Learning to ride, falling down, getting back on
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In the spring of 2020 in New York City, touch is dangerous. When I arrive to work as an emergency-room physician, I immediately don my N95 mask, a face shield, a gown, and nitrile gloves. My coworkers, all similarly dressed, are difficult to recognize. Even friends become anonymous.
I pass through three sets of doors into the zone of contamination, where negative air pressure prevents any airborne virus from escaping. My first patient is Daniel. I already know from reviewing his chart that he is forty-five years old with multiple medical problems, including cerebral palsy, which has caused some cognitive delays and spastic quadriplegia. Normally, when I enter a patient’s bay, I look at their face for a clue as to how sick they feel. Now, with faces covered, I look first to the wall-mounted monitors: How fast is the patient’s heart beating? What is their breathing rate? How high is the oxygen level in their blood?
Daniel’s monitor shows a heart rate of 115, a respiratory rate of 26, and a blood-oxygen level of 91 percent. That’s even with the oxygen to his nasal cannula turned up to six liters. Likely COVID-19. He will need blood tests, an EKG, a chest X-ray, a COVID nasal swab, and admission to the hospital. But first I examine him to verify.
Tension contorts Daniel’s face into a grimace. His bright hazel eyes track back and forth over my masked face. He looks trapped. I place a gloved hand on his shoulder, crouch down to his eye level, and smile, though I know my mask will hide it. “My name is Dr. Gallagher,” I say. “I’m going to help you today.” Daniel gives one-word answers to my questions, verifying that his chest feels tight but he is free of pain. He cannot provide a history of his symptoms, so I find a contact number for his mother and call her from his bay. She tells me about her son’s cough and shortness of breath, his medical history and his surgeries. She also tells me about his extroverted personality, his trips to Disney World, his family and friends. She has been with him every day of his life, through multiple hospitalizations. This is the first time she can’t be beside him: the hospital has a strict no-visitor policy to help prevent the spread of COVID. I switch to speakerphone so she can talk to her son. There are tears in her voice: “Danny, Mommy is here with you.” I rub his shoulder, and his expression grows calmer. She asks if he’s in any pain, and he says no. “Daddy is here, too. Mommy and Daddy are with you; we love you very much, Danny. We’re thinking about you all the time.” I try to transmit their care to him through my hand on his shoulder, and I tell his parents when he smiles.
Over the next few days I pay Danny several visits, and each time, I call his parents on speakerphone and hold his hand or touch his shoulder while they talk. When he hears their voices, his face softens, and he emerges from a haze of illness and medication. I imagine my own daughter in Danny’s situation. She is a toddler, so I would be allowed to stay with her if she got COVID. But if she were older, what would I do? What rules would I break to sit beside her?
The pandemic has forced me to realize the value of touch and presence in my roles as a doctor and a father. Where I went to medical school, all students took a course called The Practice of Medicine. It wasn’t about anatomy or disease; instead it taught students how to approach patients and slowly introduce physical contact in order to perform a physical exam. Touch is an intimate contract between doctor and patient. It tells them what they feel in their bodies is real and can be examined, and it symbolizes their doctor’s commitment to helping them heal. When I was a resident on rotation in the intensive-care unit, I learned that even terminally ill patients felt reassured by daily examinations. Their families, too, found comfort in witnessing the ritual and the bond it created.
I visit Danny regularly as he goes from receiving oxygen via a nasal cannula, to a face mask, to a respirator. When his voice becomes inaudible, I translate to his parents the words he mouths, and I fight tears after we end the conversation. He succumbs to COVID-19 in the hospital. Later a coworker and friend finds me crying in the hallway. Like me, she is wearing full protective gear. We don’t hug.
As an emergency-room physician I often have to guide family members through challenging end-of-life decisions concerning their loved ones. I’ve had these conversations hundreds of times, and they are difficult under the best of circumstances: We go to a quiet area. I have tissues ready, and I try to read the family’s reaction and pause if they become overwhelmed. When it’s over, we go back to the bedside, where they hold their loved one’s hand or brush hair out of their face. During the pandemic, I talk to families on the phone instead. I can’t see their reactions or sense their anxiety, and I struggle not to be too vague, too optimistic, or too blunt.
While I was in training as a resident, a young woman arrived in septic shock — an infection had overwhelmed her body’s normal functions — and she needed to be put on a ventilator to relieve the burden of her rapid breathing. I asked her husband to leave the room while I sedated and intubated her: an intricately coordinated and stressful procedure. Though I was initially able to stabilize her, she died the next day without ever waking from sedation. I still imagine what it must have been like for her as I put her under: looking up at a strange doctor’s masked face, feeling his hands on her arm delivering medication, then falling asleep and never waking up. Now, when I administer sedation before an intubation, I ask the patient’s loved one to hold their hand and look into their eyes as they fall asleep. Only then do I have the family member escorted from the room. It takes longer this way, but I carve out the time regardless.
With the pandemic restrictions in place, these moments, too, have become hasty exchanges over speakerphone. No one is prepared for this. I try to remember to rest a hand on the patient’s shoulder while their family talks. Too often this is their last communication.
I grew up in the 1980s and remember my family’s first computer, but I am no digital native and still find myself baffled by certain aspects of online culture. Nonetheless I’ve started practicing telemedicine, providing virtual urgent care to patients through the Internet. I can see their faces and talk with them, but they have to act as my hands. I might instruct them to press into their belly below their right ribs and see if it hurts, but I can’t know exactly where they are pressing or how hard. I have to guess how much information is lost before advising them whether to stay at home or go to an emergency room for an in-person evaluation. How strong is my conviction, how authoritative is my advice, when I haven’t even laid hands on the patient?
