From an Ebola veteran to all healthcare workers out there. I know how you feel. I've been there. I'm here for you if you need me. Please share if you feel it's appropriate.
Dr. Mike Drusano
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In health care, we are all feeling overwhelmed right now. We are overwhelmed by the number of patients, the vast unknown about COVID-19, and the lack of appropriate equipment so as to do our jobs properly.
Yes, right now we don’t have the tools to adequately treat our patients and protect ourselves. Our lives are important. We took an oath but nowhere in this oath did we pledge to be virtual cannon fodder, especially without the appropriate equipment. We have a duty to our patients. We also have a duty to ourselves. But we also have a third duty: and that is balancing the former two. For my people in health care: if you are healthy enough to go to work – go. But under no circumstances should you be forced to do something at work that would endanger your health or safety.
A few things to keep in mind: when you have it, the PPE works. I am a testimony to that. I responded to the Ebola outbreak in West Africa years back, and I never fell ill: I’m still alive. Now, much like with COVID-19, back then we did not have everything we needed at the moment we needed it. We had to improvise. What it meant to me was that improvisations in our PPE meant that we were obligated to improvise in how we approached and treated our patients. It wasn’t ideal, but it was a situation where some care was better than nothing. Yes, these improvisations placed us at risk. Coverall suits that are too large present a trip and fall risk. Yellow suits trapped heat so much more than white suits causing a lot more sweating and fluid loss meaning that there was a greater risk of hypotension and collapse in the middle of the hot zone. Nonetheless, these were improvisations I was forced to make under the circumstances. My patients needed me. Refraining from going in to care for them was not an option. But as a result, I modified my behaviors while in the hot zone so as to protect my own interests. If you do have to make subtle improvisations, it’s ok as long as it is not presenting an immediate and grave threat to safety – both the patient’s and your own. Again, I am living testimony that certain modifications still work in less-than-ideal circumstances and that these modifications do not guarantee morbidity or mortality. That being said, some modifications are absolutely unacceptable – like cloth masks or bandanas in place of health-care-grade face masks. Much like I would not have entered the hot zone without a coverall suit, health care workers should not perform deliveries without face shields or perform intubations without N95 masks. Full stop. If physicians and nurses are taken out by this, then there will be no one left to care for future patients. Again, we took an oath but that oath was not to be virtual cannon fodder.
In Sierra Leone, we were working in a setting with a collapsed health care system in a somewhat geographically isolated country that was still doing its best to recover after a protracted civil war. Oftentimes for our own safety, we were forced to truncate our rounds, thereby leaving some patients abandoned or with sub-par treatment. During times of crisis and during extremely difficult working conditions (Ebola response was one of them, so is COVID-19), this is unfortunately inevitable. The first step is accepting that we are going to have times where we could have done better if we had everything necessary (including time), but it is not our fault. We are going to lose colleagues. We are going to lose patients (including those without COVID-19) who would not have perished had they been ill the same way but only this time last year. And no, it’s not ok. But if and when these tragedies do indeed happen, we do need to be able to look back on the situation and honestly say that we did the absolute best we could under extremely sub-standard conditions. We in healthcare tend to be perfectionists. We went into the field not because it’s easy but because it’s hard. We’re not afraid to get our hands dirty, but at work, we like knowing that we are doing things in a correct and thorough fashion in accordance with the most current guidelines. So much like with Ebola, COVID-19 response oftentimes is forcing us to act in a manner that is anathema to our training and to our collective personality. This is understandably distressing.
I had several instances in West Africa where yes: I personally had to act against the basic tents of my training and to my wishes in providing patient care to a deserving and honorable patient population. These instances still follow me and I don’t think I will ever get over them. It was tough dealing with those instances then, it is still tough dealing with them now. I think that this is where our heart and brain struggle together to find some sort of equilibrium. My heart still aches for those patients. It also still punishes me every now and then for the courses of action I had to take without any alternatives. My brain nonetheless tells me that I did everything I could for them with the tools, resources, and time that I had at my immediate disposition. In recent years there was a meme about how the ball of trauma bounces around inside of a box, hitting a grief button at random. Initially, the ball is large and subsequently hits the button repeatedly. The spells of grief are frequent and overwhelming. Over time, the ball shrinks. It’s still present but it becomes less imposing and as a result, the grief button gets hit less frequently and with less force. We will have our moments of overwhelming grief and regret. Human beings though have an exceptional ability to recover from trauma. I’ve seen this myself working with refugee populations in a variety of different parts of the globe. We will hurt early on. A lot. It does not mean that we will not be able to carry on with life and with our careers. One thing I have learned about life thus far is that oftentimes we are left making not necessarily the best decision, but the one that is the least bad. Ebola was one of those times. So is COVID-19.
I think that even in non-pandemic settings there are always instances where we could have done more for our patients. We are always limited one way or another. Again as with Ebola, with COVID-19 this maxim is so much more pronounced. It goes so much further than spending a little more time with a patient or submitting a prior authorization so that the patient can save a few bucks on their prescription. Remember that we are always on this spectrum of being able to do more. It’s just that now it’s more evident. Nonetheless, we will still do our best.
In healthcare there tend to be a lot of “tribes.” We hear about the tension between physicians and nurse practitioners, nurses and physicians, and virtually everyone against medical students. The rivalries between certain specialties in medicine are well known: Internal Medicine vs Surgery, Surgery vs Anesthesia, etc. In my specialty of Family Medicine, while rotating through the hospital we usually got side-eye at virtually every hospital service until we went out of our way to prove ourselves, oftentimes having to be better than our counterparts in the specialty where we were rotating. The most important thing is that at times like this we cannot look at each other as the enemy. That is how the virus will win.
So much is out of our control now. But we still have some things that are. We still have decision-making capacity. In West Africa during the time of Ebola, If it wasn’t safe, we didn’t do it, especially if it was unnecessary or wouldn’t have much of an impact. Full stop. I personally remember having to stop another doctor who wanted to place an IV on a patient in a room with inadequate light, the patient still able to take fluids by mouth. Just because you can doesn’t mean you should. This is something to keep in mind at times like this. Lean on each other. Stop someone if they are about to do something unsafe. Sometimes people need an outsider with a more objective point of view in order to receive appropriate guidance and become better. This is the whole justification for psychological therapy, by the way. Speak up, be forceful about it, but still be tactful. They are your colleagues or co-workers, after all. You have to look at them in the face once this is all over.
I don’t have a crystal ball. I can’t predict the future. But I can guarantee that we as individuals, we as a profession, our country, and even the world as a whole will be different once this is all over. We have the capability to decide whether we are more cohesive and compassionate or spiteful and at odds with one another. The first option will take a little more effort on top of what we are already putting in, but it will be worth it.
