Behind Closed Doors

My Early Experiences Working During the COVID-19 Pandemic as a Resident Physician

Please note that dates and patient details have all been modified to protect confidentiality.

Upon returning home, in February 2020 from a trip to Florida with my wife Lauren of 5 months, I learned that my own hospital was making plans for the coming coronavirus pandemic. Lauren was a pediatric dental resident and I a medical resident, a junior doctor less than two years out of medical school. At the time, there was reporting on how the new coronavirus had spread from China to Italy. Italian doctors were pleading with the rest of the world to take it seriously. My hospital added a new wing to the emergency department, repurposed ventilators, and were converting spaces into makeshift ICUs to house the critically ill. Our ethics expert published guidelines for rationing critical supplies to patients. We were already rationing PPE in order to preserve our supply but this would prove to be too little too late.

Anticipating I would soon be taking care of patients with COVID19, I went to get “fitted” for an N95 mask. As many faces are uniquely shaped, getting fitted is essential to making sure an individual has the right mask to fit their face. Unfortunately, by this time, hospitals and private citizens had started to buy up the remaining supply of PPE. This left my hospital with one type of medical grade N95, and it did not fit my face.

I was working with an employee health staff member trying to find an appropriate mask. After failing the one mask that we had a larger supply of, the staff member working with me grabbed, from the neighboring shelf, one of three half empty boxes of donated N95s normally used in construction and said, “Let’s try this one.” Fortunately this donated mask was a good fit. He gave me three N95s from the box and said “We are expecting a shipment of new masks in the next week, so come back to see if any of them will fit you.”

Reading between the lines I took this as “Make these last for the foreseeable future.” About three weeks later, we received emails regarding a new supply of masks. Later we learned how the hospital came by these masks in an article, which reads like a spy novel, published in the New England Journal of Medicine titled ‘In Pursuit of PPE’.

While the outbreak was raging in New York, the number of patients in our hospital precipitously dropped like the waters receding before a tidal wave. Fewer people were seeking medical care. On 3/30/2020, during this time of calm before the storm, I was working my first day in the emergency department. This is a required experience for my training and not what I would be doing for the rest of my career. I was nervous and out of my element. At the start of my shift, the oncoming team and I received report from the outgoing team. There were not many patients in our section of the emergency department. They told us of the patients they were still evaluating. After hearing about all of the patients, the anxiety and anticipation of waiting for the “wave” to hit us was palpable. A senior emergency medicine resident, only months from graduation, exclaimed “I was born for this. I love my F*#king job. Let’s get to it.” He then sat at a computer with the attending physician (the supervising physician) in the center of the unit waiting for only the most critically ill patients to arrive. I took up residence at a computer next to a patient in the hallway whom we had just received report, “A 50 year old man with abdominal pain, awaiting CT scan of the abdomen”. I then proceeded to see moderate and low acuity patients wearing a simple surgical mask as I was rationing my N95 respirators.

It is a large emergency department. I could not always see what was going on in the other locations of the emergency department, but I could hear the calls for help over the loudspeaker. “Adult resuscitation to POD A alpha room 6 here now” and “Respiratory therapy to POD B beta STAT.” Soon the loudspeaker called out a resuscitation that was coming to our section of the department. Paramedics, wearing only gloves, calmly came through the doors with a motionless elderly woman on a stretcher. She was barely breathing. They brought her into a room. The attending and senior emergency medicine resident rushed in wearing N95s, face shields, full gowns, and gloves. Through the glass doors of the room, I watched them quickly assess her before intubating (placing a breathing tube down her throat) and connecting her to a ventilator. The paramedics exchanged brief words with the team and left the department to continue their work. An hour or so later she was moved to the medical ICU by an orderly, a nurse, and a respiratory therapist.

Later in my shift, another lifeless body, this time a middle-aged man, was rushed into the unit by two paramedics and an EMT who appeared to be a teenager. They were only wearing simple surgical masks and gloves. They had no N95s, no face shields, and no gowns. The patient had already been intubated enroute. He was in cardiac arrest and was receiving chest compressions from a LUCAS device (a CPR machine strapped to the patient’s torso that compresses the patient’s chest with a piston 100 times a minute). The only movement coming from his body was the silent waves made each time the piston pressed into his chest.

“We found him down and he has been getting CPR for asystole for 20 minutes. Family says he had a cough” said the lead parametric.

