Pain Management Resident
New Orleans, Louisiana
This essay 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.
“Would you like us to do everything we can?”
No other sentence in medicine torments me in the same way. A ripping sensation shoots across my chest. I reflexively curl up my fists. From my start as a pharmacy courier in high school through medical school and my anesthesiology residency, the sentence continues to stalk me. Between the cracks in ER rooms, over the wheezing of ventilators in the ICU, creeping over the chirping of pulse oximeters in the operating room. It never leaves me for too long.
It’s understandable why the phrase has become so ubiquitous in medicine. It’s the easiest way to begin discussions on Do Not Resuscitate (DNR) orders. Decisions typically made in conjunction with patients and their family members over what treatments would be preferred if something catastrophic were to happen. The menu of interventions is listed out before them: CPR, intubation, vasopressors. There’s nothing inherently wrong with these discussions; they’re essential to the practice of modern medicine.
But the phrasing is sinister. “Everything we can do.” It fails to capture the full, horrifying scope of measures that can keep a heart beating. Even more damaging, it places an unenviable burden on the patient’s family. To ask questions about the quality of life as opposed to the quantity of life makes people feel culpable. “You killed mom,” I remember one sister yelling at another in a crowded waiting room.
Every physician trained in critical care knows the toll of doing “everything.” We have all kept patients alive against their will at the request of their family members. We have dialysis for kidney failure. Ventilators for respiratory failure. The list of medications and operations for heart failure has become mind-boggling. The prolongation of life continues to become easier while the eradication of the underlying pathology remains elusive. Everyone knows the prognosis, but with each step taken forward it becomes harder to say no to more treatments.
This fear of “everything” is not irrational. We have plenty of studies looking at the prognosis of patients that undergo successful cardiopulmonary resuscitation (CPR). Roughly 60% of those who survive the initial arrest never get discharged from the hospital. Of those that can make it out of the hospital, 25% of them die within the year. None of this accounts for the multitude of co-morbidities that are common with CPR survival.
And then came COVID-19.
The practice of medicine has irrecoverably been changed, but this virus has done something I could have never imagined. It took away “everything.” While practicing in New Orleans, the medical community saw some of the worst mortality rates in the nation. ICUs were soon filled. Emergency rooms became chaos. And more than ever, we could no longer do “everything.” The idea that ventilators would be a luxury only reserved for the most deserving would have been unfathomable just weeks before the crisis. Medications that were normally available with the click of a mouse suddenly required three different forms of approval. Before the pandemic, you could expect ten to twelve health care providers to respond to a code blue to assist with CPR. Now one physician goes by his lonesome and has been instructed that continuing resuscitative measures beyond fifteen minutes could possibly waste much-needed resources. And as the cases continued to climb, the more options disappeared.
Likewise, health care providers saw the evaporation of “everything.” Before COVID-19, the idea of using the same mask on patients with airborne precautions would be incomprehensible. Yet slowly the changes came our way. First, we were only allowed one mask for the day. Then one mask for the week. Finally, your mask was only to be changed if grossly soiled. Our own societies and administrators told us lies without guilt. Bandanas are now protective? Patients and healthcare workers were placed directly in harm’s way because we no longer had “everything.”
The lies hurt most of all. While children watched their parents struggle on ventilators, they were told that hospitals were empty and that no one was dying from this made-up virus. While physicians put deteriorating patients on bypass machines, they were told that they were making up cases for increased pay. Every conspiracy theory popped up on our social media feeds. Nurses and physicians came home from twelve hours of hell to be told by their president that there was no shortage of PPE and ventilators. Simply put, we had “everything.”
I don’t know what this country will look like as we slowly try to reclaim normalcy. I don’t know if our hospitals and physicians will be able to handle the eventual ebb and flow of COVID-19 cases. There are still too many variables to know how a whole nation heals from something so devastating. But I am sure we will try everything.
Jason Gremillion is an anesthesiology and pain management resident in New Orleans, Louisiana. He continues to survive thanks to his wife and two sons, and he thinks you should stop putting those tomatoes in gumbo.