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

You're listening to The Nocturnists: Stories from a Pandemic. I'm Emily Silverman.This week, we heard from many of you on the theme of being sick. Having patients who are sick, having loved ones who are sick, or even being sick yourself.But this week's show also comes at a time when curves have been flattened, and people are starting to develop pandemic fatigue. It's a shaky time where we don't yet have effective treatments for the coronavirus, but we're still grasping for hope.This week, you'll hear voices from Michigan, Maryland, Massachusetts, California, and Ontario. The episode is called “Sick.” Take a listen.

Anonymous

I am reading My Own Country by Dr. Abraham Verghese for the third time. I'm at the very beginning and I want to read a quote. It goes:“This would be my first patient with possible AIDS…It was July of 1983. I had read the burgeoning literature on AIDS and told myself I should not agonize over my own safety. The virus seemed to spread in the manner of hepatitis B: by body fluids and blood. None of the doctors in San Francisco and New York who had taken care of scores of patients with AIDS had as yet contracted it. On the other hand, the incubation period and the asymptomatic phase of the disease could be very long. Still, simply examining the patient did not call for gloves or any other precaution.I was excited and a little nervous.”This paragraph struck me because I have three friends who had COVID or have COVID. Two of them are residents; one of them is not. Two of them are better; one of them is not. Two of them are young; one of them is not.I really didn't expect my intern year to be punctuated by a pandemic, and for it to be affecting my loved ones around me.I think I was like Dr. Verghese, excited at first, but that excitement has turned to dread, and things have just gotten too close. They just have really hit too close to home.

Emily, neurology fellow and postdoc, Baltimore, MD

My name is Emily. I’m a neurology fellow and postdoc at Hopkins. I just found out yesterday that I was positive.I don't know quite how I feel about it yet. I'm a little scared, but I'm more tired and exhausted. I started having symptoms over the weekend. On Thursday when I was in the lab, I was doing some mouse work to maintain a mouse colony. That's the main thing I've been doing. I've been going into work every day to just maintain lab stuff, but I've been the only one there.I felt like a scratchy throat and decided not to go into work on Friday. And then Saturday I had a loss of taste–was really bizarre–and smell, really couldn't taste or smell anything. So it's pretty noticeable. But I actually–I felt pretty okay besides that. And then starting Monday, I felt really crappy. And that's when I called Occupational Health and they told me I should get tested.Tuesday, I left the house for the first time in maybe four days. I was nervous. I had a mask. But, you know, sometimes people were walking by. I tried to maintain my distance. And then I got in my car and, and I drove up to the beautiful Hopkins domed building. They set up a tent there in the roundabout.And the guy who asked for my name wasn't properly wearing his N95 mask, and I had a mask on myself in the car, but I was thinking, oh man, I better not infect him because he was getting kind of close to my window. He had me roll my window down.And they directed me around the roundabout. I pulled up and then they had me swing my legs out and open the door. And they swabbed me and gave me some information, and I left. And they told me maybe just three hours later that I was positive.On Monday, I had listened to some department Neurology Zoom meeting, and they have been talking about how hard it was to manage COVID patients in the ICU, and how they have like a central hypoventilation syndrome, sometimes have difficulty initiating breaths and that the sedation requirements are very high. They have, like, a hyper arousal syndrome.Listening to that–that was a little bit hard. Last night I did feel like maybe I was having a little hard time breathing, but it's almost like a weird sensation of you don't really care? You're too tired to–to care.

Internal Medicine Resident, Ontario, CA

I'm an internal medicine resident from Ontario, Canada, and it's April 24, 2020. I'm post-call from my call shift last night, and I have essentially lost count of how long we've been into this pandemic.And I think the chronicity of it is starting to hit me and my other and the other residents I'm with. We're essentially just swabbing anybody who has any symptoms remotely related to COVID. And it's pretty humbling to see who ends up being positive and who ends up testing negative.We had one patient who was going to be discharged home, and the only reason we ended up swabbing this individual was because their home had requested that they be swabbed. And sure enough, they turned out to be positive, even though they were completely asymptomatic.Someone else had what looked like a pneumonia and really bad diarrhea, and I was pretty sure it was going to be COVID, and it turned out that the biggest cause of her problems was C. diff. So like I said, it's really humbling because you essentially never know who is going to have COVID and where you might get it from and where your patients get it from.I remember one of the patients who did test positive for COVID telling me that…that they were really careful about who they were coming into contact with. And you can just see the, just, anxiety of having tested positive with this virus.I also think about the patient today that our team had to deal with who did come into contact with somebody who tested positive but didn't want to be tested. And while obviously it's their right to refuse testing, I just find it really hard to understand why someone wouldn't want to be tested. And, you know, especially after explaining that they could put a lot of other people at risk.You watch the news and see how there's a lot of misinformation that's causing people to put themselves at risk, and is potentially setting us back from all the progress that we've made.

