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.
There are a lot of false equivalences and naiveté in this opinion piece. HCWs should rightfully be upset if they are not informed of a positive COVID status. The risk of infection from a CT scan versus an endoscopy (an aerosol generating procedure) are not comparable, and yet grouped together. The risk of infection for an anesthesiologist who is required to intubate a patient versus an internal medicine resident evaluating a patient at the bedside is vastly different. An ID doctor making policies from her office similarly does not face the same risks as those being exposed to AGPs. COVID tests have unknown clinical sensitivity, considering the gold standard should be BAL (which rightfully NO ONE SHOULD BE DOING for PUI/suspected patients); asymptomatic transmission rates/community prevalence are unknown. How is this author “basing decisions on data or evidence” when she previously acknowledges that this data/evidence is lacking given the constantly changing guidelines and novelty of COVID19? This resident is in a low risk demographic for morbidity from infection; I hope the rest of her residency provides her additional empathy training as well as the need to question policies made by those who are not facing the front line risks of said policies.
I am sorry to think that a physician “Jo” believes: “We are afraid because officials show us incomplete data, and they want us to be afraid.” It seems obvious that data is of necessity incomplete, because of complicated and insufficient lines of communication from health care providers to public health agencies. I doubt that unnamed “officials” “want us to be afraid”, but rather, informed and cautious. I bet most “officials” are about as afraid as the rest of us are, depending on our degree of understanding. As a resident there can often be push-back from nursing staff. Sadly, we are faced with multiple stressors: not enough PPE, not enough reliable testing, and not enough triage options. Also, probably not enough staff. I hope the author can hold on, stay calm, and have faith that his decisions will be qualified by his best judgment and guided by a higher power. Sometimes we can only move into the unknown and hope for the best.
It is a nurse’s duty to question and advocate, but what seems to be happening here is more than that. Ordinarily I feel like we would take that reassessment and be grateful for the renewed perspective, but fear destroys objectivity, and I am sorry those nurses are suffering so. Stay strong, teach freely and well and be patient. In our own way, we are all suffering from CoV19 friends.
Dear Ms Sunny Kung,
Thank you for so devotedly and selflessly caring for us & I say US because, as you care for the ones who are sick you inadvertently care for the healthy as well. Please never be discouraged or let the poison of fear ravage your mind, these are uncertain and trying times but We Shall Overcome have faith and may Good bless you today and always.
Thank yall for being on the front line and always remember that yall are doing the best job that yall are able too.
Not unique to coronavirus treatment surely. Typical tension among caregivers and it is part of your training. Annoying sometimes especially when you are dog tired but it will make you a better physician. Often the nurses have valuable insight and information, and even know more than you.
Eye roll
This doctor seems unaware of reports that up to 30% of Covid-19 tests are faulty. Whether that’s because the swabs were taken incorrectly or whether the test itself has not identified the virus is unknown. But two negative tests does not mean the patient does not have the virus. (The President of Harvard tested negative, but had it. He has since donated blood/antibodies for research.)
The medical staff is right to question decisions based on testing alone. The nursing staff has likely seen many “I feel okay” patients suddenly decline. The doctor should not assume he knows better than they, just because he is an infectious disease doctor. They have experience he does not. He should not be so dismissive and assume they “choose” to base decisions on “fear.” They may be far too busy to read research reports on “the data” (reports that may be faulty, as many have been), and they may be questioning him because his decisions may seem like outliers for the way such cases ought to be handled. He should get used to having to justify his decisions. A good doctor explains and teaches, so that his team gains more understanding and knowledge for future cases. A poor doctor issues orders and assumes his team doesn’t know enough or is reacting because of fear alone.
It is good that he recognizes that everyone is on edge. That would include him. Compassionate care for the whole medical staff is what is called for. Their mental health is important for all to survive this pandemic in good shape.
Clearly you barely read the article and are venting your own biases.
The doctor went into the room did an assessment on the patient and Found them to be clinically stable.
The decision was made on the overall clinical picture of the patient and was not made on testing alone as you falsely claim
He is clearly talking about a shift in staff behaviour, from before this pandemic to now, so I think he’s absolutely right to assume it is based on fear. As a physician I see this fear everywhere, and it’s mostly based on misleading statistics. We are afraid because officials show us incomplete data, and they want us to be afraid. I’m very curious to see what our society will look like when this is over. I’m afraid it’s going to be full of mistrust, resentment and shame, because it is bringing out the best in some and the worst in many. That is my biggest fear.