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Waiting For the Tsunami

“Being brave isn’t the absence of fear. Being brave is having that fear but finding your way through it.”
-Bear Gryllis


Winter in the Emergency Department is chaos normally. Viral illnesses permeate our population, and the season is usually from November to March or later.  Young moms get nervous, fevers get really high, and our volumes skyrocket. We typically see relief in late April or June when the sun comes out and everyone can be outside a bit more.

Now that Coronavirus is on the horizon, things are different. We are in limbo, not really knowing what to expect.

I have fortunately been able to test the patients that come to the ER that are suspected COVID infections, and I have done so with a handful of kids. None of the tests I ordered became positive. It’s so hard, no one really knows what the mild COVID illness looks like. The flu? Sort of, I hear. According to reports, I know most cases are usually accompanied by a fever, but what if you only have a cough? Also, the reports say that most children are spared from the worst effects of the virus, but we don’t know how much they are responsible for spreading it.

I got sick on a Friday before I was supposed to work the weekend. Our hospital had just opened a drive-by testing for healthcare providers. I wasn’t sure if I should get tested. I felt really fatigued and only minimal cough. I normally would go to work under these circumstances. But these are not normal times. We have an ill-defined, but seemingly inevitable wave of tragedy that is about to hit our medical community. The old rules don’t apply anymore.

I decided that the best course of action was to assume I had it, stay home from work and get tested. It was more scary to potentially expose an entire ER of healthcare providers than to admit I was sick and stay home.  Fortunately my test was negative. I was sort of hoping it would be positive, just so I could say I had it, it was mild, and I recovered fully. I went back to work on Sunday. By now, things really felt different. The hospital is eerily quiet. It feels like  summer, from the number of patients, but very different in other aspects.

We are all holding our breaths. Waiting for the storm, bracing for impact.

I heard yesterday that an ER doctor from our community is ‘critically ill.’ He is reportedly only 40 years old. I am feeling with increasing dread that my job is dangerous. Honestly, I am not concerned too much about the health and safety of my children, as I commented earlier, the reports out of China have very few children getting seriously or critically ill.

But I am not immune, and I am in the eye of the storm.

I am becoming increasingly aware of how hard it is to practice ‘social distancing’ in the ER. We talk to our trainees, our nurses, our patients and our patient’s parents.  Our protective gear is there to protect us, but it is had to wear all the time.

By distancing ourselves with our protective equipment, we are also distancing ourselves from our patients, which is not traditionally what we try to do as doctors. You can’t express as much when your face is covered with a mask. Connection becomes that much harder, as my compassion and sincerity aren’t able to be communicated as easily. It is also really hard to hear with the noise of the fan on in our ‘respirators.’

I start to feel crazy, wiping everything down all the time. I start to get paranoid. Did I clean my workstation enough? Do I need to clean it again, every time I return? I now am spending more time cleaning than working, it seems. My hands are dry and cracked due to the amount of hand washing and antibacterial gel.

Then there is a kid who is unexpectedly ill with a respiratory illness. Maybe they have COVID, maybe not. Maybe you put all of the protective elements in place, only to find out that a colleague that you worked with a week ago is feeling sick, and the child is negative. Or a family member you recently had dinner with was around a person that tested positive. Am I now infected? Am I spreading this illness?

This whole event is becoming very real for me. I am starting to think about my own mortality and what would happen if I got sick. In China 4% of their confirmed cases were healthcare workers. Healthcare workers had a 15% chance of their illness being severe or critical. What are my risks? I have also heard that a recovery rate is only 5% if one is sick enough to need intubation, but I haven’t seen the data speaking to this specifically.

I feel deeply attached to my role in this pandemic, to be on the front lines, doing my best to stay strong, positive and tend to the patients that need it the most. What happens when we start to question this role? Is it better for me to triage and care for my patients, or my family? Can I do both effectively? What happens if I get sick? Will I be ok? What happens if we all get sick and can’t come to work?

