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Jillian Horton is a Canadian internist and writer. Her memoir, We Are All Perfectly Fine, will be published this month.
Imagine you’re a dentist and you’re seeing a patient with an abscessed tooth. You’d normally see them in your office, where you have an array of equipment and medications to make the experience as comfortable as possible for you both. Now imagine that your office has been relocated to a parking lot, or a pier, or a toolshed. You’re expected to do the same job under a streetlamp, with some morphine and a pair of pliers.
The problem isn’t that you can’t possibly remove a tooth under those circumstances. You can, and you will – your patient needs it out, so you have no choice. The real problem is this: You know morally – viscerally – how inferior it is for your patient, and that your patient will suffer. So even though you didn’t create these circumstances, you will feel an overwhelming sense of personal inadequacy as a result. Why? Because you are the one who will perform the procedure, and your professional identity is intrinsically linked to the work you do.
To my knowledge, no dentist – or doctor – has removed a tooth, or an appendix, with a pair of pliers in the past 11 months. It’s a metaphor, and metaphors help us understand the urgency of complex situations in a language that is familiar to everyone. Health care workers use metaphors all the time, including the well-worn, “We’re drowning.” Of course, we aren’t literally drowning. But there is a feeling that we are slowly descending beneath the surface of something dark and ominous, that things will not be the same when we surface. We have lost our sense of what is normal, our equilibrium. We have become unmoored.
Jillian Horton is a Canadian internist who says the pandemic has left medical professionals unmoored due to the heavy pressure of medical work.Leif Norman
A few days ago, I messaged a colleague who works in acute care to see if she could help me with a COVID-19-related project. She sent back an apologetic text. Her husband, also a physician, was bedbound with a severe injury. She had no care for her children, all home from school, one of whom is still a toddler. My colleague was scheduled to work for a week in the hospital caring for COVID-19 patients, leaving her immobilized husband to try to care for their kids between spasms of severe and excruciating pain. “But I know so many people have it worse right now,” she added, almost reflexively. I heard quiet desperation in her words, a desire to not seem ungrateful for still having a job and an income, to not look oblivious to that aspect of our privilege and good fortune.
Isn’t it okay for us to say that being health care providers is hard right now? Yes, health care is always hard, and we know we are signing up for a difficult job when we commit to working intimately with human suffering. But we have been trained to tend to suffering in a certain way, and, while the infrastructure of our personal lives weakens or crumbles, a key tool we have relied on to do our jobs – human connection – has been fundamentally altered or taken away altogether. Yes, most people have faced the total reinvention of their workplaces, and everyone has been affected. Setting up a home office in your bathtub, teaching in a cramped classroom of stressed-out and physically distanced kids, serving coffee from behind plexiglass is all eerie, monotonous, stressful, chronically overwhelming and sad. But it’s never going to be the same as holding up a phone for a family member so they can watch someone’s mother or father die over a FaceTime call.
Harder is not “better” – that isn’t my point. You are suffering, too, whoever you are, no matter what you do. Understanding what is unique about each person’s situation helps us know how we can help them. It lets us anticipate the problems a particular person or group might be prone to – both during and in the aftermath of the pandemic. Certain health care workers face some very specific risks – namely, PTSD, postpandemic depression and suicide. And they are also grappling with a sheer volume of moral injury we have not seen in the Western world in our lifetime.
A nurse administers a COVID-19 test in Johannesburg.LUCA SOLA/AFP via Getty Images
When I try to describe what it feels like to care for patients right now, I’ve found my mind wandering back to one of my early clinical experiences and a patient I had almost forgotten. I was a medical student doing my rotation in pediatrics. The staff doctor told me to go see a child who had been admitted with a blood infection, a young baby, only a few months old. I found his name on the patient board, flipped through his chart, walked down the hallway to his room. I knocked on the closed door, expecting a parent to call out, “Come in!” But there was no answer.
I knocked again, pushing the door open. At first, I thought the baby had been taken for an X-ray or an ultrasound, because the room was utterly silent. No entourage of people fawning and cooing over a baby, no mother cuddling or feeding him, no little stack of diapers and onesies piled neatly on the windowsill. There was only a hard, white metal crib. And in the middle of that crib, lying still and silent on the mattress, there was a tiny, motionless baby.
Moving gingerly, I crept over and peered in at him, thinking I’d find him asleep. But his wide-open eyes met mine and he whimpered, as if he couldn’t even find the strength to summon me closer with a cry. I remember being shocked at his solitude, his seeming confinement, thinking with alarm, what are you doing here all alone? His lower lip began to tremble and he let out a thin wail. I leaned clumsily over the metal railing and picked him up, bringing him to my chest and holding him against my white coat. I remember how his small, unsteady hand came toward me as he tried to touch my face. I sat down in a rocking chair in the corner and cuddled and sang to him, staying for as long as I could before I had to go meet the staff doctor. I remember thinking to myself, I’m not your mother. I can’t replace your mother, I can’t make up for all the people who should be surrounding you right now, enveloping you with love.
