SGIM Forum

Perspective: Part I

Tsunami Coming

Dr. Mancini ( is chief of hospital medicine at Denver Health and an associate professor of medicine at the University of Colorado.

I am standing at a shoreline, watching and waiting tensely as a massive wave approaches from afar. My colleagues are quietly filling in at my side—as we stand in front of the many sick and vulnerable, we realize a larger number is on the way. With friends and families behind us, we are hoping that, at the end of the day, we protect ourselves enough to not place them in danger when we return home. We are readying side by side to lock hands and brace for the tsunami to hit.

I have more than 60 hospital medicine clinicians standing with me, collectively facing an opponent we cannot see but, more importantly, cannot exactly predict. An opponent that threatens our safety and challenges us to sharpen our skills to keep our communities, our families, and ourselves safe. As chief of my division, I feel the trepidation of my team, building as a deep and low vibration among us. We are being called to follow the oath we all took many years ago—to stand and protect those around us knowing that it could be our end. Yet every member of my team is preparing to step forward and serve.

I am seeing courage—deep courage—the kind you can see in one’s eyes as he/she steps into a storm. My friends and colleagues are watching patients and clinicians dying around the world; terrified and exhausted, they fight an illness without the needed knowledge and tools. Yet, here I am asking my team to do the same—a horrible request when you realize that following their oath could risk their families, even their lives. These clinicians, my colleagues, are throwing themselves like sandbags in front of the water, gathering every shred of information they can collect to equip themselves for a battle I cannot guarantee they will even know if they have won. All I can promise is that if they win today, they can fight tomorrow, maybe against overwhelming odds.

In the face of a wall of water, I am learning that communication is a crucial weapon as a leader and physician. Providing daily communications of goals and imminent obstacles has empowered my team to leave the assumed safety of their homes and fight. I am encouraging every member of my team to use new knowledge and skills to steady us in this battle. Whether it is training to become intensive care proficient or developing clinical or research algorithms for future care, we are grounding ourselves in our most natural skills of learning and adapting. Like so many of my colleagues, I have had to overcome fears to remain effective in my work. I worried about the donning and duffing of protective gear, making multiple mistakes the first few times I practiced. I worried how any subtle errors might put my children at risk. I struggled to reconcile these fears, some I have never known prior to this crisis, but it has become second nature, with practice and support. Now I don a superhero head cover, hand sewn by a colleague’s sister, to remind me I have a well of courage deeper than I realize.

I am feeling solidarity. I am experiencing for the first-time clinicians across disciplines urgently gathering, learning, and sharing. Together, we are exchanging experiences and questions through masks, preparing for a battle we can’t quite comprehend. We are learning very quickly that to survive this tsunami, we must break down our traditional practice domains and stand together. We created daily rounds where our intensivists, infectious disease doctors, hospitalists, surgeons, palliative clinicians, and anesthesiologists can discuss the wins and losses from the day before and strategize over the patients who are decompensating. We have learned that to improve efficiency and preserve PPE, we need surgical expertise in the medical ICU and anesthesia support in the ED. Domains that were historically not crossed, now forging together to prepare us for the swells ahead. We have community physicians and sub-specialists racing to the hospital to cover general medicine teams so that hospitalists and cardiologists can help cover the ever-expanding intensive care units. An elaborate structure of coverage created in days without staff hesitation. I am confident that these relationships will stand the test of time long after this crisis has passed—an unexpected gift emerging out of a traumatic storm.

I still worry that this powerful solidarity may not be enough. As the numbers far exceed our capacity and our resources become more depleted, I worry that we will be left sorting through a wreckage that none of us are prepared to comprehend. I worry how to lead my team, my colleagues, and support my family and myself as we heal from this unfathomable trauma. The damage left behind in this disaster will require healing with the entire community.

I have never known anything like this. I studied to learn the fundamental patterns of medicine. I trained to learn how to identify the red herrings when they present. I practiced with my hands-on at the bedside to appreciate the subtleties of human responses during distress. I honed all of these skills and more to ascend as a leader in my field; yet, I feel a sense of despair in the face of such a giant.

We stand in an eerie calm, as the streets empty and the hospital volumes temporarily drop—like the ocean water recedes just prior to the tsunami arriving. Our community, with nowhere to evacuate frightfully shelters in their homes, waiting for the impending natural disaster that is moving toward us. As the surge of water builds on the horizon, we feel the earth tremble under our feet and anticipate the wave, a battered shoreline, and path of wreckage in its wake. I stand hands locked with my colleagues waiting for the devastation to strike, readying our forces to rescue the sick and bring them to safety.

I am honored and humbled to be here. 


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