The attending physician and senior emergency medicine resident took two minutes to assess the patient and exchange a few more words with the lead paramedic. Unceremoniously, they disconnected the patient from the device, deeming the ongoing efforts to be futile. They pronounced the patient dead and closed the curtain to the room. The teenage EMT, dejected and exhausted, left the pod with the paramedics for their next call. I couldn’t help but wonder how many of these paramedics and EMTs would contract this virus while doing the most high risk procedures (compressions, intubations) with only minimal PPE. How many teenage girls and boys working as EMTs would have to witness the horror of exposing themselves to the virus, exhausting themselves as they worked on these patients in the back of an ambulance, only to arrive at the emergency department where the patients are quickly deemed too far gone or too much of a strain on resources.

The patient whom I had received report on at the start of my shift (“A 50 year old man with abdominal pain, awaiting CT scan of the abdomen”) cleared his throat next to me. I wondered what his CT scan showed. I pulled up the images of his abdomen, which had some pictures of the lower lungs as well. His lungs appeared to have inflammation everywhere, but his abdomen was normal.

I spoke with the radiology resident on the phone. “Hey does this guy have COVID?” he asked.

“No respiratory symptoms” I said, “but we haven’t tested him.”

“You should test him” the resident responded, “those lungs look like COVID”.

Shortly thereafter, the patient was moved to a room from the hallway. I spent the next few hours wondering if I contracted the virus from this patient, would it have made a difference if I had eye protection? Should I have used one of my precious N95s while sitting at the computer? Luckily I remained without symptoms in the days that followed despite his test eventually returning positive for the novel coronavirus a week later.

As I walked out at the end of my shift I passed the room where the middle-aged man had unceremoniously died earlier in my shift. The curtain was closed. I overheard the nearby nurses.

“The morgue said they are out of body bags and space” said one.

“Maybe we should turn the temperature all of the way down in the room until we figure out what to do” responded the other.

Later that night at home, I tried to tell Lauren about what I had seen. I couldn’t find the words to adequately describe the day to her. All I could say was “It’s really bad” and “It could be everywhere and we wouldn’t know it”. That night, I laid in bed thinking about her history of asthma. It seemed reasonable that if she were to get COVID19, she would be at increased risk of severe illness. The only person she would be coming into contact with was me and if she got sick, it would be my fault. Over the next few weeks we tried to distance as best we could. I used separate laundry, separate bathroom, and even slept in the other bedroom.

***

Although I was scheduled to be in the emergency department for the following 4 weeks, that would be my last shift. In the days following that first day, my co-residents and I were all placed on hold. We were pulled from any rolls not essential to the pandemic response efforts. They asked for our preferences on where we would be redeployed to and I requested the ICU.

My first night in the ICU during the pandemic was on 4/6/2020. Another resident and I were assigned to what was previously the cardiac ICU. This is where patients with heart attacks, heart failure, and cardiac surgery patients who needed critical care were housed. At this time, however, those patients had been moved to a smaller area of the hospital. The unit was now a COVID ICU, filled with about 20 intubated patients, all suffering from COVID19. Some had been hospitalized for weeks and others had been admitted that same day. Each room had large glass sliding doors. Taped to the inside of each door the nurses and respiratory therapists left handwritten ventilator settings, vitals, recent labs, and IV drips all pertaining to each patient. This was in an effort to keep me from entering the room to preserve our limited PPE.

Every evening my co-resident and I would walk the perimeter of the unit with our supervising fellow and attending. We would stop outside each room, read the data taped to the door and come up with the plans for the night. Each patient was discussed in the same manner “This is an X year old male/female, who is here with acute respiratory distress syndrome secondary to coronavirus.” We reviewed the patients’ complications during their hospital stay which often involved bacterial infections, septic shock, and renal failure requiring dialysis. Often, we would discuss each patient with their nurse and respiratory therapist. Sometimes yelling through the glass door to those on the inside the changes that were planned. Every night brought its own challenges in making the plans. Not only were the patients very sick but we had a limited supply of dialysis machines and valuable sedation medications due to high demand and global supply chain limitations.

On my first nightshift we had a new patient to the unit. He was the only one who was not intubated. He required ICU level of care due to severely low blood pressure. I presented the case to the ICU attending, “This is a 67 year old male who is here with acute hypoxic respiratory failure secondary to COVID19. His hospital course has been complicated by hypotension requiring norepinephrine. He is currently doing well on supplemental oxygen via nasal canula.” After discussing so many intubated patients on dialysis, it was refreshing to see a patient that was not in multi-organ failure. ‘Maybe this one will be able to go home’ I thought to myself before we moved on to the next patient.