Anonymous

I have a patient that's on continuous renal therapy and a bicarb drip who still consistently has a pH of 7.1, and I do not expect him to live. It will be our first death in-house.And I've spoken to my coworkers. I spoke at length to the attending who's beloved in our unit. She's one of our MICU attendings and we adore her, and she feels responsible.I feel like this is taking a toll on all of us, and it is devastating, not in the way that I think New York is dealing with the sheer volume of it, but in the way that we are getting to know this population of patients and human beings, and we think that we can save them. And in the end, we may not be able to. It's terrible and heartbreaking. And I don't know how we're going to come out on the other side of this.What's also really amazing in my hospital is that we've had so many travelers that have come in and just jumped in with two feet and have been working not only in the COVID ICU, but in the non-COVID ICU, which is overflowing and still with extremely high acuity.But we've had these travelers that have basically just been dumped into the respective ICUs and expected to take care of these patients. We have developed what we call the COVID ICU swim team, which is two nurses that gown up in PPE and go from room to room to room to room.This traveler that's been with us for maybe a week and a half, and on her designated swim team hour, she was in the room of one of our sickest patients when his family called so his mother and wife and children could tell him how much she was loved and how they didn't want him to die. Those of us standing outside of the room and the glass door watched her and we put our hands on the glass in support of her. And when they were done, she came out of the room.She was sobbing, and we helped to remove her gown, gloves and mask and hugged her, even though we’re not supposed to be doing that. So we thanked her for being here, and with us, and with them.

Anonymous

Today is day six of having COVID. It's been incredibly tiring, I think. For the past two days, I can barely get out of bed.I don't know if you can hear my cat. She's purring next to me. I think one of my cats actually has it. He hasn't been eating for three or four days. I'm a little worried about him. And he has diabetes and renal disease. So that's my main motivation to get up is to check his blood sugar.So far, I think my breathing's okay, but it's so tiring. It's hard to tell if I'm actually taking enough breaths at night, if that makes sense? I feel a little congested, and the nighttime is the worst, I think, because I get a little more anxious and worried about breathing. So, yeah, that's how it's going. Uh, I've had some neck pain too, so that actually feels a little better.My friend and I, my co-fellow and I were joking, because I had a cold sore too, that maybe I would have herpes and COVID meningitis encephalitis. That would be a case report. And then we made the joke that my supervisor would want me to write it up while I'm in ICU.Anyway, that's it for today.

Sam, Medicine Resident, Boston, MA

Hi, this is Sam, medicine resident in Boston.Wow. So I just found a screenshot on my phone that I took by accident. And it's from a moment when I was in a FaceTime conversation with the daughter of a patient whose father was intubated in our makeshift COVID ICU this past week.

This image of this young daughter in her 20s and father in his, maybe, 50s, who seemed like a friendly guy, despite being critically ill with a breathing tube and feeding tube and all the bands to secure those things wrapped around the middle of his face.

Well, I just needed to capture this in words because I know I need to delete this image. That father is tiny in the upper left corner where the image of yourself usually appears in a FaceTime. And then the entire screen is filled with the face of his daughter, half covered by her hand.

And it's this moment that I have seen so many times in the last week. I am preparing the family to see their father, brother, husband, son, wife, mother, best friend…intubated, sedated, critically ill in our ICU. And the words, whatever I use to describe it…it does nothing to prepare them for when I turn the phone around and they see them there for the first time. They break down crying. They burst into prayer. They're dead silent.This time, I think the intensity of what I was feeling as I was trying to hold the phone without blocking the daughter's view with my fingers, I must have squeezed the two buttons that took this screenshot that kind of, I don't want to delete and will never delete from my mind.

The most powerful intervention I have made all week is trying to bring the families in. In one instance, a patient who needed emergent dialysis–and it was a little unclear at his age if this was the right thing for him or not–and I brought his daughter into the room, he was confused with all the toxins that build up with his kidney failure. But when I brought his daughter into the room on the phone, he woke right up, spoke to her through the daze of his uremic coma, but he woke up and spoke to her.These family FaceTimes…it's just this, this parade of images. And most are sad, most are that flipping around the phone and seeing what critical illness looks like, where family just breaks down.

And some are these happy moments, or moments I want to be happy moments, when someone's been extubated, the breathing tube is out, they’re free from the machine. And I turn around the phone. Family members are terrified, confused. “What is this?” They don't even know where they are. They're waking up from being out of there. And I just thought the family seeing them would help to orient them, and sometimes it does. And other times they're not waking up. And the family is overjoyed to see the tube is out. And then they're also wondering, you know, when is my son going to be back.

Anonymous

It's Wednesday, April 22nd, 2020. I finished my first five days stretch on the COVID service last night and spent this morning trying to turn my brain off in a way and try to come down from the adrenaline high that I've been on for the past five days.I haven't had to deal with this much death back to back. I don't know how people are going to get through this as this continues to happen. And just seeing it firsthand is devastating. I haven't had really time to process this while I was on service.None of us really had the energy or the time to really just grieve. One of my friends lost her uncle last week, and she wasn't able to say goodbye. And I just…I just don't know why this is all happening. Telling families to select one chosen family member to come and spend maybe an hour at the bedside at most to say goodbye.But otherwise, all we can offer is an iPad video visit.

