Hyperalgesia: An abnormal and enhanced sensitivity to pain.
For the past several weeks, my team and our entire health system have been preparing for the Covid-19 surge. Our team started to see our first Covid-19 consults last week. Of the patients I’ve seen so far, some have died, one recovered. I have several patients who, right this minute, remain on the precarious tightrope between life and death. Covid-19 is a beast.
We have four general palliative care teams and my current team, P4, has become the inaugural Covid team. We are working closely with the ICU staff to try and figure out the best ways to care for people who are critically ill with Covid and to offer support to their families. These families have not been able to come to the hospital, so have not seen their loved one for days…sometimes weeks. They are finding themselves stuck helplessly at home as they receive play by play over the phone from doctors and nurses…kidneys worse…starting dialysis…needing vasopressors…proning and paralyzing…I’m so sorry…your brother just died…we did everything we could…
We are finding that when Covid hits, it can hit quickly and set off a chain reaction of organ failure. The lungs are ravaged first and the kidneys seem to quickly follow suit. Most of these patients are requiring high doses of sedating medications to prevent them from “fighting” the ventilator. We are having to paralyze some patients with medications so we can ‘prone’ them (position them on their belly) to try to help get more oxygen into the lungs. I feel like an intern again, overwhelmed with new information about a new disease process I’ve never seen before. But this time around, no one has seen it. There is no chapter dedicated to it in Harrison’s and there is no wise and learned senior attending standing close by to help.
While our numbers have been relatively low to this point, the work feels increasingly…heavy. Our team members take turns coming into the hospital, so Monday and Tuesday I was in the hospital, and our amazing APRN has been in house the rest of the week. I will be back this weekend. The person stationed in the hospital will take an iPad and zoom the rest of the team from the ICU so we can look at our patients though glass doors and talk to the doctors and nurses taking care of them. We are learning to have conversations with families online so that we can see each other…and seem more human. We are stumbling through difficult conversations about resuscitation status with family members who have yet to wrap their heads around the notion that their loved one, who was seemingly healthy a week ago, might die. We are trying to learn how best to acknowledge grief, fear and uncertainty through a computer screen. We are trying to support our ICU colleagues who are fearlessly and courageously caring for people affected by Covid-19. And we are trying to figure out the best way to support our own palliative care team as we continue to trudge through the murky waters, which have become abruptly deeper and more tempestuous.
When a patient experiences hyperalgesia, they have a significant pain response to a stimulus that otherwise wouldn’t cause much pain. When people ask me how I’m doing, I keep coming back to this concept…hyperalgesia. I am intimately familiar with sadness and grief. I am accustomed to death. I have developed a pretty thick emotional skin that allows me to do this job day after day, but the past few weeks seem to have stripped my heart of that protective layer. I feel raw. I feel exhausted. I have cried in the hospital. I have cried in my office. I have cried for patients. I have cried for their families. I cried watching a bedside nurse cradle her patient’s head in her arms while his family said goodbye on a computer screen.
I want you to know that, while my job can be extremely difficult, right now I have the luxury of caring for patients from behind a glass door, or from the safety of my office at home. The heroes right now are the ER docs, the intensivists, the anesthesiologists, the critical care NPs, the respiratory therapists and the bedside nurses. Good Lord…the bedside nurses. These people inspire me constantly and have risen, unequivocally, to hero status. The bravery of our colleagues, our healthcare family across the world, gives me hope. Not only for medicine and for science, but for the human spirit.
I so appreciate all of you who have been following my blog and who are reaching out with kindness and encouragement. It means the world!
Dr. Bartlett Pear
Oh…and keep staying home!