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| Fighting the virus requires a dual duty: keeping apart and staying together. |
Almost certainly, the density of New York City has played a major role in the spread of the coronavirus. While it circulated among us, millions of New Yorkers touched the same subway turnstiles and sat at the same park benches.
Now density is becoming a problem again as we try to discharge recovering covid-19 patients from the hospital. In other places, a recovering patient might return to a multistory or multibedroom home; in New York City, you’re lucky if your bedroom isn’t also your living room. People worry about going home because their breathing might worsen, but also because they might infect their loved ones.
We do what we can to prevent homebound patients from spreading the virus. We advise them to wear masks, eat separately, sanitize sinks and toilets after each use. When the risk to family is especially high, we try to arrange a stay at a hotel; if patients need extra help—with bathing, say, or eating—we might transfer them to a rehab facility that accepts covid-19 patients. If there is no other option, we simply house them in a separate wing of the hospital. Rounding on the wards, some of us wonder if the city’s density means we’re in for another covid-19 spike after this one subsides. Will we soon see our patients’ brothers and sisters, their sons and daughters?
Density is also becoming a problem in the hospital. The number of doctors and nurses we need has grown, but the space in which we work has not. In some workspaces, we sit closer than couples at a buzzy downtown restaurant.
“Every day I come to work expecting to get sick,” a colleague tells me. “When I don’t, I think, ‘Maybe this P.P.E. is actually working.’ ”
Both to increase efficiency and to prevent ourselves from getting sick, we’ve had to get creative with how we see patients. As I walk down the corridor, I now alert my virtual physician—an assisting doctor who works remotely, and is always on speakerphone—about the patient I plan to see next. She calls the patient and patches us together, while I glove up and put on a gown outside the room. I conduct my interview in the hallway, asking about symptoms, answering questions, describing medications I plan to start or stop. I enter the room only to perform a physical exam. An in-room interaction that might once have lasted ten minutes—exposing me, and later my colleagues and other patients, to aerosolized coronavirus—is complete in just a few moments.
Next week, we plan to distribute hundreds of iPads to patients to make these interactions more personal. It’s hoped that a video call, instead of a disembodied voice, might mitigate the loneliness of covid-19 hospitalization. Treating patients just a few feet away probably wasn’t what the telemedicine evangelists had in mind, but it’s working for us.
The pandemic’s challenges have brought New Yorkers closer—figuratively, of course. Yankees and Red Sox fans rooted for one another after the September 11th attacks and Boston Marathon bombings; similarly, the coronavirus has united government, businesses, and residents in extraordinary ways. Barriers to accessing public benefits have been reduced; banks have been ordered to waive mortgage payments for three months; hotels are offering free rooms to health-care workers; restaurants are sending coffee and food to hospitals. More than a dozen philanthropic organizations have united to create a seventy-five-million-dollar fund that supports cultural organizations reeling from institutional closures and community organizations providing essential services to the city’s most vulnerable.
On the sidewalks outside our hospital, a well-wisher has chalked encouraging messages. “Inhale courage, exhale fear,” one path reads. “Where flowers bloom, so does hope,” another advises.
The next morning it rains, and the chalk washes away. As I walk into my office, a colleague rushes past—a patient of his needs to be intubated.
“covid is getting really old, really fast, man,” he says.
His stethoscope falls to the floor as he runs down the hallway; I start to call after him, but he’s already turned the corner.
Most hospitals now have a no-visitor policy. It’s extreme, but it’s the only way to keep everyone safe and prevent further spread of the virus. We make exceptions only in select circumstances, such as childbirth or impending death.
Despite vast reams of data—vital signs and lab tests, CT scans and EKGs—it’s rarely clear when even a critically ill patient will die. When should I call a loved one? If I call too early, families might come to the hospital too soon, waiting for days, perhaps needlessly. If I call too late, they may not have a chance to say goodbye.
