‘Let’s Save Some Lives’: A Doctor’s Journey Into the Pandemic

There is no hope of outrunning the suffering that has settled into the hospital and the world around it, so Andrew Ibrahim laces up his blue waterproof sneakers and walks. In the time it has taken the daffodils to poke through the loamy soil and dapple Ann Arbor with pale yellow blossoms—about as long as it has taken Covid-19 to kill some 4,000 people across Michigan and over 60,000 in the United States—Ibrahim, a seventh-year surgery resident at the University of Michigan’s hospital system, has gone from a semi-oblivious commuter to a connoisseur of suburban sanctuaries.

In the same short timespan, Ibrahim has also gone from surgeon in training to critical care doctor treating severely ill Covid patients in a pop-up ICU that he helped design in the university’s main hospital. He likens the metamorphosis to the tempering of an alloy: After the relentless pressure of a weeklong ICU rotation, he plunges into an off-week of rest. Toward the end of each cycle, he senses new flexibility and resilience within himself.

It takes a mile or two for Ibrahim to shake off the anxiety, to convince himself that he does not need to be anywhere and that no one needs him. As spring gets off to an icy start with squalls and snow, he has taken to rambling ever farther from home on his days off from the Covid ICU—5.8 miles one day, 7.7 the next.

He walks slowly, temporarily liberated from the stifling masks that he must wear at all times inside the hospital—a surgical mask handed to him by a security guard the moment he steps through the hospital doors, an N95 any time he enters a Covid patient’s room. He inhales the damp spring air deep into his lungs. For hours at a stretch, he follows the asphalt bike paths and muddy trails wherever they lead, discovering parks and ponds tucked away in neighborhoods he has driven through for years without ever knowing what treasures they hid.

Staring out at the dull reflection of an overcast sky on tea-stained water, Ibrahim considers the heft of the past decade—medical school, the grueling intensity of his surgical training now just three months shy of completion, a series of personal disappointments, and a family tragedy that nearly broke him. In his muddy blue shoes, with a few miles under his belt, Ibrahim feels steady, as if everything in his life has prepared him for this exact moment.

Back in the hospital, it’s a different story.

A month on the Covid treadmill has forced Ibrahim, 35, to reflect on his own mortality with violent clarity. The work has magnified his sense of moral and ethical responsibility and provoked dread that occasionally feels asphyxiating. He worries that he’ll order a test that exposes a nurse or respiratory therapist to the virus, that he’ll miss the exact instant when tweaking a medication dosage could save a patient’s life, that he’s taking years off his parents’ lives by making them worry.

Sheathed in protective gear that is supposed to keep droplets off his skin and aerosols out of his mouth and nose, Ibrahim still finds himself double- and triple-checking every step during routine procedures that he normally does by muscle memory. “It was weird,” he says of his first days adjusting to Covid. “There was just a different x-factor about this that slowed me down.”

Securing the catheter of a central line to a vein in a Covid patient, Ibrahim ties the knots on top of the groove just the way his surgery mentor Lena Napolitano showed him. Central lines, placed into major veins near the heart, are used to care for mechanically ventilated patients with severe respiratory distress because they allow for the infusion of numerous drugs essential to critical care. Some of those drugs—like norepinephrine—are delivered through a central line because they can cause damage if administered in smaller, peripheral veins.

Ibrahim reckons he has put in more than a hundred central lines, but even such relatively simple procedures can go awry and result in serious complications: a punctured lung, severe bleeding, even an embolism—a bubble of air that can flow through the line and up into the brain or down into the heart, potentially killing the patient. Ibrahim is hyper-aware of every minute detail. He has a list and he checks it, then checks it again. He has always been meticulous.

Now there is an entirely new moral dimension: In a Covid room, Ibrahim feels just as responsible for his team’s health and safety as he does for the patient’s. Tying in a central line, Ibrahim knows that the longer it stays secure, the more time he will buy for his team before they will have to suit up again to replace it. Lately, he is often alone during line procedures that would have involved an assistant before Covid. “In this environment,” Ibrahim says, “there’s definitely a very rich awareness that you are by yourself.”

In his nightmares, he is not alone. One dream: He’s Lying in an ICU bed, immobile. He watches as a squad of coworkers prepares to slide a silicon endotracheal tube into his mouth and down his throat. “Your lungs are tiring out,” someone says in a muffled voice. “You’re not going to be able to keep breathing on your own.”

The dream is relentless. His colleagues are dressed in blue hospital scrubs, bouffant caps, isolation gowns made of a yellow, paper-like tissue, and nitrile gloves, their faces obscured by N95 respirators and clear plastic face-shields reflecting harsh fluorescent light. The paralytic drug normally administered prior to intubation is clearly working, but the sedative is not. In the dream, Ibrahim is very much awake. His throat tightens as he thinks about the research papers he has read that place the odds of a Covid patient coming off the ventilator alive at about 50 percent. The team works by instinct and feel. Hardly a word passes between them.

Another of Ibrahim’s mentors, surgery chair Justin Dimick, hovers at the bedside. “I need you to look after my parents and I need you to look after my brother’s kids,” Ibrahim tells Dimick.

Then he lurches awake.

“There are people my age in the hospital on mechanical ventilators and there are clinical providers in the hospital who are on mechanical ventilators, so it’s not a huge stretch to imagine that,” Ibrahim says. “I think a lot of us have had that dream at least once.”

