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Emily Silverman, host

Hi, this is Emily, and you're listening to The Nocturnists: Stories from a Pandemic. I just came off another stretch of shifts in the hospital and things definitely feel different.Today, there was a long line of people winding around the hospital just to get in. So I waited about 20 minutes to get into work. And when I got to the hospital lobby, there is this setup where you have to stand on these little footprints and then somebody behind a glass screen points this, like, laser gun thing at your forehead and takes your temperature. And if your temperature is normal, then you're allowed to proceed and go to work.I took care of 12 patients today, some of which were COVID rule-out patients, but the majority of which were just ordinary medicine patients.Later this month, I'll be on the COVID service, so I'll be sure to update you then.In case you missed last week's episode, we've decided to interrupt Season 3 of our show to focus on this pandemic. Well over 100 health care workers are keeping audio diaries of their experience during this time. We're featuring selected clips from their audio diaries on the show, and today, we continue with audio diaries from Indiana and other parts of the Midwest, California, New York, and Massachusetts.You'll hear the voices of a pulmonologist, an internist, an emergency medicine doctor, a reference tech at a blood center, and a newly matched medical student who's graduating early and being deployed to the hospital as an intern. If you want to lend your voice to our diary project, or send us music that you've made, or other sounds from your life in the time of COVID, visit our website at thenocturnists.com. With that, here is episode two: “Arrival.”

Pulmonology and Critical Care Physician

I got a shipment of masks sent to me by my sister and my nine year old niece, and she included this note in it:“Dear Uncle Gabe,We put 26 masks in this bag. The one extra is for Sarah (my wife). Hers is the Wonder Woman one. I hope the masks come to good use. It felt good to be helping the hospitals. We're making more. So if you need any more, just let us know. Love, Cece.”If you told me three or four months ago that I would be making every three weeks, trips to a–to an infusion center for my wife's chemotherapy and that during the third of these chemotherapy sessions, it would have been dramatically interrupted by the global pandemic, I would have said, “You're crazy.”But here we are. My wife Sarah's a pediatrician. And in January of this year, she was diagnosed with ERPR-negative, HER2-positive breast cancer. So our world was kind of turned sideways. I found myself just struggling with how to best support her.Chemotherapy is pretty much a day-long process. You go to the center and you–she has a port now and that port gets hooked up to three sequential medicines that are infused over anywhere from five to eight hours, depending on how things are going. And it was really important to me that I get to go with her and spend that time, that I set aside that time so that she and I could be together away from our kids and away from our jobs and just…be.This last time was about a week after the coronavirus sent the world into a tailspin. We knew things would be different and we showed up and the nurse came out from the infusion center and invited Sarah to come back and see the physician before her infusion. And the nurse said, “Actually, ma'am, there's no one allowed back in the infusion center or in the office spaces because of the coronavirus outbreak.” And at that point, Sarah and I just locked eyes and stared at each other and kind of sat there for a few minutes in silence.And I told her I'd go home and take care of getting some groceries, which was the first time we'd done that since the stay at home order was enacted. And I walked out…left Sarah to get her infusion by herself, which sucked.There are really three main things that literally wake me at 3:00 or 4:00 in the morning almost nightly. The first is my wife, Sarah. I worry about her just staying healthy through all this.And the second thing I worry about is the fellows that I'm charged to help train. So as the program director of our fellowship, I oversee the training of 21 pulmonary and critical care fellows who are literally on the front lines of caring for these patients on a daily basis at this point. And I greatly worry that one of the fellows is going to get sick from this. I think it's only a matter of time till that's going to happen.The last thing I worry about greatly is–I'm an ethicist and I'm helping to write the ventilator triage allocation guidelines for the state of Indiana. That's the document that outlines what we would do if we had to decide which patients got ventilators and which ones didn't, how we could do that as fairly as humanly possible in the setting of a scarcity of a resource that we've never had be scarce before. And in helping to write those, I just worry constantly that we've not set up something that's going to be easy for people to understand or executable or that the situation is just going to balloon out of control to the point where being thoughtful is just not possible.I'm ready for all this to be over, for the cancer and the coronavirus, and I just want things to go back to normal.

