Thursday, May 21, 2020

Are Doctors Heroes?

The effervescent rays of sunshine spread their warmth across my back as I walk along Omaha Beach in Normandy. French children kick around a soccer ball, shouting and giggling across a fifty-yard stretch of sand. A tranquil ocean extends into the horizon, effortlessly mingling with the sky making it impossible to tell where one starts and the other ends. Looking out across the serene water, I imagine June 6, 1944 and the chaos that once enveloped these beaches. The young American soldiers landing here faced an onslaught of bullets from Nazi pillboxes — concrete bunkers with holes to fire through — hidden safely in the hills.

Omaha Beach
Photo: Aaron Rothstein

That day alone, Americans suffered two thousand and four hundred casualties. As the bodies of young men washed ashore, the fortunate survivors endured gunshot wounds while crawling up the beach amidst the blood-soaked waves. One member of the 116th Infantry Regiment said: “They’re leaving us here to die like rats.” D-Day provides a chilling and indelible reminder of the terror of that war and its tragic necessity; of the noble and valorous sacrifice our young heroes made to rid the world of Nazi Germany.

Normandy American Cemetery and Memorial
Photo: Aaron Rothstein

I think of my trip to Omaha Beach as the 76th anniversary of D-Day approaches and I enter the hospital each morning during the Covid-19 pandemic. “Welcome healthcare heroes!” one sign reads outside an academic hospital. “Heroes enter here!” reads another. I walk in with a mask and use a squirt of Purell on my hands, as a nurse in a gown, face shield, and mask takes my temperature. If I’m afebrile I enter the hospital. A nurse standing at the entrance shouts “Thank you, heroes!” at approaching physicians and nurses. This is not restricted to hospital entrances. Toymaker Mattel created a #ThankYouHeroes toy line of nurses, physicians, EMTs, and delivery workers. Signs hanging outside of house windows read: “Thank you essential workers for your heroism!” The quarantined populace clangs pots and pans at 7 pm throughout the city streets in honor of essential workers. From cooks to janitors to doctors: all are now heroes in the public eye. This wellspring of gratitude is well-intended and appreciated. But are those of us who work in these jobs truly heroes?

***
In the mid-19th century, Thomas Carlyle, a British historian and writer, published a series of lectures in a book entitled On Heroes, Hero-worship and the Heroic in History. Though Carlyle offered some unusual theories about the role of heroes, we ought to consider the elements of his definition of a hero:

They were the leaders of men, these great ones; the modellers, patterns, and in a wide sense creators, of whatsoever the general mass of men contrived to do or to attain; all things that we see standing accomplished in the world are properly the outer material result, the practical realization and embodiment, of Thoughts that dwelt in the Great Men sent into the world: the soul of the whole world’s history, it may justly be considered, were the history of these.

A hero doesn’t just make a difference. A hero alters the trajectory of mankind, changes the soul of humanity, and, I think, takes a significant risk or makes a weighty sacrifice in the process. A hero is not a God but may seem God-like.

What about those who make a difference even if they’re not shaping the arc of history? True, there are many who, through their professions and their actions, perform moral and selfless deeds. But, as Carlyle explains, “We see men of all kinds of professed creeds attain to almost all degrees of worth or worthlessness under each or any of them.” A hero reaches even beyond such worth despite his or her imperfections.

Fortunately, there are plenty of examples throughout history of this, like the soldiers who stormed Normandy. Through their ultimate sacrifice they brought an end to Nazi genocide and sowed the seeds of freedom for millions of others. They suffered the cruel conditions at Omaha Beach and on other battlefronts to shape the world order for the better.

While physicians risk their lives during this pandemic, it is not quite the same. We come to work each day knowing that the day will end as we climb into bed, however far away from our families we are. For those of us with access to supplies, we don masks, gowns, and gloves to take care of patients with the virus and wash our hands before and after every encounter. As Dr. Greg Katz, a cardiologist in New York (and, full disclosure, my chief resident when I was an intern), writes,

After the first few weeks of the pandemic when I had a legitimate fear for my safety due to the PPE shortage, we’ve largely been able to protect ourselves working in the hospital….

When we suspect a patient may have COVID, they get a designation as a PUI, or person under investigation, and are kept in an isolated room. We only enter wearing full protective equipment - N95, gowns, gloves, head covering.

When we are in a COVID unit, the equipment is even more protective, where each physician has a PAPR along with supervised donning and doffing procedures.

Don’t get me wrong, it’s not a risk free endeavor, but health care workers who take adequate protections have a pretty low risk of getting sick.

