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From the Editor: COVID-19: How to Be a Doctor at the End of the World

BY MALACHI SHEAHAN III

My predecessor at Vascular Specialist, Russell Samson, MD, had a gift for writing from experience. Perhaps in fear of being unkindly compared with him, I moved in the opposite direction. My editorials are heavily researched, often for months. I felt that the opinions I’ve earned outweigh those that I simply held. In this piece, however, I will abandon the shelter of research and offer the lessons I have learned from a few unique experiences.

First, a review of my apocalyptic bona fides. In the 1990s, I was a surgery resident in Greenwich Village, the East Coast epicenter of the AIDS crisis. In 2001, I was part of the early rescue efforts at Ground Zero in New York City. Finally, in 2005, I spent a week in University Hospital after Hurricane Katrina. For about a decade, I felt like the Forrest Gump of American catastrophes. From these experiences, I humbly offer lessons I have learned on how to be a doctor when everything falls apart.

Lesson 1

Family first: On Aug. 27, 2005, my mother-in-law approached me. In her thick French accent she announced, “Mal, we are leaving.” She and my father-in-law had been staying with us in New Orleans and helping care for our newborn. I turned to the news she was watching intently. A hurricane that had just hit Miami was regaining strength in the Gulf of Mexico. In New Orleans, there had been a few recent false alarms, could this time be different? I should note here that my mother-in-law is a force of nature, equal parts wondrous and terrifying. As I watched her stare at the strengthening storm, I thought, “Maybe game recognizes game?” I decided to stay and work, and send my wife and child with my in-laws. In retrospect, this was the best thing I could have done for my patients.

In the aftermath of Hurricane Katrina, University Hospital was in dire condition. No power, no water, no sanitation, no lights. The backup generator was in the basement, now inconveniently under 12ft of water. Caring for the hundreds of patients would require an intense, concerted effort. Ventilator-dependent patients would have to be manually bagged around the clock. The overwhelming majority of the doctors and nurses in the hospital worked tirelessly. For some, though, the pull to leave, find their families and check on their homes was irresistible. Without cell towers or news sources, the only way to confirm their fears was to abandon their post and risk the rising floodwaters. This same scenario played out in other hospitals around the city. While it would be weeks before I could see my home, at least I had the peace of believing that my wife and child were safe.

Lesson 2

Look for the person in charge; if you can’t find them it’s probably you: The problem with unprecedented disasters is that they are unprecedented (I guess the disaster part isn’t great either). It can be very challenging to figure out who is in charge. People often look to the Federal Emergency Management Agency (FEMA) for guidance. FEMA’s mission statement is “Helping people before, during and after disasters.” In reality, FEMA is sometimes ill-equipped to carry out early rescue operations after a catastrophe. They would see that as the job of the local authorities. When the local personnel are overwhelmed, next in line is probably the National Guard. Unfortunately, I have seen this process fail in person. Twice.

On Sept. 11, 2001, New York City firefighters, police and first responders began rescue efforts almost immediately after the first plane struck World Trade Center One at 8:46 a.m. By the time the south tower started to unexpectedly collapse at 9:59 a.m., most of the local command team were on-site. A total of 403 police, firefighter and emergency personnel were killed when the towers fell, including most of the people in charge. FEMA set up its control center several miles north and was not present for the early rescue attempts. At the location of the collapsed towers, which we called “The Pile,” different groups tried to reorganize the rescue efforts. Ostensibly, the New York City Fire Department was in charge; but on the scene, it was clusters of medical and emergency personnel without any central leadership.

On Aug. 29, 2005, Hurricane Katrina decimated the infrastructure of New Orleans. The wide swath of destruction meant that aid would have to come from far outside of the storm’s path. Most of the early rescue efforts were led by the Louisiana Department of Wildlife and Fisheries, as well as private citizens with airboats. Conflict and communication problems between the state and national authorities delayed a coordinated attempt for nearly a week. Michael Brown, then director of FEMA, later admitted it took the federal government days to grasp the scope of the problem.

