Why They Took the Oath: A Spotlight on Resident Sacrifice During the Pandemic

Editorial Why They Took the Oath: A Spotlight on Resident Sacrifice During the Pandemic Stephanie B. Engelhard, MD, Samuel S. Bruce, MD, Bart K. Chwalisz, MD, Marc J. Dinkin, MD Downloaded from http://journals.lww.com/jneuro-ophthalmology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 05/04/2022 B etween March and May of 2020, hundreds of medical practitioners in New York City and the surrounding region were suddenly called up to leave their usual practice and redeploy to take care of the 54,211 COVID-19 patients who were hospitalized in area hospitals during that time period. Many whose prior occupations were in specialties far from pulmonary disease, found themselves in drastically new circumstances, helping to manage ventilator settings and pressors, and dealing with life and death situations on a minute-to-minute basis. Even the most seasoned internal medicine doctors were working in an information vacuum—not knowing the natural history, let alone the ideal treatment for this novel virus. A great majority of those redeployed were residents from various specialties, early in their career, but closest to their medical school and basic medical or surgical residency training. For these residents, this dramatic shift in responsibility was no doubt far what they ever envisioned would be part of their residency training. The fear of new uncharted territory must have been great, and yet they rose to the occasion, never asking why, but only “when can I start?” In this section of the Journal of NeuroOphthalmology, we focus on residents from neurology and ophthalmology who made this incredible sacrifice close to a year ago. We aim to shed light on their journey, their emotional state, the important lessons learned, and their advice for future residents who might be faced with similar circumstances. I sat down (by Zoom) to interview Dr. Stephanie Engelhard, who was pulled from her oculoplastics rotation during her first year of ophthalmology residency (PGYII) to work on a COVID-19 unit for 4 weeks. Her time redeployed was bookmarked by encounters with neuro-ophthalmology patients with advanced vision loss, cases which would normally be remembered as high acuity in any ophthalmology residency, but in this context were recalled as almost mundane compared with the hundreds of patients she cared for in between (Fig. 1). DR. DINKIN: DR. ENGELHARD, THANK YOU FOR TAKING THE TIME TO TALK WITH ME ABOUT YOUR EXPERIENCES. WHAT DID YOU DO DURING YOUR REDEPLOYMENT? Dr. Engelhard: I was redeployed along with a coresident to become temporary residents on the internal medicine service. I was actually a replacement for another coresident who became very sick with COVID-19. Just days before, I was scrubbing into an optic nerve fenestration surgery for a young patient with idiopathic intracranial hypertension, knowing that it was probably the last time that operating room would be used for a non–COVID-19 purpose for some time to come. All of a sudden, I found myself on the medicine floors at the height of New York’s most serious medical crisis in 100 years, acting now as a medicine resident, helping to lessen the burden on our medicine colleagues. Far away from ophthalmology, I saw 1 COVID-19 patient after another, each with his or her own story, each different and tragic. Yet the story of their illness was always the same, the laboratory results were always the same, and the hypoxia was always the same. The daily routine I had grown accustomed to in ophthalmology was replaced by the ritual of donning and doffing, by the daily phone calls to worried patient families, by the daily disinfection dance when I got home from the hospital, and by the nightly clamor of the city clapping for essential workers at 7 o’clock. Departments of Ophthalmology (SE, MD), and Neurology (SB, MD), Weill Cornell Medical College, New York, New York; Department of Ophthalmology (BKC), Massachusetts Eye & Ear, Boston, Massachusetts; and Department of Neurology (BKC), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. The authors report no conflicts of interest. Address correspondence to Marc J. Dinkin, MD, Departments of Ophthalmology and Neurology, Weill Cornell Medical College, 1305 York Avenue, 11th Floor, New York, NY 10021; E-mail: [e-mail] Engelhard et al: J Neuro-Ophthalmol 2021; 41: 1-5 1 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Editorial FIG. 1. Dr. Stephanie Engelhard is an ophthalmology resident at New York Presbyterian hospital, Cornell Campus. She was deployed from her first year of ophthalmology residency (PGYII) to the internal medicine COVID-19 service where she cared for patients for 4 weeks. Although I was working on a regular internal medicine floor, the patients were all critically ill. Our healthiest patient was on 4 L of oxygen with a saturation in the low 90s. I somehow expected to see the normal cadre of very sick patients who would come in with severe congestive heart failure or diabetes exacerbations, but they just were not coming. One surprising observation was that, for the most part, the patients were healthy before infection. The virus was not only threatening to the brittle diabetics or immunocompromised. WHAT DID IT FEEL LIKE TO BE CALLED UP TO TAKE CARE OF COVID-19 PATIENTS? Dr. Engelhard: I really had a mix of emotions. On one hand, I was happy to be able to help at such a time of great need, to use the skills I have to make