Later that night after rounds, I was paged by a nurse to come see a different patient in his 80s. I quickly arrived, standing outside of the glass doors. Inside the room was the nurse who paged me and a respiratory therapist. Each was wearing full protective gear. The patient laid in the bed motionless due to the sedatives. Attached to him was a breathing tube connected to a ventilator, a central venous catheter (a large IV in his jugular vein extending almost into his heart), an arterial catheter, pneumatic compression boots (large inflatable socks to prevent blood clots in the legs), and a heart monitor. During rounds, we had discussed that this patient had some blood around his mouth and his kidneys were functioning sub optimally. The nurse motioned to the respiratory therapist at the head of the bed who was suctioning fluid out of the patient’s lungs. The suction tubing was filled with pink fluids.

“He won’t stop bleeding” she said.

The nurse then moved the pillow and turned the patient’s head to reveal blood oozing from around the central venous catheter in his neck. There are a few reasons why a critically ill patient would have such significant disruption of their blood’s ability to clot. In the case of this patient it could have been due to any combination of those reasons. The nurse and I exchanged a few thoughts through the glass door. She then went and drew fresh blood to send to the lab and I called the pharmacy to have a medication called DDAVP sent to the ICU immediately in a last ditched effort to reverse any malfunction in the clotting due to renal failure. Two hours later the labs returned and the patient continued to bleed. He had DIC with overt renal failure, it was only a matter of time. I gave the family a call and discussed the patient’s condition with his eldest daughter and his wife at 1AM.

“Is he comfortable?” she asked.

I paused, “No, between his disease and how much we are doing to keep him alive he is not comfortable. Given that he is now worsening, he would need even more interventions including emergent dialysis and multiple blood transfusions to have a chance at survival.”

“I don’t know what to do” she responded.

This conversation went on for some time, with the family ultimately deciding he would not want to continue on like this and would rather be comfortable.

“How long does he have?” they asked.

“I cannot say for sure but without the current medications and supports, his blood pressure would likely go low very quickly if we stopped all interventions. He could pass away within hours, maybe in a day at most.” I said tentatively.

“I just want to see him one last time, please I just want to see him” his wife pleaded.

We discussed the next steps and I hung up the phone. By now the nurse had exited the room and taken off the protective equipment. Her face still showing the imprints of the mask and goggles under a thin layer of sweat.

“The family would like to transition to comfort measures” I said.

An hour later the daughter and wife arrived to the empty and quiet hospital lobby. Visitation had been severely restricted due to the pandemic. Only in cases of imminent death could a limited number of family members enter the hospital. Leaving the daughter behind, I lead the patient’s wife from the lobby to the patient’s room. By then the nurse had changed his pillow sheet and cleaned him up. We dressed his wife in protective equipment and led her into the room. For 15 minutes she stood at the foot of his bed keeping vigil, unable to sit or touch anything. When the 15 minutes was up, she was taken out of his room, de-gowned, and led back out to the lobby where her daughter was still waiting. I gave my condolences before returning to the ICU. Outside his room, I relayed through the glass doors to the respiratory therapist and the nurse to turn off the life support and make him comfortable. Two hours later I called his family to let them know that he had died. During that same night, I had this same discussion with three other families. Unfortunately, none of them were able to visit their loved one before they died.

***

The next evening followed the same routine. On rounds we noted that a 54 year old man, a father of two and a husband, who had been intubated for 2 weeks was developing worsening lung function. Talking through the glass door to the respiratory therapist, the ICU attending made some minor changes to the ventilator settings and we moved on to the next patient.

Later in the evening I received a page from a nurse stating that a family member was on the phone for the 67 year old man who was admitted the previous night. This was the man I was hopeful would do well. He had since progressed from only being on nasal canula to being intubated due to worsening respiratory status. I picked up the phone. It was the patient’s family friend who the family had given permission to speak with us.

“Why is he not on hydroxychloroquine?” he asked pointedly.

At this time it was well recognized that there was an increased risk of fatal heart arrhythmias with this medication in the setting of COVID19 and no established benefit. Few places were using it outside of clinical trials. Unfortunately, there was also still a great deal of media and presidential attention around this drug that ignored this. Even two months later when everyone knew the drug was useless at best and the FDA pulled their emergency use authorization, the president was still advocating for it and saying he took it prophylactically.

I quickly looked at his ECG (electrocardiogram; a readout of the electrical activity of the heart). ‘Thank God’ I thought to myself. I would not have to explain to the family friend how the drug does not work and all that his efforts to be informed and advocate for their loved one were misguided.