Emergency Medicine Intern

I am an emergency medicine intern. It's been a really, really, really long six weeks.I was in the emergency room, and we had patients that I turned away that I'm 100 percent convinced had COVID because six weeks ago we weren't testing them. There is this one guy here. He's just so vivid in my mind. But he had come from China, not Wuhan, but had come from China. He had a fever, he had a cough. He had a lymphopenia, which we all now know means COVID. And, you know, he came in and he was complaining of this and he had self-quarantined for a week, but he still has these fevers. And now we know–now we know these fevers go in this cyclic cycle.Anyway, I called infectious disease at that time, and I was told I couldn't test him because it was against the CDC guidelines because six weeks ago we weren't testing anybody who wasn't from Wuhan or who didn't have a known positive contact. And so I sent him home, and I sent other people home: people who had been on cruises, people who had been to Italy, who had been to Washington state recently.And it's just been sitting so heavy on me that I–I'm part of the reason this is spreading. We sent them straight back into the community because the CDC would not let us test them six weeks or five weeks ago.After that, I went to ICU for the last–this is now my fourth week–and so I sort of saw this progression in the ICU. I remember my first COVID patient. She didn't have a lot of comorbidities, and she started to crash on us.And I just remember looking at my attending and the other resident who was there, and we just looked at each other kind of, in this absolute horror that this is what COVID is. And I think until that point, a lot, you know, we–we'd heard of it. Everyone had heard of it. It was maybe coming vaguely. It didn't sound like it was that bad. And this–this woman, you know, she tanked and she was on pressors and she was intubated, of course, and we were talking about proning her and, you know, this is what first I think really drove it home for us.And it was just a time where, again, we realized this was real.So as we've run out of masks and as we've run out of ventilators, it just feels like every single patient in the emergency department right now has COVID; the whole board reads cough, shortness of breath, sore throat. The entire board. And, you know, some of them got admitted up to the ICU and their chest x-rays all look horrible.And it's just it's–it's baffling. But that brings me, I guess, to today. All of my patients today had COVID, except for one. And my patients…they're doing okay. But this afternoon when I was there, it's so weird–they're all, they all, not, they're all different people, but they all seem to be on the same trajectory. And two of them had, two of them had these blood pressures that just dropped at the same time. And we're adding pressors, and we're diuresing them. And they just always seem filled with fluid.And it’s just, every moment, you know, it feels like there's nothing we can do. We can manage airway, and we can manage fluid. And today, you know, we got told that remdesivir, which is the one drug that maybe is working, we don't know — Gilead, the company that owns it, is not letting anybody use it anymore unless you yourself are a study site. And they all have to be enrolled in the study so we can even get it for our patients anymore.And the last couple of patients that we have that turned around were all on remdesivir, and now we can't even offer that to our patients. So it just feels like we're hoping, and we're changing ventilator settings.And, you know, it's really frustrating being an intern because, you know, six weeks ago I was seeing these patients. I was seeing them without a mask, because we didn't know that this was even a thing. And now, six weeks later, I'm not even allowed in this current situation I'm in to go into the patient's room, really…though that may change soon, too, because things are changing every single day.But when you can't go into your patient's room, you know, I learned how important, I guess, touch and the physical exam is. I think you learn that in medical school, but I don't think I realized it until this situation where we're taking care of these people we never get to touch, we never get to have a moment with, we never get to show that we…you know, we never get to have that human experience with our patients because they're behind the glass door.And I think as an intern, that's a very, that's just a very difficult position to be in. I think as a resident, it's a difficult position to be in. Because they're barring us, I think, to keep us safe from some of these patients. But again, we can't–we're taking care of them. We're changing their settings. We're writing notes about them. We're on the phone about them all day long with the nursing staff. And we don't actually ever get to go see them and have this human connection with them. And that has been surprisingly difficult.But I don't know. Each day is its own thing. As I said, the rules change daily, and from institution to institution, what the mask situation is, if I were to go into a patient's room, if I don't wear PPE to go into a patient’s room, if I go into a patient's or if I don't go into a patient's room. It's just different every single day. And I honestly had to ask today during, we had a big town hall meeting with the residency, you know, talking about COVID.And I had to ask, I said, “You know, I don't even remember if I'm supposed to be wearing goggles or not when I go down to the ED because I don't remember if it's changed in the last few days because I can't keep up with the emails--just the flurry of emails that we get every single day.” But I hope my two patients today do okay. I think when I left them, they were not great, but they seemed to be stable.And there are these just these two people who in my mind now are just linked because they seem to be on the same strange, strange COVID journey together with these fevers and this pressure and the urine output and everything. And I guess I'm on this journey with them, even though I'll never actually get to be in the same room as them.It's been a hard intern year, and I expected intern year to be hard, I expected to not sleep…you know, the procedures to be hard to learn, the material to be hard to learn, it be hard to navigate the emergency department or the hospital, but I didn't expect to train during a pandemic.

