CURVEBALLS | Kaitlyn Reasoner
The pressurized stadium doors whooshed me out of the Hubert H. Humphrey Metrodome and into the night summer air to join throngs of fans outside the stadium. As a child, my father would take me to Minnesota Twins baseball games at the Metrodome stadium in downtown Minneapolis. As a special treat, sometimes he would buy me a paper scorecard. Always detail-oriented and slightly neurotic, I loved the precision of keeping a scorecard. I would carefully record the 6-4-3 double play or delineate whether a strikeout was a “K” or a “backwards K.” I don’t remember much about entering the stadium. But I have vivid memories of exiting the positively-pressurized ballpark, when the push and pull doors would be unlocked to allow the large crowd to exit the stadium more easily and quickly.
Now nearly two decades later, I was entering and exiting through pressurized doors but in a completely different scenario. Entering the negative pressure of a room or hallway of COVID-19 patients had a similar sensation, but it was not invigorating. It was not exhilarating to know I was walking directly into contaminated air. In preparation, I donned an N-95 mask and pinched it carefully around my nose. I wrapped myself in a paper or plastic disposable gown and pulled gloves onto my hands. I put on either safety glasses or a face shield for eye protection. Once this was all in place, I would step into the negative pressure area.
The Metrodome roof was bright white, puffed up like a marshmallow by the positive pressure air. With the stadium lights reflecting off the white roof, it always felt intensely bright and almost glaring. In contrast, the rooms of the COVID-19 patients seemed dim and gray. I’m still not sure how much was physical darkness and how much was emotional despair. It turns out that hope can escape even a negative pressure room. The Metrodome was always loud and lively, with exuberant fans, a booming public address announcer and a blaring sound system. The COVID-19 rooms were so quiet, often with only the rhythmic whoosh of the biPAP or ventilator, or the whir of a CRRT machine. The patients lay there alone, typically with no families around.
There were no baseball scorecards in this negative pressure world. There was only The List. Every day we would “run the list,” typically multiple times a day. But in reality, The List ran us. The List held physical reminders of what needed to be accomplished in that particular shift. In the ICU during the COVID-19 pandemic, The List might have various ventilator settings scrawled on it, next to the morning labs and the typical lengthy checklists of to-do items. The List could be used to keep track of which COVID-19 patients’ family members I’d managed to update that day. The List could be used to write down the time of death so you’d enter it correctly in the electronic medical record.
If I learned the game of baseball in the positive pressure world of the Metrodome, then I learned how to be a doctor in the negative pressure world of the pandemic. I graduated from medical school in spring 2020, so I’ve only ever practiced as a physician in the era of a pandemic. I learned to troubleshoot refractory hypoxia, because it seemed everyone was hypoxic. I learned to stay awake for 28 hours straight and still talk coherently on morning rounds. I learned to break bad news and to have difficult conversations with families; how to gently but directly tell them things were not going well. There was so much bad news. I knelt on the hard floor of the ICU late at night so I could be at a family member’s level while I told them how their loved one’s organs were failing. I sat quietly in a conference room with a patient’s family member to tell them their loved one was dead. I called the medical examiner to report the deaths from a communicable disease.
I appreciate the order and structure of baseball—the crisp infield lines, the precision of a perfectly localized curveball and how there’s a rule for everything. In the Metrodome, there were even rules about what to do if the baseball struck the upper catwalks along the inflated roof.
Medicine certainly has its moments of order and precision, like interpreting an arterial blood gas or calculating a bicarbonate deficit or visualizing your wire inside of the internal jugular vein while placing an ultrasound guided central line. But there are countless scenarios with seemingly no rules, that no one can prepare you or train you for, that seem impossible to ever learn or become accustomed to doing. No one can prepare you for pronouncing a proned patient dead. Sometimes, we would prone our COVID-19 patients with refractory hypoxia, often as a last-ditch effort when we couldn’t keep their oxygen saturations up despite any other tactics. One of my patients died like that; rotating her to a supine position would have likely hastened her already rapidly approaching death. I struggled to place my stethoscope under her body—literally deadweight—to listen for the absence of heart sounds as part of my death exam.
There is no calculation for how to respond when a family member berates you over the phone when you’re just calling to give them an update on their critically ill father who would later die from COVID-19. You’ll try to keep your voice even and calm, but you’ll feel angry and sad and mostly exhausted. The medical school radiology elective doesn’t prepare you for how to show a chest x-ray over a video call to your patient’s curious and caring family. There are no guidelines for what to say to the young woman whose fiancé died from COVID-19 and other medical complications. She was a thin wisp of a girl with dark hair, almost ethereal. I pronounced him dead and then she looked at me and said, “We were supposed to get married!” What can you even say to that? No amount of IT training can prepare you for what it feels like to host a Zoom call on your cell phone so that a family can say goodbye to their dying loved one in the middle of the night. There is no protocol for how to blink back tears without touching your eyes and contaminating yourself. The infection prevention guidelines may mandate usage of an isolation stethoscope in rooms under contact precautions. But for the death exams, I tried to use my real stethoscope for that final auscultation—this time for the absence of heart sounds—instead of the flimsy plastic isolation stethoscopes. I felt like my patients deserved that courtesy even if it meant I had to take extra time to clean it afterwards.
The Metrodome is gone now; I’ve moved away, and the Minnesota Twins have a new stadium. And the COVID-19 rooms and hallways are gone now too. Sometimes I worry that we’ll forget; that we have already forgotten. But it never was the physical spaces, was it? It was never the positive or the negative pressure. It was always the people that shared those spaces with us. I cherish my memories with my dad in the positive pressure Metrodome. And I remember my colleagues who worked so hard with me in the pandemic. And the negative pressure could not and never will extinguish the memories of the COVID-19 patients. Many of them never made it home. The COVID-19 wards may be closed but the memories of these patients will live on in their loved ones and in those of us who were entrusted to care for them in that negative pressure world.
Kaitlyn Reasoner is an Infectious Diseases fellow at Vanderbilt University Medical Center in Nashville, TN. She plans to pursue a career in academic Infectious Diseases. When not at work, she enjoys hiking, reading and spending time with her one-eyed cat, Thistle.