It’s not fighting for you that terrifies me, it’s walking away that keeps me up at night.

Conversations on the front lines of medicine look different during a pandemic than they usually do. I hate these conversations. They prepare us for the day that our hospital has more patients than provider hands. Our leaders review policies for appropriate triage strategies that run opposite of normal protocols. Normal triage protocols prioritize the sickest and closest to death and descend from there. At the point of system overwhelm, those closest to death, who require attention and resources that are no longer available, are redistributed to the end of the line-behind those with better chances of survival who require less or minimal intervention. This strategy aims to delay so that those persons do not become the ones closest to death. We switch to mitigation instead of intervention. (This is the “black tag” battlefield triage methods you’ve heard so much about. It’s real and it sucks.)

Our experts have come by our units to remind us, that if we go down, everyone goes down. More people die. We have to do things that run entirely opposite to everything we’ve ever trained to do. In order to ‘not go down’ (costing more lives) we have to suit up. We have to suit up correctly. If we don’t, we go down. This process takes time. In critical medicine, time is the one thing we don’t have. We’ve been trained to run in, guns blazing, caution be damned. We descend on the enemy- we’ve been reduced to carefully suiting up while the enemy ravages it’s victim…..as one of my writer colleagues put it, “there are no emergencies in a pandemic.” As an emergency nurse, I HATE that there are no emergencies during a pandemic. We live for emergencies. Call me an adrenaline junkie, accuse me of being broken, I’ve heard it all. Little parts of all of that are probably true. Doesn’t really matter why we are the way we are….the point is, even if we’re broken we’re useful.

Most of us in critical care are familiar with death. We’re not “okay” with it per se, but we’re no stranger this foe.

When we encounter death, we cope with it by rationalizing that we did everything we could. We walk away from a lost battle with the angel of death victorious knowing that we gave her a run for her money and she, at best, claimed her soul wounded. We never just let her take it. Never. Until a pandemic.

Pandemics steal that coping mechanism from us. When too many sick people present to us at once, we have to decide which of our actions might save the most amount of people. A hard fought war over the taking of one soul could cost us the battles that result in the loss of many more later. So we abandon those wars that have the highest probability of defeat and instead engage in the battles most likely to stave off a war.

The problem with this, is that critical care providers derive our morale from snatching victims out of the jaws of death. It’s literally what we do. We look certain death straight in the face and say “not today”. We win. We hate losing. We bring you back to life. We rinse & repeat. We take losses hard. We don’t go down without a fight unless we’ve used every weapon in our arsenals. It’s these victories that make our losses bearable.

A pandemic doesn’t let us do this. Our arsenals are depleted. Our army is small compared to the numbers of the enemy. We have to work smart and hard- but we’re not allowed to fight…..and we really like fighting. We’re asked to walk away from fights we KNOW we could have won on a regular day-but this is no regular day.

Coping is going to be hard for the critical care community after this is all said and done. I’m not afraid to fight, but I’m terrified to walk away. Please stay home. Don’t make me walk away from you. Fight for me- so that I can fight for you, on a different day, when our world returns to normal.

Check on your front line friends if the day comes when they’re having to walk away. I promise you, they’re not okay.

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