When it became apparent that COVID-19 would not just be a medical event that happened over there but was going to affect everything I started jotting some notes here. They have remained in Drafts for over a month. I am going to start publishing these diary entries.

I remember the first patient at St John Hospital that had COVID. We had been hearing about this disease. First in China, then in Italy and Iran. Then Americans had it, but they were on cruise ships. Then it was nursing home patients in Washington and then it was here, in Detroit. It was a long build up. I remember reading about the doctors in Italy and thinking, “Is it possible that I’m sitting comfortably in suburban USA and in two weeks it’ll be World War One Trench warfare”

Well the two weeks ticked off and here was the first patient. We already had a number of people that were getting ruled out for COVID. But we didn’t know what we were doing and the disease prevalence was so low we were ruling out some people that were low risk; people that obviously had alternative explanations for a fever. It was like we were sick of getting ready and just wanted to have a patient in isolation. So there were those “fake” covid’s and then there was the patient in the ICU, the patient with white-out on chest x-ray. The patient on a PEEP of 17, 100% FiO2 with PaO2 in the 70s. That was the real one. The test wasn’t back yet, but everyone knew, that was the disease. That was what was waiting for us.

That patient, patient zero, the first one with real bad ARDS also had kidney failure so they became my patient. A few days later we got PCR confirmation of the diagnosis. I took a screen shot of the report. It felt important. I remembered reading in the Italian reports how they were excited by the first positive reports and then a week later that was all they were seeing, positive after positive.

The patients began to trickle in. One by one and then two by two. Fellows were banned from seeing patients in order to conserve PPE, and protect them, so my fellow began carefully highlighting he patients on the list that were COVID-19. By the end of the week she shifted to highlighting the ones that weren’t COVID to conserve her pen, and the next week she stopped the ritual all together; our consult nephrology list was entirely COVID.

As our list mutated from the nephrology consult service to a COVID-Nephropathy service the hospital also transformed. We found ourselves taking a short cut to the inpatient dialysis unit and walking through a door and all of sudden we weren’t in our familiar hospital but some facsimile of a biocontainment unit. All the doors were shut. Everyone was in masks, hair nets and gowns. One wrong turn and you were transported to the set of Contagion. Same thing would happen in the ER. or the first week they segregated the ER to COVID and not COVID modules but the COVID patients quickly over ran their alotment and the whole ER became COVID-land.

Besides the isolation strategies the other part that made the hospital feel eerie was how quiet it became. Everyone assumes that the hospitals had to be crazy, but the truth was once they stopped allowing visitors and stopped elective surgeries, the wards became still. The cafeteria was empty. The hospital was quiet, still, and nearly empty.

Residents often ask me what is wrong with nephrology? Why don’t residents want to become nephrologists anymore?

I have a number of answers to that question, but explaining the reason means that I am explaining how other people think and make decisions. I’d rather talk about how much I love nephrology and why I find it a fulfilling career. It feels more honest and less presumptuous.

Last week I had a perfect day and it encapsulated what makes me so happy in the medical career I have chosen.

I woke up, walked the dog and headed into the hospital. I had a lecture. I hold a monthly electrolyte session with the fellows. It is scheduled for an hour but we always go long. Usually the lectures last 90 minutes. I start the lecture with a recent electrolyte conundrum that we work out on the white board. Last week’s lecture kicked off with the highest urine sodium I had ever seen.

And after discussing this case of hyponatremia we continued the potassium lecture from the previous month. The way I handle my fellow lectures is I use the slide set from my resident level lecture but instead of going through the slides in an hour, we spend three to four hours unpacking lecture. We discuss the papers and data behind each slide. The original presentation becomes a road map for a meandering discussion-based didactic session. They are among the most enjoyable teaching sessions I do.

After this lecture I went to the dialysis floor where I’m rounding this month. The full team is supposed to be a fellow, a senior resident, and three interns. But this month we don’t have a fellow, and on that Thursday the senior was in clinic and one of the interns was in his weekly lectures (he is an ER intern, not categorical medicine). So it was just me and two of the interns running the show. The service had exploded overnight so we had the work cut out for us. But we buckled down, triaged the list, saw the sickest ones first, got dialysis orders in for the new patients, and saw everyone on the floor. We even did some on-the-fly teaching and the interns got to see a fresh transplant patient who was making urine. This was great because the previous two transplants had delayed graft function and slow graft function. So this one completed the set.

At noon I had a lecture, but this time I was the audience. One of our fellows was presenting on an interesting case. This was his first time presenting the case but he is going to present at the upcoming intracity grand rounds so we essentially got to see his one point oh presentation. It was great getting to see his work because I know he had been working hard on it. How did I know he had done his homework? Because he had been discussing the case and his research on Twitter!

Then after lunch I had a meeting with the head of research and our biostatistician to go over three different resident and fellow research projects to see how they are going. This research isn’t moving fast but it is moving forward and it will be exciting. We have some good stuff in the pipeline.

After that I headed back to the ward, but got derailed by the transplant surgeon and spent 20 minutes trading hospital gossip with her. Truly one of the most enjouable diversions you can have. After that I met with my team, now joined by the senior and ER resident to card-round and make sure everyone was tucked in for the night with dialysis orders ready for tomorrow.

I then went back to my office, added a page to the NSMC.blog website for the NSMC interns.

Went home.

Went for a 5 mile run.

Dinner with my daughter and lastly worked on NephMadness until I went to bed.

Does anybody have it better than me?

What a day!