Memorial Day is supposed to be a day for us to remember, honor, and mourn the men and women who have died while on duty with the US military. Each year, I send a Memorial Day poem to my friends and family remembering their sacrifices. This year it is a simple piece from Rudyard Kipling:
All we have of freedom,
All we use or know,
This our fathers bought for us
Long, long ago.
For those of us in the medical community, we are still on the front line, going through one of the greatest wars of the past century with a new specie that has invaded our world. But unlike traditional wars, the front lines of this war move from country to country, city to city, home to home, family to family. So many of my patients have died, so many more are suffering through the residual symptoms of the Covid-19 infection's sequelae. Many of us who were infected or who cared for the infected, before and after their deaths, are still working through our PTSD.
So, as part of my own therapy, I'm going to take this time to memorialize and pay homage to the patients I have lost to this pandemic, to remind myself why I still have to complete this tour of duty. Although these patients have passed away, I will still not use their full names in order to protect the family's privacy.
Florence S.
Graciela F.
Irene A.
Elena A.
Thomas T.
Faith H.
Charlotte R.
William J.
Susan H.
Samuel C.
Florence was the first to die in my practice in early March. She had just celebrated her 100th birthday in the nursing home in July of 2019. She was weak of body but clear of mind. She had a DO NOT RESUSCITATE, do not transfer, comfort measures only status on her POLST form (physician's order for life sustaining treatments). Because of this, we did not send her to the Emergency Room nor obtained swab cultures when she developed fever one night, then passed away the next day. Not that Covid cultures were possible in the community at that time because Quest Diagnostics had just released their testing kits and none of the nursing home staff had been trained nor had the PPE to obtain the swab cultures. So I did not put Covid infection as her cause of death on her death certificate.
Graciela was my second patient to develop fever and shortness of breath at the nursing home, she was transferred to the hospital, found to have bilateral pneumonia and was placed in isolation while we await results of her test. During the waiting period, we went ahead and started her on Remdesevir, dexamethasone and IV antibiotics. Her respiratory status declined slowly over the next week and we had to increase oxygen support to BiPAP. She was 95 years old and has had moderate dementia for many years but the family insisted on full treatments. As usual, we had disagreements within our team about how aggressively to treat this elderly patient. The pulmonary and infectious disease consultants had already nixed the idea of intubation, ventilation and full chemical coding in the event of her death. Every time I donned my gown and shield to come into the negative pressure room (which is required to reduce infection spread for patients on positive pressure oxygen) the young nursing staff would hint at the futility of treatments in this age group. Every time, I would remind them that this is someone's mother, someone's grandmother and we have to try the best we can to see if their body can fight off this infection. When she continued to decline despite all measures, the hospital allowed the family to come in her room one at a time, with full protective gears, to say goodbye.
Irene A. was 98 years old and sharp as a tack. She was cantankerous and always complained about everything at the nursing home. So it was unusual when she just stopped eating for 2 days before she became obtunded and nonresponsive. She also had a DO NOT RESUSCITATE, do not transfer order on her POLST. Unfortunately, the nursing home did not have a policy allowing visitors even on their deathbeds. Thus, I was the intermediary between her only daughter and her in the final days of her life. It was traumatic for the both of us, even though I've had a lifetime's experience in counseling families through grief.
Elena A., a 92-year-old resident of an assisted living facility, also started losing her appetite 2 weeks before her diagnosis. Her son thought that she was just depressed from the lockdown and had called to ask me to increase her Lexapro dosage. She didn't develop a fever until 1 week after this. She was transferred to the hospital and passed away within 5 days of hospitalization.
Thomas T. was 69 years old and had well-controlled diabetes. He believed that he was strong and healthy and would always argue with me about coming in for blood tests more than once a year. He was married, and lived with his wife, his mother-in-law, and his son who was in pharmacy school. He, like many Vietnamese Americans, did not believe that Covid-19 infection was anything to worry about. Despite the lockdown during the month of March, he continued to go about his business, collecting rent and managing his apartment buildings, without any precautions. When he developed a fever and cough in early April, he did not think much of it and tried to manage it at home with herbs and over-the-counter medications. When he became weak and delirious a few days later, the family called 911 to bring him to the hospital. They tried all measures including IV medications, intubation, ventilation, and chemical coding but he passed away from septic shock within two days. His brother-in-law, in panic, drove up from Santa Ana and took the mother-in-law down to Orange County. She died of Covid infection in Orange County the week after he died in Los Angeles. His wife, also my patient, was brought into my office by the son for overwhelming grief, unable to eat or sleep for days. She was still in denial, claiming that her husband died from another infection other than Covid and that her mother died from old age. But her son signaled yes to me in the exam room when I asked about Covid infections.
