Each person is a world in COVID-19
Authors: E Wesley Ely
Journal: The Lancet Respiratory Medicine (2021)

I believe it is our age-old acknowledgment of the dignity and self-worth of others that catapults us into caring enough to change health care for the better. From Aristotle to Boethius and down through the centuries, we recognise the unity of body, mind, and spirit in human beings. Medicine is a vocation of service, not merely a career by which to make money. It is about the relationship between people and is unavoidably an ethical and moral enterprise grounded in the promise to do our absolute best for those in need. I fulfill myself most completely by giving myself to another suffering person. As Whitman taught me in Song of Myself, "Hoping to cease not till death…The smoke of my own breath, Echoes, ripples buzz'd whispers…the passing of blood and air through my lungs…" I take myself to each person, thinking of how she is exposed emotionally, physically, and spiritually to me as her physician. This tethers us together in an intense healing relationship that is unparalleled and requires me to quash self-interest in favour of elevating the needs of her who is burdened, unwell, and weary. But how do I stay on track in the pursuit of my vocation? The bedlam of the first 6 months of the COVID-19 pandemic was later moored by a return to previously established evidence of the best way to care for patients with sepsis and acute respiratory distress syndrome, including basic tenets of ventilator management and major elements of the ABCDEF bundle that were initially discarded. In a similar way, I often return to those who have come before me for recalibration. I sit at the feet of my elders. Dr Atul Gawande, in Being Mortal, outlined the stark reality that we too often in modern times disregard the wisdom of those with the most experience. He pointed out that in former generations, so much respect was shown to our elders that people pretended to be older rather than younger. Dr Gawande taught, "As for the exclusive hold that elders once had on knowledge and wisdom, that, too, has eroded, thanks to technologies of communication…At one time, we might have turned to an old-timer to explain the world. Now we consult Google, and if we have any trouble with the computer, we ask a teenager." In critical care, my elders often remember when we tried other things and how miserably they failed. I turn to these people to learn not because they are always right, but because of the insights and knowledge they gained from previous mistakes. To wit, I have a practice whereby I actively seek the wisdom of my elderly patients. In taking a patient's history, if I learn that she has been married for 50 years or more, I delay my next appointment and firmly entrench myself in the sitting position to listen to their story. Two couples, both married over 60 years, became my life coaches during COVID. The first was Mrs Virginia Stevens and Mr Doyle Thomas "DT" Stevens. Married 66 years when the pandemic broke out, both 88 years old and with a progressive COVID infection, they were admitted to our unit in separate rooms. I found DT exasperated and deliriously grappling to get out of his bed, insisting, "I have to find Virginia. Where did they take her?" Through some stellar work by their attending physician, Dr Eleanor Weaver, and the nursing staff, we were able to transfer them both into the same room, at which point his delirium quickly receded. I cherish the picture I have of us together, me in my yellow personal protective equipment and N95, and them, mattress to mattress, firmly gripping each other's hands like they would never let go again, smiling in recovery. Virginia told me their hearts had been sewn together over the 73 years they had known each other. The nurses and I all learned from their love for each other about the beauty of marriage. On discharge, their daughter, Karen, echoed what I was thinking about the nurses, "Can I just say that we had the most kind, helpful, compassionate, respectful nurses I've ever seen. Beyond exceptional." But as usual, the nurses all assured me they got way more than they gave. Just a few weeks later, Mary and Phillip Hill, married 61 years, both developed fever and shortness of breath. Due to diagnostic and therapeutic misadventures in rural Tennessee, they spent days being cared for by their children, Kathy, Gigi, and David. Eventually both parents and their daughters were diagnosed with COVID, but only Mary and Phillip were sick enough to require hospitalisation. Since Mr Hill had previously received a heart transplant and was immunosuppressed, he was transferred 2 h east to our COVID intensive care unit at Vanderbilt, while Mary remained in Jackson, TN. Kathy told me, "I live my life to minimise regrets, and I told Mom's doctor that if they were going to die, I had to get them together." For days, the family made impassioned pleas to get Mary transferred, while her physician explained that it would not change the outcome anyway so there would be no point medically, beds were scarce, and Vanderbilt would refuse the transfer. At Vanderbilt, however, Phillip's physicians, Dr Katherine Yates and Dr Michael Noto, felt it unjust and inhumane to keep these two soulmates apart and made sure the room next to Mr Hill remained open for his wife. Kathy, meanwhile, pled the case to Mary's physician that if he was correct, and no medical management would alter their outcome, then her transfer was even more urgent. Kathy recollected receiving the news, "A few moments later, I called to tell Daddy that Momma was coming to Nashville, and that they would be in adjacent rooms with the same care, the same nurses, the same doctors. Together." She added, "When I first heard they'd be together, I fell to the floor because that was beyond my expectations." After 5 miserable, harrowing days of being more than 100 miles apart, Mary lay next to Phillip once again. At first, they were separated by a wall, but their nurse, Lauren Birmingham, and nurse practitioner, Christy Noblit, dreamed bigger and set Mary up for all her medical care in Phillip's room. Both had thick, corrugated high-flow oxygen tubing draped below their nostrils whooshing air into their bodies, clothed in identical navy-blue hospital gowns. Mary looked to her right, arm extended to Phillip's left wrist, bruised from blood draws, and kept repeating, "Phil, I'm here. I'm here." 3 weeks into COVID, 10 days after their initial hospitalisation, and 2 days after their nurses placed them in the same room bed-to-bed, they died within a few hours of one another, holding hands and, thankful for the grace of already having had COVID, surrounded by family. Kathy told me, "We never left the room. The nurses took care of us all day—fed us box lunches and brought us a basket of snacks someone had given them. They were beyond kind." I carry a phrase in my head with me, "Cada persona es un mundo." Each person is a world. Exactly. Together the Stevens and Hills made me think of Dietrich Bonhoeffer's May 1943 Tegel Nazi prison camp letter to his niece Renate Schleicher. As she was about to wed, Bonhoeffer wrote: "Marriage is more than your love for each other. It is not your love that sustains the marriage, but from now on, the marriage that sustains your love." The embrace of these two couples taught me the complete picture of what I am called to do for my patients in critical care: to enable the path of another person's life to reach its full capacity and natural end, whatever and whenever that may be. I received explicit, written permission from the Stevens and Hill families to include the facts of these true stories for this Essay. I declare no competing interests.