“His QTC is prolonged” I responded. “Hydroxychloroquine is not even an option due to the risk this drug poses in people with a prolonged QTC. He could have a fatal arrhythmia if given this drug”.

“What about vitamin C” he asked. “I read there is a doctor on Long Island giving patients vitamin C with good results.”

High dose vitamin C has been studied in sepsis. Some ICU physicians advocate for its use in specific situations. I was unaware of its use in patients with COVID19 however.

“I will pass along to the day team who make these management decisions” I stated. He thanked the team for their efforts before hanging up.

***

On the third night, I stopped outside of a room of a man in his 40s. He was the youngest person in the unit I was covering and had been intubated for some time. A week ago he had gone into renal failure and was getting regular dialysis through a large catheter in his groin. Over the last few days his lung function worsened. Now his neck appeared oddly swollen.

“Can you feel his neck?” I asked through the glass to the respiratory therapist, the only person in the room with the patient.

She did but was unsure what she was feeling. After putting on my N95, surgical mask, goggles, gown, gloves, and face shield, I joined the respiratory therapist in the room. Feeling the patients neck I noticed a bubbling crackle otherwise known as crepitus. Leaving the room, I spoke with the nurse outside. The patient likely had a pneumothorax, or a collapsed lung, due to the high-pressure requirements to keep him breathing on the ventilator. Soon two x-ray techs and a portable x-ray machine arrived outside of the patient’s room. In a carefully choreographed series of events, the doors were cleared, opened and the machine was moved into the room. They took 3 pictures of the patient’s chest before exiting the room and spending another 5–10 minutes wiping down the machine before going on to the next patient in the hospital requiring a chest x-ray. I looked at the images and saw clear as day the patient had a mild-moderate sized pneumothorax of the right lung.

The nurse said “We should talk to the family about transitioning to comfort measures. He is only getting worse.”

“But if anyone has a chance it’s a patient like him. Young and in good health prior to all of this” I responded.

I then received an urgent page. The 54 year old man, father of two and a husband, who we had made minor ventilatory changes on the night before was declining rapidly. I arrived outside the room to see the respiratory therapist and the nurse frantically trying to help the patient. “He is going to die” one yelled through the glass. Squinting to see the ventilator, I could see that he was only getting very small breath volumes. For some reason that was not immediately clear, we could no longer adequately breathe for him.

“Grab the LUCAS device” I called down the hallway.

Knowing that he was likely to go into cardiac arrest, a nurse arrived with a red code cart (a cart filled with common emergency medications used when the heart stops beating and a defibrillator.) I frantically paged the fellow and the attending who arrived less than 10 minutes later. The patient was still alive, but barely. They both gowned up and ran into the room. For what seemed like an hour they were giving various medications, changing the patient’s position from laying supine (on his back) to prone (on his chest), and changing ventilatory settings. Eventually the patient’s heart stopped beating and they lost a pulse. They attached the LUCAS device and it delivered chest compressions via its mechanical piston. During all of this I was on the phone with the family. The patient’s wife was so upset she could not say any intelligible words. Ultimately it fell on their 20 something year old son to be the spokesmen while his mother is screaming in the background.

“Do everything, he is a fighter” he told me. ‘We are and it is not working’ I painfully thought to myself.

Five minutes later, the team got ROSC (return of spontaneous circulation; i.e. his heart is beating again). This was a short-lived win as the patient died an hour later and it fell to me to inform his family. This being the conclusion to my first three nights, I was not optimistic for the future.

***

Most mornings I would come home, eat Lauren’s leftover dinner from the night before and have a beer to decompress. Lauren would listen as I shared my experiences, sacrificing the limited time she had at home with me to these incredibly sad stories before I would go to sleep. Eventually the patient whose family friend advocated for hydroxychloroquine, vitamin C, and other experimental medications recieved an alternative treatment. Unfortunately, he did not survive and died in the hospital a week later. The young man in his 40s, with the collapsed lung stayed in the ICU for weeks. He developed numerous complications during his stay but survived and was discharged to a rehabilitation facility. I worked a few more nights in the ICU before taking over different clinical duties and the number of patients requiring ICU level of care in our hospital slowly declined. Many people including paramedics, EMTs, nurses, and respiratory therapists, risked their own health and did exceptional work for a lot of these patients. I initially wrote this in an effort to process my own experiences with no intention to share it. I hope that it can be informative for others to read. When we were seeing an explosion of new cases, it was hard to answer questions like ‘Are you seeing a lot of cases?’, ‘Is it as bad as they say?’ because ‘Yes’ doesn’t say enough.