The AAS Ethics Committee held its first annual Artwork and Essay Contest in 2021 – the topic for the essay contest was “What is the most challenging ethical issue, personal or professional, you have encountered in the COVID era?” The winning essay and artwork were selected by the Ethics Committee and will be published in the October issue of the Journal of Surgical Research. But we also want to share many of the powerful entries we received for this contest, so look for more of these essays to post as blog articles between now and the 2022 ASC – thank you to everyone who participated in the contest!
Krista Haines, AAS Committee Chair & JJ Jackman, AAS Executive Director
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Mr. Edgars loved airplanes, ham radios, and, most of all, his daughter Annie. At a spry 84 years old, he was a proud New Englander: fiercely independent and frustratingly stubborn. A diabetic foot infection brought him to the Emergency Department just a few weeks after COVID struck. If not for the pandemic, Mr. Edgars would have had a small procedure in the OR, completed a course of IV antibiotics, and gone home in time for his weekly dinner with Annie. In March of 2020, however, nothing was quite that simple. Despite a successful operation, Mr. Edgars had been in the hospital for over a week, and showed little hope for a meaningful recovery.
In his dark single room, Mr. Edgars’ six-foot frame was awkwardly folded into a chair facing the window. As I entered, he turned with difficulty, squinting through his glasses. I watched him search for something familiar about my appearance. There was no recognition even though we had gone through this ritual every morning and afternoon for nine days. With mild authority, he stated, “I’m waiting for my daughter. Is she coming today?” I shook my head, explaining to him again that the hospital was not allowing visitors due to the COVID pandemic. I promised to call Annie and update her on his progress, just like every day. He blinked slowly and turned back to the window. I changed his surgical dressing and reassured him that he was recovering well. He nodded wordlessly. The grandfatherly chatter had stopped days ago. I knew, despite the healing wound and normalizing lab values, the real Mr. Edgars was slowly disappearing with every passing moment. When I reached for the door, he looked up and asked, as if the past twenty minutes hadn’t happened, “Do you know when my Annie is coming?”
Four days later, Mr. Edgars was dead.
My colleagues offered their analysis at the following week’s M&M. Mr. Edgars’ unexpected death had to be explained. What was the reason for his respiratory arrest? Had I considered a PE? Did his antibiotics cover hospital-acquired pneumonia? I didn’t need decades of experience to know that none of those usual suspects had taken Mr. Edgars’ life. He never tested positive, but it was COVID that killed him. He was collateral damage. Deaths like his were not meticulously tracked by the CDC, but the numbers were just as tragic. However optimized and independent he had been prior to admission, once in the hospital, Mr. Edgars deteriorated rapidly without the familiarity of his routine, and the therapeutic presence of his daughter. Like countless other COVID-negative patients, he was sequestered purposefully from the virus, and inadvertently from everything he knew and everyone he loved. It was the isolation of COVID that unmasked his age, comorbidities, and, most significantly, the dementia that had been lurking just under the surface.
In hindsight, Mr. Edgars didn’t need antibiotics. He needed Annie. She was the glue that held his life together. Without her, he fell apart. At first, his mild disorientation manifested in repetitive questioning. Next came nightly sundowning that devolved to florid delirium. Finally, the creeping dementia held at bay by a devoted daughter was fully revealed: the unintended consequence of a viral infection that he did not even have. Mr. Edgars likely aspirated, arrested, and died alone in his hospital room, scared and struggling to break through a fog of antipsychotics and the firm grip of physical restraints.
As medical students, we were always taught, “Treat the patient, not the disease.” Unfortunately, there was never a corollary to modify this mantra to a pandemic. What if everyone were a potential patient? Should we extrapolate to, “Treat a hundred patients, not just one?” In a matter of days, medicine went from patient-centered to population-focused. The health of the wider community had to be weighed in every clinical decision for an individual patient. Physicians everywhere faced the daily moral distress of placing the needs of the public over those of their patients. I wondered every day as we fought so hard to save the thousands at home, did we fail the few in our care?
The sad reality was that in a pandemic, I was almost as powerless as Mr. Edgars. The greatest ethical challenge I encountered in the COVID era was knowing exactly what my patients needed and not being able to provide it. I could not wholly fulfill my Hippocratic duty of doing no harm to Mr. Edgars when I knew that his cure could be our community’s curse. Even if it had been within my purview to allow Annie to visit the hospital, could I risk the inevitable chain reaction of exposures that might trigger? In a pandemic, with whom did my professional responsibility lie? Mr. Edgars? Annie? All of their extended family, friends, and neighbors? Could I disregard the greater good to heal one man?
Of course not. Instead, I became the medical mercenary that COVID required. I could not heal, nor could I comfort. My only weapon against the raging pandemic was quarantine. I kept patients, with COVID and without, away from their families, severing the most basic of human connections in their time of greatest need. I did everything I could as a physician and surgeon to help Mr. Edgars, except the one thing that I knew would save him. I told Mr. Edgars every day that he would see Annie soon, knowing how unlikely that was. I held his hand, realizing that I was just another anonymous automaton under layers of impersonal PPE, a poor substitute for the daughter he desperately needed. I heard Annie’s voice break over the phone every evening, crushed by the realization that she would never hug her father again. I watched father and daughter, and so many others, say goodbye over FaceTime, deprived of the human contact they so deserved in their dying hours. I hated that there was nothing else I could do.
The world called us “heroes.” What they didn’t know is that we were just helpless.