Everyday Uncertainty in the ER
Within minutes of one another, two separate patients from a nearby nursing home arrived in acute respiratory distress at a local tertiary hospital where I am an emergency medicine doctor. Any other day, any other time, our initial medical assessment would begin by checking for sepsis (a blood stream infection) or pneumonia. But today, in the midst of the coronavirus pandemic, we look first for signs of COVID-19. In fact, with the concurrent arrival of two patients, we start by anticipating that we could be on verge of a clustered COVID-19 outbreak. Was the pandemic arriving at our hospital in a fury?
Both patients are taken directly to a negative pressure room in the ER to isolate them while evaluating their conditions. I am assigned to the first arriving patient who has an Advanced Directive--a written document about his medical preferences in case of a life threatening illness or accident-- stating he does not wish to be put on a ventilator.
When his wife arrives at the hospital, she confirms his desire not to “just be kept alive on a machine.” She is directed to his isolation room, and even though he is unresponsive, she starts talking to him, reassuring him even as staff members go through their standard protocols. Holding his hand she speaks consolingly, “I’m here for you, honey, by your side,” she whispers. “Just like I have been for the past 50 years,” her voice muffled through a surgical mask that partially covers her creased, worried face. She clears her throat again and again, each time trying to maintain her composure while an unsettled look of love and disquiet and tears involuntarily fills her eyes.
I wish we could discuss placing her husband on a bipap, a non-invasive respiratory support method used frequently in lieu of intubation. Bipaps form a murky, gray area when it comes to DNR/DNI (Do Not Resuscitate or Intubate). They involve a mask firmly strapped to a patient’s face connected to a machine that gives respiratory support. In some severe cases of respiratory compromise, they can even be used temporarily to avoid intubation which requires putting a breathing tube directly into a person’s windpipe. To physicians, bipaps and ventilators are dissimilar. To patients, they likely don’t know the difference between them. As practitioners, we have not educated the public on differences between them. For instance, when using a bipap a patient stays awake and is alert. In most cases he or she can be a part of the recovery process, not a bystander. A ventilator, by contrast, completely sedates a patient who thereby is unable to communicate or participate in any decision-making.
Under normal circumstances, bipaps can be used temporarily even when a patient has chosen only palliative or comfort care measures. But these are not normal circumstances. And during this coronavirus crisis, bipaps are contraindicated--meaning they cannot be used-- with any suspected COVID-19 patients. That’s standard procedure everywhere. They could increase the risk of spreading the virus; almost like tossing a match in dry tinder. Using a bipap aerosolizes-- or creates a vapor cloud-- which could contaminate an entire room with viral particles if the coronavirus is present. During this uncertain pandemic crisis, a potential tool is inaccessible even if there wasn’t a DNR.
The staff pulmonologist comes by and recommends using a non-rebreather oxygen mask to deliver a high level of oxygen. But it is not enough for this ailing, enfeebled man’s heart and lungs. The mask increases his oxygen levels but he continues with erratic, shallow breathing that soon slows, then stops. With his wife still by his side, still holding his hand, he passes away.
A few hours later a rapid test currently available to detect COVID-19 comes back from the lab. It is negative. The second patient’s test is also negative. We all breathe a sigh of relief. No cluster COVID-19 at our hospital. At least, not yet. We pray, not ever.
In the best of times, it can be difficult to talk to patients or their families about procedures or proposed remedies which they may not understand and which may have uncertain outcomes: Will what a doctor proposes work? Will I be placed on a machine and not have any input on what comes next? Will I put my family in a difficult position to decide for me? Sometimes, as doctors, we also have questions without clear cut answers. We don’t have crystal balls. We must rely on our training and standard hospital procedures.
Uncertainty is a standard operating procedure in the emergency department. It is a place where decisiveness outranks certainty. Every day, every shift, every new patient can present an ambiguous and uncertain “crisis”. Pandemics may limit or expand tools, revamp protocols, constrict our resources, or confuse our explanations but they do not change the basic orientation of emergency workers who are trained to “expect the unexpected.” We may not have all of the answers all of the time, but all of the time we are ready to face all the uncertainty that goes with this or any future pandemic.
Emergency medicine has been preparing to fight every global, shifting pandemic since Johns Hopkins Hospital first set up an “Accident Room” in the 1950s, which evolved into emergency medicine as its own specialty training beginning in 1970. We face this uncertainty regardless of our own personal circumstances: sick, hungry, exhausted. No matter. We assess, innovate, and make due regardless of the setting, resources, time of day, or latest pandemic or crisis. When you show up at our doorstep, we will be there.
Certainly, humanity adapts well to uncertainty. What we all do now is no different than what we always do. We keep going. Patience and practice can give us all the resilience needed for perilous times when there are few clear answers. When faced with life or death uncertainty, we press forward, doing our best to keep saving lives.