By Dens of Lions Encompassed

“No, she can say goodbye… and we’ll wait right here.”

Her thick, Boston accent was loud, and clear. It cut through the thick silence that both proceeded and followed. We stood at the entrance of the newly built Covid unit, as a mom held her sons hands and whispered into his ear and kissed him on the cheek. Through masked faces, the little boy burst into tears and his mom began to sob. We were surrounded by hospital administrators. Directors, physicians, providers and us. My face flushed with heat and my vision blurred through tears. I looked at my nurse, who was now the first of my staff to bring a patient to this isolation unit. Through masks and glasses, face shields and PPE I could see her eyes. She was steady and confident. A fierce, and deeply compassionate advocate.

The next day I stood on the same unit, watching through the glass doors as another nurse in full PPE played with him and read him stories. I knew she was hot, she had told me she was sweating. He looked so small in the bed. All alone. Because of the Coronavirus, all isolated patients, even if they were a nine-year-old boy could not have visitors. None. Not even their moms. I peered over the small stash of juice cups that he had started collecting on the bedside table. My nurse would tell me later that he had been saving them for his brothers and sisters at home.

These are the moments, only glimpses in this case, of the deeply moving actions that were going on at the onset of this pandemic. At any given moment, in any hospital, on any floor,  I can tell you that there are reflections of courage, of advocacy, of compassion or mercy that would bring you to your knees, tears streaming down your cheeks. It is natural to do so, when brought to the immediate face of life and death, to the utmost concern of our hearts, to the voice of God Himself.

It’s been just about two months now, from when everything started happening. Students of mine have asked me to write about my experiences. But through all the chaos and stress, I either did not have the motivation, could not dedicate the time, or simply did not want to sensationalize what we were all going through. All of us, the patients, their families, my nurses and my colleagues. It has been a strange juxtaposition as well. During these times of quarantine, friends of mine have posted amazingly insightful and beautifully composed musings on their thoughts. Their deeply thoughtful words and articulated experiences of being at home, finding the joy in spending time with their children, and mourning the lives that they were so looking forward to cherishing. 

Quarantined viewers at home were riveted by updates on the news, glued to social media or learning from the next opinion piece or research pre-publication. To many, the world became a self isolating, insulated bubble of internal dialogue and emotional turmoil. We all watched in horror about the situations around the world, the nursing homes abandoned, the heart wrenching decisions of who to care for and who to let die, and listened to the voices of exasperated doctors sobbing in NYC. But ultimately, at the end of the day (or much sooner) most could just turn off the TV, put away their phones and just mind their chores at home, eat some snacks or go on walks outside. For a few of us, it seemed like it would never end.

After several days, maybe weeks of not hearing from me, a coworker sent me a joking text about being absent. In my frustration, I wrote “I have multiple nurses out positive for Covid, many nurses out on quarantine waiting on test results, almost all of my Pediatric staff out so we just closed the unit. I’m adjusting our PPE requirements and communicating that out to the staff every day, I’ve been purchasing PPE on my own or picking it up from all over the state. We’re doing construction to outfit rooms in the NICU, making birth plans for positive or suspected Covid moms, to decide what to do with their babies, where they will go, and if we will separate them or not and where. We’re changing plans for infants whose moms had already delivered and are discharged, talking with other NICU’s to establish standards for PPE, advising nurses of what patients they need to wear what with, I’m in 3-5 meetings every afternoon, I have several nurses out on medical leave because they are immunocompromised and I’ve been here every day for 14 hours a day. I don’t have answers for my nurses asking about their paychecks who are being put on quarantine. I don’t have enough PPE every single day and have to fight for supply from the Command Center. I hear nurses crying in the bathroom next to my office every day.”

While the world stopped outside, time stood still inside. Time froze, and at the same time was frantically saturated with panic. Every day was the same. Meetings. Planning. Where was this mom going to deliver? Where would we take the baby? Could anyone visit? What about this situation? How do we plan for that contingency? Algorithms and flow charts were made. Several a day. And changed multiple times a day. Who had the answers for this? How could we get that? Another nurse is out? Who made that decision? When are we getting results for this staff member? We need to track who amongst our staff is traveling where. What if they live out of state? What if they were on a cruise? What if their husband works with someone who was positive, and had to be tested? Would my nurse need to be tested too?

I manage an incredible staff of almost 100 Registered Nurses, Nursing Support Technicians, Patient Service Representatives, unit specific PRN (as needed) nurses, divisional PRN staff (nurses who work in multiple units, including my units of NICU and Pediatrics) and support staff (student workers, volunteers). While we are on the front lines (they, more than I), we are not at the foremost front. But in our larger division of Maternal Child Health, we function like a microcosm of the hospital within the hospital. Our Labor & Delivery Triage sees patients 24/7, scheduled and unexpected. The same unit labors and delivers babies vaginally as well as by C-Section, and manages very critical moms both before and after delivery including massive hemorrhage and emergency deliveries. Our Mother & Baby post-partum unit recovers many of these moms, or monitors our long term patients sometimes weeks or months before they deliver. We in the NICU provide care for the sickest of babies. We have had patients as small as 300g, smaller and lighter than a bottle of water. No matter how small or early they are, our tiniest of patients undergo the same course of care and procedures that any adult would have to endure. Intubation. Ventilators. Multiple central lines and IV’s. Drug withdrawal. My Pediatric unit cares for many families in our community, and we are proud to be a trusted resource for the city. Our unit delivers more babies than any other hospital in the city, we have birthed nearly a quarter of all the infants born in Baltimore, so we are very busy. And through all of the pandemic, we didn’t stop. In fact, we were slammed.

