[FRONTLINERS] ER doctor deals with grief, death in the coronavirus pandemic

Dr Kirstie de Luna deals with pain every day in the emergency room of the East Avenue Medical Center, the subject of recent headlines due to a surge of unclaimed bodies during the coronavirus disease crisis. Since the start of the pandemic, De Luna has been first in line to face suspected COVID-19 cases who pass through the ER door. She says it's always tough to tell patients how critical their condition is. When a patient dies, De Luna cries herself to sleep, alone, and far away from her family in Tuguegarao. This is the story of Dr Kirstie de Luna, told in her own words.  

 


I am Dr Kirstie Ann de Luna. I am 28 years old. I’m currently a second year resident at East Avenue Medical Center Department of Emergency Medicine. Being in the emergency room, we are the frontliners. We are literally the ones catering to all the patients coming in our emergency room, whether COVID-19 or non-COVID-19 patients. We cater to them in any kind of emergencies.  

Let me start from what happened in January, from where it all began. I think our first case was confined at the San Lazaro Hospital in January. When Department of Health Secretary Dr Francisco Duque III had an interview confirming our first COVID-19 case, I think everyone panicked. Even East Avenue really was not ready for that kind of situation, for a surge of cases.  

Last December, I already had an experience handling a surge or what we call "mass casualty incident" in our hospital. "Mass casualty incident" happens when there’s a certain surge of patients coming in. They came in one go, about 80 to 100 patients.

Last January, we already had the lambanog case. We had a total of 83 patients, all of whom arrived on the eve of Christmas, on December 23 and 24. So I think we’re already trained on how we should set up our emergency room for those kinds of patients. 

And then we were already anticipating the possible surge of cases because of the Taal Volcano eruption come January. We already prepared. When the first COVID-19 case was confirmed, we already mobilized our emergency room, setting up for COVID-19 patients. 

That time, we did not admit everyone. Many of them come with undifferentiated symptoms. If they have simple cough or colds, we let them stay in a certain tent and that’s where we assess them. There’s a certain guideline we have to follow. The guideline though was revised every week. That was really a struggle for us because we don’t know when the algorithm would be changed.

When do we admit a patient? When should we let them go home? When do we have the patients tested? So what we really did was just make a census of every patient coming in with respiratory problems. If they don’t have any travel history, we tagged them as persons under monitoring, so they go home.  

At that time, patients would come in one by one. They would arrive even with just very mild symptoms, simple respiratory symptoms like colds, cough. That was really a struggle for us because it halted the normal operation of the ER. This is because even though we have COVID-19 patients, we also do not stop catering to trauma patients, the stroke patients, to the normal scenario in the ER.

I think that’s our biggest struggle: How will we, being in the field, being literally the frontliners, how will we divide ourselves to determine if this case is COVID-19? If this person is a trauma patient, what if he also has COVID-19? That was really hard for us because the algorithm wasn’t complete then and it keeps on changing every week. 

Come February, we set up our triage differently already. We literally stay outside the hospital. We screen people there. All of us residents, we go on duty for 12 hours in two shifts. So there are different residents on duty every 12 hours. We wear our personal protective equipment (PPEs). Our PPEs were limited then. 

How has it affected us? On a normal day, we cater to about 300 to 400 patients in the emergency room. There are so many of them. But come February, the virus struck. Although the number of patients dwindled, like they went down to 100 to 200 patients, their presentations of the disease were very different. That time, other patients also had diarrhea. 

We handle really severe cases. Patients come in with undifferentiated symptoms and tell us, “Doc, I have colds. I have fever. Is this COVID-19?” These are their usual concerns so we also reassure our patients that it doesn’t mean that when you have symptoms you automatically have COVID-19. We advise them to undergo self-quarantine first and we tell them that it’s very important to really take care of themselves, to isolate themselves, to maintain social distancing. And then if you have persisting respiratory problems, you come back to the hospital.

We really have critical patients coming in. We have our resuscitation area for critical patients outside the hospital. We’re just in a tent. We literally look after our patients there. For patients who require intubation, the more critical cases like high-risk pneumonia that need to be intubated, of course the family would ask you, “Doc, the patient isn’t a COVID-19 case. Why are we outside? Why aren’t we allowed to go inside? Why does our patient have to be intubated?” We tell them that doing so would help the patient. We tell them, “This is for the sake of your patient. We’re doing everything we can to revive or resuscitate the patient.” So we try to console them.  

We had a patient who died and her test later come out positive for COVID-19. The patient had a stroke. She was CKD or a chronic kidney disease patient, a dialysis patient. Her relative was really crying. I was attending to the patient. I had to resuscitate her. Although the patient was stable at the time, eventually, she expired.  

Her sister told me, “What’s happening in the Philippines? My patient was supposed to just undergo dialysis. Why is she suddenly under suspicion of having COVID-19?” She was really crying because they both had nowhere else to go. I told her, “Ma’am, you have to be strong for your sister. This will all be over soon. It doesn’t mean that she’s here that she is COVID-19 positive. We’ll see. We’ll have her tested to see if she has COVID-19 or not.”  

Then the sister said, “Doctor, please do everything you can because we only have each other. She’s my sister. She doesn’t have a husband nor children. I’m the only one who’s been taking care of her since she started having her dialysis. I hope she doesn’t have COVID-19.” It’s hard because we did not know yet the status of the patient at the time. 

Eventually, we found out the patient was positive, then she expired. During one of my duties, the sister, who was very familiar with me, saw me. She came up to me and said, “Doctor, my sister died.” She didn’t know yet the positive status of the patient. I told her she will be officially contacted regarding the COVID-19 status of the patient, but it’s going to take a while. 

