It’s been more than three years since the COVID pandemic began, causing over six million deaths worldwide (as of April 2023). While things have largely returned to normal thanks to vaccines, lockdowns, and public health measures and with the Public Health Emergency recently ending, life is a “new normal.” No one who has come out on the other side of the height of the pandemic has remained unaffected, whether physically, emotionally, or both. This is particularly true for the frontline healthcare workers who cared for very sick patients despite the fear of becoming ill themselves. “We experienced a huge trauma, an experience that we never had before, and I don’t think we speak about that enough,” says Naftali Kaminski, MD, of the pulmonary critical care team at Yale New Haven Health. Kaminski is the Boehringer-Ingelheim Endowed Professor of Internal Medicine and Chief of Pulmonary, Critical Care and Sleep Medicine, at Yale School of Medicine. “People who do critical care are used to seeing death, but 80 percent of it is death within context. What we saw in Covid was death out of context. We never thought we’d see people die of infection in the 21st century.” Kaminski compares working in the hospital during the initial months of the pandemic to working in a battle zone. “This was our finest hour. We didn't go back home because we never traveled, but we came back to our life carrying memories and scars.” Here, five critical care physicians reflect on the experience of caring for critically ill patients during the pandemic and how it has changed them, as people and as doctors. Elaine Fajardo, MD Assistant Professor of Medicine (Pulmonary, Critical Care and Sleep Medicine); Medical Director for Respiratory Therapy, Internal Medicine One thing that really stood out for me was how quiet the ICU was. Usually, there's a lot of bustling and a lot of people. It’s noisy. There are alarm systems, there's the sound of chatter and the sound of ventilators, and usually the patients’ rooms are open. When you walked into the Covid ICU, it was silent. The doors were all closed, and staff was reduced. The alarms were only heard inside the room and the masks, and the PPE dampened what you could hear. The beginning of the pandemic was marked by a very rapid unstable feeling. It seemed like almost every day, or every few hours, there was a new bulletin coming in. I was not prepared for the extent to which it affected the psychology of our staff. When you go into healthcare, you go with the intent of helping people, and it's usually not at the cost of your own personal safety. And so, simultaneous to patient care, we were also trying to protect our own staff and feeling very responsible for their wellbeing. People weren't feeling safe, and it's hard to go to work and it's hard to go home to a family when you're not sure if you're bringing the virus with you. It was almost a sense that you're putting yourself into danger when you walk in the room. And I think each individual had to confront that for themself, you know, to really ask themself why they were going in. Klar Yaggi, MD, MPH Professor of Internal Medicine (Pulmonary, Critical Care & Sleep Medicine); Director, Yale Centers for Sleep Medicine, Pulmonary, Critical Care & Sleep Medicine In some ways, the second wave was worse than the first wave because at that point we had the vaccines, but we still had patients who were coming in and dying. I remember how painful that was, and the anger and sadness because they could have gotten the vaccine. We had patients coming in who were realizing that they were going to die, and they might have prevented that from happening. They were anti-vax, or skeptical. It was tragic for the individual patient, and it was also maddening to put other patients that we had in the hospital who were immunocompromised at risk, as well as our providers, so there were all sorts of weird feelings at that time. Obviously, patient autonomy is one of our main ethical platforms. But after experiencing people dying unnecessarily like that, I find myself being a little bit more vocal than I was before with patients. I think I'm a little bit more blunt about what the data show, what the research shows. I’m actively trying to dispel incorrect understandings of diseases. Research has always been a part of the work that I do. Particularly with the politicization during the pandemic, it crystallized the importance of research as a tool for building knowledge, for facilitating learning, for increasing public awareness, for disproving falsehoods and confirming truths. I feel really good about being an academic physician and supporting research and doing research and moving that needle forward. Shyoko Honiden, MD, MS Associate Professor of Medicine (Pulmonary, Critical Care and Sleep Medicine); Director, Medical Intensive Care Unit, Internal Medicine The pandemic really made me think about the fragility of life and what it means to be human. Covid, after all, was an equal opportunity killer. Although we were equipped with sophisticated tools and machines, I felt like the most powerful thing that I was able to offer were conversations. Particularly in the early days, a common refrain to