And This Was The Fourth

May 10th, 2020

"RAPID RESPONSE TEAM".

I remember the first time I had met her -- a few weeks ago and, actually, on the first night I had returned to work since this pandemic began.  Prior to this, donning, doffing, and the decompensating COVID patient were -- for all intents and purposes -- theoretical to me.  Everything was new.  In fact, I had put my CAPR on for the first time just minutes before and goodness knows if I even did that correctly.  

By the time we got to her room, two other providers were already tending to her and after gowning up we headed inside.  I remember the room being inordinately loud because of the ventilation system and as we used the phone interpreter I thought to myself, "I can't hear a word of what's going on."  Quite hypoxic, uncomfortably tachypneic, and intermittently vomiting, this patient needed to move to a higher level of care.  While we awaited the arrival of the ICU team, I remember using my rudimentary Spanish to communicate with her as we had lost our phone interpreter -- not uncommon even in the pre-COVID era.  I spoke with her brother about the events that had transpired, that she would be moving to a different area because she was so sick, and that she would likely need to be placed on a ventilator.  In a few minutes we were able to move her to the ICU and within the hour, she was intubated.  

The second time I met her, she had been on the general medicine floors for a few days after her stay in the ICU.  Though she had previously been improving, she again was increasingly hypoxic and for the second time, she was moved to the ICU to be intubated.  And again I spoke with her brother.  Familiar this time, I was perhaps able to provide some comfort during much uncertainty.  

As I met her for the third time, she was still requiring high levels of supplemental oxygen though this time I was admitting her to a unit in the hospital where she would be more closely observed while we tried to wean away the respiratory support we were giving her as she continued to recover.  She recognized my face.  I smiled, explained our next steps, asked her a few questions, and gave her reassurance that she was finally getting better.   As had been my practice, I called her brother.  He recognized my voice.  

"RAPID RESPONSE TEAM". 

Another emergency -- and at this point in the pandemic these were fairly commonplace.  The emergency was hypoxia nearly every time and our management had become algorithmic.  I'm not sure I ever became comfortable with the unreal level of acuity we had been experiencing, but it certainly had become routine.  We reached the room called overhead with our PPE in hand and realized this was more than worsening hypoxia -- the patient was pulseless and this was a code.  

At the start of every code, it always takes me a few seconds to orient myself -- to evaluate who is in the patient's room and what roles they are serving, to assess what roles remain to be filled and what equipment or supplies are still needed, and to get more background information.  Codes are often enveloped in commotion and chaos and so naturally, after getting my bearings, I leaned over to one of our team members on a mobile workstation and asked them, "Who is this patient?"

I met her three times so far, as I said -- and this was the fourth. 

How could that be? She was getting better in days past and was hoping to leave the hospital soon. Had we thought of everything? She had had a small pneumothorax on her last chest x-ray -- could it have gotten worse?  Was she on a blood thinner? Did she have a clot in her lungs? Could she have fluid around her heart? The list went on as we pored over her medication list and recent labs hoping to find an answer.  As time passed, we were increasingly aware that we weren't likely to bring her back and the gravity of this personal defeat settled in.  

I cannot remember the time of death but for this young woman any moment would have been too soon.  I could feel the tears begin to form -- that moment when you have to blink so forcefully but can't seem to rid yourself of the blurry film of saltwater you're afraid others will notice.  Another team member had called her brother while we were resuscitating her and after reiterating that we must keep going his only question was, "Can I see her?"  The answer in non-COVID times was: "Of course, yes." After consulting with those much better versed in hospital policy than I -- the answer now was: "Sorry, no."

Like I had so many times before, I called her brother.  He recognized my voice.  Only this time, I couldn't reassure him that she was going to be okay -- I had to tell him she was gone.  I cannot remember exactly what I said but this was one of the hardest conversations I have ever had.  Delivery of bad news was nothing new for me but for some reason, this time, the many "I'm sorry"s -- my voice cracking more with each one -- just wouldn't do.  Incredulous, her brother had only come to the realization she had died about three minutes into our conversation -- and that was traumatizing enough.  To be asked, through uncontrollable sobs, whether he could see her and to repeatedly tell him "No" -- was horrifying.  In closing our conversation --  having him thank me "for everything" was even worse. 

Deep down, I knew I wasn't to blame and that we had done our best.  Though if I'm honest, her death impacted me in a way only a few others have in my short career: a 26 year-old with a catastrophic variceal bleed in the setting of alcoholic cirrhosis, a 29 year-old with metastatic lung cancer whose parents reminded me of my own, and a 32 year-old with metastatic gastric cancer whose daughter was too young to understand why her father was leaving her.  Each patient's passing deeply personal and career-changing -- each in a different way.  

Perhaps it was their young age similar to mine serving as a reality check to my own perceived invincibility.  Maybe it was my lack of preparedness, overall, for their quick decompensation -- borne in part by some element of denial.  For my patient, there is certainly also the additional layer of complexity that a global pandemic would entail.  We all process death and loss differently but it's what we learn and how we grow from these experiences that define us.  

If you had asked where we would be -- 2 months ago when this began -- I would not have predicted our current state.  I say this -- and not to be facetious -- but what an interesting time to be a healthcare provider.  For many of us, especially those of us early in our careers, this time has been a whirlwind of change, unforeseen obstacles, and surprising victories.  We're at a unique juncture in the medical world and for the first time since some more notorious epidemics -- we're flying blindly.  Guidelines are changing from week to week and we're making judgments about therapeutic interventions in a data-free zone.  We're relying more than we previously had on the anecdotes of those who have traversed this terrain before us.  It's a weird place to be. 

Things are steadily improving in New York -- the difference is palpable.  And though the world has moved on to conversations on reopening and the prospects of our collective summers, it's important to remember that we didn't all make it here.  Like my patient above, we've lost too many in this crisis.  But with each loss, comes another lesson.  A lesson in gratitude -- for my job, my health, and my social supports.  A lesson in teamwork -- among the doctors, nurses, PAs, NPs, respiratory therapists, and everyone in-between.  A lesson in perseverance -- the resolve to always give it our all.  A lesson in caution -- to never be too confident and to never be driven by ego.  And a lesson in respect -- for all that we currently know and for the even greater amount that we do not. 

Each loss is not in vain and, though they hurt, they will make us better just the same.