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When Duty Calls, and Menaces When Duty Calls, and Menaces
(8 days later)
We’re a married couple, both doctors, originally drawn to medicine because we want to be of value at times of need. But as Chicago approaches its projected surge, and with infections likely continuing for months, we’re debating what we can and should do.We’re a married couple, both doctors, originally drawn to medicine because we want to be of value at times of need. But as Chicago approaches its projected surge, and with infections likely continuing for months, we’re debating what we can and should do.
If we’re asked to treat Covid-19 patients, we want to help, in part because we don’t want the burden to fall on residents and other trainees. But Veena is an ophthalmologist. Manish is a pediatric surgeon. Until now, being effective has meant honing very specialized skills in those areas. Veena has not practiced in an intensive care unit in years. Manish is pulling out his old textbooks before bed. We worry about practicing outside of our specialties, trying to solve life-threatening problems when we’re not really the experts.If we’re asked to treat Covid-19 patients, we want to help, in part because we don’t want the burden to fall on residents and other trainees. But Veena is an ophthalmologist. Manish is a pediatric surgeon. Until now, being effective has meant honing very specialized skills in those areas. Veena has not practiced in an intensive care unit in years. Manish is pulling out his old textbooks before bed. We worry about practicing outside of our specialties, trying to solve life-threatening problems when we’re not really the experts.
Our ophthalmology and surgical patients need us, too, but treating them carries some risk of infection as well. We worry, every time we enter the house, about spreading the disease to our family.Our ophthalmology and surgical patients need us, too, but treating them carries some risk of infection as well. We worry, every time we enter the house, about spreading the disease to our family.
How do we balance between protecting our patients, our trainees, our family, ourselves and our moral sense of why we do what we do?How do we balance between protecting our patients, our trainees, our family, ourselves and our moral sense of why we do what we do?
VEENA and MANISH RAIJI, ChicagoVEENA and MANISH RAIJI, Chicago
Dear Veena and Manish,Dear Veena and Manish,
When I asked other physicians, as well as medical ethicists, about your quandary, the first thing they said was: They’re glad you spoke up. As health workers in New York essentially rush into the equivalent of burning buildings, and earn nightly standing ovations for it, many doctors have felt it is taboo to express any reservations about lending a hand.When I asked other physicians, as well as medical ethicists, about your quandary, the first thing they said was: They’re glad you spoke up. As health workers in New York essentially rush into the equivalent of burning buildings, and earn nightly standing ovations for it, many doctors have felt it is taboo to express any reservations about lending a hand.
But with private practices shuttered and elective procedures canceled, there are doctors around the country watching edgily from home, feeling guilty that they haven’t done more, and weighing whether and to what extent they are willing to risk infection — or spread it — by treating either Covid-19 patients or others. Hospitals are reconfiguring staff and preparing for a long slog, relying not just on emergency and critical care physicians, but also on doctors like you who work in other specialties.But with private practices shuttered and elective procedures canceled, there are doctors around the country watching edgily from home, feeling guilty that they haven’t done more, and weighing whether and to what extent they are willing to risk infection — or spread it — by treating either Covid-19 patients or others. Hospitals are reconfiguring staff and preparing for a long slog, relying not just on emergency and critical care physicians, but also on doctors like you who work in other specialties.
In New York, the conflict over who should work is rising: So many staff members at public hospitals have called in sick that administrators, suspecting that not all the absences were valid, began requiring doctor’s notes. That change in policy outraged some nurses: “Don’t blame us for the government’s lack of preparation,” one told The New York Post.In New York, the conflict over who should work is rising: So many staff members at public hospitals have called in sick that administrators, suspecting that not all the absences were valid, began requiring doctor’s notes. That change in policy outraged some nurses: “Don’t blame us for the government’s lack of preparation,” one told The New York Post.
At many institutions, protective personal equipment is still in short supply. At least 9,000 medical workers responding to the outbreak in the United States have been infected and dozens have died.At many institutions, protective personal equipment is still in short supply. At least 9,000 medical workers responding to the outbreak in the United States have been infected and dozens have died.
Sitting out the pandemic could mean letting the burden fall on colleagues, missing a defining hour for medicine and defying the precept that, whatever your specialty, you’re a healer first.Sitting out the pandemic could mean letting the burden fall on colleagues, missing a defining hour for medicine and defying the precept that, whatever your specialty, you’re a healer first.
