When Breath Becomes Despair

By Juhi Varshney, MD

At Jackson Memorial Hospital, each shift begins with a sign-out, where we review every patient in the emergency room with the medical team about to leave.

In Room 1, we have an unvaccinated COVID-19 patient, intubated a few hours ago, who now needs an intensive care unit (ICU) bed; his family has no idea because we couldn’t reach his emergency contact. In Room 2, there is a young woman who is breathing for her life. She’s stable for now, but could potentially decompensate quickly so she will have to be monitored closely. In Room 3, a patient who I saw 20 hours ago has yet to be moved from the ER to a room. She had told me about her journey in life and all that she has had to overcome, but it doesn’t look like she’s going to survive COVID. In Room 4, there was a critically-ill patient who tested negative for COVID but had suffered a stroke and needed an ICU bed that we just did not have. All of these patients are alone in their beds because it’s too dangerous to allow visitors for most patients.

I started my emergency medicine residency on July 1, when we barely saw COVID patients and when the pandemic almost felt like an afterthought.

Now, every shift I watch patients fight to breathe. There are days when we step out of a code to find a line of patients, gasping for air, wheeled into the department. The nurses scramble to get them on the monitor, and my senior resident rolls in the BiPAP machine himself because the respiratory therapists are tied up across the hall. We watch as our patients’ saturations dip low and their respiratory rates climb up high, a frantic beeping of the monitors the background music to our work.

“Have you ever seen respiratory distress?” I asked a new medical student. She had not. We could see the sheen of sweat across our patient’s forehead. I pointed out the muscles in his neck that were pinching with each breath, accessory forces recruited to help breathe when the diaphragm is starting to tire out. We watched how our patient’s belly shook with every breath, a sign that his chest wasn’t strong enough to breathe by itself. We pulled out our stethoscopes to listen closer, and as I glided my bell across his damp skin, I hoped that we would not have to intubate him.

My first intubation was on a patient brought in by ambulance for a cardiac arrest. We performed multiple rounds of chest compressions, and we tried to use a ventilator on him, but we could not bring him back. Talking to his family was the first time I had broken tragic news as a new doctor. His niece had watched him fall, called 911, and stayed with him while the paramedics arrived. I told her that she did everything right, and I hoped she believed me. When her uncle’s tests came back, we realized COVID hypoxia had caused his heart to stop.

I have intubated more patients since – more than I expected to one month into my residency. Intubation is a difficult procedure and securing an airway is a lot of pressure. I want to be proud of my learning, how I’ve gotten more comfortable with the equipment and all the steps, but a lot has to go wrong for a patient to need intubation. I usually enjoy reading up on patients a few days after shift to learn about their hospital course, but I haven’t been able to bring myself to look them up because I am afraid of what their notes will say.

We’ve seen a wide range of cases. I met the sweetest older woman on chemotherapy, who got both doses of her vaccine months ago. Everyone at home was vaccinated, too, but she tested positive that day. When I told her the bad news, her face completely crumbled. I couldn’t help but wonder: if more people around her had been vaccinated, could she have been spared the virus?

I saw a young mother who looked terribly ill and was barely able to walk. She had been too nauseated to hold down food or water, and she was now dehydrated. Her whole body ached, and I could see her wincing with each cough. When I asked if anyone else at home was sick, she started to cry. Her 1-year-old daughter had spiked a fever the day before. No one in her family was vaccinated. A space opened up between us, and I could feel two choices: I wanted to find out why she had resisted the vaccine, but in that moment, she looked so fragile. I decided to lean in, and I told her that we could talk about the vaccine later. For now, we would focus on making her feel better. A few hours later, she was stable enough to return home. I had to warn her that she needed to isolate for 10 to 14 days, away from her children, and that any time she spent with her kids would put them at risk of getting sick. I mentioned that the CDC recommends getting the vaccine after she fully recovers from the infection, and she nodded in agreement.

I have been trying to recommend vaccination to all of my patients. I tell them that getting vaccinated is an act of love showing how deeply you care about the health of the people around you.

For some people, talking through it with a doctor has helped. There is just so much information out there, and it can be hard to know what to trust. If you follow the news, it can feel like a lot of people get bad reactions to the vaccine—and what’s the difference whether you feel sick from the virus or from the vaccine?

But that’s not what we see in the hospital. Most people who get the vaccine feel a sore arm and a day of body aches. The number of people who get complications from the vaccine is almost zero compared to the number of people who get complications from the virus. I tell my patients how I got my shot back in January, and I love how it has made me feel safer and made the people I spend time with more comfortable.

The pandemic’s sweeping changes have made it hard to feel control over our lives. Making a decision on the vaccine is one way to regain some of that control. I know there are a lot of concerns about the vaccine, and I think it is so important that everyone thinks about the vaccine carefully.

But from where I stand, it feels like too many people underestimate the cost of not getting vaccinated. COVID-19 is an ugly disease. Not everyone ends up in the ER or ICU, but when they do, it is devastating. Even “mild” cases of COVID-19 have real risks for long-term complications and disability.

And every patient who comes in with COVID-19 means one less bed for a patient brought in for a heart attack, stroke, or car accident. When weighing out your decision, you have to be honest with yourself about the risks of being unvaccinated.

A few weeks ago, I had a patient tell me that the virus was a hoax, and that the media was brainwashing me. He seems like an exception. Most of my patients have been open to, even interested in, talking more about the vaccine. And there are a lot of people who believe in its power. Our hospital system recently announced strict vaccine requirements for all employees because the evidence is so overwhelmingly good. This new measure is going to keep our patients safe.

Before a long night shift, I’ll get to the hospital early and turn on a guided meditation in my car that invites me to focus on my breathing, to draw on my inner strength, and to relax with each exhale. Clearing my mind helps me open my heart before my shift. These last few weeks, the simple act of regulating my breath has felt more precious. The Buddhist monks have developed a practice called tonglen: with each breath, they take in the pain and suffering of the world, and then exhale goodness. On my inhale, I think back to my hardest cases, and I touch the sadness, regret, and weariness inside of me. On the exhale, I breathe out gratitude to be an emergency physician where every day, I get to greet people in their hardest moments with relief and comfort.

The pandemic has shown us, time and time again, how deeply connected we all are. All of us are safer when one more person in the community is vaccinated. It is easy to think that COVID will never happen to you, that the virus will infect someone else because you’ve been just fine for the last 16 months. You might be right, but we’ve got hospitals full of unvaccinated patients who made that same gamble. This delta variant is worse than last year’s virus. I came to emergency medicine to help ease suffering. Now when I see patients in despair, it hurts to know that they’re just too late for the best treatment against the virus that has been widely available.

Like many of us working at the frontlines, I’ve felt breathless in this rising surge. Author, filmmaker, and activist Valerie Kaur once said “Breathlessness is a sign of your bravery. It means you are awake to what’s happening right now: the world is in transition.” We’ve got the power to transform what’s happening here in our hospitals, in our city, in our world – one vaccine at a time.

Juhi Varshney, MD, is an emergency medicine first-year resident at Jackson Memorial Hospital, the flagship hospital for Jackson Health System.