And this…this made me remember a poem I heard last week on the radio, a woman from the U.K. whose sister had just passed away.

The poem was called “My Sister is Not a Statistic.” It really just sat with me. You know, these are all patients who–who passed away. And, you know, as a medical professional, I was not surprised. You know, we knew from the beginning that they weren’t going to do well. Because statistically, they weren’t going to do well with their age and the comorbidities, and we have, you know, these COVID risk factors scores that our computer system tells us about.But, at the end of the day, these are human beings.On the bright side, we also had patients who we were able to discharge home or to a place where they could continue to recover. We had some bright moments. We took a patient who was transferred out of the ICU after she was intubated for 16 days. And she's doing okay. She's–she's working on her rehab and getting stronger day by day. And uh…we had a funny moment the other day with her main subject of complaint was that she was hungry and wanted pizza because she was sick of the food she was getting in the hospital.

And as I was talking to her and examining her, I noticed she had no teeth, and I thought that maybe her dentures were removed while she was intubated. But she told me that she actually was supposed to be getting dental implants, but her procedure was obviously halted with the…with the epidemic.

And I joked with her and I said, “How are you going to eat your pizza with no teeth?” And she just gave me this look and giggled, with her toothless mouth and just laughed and said, “Well, I guess…I guess I'll take mashed potatoes, but I really do want pizza.”

I hope she gets to have a pizza very soon.

Anonymous

Today is Friday. It's about noon, I got up about an hour ago, and I made some coffee, it was exciting.

But then I can't really taste it. But I haven't made coffee in over a week, so I thought I would make some. I called my vet this morning. My–one of my cats hasn't been eating for about five days. I think he has COVID. They're going to prescribe some antibiotics and my cousin is going to pick them up and drop them outside my door, so that's good. I'm not excited about giving him more medications and things, though.It's a lot of work, but I'm worried about him. Um, I don't think there's much else going on. I had the energy to get up to the couch yesterday around 7:00 and watch Tiger King. That was fun.

I'm still a little worried about my breathing at night. It just seems hard to get in a position that feels comfortable. And one of my co-fellows actually bought a O2 sat monitor last month through Amazon, so I'm debating about asking her to drop it off. I don't want to freak people out, but it may just help with my peace of mind. Although then I’ll contaminate it, but I don't think she needs it.So anyway, I was doing some spring cleaning a couple of weeks ago, going through some old stuff, and I pulled out this calendar that I made when I was 13. It's one of those day calendars where you flip a page and it tells you a thought for the day. This calendar, I really like it. It's pretty funny. Um, so I went to the day–the day that I first developed kind of more severe coronavirus symptoms, and it says, “Watch for big problems. They disguise big opportunities. April 13th.” It's very optimistic.

I'll flip through the other pages the next couple of days, “Take a lot of photographs.”

“If you could be launched two thousand years into the future or into the past, which would you choose? Why?”

"Today is “Don't be called out on strikes, go down swinging.”

“Never hesitate to say no when you need to.”

“What happens when you die? April 19th.” Hopefully that's not an ominous sign.

“You always have a lot to learn. April 20th.”

Anonymous

My days lately have been pretty up and down. Sometimes I think I'm doing great. And then, man, last week…I just had a week where I felt so resentful of my patients. What they considered urgent didn't seem legitimately urgent for a pandemic. And I think I was just in a bad mental place because everyone who came in, I was grumpy about.

And it was such a delight to come back to the office on Monday. I had a full day of OB patients, and with all the jumble that's happened, moving much of our care to virtual care. Those of us who are in the office are kind of just seeing everyone's patients. So I'm not always seeing my own, but it was a little bit of a treat because, instead of seeing only super high risk, super complicated patients, I saw a number of totally normal, healthy, pregnant women.

And…and then I also diagnosed several pregnancies and did their first ultrasound. And just listening to the baby's heartbeat took me back…and thinking of, somehow it just, whenever I really enjoy that sound, I think about being awake in the middle of the night on labor and delivery, and it's totally quiet. And I'm just sort of, you know, either… I imagine that I'm back in my residency and I'm sort of tying up loose ends before I lay down for an hour or two. Or maybe I'm up very early in the morning and I'm rounding before the patients are even awake. And I'm just–that's the only sound I hear, just going from room to room, like listening to the fetal heartbeat. And there's something just so, like, comforting and beautiful about it.

And listening to these heartbeats all day yesterday brought me back to that sort of safe, I guess, kind of womb-like place. And it made me feel so hopeful. And I realized, man, I've really been missing that, uh, because…this has been a really hard time, and there's not a lot of hope out there, so I wanted to share this lovely sound.

This is a sound that's been giving me hope.

HEARTBEAT

So lovely to think that even in a pandemic, there's new life growing

.HEARTBEAT