Intern Year – A Geographical COVID Experience From Across The US

Daniel Ricotta, MD FHM
Beth Israel Deaconess Medical Center - Hospital Medicine Program
Assistant Professor of Medicine, Harvard Medical School
SHM Physicians-in-Training Vice-chair

Boston - Pots bang outside windows in India and Canada. Italians sing outside balcony windows. American police applaud outside hospital entrances. Physicians become regular guests on primetime television. Over the last few months, the world has been awash in stories of front-line healthcare workers facing the COVID-19 pandemic.

Often not told in these stories are the experiences of thousands of residents and medical students across the country who have sacrificed to meet the moment. Trainees, arguably more entrenched in the day to day care of the suffering than their supervising attendings, have largely been absent from public view. From truncated medical student education and canceled residency didactics, to everchanging recommendations and depersonalized bedside encounters the perspective of trainees give the world an important, if uncelebrated, window into daily life around the United States in the era of COVID. Here are a few of their stories...

Cody Gehring, MD
University of Washington Internal Medicine Residency

Seattle"These are uncertain times.” A flood of emails, texts, social media postings, wash over like a wave.  More cases, not enough tests. They need to be ruled out. Results are “inconclusive.” Only one family member can visit. “I’m sorry, your loved one has died.” They view the body through a window. A caring husband stands at the bedside with a PAPR on. His wife can’t speak. Do we have enough masks?  The daily emails keep coming. I look at the prediction models and read the news after my long shifts.  I can’t sleep. I stop visiting my family and walk past boarded up windows on my way home. The Mayor visits us on rounds. We are on the News.

I write notes, put in orders, review labs and imaging. I don a face shield, N95, gown, and gloves. “Should I be using up these precious resources as a trainee?”  More and more references to PPE shortages in our emails.  “I’m just an intern.”  I am asked to defer going into the room to preserve PPE. I call into the room to talk to the nurse. I feel guilt. They are putting themselves at risk so the patient does not die alone.  “Please make sure to try and consolidate your orders and be thoughtful about how many times you make us go into the room.” I worry about mistakes. Doctors and nurses are being intubated. I’m tired. I have chills. I drive through a parking lot and roll down my car window.  A nurse swabs my nose.  Their face is obscured by a mask and face shield.  I see myself in that hospital bed. The test comes back negative a day later.

A WWII veteran has COVID.  He does not need any supplemental oxygen; his vitals look good. He is out of the woods!  We wait for a negative test to discharge to a nursing facility. He misses his wife. She cannot figure out how to use Facetime.  He is hard of hearing and cannot understand her over the phone.  He had “boots on the ground” during WWII. He tells me about walking around ground-zero at Hiroshima after it was bombed. He hopes for nuclear disarmament someday. I feel like I should be doing more. “We are all in this together. We have to take care of each other, he says.”

Working as a trainee during the pandemic has felt like a strange dream. I am still not fully sure what I will take away from this. During residency, I am indoctrinated with modern medicine – the burden of charting, writing orders – “treating the computer.” Yet this crisis has brought out a deeper desire for me to be at the bedside. To bear witness to suffering. I am further reminded that behind every order is a nurse, respiratory therapist, healthcare aide, pharmacist, lab tech, environmental services, amongst many others. I long to be to be with my patients, their families. My colleagues. Physically distant, but not socially. Together.

Mohammad Sultan, DO, MS
Ochsner Medical Center Internal Medicine Residency

New Orleans – The ICU is a challenging place to train under “normal” circumstances. It’s where we care for the sickest patients in the hospital and death is not an uncommon outcome here. Still, the work critical care doctors do daily is nothing short of heroic. They are trained to heal patients who are facing dire circumstances- conditions that only they truly have the specialized expertise to manage. I admit; I still find the setting intimidating at times. However, I could never have imagined that we would be in the thick of a pandemic at the start of 2020. As an Internal Medicine resident in the crescent city, I find myself amazed at the great fortune I’ve had to do what I do. Every day is a lesson in humility- there is so much I know, yet so much more I have to learn. The ICU serves this reminder to me in particular.

