Trainees on the Front Lines of COVID-19: An Interview With Dr. Nicole Cruz of New York Presbyterian Hospital

Dr. Urshila Durani: Describe yourself and what you were previously doing for fellowship prior to COVID-19.

Dr. Nicole Cruz: I am a third-year hematology-oncology fellow at Weill Cornell-New York Presbyterian Hospital. I’m an aspiring physician-researcher with interests in translational research in AML [acute myeloid leukemia]. When the COVID-19 pandemic started, I was on my research elective month working on my RTAF [ASH Research Training Award for Fellows] project in the laboratory of Dr. Monica Guzman. I was testing a small-molecule compound in primary AML samples and learning a new laboratory technique that I need in order to complete my research proposal.

UD: How did you find out you were being redeployed to work in the hospital?

NC: About one week before my deployment, we had been receiving emails from our program director and the medicine department informing us of a potential deployment. The first email was asking for volunteers and other information that they would use to select your deployment place, such as years since residency graduation, last inpatient experience, how comfortable you feel taking care of admitted patients on your own, and how comfortable you feel taking care of patients in an ICU [intensive care unit]. Our program director also asked us to inform him of any extenuating circumstances that would prevent us from engaging in direct patient care, such as child care or chronic illness. He did an excellent job protecting those fellows from being deployed. I was the first hematology-oncology fellow to be deployed. It was a stressful situation because I received the phone call three hours before the shift started. I was deployed to the ICU and the medical floors of Lower Manhattan Hospital — a different hospital that is also part of the Weill Cornell-New York Presbyterian system. I would function as a hospitalist admitting COVID-19–positive and –negative patients to the ICU or medicine teams. It was shocking to see and hear what was going on in the hospital. The ICU was full of patients, nurses, and doctors. It looked like everyone was running around trying to save a life. It looked like a war zone. I remember telling myself, “You need to focus, shake that fear away and concentrate on the task at hand.” The next day, either the situation was more under control or I got used to it.

UD: What did you do, if anything, to prepare for this?

NC: Knowledge-wise, I read about the disease, the treatments, what other institutions were doing, and what our own institution was recommending. I refreshed my ventilator settings knowledge, acid-base disturbances, vasopressor dosing, etc. Physically, I ate as healthy as I could the first few days to make sure my body and immune system were in top shape in case I got the virus. Unfortunately, this didn’t last long because I don’t have time to cook or exercise, so now I just eat what I find in the hospital. Mentally, I prepared to be deployed and to work in a high-stress environment. I also prepared myself mentally in case I got infected. I made sure I had a thermometer, a pulse oximeter, acetaminophen, and nasal decongestants in case I got sick. Emotionally, I could not prepare for this.

UD: Were you given resources to prepare?

NC: Our medicine department did an excellent job in creating guidelines for admission, escalation of care, ICU management, anticoagulation, and trials. We receive daily emails with updates to those guidelines or any relevant publications. I’ve always felt prepared, supported, and with enough PPE [personal protective equipment].

UD: What is your role on service?

NC: I am currently alternating between the night shift in the ICU and the medicine floors. In the ICU, I take care of three to five patients. We have one or two ICU attendings, one anesthesia attending that does all the intubations, and PAs [physician assistants] that do all central lines or A-lines. When I’m working on the medicine floors, I am only doing admissions and helping the PAs with management of sick patients on the medicine floor.

UD: What have you struggled with most during this time?

NC: The two most difficult things during this time have been goals of care discussions and seeing my patients die of COVID-19. I thought that being a hem-onc fellow would have prepared me for having goals of care discussions with suspected COVID-19 patients. I was so naive to think that I would be the most equipped physician to do this, but I quickly realized that this was not true. I needed to learn quickly how to have goals of care in a pandemic, where the patient is not a cancer patient but a healthy patient that three months ago ran the New York City Marathon, yet now feels weak, short of breath, has a fever, and decided to come to the hospital. What I didn’t realize at first was that many of these patients are otherwise relatively healthy and living a completely normal life. It is shocking for them to have a doctor in the emergency department ask them about their code status and health care proxy, so I have to explain why I am asking this question. I have to tell them that although they feel fine now, they could get sick really quickly because of the virus. I see how their facial expression changes. They are suddenly scared, although that was not my intention. I try to give them hope and tell them that many patients go home within a few days and that maybe they will be one of those. Many respond with, “I just came to the hospital because I have shortness of breath” or “because my doctor told me to come.” Many of them can’t answer the question at the time, so I give them time to process it and tell them to think about it because a different doctor might ask them that same question later in the day.

