So much has changed since the first surge of COVID-19 hit Massachusetts.
The state saw cases decline and infection rates drop. It experienced a second surge. Hope arrived with the development and rollout of vaccines that lives would be saved, and that an end to the pandemic was within reach.
But the effects and trauma of that first wave — and all the suffering that has followed afterwards — remains, lingering for doctors and nurses who worked on the front lines in the spaces of intensive care units, where they cared for patients sick and dying from COVID-19.
Looking back at those early days of the first surge, Dr. Lakshman Swamy told Boston.com that a year later, it is still difficult to talk about what he and his colleagues experienced working in those ICUs.
The pulmonary and critical care doctor at Cambridge Health Alliance, who also serves as an instructor at Harvard Medical School, said it was a time when health care workers felt they were responding to their calling, so there was tremendous motivation to meet the crisis. He was working in the ICU at Boston Medical Center when the first surge hit.
“I know in the start I pushed myself way too hard, just immersed in COVID nonstop,” Swamy said.
Not just in reading the news. The doctor and many of his colleagues worked to read as much of the scientific literature as possible, listening to podcasts and absorbing all the latest information available on the virus.
“I remember one of my colleagues told me his home was like a COVID research unit, and then he’d come into the ICU and work and it was just nonstop,” Swamy said.
It became all-consuming, he said. And it was paired with a profound sense of fear the doctor said he’d never before experienced.
It felt like society was crumbling, and everyone was scared of getting sick.
“That’s the bottom line,” Swamy said. “I still remember the looks in the eyes of my colleagues when I would walk in and we’d just look at each other and be terrified. This was [at the] start and people didn’t know when or what mask to wear. We didn’t have masks — PPE shortages were really acute then. We were reusing things, we didn’t know how you could get it. We didn’t know if we were at risk of getting it, if it was inevitable that we’d get it and bring it home to our families. That was really scary.”
The fear was a huge part of what made the first surge so difficult. And the settling of that fear in the workplace created another feeling for those on the front lines of patient care: The hospital no longer felt like home.
“The intensive care unit felt like a second home to me,” Swamy said. “I’ve been there for six, seven years and I knew everyone there, we were really close to each other, like a second family. And suddenly we were scared of each other. I remember being scared of my colleagues. Scared that I would give them coronavirus and that they would give it to me, if we were in too close contact with each other.”
The learning curve on the virus would take some time.
Eventually, Swamy said, he and his colleagues came to know they’d be safe as long as they were wearing their equipment. But that lesson really wasn’t learned until the end of the first surge.
“I remember how much it felt like when the cases started going down, it was kind of like, ‘Oh my God, we lived through this, we made it,’” the doctor said. “Obviously it wasn’t that simple, but just the feeling that that was the time when it really felt like, ‘Wow, I can rely on this protection that I have.’ And then things changed.”
Even once COVID-19 cases began to drop and surge staffing was pulled back, the ICUs remained as full as ever, with people sick with non-coronavirus illnesses.
“There was no reprieve,” Swamy said. “We were just getting hit harder and harder even though it wasn’t COVID … So it was hard for a while.”
It wasn’t until the summer that the level felt dramatically different, the doctor said. It seemed quieter and safer.
Health care workers felt better, like they could catch their breath. It also allowed them to think about everything they had experienced and witnessed, and gave them a chance to attempt to process it.
But still, until vaccines arrived in December, uncertainty remained. Getting vaccinated felt both unbelievable and overwhelming, Swamy said. The vaccine made him feel safe, but it didn’t change what he was seeing in the hospital.
“It’s been just been a wild rollercoaster of emotion,” he said.
And even with the changes brought by lower case rates and the hope of vaccines, the trauma remains.
‘You walk in those rooms and there’s a lot that you’re bringing in with you’
Before the pandemic, health care providers working in ICUs were accustomed to taking care of very sick patients, and deaths in the units occur daily, Swamy said.
But what made the first surge — and those that followed — so different was the volume and degree of suffering.
“The fundamental problem to me was, and I’m not criticizing this at that time, but we didn’t have families at the bedside,” Swamy said. “So people were really dying alone, it felt like, with just us standing there covered in all of our PPE, no family members, no loved ones, and then it was iPads and FaceTime … It’s hard to build that wall up of just being kind of numb to it when you’re holding up the phone and people are just bawling at the other end.”
