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God Was Still Good

“Don’t forget to get your flu shot.”
That was what we were all hearing from our medical societies and research communities in February 2020.  Publications emphasized that our public health efforts should be directed towards influenza.

By Tim

Obviously, it was too early to make this call and the medical community was wrong. As cases started to pile up in the USA, it was unreal. In medical school we learned about the 1918 flu pandemic, but this was different.  
At the time, I was one of the associate program directors for our Family Medicine residency program and Sports Medicine fellowship.  I was also the physician lead for our academic clinic.  Our hospital was uniquely situated as the largest hospital between Duke University and central Virginia. With low vaccination rates and limited health resources to begin with, it was only a matter of time we would be caring for patients from south central and southeastern Virginia.
Everything shut down. Elective surgeries were canceled and outpatient visits were limited. At the time, we did not provide telemedicine visits. Our residents were scared, and our patients needed care.  We needed attending physicians to cover our inpatient service, but no one wanted to. People were apprehensive.  Out of 7 faculty members, it was up to me and one other attending physician to cover the entire hospital.
There was no vaccine at the time and we were still learning how this virus spreads.  My shift was to drive down to work 7 days straight and be on call for 3 of those nights. I did this every other week to every 3rd week for months. As a family we decided it was best for me to stay in the basement and then wait 3 days after a hospital week to make sure I had no fever or symptoms before I came up to see my family. In total, I was isolated from my family for 162 days of the pandemic. At first, I was sleeping on the couch, but months later we got an inflatable mattress, a small refrigerator and microwave. This was a deeply challenging time. My wife would leave food for me at the top of the steps and my children would write me notes and drawings and slide them under the door.
The COVID-19 pandemic brought unique challenges to patient care, which included providing high-quality care while limiting in-person contact.  Stay-at-home orders, public fear, and evolving local health department guidelines limited patients from being evaluated by their physicians, following up on their care, and obtaining refills for needed medication.
We knew patients who were older with specific comorbidities had the highest risk demographic for morbidity and mortality and our health system did not have telemedicine capabilities early on.  I reached out to some of our quality metric specialists to get a list of our patients who were at the highest risk of morbidity and mortality if infected with COVID.  With the help of our senior resident physicians, we made telephone calls to proactively address the safety and medical concerns of these high-risk clinic patients. Our efforts were an attempt to minimize Emergency Department visits and hospitalizations. We called 255 patients who were high-risk. 12% needed a prescription, 9% had an urgent request, and 36% had a change in their medical management and we positively impacted their care in that they: had a prescription refill, had a proper follow-up visit, received help getting baby formula, or had other similar concerns addressed.
Unfortunately, this was also a time when our ICU physician group was in contract negotiations with the health system. We used to have in-house ICU doctors that were physically present; unfortunately, the bottom line was prioritized over patient care and we contracted with another intensivist group that would see patients only virtually. I knew this would be a tough pandemic, but having to manage patients without them ever physically being seen by an ICU physician made it even more difficult. We also had an open ICU - meaning that, as the admitting medicine physician, the patient will ultimately be under my care with the virtual ICU physician serving as a consultant. 
“Quit telling me I have Covid!!!….This is not real!!! Get this mask off of me!!!….”
I remember hearing her scream this every day.  I remember her like it was yesterday. She was one of my first COVID patients. She was an older lady, from a very rural part of south-central Virginia. Every day, she would take off her oxygen, we would watch her oxygen saturation drop, she would become very tired and nearly pass out, and we would scramble to put her mask back on. To her very last breath she denied this virus was real. There were several patients like her who passed away in denial that this was a real thing.
There was a scarcity of data on which therapeutics should be used. Should we avoid NSAIDs? Use steroids only for patients with underlying lung disease?  At high or low doses? Plaquenil? Vitamin D? Statins? Doxycycline?  Should we prone patients? Convalescent plasma? High dose Lovenox?
Working my entire career in an academic setting, I was hesitant to jump on any bandwagons and treat patients simply based on what others were doing instead of relying on well-designed studies. Could these treatments pose more of a risk of harm than benefit? We didn’t have the answers for this. 
I held weekly journal clubs with our residents and, as our health system started to design protocols for COVID therapeutics, I asked many questions and challenged some of their algorithms.  They started to trust my critical appraisal of the literature and asked me to join their committee and we were able to develop a good number of evidence based COVID therapeutic protocols. 
A few months in there was a PPE shortage. We all were wearing the same N95 mask all week treating multiple patients with COVID. Nobody knew if our masks still worked at that point, but it was all we had. 
Then out of the blue our health system announced that N95 masks will not be provided for patients with respiratory symptoms or patients under investigation for COVID until their test came back positive for COVID. I was deeply concerned and our residents were terrified. I remember being on call and a resident called scared and crying to me: “I am in the emergency room and have to admit a patient, but the ER won’t give me an N95 mask!” This patient was on oxygen with respiratory symptoms and was clearly not doing well. How were they going to examine this patient? Fortunately, I had some extra N95 masks and was able to give one to this resident to care for this patient.  This was unacceptable.  Where is the evidence for this policy? I drafted a letter after reviewing the literature further. I also reached out to several other colleagues and friends of mine in Cardiology, Nephrology, Infectious Disease, and other hospitalists. I scoured all the evidence and the guidelines for PPE that we had to date for this virus and I drafted a letter to send to our administration. I got a return saying that this policy came from Corporate, who managed health systems across several states. So, my administration forwarded my email to the corporate headquarters. I was nervous…I could get fired. Just a few weeks before that, we were asked to furlough a good number of our staff in the clinic and that was hard enough already.
When I received a reply from Corporate, they agreed that their policy was not an evidence-based decision. This letter brought about a policy change that affected our entire health system. It was a big win. I remember the thank-you’s and gratitude I got from nurses, other physicians and staff as we did our rounds in the hospital. This was just a small example of the many occasions there was a disconnect between healthcare administration and physicians on the ground during the pandemic.
The youngest patient we cared for that passed away was 30 years old. One of my saddest memories was of an elderly couple in their 80s. They both were admitted with COVID for weeks. The wife eventually recovered and was ready for discharge, but she didn’t want to leave the hospital. We were able to arrange for her and her husband to spend a day together before she went home and I remember them laying in bed together, holding each other for that last moment.  That week was also their anniversary week.  The wife knew it would not be a good outcome for her husband of several decades.  She eventually went home and her husband passed within a week.  
Fast forward several months, we finally got a vaccine, but people were still hesitant to get vaccinated. One of the most horrifying screams I heard was in the ICU when we had to terminally extubate an older male. His daughter wanted to visit him from South Carolina and bring up his grandchildren because they have been apart for so long.  What she didn’t know was that one of her kids had COVID. Since this patient’s wife had passed away, it was up to the daughter to decide when we would stop treatment with our guidance.  He was on the ventilator for over a week and it was to the point of medical futility. We did everything we could for him. I remember standing outside the room with her as she screamed as her father was being extubated.    
In the midst of all this, Pastor John Park asked me to share my testimony to our church. I felt so disconnected from church, friends, and family at the time.  All I knew was COVID, patients, and that I missed being around my family. This opportunity was a blessing for me and ignited my walk with Him again. God was good during the pandemic. I had several opportunities to pray with and for my patients, resident physicians and faculty colleagues. My sister was also able to have her first child during this time and I became an uncle. The Lord is still healing my family after being apart for so long.
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