A Pandemic in Residence

Essays from a Detroit Hospital

Selina Mahmood

• Publisher: Belt Publishing
• Year: 2021
• ISBN:
  9781953368157
• Topic: Literatura
• Subtopic: Ensayos literarios

A debut essay collection of remarkable breadth and erudition by a young Pakistani-American doctor and writer.

During the early months of the COVID-19 pandemic, Selina Mahmood—in the middle of the first year of her neurology residency—found scraps of time between grueling shifts to write. The resulting A Pandemic in Residence: Essays from a Detroit Hospital is her personal and meticulous document of an unprecedented year in medicine, and the debut of a young and uncommon talent. In the tradition of writers like Oliver Sacks and Paul Kalanithi, Dr. Mahmood takes the science of neurology and spins it into poetry, exploring theories of the mind, Pakistani-American identity, immigration, family, the history of medicine, and, of course, the challenges of becoming a physician in the midst of a global health crisis. Skipping nimbly across continents and drawing inspiration from an array of sources ranging from Thomas Edison to Yuval Harari to Beyoncé, she has with this collection crafted an elegant, incisive, utterly original investigation.

A Pandemic in Residence is a must-read for anyone seeking insight into our universal search for meaning.

MARCH

TESTING

Sunday

Sometimes it takes the collapse of a system to see things clearly.¹

I’m three quarters into my first year as a neurology resident. The World Health Organization declared a coronavirus pandemic on March 11, 2020, and Donald Trump announced a national emergency in the White House Rose Garden on the 13th. Just for cultural pin-dropping, the top three songs on this week’s Billboard Hot 100: “The Box” by Roddy Ricch, “Life is Good” with Future and Drake, and “Circles” by Post Malone. The Weeknd’s new album, After Hours, is dropping in a week.

The bars are emptying as we try to make sense of it all. A neurology department-wide Skype meeting is held on Sunday, March 15 (Dua Lipa’s “Don’t Start Now” has replaced Post Malone’s song). Medical students will no longer be rotating in the hospital. Everything that can be done remotely will be offsite. I pace the ground floor at home, microphone muted, listening to the neurology chair’s reassuring voice punctuated by sixty chaotic others.

In med school we’d studied the last influenza pandemic, known as the Spanish Flu, which at the end of World War I killed more people than the war itself. We learned the properties of Orthomyxoviridae that allow it to quickly mutate, and that it was only a matter of time before another flu pandemic came around. COVID-19 (a shorthand for “coronavirus disease 2019”) is from a different family, Coronaviridae, of which SARS and MERS are also a part. The argument in the news media about this not being “just the flu” has been baffling—“just the flu” has its own weighty mortality in elderly and immunocompromised populations.

There are two modalities to medicine: immortal and mortal. The immortal part is the education and research that goes into it and naturally draws the human ego and senses: + ssRNA, RNA dependent RNA polymerase, genetic recombination. The mortal part is the craft, which involves patient care and requires the creation of purpose out of purposelessness: how not to have a god complex and still … serve? What’s the unclichéd verb for what we’re supposed to be doing?

Back to the voices—

“But how are we going to remotely evaluate speech for so many stroke patients?”

“What are we doing to get more PPE?”

The thin, orange-sliced, towering windows that flank the main door to our house open onto a still-wintered suburban Detroit, the darkening sky darkening ugly patches of snow with it. Is it real or is it not? How much of this is spectacle and how much of it is real and how real? As much as a mind or more, maybe greater.

Monday

My teaching hospital has started taking drastic measures before many others in the nation, and is doing a remarkable job. However, it is doing so outside of what should have been an earlier, federal government-initiated preparedness. Rather than this being a streamlined nationwide action, it’s been entirely too fragmented. Without having had a simulated health response, we’ve been left to on-the-moment trial-and-error planning. The information pouring in is saccadic (vertically so).

The screening process began misshapen today. Lines wound all the way out to the parking structure under a dark morning sky, and mask-less hospital personnel waited an hour just to get into the building. Apparently, this is being done in other hospitals in the county. The unfortunate part is that non-hospital personnel have been joining these lines thinking they’re in line for COVID-19 testing only to find just an oral thermometer and a few screening questions after waiting for hours.

Tuesday

Shaking hair and shedding layers of melting snow, we leave our coats to mold on the coat rack in our stroke unit workroom. Everyone is in scrubs now—it makes sense to wear scrubs. I log into our electronic medical system to chart review my patients in our rapidly dwindling patient list.