“There’s a feeling of, ‘Oh my god, I’m not going in, I’m not working,’” said Dr. Stephen Goldstone, a surgeon in New York who is mulling whether to volunteer. “I feel totally guilty about not being there,” he said, especially because he has taught medical students that doctors are obligated to treat patients even when it means putting themselves at risk.“There’s a feeling of, ‘Oh my god, I’m not going in, I’m not working,’” said Dr. Stephen Goldstone, a surgeon in New York who is mulling whether to volunteer. “I feel totally guilty about not being there,” he said, especially because he has taught medical students that doctors are obligated to treat patients even when it means putting themselves at risk.
But that idea has not been tested in our lifetimes the way it is now. Even medical ethicists are divided about the degree to which medical professionals are required to put themselves in harm’s way. This is a question many of them have studied only in much more limited situations, or in the abstract. Now it’s pervasive and urgent, and everyone’s well-being rests on the answer.But that idea has not been tested in our lifetimes the way it is now. Even medical ethicists are divided about the degree to which medical professionals are required to put themselves in harm’s way. This is a question many of them have studied only in much more limited situations, or in the abstract. Now it’s pervasive and urgent, and everyone’s well-being rests on the answer.
“There are certain duties that go with your position in life,” said Dr. Steven Miles, an emeritus professor of medicine and bioethics at the University of Minnesota, adding that he had contracted tuberculosis, staphylococcal pneumonia, hepatitis and dysentery while treating patients in developing countries. “If we’re going to give doctors the monopolies on these tools, and compensate them, there comes a time when we say, ‘We’re going to need you for this work.’”“There are certain duties that go with your position in life,” said Dr. Steven Miles, an emeritus professor of medicine and bioethics at the University of Minnesota, adding that he had contracted tuberculosis, staphylococcal pneumonia, hepatitis and dysentery while treating patients in developing countries. “If we’re going to give doctors the monopolies on these tools, and compensate them, there comes a time when we say, ‘We’re going to need you for this work.’”
If firefighters refused danger, he said, “we couldn’t have a fire department.”If firefighters refused danger, he said, “we couldn’t have a fire department.”
But firefighters at least wear full protective armor. They risk their own lives, typically without fear of inadvertently transmitting the danger to someone else. “The No. 1 rule is: You don’t create two victims,” said Dr. Douglas Diekema of the University of Washington, who argued that the continuing shortage of adequate protective gear somewhat lessened the moral obligation for health care workers.But firefighters at least wear full protective armor. They risk their own lives, typically without fear of inadvertently transmitting the danger to someone else. “The No. 1 rule is: You don’t create two victims,” said Dr. Douglas Diekema of the University of Washington, who argued that the continuing shortage of adequate protective gear somewhat lessened the moral obligation for health care workers.
Updated June 24, 2020 Updated June 30, 2020
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
Scientists around the country have tried to identify everyday materials that do a good job of filtering microscopic particles. In recent tests, HEPA furnace filters scored high, as did vacuum cleaner bags, fabric similar to flannel pajamas and those of 600-count pillowcases. Other materials tested included layered coffee filters and scarves and bandannas. These scored lower, but still captured a small percentage of particles.Scientists around the country have tried to identify everyday materials that do a good job of filtering microscopic particles. In recent tests, HEPA furnace filters scored high, as did vacuum cleaner bags, fabric similar to flannel pajamas and those of 600-count pillowcases. Other materials tested included layered coffee filters and scarves and bandannas. These scored lower, but still captured a small percentage of particles.
A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.
The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.
The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
No one I spoke with thinks it would be irresponsible of you to treat Covid-19 patients despite coming from other areas of medicine. Doctors with varied specialties are doing so — many working under supervision, handling tasks like monitoring oxygen and blood pressure or collating lab results.No one I spoke with thinks it would be irresponsible of you to treat Covid-19 patients despite coming from other areas of medicine. Doctors with varied specialties are doing so — many working under supervision, handling tasks like monitoring oxygen and blood pressure or collating lab results.
