Details of patients have been changed to protect their identities. Descriptions of Covid are exactly as I witnessed them.
On a recent ER shift, I took care of a three-month-old baby who had Covid. I had just finished suturing a laceration and had admitted a Covid patient to the medical floor, when the phone rang at the ER doctor’s desk. “I have a nervous family in the waiting room who says their baby isn’t breathing right,” the clerk said.
“Send them back,” I responded, and hurried to the only remaining empty patient room. “And call respiratory therapy,” I added. “Quick.”
A nurse ran behind me into the room and we watched as the baby’s family unbuckled him from the car seat. Then the nurse took the child from the mother and began undressing him. A respiratory therapist hooked the baby up to a monitor and I leaned over with a stethoscope.
His heart rate was rapid. Lung sounds were clear, but there was a lot of upper airway noise, gurgling, like the child was trying to breathe through thick mucus. Then the pulse oximeter beeped and signaled: oxygen saturation was 94%. The child was safe. For now.
“We were at a family birthday dinner,” the baby’s grandfather explained, “and he just started not sounding right. We thought we’d better bring him in.”
“Did he have a normal delivery?” I asked, turning to the mother.
“He was born at 40 weeks,” she said, and had been healthy since.
“Has anyone else in the family been sick?” I asked, continuing my line of questions.
“We’ve all had a bit of a cold,” the granddad offered, “but nothing too serious. Just stuffy noses.”
My heart sank, afraid of where the conversation was headed next. “Has anyone in the family had a fever?”
“My teenage daughter had one a few days ago, but she’s feeling better now,” the mother explained.
I took a big breath. I was pretty certain, between the baby’s symptoms and what his caregivers were telling me, what the child’s illness was. But I had to ask the next question. “Are your family members immunized?” I ventured. “Against Covid?”
“No,” the mother said.
“We’re all healthy,” the grandfather added.
When I got my first dose of Moderna’s Covid vaccine on December 23, 2020, it felt like a holiday—and not just because it was two days before Christmas.
I had been interviewed about the vaccine by a local radio station the day before, talking on live radio about the pandemic and how eager I was to get the shot. “My colleagues and I will still be working harder than we ever have in our careers,” I told the radio host in a breathless, eager voice when he asked how I felt about getting the jab. “But to not have to worry about taking the illness home to my family, or getting sick myself,” I said, “will be such a big relief.”
The night before, my kids and I had taken the dog and climbed up high on a snow-covered mountainside to watch the convergence of Saturn and Jupiter, the rare “winter star.” Getting the shot two days later felt like the experience of watching the star—a bright prick of hope in a dark night sky.
Help is on the way, I thought—and not just for me, but for all the patients I had taken care of. If the Great Influenza pandemic had lasted more than two years, 21st century science and vaccines had cut that timeline in half. “Hopefully it will not be that long before the shot is available for everyone,” I had told the radio host. “I’m tired of watching patients die. Especially alone.”
But the last nine months have proved my hope naive. Having spent so much time in the Covid-drenched world of the hospital, it was hard for me to imagine there were folks who might not want the shot as much as I did. To my mind, the decision was pretty clear: while all vaccines come with some risk, whatever risk the Covid-19 vaccine posed was infinitesimally small compared to the risk of the disease itself. I was pretty sure the dying patients and suffering families accumulating around me felt the same way.
But I forgot that not everyone was suffering and dying. That for people whose luck or privilege had protected them from the most deadly reaches of the disease, Covid—with its mask-wearing, vaccine-taking, travel-restricting mandates—was mostly a nuisance. Why take a jab when there seemed to be no risk to doing nothing at all?
In my pre-Christmas vaccine-flushed gratitude, I had also underestimated the power of the misinformation industrial complex. I never imagined the doubt it could sow about the vaccine and the fearsome virus it was designed to save people from.
“We’ll have to test your baby for Covid,” I explained to the mother. “As well as influenza and RSV. And we’ll get a chest X-ray.”
“Do you really need to do all that?” the grandfather asked.
“We need to know what’s making the baby sick—and to learn how to protect him,” I replied, listening to the child suck in each breath through a column of mucus. “I hope the test is negative, but we’d be crazy not to check given all the Covid we’re seeing.”
“You mean there’s that much out there?”
“Yes,” I responded, wishing I could pull back the curtain to reveal every other Covid patient in the Emergency Room. “There is that much out there.”
Then I explained that while we were waiting for the tests, we would keep the baby hooked up to the pulse oximeter and cardiac monitor. I wanted to watch his vital signs closely. “And I’ll have respiratory therapy suction his mouth and nose. Babies can’t clear all those secretions on their own,” I added. “Sometimes suctioning helps.”