All admitted patients suspected to have been infected were initially having their labs sent out. The country did not have adequate equipment for testing. The pandemic is revealing the problems that arise from virtually zero home production of essential supplies. We have testing available now, the first hospital in Michigan to start in-house testing, but measures are still progressing slowly. Trump’s press conference today was a joke (as if anything else was to be expected, with the CDC budget cuts and the disbanding of the pandemic response team in 2018).

We’re no longer admitting patients who shouldn’t have been admitted in the first place. Admissions that end up doing more harm than good in the long term—a defensive form of medicine that I’ve often questioned. Instead, we’re triaging people who don’t need to be in the hospital, where they’re at a higher risk of developing an actual infection or problem.

We’re dealing with acute illnesses and finding the necessary time to attend to their conditions without feeling like humans that would have been better served as robots. People are presenting to the ED for issues that should be addressed in an outpatient setting but can’t afford to due to lack of insurance or social support. HIPPA violations are lifting enough for us to start an effective means of tele-medicine, something discussed for years but only now coming to fruition. I don’t want to just be another meme (in what is quickly becoming a very robust meme game), but this feels like what being a physician should be like: the chance to feel meaningful.

Wednesday

Viktor Frankl is best known for having studied and written about the importance of meaning. An Austrian neuropsychiatrist and Holocaust survivor, he developed logotherapy: the therapy developed from the concept that finding meaning in life is a human’s primary purpose. His memoir, Man’s Search for Meaning, recounts his time in the concentration camp, and details how even in the most dismal human conditions he and the other prisoners were able to find spiritual integrity—that in fact calling forth spiritual integrity in acute duress provides the opportunity to achieve greatness.

Frankl flips the idea that meaning is found in human agency in creating a future to say that whatever future unravels has the potential to have meaning created out of it. Perhaps not surprisingly, for Frankl meaning is inexorably linked to suffering:

“Long ago we had passed the stage of asking what was the meaning of life, a naïve query which understands life as the attaining of some aim through the active creation of something of value. For us, the meaning of life embraced wider cycles of life and death, of suffering and of dying.”

I’m trying to avoid contact with my family and isolating myself in my room when I’m home. Despite the movie Contagion’s uncomfortably parallel narrative, the announcement of the pandemic has been surprising for the U.S., where order and routine are akin to godliness. The standard, strictly ordered medical system has been replaced with confusion. Despite daily email updates, we are still uncertain of what is being done and needs to be done. Rules about what counts as safe protection and possible treatment modalities are changing on the hour.

Thursday

We had a patient, Mr. Tracy, transferred to us from vacation in the Caribbean in the middle of the week. He’d been on a cruise, developed a hemorrhagic stroke, a brain bleed, and was flown back to us for treatment. I wasn’t able to see him for over an hour when he initially arrived via air ambulance, because I couldn’t figure out where to get protective gear.

While pictures of people in masks and gloves in supermarkets have been circulating on social and news media, we still have a crippling lack of masks. There are usually masks available outside patient rooms, but visitors had been taking them in the days leading up to the actual announcement of a national emergency and we’ve been left with an even shorter supply than anticipated. However, one of my seniors saw this wonderful display of human comradeship and had the presence of mind to stock a supply for us in the workroom ceiling. It was here that I was finally able to find a mask before going into Mr. Tracy’s room. We’re told to keep PPE, including surgical masks and N95’s, in labeled brown paper bags to reuse for a week.

It’s cumbersome maneuvering in protective gear. I spend an inordinate amount of time trying to maintain OR-like sterility without any of the basic facilities to do so. The N95 has a musty smell that takes a second to adjust to. Once inside, I was only able to make out some of Mr. Tracy’s frustrated history through my yellow plastic gear. His Broca’s area, the part of the brain responsible for speech, had been affected by the stroke. The result of this was that he could understand what I was saying, and knew what he wanted to say, but the words just wouldn’t come out right. Broca’s aphasia is an understandably frustrating condition, but Mr. Tracy’s situation has been made even worse by the timing of his stroke. Visitors have been banned (not to save masks, there really aren’t any to save, but to facilitate social distance) and that means Mr. Tracy has been physically isolated from his spouse and family. He can only reach out to them through fragmented air waves. I got his wife on the speaker to help calm him down: “It’s okay honey, I know, I know.”

Our inpatient team decided to split itself, with half of us rounding from home while the other half comes in to work in person. Mr. Tracy’s brain imaging was concerning for an aneurysmal source of the bleed, so I put in the neurosurgery consult from my laptop in bed, and called the resident on call. Cross-legged on my white comforter, I then called his wife.