On Good Friday, in a panic I sought out our Chaplain to ask if he could hear my confession before Easter. He and I sit on committees together, and he is a Chaplain in the same order that I belong to, The Order of Malta. Almost immediately upon sitting down, I began to weep. Relieved that my staff could not see me, and add to their anxiety, I shared with him that on that night one of my own nurses would be admitted to the Covid floor (expanded from just a unit, it had now taken up a whole floor). Earlier that day, a 13-year-old mom had to deliver alone without anyone by her side because she was positive, and another mom delivered a stillborn infant. Since she was in isolation, she could not have her husband with her, and this new father never got to see his baby son. I had been awake since 1am, since I started sleeping along to protect my own wife and family, somehow paranoid that someone might break into our house. But I preferred the distraction of wake to the endless nightmare of sleep. In that same day, I watched a high level administrator tear up as she was admonished by someone higher, and one of my peers told her staff that she had resigned. And my nurse that was to be admitted that night? She is expecting and she and her husband have two little girls at home.

My fellow managers and I all had our share of nightmares. Mine included staff that came to my office to resign. My friend’s had us all in the newly built Covid nursery, covered in blood and surrounded by dead mothers and their babies. I was reminded of this quote by Aeschylus,

“He who learns must suffer, and even in our sleep, pain that cannot forget falls drop by drop upon the heart. And in our own despair, against our will, comes wisdom to us in the awful Grace of God.”

Anticipating the surge of patients based on the projections and models from other countries and neighboring regions such as New York, we did our best to protect and create reservoirs of supply. Suddenly it felt like we didn’t have enough. Sometimes we didn’t. The unit next door did not have surgical masks… for surgeries. On one of our meeting with the Manager of the ICU, including the Covid unit she told us how she got all of her staff eye protection since they did not have it beforehand. And when we started to frantically order our own supplies for our staffs on Amazon or Ebay, she informed us that the only reason she had them already was because they were ordered the month before. Even now, as I write this I have eye shields that are supposed to be delivered to my house. I ordered them two months ago from China.

As walls were literally being constructed all around the hospital, and construction grade plastic sheets adorned my unit, I spent the hours after getting off work going to Home Depot or Lowe’s to search for N95 masks or eye goggles. If I wasn’t met with silent irritation from the employees, I was met with laughter. I visited, I called, I searched online and I drove hours. My most fruitful searches were from the Next Door app, from people in the neighborhood (or far off neighborhoods) who responded to my pleas for PPE. Boxes were left for me at our front door. Bags of masks were left on porches, and as I ran up I was sure someone would think I was stealing Amazon packages. Messages said they could leave a few masks on a corner. Someone placed some in our mailbox. And one night I drove far into the county and waved thank you to an elderly retired nurse for the bag of N95 masks that she had hung in a plastic grocery bag on her doorknob.

At work, nurses came into my office trembling with anxiety. Eyes red from crying, voices shaky with fear. One of them told me that due to her health, her doctor said she could no longer come into the hospital. And since she was pursuing an advanced nursing degree she wasn’t even sure how this would affect her career choice. Another broke down as she intimated that her toddler son had just been diagnosed with a brain tumor, and as he would be starting chemo she could not in good conscience risk exposing him. Another nurse told me about the mounting medical bills they had accrued in seeing specialists for her son, and would be selling their house. A colleague lost her teenager to cancer.

We listened to conference call meetings every morning, and attended virtual WebEx meetings  every afternoon. The numbers were climbing. New units were being built and designated. Nurses, long retired from critical care units who now worked in procedural or outpatient areas were being called back into service in intensive care. I think I remember them saying over 70 nurses had been skilled up in just two week’s time. And I would hear stories of nurses, so far out of their element working on Covid units with no training, no access and no support, panicked with tears rolling down their masks, fogging up their eye shields as Covid patients were dying all around them. I was constantly texting my nurses that worked at other hospitals too. Prestigious hospitals and huge medical centers here in the city, as well as multi-site healthcare systems into DC and Virginia. Nurses were calling their friends up in NYC for me, writing out protocols and visitation guidelines and updates. I started my own website to collate all of the information for my staff so they could easily see what was going on, find out the most recent changes, and watch my daily updates online. Up ‘til now, with the exception of weekends I have not missed even one day.

It’s been hard on the family at home too. We rearranged our sleeping configurations and even moved my oldest son’s hospital bed. Now I’m all the way on one side of the house while Jen and the kids are all the way on another. I use a separate bathroom. Hope stops herself, even last night from almost hugging me as I walk in from work at night. The other weekend as we finished watching a movie, she turned around and said “I forgot about the Coronavirus! It felt like it used to! I can’t wait until it is over.” My eyes teared up and I steadied my voice. I kissed her hair so she would not see my face. “Me too, little girl.”