families was “we are doing the best we can, but I still don't know if I can save your mom, save your dad, save your brother, save your sister.” I invited families to share something about their family members. I’m meeting them in a hospital gown, fighting for their lives, half unconscious. Who is she? What music would he like to hear? What would they find comforting? I remember families calling from the parking lot, knowing that they couldn't walk in, but wanting to feel just a little bit closer to their loved ones. Covid really gave me a chance to reflect and to appreciate the struggles that families and patients go through on a daily basis within our four walls. It was a period in which you doubled down on your sense of compassion and purpose. I feel like I’m forever changed in so many ways. Margaret Pisani, MD, MPH Professor of Internal Medicine (Pulmonary, Critical Care & Sleep Medicine) The hardest part was having to take care of these patients with no families present. I remember a gentleman that had been there for a while and wasn't getting better. At that point we had started having families see their loved ones with iPads. I remember how sad I felt sitting there watching his family say goodbye to him through an iPad. It always felt really bad giving horrible news to people, families who have never met me, never seen me or my team working hard to care for their loved ones. I’m just a voice on the phone. How could they possibly trust what I'm saying? Normally, pre-Covid, we had families in the room. They saw us going back and forth all day, checking on their family members, adjusting ventilators, all those kinds of things we do. And they develop a little bit of trust because you see them, you talk to them. It was hard for me and extremely hard for family members to not have that face-to-face interaction. I remember being afraid for myself too—like, oh my God, if I get sick, I'm going to be stuck in a hospital room all by myself with no family support. For me that was the hardest thing, all those people who died alone. I mean, they died with us, but not with their families. Jonathan M. Siner, MD Associate Professor Term; Clinical Section Chief, Section of Pulmonary, Critical Care and Sleep Medicine, Internal Medicine; Medical Director, Tele-ICU; Associate Chief Patient Safety Officer, Yale New Haven Health The news was overflowing with reports of new "cures" and new approaches to what was a very new disease. Even if we didn't know exactly what to do for everything, what we knew from the data we had from the past 20 or 30 years in critical care turned out to be mostly the right things to do. At the same time, I think one of the things we learned is how adaptable we were, across the full spectrum of the individuals involved in healthcare. People did all sorts of different things that they were either afraid to do or didn't know how to do, and we solved a lot of problems. We knew that consideration was being given to splitting ventilators elsewhere due to concerns about adequacy of the supply of ventilators, and we knew from our calculations as our volume of patients increased that there was clearly a point at which we would not have an adequate supply. Several physicians, respiratory therapists, and trainees from different departments set out to try to devise a system that would allow patients to share ventilators, so we knew we had an option (even if it was a bad one) before the actual emergency arrived. We did ultimately have a trial of one device which worked well but it was highly complex, and it confirmed for us that it really was the last resort. At the time of the trial, we only had eight ventilators available for the entire health system and since several needed to be on standby for obstetric and surgical emergencies, we were essentially down to our last few. In the end, there was actually a lot that went well but it was impossible to know that at the time. More than two thirds of our patients who went onto mechanical ventilators survived and hospital survival was quite good as well. There was a real concern that there would be few or no survivors among the sicker patients, particularly right at the start, and that didn't turn out to be true. Governor Ned Lamont held a press conference announcing the end of the Public Health Emergency on May 11, 2023. As Kaminski sat in attendance, he reflected on the first months of the pandemic and the grinding years that followed. “I kept thinking how fortunate I am to work with such an amazing team. Our faculty, trainees, and staff had no hesitation. Our physicians provided the best possible care with minimal evidence or rest, our researchers shifted their gears to try to understand that disease and solve it, and our staff volunteered to support in any possible way, from distributing PPE to snacks; and most importantly, despite the need to stay away from each other, we stayed together,” he said. “I’m still at awe by what I saw.” The Section of Pulmonary, Critical Care and Sleep Medicine is one of the eleven sections within Yale School of Medicine’s Department of Internal Medicine. To learn more about Yale-PCCSM, visit PCCSM's website, or follow them on Facebook and Twitter.