BOSTON — It has been months now, but the brown paper bags are still here — piled on the shelves in the hospital conference room where the residents cautiously lower their masks to eat lunch, stored in corners throughout the unit, each bearing the name of its owner written across it in Sharpie.
Some are empty, others still hold used personal protective equipment, now forgotten. In the room where doctors rest when we’re on call, the paper bags blanket an entire bunk. My own name must be there somewhere. When I close my eyes on an overnight shift, I sleep beneath the reminders of the spring surge.
Nine months after the first Covid-19 cases were reported in the United States, it is a strange time in the hospital. We spent the summer in what felt like a sort of haze, treating the usual critical care diagnoses of cancer and heart failure and sepsis, under the shadow of the coronavirus. Perhaps it was the warm air and the bright sun, perhaps it was the sight of people outdoors, eating and drinking and laughing, but it was easier to feel that normalcy might be around the bend.
But now, as the air grows crisp here in Boston and the nation endures an average of 59,000 new cases a day — levels that we have not seen since August — the threat of a “third wave,” or a winter surge, of this virus builds. And we find ourselves once again in limbo, haunted by the ghosts of the spring while steeling ourselves for the resurgence of illness and isolation that might come.
At the start of the night I pace the unit, checking in with the masked nurses who sit in front of the patient rooms. It is just 7 p.m., but it is already dark outside. We used to watch the sunset over Boston through these windows, a beautiful explosion of color in the midst of unending sadness. I join two of the nurses who are midway through their conversation. For the past few days, I learn, everyone has been gearing up for a wedding. It was a dying woman’s last wish. There were plans for the cake and the marriage license, everyone excited for a celebration — even one bookended by tragedy — when the patient decided to call it off. Maybe she was delirious, maybe it was just last-minute jitters, but she had made her decision. A critical care version of a runaway bride. This is what passes for humor these days. I smile cautiously under my mask, uncertain whether I am meant to laugh or cry.
An alarm beckons one of the nurses into a patient room. Alone again, my thoughts turn to the virus. Our last Covid-19 patient died a few weeks ago. Standing outside the room that had been hers, I think of her final days. How her husband sat on a folding chair, watching his wife through the glass. He did not want to enter if he could not hold her.
I wonder now if we let things go on too long. Perhaps the unexpected recoveries we saw during the spring had blinded me to the reality of my patient’s decline. Perhaps I was so eager for a success that I offered hope where there was none to be found. I am thinking about this, remembering my patient’s husband as he left the hospital that last time, soft-spoken and so unfailingly polite, when I see one of the residents approaching.
He wants to tell me about a patient on the general medical floor who might need to be transferred to the intensive care unit overnight. It’s an elderly man with Covid-19, he begins, and I can’t help but interrupt him. “Is this a new diagnosis of Covid?” I ask, surprised, although I shouldn’t be. He nods. He is taking care of a handful of patients on the general medical floor who have been newly infected with the coronavirus.
I want to ask more, about how this patient might have gotten sick, about whether the patterns are similar to what we saw in the spring, but of course I know the answers already. These are the vulnerable and the unlucky, the lives that would be sacrificed were we to pursue a strategy of herd immunity through widespread infection. This is what might lie ahead as we enter the winter. It is the sentinel bleed, the few drops of rain that herald a storm.
“At least we know more now,” I offer. This is not false reassurance. We know that masks and distancing, testing and contact tracing, can prevent spread. Though there is no magic bullet for this disease, we know that a simple inexpensive steroid seems to save lives. The data for remdesivir, the antiviral so many families sought so desperately early on, are less clear, but it is likely helpful for some patients particularly early on in their disease course.
Perhaps more important, we have learned what doesn’t work. We no longer rush to intubate earlier than we would in other diseases. For those patients who do need intubation, we recognize that meticulous critical care itself — the daily drudgery of managing volume status and checking labs and titrating ventilator settings — is a lifesaving intervention. Indeed, recent studies have demonstrated a significant drop in mortality among hospitalized patients with the virus. This should give us reason to be hopeful.
But mortality is not the only outcome that matters. We have also learned that infection with the coronavirus can bring with it a host of prolonged, debilitating symptoms now termed “long-haul Covid” even for those with only mild disease. And the impact of this virus is not isolated to those who are infected. I think of the rest of the patients in the hospital, their long and lonely admissions. I think of the families who struggle with our visitor policies, the pain of having to tell them that their loved one is critically ill but because the patient is not actively dying, the family can’t spend the night. To say nothing of the cost to the elderly and isolated. I cared for a man recently who lived alone and had barely left his home in about six months. Only after he died did I realize that our central lines and breathing tube and finally chest compressions might have been the only physical contact he had felt since the spring. The true cost of this pandemic will not be measured in a body count.
So we control what we can. Looking ahead to the possibility of another surge here in the Northeast, as the cold air drives us indoors, we refine our protocols and procedures. We arrange schedules. We make cautious plans to see the people we love. We laugh when we can, even if nothing is actually funny, because that is better than the alternative.
A few days after my overnight shift, I check in on the patient list in the unit. The elderly man has worsened despite our most current therapies, and he is now intubated in the intensive care unit. As I read through his notes, I feel it all rush through me, the anticipation and the dread and the frustration and sadness of avoidable suffering. I close my eyes and I find myself thinking again of those brown bags of personal protective equipment. I hope that we will not need to make room for more.
Daniela J. Lamas is a critical care doctor at Brigham and Women’s Hospital in Boston.
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