Inside these walls: An ICU doctor describes the enormity of challenges faced amid pandemic
Hope has long left these halls. The tunnel elongates as the single glimmer—a highly efficacious vaccine signaling an end to this fight—fades.
Inside the swinging doors of the intensive care unit, death and devastation consume us. Outside, the sun continues to rise and fall, the rhythm and routine of life plod onward. Lines of cars pass the jumbotron at the city’s edge announcing “Covid Cases Up” and “Hospital Resource Strained.”
I wonder if people notice the pixelated words on the sign, their meaning, if it impacts their day-to-day life? Is it a reminder to wear a mask at the grocery store? Do they think about what may happen if they get into a car accident or have a heart attack? Does it offer motivation to get vaccinated? Do they hesitate to visit us when they really need to come?
As a physician in the intensive care unit, the sign conjures a sustained and incessant, unfolding tragedy for me. Strained, I think, lacks illustrative poignancy.
There has been an exodus of healthcare workers from our hospital. Like everywhere, we are sad, exhausted, disenchanted, angry, and burned-out. Many are seeking new professions, retiring, or are lured by travel wages and crisis pay. The healthcare sector has lost nearly half a million workers since 2020 and as many as 66% of critical care nurses have considered leaving the profession entirely. Paradoxically, the number of patients has grown significantly and they are sicker than ever.
For those of us who remain, our arms and legs shake under the heavy weight of a healthcare system in duress. More patients pile in as both a direct and indirect impact of the pandemic. Still, we don our yellow gowns, blue gloves, and now hazy face shields and sit with fear, sadness, courage, memories, and devastation. People, so many unvaccinated COVID-19 positive people–slip away, eerily lucid and aware of their demise to the last minute.
Many patients still linger in my mind, their families’ faces as tiles on a screen or voices on the phone. My list of intended condolence cards I have yet to write is long and overwhelming, scribbled handwriting–mine–names I cannot forget.
I remember one patient in particular, his brown eyes wide-open, the blacks of his pupils like discs, his lungs failing. We joined hands at his request; my blue rubber gloves separated us by imperceptible microns. The air between us was swollen with hope and fear. He requested a prayer and made me promise he would not die. I heaved my words to the sky and begged his god, mine, whoever would listen and promised. Then I reached for more tangible tools and earthly fixes: medication and intubation. The flat line stretched across the monitor—much like the long ocean horizon–posing the question of what is beyond. I still hear my voice reluctantly instructing CPR to stop minutes later. He was my age. I still feel his hands in mine. His mom was unreachable as she was getting her vaccine.
Over the last 20-months, we have seen over 3,000 COVID patients and nearly 350 deaths in our 182-bed hospital. Early on, we played The Beatles song, “Here Comes the Sun,” for each survivor discharging. We celebrated our 100th, 200th discharge clapping as loud and crying as hard as our patients and their families. The beginning feels distant, the vaccine but a lofty dream.
In May 2020, the Navajo Nation surpassed New York City in per capita COVID-19 cases. As the New Mexico “hub” hospital for the Navajo Nation, the limited capacity of the Indian Health Service facilities became evident as our wards and ICU filled. Health disparities were tragically magnified as the pace of hospitalizations and death from COVID-19 occurred at a rate notably higher among American Indians.
In the beginning, we wondered if we too would fall ill, and take COVID-19 home to our families. Some of us did. A paramedic texted his friend “I think it is time for me to be intubated,” aware of his declining status. We remember each of those who are no longer here.
At the time, our entire county was shut down for a case positivity rate of 9 per 100,000. Today, in San Juan County, our case positivity is 154 per 100,000 new cases. We are in our 5th surge and it is far bigger than any we have ever experienced. All ICU beds have been full across the state for weeks.
We make countless daily phone calls reaching across the west to find our patients’ beds; there is no space anywhere. Our COVID-19 patients are younger now. They are in their 30s, 40s, 50s, and they are dying.
We are now struggling to care for easily treatable diseases due to the sheer volume of COVID-19 positive individuals requiring care.
Surgeons now operate on more advanced cancers due to missed routine screenings. Elective procedures were put on hold in order to treat the more acutely ill. Breast and cervical cancer screenings dropped by 87% and 84% respectively when compared to the previous 5-year average. Colon cancer screenings have dropped by 28% to 100% at different points in the pandemic across the world. Delayed cancer diagnosis will play out with an increase in advanced, preventable cancers over upcoming years. The projections are grave.
