I have been absent from these pages for a very large portion of the past year. Bear with me, because I am far overdue for a venting so this is probably going to be long.
I used to post regularly here (and on social media) about my experiences in the pandemic, but I made the near-fatal mistake of making a post on an office computer in my for-profit-corporation owned Medical Center. We apparently have Bossware installed on our hospital computers. I didn’t even know what the hell that was...until I got called to the corporate C-suite for a nasty dressing down. In retrospect, I should have known better.
They were not happy with some of my online descriptions of our situation. Not because they weren’t true (because they most assuredly were accurate and factually correct)...but because it made them look bad. Like they didn’t care about anything but corporate profits, and did not care about the front line employees. Horrors. We can’t have that.
I was basically ordered to shut up, or else.
I was, it was made clear, very replaceable.
Right now, for the first time in, well, ever, new EM residency graduates cannot find jobs. That would seem to be counterintuitive, at the height of a pandemic, but because outpatient ER visits have plummeted (because most reasonable people were/are staying the hell out of the ER because they were/are afraid of getting COVID, and the hospitals have lost that revenue, as well as the admissions they generated, and also because they had been forbidden to schedule any elective surgeries or procedures. Money for staffing dried up. We all took significant pay cuts ‘for the duration of the emergency’.
Faced with this crisis they did what corporate bean counters do.
They fired (“furloughed”) as much staff as they could.
Cut backs? More like amputations without anesthesia.
After that, I scrubbed my social media accounts, and my diaries here. It wasn’t just that I didn’t want to lose my job. By that time, I had a ton of experience treating pandemic patients, and I didn’t want to let go of the controls. No one, really, is not expendable, but this is my town. This is my community. I was damned if I would not be there when they needed me. So, I grabbed my forelock, bowed and scraped to the ‘C’ people, and went back to my department to try to do the best job I could.
In the time since I last posted, much has changed, mostly not for the good. Our county was listed a few weeks ago in New York Times story, naming us as one of the top ten fastest spreading hot spots in the country. Lucky us.
After what I have seen and experienced the past 6 months or so since I last posted a diary, I decided “Screw it”. Writing was always very therapeutic for me, I needed to vent in the worst way, and so I am going to post and hope they aren’t looking. (Obviously, not on an office computer.) If they do, well fuck ‘em. I have had it up to my ears, and then some.
This year has been a nightmare, for all of us. I cannot even begin to grasp the enormity of what has happened, to us, to me, to the country, and to the American healthcare system. At least, not yet, not fully. I remember back at the beginning of the summer, reading stories about the situation in Italy, (including a diary here from a colleague there) and then in New York, and being horrified at what was happening, and just holding my breath, hoping that the Trump administration would, finally, wake up and mobilize against this dire threat to public health.
As if.
Since that time, I have watched our situation gradually, slowly, but inexorably, get worse.
And worse.
And worse.
The trickle became a stream, then a river, then finally, this past month, a tsunami.
At first, we had next to no PPEs. N95s that we’d wear for a week at a time. Garbage bags and tape when we ran out of gowns. Makeshift masks. Constant stress. Sleep disturbances. Taking off our clothes on the porches of our houses. Not being able to hug our kids or hold our spouses, because we didn’t have rapid tests...or any tests at all. at first, and we didn’t want to risk bringing it home.
The first wave came, and went. It never really went away, but some days were almost decent. Then the case load began to climb. sharply.
We got more, better PPE, and could wear a “single-use” N95 for a day, instead of a week. Tyvek gowns replaced the blue plastic and yellow jokes we wore. Gloves remained a problem in some sizes, but still, it was, from an equipment standpoint, better.
The Thanksgiving surge was pretty bad, we thought.
Until the post Christmas surge.
From a medicine standpoint it got steadily worse. There were more patients, and they were sicker than ever. And still, people just wouldn’t damn do right. My wife is a critical care nurse, and when we would make runs to the stores, we’d be stunned to see still see far too many people in our blood red state not wearing masks, not distancing, and we’d see posts on social media of big gatherings of unmasked fools.
All the while, the numbers continued to climb.
Treatments improved, some. We got enrolled in the Mayo Clinic trial of COVID convalescent plasma, and remdesivir became more readily available. We got more skilled in treatment of COVID patients, but still the numbers climbed.
Death was our copilot.
Sometimes it was swift and merciful. Sometimes it was agonizing and painfully slow, both for the patient, and for their loved ones. Our handling of the transition from life to death evolved too. Initially, everyone was locked down, no visitors at all, but the whole process of people saying goodbye on phones and tablets was wrenching for everyone involved. You can only see wives and husbands and children say goodbye electronically just so many times before you start to lose your shit. Finally, we decided the only humane thing was to allow the immediate family to gown, glove and mask up, so they could be with their dying loved one, for one last time. Scientifically, and medically, it probably isn’t wise, and yes, some of them probably contracted COVID as a result, but we explained the risks in detail to them every time, and literally no one decided not to go ahead and be with their family member.