While we make a dramatic difference in the lives of our Covid-19 patients, we are doing what we do every day, whether there is a contagion or not: helping patients as we swore to do when we entered the profession. This is not to say that there are not heroes among us. For instance, the late Dr. Lin Wenliang, a Chinese ophthalmologist who faced censorship from the Chinese government while risking his life and reputation to warn the world of the pandemic, is a hero. And yet, even while some physicians and nurses selflessly volunteer on Covid-19 units or in overwhelmed hospitals, a good number of us sometimes shirk our duties. In a piece for Quillette, Amy Eileen Hamm, a nurse, writes about how some doctors and nurses would rather not have to work.

To be sure, this is an exceptionally difficult time, even as tragic hospital work goes. Read the terrifying diaries of those working during this frightening contagion:

The evening before I’m due to return to the hospital, a colleague messages our group to say that a 49-year-old Covid patient of hers, who was waiting in the E.R. for an inpatient bed, was found blue and dead in a chair. Nobody even knows if he gasped before he died.

These stories echo throughout the daily news reports. Moreover, this virus takes a horrible, irreversible, and deadly toll on some of the doctors and nurses themselves, many of whom die or suffer from Covid-19. At least several thousand health care workers have been infected by the virus, and some dozens have died. Indeed, one mustn’t forget or dismiss the awful consequences and sacrifices of working in a hospital during this contagion, whether we call these workers heroes or not.

But it is confusing to call them heroes while hospitals and government bungle a response to the pandemic. For example, some physicians and nurses do lack the appropriate PPE to shield themselves from infections. This is not true at every institution, but it was prevalent enough at one time to endanger doctors and nursing staff. And if they protested against such shortages, as Dr. Ming Lin of PeaceHealth St. Joseph Medical Center found out in March, hospitals threatened or dismissed them. Other physicians, in the face of plummeting hospital revenue, face pay cuts of up to 40% as well as staffing shortages. In a survey one-fifth of physicians experienced pay cuts or were furloughed due to the economic tragedies of the pandemic. True, many institutions experience financial hardships. However, hailing physicians and nurses as heroes while making these cuts and threats does not change that reality as much as it reinforces it.

Ultimately, using the “hero” misnomer reveals an appreciation for those treating Covid-19 patients. But let us not confuse gratitude with near-deification. Doctors and nurses are humans, filled with cowardice and courage, both of which manifest in different ways. Physicians do not storm Omaha Beach in the face of gunfire. Nor is the soul of the whole world’s history the history of them. By obfuscating this, we needlessly amplify doctor’s and nurse’s deeds and diminish our own failures to aid society’s healers.

We should not call our physicians and nurses heroes, even if many of them act courageously. Nor should we call them by the anodyne and mundane name, “health care providers.” They are, perhaps, something in between.

Thursday, April 30, 2020

The Other Victims of Covid-19

“I just want to run this case by you,” the emergency room doctor at the other hospital told me on the phone. We frequently get these calls from other hospitals. Smaller emergency rooms with fewer resources often don’t know what to do in complex situations. After all, scientific literature in medical subspecialties changes rapidly and for a non-specialist these cases offer difficult conundrums. Moreover, smaller institutions don’t have access to specialists around the clock. Consequently, they turn to other medical centers for help. The physician told me the details of the case. A woman in her sixties with high cholesterol, diabetes, coronary artery disease and lung disease (COPD from years of smoking) developed some weakness on her left side about 1 week prior to arrival. The day before she came in her weakness worsened and she could barely walk and couldn’t lift her left arm. She called 911 to bring her to the hospital.

Her symptoms were consistent with an ischemic stroke – a blood clot lodged itself in a blood vessel cutting off circulation to the right motor cortex in the brain. (In our brains, the right side controls the left body and vice versa.) The emergency medicine physician ordered an MRI of the patient’s brain and intracerebral vessels. The MRI confirmed the diagnosis, showing a stroke with a clot in one of the large arteries known as the middle cerebral artery. Was there anything, the doctor wondered, we could do for this patient?

In the treatment of stroke, we often say “time is brain.” And the scientific literature bears this out. Approximately 1.9 million neurons die every minute the brain is deprived of blood flow. Ergo, strokes require immediate intervention for the best possible outcome. For those who present within four and a half hours of symptom onset, we give them tissue plasminogen activator (tPA). This drug breaks down clots in the body and though it poses a risk for bleeding, multiple trials demonstrate significant efficacy. Beyond four and a half hours, brittle vessels and brain tissue lead to an even higher risk of hemorrhage, outweighing the benefit of the drug. In patients with a clot in a large vessel in the brain (like the patient I was called about) we can use a catheter to pull out the clot from the blood vessel. Remarkably good evidence supports using this procedure up to twenty-four hours after symptom onset. Patients with large clots come in without the ability to walk, see, or speak. Ten to fifteen years ago they would have died in a nursing home. Today, with timely treatment, they can walk out of the hospital 2 days later. But if patients present after 24 hours from symptom-onset we can offer little beyond rehabilitation and secondary stroke prevention.