Lesson 3

Truth, fiction and my wife’s friend who knows someone who works at City Hall: A recent email told me that if I can hold my breath without coughing for 30 seconds, I don’t have COVID-19. Reassuring and, of course, nonsense. And this was sent by a physician.

After Katrina, with the city flooded and in complete darkness, anything seemed possible. Reports of beatings, rapes and murders at the Superdome were rampant. Our own mayor amplified these claims. Similar rumors spread through the hospital. Our junior residents heard from the nurses that a sexual assault had occurred in OR 3. Even after we determined this was a fabrication, the damage already had been done. People were spooked, and everyone began to look suspicious.

Lies and misinformation spread quickly during disasters, mainly because they seem possible. As doctors and leaders, it is our job to debunk the myths and have a coherent plan for organizing and sharing information. Failure to communicate creates a void easily filled with rumor. Better to share actual bad news. It is often better than what people will come up with on their own.

Interlude A

The Coca-Cola conundrum: When society’s rules crumble, it is important to have a code. There were times after Katrina when it seemed that we might be abandoned. Some of our patients would die slowly and painfully without rescue. Drastic measures may have to be taken. Could euthanasia be considered? But what if help was imminent? No one wants to go full “Lord of the Flies” just as the Navy arrives. Over- or underestimating the severity of a situation can lead to terrible decisions.

The day after the hurricane, our surgical team was in the OR lounge, trying to create an accurate inpatient census. The sub-specialty doctors were gone; we would have to combine all the patients into one surgical service. Temperatures were over 110 degrees in the hospital. Someone mentioned being thirsty. The mid-level surgery resident eyeballed the soda vending machine in the corner, then looked over at me. Electricity had been knocked out long ago. Coins would be of no use. He wanted to take a crowbar to the machine. No, I said, it had only been 36 hours. We weren’t going to start destroying private property like animals.

Two days later, we were back in the same lounge, our situation now made worse by time and deteriorating conditions. Again, the resident wearily pointed toward the soda machine. As I nodded, he smiled and produced an orthopedic instrument that resembled a Dark Ages nightmare. He made quick work of the machine’s casings, and the entire team enjoyed a round of delicious—albeit quite warm— soda. He had even saved a lime from the cafeteria to cut into wedges. After all, we weren’t animals.

Lesson 4

Be cautious, not afraid: September 1994. The patient was young, younger than me. Maybe 20? His AIDS-defining illnesses were apparent, his vision dimmed from Cytomegalovirus (CMV) retinitis, his breath rasping from the pneumocystis pneumonia— Kaposi’s sarcoma lesions covered his body. That’s why we had been called. The lesions were necrotic and bleeding. I needed to debride and oversew them at bedside. As I approached the wounds with a #10 blade, my hand trembled. I thought the movement was imperceptible, but my chief resident pulled me back and looked directly into my eyes. “This man has AIDS.” he told me. “Not HIV, AIDS.” He spoke calmly and softly so that only I could hear him. The message was clear: Cutting myself could be fatal. I needed to be careful, not fearful.

Fear is contagious, especially when it comes from authority figures. When I’m flying and we hit a bad patch of turbulence, the flight attendants are my barometer. If they look chill, then I’m not worried. But if they look a little freaked, then you better believe this $8 mini bottle of chardonnay is about to get crushed.

Patients obviously look to physicians for comfort. They want to know that we are in this together. Try to be comforting even when you don’t have any answers. The most common question patients asked me after Katrina was when will they be rescued. I always replied, “I don’t know, but before me.”

