I step through the sliding glass doors of my hospital’s emergency department and immediately look for the paper bag with my name scribbled on the outside. It contains my previously used surgical mask. I put it on, breathe deeply, and wrinkle my nose at the smell. It’s a stale, tired scent, unrecognizable and unpleasant.
Hellos from the triage nurses behind makeshift plexiglass distract me from the smell. I greet the other docs, nurses, physician assistants, techs, unit secretaries, social workers, interpreters, housekeepers, and the others I’ve worked alongside for years. When they notice my clean-shaven face — I shaved my beard the night before for the first time in 30 years to make a tight seal with the N95 mask — I hear a few cutting barbs and dramatic gasps.
I smile. The mask smell, high in my nostrils, is washed away by the banter with these people. I’m at considerable risk for being exposed to and infected by the coronavirus in the emergency department, but somehow I feel most at ease about Covid-19 when I’m at work, among people I trust.
What I can’t track or make sense of is the response from leaders who should be bastions of guidance and support. One day we’re told that providers must scrupulously don an N95 mask, face shield, portable gown, and gloves. Then the shortage of personal protective equipment somehow alters scientific evidence, and the Centers for Disease Control and Prevention now believes that surgical masks, which fit like a pair of old khakis, should be more than adequate.
And we can reuse the N95 and surgical masks which, after a day or two, take on a mysterious odor.
I know what that smell is now. It’s mistrust.
I feel abandoned by U.S. leaders who appear to be bungling through a national catastrophe with unearned bravado. When stockpiles of personal protection equipment resemble the toilet paper aisle in grocery stores, I anticipate a declarative announcement from them and the CDC that they have good evidence, excellent evidence, the best evidence ever, that taking a marker and drawing an N95 mask on your face is just as effective as a surgical mask. But you must use a permanent marker, preferably a Sharpie.
In a time of crisis, transparency and trust are essential. But trust has become a resource as scarce as personal protective equipment, and it can’t be manufactured, even as an afterthought. Which explains why I feel comforted when I’m working in the emergency department. Being exposed to Covid-19 also means being surrounded by people I trust inherently.
There is a moral mission to emergency medicine. The sliding glass doors open to anyone and everyone. Our practice is a dance, sometimes a race, and on occasion an arm-wrestle with the unexpected. Fortunately, I work hand-in-glove with dedicated and passionate folks who have big personalities, bigger hearts, and the resilience of Gumby. We’re used to diagnostic uncertainty, responding to desperation, to bodies and lives in crises. We’re trained to respond quickly based on limited information. Since testing for Covid-19 is as scarce as personal protective equipment, we know our foe but can’t always see it. Caring for our patients will require caring for each other to ensure that we stay safe and healthy.
Emergency departments have been described as quasi-public spaces situated between the community and the hospital itself. Even before Covid-19, this space buckles from the strain of serving two masters: meeting the growing needs of communities in crisis while satisfying the demands and working within a stressed hospital. Emergency staff are practiced in doing more with less.
In the midst of a pandemic, it might sound counterintuitive to confess that I feel most in control in the very space where there’s a lack of personal protective equipment. My emergency department boasts two CT scanners, a cardiac catheterization lab, an MRI suite, and now resembles an elementary school lunchroom with reused masks in paper bags propped on shelves.
Covid-19 poses a challenge on a magnitude that will destabilize us in a manner we’ve never before experienced. Luckily, protection comes in the form of the talented, tenacious, and compassionate people who make the emergency department hum. I cherish my colleagues more than ever because we’ve been through so much together, albeit on a much smaller scale. We’re practiced at personal risk and having each other’s back, being frequently on the receiving end of violence, verbal abuse, and infection.
We’ve endured troubles, shared triumphs, and exposed our vulnerabilities. I’ve been at my worst and at my best with my colleagues. Because of them, I’ve grown into a better doctor and hopefully a better person. These are the people I trust most in this crisis.
Emergency doctors everywhere in this country are doing the same thing I’m doing: caring for patients, huddling with amazing nurses to make sure we’re all on the same page, swapping stories with crackerjack techs, and maybe ribbing the indispensable unit secretary about her overhead call for the owner of the red Toyota to please move their “cah.”
We’ll talk about what this cough means or whether that patient with diarrhea might be harboring Covid-19. We’ll gown up, mask up. We’ll secure and tie the backs of each other’s gowns and diligently check for gaps in protection that’s more permeable than we’d like. We’ll remind each other to drink enough fluids. And don’t forget to eat, too. We’ll check in and ask how we’re doing.
We’ll struggle through decisions based on guidelines that have a whiff of fiction to them and aren’t completely helpful: When there are not enough tests for SARS-CoV-2, the criteria of “prolonged, unprotected close contact with a patient with symptomatic, confirmed Covid-19” has limited utility.
The masks I’m expected to wear take on a gamey odor with too much use. Luckily, I’m vitalized by the camaraderie, strength, and dash of humor from these extraordinary people.
Everyone should be practicing social distancing. Health care providers, especially those who work in emergency departments, can’t do that. The only way they will make it through this difficult time is through trust and coming together. Fortunately, that’s something we’ve been working on for years.
Jay Baruch, M.D., is associate professor of emergency medicine and director of the medical humanities and bioethics scholarly concentration at the Alpert Medical School of Brown University.