October 8, 2020
Sewanee, Tennessee
Dear Adam,
It’s important for me to write this story—acknowledging it is only part of the story—of these last few months as an ICU doctor during the COVID-19 pandemic. This pandemic became personal for me early on. Merkeb Y., our former nanny, whom we loved as a member of our family, was admitted to an ICU on March 28, 2020, as she was rapidly deteriorating with respiratory failure from Coronavirus.
Seven years had passed since she had been our children’s caregiver, but Merkeb and her family remained an important part of our family. She and I spoke if not frequently, regularly. She and her family would sometimes join us for holiday meals and family celebrations. She cooked us her amazing dishes that we loved—a mix of Eritrean / Ethiopian, Italian, and Arabic cuisine that amazed everyone who tasted them and reflected her migration path from Eritrea to the U.S. Her family attended my husband’s swearing-in ceremony as a US Ambassador, and our family was present for her husband’s induction as a pastor in their large, evangelical church. She was the kind of woman I learned early on to not give gifts to, because she would invariably pass them on to people she felt more in need of them than her. If I wanted to treat her to a massage, I had to physically take her to the masseuse myself.
Merkeb’s admission to the hospital occurred during the early days of the pandemic, as it proliferated near our home in the Washington, DC, area. We were still learning so much about the disease. From my home, I reviewed Merkeb’s chart remotely. I was in daily contact with her medical team and family. She was desperately sick from this disease, but I had heard a story early on about the original SARS coronavirus outbreak in Canada that gave me some hope about her prognosis: ICU doctors there had seen a subset of patients who neither died immediately nor quickly improved, but often required support from a ventilator for seven to ten weeks in the ICU—an almost unimaginable amount of time.
Merkeb had been in an ICU and on a ventilator for thirty-five days. She was improving, and her ICU doctor there had started to consider a tracheostomy for her. We discussed the possibility, and I told him I was not opposed to it. I understood this to be the natural course for a patient who would require long-term weaning from a ventilator. I also recognized that she had a large goiter, which a friend and colleague who was an ENT surgeon was scheduled to remove August 12, 2020.
We had been urging Merkeb to have a thyroidectomy for years. But true to her nature, she always put others ahead of herself and had used her limited resources for the joy and growth of others. As a result, I was now pointing out to the intensivist on the other end of the call that hers would not necessarily be an easy trach, and that he should consider contacting the hospital’s ENT. I also gave him the contact details of her ENT, Dr. S., so that the two could speak freely. Over the next forty-eight hours, the ENT at the hospital she was at refused to do the case, citing medical concerns. Her intensivist updated me of this and told me that upon hearing of this, Dr. S. was trying to get her moved to a hospital where he had privileges so that he could perform the tracheostomy and the necessary thyroidectomy. I immediately reached out to Dr. S. and said, “What do you think about moving her to my hospital?” He had recently been granted privileges there. Being on staff in the ICU, I thought I could facilitate the transfer.
ICU beds were a rare commodity at that time. Ours were full, and patients were overflowing into other parts of the hospital. However, I hoped by getting Merkeb transferred that I’d give her the best odds for a positive outcome. For the past month, I’d seen firsthand the devastation this disease caused. In addition to decimating the lungs, it causes shock, kidney failure, and a slew of neurological injuries that we’d never seen before—even in young, healthy people. Every night, I reviewed Merkeb’s chart. I read for signs of improvement and, often seeing none, took solace in the fact that she’d made it through respiratory failure and shock but had not suffered from kidney failure or in particular a devastating neurological injury.
Dr. S. and I both agreed that getting her to my hospital was the best possible option. We also agreed that, in her current condition, she would languish to a certain death without further intervention. We could not ethically let her go that route, especially considering that she was awake and following commands, not to mention that her family still wished to continue her treatment. If she truly was to be among the cohort described in the Canadian experience, we had to continue trying to give her a reasonable chance.
After nearly forty days in the ICU, Merkeb arrived at our hospital the next morning. I went to see her—not as a doctor but as the friend of a woman who is family. I had worked behind the scenes while she was under the other hospital’s care, getting her tocilizumab, an immunosuppressive drug, early in her admission. I had also asked that she be considered for ECMO evaluation—a machine bypass of the lungs to deal with severe acute respiratory failure—although she was ultimately deemed not sick enough. I ensured that she was among the first patient to receive convalescent plasma. I felt that if there was any connection I could use, any resource I could employ, this was the time to do it. I arrived on May 8, 2020, full of pride for having done all that I had done, which included her transfer to our hospital for ongoing care and surgical treatment that she needed. I have seen critically ill patients for well over a decade, but my Achilles’ heel is the severe illness of those I love.
