The view from two residents inside an ICU’s pandemic crew: Covid brain, relentless sorrow, and kindness in calamity

“Welcome to the Covid crew,” read the email we received in mid-March.

With that quick introduction, we started work in the first medical ICU team focused on the care of patients with Covid-19 at Boston Medical Center, a safety net hospital. Little did we know that the next few weeks would be the most trying times of our medical careers to date, and possibly ever.

Even though we had read reports about Covid-19 from China and Italy, we were blindsided by the ruthlessness of the virus. On our first day, we neither fretted about contracting the virus nor worried about the strain it could place on the health care system. We assumed that we would practice medicine as we had been, and that this too would pass.

That changed in a flash, and it is now hard to realize just how naïve we were. We write this for our fellow residents who embark upon similar journeys, possibly through much harder times.

Covid brain

Not long after we started our rotation, we discovered the Covid brain — in doctors, not patients. It is the mindset that takes over when you step into a Covid unit.

Despite years of honing our clinical reasoning skills, this condition prompted us and others to leap to a single diagnosis for all complaints: Covid-19. The fear of missing it and the risk of exposing others if you do makes you send multiple swabs from various orifices until you get a positive result.

The Covid brain is in a constant state of high stress. We found ourselves more short-tempered than usual. The attending physicians we work with had previously applauded us for being patient and levelheaded. But we found ourselves on more than one occasion exchanging curt remarks with each other. Apologies were frequent, sincere, and free flowing to others, though less so to ourselves.

One good thing is that the Covid brain learns quickly. We became more efficient by bundling orders to limit the number of times nurses needed to enter patient rooms. We learned to communicate better with our teams. We quickly mastered the art of charades through the glass doors of patient rooms. When that failed, we used walkie talkies and baby monitors. Ever wondered how many doctors it takes to operate a walkie talkie? Four.

If we were experts in anything by the end of the day, we were novices again in the morning. When our hospital, like so many others, experienced shortages of the medications needed for intubation, we had to adapt. The medical center’s savvy pharmacists taught us about creative alternatives to protect our dwindling stash of medications as if it were gold. We learned about the futility, and some may say stupidity, of trying to correct insignificant lab abnormalities, like a borderline normal potassium level. We were amazed at the number of imaging studies and tests we began to view as unnecessary, asking “Will it change the patient’s care plan?” before each click of a mouse.

The Covid brain will test your limits and sometimes push you past them, but it will certainly make you a better doctor.

Relentless sorrow

Patients in areas of the hospital outside the ICU often decompensated in alarming and unpredictable ways. One minute they would be breathing comfortably, the next they would be in severe respiratory distress needing immediate transfer to the ICU. The number of rapid response, STAT airway, and CODE BLUE overhead pages directing us to one of the hospital’s dedicated Covid-19 wings skyrocketed. We began documenting detailed goals of care conversations for all patients on admission, even the young and otherwise healthy.

To conserve our personal protective equipment, we limited the number of times we visited patients. Instead, we watched their vital signs on monitors, read their labs from screens, and observed their breathing patterns through glass doors. We missed terribly the human contact with our patients — a reason many of us chose to go into medicine.

We placed next-of-kin contact information in the top line of our daily notes, accessible at a moment’s notice. We grew accustomed to giving bad news to families over the phone, never having met them but having gotten to know their voices intimately.

Working in New England’s largest safety net hospital, we saw firsthand the disparities in Covid-19 mortality. Entire extended families living in close proximity without the ability to adequately isolate themselves were admitted to the hospital en masse. We had family members on various floors of the hospital. We got used to calling the hospital number to reach them, instead of their personal number.

As we made call after call after call, we waited with fingers crossed for a patient to wean off the ventilator. Although we cheered for each one who was liberated from the machine, many needed to be reintubated. Short-lived moments of joy were often quickly replaced by disappointment, frustration, or both.

And when we had exhausted all options, we stood in the hallway with a spouse or parent on the phone as a nurse held their dying loved one’s hand in the room. We wept for the families who grieved in isolation.

Kindness in calamity

Despite these hardships, we imagine that we will look back on our time in the Covid-19 unit with gratitude and awe. Patients’ loved ones, facing the darkest days of their lives, frequently ended calls with “Please take care of yourself and your family” and sent us prayers and well wishes.

Our co-residents came by the workroom daily to check on us. Residents from other programs in the hospital eagerly supplemented the Covid-19 workforce.

Friends offered to get us groceries or launder our growing pile of scrubs. Encouraging texts popped up on our phones. The ICU director was in the unit every day, and the residency director checked on us by email, not only ensuring we had enough support staff and equipment but also checking on our mental well-being. The chief residents brought us a plant to cheer up our windowless workroom.

Ask and it shall be given. That was the message we got from our leaders and was reiterated by the greater community. We found posters with motivational quotes taped to the front doors of the hospital. Several restaurants around the city adopted our ICU and regularly sent us food. The nursing managers brought the unit sports drinks when they heard that staff members weren’t drinking enough, and the attending physician hand delivered bottles to us.

Even as our hearts were depleted by the suffering and death we saw every day, simple acts of kindness filled them up again.

To Covid crews past, present, and future

Our rotation on the Covid crew was one of rapid adaptation. That’s hard to imagine since Boston appears to be near the peak of the pandemic, not the end.

We are grateful to the teams at the “front” of the front lines: the paramedics and emergency department staff, who face the highest risks of all. To the inpatient teams and nurses stabilizing patients on the general medical wards, the respiratory therapists, and the housekeeping staff, we take our bouffants off to you.

To the ICU nurses who held our hands and our patients’, we are indebted to you. To the outpatient teams who help patients stay safely at home, we will not survive this pandemic without you. To our neighbors at Boston Healthcare for the Homeless who are practicing “tent medicine” to keep the city’s most vulnerable population safe, we look up to you with respect and admiration.

To our colleagues in New York City, we are left speechless at the situation you are facing. While the stress and sorrow may be many times what any of us expected or have ever experienced, we hope that you too can seek solace in the kindness and support of your community. You are our heroes.

Finally, to the residents who are preparing to start their ICU rotations, welcome to the Covid crew. This battle will forever connect us.

Iniya Rajendran, M.D., and Stephanie Van Decker, M.D., are second year residents in internal medicine at Boston Medical Center.