Adults
During the Covid-19 pandemic, silos between specialties have often disappeared. Many practitioners have taken care of whomever needs it, wherever in the hospital they are located. In this spirit, pediatric emergency physician Dr. Rachel Kowalsky tells a story about caring for adults.
Adults
by Rachel Kowalsky
I squinted at my computer screen through my face shield. It was streaked with residue, and my glasses were fogged up. Everything I looked at was an approximation of the real world. But yes, I could see that my next patient was eighty-two years old-- the oldest person I would care for since graduating eleven years ago from my fellowship in Pediatric Emergency Medicine. I am a pediatrician. I care for children and young adults up to age twenty-one. For me, a thirty-year-old is elderly. Eighty-two is uncharted territory.
My patient had osteoporosis, hypercholesterolemia, and dementia, and according to my e-board, she had fallen down outside her home a few days ago. Now she had back pain. A redeployed resident from rehabilitation medicine sat next to me, scrolling through her voluminous medical record.
What was I—an emergency pediatrician— doing in Urgent Care, seeing an 82-year-old?
When COVID-19 hit New York City, two things happened in our children’s hospital. First, my pediatric emergency group, like many groups across the country, stepped up to help offload the burden from our friends and colleagues on the adult side. On Telemedicine, we saw patients of all ages. And we covered shifts in our department’s urgent care, Area D. This is where I saw my 82-year-old.
The second thing that happened was, On March 25th, we closed our children’s hospital. The children’s beds, and their ventilators, were needed for sick adults who were lining the hallways of the adult emergency department. Our hospital was literally overflowing. So all pediatric inpatients were transferred out.
This wasn’t all bad. There are many ways in which adults are easier to care for than children. They swallow pills. They are fully immunized. They have met their milestones. Finally, they don’t get upset when you ask them to keep an empty stomach until we’re certain it’s okay for them to eat.
I went to my patient’s bedside, and she smiled up at me, toothless as a baby. “Hello dear,” she said. Then she added, “Can you tell me where it hurts?” I understood that she was echoing the words of the triage nurse, that this was part of her dementia, but I felt the urge to answer her honestly. “My nose hurts,” I wanted to say. “I think my mask is too tight.” Instead I said, “I heard that you fell down.” Which isn’t so different from how I might begin a visit on the pediatric side. And she said “yes, I did,” and she showed me where it hurt.
We got along well. I’ll bet most pediatricians found that they enjoyed their older patients during COVID. It was refreshing to have an adult conversation—more like talking to a friend or neighbor than talking to a patient.
But it wasn’t perfect, and here’s why. Children are extremely resilient. Even the sickest ones. A few years ago, I resuscitated an unresponsive twelve year old with bacterial meningitis. The next time I saw him in the emergency department, one year later, it was to evaluate him for a football injury. That was one of the best days of my career. I couldn’t get over how healthy he looked, how vital and strong. You look amazing! I said to him. You’re playing sports! But the boy was matter of fact, smiling up at me as though there had never been any question about his recovery. Children usually get better.
But adults live with disease and discomfort. They accumulate comorbidities along with wisdom and experience over the years. An 82-year-old who falls makes me afraid for my parents, and reminds me of my own mortality. A two-year-old who falls is just learning to climb the stairs. I don’t know if the difference is good or bad; it is simply true.
Here’s what I do know: to care for a child is to invoke all of life’s prospects. There is nothing but future ahead for a child, and maybe greatness. Children are tiny placeholders for a life that is full of possibility. Rita Charon, who built the field of narrative medicine, said “the care of the sick unfolds in stories,” and to me, pediatrics is chapter one, the opening scene. I love chapter one. That’s my chosen chapter.
Well, I learned a lot of medicine. Somehow all of my telemedicine patients were hypertensive, and I’d keep them on the phone making small talk while I pored over textbooks and online resources to see whether I should start antihypertensives, and what the right dose would be, waiting for my friends in adult medicine to write back on our group chat. I performed some of the most comprehensive review of systems of my life, terrified that I would miss a myocardial infarction, aortic dissection, or other catastrophic adult event.
My 82-year-old patient was okay. She said I was friendly; most pediatricians are extremely friendly. We hone our communication skills on 3 year olds who are hiding under the sink. I told her she was friendly too, and that I was happy to meet her, which is true. You can’t discount the importance of proximity to another human being during a pandemic that creates untouchables.
Finally, we needed each other. She needed an x-ray. I needed to do something to help my adult colleagues who were exhausted and demoralized—who on the other side of the double doors from me were intubating 82-year-olds, not diagnosing their compression fractures.
And yes, my patient had a compression fracture and was able to be discharged home. The rehabilitation medicine resident taught me that this is a common injury in people with osteoporosis, and she showed me all of the osteoporotic areas on the x-ray.
At the end of the day, I took off my face shield and the world came back into focus. One of the nurses told me my visor would be less streaky if I washed it with soap and water, and she was right.
We are coming down the far side of the curve now. On June 10th, we are getting our inpatient units back. The children are officially returning to our hospital. I will be so happy to see them. But if this ever happens again, I’ll be back in the mix, sadder but wiser, ready to greet my new friends, the ones I learned so much about during this strange chapter in my life: the adults.