Her nurse asked me for a variety of orders, and I informed her I was not the doctor in charge of her care. I was just visiting. She was confused, but when she saw my eyes brimming with tears while I looked at Merkeb, she quietly walked away. I took a deep breath and entered her room. This was early in the time of COVID-19. Due to the highly infective nature of the virus, we were not allowing family to visit loved ones unless it was to withdraw care. I saw then how Merkeb looked. She was fifty-seven, a mere ten years older than me. Yet despite her youth, forty days in the ICU had ravaged her in the ways I had feared. I kept saying her name, “Merkeb, Meribiyea, Merkebina semashign?” Despite my saying every affectionate derivation of her name, when I asked if she could hear me, she didn’t respond. She was able to open her eyes but did not appear to register that it was me talking to her in our shared language of Amharic. She appeared confused, exhausted, swollen, immobile, and scarred across her face where she had lain for sixteen to eighteen hours a day just so she could maintain adequate oxygen levels.
As I held her hands, I looked at her and quietly wept. I stared out the hospital window, feeling powerless. I went home and called her husband to explain what I’d seen in softer terms, but I was realistic with him as I had been the entire period of her hospitalization. He had spoken to the palliative care doctor for each of those days with patience, and he insisted quietly that we just keep trying to do our best. Now I wondered if we had done the right thing. That afternoon, my husband—my wise sounding board—asked me again if we were doing the right thing. I replied that we were doing what we were often asked to do, which was to “keep doing our best.” That night, as I lay in bed thinking of her likely future complications, I knew I would return each day to see her. I would work with her on her mobility using passive range of motion exercises, and I would continue to ask after her when I was not working. I felt good about my choice. I could take some control over the situation and feel as if I were working toward her positive outcome rather than just feel overwhelmed by her condition.
As I readied myself to go to work the next morning, I remembered a Christmas ornament that the husband of a patient I had taken care of during my ICU fellowship days had given me. It was a weighty crystal star formed by a circle with rays emanating from four sides with a crimson red cord. On our Christmas tree it appears like the star the wisemen followed to Bethlehem. His wife, a young Ethiopian woman in her thirties, had developed septic shock within days of their marriage. Her treatment required a ventilator, dialysis, surgery, a tracheostomy, a feeding tube, and weeks in the ICU. This was followed by more time in the hospital and months of rehab, after which she walked back into the ICU with her husband to thank us for saving her life. Her only visible reminder of the time with us was a small scar on her neck from multiple central lines and the small horizontal scar where the tracheostomy had once been. Every time we decorate our Christmas tree and I see that ornament, I am filled with tremendous gratitude for the life of that young woman.
I thought of her as I readied myself emotionally to go in and see Merkeb, prepared to do range of motion exercises and whatever else she needed. That memory fortified me in my decision to fight hard to get Merkeb to this point. I entered her room as the nurses were giving each other report. I asked the night nurse, who was getting ready to leave, how Merkeb’s last several nights had been. She indicated that she seemed better than she had been on arrival. I spoke to Merkeb. She now clearly recognized me. She could raise her eyebrows for yes, and slowly, weakly shake her head for no. I spent over an hour with her, asked her if she knew what had happened, and if she wanted to know. She indicated that she did not know but wanted to, so I updated her on what had happened since she was last conscious—what had happened to her and to the world, and how she had ended up at the hospital where I worked. I explained that the world had largely shut down in the pandemic as social distancing seemed to be the only thing able to contain it. I told her that the people she loved—her husband, son, and daughter; my kids, my husband, my brother, mother, father, the list went on and on—had been praying for her recovery. And soon after our talk, I left, promising her we’d see each other tomorrow.
When I returned the next day, I offered to braid her hair. She indicated she would want that. While I braided her hair, I considered that the next day was Mother’s Day, and that what all those people who loved her had each quietly told me, regardless of their age, was that Merkeb was a combination of an angel and a mother to them.
That day, a nephrologist colleague stopped me and asked about my famous grandmother. He had recently visited my home country of Ethiopia, and with a favorite guide of mine had toured some of the historical northern sites, including the famed city of Lalibela. I corrected him and said that he was likely referring to my great-aunt, my mother’s aunt, Shewareged Gedle. She was a patriot and liberation fighter against the Italian occupation of Ethiopia who was tortured by the Italians when she refused to give them information about the rebel fighters she led. I was buoyed a bit by the recollection that I come from a long line of women warriors. I left the conversation realizing that my mom, my great-aunt, and my grandmothers had fought powerful sociopolitical and historical forces and triumphed. My father, in his quiet but insistent struggles, as well as his uncle, Abeba Retta, who helped his entire extended family receive an education—these people also served as the basis for my very persistent—some might say dogged—temperament. They also contributed to the strength I could draw on as I continued to support Merkeb.
