COVID and the Break in the Acute Care Surgery Coat of Armor

The thing about acute care surgeons is that we always show up with our invisible coat of armor. Over years of training and experience with grittiest and most tenacious role models and mentors guiding our way, we become resilient. We learn to provide timely and high-quality care to all those in need whether it’s 2 am or 2 pm, whether it is a weekend or a holiday when everyone we love has some respite, whether its a pedophile from the federal penitentiary or the sweet old lady who reminds us of grandma who needs us to help urgently, whether it is a slam dunk easy case or the risk of mortality is high in the best case scenario. We do this despite the momentary cost to our physical or emotional health because that coat of armor shields us.

Often we are where the buck stops when patients are complex. When our colleagues need help figuring out the culprit on their differential diagnosis or an extra set of hands they call us.  Can’t figure out if the nausea is from an intra-abdominal source, call acute care surgery. Can’t figure out if the source of florid sepsis is GI perforation, call acute care surgery. Can’t figure out if this skin exam is consistent with cellulitis or necrotizing soft tissue infection, call acute care surgery. Can’t figure out if the airway pressures are rising due to abdominal compartment syndrome, call acute care surgery. Urgent central venous access, call acute care surgery. Difficult airway, call acute care surgery.

Like every town’s fire brigade, we are there. We show up whether or not there is a fire to be put out because someone was concerned enough to ask for help. We have chosen our specialty because we are committed to helping not just our patients but our colleagues, in even the most inopportune circumstances. To do so, we truly function as a family. I may not have chosen to be friends with them outside of work but at four different jobs with a team based approach to emergency surgical care, I have alway loved and cherished my team members like family. It’s like wedding vows. We are in it together and would lay down across rail road tracks to help each other do right by our patients.

In these unprecedented times surrounding COVID-19, from preparations to actual care of extremely critically ill patients, this family’s invisible coat of armor has started to crumble.  Our ER, hospital medicine, and medical intensive care colleagues still need us for those vexing matters that are routinely part of our work responsibilities. However, we may or may not be able to offer these patients with the inflamed organs or perforations the same kind of care that we might have as recently as two weeks ago. We might have to offer something that is likely non-inferior. It may be non-operative or operative in the old fashioned way we did it long before fiberoptic cables and robots.  These alternative decisions might be because we have to be proactive about using supplies. They might be because asymptomatic carrier rate is high and we need to protect the surgical and anesthesia workforce. They might be because we simply don’t have the physical space to provide surgical care. Meanwhile, given our critical care expertise we are, of course, available for managing patients whose only known issue is COVID-19. We understand ventilator management, and ARDS, and reversing I:E ratios, and proning. We have put young previously healthy patients on ECMO before. We remain here – day and night – to help. We are searching for scarcer and scarcer PPE so we don’t miss a beat when you need us.

All of this is happening for each of us on the front lines including EM, IM, and MICU all day every day (even while others might be figuring out their new normal mostly at home) while our families are struggling from social isolation in general, from knowing we are in the direct line of fire, or seeing how preoccupied we are with being prepared given so much uncertainty. Like our other front line colleagues, there is no down time for acute care surgeon, even those who have been put in the “bullpen” at home in case we start losing faculty to COVID-19. Because being out of harms way means that someone else is in harms way, the moral distress of sitting out is paradoxically crippling. On top of this worry for work family, where ever we are stationed, there are a dozen relevant emails before the crack of dawn. Multiple remote conferences to stay up to speed. At best you a catatonic shadow in the lives of your real family when they truly need you – the medical person in their life – to have no breaks in the armor. Some of us, have gone to extreme measures of isolating in separate quarters within the home or in entirely separate locations from our loved ones – the ones’ whose snuggles and kisses are such a critical part of our day to day resiliency when things are at baseline.

When you play so many key day to day safety net roles across a health system when things are acute care surgery “normal,” the extreme abnormality of COVID-19 is a serious hit. There are so many moving pieces that we must be totally on top of.  From where to enter the hospital, what to don where and when, where patients will be cohorted, whether surgeries can be performed, where overflow ICU beds will be, how to protect our trainees… the list goes on and on. Each bit of uncertainty, each disruption to our typical decision making or daily practices, each pang of guilt or worry regarding the work family or the home family, along with the constant use of brain power to keep us COVID-related issues is physically and mentally exhausting even before you’ve passed that soviet-era temperature checkpoint to start your day at work.  It chips away at the invisible shield of armor that usually shields us. So we have to figure our other ways to be resilient in these trying times because our usual mechanism is failing us.

But there is a fire somewhere and we are needed. I am sure that in sickness or in health we acute care surgeons will figure it out.