Stories from a Pandemic: 4. Air
Synopsis
This week we discuss ventilator hacks, breathing tubes, search and rescue, and ministries of presence.
These voices come from New York, Colorado, Maryland, Indiana, Atlanta, and California, and include a family physician, nurse practitioner, veterinarian, medical student, two interns, and a hospital chaplain.
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CREDITS
Hosted by Emily Silverman
Produced by Emily Silverman and Adelaide Papazoglou
Medical Student Producing by Vishal Khetpal and Raphaela Posner
Audio Engineering by Jon Oliver
Original Music by Yosef Munro
Featuring the song “Lean on Me” by Bill Withers
Illustrations by Lindsay Mound
The Nocturnists is made possible by the California Medical Association, the Gordon and Betty Moore Foundation, and people like you who have donated through our website and Patreon page
TRANSCRIPT
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The Nocturnists: Stories from a Pandemic
Part 1 Episode 4: "Air"
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.
Emily Silverman
You're listening to The Nocturnists: Stories from a Pandemic. I'm Emily Silverman.
One of the interesting things about a pandemic is that it doesn't distribute itself evenly. There are hot spots and cold spots and these change over time. And yet, the diary entries that you're sending are still tie together really well each week.
I just got off a five day stretch in the hospital on our COVID service, where I faced a lot of the same challenges that you've all described in your audio diaries: figuring out how to provide care at a distance, suppressing the chronic fear and anxiety that comes with being exposed to this virus, and finding my rhythm as I don and I doff my PPE.
But for the past few days, one of the things that's really kept me going is excitement about sharing this episode with you. I'm really proud of this episode, which features voices from all corners of the country, including a veterinarian and a hospital chaplain. It's called “Air.”
Nurse Practitioner, New York City, NY
RINGING BELLS
New York City, Friday evening, April 10: this is how we salute the health workers and how we make it through our day.
This is Holy Week and Passover, and it's been quite a journey for me myself. Today, I was able to see several patients finally, after several days of being on the phone with IT, with symptoms of cough, fever, chest pain, nasal congestion, sinusitis, and triaged and helped them stay away from going to any other more challenged areas.
I’m new at this particular clinic. So going through all kinds of different emotions, from being grateful for my attending and the other nurse practitioner and at times feeling, “Wow, they might lay me off because I'm new and I'm not seeing as many patients.”
Or, on the other side of the fear is, “Wow, they're going to send me to the ICU, the ER,” because they've been talking about redeploying employees and just not having the training and the experience to really be able to be of help there, I don’t think.
So between feeling impotent and helpless and useless, to then feeling nervous and scared about, you know, what is the future. It's probably like how most of us feel.
The most helpful is two things every day. One is I listen now to the New York Governor Cuomo and his daily talk, because I feel he's a voice of sanity and really helps me stay grounded. The other part is at seven o'clock each night, me and my neighbors, we all go out on our balconies, ring bells, hit pots, you know, and sort of have this evening ritual like a lot of other New Yorkers on their block and in their apartments and houses, and salute the healthcare workers.
Every night the Empire State Building is lit up in red. It's a pumping heart. Those things help with the solidarity. I was able today to watch a little bit of the Good Friday service that they have at St. John the Divine, and that was moving and gave sustenance. I pray for everybody, every day, and maybe I was suffering, now it’s making us more sensitive and more aware for all the suffering we've been creating for so many other species with our species-centric consumption. And I hope and pray that this wake up call is going to help us live in a way that's more sustainable for everyone. That is my hope.
And I'm trying to figure out, how can I contribute to make that happen? And to me, I feel as a healthcare professional, that's what we should be thinking about as we go through this difficult time right now with our patients. How can we all contribute to really changing this way that's not sustainable?
So that's my prayer and my hope.
RINGING BELLS
Primary Care Doctor, Baltimore
This is Susan from Baltimore. Today is Sunday, April 12th.
It is a holiday for everyone to some degree or another. Today for many is Easter. For me, of course, it's Passover, and Ramadan also begins soon for those that celebrate that.
It's been a very challenging few days. I was going to be rotating out to working from home. First day of that was this past Wednesday. That was most interesting. I have never worked from home before. Telemedicine, to me as to so many other primary care providers, is a new thing.
