“What are our capabilities if our critical patients develop renal failure and all the hospitals in town have no capacity to absorb them?”
As the chief of the nephrology department in a small hospital in a small city, this question has occupied me all week. If a person’s kidneys fail, there is a fallback procedure, a miracle of modern science, with which physicians are capable of cleaning that person’s blood when the kidneys are no longer capable of doing so. A technology available for little more than the past half-century, dialysis has saved the lives of countless individuals. However, for critically ill individuals whose bodies are incapable of generating a strong blood pressure, the added stress caused by normal dialysis can be more than the person can tolerate. For these critically ill patients, removing the amount of blood necessary to filter through the machine can be deadly if done in the standard way.
Fortunately, we are still able to perform dialysis on the medically labile among these critically ill patients, but continuously instead of in a discrete session. Running the procedure at a slower, gentler pace produces less of an adverse effect on blood pressures. However, continuous dialysis requires 24/7 monitoring by physicians, nurses, and technicians comfortable administering this different modality. Small hospitals normally transfer patients who require continuous dialysis (commonly referred to as CRRT – continuous renal replacement therapy) to larger hospitals nearby that perform this procedure routinely.
Now the world finds itself in the midst of a pandemic the likes of which has not been seen for more than a century. Severe acute respiratory syndrome Coronavirus 2, the virus causing Coronavirus disease 19 (COVID 19), has been associated with hundreds of thousands of infections and thousands of deaths worldwide. As of earlier this week, we now have confirmed cases in our city.
For weeks now the media has been haranguing us non-stop with COVID 19 news. Wuhan, China, a city with a population of more than 11 million, is basically becoming a ghost town. Deaths are occurring in Italy because the healthcare system lacks the capacity to treat as many critically ill patients as the country currently has. Meanwhile, selfish individuals hoard medical supplies, hand sanitizers, and toilet paper. The media, foreign governments, and even our own government have disseminated so much misinformation that it is difficult to separate truth from error. Facebook, a bastion of spreading pseudoscience and medical bunk, has been an infuriating mess of confusing nonsense, with dozens of useless pieces of advice for every good one.
During this crisis, I have already been barred from traveling to take our planned vacation for Pesach. My wife and I were already resigned to being unable to visit with our families for the holiday, but now it is likely that I will be working in the hospital during arguably the most family-oriented holiday in the Jewish calendar. On occasions when I find myself in the hospital, in front of a computer working (activities that would normally be forbidden) on Shabbat, I sometimes think of Vayikra chapter 18, verse 5, which states, “And you shall keep My statutes and My ordinances, which Man shall do and live by them – I am Hashem.” The Talmud famously states that “live by them” means that you, and others, shall not die by them. Thus, a potential loss of life and health supersedes nearly every commandment, even one as important as Shabbat. Although driving in to work to treat ill patients seemed extremely odd years ago when I was still a junior physician starting training, those feelings have vanished.
Any rabbi worth his salt (which is an important measurement when one is a nephrologist) will be immeasurably better versed than I in the Halachot pertaining to a health crisis. Nevertheless, I called the rabbi of my shul last evening to discuss plans for this Shabbos’s Davening and classes, mainly to give my opinion that the shul should close. After a short discussion, the rabbi agreed with my opinion and decided to suspend all classes and services. This decision has precedent, as other synagogues across the world have been making similar decisions over the past several weeks. Additionally, there are countless stories of rabbis suspending services, closing synagogues, and mandating restrictions on fasting, even on Yom Kippur, the holiest and most important fast day of the year, because of previous medical emergencies.
There will be no minyan in my shul this week, partly from my advice. Living in a small Jewish community, I have said many times in shul, “Heaven forbid that we have no minyan here because of me.” I try my utmost to be present whenever possible, but this situation is different. Despite knowing that closing was the correct course of action, I spent many hours last evening contemplating my advice, and my part in the shul closing still haunted me when I awakened in the morning.
Every day I arrive at my hospital prior to sunrise, so I have generally work for several hours before I am able to don my Tallit and Tefillin and say the morning Tefilot. With the current pandemic and the needed flexibility to change protocols instantly to keep up with an ever-evolving understanding of SARS-COV-2, my days this week have been very long and never standard. I have had days in the past when I have had to miss Z’man Tefilah, but not even having time to eat or sit for more than a few minutes to answer a critical email has been the standard so far this week. Today I made an additional mistake – I checked Facebook before coming to work. In one group where physicians and mid-level practitioners come together to share COVID 19 information and updates, multiple individuals talked about hoarding supplies of one medicine with potential benefits for personal use. I rushed all morning from meeting to meeting, calling patients, and drafting policies, all while being absolutely infuriated by the behavior described in those posts.
Thankfully, around noon today, more than seven hours after I arrived at work, I was able to grab a few minutes to daven. When one can relax and stand before the One Who “makes peace and creates all,” the high stress of the day melts away. How can it be that an individual would feel less anxiety when speaking to his Creator? I remind myself that although our illusion of control now appears shattered, Hashem is here for us and always will be.
Si’man 336 of the Shulchan Arukh Yoreh De’ah opens with the statement, “The Torah has granted the physician permission to heal, and it is a religious duty which comes under the rule of saving an endangered life.” Saving the life of a fellow human being is such a great imperative that it supersedes everything else in Jewish law. If so, why by healing does “Hashem grant permission” to perform the commandment (especially one deemed so very important), but not by any other commandment do we require this permission?
As we sit in judgement during the high holidays, we say in Unetanneh Tokef that it is Hashem who determines our fate: “How many will pass from the earth and how many will be created; who will live and who will die.” If Hashem makes this determination, we might therefore say that health and disease are fully under the will of Heaven, and thus we are forbidden to interfere. Therefore, the Shulchan Arukh teaches us that Hashem wants us to do everything in our power to save a life, even if it would mean having to break nearly any and every other commandment to do so. Because we are given permission to heal, we must do everything in our power to do so, exerting ourselves in this pursuit to our utmost. In fact, we healthcare workers are partners with Hashem in bringing patients back to health. Just as Hashem originally created in the world a single human life, the Mishna in Sanhedrin teaches us that one who saves a life is like one who has saved the whole world.
So, what do we do if the hospitals in town are at capacity and our patients need CRRT? When the community standard of care is not available, how do we step up and do our part to save those who need us?
We do every darn thing possible.
Unsurprisingly, doing everything possible is the unified thought and feeling of everyone in my hospital. I have been an exceedingly small part of bringing this goal to fruition, and seeing everyone step up to be prepared to handle anything that comes our way has been a truly humbling and inspiring experience. Every nurse, technician, physician, and other healthcare worker on the ground is running at full force to do his or her part, while our administrators and support staff work seemingly non-stop to address the needs for patient care that their clinicians bring to them.
With Hashem’s help, this crisis too shall pass. Until it does, your health care workers are all braving this pandemic to treat the ill. So too everyone must do his and her part to protect the most vulnerable among us. In this pursuit, we are all healers and partners with Hashem in saving the world. We do not want, Heaven forbid, the blood of our loved ones to be on our hands by inadvertently spreading a highly infectious and potentially life-threatening disease to those who cannot fight it. Please, follow the recommendations from the CDC. Practice social distancing as much as humanly possible. Even with Pesach coming in the near future, minimize the number of people at your Seder and do your best to avoid hoarding household goods, cleaning supplies, or food.
Contact your doctor if you have medical questions, and everyone, stay safe. B'hatzlacha.