I was a ‘perfect setup’ to be fooled by Covid-19

“Hi, this is Pooja,” I answered my phone promptly. I had been waiting all day for this call from the occupational health department at the hospital where I work. Though I had tested negative for Covid-19, it was my eighth day of isolation for a “deep, dry cough” that seemed to be improving, and I was eager to return to work.

“Any malaise?” the nurse asked.

“Yeah but … I always … have that … I’m an internal medicine … resident physician here,” I half joked. I didn’t clarify that I was sleeping 12-plus hours a day, convinced that I was just “catching up.”

“Fever?”

“No.”

“Are you having trouble breathing?”

I paused. “I’m not sure …”

“It sounds like you’re having difficulty breathing.”

“Yeah, I mean … I thought … I was being … a hypochondriac … but it’s only … really noticeable … when I’m walking,” I told her as I sank further into my couch. A friend, who happens to be a nurse, had dropped off a pulse oximeter for me when she first found out I might be sick. I had been using it to measure my oxygen levels and reported to the occupational health nurse on the phone that they were normal.

Was I having difficulty breathing? I didn’t think so — I was probably just out of shape.

I was exasperated as I hung up the phone. That conversation, which was intended to be a follow-up to clear me to go back to work, led instead to a referral to the hospital’s respiratory illness clinic.

At the respiratory clinic the next day, the doctor determined that my breathing was too fast and my temperature was borderline high. Reassured that my chest X-ray was clear and that I was a medical resident — presumably health literate and plugged into care — she warned me about Covid-19 and sent me home with a prescription for an albuterol inhaler. Having taught patients how to use an inhaler years ago, but never having used it myself, I watched instructional YouTube videos and clumsily fumbled with the canister, hoping that some of the medication made it into my lungs.

But I wasn’t feeling any better the next morning, and I didn’t know who to turn to. Like many resident physicians, I had never truly connected with my own primary care provider, never seeming to find the time or organizational capacity to plan for an appointment. So I called Dr. R, a mentor of mine, who was familiar with the respiratory illness clinic.

“I just … have a cough … I don’t … know if … I have … trouble breathing,” I told her. This is ridiculous, I thought to myself. How could I not know if I was having shortness of breath?

“You’re not able to get three words out without taking a breath. I think we can accept at this point that you’re having trouble breathing,” Dr. R replied.

“Why do you keep worrying about work?” another attending physician asked when I called to update her on my situation. “You wouldn’t go to work anyway if you were feeling sick, Covid-19 or not, right?”

But I would. I have.

Of course, this time was different: We are in the midst of a pandemic.

Later that day, I texted Dr. R because my pulse oximeter showed that my oxygen levels dropped when I exerted myself and that my heart rate was persistently between 90 and 130 beats per minute, a sign that corroborated my feeling dehydrated. I told Dr. R that I wanted to avoid the emergency department — if I didn’t have Covid-19, I would surely get it there. And anyway, I wasn’t sick enough to be admitted to the hospital. Was I?

After consulting with an attending physician in our ICU, Dr. R called me back. “Pooja, we think your test could have been a false negative. We should plan for an emergency. … We’re worried about you, and if you don’t improve in the next day, we will probably recommend that you come to the hospital.”

She took down my address — in case I needed an ambulance — and my emergency contacts. Day 10: I read the literature and knew I was at risk for developing respiratory failure.

“Don’t worry,” I said to my sister as I called her with a vague update. “I’ll be fine,” I told her with a confidence I didn’t have.

I dug my signed health care proxy form out of my backpack and stuck it to my refrigerator. Just a week earlier, I had officially declared that my sister, who is an oncologist in New York, would be my decision-maker should I become unable to make decisions for myself — a declaration mocked by some of my peers, who dismissed it as dramatic and unnecessary. I was too young to fall sick, they said.

On the nightstand next to my bed, I carefully lined up my albuterol inhaler, my pulse oximeter and thermometer, and bottles of Gatorade and Pedialyte to help with the dehydration. I set phone alarms to wake me every four hours so I could check my vital signs and take a dose of albuterol. Finally, I got into bed and rolled onto my front — the “prone” position, an unusual posture for me but one that could ease my breathing.

“How could this happen?” I thought to myself, when I should have been wondering, “How could it not?” I had recently written that I was the “perfect setup” for an asymptomatic carrier. But the reality is, there’s no such thing as a perfect setup. We hear story after story of young people with no underlying diseases getting sick with Covid-19; whispers of resident physicians becoming critically ill after serving on the frontlines. So why do residents like me still believe, deeply to our cores, that we are not at risk?

The symptoms of Covid-19, we’re now told, are dry cough, low-grade fever, body aches, sore throat, fatigue, and, in more severe cases, shortness of breath.

But how can resident physicians and other frontline workers report symptoms when we’re used to minimizing and working through our own illness? How can we gauge fatigue when we’re used to feeling tired? When we’re used to pushing through 28-hour call shifts, and living with the physical and emotional consequences of exhaustion and burnout? How can we gauge shortness of breath when many of us have never experienced it before?

How do we realize we’re getting sick?

Over the next week, I closely monitored my vital signs and breathing, reported them faithfully to Dr. R, and used them as a guide to slowly wean myself off the albuterol.

In my small, one-bedroom apartment, I was my own caregiver, but I had a team of mentors, peers, and family members offering advice, support, and deliveries. And I started getting better.

But what if my friend hadn’t dropped off the pulse oximeter? What if the occupational health nurse hadn’t noticed my irregular breathing? What if I hadn’t decided to reach out to Dr. R, for advice about the logistics of clinics without knowing that I actively needed monitoring and care?

April 17 marks my 26th day of isolation, and I’m hopeful it will be my last. As I pace my bedroom, grateful that this activity no longer makes me short of breath, I can’t help but worry for my colleagues and friends. While we might urge our patients to seek medical attention under similar circumstances, “sick” for us often means “sick enough to be admitted to the hospital.”

But during this pandemic, with all of its unknowns, I worry about frontline workers who are interacting continuously with the virus, well-acquainted with sickness and healing in others but not necessarily in themselves, and accustomed to dismissing their own symptoms. In fact, I worry about all young and otherwise healthy people who do not know what it is to feel sick, who are convinced by others (and ourselves) that we will experience minimal symptoms from Covid-19, and who are unfamiliar with navigating the health care system. I worry they may not get care before it is too late.

Pooja Yerramilli, M.D., is a resident in the global medicine/internal medicine program at Massachusetts General Hospital. She is a policy fellow with Seed Global Health and recently served as a consultant to the World Health Organization’s Office for Health Systems Strengthening.