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

It doesn't take much for the human psyche to come undone. Anyone who's had a patient with ICU delirium knows this.Even after a relatively short time sedated, paralyzed and intubated, patients wake up disoriented in time and space with delusions and hallucinations. In some cases, they can even become aggressive or violent. Does this sound familiar?It's nine weeks into shelter in place and looking around, I'm reminded again and again of how little it takes for people to lose it.We know the virus can't survive when we isolate ourselves. The question is: can we survive the isolation?This week, many of you have shared with us what it's like to be a health care worker in a post-surge world. For many, it feels like a sort of coming-down. The emergency is over, but we don't feel relief–just a lingering unease.This episode is called “Bad Trip.”Anonymous
Ha, freedom! I just got out of work and I’m walking to my car and the first thing I always do, the second I get off hospital property is take off my N95. It feels like my face is finally free from the straps of the coronavirus.You know, it's been much busier with psych patients. Although this last patient wasn't a psych patient–I was triaging a person who had eaten an edible for the very first time and was extremely anxious. And needed a lot of reassuring, but the kind of reassuring she wanted–she kept asking if everything was going to go back to normal.And I kept telling her, yes, don't worry, you're going to be okay. It's going to go back to normal like it was before. And then I realized, wait a minute, when most of us have been expressing the desire to just go back to how it was before, it was in relation to the coronavirus. Not from being high.So, it's almost like every other day there's some new mind-blowing experience and it's just some new strange reality that's so different from before, like we can only process so much.Lately, I've been watching a lot of Netflix, and been watching The Matrix again–rewatching it. I just keep thinking about the choice that Neo has to make, whether he takes the red pill and learns the unpleasant truth, or whether he decides to take the blue pill and stays in blissful ignorance.Unfortunately, we all know that life is going to forever be altered in ways that we can't fully predict yet.

Jenny, Medical Student, Philadelphia, PA

Hello there, this is Jenny, medical student from Philadelphia, currently volunteering in transport. Last shift I did was actually an afternoon shift, so I got to do something new. I got to do discharges of COVID patients.Our hospital has so many COVID patients that they just do like one announcement a day about how many are getting discharged that day, and then play a little snippet of the Rocky theme song.Actually, I went into a patient's room to take them to a CT scan when they made the announcement and played the, like, Rocky music. And then had to explain to that patient that they were not getting discharged–they were just going for a CT scan.So that was awkward.A few of the floors in the COVID building at my hospital–they're not meant for patients, they're like outpatient rooms–and so they don't have any windows. There's, you can't really, like, dim the lights. It's either, like, they're completely off or they're completely on.They took the doors off and sealed them off with tarps. Not a lot of air circulation. There's no beds. It's just stretchers. And, you know, there's not a lot of people going in and out of there. So it seems like it can get pretty lonely.I took a woman out of there last week who was just like, sobbing. Her test had come back negative, and so I was taking her over to the non-COVID building and she was just, like, sobbing the entire time. She was so, so done with being in that room. She just kept saying, “I can't take it anymore.” And when we got to her new room, it had a window in it, and she just started crying even harder. She was so relieved that it had a window in it.I don't think I really thought about, like, how isolated the patients were. And, you know, now every time I take a patient over to one of those rooms and leave them there, it kind of breaks my heart a little bit, knowing just how alone they're going to be.I don't know, I think it's interesting how we as a society really value our independence. Um, but I think we're really learning how dependent we all are on each other. And that we're more dependent on other people, and we need other people more than we thought, and we're not just our own individual entities that can just exist on our own and just make it on their own. When we take each other away, we kind of all go a little crazy.I mean, this is a time when we're all kind of alone, I guess, and you can see how we're really not meant to be. People are getting really upset about it and, I guess, like, rebelling about it now. And I get that.But it also makes me really scared to not be isolated anymore. I'm afraid of what's going to happen.Actually, yesterday, I also had a patient who was telling me as I was taking him up to a floor about a barbecue that he had, and he said it was on Saturday, and yesterday was Tuesday. And he was talking about how he had all of his family over, and he made all this food and he said that they wouldn't eat it, and it was too much food. And that was his whole story–was that he was mad at his family for not eating all the food he made.And I really hope maybe he just said the wrong date, or... but he said this past Saturday. And now he's on a COVID ICU floor.So I'm really hoping that it wasn't this past Saturday that he had a big barbecue with all of his family and friends. So that would be, not…great.

