Charlotte Robinson, Wake Forest University School of Law JD ’22
The room feels darker than most. It is cold and uninviting. For someone who works in a hospital, you’d think I would be used to this environment. I should have adapted to it. After all, no one has ever described a hospital as sunny and welcoming. I look around the waiting room of the psychology wing, taking in all the textbooks and self-help books, stewing. As I wait, I can hear every beat of my heart. My ears feel muffled, like when you swim underwater. I finally understand how patients must feel waiting for their doctor to show. Why make an appointment if you can’t commit to the time you offered? The door to her office creaks open, and I hear the small click-click of the doctor’s heels as she walks out to grab me. We walk the three feet back into her office. It’s even darker than the waiting room. Dr. Markin sits down at her desk and opens a folder. It’s thick. I know it’s my patient master file – a simple manilla folder than contains all my patients and their stories. For such a simple folder, it’s mere presence makes me nauseous.
In spring of 2020 the world was plagued with a pandemic: COVID-19. Almost everyone faced the virus, in their own way. They lost family members, got sick themselves, suffered severe and permanent health problems, or had to adjust to an entirely new reality of life spent on Zoom. While the degree to which the pandemic affected each person varied, its consequences were significant. The pandemic also highlighted a great divide among humanity. The vastly different experiences people had during the height of quarantines and lockdowns showcased privilege in a way we hadn’t seen before. Being locked in a mansion is a starkly different experience from cooping up in a three-hundred square foot apartment. Personal decisions made by people during the pandemic created snowball effects that later changed the course for others. I would know. As an ER doctor working in New York City, I heard all their stories. Between March and May of 2020, over 200,000 cases made their way into New York hospital systems. It was during that time that I had to make some of my own life-changing decisions. Today, I am being forced to face them. To accept that this is my new reality. The chief of the hospital has decided that every employee must undergo a mental health evaluation.
The administration and board of trustees, who sit in their fancy offices and only read about the death tolls, have decided that people like me need to be cleared for practice. They fear that all the death we have seen in recent years will affect our mental health, and in turn our ability to care for our patients. I got an email, as stale and curt as the people writing it, that told me to show up here. Dr. Markin, Chief of the Psychology Department, was going to have a “conversation” with me. Dr. Markin said that a survey of 20,947 physicians and other workers found that 61% of those surveyed felt a high fear of exposing themselves or their families to COVID-19, while 38% self-reported experiencing anxiety or depression. Another 43% suffered from work overload and 49% had burnout. So, she wanted to assess me and all my wins and losses and decide if I have the mental clarity necessary to continue working. To make sure that as a treating doctor my inherent god complex hadn’t gone out of control during the pandemic. The evaluation was for my health, and my patient’s safety.
She opens my patient file. It’s so thick it makes a thud against the hard glass countertop of her desk. I know how the process is going to work. My colleagues shared previews from their own sessions. We will talk about some of the patients I recently saw, and their outcomes, and my ability to react to these conversations will be assessed. I can see the intake picture on the first page of my patient’s overview tab. I wish I could tell her that she needn’t worry. With all the losses I faced, I feel less like God and more like the Devil himself. These patients, these times – they are my nine circles of hell.
Marie D., Age 64, DOB: 05/30/1957
I met Marie on March 12, 2020. She was brought to the emergency room via ambulance. Her husband of forty years had called 911 after noticing his wife could not breathe. He came in right behind her, running and yelling for his wife. She was in Bay 4, being assessed by the on-call resident. I walked over and listened to her heart. The cold metal of my stethoscope caused her to wince. Marie was a retired teacher, a wife, a mother to three, and a grandmother to seven. After spending most of her life teaching art in elementary schools, she decided to retire and volunteer more often at her local church. Her husband told me all of this, I guess in hopes that I would be more inclined to save the life of an arguably decent human being.
I didn’t have the strength to tell him that if his wife had Covid, her being decent would not change things. Just in the last forty-eight hours, the hospital had declared 16 people dead due to respiratory distress, subsequent to a Covid diagnosis. I hoped Marie had a cold. Honestly, I hoped Marie was having a heart attack. I hoped she had anything but Covid. You see, I know how to treat a cold. I know how to treat a heart attack. Treating my Covid patients brought me back to my first year in medical school – I knew nothing.
