Lachlan Rutledge, 37, is discharged from the E.R. after three weeks of treatment and their teenage son arrives at the hospital
The Rutledge family lives in the sunny suburb of Broken Arrow which has a dentistry called Super Smiles and a frozen custard shop. Their front porch is home to potted succulents, an abandoned scooter and a 140-pound Great Dane named Thor.
But their lives are far from ordinary. The last time Lachlan needed to see an allergy specialist, his mother packed the car with his nebulizer and medications for a 14-hour drive to Denver, leaving her husband, their two other sons and her mother, who was undergoing chemotherapy, for two weeks. Later, when doctors told her that Lachlan’s disorder appeared to be causing stomach ulcers — but that the sole pediatric gastroenterologist at Saint Francis wasn’t available for months — she began planning a journey to Dallas.
On the morning of September 9th, Lachlan was in the hospital and the E.R. was busy, so Ms. Rutledge put him up to a pulse oximeter to keep his heart rate down.
“I know you guys are exhausted at this hospital, and I get it,” she shouted, leaning over Lachlan’s bed to level her eyes with the attending physician on the other side. “But you will not send this child home so he can watch his own vitals drop.”
Lachlan was discharged from the E.R. after 10 hours with a course of steroids to fight the inflammation in his lungs. He sleeps in his parents’ bedroom so they can check his oxygen levels and administer nebulizer treatments every few hours throughout the night.
FRESH AIR: The First Year of COVID-19 and its Implications for Emergency Room Physicians, Nurses, and the ER
This is FRESH AIR. I’m Dave Davies, in for Terry Gross. More than 3,600 American health care workers died during the first year of the Pandemic. Our guest, emergency room physician Farzon Nahvi, says that was a time when he and his colleagues were improvising means to treat patients and protect themselves. He says in his new book that hospital administrators were like frontline medical workers in not knowing what to do. For a time, some hospitals banned physicians and nurses from wearing masks at work, fearing it would frighten patients more than reassure them.
Let’s take a break. Let me reintroduce you. We are talking with a person. He’s an emergency room doctor at Concord Hospital in New Hampshire. His new book is “Code Gray: Death, Life, And Uncertainty In The ER.” We’ll keep talking after this break. This is FRESH AIR.
There are a lot of difficult questions to answer for patients and their families at the end of the book. And you write that you don’t have a chapter where you can answer these questions, I mean, that these are unsolved dilemmas that – you say you hope you provide we, your readers, with a measure of discomfort so we can consider some of life’s important questions…
It felt in that moment that we were one step ahead of all the guidance we were getting because we were there on the ground experiencing this. One or two weeks later, we would get the guidance. So we were really relying on each other for everything – what to do, how to treat people, what our situations were like in our different hospitals. If family members got sick, we would ask each other to look after them. During the early part of the Pandemic, things were happening on the fly so it was important to have it covered.
Nahvi: I think the early stance that COVID is not an airborne disease, when in fact we later on learned that it was, and other countries said that it was – by not treating it that way, I think we put a lot of ourselves at risk by not encouraging mask use early on. Two of the physicians I worked with died early on. I worked alongside an overnight clerk and he and a patient transporter both died. Two physician assistants that worked in the ER with me did not die, but they were young guys. They were intubated in the ICU, they were in their 30s and 40s.
It was not the same time period. And it’s very difficult to kind of get into that mindset again, to remember what it was really like, because we’ve come such a long way with vaccines and kind of with time and the virus mutating on its own. I spoke with a colleague of mine who is an internal medicine doctor and she told me it was related to childbirth. She is the mother of a child. She said the earlier period was just like a childbirth period, where you have a very dramatic experience and then everything is done quickly and you are back to normal.
You look back and say, hey, is that actually as I remembered it? Was it just as crazy? And it was. That dramatic episode was brief and it’s hard to appreciate it in the future.
COVID-19: Seeing a Psychiatrist in a Psychological Emergency Room: What I’ve Learned in Three Years?
NAHVI: I’d say, yeah. In the text message thread in the book, there are some parts where coworkers might ask each other if it is safe to use the health insurance for seeing a Psychiatrist. And I know a lot of people that saw therapists for the first time because of this. And I think it’s not just that people were dying, and it’s not just that this was a scary time for us. It’s also, as I was saying, this kind of loss of confidence in our system making the right calls to protect us.
The CDC and kind of our health care institutions at the highest levels weren’t making the right calls to make us feel safe because it’s one thing to say, hey, you know, there’s this big scary thing that’s happening, but you guys are in the position to help, and we’re calling on you to help out. And it might be risky, but we’re all in it together. But it’s another thing to say, hey, this big thing is happening. We want you to help, and we are going to support you 50% of the way. So I think a lot of people had that sense that there wasn’t as much trust in our institutions as we would like to have had. It became a lot scarier because of that. I think the stress comes from that.
