Team PM&R to the Rescue! A Pandemic Story

by Margaret Beckwith, MD

The alarms started blaring from room 214 for the umpteenth time. The pleasantly demented, bubbly little old lady with her matching pink flower comb, nails, and purse was pulling off her non-rebreather mask again. Pulse oximetry was reading in the 60’s. Despite her low sats, new restraint mittens, and prone positioning, this COVID patient with the smushed face cheerily asked without missing a breath, “Dear, do you think you could get me some coffee?”

“It’s 3am and I think that’s a terrible idea,” I exasperatedly whispered to myself. “How about some water and if we tuck you into bed?” I proffered with artificial brightness like the fluorescent lights illuminating the hospital. The patient gave me a very unamused, mirthless expression from her adult tummy time position.

Since being pulled from PM&R residency inpatient rotations and deployed to the COVID units in New York City 6 weeks ago, I recently jumped headfirst into a fast-moving, committed relationship with coffee and I commiserated with my patient. Not only was the hospital short on staff and personal protective equipment, but coffee, the nectar of the gods, the gasoline of life, the fuel of the 24/7 world, was also now a rare commodity in the hospitals. “As soon as the kitchen opens at 6am, I’ll make sure you’re the first patient served piping hot coffee,” I promised her as I backed out of the doorway and banked on her forgetting our conversation and my little white lie.

It was not to be. The patient was in fine form tonight. Every ten to fifteen minutes until 6am a disgruntled, indignant voice shouted from the room, “Do you have any respect your elders?! Where is my coffee?!” I had to chuckle. At least she was giving me some comic relief in-between codes tonight. It’s always fascinated me what demented patients are able to remember.

Just before 6:30am handoff, I stopped by her room with a warm cup of Joe and asked her how her night was. She indignantly replied, “Well, you guys kept me up all night long running in and out setting alarms off!”

I walked home to my apartment as sun rays started to peak through the spaces between the skyscrapers. Filled with a good feeling I mused, “With her spunk and determination, I’m pretty sure she’s going to make it. Didn’t Eisenhower say, ‘What counts is not necessarily the size of the dog in the fight but the size of the fight in the dog?’”

As soon as I stepped foot into my tiny city apartment, the exhaustion hit me. In the terms of my British relatives, I was “absolutely knackered” — but I couldn’t sleep. My mind was racing, the inner monologues of mental chatter meddled with my head. I felt like I was drowning in a colorless, inescapable, slowly asphyxiating abyss of anxiety and fear. I shot up from my bed with my heart racing and sweaty palms realizing I had hugged my dog, my lifeline throughout residency, before fully decontaminating earlier in the morning. “Firetruck!” I cursed. This pandemic was not only turning me into a triple under-the-eye bags monster but also a potential dog murderer. Obviously if the zoo felines were infected by an asymptomatic staff member then Queen of the COVID wards over here is certainly going to infect her precious dog. How could I have been so careless and selfish? I’d only worked 80–90 hours/week over the past 5 weeks and this was considered nothing substantial by any means to the older physicians who thought duty hour limitations were for the weak and cried tears of joy when they were lifted. I took a deep breath and noticed it was not as voluminous as usual.

“Well that’s what happens when you don’t workout for a few weeks, M’dear,” one of the gobby voices in my head yelled at me. “Your lung capacity decreases!!” Another voice snarked that my facial bruising and subsequent edema from wearing my N95 12+ hours day likely loosened the seal around my mask and let the thin, ugly fingers of coronavirus slip underneath. This was it. I knew it. My time had come. By morning the coronavirus would overtake me and I’d be too weak to even reach for my phone and call 911. I’d die alone, like so many of my patients these past few weeks. One of my occult fears was about to become true.

Should I start writing my COVID letters now so that when someone finds me they have something to give my family? Do I leave a cheeky note or two for my top ten friends? How many days of food and treats should I leave out for my pet? Maybe voice recordings on my external hard drive or a little video would be better. Someone would eventually find it. My family is going to be so annoyed but not surprised that I haven’t written my will yet. Whatever, they should get everything anyways. It’s not like I own anything but a couple hundred thousand dollars of debt and a net negative value at the ripe old age of twenty-eight.

