She was a family friend we'd known for years … for so long that she knew me before I was even cognitively aware I knew her. At 87, she'd fought through difficult illnesses, multiple surgeries, losses. Her ever-present husband, her north star, her rock, had recently sustained a fall. Through the grace of whatever greater power exists in the universe, a small subdural hemorrhage was self-limited, despite anticoagulation for chronic atrial fibrillation.
Both she and her husband, residents of an assisted living community many states away from where I live, were diagnosed with COVID-19 in early summer. They both received monoclonal antibodies, and both “recovered”—with quotation marks around the word because COVID likely never leaves 87- or 92-year-old humans as they were prior to the virus.
Early one Saturday evening she developed abdominal pain. Ever the stoic, she “rode it out” through the night, and felt a bit better by the next day. But then came Sunday night, and with it, severe abdominal pain, nausea, and vomiting. By the next morning she was clearly ill, and went to the Emergency Department after being advised by her internist.
On arrival at the hospital she was uncomfortable but not in severe pain. She was tachycardic, dry, with acute-on-chronic renal failure. Complete blood count revealed a white blood cell count in excess of 30,000. Doctors ordered IV fluids for her dehydration, antibiotics for her presumed infection, and a computed tomography (CT) scan. A COVID-19 test performed on admission was negative.
Transferred to a room, IV fluids and antibiotics were continued, with the CT order still pending. Day turned to night, and abdominal pain and vomiting recurred. Now emergent, the CT scan revealed a small bowel obstruction. She rapidly decompensated, requiring pressors to maintain blood pressure and intubation/mechanical ventilation to support oxygenation.
Because of the CT findings, a surgeon was consulted. Review of the scan confirmed the obstruction, and the option of surgery was discussed with her family. Feeling that surgery provided her only chance of survival, consent was obtained and the preoperative checklist begun. That cadence included a repeat COVID-19 test, part of the “hospital routine” despite a negative test hours before.
This time, it was positive.
Ever-changing, ever-evolving, COVID requires us to regularly rethink our strategies and tactics. Yes, she had COVID 2 months prior, and the newly positive test could certainly be caused by viral remnants. But, she lived in a state where the rate of BA-5 had gone from 20% to 80% in the same 2 months. And, she lived in a facility where a new outbreak had gained momentum. So, certainly, this could be a new infection.
Knowing my background, the family sought my opinion. This despairingly familiar scenario had been discussed among my colleagues and me numerous times. But not about a family friend.
I consulted my colleagues, asking the opinions of those whose advice and counsel I regularly seek. The consensus was that, although COVID was not the main threat to our friend's life, it would complicate all of the other obstacles lying in the way of her potential survival. And so their majority opinion was, yes, assume it's a new COVID infection, and yes, treat her.
At the request of our friend's family, the infectious disease specialist who'd been consulted called me to discuss her case. I was interested in his opinion, eager to explore the nuances, hoping to help our friend live to see another holiday with her children.
He first told me his reasoning regarding why he did not feel she had a new COVID episode, and why treatment would be challenging. He discussed the issues with remdesivir in the setting of renal failure, and his belief that treating COVID wouldn't alter the outcome of a desperate situation.
But then, to my shock and disbelief, he told me why he really felt she shouldn't be treated for COVID.
He told me his belief that “COVID is a political disease–it's not a real disease.”
And if it is a real disease, “BA-5 isn't a real thing, anyway.”
In terms of therapeutics, “I never prescribe Paxlovid [Pfizer Inc, New York, NY]—it's a plot from Big Pharma. I cannot believe you actually prescribe it.”
Continuing his COVID inquisition, he asked: “do you really think that the vaccines protect anyone; do you really think masks protect 100%; do you really think distancing helps?”
And, as a final question, “Do you really believe people should be giving these shots to their young children?”
Stunned, feeling adrift, I asked him “Please repeat what you just told me so I can be certain I heard correctly.”
He repeated his trope, confirming that indeed I'd heard the unbelievable. He then offered to “prescribe whatever you want me to even though I don't believe in it.” I told him I'd not be the one to order medications, and that he is the one responsible for his decisions. My best option, I felt, was to end the conversation, and pray for our friend … which I did.
Several days later, I learned that after he spoke to me, he had the same talk with our friend's family, as they sat in vigil at her bedside. He made it clear to them that he had strong beliefs about COVID, mostly centered on his conviction that at best it is overstated, and that at worst it is a fabricated farce.
Our dear friend's course was stormy. Although she survived the surgery, confirming obstructing adhesions, she never emerged from anesthesia. She became progressively hypotensive and refractory to pressors. She was never weaned from the ventilator, and I was asked to counsel the family through a do-not-resuscitate discussion.
We lost her, peacefully, a short time later.
In the aftermath of her death, I had time to think about her, and the opinions of the infectious disease consultant. I know that we've become a nation of deniers … of climate change, of election outcomes, of science. And that cultural cancer has another manifestation: some seem to accept the denial of sympathy and empathy to people in pain.
The background of pain and loss, and the way my friend was cared for, gave rise to many emotions. I was, and still am, angry. I'm a primary care internist, and COVID has become a constant in our lives. I've spoken with people skeptical of COVID's very existence, and others who won't be vaccinated because they've fallen prey to an epidemic of toxic disinformation. I've been castigated by a patient who didn't “believe in COVID,” reassuring me he's confident I was getting rich because of the fictional disease. And, with his words echoing in my head, I entered the next examination room to see a woman who was still recovering from the amputation necessitated by arterial thromboses from COVID. But never had I been confronted by a fellow physician who shared those beliefs, and espoused them freely, and destructively.
But betrayal seems to be the thing I feel the most. We consider our fellow physicians to be our kindred travelers. We may disagree about treatments, procedures, or even the system in which we practice. But we have an understanding that we believe in science, we understand processes and scientific methods, and we can speak intelligently and dispassionately with each other about our craft. We also believe in a normative behavior that doesn't tolerate the substitution of politics for patient care. And we surely expect that the sacred space of our relationships with patients not be poisoned by a toxic political agenda. Yet our friend's infectious disease consultant crossed all of those lines, without apology. He betrayed his patient, her family, and all of us who do the difficult work of doctoring. And I fear he's not alone in his beliefs, nor in his willingness to use his position of authority to advance an agenda that is far removed from the best interests of his patient.
"To do no harm” is a foundational principle of medicine. Harm can be caused in many ways—through a diagnostic test, or a prescribed treatment, or a failure to do one or both. But, perhaps now more than ever, the words we choose to use can be harmful. And when we speak from our position of knowledge and responsibility, we must carefully pick our words … or risk causing for others the harm someone dear to me experienced so recently.