With COVID-19 at its peak, I find myself back in “the unit”- simultaneously apprehensive and excited to face the task of caring for patients afflicted by this novel virus. At the time, every patient in the ICU is admitted for acute hypoxemic respiratory failure for confirmed or suspected COVID-19. The unit is completely closed off- we now work in what we refer to as a “dirty” unit. Entering and exiting requires us to “bunny-in”/”bunny-out”- a silly saying for an extensive process for putting on/taking off all of your PPE- including full body suits, bouffant’s, gloves, N95’s, surgical masks, shoe covers, protective eyewear, all mixed in with multiple rounds of hand sanitizing. This process is challenging in itself- you can’t help but calculate how costly it could be to mistime your restroom breaks during a 13-hour shift. Still, I was grateful for access to these resources that I was saddened to hear many of my colleagues in other parts of the country were lacking. 

Reflecting on that time, it was not uncommon for me to think “Am I safe?”, “Do I have an appropriate seal on my N95?”, or “am I even qualified to help these patients?” There was admittedly much self-doubt mixed in, but I found comfort in being busy with little time left to focus on my own insecurities. Many of our patients were intubated, but some had managed to get by on BiPAP. One of those “lucky” patients was one I was caring for; a Vietnamese gentleman whose intubated wife was next door. I took to him immediately. Perhaps it was because his family reminded me of my own- 2 self- made immigrant parents whose children were the central, unifying force in their lives. We had little in the way of verbal communication (as it was difficult to speak over the machine), but every morning he would insist that he needed to get out of the hospital so he could return to work to support his family. At times, his determination was my source of strength.

While he hadn’t made much improvement over the week, his wife had successfully been extubated after a few days on the ventilator. Their five children had finally found a beacon of hope. They were optimistic that her clinical improvement would serve as a catalyst for their father's recovery. I was committed to this version of their story as well. I came into work the next morning with a sense that things were on the mend. I was wrong. His wife, like so many others afflicted by COVID-19, was in a prothrombotic state and had developed a mural thrombus in her heart. This thrombus subsequently released multiple emboli throughout her body resulting in a life altering stroke. And in an instant, she was gone. His family arranged for a funeral service not too long after she died and he was going to participate in the service remotely via iPad. However, on the morning of her funeral, he acutely decompensated and was emergently intubated. He died a few days later.  

I still think about this family to this day. While all patients have a compelling story, I tend to remember the ones who pass under my care. It can be tough. I’ve found that sharing their story has helped me come to terms with the outcome. Reflecting back to that time, I find comfort now that we did everything we could for them. Despite the sting that accompanied this loss, I’ve come to appreciate that each day is a new opportunity to make a difference in our patient’s lives and they are always worth it. 

In honor of all the healthcare providers I worked with in the COVID ICU: “True heroism is remarkably sober, very undramatic. It is not the urge to surpass all others at whatever cost, but the urge to serve others at whatever cost.” ~Arthur Ashe 

Chip Bowman, MD, MPH and Alicia Philippou, MD
Both PGY2's
Mount Sinai Health System Internal Medicine Residency

