health and illness, warning signs, the importance of staying hydrated. I am fine because my family and friends have sent me enough food and love to get me through 3 pandemics. Because I live in a luxury apartment and building staff are leaving my deliveries outside my door. 

Because last night, already in bed at 7 o'clock, I heard cheering outside. I made my way to my balcony -7 strides from my bed, 3x6 feet in size- and I realized from porches and fire escapes and open windows all around people were cheering, both literally but also symbolically, for the change of shift at the nearby hospital. I greeted my neighbor, on the balcony right next door. What are they cheering for? I asked her, more out of awe and marvel than because I didn't know. They're cheering for you, she said. I'm fine because this neighbor texted me shortly after to ask if I had a sore throat and would like some lollipops. 

Suffice it to say, I am fine because I'm really, really lucky.

It goes without saying not everyone is getting this lucky. People of all ages are sick, and that they are sick alone in hospital beds is a heartbreaking reality that I think has made my colleagues and my heart ache as much as any piece of this. More than ever, in this age of digital connection we are appreciating the importance of true connection. Of our health. Of getting really lucky.  

My view from the E Team

I’ve been asked by all my loved ones, my family and friends, what it has been like. Now that I spent one day on ‘Team E’, the COVID team (both confirmed cases and those being ruled out but sick enough to require hospitalization), it still remains pretty hard to describe but I can try to write down some thoughts. Of note I’ve done so much less than other people.

Hospital life has truly turned upside down. Every aspect of what I’ve been trained to do -and do well- every convention and protocol and all the structure, is literally gone. Both physically and mentally, the space has changed in the most palpable way.

Almost every patient room door is now closed and has 4 signs on it- denoting that it is an isolation room with a COVID patient (again, either confirmed or being ruled out. A lot of the cases we’re ruling out, almost certainly have it though- we can already just tell based on signs and symptoms). For now, each COVID patient is being roomed separately. Though eventually (soon) we will probably have to cohort multiple positive covid patients together, just given the numbers. So on a door there’s a stop sign to catch your attention, a sign in sign (which we’re not really using- a pen would be another thing requiring disinfecting), and then a sheet or 2 describing how to wear our PPE (personal protection equipment) properly.

I haven’t been down to the ER or this area we denote the EW which used to act as a low acuity ICU but is now entirely a respiratory unit. As is the ER. They’re both only for patients with respiratory symptoms. I’ve heard they’re both very intense places now.

Basically yesterday, on Team E, my friend/colleague Jon, 2 PAs and I went down a list of 20 patients and saw all of them. The PAs stayed outside and wrote notes, fielded and made calls, handed us supplies, put in orders… and Jon and I (sometimes both of us, sometimes one of us) gowned up and went into each room.

Throughout the day, there were probably 5 SPRT (special pathogen response team) alerts. They’re like the rapid responses/codes I’ve told a lot of people about, but they’re on the COVID patients, and instead of a dozen or more people rushing in the room, since we are being careful with preserving our PPE, only 2 or 3 of us go in (2 doctors, a nurse, a respiratory therapist) and everyone else stays outside and peers in through the door window. The anesthesiologists (who intubate) are part of that group who stay outside- waiting for the go ahead as to whether or not we think the patient needs a breathing tube (a sacred vent) immediately. Thank gd no one needed that escalation of care at the SPRTs yesterday.

All the patients have similar symptoms (though they don’t all have all of them)- bad headache, myalgias (muscle aches), high grade fevers, dry cough, and difficulty breathing. A lot of them have diarrhea too. And we’re noticing that there are a couple patterns in terms of how patients do, like how their illness evolves. 

But the scariest symptom is the hypoxia -low oxygen- as patients just become more and more hypoxic over time, some leveling out and some crashing typically around day 7-10 (my sense at least). Again, that’s day 7-10 of symptoms, so if they come in on day 3 or 4 you have to account for that.

Now of note these people who are hospitalized have a coronavirus *pneumonia*, which is different from the pattern that people have in the community, the pattern -thank gd- my colleagues and I would almost certainly get.

It’s jarring how many patients there are… that we have a zero visitor policy in the entire hospital (so hard to be sick alone). During a SPRT yesterday with a 32 year old patient who was doing really poorly (she has end stage renal disease so has an underlying illness), in the room it was Jon, me, a nurse, a respiratory therapist, the patient (solely Spanish speaking), and on her sparkly pink iPHONE, her brother- translating and asking questions. Doctor, is she ok. Doctor, how are you treating her. Doctor, can I come in and be there with her.  In this moment, I think she will be ok. In this moment, we don’t know how to treat her. In this moment, I am so so sorry but no, you cannot be here with her. So incredibly stressful for patients and their families.

It’s a process to don (put on equipment) but also doff (very carefully take it off). It’s the doffing piece of it that matters, because at that point the equipment has come into contact with the patient. It’s hard to balance when we’re beside with the patients these priorities. Because I’m so wired by that convention, structure, skill, bedside manner that I mentioned earlier. You go in and you want to get close and hold the patients hand or stroke their shoulder. But you’re also making sure the patient has their own mask on, that yours is on tight, that you are safe.