Inside, Outside, Upside Down is the title of a children’s book written by Stan and Jan Berenstein to teach young children about spatial awareness. Over the years, this little, profound book has been adopted by adults to denote the topsy-turvy reality of life. When I was asked to reflect on the nearly two years of the COVID-19 pandemic, the title of this simple book immediately came to mind. As a hospital chaplain working in an academic health care center, providing care for the sickest people, I have often felt like the world has been turned “inside, outside, upside down.”
When the pandemic began, my first task as the director of spiritual care for the three hospitals in downtown Indianapolis was to decide how our department would respond to the anticipated patient needs. As non-clinical departments and personnel were encouraged to stay home and eventually work from home, we were faced with the same decision. As we reflected upon our role as chaplains, our department committed to stay on the units with our patients, their loved ones, and the staff. We believe our presence is important for the well-being, support, and care of everyone as we work to assure that compassion remain a hallmark of our care. Like military chaplains who go into combat with their units, our department made the gutsy decision to stay with our units, in our buildings, and with our people as the virus invaded our community.
Were we scared? Yes. Were we anxious? Very much so. Yet, this is our calling, and God never promised us it would be safe. For some of us, putting our health and lives on the line was a new consideration. We had bought into the community illusion that pandemics were a thing of the past. For others, especially those who had worked through the advent of HIV/AIDS epidemic, Legionnaires’ disease, H1N1 flu and had kept abreast of the warnings from epidemiologists, the pandemic – while concerning – appeared a bit more manageable because of these past experiences. All of us knew the risk of getting infected. There were no vaccines at that time, and we shared in our fear and anxiety.
As the supply of Personal Protective Equipment (PPE) such as masks, gloves and gowns dwindled, we had to make another quick decision. Would we be able to visit patients? The hospitals burned through our supply of PPE in less than a week. We quickly offered the chaplains refresher, hands-on education on the proper way to don (put on) and doff (take off) PPE. We had to improve our skill in following this procedure for our own protection and the protection of others. We limited our use of PPE, realizing that the patients needed the physicians, nurses and respiratory therapists at the bedside. This cut us off from our patients, pushing us to reset how we made visits.
As the shutdown of our communities went into effect, visitation by loved ones was prohibited. We immediately honed our technology skills utilizing virtual platforms in order help loved ones remain in contact with patients and their care teams. As chaplains accustomed to face-to-face visits, we were pushed into learning how to use our iPads and smart phones to maintain some connection between patients and their families. Quickly we realized we would be facilitating end-of-life conversations between physicians and families via a miniature video screen; not ideal. This was new, uncomfortable and anxiety producing for all of us. Yet, it had to be done to provide the compassionate care to which we are committed.
We stood with physicians, frustrated that the usual ways to treat lung infections proved futile in the presence of this deadly virus. The mucus in the lungs bound itself to the lung walls with such strength that respiratory therapists and pulmonologists (lung physicians) risked rupturing the lung wall with the suction used to remove it. The normal antibiotics seemed useless. Often in a matter of minutes patients would crash. Their lungs filling and their hearts pounding, they would suddenly die from the onslaught of the virus upon their bodies. Others would linger, their bodies fighting to ward off the virus as the respirators pushed air into their clogged lungs. Some survived; many did not.
The virtual visits continued from the doorways and hallways. After two weeks of being in the hospital, an older gentleman facing the decision to let his dear wife die from the disease asked to be able to see her one more time. As the chaplain held the iPad, he read Psalm 23 and, together, they said the Lord’s Prayer. The husband then said over the audio, “Love you, honey. See you in the stars. Goodbye.” He hung up the phone. The chaplain stayed with the staff who removed the respirator. A nurse said, “this is no way to die.” We were all heartbroken and scared. Our spirits were turned “inside, outside, upside down.”
In the early days of the pandemic the community rallied around us. We were self-conscious as cars filled with food and gifts came to the hospital declaring us “heroes.” The support was helpful, lifting our spirits as we faced days of death and destruction. A laundry in the city provided free laundry service for several weeks. It was a helpful perk since we had no time to wash our clothes. Church members from diverse congregations and faiths gathered on the lawns of our hospitals to pray for us and our patients. We felt encouraged, appreciated and empowered to keep showing up during that time. We were proud of our work, the care we provided, maintaining the compassionate presence. It was an upside of these early days. Today, that feels like it was in another era.
One of the big shifts for us has been the realization that the focus of our care was shifting to include the staff. We provided them with tranquility carts loaded with snacks, the most popular being chocolate. As the nurses said, “a tranquility cart without chocolate is just a cart.” There was no tranquility without chocolate. We provided Compassion Circles, organized by our continuing education team in partnership with the employee assistance program team; we utilized the Psychological First Aid and Critical Incident Stress Management intervention models to provide further support and care for employees. All the while, we kept hearing news of a vaccine. We hoped. We prayed. We kept doing our jobs.