a difference. On the other hand, I definitely had concerns both about what my specific responsibilities would be, and whether or not, I would be qualified to help such high acuity medicine patients as an ophthalmology resident. I also worried about the risk of exposure and my family’s safety as a result of my redeployment. There were so many unknowns at that point that it was really difficult to wrap my mind around everything that was changing so quickly. That said, it is amazing how quickly you can adapt to new circumstances. Only weeks before, I would not have been able to imagine how much my life would change in such a short time. It was distressing to see whole families present to the emergency room, all suffering from COVID-19, all on nonrebreathers. Patients would tell you things like “my brother is on a nonrebreather across the hall,” or “my cousin just died from COVID-19.” It made us suspect a genetic predisposition. WHAT NEW SKILLS DID YOU HAVE TO LEARN FROM SCRATCH OR REVIEW? Dr. Engelhard: I had to review medication dosages, things I used to know off-hand. It came back quickly. I had to learn all the logistics of being a primary team. I did my intern year 2 elsewhere, so there were a lot of logistical things I had to learn very quickly. I reviewed some physiology as well. I learned a lot about tracheostomy management during that time. It was truly a big learning curve for everyone although. All of us, not just off-service residents, were also trying to learn about the disease, so there was a lot of reviewing all the new data that were coming out daily to see what we could incorporate into our practice. We would quickly listen to their heart and lungs, look at their legs, searching for deep vein thromboses, and check how much O2 they were on. If we needed to talk to them more, we would call them in their room. The most difficult thing was calling the families. We did not even know what to tell them. Sometimes patients would look better for a few days and then descend again. That was always so difficult. HOW DID YOUR TREATMENT OF PATIENTS WITH COVID-19 EVOLVE OVER TIME? Dr. Engelhard: it was exciting to be at the forefront of learning to treat a brand-new disease. A lot of our treatments shifted over time as we had a better understanding of the illness. Almost everyone received hydroxychloroquine initially, and later, we started enrolling patients into the remdesivir trial. Our daily struggle was to get patients into one of the trials, hoping for their sake that they met the criteria. We started putting certain patients on steroids very early depending on their clinical course and pulmonary function. As we were starting to see coagulopathies and strokes, we implemented new anticoagulation protocols. The challenge of trying to figure out the ideal treatment for our COVID-19 patients was one of the highlights of the experience. HOW WOULD YOU DESCRIBE THE SUPPORT YOU RECEIVED FROM YOUR COLLEAGUES AT THE TIME? Dr. Engelhard: the support was constant. From the ophthalmology side, our department was amazing about Engelhard et al: J Neuro-Ophthalmol 2021; 41: 1-5 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Editorial keeping us connected to the greater ophthalmology family. My coresident and I received daily heartfelt messages and calls from dozens of attendings, fellows, coresidents, and department staff during our time out of the department. From the medicine side, our team immediately accepted us as part of their own. They were always saying how much they appreciated our help and were so willing to help us through things we were not sure about or needed help with. There was also good camaraderie among the attendings and nurses from around New York and out of state who came to help. Everyone was on the same page with a common goal. WHAT WAS YOUR MOST POWERFUL MEMORY FROM THOSE DAYS? WAS THERE A PARTICULAR PATIENT THAT LEFT AN IMPRESSION ON YOU? Dr. Engelhard: I remember my first day vividly. I met my new team that morning to preround. There were so many medicine teams then that my team actually did not have a workroom, just some computers-on-wheels at the end of the hallway in front of giant windows. From the eleventh floor, we would sit and work overlooking the East River and the city skyline to the south. It was a beautiful view, but it was eerie too, looking out over a city that had screeched to a halt except for the bustling inside the city’s hospitals. The first thing the senior resident said to me was “welcome to the front lines.” It was surreal. On my first day, we had 3 patients on our team who needed intubation before 10 AM Many of the others were on 60 L nonrebreather and saturating in the 80s. It is amazing how fast our standards for “doing well” changed. On rounds, we first headed to the emergency department (ED), stopping outside the big double doors to ensure we were all double masked with eye protection. Everyone understood that the ED was ground zero, and everything there was considered potentially contaminated. Normally, the ED is bursting at the seams with patients and families crowded into every possible square inch of space. Normally, when I go to the ED, it is like a video game as I maneuver my slit lamp-on-wheels through the crowds of people, trying not to run over any toes, while simultaneously carrying my indirect on one arm and a backpack full of equipment on my back. That day was different although. It was quiet. All the patients were in rooms behind closed