Coronavirus and its symbiotic relationship with racism, decreased immunity, old age, mental illness, poverty, and a failing government have made 2020 not only feel like, but actually revert into an actual dystopian nightmare, with increasing inequity, inequality, and injustice propelling our nation into an overdue war on racism. From April to June, my role in the hospital and in the community has taken on many shapes and forms. This piece focuses, through my reflections working on the frontlines — without a mask — on the relationship between the emergency room and medical floors, virtual palliative care, equity and equality, and well-practiced healthcare.
In April, I was one of the first ten residents in my program redeployed to treat coronavirus patients. One of my primary roles was in palliative care. With the increased rate of patients rapidly being transferred to the ICU, discussions around code status and sometimes comfort care needed to be completed compassionately and quickly. As a child psychiatrist by trade, I am far savvier with long-winded exchanges and nonverbal communication in person — with very alive children. Instead, I found myself trapped in a profoundly unhuman situation: swallowed by my couch, telling families I had never met‚ through an iPhone speaker, about their dying loved one — who I had also never met.
I knew I was safe from the virus, from sweating underneath a bucketload of PPE, from the swarm of back to back Code Blues, and a lonesome commute on an empty subway at the crack of dawn. But within minutes of my virtual introduction — “Hi, I’m Dr. Chhabra,” the words “ventilator,” or “if it’s the end of life,” would need to make their way out of my mouth, outloud. With my ear glued to the phone, I’d hear the tears of a wife comforting her children, the fierce longing of a son with no smart phone to FaceTime his Mother, and the powerlessness of a patient, in their room, with only the company of coronavirus
for the night.
If I’m honest, there were times I fantasized that I could be in the hospital, so I could, even for a moment, put a face to each 8-digit MRN. I had taken for granted the beauty in observing someone’s way of being, of feeling physical and emotional presence in space, and the power of touch. My quiet, brick-inlaid, tiny apartment did not mesh with chaos, calamity, and coronavirus. I remember thinking to myself once, if only I was an ER doctor, I could be there, and all this wouldn’t feel so real — I could do more.
But inside what felt like a living hellish underworld came immense reflection, and with that, lessons to be learned. Although I primarily worked with ICU and medicine patients, these reflections remain pertinent to ERs.
First, is there a space for psychiatrists to be utilized in ERs beyond the extra needs coronavirus demanded? During this time, we have helped families, patients, and medical teams process grief, uncertainty, loneliness and powerlessness, while we are also processing this ourselves. We have facilitated effective communication, which can be, whether we like it or not, as life-saving as a medication. These processes inevitably exist in the emergency space even if a worldwide pandemic is not spreading. Psychiatric principles are important to various aspects of medical care and experiences, as grief, uncertainty, and powerlessness are not exclusive to this virus. Whether we like it or not, feelings, dialogue, and heaviness are pervasive during emergencies. Emergencies may be a daily experience for us, but for the patient, it may be their first. Whereas I feel at ease in the hospital, a patient may feel vulnerable and scared during an intimate or influential moment in their life. While coronavirus may have forced psychiatry to take on other roles, I wonder if skills used in psychiatry should be available to bring compassion to all patients who come through our doors — including the ER — and not be reserved solely for “consults” on mental illness.
Second, how can an emergency room visit be used beyond the medical emergency itself? Can it be preventative? Can families make important life choices during these interfaces? ER visits are often seen by providers and social workers as an opportunity — finding a shelter bed, STI-testing, connection with primary care or insurance. Why not education around end of life care, even if it is not the end of life? This is an opportunity for training and also to recognize the importance of palliative care principles and standards in a hospital setting. Advanced care directives are often — especially in healthy individuals who were unaware 3 months ago that they may contract a deadly virus — not completed. ER visits and primary care appointments — both frequent meeting points for patients — can be that opportunity to educate families on having these discussions. When we think of ERs we think urgent and life-saving, and while this is true, ERs can also be a chance for prevention, connection, and education.
Third, effective healthcare involves the marrying of a bigger picture with meticulous attention to detail, all with the game of collaboration. On my best redeployed days, I felt like an iPad with arms and legs; videoed into every room — an essential part of the team. The best teams narrated what they were doing, articulated clearly, and communicated with me more frequently given that I was not physically present. My presence prevented me from missing important parts of patients’ situations or plans, forged a connection with the patient beginning each morning, and helped me feel the togetherness often felt while walking side by side with a colleague down the unit. In ERs, life-changing decisions are made swiftly and interactions can be quick or prolonged, and often intense. How can ERs reflect on the small gestures that can go a long way, and inevitably influence
the bigger picture?
Fourth, redeployment taught me about humanity, at the end of the day, taking precedent above all. Not having a mask on is a big deal. I realized this one stir-crazy morning when a patient told me I was the only member of the team she recognized. While it didn’t feel real for me, an unmasked face brought some semblance of normalcy to worlds turned upside down. In fact, screens cannot overcome tears, smiles, grimaces, and eye contact like goggles, an N-95 mask, and a gown can. And something about being far away, I felt, allowed for patients to lean into their vulnerability — sometimes telling me more than in a room full of doctors. Vulnerability is vital — especially when someone’s only interaction with the healthcare system may be the ER. During these moments, patients may not be thinking about their lab result but forever remember the way the result was given to them by the provider. How can we bring even more humanity into ER spaces, while not letting go
of practicing evidence-based medicine?
And fifth, virtual medicine meant I was on the news a lot, finding solace in the ritual and trajectory of my day with that of the news. I first read about the science and statistics behind coronavirus statistics, then (albeit published too late) about the racial disparities due to structural racism in coronavirus infection and death rates. Why was it that my hospital had a several-tier palliative care service that was padded by psychiatrists, when one in the Bronx had no palliative care service at all? Why weren’t doctors evenly distributed in our city? Why were some residents forced to be redeployed, sometimes without PPE, and others feeling guilty and helpless at home, wishing for redeployment? And why are innocent Black folks being killed by cops on top of already being murdered by coronavirus and structural racism?
These are the questions with no easy answers. These last few months left me questioning justice — specifically doing justice to what we are trying to do. Doing justice to an unexpected conversation about a ventilator, doing justice to an inseparable bond when daughter can’t see her dying mother, doing justice to wearing an N-95 mask, and doing justice to a job not meant to be practiced at home. And beyond this — doing justice to brown, Black, and other marginalized people, specifically those who have been forced to bear the consequences, even and especially in our hospitals, of colonialism and longstanding oppression. Despite the passage of time and rapid modernization, we are nowhere near doing justice to equity and equality in 2020. The last 90 days have been a stark reminder that the world is going to throw at you what it wants, and also that what seems impossible can also be made possible, when a pandemic hits. If emergency medicine and healthcare policies can drastically shift as a result of a deeply contagious virus, they can also shift as a result of a different and equally contagious pandemic — racism.
Divya K. Chhabra - MD, Child Psychiatry Fellow in NYC; SAMHSA Minority Fellowship Chair
I had taken for granted the beauty in observing someone’s way of being, of feeling physical and emotional presence in space, and the power
My quiet, brick-inlaid, tiny apartment did not mesh with chaos, calamity, and coronavirus...But inside what felt like a living hellish underworld came immense reflection, and with that, lessons to be learned.