I took Marie’s vitals. The nurse took her blood. I turned to her husband and told him that we needed to test Marie for Covid. When I told them, I remember looking at her face. She didn’t seem surprised. She knew that might be what was making her respiration so difficult. She had accepted it. Her husband, on the other hand, turned pale and clammy. I could see the sweat imprints his hands were leaving as he wrangled with her hospital bed frame.
Her test came back positive. At this point, Marie’s oxygen level was dropping lower and lower. Despite being a generally healthy woman, her age presented additional concerns. I immediately had her admitted and placed on supplemental oxygen. Nevertheless, Marie’s health deteriorated faster than her husband could get her soup and cough drops. I physically couldn’t keep up with the speed at which patients were succumbing to the virus. One second her stats were improving, the next she was in cardiac arrest. I broke her ribs performing CPR, and it still wasn’t enough. That day Marie’s husband said goodbye to his wife of forty years. I couldn’t even mourn the loss of my patient before I had to slap on another N-95 mask and move on to the next patient.
Eduardo M., Age 39, DOB: 06/20/1982
Dr. Markin flips the page. Her gaze is fixed, and I can’t tell what she’s thinking. She opens the next tabbed section and begins reading. Eduardo Montez. She reads aloud all the information on his intake form, but that isn’t what I remember of Eduardo. I remember how he came in and looked as overwhelmed and confused as the rest of us. Eduardo was from Santiago, Chile and didn’t speak more than ten words of English. He didn’t need to say much. His Covid test came back positive, and we both knew the situation he was in. It’s in times like these that one truly understands how much the face can communicate, and we were seeing just the upper half. His mask covered what I am sure was a worried and frightened grimace.
We were finally able to find a translator that could help us communicate with him. We learned that Eduardo was a janitor at a local high school. He spent his days cleaning up after people that didn’t have the common decency to learn his name, let alone thank him. He told us he was careful – he wore his mask, washed his hands, and avoided contact with as many people as possible. Sadly, the students at the school were having a harder time understanding the importance of adhering to these health protocols.
I asked him if he had any family that he needed to contact and make arrangements for – children of his own. Eduardo spoke of his family with such joy. It was one of the only times one wouldn’t think he was sick, gasping for whatever oxygen he could. He told me about his mother, who still lived in the same house as her four children and seven grandchildren. A nurse joked that his home might have been more crowded than our emergency room. We all shared a dry, sad laugh. What worried me most was that their shared living spaced meant he must have had significant contact with all of them in the past several days. I worried about his elderly mother and whether she’d test positive as well, or if he had passed it onto his infant child. His family kept calling and asking when they could come visit. It was hard explaining to them that the hospital, like hospitals nationwide, had switched to a no visitors policy to help contain the spread.
As the days passed and Eduardo’s condition didn’t improve, I found myself getting more and more infuriated with the layers that stood between us. I had a patient that I couldn’t communicate with using words, and thanks to the various masks, goggles, and face shields I wore, non-verbal communication was extremely limited. On top of it all, the week that Eduardo was admitted, the hospital experienced its first wave of healthcare worker contamination, so we were short staffed. Our translator, Natalie, tested positive. I had to use a resident, whose Spanish knowledge was limited to the two years of courses he took in undergrad, to explain to Eduardo’s family via FaceTime that he needed to be put on a ventilator. His lungs were ravaged by the virus and needed a break. We all needed a break.
My infuriation with my inability to communicate with Eduardo was nothing compared to the silence I experienced walking into his room for the next nine days. I sat with him and listened to the quite hum of the ventilator that was breathing for him. I video-chatted with his family so they could see him. They sang to him, spoke to him, showed him pictures of letters that his children had written wishing him well. Eduardo’s family kept him on the ventilator for some time before they realized that he wasn’t going to come back – he would never be the same Eduardo they had brought to the hospital all those days ago. The ventilator wasn’t going to change Eduardo’s outcome. Instead, the ventilator provided his family with the time they needed to grieve him and say goodbye. Once they realized they would never truly come to terms with losing him, they told us to unplug him.
“Eduardo wouldn’t have wanted to live this way – with machines breathing for him” they explained.
I pressed the “power off” button on the ventilator, ending his suffering and extending mine.