I sometimes love scrolling through social media to see what all my friends and family are doing. Sometimes it is a longed for escape. Sometimes I am jealous, missing the intensely deep and introspective monologues that come from parents suddenly finding moments of joy with their kids. The talk of constantly eating. The non-stop sweatpants, the shaggy hairstyles or frustrations with distance learning for their kids. I am sad for the missed graduations or proms, and I am sad for my son to not be able to perform with his friends The Wizard of Oz. After landing the role as The Wizard, he and the cast were just so excited. I miss teaching martial arts. I miss my students and their friendship.

And I will say it has gotten better. There is a lot less palpable stress in the air. My staff, though stuffy from having to constantly wear double masks, eye goggles or face shields, are laughing more and chatting. And eating! There is so much, and we are so grateful. I think our donors are grateful too. One man, leaned over and had to put his hands on his knees as a few nurses waved thank you for a delivery, through the glass walls of the lobby. Others sent letters, and elementary school students drew pictures. Many of my nurses families also bought us meals, including my own parents who bought us all sandwiches and salad. As Managers, we’ve spent many late night here updating our teams and making sure updates were communicated. And even this morning, the Manager right next to me came in at 3am to take care of patients. 

And that’s the other thing. Life is still going on. Our units are still busy. Regardless of Covid. Moms are still in labor, babies are still being born. One of my staff just had a baby this morning! And I know this is financially hard for many people, but while some have had enough of this and are sick of being stuck at home, my team has been working to the bone. Not one complaint (though lots of audible sighs!). It is a privilege to lead them, but in truth it is they who lead me by inspirational example.

I shared something with them as all this broke out. It is from a historical fiction novel, about the Order of Malta. More specifically, The Sovereign Military Hospitaller Order of the Knights of Saint John of Jerusalem, Rhodes and Malta. It captures how I felt at the time, that steadied my resolve.

From the chapter, “By Dens of Lions Encompassed”

La Valette at last rose to his feet, one hand on the table to favor his wounds.

“My beloved and honorable brethren,” he said, “I’ve listened to your counsel with the greatest care, and the highest respect. But I reject it.”

The council members stiffened in their chairs. Some leaned forward.

“The military case for abandoning the town is powerful, and you make it well. Perhaps, as you suggest, it is incontrovertible. But we are not here for a military purpose alone.”

“God has willed that we face this moment for a reason. Our Faith now meets its sternest test and we must ask ourselves: What does our Holy Religion mean?”

He looked about the table.

“What is it’s justification? It’s essence? What is it’s reason for being?”

No one answered, for they knew he would. 

“We are not mere soldiers, noble though that calling may be. We are the Knights of the Hospital of Saint John the Baptist of Jerusalem. We are the Hospitallers. The defense of the faithful pilgrims to Jerusalem was our original calling. Tuitio fidei et obsequium pauperum. It is the first and last rule of our Order: Defenders of the Faith and servants of the poor. We defend the Faith most truly not by feats of arms but through our service to the poor. And in return, our service to the poor strengthens and protects our Faith. You will all recall that on our profession as Knights we made a solemn promise: to be servants – slaves – to the poor of Jesus Christ.

To the Blessed, to Our Lords the Sick. Do they not belong to Our Lord Jesus Christ? And are they not to be treated – and protected – as we would treat and protect Our Lord Jesus Christ Himself?”

He spoke with a quiet but intense passion. Amongst the old knights, Starkey saw some with tears rolling into their beards.

“We are by dens of lions encompassed,” said La Valette. “Is this, then, the time to abandon Our Lords the Sick? To fling our numberless wounded upon the mercy of Moslem fiends? To condemn our brave Maltese brothers in arms, and their women and their children too, to the chains of the Turkish galleys? Are we to forsake our most Sacred Infirmary in its hour of greatest peril?”

He looked about the table. Many were too ashamed to meet his gaze.

“This fortress will not accommodate more than a thousand, you are right. But outside its walls are many thousands more. It may well be the Divine Will that our Holy Religion be buried in these ruins, and that our Order will be no more. That in itself is not something to be feared, for God and His Angels and Saints await our coming. But if we leave our sick and our poor to die without us, the Religion will have perished already – and for Nothing. For without our sick and poor, we are Nothing. The Religion is Nothing. And even should it then endure, its honor would be stained in the eyes of God, if not the eyes of men, until the End of Time.”

– Jean de la Valette, in “The Religion” by Tim Willocks, addressing the Knights of Malta

 

I wrote this off the cuff, I’m not sure if I will do anything (more) with it. But for those of you curious, here is a little glimpse. I hope that I have been respectful in all of my descriptions, but again this was extemporaneous, train-of-thought. I work at an incredible organization with an amazing staff, I’m very blessed to be able to even share the experiences I’ve had. God knows it has been much harder for many more of my peers and counterparts.

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Newly assembled Labor & Delivery OR on the rapidly constructed Covid Unit.

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