It was my sister’s suicide that forced me to acknowledge the reality of my childhood.
It was Dr. Breen’s suicide that forced me to acknowledge the reality of my ER.
The question then becomes: What do you do with that insight?
Fail, fail, fail, fail, succeed
Monthly Archives: April 2020
Pandemic Phase II (Part 1)
In phase I of any emergency, you don’t overthink – you just respond. This is the part where you are focused on surviving and performing your job, and if you’re well trained you go on automatic pilot. If you overthink you won’t be able to function because you’ll be paralyzed by fear.
So you wake up, put on your uniform, and go to work. Then you come home, go to bed, and get up and do it all over again. This goes on as long as necessary until the emergency is resolved. Whether you’re a soldier in a war or a nurse in a pandemic, you do what you’ve trained for.
Then at some point, the initial emergency is over, but your brain doesn’t understand it yet. So there’s a period of time where you’re a little lost. The pandemic/war analogy is a good one, because in both you know you could die at any time. In both, you see so much death that you become numb to it. In your world, you’re either alive or you’re dead. Your lizard brain has been in fight mode so long it doesn’t know how to turn it off and return to normal.
The really fucked up thing about the viral pandemic is that you know it won’t end until there’s a reliable vaccine. So this could go on for years. It creates an untenable state.
Soldiers are trained for the chaos of battle. Emergency nurses and doctors in a first world country are trained to respond to mass casualty events, but they expect the supplies they need to respond will be there. When they aren’t, it creates a powerful internal trauma. They begin to feel helpless yet are still expected to do their job, so that’s what they try to do. There is not a single colleague I am aware of that didn’t feel like they wanted to be there for the sick and for their peers.
Right now, for the moment, in NYC it appears to have plateaued, so for the first time there’s a pause to reflect. But your brain has trouble switching into reflection mode because it still thinks you might be killed at any moment – and truthfully, it’s right.
But now in Phase II, you begin to reflect on all of the first responders who died, and it’s overwhelming. There are the deaths from the disease, and then there are the suicides from responders so traumatized by what they saw they couldn’t bear it.
And while you’re trying to put your prefrontal cortex back in charge, you realize that as soon as the quarantine is relaxed, it’s all going to start up again. And if you didn’t get sick, you have no idea whether your body built up any antibodies to protect you, so until there’s a vaccine your brain has to stay in fight mode indefinitely.
A couple of days ago one of my younger peers who has a military background and took part in active combat was in the locker room getting ready to go home. Casually, while getting his gear together, he said something that stopped me in my tracks: “This is scarier than anything I saw in Afghanistan.”
It’s going to be a long road ahead.
RIP Lorna M. Breen, MD
The first time I met you I was so intimidated. A new ER nurse who felt like I knew nothing, working with the medical director of an ER that was part of a well-respected NYC teaching hospital. I was eager to learn, and you were imposing but patient in teaching me, never making me feel stupid because I didn’t know something. And there was so much I didn’t know. I came from a med-surg background, which I would soon learn has very little overlap with emergency medicine.
I’d always wanted to be an ER nurse, but right out of school it seemed crazy to go into that environment without some experience, so I worked for four years with stroke and traumatic brain injury patients before finally getting my first ER job – where I ended up staying for ten years.
I had the privilege to work with you as an ER doc and then as a friend. You were always there to listen, teach, and mentor me. When I became focused on implementing a new program for a nursing procedure in the ER, your support and guidance allowed me to start and eventually write a new hospital policy supporting this change, something I would never have been able to do without you. In fact, my whole grand idea came from a code I did with you where you asked me to do something and I didn’t know how to do it. I was determined not to let that happen again, and you patiently supported me as I struggled years to see it through. When I finally succeeded you just smiled as if you knew I’d get it done all along. I was never quite that sure, but you gave me confidence.
Your door was always open, and whenever I spoke you would look at me intently like whatever I was saying was the most important thing in the world. Invariably, within minutes whatever problem I was struggling with would be solved. You always seemed like the smartest person in the room.