I hear that the pediatric doctors will be pulled to care for more adults, there will be a sense of ‘all hands on deck’ if it gets to epic proportions. What about our mental health? What about our ability to stay resilient in times of crises? I understand that I and my colleagues are in the field we are because we like this atmosphere. But I also would like it to end quickly. The idea of weeks of this, massive amounts of patients, uncertainty, possibly working more than ever to tend to the ill is daunting.

I can imagine that too much stress and work could lead to the healthcare providers being prone to illness. A few companies, Headspace and Ten Percent Happier are providing free services for healthcare workers during this time. Many facebook groups are popping up, one for support of colleagues, the other to share clinical data and treatment modalities.

Life in medicine, as in other areas as well, will be remembered as ‘before the pandemic’ and ‘after the pandemic.’ We will never be as ill-prepared from a testing, staffing, availability of personal protective equipment, as we are in this moment.

I am taking it day by day, watching the trackers closely, anticipating that things are going to get a lot worse in the next few days to weeks. I hope all of you can stay safe, stay home, and get support or help if you need it. Don’t be afraid to stay home from work to get tested either, we are all in this together.

How are you coping? Please leave a comment about what the impact has been on you or your job, family, etc


Working In Medicine–How I Learned to Ignore My Health

“Learning to treat ourselves lovingly may at first feel like a dangerous experiment”—
Sharon Salzberg


This begins a three part series about working in medicine, how we have a hard time taking good care of ourselves, and what happens when we don’t. 

“I don’t think you should go back to work. Being on your feet all day could cause this to happen again. What would you do if a sick child came in at the same time you started bleeding? No one wants to make that decision.”

This is the conversation I had last week with one of the doctors that was taking care of me after I was admitted to the hospital for pre-term bleeding. I feel like I am repeating myself when I say, I was 30 weeks and had just finished a long shift in the ED when I started bleeding. Unfortunately, this is exactly what happened.

It was a very similar experience to the one I had during my last pregnancy. I was feeling good, I had no pain, but after working all day, I started to bleed. This time it was 3 am. I was getting ready for bed, and right before I left the bathroom, I felt liquid down my leg. I thought to myself, “please don’t be blood, please don’t be blood.” Then I turned on the light, and there were large red drops spattered on the tile.

There was no way I was waking my son up at 3 am to go to the hospital, so my husband stayed home, and I drove myself. After evaluation at our closest hospital, I was ambulanced to the tertiary care center—this time because my baby was only 30 weeks, last time it was because he was profoundly tachycardic. Thankfully I have had no additional bleeding and after 5 full days in the hospital, I was discharged with instructions to ‘take it easy, don’t go back to work, and if there is more bleeding,  we will keep you in the hospital until baby is big enough to come out. Also, if you bleed and don’t stop, we will deliver the baby.’

What has been so shocking to me is my reaction to this chain of events. I, like many of my colleagues, pride myself on my resilience. I am also proud of the amount of ‘grit’ I have developed throughout my career and my ability to “power through” challenging situations. I am a hard worker who is passionate and I truly love my job. I do not see myself as weak or incapable or often needing help.

But this, this was different.

The first night I was in the hospital, I thought, this is no big deal. We will be able to go home, I go back to my normal schedule, everything will continue as planned. I had developed an intricate, well thought-out work schedule to slowly decrease my clinical time as I got closer to delivery. This included me working close to resident hours during my second trimester to get all my clinical hours in. However, in the hospital, each day passed and every doctor that I saw (there was a different one every day) used increasingly urgent language to give their professional opinion and recommendations about my plan. They all recommended I didn’t go back. That was not the message I wanted to hear.

When the conversation was put in the context of my health vs. that of my patient’s health, I had a bit of an internal crises. I certainly hadn’t thought of it like that. Up until this point, I still was thinking about what I was comfortable with. About how I was going to communicate the fact that I would need to slow my life down a bit, how I was going to advocate for myself and how uncomfortable that made me.

