By Yassmin Hegazy, M.D. (PGY-2)

Headshot of Dr. Karla Williams, MD (Assistant Professor, General Internal Medicine) in white medical coat, 2019.Sheetal Gandotra, M.D., Assistant Professor, Division of Pulmonary, Allergy, & Critical Care MedicineA Toronto native, who completed her medicine training in Rochester, New York and critical care fellowship at Wake Forest Hospital, Dr. Sheetal Gandotra is one of our leading UAB critical care physicians. While she attends the resident and nurse practitioner ICU teams, Medical Emergency Team (MET), and fellows' pulmonary clinic, Dr. Gandotra has been on the front lines during the onset of the COVID pandemic and now multiple COVID surges. I had the chance to sit down with Dr. Gandotra to talk about her experience and perspective working the ICU during COVID. 

Q: What made you choose pulmonary critical care?

A: I always knew since I was in high school that I liked higher acuity settings. In high school, we were required to do volunteer work as a requirement for our high school diploma, and I did mine in a hospital. I did everything from serving water to patients to being the person in the surgical waiting room keeping families updated. One of the things that stood out to me at the time was I liked the higher acuity settings. In my medical school rotations, I practiced the total spectrum of general internal medicine, but there was always some added personal value that I could bring to families of the sickest patients, even when those patients suffered from an incurable disease and the focus was on end-of-life care.

I think also for me having grown up in Canada, I had grown up with a very different healthcare system. I found outpatient medicine very challenging in the U.S. because I didn’t have a great understanding of how insurance worked and found that very limiting. I knew I was tailoring myself towards an inpatient career where it has less of an immediate impact.

Q: How has working through multiple COVID surges in the ICU impacted you?

A: When you’re in it, you don’t have time to reflect because it’s just one thing after the next. You are in a team, and that team needs you to function. Looking back, we were so fortunate to be in a system that prepped early. In February and March 2020, we started PPE training and did a really good job of prepping prior to having our first patient with COVID-19. I’m fortunate to be part of that because that wasn’t true for my colleagues across the country, where they start prepping after their first cases.

Our practice changed. We were a division that thought hard about how to protect our staff while also providing the best care to patients, and we did that well. The support from other divisions with staffing stood out to me. We had a cardiology team with a senior pulmonary critical fellow paired with a cardiology attending, and on the flip side, a pulmonary critical care attending paired with a cardiology fellow. I think those sorts of things were demonstrations of people stepping in to help when our services were clearly over our usual capacities. We were fortunate to be able to do that and expand to help the community.

Q: Which COVID surge stands out to you the most?

A: Delta stands out as being different for a number of reasons. One of the reasons is that it seemed to be a younger population of patients. I was on service during the initial phase of delta in August 2021. Starting and ending my day in the OB unit was very different. I took care of more pregnant COVID patients and more pregnant patients than I had in all my training. That’s daunting because we all see ourselves in them. They are otherwise healthy and at a time in their lives when contact with medical care is usually a happy time. In normal times, the vast majority will deliver and be discharged right away, and that’s not what we saw.

Q: What have you found challenging in the COVID ICU and taking care of COVID patients and their families?

A: When all you see is COVID during your ICU time, the disease process can become complex and variable for each patient. You still have multiple systems affected and are providing critical care at the extremes. It’s still a homogenous population in terms of disease etiology, and that gets tiring. It was also a time when our team was struggling with the poor vaccination rates in our communities. It was challenging to convince people to get vaccinated as a way of preventing severe disease. That made it very hard to take care of patients when some of our staff thought it was preventable. To me, the saddest portion of all of that is that we didn’t do a great job of messaging about vaccines. There was so much uncertainty for our patient population, who may not have had the same understanding as us. If you talk to them in clinic or after their critical illness, it’s clear that they were worried about the safety of the vaccine. To me, it felt like we failed to provide adequate vaccine education and access, which made it hard.

Q: How did you balance taking care of patients while also taking care of the team and yourself?

A: It’s so easy to be frustrated by the challenges of the ICU, especially with being busy during staffing shortages. As attendings, we always remind the team that we are all doing the best we can under the current circumstances and sometimes that will fall short of what we expect for ourselves and our system. In the setting of a pandemic, we need to give ourselves, the staff, and the team grace. If we are doing what’s best for our patients, then that’s what we need to be doing. Also, we recognize that for residents, it can seem like it is all COVID. But we all have learned a lot about viral immunity and epidemiology during this, and how fast systems can adapt and implement safety mechanisms. I feel fortunate to have been a part of that. In the worst of situations, we are still providing education, learning, and care to our patients.

Q: How were you able to make sure mental health was addressed?

A: I think that the attending has the role of making sure that the team is managing their mental health and putting in place mechanisms to do that. It’s important to make time to talk about weekends and what else we are doing in our lives besides patient care. For me, it’s always nice to know where you guys come from, what you are doing on a weekend, and what good things are happening because hopefully life didn’t stop for us during the pandemic, and we found ways of maintaining our well-being outside of the hospital.

Q: How do you keep a non-biased approach to non-vaccinated patients and their thoughts on non-evidence-based therapies?

A: In fellows’ clinic, it always strikes me that we have a lot we need to get through in our clinic visit, but it’s important that every touchpoint a patient has with healthcare, that we address vaccines. The fellows and I will always ask if they are vaccinated or if they have any questions, and having a non-judgmental view is important. I try my best to remember that not all our patients are going to have the same access to education or statistics training, and they have real reasons to be afraid of new vaccines and medicines. For example, in pulmonary clinic, Dr. Solomon put together a quick FAQ about how to get registered, and a little bit about his personal experience, which I though was helpful to patients. Sharing my experiences with the vaccine and acknowledging that there are side effects is important. People value hearing that from their continuity providers, but also from a physician who works in the ICU. It’s not always going to work, and not everyone will do what you ask them to do. Still, I think it’s our job to educate, advise, and recommend, and then invite concerns and re-discuss each clinic visit.

The same thing applies to the inpatient setting. I really tried to understand what people are hoping to achieve with non-evidence-based therapies. We were fortunate to be a part of clinical trials, and that was an opportunity to offer additional investigative therapies to some patients, like those who are reaching for things that we don’t consider evidence based.

Other than asking about vaccination status on admission, I don’t tend to bring it up. For some patients, it’s a pain point or they have regret over not getting the vaccine.

Q: It’s been a difficult past few years because of COVID, any moments the ICU that’s kept you optimistic and given you hope?

A: We were looking to build a critical care clinical trials program and be able to offer patients coming to UAB the opportunity to become a part of investigational trials which we do in other arenas. We have been able run multiple trials for patients in the ICU, particularly when there weren’t great treatments available, which has been a silver lining. Because we have a tele-ICU system to help the community with critically ill patients, we were able to provide critical care expertise, even when we didn’t have ICU beds to accept transfers. We were also able to provide telemedicine for our patients that can’t always make it to clinics.

The humanism I saw in people caring for patients, and the strength we showed as a system, was incredible. I am fortunate to be a part of a large health system that adapted and was flexible in order to take care of these patients. We are a large division and were fortunate that when there were people who needed their clinic covered, we had a backup system. Also, the other divisions lending us trainees or faculty to help is something that speaks well for our system. The thing that stands out is the humanism I saw, from the staff that cleans our ICU, to the bedside nursing staff, RTs, NPs, residents, fellows, and faculty. Being able to provide good care, whether its curative or end-of-life care, in these challenging situations in the last three years is what stands out for me.