The Country Is Reopening. My Patients Are Still Suffering.

Nursing home residents. Cabdrivers. Immigrants. Covid-19 has become a disease of the vulnerable.

I stood at my patient’s bedside as she picked at the sheets, eyes roving, seemingly unaware of my presence. When I placed my stethoscope on her chest, she started to moan. It was a sad sound, high-pitched and pleading. I set down the stethoscope and touched her hair with a gloved hand. “It’s OK,” I said through my N95, hoping that she could understand the meaning if not the words. “You’re safe. We’re taking care of you.”

My colleague who admitted her overnight had summarized her case to me with one word — neglect. The patient was in her 70s with a diagnosis of dementia. She was here in the hospital with me only because her daughter had told the nursing home staff to call 911 when she saw her mother on a video chat and realized that something was wrong. Not only was her mother Covid-19 positive, she was near death. Her sodium was dangerously high, at a level that can only be reached if someone is deprived of access to fluids. Her kidneys were shutting down, also due to dehydration, and her blood had stopped clotting, at least in part because she didn’t have sufficient nutrition.

I pulled the door shut, thinking of the other nursing home residents I had seen grow sick and die from this virus. Loved ones are still prohibited from visiting these facilities, which means the elderly are more isolated and defenseless than ever. I remembered the images from a local veteran’s nursing facility where the virus spread like brush fire. More than 70 veterans died. I had to do something.

I called my patient’s nursing home. The woman at the front desk was clearly overwhelmed, dealing with lab results and family phone calls and “the deaths,” she told me, but she passed along my name to a nurse manager who called me back a few minutes later. My patient wasn’t the only Covid-positive one at the facility, she said. There had been an outbreak and nearly all of the residents had turned positive. Many on the staff had, too. As a result, the staff members had all been quarantined, leaving a few administrators and some temporary nurses to care for the residents.

I wanted to take my fury out on her, but she sounded so young and scared that I stopped myself. It was not her fault. When she asked me if my patient was going to be all right, I could swear I heard her voice break. I told her that I was not sure.

She promised me that the staffing had improved and the other residents were safe. But I felt no better. In desperation, I called 911, hoping to get emergency assistance to the residents I believed might still be suffering in the nursing home. An officer with a kind voice told me that his own grandfather had died of Covid-19 in a nursing home a week before, so he understood the gravity of the situation, but there was not really anything he could do, either.

Part of me imagined myself driving out to the nursing home like a good guy bandit in full P.P.E., breaking in and letting everyone free, but that is a daydream of a doctor’s own critical care delirium. And maybe the nurse manager was right. Maybe everyone else was safe. But that’s hard to believe.

Walking through the coronavirus intensive care unit each day, I wonder how each of my patients might have been exposed. In the early days of the pandemic, the answers revealed a certain degree of privilege. Some patients had recently returned from international travel or ski trips, others may have had contact with someone who had attended the ill-fated local Biogen leadership meeting or a similar conference. But those who can afford to quarantine have now spent the past months safely ensconced in their homes and the answers have changed.

Covid-19 has become a disease of the vulnerable. In addition to the nursing home residents who make up more than half the deaths in our state, I recently cared for a cabdriver, an immigrant father who worked at a discount liquor store, a food deliveryman and an assistant at a skilled nursing facility. All of them kept working even as the rest of the city sheltered in place. What choice did they have?

We call our patients’ loved ones each day, often with the aid of an interpreter, to give updates and to set expectations for what might be ahead. The conversations increasingly leave me feeling impotent and frustrated. I recently talked to a teenage son who begged me to do everything I could so that his father, who was intubated and on maximal ventilator settings, would make it back home. All I could tell him was that we were doing the best we could, but there was a real chance that his dad would not recover. “Keep trying. I’ll be waiting for good news from you,” the boy told me.

I hope we will be able to give him that news. But his father’s lungs are no better and I cannot change that. All we can do is manage his ventilator and take meticulous care of his other organs. And wait. I am struck by a similar feeling of powerlessness during my morning physical exams, as I listen to the heart and lungs of a relatively young man who suffered a catastrophic Covid-related stroke. He was working as a cabdriver and living in a crowded apartment when he got sick. The notes tell me that he liked to play soccer and that his children are in Cape Verde waiting for him. He has a kind face, but his eyes are now vacant. It is clear that he is not going to be OK.

Today, with aggressive hydration and antibiotics, my patient who arrived by ambulance from the nursing home is getting better. That is a kind of victory, but it’s hard to see it as such amid all the loss and the systemic inequities this virus has made visible. I can hope that those in power learn from the hundred thousand who have died and implement real change to protect the vulnerable among us, but like my phone call to the police, it sometimes feels as if we are screaming into a void.

So for now, as our country begins to reopen, we control what we can. We tweak ventilator settings and manage renal function and electrolytes. We call family members and tell them that we are doing everything possible for the person they love, but that it might not be enough. “It’s just not fair,” another patient’s sister cried. Her brother had contracted Covid-19 in his group home and was not going to make it out of the hospital. “I know,” I said. “None of this is fair.”

Daniela J. Lamas is a critical care doctor at Brigham and Women’s Hospital in Boston.

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