Before COVID, when I came home from work, my two-year-old daughter would sometimes yell, “Papa!” and run and tackle me. These days I return home and go directly to the shower without hugging my eager daughter or touching anything. Physical touch is integral to her development: nestling into my side while drinking a bottle of milk or receiving kisses on her booboos. But now touch is also the feeling of my hands incessantly washing hers, and kissing with face masks on in public. There is a new absence of touch when I keep her six feet away from neighbors, when she has to play virtually with friends, and on video calls with Grammy. I wonder what touch will be like for her in a year, or when she is my age. How will this restraint from contact affect her sense of family and community?
In the midst of COVID’s disruption, the country is rocked by the killing of George Floyd by the Minneapolis police. The protests that follow expose the racial inequality in our society.
On shift, I learn that my next patient is a young woman, Pamela, who’s been a victim of assault. I take a deep breath to center myself. Treating people injured by violence is emotionally tough. If I don’t protect my feelings, I run the risk of becoming overwhelmed and unable to properly care for my other patients. But if I wall myself off too completely, I won’t be able to provide the empathy and support this woman needs.
Two police officers stand outside her bay, talking calmly and glancing at their cell phones. Is this a good thing or a bad thing? I nod a quick greeting to them and turn my attention to Pamela, a Black woman who sits up stiffly in bed, one wrist handcuffed to the side railing. Her face is bruised and swollen, with abrasions over her right cheek, around her eye, and on her forehead. Her eye will soon swell shut. Dried blood clings to her nostrils and upper lip. I crouch beside her bed and see tears well up in her eyes and roll down her face — until she clenches her jaw firmly to stop crying. She wears meticulously placed false eyelashes, a plum tint on her lips, and designer jeans that are scuffed at the knees and matted to her legs with dark blood.
“This is not me,” she says as she begins to tell me what happened. “I work. Hard. I have two little kids. I’ve never been to a protest before.” She pauses to look into the middle distance, then continues. “But I just couldn’t shake it. Not this time.”
She says reading about the protests on her phone wasn’t enough. She had to see it for herself, to feel it. She picked a time when the crowds would be thin. She just wanted to be there for a moment, to witness. She describes peaceful protesters kneeling, chanting, demanding recognition and an end to systemic racism and police aggression. Police officers formed lines facing the protesters.
“Just standing there,” she says, “all tough because they had batons and guns.” She noted how detached they seemed. “They weren’t listening. They didn’t care. So I stood up and yelled. I had to. ‘Kneel with us. Don’t you understand what’s going on here now? What’s going on in our country?’ But they wouldn’t kneel, and it made me so angry. I must have yelled some more. I don’t remember what I said.”
She tells me one of them shouted, “Get her! Put her down!” and three others came at her with batons. Her breathing becomes rapid and choppy as she tells me this, and fresh tears run down her cheeks and drip off her chin. “They pushed me down so hard, three of them. And pinned me down.” She shakes her head, and her lips tremble. “It’s not right. I’m supposed to have freedom of speech. They are supposed to protect that, not throw it to the ground.”
Pamela looks to me. For answers? For help? Tears threaten to fall from my own eyes. I reach out and hold her hand. She grips mine hard and cries.
“I’m sorry,” I manage. “I’m sorry this happened to you.”
Time flows strangely, and I’m not sure how long we sit like that. Eventually she lets go of my hand.
I will never know if our physical contact helped Pamela heal. If I were her telemedicine doctor, I would have ordered the same tests: a CT scan of her head and face, to assess for internal bleeding, and an X-ray of her knee. The information I gathered would have been the same. Would the outcome have been any different?
That night I hear helicopters through my open bedroom window. I do not sleep well.
Later in the week, I pause by a racial-justice protest on my bike ride home from work. Many people, some of them my neighbors, representing diverse races and ages and walks of life, have gathered along the sidewalk. Some hold signs. Others hold hands. As a doctor I know that touch sensors in the skin send signals to the brain, which releases dopamine and serotonin to reduce anxiety, and oxytocin to foster social bonding. These protesters may not know any of that as they seek out touch to create a sense of identity and community, but they know they feel less alone.
At home, after I shower, I hug my daughter tighter and longer than usual.
I sent Timothy Gallagher’s essay on the necessity of touch to the nurse practitioner who, four months earlier, gloved and masked, had squeezed my shoulder and rubbed my back as I described my mental and physical pain to her. Her touch felt like more than an act of simple human kindness. It was as if she was administering a powerful jolt of energy.
Though I haven’t seen her since, Gallagher’s essay prompted me to tell her how much she had strengthened me with her touch, and to say I wish I could do the same for her during this trying time.
Timothy Gallagher showed how touch can form a bond between physician and patient [“The Practice of Touch,” December 2020]. The way he listens to his patients and experiences his own emotions made me think of Helen Keller’s quote: “The best and most beautiful things in the world cannot be seen nor even touched, but just felt in the heart.”
Timothy Gallagher is a perfect example of the sort of frontline care providers who understand that healing patients and their families goes well beyond what can be accomplished through medicine alone. Having recently spent the night in the emergency room, I was awestruck by the compassion shown, and sacrifices made, by providers like him.
My heart ached for Timothy Gallagher, for his patients, and for his family [“The Practice of Touch,” December 2020]. His explanation of the physiology of touch was a poignant reminder of what we are losing during the pandemic.
My partner and I are part of a community that gathers annually to follow the teachings of psychologist Virginia Satir, who extolled the importance of hugs: four hugs a day for survival, eight for maintenance, and twelve for growth. How many of us are currently not even crossing the threshold for survival, let alone maintenance or growth?
I thought about the fact that our community was unable to gather this year, because of COVID. Then I thought of my son, who turned thirty-five today. He lives alone across the country and has had no human touch since March. It was then that the tears came.