I'm on my eighth hour Saturday working in suffocating protective gear - mask, face shield, gown and gloves - when an elderly patient is wheeled into room 23 of my hospital's emergency department. He's confused and gasping for air as his family tells me over the phone that he doesn't want any "heroic measures" performed: no aggressive resuscitation, no breathing tube. Under normal circumstances, there are a few tricks I might try before I have to put a breathing tube down someone's airway and connect them to a ventilator, which breathes for them.
But now those less-invasive breathing interventions could wind up spraying contagious viral particles into the air, putting my other patients at risk of contacting this patient's presumed illness, covid-19. So I place a simple breathing mask over his frail face while I watch his oxygen levels fall below a viable level. At that point, I lock eyes with the supervising ER doctor standing nearby, and he dismally mutters: "This is only the beginning."
He's right, and that's my worry. This patient is the first of many who are about to come to us, suffering.
My colleagues and I are used to reacting in a crisis, working long hours and making life and death decisions - that's our job. But the coronavirus crisis is a different kind of test: Every shift is different; guidance is coming in from every direction; in some cases, we're watching people die in front of us; we yearn to be at work, but we're also trying to keep ourselves alive. We're doing everything we can, but right now, it doesn't feel like enough.
We don't know yet if the patient in room 23 has covid-19. We've seen a spike of patients arriving with similar symptoms: high fever, cough, difficulty breathing - all of the signs we've been reading about. We are taking precautions as if each patient is positive for this new and terrifying disease. But right now, we can't do enough tests, and when we do test, we can't get the results back fast enough.
I don't know if my patient in room 23 will test positive. I know he's dying, and dying alone. He's cut off from family who aren't allowed to visit him, for their own safety. I take a moment to call his sister and on the other end, I hear crying - all I can say is, "I'm sorry." She wants to know how she can see him but I don't know what to tell her; the hospital rules are changing by the hour. As soon as he's admitted to our inpatient team, his new room is ready immediately - the hospital knows we need room 23 again. And by the time his sister calls me back a half hour later, he's already gone from the ER, moved to the new and already overflowing "covid-19 rule-out" floor.
We're a large hospital in one of the biggest cities in the world, but ER space is always limited - even more so now. Room 23 was part of the pediatric unit, but that unit has moved so we could transform it into a temporary respiratory unit for anyone with fever and cough. Between patients, the room gets a "terminal cleaning": surfaces scrubbed, curtains replaced, tubing exchanged, and, almost miraculously, it gets done in about a half hour.
In the meantime, I start talking to a young woman sitting in a chair outside the room. She is healthy with no medical problems other than her current fever and cough. She knows these are the symptoms of covid-19 and desperately wants testing. Ours is the third hospital she's visited today. No one else has explained why staying home, fever and cough notwithstanding, is the best thing for her and for the whole city. She's panicked about the coronavirus, and I can understand why - I'm scared, too. But I hide my own worry and explain that we just don't have the resources to test someone in her current condition. She grapples with the notion that my management of her symptoms and my recommendations will be the same, regardless of her status. The comfort of her knowing if she is actually covid-19 infected is a luxury I am unable to provide.
I urge her to go home and stay there - to presume that she's infected and to act accordingly. She asks if she can still travel, fearing she may lose her job if she doesn't. I discourage her, explaining the importance of social distancing, though some of my own friends and family members have ignored these same concerns. I discharge her with a note that begs her manager to understand the situation. Most likely - hopefully - she'll be ok physically. But no doctor can help her deal with lost wages, insurance coverage or how to pay for rent and groceries if she gets fired.
By then, room 23 is clean again. An ambulance calls en route with another patient in respiratory distress. ETA: five minutes. I'm relieved: It's just enough time to reset from the previous conversation. As I wait, an administrator runs by with changed guidelines, the fourth version in the last three days, detailing new processes for admission and testing. I decide to tackle that later, so that I can focus on the next patient.
Paramedics roll a stretcher into room 23 with a middle-aged man, coughing loudly and hungry for air. I don't know if he has covid-19, but I assume he does. For days, his family members had told EMS, he hadn't wanted to leave home for fear of getting others sick. Today, he collapsed, and his family realized he had waited too long. From my training, I've learned to recognize when a patient is working too hard to breathe on their own, and I see it in this man. His body is on the brink of giving up. Fortunately, I have a nearby available ventilator to use on him - the silver lining of withholding resuscitation from my previous patient.
Our team decides to put a breathing tube in to assist his failing efforts. I pause. I'm nervous - not so much for the procedure, but for the imminent exposure and risk I'm creating for every person in this room as I prepare to place my head and hands near his mouth. We clear every non-essential person out, leaving most of us still there, and proceed.
The procedure goes smoothly. I secure the tube and examine his body, only to notice a large bruise on his side. The x-ray reveals a broken pelvis, presumably from his fall. I quickly call the orthopedic surgeons, but my request for extra hands is denied: The surgeons are no longer seeing non-emergent patients at the bedside if they are being "ruled out" for the coronavirus. Too dangerous. Anger washes over me, and my mask feels even more suffocating. Aren't I already in the same danger? Is their life worth more than mine? Didn't we all go to medical school hoping to do this very thing - help sick patients? I stop and take a breath through my mask. They're right: The guidelines do call for exposing as few doctors as possible to the virus. I feel my frustration melt into exhaustion.
Suddenly, an alarm goes off. I temporarily forget my own troubles. It's time to talk to his family. My walk to the waiting room is too short, and I realize I have no idea what I'm about to say. I grab a few valuable facemasks and flyers on self-quarantine and walk into a room with his family. My body confirms for me that my protective equipment is just as tight as when I started half a day ago. My head is pulsing as I try to answer their questions. I ask them to assume that they are infected with covid-19, though I have no way of verifying that. They ask for tests, which I still can't get. I tell them to stay at home and give them strict instructions about when they can come back to the hospital. Finally, I have to tell them there is absolutely no way they can visit their critically ill father right now.
I walk back into the unit wondering if my first patient has died yet. If that young woman will gamble her job security or her health. If my last patient's sons will get to visit him. I reach the workstation and admit him into the hospital.
We need room 23 again.