Anonymous

So I just got done with a week working at the COVID rehab unit at a nursing home. You know, trying to help people through the usual post-hospital stuff of, like, weakness and delirium and depression, and everything that comes with it.But at the same time, I was so jumpy the whole time of, like, what am I missing? You know, this person threw up after lunch. You know, is it just because lunch was bad, or because something with COVID that is a late complication that we don't know about yet?You know, if my patient slept poorly because of a headache: was it some kind of clot that they were having because COVID causes these, you know, clotting disorders and strokes? Or was it just a headache?And it's hard to like, work in this realm of like, no knowledge. Because since this is a new disease, all that's generally known is about the short term, acute stuff and not really much about the medium and long-term complications of it. And…I don't know, I mean, I hope I did as good a job as possible.Plus, you know, I'm still wearing all of the crazy protective gear, because these patients are still testing positive, which is why they're in the COVID rehab unit, as opposed to just any old nursing home. And every time I go in, I'm like, wanting to spend as little time in the room as possible, because I'm still nervous about, you know, catching COVID from these patients who are still shedding virus.But at the same time, like these patients that I've been seeing, a lot of them are really depressed and traumatized by the fact that they were hospitalized for weeks or a month, and sedated for much of that time and have no idea what happened to them.And so, you know, when someone is traumatized, you want to be there for them, and give them a pat on the back and just reassure them that it's okay to be a little bit scared or freaked out, and…So I have these like dueling feelings of wanting to leave as fast as possible, and wanting to stay as long as possible.You know, everyone talks a lot about, like wanting to get back to normal, and I'm like, “What is normal anymore?”

Calvin, MFM fellow, Bronx, NY

I’m a maternal-fetal medicine fellow in the Bronx.As we continue to treat patients in this COVID-19 pandemic, and begin to observe many interesting aspects of disease from a medicine standpoint, but also from a social standpoint–I remember going into this one patient's room. She was in her mid 30s, African-American female, about 35 weeks pregnant, and was admitted to hospital for a cardiology evaluation.At this point, our hospital has begun universal testing for COVID-19, and we began to tell her that every patient on admission would receive a swab to test for the presence of the SARS-CoV-2 virus.And upon receiving this news, the patient immediately became irate and became scared, even. She was tearful. She started to scream, “I'm not letting you give me the virus. I've heard about this. I heard about you guys swabbing and giving people the virus. I do not want that in my nose. There's no way in hell I'm going to get that virus. I came in feeling healthy, and I want to leave feeling healthy.” And she went on and off.And what I could hear, aside from her being incredibly upset, was the deep distrust that the patient had, and that many patients who are Black have, for the medical system. Who time and time again have taken advantage of vulnerable communities when it came to testing particular treatments for conditions, such as the infamous Tuskegee syphilis experiment and the Mississippi appendectomy, in which patients underwent sterilization procedures unbeknownst to them.Time and time again, they have reason to not trust us. And rather than be defensive, it's up to us to be understanding–to understand where they're coming from and to try to rebuild that trust…that we can restore the idea of patient centered care even in the midst of a pandemic.

Ian, Covid vaccine subject, Seattle, WA

Hey, this is Ian H. in Seattle, I'm recording this on May 18th.

Two weeks ago, I got my second and final injection of the world's first experimental COVID vaccine. I'm feeling perfectly normal now, no symptoms to report today. I actually feel exactly like I did before this trial started, which is to say that my health is fine, but I'm sick of being stuck in my apartment.There was some big news today from Moderna, which is the company that made the vaccine candidate that I got. They released their first bit of data from this vaccine study. It showed that all 45 participants, including me, became what's called “seropositive.”And that means that our blood now contains antibodies as a result of the vaccine. In the eight study participants who were tested further, all eight were found to have helpful antibodies that blocked the growth of the virus in a lab setting.It seems likely that I have the same antibodies, but we don't know that yet. This is really cool news. It's an indication that the vaccine might be working. It's an early indication, but it doesn't mean anything definitive yet.We don't know if this vaccine or any other one actually protects people from COVID, and we won't know that for many more months. It's pretty weird to learn about your own body from a corporate press release. Reading about Moderna’s results on Twitter this morning was actually the first that I learned about my own condition, that I had produced antibodies.There's still nothing for me to do now but wait. I'll be going back to the clinic for more blood work this week. I'll get to see the physicians and nurses there, who are starting to become something like my friends at this point. They seem hopeful. I'm certainly hopeful, and it's nice to feel hopeful about something.