The ruminations became too much. I felt like I was turning into one of the nutters that everyone chats about at happy hour. “Don’t plotz” the sagacious voice of one of my Jewish medical school roommates counseled me from an old memory. Yes, yes, okay, don’t explode. Exceptional advice. Thanks, Brain, appreciate you being there for me. Even though I had to be back at work in less than 8 hours, sleep was unequivocally not going to be an option. I reluctantly opened up my web browser to Headspace, the meditation app that fellow residents had been raving about for the past few weeks. I have never been much of a meditator nor found an inner need for it as I’ve always prided myself on falling into REM sleep within 5 minutes of jumping into bed. Now was different. My toolbox of coping strategies needed to be expanded. I signed up for Headspace. I scrolled through the different meditation titles. Ha, “Love Oneself,” This girl is the mother ducking boss at treating herself regularly. Don’t need any help there. I continued to scroll through the remaining meditation options. “Breathe,” well I definitely might need assistance with that later on tonight I thought as I inhaled another mediocre, insufficient “big” breath. “Eating with appreciation?” I think I could probably teach that course. Any warm meal that is not composed of pasta is a five-star feast in my personal handbook. I took a moment to reflect on the recent generosity of food of donated meals at the hospital provided by community kindness before finally landing on the meditation series I was looking for: Managing Anxiety. Mmm, yep, bingo. Let’s go. I started the series. A very polished British accent started cajoling me, “Take a deep breath.” I wanted to throw my laptop across the room. Mr. Sophisticated British Man, this is probably the worst advice you could give me right now. I immediately exited out of the browser and reflexively picked up my phone like any conventional millennial under stress.

I noticed one of my co-residents had added me to an NYC PM&R resident WhatsApp group chat where residents were sharing their sentiments (the good, the bad, and the ugly!) and exchanging insight on how different hospitals were providing medical care for their COVID patients. It was almost like being part of a mini think tank! I was immediately drawn to the chat and loved that residents were leveraging their knowledge resources to facilitate the exchange of ideas in hopes of optimizing care for COVID patients across the city. It was how I always envisioned medicine; magnanimous, civilized, and educated. It was also a safe space free from unrealistic, nausea-inducing Pollyannas in ivory towers far from the front lines who were out of touch with reality and who shared impractical, worthless advice. All of us in the group chat had been pulled off of the rehab units and were deployed to the specialties/floors that needed extra hands such as internal medicine, emergency medicine, intensive care units, and COVID units. The timing of this group text was providential.

A personal, almost poetic in nature, journal entry shared by one of the residents at Montefiore caught my eye and really resonated with me:

Many in the group chat further discussed the difficulty of coping with the newfound stresses of being thrown into deadly, unfamiliar working environments with daily policy changes, observing multiple patients pass away each day and feeling inept, coming home with even more anxiety about accidentally contaminating someone in the family despite taking 45 minutes or more to decontaminate at the hospital each day, and being unable to exercise properly with all the mandated gym closures.

I read on as various residents shared their personal stories and struggles.

In pre-COVID days, Amy Park, DO, Hofstra Northwell, lived with her elderly grandmother and would help take care of her after work. Due to concerns about her grandmother’s frail health, Amy started staying in one of the local hotels to avoid accidentally exposing her grandmother to the virus. It was very mentally taxing being uprooted from both her normal PM&R activities and home life. However, Amy was able to find stalwart support from her co-residents and was able to keep in touch with family and friends via multiple video chatting platforms. Amy shared that some newfound positivity for her during these capricious times is that many old, neglected friendships were rekindled as thoughtful, selfless friends from previous chapters of her life reached out when they found out she was on the frontlines. For her, reconnecting with them was like discovering lost treasures of the sea and has been a blessing in this chaotic storm of muddled uncertainty. She has also been able to take advantage of many of the free at-home virtual workouts being offered by Peloton, DownDog, FitOnApp, Orange Theory, Les Mills, Nike Training Club, and Lifetime fitness and highly recommended them to other residents as an avenue for managing their personal stress and health. Amy ended her reflective text to the group by reminding us that just as no amount of make-up can cover up an ugly personality, our outer facades are often a mirror reflecting our inner world. With so many patients and the community relying on us, we must make it a priority to hold each other accountable for our individual well-beings on a daily basis as positivity and kindness are contagious…more contagious than COVID.

Another resident from Metropolitan Hospital Center summed up Dr. Park’s words with a quote from Mark Twain and responded: Kindness is a language that the deaf can hear and the blind can see.

I found comfort in this group chat and continued reading through the words of wisdom from my peers.