It’s also been incredibly difficult to see my patients die because of this virus. Our patient population is the most vulnerable of all and you live in fear that one of them will get infected. You don’t know which of your patients will get it or whether they’ll survive. When your patient gets admitted to the hospital, you know something that they don’t know. This might be the last time you see them and the last time they see their family. You have to see and talk to them through all your PPE. You hope that they know you well enough to recognize your voice and the way your eyes squint when you smile but just in case you tell them your name, “Hi, it’s me. Dr. Cruz.” It’s heartbreaking what they have to go through. They are completely alone because visitors are not allowed, and I feel so powerless against it. I’ve tried video conferencing the family so that they get a chance to say goodbye, but it’s not the same. It’s different when your patient dies from cancer, because most of the time you have time to prepare the patient, the family, and yourself. Our patients should pass away surrounded by family, not alone and scared. When you are treating cancer, you offer hope and treatments before telling them that it’s time to go. Against COVID-19, you have no proven effective treatments and no hope to offer them. When your patient gets infected and admitted with hypoxia to the hospital, you reflect on everything that your patient has gone through to beat their cancer, all the hugs and smiles you shared, and now this virus just takes it all away in a matter of days, with no warning. It is very frustrating.

UD: Do you think this experience has affected your life views (on medicine, your career, etc) in any way?

NC: I have gone through different phases in these few weeks. The first two weeks I questioned why I decided to pursue a career as a translational researcher. I was frustrated because all the research and knowledge that we have has been futile against this virus. I kept thinking that at the end of the day, the only way I could help people was by being a doctor and not a researcher. Now that taking care of COVID-19 positive patients has become my new normal, I’ve realized that the reason this virus is so deadly is because there is very little research in this area. Research is needed to help prevent a pandemic, and research is needed to cure cancer. Now I’m eager to start my research again and find answers that can one day help save someone’s life. I’ve also realized just how much I like working in the hospital. I missed the action and my colleagues. I’m hoping my future endeavors as a clinician-researcher include some inpatient clinical time as well.

UD: How are you coping with the heavy workload and the emotional stress of what you are doing?

NC: I don’t think we are coping. I think we are all just pushing through hoping that each day you have the energy to keep on going. We are all doing things that we never thought we would have to do again, and it’s ok because we are all in this together; we are learning on the go. We are helping and picking each other up. It’s been refreshing to see the incredible camaraderie between physicians, nurses, and PAs. This situation has made us more empathic and more human, so every day I go to work happy to work with these heroes. Despite it all, you’ll find that in the middle of the pandemic, your physician instincts will kick in. You’ll push aside the fear, put on a smile — and your PPE — and realize that there is nowhere else you’d rather be.

UD: How are you trying to stay connected to your hem-onc life during this time?

NC: Even during a pandemic, you are a hematologist-oncologist 24/7. Making sure that I am there for my clinic patients when they need me has been challenging. At first, I wanted to do everything on my own, but I quickly realized that it was going to be very difficult, so I requested the help of my amazing co-fellows. While I sleep during the day, they are covering my urgent clinic phone calls, and if a patient needs to be seen, they help with that as well. Our clinic assistants are letting my patients know that I am working nights and [that] I have to sleep during the day; so if there is an emergency, my co-fellows take care of it. If it’s not an emergency or if the patient wants to talk to me specifically, then I call them as soon as I wake up. By now, most of my patients know that I’m working nights, so they understand if I take a little bit longer to return their call. On my nights off, I watch different webinars, I join my lab meeting, and study for the hematology boards to keep the hem-onc knowledge fresh. Also, you’ll be surprised at how much hematology we are practicing with the COVID-19 patients. New anticoagulation guidelines are being created and updated daily by each institution because they are hyper-coagulable patients. Some of them are thrombocytopenic, on DIC [disseminated intravascular coagulation], or bleeding, so hematologists have become a crucial part of the COVID-19 workforce alongside the infectious disease and ICU doctors.

UD: Do you have any advice for fellows preparing for redeployment and/or coping during this time?

NC: You need to prepare yourself mentally to practice medicine like you’ve never done before. Medicine in time of war. It will still be the good medicine, and patients will still receive excellent care, but you will learn to work with limited resources and personnel. You might find yourself helping a nurse to clean a patient or helping a nurse dose metoprolol and Lasix during an emergency because they are taking care of another emergency. You might find yourself admitting patients to the medicine floor that in any other situation would have been admitted to an ICU. The hospital system and nursing staff will help you to make this happen, so don’t stress too much about it.

My second piece of advice would be to find something to look forward to on your days off, and at the start and the end of the day. For example, we receive delicious meal donations at the hospital, so we all look forward to breakfast and dinner time. Perhaps it’s because food brings people together, or perhaps because we have something in common to look forward to. When I get home, I look forward to playing with my new puppy, and on my days off, I look forward to having a nice glass of red wine. These are the little things that keep us motivated. I would also recommend that you find one or two co-fellows that have similar deployment schedules. My best friend was also deployed to cover the night shift, so we understand what each other is going through.

Interview conducted and edited by Dr. Urshila Durani of Mayo Clinic, Rochester, MN