Susan, Baltimore, MD

It's Susan B from Baltimore. I've opened my office door so you can hear the overhead in the background. It's playing music. It's one of the local lite rock stations. And it, I keep it turned up so that when I'm in an exam room, my patients won't hear the noise from the hallway. I got to tell you, it gets old hearing the same songs over and over and over. It's like being trapped in an elevator. Although the songs may have a little bit more beat than elevator music, it still gets old.The Governor's about to come on in about half an hour or so and let us know what's next in the “road to recovery” is what they're calling it here: “phase one.” I don't know what that means, neither does anybody else.Nothing much exciting going on, we are back to all doctors in the office. All the waiting rooms here have chairs. There's lines indicating who should stand where. Most everybody is pretty accommodating and adaptive.I did have one patient yesterday who got angry. He thinks it's all a hoax, and there's nothing the matter, and they should open up the economy. And he got a little aggressive with the front desk and tried to touch them.Everybody got upset. “We are all hysterical,” is what he said. It's very weird.But again, most everybody is quite accommodating. They understand, you know, everyone's wearing their masks, except for this gentleman, of course, who refused. It's, you know, it's the new world. I'm sure there will be more of this going forward. I think people will eventually start to come back to the office. There's still a lot of people that are afraid and aren't coming or calling or doing the telemedicine visits.Now, I think there's a lot of, just, fatigue. People are tired of being cooped up. They can't wait to get out. But they're not…the majority of them aren't just going out, because they understand the realities of this new world.

Meds-Peds Resident, Newark, NJ

I'm a fourth year med-peds resident in Newark, New Jersey.I was diagnosed with COVID just over a month ago now, and actually needed to be admitted to the hospital that I am doing my training in. I initially got tocilizumab the first night that I was there, and got started on hydroxychloroquine, but that had to be stopped because my QTc got too long.And then, on my second day, I was started on IV steroids. It helped for a little bit, but I still actually kind of continued to worsen.When I was first admitted I was on 4 liters nasal cannula, had to go up to 6 liters, and started having increased work of breathing by, like, day three.One of my co-residents texted me that day and was like, “Are you getting intubated?” And I was like, “What?” Plans weren't always clear. So I kind of freaked out and was talking to some other co-residents and thankfully, they were able to, like, calm me down.And then I found out, I wasn't being intubated. They were going to keep high flow at bedside just in case I needed it, because I was breathing in the 50s, 60s and then satting about like high 80s, low 90s. So, yeah. Thankfully, we were one of the sites for the remdesivir trial. So I was started on that, and started to improve after that.It's crazy: the transition from hospital to home. I didn't realize I had been in the hospital for that long, until I actually did the math because all the days went so fast and kind of melded together. And so to be back home was really strange.One of my attendings–he had also been admitted and got discharged before I did–and was kind enough to call and check up on me.And something that he said triggered something in me. He was like, “We did it. We made it!” And I think because of hearing all these stories about people not making it made me really scared. Like, did I really make it? I don't know. What if things get worse? And I mean, I also had this fear in the hospital, too, when everybody was saying, like, “Oh, you're getting better. You're getting better.”But it almost felt like one wasn't supposed to get better. One was supposed to stay sick, as twisted as that kinda seems. I had actually been debating, when I first got sick, if I needed hospitalization, would I want to go to the hospital that I'm training at, or go to a different hospital?I found out after that the other hospital that I was even, like, debating going to wasn't doing the remdesivir trial. So, just, kind of the sheer luck that I happened to go to the hospital that I’m training at, and they were doing the trial.But then also…I guess when they started doing the trial, because of the way that it had gone through IRB, only people who spoke and read English were able to consent for the trial.

Meaning anybody that needed, like, an interpreter to communicate with our medical team wasn't eligible to even be considered for the trial–which is so infuriating because I heard from many co-residents about how some of their patients like would have been such prime candidates for remdesivir, but because they only spoke Spanish, they weren't allowed to be considered.One of the fears that I had also had earlier, but also continues to a lesser extent, is…what if I get sick again? What if I get reinfected? What if it comes back, or what if I'm spreading the virus unknowingly?

Ramona, Endocrinologist, Southern California

So I haven't posted in probably almost close to two weeks because I didn't think there was much else that could actually happen, but it just seems to keep coming.

My practice manager, who I also take care of as a patient, also functioning as my biller, wasn't feeling well for a few days. Then she couldn't get out of bed, and I had to beg her to go to the emergency room.

Her first response was, “I don't want to die of COVID.” But I told her that if she didn't go, she might die in her bed.So I was able to coerce her to go to the emergency room. And turns out she was in acute renal failure, with a creatinine of over 8, and rhabdomyolysis with a CPK over 50,000. Unmeasurable. So people are dying from other things because they're so damn afraid of this virus, and they're so afraid that they go anywhere that they're going to catch this virus and die, that they're dying from other things.

