There is a phenomenon sweeping across various medical circles on social media that is forcing people to address accusations from those who were not on the front lines of COVID at the beginning of the pandemic. Though I have refused to pay much attention to the details, I have become more and more enraged at the audacity and frank ignorance that it takes to judge when not in the arena. Now, I will admit that I am the first to state that we should always ask why, always question the status quo. And we should always become suspicious when people close ranks and refuse to be addressed or questioned by outsiders or those with a differing perspective or opinion. I feel this way about medicine, about policing, about government, and about the military. As a Navy veteran and physician, I am 100 percent a disruptive physician and am known for attempting to make “good trouble.” But this isn’t good trouble.
This group of people who have never been to war tells us what war is. People who have never taken an oath and then lived up to that oath in a time of distress and danger. Never left their home or the safety of their practice and dove into a disease that is nothing like anything we had ever seen before. They never watched men and women practice so far outside of their comfort zone they sometimes contemplated or even completed suicide. We knew what we were doing wasn’t perfect. But we couldn’t stand by and watch people die in the streets. We did everything we could. We held hands, intubated, ventilated, circulated, and never stopped hoping that the vicious foe would let us win … if even just once.
We did not do anything that we didn’t think was the best thing for each individual patient in front of us at the time. So many of us would work for 12 to 14 hours, days in a row, and spend every spare minute reading literature that was flying at us as fast as anyone could publish it. There was no textbook for this disease. I still stand firm in my opinion that this disease is not the flu and not standard ARDS. No amount of wishing it to be will make it so. We did not know how to sedate this, how to feed this, how to support this, how to fight this, or how to ventilate this … and that had nothing to do with ignorance or malevolence. And even now, three years later, I question whether we really know much more about how to save those who are the most critically ill with this disease. We still do not know. And that again has nothing to do with motivation, passion, or ethics. This disease is Hell on earth, and we are forced to be the gatekeepers of death while at the bedside of those most critically affected.
To those who have these opinions, I want them to explain to me the concept of dead space ventilation. I want them to explain to me how the microclots in the pulmonary circulation lead to massive increases in dead space and that with additional ventilatory support, you have added dead space. But without ventilatory support, you have a patient on non-invasive ventilation with a cardiac output revved up to 8 to 10 liters per minute because of the superhuman metabolism this disease causes the human body to invoke. Which then leads these patients to take astronomically large and dangerous tidal volumes that cause damage to the lungs. Yet when you control the ventilation once they can no longer sustain themselves independently, you can’t keep up with their body’s demand. I want them to explain to me the uncontrollable glucose intolerance and the resulting end-stage diabetes these patients face. I want to understand the inability to safely sedate these patients while also being able to complete neuro exams and provide life-sustaining and life-saving physical therapy. I want them to explain to me the profound gastroparesis, the level of bacterial superinfections, and the overwhelming inability for the right side of the heart to push against the ever-increasing pressures of a clotted and stiff vasculature. I want to understand why COVID is now a risk factor for acute cardiac/vascular events even if mild during the original illness. This isn’t because of a ventilator; maybe they can explain it to me. Explain it to me like I’ve never been at the bedside in New York City in April of 2020 and then in Cincinnati for three years taking care of this disease. They must know better than I. It seems they knew from the beginning. I want them to tell me what I and so many others did wrong. What was it exactly we should have been doing?
We will learn about and refine our knowledge of this ever-changing foe until my career ends. Maybe someday we will find a way to adequately and safely ventilate these patients or even ECMO these patients back to life. For now, we are still left to do the best we can with the knowledge we have. We never once did anything that we thought was going to harm a patient. So many of us did things that directly injured or harmed ourselves to potentially save or prolong the lives of others. I did not leave my children and fly into the belly of the beast in NYC to harm people. Neither did any of the other amazing people I met in the trenches. Every day was a lesson in humility and grace (for ourselves, our colleagues, and our patients). We struggled with the care we were forced to provide, but this was battlefield medicine, and the only thing we had to offer these patients was what we had in front of us. And sometimes it wasn’t enough, but we knew that. We wanted people to live. We wanted them to survive. We tried so hard.
People keep questioning why “it was so bad in NYC.” And I say because it came through the ports of entry and those of us on the front lines in NYC, New Orleans, San Francisco, and Washington held the damn line while the rest of the country shut down. These cities are urban areas, filled with multigenerational homes and an inability to socially distance. Say what you will about the benefit or harm of the public health measure we took, but as bad as it became across the country after April 2020, it would have been so much worse if we didn’t stop this death tsunami from rolling from the coast inward. I know that there were pockets of communities and hospitals across the country who fought like hell just like those of us on the coast from the beginning, and all of us who were at the bedside during those times know exactly what I mean when I say that we did the best that we could.
And we tried our hardest to live up to our oath and our profession, but we sometimes had to stretch to an uncomfortable position to accommodate more patients. No one denies that the level of care could have been better. No one. Including those of us there. But we know that the level of care we gave was everything we had … and more. Some even gave their lives. Which brings me back to those who think they know better now … where were you when we were dying or in the throes of trauma that would lead to the PTSD we have now? How small can you make big claims while free of the pain we all carry daily? Even if the data eventually shows that there were things we could have and should have done differently … it doesn’t matter. We didn’t have that data then, and we did everything we could to allow each person to return home to their families. Even if it meant not returning to ours.
Nicole M. King is an anesthesiologist and intensivist.