Hot Spot: A Doctor's Diary From the Pandemic

By Alex Jahangir, Katie Seigenthaler and James E. K. Hildreth

When Nashville identified its first case of coronavirus in March 2020, the city was between Public Health Department directors and as unprepared as the rest of the world for what was to come. Dr. Alex Jahangir, a trauma surgeon acting at that time as chair of the Metro Nashville Board of Health, unexpectedly found himself head of the city's COVID-19 Task Force and responsible for leading it through uncharted waters.

What followed was a year of unprecedented challenge and scrutiny. Jahangir, who immigrated to the US from Iran at age six, grew up in Nashville. He thought he knew the city well. But the pandemic laid bare ethnic, racial, and cultural tensions that daily threatened to derail what should have been a collective effort to keep residents healthy and safe.

Hot Spot is Jahangir's narrative of the first year of COVID, derived from his op notes (the journal-like entries surgeons often keep following operations) and expanded to include his personal reflections and a glimpse into the inner sanctums of city and state governance in crisis.

• Language: English
• Publisher: Vanderbilt University Press
• Release date: Sep 15, 2022
• ISBN: 9780826505088

Alex Jahangir

Dr. Alex Jahangir, an orthopaedic trauma surgeon, is vice-chair of Orthopaedic Surgery and professor of Orthopaedic Surgery, Medicine, and Health Policy at Vanderbilt University Medical Center. Dr. Jahangir was named to the Metro Nashville Board of Health in 2017. He served as head of the Metro Nashville COVID-19 Task Force for the entire two years of the Task Force's existence.

Book preview

INTRODUCTION

I am an orthopaedic trauma surgeon. I specialize in intimate disasters defined by blood and broken bodies. Show me somebody whose every bone is shattered and I will know what to do. Show me somebody whose life is draining away, and I will remain calm, reminding myself of a saying in trauma surgery: all bleeding stops. I have spent years training—and training others—not just to fix, but to heal: to help people move past shock and damage and reenter their lives again.

In 2020, I became both doctor and patient. I was shown a city whose every norm was shattered by the worst health crisis of our time. By virtue of fate and circumstance, that city—Nashville, Tennessee, where I had immigrated from Iran as a six-year-old child—looked to me to decide what to do. I didn’t know. I lived in that city with my wife and young children, my parents, grandmother, extended family, colleagues, and friends. Nashville was part of me and I was part of Nashville. I was shattered too.

In this we were all the same. Leaders of nations, leaders of states and cities, leaders of companies and congregations and schools, parents of children, essential workers, rich and poor, young and old, solitary souls living in cavernous houses and generations crammed together in tiny apartments. In the early days of the pandemic, we were all stunned and scared by what we didn’t know.

My hometown asked me to help figure it out. Given my position in March 2020 as the chair of the Metro Nashville Board of Health, the mayor asked me to lead the Metro Coronavirus Task Force, later known as the COVID-19 Task Force. Like everyone working with me, I was initially at a loss. But I was able to join with some of the best minds and hearts I have ever met, and together we did the best we could.

We needed to move mountains, and some days we did. We were able to accomplish things on behalf of Nashvillians that—sometimes mere hours before—had seemed impossible. On these good days, I felt myself part of something larger, more powerful, and more consequential than anything I’d ever experienced. I walked in the clouds with my compatriots, both humbled and proud to be a human being and an American—living in a country with a singular capacity for ingenuity and innovation.

On other days we failed to move anything in the right direction, much less mountains. On these days I cursed my feet of clay and my limits, particularly my naivete and ignorance of the interdependent and complex systems that make our cities work. I also sometimes found myself helpless as competing interests attacked each other and attacked me, or as selfishness and fear overcame our better natures, or worst of all, as politics rather than people’s needs drove decisions.

On the bad days, I was filled with sorrow, frustration—and something more, something unfamiliar. I had known sorrow and frustration. I had known failure. I had struggled to save people’s lives and lost them when their injuries proved too much to overcome. But I had never known anger like the anger I felt when people who had the power to help solve the massive problems of the pandemic refused to do so, preferring to duck and posture and blame and lie, then leave local officials and volunteers like me to deal with the fallout.

It was weird to be Nashville’s hero on the good days and Nashville’s villain on the bad ones. I wondered how a guy like me—a classic striver who grew up trying to make good on my opportunities—wound up becoming either one.

I couldn’t wonder for long. The sun seemed to rise every morning on something unprecedented. An unanticipated challenge, an unforeseen consequence, an unbelievable conspiracy theory, an unexpected kindness. It was mind boggling. The minute I internalized one unheard of thing was the minute another stepped in to take its place.

