Episode 6: Space Oddity
Synopsis
The acute phase of the COVID-19 pandemic is over, but some things are here to stay. How have N-95s, face shields, gowns, gloves and ventilators inserted themselves into our everyday lives?
A nursing home doctor brings us inside a COVID-era home visit; a speech and language pathologist gets up close and personal with one patient’s mouth; and an ER resident reflects on the oddity of our COVID-era dependence on machines.
LISTEN
Contributors
This episode features the voices of: Claire Chuck Bohman, MDiv, BCC; Lori-Ann Edwards, MD; Allison Horan, MD, MSc; Lauren Klingman, MD; Laura Perry, MD; and other healthcare workers who wish to remain anonymous.
CREDITS
Host: Emily Silverman, MD
Podcast Producer: Adelaide Papazoglou
Associate Producers: Isabel Ostrer, Molly Rose-Williams
“Life on Mars” by David Bowie, performed by Almaz Dessie, MD
“Pandemic Theme” composed by Yosef Munro
Series illustrations by Nazila Jamalifard
Audio Engineer: Jon Oliver
Production Assistants: Hannah Yemane, Ricky Paez, Siyou Song
Support for The Nocturnists comes from the California Medical Association, the Patrick J. McGovern Foundation, the California Health Care Foundation, and people like you who have contributed through our website and Patreon page.
TRANSCRIPT
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The Nocturnists: Stories from a Pandemic: Part II
Episode 6: "Space Oddity"
Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Claire Chuck Bohman
I was in a patient room, visiting with a patient. We're speaking Spanish. It's a COVID positive patient and he's in a lot of distress, really suffering and struggling with his fear of death. And why did he get COVID? Why is he ill, you know, why did the universe let me get sick like this? As we're talking, I realized that I don't have the right PPE on. I'm, I don't have a gown, I don't have gloves. And then the team comes in and they're all speaking English. And they're like, "Okay, we got to turn him." And he's not really understanding what's happening. You know, he's right in this moment of realizing the meaning of his suffering. He's just like, right at that critical moment. I'm trying to support him in that meaning making at the same time, I'm feeling really anxious and worried about the fact that I don't have the right PPE on and the team is all kind of talking in English at the same time. And it's just like this whorl of anxiety. So then I realize that I need to close the visit. So we like miss the a-ha moment.
And as I'm leaving, I realize that my N95, it's like folded over in my mouth. Throughout this pandemic, I've had a lot of dreams about N95s. Most of the time, they're like falling apart in my mouth. And then I wake up choking on the N95 and coughing and it's, it's really hard to put my mask on the next day after those dreams. But in this dream, it wasn't falling apart. It was more like I was like, kind of like half eating it. And I'm outside of the, the room and I'm worried about the fact that I don't have the right PPE on and am I in danger? And do I need to report this? And who do I need to report it to? And I'm also worried about the patient because he just was like at this critical moment. And I had to leave him and I'm just kind of in a panic and there's people in the hallway and I'm embarrassed that I don't have the right PPE on and all of a sudden, the like dream changes. I'm at this like playground near the house where I grew up when I was a kid. And the whole dream kind of morphs and changes into something else.
Emily Silverman
You're listening to The Nocturnists: Stories from a Pandemic. I'm Emily Silverman. Connection. It's as basic to human beings as food and water. Without it, we grow dim. We close up, we get sick. This is true whether we're young as a newborn baby, or living well into old age. But COVID times has brought facelessness and disconnection into center stage. How have N95s, face shields, gowns, gloves, and ventilators inserted themselves into our everyday? This episode is called "Space Oddity."
Laura Perry
If you've ever tried to like FaceTime with your grandma, you sort of know what it's like to do virtual visits with an older adult. Let's say they have a rash, and I want to look at it. I would put the odds somewhere between like 5 and 10% that I'd successfully be able to look at the rash, over a video visit. I had one patient who had this, actually this is a good example, who had a rash in his axilla, his underarm. And his daughter, you know showed me over the video. And so I thought that just kind of looked like tinea or ringworm. And so I prescribed an antifungal but it just wasn't getting better and wasn't getting better. So after about two months, I went to see him. And as soon as I walked in the room, I knew, oh, this is pseudomonas, because it smelled that way.
