Read the introduction to this piece by James L. Knoll IV, MD: A Dose of Much-Needed Medicine.
OR WAIT null SECS
His symptoms worsened throughout most of his hospitalization, leaving him to ponder a grim reality: “This is it. This is how your story ends.”
I really hope I don’t get coronavirus.
Read the introduction to this piece by James L. Knoll IV, MD: A Dose of Much-Needed Medicine.
These thoughts would later haunt me. On Friday, March 13, 2020, while working at a community hospital in the South Bronx, I began to feel vague, nonspecific symptoms of general malaise, myalgia, and fatigue. When I returned home that evening, I was scared and in denial.
Before the United States was overwhelmed with coronavirus disease- 2019 (COVID-19) cases, many of us watched reports on television revealing the plight that people faced in other countries, especiallyItaly and Spain. It was agonizing to see the frightened facial expressions of health care workers fully clad in personal protective equipment (PPE), working around the clock and under extraordinarily difficult conditions. During the first few months of 2020, there were no clear rules or regulations about face masks or social distancing in the United States as we enjoyed our lives in denial, thinking it could not happen here. My colleagues and I continued with our usual clinical duties. This ignorant bliss was short-lived as the United States soon emerged with the highest number of cases and fatalities in the world, and New York City, where I work and live, became the pandemic epicenter. At that time, it never entered my mind that my life as I knew it would dramatically change.
As COVID-19 statistics began to worsen and news reports grew grimmer, I recall worrying about my safety. When my symptoms first surfaced, I did not even want to consider the possibility that I might have contracted COVID-19. I was frightened by the idea that I might need to be hospitalized—or worse yet, be placed on a ventilator. I began taking ibuprofen and regularly taking my temperature. I held out hope that if I did have coronavirus, I would only experience mild symptoms requiring a simple 2-week home quarantine.
My hopes were soon extinguished. Over the next few days, my health quickly deteriorated. I had a complete loss of appetite, nausea, shortness of breath, dry cough, high spiking fevers, severe muscle pain and stiffness, worsened fatigue, dizziness, and episodes of profuse sweating. My mother (a retired women’s health nurse practitioner) rationally insisted that I seek medical care due to my deteriorating condition. As a physician, I logically understood that my symptoms were getting worse and I needed medical attention. However, I also could not help considering what I had seen on the news. I had a strong emotional response to the stories and images and found myself scared at the prospect of going to a hospital only to never leave alive. Thoughts of dying alone crept into my mind. Next, I began to worry about my parents being heartbroken over my death, to the extent that it might result in their own mental and physical deterioration.
I was genuinely frightened that I would never see my friends again. I was scared that I would not have the chance to get married or have children. I had fleeting visions of some memorial built with the names of people who died from this virus and visualized my name carved onto it and eventually being forgotten. I was scared to leave behind Azul, my French bulldog, who remained at my side before and after my hospitalization. As a junior attending physician, I felt I still had so much to give and do for my profession and patients. All these racing thoughts, and more, filled me with fear.
Facing my reality
In time, my mother’s sound advice and my rapidly advancing respiratory distress forced me to set aside these fears in favor of pure survival. I had reached the point of no longer being able to manage from home. On March 17, 2020, I went to a local urgent care center to get tested, yet I still maintained an irrational hope I could be treated as an outpatient. I petted mydog, very worried that I might not see him again. I covered my face with a bandana and took a taxi to the urgent care center; although it was onlya few blocks away, I was too weak to walk. I arrived at the urgent care center disoriented and light-headed. The treating physician assistant said, “Dr Tirado, you are very hypoxic and your oxygen saturation is 87. I need to give you oxygen and put an IV [intravenous line] in you. We have to send you to the emergency department (ED) and you will be tested for coronavirus. You are going to be OK.” In that instant, all my hopes and wishful thinking for outpatient treatment were utterly extinguished. I felt dissociative and not entirely conscious. I was able to utter “OK,” and I knew my life was now in the hands of others.
I was transported by ambulance to a nearby ED, where I was held overnight. I received IV antibiotics, supplemental oxygen, and IV fluids, and underwent various procedures, including a chest X-ray and labs, before being admitted to a medical floor. I was diagnosed with pneumonia. After completing a course of IV antibiotics, I was started on oral doxycycline; a few days later this was switched to azithromycin and hydroxychloroquine. Hydroxychloroquine was just beginning to be used for some patients; it wasn’t until after my hospitalization that data indicated this drug was not an effective treatment.I was also given high-flow nasal cannula oxygen therapy to help keep my oxygen saturation above 90%.
My time on the medical floor was emotional and mind-bending. I recall lying in bed staring at the ceiling and thinking, “How did I get here?” and “What happened?” I remained light-headed and fatigued, my mind swirling with the recent events. I had some sense of relief that I had made it to a medical unit. Nonetheless, I intermittently emotionally tortured myself by going through every possible moment in which I might have contracted COVID-19. I continued to have waves of disbelief that this was happening to me. My symptoms continued to worsen, leaving me to ponder a painful potential reality: “This is it. You did everything you could. And this is how your story ends.”
My status was tenuous the first few days of my hospitalization, and I experienced no relief of symptoms. I knew my condition could easily worsen to the point of needing a ventilator. I prayed that would not happen, as I knew it dramatically increased the risk of a poor outcome. Other challenges were mounting—I had no change of clothes and the hospital was low on supplies such as gowns, blankets, towels, and the like.
My mother stayed in my apartment both to care for my dog and because she felt it was important to be close by in case of an emergency. After I informed my mother about the various shortages at the hospital, she offered to to drop off items for me. She understood there were restrictions on hospital visitors.I resisted because she would be putting her life at risk. As it became clear my hospitalization would not be short, I relented, but I felt a knot in my stomach as I knew she would be putting herself in harm’s way.
