SGIM Forum

Breadth: Part I

Specific Situations I Never Imagined that I Would Be In

Dr. Grabscheid ( is associate professor at Mount Sinai Health System, specializing in hospital medicine.

You have spent your entire career going to the guide-lines, following algorithms, pulling up evidence-based articles, hunting down recommendations from experienced seniors, etc. Now, for the first time, there are no clear sets of instructions or even any experts. So how do we as physicians respond to these challenging situations?

Here are a few scenarios that I, as a New York City Hospitalist, have recently faced:

  1. A rule-out COVID-19 patient has a psychiatric disorder and keeps leaving his isolation room and running in the hallways without a mask. How do I simply get him back into his room and have him stay there?
  2. A CHF patient has been in the hospital for a few days. On the day of discharge, he suddenly looks terrible with generalized malaise and a cough. Is it COVID-19? Do I now put the patient in isolation and test for that? If the patient turns out to be positive, will I and the whole staff panic over the many days of exposure?
  3. The world news is depressing. Here comes a patient after a suicide attempt. By the way, he has a cough. How do I put this patient in an observational setting?
  4. Patients come in with “normal” things, like a pericardial effusion or dysphagia. But, all of a sudden, subspecialists can’t come any more to do the consults. I learn that they are reserving their hours in case there are massive staffing issues. I understand the logic. But now what?
  5. I need to make beds for the expected patient surge. One of the current inpatients has a finding of a renal mass, suspicious for carcinoma. I thank the patient for understanding his hasty discharge and tell him he must follow up with his outpatient provider. Turns out, the outpatient provider is not available until further notice.
  6. An undomiciled patient leaves against medical advice (AMA) while their COVID-19 test is pending. How will I contact them with the test result? And how can this patient self-quarantine?
  7. I have to round on 16 COVID positive patients all with acute hypoxic respiratory failure. How do I remember who is who, as my rounding list is under my PPE and untouchable?
  8. Ventilators are a limited resource. I am putting patients on non-rebreather masks and high flow nasal cannulas at the same time, hoping it will do the trick (even though I don’t remember this being a real combination last time I went to a pulmonary conference).
  9. An 89-year-old COVID-19 patient has a significant cardiac history. Do I tell him that his wife has just died and that their son is sick from the virus? Is this a heart attack waiting to happen?
  10. The hospital asks me to staff the new COVID-19 ambulatory testing site. Incidentally, a former doctor colleague I know recently has been doing that in the community. And wait, I just heard he was on a vent at a different hospital. How do I feel about being “volunteered” to staff the testing center?
  11. A truck pulls up to the hospital. It is a Portable Morgue Unit designed for a mass fatality incident. What does that do to my mental health?
  12. I am the primary caretaker for my family, and they are scared for my safety. I need to be around for them. But, by now, I have been exposed to the virus repeatedly and am just waiting to become symptomatic. Do I quit? Don’t I need the health insurance that comes with the job now more than ever?

What have I learned from this so far?

  • You will compare notes with colleagues to see if they have experienced the same. These notes will be your makeshift guidelines.
  • You will learn to make (and stand by) decisions even if you aren’t sure your decision is the right one. They will abide with the philosophy of doing no harm.
  • You will be totally flexible and accept that every day is a learning curve; the way you practice today will be very different from how you practice tomorrow.
  • You will learn that you can do all of this while being quietly terrified. And that is OK.
  • And, you will proudly do the best you can during every shift.

In time, you will be the expert.


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