[An anonymous submission by a physician at a New York City-area hospital.]
If you wanted to concoct a story of a cruel, vengeful god who plotted to induce madness upon all of humanity, you could not do better than the COVID-19 pandemic. Under normal circumstances, all it takes is a few sensible, simple, commonsense hygiene practices to prevent infectious illness from becoming a major public health problem. As diseases go, the usual suspects are pathogens we know well (influenza, rhinovirus, etc.), whose disease courses tend to follow a familiar and predictable narrative: prodrome, syndrome, convalescence, immunity. Serious illness is an exception to the rule with these players, and it clusters predictably in familiar groups of outlier hosts: the very old, those with severe medical problems, the very young. These individuals are at risk roughly as to how old, close to being newborns, or medically complicated they are.
So we’ve become used to a certain logic and proportionality in managing communicable diseases for both individuals and populations: follow good commonsense hygiene practices as much as you can; identify the high-risk outliers based on well-established principles and manage them more intensively than the others; watch closely for deterioration soon after the onset of the syndrome, and if things look OK, the vast majority of the time they’ll be OK. Do most of the right things most of the time for most of the population, and things will be mostly fine.
COVID-19 defies all our notions of logic and proportionality. Commonsense hygiene practices are very clearly not enough to keep it from spreading like wildfire. Every day you hear about people getting sick despite their having taken what seem to be reasonable precautions. The volume and frequency of new patient presentations is dizzying, but the course of hospitalization is long and apparently immutable. When hospitals are handling the usual mix of diseases, they’re able to stay in homeostasis by discharging roughly the same number of patients as they admit on a day-to-day basis.
With COVID, it seems on the average day like we’re doing five new admissions for every discharge, at least right now. It’s not hard to see why we’re running out of places to put these people. (And even if we find the places, where do we find all the caregivers to deploy into them?) The course of the disease is erratic and unpredictable. People who sound low risk based on age and medical history are popping up with life-threatening cases. People who look like they’re OK to stay out of the hospital or like they’re about to pull through, suddenly fall of a cliff. They then seem like they’ve recovered somewhat, but fall off an even steeper cliff some days later.
The pandemic requires collective action, but at the same time requires the disintegration of collectives. We must endure unbearable stress and boredom to survive, but so many of the normal mechanisms for releasing stress – socializing, community, live entertainment, sports, commerce – have been abolished. We need to alter the age-appropriate behaviors of our children, yet don’t really know how much of the macabre truth we should be telling them. We need more healthcare workers to care for all the patients, yet everywhere we look they’re being taken out of the worker side of the equation, and added to the patient side.
And about that: Yes, it’s happening. We’ve had to treat numerous doctors and nurses as patients at my hospital. Some of them are not doing well. None of them has failed to meet or exceed whatever the shifting standard of self-protection was at the time they were exposed. You think about this every time you open the door to the room of a COVID-19 patient.
So what qualifies as PPE in my neck of the woods these days, and how does it actually work where the rubber meets the road? You’re issued an N-95 mask that’s yours for the shift. If you got your hands on a set of goggles in the early days, you’ve got that. If not, you get a face shield about the size of the bill of a baseball cap that’s made out of flimsy plastic like those cartons they sell salad greens and strawberries in. For the most part, you strap your N-95 and face protection on at the start of the shift and try to line up all your COVID-19 patients (a.k.a., all your patients), and see them one after another without touching, adjusting, or taking off the mask and face shield. Those who’ve been there before us have said you don’t want to be whipping a contaminated mask off your face and then putting it back on.
At the threshold of each room, you don a pair of nitrile gloves, then a rather pathetic-looking cloth gown. It looks like the smock you used in second-grade art class, and has two ties in the back, one behind the neck, and the other at the beltline. If you aren’t good at tying knots behind your back with gloves on, you spend a bunch of awkward, sweaty moments fumbling around. I’m eternally grateful to the handful of volunteers–mostly nurses from the outpatient surgical center whose day jobs have shut down–who circulate on the units, and will come and tie your gown for you. I try really hard to break my usual tunnel vision to stop, thank them, tell them my name, ask them theirs. So now you’ve got your gown on and the last step is that you put a second pair of gloves on, and go into the room.
You go into the room, to find the crappiest Fisher-Price-looking toy stethoscope you could imagine, usually artfully hidden in the last place you’d look by its last user. And there’s your patient, usually on 100% O2 via face mask. You start by asking the standard “how-are-your-symptoms” questions and noticing that when you talk, the movements of your mouth pull the edges of the mask off of that tight seal it’s supposed to make on your face. You compensate by trying not to move your mouth as much when you talk. But now you’re talking in this weird Steve Urkel-like voice, and the patient can’t understand half of what you’re saying.
