American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Return to “Normalcy”?

In our continuing series, we include reflections from Anthony J. Vine, MD, FACS, Assistant Clinical Professor of Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, and Member, Board of Governors, American College of Surgeons. Dr. Vine writes about his experience on the job in New York City.

Although former President Warren Harding (b. 1865) has been credited with the first use of the word “normalcy,” to describe a state to which he desired the country to return after two decades of reform, the term normalcy initially was used in the formulation of a particular mathematical principle of x and y in a tangential equation in 1855, according to Merriam-Webster. Having been an English literature major at Princeton, despite my university’s excellence in theoretical mathematics, I still have those occasional “math nightmares.”

Whether it be normalcy or normality—the latter being the more accepted literary noun—we all want “it” back as soon as possible. What is normality in the daily life of a surgeon? Well, it may start with: a 7:00 am residents’ conference or a 4:00 am emergency, followed by either elective, oncologic, or trauma cases—whatever our specialty may be—then maybe office hours, greeting postoperative (post-op) patients or evaluating new patients with a hug, a pat on the back, or a warm handshake; rounds with a team of residents and fellows side by side, not six feet apart; then maybe a dinner outside at a restaurant with family or colleagues.

My last two days in the medical intensive care unit (MICU) just have not given me even a glimpse of that notion of normalcy. As morning rounds were progressing, there were two more deaths—a 77-year-old Asian gentleman with five grandchildren (the patients’ personal details are scribbled with an erasable sharpie pen on the plexiglass doors of the negative pressure rooms, along with arterial blood gas results, medication drips, and to-do lists…) and a 32-year-old African-American woman. But suddenly, about five nurses from my usual surgical floor upstairs appeared—masked and gowned—in the MICU, greeted me, and asked, “Dr. Vine, what are you doing here?” I told them I was volunteering and had been assigned to assist in this unit, and I proceeded to ask them the same question, and then I found out that the deceased 32-year-old was the sister of one of our gastrointestinal (GI) care nurses I knew so well. The patient’s sister and mother were permitted, by the hospital’s policy, to enter the ICU and to be with their loved one. They were gowned and gloved, but no one could hug, and no one could cry on a shoulder; they could release only the loudest of heart-piercing wails that the negative pressure room had no ability to vent to the outside realm. The chaplains appeared, as did our GI Clinical Nurse Manager, Lorisa Richards, MS, FNP, RN, and all I could do was to stand in prayer with them. They were not just co-workers attending a friend’s death—they were our own surgical family from our GI Care Center Unit upstairs. We all cried.

The next day, Saturday, in the middle of MICU rounds, I received a consult from a gynecological/oncology (gyn-onc) colleague of mine to please go evaluate a 60-year-old woman status post multiple operations for metastatic ovarian cancer who was in the COVID-19-negative ICU. She had been admitted with a small bowel obstruction (SBO) two days prior by the gyn-onc team, eight days after having received Avastin, now with a white blood cell count that had dropped from 16.8 to 1.6, hypotensive on a norepinephrine drip, and with peritonitis on exam, not to mention a very mildly elevated troponin (with a normal cardiac echo). The entire clinical picture, along with the computed tomography scan showing a high grade SBO with transition zone, her physical examination, and laboratory values, were ominous to me for ischemic bowel. But what to do? Operating on such a critically ill patient such as this 10 days post-Avastin could be fatal, but not exploring for ischemic bowel in this mentally intact, vital 60-year-old patient could be a similar death sentence.

After discussion with the patient—fully alert—her husband, and the gyn-onc attending, my resident and I proceeded emergently to the operating room, where indeed there was an internal hernia with one foot of mid-distal gangrenous ileum due to an adhesive band-internal hernia. I performed a resection, end ileostomy, and mucus fistula (not knowing whether there was a competent or an incompetent ileocecal valve). I went back to the MICU after that to finish my shift, but checked on her four times before I left for home at 8:00 pm. Upstairs in the MICU, there were another three people very close to death, one of whom had been placed on extracorporeal membrane oxygenation overnight, but who still was deteriorating. I passed by the surgical non-COVID-19 ICU to visit the post-op patient one more time before leaving the hospital: she was still on levophed and vasopressin, with an unchanged lactate of 5.

I spoke to the patient’s husband several times—I had operated on their son’s hernias and his mother’s colon cancer in the past—yet, because of COVID-19, he was not permitted to come visit her in the hospital. And I could not, as is my usual routine, wander down to the family waiting area to chat and sit with him post-op.

Another day filled with extraordinary suffering and the omens of further mortality. Another decontamination ritual as I arrived home. Another late-night trip to the grocery store wearing my mask and porting my alcohol hand wash—it’s always less crowded there anyway between 10:00 and midnight, but it felt more deserted and lonely tonight.

When will normalcy return? And when it does, what will it be like? I cannot imagine how much post-traumatic stress disorder we will encounter after this viral war, after this crisis has subsided. Will we be eating at a restaurant rearranged with now only three or four tables in the establishment as we, wearing our masks, sip puréed veal parmigiana through a large-bore straw? When will I do my next elective laparoscopic herniorrhaphy? When will we go to a baseball game or to a New York Philharmonic concert?

My 57th birthday occurred on April 15 (the “old Tax Day”), and I received a most special gift in the mail from a close friend—really almost a brother to me: a gorgeous violin bow that he had fashioned himself from an exquisite block of sacred Pernambuco wood. Of course, after unpacking and immediately throwing away the UPS box, and then wiping with Lysol the PVC tube in which it had been so carefully wrapped, I had to let it sit for three days. The anticipation of looking at it and drawing it across my violin strings was almost unbearable, but I had to abide by my COVID-mania. When will I play chamber music again, and will we have to sit six feet apart to play a Beethoven quartet? I don’t know what the new “normal” will be and when it will occur, but I certainly look forward to penning more optimistic and, shall we say, “normal,” chronicles in the near future, heaven permitting.