When I finally set him back down in the crib, I remember the spasm of distress that rippled across his tiny face, how he cried as I walked away, what it felt like to leave him alone without a surrogate for the enormous, irreplaceable, fundamental thing that was missing at that moment in his life.
There have been an abundance of first-person narratives by health care workers throughout the pandemic about experiences that are very much like this – the abandonments frequent, the situations far more dramatic. I can hardly read those stories; they evoke an almost visceral reaction. Why? Maybe it’s because I already know what it’s like to feel inadequate in the face of that kind of pain. Maybe it’s because I knew these things could or would soon be happening in a hospital near me. Maybe it’s because they’re told in the middle of a trauma – in medias res – unfiltered, unpasteurized, written in one long, muffled scream, as dangerous to hold as a hot piece of coal. Or maybe they just remind me of all the difficult things I’ve seen in the course of my career – tragedies and losses I don’t necessarily want dredged up on command, like the memory of that little baby I left behind more than 20 years ago, alone and silent in his cot, his dark eyes looking up into the void around him.
Do we say to that baby, other babies have it worse? Of course we don’t. You don’t really want to think about what it was like to be that baby, and neither do I. And you don’t really want to know what it’s been like to do some of the things health care workers have had to do during this pandemic. Even if you read the narratives – unless you’ve done something similar in your own life – you don’t understand. I know I don’t understand many of your challenges either. Maybe you think you understand ours, because you read the articles about our experiences all the way through, but that just means a narrator was able to tell the story in a way you could actually handle, let you look at the light without being blinded, gave you the dark glasses you need to look at an eclipse without burning the back of your eyes.
Health workers cry at a memorial for a nurse who died of COVID-19 at a hospital in Leganes, Spain, last April.Manu Fernandez/The Associated Press
I’m not going to tell you any of those hot-coal, look-into-the-light stories about what it’s like in the hospitals now – the terrible things my colleagues have witnessed in the ICU and on the COVID-19 wards, the swift and drowning-in-mucous deaths, the gut-wrenching goodbyes over cellphones and iPads, babies left motherless, grandparents and parents erased from the Earth. I’m not going to tell you about the day-to-day, garden-variety COVID-19 suffering I bear witness to as a doctor who cares for people living with addiction, the myriad struggles, the ways in which the pandemic has amplified the chronic misery and hardship of this population. I’m not going to tell you about the grotesque suffering of our elderly, the disproportionate burden placed on the shoulders of so many vulnerable and marginalized groups.
You don’t need me to tell you, because if you are a health care worker you already know. And if you aren’t, if your life hasn’t been touched by this kind of loss, I don’t think you can understand it – especially the silence, the grief of the missing entourage, the last, lonely breaths, or what it is like for health care workers to leave people alone in those rooms at the very worst moments of their lives. If you think these stories aren’t real, nothing I say can change your mind, and your words will only further traumatize my health care colleagues, many of whom are already struggling to reconcile the betrayal of that cruelty and arrogance with their basic faith in humanity.
I asked a colleague how he was doing the other day. He said, “Isn’t that question kind of irrelevant?” I knew exactly what he meant. The night before, one of my sons was crying with frustration. He missed school, he missed our family, he missed his friends. He said he was just so lonely. Holding him, I asked him to think about what would happen in a prepandemic world if our house burned down. I told him our neighbours and family would rally around us. They would make soup, they would give us shelter. They would find boxes of hand-me-downs for the kids, send fruit baskets. They would lift us up and carry us through. But right now, 11 months into this disaster, it’s as if everyone’s house caught fire. Some people only had a little damage. Others have nothing left. Everyone is, out of necessity, looking inward, trying desperately to put their house in order, preoccupied with their own losses. Our isolation compounds daily.
It has made a difficult job that much more difficult, a sad job that much sadder, the grief of our patients that much more impermeable. No one – even the sick and the dying – can be the centre of healing attention because there is no centre of anything right now. So many people have it so much harder than health care workers. But make no mistake, this is hard. It is very hard. The hospitals are quiet because the entourage is missing. And you cannot imagine the weight of the silence.
Front lines of the hard times
Early in the pandemic, Juno-winning musician Joel Plaskett performed a song he wrote in honour of front-line health care workers on a livestream with The Globe and Mail from his studio in Dartmouth, N.S. studio. Listen to it here.
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