The road is quiet. Eerily quiet. It’s supposed to be rush hour but mine is the only car on the road. Another reminder that nothing is normal these days. Only essential workers went to work now and I, guiltily, was thankful to be one. It allowed me an escape from home quarantine. And I welcomed the unnatural peacefulness of the road, reminding me of early mornings before dawn breaks when the world seems to be yours. Ramin Djawadi’s ominous Game of Thrones soundtrack played in the background, highlighting the abnormalities of current daily life. I used to listen to educational podcasts on my commute, learning about new guidelines and literature in medicine. These days, my evenings and nights were consumed with reading about the virus and my mind needed the relief the commute provided.
As an infectious diseases physician, I got trained for such a situation – a pandemic. But no one really ever envisions being in one – despite the many articles I had skimmed over the years that warned of the inevitable. Now, rereading some of those articles, especially the ones specifically predicting a coronavirus outbreak, sent chills down my spine. The future was written, in print, back in 2005 and 2006 and 2010. And yet so many of us refused to believe it when it was in front of us.
These days, there was no need to search for a coveted parking spot. The hospital garage sat empty except for a smattering of cars on this Monday morning. I entered through the designated entrance and bent my head down to have my temperature checked. No words were exchanged. Grimness permeated the atmosphere. I encountered no one else as I walked the silent hallways to my office. I missed my coworkers, their banter and laughter. The virus had caused everyone to keep their distance.
At my desk, I opened up the electronic health record and scrolled through the COVID list. Five new patients were added overnight. Far fewer than the numbers coming out of New York and Boston. But five was still five more than zero.
Over the next hour, I scribbled numbers next to each name – the highest fever, the oxygen level, how much supplemental oxygen they needed overnight, who needed more and who needed less. Ventilator settings, white blood cell count, lymphocyte count, levels of inflammatory markers. The numbers squished together but provided a false sense of control that I clung onto desperately.
As a break, I scrolled through the photos on my phone. I found the one of me and all my coworkers decked out in encapsulated hazmat suits, negative pressure respirators, and gloves. It was a drill back in September for the division to practice how to put on and take off personal protective equipment. Who knew PPE would become a household acronym six months later? We looked like puffy aliens and we were oblivious of how soon we would all use those skills to save our lives.
“Remember this photo? Who knew we would need all this so soon in real life? ...” I texted one of my coworkers.
“Feels surreal, doesn’t it?”
“Feels like foreshadowing in a fiction thriller novel.”
“How many news from overnight?”
“Oof, good luck.”
Luck. I will need that. With that, I sighed, tucked my phone away, and took my paper bag with the carefully placed mask and shield. Because of shortages, we had been asked to reuse our N95s and shields. I was grateful for being taught the sterile technique in medical school when scrubbing into the operating rooms because it came in pretty handy these days.
Up on the intensive care unit, the hospital was bustling. The only thing setting it apart from a normal day at work was all the staff wearing masks and all the doors to the rooms closed shut. I started with the first new patient – an elderly woman with cancer of her immune system. The cancer was stable and she was doing well, until she got sick with the virus. I donned my PPE carefully, making sure not to cut corners. The type of gowns available changed every day due to supply shortages, and today’s gowns were made of thick, plasticky, Pepto-Bismol colored material. A nurse walked by and laughed.
“You look like you wrapped yourself in a shower curtain.” I smiled through my mask even though she couldn’t see it. Then I opened the door and stepped inside.
It was dark and the first thing I noticed was the sound of oxygen being blasted into the nostrils at high speed in an attempt to push as much oxygen into her lungs as possible. The woman looked frail.
“Good morning, Ms. S. How are you today?” The woman nodded slightly. I proceeded.
“I am one of the infectious diseases physicians. I wanted to talk to you about your treatment options and answer any questions you may have about the virus and the treatments we have available.”
“My husband.” She paused to take a breath. “Please call him.”
I proceeded to examine the woman and did not ask further questions, realizing it took a huge effort for her to even say basic sentences. I gave a short spiel of what I knew about the virus and what I would be doing for her in the hospital. I tried to keep it optimistic even though we both knew the situation did not look good. Then I carefully took off my PPE, exited the room, and, via a dance of glove exchanges, placed my mask and shield back in the bag.
I found the patient’s husband’s information in the computer and called him. He answered immediately.
“Hello? How is she? Is everything alright?”
“She is requiring a lot of oxygen but so far she does not need a breathing tube, which is a good thing. She told me she wants to defer any decisions about treatment to you.
“Oh … alright ...” He sounded surprised.
“We have multiple treatment options that we can offer. Only one has been approved for emergency use by the FDA.” I told him the options he had and how each was administered and how it worked. At the end, I asked what his thoughts were. There was a pause.
“What are the long-term side effects of that medication?”
“Well, unfortunately we don’t really know at this time. But it seems safe from the studies that have been done so far.”