Eugene Palatula, MD from New York Presbyterian empathized with Amy and said that he too was utilizing the housing services set up through his program and quarantining away from his pregnant wife and two young daughters (ages 3 & 5). For Eugene, watching patients gasping for their last breaths and dying alone due to the No Guest Policy in the COVID Units has been crushingly heartbreaking and made him feel like not only had he been stabbed in the heart but that someone was twisting the knife around in it too. He was certainly not the only healthcare worker experiencing these agonizing emotions. Given how traumatic this has been for patients, families, and healthcare workers, Eugene’s hospital recently relaxed their No Guest Policy and has been permitting 1 family member with full PPE to come into the COVID wards for 5 minutes and say goodbye. Eugene highly recommended that other residents advocate for these humane policy changes at their sites. While it’s been tough for Eugene to only see his healthy family on his single weekly day off through a screen glass door and/or 6' away, he takes comfort in knowing that his hello-goodbyes are only temporary and wished all of this was just a transient bad dream of mass hysteria proportions like the Tanganyika Laughter Epidemic where no one died and everyone recovered.

Maryam Hosseini, MD of Montefiore related to Eugene’s situation and offered insight on her meticulous decontamination ritual for when she returns home to her young family from her COVID shifts. The entrance to her home is known as the “Dirty Area” where no one but Maryam is allowed. As such, she does all the laundry and grocery shopping in addition to working so that her other family members do not have to leave the dwelling. When Maryam returns home from work, she fastidiously wipes down everything on her that can be wiped with a Clorox wipe including her hair pins and changes her clothes in the Dirty Area. Clothes and items that can be washed are placed in a bin called the “Transition Zone.” After she sanitizes her hands with alcohol, she races to the shower while her husband sprays the items in the Transition Zone with disinfectant and then washes the items with while donning gloves. Even though Maryam has always been a clean machine, COVID has taken her household cleaning to extraordinary, previously thought to be unattainable, levels. For Maryam, some of her most sanguine moments have been during daily reflections on actively being part of a team of many different specialties that were able to coalesce and work towards a common goal. She herself had learned new skills that she never foresaw herself mastering such as placing nasogastric tubes, drawing up ABGs, and proficiently changing ventilator settings. Meeting residents from other specialties that she would have otherwise never crossed paths with has been another silver lining for her.

Chanel Davidoff, MD, Hofstra Northwell chimed in about her personal strife. One of the most difficult, recurrent part of her day has been her inability to give patients’ families closure on prognosis due the unpredictable spectrum of the disease. Ironically these tough conversations have also been the most rewarding. Despite feeling futile and too commonly using the phrase, “We don’t know” in discussions about goals of care, anxious families have counter offered an overwhelming amount of gratitude which brightens Chanel’s day. While the world is tensely awaiting a magic bullet, the next best discovery throughout this pandemic for Chanel has been Zoom happy hours where she can meet up with her friends and wearing sweatpants is fashionably acceptable. In her comical words, she exclaims,” You mean, we get to hang out with friends but don’t have to coordinate outfits or wear real pants? It took a pandemic to discover this genius?!” She also jokingly shared that her residency renamed the Faces Pain Scale the Fauci Pain Scale in Dr. Fauci’s honor before signing off for the night.

The group chat was on fire! I could barely keep up with the constant stream of messages and it felt good to connect with other budding physiatrists.

A message that caught my eye further down in the group chat was from Malcolm Winkle, MD, SUNY Downstate, who said he had recently recovered from COVID. In March, he started having muscle aches, a mild cough, headache, and subjective fever for two days. For him, drinking significant quantities of tea and taking both ibuprofen and Tylenol helped alleviate the burden of his symptoms. After he was symptom free for 7 days and had not used antipyretics for 3 days, he was cleared to return to work immediately. He initially felt a bit ambivalent about his health clearance; on one hand he was eager to get back to the front lines and help out where he was needed most, but on the other hand, he was concerned he might be doing more harm than good given the current lack of information about post-symptom viral shedding and likelihood that he might still be contagious. Nonetheless, he returned to work and was exceptionally careful with ensuring that he followed PPE policy to a tee in order to avoid unintentionally infecting patients. Malcolm also considers himself very lucky as he has had multiple healthy, young colleagues contract more severe forms of COVID requiring multi-day hospitalizations. Together, he and his wife created a COVID decontamination protocol similar to Maryam’s to prevent inadvertent spread of germs at home and so far his immediate family has been spared of COVID symptoms.

