“A single death is a tragedy. A million deaths is a statistic.”
Strange that a quote falsely attributed to Stalin could so aptly capture a physician’s experience of 15 months of a pandemic, but there you go. Ever since the first cases of COVID-19 appeared in New Mexico in the far corners of the Navajo Nation, I have found myself caught in coexisting states of tragic loss and statistical numbness. To adequately capture the experience of being a frontline health care worker without slipping into a series of heartbreaking anecdotes or vitriolic rants or self-pitying complaints is likely beyond my literary talents, but I feel like I owe it to myself and my companions in the proverbial trenches to try.
My first essay on the “pandemic experience” came shockingly easily. While I am normally a person who struggles to write, I completed 90 percent of the final piece in one Sunday afternoon in the ICU physician’s office. I had just witnessed the death of a 32-year-old man on his birthday from COVID-19, and the emotions were so raw, so overwhelming, that I had to put some of them on paper or risk a complete meltdown. But summing up a year where I’ve been a witness to dozens upon dozens of those kinds of losses has proved to be far more challenging. The rage has become resignation, the sorrow so much scar tissue. And revisiting those scars has been difficult—so intimidating a task that I was unsure where to begin.
As I turned over in my head various ways to structure this “one year later” essay, I came back to one of the (surprisingly) greatest challenges I’ve had—answering the simple question, “How are you?” While I, like so many, usually respond with a glib or at least superficial response, the truer answers would make virtually anyone sorry they had asked. And yet, in quiet moments, I keep coming back to that question—how am I? Here is the full, honest, unrestrained answer:
In the early months of pandemic, I was most angry about the parade of deaths of those younger than I, the cruel unfairness of so many lives ended prematurely. I was angry about seeing entire families decimated by the virus, with multiple generations dying in hospitals at the same time, and with my being utterly powerless to stem those losses. Witnessing the damage wreaked upon underserved and underresourced communities like the Navajo Nation led to an almost perpetual state of righteous indignation. That this annihilation could go on while the privileged and unaffected prattled on about the virus being a hoax or “like the flu” only served to fuel that rage.
In the middle months, wave No. 2 or No. 3 (I’ve lost count by now), I was angry about the preventable deaths that always seemed to follow any type of “reopening.” Deaths that didn’t need to happen, if people had just been more diligent about mask wearing, hand hygiene, avoiding groups. The consequences of a rush to normalcy played out in my ICU, where nearly half the COVID-19 patients placed on a ventilator would die slow, protracted deaths, bodies invaded and perforated by all manner of plastic tubes.
‘My primary anxiety today is for what comes after. For the toll—physical, psychological, emotional, spiritual—that health care workers the world over will pay.’
I am still angry at death. I am so frustrated that people continue to die from COVID-19 today. Deaths that could have, should have, been prevented by the vaccines that have been available to any adult in my state for months now. Angry that laxity and the false belief that “it’s over” could result in more suffering, more loss. Angry at the sheer unnecessariness of it all.
For anyone who has worked in an ICU, inpatient ward or emergency department during the pandemic knows without equivocation the bare fact of this year—that so, so many have died and even more have suffered. We have witnessed it with our own eyes, these terrible, prolonged, lonely, suffocating deaths. Anyone who dares dispute this brutal truth disrespects the dead and those who mourn them—and is a deserving target for the inchoate rage bubbling inside us.
Fear permeated the hospital in the early days of the pandemic, to the point one could practically feel it radiating from the walls. There was so much we didn’t know.
This fear was exaggerated, perhaps, but not irrational. All of us heard the cautionary early tales of doctors, therapists and nurses in China who had died of COVID-19, and similar tales from Italy, the United Kingdom and New York. A week after I had a high-risk exposure, a colleague from my hospital was infected. He was perhaps the most energetic, optimistic, fittest ICU specialist I’ve ever met, and he was on home oxygen for months; couldn’t take a shower without almost passing out; was, on several occasions, ill enough that he probably should have been admitted to our hospital; and was only able to return to ICU work after a four-month convalescence. The proximity of this “there but for the grace of God” event put a knot in my stomach that still returns if I let it stay on my mind too long.
