On Joy and Sorrow in Our Long Winter

 From the 12/30/2020 newsletter

Perspective

 

 

On Joy and Sorrow in Our Long Winter

 

Ana Istrate, MD MS – Internal Medicine PGY-1 Resident

 

 

Dr. Istrate reflects on how her rotation through the COVID ICU as an intern is inextricably tied to the rest of her year …

 

 

 

Then a woman said, Speak to us of Joy and Sorrow.

  And he answered:

  Your joy is your sorrow unmasked.

-Kahlil Gibran, “On Joy and Sorrow”

 

 

At the beginning of this strange year, I took a solo trip to Washington DC, a city I had never seen before. Sunlight hit the Reflecting Pool like a knife, the air was uncommonly warm, and the National Mall was full of maskless strangers. It was impossible to find a quiet moment at the Lincoln Memorial. I met a family friend at the National Gallery of Art, where we made our way through currents of people, half in conversation with each other and half in conversation with the paintings and sculptures around us. I remember the contents of that conversation much less than I do the feeling of being in it, like floating on a raft through a luminous city, watching the threads of our childhood ripple in its wake.

 

It is curiously difficult to disentangle that more recent memory from all the memories of our lives that resurfaced then. Lately I find myself running through the locales of my past as if turning the pages of a photo album, aware that I am looking for a particular photo without knowing exactly which one. There is no living memory that seems best poised to clarify our present trial.

 

 

Rotating through the COVID ICU

 

Fragments of time in the COVID ICU remain more salient than what took place there: squinting through the glass doors of negative pressure rooms to see if oxygen requirements had shifted or ventilator settings had been recalibrated, noticing the unforgiving brown-red of facial pressure ulcers as we prepared to place another line, and catching a glimpse of our medical student’s eyes full of tears after our youngest patient had died. Equally vivid is the sensation of walking in each morning to be greeted by my co-residents’ familiar faces. It went unstated, as many important things in our lives somehow do, but they fueled my optimism.

 

I remember placing the phone back in its cradle at the end of one of my night shifts, having told a wife, whose halting, soft voice I don’t think I will ever forget, that her husband was not long for this world, to find one of my co-residents sitting next to me, prepared with morning eyes to receive the story of that night. It’s curious that we call these transitions of care “hand-offs.” At times, it seems we redistribute emotional loads too. (There is a certain generosity, I’ve also found, in the springing to action so specific to ICU care.)

 

Those of us who are interns have barely any point of reference for what being a physician was like before this pandemic, and we still spend much of our time taking care of non-COVID patients. We take it on good faith that the medical ICU was busier and more strained this winter than the last. For better or for worse, this profession and its members stand firm in their resolve to soldier on. And so, the mental and emotional burden on all those involved in patient care is nothing new under the sun, but perhaps more profound. I know I am not alone in the constant oscillation between hopefulness and seemingly impermeable disillusionment that this long season has brought us. There is a particular sting in the signs of indifference we encounter these days. It is present in the nonchalance of maskless strangers and the well-rehearsed backtracking of policymakers. Mercifully, we have little time to ruminate. That is the blessing of apprenticeship and its demands.

 

 

The thread unraveling behind us

 

And yet, that rushing in fragmented haste from one patient or idea to the next bewilders us into forgetting that there is a thread unraveling behind us. Grief, rather than being reserved for clearly demarcated losses, is less a discrete emotion and more a slow change of climate. At its most acute, it leaves us in tears. But mostly it is the inseverable string that links one loss to the next one in our lives. It becomes impossible to separate experiences, sleep deprivation notwithstanding. The death of my last patient in the ICU—a middle-aged, cadaverous man whose pancreatic disease marched him coldly into heart failure and whose death wish in his final hours left me heartbroken despite his ever hostile (wounded) demeanor—had nothing to do with COVID, and yet I cannot extricate his story from the pandemic playing out in the background.

 

So many of us take comfort in relegating this year to the corner of exception. We are keen to label this pandemic an anomaly. It is with a perverse kind of thrill, too, that the media delights in labeling this moment (and the next) as a historical turning point. And there is no doubt that, given everything that has happened, it will be. But how many of us can feel such cosmic shifts in our own inner worlds? It is frequently beyond the intimacy of human experience. Many of us have never confronted loss in so swift and raw a form, though we have been cognizant of it (I don’t only mean the loss of life but also the loss of dignity and patience and faith). I wonder if we can forgive ourselves when it all seems so muddled and even collides with the small joys we still discover in our lives.

The view from here

 

And lately, there is more cause to hope than there has been in the past year, though I follow the news from California and other overwhelmed regions of the world with a heavy heart. A collective joy surrounds these early vaccination efforts, which stems from a deep sense of relief. I couldn’t help but grin like a fool behind my mask as I felt the needle sink into my deltoid. (My vaccination card will be passed down through generations, I semi-jokingly tell my family and friends.) The winter solstice is behind us, and a new year is about to begin. In six months of residency, I have encountered more kindness than I ever expected. The waters of the Reflecting Pool greet me every time my cell phone wakens, and the Lincoln Memorial sits in the corner of that photograph like an afterthought. Life has not yet given me cause to change the backdrop, though the thread has unraveled so fast and far from there. Somehow, there’s no separating that afternoon from all the ones that followed.

 

 

 

Ana Istrate, MD MS received her MD from Case Western Reserve University. She is a PGY-1 in the Internal Medicine Residency Program at MCW.