Feet Firmly on the Ground: COVID-19
I awoke with a jolt and fumbled around for my phone to check the time: 1:45 a.m. I was once again wide awake, four hours past falling into yet another restless, exhausted sleep and three hours from my morning alarm. The past few days were all the same: exercise, go to work, return home exhausted (both mentally and physically), succumb to an angry sleep, wake in the middle of the night, lie in bed while my mind wrestled with (and mostly lost to) anxiety and fear, repeat. Every night, the same questions haunted me: How in the hell was I truly going to avoid getting infected? What limits would I really be willing to place upon the care I received? And ultimately, would I die from this disease?
I willed myself to return my phone to my night table, to not fall down the rabbit hole of Twitter, Facebook and The New York Times. Instead, my mind wandered from proning, PEEP and PPE to a decidedly simpler time in my life when I studied naturopathic medicine and yoga in Portland, Ore. My teacher would regale us with poetry by Mary Oliver as we drifted off to sleep during savasana [corpse pose].
You do not have to be good
Yes, the past few days had all been the same, but they were remarkably more different than anything I experienced in my two decades in medicine. As I walked into the hospital that morning, I was greeted by a line of coworkers waiting to be queried about fever, cough, sore throat and potentially unprotected exposures. After passing the brief screen, I grabbed a mask and then was scolded for not slathering my hands with sanitizer. As I walked to my office, I wavered between feeling immensely grateful that my hospital had PPE and immensely annoyed that I was treated (and reacted) like a petulant child.
I had gotten into the habit of seeing the few patients under investigation on my list first. As I trudged up the stairs to the COVID-19 rule-out ward, I wavered again, this time between feeling exceedingly grateful that the majority of my patients were not suspected to have COVID-19 and exceedingly guilty that I was hesitant to round on the few patients who were potentially infected. How could I justify my fear while colleagues just 700 miles north were rushing between rooms with no PPE, rounding on patients who were all presumed to be positive?
Tell me about your despair, and I will tell you of mine
I donned a mask, face shield, gown and gloves and entered John’s room. He was lying cattywampus across the bed, fumbling with his sheets and looking utterly defeated. “What?” he hollered when I asked him how he was feeling. “I can’t hear you! I lost my hearing aid!” After a series of hand motions and a lot more yelling between us, I finally located his hearing aid lying under the bed.
“So, tell me,” I asked once the hearing aid was in place. “How are you feeling?”
“I’m scared, Doc. I was a medic in Vietnam. Did I tell you that?” I began to assure him that yes, he had told me that yesterday, as well as two days before, but he kept talking. “And I was scared then. But I’m scared now, way more scared. What if this kills me?”
I had no easy answers. Instead, I cleaned off his bedside table, arranged his breakfast and handed him an opened carton of milk. We called his son on speakerphone so I could provide an update. He shared stories of battling cancer and again declared, “I’ve never been so scared.”
My next three patients were similar to John—elderly, disoriented and frightened. In between asking about symptoms and examining wounds, I made certain to do all of the tasks I often rely on families to perform: I straightened sheets, opened milk cartons and wiped crumbs from gowns. I called each family with an update and was met with a mixture of anger, fear, sadness and relief.
Of all the palliative care skills that I’ve learned over the years, the one that seems to come most naturally to me is empathetic presence, the ability to hold space for all the feelings. And so as I called each family, I did one of the few things I could do: I listened. When silence didn’t seem appropriate, I acknowledged that with “Yes, this is a frightening time.” I asked, “Please tell me more about your loved one.” And I encouraged: “Keep talking. I am here for you.”
Meanwhile the world goes on
Next, I headed downstairs to round on the rest of my list. One patient recounted, in painstaking detail, his memories of his entire ICU admission, including days of intubation, deep suctioning and painful dressing changes. Another patient had a wound infection that was going to require conscious sedation and a bedside debridement. A third had just ripped out both his IVs and his nasogastric tube, and was vomiting into his lap. None had COVID-19 but all were suffering, both physically and emotionally.
Whoever you are, no matter how lonely, The world offers itself to your imagination …
On my way to the OR for an emergent laparotomy, I took a quick detour outside. I peeled my mask away from my nose and mouth and turned my face toward the sun. As my black jacket absorbed the heat, I reveled in the utterly delicious feeling of being warmed from the outside in. Two purple Eastern Redbud trees bloomed against a shockingly blue sky and, beyond that, the Blue Ridge Mountains showcased their splendid mirage. I sat down and, as I have been prone to do these past few weeks, started to cry.
“Red, are you okay?” asked a familiar voice. I turned around and realized I had walked past a favorite work friend sitting on a nearby bench. Just as I had done for the patients and their families, she offered me several precious moments of empathetic presence. Few words were exchanged and, as has become our collective custom, no hugs were given. But as I walked into the OR, I felt more grounded and more connected than I had in days.
… Announcing your place In the family of things
As I donned another mask, face shield, gown and gloves, I had no new answers about avoiding infection. As I paused for a timeout, I had no greater understanding of my personal health care preferences. And as my scalpel slid through skin, I had no less anxiety about dying from this awful disease. But for the moment, my feet were firmly planted on the OR floor, my mind was firmly focused on the patient in front of me, and my heart felt firmly connected to all of those in health care who do what we do.
[Excerpts from the poem “Wild Geese” (1994) by Mary Oliver are indicated in bold text throughout article.]
Dr. Hoffman is an acute care surgeon and hospice attending in Asheville, N.C. You can listen to her podcast, The Surgical Palliative Care Podcast, at https://apple.co/ 33H6s5w.