We have spent the past year reacting to crisis after crisis, planning for the next wave and tallying the cost of this virus in body count. Here in the hospital, where we meet patients in extremis, it often feels as though the alarms are so loud that it is impossible to hear anything else. But now, as the number of new coronavirus cases mercifully falls throughout the country, a quieter suffering demands our attention. Though we have always known that the cost of this pandemic would be greater than the number of the dead, we are only beginning to understand its true magnitude. In what might be a final wave of this pandemic, we find ourselves treating patients who have avoided the virus only to succumb to its many unintended consequences — addiction, untreated disease and despair.
I recently cared for a young man who had barely left his apartment for months. By the time he made it to the emergency department, his organs were failing as a result of the heavy drinking that he must have turned to in his loneliness. When his mother arrived at the bedside, shocked to find her son intubated and on dialysis, she told us how he had struggled, first when his job had gone remote and then when he was let go. She and her son talked on the phone every week, but they had not seen each other for months, a decision they had made out of love to keep each other safe. She knew that he was having a tough time, but it is so hard to truly appreciate the depth of someone’s suffering over the phone. As we talked, she started to stroke my patient’s arm and then stopped. Had we tested him for the coronavirus? I explained that we had, multiple times, and the tests had all come back negative. He had managed to stay safe from that threat. But he was not okay.
In this, he is not alone. It comes as no surprise that alcohol consumption is far higher among adults this year. Drug overdose deaths are the highest they have been in any year in history. And these are not the only secondary effects of the pandemic. Another recent patient of mine, a woman with multiple complex chronic diseases, was so terrified of catching the virus that she refused to see a doctor, even as she grew sicker at home. When she was so short of breath that she had no choice but to come to the hospital, she made sure to dress nicely and carried her good leather purse. She had not gone anywhere in so long that even the emergency department felt like an event. She died a few weeks later, and we packed up those clothes and purse in a plastic bag for patient belongings.
We do not yet know how delays in routine care and screening will impact mortality on a population level in the months and years to come. But a colleague of mine who works as a palliative-care doctor tells me that she has recently been called to the emergency department to see patients with new diagnoses of advanced cancer, who are presenting for the first time with widespread metastases, too late to be helped. Some of these patients missed their scheduled cancer screenings, first out of necessity and then out of fear. For others, telemedicine appointments, which by definition do not include a full physical exam, might have failed to pick up subtle signs of worsening disease. These people were scared. They just wanted to avoid getting sick. And yet.
The long shadow of this disease is everywhere. I cared for a woman with lymphoma who was sent to the hospital after she started spiking fevers at a rehab facility where she had spent the last three months. Once we treated her sepsis and it became clear how quickly her cancer was progressing, she asked to see her teenage children and husband. The rehab facility had been in complete lockdown, and she had not hugged them since November. Though my hospital’s rules still limit patients to only one visitor at a time except for when someone is actively dying — at which point two people are allowed at the bedside — we were able to get an exception. Watching the small family’s tearful reunion from outside the room, I realized that my patient had been separated from the people who loved her for what might have been the last decent months of her life. She, too, had stayed safe. But at what price?
Our public health system, already stretched to its breaking point, is poorly equipped to deal with the wave of social isolation and mental health issues that are inevitably coming down the pike. In my hospital, we started a multidisciplinary clinic where we see people who have survived the coronavirus, screen them for common issues they might face and offer referrals with the goal to help them reenter their lives. But there is no such plan for the rest of our patients and their families, who might have stayed safe from the virus but were broken by it anyway. For now, those of us in the hospital do what we can. We intubate those who cannot breathe on their own. We give fluids to deal with dehydration and malnutrition. We call social workers and arrange legal guardianship for the people who have no one. This type of tragedy is not new. But there is more of it now, and as we look ahead toward a more hopeful future, it all feels more poignant.
As I stood at my delirious older patient’s bedside, he moaned and flailed about, batting his arms and kicking his legs free of the hospital sheets. I tried to make eye contact and to explain that he was in the hospital and that he was safe with people who were trying to make him better, but he pulled away. Maybe with more fluids and time, he would start to wake up. But maybe the pandemic had exhausted what little reserve he had. He had been so alone for so long. I took one of his arms and moved it away from his oxygen tubing. Then, thinking about how long it had been since he felt another person’s touch, I paused a moment to hold his hand before letting go.