It was a December evening, just prior to the Omicron COVID-19 surge when we were still dealing with the complications and casualties of the Delta variant. I was the tele-intensivist working that night, covering over 20 sites across the country. Many of the ICUs were full, with more than 40% of the admissions having the COVID-19 diagnosis. Residents were calling for assistance with admissions and ongoing issues from some of our ICUs.
I began my shift by running the list with a resident in the Midwest who had called me at the start of hers. She already had a full census, carrying 6 very sick patients with COVID-19 pneumonia and ARDS requiring high PEEP and FiO2. We discussed the effects of alkalosis on the cerebral vasculature of one patient and the sites where she could place an arterial line in another. We formulated a treatment plan for the night. She shared that the night to come looked very busy and that she'd be in touch. I encouraged her to do so.
As soon as we hung up, I received an alert from an ICU on the East Coast. I clicked the room number on my monitor, and I was instantly able to visualize the room. A nurse needed help with how to address agitation in a COVID-19-positive patient on BiPAP. As we discussed recommendations, I saw how tired her eyes were through her mask and face shield. As I documented our discussion, I received a text about a code. It was a patient carried by the resident who called me. I put on my headset and visualized that room—the staff at the bedside, one doing chest compressions, one manually ventilating the patient with an Ambu bag, and another giving the first dose of epinephrine. The 3 heads looked up as I introduced myself and offered assistance. One of them gave me a thumbs up—they were okay. Just then, I was notified of another emergency in the same ICU about 3 doors down. I looked in that room and a similar scene was being played out. I toggled between both rooms, on occasion gently reminding staff to give another dose of epinephrine at the appropriate time and placing orders for labs when asked. At the end of it, one patient lived and the other did not.
An hour later, I learned that the serum potassium of the patient who survived was 7. It was 2:00 am. I tried to reach that resident, the one I spoke with earlier in the evening, but had to leave a message. Five minutes later, she called me.
“You tried to call me. Was it about that guy's potassium?” Before I could respond, she continued, “I was talking to the family of the patient that died.” She paused. “I have had to tell so many families this year that their loved one has passed. I really fear for the unvaccinated.”
She went on. “I don't know if you have time for this. I am 28 years old and a senior resident. I've been training for 22 months now. I haven't seen DKA or AFib with RVR. I only treat COVID. It is all I know….”
There was an awkward silence as I searched for something meaningful to say. I offered, “I completely understand where you are coming from and feel for you and your fellow trainees. This has been a hard situation for you all, I…” She cut me off. “There is a code on the floor. I will touch base with you later.” And she hung up abruptly.
Her words haunted and stung me as I heard the anguish in her voice. For the rest of my shift, I checked in on her sick patients. From afar I marveled at how she competently addressed metabolic abnormalities, managed complex vent changes, and kept the remaining patients on her census alive.
I wondered how she was managing this level of stress, so much more than those of us farther from the front line—work-related stress and the stress from lost professional opportunities, which would only deepen as the pandemic wore on. What would her learning gap be?
Or maybe she would encounter unexpected learning opportunities. In social isolation, would she find a renewed priority for family and friends? Would her experience with managing difficult conversations make her a superior communicator with patients and families? Perhaps she would become a more compassionate individual. From seeing up close the results of health inequities and the importance of public health, would she more effectively advocate on behalf of her patients? Unlike prior generations, would she have a greater comfort level with telehealth and embrace its progress? But most all, out of pandemic hardship, would she become more resilient and build a better world around her? Will she, with others like her in medicine, become our greatest generation?
I suspect she will do just fine. The regret I have is that I didn't get the chance to tell her how well she did that night and to give her the encouragement she seemed to need. Since then, I try to give residents not only constructive feedback about their work, but also the support they deserve. Even if it is from afar.
