Orientation

A black and white photo of a doctor in half shadow looking intensely into the camera “The patient stands there, and 
you stand here.”

Mark was pointing at two X’s made of wide yellow tape on the carpet. They were 6 feet apart—the new safe distance—and indicated where we were to stand when reviewing chest X-ray results with patients.

This was part of the March orientation for the brand-new respiratory illnesses clinic, serving patients who needed an in-person evaluation but weren’t sick enough to be sent to the emergency room.

Orientation is a little unusual when everyone you see is wearing a mask and goggles. Some of us had goggles over our glasses. I knew a few of the people and recognized them by their eyes, voice and general shape. The others? I got a few first names, but that’s about it. I’ll never know if I pass them in a hallway someday. Even though we were working together in this crucible of a clinic, we were somehow having a self-isolating experience. Fitting, I guess.

In this pandemic there’s a lot of sorting that is based mostly around the fact that we don’t have enough, or fast-enough, tests. Patients first call their doctor’s office and answer a bunch of checklist questions. The criteria change every day. So far, people who are not in a high-risk group will most likely be asked to stay at home and monitor symptoms. We call them back three times over the next week to see how they’re doing.

Sometimes on the phone, people are told to go to the emergency room. And sometimes they are booked into this new urgent clinic where I am working.

Patients get escorted through a rabbit’s warren of makeshift walls designed to keep everyone as far apart as possible and are finally ushered into an exam room, where I get to see them. The first thing I have to do is ask them not to touch anything but the exam table. Then we look each other in the eyes.

And I realize how unhelpful this is. I’m disoriented.

As a doctor, I rely on being able to study my patients. In a normal visit, I watch them walk down the hall to the exam room; I see them climb onto an exam table. And I get to see their whole face. How tired are they? Do they have trouble forming words? Is their mouth dry? And, because I know them, I know what is normal and what is not.

Here, I have none of this. I get the clearest feeling I’ve ever had of having one hand tied behind my back.

And what must the patient feel? Already sick and scared, they can’t be reassured talking with this masked stranger who is wearing two sets of glasses.

I next try what I normally do: I ask the patient to tell me what’s going on. My first patient, a man in his 60s who has just finished radiation for a cancer, starts to tell me how he’s been feeling. But I have to stop him.

I recall that the system—the incredibly efficient system built by really smart people at my hospital—doesn’t really care about his full story, even though I do. My natural doctor’s reflex and curiosity are of no matter. I can almost feel my second hand being tied behind my back, but knowing that it’s for a greater good eases this sensation.

I must turn to the computer and start going through the checklist of symptoms. Everyone I see this day 
qualifies for the SARS-CoV-2 test. Two-thirds of them will test positive.

I also order some chest X-rays to help sort the sick from the sicker. I stand in the hallway and see one of my colleagues standing on the yellow X while she tells a patient that he’ll have to go to the ER. The X-ray shows a pneumonia, and it’s likely COVID-19. I can’t read how the patient is taking the news. Closer to me, I hear our nurse call the ambulance to take the patient on a two-block ride to the ER. The patient is ushered to a special waiting room.

I wait for my patient to be escorted to the yellow X, and I walk down the hallway with better news to deliver. I smile under my mask as I tell him that his X-ray is normal. I look at the corners of his eyes to see whether he’s smiling. He doesn’t seem to be. I keep talking, trying to center my smile in my eyes and forehead, but it doesn’t seem to be working.

Why should he be reassured? I have nothing really to offer him. He’s not feeling well. Why should he smile? Is he any less scared than when he came in? At this moment, I can’t find out the answer to this question.

In 24 hours he’ll get the call that his test is positive, but the advice won’t change much. Self-quarantining will become self-isolation. We’ll continue calling to check in. If things get worse, go to the ER.


Remote

A black and white photo of a man leaning over with his hands on his knees At exactly 9 a.m., I dial the phone number of one of my patients. She didn’t want a video call, because, she said, “I only have a flip phone.” There’s a lot of disorienting background noise when she answers. I wonder whether it’s a bad connection, but then she sounds like she’s walking. She explains that she’s just getting off the T.

An odd beginning to a medical visit.

I’m used to it by now, though. Another of my patients was in the checkout line at the grocery store. Some take the “virtual” appointment with the same solemnity as they would a regular in-office visit. I imagine that these are the same patients who always come early and dress up a bit.