New York – A wise senior resident at the beginning of intern year encouraged me to reflect on my experiences at the end of each rotation. Now, as I transition into the second year of residency, I cannot help but reflect on the past year without noting the extreme impact of COVID-19.
I spent this spring in a harrowing environment during which rapid decompensation and death felt frustratingly inevitable for many of my patients. Working in New York City during the peak of COVID-19 was a time when I was consistently afraid of what the day would bring. The only constants were the struggle to keep up with the rapidly changing protocols and the need to make innumerable devastating family phone calls. The pandemic turned medical teaching on its head. Now attendings, senior residents, and interns were all in the dark together, as we were constantly discussing new studies and global statistics desperately searching for clinical guidance. Morning report and noon conferences were replaced by on-the-job and zoom trainings in managing hypoxia and ventilators. Deaths occurred so rapidly that it was common to walk into a morning list that had several fewer patients than the evening before. Some residents dreaded picking up younger patients as it could mean watching someone nearly your age die of this unrelenting disease. Meanwhile, others rushed to care for these younger patients hoping that maybe this was a patient who they could save. Unfortunately, this care often felt futile as young, old, healthy, and sick all died regardless of our desperate attempts to help them.
While each of us was pushed to our limits, I am thankful to have been part of a community that tried to make it bearable. The Mount Sinai and Elmhurst residency programs and hospital leadership team were eager to support frontline providers through new and constantly revised policies. Masks, while in short supply, were always available thanks to the organizational prowess of the residents and hospitals, as well as the generosity of the community. I saw the medical system band together, as staff from all departments found ways to quickly unite in the name of patient care. Suddenly the role of the medicine intern was performed not only by medicine PGY1’s, but also by senior residents from other specialties who had chosen to volunteer their time on the front lines. Inspiringly, members of the team at every level rapidly adapted to a constantly changing environment with grace and camaraderie.

Starting off my medical career during this devastating experience will undoubtedly change me. Despite the support received from the community, the residency program, and my peers, walking into work during the pandemic often felt overwhelming. Training during this pandemic taught me about the ability of the healthcare system to adapt to crises and the importance of community support. Reflecting back on this year, I realize that I am no longer an intern; I am a resident who has adapted to and survived a pandemic. I am determined to use my career to continue to promote positive changes as I go forward in remembrance of the patients lost and in celebration of those who survived.

Daniel DePorre, MD
Henry Ford Hospital Internal Medicine Residency

Detroit – In many ways my COVID experience has been similar to that of other millenials. I self-quarantine, scold my parents to do the same, sign on to countless Zoom meetings, and binge watched “Tiger King.” However, prior to testing positive for COVID, my experience was different. It is mid-March and the pandemic is here in Detroit, one of the hardest hit cities in the country. While my friends and family are sheltering-in-place, avoiding the virus, I am doing the opposite. I am working in the Medical Intensive Care Unit (MICU) at Henry Ford Hospital.

I am not a “tip of the spear” resident. I get no exhilaration from decompensating patients and I don’t thrive in the chaos of the MICU. That said, my March MICU month is different. Of course, I am still exhausted, both physically and emotionally, but I am not burnt out like I have been on other MICU months- in fact, far from it. I have a sense of purpose which has never been more invigorating, and I feel valued (an all too rare feeling for a resident). I am no longer answering inane coding queries or calling insurance companies for prior authorization. Rather, I spend my time comforting patients, updating families, and reading everything I can on the disease I am treating- looking for anything that can be considered somewhat “evidenced-based.” My frustration with the situation motivates me like a call-to-arms. The pandemic terrifies me and I constantly worry for my patients, but it gives me an opportunity to practice medicine the way I hoped I would.

But while I am reinvigorated with a sense of purpose, there is a dreadfully ironic caveat. The medicine I am offering isn't working. When the first wave hits the MICU, we start patients on lopinavir/ritonavir, we eventually add vitamin C and zinc. Later we change to the now contentious hydroxychloroquine, and then add azithromycin and steroids, all while eagerly awaiting approval for remdesivir. It’s not just our pharmacologic treatments that are failing us; our ventilation management is suboptimal too. We find more and more pneumothoraces in the setting of the ARDS net high-peep protocol. Even my humanist therapies of sitting and talking with patients are limited by my PPE. It's hard to sound calming when dressed in a blue gown, trying to yell over the high flow oxygen, all the while muffled by an N95. The few moments of hope are also transient. We extubate our first COVID patient, and he returns to the MICU intubated a few days later. Medicine is often Sisyphean, but this is more than that. When it is coupled with limited PPE, ever changing and contradictory policies, and the conspiracy theories that permeate not only the public but the government as well, it is heartbreaking.
Luckily for me, I have my co-residents and per Mr. Rogers’ sage advice I am able to “look for the helpers”. I see my colleagues’ dedication as they volunteer for extra shifts, even full months in the MICU. I see their academic curiosity motivated by desire for better care as they obsessively research and update the team on any COVID trials or news that could be of use to our patients. I see their pioneer spirit as they experiment with self proning. And above all, I see their compassion as they tend to patients, taking the time to comfort them, to connect them with family, to get to know them, or to just be with them. I see in my colleagues a new generation of doctors forged by their COVID experience, and I am again inspired and invigorated.