NAHVI: I did, yeah, for the first time in my life. There’s this wonderful collaboration between those of us who are in it together and texting one another. And one of those things was there’s a group of therapists that actually got together, and they weren’t ER doctors, so they couldn’t help out in those early stages of COVID in the ER, but they decided that they wanted to help out by supporting us who were working in the ER. They provided free therapy to anyone who wanted it.
I’ve never been in a situation in which I felt that I needed therapy. But because it was so available and because these people were coming from just this genuine desire to help us, I took him up on it, and it really was – it was very helpful, actually. And I appreciate that. I’m doing well, and three years later, I’m doing okay. It’s most likely due to the experience I had.
NAHVI: You know, there was just a lot of anger at that time. I’m not necessarily an angry person by nature. That’s not something I like to do. I remember being very angry and having someone help me through it, I think it was incredibly valuable.
Bringing a woman to the emergency department: What do you do when an ambulance arrives and tells you it’s not going to be revived? NAHVI: The book about life in the ER
So the book is about life in the ER. When you hear that an ambulance is going to take a woman who has not had a pulse for over 30 minutes to a hospital, it’s like being on duty in a different part of NYC. It’s clear to you that she’s died and is not going to be revived. What do you and your team prepare to do when the ambulance arrives?
NAHVI: You’re aware that it is. Yeah. We need to make sure we’re all on the same page. We communicate with the team while I lead the attempt, and we say, hey, we have a 45 year old female. She came in with X, Y or Z. We did X, Y, or Z. We did not feel a pulse. There is no return of the flow of air. It’s been 45 minutes. It’s time to call this code and death the same thing. Does anyone have a better idea? And we do this to review to make sure we’re not missing anything because we want input from everyone on the team. Sometimes our nurses have great ideas and sometimes we don’t and it’s important to continue that.
NAHVI: There are two ways to think about that. The first way – and for me, the most important way – is that that’s their right. It is their right to make a decision if they come in or not. The second thing is – your question has a lot of validity. In previous generation, in previous eras, we didn’t used to let people in the room. We used to protect them from that experience when they were young. But more recent research has demonstrated that actually helps the people who survive that experience. Family members who witness their loved one dying are less likely to grieve the same way than those who are not in the room. You can imagine that it will give you some kind of closure and an understanding that the medical team did everything they could have done.
And so if the person didn’t make it and they did end up dead, that every effort to keep them alive was made. A lot of people experienced this, when people weren’t allowed there, because we could look at the research and the data. I think we think that it’s horrifying to watch someone during the final moment as they die, and it is, but the more horrifying thing is to not watch it, is to not be allowed to be in that room. During COVID a lot of people went through that.
The husband of a woman who had died watched as your team tried to resuscitate her. When you sat down, what was your approach to communicating with him? What was it like?
It’s a dramatic scene where someone is about to die, and we want everyone in that room, no matter who is on my team with me. I do not want someone to say, hey, I think we should have done this after we did it. So we do review that. As long as everyone buys in and we’re all on the same page, then we proceed, and we say, OK, time of death, 10:32 a.m. or whatever it is. And that’s usually how it ends.
NAHVI: Asking them what they know is the first thing you should do. Before I even say anything, I say, hey, we were in the same room together. Tell me what you know up until this point, and let me fill you in on the rest. And that gives me some time to actually get a better understanding of who this person is. What are they aware of medically? What have they seen? But also, how am I going to speak with them? And it kind of helps me frame my conversation. I might put them in on the rest.
We tell our friends or family members that everything is going to be alright when they’re going through a hard time. Usually, we give them reassurance. And this was the first time in my life where someone came in, and they probably had some fear deep back in their mind that something catastrophic was happening, and I had to go confirm that. And I was fighting this deep, deep desire inside of me to not want to tell her that truth, to try to avoid that as much as possible.
I walked away from the conversation because I didn’t tell her that she had cancer. I had used all these euphemisms. I told her that the CAT Scan came back and there were some tumors in there. And she said, what could those masses be? I told them they could be bad things. She wanted to know what those bad things were. I said that we’re going to have to have a biopsy to confirm it. It went so against everything I wanted to do that I couldn’t get myself to do it. That was a troubling experience for me.
NAHVI: Well, yeah, absolutely. I had this recognition immediately after I walked away. I was wondering, oh, geez, I didn’t even tell her. And then, I had to have this awkward about-face where I walked back and say, hey, you know, I don’t think I actually communicated as well as I could have, and I had to. I was talking about things that looked like they had a cancer type called Metastases.
