OMAHA, Neb. (KMTV) — As mask mandates come to an end and shots are going in arms, the impact of COVID continues to be felt in the community. A resident doctor at the University of Nebraska Medical Center (UNMC) recently shared his story of “moral injury,” feelings of powerlessness and mental scars left behind as he and others did the best they could to save lives.
The following, by A.J. Spanel M.D., was shared on UNMC's website:
80/45. . .78/42. . .75/40. The bright red numbers flash across the monitor like streetlights on a stormy night. Beads of sweat stream down my face and gather on my chin underneath my N95. I use the sleeve of my gown to wipe the fog of condensation off my face shield to see the IV tower across the room. Norepinephrine, epinephrine, vasopressin, phenylephrine, all maxed out. Alarms blare like sirens. My heartbeat surges to match the frantic cadence of the telemetry monitor. My isolation gown feels like a straitjacket as I attempt to weave the ultrasound probe across my patient's chest through the tangled web of wires and tubes. Eventually I'm able to steer the probe into enough positions to assess his cardiac function, which adds to my suspicion that, in addition to severe COVID-19 pneumonia, he may now also have a pulmonary embolism. Regardless, he's too unstable to make the trip for a CT scan to confirm. I gaze back toward his face. So lifeless and cold. A phantom of the man I admitted less than 48 hours earlier.
A knock on the glass and a muffled voice snap me back to reality. "The patient's wife has arrived," the nurse informs me through the window of the isolation room. "She's just down the hall outside the unit."
"Can you have the pharmacist deliver up a syringe of TPA?" I ask as I remove my protective suit to dejectedly retreat from his quarters.
The brief walk between the isolation unit and the waiting room seems eternal. My feet feel as heavy as sandbags. I push through the double doors fortifying the isolation unit to find a middle-aged woman sitting on a nearby chair. Her eyes are bloodshot and tear-filled, her knuckles as white as the tissue paper she's clutching.
These images are still so vivid in my mind, permanently etched like a scar. The stress of those few days in the spring of 2020, my first manning our COVID-19 ICU at UNMC, had drained my body and mind. In my three years as an internal medicine resident, I had counseled countless patients and their families through end-of-life circumstances. I'm comfortable with these discussions. I've been trained well to handle them. But this one was different. It was my first of the pandemic. In less than two days, I'd cared for a relatively healthy middle-aged man as he progressed from a mild cough and breathlessness to death's doorstep. It happened too quickly. So quickly, I hadn't processed it myself. And I felt powerless to stop it. How was I going to explain this to his wife? And how could I justify the fact that neither she nor any of their adult children had been able to visit him? How could I rationalize why they hadn't even been able to speak with him before he was intubated?
The sudden shriek of a pager was the first in a cascade of cataclysmic events signifying the beginning of the end.
"His oxygen saturation is dropping and he's working really hard to breathe," my patient's nurse alarms me when I return the page. "He's maxed out on high flow. I'm not sure he has much time before he needs to be intubated. He can barely speak, but said he wants to talk to his wife first."
"I'll page for the intubation and try to call her. Can you get the tablet up and running for a video call so he can see her?" I ask while as I frantically gather my protective equipment and scramble down the hall toward his room.
At that time, our hospital policy prohibited any visitors to patients admitted in our COVID unit. This was understandably terrifying and frustrating for patients and their families. It felt unnatural to us as providers and presented the novel challenge of providing telephone updates to relatives regarding the status of their loved one, often multiple times per day. I had spoken with my patient's wife and children numerous times during the first hours of his hospitalization, providing reassuring words to every anxious question. Yet in this moment when it mattered most, I was suddenly unable to reach them.
"You have reached the mailbox of . . ." I then try his son. No answer.
"Is the tablet ready?" I ask through the window as I throw on my isolation gown, douse my gloves in rubbing alcohol, and yank the face shield over my N95 to enter the room.
"It won't connect to the internet," she replies while vigorously tapping on the screen.
Panic grips me as I begin to understand the finality of the situation. If we don't get his wife on the phone now, he may never talk to her again. The anesthesia team begins prepping for intubation at the head of the bed. He's now gasping for air. Drowning. Unable to utter a single word. Our eyes lock. His arm listlessly lifts in my direction as if he's reaching out. Trying to grab hold of something, anything, to avoid being washed out to sea.
I quickly grab his cell phone from the counter and again dial his wife. No answer. His body goes limp. His eyes close. His hand falls softly back to the bed as the laryngoscope lifts his jaw, allowing the endotracheal tube to slide into place.
Seconds later the ringing of the phone in my hand breaks the silence.
"Hello? What's going on? I'm so sorry I was outside for a minute."
A tear crawls down my cheek, mixing with the beads of sweat under my mask.
