Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman

Hi, everyone, this is Emily, and you're listening to The Nocturnists. I'm still here in San Francisco recording from home. California has been sheltering in place for a little over three weeks now.

Some of us are finding a new normal, and some of us are still trying to find a foothold as we grapple with new routines, new child care responsibilities, and the unpredictable behavior of this new disease.

We've been learning about the virus's physical shape, its genetic makeup, its epidemiology, its clinical presentation, and how its contagion affects everything, from hospital workflows to visitation rules.

For those of you who are tuning in for the first time, this is a special series of The Nocturnists, a medical storytelling show, by health care, for health care. Well over a hundred of you have signed up to keep an audio diary about your experience working in the midst of this pandemic. And each week, we feature selected clips from your diaries here on the show.

Our goal is to serve as an outlet for truth-telling, self-expression, and community among health care workers, because we are hurting so much right now and facing unimaginable challenges.

Listening to your voices certainly brings me a lot of comfort as I gear up to staff our hospital's COVID service later this week. If you want to lend your voice to this project, learn more at thenocturnists.com. And now allow me to introduce Episode 3: “Virus.”

Anonymous

A week ago, we had four positive COVID patients. Six days later, we have 13. Almost every single one of them are intubated. Paralyzed. About a third of them are proned. Most of them are pressed.

They do not behave the way patients in acute respiratory failure behave. They are so labile and so unpredictable and so different than any other patient I have ever seen in my almost 20 years of ICU experience. And I can't even begin to wrap my mind around it.

Medicine, as I know it right now, is not working for these patients and that terrifies me, because I just feel like we're treading water, and I don't know how to get them out of it. And I feel like we're still not gaining any ground. I'm at a loss, and I'm scared and I don't know what the next six weeks are going to look like.

What I've noticed is that the patients that we have right now are predominantly male, Latino… most of them are coming in as undiagnosed diabetics.

Of the patients that we've had recover so far, two of them have been–they've been female. One was an 86-year-old woman who told me she had no time for this. I think, for whatever reason, it looks like the women are doing better than the men.

What we consistently see, however, is the patients coming into the emergency room hypoxic, tachypnic, their chest x-rays and CTs look terrible and consistent with what we've seen with everybody else. They come up to the unit. We look at them for a while and then within, I would say, six hours, we intubate them.

I take solace in the fact that we actually have had two patients actually leave the unit and do well. So I'm hoping that that's that trajectory moving forward, but I'm not optimistic at this point. Today was not a good day.

Internal Medicine Resident, New York

I'm an internal medicine resident in New York. Today is Saturday, March 28th. Today, I managed my own mini-ICU in the emergency department.

I had two intubated patients that we had to intubate in the morning, but there were no ICU beds available for about three hours. And so, we had our anesthesia team intubate one of them. The other one had been intubated overnight. But because the, you know, everything was so busy in the ED, no one had been watching over her, so when I went to pre-round on her from coming down from the floor, I saw her from across the room reach over and pull her tube out because she hadn't been adequately sedated.

So I literally ran over–thank God the anesthesia team was nearby. We re-intubated her and got her properly sedated.

But I kept walking from one side of the ED to the other, managing these two intubated patients, trying to get their sedation high enough to make sure that they were sedated enough and making sure that they had–were on the right vent settings. And just waiting…waiting for the ICU triage resident and the attending to come down and just check up on these two patients and waiting for an ICU bed to become available.

We ended up–I ended up asking the overnight team who was signing out to us four new patients to come down to the ED to tell me about the four new patients while I was managing these two intubated patients, and then at the same time got a new admission in the ED. It's just…and–and also managing 16 patients on the floor.

It was just…it was insane. It was both insane and exhilarating because my training had taught me how to do this, even though in no situation was I actually supposed to be in this situation.

But I felt–I felt like residency had taught me the tools to take care of this, which was kind of incredible.

But now I'm exhausted. This is definitely not sustainable.