As we came to the end of 2020, hope began to emerge. The vaccines were ready. We had a worship service to commemorate those who had died, support those who grieved and provide encouraging hope for all of us. In December, we began to receive the vaccines with applause, celebration and much fanfare. We were excited, renewed and full of hope as we entered a new year.
These were the “inside” days when we took a deep dive into the reality of a deadly pandemic that touched us all.
2021 became the “outside” year. The outside forces began to mount their resistance to the vaccine. Being the husband of a microbiologist and a student of epidemiology since contracting the H1N1 flu in 2009, I was surprised, shocked and stunned. As the son of an oral surgeon, I had been around medicine all my life. Medicine had saved my life from cancer at the age of 3. Medicine had provided for my well-being and education. My sister had become a medical librarian, and, prior to entering ministry, I was a sports medicine/physical therapy student. I knew, in layperson’s terms, the science behind the vaccine. Yet, the resistance grew. I was personally attacked when I posted on social media messages encouraging people to get the vaccine. I was told I did not trust Jesus and that my faith was weak.
Other members of my staff and their families suffered similar attacks. It was a bleak time for us all. As this happened the surges of the virus kept coming. People kept dying, and we continued to care for staff, patients and their loved ones. We fought back by finding a “new normal” through wearing masks, taking the vaccines and boosters, and continuing to limit our contact with others. All of us were touched by the spiritual and moral distress from this intense situation.
At the same time, we as chaplains stood in the paradox, in the land of Middle Earth, as Tolkien might say. We knew the science was valid: Messenger RNA science has been around for decades and is the basis for many of the cancer treatments we utilize today. We knew it was not a government plot or an evil manifestation. Yet, members of our churches, families and friends believed otherwise. We lived in the vice between these voices. These were the days of the “outside.”
The “outside” voices, fears, anxieties and ideologies seemed to be driving us into resisting the very things that could win this ongoing battle with the viral world. This was no time to blame. It was a time to thank God for the intelligence and understanding given to us to create a vaccine that could save us. Yet, we had to take the shot.
As a child of the 1950s, I found myself reflecting upon my childhood. I grew up with a friend who wore braces on his legs. Bobby used his crutches to walk to school faster than I could. As a person plowing through the ravages of polio, he found ways to survive and thrive. When the polio vaccine came about, we all lined up to take the droplet on a sugar cube. Our parents had lived through images of children in iron lungs and a president who could barely stand. There was absolutely no way any of us would not get the vaccine, no matter how novel it might be. What had happened to us, I wondered? Why are we so resistant? My only answer lay in the reminder of the powerful individualism and diminishing sense of community that continues to hamper our society and world. During these “outside” times, I grieved for the sense of community I enjoyed as a child: the strong Methodist and Presbyterian churches in which I was raised. My hope diminished during the “outside” days.
Throughout this time, chaplains continued to do their jobs. We enjoyed a few weeks and months when the virus slowed down. Then came the delta variant and, then, the omicron variant. Just today we learned they have merged into what is being called “delticron,” and we have patients with both COVID and the flu. The “inside” work goes forward. The “outside” battles continue. Yet, our world – our lives – feel turned “upside down.” Today, it feels like we live in an upside-down world.
This past week, one of our resident chaplains wrote a Twitter thread about his experiences. Rabbi Michael Harvey goes on in his thread to describe an event that took place during one of his overnight shifts. A patient had just died because of the virus. As he walked by the on-call nurse Michael asked, “Was he vaccinated?” The nurse responded, “I don’t know. I don’t ask any more.” As Michael says, “she’s right.” It does not matter. What is essential is that we provide all our patients and their loved ones with compassionate care. That is what we are all about. That is why chaplains are in our hospitals. That is our mission and purpose.
We are tired; physically and spiritually exhausted. While we are spent, the staff remains professional. The units remain calm in the face of an overwhelming number of patients, codes and deaths. When we cry, we weep. When we celebrate, it is with a smile or grin. We find ways to laugh with one another.
Physicians, nurses, respiratory therapists, environmental services, social workers and, yes, chaplains: We are all in this together. We care for our patients, their loved ones and one another — together. This faithful togetherness is the source of our resilience and strength.
Throughout this pandemic, we continue to be on our units and at the bedside. Chaplains have come alongside patients, their loved ones and the staff providing a comforting, supportive presence through overwhelming challenges. This is our mission, our purpose — our calling.
Today, my spiritual offering to our nursing staff was small beach balls in the break rooms and magnetic dart boards with an image of a coronavirus in the bullseye. Most of us no longer want or need to talk about the pandemic. We need to play and discover some kinetic release from the stress and strain of living in an “inside, outside, upside down” space. As Deuteronomy 30:19 reminds us, “I have set before you life and death, blessings and curses. Choose life that you and your descendants may live.”
There is life and hope as we journey through being turned “inside, outside, upside down.”