Jonathon B., Age 57, DOB: 02/15/1964, Days on Ventilator: 51
I didn’t think it could get worse, but you know what they say. Test the world and it will show you just how cruel it can be. My experience with Jonathon marked what I originally thought was the rock bottom of the pandemic. I remember during his intake process he was telling us about all the things he did right. He ran, he ate healthy (emphasizing that he was an organic only, cage-free eggs type of healthy), and never skipped an annual checkup. His wife wouldn’t allow it. But Covid didn’t care. He was struggling to breath as much as the next patient and was developing back and chest pain. With each patient that came, the time between their stay in the emergency room and their transfer to inpatient shortened. At this point we were picking up on patterns. Certain oxygen saturation levels meant an immediate need for supplemental oxygen. Jonathon was at that level. I asked him how long he had been feeling this sick, and he admitted to delaying treatment for fear of entering the hospital. I remember him joking that “I’d rather die at home than in some cold, dark hospital.” He looked at me hoping that I’d tell him he wouldn’t die, not here and not due to this. But I couldn’t. My sanity was hanging on by a thread and my ability to be forthcoming and honest was my only savior in all of this. I wouldn’t offer false hope. I needed my patients to fight with everything in them, but I wouldn’t make them believe this wasn’t about to be the battle of their life.
Jonathon seemed to understand. His wife called him daily and he promised to never miss a call. I distinctly remember passing his room in the hallway and hearing her jokingly bicker at him about “owing her a lifetime of apologies” for putting her through this. He’d laugh, a sound that resembled a dying animal more than a happy human, and tell her “I was just trying to take advantage of our ‘better or worse’ vows. Afterall, how am I supposed to keep ‘forever’ interesting?” Jonathon couldn’t keep his promise of forever, just like I couldn’t offer much in the form of hope. She called the next day, and he couldn’t answer. I am sure Jonathon would have responded, but we had to put him on a ventilator in the middle of the night shift, an emergency that didn’t allow us time to seek his wife’s permission. He had a tube about one inch thick in diameter lodged down his throat doing what his body couldn’t do on its own anymore: breathing. I answered her phone call and broke the news. Her face silently sobbing on the screen is forever ingrained in my memory. I didn’t know how to tell her that Jonathon was lucky. Can you imagine that? Lucky he was on a ventilator fighting for his life. But he was, because at least he had a ventilator. He took the last one available in the entire hospital. Our Chief Resident mentioned that we’d have to begin diverting patients to other hospitals, until our Chief Administrator shared that all hospitals were in similar situations. We had to make do with what we had.
I felt my chest constrict. We were already losing the battle against Covid, getting cases faster than we could sign discharge papers for the few that survived. Now we didn’t have enough tools in our tool belt to even make a dent in the influx of patients we were receiving. I walked quickly down the hall, searching for a storage closet to hide in. I walked into the room around the corner and leaned against the closed door – taking a deep breath. I opened my eyes to a room lined with body bags. It looked like we were running out of everything, not just ICU beds and ventilators. Our morgue was at capacity, just like every doctor in this building.
Zinasha W., Age 31, DOB: 03/11/1990
We thought we’d see a light at the end of the tunnel. In December of 2020, the Covid vaccine was made available to all healthcare workers. Most of us got vaccinated. While there was the obvious uncertainty about how our bodies would react to the vaccine, after everything we saw, most of us decided it was a chance worth taking. I was fortunate. My reaction to the vaccine was minimal, like the arm soreness one experiences with the flu vaccine, and nothing more. It gave me some semblance of peace to know that I was walking into work each day more protected than the last. Soon enough, the vaccine would be available to the most at-risk populations. From that point forward, more and more people would be protected and less likely to face severe hospitalizations from the virus. Or so we thought.
With the vaccine came anti-vaxxers. These were people who, for various reasons, elected to not receive the vaccine. Many of my colleagues spent time trying to convince people otherwise. They gave out pamphlets, went on TV shows and radio stations, and shared the promising data that had been published about the vaccine and its efficiency. I couldn’t do it. I couldn’t imagine how some of the same people who sang songs from their balconies in Europe were now refusing to get vaccinated. It was like coming up for a breath of fresh air after a long lap in the pool, only to be pushed back down under the water’s surface. I felt like I was constantly drowning while the lifeguard on duty just watched. So, while others chose to spend their time trying to get more and more people to get vaccinated, I simply hoped that me doing my part would be enough to keep myself and my loved ones safe.