Internal Medicine Resident, Montreal

Good morning. It is 6:30 a.m. on April 4th. I’m one of the internal medicine residents in Montreal, Canada, and I am coming at you, live, post-overnight shift in the emergency consults–well, general internal medicine, emergency consults. Honestly, like, at this point, it's also just like everything else, COVID consults. COVID, COVID, COVID.

Um…and if you couldn't tell from how articulate I'm feeling right now, I'm kind of sitting in the call room watching the sunrise. I kind of bathe the city and I'm, like, sort of like, lost in this like trance of a high LDH, high D-dimer, or a high CRP, low lymphocytes, bilateral hazy infiltrates on the chest x-ray, one liter or two liter, three or four liter, high flow oxygen, intubation, no intubation, not enough beds in the ICU for intubation…phone calls.

“Can I come see my dad?” “No, you can't, I'm sorry.” “What's going to happen?” “I don't know. I'm sorry. I'm sorry, I'm sorry, I'm sorry, I'm sorry, I'm sorry.”

I remember like a few weeks ago just being like this kind of excitement about that, maybe first case and now it's everywhere and the ICU is full and several wards are full.

And I just feel like it's just getting started, like the pace, like the rate of change is just faster and faster. So, you know, like I don't think I see, like an end to this. It feels selfish and stupid to say. But like for a young doctor, this is kind of–there's a level of this, conceptually, that's exciting. And I remember feeling excited about this work being like, oh, my God, a pandemic. This is like, kind of the holy grail of the discipline, like, where we can maybe make the biggest difference. But, you know, just like, the sheer amount of, like, I guess, suffering that everyone is going through is just, like…It feels really selfish that on any level I could have thought about this as something, like, exciting.

And I'm not even sure that this is going to record properly through this plastic bag, but–that my phone is wrapped in–but it will be worth a trial.

Still just trucking along, waiting for the D-team to give me a chance to get some rest. It's like two weeks into the pandemic, and I'm already pretty tired.

Anonymous

This is my day 9 out of 12 working. I have kind of lost track of the days. I’m having to wear a mask at work all day long, which I think affects my carbon dioxide levels and makes me super sleepy. So I'm not sure how masking has made me more efficient.

I think it's made me a bit more tired. And then nobody can understand what you're saying with the mask on, or at least no one can understand me. And you can't see people's facial expressions with a mask on–except for their eyes, which are plus or minus expressive in some people. So it does make communication a little bit more cumbersome.

Plus, we are trying to do social distancing in the hospital. So I do find myself shouting at people when I get home, and I'm, like, a little dehydrated because I haven't been able to drink water all day because I've had the mask on. And my throat is like a little scratchy because I've been screaming at people from six feet away all day.

And so then I'm always worried that I have COVID-19, because I am out in the hospital, in the labor and delivery floor, on the wards, looking at babies, and meeting 20 people a day, plus. So it's very busy.

And–and, of course, that worries me because I know how deadly this virus is. I see what a lot of my contemporaries who are in medicine are doing on the front lines, and I'm terrified of getting it and of dying. I question my own mortality in the setting of the virus all the time.

However, there is a part of me that just wants to get COVID-19. I hate living with the constant fear of getting it, and I was like, “Well, if I could just get it, then I'll have it for a few weeks and then I'll know that I had it, and I built some immunity.”

And my husband's healthy, too. I should note, he's a little bit older than me, which I always like to make fun of him for. He's turning thirty-eight this month. But I think he'd be fine. I'm the–I'm usually the one to get sick, and he's usually the one to always be fine if something from our toddler creeps through the house.

Our toddler has not been a vector for disease now because she doesn't go anywhere. I'm the vector, like I am the health care worker. I am the one going out every day–no one else is. I'm the one who could get everybody sick.

You know, it's just us, we haven't seen my parents. If I knew that I could get it and recover, then could I see my family?

Geriatrician

We are day whatever of Corona Land. And, at this point, I'm just angry. I and my colleagues in geriatrics have been saying for decades that the U.S. healthcare system is broken. And the people who suffer the most are the old people. And I don't know why I expected that in a pandemic, things would be any different.

I've spent the last week trying to convince my colleagues to start some research. I've been scouring all of the websites where there's research posted and realizing that not a single one of them is thinking about old people! Every single thing we know about this disease is that the people who die the most are the people above age 60 and especially above age 80.