I really strongly preferred in-person visits, I found the virtual visits really unsatisfying. Since we were doing this combo of in person and virtual, a lot of times I'd spent one half the day seeing patients in person and the other, you know, trying to get to the office in time to have a decent internet connection. But there definitely been some times where I've done like a virtual visit from my car, which is not the best, don't recommend that. The patients that I took care of got to be in our program house calls because they, for the most part had family members who were already caring for them. I had a few patients who lived alone, who were generally the patients who were doing the worst. But most of my patients had really strong caregiving setups. Typically, these were people who were really cared for and loved by their family and who'd somehow figured out a way to make it work. And those family members were terrified of COVID. And so what they did was sort of hunker down more. Not a single one of my house calls patients got COVID while they were at home. Several got it while they were in nursing homes, you know, for rehab after a hospitalization. But those were the only ones of my patients who got infected.
Sometimes before I meet the patient, I'll have a sense of what it might be like because maybe they've been a patient of one of my colleagues who would see them in clinic. But you know, typically imagine I'm walking up the front steps, lugging my very large bag, which has my laptop and charger and mobile hotspot and my stethoscope, my blood pressure cuff, my thermometer, my pulse ox, all sorts of phlebotomy equipment. Maybe I'm bringing a vaccine along with me so I've also got a lunch bag with an ice pack and a vaccine in there. A variety of papers. And this is in one of those sort of rolling suitcases that's half size. So I'm lugging that up the stairs, you know, and my territory was sort of the western and southern parts of San Francisco. So that almost always meant a full flight of stairs up to someone's house hoping that the doorbell works, ringing the doorbell, wondering who's gonna answer. Almost never is it the patient. Almost always, it's a caregiver, typically a family member. So I kind of walk in, you know, look around, where am I supposed to sit? Usually, you know, it's, it's sort of like being a guest but uh, oh, you know what a, a different kind of guest. And sometimes the family members would offer me coffee or food, that ended with COVID, of course. Sometimes there was a dog. Sometimes there was a psychotic family member. Sometimes there was piles and piles and piles of stuff. And you'd have to sort of navigate a circuitous route from the door to wherever the person was. Sometimes there were bugs. And then, usually, there was someone who was very grateful to see me. A lot of times I was seeing people who hadn't seen a doctor in a long time because they couldn't get out the house. Sometimes I'd sit on people's beds to examine them. A lot of times, someone would bring me a chair, sometimes I'd just crouch next to their bed.
And I was my nurse, I was my scribe, I was my phlebotomist. And, you know, then they'd want me to fix everything. You know, a lot of times by the time I would go to see someone, everyone was already sort of at their wit's end, the family and the patient themselves. And sometimes what I did was something little, you know just stopping a couple of medicines that were causing some side effects, improving a bowel regimen, disimpacting cerumen from someone's ears. I mean, that can't be understated, how much better you make someone feel by taking their wax out. But then I also had to be the enforcer, you know, asking family members to wear masks. It was uncomfortable. You know, because it's their home that I'm going into.
Stephanie
I am a speech language pathologist in the Bay Area and I have continued to see folks in their homes since March of 2020. During the pandemic, our biggest role has been with our trach patients who are coming home from the hospital with new trachs in place. And getting those folks set up with some speaking valves. And then are, of course, just folks with dysphagia, or difficulty swallowing. We had a staff meeting, sometime in the beginning, when, when the rules were changing, and, and the rule was, well, now every patient has to wear masks for the duration of the visit, they have to be masked. I gently, gently reminded folks that, I, 90% of my day is spent in people's mouths. I'm looking at their tongue and their teeth, and if they're managing their secretions. And sometimes I'm doing their oral care. And I'm feeding people and I'm trying to test their cough strength. I spend a lot of my time very close to people's airways, and I can't do it with the mask. So it's been, it's been a weird year.