So there were lots of challenges in general. It's kind of hard to do a good exam and diagnosis when you're seeing a person on a screen. Sometimes you can. Sometimes you can't. All things considered, it went well. And then the next two days for me were a religious holiday. I'm Jewish. So it was Passover, which meant for me no work, which in one way is good, because it's a disconnect, but in another way, in many ways, this year is especially bad. One, I didn't have contact with my patients because part of my observance is not to work, but more so, holidays are family time, and there was no family here. So like most of you, being bereft of family was difficult. We can blame COVID for that. Thanks so much.
And of course, personal note, my daughter–she's still in the hospital, but yesterday delivered a baby. Two pounds, one ounce, came out crying, Apgar's 8, 8. That's excellent for a 26-week-old gestational age baby. They are both doing well. They are still in the hospital, of course, and unfortunately, I can't get to see them. But technology does shine here. We've had a FaceTime visit, at least I have with my daughter, and she looks pretty good. Seen pictures of the baby.
So this new and different, challenging world continues. For me, as an outpatient family practitioner, it means more contact through telemedicine and less physical contact, which is very, very difficult. I like being with my patients. I like to be able to look at them up close and personal, examine them and touch them.
And this era of COVID-19, novel coronavirus, is just impossible. But we will all persevere.
Psychiatry Resident, Atlanta
I'm thinking about how things have been going during this–this time of COVID, um…one patient has particularly stuck with me.
It was earlier on in March during my ICU rotation, we had gone down to the ED to admit this patient who…he just–he really tanked. He, um, you know, was not much older than me, about my age. No previous medical comorbidities, you know, came in talking. Almost immediately had to be intubated.
And it just…things were never–things were never looking good for him. Um, you know, immediately–compliance physiology was awful, was immediately in ARDS. Constantly changing ventilator requirements. Some really scary compliance physiology. Increasing pressors. We were trying to throw him lines in this tiny, tiny room in the ED, all the while, you know, trying to make sure we had the right PPE.
I mean, it was–it was terrifying. And as the seconds tick by, you know, things are looking worse and worse. For this, for this guy, and, um…you know, I think, sometimes, in an effort to cope, um, when a case looks really bad, we kind of all say to each other, “You know, well…you know, this patient's going to die.” We know–we know that. Even–even when we're, of course, being as aggressive as we can be. There's this sort of knowing conversation or exchange you have with each other as providers. Um, the sort of sense you gain over time when a patient has hit a point of no return, when things become futile.
I also find those conversations–especially as a sort of green trainee early in my residency–I find those conversations quite striking, quite jarring. And I just, I really wanted to, you know, stop and take a moment to reflect on that…particularly because in this case with this one patient, he actually, you know, against all odds, ended up getting better.
And while most of the people during these past few weeks have not, in the, in a similar situation, he did. And I wanted to take a moment to reflect on that.
Pulmonary & Critical Care Physician, Indianapolis
I just got back from a long run on a really pretty day, and I opened my mailbox and found a letter inside. I thought it would be worth sharing, so I'll read it if that's okay. Wasn't in an envelope or anything. It was just folded in–in my mailbox. The only thing in there.
“Hello, Doctor. My wife and I live just south of you. I'm the guy with the machine shop lab we built here when we moved in four years ago. I'm a retired engineer who has designed and prototyped for medical instrumentation, mostly for a local lab a few years back. Nowadays, I build mostly model steam engines. Our next door neighbors just told us you were playing a part in the distribution of ventilators in Indiana.
If that's correct, it's a little ironic because I've been working on an emergency BVM microprocessor, which is…” Sorry. “BVM microprocessor-controlled-actuator in my shop over the past few days. That would be a way to deliver breath with a very simple device.
Unfortunately, I don't have enough time or critical components to consider this rush and never anything more than a science fair project. I did produce two working mockups, though. However, I really would like to help in some way, pro bono, of course, in fabricating, modifying or servicing specialty parts for medical instrumentation during these times.
For example, if Indiana is considering making some adaptive equipment to serve two patients with one ventilator, I might be able to help with machining parts. Is there any way I can be of help, no matter how small the project? Please feel free to contact me at any time. If this doesn't fall within your domain, could you please direct me to the appropriate person? Thanks for all you were doing in the medical field in these critical times. Signed, the sender.”
It's funny because…I am doing this–or I'm not. Helping support one of my fellows who is pushing forward with a lot of engineers to do split vent instrumentation.
And I just thought we were sharing this letter because…it is emblematic of a lot of the support that we in the medical community have received in the last few weeks as this pandemic has moved forward. So I just thought it was really cool, and I'm going to go down and knock on his door and stand six feet away and say, “Thank you,” and let him know how he can help.