I soon learned that for each patient that my colleagues convinced to get vaccinated, they were saving multiple lives – not just the one belonging to that individual patient. And I should have spent more time talking to the people around me, truly trying to understand the reasoning behind their hesitancy. That might have saved Zinasha. Zinasha came into the emergency room complaining of chest pain. Surprisingly, she didn’t have a cough or any other flu symptoms. I ran a Covid test because it had become standard practice, but it wasn’t a diagnosis I was expecting in my differential. I thought I had a good old-fashioned cardiac case. And, if we are being honest, I had never been so happy to treat a young woman for heart problems because heart problems were something I knew how to treat.
I should have known better, and so should have Zinasha. Her Covid test came back positive. She had developed heart problems secondary to a Covid infection, and her chest pain was caused by her heart struggling to pump blood to the rest of her body. When we inquired about her vaccination status, she explained hurriedly and desperately that she wasn’t an anti-vaxxer, she was just waiting for time to do more research on the Covid vaccine. She felt like the studies had been rushed and that the side effects were unknown. She worked full-time at her local bank on top of being a part-time “TikTok influencer” and just didn’t know when she’d be able to take time off for the vaccine. When she was explaining it all to us, I could see the desperation in her eyes, her regret. I didn’t realize how deep her fear ran until two days later. I was looking over her file, rechecking her statistics, hoping for improvements. She looked at me and told me she wasn’t marked as an organ donor on her license. My confusion must have been clear by my raised eyebrows.
“I didn’t mark it because I heard that if you are an organ donor doctors are less likely to save you in an emergency,” she clarified. “We are worth more to you all dead than alive. So, I didn’t have it marked on my license.”
I couldn’t muster a single word.
“I guess you must think I was asking for this. After all, I didn’t get the vaccine when it probably would have saved me this hospital bill,” she sadly wondered aloud.
I sat by her and explained that similarly to your organ donor status having no influence on the level of care you’d receive at a hospital, neither would her vaccination status.
After all, with all the patients I had lost recently, I couldn’t take one more. Vaccinated or not, it was a human life I had sworn to protect. But my oath didn’t matter much to the virus. Zinasha passed away seventy-two hours later, but not before pleading to her TikTok followers to get vaccinated. To not wait. To find the time to do the research and have the necessary conversations.
I wish I had taken the time to have those conversations with my own patients. Maybe it would have saved someone like Zinasha.
Elizabeth R., Age 29, DOB: 07/07/1992
The hospital administration decided we needed to get some separation from the pandemic, or as much separation that was possible for a healthcare worker. In order to better protect non-Covid emergency patients, the hospital had opened a separate wing for all those that tested negative in the ambulance. Walk-ins that tested negative at check-in were also re-routed here. This was the land of arm amputations, heart attacks, and debilitating migraines. It was like Disney for anyone who had been tied to the emergency room since March 2020. I was so rejoiced at the chance of treating something that wasn’t Covid that I pulled out my old medical school notebooks to do a quick review the night before.
I walked into the clinic feeling on top of the world. It probably wasn’t healthy for me to be so happy at the idea of treating sick patients at all – but the emphasis was on the Covid-negative status of those sick patients. These patients I could treat, and it wouldn’t be a game of chance. I could develop a plan of action that, statistically speaking, would probably solve the majority, if not all, of their problems. I was told to report to Bay One. There, I found Elizabeth, a 29-year-old who was recently engaged. She spent the better part of our work-up showing us her gleaming new ring, whose shine rivaled the brightness of my mood this morning.
Elizabeth was in for a swollen ankle, a byproduct of a lousy fall while rollerblading the afternoon before. An x-ray confirmed that the ankle wasn’t broken and that a simple wrapping and Ibuprofen regime would suffice. As she was signing her release forms, a nurse asked if she had received her Covid-19 vaccine, and if not, if she was interested in more information. I hadn’t even noticed that her medical history didn’t include it; I was so focused on the fact that she wasn’t Covid positive upon arrival. This wing felt like a bubble away from the outside world, one where we were all safe from Covid.