Though the patient was out of the time window for any acute therapy, I asked the physician to transfer her to our hospital to ensure she didn’t worsen further. After arriving by ambulance, I met the patient in the emergency room. On my exam, she barely lifted her left arm and leg, hopelessly struggling against the necrotic brain tissue. I discussed her condition, what had happened, and how we might help. We would have her do as much rehabilitation as possible to take advantage of neuroplasticity and get her stronger.

“Will I ever be able to live by myself again? Or walk again?” She asked.

Unfortunately, given the size of her stroke, she would likely require help to cook, walk, and drive. At least in the near future, her whole life would be dependent on the help of others. What would come one year down the line was uncertain. I told her not to lose all hope. Rehabilitation after stroke takes months and patients can make significant strides.

“Also,” I asked, forgetting myself, “any reason for waiting to come to the hospital?”

“Yes,” she said. “I was scared about the coronavirus and I wanted to avoid getting sick.”
***
Before Covid-19 hit the United States, I saw many patients who, alas, presented too late for treatment. Occasionally they couldn’t even use their dominant arm, but they waited hours or days to seek help. Some said they thought their deficits would improve, others worried about the hospital bill, or were skeptical of physicians. The data over the past few decades corroborates this experience. In a 1997 study in the Annals of Internal Medicine, physicians examined patients with myocardial infarction, or heart attack, and the delay between the onset of symptoms and hospital presentation. Forty percent delayed their presentation for over six hours. In a 2001 study, one-third of patients with symptoms like abdominal pain, chest pain, and shortness of breath – all potentially serious – delayed seeking care. And over two-thirds of these patients waited because they thought the problem would go away. In a 2019 study, Greek physicians found that of patients presenting to the hospital with acute stroke symptoms nearly one third arrived over four and a half hours after their symptoms started, putting them outside the window for tPA eligibility. In other words, even prior to the pandemic, many patients either chose not to come or physically could not come to the hospital despite life-threatening symptoms.

Covid-19 directly causes physical devastation and in so doing exacerbates the kinds of delays described above. The exact death rate from coronavirus alone is unclear given our lack of widespread testing and our ignorance about how many people actually have it. At one point, the case-fatality rate in China was 2.3%, in Italy at another point 7.2%, while some estimate 1-2% and lower. Whatever it ends up being, it is highly significant and crippling. As of this writing, notwithstanding drastic quarantine measures, the virus has claimed over two hundred thousand lives worldwide, and that number continues to increase. Most of us understand the risk and we seclude ourselves to mitigate the disease’s damage.

However, there are unintended effects of the current mitigation campaigns. There will likely be an increase in morbidity and mortality from other diseases. For instance, other hospitals and our own emergency room call us less frequently. My colleagues are seeing this as well; far fewer stroke patients come to the hospital now. Another colleague recently admitted a patient with a massive heart attack who stayed at home for fear of Covid-19. It’s not that the incidences of stroke or heart attacks are acutely falling – a highly unlikely scenario. Unfortunately, among other possibilities, I suspect patients, afraid of the virus and for their lives, avoid the hospital. They stay home with incapacitating symptoms, as the patient I treated did. Our public health response to the virus, though appropriate, compounds patient hesitancy to seek help.

The most up-to-date data bears out these anecdotes. In a small and imperfect observational study from Hong Kong during late January and early February, patients with bad heart attacks took nearly four times as long to present to the emergency room as others in prior years. Another study in the Journal of the American College of Cardiology collected data indicating a 38% drop in calls for certain types of heart attack emergencies across major hospitals in the country. And it’s not just in vascular disease where these kinds of delays and deficiencies occur. Reportedly, vaccine prescriptions have plummeted during the pandemic, too. Public health experts in England have warned that cancer deaths as an indirect effect from the virus will be higher than those directly caused by the virus. A New England Journal of Medicine article tells multiple stories of patients who were misdiagnosed or experienced a delay in care due to bias in favor of or fears of Covid-19. A full accounting of this kind of delay in or lack of treatment has yet to be done. But these are the other casualties from the Covid-19 pandemic: patients with treatable conditions who do not get treated in time.

How do we communicate urgency to our patients during this bizarre and frightening time? An ideal public health policy advocates staying home but encourages patients to seek treatment if something goes wrong. Unfortunately, in the chaos of a pandemic, myopia reigns and we focus on one disease to the exclusion of others. A deadly disease is deadly and requires treatment regardless of the contagion around us. If we and our leaders cannot modulate our message we may face an even worse, and preventable, tragedy.

