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After the Match

After the Match

When the Residents' World Turned Upside Down

Cook, Thomas MD

doi: 10.1097/01.EEM.0000669340.70400.fb
    coronavirus, COVID-19

    Thirty years ago, I entered internship with all the usual anxieties. Even after all the education, medical school graduates still wonder if they will be able to handle the grueling pace and long hours. On August 2, 1990, after 32 days of practice, everything changed. Iraq, a country most Americans had never thought about, invaded Kuwait, a tiny country even fewer knew existed. This was passing information for most residents. Their minds were focused on learning medicine. But for me and the others in my residency program, we were suddenly involved in global events.

    We were residents in the emergency medicine program at Fort Hood, TX, one of the largest military installations in the world and home to the 1st Calvary Division and the 2nd Armored Division. We soon found out both units would deploy in Operation Desert Shield, and suddenly everyone wanted to know more about Iraq and Saddam Hussein. We learned that he possessed one of the largest armies in the world, with one million men in uniform. He had used chemical weapons in a previous war with Iran, and most suspected he also had nuclear weapons. He was also ruthless.

    So one month into residency, our entire world turned on its head. We had worked for years to prepare for our professional training, and now everyone around us was going to war against a massive, battle-tested army on the other side of the world. We went from reading textbooks to writing wills.

    We were scared. There were a lot of unknowns, and we all thought the worst would happen. Due to the concern that Iraq would soon invade other countries in the region, both divisions at Fort Hood rapidly deployed to the Middle East, and it soon became apparent that many of the residents in our program would be shipping out with them. Unit commanders wanted physicians who were deemed the most capable of working with limited resources in challenging situations. As an intern without a medical license, I was non-deployable. Half of our residents were sent off to the impending war, however, several with only 13 months of experience.

    How many PGY-2 residents feel ready to take on something like this? You not only have limited medical experience, but you are also traveling to a hot, dry, hostile place and living in a tent. You eat tasteless food, shower once a month, and carry around a gas mask with you at all times. Not to mention if you are involved in a chemical weapons attack, you need to self-administer atropine and Valium to stay alive.

    Do you see some parallels with the COVID-19 pandemic? Rapidly spreading threat; your entire world changes in a matter of days; an overwhelming sense of loss of control; the need for personal protective equipment at work; and the potential of dying in the line of duty.

    Downstream Effects

    Meanwhile, back home at Fort Hood, the 12 residents left behind, half of whom were interns, worked with a piecemeal cadre of attending physicians to staff an ED with more than 60,000 visits per year. Duty hours for residents did not exist in those days, so we worked a grueling schedule to keep the ED going.

    In the end, the Gulf War was a rout. Our military was well trained, and our government put together a global coalition of countries to defeat the enemy. The total number of U.S. deaths from the conflict was 149, and all the residents from my program came home safe. In my discussions with them after their return, most said they appreciated the unique experience.

    As I write this column, the entire world is in a different war. Two months ago, the thought that emergency physicians around the world would experience what many of my colleagues went through three decades ago seemed impossible. Right now, it's evident we are not well prepared, and global casualties seem likely to go into the millions. When this column is published, what will the world look like? How many will be dead? How many emergency physicians will be afflicted by this disease? Will we all eventually get sick?

    What will the effect be on the roughly 8000 emergency medicine residents, a third of whom are beginning their training in July? They will undoubtedly learn how to care for hypoxic, dying patients in a dangerous environment, but there will be other downstream effects from shutting down the world. Currently, the patient census in my ED is way down because people fear coming into contact with COVID-19-positive patients (and hospital staff). And with curfews, stay-at-home mandates, and substantially less automobile traffic, there is a significant drop in trauma and other common pathologies that residents need to see in the course of their training.

    It affects their didactic training as well. Conferences are not possible right now. How will interns orient to their new work environment in June without the ability to meet in person? If you cannot go through orientation, you cannot start working and your final year of residency training may extend past June, which will run into the next class getting ready to matriculate.

    Many teaching hospitals operate on thin margins, and the sudden loss of revenue-generating clinical services (e.g., elective surgeries and procedures) may push some of these institutions down the path that sank Hahnemann. Could the future of postgraduate medical education be relegated to corporate behemoths that can afford it?

    Finally, what will be the emotional toll on interns starting training amid this catastrophic event? Everyone in the nation is captivated by images from New York City, Italy, and points in between. Several states are permitting senior medical students the ability to graduate early and get into the fight. Granted, we all have the urge to help, and there is an appeal in being able to say we survived the experience. But when we see emergency personnel wiped out by the events of the past month, it seems likely this will take a significant toll on many new medical school graduates jumping into the fray. We do not know how this will end for our patients and ourselves, but it is something we will talk about for the rest of our lives.

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    Dr. Cookis the program director of the emergency medicine residency at Prisma Health in Columbia, SC. He is also the founder of 3rd Rock Ultrasound ( Friend him, follow him on Twitter@3rdRockUS, and read his past columns at

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