Less than a day later, I found myself seated just outside the double doors barricading this woman from her husband, not one hundred feet from him. She wiped the tears from her cheek with one of her white knuckles as I stuttered through the lump in my throat, struggling to find words to depict his probable fate.
"We're doing everything we can, but it appears the virus is taking over his body despite all of our medications and treatments. He may now have a large blood clot in his lungs. His blood pressure keeps dropping, and he's very sick. I'm worried he may not have much time left."
"That can't be true. There has to be something else you can do. Won't the medications help? Are you giving him everything they've been saying should work? Our children are driving in from out of town and will be here tomorrow."
"I'm not sure he has the strength to make it to tomorrow. And if his heart stops, I'm not sure he'll survive CPR," I inform her with a somber tone.
"You have to save him. You need to do everything. We can't live without him. This can't be real. I was just talking to him yesterday. He was fine a few days ago." Her words become frenzied as she begins to lose hope.
I exhausted the little energy I had left attempting to console her, yet after walking away, I felt as if I had done nothing for her. I pushed back through the doors of our isolation unit only to hear her grief intensify. Her cries could be heard throughout the unit. I felt defeated. My first real experience with COVID-19 matched everything I was seeing on TV each night.
Then just minutes later, my shift was over, and the time had come to hand off to our night team. It felt uncomfortably abrupt and wrong for me to leave. I had the sense I was abandoning this man and his family at the climax of the fight we had endured for the past two days. When I arrived home, the many dialogues of the day echoed through my head, keeping me up for most of the night. The next morning when I returned to the hospital, my fears were confirmed. He died not more than an hour after I left. His children were not able to see him. His wife was only able to hold his hand a few minutes as he passed. While I did everything medically possible to prevent this outcome, I felt responsible.
Without a moment's solace, I was quickly swept away that morning by the relentless chaos extending over the next few weeks in the ICU. I was at the bedside of over a dozen patients who passed of COVID-19. I had many similar conversations outside those double doors. I told many husbands, wives, and children they were not allowed to be with their loved ones who were battling for their lives. With each interaction, a fog started to come over me, and I began to feel numb. I started acting differently at home. I was on edge and easily irritated. My friends and family began to ask if I was ok. I just waved the questions away, saying my days at the hospital had been stressful. I didn't provide any details. I didn't think anyone would understand. Under my façade, I knew I wasn't ok. My world was in a slow downward spiral.
A few months later, I had finally found some reprieve on an outpatient rotation but was still stuck in the doldrums. I was on the mend, but not yet back to being myself. The whole year had been a constant stream of disasters. I wasn't sure 2020 could get any worse, but I just couldn't shake the sense that another tragedy was around the corner.
Then my mom told me about her cough.
"Please go get tested," I pleaded with her. "Oh, it's nothing," she would say, "probably just some allergies. They always get bad this time of year." She didn't know many of the patients I had cared for used this exact phrase to describe the onset of their symptoms, just weeks before the virus claimed their lives. Fear crept over me as my mind played out the worst of scenarios. As she was now five years cancer-free and no longer on chemotherapy, I began to rationalize that she would be fine even if she did test positive. She was healthy and strong. But then again, so were quite a few of my patients. Eventually she was swabbed and was negative. I was so relieved it wasn't COVID.
But her cough didn't improve.
It started to get worse. Quite a bit worse. Days turned to weeks as she became increasingly short of breath. Throughout each of our video calls, she would stop mid-sentence to cough in her sleeve and take a few deep gasps before continuing. This was definitely not allergies. Could she have had a false negative test? My fears returned.
Then one dreary fall afternoon, my phone rang in the middle of clinic. Usually, I would silence such calls and step out later to return them. But for her to call at this time of day, I knew something must be wrong. I flashed back to those essential moments months prior when I failed to reach my patient's family. I answered immediately. I was met with a breathtaking silence. When she did speak, her voice was tremulous and soft. I prepared for the worst as a stream of images from my days in the ICU flooded into my mind. She was in fact on her way to the hospital. The hospital where I work. Her symptoms were progressing.
But it wasn't COVID. It was fluid.
A lot of fluid, from what she was told by the radiologist who performed her CT scan. A pleural effusion. Large enough to collapse her entire right lung. She was being sent directly to the hospital to have it drained. She wanted to know what had caused the fluid. She was scared. In my internist mind, I knew exactly what had caused the fluid. I was terrified.
I dashed out of clinic and sped toward the hospital through the torrential rainfall that had commenced. Struggling to make out each streetlight, I used the sleeve of my shirt to clear the condensation from the windshield. My effort was to no avail as tears filled my eyes. A storm of emotions overcame me. Panic and despair were the first. Guilt and shame followed shortly after. I began to understand my fear of this deadly virus had blinded me from the truth: my mother's cancer had returned.
