Cardiac Surgery Resident
Hospital of the University
of Pennsylvania
Philadelphia, PA
This is part of our series, Flattened By the Curve, which features the voices of doctors, nurses, healthcare workers, and others on the front lines against COVID-19. For information on how to submit, click here.
Standing quietly outside of her room, I blankly stared at her monitors, searching for a solution to her rapidly worsening septic shock.
“She’s full code. What do you want to do?”
This question struck at the heart of the fear we all shared. Not only did performing chest compressions on a COVID-19 patient present a formidable challenge in and of itself for the staff, but this patient was also far too frail and sick to derive any meaningful benefit. This patient was an older woman who was admitted from a nursing home that evening, who despite already having been placed on a ventilator, rapidly continued to worsen. Her kidneys also failed to the point of no longer making any urine, which signified a dire prognosis. With each passing hour, it seemed less and less likely she would survive the night.
As I picked up the phone and dialed her next of kin, I felt as much anxiety as when I made my first skin incision or performed my first sternotomy. This was not a conversation I was used to having. Tonight, it was my responsibility.
At the onset of the pandemic, the junior to mid-level residents in my program – eight of us in total – were called back from our respective rotations to work in a 12-bed ICU, one of many created at our institution for the purpose of taking care of COVID-19 patients. Our skillsets as cardiothoracic surgical trainees were conducive to taking care of this patient population who, as more of a rule than an exception, presented with failures of multiple organ systems. Day-to-day, we helped manage ventilator settings, vasoactive medications and at times, advanced platforms such as extracorporeal membrane oxygenation, or ECMO for short. After all, the cardiopulmonary bypass machine was within our armamentarium.
While we all shared some degree of frustration at the impact this would have on our training initially, we all agreed the job was necessary for the common good. Providers and trainees at every level across the country were making sacrifices to prepare a unified front against the pandemic. Yet, it also took us on a dramatically different path from the one which we were used to. We typically spent most of our days in the operating room, working with our hands to repair valves and blood vessels. This new role came with a set of unfamiliar, daunting challenges, one of which was having frequent end-of-life conversations.
“Hello, this is Dr. Han. I’m sorry to call you late in the evening. I’m taking care of your sister.”
“Oh! We have been hoping to hear from you. How is she doing?”
“I just had a chance to meet her. Unfortunately, she tested positive for COVID-19.”
Her worst fear had been confirmed. She began to cry over the phone. I stayed silent, not knowing how to best comfort her given these complex circumstances. All I could do was listen to her as she tearfully repeated, “Please tell me she’s going to be okay.” I knew the next part of the conversation would not get any easier.
For the next several weeks, these scenarios continued to occur daily. Most of our patients were from nursing homes. They were old and frail, which rendered them particularly vulnerable to succumbing to the virus. We took part in many phone calls with family members where we discussed end-of-life care. One patient in his eighties with severe dementia who was already dependent on dialysis had clearly expressed in his Advanced Directive that he did not want to be intubated or resuscitated. His sister and son, overcome with grief over not being able to be by his side as he neared his death, asked if there was really nothing we could do. This was yet another question I was not accustomed to addressing. We had a conversation about Advanced Directives, and the logistics of pursuing comfort measures. Then I set up a video call on my phone and handed it to the nurse who was already inside the room. There they remained with him until he passed, as close to him as one could possibly be while being physically separated, tenderly watching him from a screen that glowed warmly inches from his face.
Over time, we continued to grow more and more cognizant of the patients’ social and family situations. “Have you talked to the family today? Do they understand what’s going on?” became a part of our daily handoffs, prioritized on par with communicating allergies, medication requirements, and ventilator settings.
We have come to do so not because of any mandate, but because we all witnessed firsthand how important it can be to provide the level of care these patients deserve. For all of us, these conversations will remain in our surgical repertoire, and hopefully shine through in future scenarios where we will need to navigate complex, humbling conversations with warmth and empathy.
Also, just as unexpected, we have learned to rely on and to be vulnerable with one other throughout the pandemic. As our camaraderie deepened in this unforeseeable crucible, both demanding yet offering unique windows for reflection, we learned to cope together and to show our human sides, no longer competing by display of prowess or of being hardened, but rather accepting others with openness.
One of our interns texted out to the rest of the group one evening after losing a young patient to COVID-19. “I just called the family,” his text read, “The son’s response was, ‘Well, thank you. I just want you to know that you all will always be my hero. Thank you for what you are doing.’” He shared the vulnerability and loneliness he felt in that moment. We all replied to him with words of encouragement. A few years ago, or in our usual circumstances, I wonder if we would have ever been as willing to share our feelings as openly.
We have all lost too much from the pandemic. The trauma on healthcare workers is irrefutable. Those at the frontlines have and continue to face tremendous occupational risk, both physically and emotionally, while losing touch with the aspects of their lives that provide a sense of normalcy, such as being with family and friends. Trainees also struggle with uncertainty as their career goals have been placed on hold indefinitely.
But though unexpected, we have also gained a little in walking these unfamiliar territories. They are there, if you choose to look for them, and in my case, it gives me hope we will emerge from this tragedy as better people. For the surgery residents in our program, it has reminded us and instilled in us the imperative of talking to families daily, to not shy away from, but rather to lean into emotionally challenging, end-of-life conversations with patience and empathy. It has taught us to be vulnerable with one another in ways that defy the existing culture.
As Dr. Craig Smith, the chair of surgery at the New York Presbyterian Hospital, which has seen some of the most devastating faces of the pandemic, writes, “I will acknowledge that ‘hope’ has its detractors…” as some say “Hope is not a strategy.” Yet, looking back on the last few months, I am with Dr. Smith on this one.
“I think I will hang onto mine. It pushes me out the door.”
Jason Han is an integrated cardiac surgery resident at the University of Pennsylvania and a writer for the healthcare section of the Philadelphia Inquirer. He is interested in the intersection between surgery, ethics and narrative medicine.