Wednesday, April 15, 2020

A Journal of the Plague Months

Hostile to the past, impatient of the present, and cheated of the future, we were much like those whom men's justice, or hatred, forces to live behind prison bars.
— Albert Camus, The Plague
From 1665 to 1666, the Great Plague spread through London. Caused by a bacteria transmitted by the bite of a rat flea, it killed nearly a quarter of London’s population in the span of 18 months. Such a deadly conflagration must have seemed strange and terrifying to its victims; there was no germ theory to explain its spread, and the bacteria wasn’t even discovered until the late 19th century. Lack of understanding must have greatly amplified the terror caused by the symptoms: fevers, chills, headache, swollen lymph nodes, gangrenous limbs, and a tortuous journey to the other side. Attempts to ward off the disease included bonfires to cleanse the air, smoking, killing dogs and cats, sniffing sponges soaked in vinegar given to the sick, and bleeding patients with leeches.

Wikimedia
In 1722, Daniel Defoe, of Robinson Crusoe fame, published A Journal of the Plague Year. Though he was only around five years old when the plague cast a pall over London, Defoe wrote the book through the eyes of an in-person narrator, based on his collecting of facts, statistics, and journals. What emerges is an imaginative yet historically detailed account of the horror engulfing London. In an introduction to the book, UVA English professor Cynthia Wall writes: “Defoe was fascinated by this history of darkness, pain, and fear.... [H]e was always interested in how human beings behaved under conditions of great stress.”

That question is a perennial one. Plagues always come and go, from smallpox, bubonic plague, and influenza to the coronavirus. Nature often pits species against each other, and during pandemics the simplest organism pits itself against the most complex. In the new coronavirus, many of us bear witness for the first time to a widespread and frightening infectious disease. But the way we behave in the throes of this threat is neither strange nor unprecedented. Despite the advancements in germ theory, our fears, reactions, and actions remain altogether familiar. Some of this is due to the nature of avoiding the disease (isolation and quarantine), but some of this is due to human nature. In reading Defoe’s Journal, one senses his descriptions of the plague could be used for our encounter with today’s Covid-19. Below, I juxtapose my own voice (in regular font) to Defoe’s (in italics) to demonstrate just that.
***
Only weeks ago I walked home from work and the streets were packed with students, tourists, physicians, professors, campus security, nurses, and others heading out of their offices. I waited on the street corner in a throng of people, and as the traffic light turned green for us, we bolted, as a herd, to the other side. Even when I came to the hospital at night, the music and shouting from undergraduate parties percolated through the crisp wintry air. Now, with a quarantine in place to stop the spread of Covid-19, I walk home alone. It is rush hour and the empty streets offer only the echo of my clogs hitting the ground.

Chestnut Street, Philadelphia at 5 pm on March 19

It was a most surprising thing, to see those Streets, which were usually so thronged, now grown desolate, and so few People to be seen in them, that if I had been a Stranger, and at a Loss for my Way, I might sometimes have gone the Length of a whole Street, I mean of the by-Streets, and see no Body to direct me....

Restaurants and bars and construction sites, once bustling and clamorous, have morphed into inhospitable vacancies.

All the Plays and Interludes, which after the Manner of the French Court, had been set up, and began to encrease among us, were forbid to Act; the gaming Tables, publick dancing Rooms, and Music Houses which multiply’d, and began to debauch the Manners of the People, were shut up and suppress’d; and the Jack-puddings, Merry-andrews, Puppet-shows, Rope-dancers, and such like doings, which had bewitch’d the poor common People, shut up their Shops, finding indeed no Trade.

Alas, such closures, even if they are necessary to stem the tide of the virus, come with significant consequences for the economy and human lives. In the United States the number of jobless claims hit a record high, the markets experienced a free fall, the Federal Reserve’s index of financial stress is the highest it has been since the financial crisis over a decade ago. Airlines, hotels, opera houses and others lay off and furlough thousands of workers due to a fall in revenue. Many small businesses and gig-economy workers are now left without a source of income.

Tradesmen and Mechanicks, were...out of Employ, and this occasion’d the putting off, and dismissing an innumerable Number of Journey-men, and Work-men of all Sorts, seeing nothing was done relating to such Trades, but what might be said to be absolutely necessary. This caused the Multitude of single People in London to be unprovided for; as also of Families, whose living depended upon the Labour of the Heads of those Families; I say, this reduced them to extream Misery.