doors. There were no visitors and no patients wandering the halls. Behind every door, there was another COVID-19 patient being admitted with scary oxygen saturations. The team told me: the history is always the same, admit the patients, contact infectious disease to try to enroll the patient in clinical trials, and monitor the oxygen saturation. Call the intensive care unit when you max out on the oxygen. It was frightening. There was hope, however, despite the horribleness of it all. We were truly at the forefront, and there was no Engelhard et al: J Neuro-Ophthalmol 2021; 41: 1-5 guidance from history about how to take care of these patients. Everything was new, and we were learning rapidly as we were going. There was excitement about new possible treatments. I was there when we realized that COVID-19 is associated with coagulopathy and was among the first people in the country to start treating patients with our then new anticoagulation protocols for COVID-19. We ordered a number of laboratory tests on patients to see if we could find a biomarker that could be helpful for tracking or prognostication. We started treating some of the patients with steroids. It was exciting to be at the forefront. Without fully realizing it at the time, we were setting the treatment standards for the rest of the country to follow. So much of the early data came from here. From our work. From our patients. It was also so hard to watch patients suffer and only be able to see their family through video chat. It was frustrating not being able to spend as much time in patient rooms as you normally would because we were trying to limit length of exposure. On my last day, we received a new overnight admission who had severe vision loss over a few months preceding as well as other neurologic symptoms and a new large intracranial mass on MRI. Of course, the patient needed to be seen by ophthalmology, so I consulted myself. I have never been so excited to see a consult! The joy of getting my equipment and focusing on eyes for the first time in weeks was thrilling and reminded me how much I love ophthalmology and how fortunate I am to get to do what I love (The medicine residents did not seem to enjoy it as much!). DID YOU SEE ANY OPHTHALMOLOGICAL OR NEUROLOGICAL COMPLICATIONS? Dr. Engelhard: the first few days, I was still thinking about the patients’ eyes. But it is amazing how quickly your focus can shift. Within a few days, the eyes faded into the background, which is so surprising for someone like me who focuses on them so intently most of the time. We also saw and heard about patients with other neurovascular complications from the virus. WHAT ADVICE WOULD YOU HAVE FOR RESIDENTS BEING CALLED UP IN THE FUTURE FOR THE FIRST TIME? Dr. Engelhard: embrace your feelings about the redeployment, all of which, positive and negative, are valid. Know that the uncertainty is far more anxiety provoking than actually doing the work. At the end of the day, there is a certain comfort in the work. You know that you used your skills to help when help was needed. Know that you are qualified for this; you have the necessary skills and have been well trained. Keep a log of your days, notable things that happened and your reflections on them—you will want 3 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Editorial to go back and revisit them some day to remember what it was like. Dr. Samuel Bruce was a first-year neurology resident (PGYII) taking care of demyelinating disease, strokes, and headaches when he was asked to report for duty in a newly formed COVID-19 ICU (Fig. 2). WHERE WERE YOU REDEPLOYED? WHAT WERE YOUR RESPONSIBILITIES? Dr. Bruce: during the peak of the pandemic, I was deployed to the neurological intensive care unit, which had ceased taking care of primary neurology patients and was now devoted exclusively to critically ill COVID-19 patients. Then, I was deployed to the intensive care unit at a downtown Hospital, which was also devoted exclusively to critically ill COVID-19 patients. For both of these stints, I was the first-call medical provider for a subset of COVID19 patients on the unit. My responsibilities included medical management, which was heavily weighted toward ventilator management, and communication with family members. After a number of weeks covering these ICUs, I then moved on to the neurology consult service, where I was 1 of 2 neurology residents on the service performing consults throughout the hospital for neurologic complaints. Almost all of the consults at that time were on COVID-19 patients, as people without COVID-19 were avoiding the hospital, and the timing was such that many of the initial wave of critically ill COVID-19 patients were being weaned off sedation for the first time, unmasking neurologic pathology. WHAT SORT OF NEUROLOGIC PATHOLOGY DID YOU SEE? The most frequent type of neurology consult we received was for patients not responding to any stimuli after weaning of sedation. More often than not, this was due to prolonged effects of deep sedation over many weeks, especially in the many patients with kidney injury who had impaired ability to clear the sedating medications. In most of these cases, patients would begin to regain some level of consciousness after a day or 2. In many cases, however, a computed tomography scan would reveal that the patient had suffered a massive ischemic stroke or intracranial hemorrhage that was clinically silent because of the effects of sedation. We also saw a variety of peripheral nervous system pathology. Many patients experienced critical illness polyneuropathy and compression mononeuropathies, and we saw multiple cases of Guillain–Barre syndrome. 