Over the course of the next few days, Merkeb received a tracheostomy and a PEG tube (a feeding tube placed directly into the stomach through the abdominal wall). The scarring on her face started to improve as she no longer required proning. I would come and sit with Merkeb and assist with her range of motion exercise. I brushed her long black hair, which had become horribly matted. She would weakly move her fingers and toes, but she appeared to have severe myopathy and could not move much other than a few digits and her facial muscles. Yet each day I would pray for her improvement and give thanks for her stamina, which had brought her this far. We found a blood clot in her arm where an IV had been and continued the blood thinners that had been started at the other hospital for a clot in her leg. On May 18, I went to see her when my shift ended. She smiled as always at seeing me. I made a Facetime call to her son and husband who were driving to New York to pick up her daughter. Her husband was upbeat as always, but her son, who was in his mid-twenties, always broke down during these calls. Merkeb looked at me confused, as if to say “why is he crying?” After regaining his composure, he spoke with her for a few more minutes. Then we made a Facetime call to her daughter, who was a couple of years older than her sibling and always very happy and composed to see her mother. When we got off the call, Merkeb asked me, “When can I go home?” I told her she needed to be much stronger and that’s why we were doing daily exercise with her. She had been asking me this for the last several days.
I woke a few hours later to a voicemail from her husband. He said the hospital was trying to reach him about a procedure. A text from my colleague on duty asked me to call him. I immediately opened her electronic chart and saw he’d ordered a head CT. Unable to see any images, I ran upstairs sobbing to my husband, saying that something had happened to Merkeb and I needed to go back to the hospital. I was unable to reach my colleague en route, so I ran straight to Merkeb’s room. She was comatose when I arrived. Reopening her chart, I beheld the images of COVID-19 devastation. An intraventricular hemorrhage. Left untreated she would die from it. Even with treatment, I knew her chances of meaningful recovery were close to nonexistent. My colleague had been alerted by the staff of my arrival, and he told me what had happened. She had become unresponsive, her heart rate had slowed into the thirties, and her blood pressure had soared, then plummeted, and then she stopped breathing over the set respiratory rate of the ventilator. This triad, known as Cushing’s triad, is a hallmark of increased pressure in the brain and heralds the path to brain herniation, and death. The neurosurgeon was called in, and she placed a drainage device into Merkeb’s brain. I stayed and offered to help in any way I could. Merkeb’s hair was cut to the scalp to allow for insertion of the drainage catheter. I watched her hair fall away, mowed from just right of center of her scalp to the middle of her crown. I held her head in my hands as the surgeon drilled by hand into her skull to insert the catheter and secure it to her scalp. The fluid, which should normally be clear, was grossly bloody. As the surgeon worked, she said, “You must know she will not survive this. We are just buying a bit of time.” Tears welled in my eyes, and I thought of the first time Merkeb came into our lives. She arrived with her husband. I was expecting our second son any day, and she radiated love and warmth. She had brought me a silver carafe filled with aja, a hot oatmeal drink sweetened with honey that was to help stimulate breast milk production. I thought of how she would carry our younger son on her back, wrapped in a netela (a handwoven, cotton, traditional Ethiopian scarf), the warmth of her radiating to him as she sang and worked. I thought of the time she had her husband drive her to work in a blizzard, knowing I was expected at the hospital and insisting that he drive me to and from my twelve-hour shift in near white-out conditions. I thought of her calls to ask for my help when her own family was sick and my earnest attempts to support, advise and reassure her. Of her transition to my brother’s home and becoming their older son’s nanny, filling that home with her love, joy, and dedication as she brought aja with honey, wrapped their son in a netela and grew close to my brother and his wife just as she had with us.
I wondered: after all the time we had spent together, had we been placed on this path to collide unavoidably at the end of her life? The next CT was worse. The drainage catheter was now blocked with blood. A final CT a few hours later showed irreversible and devastating brain damage. Her family was on their way to see her. They knew that this was their goodbye visit, but they were heartbroken when they saw her. The tubes poking out from her skull and neck were tough to see, but that mowed portion of her hair was a glaring reminder of what had been taken from her in the attempts to save her life.
