My pager wakes me at 4:00 a.m. It’s from Jill, a nurse on the medicine floor. “Mr. M is on 4L of oxygen. I think he needs to go to the ICU. Please come assess.”
A few minutes later, I am outside the patient’s room, going through the laborious but essential process of donning personal protective equipment. I take off my jacket, sanitize my hands, put on gloves, cap, gown, surgical mask, and face shield, then finally enter the room. Mr. M says he feels fine, no different from when he first came to the hospital a few hours ago on two liters of oxygen per minute. After my assessment, I decide that he doesn’t need to go to the intensive care unit.
Jill is quick to say, “I was told if Covid rule-out patients have an increasing oxygen requirement, we should be cautious and transfer them to the ICU quickly.”
“It looks like his Covid tests have come back negative twice, once in Vermont and once here,” I reply. “The infectious disease doctors said one negative test here is good enough for us to rule out Covid.”
Mistrust seeps through the assembled group of nurses, nursing assistants, and respiratory therapists. “Who knows,” says one. “He could have been exposed to the virus on his way from here to Vermont.”
They were clearly disgruntled about my decision not to transfer Mr. M to the ICU. I tried to reassure them by providing evidence, but I could still feel the tension and fear. The nurses wanted another M.D. to act as an arbiter of my decision but were finally convinced after I cited the patient’s stable vital signs, laboratory results, and radiology findings.
Everyone in the hospital is understandably on edge. Uncertainty is everywhere. Our hospital’s policies have been constantly changing about who we should test for Covid-19 and when we should wear what type of protective personal equipment. Covid-19 is still a new disease to many clinicians. We don’t know exactly which patients should go to the ICU and which are stable enough to stay on the regular floor. And it is only a matter of time before we run out of masks and face shields to protect front-line health care workers.
Every night during the pandemic I’ve dreaded showing up to work. Not because of fear of contracting Covid-19 or because of the increased workload. I dread having to justify almost every one of my medical decisions to my clinician colleagues.
Since the crisis began, I’ve witnessed anxiety color the judgement of many doctors, nurses, and other health care workers — including myself — when taking care of patients.
As a resident in internal medicine and a future general internist, it is my duty to take care of these Covid-19 patients and reassure them that we are here to support them. That’s what I expect to do for all of my patients. What I did not expect from this pandemic is having to reassure other doctors, nurses, and health care workers about clinical decisions that I would normally never need to justify.
Sometimes it feels like pulling teeth just to ask for a necessary blood draw or to obtain a chest X-ray. Critical tests like CT scans, MRIs, and endoscopies are being delayed or even deferred because of the risk that the clinicians who do these procedures might be exposed to the coronavirus that causes Covid-19.
The team that admitted Mr. M to the hospital decided not to get a chest X-ray, even though his chief complaint was shortness of breath, one of the many possible symptoms of Covid-19. There is emerging literature on diagnosing and treating Covid-19 patients that is easily accessible to physicians and nurses, but some of them are choosing to make their medical decisions based on fear — such as pushing for unnecessary testing or admission to the hospital, which may lead to overuse of personal protective equipment and hospital beds — instead of basing decisions on data or evidence.
I am constantly surprised that I must defend my ability to properly take care of these patients, and by the divisions this pandemic is creating within the health care community.
When I decided not to transfer Mr. M to intensive care, nurses pushed back on my decision even though he was clinically stable. I have heard surgeons, anesthesiologists, and their nursing colleagues complain they were not told by other physicians that their patient was positive for Covid-19. Some clinicians don’t trust the ability of infectious disease doctors to make decisions about which patients to test and how many negative tests are required. Others are refusing to perform procedures or care for patients unless they are confirmed as Covid negative.
Patient care can be compromised because of the fear and anxiety that clinicians have about Covid-19. Some are afraid of contracting Covid-19 (a surgeon colleague of mine said she “didn’t sign up for this job to be exposed to a disease that has a two to three percent mortality rate”). Others are worried about spreading Covid-19 to patients or workers in the hospital — or to their family members.
During a time when collaboration among different types of medical providers is essential, conflict or division often prevents us from providing the best care for patients. This realization makes me more anxious than the fact that we will soon run out of personal protective equipment and ventilators, or the high likelihood that I may unknowingly pass the virus to a patient or colleague.
Yet there’s a thread of hope through all of this: the kindness and responsibility of others. The nurses in the emergency department who help me build plastic disposable stethoscopes so I can see patients without contaminating my own stethoscope. The patients who make jokes about my wonky get-up in gown, face shield, and N95 mask. The people who donate blood. The people who donate time, money, and food to those who don’t have the means to prepare for the pandemic. Those who practice social distancing. And most of all my colleagues — nurses, respiratory therapists, physicians, workers who staff the front desk, security personnel, phlebotomists, pharmacists, patient care assistants, environmental services workers, and more — who are fighting every day for their patients, despite the chaos and the risks.
By working together, we will survive Covid-19.
Sunny Kung, M.D., is a resident in internal medicine at a Harvard-affiliated teaching hospital.