Only the supermarkets bustle with perpetual activity. Even there, however, something unsettles. As I walk in, a hush overtakes the entire floor. The volume of music is lower than usual, few conversations take place, no one speaks on a cellphone. The occasional cacophony of clanging shopping carts drowns out other ambient noises. Some shoppers wear masks and gloves, others don’t. They all rush to complete their shopping, heads down, stealing furtive and suspicious glances at others. Some, outwardly hostile, cut off comrades to get to the avocados or the bananas first. Handmade signs hang throughout the store limiting two milk cartons or two packages of butter per customer, as people scramble to store provisions. Shelves of canned goods lie empty, with the exception of canned beets (even during a pandemic, people haven’t lost their taste).

I must here take farther Notice that Nothing was more fatal to the Inhabitants of this City, than the Supine Negligence of the People themselves, who during the long Notice, or Warning they had of the Visitation, yet made no Provision for it, by laying in Store of Provisions, or of other Necessaries; by which they might have liv’d retir’d, and within their own Houses, as I have observed, others did, and who were in a great Measure preserv’d by that Caution.

As I walk home from the grocery store, those few people left on the street keep their distance from each other and from me. At the hospital, the same sense of anxiety and precaution exists. A nurse coughs in the hallway and everyone walking in his direction about-faces. A patient comes into the emergency room who spent an hour in a New York City airport two weeks prior and, though he is without symptoms, half a dozen phone calls are made to get the patient isolated and tested for Covid-19. We hold conferences by phone or by Zoom, we speak to each other while six feet apart, we all wear masks. We do all this with good reason. How can one know who’s infected and who’s not?  Who is the one person who will infect hundreds or perhaps thousands of others? Everyone potentially carries the enemy and we must treat them with caution.

It was a very ill Time to be sick in, for if any one complain’d, it was immediately said he had the Plague. (...)

And when People began to be convinc’d that the Infection was receiv’d in this surprising manner from Persons apparently well, they began to be exceeding shie and jealous of every one that came near them.

Then I say they began to be jealous of every Body, and a vast Number of People lock’d themselves up, so as not to come abroad into any Company at all, nor suffer any, that had been abroad in promiscuous Company, to come into their Houses, or near them; at least not so near them, as to be within the Reach of their Breath, or of any Smell from them; and when they were oblig’d to converse at a Distance with Strangers, they would always have Preservatives in their Mouths, and about their Cloths to repell and keep off the Infection.

Some disagree with strict measures and act as such: spring breakers in Florida, some religious communities who have insisted on gathering in person. Ergo, the virus hit these groups particularly hard.

And tho’ it is true, that a great many Clergymen did shut up their Churches, and fled as other People did, for the safety of their Lives; yet, all did not do so, some ventur’d to officiate, and to keep up the Assemblies of the People by constant Prayers. (...)

And indeed when Men are once come to a Condition to abandon themselves, and be unconcern’d for the Safety, or at the Danger of themselves, it cannot be so much wondered that they should be careless of the Safety of other People. (...)

By the Well, I mean such as had received the Contagion, and had it really upon them, and in their Blood, yet did not shew the Consequences of it in their Countenances, nay even were not sensible of it themselves, as many were not for several Days: These breathed Death in every Place, and upon every Body who came near them; nay their very Cloaths retained the Infection, their Hands would infect the Things they touch’d....

The consequences of ignoring the stay-at-home orders are not just devastating for those we encounter at work or on the street, they are deleterious to our families and friends. In New Jersey, one woman and three of her children died from the virus while other infected family members required ICU care — all likely contracted the disease at a family gathering held on March 10th. One family in rural Georgia faced a similar tragedy after a funeral on Feb. 29th became a “super-spreading event,” causing relatives to fall ill.

They told us a Story of a House in a Place call’d Swan-Alley, passing from Goswell-street near the End of Oldstreet into St. John-street, that a Family was infected there, in so terrible a Manner that every one of the House died; the last Person lay dead on the Floor, and as it is supposed, had laid her self all along to die just before the Fire.

In order to prevent such contagion, family members cannot be with their loved ones in death. Though understandable, this is heartbreaking. I, unfortunately, have seen this with some of our patients. And many have died without family at their side or at their burial, and family members saying goodbye over FaceTime.

I could give several Relations of good, pious, and religious People, who, when they have had the Distemper, have been so far from being forward to infect others, that they have forbid their own Family to come near them, in Hopes of their being preserved; and have even died without seeing their nearest Relations, lest they should be instrumental to give them the Distemper, and infect or endanger them.

Coronavirus has also caused material shortages. Doctors make their own masks, ventilators are in short supply, morgues are overflowing, trenches are dug to bury the dead.