There is nothing in this world quite like a mom, and I know I am lucky to have a good relationship with mine. She braved the streets of Manhattan—swirling with both imagined and real contagion—and dropped off a bag full of clothing, toiletries, a towel, a blanket, and one of my dog’s toys as a reminder to keep fighting for my life. I remember grabbing the toy in my hand and thinking, “OK, you can do this; you can stay alive.” My symptoms were in full force and I still felt awful, but holding Azul’s toy, I felt a renewed spiritual burst of energy.
Throughout most of my hospital stay, I spiked fevers and experienced shortness of breath, headaches, and a persistent dry cough. It was difficult for me to speak on the phone. Consequently, most of my communication with family and friends was limited to texts. The cycles of sweating, fevers, chills, and muscle aches persisted. At one point, the body aches and joint stiffness were so painful, I required morphine and it brought me only fleeting relief. The pain precluded any restorative sleep. My poor appetite resulted in a 20-pound weight loss. All of these compromised my ability to focus and concentrate on simple things like watching television or playing a game on my phone. I developed new symptoms that seemed strange to me, such as an unquenchable thirst. I drank copious amounts of water yet could not rid myself of an overpowering salty taste. It seemed as though my mouth was full of Himalayan salt, and I had the sensation of salt crystals forming around my mouth, nostrils, and eyes. Of course, I could not see them when I looked at my face in the mirror.
Family or friends supported me virtually through phone calls, emails, and texts. I had moments of feeling sad, depressed, and lonely, but their messages of hope and encouragement helped me stay alive and cheered me up. They also helped distract me from focusing on how truly awful I felt.
Lessons in empathy
In psychiatry, we often discuss the importance of having strong social supports. I can attest to this truth. I am grateful to all the hospital staff who were, directly and indirectly, involved in my care. The nurses who took care of me were fabulous; the respiratory therapist who added a humidifier to my oxygen intake helped me breathe easier; and the custodial staff who insisted on changing the sheets helped ground and humanize my time in the hospital. I am forever in their debt, as they cared for me and helped keep me alive. Every staff member who entered my room was fully clad in PPE, and I could only imagine how scared they felt when they entered my room as well as the rooms of other patients.
The most memorable conversation during my hospitalization was with a young Latino resident assigned to my case during the first half of my hospitalization. He reminded me of myself early in my training. He saw I was not eating, and with genuine compassion, asked me, “How are you doing?” It was the first moment I had allowed myself to cry. I said to him, “I am so scared. I don’t want to die.” He put his hand on my shoulder and said, “You are not going to die. People who have coronavirus have walked out of here.” Then he added, “Also, you can’t die because we don’t have enough psychiatrists—and even fewer who are Latino! You need to live.” This act of compassion followed by humor gave me hope in a very dark moment. In one of our last interactions, this physician handed me an incentive spirometer and encouraged me to use it to strengthen my lungs, lessen my dependence on supplemental oxygen, and improve my shortness of breath and dyspnea.
In the second half of my hospitalization, a female resident of Middle Eastern descent took over my care. It was with her encouragement that I was able to come off the high-flow nasal cannula oxygen therapy. My body temperature began to normalize, and I had fewer spiking fevers. She was pleased to see my progress and informed me of my likely discharge in the next few days. She was aware that I am a psychiatrist and felt comfortable enough to share her experience of working on a COVID-19 unit. She alluded to not being able to discuss her feelings or reveal how frightened she felt, adding that speaking to me was a brief reprieve before she would have to move on to the next patient. I was able to appreciate that she put back on her mental armor so that she could continue to perform her clinical duties. She thanked me for the moments of openness and the reprieve our conversation gave her.
On March 25, 2020, more than a week after entering the hospital, I was discharged. Although I was no longer experiencing high spiking fevers, I still had dyspnea, cough, fatigue, myalgias, and poor appetite. As part of my discharge instructions, I was told to quarantine at home for an additional 7 days. I remember being brought downstairs in a wheelchair by hospital staff and feeling a combination of exhilaration, fear, and fatigue. The hospital lobby was empty, and the streets of Manhattan were eerily quiet.
As I waited for a taxi, I called my mother to let her know that I was on my way home and that she should leave. We were both aware that I could not be around her as I was potentially contagious. As my taxi pulled up, I saw my mother standing out front waiting for her taxi. I wanted to hug her and talk to her, yet I was gripped with fear about exposing her to the virus. I was so exhausted that I only managed to wave to her and say “Hello” before heading up to my apartment. My mother would later tell me that she could see I looked tired, scared, and pale, and that my breathing was labored. I did not start to feel like myself until about 2 to 3 months after hospitalization.
Most of my symptoms have resolved, but I continue to have occasional lingering shortness of breath. Since my discharge, I have reflected on my near-death experience. It was profoundly humbling, and I recognize how lucky I am to be alive. I am left with a feeling of being blessed with a second chance at life, as well as a desire to discover why I was given it and what I can do with it. I am still working on this.
COVID-19 has been life-changing for everyone. It has and will continue to impact how we think, feel, and interact with each other, and how we live our lives personally and professionally.
My survival as a physician, and specifically a psychiatrist, has been spiritual and emotional. The experience has motivated me to share my story, as well as some practical advice I learned (Table). My sincere hope is that my words might help bring comfort and hope to others who must confront this tragic disaster or may be dealing with a similar situation during this trying time.
Dr Tirado is a forensic psychiatrist at Lincoln Medical Center in the Bronx, NY, and assistant clinical professor of psychiatry at Weill Cornell Medicine, New York, NY. The author reports no conflicts of interest concerning the subject matter of this article. ❒