I remember hanging out with you last year at our annual ER party, laughing and having cocktails on a boat we’d all rented to cruise around New York’s harbor. You seemed so happy to be with your crew, the nurses and all the rest of the staff who make our ER run. You were our boss and we wanted to make you proud.
You will always be in my heart, and I wish you knew how many lives you made better.
RIP my dear friend and esteemed colleague. You are gone but will never be forgotten. I wish I could tell you that as devastated as our ER was by the COVID pandemic, it would have been much worse without you at the helm.
An Immensely Tragic Day in my ER
It’s late after a long, emotional, and disorienting day in the ER. What I want to write is going to require some thought and time, so it will have to wait until tomorrow.
Suffice to say, there will be a lot of casualties and PTSD after this acute phase ends.
I guess it’s beginning now.
You Think You’re Getting Off Easy?
Not so fast buster – there are some things you can’t unsee. You might be thinking I’ve got this shit covered but boy would you be wrong.
Things have a way of surfacing in the most inopportune times. You might find yourself inappropriately emotional and wonder What’s going on?
What’s going on is simple. You can’t keep pretending you’re invincible forever. That 800 pound gorilla you think you can keep ignoring? I’ve got news buddy.
He’s going to kick your motherfucking ass.
It Exploits the Weak
That’s what the virus does – it finds the weakness in everything. Your immune system, the moment you let your guard down. Then it moves in.
Our healthcare infrastructure; it looks for its weakness and exploits it. The impoverished, the uninsured, the unhealthy. Finding holes and systematically breaking them down.
It exploits the ER’s weakness – its chaotic environment, its disorganization – and methodically breaks the whole thing down.
Weak leaders and the weak minded – dropping them in one fell swoop, like taking candy from a baby.
Unprepared virologists and infectious disease experts, made to look like bumbling school children.
Helen Ouyang said it best: It does what it wants.
The Setup
He didn’t see it coming – no one ever does. Sitting there in the clothes he thought made him look good, but I guess that’s what we all do. We never see ourselves the way other people do. Why is that?
It all made perfect sense to him, at least the way she told it. Her eyes never seemed to lie, and god knows he wanted to believe her. But men are such saps, always falling for the dumbest shit. Especially the dumbest shit – they just need to want it to be true.
That’s how life works, isn’t it? We all tell ourselves the story we want to believe, even if it’s one where we lose. All he knew was that right now, he wanted to believe more than anything.
He’d been around though. Enough to know he was probably wrong.
But what’s the harm in pretending?
Another Powerful COVID Diary Written by a Colleague
Maybe I’m prejudiced, but I think ER docs are a special breed, and I have been fortunate to work with many brilliant ones. Jason Hill is a good example; smart, compassionate, quick to respond, and always willing to teach.
Buzzfeed just published his COVID diary – if you want to know what’s been going on in NYC ER’s (more specifically mine) for the last six weeks or so, this is a good place to start.
It’s been an honor to work with all of my colleagues responding to the pandemic. Docs, nurses, EMS, PAs, NPs, ERTs, respiratory therapists, radiology, security, nursing management, volunteers, and everyone who came from other areas of medicine and nursing to help. I am humbled by their strength.
I will forever mourn all of those we lost.
Movies That Made Me (Part 2): King Kong
Although I don’t want to do this in any kind of chronological order, the original 1933 version of King Kong, directed and produced by Merian C. Cooper and Ernest B. Schoedsack, absolutely blew my mind when I saw it on my parents black and white TV as a young child. It’s certainly one of the first movies I can remember seeing, so I’m guessing I was around four or five-years-old at the time.
Jesus – I’m going to sound fucking ancient here, but this was one of those films that would be shown once a year on television (I have no idea why). I think it goes without saying – after the first time, I would do my best to never miss it.
At first, I probably thought it was real, which only added to its appeal. A giant gorilla rampaging in NYC! Tossing around subway cars like toys! Crushing people underfoot! Ripping what looked like some kind of dinosaur’s head apart on Skull Island! Throwing men around like dolls! Seriously – I thought it was the coolest thing in the world and was one of my first experiences of the power of film.