4 FIG. 2. Dr. Samuel Bruce is a neurology resident at New York Presbyterian hospital, Cornell Campus. He was deployed to the neuro-ICU that was converted to a COVID-19 ICU and later served on the neurology consult service at a time when nearly all the consultations were for neurological complications of COVID-19. WHAT DID IT FEEL LIKE TO BE CALLED UP TO TAKE CARE OF COVID-19 PATIENTS? Dr. Bruce: my first and foremost reaction was “this is why I took the Oath.” I think most of us in medicine went into this field at least partially out of a sense of service. We want to serve our patients, we want to serve our communities, and we want to serve humanity. This pandemic was a chance to do all of that. Our skills were desperately needed, and I felt privileged for the opportunity to deploy them. Do not get me wrong, I was scared too: scared of dying, scared of spreading the virus all over, and scared that I was not up for the challenge. But mostly, I was ready for action. WHAT DID YOU DO WHEN YOU WERE NOT DIRECTLY CARING FOR PATIENTS DURING YOUR TIME REDEPLOYED? Dr. Bruce: redeployment was a busy time, but we were all just totally consumed with the virus. Every moment that was not spent on patient care and family communication was spent reading about the pandemic because we were just so starved for information that could help us. We read every case series and article that came out in the early days of the virus, as well as every op-ed and account from China, Italy, and any other country that got hit hard before us. We were also all obsessed with how the case count was evolving in Engelhard et al: J Neuro-Ophthalmol 2021; 41: 1-5 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Editorial various places in the United States and the various predictions that were floating around about what the summer would look like, and how long a vaccine would take to develop. WHAT NEW SKILLS DID YOU HAVE TO LEARN FROM SCRATCH OR REVIEW? Dr. Bruce: the family discussions were something for which we could not have prepared. Visitors were not allowed in the hospital throughout the peak of the pandemic, so for patients’ family members, what we told them over the phone was the entirety of what they knew. We had to learn how to explain the medical status of their loved ones, despite not really having experience with this disease and knowing its clinical course. We had to ask them to make medical decisions on behalf of the patient on the basis of little certain knowledge about the course of COVID-19, without ever meeting the person giving them the information, and without seeing the reality on the ground and whether it added up. In the all too frequent case that the patient died, family members wanted to know what happened, whether it could have been avoided, how and when they can retrieve the body, and whether their loved one felt alone when he or she died. We rarely had answers to these questions and had to learn how to offer our empathy without being able to offer closure. DESCRIBE THE SUPPORT FROM YOUR COLLEAGUES DURING THOSE DAYS? Any fears about whether I could rise to the occasion disappeared quickly, mostly because I could see everyone around me rising to the occasion. As far as feeling supported, one thing that was really crucial for us as residents was seeing the “all hands on deck” mentality. Attending and fellow staffing were doubled in the neurointensive care unit during the peak. A few of our neurology attendings volunteered for the front lines and worked in the emergency department throughout the surge. The entire Engelhard et al: J Neuro-Ophthalmol 2021; 41: 1-5 pulmonary/critical care division was amazing. They came to the neuro-intensive care unit multiple times per day and seemed to be lending their expertise to every unit in the hospital. Looking back, do you feel like your time working for covid-19 patients has had any value in your resident education as a neurologist? Dr. Bruce: Definitely. It taught me that we are often called to respond to problems outside of our area of expertise, and we have to be ready. We as physicians have a not-so-easilyreplaceable skillset, and that skillset will, from time to time, need to be deployed outside of our comfort zone for the greater good. To be reminded so vividly of this truth during my residency training, I am sure I will never forget it. WHAT ADVICE WOULD YOU HAVE FOR RESIDENTS BEING CALLED UP IN THE FUTURE FOR THE FIRST TIME? Dr. Bruce: keep an open mind, stay flexible, make adjustments, and be humble about what you do and do not know. This glimpse into the perspective of an ophthalmology resident and a neurology resident who served during the pandemic highlights just 2 of the hundreds of doctors, nurses, administrators, and other front-line workers who devoted themselves to the fight against the novel threat of COVID-19, with great sacrifice to themselves. We hope this interview will help remind our readers of the profound way in which our community was overwhelmed by the early wave of the pandemic, but most importantly to celebrate our brave residents, who in many ways are the life blood of our hospitals and of our neurology and ophthalmology departments, and who rose up to serve our sickest patients in their time of need. 5 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.