PGY3 medical resident
Emergency Medicine Attending
Interviews about Covid-19 with Dr. Joshua Schwarzbaum, an emergency medicine attending, and Dr. Isabel Villegas, a PGY3 medicine resident, took place over a 10-week period. Here is a brief look at how The pandemic affected them over this time.
It’s the beginning of April, at the heart of the pandemic, and the number of desperately ill patients on 2 North feels overwhelming. Residents like Dr. Villegas are just three months away from graduation and this, she feels, is their final examination. Only there is no cramming for the test. And patients’ lives are at stake.
“Patients are gasping for air, patients are crashing, and you can see the fear in their eyes,” says Dr. Villegas, who grew up in Quito, Ecuador. “I’m physically exhausted, it’s emotionally draining, but I’m not feeling burnt out. We know we have to sail this boat together.”
The death toll in New York City from the disease will reach 27,000 by the end of the month, and the people in this borough are among those most impacted. It’s all part of a vicious cycle. Much of its population contends with food and housing insecurities. This leads to chronic illnesses like diabetes, high blood pressure, and cardiovascular disease, with a propensity for obesity. These are all conditions the virus preys upon. The morgue at St. Barnabas Hospital can no longer accommodate the number of deceased patients – hence the two large refrigerated trucks notso inconspicuously parked outside the hospital’s loading dock.
Dr. Maria Villegas (she’s known as Isabel) and her fellow residents know now is the time to up their game, “for PGY 2s to behave like PGY 3s, and PGY 3s to act like attendings,” she says. At the same time, the young doctors know they too are standing close to the fire. “No one is saying they are too afraid to hold the hands of our patients,” she says. “We know we’re at high risk, but no one is hiding behind the door.”
A significant number of the hospital’s medicine residents come from South and Central America – in total, the three classes of residents represent more than 30 different countries – and so many can converse with patients in Spanish, the language both find most comfortable. This is particularly important at times like this, with patients fighting for their lives without loved ones by their side. Outside of an occasional phone call to family, they are on their own. Yet, a shared language gives heart to many. Residents, who too have been separated from their own families for months while living in the Bronx, provide a life buoy. Yet, this bond too also presents consequences.
One resident forms a quick rapport with a patient. The older woman reminds her so much of her mother back home in the Dominican Republic. The resident consoles the patient. She takes her hand to give her comfort. And when she dies, just hours after they meet, the resident becomes inconsolable.
At about the same time, Dr. Joshua Schwarzbaum is launching the first of the increasingly well attended Sunday night Webex meetings for emergency medicine residents and attendings. It’s part of a wellbeing initiative that until now hadn’t quite gotten off the ground. He’s teamed up with theologian to help his colleagues cope better with the stress and uncertainty of the pandemic.
The weekly meetings, he says, are intended to help participants find the positive within the negative, to keep moving when feeling overwhelmed, to come up with new strategies during unprecedented times.
“It’s a challenging time, but everyone is working together during a period of uncertainty, from the executive team, to the doctors and nurses, to the techs, security, clerks and environmental service team. It’s been much better than what you read about at other hospitals.” He admits that it’s a time that “can have scary aspects to it. But, this is what I’ve trained for. I feel I’m blessed to be able to do what I do.”
Dr. Schwarzbaum, who also works part time in addiction medicine, has been involved in emergency work since high school. He became an EMT at the age of 18 with Mamaroneck EMS and currently is the medical director of the Bronx and Manhattan divisions of HatzolahVAC, an ambulance service started in Brooklyn in the late 1960s to both improve EMS response time and address the needs in the Jewish community. He’s also volunteered as an emergency doctor for a medical transport company.
“There is a lot of trial and error at times like this, but that’s okay as long as it’s not paralyzing, and that we keep moving,” he says. “Everyone is doing their part and going above and beyond and helping foster a successful environment, accommodating change as we go along.”
As medical experts tell us incessantly on television, it’s all about flattening the curve. The term has become every bit as ubiquitous as cars have become scarce on major arteries throughout the city. Several weeks ago, it meant nothing. Today, it’s the definitive grade measuring the city’s ability to tame the pandemic. Dr. Villegas says she is seeing patients so weak that “the simple act of turning them from one side of the bed to the other leaves them exhausted. It’s like mission impossible. They don’t want to drink or eat, and they can quickly become dehydrated.”
There are barely enough ventilators at the hospital to cover the pent up demand for them. This brings medical leadership to the heartbreaking discussion over how the remaining ventilators should be distributed, which patients would get one and which would not. Respiratory therapists and doctors by now have connected patients to nearly all of the available 100 or so ventilators, with the hospital turning over every conceivable leaf to locate more. Fortunately, no such life-and-death decisions need to be made.
Those ventilators that do eventually arrive look as though they were retired during the Reagan administration.
Dr. Villegas recalls one patient, a man in his 50s, who refused to be intubated. “He didn’t want to burden his family,” she says. “He knew he wasn’t doing well, but he refused any kind of intervention. He was having trouble breathing, but fought to the end. I tried to tell him that this (going on a ventilator) might be his best chance, but he was so firm about it. Many patients say this, but when they feel they can’t breathe, they reverse their wishes and agree to get intubated. Some end up on the machine for two months and get other complications. We’ve had patients who have been on for weeks, and then die. But he was stoic. He wanted to die with dignity.”
Several hours later, he did.