There's not a single research trial that's actively trying to recruit old people. And I've talked to several of the PIs of these trials about what you'll need to do to actively recruit old people. And they decided that that was too hard!

So let's make another f***ing trial where we learn everything about how it works in young people when it's not a young person's disease. Let's make a vaccine that only works in young people, just like the flu vaccine and just like the pneumonia vaccine that we already have. Great! We'll have a vaccine that doesn't actually help the people who are being hurt the most!

In the first few weeks of this epidemic, they closed the geriatrics unit because it needed to be taken over as the COVID unit. It only took until this week that they realized, “Oh, maybe we should have some geriatricians on the committees that are helping plan things.” Yeah, in an epidemic for old people, maybe you should reach out instead of us trying to wedge our way in!

I am so tired of being an expert in the medicine that affects the people who are the most vulnerable to our health care system's failings, and having a system that doesn't care. And I'm tired of that now in the context of a pandemic that is particularly affecting my patients. The people of America might care about their grandma, but health care certainly does not.

My one patient who I admitted to the hospital with COVID, has been in the ICU now for a week and a half.

Hey, babe, I'm doing my audio diary. My partner came down and he's like, “Are you okay? Why are you yelling at the mirror?”

Yeah…I mean, I'll be fine. I wish that the U.S. had a functioning health care system that cared about the old, the poor, and the vulnerable. And I really wish that anyone in charge was listening.

COVID vaccine subject, Seattle

Hi, this is Ian in Seattle. I'm recording this at 10:30 on Wednesday, April 8th. About an hour ago, I received my first injection of an experimental coronavirus vaccine. I'm one of 45 healthy volunteers participating in an early Phase 1 trial.

The injection didn't hurt. They had me wait at the clinic for an hour afterwards just to make sure I didn't have any immediate negative reactions. But actually, I'm feeling fine, totally normal. My shoulder doesn't hurt, no headaches or anything like that.

This trial is looking to see whether this candidate coronavirus vaccine is safe. We could know that in as little as three months, but I'm scheduled to come back to the clinic for 14 months.

I first heard about the trial from a colleague. Actually, the call was specifically for healthy volunteers aged 18 to, I think, 55. I've never been a subject in a clinical trial before for a vaccine or for anything, but I've been around a lot of scientists who do vaccine design work. And in fact, my girlfriend works in a clinical laboratory that processes samples from patients in clinical trials.

So both at work and in my personal life, you know, vaccine research is something I've–I've been adjacent to for a little while.

I think my background training as a scientist certainly has influenced my decision to participate here. You know, I studied molecular biology, so the idea of making new vaccines and doing things to…to human cells doesn't strike me as…as foreign or creepy like it might to some.

I think the best way to understand this particular experimental vaccine is to contrast it with traditional vaccines. So normally, a vaccine would work by taking either an entire virus that has been killed or just a piece of that virus and injecting it into a healthy person in hopes that their immune system is going to recognize it and respond by making antibodies. And then the hope is those antibodies protect that person from an actual infection.

What's going on here is a little bit different than that. Rather than being injected with the virus or even a piece of the virus, what I'll actually be receiving is a little snippet of the virus's genetic code. In this case, a single mRNA molecule–messenger RNA. And that genetic code is going to hopefully enter my cells and temporarily instruct them to make one of the proteins from the virus, in this case, the spike protein.

And it's that spike protein, if it gets made, that hopefully my immune system is going to react to. It's going to make antibodies against it, and hopefully those antibodies would be protective against the real virus. I don't believe there are any licensed vaccines that have used this mRNA technology.

It's not yet known whether this way of stimulating the immune system is actually going to work in humans. So that's one of the things that clinical trials for any coronavirus vaccine are going to have to evaluate. And it's one of the reasons why you can't just rush a promising vaccine out of the laboratory and start giving it to a lot of people.

The city has been on lockdown for many weeks now, and, you know, I can feel that all around me, so although I don't personally know somebody who's been infected, I certainly feel the virus around me every day.

