Somnath Bose is an Assistant Professor of Anesthesia at Harvard Medical School and Staff Anesthesiologist/Intensivist at Beth Israel Deaconess Medical Center in Boston
By the time I picked up my week of service in a COVID ICU in early April, it was amply clear that our state had become a hotbed of COVID-19. Social distancing was in effect: streets empty, commute times significantly shortened, business establishments closed, and every single aspect of residual human interaction overwhelmed by the all-encompassing virus. I did not expect the ground zero of this fight, namely hospitals, to be particularly immune to these social changes. Walking in on a Monday morning, I knew that this was not going to be just another week of ICU service. Yet what I experienced through the week was way more than what I could have imagined. We were truly upended.
Red symbols strewn everywhere denoting restricted entry served as a grim reminder of what was going on all around us; this was most pronounced on the ICU floors. The unit looked cluttered, busy, almost unrecognizable, with piles of personal protective equipment, myriad pumps connected to patients through extra-long tubing and a constant cacophony of alarms no longer contained by the doors of the individual rooms. It seemed like a zone of controlled chaos. However, it was refreshing to note that some things had not changed, most notably the unwavering dedication of our team to patient-centered care which seemed reinforced through the crisis.
We start rounds and everybody steps up as if this is business as usual when it clearly is not. It is evident that not only are we taking care of our sick unfortunate patients but all of us are in the midst of dealing with our personal anxieties. Each of us has unique sets of undeniable concerns and trepidation. Most if not all of us wear our best defense mechanisms to work and focus on the task at hand: getting patients better. My personal worries fluctuate between “what if I am an asymptomatic carrier and at risk of infecting my family members, colleagues or other patients?” and “what if I get sick and need mechanical ventilation?” Speaking to my team members, I find similar themes, though some are even more morbid. Not letting ourselves be paralyzed by our fears, we plough through rounds, keeping ourselves distracted by reviewing bits and pieces of the deluge of COVID-related literature, interspersed with unrelated banter to lighten the mood.
Rounds are different nowadays. With visitors being restricted for obvious reasons, rounds are now essentially jargon laden conversations between different team members. This almost seems like a step backwards from all the gains of years of work aimed at humanizing ICUs. While the restrictions are appropriate to stem the tide of this ongoing pandemic, it makes us wonder about the ongoing collateral damage to the family members of those afflicted by the disease. We prioritize communicating with families, sometimes many times a day; but as days go by and we resign to this new workflow, we are becoming increasingly cognizant of the constant challenges this presents. Breaking bad news, sharing unfavorable updates, having difficult conversations regarding goals or limitations in care are beginning to test even the most experienced among us. It isn’t that we as critical care physicians have not been trained to approach such issues, but the current situation represents a departure from the norm. For example, when calling a distraught daughter to explain that her mother isn’t doing well and asking her to make tough decisions when we haven’t even had the opportunity to interact face to face to build a relationship is tough to say the least. Our tribulations however pale in comparison to what the family members are going through. I cannot even begin to comprehend what it must feel to converse, entrust complete faith in some distant faceless member of a medical team and make decisions, sometimes difficult irreversible ones about near and dear ones. Despite our best efforts to preface our calls with some degree of reassurance, it is unsurprising that each telephone call naturally evokes a feeling of impending doom for the listeners on the other end of the line. This unsettling realization has prompted home grown solutions with donated iPads to facilitate some form of family presence to bridge the gap. Clearly this is not enough, and we need more robust solutions to tackle the problem, as it has become amply evident that the pandemic is not receding in a rush. This may actually be an area where our technological giants could jump in to build HIPAA-compliant tools or devices to mitigate some of this collateral damage that continues every single day. At least that’s my sincere hope.
It would be incorrect to say that my week in the ICU was full of despair. The overwhelming support from the community has been truly heartwarming. Delicious meals, beautiful flowers and even uplifting graffiti pop up unexpectedly and serve as a pleasant reminder of how the community is rallying with us in spirit if not in body. Within the walls of the ICU, transient moments of gloom are routinely interspersed with success stories of patients liberated from the ventilator, sometimes after prolonged periods. And, yes, the growing accounts of people eventually getting home continues to help us power through. An impromptu tradition of “ringing a bell” has come up to celebrate small victories such as “extubations”. While the bells continue to toll and the tally chart of people returning to their homes grows daily, we are pining to go back to our routines both at hospitals and beyond. Godspeed.