I think back to a patient, this person was a trach patient who had a PEG feeding tube placement, and they were bed bound, and not really communicating at time of discharge home. So they were in the hospital for a very long time, they had an extended and complicated hospital stay. And the fact that they were even transitioning home was a big deal. My referral was for voicing, speech, and maybe down the line eating. So a speaking valve briefly, is a one way valve, looks like a little cap, that you put on to a trach. It lets air in but you can't breathe out. So if you have had a trach for months and months, it feels different, to say the least. It can, it can feel like you're, you're not able to get air or that you're not breathing, it can produce a lot of anxiety, and some people just can't tolerate it. The other thing is that when you put the speaking valve on, you're going to be able to feel more up through the larynx and pharynx of your oral cavity because you're pushing air up through that. So if there are secretions there, which there usually are, you're going to feel them. It's not uncommon to have a very deep cough or a few coughs when you first place the valve. You can verify this with your, your neighborhood speech therapist. So there was lots of things involved in getting this trial done. But we pushed and pushed and practiced.
And it was finally time. And it's super exciting when somebody is going to, is ready to have a speaking valve because they haven't been able to voice up until this point, they have had no voice they've been writing and nodding and thumbs up and thumbs down and using communication boards, but they have not been able to use their voice. And so it's really exciting for the patient. It's really exciting for the family. And because I know what's coming, it's really exciting for me. And so I am in head to toe PPE which includes a face shield. And I am placing this speaking valve and I'm turning it and the patient is sitting up and I say, "Okay, you know, tell me your name." And he inhales to give me a nice, a nice deep voice. And of course he coughs. He coughs so strong, the speaking valve flies off his trach and hits my face shield. There are also secretions that are coming from his trach and there are a few secretions on the actual valve that hit my face shield. And I, everything was fine. He was fine. We put the speaking valve back on. He tolerated it wonderfully. But I just couldn't help in that moment think, how on earth and why on earth did we ever do this without face shields? This, this is wild that this was something we ever considered normal of placing a speaking valve, being super close to somebody's airway and having things flying off possibly. If things go back to quote unquote normal I'm going to have to keep this face shield for speaking valve trials because there's no way I'm going to do this without a face shield now. The patient ended up doing very well with the speaking valve. And unfortunately, they transitioned to a different service area so I did not get to see the process all the way through. But I do know that at the time of discharge, there was a decannulation appointment scheduled, which means that the trach was going to be removed. So that's, that's one of many memorable pandemic stories I have.
Allison Horan
COVID is, is debilitating for psychiatry. The ways in which I've really felt the strain is in what it means to wear a mask when you're treating someone psychiatrically. In psychiatry, the medications you prescribe are just the tiniest piece of the puzzle. So much of the work comes from being able to be with someone in the darkest of their despairs. You know, most people who are admitted to an inpatient psychiatric facility are in a really rough patch. There's a lot of therapeutic power and being able to just be with someone, but so much of that is being able to connect using our faces. One of the greatest tools we have in psychiatry is, is our body language in our faces. And to have our faces covered, it makes connecting with people much more challenging. You know, when you walk into a room with a new patient who you've never met, right, and someone who is inevitably, in a deep amount of pain, you start gathering information from that person the moment you walk into the room. In how their face and body responds to your presence in the room, the degree of eye contact they make, the way they express when they're speaking to you, the words they're using, the, the, the volume of their voice. All, you know, all of these kind of just like subtle cues that you can feed off of to, to one both, like start like matching and working with that person and starting to make them feel comfortable, but also just getting a diagnostic impression of what flavor of pain they're in. And of course, right, there's, there's the obvious fact that like, when you're wearing a mask, the patient can't be reading off of you and you can't be reading off the patient as well.
I find myself having to ask people to repeat themselves more often, it's like, often harder to hear people. Or like if someone's manic, and they're, you know, they're really hyper verbal, and they're wearing a mask, it's so hard to understand what they're saying. And the therapeutic rift, you know, is just broadened every time you say, "I'm sorry, I didn't catch that. Can you repeat yourself?" You know, all of these sorts of, where they're like, "No, I can't repeat myself." Like, and I would be feeling the same way, like fuck you, like no. And so, you know, there's these far more like physical limitations when there are masks involved. And not to mention, you know, sometimes you know, you have people who they're very psychotic and they have, you know, very severe mental illness going on and they're not wearing masks and are, you know, are upset by being asked to wear a mask and there's additional rifts. And, you know, I've, I've had patients terminate interviews because I've, I've asked you know, you need to put your mask back on and they're paranoid and trying to make sense of why it is that everyone's wearing masks. It can be really difficult if you're amidst any sort of psychiatric episode. But then like I, I hail the mask right? It's like this blessing and this curse. We need the masks I, I tout the mask, I love the mask and I hate the mask. It's, it's both.
