On Osler and COVID and Carrying the Day

Tiff Bombard, MD

COVID-19 is starting to feel as if it should be re-named COVID – 19, 20, 21... Hopefully that is not the case, but it sure feels as if it has been with us much longer than it actually has. At the beginning of the pandemic, we didn’t even have testing. Remember way back then?  If you had a negative influenza test and suggestive chest imaging in the face of viral symptoms, you were presumed to have COVID. Since then, we have evolved an array of nasal swabs (with varying sensitivities) and serum tests, and our inpatient treatments for the sickest patients have evolved steadily as well. Testing and treatment will clearly be moving targets for the foreseeable future. What we do know it that this virus is unlike anything we have experienced in our generation. The sick patients are sicker. The poly system effects of the disease are devastating (long confinement to ventilators, hemodialysis, PE). The disease is seemingly random in whom it strikes with venom, and whom it leaves with mild or no symptoms to blissfully carry the disease to others.

I am an emergency physician. I practice primarily in a receiving center, but I also moonlight in smaller emergency departments. Here in Northern New York we have been mercifully spared the brunt of the disease. I listen to my colleagues from New York City talk about seeing case after case after heartbreaking case and in so doing commonly getting sick themselves. Here the experience in the emergency department is different. Here, rather than coming at us in an overt, unceasing assault, COVID creeps in ambush. We sometimes go days without seeing a patient suspicious for disease. It is common to get the call from the hospital occupational health human, notifying us that the nice, non-sick lady we treated and admitted for NSTEMI two days ago ended up with a positive COVID test. “Were you wearing your N95, doctor? And your eye protection? How about a gown?” - “Seriously?” I think, “a gown?  She was afebrile, not tachycardic, didn’t even sneeze!” Then I think with my better brain, “did I let the nurse in that room forget his eye protection? Did I see the clinical assistant scratch her nose under her mask?  Will they get sick?” I worry. Once more I ratchet up my caution one more notch.

And then the sickest patients arrive. They look, well, sick. Some are clearly precipitously failing. They can’t ventilate. They can’t oxygenate. We gown and glove and bonnet and N95 and PAPR. We intubate and resuscitate. We consider steroids. We struggle with sedation. We start vasopressors. We place a central line or a hemodialysis catheter and pass the patient along to our ICU colleagues for a trial of the latest treatment attempts. We try to comfort their family members on the phone.

Some patients look deceptively fine while sitting on the bed. They are young. They don’t smoke. They don’t have diabetes and aren’t immunocompromised after a renal transplant.  They say, “Doc, something is wrong with me, I feel terrible. My chest is heavy. I can’t seem to get a good breath.” They just look anxious. They have a history of anxiety.  Maybe that’s all it is. We’re all a little anxious after all of this social distancing. And yet. And yet - Dr. William Osler was one of modern medicine’s founding fathers. He practiced in the later 19th/early 20th century and helped to found a little hospital in Baltimore, Maryland called Johns Hopkins. You may have heard of it, and him. He wrote some advice in much flowery language that boils down to this: ‘listen to your patient, he is trying to tell you what is wrong.’  When you walk this patient, she becomes hypoxic. When you look at his vital signs, he is tachycardic. When you take their core temperature…  And the next day she is on high flow. And that night he needs intubation. And so it goes.

Our grandparents and their parents and their parents before them knew our pain. Their friends and family, their children and grandchildren knew vast morbidity and mortality from smallpox and polio and measles and Spanish influenza. They wore masks and gowns and fear. They performed the best medicine of their day, rejoiced when they met success and when they did not, sat at bedside and comforted the patients who were quarantined to otherwise die alone. They and their colleagues contracted and died of pandemic viral disease. They persisted. Eventually, solid science coupled with good medical care and a dollop of kindness won the day. This will happen for us too. In the interim, their responsibilities, and our responsibilities, are the same as they always have been. Resuscitate the dying with all of the fierceness and strength and skill and technology that we are given, listen to the patients and their families, carefully treat the sick, try not to pass disease to the next patient or ourselves. Stay vigilant. Take good care of each other. Heave up and carry the day.  Because, my friends, in the end, we are the only ones who can.

Tiff Bombard, MD is an emergency medicine physician née paramedic who practices in northern New York. You can reach her at tbombardmd (at) cvph.org.