Although she and her colleagues routinely work grueling 12 hour day, it’s more the mental than the physical exhaustion that gets to them. With as many as eight to 10 members of their colleagues down with various levels of illness at this time, the burden becomes increasingly overwhelming. Dr. Villegas says regardless of whether you have a family – she lives alone – she and the other residents share concerns about their health. “If you have kids, you don’t want to bring this home and contaminate your family,” she says. “When you’re by yourself, it’s also hard because you’re tired and want someone to take care of you. You can’t hang out with friends because you need to keep your distance so you’re either working or sleeping.”
Dr. Villegas admits that her family back in Ecuador remains anxious about her health. She’s very close to her parents, brother and sister, but tries to minimize the phone calls back home so as not to worry them. Instead, she communicates with them primarily on social media. “They’re not nervous people, but it’s the uncertainty of not knowing if I get sick. No one will let them fly in and that concerns them.” She admits to crying at times, but has always remained stoic when calling home. At times, when she speaks to her mother, she hears her mother’s voice crack when they say goodbye.
Like many of the medicine residents, she’s a little older, at 33, than most residents in other specialties. She’ll be starting a two-year fellowship in nephrology at Johns Hopkins Medical Center in Baltimore this summer. It took her four years after medical school to get to where she is today, spending a great deal in terms of effort and money to pass the necessary tests, and then bucking the odds to get selected for a residency in the United States. She considers this “like winning the lottery.” Yet, it has meant leaving the security of what she knows behind and coming to live in a country and a county she never knew before.
“It was real hard getting used to the Bronx,” she says. “People in my country are not so loud. Sometimes you feel like everyone is yelling at the same time. In both English and Spanish, it was hard to adjust to the different accents. I was also afraid of the Bronx. I feel more confident now, but I’ve learned you have to be careful.
” The ER staff works feverishly. They are seeing much more death, in a much shorter period of time, than they ever have before. As one resident says on a cable television show, “I’ve seen more death in three weeks than I did in three years.” Nurses must care for nearly twice the patients, all critically ill, than they would normally. Meanwhile, because of the sheer numbers of critically ill and dying patients, residents must learn to make choices. Their instinct to valiantly jump in to try to save the life of every patient they see in trouble is no longer realistic. Instead, they must work as part of a team, exerting their efforts to treat those patients with the best chance of survival. They do this to the haunting melody of more than a dozen ventilators vibrating as one.
“It’s changing the way we’ve been taught about care,” says Dr. Schwarzbaum. “When you train, even though there is uncertainty in emergency medicine, you’re still able to evaluate the patient and admit or discharge them. Now things are turned on their head. You’re not just able to look at each patient and treat them in the best way possible for them, but you need to consider the population as a whole. You have to look at the global picture. Yes, from the micro-level of the patient, but also the macro-level of the community and what’s going on around us. In the past, we could just focus on the micro-level, or the patient. All of us understand we have new directions with constantly changing protocols. There is a lot of trial and error, which has not been proven, and this introduces uncertainty.”
Dr. Schwarzbaum has worked in extreme conditions before. He attended medical school in Israel where he witnessed the aftermath of terrorist bombings. But he admits to never seeing something like this – so many critically ill patients, all alone. “You would see significant loss of life at one time, but not nearly what we’re seeing now,” he says. “There are different strategies in dealing with something that happens quickly and is then over vs. something that is repeatedly happening over and over again. We’re managing so many sick people at one time, one bed with a critically ill person in it is side-by-side with the next bed with another critically ill person. You’re managing so many people at once, and some are so sick you can’t develop relationships with them and it’s hard to reassure them.”
It comes down to having resilience, he says. He adheres to the writings of Victor Frankl, an Austrian neurologist and psychiatrist, and a Holocaust survivor. It’s a belief, says Dr. Schwarzbaum, in finding the good in everything. “It’s not to say you shouldn’t be grieving or sad, there are ways to find meaning and purpose in the world. If he could find it through the Holocaust, we can find it in something like this.”
As difficult as it is, he sees it, in fact, as an opportunity. “This presents a chance for people to really grow within the field of emergency medicine, to see the world in a different way, and to implement changes in what we’re encountering. The pandemic is certainly not good for humanity, but we should be able to take things from it and learn from it and become better doctors and better people.”
It’s well into May now and the situation, after eight chaotic weeks, has become more manageable. The volume of Covid patients has declined dramatically. Dr. Villegas says she feels calmer and that things are under more control. “Still, it doesn’t change the sadness of people not having family around or the number of very sick people that are still here,” she says. “Patients are still talking on the phone to family one minute, and crashing a few hours later.”
In hindsight, the experience, she says, has been positive. “Professionally, it helped us learn to handle something like this. We’ve had to work at the level of an attending. We’ve become secure in what we were doing. I think it has hardened me, but not to the point of being insensitive.”
Likewise, the ER has also slowed down considerably. “We can spend some time to debrief now, and that has really helped,” says Dr. Schwarzbaum. His outlook echoes the words of Victor Frankl, who wrote: “When we are no longer able to change a situation, we are challenged to change ourselves.”
“There’s a lot of uncertainty about the future,” says Dr. Schwarzbaum in discussing the possibility of Covid-19 returning. “We don’t know what’s going to happen next week or next month. With the Spanish flu, the second wave was a lot worse. We don’t know where it will go or what it will look like, but we feel we now have the tools to respond to it.”
