Barriers. Barriers of yellow tape and plastic mark our makeshift rooms. Red zippers define the “ENTER” and “EXIT.” In the middle is a window of still clearer plastic, partially obscured by taped ECGs. Barriers are put up to keep us safe, but they can do so much more, if we let them.
A tap on the plastic window has become the universal command of attention from the nurses, residents, and respiratory therapists alike, never overpowered by ICU beeps, rings, and humming machines. Hallway cleaning stations hold helmet-shields, labeled with nurses’ names as if they were football players. With bright shades of pink, green, and purple, they transform this barrier to a medium of expressing their relentless hope.
Our new water cooler talk is all about PPE, discovering together how our plastic gowns du jour are supposed to be tied. My donning ritual is only outshone by my doffing. My COVID gear lies in a big plastic bag, replacing my white coat on one of the real — not makeshift plastic — walls. I feel the relief of fresh air when I exchange my N95 mask for a surgical one, and when I take off my face shield, my headache disappears.
We sit down for signout. The running list of the primary problem, “acute hypoxic respiratory failure secondary to COVID-19,” is mundanely discouraging. Their similarities mount an all-new barrier for me: getting to know my patients deeply. I find myself choosing to deliberately highlight their differences. “Mr. M wasn’t extubated today because of his mental status. Hopefully, he will be ready by tomorrow for you,” my co-resident tells me. “Hopefully!” I say as I take over his care as the primary ICU resident.
The next morning, I watch Mr. M from outside his window. He is one of the exceptions. He has a room with real barriers: real walls, a wooden door, and a glass window. He lies in the supine position, saturating 98% on minimal vent settings with no hemodynamic support and minimal sedation. “He has a good cough but won’t wiggle his toes,” says the nurse. I nod while accepting my precisely dispensed share of hand sanitizer, as if it’s a communion in my hand, holding a promise of safety.
I try to project my voice to get his attention, but I soon realize that the voice I am making sounds little like my own. My voice raises to overcome the mask and shield barrier, producing a string of phonemes in an intonation that I barely recognize as human. Holding his hand in my foamy, gloved one, I turn his plastic bracelet to see his last name. Ah, yes, I remember now.
My attempt to ask him to wiggle his toes fails. I remember his Arabic last name and make the split-second decision to speak Arabic, hoping he might understand me. Turning my eyes to his feet, I watch his toes wiggle. He is right there with me, following every command. I rejoice silently that despite every barrier between us — acoustic, linguistic, and even plastic — we found a way to connect.
Later that afternoon, I see him without an endotracheal tube. I hear his real voice for the first time. I wish he could hear mine. In Arabic, I call him “uncle” instead of “sir,” a deferential formality I employ when speaking with any Iraqi male patient similar in age to my father. He says his throat is dry, and with a tongue that gives away his first language, I suddenly feel at home. Despite all the layers of personal protective equipment, at that moment, I feel unmasked. I’m reminded of all the times as a child how my own father would fall asleep on the couch, how he would — though an English speaker — respond in Arabic in his deep sleep to my begging him to stay up. He asks for a cup of hot tea, which makes me laugh. It’s something my dad would say. “I’m going to call your daughter now to tell her the good news!” I tell him as I struggle to remove my gown in one sweeping motion.
I had missed parts of his presentation every day as I ran to take care of another patient, call another family, or place another consult. There was always a barrier to me really listening to what made his case unique. I had focused on numbers as objective evidence of his clinical status. I didn’t leave room to evaluate individualized delirium, and ultimately the treatment was the same: stop, watch, and see. I had built a wall behind which I was protecting myself from yet another case of tragic clinical deterioration.
“He wasn’t extubated today because of his mental status, but maybe tomorrow!” is signed out to me again about a Bengali-speaking patient. I respond with “hopefully” … and actually mean it. I look at my COVID gear bag. I take a deep breath in preparation for another N95 mask donning, grab a plastic bag, and throw my phone — with an interpreter on speaker — into it. I zip the bag as I zip myself into another room, hoping the beeping IV pumps don’t obliterate our voices, allowing me the chance to see if there is understanding behind my patient’s steady eye contact. The toes wiggle again. I hope the excited tone of my voice is as recognizable as the universal window tap.
I’m struck with the sad realization that this new reality may not disappear soon. I hope for the day that the plastic walls with yellow tape and red zippers come down so that I can peek in and wave to the bedside loved ones frequently, my treasured ritual. I envision the days when I’ll laugh again as patients jump at the touch of my cold, ungloved hands and then console me with, “Cold hands, warm heart!” However, until then, I will keep finding ways to make this ICU mine and theirs, whether it’s a cheeky apology for my voice or finding a charger for their phone.
Aula Ramo is an internal medicine resident.
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