Direct Care for COVID-19 Patients During the Early Stages of the US Pandemic: The Uncertainty of It All.
The news media has been rife with data and stories about patients who have gotten COVID, but the inner monologue of the providers caring for these patients has been largely unheard. I was on the COVID service from the 11th to the 15th of March, relatively early into the Bay Area’s part of the pandemic. UCSF is trying to minimize the number of providers that are exposed to COVID+ patients, so we have been consolidating them all under one attending. I had five positive patients and discharged three of them to finish recovering at home. I was one of the first to volunteer to serve on this team, in large part because I am young and single, so the pathology from the infection and the risk of transmission to others are both less severe for me than it would be for someone else. Despite this, I still had a steady feeling of anxiety throughout my five days, because if I developed symptoms at any point, I would have to leave the workforce for two weeks. The guilt I would feel if that happened would be overwhelming.
We all received in-person training prior to starting service, and I had watched the instructional videos for how to don personal protective equipment (PPE) numerous times. It seemed pretty routine: wash hands, N-95, gown, face shield, gloves, enter. But what looked simple in the video was still a mess in real life. After gowning up, I might realize there was no face shield and would have to walk around the ER begging a nurse to find me one. Sometimes, the PPE was kept at the nurse’s station instead of the designated spot outside the patient’s room to prevent theft (yes, really). Even on my first day, we were told the N-95s were already running low, so I put on a powered air-purifying respirator (PAPR) for the first time. The helmet looks a lot scarier than it is, like something out of a post-apocalyptic movie like World War Z or Contagion. Using a PAPR added a layer of complication, because the gown goes on first, but the cord connecting the PAPR to its battery pack has to go underneath the gown. This required an awkward maneuver of snaking the cord over my shoulder, down my back and into the battery pack on my hip. But once on, it actually felt pretty nice as the continuous stream of air blew over my face, inflating the face shield in front of me.
Two days into my time on service, the CDC informed us we no longer needed to use N-95s or PAPRs for most patients. This certainly simplified the process, but the ever-changing guidelines also caused a general anguish over what provided the best form of protection.
Inside the rooms, I felt the distance between me and my patients. I listened to their lungs with a disposable stethoscope, which was one step above Fisher Price. I could barely hear their lung sounds, which seemed like a pretty important thing to hear when the primary manifestation of your patient’s disease is pneumonia. I felt like I was wearing too much PPE and simultaneously not enough. They could not see my facial expressions but I could see their fear, an asymmetric exchange of information. But in stark contrast to my face, my shoes and hair remained uncovered. I found myself wondering whether my shoes got contaminated every time a patient coughed.
The patients were getting no physical therapy while in the hospital since we were minimizing number of people in contact with them, so I decided to teach them the exercises myself. I sat down on my patient’s bed to teach him some leg exercises, and immediately thought (or maybe even said out loud), “Oh fuck,” as I realized that my gown did not cover the back of my pants. How much these things mattered, I don’t know, but that was exactly the point. Not knowing whether I was a walking vector made me hyperaware of every single thing I touched or sat on for the rest of the day.
Doffing the PPE was the most stressful part of the process. We are supposed to pull the gown forward off our bodies, pull the gloves off with it, and roll it up into one bundle, all while touching only the inside of the gown. Sounds simple, but what no one told me was that this flimsy yellow gown would cling to my clothes with static as I tore it off. We are supposed to pull our face masks and eye shields off from the back as well, but what happens when the ear loops for the mask get tangled up with your glasses and they come off too? And how am I supposed to take a helmet off without touching the outside? I felt like I was self-contaminating every time, and I ended up washing my hands between every step, three times more than anyone recommended.
Once out of the rooms, I shifted my concern to the worries of my patients’ families. Since they were not allowed to visit, patients’ loved ones were understandably very nervous and wanted a daily update. Both the patients and their family members had excellent questions that I did not know the answers to, not because I am uninformed, but because no one knows the answers and the data is changing daily. “Can I go back to my house, where half my children are positive and the others are negative?” “How long will I be infectious?” “Will I have long-term lung disease?” “Can I get re-infected?” These were some of the most common worries. While the Infectious Diseases specialists were following some of the patients, they also found themselves struggling to answer questions with so little data out there. In some cases, I knew more than the specialists, having been on calls with the CDC to exchange preliminary information.
In the end, I tried to answer their questions to the best of my ability, always with the caveat that things are continuing to evolve rapidly. I spoke with confidence to impart the reassurance they needed, but the only thing I was ever confident about was the uncertainty of it all.