Hospitalist

I just finished my first week on the COVID service. I was the second hospitalist to staff this service, it’s slowly growing. The day I left, we had to expand to a different–second service.Our system is just not set up to confront a pandemic with the patient population that we have. I'd say over half of our patients are homeless. A lot of them have psychiatric issues, substance use issues. And increasingly we're running into situations for which there are no right answers, with extremely difficult ethical components.I had two patients this week waiting for their test results to come back who wanted to leave the hospital against medical advice. One was withdrawing from alcohol. The other was having a manic episode. And I think the part that was hardest was how little support I had in trying to delve into this uncharted territory. The first time I had–actually both times–I had really excellent nurses I was working with who I respect so much and who are risking their lives every day in ways that we can't imagine.The nurses are going into these patients’ rooms more often than we are as physicians. They are getting as close to these patients as anyone. They are most at risk. And in both these situations, our nurses were just bad**s. But I don't feel like I can say the same for everyone else. Had a hard time getting providers to come see my patients. There is a lot of pushback. There's a lot of people who don't want to go in these rooms, and these are patients who don't even have confirmed cases. They're just waiting for their tests to come back.I would never ask someone to see somebody that I didn't think was necessary in these circumstances. And I understand that the idea is to minimize contact as much as possible, and I understand we're trying to sacrifice one physician at a time, essentially. I guess I'm going first. But we had…just a really difficult time getting people to–to help. That's, I think, what's feeling the most lonely about these first few days.Yesterday, I was promised that the first spots would be available for homeless individuals waiting test results so they didn't have to stay in the hospital, but the hotel contract fell through, so they remained with us. I'm scared that we're going to run out of beds soon for these reasons–not because people are too sick and need to be in the hospital, but because our vulnerable patient population will have nowhere else to go. I'm not sure what to do.At one point this week, I was stuck in a room with a patient. I was fully gowned and in all my protective gear, and he was really getting angry. He was manic. He was yelling. He was throwing his arms up in the air. He was coming towards me at the door. I was trying to calm him down, trying to offer him support, love. It wasn't working.He followed me out into the room between the hallway and his room, and finally out into the hallway. I asked security to come, but I knew that they wouldn't help if they did, because they had said so the day before. So what are we supposed to do? If he leaves, he's a public health risk. If he stays, he is a risk to himself. He's a risk to our staff.I think I cried three or four times yesterday. Having a hard time differentiating between a panic attack and shortness of breath. I had a near meltdown during a family meeting the other day where I felt like I was getting sick, and I could hardly participate in the conversation because I all of a sudden was so terrified I would be getting this kind, sweet family sick. I think it was all just panic. Every day I go home, I have a glass of wine and my symptoms go away.

Intern, New York

I am walking down the middle of Park Avenue right now in Manhattan. It's just after noon on a Tuesday. Normally this avenue would be completely packed, but instead it's entirely empty.NYPD has cordoned off Park Avenue. My guess is to allow some space for people to be outside in a socially distanced manner. I realized I hadn't been outside in like three or four days, and I desperately needed just a breath of fresh air. So here I am, walking down Park Avenue. It is bizarre.This week's been really weird. I am officially going to be graduating from medical school either tomorrow or Friday, still a little unclear to me…but by the end of the week, I'm going to be an MD, which is still kind of blowing my mind. I am set to start working at a New York City hospital this Sunday. I'll do a week of, kind of, training, simulations and that sort of thing, and then I will be on an internal medicine floor. The plan right now is to not have us doing much in terms of, like, patient-facing work.I'll be doing intern work, which for the most part will be, you know, writing notes, putting in orders. But the administrators coordinating this whole effort have been pretty upfront that while they want to keep us “COV-interns,” they’ve started calling us, as far away from the epicenter of COVID cases, that as the situation evolves and changes, that also may evolve and change.So it's–it's a pretty strange place to be right now, not having much to do right now, but knowing that my plate is going to be so full in less than a week. It's strange walking down the streets of the city and seeing just how empty it is. But I know from my friends and colleagues who are residents and attendings and NPs and PAs and all other sorts of support staff working in the hospital, how totally slammed they are.It's like petrifying to me that this city is so strained that…they're having to call on med students to graduate early and help and…You know, while on one hand, I know I know a lot, and have worked really hard the past four years, I probably know more now about things like congenital adrenal hyperplasia than I will at any other time in my career. But in a much more real sense, I know absolutely nothing. So listen, if there's a way for me to help, you know, sign me up.