Veterinarian, New York
I'm a small animal emergency and intensive care specialist for veterinary patients in New York City.
My brother works as an emergency attending physician in New York City as well, but with other species–the other species, human beings–and we talk every day. We talk about how he's keeping himself safe, what he's seeing. We used to talk about all the cases we would see at the hospitals, and compare whose job was harder and how we each would have managed our respective cases to see if we could do each other's jobs. But we really haven't talked about that anymore.
We just talk about what each of us is doing to help people. We successfully were able to donate all of our mechanical ventilators to the neighboring hospitals in New York City. The vents that veterinarians use are identical, for the most part, that they use in people.
And we, you know, through our network of hospitals, in my network, through my residency, which I also did in New York City, I was able to rally together all these ventilators. I think in total we had seven we were able to send out. You might say, well, that's seven ventilators. I think the hospital needs tens of thousands, or the city needs tens of thousands. But, you know, for anyone not medicine, everyone knows a ventilator can save a person's life.
And every little bit helps. We had a company come and pick up all the ventilators in the city. They drove around to all the hospitals that I helped organize, and they picked up all these vents and transported them to the hospitals where they're currently in use. My organization has donated some PPE as well.
It's hard to organize. Human hospitals need to vet what equipment they're taking in, need to make sure it's functional, and need to make sure they have people that can run the equipment. Need to figure out and transport it, and make sure they keep track of it so it can go back. After all, we, you know, we use ventilators for our own patients. And we made a collective decision that these are extenuating circumstances, unprecedented circumstances, that–that require us to to pick and choose humans over animals.
And I've had–I had a little bit of pushback, and I had some people reach out to me and say, “What about my pet? What about the animals that need vents?” And my answer is, “If your mom or your daughter or your sister or brother needed to go on a ventilator, and it was between that person and your neighbor's dog, I think the decision would be quite clear.” People always come first.
Medical Student, Denver
It's April 5th in Denver. This is Rachel, the medical student. You may hear Ruth the cat in the background. Denver is on shelter in place orders, but after you spend the whole day in the house, you gotta do something, so I go running through the streets of the city at night. I
t's a surreal time to be a medical student. And we're not able to be in the clinical environments right now because there's not enough personal protective equipment. I'm in this funny place where I'm transitioning towards residency, and there's a lot of paperwork to be done. And so I'm working through that. And I'm also talking to friends and family. And I don't think I've ever heard the word ventilator used so frequently, even in the ICU.
This is crazy, and it's crazy to hear the things people say about it. You know, to hear Andrew Cuomo talk about splitting ventilators–which is something that even the ICU physicians I know, the intensivists, don't talk about and haven't talked about until now and… To hear politicians talk about bag-masking patients.
And then to really get a sense that the people around me are tuning into that and they are looking up what it means, and my dad is calling me and saying, “What is this breathing tube, and what would it mean if I were on it?”
And–and I'm ending up having a lot of advance directive planning with people, and it's a really strange thing to be in a world where we are coming to terms with what the end of life looks like in this really big way, through the lens of the American healthcare system. And I don't know what the other side looks like.
The weather is getting nice, and so people are hanging out on their balconies and their porches and their lawns. And at night, you know, you kind of give the transition from barbecue to people out smoking in the evening as I go around the neighborhood at night.
And in a lot of ways it feels like a normal spring evening, like a really quiet one, but people are out in, you know, their family units and small groups that live together, but they're out. There laughing. There's the continuation of life, as it always was.
Which reminds me a lot of this experience I had before medical school, which was so traumatizing that I didn't include it on any of my applications because it was just a freak moment where I was a teenager and some friends of mine got seriously injured on a mountainside in early summer.
I was there. And so I helped as best I could as a teenager, and I didn't know any medicine, but we were up above tree line, with the wind going and the clouds passing over and raining on us. And I was worried that my friends were going to die, for an entire day.
And it was nightfall by the time the Rocky Mountain Search Rescue and the helicopters organized to get us off the mountain, which was just a miracle. And one of those things where I thought, that's the best magic trick I've ever seen…and kind of quietly propelled me towards medicine.
But at any rate, I was really struck when I was in the helicopter by the change in temperature of the wind that was coming through this little hole in the–the Plexiglas, I guess, beside me. It was freezing on the mountain. And within a couple of minutes we were down on the front range and it was an 80 degree summer night and nobody around me knew what I had just been through.