You’re supposed to get in and out of these rooms quickly, with as little contact as possible, to minimize the risk of your checking into one of them yourself. You don’t sit. You don’t lay your hand on the bed rails. You don’t shake hands. You don’t hand out your business card. You swoop in with Baby’s First Medical Kit stethoscope and listen to the patient’s breathing, wondering why you’re doing this. Even if you heard Tchaikovsky’s 1812 Overture through those hard plastic earpieces, it wouldn’t yield any management-changing information. But procedures.
Your patient of course wants to keep you in the room with a thousand questions and requests:
- “How much longer do I need to be here?”
- “Is there any treatment you can give me that works better than what we’re doing now?”
- “Am I going to die?”
- “Can you heat up this coffee for me?” (Really.)
- “Can you wait here while I conference in my entire family on my phone so that each of them can ask every question they’ve come up with since we did this yesterday?”
It’s really hard to set limits. You have no good answers to any of these questions. The hospital allows no visitors, for obvious reasons. The families and spouses always have dozens of questions about everything, including whether they have “it” themselves, and want your advice on how they should manage every detail of their daily lives. People will literally describe the entire layout of their house, room by room, tell you about everyone who lives there, and ask what they should do. You feel badly for everyone involved, but you have to stay on mission.
You gracelessly bow out, but here’s the really awkward part: the station where you doff your gloves and gown is in the room! So you have to stand there like an idiot taking all of this stuff and depositing it in lidded bins, carefully trying not to contaminate yourself while your jilted patient stares at you. I won’t describe the technique behind this, because at this point I’m convinced there’s no actual way to do this without some contamination. Think about it: after all that, you’re supposed to take both pairs of gloves off and exit the room by grasping the door handle with your bare hand.
So now you go find a sink, wash your hands, try not to think too hard about what goes on at a microscopic level on those faucet knobs, and do the whole thing again, and again, and again, and again.
But hey, glass half full: you’re the doctor, not the nurse or respiratory therapist. You may have 15, 20, or more of these patients to see on your shift, but for the most part you’re in and out once, and then working on the plan of care based on vitals, lab values, X-rays, and the input of the nurses and techs who are your eyes and ears. Your average floor nurse might have six patients, and for each of them he or she is in and out of the room I don’t know how many times: 10? 15? It’s mind-blowing. Sometimes it’s because they patient’s gasping for her last breath. Sometimes it’s because he still wants someone to heat up the coffee, and the doctor of course blew him off. Sometimes it’s because they’re 93 with end-stage dementia and they don’t actually need anything, but the only thing they know how to do anymore is shout
NURSE! NURSE! NURSE!
all day and all night. And I can’t describe the daily work-life of a respiratory therapist right now, because I literally will not permit myself to think about it.
In the ICU’s and one of our other units that was built solely for the purpose of treating COVID patients, the one doctor assigned to that unit is issued more of a “lunar walk”-looking jumpsuit that has a hood that covers the hair and more of the face. If you’ve got some gear of your own (I have a few colleagues who got their hands on those heavy-duty face shields of the sort used by welders), no one at our place gives you trouble about it.
By now you’ve no doubt heard the accounts of doctors and nurses fired or suspended for blowing the whistle outside their own workplace about deficient PPE. I imagine that normal people are dumbstruck by this: how is it conceivable that at this, of all times, a healthcare organization would take someone out of the workforce for voicing a safety concern? There is essentially no debate at this point that what many healthcare organizations deemed “appropriate” PPE in February is absolutely not adequate in April. The “standards” of “appropriateness” were only too obviously defined by the constraints of what was readily available.
The situation we face is roughly as if a SWAT team was about to apprehend a drug lord in his heavily armed fortress, and as they started to gear up, found that there were no bulletproof vests in their lockers. So they were told by their commander, “Just use what’s there”–except that all that was there were the fleece pullovers from last summer’s golf outing. At which point the brass hastily drafted a memo proclaiming that fleece pullovers can stop bullets, “if worn properly.”
Those accounts of healthcare workers have justifiably sparked outrage, and the news of recriminatory firings is understandably shocking to those outside the frontline clinical healthcare workforce. For those of us who do this every day, it’s just the same shit, different crisis. Perhaps it will prove a tactical error for our employing organizations to have employed the same standard operating procedure for the COVID-19 pandemic as they’ve used to solve every organizational problem for years, but that remains to be seen.
