This is the first installment of Dr. Asha Shajahan’s essay series on being a healthcare worker during a pandemic.
Day One: Superheroes
I left home nervously for my first COVID-19 unit shift. I had seen COVID-19 patients in my outpatient office and also seen homeless patients on the streets, but this was different. These patients were critically ill, fighting for their lives in a pandemic. The freeway was void of cars. COVID news played on my car radio. I changed the station to clear my mind. Lawn signs lined the street leading to the hospital reading “healthcare hero!” and “We support our healthcare workers.” Who would have thought those little signs would have such an impact on my psyche? I felt encouraged.
At the hospital entrance, a staff member greeted me. She wanted my clearance to enter the building as if it was a top-secret center. It wasn’t just my ID badge that granted permission to enter, rather the results of a symptom screening app downloaded to my phone. No cough, no fever, no recent exposure to COVID; I was clear. She squirted sanitizer in my hands, handed me dark purple gloves and a blue surgical mask. This is how every shift begins.
I’ve worked several 12-hour shifts in my career, none quite like this one. The hospital was empty — don’t get me wrong, it was full of 150 COVID-19 positive patients, but the hallways were lifeless. There were no nurses gathered at the nurses’ station. The Starbucks was dark and closed. No families were in the waiting rooms. There was no laughter or music, just an eerie stillness. My footsteps were loud in the silence. The unit doors were all closed, with signs in red stating HIGH ALERT. Patient doors were closed with signs noting, “Enhanced respiratory contact precautions required,” a signal that nobody should enter without personal protective equipment (PPE). Cabinets lined the hallways, replacing the usual computers and workers. Inside the cabinets were gowns, gloves, and hand sanitizer.
Everyone had masks on, all different kinds. Several had N95 masks, others had surgical masks, and some even had trendy homemade colorful ones. It felt like a strange masquerade ball. It was odd seeing only people’s eyes. The nurses’ eyes looked different than they had in the past. Now, they were bloodshot red, fatigued and sad.
On my way to pick up my PPE, I saw a drawing on the door. It was a picture of Superman, standing among healthcare workers as fellow heroes. Our hero suits are not nearly as stylish as Superman’s: first, gloves, then an N95 mask, checked to make sure it was fitted properly, with no air coming through, then a surgical mask over it. Behind the layers, it’s hard to breathe. Goggles covered my eyes; a face shield, with a rubber crown was placed on my forehead. A pale yellow gown was draped over my scrubs. My hair, tied back in tight bun, was covered with a surgical cap. My armor was on. I was ready for war.
I reviewed my patient list and was shocked at the range of ages, 18 to 103, all with COVID-19. There were many patients who tested negative but had X-rays with bilateral infiltrates and lab tests consistent with COVID. It was alarming that 30 percent of tests had produced false negative results. I wonder how many people were sent home with a “negative.”
A familiar face came into the doctor’s lounge, a seasoned colleague. He advised me that nobody was going into the rooms of patients unless absolutely necessary. Patients received one physical exam a day unless otherwise needed. “Don’t go in the room unless you have to. You can FaceTime or call them on the phone if you need to speak to them.” With fear in his blue eyes, he said, “Asha, you’re young. I know you like to go above and beyond, but COVID is different, your life is at risk.” It felt unnatural and impersonal to avoid patient rooms. But I understood the circumstances. It still felt unreal that all of this was caused by a hidden, microscopic virus.
My phone rang; a patient was having difficulty breathing. My heart was racing as I entered the room. Here goes, I thought. The fear melted as soon as I saw her lying in the bed. She had oxygen on and was struggling to breathe. Her heart rate was high. She was anxious. Her hands were shaking. Her TV was blaring. “What are you watching?” I asked. “Oh, I dunno, something on the Hallmark Channel,” she said, winded by the sentence. We proceeded to chat about my favorite show, “The Golden Girls,” often in reruns on the Hallmark Channel. She smiled, and her respirations decreased. She appeared calmer.
After I examined her, I joked about how my mask made me sound like Darth Vader. We both laughed. She said, “It’s scary to be in here all alone.” After a few minutes of conversation, her vitals normalized. She had COVID-19, but that wasn’t her immediate problem; it was loneliness. I went back to the doctor’s lounge to grab a get well card made by my nieces. I noticed a flower pot filled with bright yellow flowers in the hallway. Inconspicuously, I looked around. It couldn’t hurt, I thought, plucking a yellow flower from the pot. I handed it to the patient, and her eyes welled with gratitude. “God bless you,” she said.
I wasn’t sure if she could tell I was smiling beneath my mask. I responded, “I’m here all night! Holler if you need me.”