It was a great Mistake, that such a great City as this had but one Pest-House.... I say, had there instead of that one been several Pest-houses…I am perswaded, and was all the While of that Opinion, that not so many, by several Thousands, had died. (...)

I say they had dug several Pits in another Ground, when the Distemper began to spread in our Parish, and especially when the Dead-Carts began to go about, which, was not in our Parish, till the beginning of August. Into these Pits they had put perhaps 50 or 60 Bodies each, then they made larger Holes, wherein they buried all that the Cart brought in a Week, which by the middle, to the End of August, came to, from 200 to 400 a Week.... But now at the Beginning of September, the Plague raging in a dreadful Manner, and the Number of Burials in our Parish increasing to more than was ever buried in any Parish about London, of no larger Extent, they ordered this dreadful Gulph to be dug.

The Pest House and Plague Pit in Finsbury Fields (Wikimedia)

In the midst of the chaos, fear, and tragedy, some have advertised unproven remedies, sometimes for personal profit. In March, Dr. Vladimir Zelenko used a combination of the antimalarial drug hydroxychloroquine, the antibiotic azithromycin, and zinc sulfate to help patients, saying that one-hundred percent of his patients survived the virus without any hospitalizations. At the time, little was known about the potential effectiveness of hydroxychloroquine for Covid-19 to put much confidence in this; an NIH trial is now underway. Other claims have been more outrageous. The FBI recently arrested Keith Lawrence Middlebrook, an actor who has been charged with soliciting investments in a company claiming to have a cure and prophylactic drug for the disease. And in March, the state of Missouri sued televangelist Jim Bakker for selling a spurious antidote on his show.

On the other Hand, it is incredible, and scarce to be imagin’d, how the Posts of Houses, and Corners of Streets were plaster’d over with Doctors Bills, and Papers of ignorant Fellows; quacking and tampering in Physick, and inviting the People to come to them for Remedies; which was generally set off, with such flourishes as these, (viz.) INFALLIBLE preventive Pills against the Plague. NEVER-FAILING Preservatives against the Infection.... INCOMPARABLE Drink against the Plague, never found out before.

Some resort to thieving. In Australia, some have stolen personal protective equipment and hand sanitizer from hospitals. Others use the pandemic to defraud unsuspecting consumers: the FBI sees a rise in phishing emails from fake charity organizations, the CDC, and airline carrier refund accounts to steal people’s money.

That there were a great many Robberies and wicked Practises committed even in this dreadful Time I do not deny; the Power of Avarice was so strong in some, that they would run any Hazard to steal and to plunder.

Some hospital leaders have been accused in the press of fleeing the chaos, instead of leading from the front.

It is very certain, that a great many of the Clergy, who were in Circumstances to do it, withdrew, and fled for the Safety of their Lives.

In the United States, most of this could have been prevented, and the failure of our leadership to respond swiftly when it had the chance, instead of playing down the threat, will go down in history as a colossal, deadly mistake.

But it seems that the Government had a true Account of [the Plague], and several Counsels were held about Ways to prevent its coming over; but all was kept very private. Hence it was, that this Rumour died off again, and People began to forget it, as a thing we were very little concern’d in, and that we hoped was not true.

Even in the midst of failure and greed, there is hope. While some of our officials were slow to respond, many are demonstrating remarkable leadership and resolve. Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, is one of them. He regularly speaks with all kinds of public figures including basketball stars, talk show hosts, and Silicon Valley executives, to update the public on the virus and the plans of the Covid-19 response team, all while dodging partisan politics. Always well-informed and steadfast, he understands how serious this is and what needs to be done to mitigate it; and he communicates frankly and clearly to his audience. As thanks for this, he received numerous threats and the Department of Health and Human Services beefed up personal security for him. Captain Brett Crozier of the Navy’s USS Theodore Roosevelt disseminated a memo warning Navy leadership about a Covid outbreak amongst his crew on the ship, bringing attention to a deadly scenario. For this act of leadership, unfortunately, the Navy removed him from his post.

But ‘tis true also, that a great many of [the Clergy] staid, and many of them fell in the Calamity, and in the Discharge of their Duty.

Other charitable actions give us hope, too. The government, notwithstanding some dithering, passed a massive financial package to help those affected economically by the virus. While some will undoubtedly need more, this is a good start. And private donors stepped up as well. Whatever one may think of his politics, Sheldon Adelson, a Las Vegas hotel mogul, pledged to pay all his workers for two months despite the brutal economic downturn hitting the hospitality industry. The New England Patriots owner Robert Kraft sent the team plane to China to pick up over 1 million N95 masks and bring them back for healthcare workers. And here is a list of 30 companies donating their proceeds to relief charities. These are just a few of many examples.