In the past few decades, healthcare organizations have consolidated mostly into large corporations with a centralized power structure that consists essentially of people who engage in no consequential activities in the domain of patient care. As far as frontline clinical workers are concerned, our contracts all contain language that gives our employers sweeping powers, especially to terminate us for just about any behavior they don’t like. Because the employing organizations are large and powerful, there is generally little-to-no room for negotiating the terms of the “standard” employment agreement. In spite of the fact that there may be high demand for physicians, particularly during a crisis like COVID-19,, there are lot of forces that make losing a job a career-defining and potentially life-defining event that doctors and their families just can’t afford to mess with.
First of all, given the fact that virtually all healthcare organizations are the same in this regard, you are by and large trading the devil you know for a devil you will have to spend time and effort getting to know.
Secondly, in order to work anywhere, doctors are subjected to lengthy and onerous credentialing processes. I would say “rigorous,” but they’re really not; they’re good at weeding out disobedient and contentious doctors, not so good at red-flagging the incompetent ones. The biggest red flag for credentialing committees is someone who left his or her last job under a cloud or amidst that dread phenomenon, conflict.
Thirdly, if you’re a practicing doctor and you have a family, you’ve generally put together a highly structured life in which every little detail is coordinated: where you live, where your kids go to school, what other activities they do, what your spouse does, what schedule and hours you work, all these things operate in a precarious balance. If your job changes, your whole life gets turned upside down. And remember, at any given institution, if the terms are a deal-breaker for you (hours, scheduling, etc.), it’s not as though you can expect to negotiate a better agreement with HealthCo, Inc.
Finally, the employment contracts of doctors contain “restrictive covenants,” that is, clauses that forbid a departing doctor from seeking employment with any prospective employer in the same geographical area. For many of the multi-facility mega-practices, the covenant states that you’re forbidden from working within, say, a 30-mile radius of any place they do business. And we’re talking about corporate entities that may have an outpost in every locality for 100 miles in any direction.
As an aside, it’s often argued that the enforceability of restrictive covenants is legally shaky. It’s all a bit irrelevant, actually. For one thing, jurisprudence differs state to state in case law; your state may in theory be favorable to your situation, or unfavorable–the luck of the draw. It’s also practically unfeasible, as in the case of a former colleague of mine who fought a restrictive covenant, taking on his former practice and its army of lawyers. In his own words: “After spending six years of my life and $175,000 of my own money, I ‘won’!” Sort of.
The culture of healthcare organizations follows from their structure. They are consolidated and centralized to exploit economies of scale, and to promote ease of maintenance by managing everything via top-down edicts. As a doctor or nurse, the policies that form the basis for your everyday marching orders come from people who never touch patients, who never directly interact with you, and who generally spend their entire work lives at “corporate,” i.e., in other buildings far away.
Their edicts are mediated by middle managers. In healthcare organizations, middle managers frequently are nurses or similar healthcare personnel who pivoted to a non-clinical career at some point and have now gone native with the “suits.” The pivot happens for various reasons, most of which you can guess at, centering around money, lifestyle, burnout, and clinical competence (meaning incompetence). The middle managers tend to share several key traits: ambition; careerism; insecurity; a tendency to overstate and exaggerate their past exploits in the clinical world; a remarkable susceptibility to groupthink and agit-prop campaigns; and steadfast obedience and loyalty to the chain of command. They know that the one thing that’s most important to them–job security in their new and improved lifestyle– depends heavily on “hitting metrics” and “making budget.” Outliers, debate, dissent on policy matters, and complaints about inadequate resourcing are, for them, a “problem.”
The result is that healthcare organizations have become masters of foisting unsupported mandates onto the frontline clinical workforce and forcing clinical workers to internalize the stress and damage created by these mandates, all the while expecting them to pull rabbits out of the proverbial hat when bad decisions threaten “outcomes.” We are, after all, the schmucks who took the oaths. Not them.
So, it’s nice to hear people call us “heroes” for coming in to work amidst great stress and risk and making lemonade out of whatever PPE we’re given, but people should keep in mind that we have no viable alternative to what they perceive as heroism. It’s not like you can elect not to work in the interest of self-preservation. As the COVID-19 pandemic touched down in the US, healthcare organizations in affected areas invoked “internal disaster” protocols: employees are not allowed to call out of work for any reason other than medical illness, and for that they require a doctor’s note. (Anyone’s guess as to how you go about getting one.) I’m not sure it’s heroism if you don’t have a choice.