Medical Laboratory Scientist, Midwestern US

I work at a blood center in the Midwest as a medical laboratory scientist. A few weeks ago, blood donations just dropped like a lead balloon. Schools closed. Churches stopped meeting. Gatherings were canceled, and all of those are places where we do mobile blood drives, so if they're not happening, the blood drives weren't happening.We got hit pretty hard by this. We try to keep a minimum of 300 O-positive units on our shelves, and at one point, in between shipments, we got down to around 40. It ended up being okay–we got resupply, but that's still really low.Thankfully, blood centers across the country just started campaigning for donors and, you know, people have just stepped up to give. At least for now, we have an adequate supply, especially since elective surgeries have been canceled and demand is substantially down.Even so, I'm not seeing very many O-units that are more than a few days old. They just–they don't stay on our shelves very long. They come in and then they go back out to hospitals that need them. Other types are doing better, but it's less of a buffer than I think anybody would like. For me, the people that I'm concerned about are my regular, multiple antibody patients.Most of them have conditions that are going to make a COVID infection pretty dangerous for them, and since they can only get very specific units, if we don't have blood on hand because…maybe there's only 10 or 20 donors that we know of who can give blood that's safe for them. If we don't have those units, we just have to start testing units at random and hoping we find something. Usually we can, but that still takes time.For the extremely rare units, if we can't find them, we would normally buy them from somewhere else in the country, but now the supply chains are really screwed up. More than one ultra-rare unit has just been ruined because of shipping delays like, “Oops, it sat in an airport for twenty-eight hours and now it's too warm to safely transfuse. Sorry.”And that's bad for multiple reasons, not the least of which is those units are very hard to replace. And all this just causes delays, and it keeps the people who need the rare blood in the hospital for longer–maybe days?And I know everybody is doing their absolute best to keep these vulnerable patients safe and not expose them to COVID. But what I've heard from friends in patient-facing roles is that it's just everywhere and, I…I hate the idea of exposing these people to even more risk, because it's so hard for us to find safe blood. It's nobody's fault, but I hate it.On a brighter note, multiple blood centers in the country are starting convalescent plasma programs and, you know, hopefully, they're demonstrated to be helpful in helping treat patients. And if that's the case, that's something else that we can bring to the table to help fight this stupid disease.

Internal Medicine Resident

Hi, this is Sam. It's been about a week now of working on nights and supervising the junior residents on the floors and in the ICUs…Every night having COVID patients crash, or patients who might might have COVID and surrounded by all the uncertainty and fear that brings, crash and be brought to the ICU, intubated emergently, having their hearts go into wild, unpredictable, and dangerous rhythms. And it's–so about a week and a half of being on our nights with that.And I'm coming to the end of this two week rotation. And something happened tonight that got me reflecting on how this is weighing on us as doctors.I was called into a room of one of our junior residents performing a relatively urgent placement of a large IV in the neck–a central line. The patient was unstable after getting intubated, and they’re getting some powerful medications to push up the blood pressure and needed this line quickly. And when I came in there, he was someone who had–who knew how to place these, but was struggling.And you could tell he was forgetting the regular steps. His hands were at awkward angles, misplacing different pieces of the equipment. And I tried to just provide some calm, just said, “Stop. Think. Tell me what you have to do next.” And when I saw him take a breath, he had every answer for me.And I think it was the fear that came with these patients, the fear of ourselves getting infected in this time–particularly, right after the breathing tube went in is when we need extra protection. And the unpredictable way these patients go down fast, that he had just witnessed with the patient that he was trying to give this lifesaving procedure to.And so that worked for a while, calming him.And then I realized that he was continuing to sweat and his mask was starting to slip off his nose in a way that might not really protect him. So I got on some sterile gloves and kind of, you know, handed him what he needed, helped him angle his hands and steady them, my hands on his.He told me when we stepped out just “Today…today we were crushed.” This was in an ICU that wasn't regularly receiving these patients. It had some open beds ready in preparation for the deluge, and the deluge came. As I stepped out of that, I was walking back to then go talk with my parents. Now, my own parents have been sick, and I suspect it is COVID. They never get sick and they're on the older side, and it's like this unending flu.And I've had them monitoring themselves carefully at home. And I think they're getting better now. But I made this time to talk to them on FaceTime just to see their faces. They give them that–visual, moderate monitoring that, you know, sick/not sick eyeball test that we all learned to do at this point in residency, but from my own parents.That was when I started to feel crushed. I started to feel myself shaking and trembling and, you know, futzing with my own phone, my own angles were off. My equipment was not familiar to me in the way that it usually was…except this was just my own phone trying to set up a FaceTime with my parents. And I realized that for me, getting in there, doing that line, that was the escape. That was the escape from the stress of coronavirus, the focus, the procedure, the knowing something I knew how to do in a more of a Zen-like way. This, then, was the reality for me–the reality outside the room.It's not–it's not escapable whether it's in the room or outside it. I don't have an answer. Just, you know, seeking the reassurance that my parents are getting better, and that that patient might get better. You never know who you're going to care for these days. Maybe the patient in front of you or the colleague beside you or the parents at home. That's all I've got.