Stephanie
Wearing all the PPE has changed the way I interact with patients and, and I think the way they view me and interact with me. I am in an N95, a face shield, a gown. I wear glasses as well. So sometimes I'm also in glasses with the face shield with the N95. Whether I'm a nurse or a physical therapist coming in, we're all in the same PPE. It's hard to tell us apart. You know, we, we don't look like people and we don't look like caregivers. It's almost like delirium inducing. Having these spaceship people come in and ask you kind of the same questions every single visit in our crazy gear before we even sit down to do our, you know discipline specific tasks.
Laura Perry
Are you delirious? I think I am. To answer the question of what the COVID nursing home is like, you have to know sort of what's a nursing home like. It's not like the hospital and it's not like the clinic at all. The closest thing I can think of is, it's a little bit like a college dorm, where you have these, you know, rows of rooms with people sharing space. But imagine if the college dorm instead of being filled with, you know, horny 20 year olds was filled with people who have the coping skills and ability to understand as young toddlers, but the bodies of someone in their 80s, who's had a lot of stuff happen to them. Usually, a nursing home is filled with a lot of activity. You know, I think about the nursing home where I trained. And, you know, it would always be filled with music and the visiting dog, and you know, people eating ice cream as a bribe in exchange for taking their medicine. And there was a lot of chaos. I trained on the unit for people with severe behavioral disturbance. And so there was always one woman just sitting in her wheelchair right next to the bathroom, just screaming out, "Help! Help!" over and over and over again, and then going back and forth to the bathroom probably, you know, 10 times an hour. No, because no matter what, no one could figure out what it was that was bothering her so much. So there's a lot of chaos. But there's also a lot of fun and, you know, drama, you know, the same way you'd see in the cafeteria at an elementary school. Some of those same dynamics are present in the dining room of a nursing home, you know, "you can't sit with us," type of nonsense. Every so often people throwing stuff at each other. And I loved it.
So then COVID. Now it just feels like a prison, where everyone has to stay in their rooms. None of our folks are good about wearing masks. And I think despite everyone's best efforts, everyone's gotten a little stir crazy. Everyone's a bit depressed. The COVID nursing home where I worked in the spring, and the summer was a rehab facility or rehab unit within the nursing home. Mostly I was sort of seeing what could patient tell me about the hospitalization? How are they organizing their thoughts? What did they remember? Because if someone arrives at a rehab unit still delirious, which was common, it's going to be really a lot harder for that person to reintegrate into the community, if they don't even know what happened the entire time they were in the hospital. And I just kept thinking about that on a population level scale. First of all, we have a huge overabundance of providers to do acute care and hospital medicine, and a real lack of people to do the much harder, follow up long term stuff. And especially the things that make people well, after they've been through such a traumatizing event, are not medical, really. It's listening and helping people get good sleep and helping them make sense of things. And I just see this ever growing wave of people who are going to need this intense care that we don't have the ability to provide in this country and it was pretty overwhelming. I, maybe, that was where I felt the most like I was drowning was when I was really contemplating that a lot.
Lauren Klingman
Towards the beginning of COVID, one of the hospitals I was rotating in, they were trying to figure out how to best accommodate all the patients because we all know there are only so many negative pressure rooms in many of the hospitals. And there was this red, like duct tape piece of line that extended six feet outside of a patient's room and you were allowed to cross the line if you had your full gear on, and you weren't allowed to cross the line if you didn't, and to me I was like this is, this is almost like, it was not comical, COVID's not comical. But that specific little incident almost felt like part of a play where like you were like hopping over this red line. And I was like, this does not feel like this is a real situation or a real scenario that I am experiencing.