Merkeb died on May 19, 2020. I collected her possessions from the hospital, cleaned them, and then took them to her family. Her son asked about a necklace of hers. “I gave it to her as a gift. Actually, I wanted to give it to her as a gift, but she insisted on paying for it and then was so appreciative of the gift I’d given her,” he said. I hadn’t seen such a necklace among her belongings. We laughed about all the joy we’d shared with her. Then I went home. Having thrown away the bag that her belongings had been in, I decided to check our trash bin to see if I’d missed anything. There was another biohazard bag, so light that I’d missed it, which contained the necklace.
Three days later, the family held Merkeb’s memorial service—my first COVID funeral. It was a fast event because the funeral home staff wanted to get the body in the ground as soon as possible. It was almost as if they were afraid they would get the virus through the casket. Adding to their urgency were the hundreds of people were in attendance, all of them very emotional, and their very presence a violation of the state’s restrictions on crowds. Merkeb’s son went to the car as soon as the body was interred. I knocked gently on the window, and he opened the door to express his thanks for the care I’d given his mother. I unclasped her necklace from around my neck and placed it on his, thinking that if nothing else the return of the necklace that reminded him of his dear mom would make this day just a little less awful.
A few days later I was back at work. For weeks, I could not think of Merkeb without crying. As friends called with condolences, my efforts to thank them would be choked by my silent sobs. Before she got sick, we had made plans for her to come to Sewanee. She was an incredible organizer and had helped us during our last three moves. Each time I listened to her voicemails that I’d saved, I saw how she’d shown signs of COVID-19 early in those calls, and that even as she was deteriorating, she had no idea of how bad it would get. None of us did at that point.
Being the first to suffer any medical disease is among the worst positions to be in. Merkeb was among the first round of COVID-19 patients in our area. In these situations, medical teams are learning on the go, and as we now see, Merkeb likely had no benefit from all those early trials she was placed in. I did as she had asked me to in her small voice when she was being taken to the ICU: “Leelie, pray for me.” Never once did she say she was scared. Never once did she ask for help. She just asked me to pray for her, and I did. Every day I prayed for her and the patients I was taking care of, for their families who were struggling. I prayed for the staff at the hospital who were at the bedside far more than I. I prayed for my colleagues and my family. I can see now how the thing Merkeb asked of me helped me. Her request helped me take better care of my patients. Her request helped me empathize more with them and their families.
I was seeing over eighteen patients every day. At night I was taking care of the entire ICU, which was filled to capacity with COVID-19 patients. There were twenty-eight patients in our ICU. The ER held another four to six ICU patients. The step-down unit was filled with patients that were all struggling to breathe but wanted to wait and see if they could avoid a ventilator. The sheer number of patients was staggering, and the severity of the illness in the ICU was the likes of nothing any of us had ever seen. When patients asked if putting them on a ventilator would make them better, I answered them honestly: it would just give them time to see if their bodies could fight the disease, but it was not a cure. My patients were people in their thirties, forties, and fifties. When I came to them with the ICU team and our anesthesiologist, they were scared, panting to breathe, and exhausted from the effort. Very few older people were in the ICU with COVID-19 because they often self-selected away from aggressive care. People in their eighties said they knew they were dying and didn’t want to die connected to a machine. My days and nights were filled with these patients and their families. I would spend on average two hours each day talking to families. Often through a translator. They all wanted to be updated, and as they could not see their loved ones, they had to rely on what we told them regarding their status.
Merkeb’s final request of me had helped me more than I had been able to help her. It helped me get through what would otherwise have been emotionally draining days. There were mornings when I was post-call that I was physically exhausted but felt mentally strong. Merkeb’s illness and death personalized COVID-19 and gave me the patience to deal with everyone at work from the following perspective: we were all doing our best in an impossibly challenging time.
Merkeb’s death was not to be the last of this awful disease, but it was the one I felt most acutely. Our lives were so connected for so many years. It now felt like a void had come to all the parts of my life she used to inhabit. All the things I had hoped to learn from her, including her amazing cooking techniques, were opportunities missed. All the ways she’d lived her life caring for others I now remembered. Our boys and I speak of her as we drive to and from their school. The release of our Sewanee angel at the University gates always triggers a reminder of her in all of us and leads us to share a memory of her with each other, and two of us nod as one of us says “remember how Etye Merkeb used to . . .”
In lieu of payment, our friends and contributors to the Corona Correspondences are dedicating donations to nonprofits and independent businesses in their communities. Selassie’s contribution will be directed to Medhen Orphan Relief Effort.