Yet throughout the first year of the pandemic—as I continued to work on the front lines as a trauma surgeon and to muddle through as a husband and father and son and brother and Nashville citizen—I managed to practice one small ritual to keep myself grounded: almost every day, I wrote down what had happened.

I did this with the discipline instilled in me by my surgical training. Each time a surgeon finishes operating on a patient, that surgeon takes what are called op notes—a quick and dirty record of exactly what was done, how it was done, and what the results were. These notes capture the crucial details of a procedure while they are still fresh in the surgeon’s mind. Op notes aren’t pretty, polished, or poetic, but they get the job done. And they inevitably become part of a larger medical plan of care for patients. They are a record of trauma. They aid in recovery. In other words, op notes are the foundations of life and death stories.

As I entered an entirely new arena of life and death, I took this tried-and-true habit with me. I kept taking op notes. At some point each day, usually late at night and on my last nerve, I would scrawl a few salient facts in a notebook I’d set aside for the purpose and then crawl into bed.

Toward the end of 2020, as all of us were trying to take stock and hoping for better things in 2021, I went back to my notebook’s disjointed sentences and half-finished thoughts. I had a hard time absorbing what I was reading, even though the words were my own. I could not believe all that had happened—not just the relentless toll of the pandemic, but the reckoning with systemic racism, justice and health disparities, and the laying bare of national divides so deep they turned even the simplest acts (to wear a mask or not to wear a mask) into the most aggressive confrontations. And yet, if my notes showed me anything, it was that we kept on trying despite ourselves. We kept moving forward.

I decided to flesh out my op notes—to use them to recreate what it was like for one doctor heading up one Task Force in one American city over the course of twelve frenetic months. As I wrote, I became aware that much of my experience had been a year-long lesson in leadership and self-discovery. I witnessed people in arenas large and small willingly step into voids, put self-interest aside, take the reins of runaway challenges, and somehow bring them under control for the good of others. I tried my best to emulate them. I saw people who could not or would not do this, to the detriment of others. I tried my best to do the opposite. For me, the pandemic laid bare the reality that we are all in the same boat, whether we like it or not. It also showed me that each of us has the capacity to either right the boat or capsize it.

I have not included every note I wrote. Many of the days during the pandemic’s first year were just a slog, numbing in their sameness and heavy with inertia. We all had those sorts of COVID days. But others startled me into remembering and cried out for deeper thought. These are the ones I want to share.

These are my op notes from the pandemic, one perspective on the larger story we endured together in Nashville. It is neither autobiography nor history. As I write this, the COVID pandemic is still playing itself out. The bleeding has not yet stopped. Comprehensive accounts will be written by those who, given perspective and distance, can offer a panoramic view. By comparison, my op notes are a snapshot; my ruminations an attempt to bring depth to the picture. It is not the one-dimensional story of a superhero or an arch villain. Rather, it is a life and death story, an immigrant’s story, and a native son’s story. It is the story I lived in my American hometown from March 2020 to March 2021. It is the story of that town’s determination to withstand a year of relentless trauma, to begin to heal, and to start getting back on its feet again.

SURGE 1

MARCH 8, 2020–MAY 31, 2020

MARCH 8: Cases 1; Deaths 0

The first case was reported in Nashville last night. The Mayor’s Office asked that I do a press conference the following day. The first patient is a woman. I was told to deliver the message of Stay calm and we will get through this.

It began on a Sunday. I should have been coaching my daughter Layla’s basketball team in the final game of a tournament. Instead, I found myself in a small room in Nashville’s Lentz Public Health Center, wondering What the hell am I doing here?

I knew the Lentz building well. I am a child of Nashville’s public health system, the son of parents who fled a nation destabilized by war to give my brother and me a better life. I got my vaccinations and dental checks at the health department, alongside the children of other families who could not afford private pediatricians. The people of Metro Nashville’s public health system took good care of me. I believed in public health and, in 2017, had jumped at the offer to take a position on the city’s six-member board of the Metro Public Health Department. In October 2019, I was named chair of the Board of Health. The board held its meetings in Lentz.

But Sunday, March 8, 2020, was a different deal.

The city’s new mayor, John Cooper, walked in and sat down across from me. I had never met him in person. We briefly introduced ourselves. Then he began reviewing his remarks with his team. Dr. Adrienne Battle of Metro Nashville Public Schools (MNPS) and Director Chief William Swann of the Nashville Fire Department also walked in, also with their teams. All of these public servants seemed to know what they were doing. I had no clue.

I passed the time before the first press conference of my life thinking about my family and about the circumstances that had brought me—an Iranian immigrant who’d lived most of my life in the southern United States—to what was, by now, a very crowded room.

I couldn’t get the fact that I was missing Layla’s tournament out of my head. Maybe this was because I understood, if only subconsciously, that the coming days were going to continue to rob me of time with my wife Helen and our three young daughters. Layla was our oldest at nine. Kate and Elise were only seven and five.

