Portal de Periódicos da CAPES

Life is trouble, only death is not

2020; Medknow; Volume: 6; Issue: 2 Linguagem: Inglês

10.4103/ijam.ijam_58_20

2455-5568

Thomas J. Papadimos,

Ethics and Legal Issues in Pediatric Healthcare

This work represents thoughts regarding a small sliver of my life during this pandemic that I would like to share with you, the title of which is taken from a major work of Nikos Kazantzakis, Zorba the Greek. This story is about the relationship between a young intellectual, Basil, who had a proclivity for abstract thought, and a 60+-year-old man, Alexis Zorba, who has lived an authentic life and had a true enthusiasm for living, for which this young man yearned. As I go through these tough times witnessing trouble and death, I fondly remember one of the Zorba's quotes, “When everything goes wrong, what a joy to test your soul and see if it has endurance and courage,”[1] especially when partnered with an inexperienced junior resident. I have held two positions concurrently as an anesthesiologist over the last several years, one at the University of Toledo Medical Center (UTMC) and the other at The Ohio State University Wexner Medical Center (OSUWMC). While I was always welcomed to work in the intensive care unit (ICU) at OSUMC (I am a board-certified anesthesiology intensivist), my access to critical care work at UTMC was always blocked by the internal medicine department. I cannot really say why. That is, until COVID-19 appeared in Northwest Ohio and the ICU was overwhelmed, wherein my services were requested. I was asked to create an anesthesiology critical care team. I was given two nurse practitioners on a daily basis, but my biggest surprise occurred when a 1st-year anesthesiology resident offered to help our team. He wanted to do an ICU fellowship, so he thought that this would be a great opportunity. He was young, idealistic, a pleasure to be around, and very eager for me to pass on to him my 67 years of life experience, which had its share of stumbles. We needed help and I was not going to say no. Yes, indeed, here, we had an old “Zorba” and his young partner. My specific instructions from hospital administration, in addition to implementing an anesthesiology critical care team, were not to go into any patient rooms because of my age and because my valuable expertise could be lost if I became ill (Oh, hush now!). Hence, I agreed. My spouse was concerned; however, as long as I stayed out of patient rooms, she could live with it. However, I found it difficult to just stand there and watch my junior resident, as well as nurses, nurse practitioners, and respiratory therapists, put on their personal protective gear and take the risk of entering patient rooms. ”I am sorry, wife,” I thought to myself, “I did not spend 24 years in the U.S. Navy to run from a battle just because I got old (I am definitely an old salt).” You know that old saying, death before dishonor. Well, that is not entirely true. I was just too damned embarrassed to stand there and direct others into harm's way. Hence, of course, I did the foolish thing and decided to actually practice medicine. There is no fool like an old fool, but then looking at my young resident colleague, I also thought, there is no fool like a young fool, either. Hence, that made two of us. I very much wanted to tell him, “the first thing you need to understand, which I learned early in my U.S. Navy career, is never volunteer for anything!” However, I did not. I held my tongue. I needed the help. My first opportunity to actually provide direct care for a patient involved a very obese gentleman with COVID-19 who was tachypneic and gasping for air. He needed an airway immediately. My resident was very eager to do the intubation. We both put on our powered air-purifying respirator (PAPR) gear. He entered the room first and got everything ready. Then, a couple of things happened. I was suddenly having trouble breathing and perspiring as if I were in the Amazon Jungle. At first, I thought it might just be anxiety, and then, I realized my airflow had not been turned on. Problem 1 was solved. I say “Problem 1” because I did not know at that time there would be a Problem 2. Mind you, I was very concerned about exposure to the virus and had more than a little trepidation. For some reason, I had forgotten how claustrophobic I could become. As I entered the room, the enclosed space of my PAPR hood seemed unbearable and caused my mind to flashback to the docks at the U.S. Submarine Base in Norfolk, Virginia. Suddenly, I was an intern again (1978–1979) on a submarine for the first time – and the last time. I cringed at the thoughts and recollections of being below the water line and those horrible feelings; the fears came flooding back into my consciousness. I may have been standing still, but my brain was rattled with the ping-ponging of crazy thoughts. Again, I started sweating profusely and became tachypneic, and I felt that old panic. I gained a measure of self-control by berating myself for having fear in the presence of a resident who did not seem to have any, and the fact that there were plenty of nurses and respiratory therapists doing this ad nauseam. Over a very short period of time, I quickly grew accustomed to my gear, my environment, and got on with providing my patients with good care. The resident and I worked well together, but on occasion, things would go sideways. One morning, he went into the room of a patient to place a femoral central venous line. The patient was COVID-19 positive but was not intubated (spontaneously patients are more likely to infect you than intubated patients, theoretically). He struggled with the line as I watched him from the room's window. The patient's groin started to bleed more than I cared for, and the patient was obviously uncomfortable. I had my N-95 mask on, but not a PAPR. And of course, I entered the room quickly without thinking to assist my resident, when suddenly the patient became apneic and hypotensive. The decision was made to intubate the patient. The resident tried to mask ventilate the patient and I had to stop him because that was not protocol. He then tried to place the intubating blade in the patient's airway before he stopped breathing. I had to correct him again. I noticed my glasses were fogging and I could smell toast and breakfast from the hallway. Great, so much for being fit tested! It was kind of amazing at this point because I really did not care and I did not panic. We intubated the patient and moved on. This is what happens in combat, in the face of an enemy, you reach a point where you tend to disregard your safety when trying to complete the mission (in this case, as long as the patients get taken care of). You have to protect yourself, if you work too many hours in the ICU, you go from fearful to careless. I spent over 225 consecutive hours in the hospital and I was getting careless. The resident and I did not finish our tour of duty in the ICU dancing on the beach by the sea as did Alan Bates and Anthony Quinn in the movie, Zorba the Greek. We finished exhausted, but he did learn, he did appreciate, and he did develop a healthy respect for this serious disease, understood caution, and the service needed in the ICU; as did I, relearning lessons that were once learned that had been forgotten. My resident did a terrific job. However, 45% of our COVID-19-ventilated ICU patients died. This was not a happy time, and this pandemic is nowhere close to being over. Life is trouble, but whether only death is not, depends on your perspective. For me, it did not quite end there. No, I did not have COVID-19; however, on day 10 of my total exhaustion, I was feeling exceptionally weak and my left leg was ecchymotic and edematous. I took a stroll to the emergency department and checked in. It turned out that I was severely dehydrated and has torn muscles in my calf and thigh – from too much standing – resulting in two large hematomas, and thankfully no deep vein thrombosis. I know I am too old to be doing this; however, we must persist in this effort because, as George Addair said, “Everything you ever wanted was on the other side of fear.”[2] I need for us all to get to the other side, but to get there safely. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Ethical conduct of research The author of this manuscript declares that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to not require the Institutional Review Board/Ethics Committee review and the corresponding protocol/approval number is not applicable.