I’m considering whether it’s time to make the call for a patient of mine when I come across a video on CNN. In it, a woman describes her last interaction, via FaceTime, with her forty-two-year-old husband, who has been fighting covid-19. Doctors tell her that, despite their best efforts, his life is coming to an end. Someone carries the phone into his room, where he lies unconscious, so that she can see and speak to him for the last time. She thanks him for writing her love letters, for making her coffee, for the years they spent together, as his pulse weakens, then stops. She plays their wedding song.
here are patients who want to leave the hospital but probably shouldn’t, and others who don’t want to leave but probably should. Some people, even when they require a constant flow of oxygen, demand discharge; they’re anxious about a long hospital stay and the prospect of suffering alone. Others fear leaving even after they’ve recovered. covid-19 is a new disease, and no one can say for sure what will happen when patients go home. The confidence I draw upon to reassure patients after an asthma attack or gallbladder infection has not yet developed for the coronavirus.
A friend tells me about a case that haunts him. A patient comes in with fever and cough—both relatively mild—which quickly improve. Soon he can sit, eat, and walk without oxygen. He wants to leave, and does. Two days later, the patient’s daughter calls; her father is in extremis. Within twenty-four hours, he’s intubated in an I.C.U., where, two weeks later, he remains.
We discuss what might have been done differently. Had my friend missed some subtle clue? After a careful review, we still have no answers. We can’t keep everyone in the hospital forever.
It sometimes feels as though we’re fighting dual epidemics: the coronavirus and loneliness. My patients often grow tearful when I tell them they’re ready to go home. They are glad to have survived the virus, but also relieved that their solitary sentences are coming to an end. On more than one occasion, a patient has thanked me for releasing them from “corona-jail.” Some may not have seen a fully unmasked face for weeks. No lips, no teeth, no noses or cheeks. They want to see a friend smile.
Witnessing this isolation takes a toll on doctors and nurses, too. In the I.C.U., clinicians are used to caring for patients who are intubated, sedated, or simply too ill to speak. That challenge, though, is usually offset by the richness of their interactions with family. Now we see only oxygen tubes and heart monitors; we hear only labored breaths and bedside alarms. There are no families whispering well wishes or holding patients’ hands. Watching someone suffer alone is its own form of punishment.
Before the epidemic, in many I.C.U.s, families would join teams during rounds. Family members might be encouraged to bring in a favorite hat, blanket, or sweater; on the wall beside the ventilator, they’d hang poster boards filled with photos from graduations, weddings, and vacations. All this gave us a deeper sense of the person lying unconscious in front of us. It helped us understand our patients’ lives and loves and dreams, at a time when illness had robbed them of the ability to speak for themselves.
Now many doctors treating the coronavirus find that their patients’ isolation is paired with their own. Some are socially distancing from their own families—sleeping in hotel rooms near the hospital to avoid exposing their households to the virus. Others go home, but eat and sleep separately, in the basement or a garage. As weeks pass away from friends and family, we find ourselves leaning more on each other—providing not just clinical care to our patients but emotional support to our colleagues.
In life and in crisis, we seek rituals of connection. A new one has developed on my morning commute. I enter an Uber—many now with plastic shields duct-taped from the ceiling to the seats, walling me off from my masked driver. We cruise up an empty Manhattan highway, the sun rising over the East River. I’m wearing scrubs; inevitably, the driver asks what it’s like in the hospital. Is it really as bad as they say? When is it going to end?
This morning, a driver tells me that while the volume of riders has greatly decreased, the proportion of doctors he transports has risen.
“My wife thinks maybe I shouldn’t drive no more,” he says. “But I told her, ‘If I don’t drive, how they gonna get to work?’ ”
I find myself oddly emotional—maybe because I haven’t slept, maybe because I haven’t seen my own family in the weeks since the coronavirus consumed New York. We pull into the circular driveway at the hospital’s front entrance.
“Anyway,” he says. “Thanks for your service.”
“Thanks for yours,” I reply, gently closing the door behind me.
Dhruv Khullar is a physician and writer in New York City.