There is a conversation that's emerging online where some people, including some scientists, are floating the idea of challenging certain people who have been participants in a vaccine study with the actual virus to see if they get infected. And the thinking there is…Normally for a trial where people are not intentionally exposed to the virus. In the later stages of the trial, you have given an experimental vaccine to many, many people, hundreds, maybe thousands of people, and epidemiologists will monitor those people over time as a population and look to see did the vaccinated population actually get less of the disease than the non-vaccinated population.

That's one of the ways to measure efficacy in people living their normal lives. The thinking with a challenge study is you could speed that up if you took the vaccinated population and directly expose them to the virus. You didn't wait for them to come across it in their lived environment. And then you would see directly if those people got sick or not. If they don't get sick, you have very strong evidence that the vaccine you're trialling is very effective in preventing infection. And then you could roll it out to more people more quickly with confidence.

Of course, there are tons of risks there. This is a deadly virus. It's very easily transmitted. People can be infected with very little symptoms. They can go home after the experiment and give it to their kids or their grandparents. It may just not be the kind of thing that we would want to do.

Anonymous

Today, I found out that our patient that was in the ICU intubated passed away on Friday. Her family had to say goodbye to her via a computer monitor that was brought into the room.

Prior to her passing, there had been a discussion with the patient's family and it looked like her condition was not improving, and in fact, it was worsening a lot. And there was a discussion made as to whether they were causing more harm to her by keeping her on life support.

After various discussions with the family and the patient's PCP and other physicians who have treated this patient, they knew that this patient would not want to have a tracheostomy and PEG tube placement and all those things. And since she was going into multi–multi-organ failure, the decision was made to withdraw care. And it just made me sad to think of all those people who are currently battling this disease and have it and their family members are not allowed to enter the room in their final moments.

It made me quite emotional today thinking about that. And…it's got to be hard. I know that our hospital has made the decision to have a no visitor policy unless there's a certain…case by case. But this case, I know, they made no exceptions. I think, for COVID patients, that those patients would definitely not have visitors in the room at the end of their life. Oh, so, yeah…Other than that, I think that was the hardest news I got so far during this time.

Our other patient that last week was pending and we didn't know if they needed to be retested, ended up getting retested, and they are positive for a COVID-19. They are at home, self-isolating. They’re sick, but not too sick to be in the hospital. They don't meet criteria for hospital admission.

I already did talk to the patient today, and they're very anxious because it sounds like they were not needed to be hospitalized. But just knowing that they have it, and all the news that they keep hearing, that this week will be the Pearl Harbor, the 9/11 of this pandemic–hearing that news, that patient was very anxious and is wondering, you know, “Because I have it, am I going to die?”

So, I mean, we don't know. We don't know if that person is going to get worse or not. But we are going to continue to monitor, and we'll see what the rest of this week brings.

Medical Student, New York City, NY

So I'm a fourth year med student in New York City. All of the rotations have been canceled, I'm done with my graduation requirements. So I've just been social-distancing in my apartment, occasionally going to occupational health services to answer the phone lines of sick employees.

Some of my classmates and I formed a band during our first year, and we were looking forward to this time, the end of fourth year, to really focus on our music and to kind of get a bunch of songs together that we could play for our classmates as a goodbye. But that was before all of this happened. And now we've been reduced to sitting outside, six feet apart, and trying to play music together.

I’m recording this in the Bronx, where the soundscape has mostly been the sounds of sirens and not a whole lot else. So I thought I'd add to it a little bit. Bjork is one of my favorite musical artists of all time, and she has this album from a few years ago called Biophilia, on which she sings about lots of different biological phenomena, including one that's quite popular right now: viruses.

SINGING AND STRUMMING GUITAR

Like a virus needs a body, as soft tissue feeds on blood, someday I'll find you, the urge is here, ooooh.

Like a mushroom on a tree trunk, as the protein transmutates, I knock on your skin, and I am in, ooooh.

Like a flame that seeks explosives, as gunpowder needs a war, I feast inside of you, my host is you, ooooh.

DISTANT POLICE SIRENS