As we dive deep into the Covid-19 pandemic I wanted to share a poignant and vulnerable post from one of our Neurologists to our health care workers. I think it has applicability to those who of us who work in healthcare as well as those of us navigating this in other ways across the world. Stay strong and thank you in advance for all you/we will do!
“Most of you know, I served in Afghanistan in 2010-2011, after the “surge” started in 2009. A few of your colleagues have similar experiences, but may not talk about it. I do talk about it, but haven’t shared all of what happened because, in honesty, I never know how to tell the story truthfully without either sounding unrealistically heroic, or dwelling on all the scary things and all the mistakes I made. The truth is somewhere in the middle–at least I hope it is in the middle, because I know it’s not on the heroic side.
So here it is:
1. You have actually already done this. You have already had call nights that have been miserable. You have already had to triage things that are “untriageable,” like 3 (or more) immediate/time sensitive emergencies that have to be treated right away, but there is only one of you. It feels awful. Your choice is the right choice, because any choice in this circumstance is actually an illusion (there is no actual choice, just a bad situation). The situation is what it is. What you decide is right even if someone else would have done it different because you are the one doing the work, not them. You are always better than no one (a lot better), and the reality is that if it isn’t you, there might be no one to do it. It feels bad, the outcomes will not be perfect–the outcomes may even be bad, but you are doing the right thing.
2. Practicing outside your area of specialty is incredibly uncomfortable I’m neurologist. Blood is not my thing. Even now, it still isn’t my thing. Viral pathogens are no one’s thing. There is a lot of fear working in an area where you essentially have medical student level of knowledge. You will feel awful, and stupid (if you are a normal person—I envy those who always think they are right), but you will still get things done. It is ok to feel bad, and you will feel bad—just expect it. Later you will joke about it with friends or others who were there. It’s surprising how far you can get with just medical school level of knowledge. Other more experienced providers may be too busy to help, but when they can, remember what they say for the next patient. When you have time, read about things that you are worried about (for me, there was a ATLS book that I had to order from home—was not actually helpful, but it made me feel better). You will feel you are doing a worse job than you are.
3. Fear acts on all of us differently, and is different in the same person at different times At some times you will feel like you froze. Most likely you did, but no one saw. Time dilates, so a few seconds or even a minute feels like forever. This is really hard to accept when you are a more senior physician, because you would think we’ve already gotten through the scary parts. If you have to go slow, then go slow. If someone else has to take over for a second, it’s ok. You didn’t fail. There will be days where you are on the top of your game and you are doing everything right, and days where nothing feels right. Most likely, you are doing the same thing, equally well, on both days. If you can help others in their moments of dread, try to, but you will likely be too busy to notice, and others will be too busy to notice you. Don’t think you will always freeze if you did once (or five times), and don’t think others will always freeze if you catch them. The reality is that we all will struggle at different times and in different situations. No one is perfectly brave all the time. One day the a situation may seem insurmountable, the next routine.
4. Nothing will go “to plan” It is nice to have a plan. It does give a framework and options. It at least tells you where the resources are. As soon as the helicopters land, the plan turns into a list of things that doesn’t happen. Don’t be surprised. You still need a plan though, and you will find which parts work, which don’t, and adapt. At first, there will be too many variables that even the most future thinking person will not be able to predict. People are also independent and may not follow the plan even when it is a good one. It will change day to day, generally for the better. If 10% of what we plan happens, and we have 50% of what we need, our leadership has done an amazing job. So far, I think we are going to beat those numbers. We are pretty lucky to have the leadership that we do—I’ve had way worse. (I’m biased, but I do overhear things, and I worked at a few other hospitals before here). I know that there has been no days off for the leadership trying to coordinate, make contingencies, beg, borrow, and probably steal the resources they can. I’ve watched a pregnant lady go 3+ weeks with no days off in her 3rd trimester (makes me feel like a little inadequate–not gonna lie). Are there things they aren’t telling us? Sure, there has to be. We will need to get over that. They don’t tell me everything and my spying isn’t perfect. In Afghanistan I had no insider knowledge. But, they do have to make decisions just like we will–trying to get things organized for the greater good. In the end, it’s not about us; it’s about getting the job done.