Just fifteen hours before the press conference, Helen and I had been having dinner at our house with some friends and their kids, who were in our girls’ classes at school. As we were getting ready to eat, I got a call from the Metro Public Health Department. The call itself was not unusual—I’d been serving as the department’s board chair for five months and frequently received calls from the staff. But what these staff members had to tell me was about to change the life of every person in the city: COVID-19 had arrived in Nashville.

Like the rest of the world, we’d been following the virus’s trajectory, watching its slow but inevitable journey closer and closer to us. Now COVID was here. The Health Department would be integral to the city’s efforts to make sure it didn’t stick around. The people who called me said the Mayor’s Office wanted me at a press conference in the morning to deliver the message that the city would get through this and to call for calm.

I was being asked because Nashville, at that moment, didn’t have a director of Public Health. As the department’s board chair, I had just finished leading the search for the new director, Dr. Michael Caldwell. He was scheduled to start on Monday, March 9—the next day. Dr. Caldwell had been invited to speak too. The March 8 press conference would be his first introduction to Nashville and Nashville media. I would be there to provide backup.

This was fine by me. I knew my strengths and weaknesses. While I’d been on the Health Department’s board for three years, I’m not a formally trained public health expert. I’m an orthopaedic trauma surgeon—director of the Division of Orthopaedic Trauma at Vanderbilt University Medical Center (VUMC). I’m usually good in a crisis, but this was a crisis I didn’t fully understand.

I took my turn at the podium. I read my prepared remarks, just like I’d practiced over and over in the mirror the night before. I called for calm and turned the microphone over to Dr. Caldwell. Then I stepped away.

MARCH 8, 2020. Press conference announcing the first case of COVID-19 in Nashville with Fire Department director chief William Swann, Nashville mayor John Cooper, and me. Photo courtesy of Michael W. Bunch / Metro Photographer.

Or at least I thought I did.

MARCH 12: Cases 5; Deaths 0

By mid-morning, I realized there needed to be a more focused effort on this problem. Drew up a response plan and shared it informally with the Mayor’s Office. The Mayor’s Office called to offer me the position of director of the coronavirus response.

The days after the March 8 press conference were a whirlwind. I was running on two things: instinct and adrenaline. There was no template.

On March 12, in the surest sign yet that America’s core was shaken by the implications of COVID’s arrival, the SEC cancelled its NCAA March Madness tournament games in Nashville. The NBA and NHL cancelled the remainder of their seasons as well.

Mayor Cooper had been elected the previous September, only six months prior. He and his team were new to the business of running a city—and they had already been hit with a massive crisis only one week before: late on the evening of March 2, a deadly EF4 tornado ripped through Middle Tennessee, destroying lives, homes, and infrastructure, and leaving monumental devastation in its wake. In total, the supercell storm was responsible for more than $1.5 billion in damages and over one hundred thousand power outages. It left twenty-five people dead including two Nashvillians. It was the sixth deadliest tornado in US history.

As soon as disaster struck, Nashville did what Nashville does best. The capital city of the Volunteer State saw people come out in droves to support one another, just as they had after the devastating floods of 2010. Thousands of citizens walked out of their houses and into the streets to lend a hand—so many that local leaders had to issue public service announcements asking volunteers to stay away from the hardest hit areas, which were riddled with downed trees and powerlines.

Our family was part of a typical Music City volunteer brigade, one of my favorite things about being a Nashvillian. In fact, on Saturday March 7—just hours before I would learn of the first reported COVID case in Davidson County—Layla, Kate, Elise, Helen, and I met up with a dozen friends and neighbors on a stretch of sidewalk along Twelfth Avenue South, a busy thoroughfare near our home, to collect supplies and funds for storm victims. The neighborhood kids had made posters and were doing their best to attract the attention of cars and passersby.

As we were helping our kids collect diapers and paper towels and detergent and toothpaste, the talk among the parents was about more than the disaster we’d all just lived through. Some were asking if there was another disaster to come. They wanted to know what I thought about this coronavirus, and whether it could wreak the kind of havoc in the US that it was wreaking in other parts of the world. I said I believed it could if we didn’t prepare. Looking back, I don’t know if I fully grasped what I meant.

Like all of my colleagues at VUMC and my fellow members of the Board of Health, I had been following the pandemic’s deadly trajectory across Asia and into Europe. Life in countries like Italy had come to a standstill; patients were dying horribly, hospitals were running out of beds, and healthcare workers were being forced to choose who to treat. Many of us—especially those with responsibilities for public health—feared the same thing could easily happen in Nashville and every other town in the country.

In normal times, we would have awaited and received clear guidance from the Centers for Disease Control (CDC), with