NAHVI: I don’t believe that she was confused. I think she knew. I think she probably held on to some hope ’cause I didn’t close that book for her. But I think that she knew.
How physicians deal with death: The case of the 43-year-old woman who died at the end of his life, when the clerk answered the phone and told you that she had died
When someone dies, there’s not much information that I need to give you in terms of the next steps of your treatment or whatnot. A lot of that is reassurance for someone that they did the right thing, that the paramedics who took care of the patient on the way to the hospital did the right thing and so forth. And I might give them specific examples of the things we did to try to resuscitate her and how those were unsuccessful. It is important for me to let them know that the event that happened wasn’t a life threatening situation, it was just an event that was outside of our capacity to treat.
They had daemons. In the case of the woman who – the 43-year-old woman who had died and, you know, you let the husband sit with the wife’s body, and then you spoke to him. And at some point, then you have to put in your notes. I mean, you fill out a death certificate. You put in your notes. And one of the note – things that you note is that these notes that you are writing are going to be gone over in detail by the hospital’s business department. What are they looking for?
NAHVI: Yeah. There is an ER that is busy. It is a chaotic place. And we have a lot of rules on visitors, on who is allowed where and who is allowed to do what. When someone dies, we usually allow their family members to do what they want. There’s no visitor rules anymore. If four or five people want to come in, that’s OK. If they want to stay in the room with the patient, that’s OK.
How physicians deal with death is what you write about. I’ve asked you to read it here, but you should check it out. The book is in the middle. You want to just share this with us?
DAVIES: It’s something that’s a part of your life. You mentioned in the book that your father-in-law became ill with COVID and had stopped breathing once. He was not near you. An ambulance crew had taken him to the hospital with a breathing tube. You called the ER to make sure he was doing well. You knew when the clerk answered the phone that he had died. How did you know?
I know her job. I know what she’s doing. She is looking at a list of patients. And she has a lot of stuff going on. She is very busy. And if it’s a patient with an ankle sprain or with, you know, even a heart attack, you get that information. And then you look at it. You kind of say that I’ll get back to you in a little bit. She just completely changed her tone when she noticed we were calling for my wife’s father and he had died. And it was very evident to me of exactly what happened on the other end of that line.
You write that you never get used to death even though you’re around it a lot. And people wonder how you deal with it. How do you?
NAHVI: People give all sorts of answers for this. I think the honest truth of what we do is we just ignore it. We pretend that it doesn’t exist. And we don’t really acknowledge it. That’s our culture. I think medicine is a very apprenticeship kind of culture where we see people before us, and we emulate the way they do things. And I think, for better or for worse, the way it’s always been, we kind of just ignore it.
And I think there’s a lot of people out there who say that this kind of compartmentalization and detachment is necessary, that if you get too close to those experiences and take them too seriously that you’re going to get too attached and you can’t perform your job. But I think that’s a misread. It’s a good way to cope, but I think it’s not very good. I don’t think you could pretend to be unaffected by this stuff. One of the reasons that I wrote this book was to explore that with myself and others.
They used to call them the “DAVIES.” Yeah. Well, it’s interesting. You say that ignoring it is, I guess, a way to function and get back in there and handle the next day. It’s not healthy in the long run. I don’t know what the alternative is. Writing a book for you was helpful. That’s…
I was an attending physician once. I was supervising one of the residents that I worked with. Someone died at the end of the code. We called a time of death. And he just spoke up on his own. He hoped that everyone can stay in the room for another 30 seconds. I just want to acknowledge that a human has died. He said that they didn’t know this gentleman, and that he said “word for word”. We don’t know his name. But just as we have people in our lives that we love and people who love us, we can assume that this gentleman had people in his life that he loved and people who loved him. We should have a moment of silence in recognition of that and also in recognition of the death of someone. And the whole thing lasted maybe 15 seconds. But it just transformed the way I experienced those things from then on out.
And I copied him. He was my resident. I was supposed to be a supervisor teaching him, but I took that from him. And since then, I’ve been doing that every time that someone dies in the ER. And every time I do that, I have people come up to me – nurses that I work with, technicians, respiratory therapists – and they say, thank you for what you’re doing. So you can tell that there’s this unmet need of how we deal with things in the ER. And I don’t know that I have all the answers of all the things we could do to make this better. I know there are ways that we can do better, from the experience that I’ve had. And I think the first thing we need to do is start talking about it to see how we can kind of have that conversation and begin this process.