5. Resources will be limited In Afghanistan we could get much of what we wanted, and were very well supplied. However, there is never really enough when things get busy. Even though we could get things we needed, it took a minimum of 3 days to fly in, which is too long to be useful most the time. Right now, the whole country (the entire world) has limited supply. We have to plan that there is no back up, because even as more masks/test kits/[whatever else] are made, the rate will likely be slower than our use, especially now. When you use a supply, it is not there for the next day. So we have to be careful. Only use what you need. If the precautions are droplet, not airborne, then use droplet. For Afghanistan, it was generally blood products, surgical supplies, and things that just were not predicted would be important. Here, it’s likely PPE. Save airborne (N95’s etcetera) for the high-risk airborne situations. “This is ideal” has to be replaced with “good enough,” “acceptable,” “borderline/but workable,” sometimes even “sketchy.” This is still better than not having a resource when you really need it in the worst situations. And, we may need to plan for that too. The situation is not perfect, and it never will be. It is a very hard mindset to be in for our culture. We don’t tend to live without grocery isles filled with toilet paper, but that is the current reality.
6. You will not be perfect You will be far from perfect. You won’t be able to practice medicine to the level that you want. We all have very high expectations for what we do. You are not going to practice to the best of your ability, even if this is your area of specialty. There just isn’t time. Trying to be perfect for one means that you may not have been good enough for the majority. These are situations where you just do your best. Just being there, being a body that has some medical knowledge is helpful. Even in the smallest roles.
7. We will be exposed For Afghanistan, that exposure was rocket attacks on the base (which were frequent) and people carrying grenades and explosives into the trauma bay (rare). We were at risk all the time, at the hospital and in the barracks. In this situation, the potential exposure is everywhere. It may even be a little scarier, because you can’t really see the threat. It is important to be vigilant, try to protect yourself, try to protect your friends, but realize that exposure is going to happen. It might have already happened, or happen when you get off work to pick up milk on the way home. Some/most of us will get sick (maybe all of us). Luckily, most of us are not high risk for complications, and our kids are also low risk. Plan on getting exposed. Sadly, this is part of the game. Even in a perfect situation, we are exposed to things every work day and things are not going to be perfect.
8. You will be judged unfairly Mostly, you will judge yourself very unfairly. Your expectations are going to clash with reality. There is only so much you can do. Most likely, you will find you are not the hero you want to be (that was the most disappointing for me). Even when you do something heroic (and you will), it won’t feel like it. Others will praise you for what you feel are mistakes, and may even criticize you for things you did well. It is worse when it is clearly unfair–when others are making decisions about you with incomplete information or poor baseline knowledge. Just be ready for it. It won’t be fair. It doesn’t make it feel any better, but knowing it is going to happen helps a little.
9. Humor Helps The humor is going to be dark. Anyone who was not there, will not understand. The jokes will sound awful, but it will be funny. Don’t feel bad for laughing. Don’t feel bad for making horribly inappropriate jokes. You will get booed for the bad ones, and people will laugh for the good ones. Both are helpful. Better to cope with laughing than crying, although both are acceptable. …so does profanity The occasional F-bomb feels fucking great. The situation is crazy, we’re fucked. Now, lets try to unfuck things. Profanity is fucking awesome. I mean seriously…fuck. (Shit, I can tell you, it was fucking hard to get rid of my motherfucking deployment potty mouth. Use it if you need to…just not in front of television cameras, and tone it down for the kids).
10. We are all in this together We are all in the same boat, although different parts of the boat at different times. You will see the best even in people you don’t like. You will likely make grudging friendships. Roles will vary. Nurses may act as doctors, doctors may act as nurses–we all have to get things done. Don’t forget how important other roles are. It’s not all about the doctors and nurses. EVS, Lab, pharmacy, bed control, administration, food service, and so many I probably have neglected, all make it so we live through this – no one is sleeping well, and we can’t do our job without each other. Don’t diminish the roles of others. Everyone is working their asses off.
Most important. Be kind to each other. If there is conflict, try to view it from another person’s perspective. They are likely working well outside their comfort zone. They aren’t going to do the same things you will, and sometimes they will be right, and sometimes they will be wrong–just like you. If someone is clearly losing it, let them go until they do can’t go anymore (they won’t want to stop until they are ready), then make them sit down. Make them eat, have coffee, a coke, anything, for as long as they need. They will be back sooner than you expect. Sugar, sleep, and breathing fixes everything.
So that’s it.
Hopefully this helps if it really comes to it. I’m praying it doesn’t, and pretending I’m ready if it does (pretending also helps but this is already too long). I’m not really an inspiring speech kind of guy – clearly. My corpsmen and the nurses I worked with can attest to that, but we did get things done. We won’t be famous for what we do. We will put ourselves in bad situations to help others. We won’t get medals or ribbons to even say we were there, or to say we did a good job. But we will be able to participate in the most noble of pursuits, helping others.”