The Concern also of the Magistrates for the supplying such poor Families as were infected; I say, supplying them with Necessaries, as well as Physick as Food, was very great, and in which they did not content themselves with giving the necessary Orders to the Officers appointed, but the Aldermen in Person, and on Horseback frequently rid to such Houses, and caus’d the People to be ask’d at their Windows, whether they were duly attended, or not? (...)

Nor was this Charity so extraordinary eminent only in a few; but, (for I cannot lightly quit this Point) the Charity of the rich as well in the City and Suburbs as from the Country, was so great, that in a Word, a prodigious Number of People, who must otherwise inevitably have perished for want as well as Sickness, were supported and subsisted by it.

Difficult times lie ahead. It remains to be seen how successfully we get through the worst and how quickly we will settle back into a relatively normal life. One hopes that it is soon enough to help those in dire economic straights, but not too soon as to cause unnecessary death. I imagine we will one day witness what Defoe described:

It is impossible to express the Change that appear’d in the very Countenances of the People.... It might have been perceived in their Countenances, that a secret Surprize and Smile of Joy sat on every Bodies Face; they shook one another by the Hands in the Streets, who would hardly go on the same Side of the way with one another before; where the Streets were not too broad, they would open their Windows and call from one House to another, and ask’d how they did, and if they had heard the good News, that the Plague was abated.

Wednesday, February 26, 2020

The Absent Oncologist

We admitted the patient to our service from the emergency room to treat her for thrombocytopenia (an abnormally low platelet count) and spontaneous bruising. The patient, in her fifties, was otherwise healthy. True, she had been treated for stomach cancer nearly seven years ago, but it was in remission and had been for a while. She had no issues eating or drinking, no problems going to the bathroom, no blood in her stool, no vomiting, no bloating, no severe acid reflux. In other words, she had no residual gastrointestinal symptoms.

Over the next two days, we ordered other labs, and their results concerned us. Not only were the patient’s platelets low and getting lower, but other blood markers were abnormal, too. Her fibrinogen, a protein that circulates in the blood and helps the blood clot, was also dangerously low. Her INR (international normalized ratio), which measures the time it takes for the body to create clots, was high. These aberrations indicated disseminated intravascular coagulation (DIC). In this disorder, the bloodstream rapidly forms clots, thus exhausting the body’s platelets and clotting factors. With fewer available platelets and clotting factors, patients also experience bleeding. DIC induces a terrifying, circular, and deadly process of clotting and bleeding. As one study showed, if the underlying cause of this brutal pathology is not controlled, mortality is over 20%.

A plethora of disorders, including bloodstream infections and malignancies, cause DIC. But the patient did not have a bloodstream infection — all of her blood cultures were negative and she had no symptoms of an infection. On day two of her hospitalization, we obtained a CT scan of her abdomen and chest, looking for a malignancy. Tragically, metastatic gastric cancer lesions riddled her liver while a recusant growth consumed her stomach leaving little normal tissue in its wake. Unfazed, she calmly stated she understood and asked what her next options were. Though her husband seemed more shaken by the diagnosis, he, too, wanted only to know what came next. This was a diagnosis she had faced and survived before. She believed strongly she could survive it again. We told the patient and her husband that we would contact her oncologist, the same one who had treated her gastric cancer originally. She would, we explained, help us figure out what treatment options existed. It was as if there was a transient release of pressure in the room; they trusted the oncologist and were glad that we were getting her involved. Since it was late in the evening, we promised to reach out first thing in the morning.

On the third day, I called the patient’s physician. Because she was busy seeing patients in clinic and unavailable to take my call, I left a message with the secretary asking that she call me back as soon as possible. The secretary also took down the patient’s information so the oncologist could at least look at the scans and laboratory results to get an understanding of what was going on. When we rounded that morning, I let the patient and her husband know of this development; all of us expected the oncologist would reach out to our team later in the day. But by the end of day three there was no word. I spoke with my attending physician about our dilemma. Since we were not oncologists, we could not prescribe chemotherapy and we didn’t know what the appropriate treatment should be for the patient. All we could do was treat the DIC by transfusing platelets and control the patient’s pain and nausea. Suspended in a kind of medical purgatory with our patient and her husband, we waited for some direction. Our attending physician reached out to the oncologist that evening via email. Perhaps a fellow faculty member’s missive would indicate the urgency of the matter.

But day four brought more of the same. None of us had heard anything from the oncologist after three calls that day. The patient and her husband became understandably more frustrated and their future seemed much more opaque. The patient’s husband pulled us aside and sternly rebuked us. How could we let her sit here like this with no treatment? What was our plan to help her? How were we going to deal with this resurgent cancer diagnosis? With no good explanation we deferred and equivocated, stating that we were doing our best to get in touch with the oncologist who would hopefully give us some guidance soon.

