A Resident’s Reflections on the Brigham’s COVID ICU Launch
My attending, Dr. Sarah Rae Easter, and I joined a small group of nurses in a clean, empty room. The nurse at the front of the group was demonstrating how to don and doff, or how to put on and remove our personal protective equipment (PPE). Putting on and removing PPE properly is important in order to avoid self-contamination and reduce further spread of SARS-CoV-2, the virus that causes COVID-19. Once this session ended, we attended a workshop on ventilator settings. We then circled back to our unit to prepare for the rest of the afternoon. It was Thursday, March 19th. The very first COVID ICU and team had just been activated and we were about to admit our first patients.
Challenges of Caring for COVID-19 Patients Early in Crisis
The next few days were a whirlwind as things escalated quickly. As with anything starting from scratch, our work in the ICU required a great amount of quick learning and adjustments on the go. Health care providers from all disciplines came forward—critical-care-trained attendings and fellows, surgery and anesthesia residents, teams from infectious disease and palliative care, ICU-trained nurses, respiratory therapists and many more.
Together, we were trying to figure out how to optimize patient care with the universal paucity of information providers globally had early on about the virus. Our patients’ clinical statuses were extremely fragile, and the acuity at which they could deteriorate was what kept us on our toes most of all. Was our medical decision-making, to the best of our knowledge of such a novel virus, adequate enough to protect and save our patients? The pressure to do so and the uncertainty of our efforts were daunting.
Throughout the day we were constantly pulled in different directions, and every hour brought new change and action. One moment we were calling patients’ families and consultant teams, and the next, we were urgently on our way to the ED to evaluate a new patient’s need for ICU level of care. While we were working with materials management to gather equipment to create a well-stocked shelf for central and arterial lines, we suddenly had to break away and call anesthesia for a STAT intubation—a procedure in which a health care provider places a breathing tube through the patient’s mouth into the trachea. Our morning and afternoon rounds were frequently interrupted by an alarming ventilator or cardiac monitor, indicating a patient’s rapid decline requiring our immediate attention. We often worked into the night to finish up tasks, and yet, somehow these long, packed days passed quickly in the midst of all of the chaos.
Comforting Families of COVID-19 Patients
One of the more distressing challenges we faced, and still do today, was figuring out how to gracefully alleviate the worries of concerned families unable to see their loved ones, due to a newly established, hospital-wide no visitor policy. Daily phone calls were held with family members to discuss a patient’s progress, or not infrequently lack thereof, and to console them when things took a turn for the worse. It was important to recognize that we were not only caring for our patients, but also for their families and friends.
These conversations with parents, spouses and children were often a flood of emotions, as we felt their agony over the gravity of the circumstances coupled with their inability to be at their loved one’s side. And yet, within the same phone call we also received expressions of thankfulness for our hard work. So here we faced another internal struggle. Was our hard work actually sufficient in taking care of these patients? If it was, how come so many of our patients were requiring extreme measures and were still unable to be weaned off the ventilator?
At times it seemed unfair and wrong to accept these words of appreciation, as we felt helpless in the little progress we were making and as no one could predict how our patients were going to be, let alone if they were going to survive. Deep down, we wished we could do so much more. Deep down, we felt unworthy of their gratitude.
Moral and Ethical Decision-Making During COVID-19
A particularly somber and difficult case our team dealt with early on involved a fairly young patient already in the final stages of a terminal illness. She had many reasons to be critically ill, but testing for COVID as the cause of her decline was necessary. Given significant worsening of her health, her family opted to transition our focus from lifesaving actions to comfort-oriented care.
During this transition to comfort measures, one of the most trying factors our team had to iron out was how to sympathetically allow the patient’s family to be at her bedside when visitors were restricted from the hospital. There were no policies in place yet for this situation, and so we involved the palliative care team, biothreats team, the charge nurse and the chaplain in several discussions around this moral and ethical responsibility of our team.
How can we make it possible for her husband, her children, and her parents to hold her hand and whisper in her ear that they were there with her, so that she would not have to die alone? But on the other hand, how do we protect these individuals from the dangers of viral exposure—especially in a high-risk environment such as the COVID ICU—and the chances of contracting the virus and further spreading it elsewhere outside of the hospital? Even though her presentation was low risk for COVID infection, if we were to allow visitors for this one patient, how do we justify and decide for all of our other patients who could be seen, touched and held by their loved ones?