I was consoling the sister because I pitied them since they only had each other. They don’t have any other family anymore. They don’t have husbands. The two of them used to be together all the time. She stood by her sister despite the situation. I know what difficulty dialysis patients go through. That was her life every day. 

It’s so hard. It’s painful having to talk to patients to tell them they’re really in a bad situation, that their situation is critical already. Every day, every duty, I really pray before I go into the battlefield. I hope no one expires. I hope everyone heals. Because it’s really, really hard to present yourself to the relatives. Because you’re a doctor, they expect you to be really strong who can deal with intense emotions. But at the end of the day, we’re still human. Every day is a struggle. Being a doctor is a struggle. Explaining to the relatives the situation of the patient is a struggle. 

We have to wear our PPEs for 12 hours. Imagine this: you’re already wearing your PPE then you have to resuscitate someone, you have to do everything, then you have to explain to the family what happened. After one duty, I came home and I broke down crying. I asked, “Why, God?” (READ: [OPINION] We need to talk about death and dying)

There’s so much pain that comes with being a doctor and while you want to save a life, your efforts aren't enough sometimes. Why? You study medicine for a long time. You think you know everything. But when you’re in the field, you suddenly become clueless. Then a patient expires before your eyes. There are recoveries, but some patients arrive at the hospital in bad shape already.  

I really cry at night. I just pray. I just put on my scrub suit. I put on my mask. I drive to work. I have to face them. So it’s just a matter of having the dedication, I think. That’s what really inspires me to get up. I really, really like catering and talking to patients. Even if it’s hard, it’s part of my work. It’s part of being a doctor. I think that’s really what rewards me also. What pains me really rewards me, too.  

It might be a difficult thing I have to do, but if I see them recovering or I see them happy, that’s also very rewarding. Or, when the patients who arrived in a critical condition recover successfully. being a doctor, I think it will not replace any feeling in the world.  

I myself experienced being on quarantine. At the start of March, when we were planning out the ER and then we had patients coming in by the dozens, I started developing symptoms. It was a simple sore throat and dry cough. I had to isolate myself. I stopped being on duty for a while.  

I quarantined myself and tested myself for COVID-19 also. When I was under quarantine, it felt like I was really a patient because I was in my room, alone. It was a struggle because I’m also a frontliner, so I can see the messages, the updates and I can’t do anything about them because I have to protect myself first. More than the symptoms you experience, it’s the mental health and the emotional burden that you carry because you don’t know if you’re positive or negative for COVID-19. It was a struggle to sleep at night.  

I’ve been based in Manila for my pre-medicine course and medical school. My family is from Tuguegarao, up north in Cagayan. I had this habit of – even for just once a month or whenever I have a day off, even it’s just for one day – I would book a flight or book a bus trip going home. But this year, I haven’t gone home even once. 

How do I adjust? My sister returned back home before from Oman. Even if they were just in Manila, I was not able to see them. I missed them so much and I wanted to see my niece because they stayed in Oman for a long time. My sister stayed there for 5 to 6 years. I really wanted to see my niece. She’s big now; she’s 6 years old.

What made me want to cry, the biggest struggle for me, was that I couldn’t see them. Then my uncle had a stroke but I couldn’t  see him also because, even if they were just in Manila, I couldn't travel to see them because I might put them at risk of contracting the virus since I myself was exposed to many, many patients.

Even though I really, really want to go home, I want to see them, I want to eat out with them, I have no choice. I have to protect them. To protect them, I have to distance myself, which is really, really painful for me because I'm really, really close to my family. 

My other sister lives in Ireland. She’s also a frontliner. She’s a nurse at an intensive care unit. I also have nephews with her. She can’t go home even though she wants to. My parents, they understand our work. My two sisters are nurses and then I am a doctor, so they really understand our profession. But of course, they are still my family. They’re still my parents. I really want to see them.

I’m hoping this will end soon. I will really come home to hug them and see them again. Also my nephews and my sisters. And I’m just really praying for everyone, for this pandemic to stop and for us to lead a normal life again.  

I think what keeps me going is my dedication and passion. I really, really wanted to treat patients. Even if that’s exhausting, I really know what I got myself into. I chose this field, I chose being in the emergency room, I chose this every day of my life because this is what I am trained to do. What really keeps me going are my family also and my friends, my co-residents, my consultants, my mentors, who really support us.

At the end of the day, no matter how difficult, I’m willing to go to work, I’m willing to extend my duty hours because I think, more than anything else, that’s what inspires me to go on with my life. Choosing this field, I think, being on the battlefield, is really also what keeps me alive. It’s what fuels the desire in my heart to pursue this passion even if the situation is like this.  

I just get up, I wake up, I put my scrubs on, I put my stethoscope on, I put my mask on, put my PPE on. I think life goes on. The world will not stop for anyone. So why would you stop for anything, right? You just go on with your life and do what you know best – and that is being a doctor and treating patients. – Rappler.com

Editor's Note: Rappler interviewed De Luna on April 11, 2020. All her quotations have been translated to English.

TOP PHOTO: A HERO. Dr Kirstie de Luna wears her full protective gear against COVID-19 outside the emergency room of East Avenue Medical Center. Photo courtesy of De Luna   

Mara Cepeda

Mara Cepeda writes about politics and women’s rights for Rappler. She covers the Senate and the Office of the Vice President. Got tips? Send her an email at mara.cepeda@rappler.com or shoot her a tweet @maracepeda.

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