6 minute read
Young Physicians: Hero
Priya J. Ghelani, DO FAAEM
I have heard this word in a variety of permutations over the past few months, whether on social media platforms, in the news, or when friends and family address me as the emergency medicine physician taking care of coronavirus patients. Caring citizens have sent care packages and kind notes letting me know they are thinking of me. My fellow colleagues say they have been going through some of the same, and it feels equally strange. While the appreciative gestures have been nice, the question remains. Do you feel like a hero?
If there is a specialty in the house of medicine that is generally even-tempered, ready to resuscitate at the drop of a hat, and constantly humbled by the pathology we too often diagnose and see, it is the field of emergency medicine. There is a certain personality that is associated with the willingness to be able to function with maximum unpredictability with often minimal recognition, while facing an indefinite number of stressors at any given time. Taking care of exceptionally sick, often unconscious, and sometimes dying patients on a regular basis, some of the most vulnerable in our society, requires a certain resiliency and hardening of the human spirit. It is with great pride that we refer to our specialty as the one in which the lights are always on.
What is it about the word “hero” then that feels so unsettling? Why have we as emergency medicine physicians been labeled as heroes, almost overnight? My fellow EM colleagues consistently come early, stay late, and work hard each shift as we took an oath to do long ago — that hasn’t changed. Is it because now our own lives are in jeopardy, and we are subsequently putting our families’ lives at risk? Is it because we are some of the few who are qualified to be on the frontline, and therefore some of the most likely to be sacrificed? Is it because during this pandemic, our ERs have turned into war zones, with patients dying in droves, and there is now a greater sense of empathy for those who witness death at such a scale?
We as physicians strive to deliver the best care for our patients. So do many of our coworkers on the frontlines – paramedics, nurses, custodial staff, respiratory therapists, patient care assistants, security staff, and countless others. We are undeniably only one piece of the puzzle, lost without the rest. While we were frustrated by the lack of protective equipment, our medics routinely brought in the masses wearing only a mask. For those of us at county hospitals, resources on a good day are stretched thin. Our ICUs and medical floors frequently have no beds available, leading to lengthy boarding times, sometimes days at a time. The areas with the lowest socioeconomic populations in New York City transformed overnight into petri dishes of coronavirus infections and our ED, as it often does, became overwhelmed as the volume of critical patients skyrocketed. Our underprivileged communities became an abysmal example of health disparities. However, our staff, despite a sense of palpable fear, took this in stride, and got to work.
I do not feel like a hero. When we first encountered coronavirus patients, we relied on minimal data we had from across the world. A lack of tests, we repetitively explained to patients, was the reason as to why they could not be diagnosed appropriately. Each radiograph looked nearly the same, a disastrous chaos of white-out multilobar pneumonia, as did their clinical presentation, varying degrees of hypoxemia. In the beginning, we intubated early, trialed high levels of alveolar pressure, and calculated each patient’s P:F ratios. Hospital administrators were fearful of utilizing non-invasive ventilation strategies, and our pendulum of management swung accordingly. We kept
patients dry as the limited data recommended, arguably plunging many into renal failure, and ultimately into multiorgan failure. Despite spending our time away from work reading data, listening to our colleagues in China and Italy, and studying complicated ventilation strategies, we were driving blind, often with ever-changing data. We followed our admitted patients, realizing many of them were decompensating quickly. There is perhaps nothing more heartbreaking than realizing a patient you took care of who seemed to be improving, later died. Or to take care of a critically ill colleague, one of your very own. A dull record player droned on repeat in the background, constantly reminding us of the fragility of our own lives.
We eventually recognized that we had it backwards, that no hospital has the resources to care for a few hundred ventilated patients, and that we were rapidly running out of resources. Preliminary data associated early ventilation strategies with increased mortality, and we recalled the dozens of patients we had intubated. We offered elderly patients the minimal management options we had shy of invasive options, recognizing these were likely futile treatment strategies. The new normal became seeing patients on a non-rebreather mask and nasal cannula tubing underneath, sometimes on a morphine drip, which seemed to cure their air hunger as much as it cured our own anxiety of seeing patients in distress. Stretchers had a paper attached to them dated and timed with their oxygen saturations on their oxygen flow rates, and boarded patients in the ED were flipped around the clock like rotisserie chickens. We became painfully comfortable with resource utilization and when to offer invasive ventilatory options with an ever so depleting supply. We taped masks delivering life-saving oxygen with Band-Aids on the faces of our patients with dementia, and used vests and soft restraints to prevent them from starving themselves of oxygen, infuriating them all the more. It was difficult to not have a sense of near-repulsion with ourselves. This entire saga felt far from heroic.
Would I have appreciated better protective equipment and more readiness from our government, without a string of failures from the CDC? Greatly. Would I have loved to not come home feeling like I am putting my family at risk? Of course. But if we are going to have a candid conversation about risk, let’s be honest. I know I am not the first emergency medicine physician to have been threatened at work, that it hasn’t happened only a few times, and it undoubtedly won’t be the last. Nor will I hold my breath waiting for overdue reform. The idea of putting our lives on the line is not novel, although rarely has it been a conscious decision. I believe those of us who love our field have learned to accept our job wholeheartedly, from the less desirable parts with those that feel reminiscent of our calling. The alcoholic in our hallway may not be dying, but surely deserves care, as does the ruptured ectopic, and the massive hemoptysis.
Perhaps my issue with the word hero is several fold. What we were doing seemed to be nothing new — we have always gone above and beyond, trying to provide the best care we can, even when everything seems to be against us. My humility reminds me I have undoubtedly made painful mistakes along the way, especially early in this pandemic. We as physicians are only one part of the equation, hopeless without the rest, who risk their lives to care for others every day. And this construct we are a part of in health care is a recurring reminder that we continue to fail society’s most vulnerable. I, for one, am earnestly still trying to come to terms with the word “hero,” and can only empathize with my fellow colleagues who feel the same. That said, despite what may come, I take solace in knowing that our light will always be on.
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