Faith H. was admitted to the nursing home in October by her family. She was 82 years old, had advanced dementia, and spoke in word salad with every question; meaning her answer were composed of real words but the composition made no sense. Physically, however, she was tall, strong, and healthy . I had called and spoken to her husband and daughter about the wisdom of this move given the high exposure to essential workers in the nursing home. Although all the nursing homes and staff were taking proper precautions at this time, some of the homes were testing a quarter of the staff every week. However, I had put off nursing home admissions for most of my patients due to the fact that nursing home staff were constantly being exposed to their family and community and by the time they tested positive, each staff member would have already had days or weeks where they could spread the disease. The family was aware that there was an increased risk of contracting this virus in the nursing home setting but they were not able to care for her anymore due to the husband's own physical illness and her daughter living out of town. Three weeks later, the patient was transferred to the hospital for pneumonia and passed away from Covid-19 infection.
Charlotte R. was a highly functional 88-year-old who had mild congestive heart failure. She lived with her 92-year-old husband and 57-year-old daughter. Immediately after Thanksgiving, she was admitted to the hospital for pneumonia. Her daughter was admitted to the same hospital a week later. Her husband, who developed upper respiratory symptoms 2 days after she was hospitalized, was able to recover from home after 1 week. Both Charlotte and her daughter were my patients but they were admitted to a hospital where I did not have privileges at. During the November, December, and January surge, hospitals all over the San Fernando Valley were packed to the gills and ambulances were diverting patients to any facility that had an available ICU or ER bed. Many hospitals, like mine, had to turn same-day surgery centers and pediatric ICUs, and endoscopy units into makeshift covid ICUs. Orthopedic wards and Chemotherapy wards were turned into respiratory isolation units. All elective procedures and surgeries were canceled during these months. After 6-8 weeks of hospitalization, despite being given all available meds and treatment including intubation and ventilation supports, Charlotte passed away. Her daughter was discharged with a speech impediment from a stroke that happened during her recovery from covid. Her husband told me they had a drive-through funeral for her about a month after her death due to the overwhelmed mortuary and cemetery demands of those months.
William J. was an 82-year-old with severe diabetes, hypertension, and the beginnings of vascular dementia. His mental status had been in decline after his wife passed away in 2018. He did not get along with his children and believed that were just trying to get rid of him. He was in the hospital for months at the beginning of the pandemic due to multiple toe and foot amputations from gangrene, then acute arrhythmia requiring pacemaker placement. Either through sheer luck or extreme precautions on the part of the acute rehabilitation center, he did not get covid in the March and April surge, got well, and was discharged home in May for recovery. In December he was brought into the hospital close to his home and treated for Covid pneumonia and gastroenteritis then discharged to home on oxygen. He was brought to another hospital a week later for worsening shortness of breath and was found to be in acute renal failure. Despite all noninvasive measures, his kidneys continue to decline to the point that he required hemodialysis. This option was discussed with the family but was deemed to be too aggressive. He was placed in palliative care and was able to pass away peacefully without pain or distress.
Susan H. was 81 years old and lived by herself in her own apartment. She has been my patient for 15 years and took meticulous care of herself and her diabetes. She had not gone anywhere since March 2020 but was constantly getting visits from her many children who were dropping off groceries and food. She developed weakness and was brought to a hospital in January 2021. The family contacted me to see if I could transfer her to my hospital for care because they had no Vietnamese-speaking nurse at that hospital and the family was not allowed in. This was not possible for a multitude of reasons and the hospitalist at that facility did not return my calls. I was told several weeks later by her fellow church member that she passed away in the hospital from a Covid infection.
Samuel C. was 81 years old and married to a 66-year-old wife. They both had minimal underlying medical illnesses. He developed a diffuse body ache with low-grade fever in January and thought it was his gout flare. When it did not go away after 2 weeks, he came to the hospital and was admitted for bilateral covid pneumonia. He was treated with dexamethasone, ceftriaxone, remdesivir, tocilizumab, and convalescent plasma. The patient gradually improved and was slated for discharge 2 weeks later but suffered acute respiratory distress on the day before discharge. The hospital team checked for anything that could have caused the acute respiratory failure but could not find anything other than a persistent covid positive swab. He was started on another course dexamethasone, remdesevir and convalescent plasma but his respiratory status and renal function kept declining. He was intubated 3 days later but, despite all the ventilation support , his lungs could not recover and he passed away 2 days after that. His very bewildered wife still cannot accept the fact that he had Covid pneumonia. She insisted that this was all a hoax, that all he had was gout, and that the hospital had screwed up somehow. Last I heard, she was still looking for people to review the chart and support her complaint against the hospital.
I swear my Internal Medicine private practice is not normally this heart-breakingly sad, and I didn't even tell you about the patients I've lost contact with, those who just seemed to have dropped off the face of the earth, those who survived only to bury half their family or those who still cannot work from covid complications months after their infections.
Even though I take care of the sickest and most elderly group of patients, the mortality rate in my practice ranges from 2-5 persons a year, 6-7 in a bad year. My practice is normally full of joy and fun because my patient population of mixed immigrants in the middle of the San Fernando Valley are the sweetest, least entitled people in America. But this year has just been a dark year. I can only hope that the vaccine will reach many people and continue to work against the new developing variants. So hopefully, covid-19 will become just another background virus that we can deal with instead of these overwhelming surges every few months. It certainly is not going away anywhere soon, if the stats from other countries are any indications.
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