The critical care doctor said the pandemic put a “fine edge” on the reality that many people went through a lot of agony and trauma in ICUs when doctors were forced to use life-sustaining measures, absent clarity on what the individuals or their families might not have wanted. That fact needs to be addressed by families, and society more broadly, by having conversations with one another sooner, and more frequently, about “what would I want, what would I not want” should they land in an ICU, he said.
“We put families in a terrible position in this country where your elderly loved one is sick and you’ve never had that conversation with them about what they would or wouldn’t want,” Swamy said. “It’s not about who should get what … it’s about who actually wants what. And it’s so often we have a family communicating with us where one person is saying, ‘This person would never have wanted this.’ But that conversation wasn’t had. And not only is that human being suffering on that ICU bed, but the family is suffering and they’re in incredible duress trying to figure out what to do. And that’s not fair. That’s not fair to anyone involved in that.”
For the doctors and nurses, meanwhile, it’s harder now to be in the ICU than it was before. There are triggers throughout the space, reminders of what was experienced in the rooms by patients and health care workers alike, he said.
“There really is this stain over the ICU … that even now when I take care of someone who doesn’t have COVID at all and has something that gets better relatively quickly, you walk in those rooms and there’s a lot that you’re bringing in with you,” Swamy said. “Because I remember when I was in that room resuscitating someone … I remember seeing the same person in that bed for weeks on end, critically ill, having one problem after another and then eventually dying. That’s not something that you can easily forget or ignore.”
Before the pandemic, it wasn’t unusual to have those kinds of lingering intense memories of dramatic moments from caring for patients in one or two rooms.
But now, the challenge is greater because the wave of suffering that occurred was experienced in almost every room. Each one now bears so many memories from the first surge, Swamy said.
And echoes continue as new patients sick with COVID-19 keep arriving in the hospital.
“Now, it’s like this extra question of, ‘Oh my God, we could have vaccinated this person. Why was this person not vaccinated? Why was this elderly, Black man not vaccinated? What is going on here? We could have stopped this,’” Swamy said.
‘We need to really aggressively get support to the front line workers’
The doctor said there remain a number of steps to be taken to mitigate the trauma experienced during COVID-19 in ICUs. Among the most important to him is getting families back to bedsides again, allowing them to see their critically-ill loved ones.
Doing so will help not just families, but the physicians and nurses as well.
“It makes a world of a difference to have family members connect with them so we can humanize their experience,” Swamy said.
But Swamy said he remains concerned that the impacts to the mental health of health care professionals during the pandemic will result in individuals in direct clinical care positions finding ways to do less of that work. Burnout among doctors was already a phenomenon, leading to physicians deciding to cut back on clinical care time, he said.
“To be honest, this is what I’m doing,” Swamy said. “This is what I did after last year and now I work part-time in the ICU and part-time in an administrative role. That was something I was always interested in, so I think I’m a little bit of an exception there. But I have to admit, part of it is just, it’s not the same to work in the ICU … So I worry that the default is that people leave, leave the bedside, leave the ICU.”
It’s not a good solution to the problem, he said, since it will likely see the people with the most experience leaving, for other work or retiring early.
Instead, more has to be done to find ways to support the health care providers and improve the work itself and address the “slow burn” that was already happening.
“Before, I think a huge part of it was needing to fix the systems that we work in,” Swamy said. “That’s still true. But in addition to that, I think we need to really aggressively get support to the front line workers. Before the pandemic, I did not have a therapist, I told people everyone should have a therapist — I was one of the people who said those things. I never had one. And it really took this crisis for me to find that for myself. And it’s an enormous, enormous help.”
There is still so much stigma around access to mental health care and barriers remain to getting therapy, which needs to be urgently addressed, he said. The support is missing and it needs to be there for everyone.
“Everyone has suffered a lot through this — it’s not just the clinician,” Swamy said. “Everyone has really been through a lot, and I think we need to really find ways to acknowledge that and support each other.”
In the meantime, doctors and nurses working in ICUs still expect to see more surges of COVID-19.
The difference now, Swamy said, is they know what it will look like and are better equipped to deal with it.
For himself, the doctor said he’s trying not to be pessimistic, given the pace at which vaccines are being administered — doses that a year ago he never imagined would be as effective as they are at preventing the disease.
But it can never be fast enough.
“It’s hard to balance, though, when you see people who are sick who could have been vaccinated and it didn’t happen, and you’re seeing the same thing as before,” Swamy said. “The patients looked the same as they did in March of last year. They come in with bad COVID. We’re worried about it.”