Almost everyone feels unprepared, because the disease is so new and the treatments are still so uncertain, doctors said. “Would they still call us heroes if they knew we felt so helpless?” Dr. Craig Spencer, director of global health in emergency medicine at NewYork-Presbyterian/Columbia University Medical Center, recently wrote. That’s an unsettling change for ultra-specialized doctors like you, accustomed to working with more order and control. Dr. Megan Ranney, an emergency physician in Providence, R.I., said the chaos of treating conditions like gunshot wounds had been the best emotional training for the coronavirus. “We’re used to working at the liminal edge of the health care system,” she said.Almost everyone feels unprepared, because the disease is so new and the treatments are still so uncertain, doctors said. “Would they still call us heroes if they knew we felt so helpless?” Dr. Craig Spencer, director of global health in emergency medicine at NewYork-Presbyterian/Columbia University Medical Center, recently wrote. That’s an unsettling change for ultra-specialized doctors like you, accustomed to working with more order and control. Dr. Megan Ranney, an emergency physician in Providence, R.I., said the chaos of treating conditions like gunshot wounds had been the best emotional training for the coronavirus. “We’re used to working at the liminal edge of the health care system,” she said.
The key to volunteering, other doctors said, is to find your own toehold. Several weeks ago, as the crisis climbed in New York, Dr. Judith Salerno faced a quandary similar to yours. For years, she had been running nonprofit organizations, seeing only a few geriatric patients on the side. “I was sitting doing Zoom conference calls, and all I heard were the sirens and the ambulances,” she said. Although she hadn’t worked in hospital medicine for many years, she volunteered at Bellevue. On her first day, she felt like an intern all over again.The key to volunteering, other doctors said, is to find your own toehold. Several weeks ago, as the crisis climbed in New York, Dr. Judith Salerno faced a quandary similar to yours. For years, she had been running nonprofit organizations, seeing only a few geriatric patients on the side. “I was sitting doing Zoom conference calls, and all I heard were the sirens and the ambulances,” she said. Although she hadn’t worked in hospital medicine for many years, she volunteered at Bellevue. On her first day, she felt like an intern all over again.
But she found her place in palliative care. Her counterparts in the I.C.U. had no time for the delicate work of talking patients’ families through end-of-life care — remotely, no less — so her team is doing it. Once she began working, she said, her sadness increased, but her anxiety and feelings of helplessness abated.But she found her place in palliative care. Her counterparts in the I.C.U. had no time for the delicate work of talking patients’ families through end-of-life care — remotely, no less — so her team is doing it. Once she began working, she said, her sadness increased, but her anxiety and feelings of helplessness abated.
In the coming weeks you, too, may decide to plunge into the Covid-19 emergency. But ethicists say that your obligation is not the same as that of the emergency room doctors, respiratory therapists, and others on the front lines. They have the relevant core skills. The obligation to volunteer is lower than the duty of essential workers not to abandon their stations. A rule of thumb for everyone in medicine right now is to “find a role to serve that matches your training and abilities and is specific to the conditions of today,” said D. Micah Hester of the University of Arkansas for Medical Sciences. By continuing to see patients at risk of losing their vision, and performing emergency pediatric surgeries, you’re already doing that.In the coming weeks you, too, may decide to plunge into the Covid-19 emergency. But ethicists say that your obligation is not the same as that of the emergency room doctors, respiratory therapists, and others on the front lines. They have the relevant core skills. The obligation to volunteer is lower than the duty of essential workers not to abandon their stations. A rule of thumb for everyone in medicine right now is to “find a role to serve that matches your training and abilities and is specific to the conditions of today,” said D. Micah Hester of the University of Arkansas for Medical Sciences. By continuing to see patients at risk of losing their vision, and performing emergency pediatric surgeries, you’re already doing that.
For years to come, Dr. Hester fears, medical workers may ruminate about the trade-offs they are making during this period for their patients, their families and their own health. “It’s the story you tell yourself” about this time, he said.For years to come, Dr. Hester fears, medical workers may ruminate about the trade-offs they are making during this period for their patients, their families and their own health. “It’s the story you tell yourself” about this time, he said.
He offered a gentle warning that you and your colleagues are likely to face moral residue — the lingering discomfort, he said, of “choosing between or among our moral convictions, letting some go in order to fulfill others.”He offered a gentle warning that you and your colleagues are likely to face moral residue — the lingering discomfort, he said, of “choosing between or among our moral convictions, letting some go in order to fulfill others.”
Lauren Messman contributed research.Lauren Messman contributed research.
Dilemmas is a new column about dealing with the human quandaries presented by the coronavirus pandemic. Please send yours to dilemmas@nytimes.com.Dilemmas is a new column about dealing with the human quandaries presented by the coronavirus pandemic. Please send yours to dilemmas@nytimes.com.