Andre Scarlato, MD
Swedish Cherry Hill Family Medicine Residency

Seattle – Sick vs. Not sick; it’s one of the fundamental lessons learned during intern year. And Ms. A was sick - sick from a ravaging metastatic colon cancer at age 39. What I didn’t know though when I first met her was how the COVID pandemic would come head to head with the end of her life.

It is March in Seattle and being the first place where cases were documented, the area health systems were already in full response. With the turn of a new rotation block, I was back on our inpatient family medicine service. And that’s when I meet Ms. A. She came to our service after a prolonged hospitalization related to her colon cancer, now having difficulty breathing and found to have widespread intraperitoneal and pulmonary metastases with malignant pleural effusions causing acute respiratory failure.  After receiving morning signout, I knew what conversation lay ahead.

“Well is she actively dying?” The charge nurse asked me. I nodded ‘yes’ while simultaneous thinking about how this was my first time making that judgement call on my own as an intern.
“Then only two visitors. That’s the hospital policy with the current pandemic. No exceptions.”
Sitting at her bedside with her husband and sister, I spoke frankly about her prognosis and the gravity of her current condition. Much to my surprise, I was the first to break the news that she had metastatic cancer and that she was going to likely die soon.

Why didn’t we know this? We thought she just had a blockage in her colon. Why can’t she breathe? How do you even know she is going to die? Why is this the first time we are hearing this? Why didn’t this get caught earlier? Could we have avoided this?

Their deep rage and frustration was palpable, painful.

All I could do was apologize. While I didn’t know the specifics of her care leading up to this hospitalization, it seemed clear to me that the severity of her disease could have been prevented. I apologized for the health system that failed them; apologized for the barriers that she faced as a Somali speaking immigrant navigating the white English-speaking U.S. medical establishment; apologized that her course had gotten so severe and she never fully understood that she had a terminal condition; apologized that her colon cancer wasn’t caught sooner; and apologized to myself for being a part of the establishment that had failed her.

And just as I felt like we had made a connection, my relationship was lost after having to communicate the current hospital rule of a maximum of two visitors because of the COVID pandemic. Yet another barrier.

“You won’t let us in because we are not American.”             

My heart sunk, hearing these words. This anger and hurt was symbolic of a deeper projection of their frustration toward the health system and how it had failed them. Despite my hopes to grieve with them, I was still the upholder of that same medical system and was complicit in coming up short taking care of her. I was bearing witness to deep and painful wounds and could not help mend them, trapped between my responsibility to Ms. A and upholding public health safety. I pleaded over the phone with the hospital nurse supervisor to make an exception while at the same time implored with the family to understand the extraordinary circumstances of the current pandemic. 

Ms. A’s death still brings up moments of questioning where my responsibility lies as a physician. Don’t I have a responsibility to do what is best for my patient and to not inflict harm? It certainly felt like I was doing more harm by not allowing the rest of her family to see her. And yet at the same time, I couldn’t possibly negate those restrictions to jeopardize the multiple other patients hospitalized.

But perhaps this is the essence of being a physician. Perhaps it is about living in these tensions, of knowing that we are limited in our ability to heal and that there is much outside of our control. We are both representatives for our patients and advocates for our community, and at times these two responsibilities can feel at odds with each other. The COVID pandemic has made that all too apparent.

I am still working to accept these diametrically opposed responsibilities in Ms. A’s case. Meanwhile I continue to reflect on the hours watching her talk to her family over video in the last moments of her life, listening to them share memories of her life and the mark she made in this world as she dipped into unconsciousness.
Posted by Daniel Ricotta on Jul 23, 2020 3:43 PM America/New_York