One day, several months ago, a respiratory therapist I was friends with, and who had known my wife since elementary school (and played softball with) came in while I was on duty. She was cyanotic and gasping for breath. Her chest xray was horrendous. Both lungs were whited out. Her oxygen saturations on room air were in the 60s. She had stayed away as long as she could, hoping she’d turn the corner, but finally, she knew she was in deep trouble. We all knew her and loved her, and we pulled out all the stops, and went to the wall for her. Everything I had, I threw at her. She seemed to improve a good bit, but the hospitalist still felt that she needed to be moved to ICU.
She held her own for a couple of days, but then began decompensating, and was not doing well. I went to check on her, and she told me that the pulmonologist was on his way to the unit, to intubate her. She had finally worn out, and even on BiPap, she was unable to maintain her O2 sats. OF course, by this time, we were all well aware that intubation and ventilation was the last ditch effort. The percentage of COVID patients who come off the vent is very small. As a respiratory therapist, she was painfully conscious of that as well.
I gowned up and went in to see her, and held her hand as she told her husband what was happening. I was preparing to leave, when she looked at me, and said “I don’t want the pulmonologist to intubate me. I know him. He’s clumsy. He’ll accidentally knock out my damn front teeth. I want you to do it. Please?”
What am I supposed to do? Say no?
This was not the first time I had intubated a friend, but the first time had been decades ago. A pathologist friend of mine had gone on vacation to the southwest, and brought back a Hantavirus type infection. He also had whited out both lungs when he came to the ER. Right before I sedated and tubed him, he said “I trust you.” Those were his last words. He died a week later. That was all I could think about when I got ready to perform the intubation.
The last thing she said to me, as we pushed the Etomidate and Rocuronium to put her under and paralyze her: “I trust you, and I am going to beat this stuff.” Everyone in the room was crying when we finished.
She made it.
She has come off the vent, but it was a long haul. She ended up with a tracheostomy, and had a mild stroke, and is in rehab now, but she made it.
The numbers kept climbing.
Every single hospital that was large enough to have an ICU in our state went on diversion. (That means you have no beds available. None.)
Every. Single. One. And we are all still on diversion.
We began to have to ship patients out of state when there were no beds here.
That was around the time the level of COVID denial went to ‘Certifiably Insane’.
I was screamed at and threatened for over an hour by a family whose loved one had to be transferred out of state for specialized care we (and no one else local) were able to provide. They demanded she be sent to their hospital of choice, and simply refused to believe that this was not possible. “I don’t think you know who we are!” They even called their congressman (who they ‘knew personally’). After they got off the phone with him, they looked shell-shocked. Suddenly, privilege and entitlement had gotten them exactly nowhere. Finally, after hours wasted, the patient got airlifted.
We have treated dying patients who screamed at us that they didn’t have COVID. They denied it to the bitter end.
I had a family demand that all evidence of COVID be scrubbed from the medical records of their now-deceased family member. When I explained that it was a legal document, and I could not change it, even if I wanted to...which I did not... they threatened to sue me, the hospital and any physician who had written a note in the chart. No words.
The beds are always full, now. All of them. Everywhere.
We keep multiple holds in the ER because there is nowhere else for them to go. Ventilator patients, COVID patients, trauma patients, everyone. We have to wait for a discharge or a death upstairs to get them moved out. We have triaged, examined, worked up, admitted, treated and discharged patients who never saw anything but their exam room in the ED.
Since all the beds are occupied, we have to see patients anywhere we can. We have turned closets into makeshift exam rooms. We see patients on gurneys in the hallway. (HIPAA has suddenly gotten rather.... bent.)
The last month or so, the wheels have completely come off. The system is broken.
It’s a rare day that we don’t have ambulance crews lining the walls, because we just have nowhere to put their patients.
We have coded patients on ambulance gurneys.
We’ve had patients code in the waiting room.
We are to the stage where people are dying because we just don’t have the resources we need to treat everyone.
It’s just surreal to us, to go out in public to get groceries, and buy gas, or whatever, and still...we see people without masks, not distancing, not anything. We are losing 3 to 4,000 Americans a day...and, still, it just isn’t real to them. No one gets it, until they or a family member get it: SARS-CoV2. Then, it gets real, real quick.
We watch our social media feeds in absolute horror...the unmasked gatherings, the parties, the get-togethers...unreal. They call us ‘heroes’ — then stab us in the backs.
Finally, finally, though, we are getting some hope.
The vaccines are here..and most of us are vaccinated now. My wife cried when I got mine. She’s a hard-ass critical care RN, but she bawled like a baby. Well, hell….I cried when she got hers.
We have some actual real drugs and treatments now, so our patients have a fighting chance.
We finally have a President and an administration that gets it, and is moving to do the things that should have been done a year ago. From everything I am reading, as the facts come out, it was far, far worse behind the scenes than we knew, and worse, even than we feared. To me, and to a lot of us on the front lines, Donald J. Trump isn’t just a treasonous, lying, evil bastard. He’s a mass murderer. So many lives, that have been needlessly lost.
Unreal.
This coming week, my wife and I, and many of our friends and colleagues, are volunteer staffing a local drive through vaccine clinic. We will all be doing this three days a week, as long as we are needed.
Finally, we are taking the fight to the virus.
Finally, we get to play offense for a change.
Damn, it feels good.
We are America’s healthcare workers.
We are exhausted, we are burned out, we are morally injured, we are angry as hell, but…
We are still in this fight.
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