I had no idea, it was just like, the concept of it being a normal night, and warm and quiet and peaceful, was earth shattering to me. And I think that, I feel like I'm the person down in the valley right now, just sitting in a normal place and life almost–and a lot of my peers and colleagues are experiencing something that's just monumentous.
But if you're not right at the heart of that, it's really hard to grasp exactly what it is. And I know that we'll be working through that for a long time.
Hospital Chaplain, Gary, IN
I'm a hospital chaplain and I've probably been a chaplain for over 20 some years. I’ve worked in hospice, worked in nursing homes, worked prison, social justice, but right now, I'm a hospital chaplain, and I just got done with another shift at the hospital.
And everything has changed. Everything's, it's–so much of chaplaincy is about perception, so much of chaplaincy, it's not what people think. It's, it's not…it's not all prayers. It's not judging. It's not saving. It’s not taking attendance. Chaplaincy is what we call a “ministry of presence,” where we listen to the person–we're there for them and their spirituality and where their values are, whether it's a religion, whether it's nature.
But everything's–everything's gone now. It's so difficult because there is no perception. Your perception, those nuances that I would see when I talk with a patient, the way their eyes move, the way their hands move, their expressions on their face, just the way they sit, just the way they interact, that's all gone now. It's gone because I'm wearing a mask.
Trying to give spiritual presence when you're wearing a mask–a literal mask–is not real inviting. Shouting prayers from a doorway…it's beyond words! A couple of weeks ago when this started, a patient was in and they wanted prayers, but I couldn't go in the room because there's not enough PPE, which–which is, I find that almost ridiculous.
We're talking about–I have a mask. I have gloves. We're talking about a paper gown, because these are patients who weren't tested positive yet. So–so what's stopping me from my ministry of presence is a dollar store, paper tablecloth I could wrap around me as a shroud?
So instead of, I’m standing in a doorway and shouting, it feels like the Hail Mary at a patient. It's not chaplaincy to me.
It's so difficult because there's these rituals, the rituals of life and death, and at–even the simplest of rituals now, we can't do. Those simple things, the simple things of just being next to someone, the simple things of like putting your hand over someone, of touching a shoulder, of making the sign of the cross on the forehead, of anointing someone with oil–no matter what the religion is–the simple things of for certain religions of whispering in their ear at the moment of death, ritual washings.
All of those things can't be done now because I can't come in the room because of this disease.
And I'm not a martyr. I'm not a martyr. I don't want to get infected. Of course, I want to be safe, but–but part of me is like, I don't understand it. I found myself listening to someone talk about his 92-year-old mother who had died, and he talked about how she was still undergoing dialysis.
But this–this fear that gripped her: this fear of this disease. Just…this was totally paralyzing her. And when he took her to her dialysis, they wouldn't let him walk her in. For two years, three years, he had walked his mother into dialysis, and he had set her in her chair and, and he had, you know, gave her Afghan. And then he'd come back and he'd come pick her up. And this day he couldn't.
And after dialysis, the nurse called and said, “We've not seen your mother like this before.” She never made it to another dialysis. And he looked at me, and as he looked at me, he started talking about his faith, and he started talking about the songs and the hymns that he and his sister had picked out for her because she was a good church woman.
And they talked about the hymns and the services. And they, even at that hour of death, their faces started to, to lighten up a little bit, to think about that matter–to think about the funeral service she was going to have.
And then they stopped. And then they looked at me and they said, “We can't have that, can we?” And I said, “No, not now. Not now, but hopefully you'll be able to have it soon.”
There's just so much of chaplaincy, where there's so much where…It's like “distanced grieving.” We're grieving from a distance. Grief is hard enough.
Pediatric Neurology Resident, San Francisco, CA
PIANO MUSIC
I'm a pediatric intern in San Francisco. My husband, his co-intern, and myself got together yesterday to sing together.
We had to work some magic to get access to a real piano. We thought those songs’ lyrics were particularly fitting, especially given Bill Withers’ recent passing. This song is a message of love and support to our East Coast colleagues.
SINGING Sometimes in our lives, we all have pain. We all have sorrow, but if we are wise, we know that there’s always tomorrow. Lean on me when you're not strong, and I’ll be your friend. I’ll help you carry on. For it won’t be long til I’m gonna need somebody to lean on.
Please, swallow your pride, if I have things you need to borrow. For no one can fill those of your needs that you won’t let show.
You just call on me brother, when you need a hand. We all need somebody to lean on. I just might have a problem that you’ll understand. We all need somebody to lean on.
FADE OUT MUSIC