By Tess Kolarik
It’s 6:45 PM, and I am walking into the small, urban community hospital where I work nights as a Hospitalist Physician Assistant. In the main entrance, I am greeted by a screener and the same familiar questions: “Any new cough, shortness of breath, fever, or exposure to a COVID person without proper personal protective equipment (PPE)?” My temperature is taken, I am given a shift mask, and as I pass the first test of my shift, I make my way up to our newly concocted ‘COVID unit.’
My general night-time duties normally include admitting patients, answering pages from nurses and running codes (troubleshooting a patient who gets sicker). With the help of both internal and family medicine residents, I am the main person overnight. To clarify, there is no doctor; I am the person who deals with all of the issues, and I am able to independently make decisions regarding patients’ care. In light of the current pandemic, my duties have changed to only running our COVID unit. I work seven days straight and then have a week off. I am about to spend the next week’s-worth of twelve-hour, overnight shifts in a negative pressure environment (hospital technique that does not allow contaminated air to escape the unit) in a PAPR (a form of PPE; a battery-powered head mask that provides positive airflow through a filter that kind of looks like a space suit).
We have the capability to take care of only 10 patients in this new unit. I have thus far taken care of patients on a wide spectrum. I’ve seen patients without respiratory complaints who don’t need oxygen at all, to those that are intubated, sedated, paralyzed and prone (laying on their stomach and given a paralytic medication so that our ventilators can do all the work for the patient's lungs). I have patients that are full codes (escalate care to the highest capability), DNR/DNI (keep alive with medications but don’t do chest compressions or intubate) and CMO (comfort measures only; prepare and keep comfortable for impending death).
The unpredictability of my overnight shift is an enticing facet of my job; I never know what I am walking into. Some nights have been slow; my patients’ remain stable and everyone sleeps. I’ve experienced other nights where I’m in contact with our telemedicine critical care doctors for hours, doing our very best to keep an unstable patient alive; fighting to save their life (I talk with ‘ICU’ doctors over an app similar to Facetime when I need help). As my week unfolds, I see patients slowly get better or worse. Sometimes the deterioration is gradual, and sometimes it’s like the flip of a light switch.
We have an unspoken rule on our unit- maybe the only real rule overnight- that no one dies alone. Death looks different for every patient. Some patients appear to be in a coma-like state, some experience difficulty breathing, and many go through states of confusion, or what we would call delirium at the hospital. Regardless of how death declares itself, we have a medication to alleviate any uncomfortable symptom a patient may experience. In these moments, Covid-19 has forced me to step into a new role as a pseudo-family member for these dying patients who can’t have any outside visitors. I am uncertain if the soothing words, hand holding and shoulder squeezing is for my patient, or for me. Calling family members in the middle of the night to tell them that their loved one has passed away is one of my least favorite tasks. Making the dying a priority allows me to tell family that their loved one died comfortably, surrounded by myself and several nurses. And while this feels like a consolation prize, it’s the very best I can do in an awful situation. During these unprecedented circumstances, we are all feeling an unfamiliar heaviness- patients, healthcare providers, family members.
I would be lying if I said I didn’t feel the pressure; the burden to do a nearly perfect job taking care of volatile patients as a new provider without feeling that my inexperience is a disservice to my patients. I have been a practicing Physician Assistant for— almost to the day— one year. While I have had years of previous healthcare experience and death is not new to me, I can’t say that there has been anything specific in my past training to prepare me for a global pandemic. And while I can read every article published about COVID-19 and continue to study medicine, there are simply going to be situations and obstacles that I have not encountered before. I gravitated to my current field after years of self-exploration; believing it to be somewhat of a calling. While COVID-19 possesses some familiar characteristics as prior viruses, the unfamiliar is both intriguing to me from an academic perspective and terrifying to me as a provider treating the unknown. Prior to quarantine life, I had a well-balanced routine. I looked forward to my on-weeks, excited to immerse myself in a dream career after a full off-week to ‘blow off steam.’ With this newly added pandemic stress, I’ve realized how much I rely on my on-week to have meaning in my life as well as an additional layer of anxiety wondering if I am invisibly infectious when outside the hospital.
I would never have thought that I would have such a formative experience so early in my medical career that will, no doubt, shape the future of medicine. I feel very contradictory; the science is so cool and yet, I have felt overwhelmed at times. I look forward to going into work, and I also am so relieved to finish each shift and leave. To put this into perspective, I am in a small, community hospital with all the appropriate resources (i.e. PPE, medications, staff) in a city that isn’t being hit too hard by COVID-19. I couldn’t even fathom being in the epicenter of this pandemic. For instance, New York City providers have been working weeks straight. There are nurses that volunteered to go to NYC to help, and then died of the coronavirus. In Italy, decisions were made to take patients off of ventilators to die in exchange for giving ventilators to patients with better prognoses. Despite all of this, I walk into work telling myself that I am capable; that I am the best version of myself, because I am doing something that I love and believe in. I look forward to the unknown end date of COVID-19. I hope that we can all be more aware, and be better prepared in the future for the next medical hurdle that is certain to come.
Tess is a nighttime Hospitalist Physician Assistant in a community hospital just outside of Pittsburgh, PA. Her former training includes a Critical Care Fellowship where she worked 60-75 hours a week for 6 months prior to taking her current position. Additional preparation includes being a Patient Care Technician, Emergency Medical Technician (EMT) and Clinical Researcher for brain bleeds (Subarachnoid Hemorrhages). On her off-weeks, you will most likely find her jogging or doing crossfit and being a cat mom to 6 cats.