“OK,” the mother acquiesced and grandfather nodded. And then I watched as they oriented themselves to the dizzying world of the Emergency Room, where lifesaving machines have bright lights and buzzing signals, and caregivers dress like astronauts going to the moon. “But only if you think it’s necessary.”
Welcome to my world, I thought, watching them take it all in. And then I left the room to order the tests.
In the early days of the pandemic I saw individual faces: the first Covid patient I diagnosed, the first person I put on bi-pap, the first individual who died.
Now I see categories, with too many faces to count populating each category: the patients with mild Covid who express relief when I tell them they can go home; the patients in respiratory failure who breathe through grimaces and pursed lips; and the patients who stare at me with fear and resignation when we talk about intubation. Then there are the grieving family members whose eyes fill with tears as I give them bad news, and the newly expired bodies who stare straight ahead when I pronounce them dead.
But some individuals stand out: the man who kept saying “gracias,” over and over again through his bipap mask every time I entered the room, and the woman whose family brought her to the ER directly from a local entertainment venue because they were concerned she did not have her usual energy. She had an oxygen saturation level of 72% and died 10 days later.
Sometimes these patients yell at me. They refuse to wear masks and tell me Covid is a hoax—even as they rely on me to provide care. “Do you know what the real pandemic is?” one of them said to me.
“What?” I responded, hooking him up to oxygen and administering medicine.
“Fear,” he replied, and then lectured me about how Covid was nothing more than the flu.
But some things are worth being scared of, I thought to myself as I left him to take care of the patient dying next door.
Examining a baby and ascertaining their respiratory status can sometimes be a hard thing to do. Technology—pulse oximeters, thermometers, X-rays—can help, but because babies cannot speak, a lot of understanding how sick they are comes down to observation.
For this reason, I always completely undress a child in respiratory distress. I look at their necks, ribs, and abdomen to see if they are requiring extra muscles to breathe. I listen to their lungs and over their throats and noses with my stethoscope. I also often hold the child in my arms, sitting on the gurney with them against my chest, measuring their work-of-breathing by how their small bodies move against mine.
I also, always, watch babies feed. In the first few months of life, infants are obligate nose breathers, with anatomy that makes breathing through their mouths not impossible, but difficult. Feeding becomes a particular challenge, because the baby cannot simultaneously eat and breathe, creating a vicious cycle where a baby will refuse food, leading to dehydration and sometimes even death.
That night in the ER, I observed the baby in all these ways. I undressed him but did not see any accessory muscle use. He breathed loudly but without any decrease in oxygenation when I held him in my arms. And later, he took his mother’s breast without any distress.
But despite these good signs, I still worried about the child. Babies have incredible reserve. They can chug along fighting a terrible illness for hours until they finally crash. This means family members need to be especially attuned to a baby’s needs. Caregivers also need to know how and when to suction a child who is struggling to breathe—and be willing to get medical help when that does not work. A baby with a solid respiratory illness can tire out even the most resilient and loving adults.
I hope they are up for it, I thought to myself as I looked at the baby, his mother, and grandfather.
Covid has been around long enough that in addition to acute Covid, I have also seen some of its other faces. I have not yet taken care of a child with Multisystem Inflammatory Syndrome, but I have met plenty of long-haulers and taken care of people months out from the disease who still have chronic cough and intermittent hypoxia. Others have cardiac issues. A marathon runner came to the ER with an unexplained irregular heart rhythm and chest pain. Another healthy 30-year-old, who recovered from a mild case of Covid last fall, returned to my ER months later in heart failure.
But other Covid casualties are patients who have never even had the disease. These people are the pandemic’s collateral damage—individuals whose medical care suffers because hospitals are full of people sick with Covid.
In recent months, I have boarded patients for extended periods of time in the Emergency Room because transferring hospitals were full and not accepting patients. My colleagues and I have also struggled to get patients with heart attacks and intracranial hemorrhages to cardiac catheterization labs and neurosurgical ICUs. And despite our best efforts, sometimes the ordinary, bread-and-butter Emergency Room patients—the folks with lacerations and sprained ankles—spend long times in hospital waiting rooms because doctors and nurses are tied up dealing with Covid.
“Getting an immunization is my choice,” vaccine deniers in the ER sometimes tell me. “Not getting it is my right,” they say, as if remaining unvaccinated is a decision that just affects them.
Maybe so, I think to myself. But if that’s true, then why are the rest of us left paying such a high price for your choice?
Back in the ER, the patient’s grandfather is angry. With me. Despite maintaining a good oxygen saturation and having a clear chest X-ray, the baby’s Covid test has returned positive. While I do not think the baby requires admission to the hospital, the positive Covid test necessitates other conversations. About quarantine. About isolating the child from other members of the family. “And you should be evaluated, too,” I suggest to the grandfather, whose own, dry cough has punctuated his grandson’s ER stay.