Lesson 5

The trainees are vital: University Hospital only lost three patients in the week after Hurricane Katrina, two of whom were terminal. This despite a lack of power and running water. Community hospitals in the region lost 10 times as many. I credit this difference to the residents. While the militaristic nature of our surgical teams may not always be ideal, it is incredibly efficient in times of crisis. After Katrina, patients could be rescued via airboat from the emergency room (ER) ramp or via helicopter from the roof. Rescue personnel were under orders not to enter the hospital. The doctors would have to get the patients out. Many couldn’t walk and would have to be carried up eight or nine flights of stairs. The prevalence of obesity among the non-ambulatory was not trivial. Since everyone on the team had clearly defined roles, difficult tasks were performed expediently. No patients were left behind. And all the doctors got to enjoy a nice hot Coke afterward.

Interlude B

Cloudy—with a chance of extinction: As I prepared to leave our home and head to the hospital before the storm, I decided that I should secure our valuables. I then had the depressing realization that we didn’t actually own any valuables. Maybe my hard drive? Better preserve that minor amputation draft for posterity. Just before unhooking the computer, I decided to check the forecast. I guess I thought it would be “funny.” I visited one of the weather sites, which usually would have said something like, “Highs tomorrow in the 80s with a 30% chance of afternoon thunderstorms.” Well, not this time:

“Most of the area will be uninhabitable for weeks… perhaps longer…the majority of industrial buildings will become non-functional. All wood-framed, low-rising apartment buildings will be destroyed. High-rise office and apartment buildings will sway dangerously…a few to the point of total collapse. All windows will blow out…persons…pets…and livestock exposed to the winds will face certain death…power outages will last for weeks…water outages will make human suffering incredible by modern standards…”

Hmm, I thought: So yes to the umbrella?

Lesson 6

Maintain routine: During an emergency, people tend to run around putting out fires. At University Hospital, we tried to continue our routine, even when it seemed absurd. We were low on food, the air was poisonous with sewage, and, worst of all, someone had stolen my deodorant. Still we charted, checked vitals, and continued the mundane. As our ability to care for the patients became compromised, there was a powerful desire to disconnect from them.

One woman developed a gastrointestinal bleed we could not control. We tried to prioritize her rescue. Every night the nurses would seal her chart in plastic so it wouldn’t be ruined in the transfer. No rescue ever came, though. Seemingly unable to face this horror, the nurses just kept her chart sealed, waiting for the escape that would never happen. Every morning, we would break the seal and resume her charting. It wasn’t right, it wasn’t fair, but we had to force ourselves to face our reality.

Lesson 7

This too shall pass: With the clarity of history, events seem much more self-contained than they were experienced. In the mid-1990s, AIDS seemed uncontainable, and widespread transmission of the virus to the general population appeared to be probable.

After 9/11, another attack seemed imminent. Working at Ground Zero, when the rare military plane passed, it was terrifying. Rescue workers covered their heads and ducked.

On Aug. 31, 2005, FEMA declared New Orleans unsafe for further rescue operations. The airboats and helicopters stopped coming. The governor called for a day of prayer. We were alone.

At University Hospital, hundreds of people were still left in rapidly deteriorating conditions. Outside, the water continued to rise mysteriously, long after the rain had subsided. Inside, the heat and humidity were overwhelming. Human waste was left unattended in the halls and stairwells. Most of our team started sleeping on the roof, where the air seemed slightly less toxic.

On the morning of Sept. 2, we were awakened by a massive explosion in the southern sky: a chemical plant, I later learned. As the mushroom cloud dissipated, the morning sun began to illuminate the city. Untended fires were burning in buildings throughout the city.

Looking down, the floodwaters—which had once been clear enough that I could see a large catfish swimming in the parking lot—were now black and slick like oil. Finally, I allowed myself to feel the doubt I had seen in the eyes of my patients. Maybe we wouldn’t be getting out. New Orleans had been leveled by wind and drowned in flood. And now it was on fire.

Though the feeling had barely a moment to fester as the sky was soon filled with Chinook helicopters—or double whirlies as I referred to them before I conducted a Google image search while preparing this. The impasse between the state and federal governments had resolved. The National Guard was here. Finally.

We don’t always know when the sun will rise. To be a good doctor, sometimes you just need to believe it will.