When I was a kid, my father would tell us stories about his dad, a general practitioner in rural Indiana. During the late 1940s, the years of the polio epidemic, Grandpa didn’t let anybody near the car. None of the kids were even allowed in the garage. Each night, arriving home after making rounds, he climbed out of the car, stripped and stood in his underwear in the garage to wash himself with a solution of bleach and water, so that he wouldn’t carry the virus to his family.
I’m writing this during the third week of March 2020. The coronavirus pandemic has hit our nation’s coasts, but the surge is still in the future for those of us in Wisconsin. I’m (nearly) beyond the stage of obsessively checking the news. For my sanity’s sake I’ve signed off Twitter and am largely relying on the links curated by the ASH website for relevant medical information. The whole experience feels a little like standing shin deep in the ocean, facing out, but wearing a blindfold. At first you feel safe, with the sun warm on your face. But then, the temperature of the water changes a bit; it gets a little cooler. There is a pull that starts at your ankles, the sand scurries in new directions around your feet, the water level drops. The wave is coming, but you have no understanding of how large it will be.
Rational fear may be a relatively new emotion for many of us. This is different from anxiety. (Did I double check the creatinine before I signed that order? Will this trial accrue? Is she mad at me?) But rational fear has been a companion to physicians, nurses, and health care workers throughout history. Physicians have waded in to treat patients during plagues and war. They have worked in refugee camps and leprosy colonies. They have opened the car door and let fear sit in the passenger seat as they drove through snowstorms to deliver babies, to attend to the dying, to minister to those who suffer.
And it has occurred to me that the work of hematology might give us some unique expertise in the midst of all this Sturm und Drang. For example, one of the things that feels most recognizable, as I sit in teleconferences about workforce management or supply-chain questions, is the experience of making decisions with incomplete data. Our profession, whether we are choosing induction for a newly diagnosed leukemia patient, pulling the trigger on thrombolytics in a patient with acute pulmonary embolism, or making any of a thousand other decisions, constantly requires that we act before we have certainty, making choices based on what is statistically likely to happen, even if things seem fine at the time. And that’s what disaster planning seems to be about, from what I can see. It requires the resolve to act early; better to be overprepared and underutilized than underprepared and overwhelmed.
As hematologists we are also very good at imagining the worst possible scenario. I’ve been mocked many times by my family for this, but the habit has served me well. Our training instills in us a seemingly endless list of complications that we anticipate and then work to prevent or circumvent. Why else do we prescribe so many prophylactic medications or line up potential third-line clinical trial options for a patient who has not yet failed second-line treatment? And then we have the other set of worries: What if they are p53 mutated? What if they get sepsis? What if they are HLA-sensitized? When should I transplant? Many of the decisions we are now making in the COVID-19 era currently require that same brand of pessimistic imagination. What if all our doctors or advanced practice providers get exposed? What if we don’t have an adequate blood supply? What if we run out of gowns? ASH President Dr. Stephanie Lee, in a call earlier this week told me that the experts say in these situations, preparations seem alarmist until the disaster hits, then they seem inadequate.
Finally, I think training for hematology teaches you how to simultaneously hold in balance both large-scale statistics and the personal aspects of your decision-making. Today, I sat with a patient— a 57-year-old woman with favorable-risk acute leukemia in first remission. I am well aware of her statistical chances of cure. I am also aware that the likelihood of death, should she contract COVID-19, is sixfold higher than someone her age without cancer. And I know that my recommendation about the timing of consolidation must, at the end of the day, help her thread the needle of those risks. Math has been an important angle of the coronavirus news (I’ll bet that in these past two months the words logarithmic and exponential were used more in newspapers than they have been in the past two decades). And yet, the pull that is keeping our populations behind closed doors these days is the human stories of Chinese and Italian nurses and doctors, and of people who might be denied ventilators or intensive care support. In medicine, we are often asked to think both of math and the personal singularity of our patients. This balancing act feels familiar.
In a way, as a community we are lucky. We can still work. For those at home, the altruism of sheltering in place has its own frustrations. In this surreal drama — critiqued and scrutinized by a million armchair pundits and social media warriors — we have one job: We go to work. No one is bugging us about metrics, readmission rates, or length of stay. No one is soliciting for participation in a useless survey about a drug I don’t administer. We are being called to focus only on the essential mission: to keep our patients and one another safe. We have trained for this all our lives; we just didn’t know this pestilence was going to be the playing field, and resource scarcity our competitor.
Doctors, nurses, and health care workers have, for generations, been familiar with fear. They have woken up in the morning, let fear in, and gone to work. Now is no different. We can do this.
