SAVING YOUR LUNGS WITHOUT LOSING OUR MINDS

Lekshmi Santhosh, MD, MAEd

After a very long day in the COVID ICU, before a very long night of finishing up notes and compulsive chartchecking, I sat with my hands patting the heads of two flopping toddlers attempting to sleep. Unable to sleep with the excitement of their brief sighting of Amma, they flipped and flopped and intermittently debriefed me on their days, “Calvin was not be nice to me!” As I sat in the dark room, with one hand patiently patting each little head, unable to move, unable to catch up on work, unable to stop the churning to-do list in my head reminding me of the things I would likely not get to tonight, I tried to break the cycle.

I tried to fill my lungs with air to pause my buzzing brain. I tried to forget the to-do list, the whining children, the man who begged not to be intubated because he would not be able to afford being hospitalized for weeks, the orphans I had to hug and say "I’m sorry" to, the patients I had to beg to get the vaccine, the colleagues I had to talk out of quitting. I remembered my rarelyused—yet often-recommended to others—Calm meditation app with a visual of an expanding and contracting circle to be timed with each breath. Instead of a circle, all I could visualize was my own head, comically disfigured, expanding and contracting with each breath, but mercifully not exploding.

Suddenly, it crystallized—it was obviously not a circle, not a cartoonish head, but the most beautiful and symmetrical unit we had fallen in love with in the first place—an alveolus. Much has been written about the importance of diastole for physician well-being, but why should cardiologists have all the fun? Allow me to introduce you to a pandemic’s guide to saving your lungs without losing our minds.

Diagnostics

We, the healthcare workforce are in critical condition, in acute distress. We have lost our resilience and our elastic recoil, or have we lost our compliance and are shrunken, stiff, and immobile? It doesn’t matter. We hope we are not too refractory to rescue measures.

We cannot bear the barotrauma. The pressure has built over the pandemic and has become additive, with dangerously high spikes at times. By day we fight a highly transmissible global pathogen and by night we elaborately decontaminate to convince ourselves that we will not infect our families. We answer texts and emails and Whatsapps from friends, family, frenemies, casual acquaintances around the world, about their friends and families who are all sick too now, and we add them to the nightly evening phone-rounding list.

The volutrauma adds insult to injury. The sheer volume of tasks to juggle the Zoom schooling, the pivot to virtual teaching, the half-finished research projects, and the Sisyphean inbox and InBasket.

We scoff at the controversial P-SILI (patient-self-inducedlung-injury), and yet we wonder how much we have inflicted upon ourselves, how much we have only ourselves to blame, how many additional responsibilities did we really not need to sign up for? We then feel guilty for blaming ourselves and wouldn’t dare speak to a friend or patient that way, yet we wonder how much of it is true.

Therapeutics

A transplant would be too dire, a last-case resort, and aren’t we just trading one disease for another anyways? Surely a new host—a career change, an institution change, a move—would just bring different problems.

There are really very few therapies that will give us a mortality benefit. First, we must immediately go into lung-protective mode. We must drop our tidal volumes to the bare minimum, and permit that CO2 to rise as it may. We must shed the nonessential responsibilities, let the house be a mess and the laundry go unfolded, and skip the make-up. Curling into this 4cc/kg ball seems drastic, but it is the only way out, and we must resist the temptation to liberalize too early when we think we are better.

Next, we must diurese aggressively for net negative fluid balance. For our alveoli are clogged and overfilled and sluggish, and we must diurese before we end up like the numerous COVID autopsies we have seen, with thick coagulated blood filling the previously delicate air sacs. We must decompress and let go of the excess expectations and worries and fears and anxieties and doubts and let it flow outwards. We must talk about it all – the lumps in the throat swallowed after every failed Code Blue, the death paperwork signed, the grim daily update phone calls. We have tried to forget and we could not. We simply cannot bear to continue to hold them in. We must cry with catharsis as the water escapes and we begin to heal.

Prognosis

It seemed dire, and the prognosis was poor, but slowly and carefully with diligent attention and patience, we begin to heal. Our compliance improves as we diurese and unburden ourselves of the barotrauma, volutrauma, and maybe even the P-SILI. We are slowly able to liberalize our tidal volumes, stretch our lungs and legs, and return to the world from where we had retreated. Conversations with strangers no longer fill us with dread. Persuading patients to get the vaccine no longer feels hopeless. We are able to feel and think clearly again as the fog lifts. We will heal.