Either way, this new system has certainly made me feel remote. I have a very good ear for voices but am slowly losing touch with all my patients. I’m also 
losing touch with my colleagues. I get snippets via text, a technology that can’t help but minimize the enormity of what’s going on. “We intubated 12 patients in the E.D. yesterday.” “I have to go tell an 84 yo COVID patient that his wife at an OSH coded but is on a ventilator now.” “I’m proning someone now who is on 7L nasal cannula; was on 2L yesterday.” “These patients are so sick!” “One of my friends who is 56 and totally healthy is in the ICU and intubated.” “Very scary.”

Forget the lingo for a moment. It’s easy to imagine that these are the final missives sent out to the world from some sinking ship.

It’s early April, and the true tidal wave isn’t even upon us yet. Right now, a fifth of our beds are taken up with COVID-19 patients. Over the next 10 days, that could rise to one-half. New units are being turned into intensive care units to accommodate the COVID-19 influx. It’s a breathtaking example of what planning, expertise, organization and resolve can do.

And yet, the most common thing my colleagues tell me is that they feel powerless. The patients just get sicker—many die—and there isn’t much we can do to stop it. Seeing it first-hand, everyone begins to imagine their own family or themselves laid low with the ruthless indifference of this lethal ailment.

So far, nothing has been proven to work.

There are other ways in which remote is the right word for right now. Without true curative therapies and bundled in all our protective clothing, we are truly remote from the sick. The last thing we have as doctors is our presence. In times of crisis, in times of death, we can stand with patients, show them our caring face, hold their hands, comfort their family.

All that’s gone now. The dying die alone—remote—in as opposite a circumstance from their arrival to this world as one can imagine.


Chelsea,
 U.S.A.

I was staring into the face of the coronavirus pandemic but I couldn’t see her well, because she was wearing a mask. I could tell she was angry, though.

The telephone interpreter translated most of the 
conversation, but Manuela knew plenty of English, and it burst out of her at times. “They told me to go home and gargle with salt water!” she said. “They told me to come back if I got worse!”

She had come back; she was worse, and everyone in her home was now sick.

We were sitting in an exam room of the respiratory 
illnesses clinic in Chelsea, Mass., a converted floor of the health center that Mass General runs. In better times, the health center serves the medical and social needs of this largely immigrant community. In the 
converted office where I stashed my coat, a flyer alerts patients in English and Spanish that they can get free help with their taxes. Some bilingual flash cards 
describe common childhood infections. Another flyer invites people to a nutrition class.

Chelsea has always been a home to immigrants. Currently, a majority of its citizens speak Spanish 
primarily. A hundred and fifty years ago, Jewish immigrants started arriving and, by the 1930s, they made up 
almost half the population. Chelsea is the place where a 16-year-old Jewish boy from New York City, arriving at Harvard College just three months before Pearl Harbor,
could find a good bagel. I’m not sure how my father found Katz Bagel Bakery, but he formed a deep affection for its smells and tastes. He brought me there as a small boy, and I remember the delight of being invited through a side door to where the men were making the bagels. How fast their hands moved as they snapped off a length from the rope of dough and deftly looped it around. Perfect rings of dough were tossed into the kettle of boiling water, the largest kettle I had ever seen. Years later, Katz’s would get a machine to do this work.

All of these yeasty memories were flooding through my mind as I drove to the health center on this bright and clear weekend morning.

By now, everyone knows that Chelsea is a hot spot for the coronavirus. Our orders were to make sure we tested everyone we saw that day. Outside, tents were set up to test people who didn’t need to see a doctor. Pairs of stenciled shoe prints, taped to the pavement, made sure that people stayed at least 6 feet apart.

In homes in Chelsea, though, staying apart, let alone self-quarantining, was next to impossible. In response, the City of Chelsea had rented out an entire Holiday Inn where people who needed to quarantine could stay. They would have room and board for free.

Everyone I saw this day was an immigrant; everyone had many people in their home, and everyone would go on to test positive. I’m not going to write about the disparities between the health and health care of poorer immigrants and the rest of us. Many people, particularly at the Chelsea health center, have dedicated their careers to understanding this problem and, more 
important, to doing something about it. I’m not going to insult anyone by writing one of those “I didn’t know it was this bad” essays.

But I can tell you something that really hit home. I talked with everyone about the Holiday Inn, how it was a good option, and everyone had the same response: “Will I be forced to go there?” As the day went on, when I first spoke of the hotel I would say twice and three times that it was optional. “Will I be forced to go there?” they still asked. I can only imagine what they were thinking at that moment. “Why have I come here? I’m going to be 
imprisoned!” I did my best to reassure them. To one patient, I said, “It’s not a prison.”

I told Manuela that her family could go to the Holiday Inn if they liked. “What’s the point?” she asked. “‘We all have it. We could just stay together.” Of course, she was right. I did point out that she wouldn’t have to worry about getting food, but she wasn’t very impressed.