Her reasoning for not getting the vaccine boiled down to fertility concerns. She had heard from a co-worker, who heard from a family friend whose son was a doctor, that the vaccine could lower a woman’s chances of conceiving a healthy baby. As someone who was recently engaged, she said that all she wanted to do was protect the chances of her and her fiancé having children in the future. All good efforts to convince her otherwise were futile as she had already decided that until she delivered a healthy baby, she wasn’t going to risk it.
Even today, I still think about Elizabeth. I wonder if she ever got Covid, the vaccine, or the healthy baby she so desperately wanted.
Ashley C., Age 21, DOB: 06/24/2000 and Michael C., Age 58, DOB: 11/25/1962
I was called to a family friend’s house around midnight on a random Friday. Long-time neighbors of my parents, Michael and Suzie were worried about their college-aged daughter. She had tested positive but remained at home in the guest house with low-severity flu-like symptoms. She never developed a fever but was apparently having some trouble breathing – especially when having intense coughing fits. I told them I could do a quick house call and check her oxygen levels. At this point, we had determined the threshold oxygen level that necessitated a hospital visit.
Michael and Suzie immediately said yes. I put on my two usual masks, a face shield, and a gown and made my way inside their house. After spending some time with Ashley, I determined that she wasn’t at the point where an emergency room would do anything more for her than what she was getting at home. I prescribed a steroid treatment that she would inhale with a nebulizer, which would help with her coughing fits. I spoke at length with Michael and Suzie about needing to quarantine away from people for the next two weeks, and to contact me if Ashley got worse.
I never got any updates about Ashley. In fact, the next time I heard about Michael and Suzie was when my mother called me to tell me that Michael had passed. He had gotten sick a couple days after I left their house, and his decline had been rapid. I fell asleep that night wondering if Ashley would ever be able to forgive herself for getting her dad sick.
Quintana P., Age 66, DOB: 09/16/1955
Quintana wasn’t a patient of mine, at least not directly. I was brought onto her case to give my medical opinion concerning her chances of post-transplant rejection or infection. At sixty years of age, Quintana’s left kidney had started to fail. After attempting dialysis for an extended period, her doctors decided that removal was best. Her right kidney would have to do a lot more work, but it was still functioning at around 90% and that was plenty. Sadly, after about six years, her right kidney started to fail as well. The first thing most families do when a family member’s organ begins to fail is get blood work drawn to determine if they could be a possible match. If a family member does indeed match, the patient can avoid the long and often unsuccessful wait for an organ with UNOS.
Quintana was lucky – her son-in-law was a match. He could donate one of his kidneys to her and was willing to do so. When I was first called onto the case, I was relieved. I figured they needed someone to do a quick workup and then Quintana would be on her way to a fully functioning organ. But that wasn’t the case. Quintana was not vaccinated against Covid. This posed a problem for several reasons, the first being that post-transplant, Quintana would essentially have no immune system. After a transplant, a patient is put on immuno-suppressants for some time so that the body doesn’t fight the new organ and has a higher chance of accepting it.
However, the biggest risk of immuno-suppressants is the higher likelihood of catching anything and everything else that is around – including Covid. Quintana’s doctors were worried that the risk of her contracting the virus was going to be too high and that the organ would be wasted. Even after having a conversation with her about, it, Quintana stood behind her decision to not get the vaccine. Her family emphasized that it wasn’t our business, and that it had no relationship to her need for a kidney. They insisted that since the kidney was coming from one of them, it wasn’t up to us to decide if it would be wasted or not. It was a risk that the family was willing to take.
The issue was that it wasn’t a risk her transplant team was willing to take. I was invited to speak with her team to give my professional opinion on whether the organ transplant would be successful, or if Quintana’s refusal to get the vaccine was indicative of her post-operation chances of success. I agreed with her doctors. Quintana didn’t receive her kidney transplant at our hospital.
Later that week, I found a note slipped under my office door that read “is it really playing God if you just spend your days signing death certificates?”
Josie L., Age 74, DOB: 01/26/1947
Josie was a longtime favorite patient of mine. She was the type that reminded people of their own grandmother, always fussing and caring about those around her. Never prioritizing herself. Not even cancer could stop this woman from checking up on all the nurses and their children, by name. Her husband often joked that whenever she had to come in, she wouldn’t let him take her away without letting her pack treats for everyone on shift in the ER. I wasn’t surprised. But God and modern medicine were looking out for Josie. In early 2018, she finally reached remission after a ten-year battle with cancer. Her visits slowed down, and her emergency room escapades all but ceased. While we all missed her and her baking dearly, we were so happy to know she was doing better things with her time than spending it with us at the hospital.
