Opinion: My ‘postmortem’ folder and the intensely personal nature of the latest Covid-19 surge

Each morning I when I arrive at my primary care clinic, the first thing I do is open the electronic medical record and hunt through my inbox. It’s a hodgepodge of folders — patient calls, patient messages, outside messages, contact center messages, staff messages, prescription messages — that often overlap and are frequently overloaded with the medical equivalent of spam. But there’s one folder, Postmortem, that’s unambiguous in its content and purpose.

As the pandemic raged from the winter surge through to the spring slog, Postmortem lit up with a dispiriting regularity. I opened it with dread as it revealed which of my patients had perished that week.

The first surge of Covid-19 last spring had been a blur. Although some of my own patients contracted the disease, the massive waves of patients passing through our medical system and through the national news carried a patina of anonymity. Death and suffering were palpable, but it also felt oddly distanced; most everything that enabled human connection had been shorn away.

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The surge that started at the end of 2020 and pressed through to the spring felt entirely different. This Covid wave has been intensely personal for me, as the dramatic increase of Covid in the community meant that every day more and more of my own patients became ill. For each new diagnosis, my patient and I would embark on a journey — often harrowing — over the course of the illness. We were acutely aware of how much of Covid-19 outcomes was a crapshoot, as the Postmortem folder regularly reminded me.

When a new message landed in Postmortem, I’d try to clear my desk and my mind before making that heavy phone call to the family. We’d talk about their loved one, share memories and grief. For many of my patients, our relationship went back 10 years, sometimes 20. We’d been connected for significant chunks of our lives, often through difficult health setbacks and searingly vulnerable moments. Saying goodbye to them via conversations with their spouses, children, and parents was wrenching. As were the Zoom funerals, which, in bitter irony, the pandemic made easier to attend.

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There is also the uncomfortably bureaucratic part of death. For my patients who died outside of our hospital system, I’d have to “inform” our electronic medical record of this turn of events. First I’d write a note in the chart detailing the circumstances death, awkwardly titled “Expiration Note.” Such is the language of medicine.

Then I’d have to attend to the “Patient Status” field. When our electronic medical record debuted two years ago, I remember how odd that field looked, since everyone’s status was listed as “Alive.” (“Well, what else would they be?” I remember thinking for each patient who walked into my office. “They’re here, right?”) But the pandemic drove home its purpose.

With a single melancholic click, I’d change the status from “Alive” to “Deceased.” And it was this mundane act that always brought on the tears. The ridiculous equivalence of a stupid computer click with the loss of a human life somehow dissolved the last of my composure.

“Are you sure?” the system would chide me, aware that changing this particular status differs from changing a patient’s marital status, or even their Covid-19 status. I know why the system includes this cautionary second step, but it always felt like salt on the wound.

And of course the minute that I’d duly attested to my patient’s deceased status, the Postmortem folder would instantly light up. Yet another alert to be attended to. Another dose of salt. “How many —-ing times,” I’d scream at the computer, “do you have to remind me that my patient has died?”

The ruthlessness of Covid destruction hit hardest when it snuck up unawares, when I’d call a patient for a scheduled televisit appointment only to learn from the family that she was in the ICU at another hospital, or that he’d just died from Covid pneumonia. I’d be all set to discuss high blood pressure and cholesterol levels and suddenly we’d be engulfed in existential terror and raw grief.

When Covid-19 vaccinations opened for the general public, I sent an email to all of my patients, explaining how to get an appointment. “Thank you so much for this information,” came one of the first replies. “But unfortunately our father died from Covid two weeks ago.”

The last time I faced this much unsparing death and devastation was during my residency, when HIV mowed down patients with a savagery I’ll never fully recover from. But the patients usually didn’t live long enough for us to develop extended relationships. Perhaps that’s why I’ve spent the past 25 years as a primary care doctor, cementing long-term connections over years of seemingly mundane blood pressure checks, medication refills, vaccinations, diabetes management, and endless bouts of tendonitis and lumbago.

Now that Covid-19 has been pillaging my patients, it feels unremittingly personal. I know them intimately and there’s no easy way around the grief. And it’s not just Covid-19. In the tenuous gaps between waves, every other disease pounced back — breast cancer, pancreatic cancer, lymphoma, stroke, kidney failure — the inevitable outcome of fractured medical care during the lockdowns. I’ve delivered more painful diagnoses in these past eight months than in any comparable time period during my career.

I multiply this by all of the primary care doctors, nurse practitioners, and clinics in the U.S. and around the world, and the scope of grief is staggering. Health care professionals have been through so much this past year, physically and psychologically. The personal losses of so many patients known and, yes, loved, adds yet another layer of anguish.

Some years ago, I stood in a hospital hallway with a distraught intern. We’d just stepped out of a patient’s room after a wrenching conversation about shifting their treatment from curative intent to palliative care. It was an emotional cataclysm for the patient, who hadn’t fully grasped the extent of their disease before this moment. The intern, whose eyes had been welling up in the room, was now weeping uncontrollably. She was only weeks into her career as a physician and this was the first patient with whom she would be intimately facing death.

“How am I going to do this for the rest of my life?” she sobbed.

That, indeed, is the question that doctors, nurses, and other health care workers ask themselves, especially if they’ve chosen specialties that seed long-term relationships.

I suppose there’s some sort of relief in the ability to feel grief. It lets you know that you are still alive and feeling which, after a year of the Covid onslaught, is no small thing. I tried to assure my intern then — and myself now — that we should be grateful we’re able experience sorrow in these genuinely sad situations. “Think of it as an EKG of our inner compass,” I’d told her. “It’s when it flatlines that we need to be worried.”

Still, the intensely personal nature of the second wave has been depleting. I’ve said goodbye to far too many of my patients. The vaccination optimism makes us all want to celebrate the downslope of the pandemic, but the stubborn trail of grief remains.

Meanwhile, Covid-19 has granted me a bitter appreciation for my lowly exam room. As cramped and claustrophobic as it is, at least I can cry there in relative quiet. Without the encumbrance of a mask.

Danielle Ofri is a primary care physician at Bellevue Hospital, clinical professor of medicine at New York University School of Medicine, and editor in chief of the Bellevue Literary Review. Her newest book is “When We Do Harm: A Doctor Confronts Medical Error” (Beacon Press, April 2020).

Source: STAT