When I got home that day, I went to my office. A Superman figurine, given to me by a former resident, years ago, was tucked away in a drawer. At the time, it was a silly gag gift. I dusted it off, and placed it on my desk. It would do, but Superman wasn’t quite the fit; the Avengers made more sense. Because to run a COVID unit takes a team of superheroes, from the patient transporters, janitors, phlebotomists and pharmacists to the nurses, physician’s assistants, nurse practitioners and doctors. It’s all of us together, only alongside the most important fighters: the patients.
Day Two: Death and COVID-19
It was chilly in the long, white sterile hall. Emerging like angels escorting a soul, four people wearing N95 masks walked beside a hospital bed covered in a black sheet. It was silent, except for the sound of the wheels of the bed rolling against the floor. They were going to the morgue. Just hours earlier, he had been in the intensive care unit, on a ventilator, battling COVID-19. His outcome was dismal. His family understood and had agreed to a compassionate wean off of the breathing machine. He was allowed two people at his bedside as he breathed his last.
I wondered if I died, who would I want at my bedside if it could only be two people? It’s a difficult decision many are making in the most horrific circumstances.
With COVID-19, the mortality is high for about 20 percent of patients. Three code blues occurred that night. One was a 30-year-old African American male. Another was 70-year-old Caucasian man and then an 80-year-old woman.
Regardless of age, I noticed that only one out of 55 patients had an advance care plan, or a set of wishes regarding end of life choices. This includes desired treatments such as CPR, being on a ventilator or feeding tube. It also states who will make medical decisions if one is unable to communicate. If this isn’t done in advance, it causes a lot of confusion. There was a family who couldn’t decide what to do. A mother wanted everything to be done to save her son who was dying. His father wanted to stop any life prolonging measures because he realized his son wouldn’t recover. In such a stressful time, the family was in conflict. An advance directive could’ve prevented this turmoil.
It was a rough night; another patient passed away. An hour went by, no family came. The nurse asked, “What do you think is taking so long?” Perhaps the family was trying to determine who would be the two to come to the hospital. Would it be a spouse, a child, a sibling, mother or father? Who would get the privilege to see him off into the next world? Nobody wants to get that call, ever. But during this pandemic, the call is so much more devastating. Families will never get closure for not being with their loved one when he or she died. Funerals will be small. It’s quite frankly a tragedy. As it turned out, the family declined to come because all members were sick at home with COVID. My heart ached. I sighed and went on to complete my rounds.
Day 3: Health Disparities
The news was raging about how COVID-19 was taking the lives of African Americans. It was not sensationalism. Of my list of patients, 77 percent were African American, which is unusual for my hospital. Institutional racism, social injustices and the consequences of health disparities are subjects I teach medical residents. Now, the disparity was staring me in the face. Detroit has a long history of racial disparities, from redlining that occurred in housing to the demolition of an African American business community known as Black Bottom. More so than racial disparities, socio-economic disparities have the biggest adverse impact on health outcomes. It’s a domino effect. If one can’t afford healthcare, then access to care is difficult. Access to healthy foods, safe neighborhoods, transportation, poor education, and affordable housing all contribute to a person’s health. It’s been said that your zip code is more important than your genetic code. Detroit has a 33 percent poverty rate. Michigan has the third highest number of COVID cases in the nation, yet it’s only the 10th largest state. It’s not surprising that zip codes 48235 and 48224 are the hardest hit neighborhoods with COVID-19 in the city. To date, there are 7,605 cases of COVID in Detroit and 605 deaths. I wonder what will change post COVID to address these health disparities. Will leaders remember that to make a community’s citizens healthier, we have to address the social factors that are making us sick? Or will it fall on deaf ears?
One of my African American friends was hospitalized on my unit. It was his fifth day. He didn’t look good, and he couldn’t recognize me behind my PPE. He looked so uncomfortable, breathing heavy. I was worried for him. His labs weren’t favorable either. If he was put on a ventilator, he wouldn’t do well. He has an extensive history of lung disease and it doesn’t help that he lives in a highly polluted area in the city. He told me, “It’s the worst feeling, not being able to breathe.” I closed my eyes and prayed. What else could I do? Hydroxychloroquine, azithromycin and zinc were the protocol medications being used, but they don’t work all the time. In fact, hydroxychloroquine can cause more complications. One patient kept going into a heart arrhythmia all night; we almost had to shock her. Other than these medications and oxygen support, we can only wait out the storm of COVID-19 and aspire to avoid intubation. The patient has to fight, and we have to hope for the best. My friend was lucky. His breathing improved and he avoided the ICU. He was safe for now.