The Comfort We Had Is Not Here I of III:
We Have No Treatment

after Anand Swaminathan, MD [ June 16, 2020 ]

On March sixth, one of our docs got sick, 
in the ICU for about a month. A week later, 
it became real for me. The first couple of shifts, 
people looked well: cold symptoms, coughs, fevers. 
We just tried to get them in and out. We had 
no testing, no treatment – we still don’t 
have any treatment – so we just tried to get them out 
before they got sicker or they got us sick. 
The main concern was us not getting sick, 
because we had seen that.

Then I worked a string of nights in mid-March 
and between the first and second nights, 
everything flipped, every patient was extremely sick. 
We went from 60 percent occupancy to almost 120 
overnight; the emergency department filled. 
We didn’t have enough nurses, they’d gotten sick. 
We didn’t have enough beds to see patients. 
We had very sick patients in the waiting room. 
We were scrambling, trying to figure out 
how to get the sickest patients back and cared for
almost all of them, men. I’ll say half were young, 
most overweight, with diabetes, high blood pressure: 
people who, the day before, worked hard labor jobs.

St. Joe’s is not a county hospital, but basically we are. 
We’re the fourth busiest in the country. Most of our patients 
have minimal or marginal insurance. Most of Paterson 
is African American and Hispanic; these men were working 
construction, loading and unloading trucks, 
laborers who went from a cough to being critically ill. 
I’ve seen patients that sick before, but never that many 
that sick at once, then over and over the next six weeks,
12-hour shifts of the same thing. I’m still dealing with that.
I saw a psychologist for the first time last week.

I think the youngest patient I had was 19. You’d see 
young people, people younger than me – I’m 43 –
go from being able to speak, to five or ten minutes later 
intubated, an hour later, multi-system organ dysfunction. 
Usually we intubate a critical care patient, and they go up 
to the ICU, but because the hospital was full, 
they stayed with us. As emergency physicians, 
we’re not used to seeing 20 or 25-year-olds slowly 
decompensate over weeks. Day after day, 
we’d come back, knowing we could do nothing. 
We have education on how to care for a trauma patient. 
We’ve seen mass casualties, we’re prepared 
for that: you get all the patients in at once, and 
it’s exhausting, but in six or eight hours, you’re done. 
We call the covid pandemic a “slow-moving 
mass causality incident.”

We remember our bad cases more than our good; 
that’s a human thing, and there were so many bad cases. 
On an overnight shift around five or six o’clock in the morning, 
notification came in on a patient who was older, extremely sick. 
By then we were three or four weeks into our surge, 
so we knew older patients who had medical issues, 
who were that sick, were going to die. Nothing we could do. 
We knew that we had two or three ventilators left
in the whole system. Is intubating this patient the right thing
to do when five minutes later I might have a 20-year-old
come in who’s really sick, but has a chance 
for a better outcome? We had to make that decision 
for a theoretical patient who could come in next, 
or who would never come in.

We had that conversation, as faculty and resident, 
while supporting her breathing, making her comfortable: we know
she’s not coming off a ventilator, we know she’s going to die
in the next couple of days, we know that it’s going to be 
a horrible death, because we’ve seen it. So, we said
we shouldn’t intubate that patient, but that’s not how 
it’s supposed to work. We’re supposed to consult a team 
that decides, because as care providers we’re too close.
In the middle of the night, we didn’t have that system in place,
so we made the decision, called the family. Of course,
the next question is, can we be with her when she’s dying?
No. And she was too sick to talk, so we got a video phone
so they could see their grandmother. That sticks in my mind, 
because it was the right thing to do, but it wasn’t the right way.
No way to do the right thing, so we did the best we could. 
There were a lot of cases like that; that was just my first. 
We did our best, but what that patient needed, what that family
needed, we couldn’t give. Helplessness—overall helplessness—
we felt, and now that we’ve passed our surge, 
we still feel as physicians.

JULIA SPICHER KASDORF