Ultimately, the patient’s husband and children were permitted compassionate passes to be with the patient in her last hour of life. Our nurses helped them don their PPE prior to entering the room, discontinuing the medications supporting her blood circulation and increasing her sedation to ensure her comfort. The patient passed away peacefully in the early hours of the morning with her family at her side. Unfortunately, her parents could not be with her when she passed. Given their older age, which placed them at a high risk for viral infection, along with the hospital policies meant to protect them, they were unable to say their final goodbyes to their daughter.
Evolution of COVID-19 Clinical Care
Many things have changed since our ICU opened its doors on day one. Multiple ICUs and teams are now in place, along with updated protocols and resources, as we continue to learn more about improved processes and treatments to manage these patients.
Early on, nurses inside rooms would write what they needed on slips of paper or dry erase boards to hold up against the window to responders outside to minimize viral transmission. We have a new video intercom system inside and outside of each room for clearer and quicker communication. There are now COVID-specific airway teams, procedure teams and prone teams, comprised of individuals redeployed from various disciplines and available at all hours to assist with their respective tasks.
We also now have donated iPads for families to call in and use FaceTime to speak with patients, whether intubated or extubated, so that they may feel their presence, share their love and understand their clinical trajectory and prognosis. Furthermore, patients are now encouraged to record messages to send to loved ones prior to intubation and sedation should they need them, as sadly, one never knows when their last words will be just that.
Inspiring Moments During COVID-19 Crisis
In the ICU, we face death and dying every day. I have changed more code statuses and signed more death certificates in the past month than I have in my past two years of residency training. Our patients’ stories are often mournful and disheartening. But we also witness acts of kindness, share glimmers of hope and celebrate small victories when we can.
A successfully extubated patient, a transfer from the ICU to the floor, a discharge from the hospital—these shared moments of triumph and joy are what we need to be grateful for and hold on to. Operation Hope is an initiative that announces an upcoming COVID patient discharge across the entire system so that people from all corners of the hospital can come together and cheer on the patient while they are wheeled outside. This victory isn’t just for the patient and their team, but for our entire Brigham community as a whole, so that we may exchange our sources of pain for beacons of hope.
Brigham Health Community Fights COVID-19
Our community has come together to fight for the greater good, and I continue to be inspired and in awe of those I am surrounded by. Dr. Easter, the first attending to take on a COVID ICU, was our dynamic and fearless leader who was resilient, empathetic and passionate about caring for our patients. She tackled every single challenge with grit and grace. Her drive and devotion made our team’s job easier every day.
Drs. Deborah Hung and Francisco Marty, invaluable collaborators from infectious disease, were at the forefront in guiding critical decisions on COVID testing, patient enrollment in clinical trials and much more. Dr. Stephanie Nitzschke, a trauma and critical care surgeon I am unbelievably fortunate to train under, has been heavily invested since the beginning of this crisis. She organizes all current and future ICUs, creates clinical protocols for new standards of care, takes on patient care herself as an ICU attending and continues to lead relentlessly from behind the scenes in determining how to serve and protect our patients as well as our own teams. Her profound impact and unwavering support continue to fuel my fire. Overall, it has been humbling and an honor to learn from such giants in the field.
Of course, this is only a handful of individuals from a whole army of people who have stepped up to take on roles they may not be comfortable with to help in any way they can. Residents, physician assistants, fellows and attendings from multiple specialties have all joined together to form ICU teams. Nurses, respiratory therapists, phlebotomists, radiology technologists, environmental services staff and so many more demonstrate the utmost bravery and fortitude. They are truly the unsung heroes in this battle, as they frequently enter patients’ rooms and expose themselves to the dangers and unknowns of the virus. Their incredible dedication is undeniable. It has been a privilege to work alongside our Brigham family during this time.
As we all look forward to the days of defeating COVID and await for some semblance of normality to return, we can continue to practice gratitude, seek purpose and demonstrate humanity. Tell your family and friends you appreciate and love them, now and daily. And at the end of all of this, hug and hold them closely. Not everyone will have this chance.
To my fellow healthcare providers, check in with your colleagues, whether they are on the COVID frontline or not. We, as physicians, often don’t practice self-care. Be kind to and support one another. Now is the time. And finally, thank you to all involved in serving those in need during this extraordinary time. Everyone is a hero in rising up and fighting this pandemic, regardless of your role. Above all else, it is the courage to keep pressing forward against adversity, the resilience and selflessness behind all efforts and the endless support shared that are essential and meaningful in protecting our community. Right now our world needs people who do well and who do good. Let’s continue to do good together, serve together and be stronger together.