She's still in the hospital–it's been almost two weeks. I don't know if she's going to make it. So now I'm doing all the things she did for me: paying my bills, making deposits, going through EOBs, making sure they get accounted for, along with telemedicine. My three kids are still home-schooling. I'm not sure I'm going to hold this together.I can't open my office, or even think about opening my office, because I can't get enough hand sanitizer, surgical masks, and I can't even get a new thermometer that doesn't involve touching a patient. All backordered–can't get any of them. So how am I supposed to open my office to care for my patients adequately?I just had a patient right now–I get called from the radiologist who I had to send them to get a biopsy of what we thought was a thyroid mass, because I had initially seen him late last year. He was supposed to get a biopsy. He never went.

Then he called my office about a week ago, saying that he thought it was getting bigger. We did a telephone, a video visit, and this neck mass was enormous, probably had tripled in size since the last time I'd seen him. So, then I get a phone call that he didn't even want to go, and was it okay with me if he did not go get the biopsy because he was afraid of catching this virus.So my answer to him was, no, I couldn't tell him it was okay, and if he didn't want to go, he would have to cancel the procedure himself, and we would document that he did not go. So apparently he went. I get a call from the radiologist who says this is not a thyroid mass, which I was suspicious it wasn't. But it was a huge mass, almost seven centimeters, and possibly lymphoma. So now we're waiting for that.So I just–I'm hoping I can hold this together because I'm just about at the end of my rope, and the end of my solutions, on how to fix all of these problems that just keep coming up. They just don't stop.

My husband still hasn't had a day off. We're going on almost 90 days at this point. He's almost losing it. He says that this is the most horrible, critical disease he's ever seen. I don't know that this is sustainable.

Anonymous 7th Grader

Today is May 14th, and before this global pandemic hit, I was a normal seventh grader. I go to school. I come back from school, and I live my daily life the same, every single day.But since it hit, many things have changed for me. I went from being a seventh grader to a nanny. I know, being promoted, early! These two siblings of mine are not very easy to handle. And also I was not paid, so that was a bit disheartening. But, I now take care of them every single day. I make their lunches, I help them go on to Zoom meetings, I help them with their homework.But other people, they're very fearful and scared, which is a normal human emotion to have right now, because you don't know how it's going to end, what's going to happen next?I like to think about positive things, and I think that we’ll grow from this experience. We'll learn from it, and we'll be even stronger, later. In honor of that, I have my two unruly siblings here with me. Ellie is nine and DJ is seven, and first I'll be interviewing Ellie, just asking her three simple questions.

Anonymous 7th Grader, Interviewer

Hello, Ellie. I know it's going to be a bit emotional for you, but I just want to ask you, does the virus make you feel unsafe?

Ellie

Um, well, no. Not really. It could to other people. But I know that my family members are staying protected because I know they work with positive COVID-19 patients. They're staying protected, but it's kind of scary.

Interviewer

Is there anything else that happens at the hospitals?

Ellie

When a positive COVID-19 patient is discharged, they play the Rocky song over the loudspeaker.

Interviewer

And yes, we are from Philadelphia, so, showing Philly pride, everyone! Woot woot! Okay, now that you're home a lot, what have you been doing with your free time? Because I've seen breadmaking and a lot of crafts, and I just want to know what you're up to, even though I already know because I live with you.

Ellie

Well, if you know that I know that we all go outside and play games, and yeah. Our grandma comes over, but don't worry, with masks and social distancing.

Interviewer

Yes. I think it's very important to do that when you're very fearful. Just go outside, take a breath of fresh air and just, really you'll feel really, like much better. So my last question is a bit heavy. How is your life different from before the virus?

Ellie

Well, at school, before all this crisis, we went to school. We–we did our work. We had lunch at school, then we came home. But now it's home and home and home and outside. But at home. Yeah.

Interviewer

OK, DJ, welcome to the show. Do you agree that online school is similar to regular school? Is it the same?

DJ

Well, it's mostly different. When we went to school before COVID was here, we had to do, like, all our things in one day. But now that we had to do it at home, and we have to have like a family members help us, it's been, like, kind of going slow. But if you have someone to help you, you can finish it really fast.

Interviewer

Is it hard for you to finish your school work?

DJ

No, since you help me, I can finish it easily.

Interviewer

I really like that answer, because I think I do a great job of helping you. And to finish this podcast, or this segment, ofh on a positive note, we would like to show you even more Philly pride with the Rocky theme song.singing, music fading in: Duh duh dun! Duh duh dun!