That was until mid-2019, when she came back to the hospital for a bi-annual oncology visit. She would often stop by after seeing her specialist and share the good news with us in the Emergency Department. That day she didn’t smile when she stopped by, and her husband’s face was streaked with tears. Without saying a word, we all knew she had fallen out of remission. By March 2020, when the pandemic began, Josie was deep in her chemotherapy treatments. The chemo had completely decimated her immune system, leaving her with no protective shield against Covid-19. Instead of coming to the hospital for her weekly treatments, the oncology department was referring patients to outpatient facilities that would have lesser exposure risk than the hospital. I stopped by whenever I was off shift, keeping her company from the other side of a window panel. I wouldn’t risk going in and seeing her in person, even with the hospital’s daily testing of the doctors. I wouldn’t be the reason she didn’t win this next battle as well.
By the end of 2020, she was wrapping up her treatments and the doctors were hopeful the cancer had been eradicated once again. Even my favorite resident, Alana, a renowned atheist, was praying to the God she didn’t believe in that Josie would go back into remission. Josie, on the other hand, was praying that her immune system would bounce back. She had spent the better part of the last year avoiding all contact with people that were not her husband or doctors. She couldn’t see her children or grandchildren as the risk of her catching something, even a common cold, could be fatal.
When spring of 2021 rolled around, Josie’s husband told us that things were looking up. Josie felt comfortable enough to go back to her teaching job at the local private college. I was surprised. College students were notoriously unsafe during the pandemic and were the source of widespread contagion. Josie’s husband told me about the school’s Covid vaccine mandate. All employees and students were to get vaccinated by the start of the fall 2021 semester. The school was requiring the vaccine and only allowing exceptions for religious and medical reasons. So, while Josie didn’t have to adhere to the requirement due to her chemotherapy regime and her doctor’s advice to wait a little longer before getting the vaccine, she felt safe knowing that most of her colleagues and students would be vaccinated. While some students and staff were fighting the mandate, I had never been so relieved to see someone’s hand forced for the greater good.
Dr. Markin shut the file. I knew we couldn’t possibly have finished; I knew I saw a hundred times more patients than the nine she had reviewed with me this morning. I looked around waiting for her to make another comment, a diagnosis on my mental state. It was then that I finally noticed the shift in lighting around me. Her several distinguished degrees were no longer gleaming in the morning sun, but by the light of the room’s artificial light. A look at the window confirmed that it was pitch black outside. I had been here for hours. She looked up.
“How do you feel about them today? Do you think about them often?”
I didn’t know how to answer. I didn’t know what I should tell her, what she needed to hear to give me the clearance I wanted. On one hand, I thought about them every day, just like a lot of my patients whose stories had touched me. On the other hand, I had never wanted to forget a period of my life more than I did this one. I was a different person today because of the experiences I had with all nine of them, and I didn’t know if that person was better or worse off than before. I looked up and answered honestly.
“I don’t know how I feel. I don’t know a lot.” She nodded and scribbled something down. I didn’t even try to strain my neck and read what it said. I figured I probably didn’t really want to know. She got up and walked towards the door, which I took as my cue that our session was over.
“Goodnight, Doctor,” she said. “Give this form to your supervisor in the emergency room next shift, you’ve been cleared to continue working.”
Did I hear that correctly? Cleared?
“You don’t think I am depressed or anxious or troubled?” I asked with a sardonic half-laugh.
“Probably all of the above, but I’d be more worried if you weren’t.” I guess that was the cost of playing God and surviving it.
Authors Note: The nine stories shared above are all representative of real people, and patients that have suffered with and/or passed away from Covid-19. While the names have been changed for privacy purposes, their causes of death being due to Covid and their ages remain accurate. Some of these stories were shared on online platforms, while others were personally known to acquaintances of the author. Their experiences and passage through the United States’ healthcare system is fictionalized and not reflective of actual events.
Photo by Wesley Tingey on Unsplash