There's a woman, and she, I was in her room, and she had so many just tubes connected to her and this machine that's breathing for her. And I'm sitting there all gowned up. And I had her daughter on the phone with me. And I'm holding the phone up. And she's having a conversation with her mother. Saying how strong she was, how much she loved her how she'd been through all of these experiences and how she was going to make it through this. And on the other end of that is this woman who truly does have kind of tubes connected to her and through these tubes is flowing, just this medication that is prolonging and trying to save her life. And she's, she's just kind of splayed there with a breathing tube down her throat and all these machines are pumping her as her daughter is talking about these human experiences that she had. And it was just kind of a moment where I stepped back. And this woman almost looks more machine than she does human at that time. And yet, there's one of the most beautiful kind of love poems or love, love narratives that I've heard come out of somebody else's mouth towards her. And it was just a moment where it did, it did not feel real. It felt like this was like performative or I was in some kind of bizarre, futuristic piece where you have this kind of half machine person getting pronounced love by this other person on a machine.
Lori-Ann Edwards
In the peak of the pandemic, being intubated was the last resort. As anesthesiologists, our presence at the patient's bedside would be met with mixed emotion. Just the thought of losing control of such a basic human function - breathing. The reality was that in our effort to help we could possibly harm. It was about 2am. And the operating rooms had been quiet. A page goes off overhead, followed by my pager, my heart was racing. I knew what this meant. I was being summoned to intubate a patient that was COVID positive. I gathered all the equipment that I would need, and basically ran to the ICU with my colleague. I could see the patient behind the glass doors, struggling to breathe, using all of the muscles that he could possibly use, just to get air in and out of his lungs. I could hear the alarms blaring, blaring and I just knew this patient was in trouble. I've done hundreds of intubations. It's become second nature to me like almost a dance routine. But every COVID intubation presented this unique challenge. Before me was a patient who, after sedation and muscle relaxation would desaturate in seconds. No amount of mask ventilation could help them recover to a reasonable saturation for you to even try to intubate again. That first attempt just had to be successful. I took the deepest breath that I could take with an N95 pressed on my face underneath a face shield, focused on my dance. I held the oxygen mask tightly to his face. He grabbed my hand and he said to me, "please make sure that I wake up to see my baby girl grow up." I said something that I always say, "we're gonna take good care of you. See you later."
Almaz Dessie
(Singing) It's a God-awful small affair / To the girl with the mousy hair / But her mommy is yelling, "No" / And her daddy has nowhere to go / But her friend is nowhere to be seen / As she walks into a sunken dream / To the seat with the clearest view / Now she's hooked to the silver screen / But the film is a saddening bore / As she's lived it ten times or more / She goes spinning the eyes of fools / As they ask her to focus on / Sailors fighting in the dance hall / Oh, man, look at those cavemen go / It's the freakiest show / Take a look at the lawman / Beating up the wrong guy / Oh, man, wonder if he'll ever know / This is the best-selling show / Is there life on Mars?
Emily Silverman
That's our show. The Nocturnists is produced by Director of Story Development, Adelaide Papazoglou. Associate Producers Molly Rose-Williams and Isabel Ostrer and me. Our Student Production Assistants are Hannah Yemane, Ricky Paez and Siyou Song. Original theme was composed by Yosef Munro. Our Audio Engineer is Jon Oliver. And our illustrations are by Nazila Jamalifard. Thanks to pediatric emergency medicine doctor Almaz Dessie for her beautiful rendition of David Bowie's "Life on Mars" on voice and piano. Our Executive Producer is Ali Block, our Chief Operating Officer is Rebecca Groves, our Admin Assistant is Suparna Jasuja, and our Social Media Intern is Yuki Schwab. The Nocturnists is made possible by the California Medical Association, a physician led organization that works tirelessly to make sure that the doctor patient relationship remains at the center of medicine. To learn more about the CMA visit cmadocs.org. Support for The Nocturnists also comes from the Patrick J. McGovern Foundation, the California Health Care Foundation and people like you who have contributed through our website and Patreon page. Thank you for supporting our work in storytelling. Join us next week as we use our collective memories to piece together how this all began and talk about what it's done to us. I'm your host, Emily Silverman. See you next time.