An Operating Room, Transformed

My first patient in the COVID-19 intensive care unit wore teal nail polish, a bright, glossy polish that contrasted starkly with her dull hospital gown, her disheveled hair, and the endotracheal tube in her mouth. My co-residents and I were bright-eyed and bushy-tailed interns when the COVID-19 pandemic hit New York City in the spring of 2020—hard. The pandemic crept upon us insidiously. First it was a postoperative patient with unexplained fevers and leukopenia. Then one of our attending physicians fell ill. Within days, we were receiving late night phone calls notifying us of COVID-19 exposures. To care for the enormous influx of critically ill patients, our hospital transformed operating rooms into a pop-up “Operating Room Intensive Care Unit” or “ORICU,” which struck us as a catchy nickname for a crisis-time workaround. For surgical residents like ourselves, the operating room is a sacred place, a place that is earned after years of being scolded for making sterile things unsterile, a place where the sounds and smells of the inpatient floors are drowned out, allowing us to hone our craft.

Without elective cases to perform or clinic patients to see, we stood by anxiously, wondering what our roles would be. It felt logical that as interns we should be the first to undergo redeployment. We were undifferentiated stem cells, awaiting signals from our environment to grow. Our more differentiated senior residents continued caring for the head and neck cancer patients who now had another reason to fear their mortality. Late one Sunday evening, we received a call from our program director asking us to staff the ORICU. Hanging up the phone we felt ourselves breathe a sigh of relief, liberated from the discomfort of standing by as the world suffered.

When I arrived at the ORICU, the operating rooms were unrecognizable. There were holes in the walls hastily drilled to accommodate a rudimentary HVAC system. Four patients occupied each room; the fortunate patients secured their own ventilator, while others shared a single machine, or were hooked up to a travel ventilator. Led by an attending anesthesiologist and critical care fellow, the ORICU team—a motley crew of neurological surgery, anesthesia, and obstetrics and gynecology residents (in addition to myself, an otolaryngology resident)—sat in the “core,” a narrow hallway outside the OR meant to house surgical supplies. Being within earshot of the OR was critical, as the heavy doors dampened beeping sounds from IV poles notifying us, for example, that the norepinephrine drip was running low. We worked as a team, helping spread-thin nurses and respiratory therapists, and learned to troubleshoot arterial lines, change ventilator settings, and push life-sustaining medications—tasks we had once taken for granted.

Miraculously, help arrived. A cheerful hand surgeon from Minnesota traveled to his alma mater to join our ranks. Traveling nurses chatted excitedly about walking through (an empty) Times Square near their hotel. These interactions sustained us as we all stood witness to end-stage COVID-19. End-stage COVID-19 was not respiratory or renal failure—it was the experience of dying alone.

So many of our patients died alone. There was the dawn I spent FaceTiming a patient's family for 45 minutes, so they could say a final goodbye to their father, husband, and grandfather. The Easter prayer I shared quietly with a patient at her daughter's request. Pictures, so many pictures, of the vibrant lives our patients had led before a virus devastated them. We continued along, working at the patients' bedsides and huddled in the makeshift workstations outside of rooms, our faces riddled with pressure marks from ever-present N95 masks, trying to manage wave after wave of patient crises as they struck the ORICU. Relying on facts memorized for my internal medicine shelf examinations buried under the specialized otolaryngology knowledge crammed on top, I fumbled through.

After 2 months, the ORICU petered out. Some patients recovered; some did not. Eventually I returned to the otolaryngology service, grumbled at consultation requests from the emergency department, and cheered with my co-residents as elective surgeries resumed.

A teal pedicure is a bold choice. One that politely says “no” to a red polish, and not-so-politely says “no” to a baby pink polish. This is how I thought of my patient with the teal pedicure, a stylish woman who had recently visited a nail salon, blissfully unaware of her impending fate. A year after her hospitalization, I recognized her name on a list of patients to contact for a COVID-19-related research study. After weeks of critical illness in the ORICU, she made a full recovery. The vitality in her voice spoke louder than her GRBAS score. I resisted the urge to ask her what color her toenails were painted now.

The holes drilled into the OR walls have not been fixed yet. I see them each day while operating, focused on honing surgical skills and taking care of the patient on the table in front of me. In Virgil's Aeneid, Aeneas tells his despondent men as they flee their burning city, “Forsan et haec olim meminisse iuvabit,” A joy it will be one day, perhaps, to remember even this. Perhaps it is not a joy to remember, but sometimes, as I take a break from the everyday chaos of residency, these OR holes remind me of the most meaningful thing I have ever done.