Here are excerpts from a sermon that Dr. Edward Telzak, chair of the department of medicine at SBH and an infectious disease specialist, gave at his synagogue in Brooklyn on Yom Kippur, the Day of Atonement.
I am an infectious disease physician. My career started with a worldwide pandemic and will end with a worldwide pandemic. I want to compare one aspect of each epidemic, in particular, and on this most solemn of days ask for foregiveness for perhaps a necessary but very painful aspect of physician behavior during the COVID-19 surge.
While a first-year resident in 1980, I saw extremely ill young men admitted to the hospital with severe and very unusual infections. Many of these men, my age or younger, never left the hospital. Of course, this was the beginning of the AIDS epidemic.
Early on there was no known cause, though there was a strong suspicion that it was spread from person to person. There was great stigma and discrimination towards these young gay men and great fear of casual spread both in the public and even in the medical community. The stigma associated with HIV only increased when intravenous drug users and their sex partners became infected. Initially, I too had concerns about my health from the potential transmissibility of HIV.
I was drawn to care for these patients irrespective of the potential risk. In retrospect I cherish the time I spent with patients prior to the development of effective treatment for AIDS. Do not get me wrong. I would never want to go back to the days before effective therapy. Many of these patients were alone, addicted and angry, isolated and rejected by their families. Some were so enraged that they were unapproachable. For many, however, though I could not treat them in the traditional medical sense with drugs or surgery, I spent time with them at their bedside, or in the clinic, as their physician.
Often, over many weeks to months, I spoke with them, and listened to them, and gradually learned their voice. I learned of their families, their loves, their disappointments and, yes, their hopes. I spoke of them often to my wife and my children. Though I could not treat their primary illness, I worked very hard to ease their physical pain and mental anguish and I believe in retrospect that this has been among the most satisfying aspects of my career.
I do not need to tell you that March and April of this year, the COVID-19 months, were a generational event for all of us. We knew from mid February on that COVID-19 would come to New York after witnessing the events in northern Italy and Spain. At my hospital, St. Barnabas, located in the south central Bronx that cares for among the poorest communities in the United States, we spent weeks preparing for a possible surge, reconfiguring and expanding ICUs, medical floors, canceling elective procedures, attempting to hire additional staff and on and on and yet when COVID-19 came in its full fury we were overwhelmed.
Within days, all of New York City, despite preparation, was overwhelmed. We did not flatten the curve in time. As one example, at our maximum we had in effect seven intensive care units when ordinarily we have two. At its height, we had 94 patients on ventilators. Normally, we have 20 patients on ventilators. Twice, we were down to five ventilators and it was the job of the triage team to determine who was more deserving of a vent and who was less deserving if we were to run out. Fortunately, New York State made serial emergent ventilator deliveries and we never had to remove a ventilator from a patient.
We saw the rapid deterioration of patients on the floors requiring intubation, sometimes as many as two to three in an hour. Deficiencies were widespread in equipment and critical staffing, especially ICU nursing and respiratory therapists. Mistakes were made. Deteriorating patients were not caught in time. These were extremely difficult times for all of us, especially the patients and their families. It was clear that the extreme quantity of patients we saw and the severity and unpredictability of their illness greatly impacted quality in so many ways. This was the effect of the surge that everyone was warning us about and yet the part that I find so problematic, perhaps the most painful part, was the large number of patients who deteriorated and or died alone without their family by their side.
Over the last several years I have led the hospital’s effort to teach younger physicians and staff at all levels to deliver thoughtful, kind and compassionate care. How to speak with patients and their families, to take the time needed to be with them, and to use language that can be understood. To take the time to sit down in their room, perhaps touch a hand or an arm when appropriate, and to learn of their concerns.
As medicine has become increasingly technological, the human element and interaction has often been sacrificed. During the COVID-19 surge, we were afraid. We knew the data and saw our colleagues get sick from COVID 19. At St. Barnabas, we lost five staff members to COVID-19. As a group, we were afraid of contracting this illness and bringing it home. We were afraid of passing it on and even requiring ICU level care and worse. We gowned and gloved, wore respirators and face shields to make it impossible to communicate to patients. And, most importantly, we configured our equipment in such a way that we could make medical changes to ventilators, medications, obtain vital signs and do so much more without ever having to enter a patient’s room. Doors were kept closed. We did everything possible to separate ourselves from our patients to minimize transmission risk. Some patients deteriorated, but not before our eyes, because we were not in the room.
This behavior is counter to everything I have taught young physicians for years and have practiced myself and it is the most foundational aspect of being a compassionate physician. You must be with your patient. Speak with your patient. And work to understand their concerns. Rather, during the COVID-19 surge, we did everything we could to separate ourselves from our patients, so we would not become infected. Of course, this makes sense in so many ways. There was a sense of foreboding that penetrated each and every day. We lost the intimacy of patient care. I feel we let so many patients deteriorate without explanation, even die without explanation, without the comfort of a family member or caring health care worker at their side. In my experience, this did not happen in the same way when we took care of patients with HIV/AIDS early in that first pandemic in New York City, when we did not even have a causative agent. But it happened during our COVID-19 experience and we let too many frightened patients deteriorate and die alone.
For these sins, forgiving God, forgive us, pardon us, grant us atonement.