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.