Legs are amputated as a consequence of ulcers growing from poorly controlled diabetes. Depression and suicide are rampant and addiction pervasive. People are succumbing to the wasteland of numbing intoxication after jobs lost secondary to the pandemic and so much death with so few mental health resources in the four-corners region. Other infectious diseases are surging in the background: syphilis rates at our hospital have doubled from 2019 to 2020 and are on course to double again by the close of 2021.
Some people are coming too late, afraid of a hospital swarming with COVID-19 or valiantly self-sacrificing beds to those “more in need.” A twinge of chest pain was discounted; he died upon arrival to the emergency department. A small bowel obstruction resulting in perforation turned catastrophic due to the delay in care.
In contrast to last fall when no visitors were allowed in the hospital, we now allow one visitor per patient. One woman sat with her dying mother last Friday and asked me, “How many people are in the same situation as me today?”
“Too many to count,” I answered.
Another family member begged for two visitors to be allowed. “That is 100 more people entering our hospital if we made that exception for everyone, and our Covid-19 percent positivity rate in this community is at an all-time high,” I explain. It was impossible, however, not to acquiesce as she looked up at me, her face streaked with tears, her husband fading, desiring some additional support, exhausted caring for their young children at home. This is no longer a disease of the elderly and infirm. My children are the same age.
I spend hours trying to help some families understand the nuances of medicine that have taken me years to master. But I can say one thing simply: We have no miracles to offer here. If you arrive in the hospital unvaccinated with COVID-19, regardless of your age, the effectiveness of the available medications for treatment pale in comparison to the highly efficacious vaccine.
There has been a distressing shift in confidence between some families and the medical team tending to their unvaccinated COVID-19 positive loved ones. A toxic seed of mistrust seems to have been planted and grown, watered with insidious misinformation rooted in misinterpreted studies, talk shows, social media memes, unreliable sources and casual conversations that are at best, misleading, and at worst, lethal.
My duty is first and foremost to do no harm. The ICU is not a buffet where you can pick and choose, it is a complex machine built to keep people alive, staffed by a highly skilled medical team. Yet, often the choice is to discount logic and dismiss our expertise. I wonder if the regret of a vaccine forgone is too much to bear. Still, I hope they know that we sit here together every day, fighting on the same side.
In my exhaustion and dark toils, I reach toward each struggling husband, wife, daughter or son with an open-mind. I welcome their advocacy. I wrap them with kindness, compassion, understanding and empathy. I listen. But I will always do what is right for their loved one and my patient. That is my duty.
But, please, know I am breaking when I stand in front of them, short of breath, running from one dying patient to the next short of breath in my N95, steadying my voice to deliver heartbreaking news. When I offer my condolences, the scorn of looks and blame in voices – for giving or not giving a baseless medication they demanded – is simply unbearable.
As of this writing, thirty percent of our county remains unvaccinated yet they account for 91% of our ICU admissions and 94% of our deaths. We have clusters of highly unvaccinated towns in our county driving our case positivity; Aztec and Farmington 41.6% and 59.6% respectively.
Many studies now demonstrate that OVID-19 surges are increasing the risk of people dying from other conditions while in the hospital due to the strain on the system. If everyone were vaccinated in our community, we would have 80 fewer people in our hospital today. We would not be overwhelmed. We would not be planning for allocation of beds and ventilators.
Come if you are sick, do not hesitate in fear or generosity (leaving a bed for someone else). Continue to visit your doctors. Stay up with your cancer screenings. Refill your medications and take them as prescribed. Seek out answers to the questions that have kept you from getting the highly effective and safe COVID-19 vaccination. Offer kind inquiries, exploration and empathic, productive information and resources to those who aren’t vaccinated.
Within these walls, we have said so many prayers, made countless phone calls, and have spent nearly two years shouldering the heavy burden of sorrow. Even when no visitors were allowed, no one died alone, because we were with them.
Regardless of what you choose, we will be here for you as we always have been. But we beg you now to choose you, your family, your friends, your community and us. And when you are driving by that message on the jumbotron, take a deep breath and think of me, of each of us, your healthcare workers. We are still here looking for those glimmers of light at the end of this tunnel. I will focus on them. I hope you will too.
Dr. Erin Philpott is a hospitalist at San Juan Regional Medical Center.