Many thanks to all the friends and family who have written, texted, called, or otherwise messaged me to check in on how things are going. I really appreciate all the well wishes and positive thoughts. I also know a lot of you are also curious about what life is really like on the “front lines” of the pandemic here in San Francisco right now. Honestly I haven’t had the time or the headspace to reply to everyone, so I thought I would take a minute to do it here as an open letter/therapeutic brain dump.
As a disclaimer, I’m only aiming to provide an honest perspective from my singular point of view. I’m not speaking for ER doctors everywhere, nor even necessarily the ones I work with directly. My views don’t represent those of my employer. As you know I’m not a public health expert, nor an epidemiologist, nor am I a basic scientist/virologist, so I a not here to educate you on the sociopolitical aspects of COVID or what the next few months look like for your 401K. But I am a patient-facing Emergency Physician. Every few days, I put on fresh scrubs, park my car in the lot at my hospital, and then put one foot in front of the other to walk up the hill to the entrance of the ER where I have worked for the last decade, wondering if this is going to be the day when the “shift” hits the fan.
Firstly, let me cut to the chase and tell you about the thing that I know you’re all most curious about: what is it like in the ER right now? I’ve worked roughly three shifts a week since the start of the pandemic in an urban community academic emergency department. I have been stationed everywhere from our outdoor triage tent to our normal everyday indoor ER. So far, I am very happy to tell you I would describe is using a word that we superstitiously never actually say out loud in the ER…wait for it: Q-U-I-E-T. Yes, there it is, I spelled it, but I didn’t say it, so it doesn’t count, right? (It is common Emergency Medicine lore that to invoke that word out loud is to unleash the floodgates of hell upon your ER doorstep.)
What were you expecting? I know this doesn’t really jive with the numbers we are seeing in our country, our state, and our city about the pandemic, which conjures up images I am sure of people taking their last breathes in hallways as we doctors decide who gets the last ventilator. There is a bit of a disconnect. Maybe this is the proverbial calm before the storm. My ER doc friends in Seattle and New York are having a different experience right now, and in a few weeks, we certainly could be there too. That’s the assumption we are operating under, and I think that it’s a prudent assumption to make. I have a few other theories, as well.
I believe that most reasonable people infer that hightailing it to the emergency department for a minor complaint during a pandemic is not a totally smart move. (*On the other hand, please don’t be deterred from coming in if you think you may have a serious emergency eg., chest pain/left sided weakness/right lower quadrant abdominal pain, etc: keeping you away is certainly not what we are hoping to achieve here, and in fact we are trying to make this environment as safe for you as possible.) I also believe that most of our patients are also getting the message that if you think you have COVID, and you are otherwise healthy and doing okay, staying away is still the right move (*generally speaking–if you are feeling very sick, if you are elderly or immuno-compromised with symptoms of COVID, or if you just aren’t sure, we are always happy to take care of you in the ER. Anyone, anything, anytime. That’s the ER motto).
And yes, I believe the calm we now experience is also likely in large part because social distancing measures and shelter-in-place orders are working, and I am really thankful to our local government officials for acting quickly and decisively to put forth measures to make that happen. As I said, I am not an expert in epidemiology, I don’t know if we are truly “flattening the curve” or rather riding a sine-wave like roller coaster which will (hopefully) have dampening oscillations in frequency and amplitude as the months move forward, but either way, I am very thankful for the relative “flatness” of this early first-cycle.
Being flat now is more important than at any other stage in the game. It has given me, and other ER doctors like me, adequate time to prepare for the surge we all fear is on the way. This includes things like: reading up on a novel disease, of which we had no prior knowledge or understanding; learning proper procedure for donning and “doffing” (the opposite of “donning,” for the un-initiated, and by far the more dangerous step) of personal protective equipment, to minimize our exposure risk; and, mentally steeling ourselves for the possibility of contracting an illness that will most likely be uncomfortable but hopefully not deadly, and the burden of knowing that at the end of every shift, we potentially bring that risk home to the people we love the most.
I am so thankful to those of you who have made the personal sacrifices to honor shelter-in-place. I know it has not been easy.
This is not to say that we are not caring for COVID patients at all yet. Quite to the contrary, roughly two-thirds of the patients I have seen on my recent shifts have either been confirmed COVID-positive or patients that we highly suspect, coined “patients under investigation.” Because of a law called HIPAA I can’t really tell you more than that–except to say that, very fortunately, all the patients that I have personally cared for to date have felt sick, but objectively haven’t really been all that ill. Most of them I have been able to send home, some right away out of our triage tent, some after standard ER treatment with fluids, a chest X-ray, and some basic lab checks. Collectively, my group has seen a few of the critically ill, some have required mechanical ventilation and intensive care unit admission, but that hasn’t been my personal experience, yet.
