As a family physician who practices in both inpatient and outpatient settings, I've cared for many sick patients and had many patients die due to various medical problems or comorbidities. Two weeks ago, an older patient with multiple comorbidities I cared for in the hospital died. However, the death of this patient -- whom I will call Tina -- was unlike any other I had experienced. Her death weighed on my mind much more heavily and felt shrouded in confusion, anxiety, self-doubt and guilt.
Tina died from COVID-19.
Even before the diagnosis was confirmed, everything about Tina's illness and presentation filled me with dread. From the time of her admission, I had a sinking suspicion she was not going to survive. Her presentation was consistent with what we know about COVID-19.
At the time Tina was admitted, there had only been a few confirmed COVID-19 cases in our county. We suspected COVID-19 but it was not confirmed for a few days, given the limited supply of tests and slow pace of testing. The unknowns and questions far outweighed the knowns regarding everything surrounding Tina's illness and admission. I was worried she had an extremely poor prognosis, but she and her family were aware of just how perilous her situation was.
Every time I admit a patient, I discuss with them their goals of care and if they would consider advanced cardiac life support or intubation should their clinical status decompensate. However, Tina brought up the subject before I could. She told me flat out that intubation was not an option given the slim chances of a meaningful recovery.
Because she had several cardiopulmonary comorbidities, I was not surprised to see Tina start to decompensate during the next few days. Although I was treating appropriately for comorbid pneumonia, COPD and acute renal injury, I felt somewhat helpless. It seemed we were out of options to support her, and things were only getting worse.
I often tell hospitalized patients, "We don't cure you, we simply provide as much physiologic and emotional support to facilitate optimal conditions to help the body heal itself." Despite our best efforts, modern medicine does not always have an answer.
The fact that Tina was dying before my eyes kept me up at night and caused me to doubt my knowledge and skill as a physician. Even weeks after her death, I still question whether there was more I could have done. I read as much as I could about this novel virus, but much of it was anecdotal and what little "evidence" I could find was not peer-reviewed. I consulted several colleagues and pulmonologists, but there were few good options. Even trying some experimental treatments did not seem to help, and I felt stuck.
What else could I do? Who else could I ask?
In addition to the feeling of helplessness regarding my patient, I was scared for my own health and that of my colleagues. I also was concerned about the expected tsunami of COVID-19 patients that was still to come.
Worst of all, Tina was dying alone. Because of safety precautions, patients were no longer allowed visitors in the hospital. Additionally, nurses, respiratory therapists and physical therapists were worried about exposure and did not see Tina as much as they would have under normal circumstances, both to reduce risk and to preserve personal protective equipment.
Furthermore, given the myriad of unknown factors surrounding COVID-19, we were unsure at the time if an N95 mask or surgical mask was required to prevent infection of health care staff, or if high-flow oxygen or non-rebreather oxygen delivery masks would aerosolize the virus and place health care workers at higher risk. The questions, anxiety and fear surrounding this patient and her diagnosis was apparent in every interaction and conversation.
On the fourth day of hospitalization, Tina's oxygen requirements continued to increase and her blood oxygen level continued to worsen. I stayed late that evening -- well after my shift had ended. After a long conversation with the family, the decision was made to pursue end-of-life comfort care. I was grateful that we were able to take away her pain and oxygen hunger.
That night her partner of 40 years came and said goodbye, and the next morning Tina died.
Tina was the first patient with COVID-19 I treated, but I knew she would not be the last. This virus is impacting thousands, if not millions, of lives. I put on a brave face for my patients, colleagues and family. I tried to let the analytic part of my brain take over, reassuring myself and others that "we were all going to be fine." However, I was really concerned for the physical and emotional health of my community.
Treating COVID-19 causes significant anxiety, but fear of the unknown was by far the most burdensome for me. It felt like we were fighting an invisible enemy, and we didn't know where it was, how large it was, how strong, when it would attack or what collateral damage it would inflict. Worst of all, we still have no real treatment.
This was a single patient's death, but it was so much more than that to me. While treating COVID-19, I felt an ominous weight on my shoulders. I felt the anxiety and fear of the patient and her family. We know COVID-19 will profoundly impact the health of our communities and change health care in ways that will likely last generations. However, not knowing when, where and the degree or magnitude of the impact makes it so much harder. I fear for my patients, my colleagues and the aftermath we will endure.
Alex Mroszczyk-McDonald, M.D., practices comprehensive family medicine and sports medicine in Southern California, with a focus on health policy, physical activity and advocacy. You can follow him on Twitter @alexmmtri.
Leader Voices Blog - An AAFP Leaders Forum
In the Trenches - AAFP Advocacy Updates
FPs on the Front Lines - Meeting the Challenge