But it isn’t so much a reverie as an electrified memory, a role reversal enacted under the paralytic of sleep. As every one of Ibrahim’s colleagues knows, the reversal could become reality from one day to the next. They’ve seen it happen.

“Walking out today after our daily chair meeting, I ran into Andrew Ibrahim, who was walking in to work overnight in one of our newly opened ICUs,” writes surgery chair Justin Dimick in a tweet from April 2. A champion of surgical quality and former collegiate wrestler, Dimick is the mentor who features in Ibrahim’s recurring nightmare. “I wonder if the general public knows what it’s like to walk into work at 6 pm with this responsibility,” he writes.

I contacted the doctors to ask if they would be willing to tell me more about physician responsibility in the age of Covid. Over the course of several weeks, Ibrahim told me his story.

At Case Western Reserve University School of Medicine in his hometown of Cleveland, Ohio, Ibrahim was what is known as a “nontraditional student”—someone who goes into medicine after significant experience in another field. Accepted to Case Western’s medical school for the first time at age 20, after graduating early from the university’s undergraduate program, Ibrahim felt uncomfortably young and out of place as he shadowed doctors on a tour. In a meeting with the dean later that day, he admitted as much. “What would you do if you weren’t a doctor?” she asked. A bit too eagerly, Ibrahim replied, “I’d be an architect.” To his surprise, the dean encouraged him to defer admission for a year to indulge his interest. If he still felt called to medicine, his place at Case Western would still be available.

Ibrahim moved to London to train at the Bartlett School of Architecture. A year later, he returned to Case Western with a plan to fuse his dual passions into a cohesive whole. “Who are the architects and who can teach me about regional planning of health care, access to care, and how you design delivery systems?” he would ask his professors and classmates during his first year. “They would just start laughing,” Ibrahim recalls with a laugh of his own. “They would tell me, ‘We don’t have architects in the medical school. You’re interested in public health if that’s what you want to do.’”

Undeterred, Ibrahim plowed on through medical school. Between his third and fourth years, he took a gap year to complete a Doris Duke fellowship at Johns Hopkins University, in Baltimore, Maryland. It was there, studying provisions in the Affordable Care Act to address inequality, that he had his epiphany: “If we were going to improve the delivery of health care, it would mean redesigning the entire delivery system, physical infrastructure included,” he realized. “It was the first time my idea of architecture didn’t seem that crazy.”

Ibrahim’s older brother, Victor, a freshly minted physician, never thought his ideas were crazy. Victor had always been Ibrahim’s most ardent supporter, especially when Ibrahim’s confidence in himself flagged. The year Ibrahim spent in the Capitol area was an opportunity to bond with Victor, who was 31 at the time, living in Arlington, Virginia, and practicing sports medicine.

Victor had grown into a man who seemed to Ibrahim almost supernatural in his abilities, like the Washington Nationals and D.C. United players he sometimes treated. On top of being a doctor, Victor was an avid runner, cooked elaborate meals, loved to sing, and even painted. Ibrahim idolized Victor. In the bedroom the boys shared growing up, Victor had only two rules for his little brother: “no snoring” and “ask anything.” Victor never tired of fielding the flurry of questions that would come from Andrew’s side of the room each night, making up imaginative and hilarious answers until the younger boy fell asleep. At one point, Victor even had Andrew convinced that he worked for Santa Claus.

The brothers looked alike and both wore glasses. Whenever a neighborhood kid would call Andrew “Little Vic,” Victor would say, “No, I’m Big Andy.” That always made Ibrahim feel good. Victor was the only one who was allowed to call him Andy. In a stroke of good timing, Ibrahim would be there for the birth of his brother’s first child in November 2011, a boy Victor and his wife, Ereni, named Luke. Dizzy with ideas and grateful for the family time, Ibrahim, then 27, returned to Cleveland to begin his final year of medical school.

That’s when he ran headlong into three seasons of grief. In the autumn of his final year, Ibrahim broke off his engagement to his first serious love. That winter, he failed his board examinations. In the spring, he failed to match into a surgery residency. “Match day” is the high point of a rigorous four-year journey, much more fraught with anticipation than graduation. It is the day when aspiring doctors find out where they will receive their advanced training. For applicants to surgery residencies, matching determines where they will spend the next five to seven years of their lives.

For Ibrahim, failing to match was as good as being told that he might not have a future in medicine. The exclusive fraternity of surgeons that he had been working so hard to join had told him that it did not want him. He found himself rudderless at what ought to have been a moment of triumph. “My god,” Ibrahim thought, “the world is over.” But what at first appeared to be a litany of biblical afflictions was only a glimpse of the devastation Ibrahim would come to know.

Ibrahim clawed back, gaining acceptance to a one-year provisional surgery residency at Case Western, what he describes as a “sink or swim” program in which every day feels like a job interview. He survived that first year and continued for two more in Cleveland before winning a Robert Wood Johnson scholarship to complete a master’s degree at the University of Michigan’s National Clinician Scholars Program, where Justin Dimick would serve as his adviser.

Ibrahim had met Dimick at a conference during his Doris Duke fellowship and the two had become close friends. Ibrahim was thrilled to be studying with Dimick, who had consoled him after he failed to match and whose support had never wavered. “He told me to keep my chin up and to remember that I had an important vision,” Ibrahim says, “to not give up on it even if the vision wasn’t totally clear.” Following two