I pulled into the parking lot at the hospital and began to make my way down the hall toward the unit where she was admitted. I eventually arrived at a set of locked double doors. Suddenly, a harsh reality sunk in: I wasn't allowed to see her. In my shock, I had failed to remember our visitor policy. There I stood, now on the other side of those doors, white-knuckled with bloodshot eyes, barricaded from my own mother as she received this devastating news.
The pandemic had finally broken me. I collapsed on a nearby bench and buried my face into my hands. In the silence of that empty hall, I was at the climax of my own fight with this wretched year. I pictured the many husbands, wives, and children I had tried to comfort not far from where I was sitting. I understood their grief. I felt the same anguish of wanting to heal, while facing the misery of separation from a loved one in distress. These feelings could not be consoled.
It's been over a year now. We're still in a fight against this virus, but we've made remarkable progress since the chaos of those early days of 2020. We're slowly lowering our guard (and our masks) as we come to the other side of this storm. We've begun to catch our breath and reflect on the wreckage left in the wake of COVID-19. To understand its impact, we must remind ourselves of all we've endured in our role as healthcare providers. Many of the adversities we faced were not novel to our field, though all were amplified to an extent which future generations in this profession may not ever fully understand. These struggles may leave us with more than a few scars.
We've experienced the pain of loss. Loss of patients. Loss of friends. Loss of family members. The pandemic claimed lives at an overwhelming frequency with unprecedented uncertainty. Often, we had little if any time to mourn these deaths before we were forced to shift our focus to another terminally ill victim. Healing is part of the ethos that drove us all toward the healthcare field and the failure to cure, although sometimes unavoidable, always leaves its mark.
We've worked long hours under an unprecedented magnitude of stress. Every day we entered the deadly virus's lair armed with N95s and the most elaborate precautions we could devise; however, nothing could quell the trepidation of becoming infected ourselves. Sleep-deprived and under varying levels of burnout, there were no reinforcements as we manned our isolation units and juggled the care of those hospitalized with other medical ailments. We fought the inevitable tunnel vision, frequently struggling to identify other masquerading illnesses as we deciphered COVID from non-COVID.
What may be more difficult for us to articulate is the moral injury we suffered. In isolating our patients, we were acting out of a desire to delay the spread of the virus, and an obligation to protect our communities as best we could. Control of the pandemic demanded isolation. But what followed this seclusion was an unavoidable sense of shame as we witnessed a new kind of pain. We mourned with husbands, wives, parents, and children while struggling to find a reassuring word, often through the screen of a tablet, sometimes outside the barricade of double doors. Many of us even experienced this firsthand with our own loved ones.
While we faced each of these unique challenges, hardships outside the hospital seemed to intensify. Financial distress plagued our society. Political unrest and racial turmoil left us sad, anxious, and angry. Some of us lost loved ones to other ailments. Others learned our cancer had returned. What's more, we suffered it all while confined to our homes and socially distanced. We were more disconnected than we've ever been. We came home from work each day to a breeding ground for mental health disorders.
There's another side to our story, one yet to be told. The assault on our psyche is not over. In recent years, we've become increasingly aware of the startling frequency with which mental health disorders afflict those in the medical profession, a dilemma only exacerbated by the pandemic.
I myself don't have a mental health disorder. I've never struggled with substance abuse. I can't say that I've ever contemplated suicide. I can't imagine weathering the past year under such conditions. Admittedly, I'm even hesitant to share my own experiences out of fear they may not be relatable without a history of these ailments. Nonetheless, I have started down the path toward depression more than a time or two. I would be lying if I said I haven't shown up to work feeling numb, maybe even going through the motions on occasion. I've been guilt-ridden, overwhelmed, and burnt out more than I'm comfortable to confess.
The bottom line? I've struggled enough to ask for help.
It wasn't easy. I wanted to look outwardly confident, unphased, "like everyone else". To blend in and keep working. To hide the part of me I felt was weak. In hindsight, I've realized this attitude is largely responsible for my downward spiral. It could have landed me in serious trouble. Had I not discussed my experiences and emotions, I'm certain I would have continued down a path to a very dark place. I now appreciate an essential truth I had always known to be true: there's no weakness in asking for help. It's OK not to be OK.
Eventually, I contacted one of the psychologists available through our hospital's PiNS (Providers in Need of Support) program. Our conversation triggered a cascade of other discussions with my friends, family, and colleagues, who universally normalized my reactions. Although I still bear the same burdens, I now cope with and understand them significantly better. I'm beginning to heal because I opened up. I'll never know what this saved me from.
So please, talk to someone. We're all in this together.
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