By Stephen Kramer, MD, Consult/Liason Atttending Psychiatrist, SBH
April 2020, Wednesday
Our hospital ethics committee calls an urgent session to consider ventilator allocation as the COVID-19 pandemic is worsening; we review the color-coding system that was developed to classify patients’ mortality rates based on their clinical condition and severity of organ failure. The system leads to a ranking of their ventilator allocation priority; decisions must be made regarding who will live and who will die. Suddenly everyone is talking about ventilators and even Donald Trump has a vague sense of their importance. I wasn’t prepared for this discussion. Where am I? How did this happen?
After the meeting, I rush to a psychotherapy supervision appointment with one of the residents. “I’m sorry,” I said, “I just left a meeting about rationing ventilators….I think I might need supervision today.” There’s an awkward moment of silence. “Well you have someone, right?”
I hesitate, not sure what the best answer would be to that question or whether to respond at all. Another decision I wasn’t up to making today. He pulls out his notebook and begins rattling on about his patients and how many of them had missed their appointments in the past few weeks, not explicitly connecting this development with current events.
I decide to ask him how he was managing. “I’m not into it at all, I don’t care.” I stare at the computer screen, again unsure how to respond. I have decision fatigue.
3 pm I meet with the medical students, who have been removed from their psychiatry rotation last week. We are scheduled to review an article about the mental health aspects of pandemics, but not surprisingly, the meeting veers into a discussion about how they are coping generally, and in addition how they are processing the medical school’s decision to have them leave their hospital clerkship. They are pensive; a few profess guilt, feel they should still be at there, that they had “signed up” for the risks by deciding to become doctors. Others confess they are relieved, their fear and anxiety somewhat lessened regarding contracting the virus and/or spreading it to family members.
I decide to disclose my anxiety-provoking ventilator meeting. One of the students tells a story about firemen he knew and how decisions were made regarding which ones went on more dangerous calls and/or received limited protective equipment in an emergency situation. There was spirited debate around the concept of rationing life-preserving resources, as well as voluntary vs. involuntary heroism, all a bit easier for us to consider from a vicarious position.
So many decisions. These days most of my decision bandwidth is channeled into determining whether I feel safe to work at the hospital. I have some underlying medical conditions that may render me more vulnerable to the virus. Surrounding these deliberations has been my sense of the collapse of reasonable guidance and measured response to the COVID crisis at every level. My colleagues and I are attempting to develop some unity on the matter, but agreement seems out of reach. The stress and fear are so overwhelming, the primitive response to contagion in the macro and micro system so palpable, that even we as psychiatrists are unable to process in any productive or meaningful way how to proceed, how to continue to do our jobs, yet stay safe.
I think I’m getting sick. I feel my head for the tenth time today; it’s warm, but I don’t have a thermometer … maybe I should buy one (but then I’d have to make the trek to the pharmacy, and do I really want confirmation anyway?). Besides, they are probably out of thermometers. I have a cough too. We were informed last week we have probably all been exposed to the virus, yet it’s not currently possible to be tested unless we have symptoms. Five of our residents have already become symptomatic, at least two tested positive, the others are still waiting for their results. Worrying about them distracts me from thinking about myself. One resident returned to work, but continued to feel unwell, it didn’t seem to make sense. I thought the guideline was seven days in quarantine … who made that decision? It probably has been revised by now.
I wish John Lennon were here, he was my hero, and he would have written a song about this
Monday: I test positive for COVID.