“Oh, it’s just a cold,” he insists. “I‘ll be alright.” But I have spent the last 18 months listening to the Covid cough and can differentiate it from the characteristic coughs of bronchitis, COPD, croup, and congestive heart failure. In fact, a year and a half into the illness, I can identify a Covid cough from across the produce section in the grocery store. I can certainly do it in my own ER.
So I press on, changing the focus back to the child. “I’m going to have the respiratory therapist teach you both how to suction the baby,” I explain. “You will have to continue to do this at home.”
“OK,” the grandfather sighs, his frustration momentarily overtaken with concern about his daughter and her baby.
Eighteen months in, Covid has changed the faces of my colleagues, too. Early on, we may have appeared nervous but were also more eager. Now we look worn out and sad, but with a battle-hardened resolve that keeps us seeing the next patient that comes through the door. And the next.
And it is not just that caring for Covid patients has taken its toll. Caring for them has also turned some of us into patients. Post-Covid, some of my colleagues walk more slowly as they move from room to room in the ER. A favorite respiratory therapist coughs into her own mask as she readies instruments for intubation. And other colleagues sometimes stop in the middle of their shifts to administer oxygen to themselves when their own levels run low.
Then there are the faces I do not see anymore: the physician and nursing colleagues who have burned out and left medicine; the ER clerk I worked side-by-side with for five years until Covid killed her; and the physician mentor who collapsed under the unrelenting strain of caring for pandemic patients and took his own life.
When I hear hospital administrators interviewed on TV describe their medical staff as “tired,” this is what they are talking about.
Back in the ER, I am worried about the baby—not because he has started doing poorly, but because I do not think his family understands how sick he is or even believes he has Covid. He is not the youngest child with Covid I have taken care of, or even the sickest, but babies are fragile and depend on the adults in their lives for care. I urge the mother to have her son evaluated by his pediatrician early the next day. I do not know how long the baby’s stable respiratory status will last.
But the grandfather is more concerned about the birthday dinner they are missing and the possibility of a misdiagnosis. “Please,” I entreat him and the baby’s mother, “please have somebody lay eyes on the child in the next 24 hours. You can even bring him back here, if you like.” They both give me a look like that is not about to happen.
But the truth is, I am also worried for the mother and grandfather. Statistically, the baby will get through Covid just fine—especially if he gets medical care if his condition worsens. The same cannot be said for the adults in his life. Hospitals in my state are full of young, healthy parents—and grandparents—who look and sound a lot like them.
At discharge, I provide information on free Covid testing, at-home Covid care, and describe symptoms they should watch for in the baby—and themselves. Then they bundle the child back into his carseat and leave the ER.
I hope they’ll be OK, I think to myself. And as I watch the family walk out of the hospital and back into that other world they inhabit—the one where fears of Covid are overblown and vaccines are not necessary—I hope that no matter how angry they are with me, they will carry a thread of this world with them. The life of their family may depend on it.
Although I have been immunized and am deliberate about wearing PPE, I usually shower before I leave the ER, especially if I have spent time in close proximity to Covid patients. On this day, the felt-memory of the baby’s ribs moving against mine stays with me so I shower in the call room.
I try not to look at myself in the rearview mirror as I pull out of the hospital parking lot. I do not like the older, more tired version of my face that returns my gaze. If I stare at myself too long, all my Covid memories come to mind, as if patients have left traces of themselves in my creased forehead and unruly grey hairs—or I am wearing the memory of my dead colleagues home on my skin.
I pull my car into the garage, shower again, and greet my kids on the front porch. They tell me about their day. Covid has changed their faces, too. My son has lost three teeth. My daughter, now a middle schooler, sometimes wears makeup.
But tonight I am distracted, unable to shake the concern about the baby and her family. I miss a key detail from a story my daughter is telling me.
“I’m sorry,” I say. “Can you tell me that, again?”
“It’s OK, Mom,” she replies. “You’re an ER doctor in the middle of a pandemic,” and all three of us laugh. This phrase has become family code for all my failings, and for the disappointments, large and small, associated with Covid. My-mother-is-an-ER-doctor-in-a-pandemic is the reason they cannot go to indoor parties with unmasked friends. It is why I sometimes forget to buy groceries, cry at TV commercials or have a short fuse. My children say these words and can laugh a little bit at my expense—and at a world they cannot control.
But tonight when my daughter repeats the phrase, she is dead serious. The words come out of her mouth with such tenderness I am floored. I look at her and wonder how I missed her growing up.
“Thank you,” I say, taking in her comfort. “But I think the pandemic might have been easier for you if you did not have an ER doctor for a mom. I’m only sorry it has lasted so long.”