One of the last texts I read that night was from “Vitamin King,” Lawrence Chang, DO of Burke Rehab who shared his hospital’s updated protocol treatment regimen for COVID. In Burke’s first week of hosting medical COVID units, one of their older patients started going into acute respiratory distress syndrome and was requiring 15 L of oxygen via non-rebreather mask. The local acute care hospital was completely filled and diverting patients. Given that no local ICUs had room for the patient, Burke was caught in a CATCH-22 as they had no manpower or resources to intubate and ventilate. The team of physiatrists turned COVID medical specialists quickly called the family with the grim update and let them know that CPR would not save the patient’s life in the event that she coded. The family agreed that a Do Not Resuscitate order was appropriate for the situation and in line with the patient’s wishes. Everyone was frustrated and felt inadequate as healthcare providers unable to heal. The doxycycline and hydroxychloroquine that the patient had already initiated the protocol for COVID pneumonia patients at that time) did not appear to be making any positive impact.

Tick, Tick, Tick. Outside of the patient’s room, the clock above the nurse’s station was practically deafening and counting down the time until the impending doom of the cytokine storm unleashed an untamable fireworks of inferno inside of the patient. In this emergent situation, Lawrence proposed to his colleagues that they throw a Hail Mary pass attempt at the patient and load her with 8–10g of Vitamin C. Although the patient’s care team was initially hesitant, they agreed to try it after Lawrence showed them some medical literature regarding high dose Vitamin C in the treatment of COVID. When the pharmacy received this order, the immediately called the physicians. The pharmacy team was also very skeptical and reminded the physicians that there was an enormous risk for kidney stones and diarrhea. Lawrence again showed the evidence-based medical publications to the pharmacists and pointed out that diarrhea from Vitamin C was a sign of “bowel tolerance” and was physical evidence that the dose was strong enough to work at a therapeutic level. Pharmacy reluctantly gave the physicians the megadose of vitamin C. No one except Lawrence had high hopes for this pharmacotherapy and other members of the team prayed that the patient would have a somewhat peaceful death overnight.

Much to everyone’s surprise and delight, the patient was doing well the next morning and had not any events overnight. Despite still being on 15 liters of oxygen via the non-rebreather, the patient stated she was feeling better and clinically she looked much better. Over the following days, the patient completed her course of antibiotics but still required the nonrebreather mask. She continued receiving 8g of Vitamin C daily for more than a week after finishing her antibiotics and was titrated down to 5L of O2 via nasal cannula and was able to participate in therapy. By day of discharge, she was down to her home COPD requirements of 2L and her Vitamin C had been titrated down to 2g daily. Looking back on the case, Lawrence was not sure if the patient’s condition drastically turned around due to the combination of antibiotics and high dose vitamin C, just the antibiotics alone, pure luck, or divine intervention. Regardless of what actually saved the patient’s life and helped her rehabilitate (and for the record she did not develop kidney stones), Lawrence’s colleagues dubbed him “Vitamin King” and credited his quick thinking and broad knowledge of COVID therapies with saving the patient’s life. Lawrence continued to advocate for aggressive nutrition rehabilitation in COVID patients with the hypothesis that either pre-COVID micronutrient deficiencies further compromised their ability to fight the infection or in their bodies’ attempt to fight the infection they quickly depleted their micronutrient stores. Pending patient’s individual conditions and needs, may of the Burke COVID teams started their patients on Vitamin D, Zinc, thiamine, and Coenzyme Q sometimes in conjunction with high-dose Vitamin C and sometimes without it. Lawrence’s medical team had a few more patients with severe respiratory distress secondary to COVID over the next few weeks . He promptly put them on 6–8g of Vitamin C daily in addition to their antibiotics and all of those patients’ oxygen requirements improved. Lawrence was thankful for working with an open-minded team in these uncertain times.

Despite the chaos and day-to-day dubiousness, one thing was for certain and reinforced over and over again in the NYC PM&R WhatsApp group text. As Eugene pointed out, emergency medicine and internal medicine attendings and residents were very appreciative and impressed with how seamlessly PM&R residents fit in and transitioned into the acute care workflow during the peak of the pandemic. Significant impacts were made by physiatrists on the front lines. As Chanel said, “Coming together as a ‘COVID specialists’ has been humbling and heart-warming. Adapting to a new environment is tough; but, doing it with the intention of supporting our front-line doctors has made it worthwhile. Having experience in providing vital information about functional barriers have aided tremendously in medical decision making. Yes, we are rehab specialists — but we are all physicians first.”

And with that, I felt reenergized and put my phone down after setting the alarm. While taking in a refreshing wonderfully deep breath, I patted my dog on the head with newfound courage and peace as she curled up on the rug beside my bed. I settled into my soft covers as the sunlight peeped through the corners of my curtains and dozed off, exhausted but excited to be part of this experience and proud to be a physiatrist.

Resident and Fellow Council of the Association of Academic Physiatry (@AssocAcademicPhysiatry)

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