My COVID-19 evenings: reflections from the back lines
Frederick L. Licciardi, M.D.
NYU Langone Health
I spend my days helping people become pregnant. I trained in such, have developed my acumen through decades of clinical activity and research, and it is what I enjoy. On one hand, I practice a profession of intricate scientific details relating to the administration of powerful hormones, oocyte fertilization, embryo culture and genetic analysis. On the other hand, successfully treating my patients requires expertise in the skills of listening, counseling and shared decision making in an ongoing process which at times goes on for months or longer. Missing from my job description, however, is having a thorough understanding of the consequences of SARS-CoV-2 exposure.
When Covid 19 ignited New York City, my immediate instinct was to hoist an ax and run into the fire. Being a physician, I am an experienced problem solver, a person of action who, in the face of disaster, wants to rise up to help. If nothing else, I thought I could make a small contribution to the collective resolution of bedlam. However, my better sense told me that at age 60, I should not volunteer. To the men and women who have been on the front lines, you demonstrate heroic bravery, especially as many of you are older than I.
The more quickly hospital beds filled, I the more I wanted to help, but what could I do? I soon found a request for physicians to volunteer for NYU Family Connect, working with groups of in-house doctors and nurses who cared for the most sick. Swept into ravaging turmoil, these teams had not a moment to themselves; much less enough time to update family members on the status of loved ones. For one month, four to five nights per week including some weekends, from 6:00 to 11:00 pm my phone would beep with Epic notifications from a case manager; “Call Mrs. Jones; needs update.”
Lacking any of the other pertinent information needed to update a family member; into the electronic charts I would dive, sometimes for long periods of time before calling. Stammering through EPIC, I reviewed admissions that were sometimes weeks in duration. I needed to learn everything Covid-19; vent settings, tracheostomy wound care, fungal septicemia, peritoneal dialysis etc. Chart reviews were interrupted by my frantic searches of PubMed, Up to Date and Google rabbit holes. Armed only with my medical school and residency medicine exposures, I crammed to understand prognosis based on the extent of ARDS, acute renal failure, thrombocytopenia, and many of the other severe consequences overwhelming patients’ systems.
Once I was prepared as I could be, I would make the calls. Sometimes the family’s questions were simple; I would report on things like the latest blood pressure or respiratory rate. Some calls were more complex and difficult; helping people understand worsening lung consolidation, or the significance of an ominous rise in the serum creatinine level. I would hear other questions that were impossible to answer, especially the frequent, “when will he come off the ventilator” or “when will she be going home.” But always with hope, no one ever asked if they were going home, just when. Sadly, as I became more familiar with trends in settings and labs, I learned that many would not go home. Just prior to making one of my calls, I desperately watched as a patient expired far away from me, my eyes lowering to follow the O2 saturation graphic on the electronic medical record. Hoping for an uptick, my fingers stabbed repeatedly to refresh the screen, but each readout became worse until the lines abruptly ended mid-page. I felt lost thinking of the patient and his family. I thought of the hospital team beside him, face to face once more with a brutally vivid, distressing, catastrophic event.
Among all of this diversity, the vast spectrum of medical conditions, mild to disastrous, there was one constant: the enduring sovereignty that ties people and families together. I would prompt this phenomenon by using the same formula for every call. Once I answered the medical questions to the best of my ability, I would ask a simple question about a relationship; such as, “It must be difficult for you not being able to visit,” or “How long have you know each other?”
Then I would just sit back and let the orations begin. I would hear of 50 years of marriage, how people met, where they lived and where they moved. There were the stories of children and grandchildren; where they were in school, what they have accomplished and what they liked to do. I heard about favorite uncles, loving husbands, and stray siblings. In my mind I would see a video of their lives from start to present, in brilliant color. I would listen as amid their exhaustion, sparks of pride and joy would transcend. That was the love, the connection, that I would hear many times each evening.
My scripted questions also elicited soliloquies of despair. My heart broke as I spoke to a young man, a hairdresser who was the primary caregiver for his mother who lived downstairs from him. He became symptomatic after contracting the virus while working, but had no other person to attend to her needs. She was the one now of whom we spoke, she was severely stricken, and he cried to me in guilt. I listened as one woman asked that everything be done for her mother because her mother had always done everything for her. Another woman had me relay a message to the medical team that she considered vital for the recovery of her intubated elderly mother: not to underestimate the strength of the woman in their care.
Coming from a large family and having kids of my own, I did not have an appreciation for how many people live in smaller groups of two as many of my callers did. The second person could be a partner, but it could also be a single child, younger or much older, taking care of his or her remaining parent or other relative. In all scenarios, with one hospitalized, the remaining family member defaulted to being alone and lonely. They were caged by circumstances beyond their understanding or control.
As my shifts approached, I feared confronting the sickness, the fragility, the evilness of disease. I was insecure about my ability to properly address the issues in a way that the families deserved. Despite my concerns, I learned that my experience in listening and counseling patients suffering from infertility equipped me well for my unfamiliar role. I was inspired, that despite their loved one’s tenuous positions, families were accepting of situations and remained eternally hopeful; again characteristics I recognized from my day job. As our calls came to an end, I would always hear how grateful they were for my time. I would thank them, say good night, and think how grateful I was for theirs.
I felt self-conscious not being one of the exceptional and admirable front line soldiers attacking the fire, but I became proud and enlightened in my support role on the back lines. Gratefully, I was able to join in the fight, using not the bold ax, but a deft hatchet, that I believe dutifully served the cause.