“Do you think this treatment will make her better?”
“It’s hard to say. We don’t know if the treatment works for everyone … or who are the people it does work for ...” I trailed off. So many “I don’t knows.” People kept looking to infectious diseases doctors, to me, for answers. And we didn’t have them.
“What do you recommend?”
I wanted to be honest and say, “I don’t know again,” but I knew I couldn’t. I had no idea what I would do for my own family member in this situation. There were so many unknowns. But a decision needed to be made and he wanted my guidance.
“I would recommend to start her on the antiviral medication. I think the potential benefits outweigh the risks.” She knew the outcome was not great if they let the infection run its course.
“Alright, then let’s do that. Thank you.”
I hung up and felt a pang of sadness. And guilt. What was he thanking me for? I had nothing to offer. Most of the treatments had no proven efficacy yet and the one that did was no better than Tamiflu for the flu. It shortened the course of the symptoms by a day or so. But it also felt like I was at least doing something, trying something.
I looked down at my list for the next patient. He was thirty years old with diabetes and two kids. I learned the last bit from the nursing note I had read earlier that morning. He was already on a ventilator and not doing well. Despite all the treatments and time, his organs were starting to fail one by one. Despite the respiratory support, blood pressure support, prone positioning, and antibiotics – nothing seemed to make a difference. And he was thirty. Thirty. Younger than me, I thought. I pushed the thought away and focused on what I could do for him, which unfortunately wasn’t a whole lot.
And so went the rest of my morning. Put on PPE, take off PPE, go through my spiel of treatments that no one was even sure worked or what the side effects were. The patients were scared and I was scared. I didn’t know how to help them. And for the first time ever, there was no one to ask. No one else knew either.
At 2 p.m., I finally made my way to the cafeteria to get lunch. The salad bar and hot food service area was closed. All that was left was the packaged food. As I was leaving, I heard commotion near the entrance.
“This is all a hoax. Where are the people dying of COVID? I don’t see anyone here, the hospital is empty!” A man was yelling at the front entrance staff. A chill ran down my spine. I wanted to drag him up to the 4th floor, to the ICU, where a 30 year old with 2 kids lay dying despite all efforts. To show the sorrow in front of him. But I couldn’t do that. Nothing I said would matter anyways. These were those kinds of times, where no one really seemed to listen to each other. So I just quietly passed by and walked back to my office.
When I was finally done with all my work, I drove back home. Again, the eerily quiet streets and empty sidewalks. Even the homeless people begging on corners disappeared. At home, I again used my sterile technique skills to take off every piece of clothing and discard them into a designated “contaminated” hamper. I had created “contaminated” and “clean” zones within our apartment and tried to get everyone to stick to them, although it was hard for others to remember. Then I showered and finally greeted my family. My husband, also a doctor, has been at home all day, as most elective cardiology cases had been canceled. My mother, also a doctor, had empty clinics daily and sent me text messages of recipes for making sourdough bread. It seemed everyone around me had slowed down and had more time on their hands, except for me. I was both jealous of their free time but also grateful that I had somewhere to go every day, whereas many others had lost their jobs or were stuck at home. I couldn’t imagine not being able to leave my house and weirdly enough, my work felt like a respite. I quickly ate dinner and then settled in to read the literature that had come out that day on the virus.
In medical school, they taught us to critically appraise literature. They taught us to trust randomized-controlled trials and view the experience of a few patients in a case series with suspicion. They taught us not to make clinical decisions based on information found on educational blogs and twitter posts that have popped up in the past decade online. We learned to base our decisions on evidence, science, and logic. And yet, now, what choice did we have? How do you critically appraise literature when there is barely any literature to read? How do you practice evidence-based medicine when there is no evidence to use?
These days, I pored over case reports coming in from China, Italy, Seattle, and New York City. Thankfully, firewalls have all been taken down and all COVID-19-related literature was free to read. I guess that’s one good thing that is happening during this pandemic, I think to myself. I scrolled through a new website that has been created to collect chest X-ray and CT scan images sent in by doctors of their COVID-19 infected patients. I scrolled and scrolled – the images were endless. I read the twitter posts of doctors in Milan and NYC who were entrenched in the battle with the virus. They tweeted updates on how the patients looked when they came into the emergency room, on the treatments they tried, and what the outcomes were. They tweeted out the patterns that they noticed. In turn, desperate rural doctors encountering their first cases tweeted questions, hoping to find guidance in an area where there was none. I guess what they teach us in medical school doesn’t apply in a pandemic. There was no class on what to do when no one knows what to do.
I came across a paper on COVID-19 effects on pregnancy.
“Oh, shit!” I had forgotten I needed to take a pregnancy test today.
As I waited for the pregnancy test results to appear, I closed my eyes and started to dose off. I startled awake when my head dropped. The stick showed a plus sign. Positive. I should have been elated, but instead, I finally cried.