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In the ER during the pandemic: A day I’ll never forget

illustration of emergency room during the pandemic

Ripal H. Patel, MD, MPH, recounts a day in the emergency room during the COVID-19 pandemic, and how it affected him deeply and personally.

I’ll tell you a secret about the emergency room. Most people that arrive in absolutely dire condition unfortunately often do not make it. And most people that come in perfectly healthy generally leave that way. It’s those times when people turn the wrong direction unexpectedly where we must summon all thousands of hours of studying and years of training to intervene and save a life.

Why do you want to be a doctor?

When I think back to those terrifying patient encounters, when I put my all into the management of a patient because their life depended on it, I often wonder back to when I did medical school interviews. Why do you want to be a doctor, people asked me. My answer was always simple: I just want to help people. I can’t count how many times I was admonished for such a response. “Then help people as an insurance salesman,” they would say, “or go wash cars. Why not help people as a social worker?” As I round about so many years later, almost 7 years into practice, I take a deep breath and state quite simply, that answer was more than appropriate.

‘He’s going to code’

And so when Jim arrived at our ER with a patch over his eye, and his wife at his side, I took one look at him and said quite simply, I want to help you.

Jim had passed out on the ride home from his cataract surgery. I found the image jarring only because my mother had just had the same procedure, and as they took her out into a wheelchair I began to cry. The surgery itself was entirely benign and of such low risk, and yet, seeing your own mother having an operation generates such sentiments. Jim was a no brainer: healthy, work-up for having passed out on his drive back home, and go home.

I caught Jim just as I had come from upstairs. I’d had to cover an in-hospital code. I found a patient on the medical floor in cardiac arrest. His C02 levels (what we expire from our bodies) had risen so high from COVID and respiratory failure he became altered, then pulled his mask off. Our hospital — one of many I cover in my locums practice — had such scant resources that no one could regularly monitor him. He died. My colleague, the hospitalist, was silent and stern. He prided himself on not having lost a single COVID patient. This was his first, and it appeared he hurt hard. I patted him on the shoulder and shared a silent moment with him — because in this pandemic that’s about all we can do — and slowly went back to the ER.

As I walked back and finished chatting with Jim, my charge nurse rushed up to me minutes later. Rip, this guy looks bad, he’s going to code. I paused. Jim? I ran out and sure enough, Jim was pale, sweating, and looked like he was about to go into arrest. And in a matter of minutes, he did.

After all our efforts…

Locums has had me work in many ERs across many states. These ERs can all be the same, in the sense of feeling very cold and lonely, with alarms blaring every minute, chatter of nurses and patients, and small isolated rooms. I’ll confess it: I don’t want to die in an ER just for this reason, so each day I strive to bring some warmth, some humor, and some personality to a place that is often so physically bereft of it. Jim was in the healthy category, and the thought of him passing away, more or less here, was not congruent with my initial estimation.

My charge was right. Jim went into full arrest. And his wife, whom an hour before I was joking with, chatting with her husband, was speechless.  Like a klutz, I ran in and out of the room, avoiding her gaze. She was in shock, looking down at her phone, trying to remain dissociated from what was going on.

As I was calling consultants, the patient was having CPR done by my staff. Several of them were in tears as they pressed forcefully up and down across his sternum, up and down, with all their weight, as many knew him personally. Sweat was pouring down their faces, and the room remained silent. Ultimately, after several attempts and over an hour, we were unable to bring him back. I stared at a 4-chambered heart on ultrasound, that failed to revive itself after all our physical efforts, all our medications. I looked down and called his time of death. I was physically and emotionally exhausted, dumbfounded, and whispered to my charge, ”Where is the family?”

Could it have been different?

I think back often to medicine, and further back to why I did locums. I always feel gratified knowing I am bringing my skill set to another locality. I feel Jim got the best care he could have gotten, and I wonder how much of his care was delayed because of the pandemic. Missed appointments. Missed follow-ups. Perhaps missed PCP appointments where warning signs of what ultimately occurred may have been caught. I felt devastated by Jim’s loss, and when I entered the family room his wife and son were there.

I was always told to not beat around the bush with death. Not say “they expired” or “they didn’t make it.” But compassionately let the family know he died. And so I did. The son and wife broke into tears, holding each other, looking back at me and simply whispering, “Thank you for all you did.”

Supporting each other

I say there are many reasons to pursue locums, but one driving force is always getting to meet new people, new faces, new practitioners. I learn from these people and become a better doctor for it. One of those people was Dr. Simons, the hospitalist, whom I had seen earlier. When I thought of that pain in Dr. Simons’s face with his death, I thought of what my own face felt like as I left the room, and at that point I ran into him again. He could see in me what he had just experienced. His was his first COVID loss. Mine was a death I felt never was meant for this day. In locums settings like this, it was really just us two physicians there, to help each other, and often to emotionally support each other.

My colleague is a sage man, both on life and medicine, deeply compassionate while skilled in clinical care. He reminded me that medicine has changed in so many ways — between the policies, the bureaucracy, the metrics, and even more challenging, working in locums localities. But that feeling, that loss, that punch in the gut, it is what grieves us, but what also pushes to make us better. That humanity, and that empathy, is the guiding light that we should all focus on in our practice.

The system seems to have dimmed that light to a flicker for so many of us by a system we had no involvement in creating. Personally, I refound my light by doing locums and dodging many of the aspects of healthcare most of us dread, so I could focus on what mattered most. I urge others to pursue the same.

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