Of course, at some point, I realized it wasn’t real – but that didn’t diminish my love for it; instead, I became even more fascinated. How was this possible? This would have been in the early 1960s, so it was almost 30 years old then, but its age gave it an even weirder sense of other-worldliness like it was some secret artifact from a time when these things really happened.
I could have given two shits about Faye Wray or any of the other people in the film for that matter. For me, it was all about Kong and the world he inhabited, whether on Skull Island or in NYC – both of which seemed pretty exotic. When I finally realized it was done with this thing called stop-motion animation, I became obsessed.
Willis O’Brien was responsible for creating this world, and the job he did with Kong was quite a magic trick – somehow, through his mastery and vision, he imbued the 18-inch rubber creature with a metal armature covered with something that looked like fur into a living thing that had emotions. The final sequence where the single-engine airplanes shot him down off the Empire State building was heartbreaking.
It was one of the first times I realized what assholes people could be.
Movies That Made Me (Part 1)
The title of this post is cribbed from a podcast of the same name by director Joe Dante and screenwriter Josh Olsen. The premise is brilliant: each episode has a guest who gets to choose the topic, which of course, is about films that influenced them. It can get pretty specific; I seem to remember an episode where Ilianna Douglas listed her favorite wide-angle shots in film history.
But it’s usually just a list of the guest’s favorite movies, often with a theme. So during the pandemic, I thought I would write a bit about the movies that made me.
Hopefully this will serve several purposes, chief among them is it will give me something to write about besides this fucking virus. And maybe, if anyone’s reading this, it might spur you to check out a movie you otherwise would completely miss.
As Joe and Josh often point out – although we now have easier access to films than at any other point in human history, we no longer have any context for understanding or appreciating them. Amazon Prime is a great example of this. You can find a lot of great films there, but if you don’t know anything about them, they just look like random titles.
Before VHS, there were only two ways to see a film – ever. You either saw it in a movie theater, or, if it was old, you watched it on TV. That was it. So if you were really into it (i.e. you’d read books about movies), they would become these legendary things that you’d build up in your mind..
VHS changed all that. Sure, in the 1970’s there were “Midnight Movies” that played cult films at midnight on the weekends at your local movie house for stoned teenagers, or if you lived in a college town (or Manhattan) there were “Art House” movie theaters, but it was the humble VHS tape that created movie rental stores where you could rent a film and go home to play it on your shitty TV.
The cool thing about the idea of “Movies That Made Me” is that they are not lists of the greatest films in history. Some of them are, at least to me, but I fully acknowledge that many are a matter of personal taste. Regardless, they are all special.
So without further ado – tomorrow I will post my first one. I have no idea what it will be, but that’s part of the fun.
See you then – stay home and stay safe!
Anecdotal NYC COVID Update
Things definitely seem to have plateaued, at least for the time being in my ER. We also have the added bonus of nurse travelers (contract workers hired for a limited time), brought in to fill low staffing caused by nurses out with the virus.
There’s still no testing unless you’re out sick with COVID like symptoms, and serology testing hasn’t yet begun. Although I am particularly curious about the latter, I realize that testing positive for antibodies is still not well understood. It would certainly seem to indicate that exposure to the virus had triggered an immune response, but whether that means one has inferred immunity isn’t clear.
Regardless, the message here seems clear: Quarantines work – stay home!
Addendum: NYC has seemed particularly compliant with the quarantine, which I suspect has led to this apparent plateau. This could all change with relaxed social isolation restrictions.
Nothing to See Here Folks
That’s right – everybody keep movin’.
Someday this all will just be a dim memory.
I Thought I Was A Good Nurse, but COVID Changed all That
I hope this is temporary, but I not only don’t feel like a hero, I feel humbled and inadequate as a nurse caught in the middle of this fucking pandemic. I feel hard and numb.