The very thought of taking my health and well-being and putting it to the top of the list was agonizing. I struggled to sleep, and for the first two nights I woke up crying, thinking about how I would never forgive myself if something happened to the baby while working. These thoughts were juxtaposed with my compulsive feelings to finish what I started, to not ask for help, to ‘soldier on,’ as I was used to, as I was trained. It also was apparent to me that my personal self-worth was inextricably linked to my ability to perform my job.

These intense feelings have led me to consider their origin and to subsequently trace the trajectory. Somewhere in the medical school, residency, fellowship training and then as an attending I stopped caring about my own personal health. You hear this all the time. Doctors are very good at taking care of others, but few of us have regular doctor’s appointments, and few of us take our own health seriously.

Until we can’t ignore it anymore.

To be honest, I am not sure when it started. In my experience, in training, we are never told that it is ok to be sick or that it is ok to take a day off. Instead, the culture is one of reprimanding us and in combination with being judged for time away makes us never want to take time off, and also to be fearful of needing it.

As a medical student, this manifested itself as I worked through cough and cold season…priding myself on finding just the right combination of medications to get through the day without coughing on everyone or passing out, and doing it while not needing any additional rest.

In residency, I prided myself on my near perfect work schedule and never needing to call in sick. Co-residents who struggled with the schedule or with being pregnant during this time were labeled as ‘weak,’ and were whispered about behind their backs. During this same time, when I made a mistake and mis-scheduled my vacation time (as I have detailed before), the hard work and dedication to my job didn’t matter. I moved mountains to get my schedule covered, but my program director didn’t care, and I had to live with traveling across the country to see my family for a weekend instead of a week. I realized in this moment that my needs didn’t matter, my mental health didn’t matter, the job was more important.

When I got to fellowship, I do believe the system was more forgiving, but I had already learned some pretty significant behaviors about caring for myself. One early morning before a shift, I was vomiting, and came to work anyway. I continued to vomit every 30 minutes to an hour while on shift which I mitigated by getting IV fluids and anti-nausea medications from the nursing staff in the back between seeing patients. Eventually I was told to go home, but not before being admonished by the attending that was replacing me, she said she was having bad diarrhea, but “I guess I’ll come and replace you.” As if I was weak for leaving.

As an attending I had a miscarriage and an overwhelming feeling as though I couldn’t tell anyone. My D&C was scheduled on my day off, and my emotional recovery was put on the back-burner. I didn’t know how to prioritize my health and well-being. When my second miscarriage happened I used the only 24 hour period I had off consecutively to take misopristol, which induces bleeding. The next day I returned to work, still bleeding, still cramping, and emotionally numb.

When we are pregnant, however, we are no longer only in charge of our own health. We now have the health of the baby to think about as well. The problem is that this way of being feels so out of alignment with our core self that it feels wrong. I believe we can intellectually understand that slowing down or listening to our bodies will help the health of our baby, but it doesn’t translate into our actions very often. We have been able to force our bodies and selves to do amazing things, like 30 hour work days, 80 hour work weeks, living on little sleep and poor nutrition. We don’t understand that this is wrong, or that it should change when we are pregnant.

Our babies need us to take care of ourselves, which we aren’t used to doing.

In the hospital I desperately needed another doctor to tell me I couldn’t go back to work. Actually, I needed 4 doctors to tell me this. And I needed them to tell me this after I bargained with them about only working half shifts, and only at times when I would be surrounded by other physicians, so if I did start bleeding, I could leave. My trusted OB/GYN peers said ‘No.’

And I breathed a sigh of relief, and I cried with gratitude that someone else had made the decision for me.

So now, I am taking the month of December off. I am eternally grateful that I won’t be anxiety-ridden walking into the hospital. That I won’t spend my time working a shift and worrying about whether or not today will be the day that I start bleeding. I won’t spend my time thinking if I do start bleeding, whether I will call an ambulance or drive myself to the hospital, hoping I don’t hemorrhage on the way there.

I know I am not the only one who has struggled with this. Do any of you have stories to share?

Next week….Part 2–Experiences of Pregnant Physicians