As you can imagine, in this kind of dynamic, securing obedience from the frontlines is critically important for healthcare organizations. The bigger and more powerful the corporation, the more important it is for them to stamp out dissent, and the more resources they have to do it. In this context, it should hardly be surprising that TeamHealth, a gigantic publicly traded national company that employs ER docs and hospitalists, famously fired an ER doc with 17 years on the job during a time of catastrophic need. Why wouldn’t they? It isn’t surprising to me.
Of course, on the subject of masks in particular, healthcare workers are hardly the only people subjected to shifting standards, manipulation, and mendacity. Had government agencies including the CDC gotten their way, we all would’ve been sent into that drug lord’s fortress in a fleece pullover. While it’s true that masks would have been misappropriated if private citizens had been allowed to buy and hoard at will, it’s also absolutely true that trying to shame people out of wanting masks with a series of implausible misrepresentations about their actual benefits made the problem a lot worse. Now, it’s all being walked back and people are talking about “masks for all.” I have yet to hear someone come forward and explain what changed. I have yet to hear someone apologize for lying to us all.
What I find most dysfunctional about the mask shortage debacle is that it could have been mitigated by transparency about very simple things. Scarcity is not so complicated that common people can’t understand it. You look in your refrigerator every day. You see how much milk you have. You know how much milk your family uses. You decide when to go out and get more, how much you need to get, how much money you can spend on it, etc. Not rocket science. Not even emergency medicine.
In the early days of this crisis, we had a lot of so-called authorities, many doctors among them, decrying the hoarding of masks: “You don’t need them. Wearing a mask in public won’t protect you from coronavirus. They should only be for healthcare workers on duty.” And we had absolutely no one sharing information or projections about the things a person obviously needs to know to make a rational, informed decision: How many masks are there? How many do the healthcare workers need? How rapidly can masks be produced? Sharing that information would necessarily have necessarily required that the authorities admit to the existence of some vulnerabilities. But admitting vulnerability in a crisis is a bad career move.
The story of COVID-19 testing follows a similar script, of course. And now the ventilator shortages are upon us, and suddenly everyone’s a bioethicist. I won’t belabor this. I’ll just say: if you really think all human lives are of equal value, then the only right way to manage ventilator scarcity is to allocate vents to patients on the basis of two criteria:
- How likely is it that this patient will actually be able to come off the vent alive?, and
- How quickly?
I’d love to tell you that “age is just a number.” At the current time, biology is operating in contempt of that adage. Age, particularly age above 70, is an independent predictor (apart from co-morbid disease status) of mortality from COVID-19. I think using age as the sole criterion for making such decisions is inappropriate and morally wrong (there are accounts of this happening in Italy). I think it’s horrible that we’re going to have to face these decisions, and that better planning years ago might have obviated this. At the same time, it really bothers me when I hear people still invoking deontology and describing the ventilator allocation problem as somehow morally beneath the dignity of a straight answer. The hard, unavoidable question is, if there are more patients than vents, who gets the vent, and why that person?
Unless Immanuel Kant can rise from the dead and build a few thousand vents in the next week or so, he has very little place in the conversation when you have one vent, three patients. This is real. You can’t wish it away.
It’s also hard to overlook the fact that our current misery is a direct product of our past flippancy in ways that the government can’t be blamed for. What’s coming into the ER today is the wages of what a lot of people weren’t doing ten or so days ago. You can lock yourself in your bedroom and sleep in a hermetically sealed chamber for a whole month now, but that won’t undo the damage at this point. The US had the advantage of knowing what happened to the Italians and still managed to have the pandemic spread faster here than it did there. Meanwhile, the Italians had almost no lead time to make a plan.
In many ways, we had a decent plan if it had been effectively implemented, but it wasn’t. No, our own people–the American people–went out and killed the plan on the ground by refusing or failing to engage in social distancing. The government can’t be everywhere shooing people back into social isolation. This is a moment when I think we really need to be asking if there is something fundamentally wrong, culturally or ethically, with the American people.
I’ve come up with an answer: Americans are soft. We want what we want. When we might not get it, we come up with all kinds of rationalizations for what we do to get it, and try our best to bargain reality out of being fully real. “All this social distancing is going too far.” “Social distancing will kill the economy.” “There are plenty of places where we could re-open the economy, right?” These delusional rationalizations reflect the ethos of a culture that has spent generations in the habit of trying to circumvent the laws of cause and effect by buying, schmoozing, ranting, suing, shooting, bombing, or incarcerating our way out of trouble.
And now we’ve met our match. You can’t buy, schmooze, rant, sue, shoot, bomb, or incarcerate your way out of everything. A virus, for instance.