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.
Sure, I’m worried. And I’m vigilant. I follow this tyrannical infection as it wreaks havoc around the globe and closer to home. It’s relentless, but mappable.
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.
Hello Dr. Baruch,
You obviously have a lot of impressive medical credentials plus a being an accomplished bioethicist.
https://vivo.brown.edu/display/jbaruchm
So here is my question:
While I applaud Gilead;s decision to abandon Orphan Drug status for remdesivir, I have a lot of problem with their decision to discontinue providing it for compassionate use. Don’t you think saving lives immediately is much more important than securing enough supply for a clinical study that may last for several weeks if not months? They don’t typically enroll dying patients/subjects for clinical studies do they? Would love to read you views, please!
I simply do not understand the most ethical triage rationale here. Please help!
Amazingly written Dr. Baruch..
Stay healthy, happy and safe!
😊
Jay
Your insight combined with all the human elements our teams deal with daily is spot on. Miss working with you my friend. Stay strong 💪
Exceptional article.Well done.
I’m surprised at some of these comments lashing out at the doctor. As if he is to blame for the broken medical system in the United States. It has been broken for quite some time. Any efforts to fix the system are thwarted. So far, no more solutions have been brought forward and finger-pointing will not help now. At least he and his staff are doing something to help every day in the front lines of this global pandemic. As far as Trump. There is also footage of him actually saying the virus was a ”democratic hoax, ” among other ridiculous things. He disbanded the group put together to handle a global pandemic response one year into his ”job, ” then knew about this oncoming threat in January and sat on it until advisors and epidemiologists from the CDC approached him with the reality of what his legacy would be. Death of millions and the economic downfall of this country. These problems already existed. But Trump’s misdirection and outright lies made them gravely worse. Instead of leading our country in a time of National Crisis he play’s the blame game and acts like a petty child instead of a world leader inspiring comfort and confidence while people (like the author) are at the front line putting their lives on the line daily. Hospitals (especially ER rooms) are already understaffed and ill equipped. They still try to provide care.
Thank you for your service, Dr. Baruch. And thank you for your transparency writing this & for your courage & bravery in the face of uncertainty. I applaud you & your colleagues as you work tirelessly every day, putting your own selves at risk. I feel your heart, I recognize your calling. I worked as an ER nurse in years past & your article took me back to that place in time where I, too, felt the trust of those around me as we unselfishly cared for the sick & wounded. It can be quite the battle field.
I am praying for you now that God will protect you, that He will provide for your every need, & empower you with His strength! God is in control! He will never leave you or forsake you. Praying for His peace to be with you.
In medical emergency situations, trust is key to patient and provider survival. The nonsense blurted from mentally and linguistically challenged Trump is sickening, and indeed provides no trust at all. All the dire needs expressed loud and clear by very competent medics are being minimized, and each day the needs / use / availability / disposability of urgently needed medical equipment and supplies is being changed – to hide the shortfalls caused by this nations’s failing leadership. The PPE shortfalls are directly caused by the retarded delayed action to curb the coronavirus spread. At the rate cases grow in the US those NOT infected will be the exceptions. Good luck to all. Stay home, and isolate as anyone you might encounter could be infected. Hunker down for a few more weeks, as rule-breakers are forcing extension of isolation time. To all heroes in the hospitals, clinic, health centres, labs, firehalls, police services, community workers, all now inundated Covid-19 fighter people : THANK YOU for trusting in each other’s capabilities, and for the team-work as you risk your lives in doing your crucial work. Thank you x 10000000.
Implicitly trying to be CNN and blaming this all on Trump is silly. He was called all kinds of names by Democrats, including Biden, for blocking all travel from China very early on. That early decision was critical and surely saved countless lives. Even after Trump’s decision, The NY mayor and a health official were telling everyone to go to restaurants, use the subway, etcetera, and not to worry because their medical system was fully prepared. Their videotaped taped statements have been shown on television, so to now hear their criticisms of others is really rich.
Thank you Janice and all who are doing the work so that we over 70 might live to tell about this precarious event in these already precarious times.
I’m staying home, living simply as always, not hoarding toilet paper (what IS that about??) and calling and emailing and sending cards to folks whom I know are feeling isolated. I’m writing and calling my congresspeople and writing to a few I’m glad are not mine to remind them of their duty to serve.
Dr. Baruch,
Your ER department does not have any ventilators? Why? What are you going to do if you need to admit patients who could hardly breath suffering from what could be the end stage of Coronavirus infection with severe pneumonia!?
Recent news says several hours in a room with hydrogen peroxide mist has proven effective in allowing safe mask reuse. Process had been developed for room decontamination a few years ago, but not applied to masks until now because nobody expected to run out of masks. FWIW
If your state is either
i) Densely populated
Or
ii) Depends on supply lines using 50% of greater overseas content for critical medical supplies
Then
It’s pretty obvious that they should have a 2-4 week stock of such essential supplies. Stuff from China is cheap, but obviously not dependable in time of crisis. You want cheap stuff from countries that are not you, you must have a plan B.
Your hospital and its esteemed professors of Important Things assumed the world was a subset of Disneyland, where everything is peachy all the time. The assumption is false.