I really love the profession, but now, after 14 years, everything has changed. I felt helpless trying to administer care to the sick and dying. We were just so unprepared – it’s going to be impossible to ever think of my profession and hospital in the same light again.
It all just fell apart – the docs, nurses and techs showed up and did their best, but we were quickly overwhelmed, and well into the outbreak had inadequate supplies to protect us. At its peak we ended up running out of pretty much everything needed to give competent care to our patients and to ourselves. So many frontline healthcare workers ended up sick – it’s painful to think about. I can’t let my mind honor the ones who died yet, because I’ve got to keep showing up – focusing on my mortality would only prevent me from doing that.
It’s difficult to describe how painful it is to try to do your job saving lives and realize you’ve run out of basic supplies. I’m talking about things like medicine and functioning equipment, or not having a plan on how to staff an overwhelmed ER when it was obvious that workers would succumb to the virus – and this from a hospital with deep pockets. With fair warning.
You can go through life thinking reality is one thing, then suddenly find out it’s something else entirely.
It’s a rude awakening.
I’ll eventually bounce back, because that’s who I am. I’ve overcome many hardships in my life and learned long ago I’m resilient.
I’m not so sure about everyone else.
Essential Reading
Helen Ouyang is one of several brilliant ER docs I’ve been fortunate to work with over the years. She also happens to be a gifted writer and just published a piece in the New York Times titled “I’m an E.R. Doctor in New York. None of Us Will Ever Be the Same.”
The subtitle is “A Covid diary: This is what I saw as the pandemic engulfed our hospitals.” When I read it, I thought this is the article I’ve been waiting for. It’s a firsthand account of what the pandemic did to the hospitals of NYC, and the human devastation it wrought both to the population and the frontline healthcare workers who did their best in a hopeless situation.
It’s impossible to tell anyone what happened for many reasons. How, no, why would you ever try to describe a mass casualty event to anyone? We don’t even talk to each other about it, and we sure can’t talk to our loved ones – because they are already scared shitless.
Of course she’s right, none of us will ever be the same. It’s going to take some time to see how that change will manifest for each of us.
One thing’s for sure: There will be a reckoning.
Important Marker
Today, for the first time in a month, I actually triaged several patients with no COVID-like symptoms.
This created a new kind of problem: Where do you put patients without COVID in an ER filled with them?
And does this mean that they have already had the Coronavirus, or are they just symptom-free carriers?
Regardless, it’s a significant change – things, at least for the moment, are starting to turn around.
It’s a tiny step toward recovery – but at this point I’ll take anything I can get.
So there’s that.
Mind Fuck
It’s like going into one of the hardest jobs you can imagine, for 12 and a half hours straight, where you are desperately understaffed, everyone’s working to the breaking point, and you may or may not even get a break to eat. All while you’re trying to take care of sick people but way too many of them are dying.
Dying from this potentially lethal, brand new virus.
Oh, and by the way – if you let your mind go there, you realize that the longer you do this the higher the odds are that you’ll get it.
But let’s be clear: Most people who are COVID positive don’t die – and they don’t need to be hospitalized. In fact, according to the CDC, there seems to be evidence that “as many as 25% of people infected are asymptomatic.”
So that’s what you keep telling yourself.
Courage
”Courage is not fearlessness; courage is what soldiers exhibit when they charge into battle despite their fears.”
– Nicholas Kristof, “Life and Death in the Hot Zone,” New York Times, April 11, 2020
If you want to see what a NYC ER looks like in the middle of this, Nicholas Kristof has produced an enlightening six minute video that can be seen here. Obviously, things have been scrubbed for public consumption, but I applaud the bravery of this hospital for allowing this.
Every healthcare professional who keeps showing up to work in COVID-19 “hot zone” outbreaks exhibits courage.
The question is: At what price?
I see it in the eyes of my colleagues – docs, nurses, ER techs, security, administration. It’s both inspiring and heartbreaking at the same time.
I keep thinking – How long can they keep it up?
Spent
Nothing left in this bank except sleep.