In between snippets of conversation exchanged with my husband about how the first day of remote learning went for our 9 year old and whether the latest nanny was likely to quit given health risks associated with working in a two-physician frontline worker household in the context of COVID-19, we also discuss some potentially dangerous scenarios. The discussion is quite mundane, between what we are having for dinner and how we would survive the long break while kids were home. Covertly interspersed amongst these routine topics, we talk about what we would do if one of us tested positive for COVID-19 in the upcoming weeks. Where would he/she be isolated? Was the basement good enough, self-sufficient enough, or would it have to be a hotel? What about the kids? Should they be sent to the grandparents? What about the other spouse? We generally stop there-either because we are interrupted by one of our kids or because we do not want to go further down the line in the unpleasant conversation.
However, the harsh reality of life is that we need to go much further down in this conversation for it to be meaningful. And not just that, but we need to think and rethink and convey to each other our thoughts, feeling, and desires, so we are on the same page. You see, my husband is one of three intensivists at the local hospital, and I am a medical oncologist. It feels as if it is just a matter of time before one of us gets it. He has many patients in the ICU that are being treated for COVID-19 currently. He intubates patients who are too sick to breathe on their own. Intubation means putting a breathing tube down the trachea and connecting this to a ventilator, which can help the lungs function. He does bronchoscopies(endoscopic examination of the inside of the airways and lungs) on people who come in with pneumonia-like symptoms or lung masses. These procedures are routine for him. They are also high-risk procedures, carrying a high chance of aerosol exposure and the spread of COVID-19. Special PPE is needed for physicians who perform these procedures, including respirators, face shields, glasses, gowns, and gloves. His astute clinical judgment, experience, and technical expertise are going to be increasingly crucial in this fight against the novel coronavirus. Although his hospital has enough PPE at the moment, or so they state, when push comes to shove, and the hospital runs out, would his call of duty prove stronger than his instinct for self-preservation? Will he rush in to save the young patient without adequate personal protection? Do I know him well enough?
I see patients who are immunocompromised at baseline, either from their underlying malignancy or from the treatments we give them. Some of them have such beaten down immune systems that they are not able to even mount a fever (which is an immune reaction to infection) when they catch an infection.
“They literally walk to their grave,” my leukemia attending once told me while I was still in training.
How would COVID-19 present in such a patient? If they do not have a fever, they would possibly pass through the temperature screen and not seem as sick as they are, at least initially, until such time that they became severely ill and ventilator dependent. We have some data from China that patients who had received chemotherapy or surgery for their underlying cancer within the past month and then became infected with COVID-19 had rapid clinical deterioration and dismal outcomes. Furthermore, given their underlying cancer diagnosis, would medical care be rationed away from my patients, if they were to get the disease? Could they, in the initial presymptomatic phase of the disease, serve as effective “superspreaders”? Am I more at risk of carrying the bug to my fragile patients or carrying it home to my young children? Do I really want to know the answer?
We should not have to think about these questions and scenarios and their repercussions. We are in our mid-30s (well, skirting 40), professionally successful with a fulfilling family life, and completely unprepared for various possible personal outcomes as this pandemic plays out. We shy away from accepting our mortality and avoid talking about potential doomsday scenarios for our family because we know what each of us would do: Take the next logical step to protect whatever and whosoever remains. We act and feel secure in each other’s wisdom and commitment to our families, duties, and society.
And as I mull over these questions, a well-known passage from Mahabharata comes to mind. On the eve of the great battle of Kurukshetra, the righteous warrior Arjun realizes that his opponents are his near and dear ones and gives up his weapons in despair. At this juncture, Lord Krishna explains, “You have a right to your actions; never to the fruits thereof.” And so does an entire army of health care workers, across the globe, wake up every single day and go to work in times such as these. Stoic, unafraid, relentless.
Aakanksha Asija is a hematology-oncology physician.
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