Friday

There has been a steady uptick in research, most of it originating from the Wuhan province in China, where the pandemic began. A small, non-randomized clinical trial by Guatret et al. (2020) studying hydroxychloroquine (an antimalarial) and hydroxychloroquine with azithromycin as treatment modalities has been published. I’ve heard through word of mouth that some physicians in New York have started using hydroxychloroquine prophylactically. There are also studies and theories floating around that fresh air and sunlight helped mitigate the influenza and SARS outbreaks in the past and that a change in season may ease this pandemic’s acceleration, though there’s little legitimate research to back this claim either. We’re being encouraged to wear surgical masks at all times, something that had been debated in the weeks leading up to this.

Dr. Peter Safar (1923–2003), was an anesthesiologist who is credited with having developed CPR in the 1950s. CPR is a part of “code blue” activations in hospitals. Safar is also accredited with the ABCs of resuscitation, the establishment of intensive care units (ICUs), and with setting up the first emergency medical system. Anesthesiologists used to run ICUs; they’ve been replaced in that capacity by pulmonology critical care doctors.

Internal medicine residents are being pulled from various rotations into the emergency department to replace their exposed associates. Our ICUs are usually at full capacity on a normal day, so our administration is preparing for the worst and creating more ICUs. Entire floors are becoming dedicated to COVID patients. It is Friday now, and overnight there were approximately ten codes spread across the various COVID floors. “This is a code blue alert, P as in papa, 566.” The hospital’s first COVID-19 death has occurred.

Saturday

A few hospitals in our county decided not to heed the WHO notices. Even though countries like South Korea (which learned its lesson after MERS) are doing a great job with extenuating the virus by testing people, the CEO of one of our local hospitals, let’s call it St. Bartholomew’s, claimed that “testing won’t help in treating patients.” St. Bartholomew’s admin also didn’t heed the Surgeon General’s advice to cancel all elective surgeries. So now, St. Bartholomew’s decisions have led it to the brink, ready to overflow with infected patients. This pandemic has shown what complete lack of common sense can look like—the initial rush for toilet paper in our country becoming a world mockery.

There’s a meme circulating (as a side note, it’s bizarre how that word, “meme,” transformed from Dawkins’s Selfish Gene into its current formulation) that I’ve found striking. Say we come up with a vaccine. Fifty or seventy or a hundred years down the line, this pandemic will no longer be fresh in living memory. We’ll relive the same story of people refusing vaccination. That’s the struggle with prevention altogether. It’s hard to imagine something you’ve never seen—it requires a modicum of belief in history and science.

But if we go the way of logic, it can be taken back a step further, even before vaccination. A lot of these viruses originate in animals, and it is possible to break the transmission from animals to humans. We can start prevention by monitoring diseases in animals and having an established dialogue between the health system and veterinarians serving high-risk areas where the disease is most likely to make that interspecies transmission. However, this requires a lot of effort with often little to show for it: the absence of a pandemic is a hell of a lot less discernible than a pandemic. Unfortunately, especially in this case, memory necessitates repetition.

Sunday

Medicine teaches you how to approach emergencies with urgency but without panic. I started my residency on the internal medicine floors, where mornings would start with my coffee masked by the smell of human excrement from open doors as nurses made their morning cleanups of their patients. I’d developed a soft spot for one of the patients who had come into the hospital two weeks previously with complications from recurrent prostate cancer. I’d gone to evaluate him when he’d been initially transferred to us from the ICU. He was angry at being moved to another floor for what felt like the tenth time. I knelt down next to him and his anger transformed into despair as he started sobbing. He was an engineer and had been trying to approach his sickness with what he called a “mechanical outlook,” but was struggling.

Cancer puts you at a risk for blood clots, so you will often see cancer patients on anticoagulants, or “blood thinners.” I re-started him on Lovenox, one of the blood thinners, before I realized that his GFR, a measure of kidney function, was low and that he had required a lower dose of medication. I panicked and called the on-call senior, who came into the workroom from one of the other four floors he was responsible for. He helped me calm down and we’d called the pharmacy to make sure they were aware. The pharmacist was eating something and casually responded that she’d already adjusted the dose, and had been about to call me about it anyway. The modern-day tertiary care medical system has a lot of safeguards involved, and the holes must align in our ever-cited Swiss cheese model for a legitimate error to occur.

No wonder already-struggling rural health care centers have been closing down at such a rapid speed. They cannot maintain the medical structure that has become the norm. The few rural centers that have survived are understaffed with doc...