I sent in a prescription to help Manuela with her cough. I stood up and removed my gloves and gown before leaving. My mask stayed on, and so did hers. It would be hard to say that we had ever really met.

As she sat alone in the exam room awaiting the coronavirus test she should have had two weeks ago, I went to another room to finish my note. Manuela’s righteous anger lingered around me. Forget, if you can, the crushing poverty, the overcrowded home, the two jobs minimum per person, the crummy education that her sons were offered, and the shoddy health care that led to her delayed test and the infection of her whole family. Forget all that and there’s still something worse.

My ilk and I had done this to her. We are the ones who go on European vacations and business trips to Asia. We, not the poor immigrants who get blamed for everything, are the ones who brought the coronavirus into the country and into our homes and offices, where Manuela and her family pull the night shift so that our lives can march along.

What could I possibly ever say to that? An apology doesn’t seem like enough. I thought of Manuela walking home later, the idea of the Holiday Inn long passed from her mind. She would have other thoughts on her mind, ones that I could never imagine.


98 Tomorrow

The page comes in just after noon from the daughter of a patient: “He is having trouble breathing and fever and cough. He is going to Mass. General.”

I do what I always do and look up the patient’s medical record. His regular doctor is doing a shift in the 
respiratory illnesses clinic, and so I’m covering.

I call the daughter back to see how I can help out. She sounds young and strong but she’s actually 70 years old herself and, because of her asthma, hasn’t seen her father in three weeks.

“He’s 98,” she explains. He has a 98-year-old’s share of medical problems. His visiting nurse had called 911. I’m relieved to hear that no one is doing anything 
foolish, like driving him to the ER. But as I listen more, I can’t help but think this is probably COVID-19 and this will probably kill him. I don’t tell her that but what I do say is no more reassuring.

She asks, “Can I meet them in the ER?”

“No. Unfortunately, right now no visitors are allowed in the hospital.”

“Of course,” she says with a graciousness that almost brings me to tears. I don’t know what to say back.

I am telling her that she can’t go see her dying father and she not only accepts this but understands it. This pandemic has clearly pushed us all into a new era.

We talk a moment more, and I happen to glance at his birthdate in the upper left corner of my computer screen. His daughter had told me that he was 98, but his birthday is actually tomorrow. I point this out, and she laughs for the only time in our conversation.

We hang up and I type an “expect” note into the computer: “97 yo man with temp to 102 and SOB.” This is for the emergency department team, but they’ll understand the situation in one glance when he comes rolling in on a stretcher.

An hour later, the doctor in the emergency department pages me: “This pt. is in ED with COVID—was made CMO, will probably pass away today.” I call back; I want to double-check that the daughter has been a part of this decision.

Then I call the daughter to offer my condolences for what is happening. At first, she thinks I’m calling 
because he has already died. I apologize for being confusing; he’s alive, but the prognosis hasn’t changed.

We talk a bit more about her father, and she cries for the first time. “I really thought he’d make it to 98…” Her voice trails off. Maybe, somehow, he’ll make it to midnight. Maybe he’ll make it to 98 and that will be something his daughter can tell herself later to ease the pain: “At this age, every birthday is a milestone, and he made it to one more.”

Back in the here and now, I ask what I can do to help. She wonders whether a Catholic priest could come to see him. I pass this message along to the team in the ER.

Two hours later I enter the electronic record and a message pops up:

You are entering the medical record of a deceased 
patient. Are you sure you want to proceed?

My heart sinks; this is what I was hoping not to see. I click on OK, hoping that more details might ease the sudden pang of grief I feel for this man I never met. In the notes and details of the case, I find a note from the Catholic chaplain. It is timed a few minutes before he was pronounced dead. At least I had done that. If not for the patient, then for his daughter.

I call his regular doctor, my friend and colleague of 15 years. He is just getting out of the clinic, heading home to take a shower, as we all do. We speak of his patient. “When you’re 97, it’s just a matter of time. Something was bound to get him. To die all alone, though—that’s what’s different now.”

We talk a few more minutes as he walks to his car and then sign off with the salutation that has become standard among those who care for the sick and dying.

“Stay safe,” he says.

“Stay safe,” I say back.


Dr. Paul Simmons ’82 is a practicing general internist at Massachusetts General Hospital, where he also serves as the assistant chief medical officer. He is an assistant professor of medicine at Harvard as well. In this article, identifying details about patients and others have been changed to protect their privacy. These writings and others are available at paulsimmonsmd.com.

Photographby Mark Ostow