On day five the patient’s mental status deteriorated. She drifted in and out of sleep. Three meal trays came and went untouched. We called another oncologist and asked him to see if he could get in touch with the patient’s primary oncologist or at least recommend some kind of treatment — later in the day he told us that perhaps there were some options but it was not his area of expertise. Not to worry, he assured us, he had spoken with the primary oncologist and she would be in touch with us soon. But she never called. The patient’s husband expressed more and more frustration and anger. Why did the oncologist, someone they had known personally for years, not even come to the bedside to see them? Why did her office not return even the husband’s calls, let alone our own? It was not just a personal affront to them but a professional affront to us. We felt helpless.

Finally, on day six, our attending got in touch with the patient’s oncologist and during a phone conversation asked about possible chemotherapy options. She replied, “What chemotherapy? There is no chemotherapy option! There’s no treatment option whatsoever.” By this time our patient was more somnolent, more often unconscious than conscious. She labored to breathe as her pale and gaunt face withered away. She was dying. I spoke with the husband and told him that we had finally heard from the oncologist: no chemotherapy options existed. We could only make her comfortable as she passed from this world. It was as if he knew this was coming, throwing his hands up in the face of this tragedy and walking out of the room in tears.

At the end of the week, the patient died.

We were indignant. Clearly, the oncologist abandoned her patient. Despite the close relationship they once had, she had not come to see the patient nor reached out to her or her husband to explain the situation. Anger permeated our team’s discussion that evening as the two residents on my team and I packed our bags and headed out of the hospital. We swore we would never do that to our patients.

One cannot know for certain what was going through the oncologist’s mind as her patient’s illness evolved. And it is difficult to malign such behavior without knowing all that was happening at the other end. Did she feel overwhelmed by the grief of her day-to-day job? Because of her closeness to the patient and the patient’s husband, did she want to avoid telling them the prognosis and outcome? Whatever the case may be, it was wrong of her to vanish when the most trying time came. Yet it is worth exploring what may have occurred.
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In his book Thinking, Fast and Slow, Nobel laureate Daniel Kahneman, an economist and psychologist, explains that psychological literature supports the concept of familiarity breeding comfort. Repetition, he states, “induces cognitive ease and a comforting feeling of familiarity.” He describes how, in an experiment run at the University of Michigan and at Michigan State, psychologist Robert Zajonc and his team placed Turkish words in ad-like boxes in the student newspapers. Different Turkish words were shown at different frequencies, some once, some up to twenty times. The investigators then sent questionnaires to the students asking about their impression of the words. Kahneman writes, “The results were spectacular: the words that were presented more frequently were rated much more favorably than the words that had been shown only once or twice.”

Medical training is nothing if not a long series of repetitions, of exposures to similar diseases and situations. An oncologist sees cancer and its morbid consequences every day. This may not breed the kind of positive reactions that Kahneman describes, but it likely elicits an increasingly tepid and nonplussed response from the physician. Poor outcomes or test results shock less than they would most others. Perhaps our patient was one of ten with similar diagnoses witnessed by the oncologist in the last month, and one of a hundred in the last year. And maybe that led to a dismissal of this fatal and unconquerable diagnosis. Why invest time in another situation like this when failure is guaranteed?

Danielle Ofri, a clinical professor at the NYU School of Medicine, thinks about this slightly differently. In her book What Doctors Feel, she references a 2012 study on the nature of grief and patient loss in the lives of oncologists. The oncologists in the study attempted to compartmentalize their sadness and grief in order to keep them separate from their work and their personal lives. But they failed terribly. Dr. Ofri writes,

The pervasiveness of death often led to a relentless sense of grief among the oncologists, not just for the patients who had died but for the patients who they knew would be dying soon.... Grief ate at these doctors, distracting them from both their families and their patients. Many reported withdrawing from emotional involvement with their patients and that their patients had noticed they weren’t fully present.

The problem, in Dr. Ofri’s eyes, is an overwhelming amount of grief thrown at the physician on a day-to-day basis. It is certainly possible, in the particular circumstance I described, that the oncologist felt too sad and too upset to come see the patient.

Interestingly, both of these theories are rooted in the same etiology: overexposure. It is a conundrum of our nature as human beings. Repetition either exhausts us or anesthetizes us. Do we need to limit physician hours or days worked? Do we need to limit physician obligations during the day to allow for these kinds of important conversations? I don’t know the answer. Until we figure out a solution, reason and empathy must keep watch over our conditioned responses, lest we abandon those most in need of our help.