The hardest part of taking care of COVID patients
If you had asked me before I started in the ICU what would be the hardest part of being a doctor during the COVID crisis, I would have guessed something about learning how to treat a new disease, dealing with complex ventilator issues in deteriorating patients, or maybe just the day to day intensity.
I would have been wrong.
Normally, when a patient is critically ill, their family is at the bedside almost 24 hours a day. In the time of COVID-19, that simply isn’t permitted.
The risks to staff and patients during a pandemic along with the imperative to be leaders in social distancing has led most hospitals to ban visitors for admitted patients. My hospital has a policy that we’re only allowing visitors when a patient is actively dying, and then we’re only allowing one visitor at a time for a period of only 15 minutes.
This has two immediate consequences:
People are all alone when they’re admitted to the hospital
Families have no idea what’s going on with their loved ones
As a consequence, I call family members of all my admitted patients once a day to update them about what’s going on and answer any questions they might have.
This is by far the most difficult part of caring for COVID patients.
By the time I get to my phone rounds, it’s already been a busy day. I’ve seen and examined each patient, reviewed all of their daily blood work, looked at their imaging studies (daily chest X-ray, EKG, any CT scans), made ventilator adjustments, reviewed and updated their list of medications, performed a bedside echocardiogram in patients with active cardiac issues, spoken with any consultants from other specialties, and communicated the care plan to the nursing staff, my residents, and any PAs or NPs that are on the case.
Then I sit down with a patient’s chart open and dial their health care proxy or next of kin. [By the way, if you’re reading this, make sure that you’ve spoken with your loved ones about your wishes if you couldn’t make decisions for yourself, and perhaps even signed health care proxy paperwork. This by itself is probably a topic for another day.]
I start each new phone call by asking the patient’s family member to explain to me what the other doctors and nurses have told them about the patient’s medical condition. These initial remarks communicate a huge amount of information regarding a person’s health literacy. It’s really somewhat remarkable how much you can tell about a person’s fluency with medical care and the system based on just a few seconds of an initial explanation.
As I hear each individual’s perspective, I calibrate the type of information I’m going to communicate based on what I perceive to be their literacy regarding these topics. As conversations go on, I occasionally need to make adjustments and either go into more or less detail, but the first impression is usually pretty close to accurate.
In the time of COVID, family members are craving information in a way that I’ve never seen before. I’ve noticed that people are asking me about lots of details that normally don’t enter into these conversations. I usually speak about patients in qualitative terms - his kidneys are doing a bit worse today, her blood pressure has been dropping so we need to add some medications to help raise it, your dad’s oxygen levels have gone down and we needed to place a breathing tube.
Now I’m being asked about inflammatory markers, white blood cell count, oxygen saturation. These conversations are venturing into a realm of numbers and units - your husband’s creatinine is 2.5 milligrams per deciliter, your sister’s lactic acid level is 3.2 millimoles per liter, your mom’s blood pressure is 85/58 millimeters of mercury.
People are researching experimental treatments. They’re asking about convalescent plasma, interleukin-6 inhibitors, remdesivir, and hydroxychloroquine. They want to know what level of urine output determines when we we’re going to decide to start dialysis and what numbers on a blood gas mean that we can think about removing a breathing tube.
People are also demanding answers in a way that I’ve never seen before. Why aren’t we giving the azithromycin? If I donate my plasma, can you assure me that it will go to my dad? How come you aren’t enrolling in the clinical trial I heard about at Mount Sinai?
With stakes like this, it’s normal for the conversation to be charged. In COVID, I’ve noticed that the tone can creep into the realm of accusation. I’ve been asked “why?” more over the past few weeks more than ever before.
In any situation with a loss of control, most people seem to have a natural instinct to try to exert control over something, even if it’s not directly related. Knowing the numbers is a way of intellectualizing an amorphous problem. Pushing the doctor to use more and better treatments is an attempt to create autonomy and agency in a situation when you have none. And since you can’t do a Zoom call with a family member who is intubated and sedated to tell them you love them, asking questions of the doctor is the only way of showing that you care.
Under the best of circumstances, these would be difficult conversations. But it’s even harder when a lot of the patients are getting worse despite our best efforts. And as much as phone call after phone call to tell someone, “no major updates, they’re still intubated, it’s still too early to know how they’ll do” really sucks for me, I know it’s worse on the other end of the phone. So I try to patiently answer all of the questions and diplomatically explain why I’m making the decisions that I’m making.
It’s the hardest part of every day taking care of these patients. But it’s also probably the most important.