It is still scary though. Even with meticulous use of personal protective equipment, I have to say it does take nerves of steel to enter an enclosed space with a patient who has known COVID. All sorts of doubt and psychological fears permeate my mind: is my surgical mask really good enough, as the WHO has recommended? Or should I be in an N-95 like the CDC recommends? The party line at my hospital is to wear a plain surgical mask; if I chicken our and grab the N-95, what kind of message am I sending as a team leader to the nurses who bravely enter the room next to me with a surgical mask? When the patient is violently coughing, isn’t the virus leaking around the sides of their mask, and how much of that is aerosolized and potentially headed my way? After I place my stethoscope upon the patient to auscultate her heart and lungs, will it be good enough to simply wipe down that stethoscope with a bleach wipe and carry-on? Should I double-bleach it just to be sure? Did I leave the room and properly remove all the PPE? Did I accidentally touch my face somewhere in the process? When thinking like this invades your consciousness, it is difficult to perform even a basic history and physical on a patient, a skill which should feel second-nature after almost twenty years of practice.
Further, all the soft skills that I normally pride myself on, and have perennially impressed upon medical students whom I’ve worked with over the years–entering the room and giving a firm handshake, sitting by the patient’s bedside, leaning in while listening and offering the gift of gentle touch when the situation calls for it–all those things are out the window when everybody is a “patient under investigation.” Worse yet, when a patient with an unrelated complaint like a broken wrist or a laceration looks at me suspiciously as a potential source of infection for themselves (they are not wrong to think this), then none of the usual waltz that typically defines the doctor-patient relationship seems appropriate anymore. I wonder to myself, will it ever feel appropriate again?
To answer a question many of my friends and family have had, it does feel like we are being cared for by my hospital administration.  I am thankful to my local hospital leadership for all the pre-work that has been done to help us. From the start, we have rapidly altered our hospital operations to be COVID-ready. Communications from leadership have been frequent and transparent. There’s been rapid efforts to expand our labor pool, and everyone from general surgeons to endocrinologists to family physicians have shown up to offer help and take on some of the burden. I am not sure we will use them, but it is heartening to see their faces as they come to orient with us. We have re-vamped our schedule for the upcoming months, with layers of emergency coverage and sick call including the “full-blown Italy” all-hands-on-deck plan. Tough decisions have been made, like canceling money-generating elective surgeries to preserve precious PPE for doctors like me who will experience the highest risk. Even our physical plant has been transformed almost overnight to increase our capacity to care for the ill. This is no small feat given the real estate challenges of San Francisco. Our waiting room has become a patient care area. Our ambulance bay is now a triage tent, and we even have a giant circus-tent like disaster treatment area which makes me think of the movie E.T.
Within my department, it has never felt so cohesive. We are educating ourselves on the best medical data regarding COVID recognition, resource-minded testing protocols, and management of patients on the spectrum from gonna-be-fine to the maybe-sicker? to the obviously critically ill. Also, I’ve been working closely and concertedly with nurses, techs, and registration staff in the ED. It feels like we are getting closer as an ED family and we all have each other’s backs, which is important as we prepare for a harrowing challenge ahead.
To be sure, the biggest challenge for me so far has not been within the confines of the hospital. Like many of you, I am a parent of young children. I am blessed to come home after every shift to two awesome but energetic middle school age boys, and a six-month-old beautiful baby girl. It only took a few days for Iris and I to realize that we were in trouble with school cancellation. We lack the knowledge, discipline, and child development expertise to be effective home-schoolers.
God bless our school teachers, I don’t think any of us understood how difficult your job was before all this.
Iris has been a hero in this regard for at least trying. She’s built terrariums with them to teach science, she’s started Isaiah on multiplication and division, and she arranged an interview with grandpa by FaceTime for social studies. The days have been very long as we attempt to prevent our children from devolving into a feral state. We vacillate between concern that they will fall behind academically, and fear that maybe we are pushing too hard when they start to fall apart after 20 minutes of reading and maybe we should just focus on being parents and loving them through a difficult time. All this while doing our best to shield them from some of our own fears about the pandemic. All this while trying in the background to keep up with endless online work meetings, watching medical lectures, and reading to keep up with everything I need to know to provide the best care I can to the unfortunate patients who do get really sick with COVID. All of this while changing a bunch of dirty diapers in a constipated seven-month-old who is starting out on solid foods. It’s a lot.
Of course, there are plus sides here. Like all of you, I’m certainly spending a lot more time with my wife and children than I ever have before. Iris and I feel strong in our relationship, something that I think crisis mode does for us. I’m learning a lot more about the way my children think, and what they think. And holding sweet baby Daphne as often as possible has been like my Ativan-equivalent. Her sweet little oblivious gummy smile calms me in those moments when I feel like everything is falling apart. Her huge radiant blue eyes transmit a message of trust and love that erases all doubt.
I know we will get through this, and so will you and your family. Thanks for staying home. Remember, you are not just keeping yourselves healthy–you are keeping all of us healthy.
lls me out. “If it’s love, we gotta kiss.”
little onion, many layers 