The fear has never really gone away; it has evolved. Fear of the unknown transitioned into a fear of drowning—being overwhelmed by the sheer number of COVID-19 cases we were asked to take on, where just finding rooms for the patients turned into an exercise in desperate creativity (yes, we put some in closets). As the waves have ebbed, the fear is now of a return to those darkest days—every small cluster of COVID-19 patient admissions elicits a “please, God, not again” response. Vaccine distribution or no, there is still a collective holding of breath among ICU staff that follows every step toward “normal.”
My primary anxiety today is for what comes after. For the toll—physical, psychological, emotional, spiritual—that health care workers the world over will pay. How are we going to cope with the repeated bystander trauma we’ve suffered? With the deep professional distress caused by not knowing whether the treatments we offered were helping or harming those under our care? How do we recover from compassion fatigue on this scale, for this long? I worry about the incalculable damage done to our collective psyche, and I genuinely fear a mass exodus out of health care once the crisis is finally over and the real reckoning begins.
For all the anger and fear that has permeated my professional and personal life this pandemic year, I have also been witness to incredible grace and nobility. I am profoundly grateful to my section chief and the brave nurses and respiratory therapists who stepped forward to take care of the first COVID-19 patients; to the junior physicians who refused (loudly) to be excluded from caring for these patients; to my nurse colleague who played the Spice Girls over the intercom on a grim day; to all the nursing, therapist, dietitian, pharmacist and physician colleagues who have struggled alongside me.
Outside of the hospital bubble, I’m grateful for those who wear masks even when they aren’t legally required to do so, who didn’t wait to see what happened to other people before getting vaccinated. I am deeply appreciative of friends who reached out and were brave enough to genuinely ask, “How are you?”—and withstand the response. I am equally appreciative of my family, who knew better than to ask. I am more grateful than I can express for the patience and forbearance of my wife for putting up with my moodiness and irritability. And I have never been so grateful for the forgiving nature of dogs, because I think my cats are still holding a grudge.
When I first started thinking about this essay, the only thing I was certain of was the title. For it has truly been a year of caring dangerously—on the most basic level, providing medical care to COVID-19 patients was dangerous. Few of us working in the ICU have ever put ourselves in direct harm’s way before, particularly not with a pathogen as mysterious and frightening as SARS-CoV-2 was in the early days. But it has also been dangerous to care—for every 33-year-old mother of six who dies in the ICU while her baby is still in the neonatal unit, every 30-year-old firefighter who dies on a heart-lung machine, every flight nurse infected while transporting a fellow Diné (Navajo) now waiting on the lung transplant list. Each of those cases takes a small sliver of your soul and doesn’t give it back.
‘I have been far, far from any kind of “health care hero.” And so I struggle every day against these darker aspects of myself, trying to find buried reservoirs of kindness and patience.’
I must confess that the pandemic has not brought out the best in me. The filter between my irascible internal voice and my spoken words has never been so porous. I have been brusque, harsh, critical, irritable, impatient and unforgiving to junior physicians under my supervision, and sadly, the same can be said of dealings with those in my personal orbit. I have been far, far from any kind of “health care hero.” And so I struggle every day against these darker aspects of myself, trying to find buried reservoirs of kindness and patience.
There are times when I sit back and wonder why doctors, nurses, therapists and other hospital staff come back to work day after day—why more haven’t taken early retirement or quit or even taken their own lives. Perhaps it’s simply because we don’t know how to do anything else or have any other way to make a living; perhaps because the work really and truly is an inexplicable calling; perhaps because we stubbornly refuse to let a microscopic enemy beat us into submission; perhaps because we know, as never before, that we are needed. Whatever the reason, we will continue to show up, today and the next day and the days after that. We will continue the fight to save the lives of those we can and ease the passing of those we cannot.
So, at the end of my next ICU shift, if anyone asks me, “How are you?” I will answer, “I’m OK.” And then I will walk out the hospital doors, stop to listen to the loud, irrepressible song of the finches congregating in the barren tree by the ambulance bay, smile a wry smile under my surgical mask, and let my feet take me toward home.
Nathan Nielsen, ’97, is an associate professor in the division of pulmonary, critical care and sleep medicine at the University of New Mexico School of Medicine.