NAHVI: They’re looking for profit, Dave. There are billers and coders in a different universe than we are. We live in the clinical space, but we are employees of a hospital, and they too are employees of a hospital. They use software and live in different buildings and they have methods to extract what we write for profit. So they look for phrases that say, hey, this indicates a level of sickness which can be a code that we put in to get billed for this or that. And they generate a bill from what we do.
What happened to a young lady that had cancer just recently died? NAHVI: What happened when a woman went to the emergency room
And in this particular case, it’s kind of disconcerting for me because this person just died, and it’s not really front of mind for me, but I have to write this note, and I do it. And the note itself is not problematic because you do have to write a note to document what happened medically. But then kind of I’m very well aware of all the steps that happen down the line.
NAHVI: It depends on the hospital I’ve worked for. Hospitals that I’ve worked in have a mission to just take care of people. I don’t get the pressure there. But many of the private hospitals I work for, there’s a phrase that’s called strive to five, meaning try to get that Level 5 billing code, you could say.
There is a Native American who calls it “NAHVI.” She was going to the emergency room because her doctor stopped treating her. She was a young lady, what’s her story? She was diagnosed with cancer. She started her treatment at a not for profits private institution after finding out she had cancer. And then what happened was that because of her chemotherapy and her cancer treatments, she took too many sick days from her job. So she ended up losing her job. Losing her job led to her losing her health insurance.
So her chemo – her oncologist wasn’t able to see her anymore because she didn’t have insurance anymore. I was working in a public hospital when he or she referred the patient to us. She didn’t know she had to go see a doctor. So she just came to the emergency room. I thought there was amisunderstanding.
I told her that I’m an ER doctor. I – if I could treat you, I absolutely would. I don’t have any of the tools. I don’t have that capability. We went from there. But that’s how she ended up in the emergency room with me.
DAVIES: It would take her weeks or months to get an appointment with an oncologist, I think she said. And she knew that if you come to the ER, they have to treat you, right? I mean, so she figured, hey, you can’t send me away.
nahvi: That was what she told us, yes. She said that she was familiar, that there was some law out there, that if you are uninsured under any circumstances, you come to an emergency room, we have to treat you. She’s correct. She had a great understanding of the situation but she did not know that we had to treat you in the ER. You have to be evaluated according to the law. And whatever we can do to stabilize you, we have to do.
She was stable according to this legislation. She was dying slowly, even though she had cancer. She wasn’t dying quickly. She was stable. And it became this kind of horrible thing that I had to explain to her that, yes, you’re protected by this law and yes, you have cancer and yes, you’re dying, but I can’t help you.
And not that I don’t want to, again, is just that I am not an oncologist. I don’t have chemotherapy. I’m not trained for that. I don’t know how to do that. You are stable in the eyes of the law. And she kind of got a little upset, rightfully so. If I was dying quickly, you had to take care of me, she said. I’m dying slowly so all bets are off. I had no choice but to agree with her.
The saisments: Right. I think you mentioned a case where a patient came in with serious side-effects from having taken antibiotics that they had bought at a pet supplies website. And you called poison control. And the guy who answered immediately had a guess about what kind of antibiotics. Send this to us.
He said that he gets cases of people taking veterinary antibiotics all the time. When you take dog or cat antibiotics, people do well, because they’re pills, and they’re the right dosage. Whereas fish formulation, it’s just highly dense, highly concentrated ’cause you’re supposed to dissolve it into a fish tank so that the fish can eventually drink it when they have their water. People who take antibiotics in fish are at higher risk of overdose. It was kind of shocking how many times it had to happen.
“Measurement of Life in the Emergency Room”, Narendra Nash Violationi, CNN, April 19, 2019, 930-1200
Someone will argue that she should have done better. The woman is trying to do everything right. She was doing her best to get a job so that she could have health insurance, but at the time, she didn’t have it. She was in the Intensive Care Unit after she fell down a staircase and had some toxicity from the process.
NAHVI: It has made me a better person and a better doctor. I think these stories live within us, whether we acknowledge them or not. And they percolate, and they come out in different ways. I think that sitting and processing them and getting a better understanding has made me understand life itself a lot better. These stories are an exploration of life in the ER, but really, they’re just an exploration of life as a whole. The ER is just life in its most extreme. Oh yeah, there’s nothing unique about it.
The ER is a fascinating place, and it exists as a contradiction. This place has a full team of people that are willing to care for you at any time of day or night. And yet no one ever wants to go there, right? We stuck you with needles. There’s long wait times. You can’t get any rest. It is cheap because it is America. So it’s this funny place where the only people that will ever come there are people that don’t want to be there. We see extremes as a result. You can understand how you feel about things in life if you understand medical, ethical, social and health care extremes.
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