Time to Vaccinate

After many months of discouraging trends, news reports and heartache, the approval of two vaccines is like a ray of sunshine breaking through the clouds on a stormy day. Yesterday, I was excited to receive the first dose of the Pfizer vaccine. Many of my patients are anxiously waiting their turn. Many others are unsure and just anxious. To allay fears, I wanted to share what I have learned about these vaccines. 

How the vaccines work: 

Messenger RNA Both the Pfizer and the Moderna vaccines are "messenger RNA" vaccines (mRNA). Normally, mRNA is made in the nucleus of our cells from DNA and acts as a code of instructions to make proteins. Proteins are used as enzymes, structural building blocks, receptors, antibodies and many other purposes. This happens on the ribosome. Think of it as a 3D printer for proteins. The mRNA interacts with the ribosome which deciphers the code. The mRNA from the vaccine codes for the Corona Virus spike protein. This is the part of the virus that allows it entry into the cells and cause infection. The mRNA goes right to the ribosome where spike proteins are produced. They are then released into the body where our immune system recognizes them as foreign material and mounts an immune response by making antibodies that attach to the spikes. 

Activating the Immune Response 

Once a person becomes infected, his/her immune system recognizes the spike and can mount an immediate response. This differs from a person who has not been vaccinated. Their immune system also recognizes the spike protein but are not able to immediately make antibodies as that process can take several weeks. One of the reasons that patients give me for not being vaccinated as that they "have a good immune system" and don't want to put foreign material into their body. To me this is like saying that a runner wants to enter a marathon without doing any training runs. Exposure to the vaccine gives our immune system a head start. Primed and ready to go, it can be prepared on race day to act right away. 

Cell Delivery 

Many vaccines in the past used altered organisms that were not as deadly. This made an individual sick to some degree. Obviously, this is not an ideal situation. No one wants to get sick to prevent illness. The beauty of the mRNA vaccine is there are no infectious particles being injected. We have never had this technology before because mRNA is quickly degraded outside of cells and would be destroyed before reaching its target. Scientists have discovered how to pack the mRNA in lipid membrane vesicles (think of tiny little soap bubbles). This membrane is similar to our cell's membrane allowing for delivery of the vaccine right into the cell. The lipid membrane in the Pfizer vaccine is unstable at warmer temperatures which is why it must be stored in special low temperature freezers. 

Foreign Material 

One of the fears that I have heard from others is that the vaccine is injecting animal DNA into our cells. This is incorrect. Animals may be involved in making the mRNA strand but it does not enter the cell nucleus and does not interact with our DNA. In addition, there is no biochemical difference in the nucleosides (mRNA building blocks) from an animal source versus our own. In reality, unless we are strict vegans, we come in contact with animal particles every day. There is no concern for these vaccines. 

Side Effects 

The side effects stem from our immune response. The first shot will likely just give an individual a sore arm. The second shot may give more symptoms related to a larger immune activation on repeat exposure. This may consist of a headache, fever, and muscle aches. For individuals who are already prone to severe immune reactions that require them to carry injectable medicine (EpiPen) with them at all times, they are more likely to have a severe reaction to the vaccine. Such patients should consult with their physician.

Safety 

I am quite impressed that we were able to get data on clinical trials with over 50,000 patients in so short period of time. Frankly, if our country did not have such rampant spread of the virus, this would not have been possible. With so many being infected, it was easier to tell how effective these vaccines worked. We have safety data from these trial participants, but obviously it is short-term data. While, no one can say with absolute certainty that there will not be long-term issues, there is no indication so far to justify this concern. We will continue to learn and make recommendations, as more data is available.

Bottom Line 

My colleagues and I are not hesitant to receive or recommend these vaccines. We know with certainty what COVID can do. Not only is it currently killing more people each day than died at Pearl Harbor or the 911 attacks, it has also surpassed heart disease and cancer as the most common cause of death. The pandemic has wreaked havoc on our society, our economy, and our families. It is time to make this all end. Personally, I have received the vaccine and am grateful to put on this protective armor as I go to work each day. As a society, we need about 75% of our population to receive the vaccine so that the virus has nowhere to spread (herd immunity). This is the message that needs to go "viral." Pass the word, get your shot. Let's put an end to this virus now.

Staring Death in the Face

Like a dreaded tsunami, the current COVID surge has flowed over our protective barriers and is flooding our hospitals with sick, debilitated patients who are literally struggling to take each and every breath. The emergency sirens have sounded, the call for help has been heard and it is all hands on deck in the hospital.  Last spring, I and a dozen of my colleagues agreed to help staff an expanded ICU to care for the expected demand.  We did some training shifts but the numbers receded and our services were not required-until now.  My hospital usually has capacity for 30 ICU patients.  We have now expanded to take 57 such patients.  Last week I did my first over night shifts in 25 years.  This week I am finishing three 12 hour day shifts. 

I am covering a unit with 10 patients.  Most of them have COVID and are on high flow oxygen delivery systems.  In the beginning of the pandemic all of such patients were put on ventilators.  It was feared that such oxygen systems would enhance the propagation of the virus.  We have since learned that it can safely be used if appropriate precautions are taken. This has greatly improved our ability to treat such patients as well as to safeguard the limited supply of ventilators.  Now if a patient has gotten severe enough to warrant mechanical ventilation, they are much more ill. Either their condition is too severe or they have lingered on these oxygen therapies for weeks and have now started to deteriorate. The grim reality is that if they require ventilation and survive they face an almost certainty of needing to be on it long term which requires a tracheostomy (a surgical hole in the neck to insert the breathing tube). They also will likely need to be in a ventilator specific nursing home till they can be weaned off of the machine. 

This last week, I have spent most of my hours having conversations with the patients and their families about this difficult reality.  Some have chosen to push forward with all we have to offer.  Others, often who are elderly or otherwise compromised, have decided that if their condition gets that bad, they would prefer that we focus on making them comfortable at the end of their life and to withhold life support.  Staring your mortality square in the face is hard. It is hard for the patient, it is hard for their families and it has been exhausting as their doctor.  The patients are tired.  They have been breathing thirty times a minute for weeks, as if they had just finished a sprint that never recovers.  The thought of being on life support for months is daunting.  Many families have a hard time grasping how ill their loved one is.  They see others in the community who are sick for a few days and recover just fine.  They are not allowed in the ICU and must gain all their knowledge from our phone calls. It is hard for them to truly see how sick their loved ones are. 

I have a passion for making sure that patients and families truly understand the ramifications of whatever decision is made.  There is a reason why almost all physicians chose to not be resuscitated and put on life support if the condition arises. We know that it is a horribly uncomfortable experience for the patient. Hollywood makes life support seem as if a simple tube is taped by the nose while the patient is able to talk, eat and carry on with life.  That is far from the truth.  Over the 72 hour span of working this week, I had the "death talk" over 10 times.  There were 3 individuals who chose to withhold life support that we made comfortable in their last hours, making sure that family was by their side. I had the heart wrenching experience of helping the family of one of my own patients to whom I had cared for over twenty years, make the decision to withdraw the ventilator as there was a certainty that he would never recover. In every case, the family was so gracious and kind.  As emotionally exhausting as it is to have these conversations, it is immensely rewarding as well.  I truly could not do it without my belief and faith in God and that they will live on in spirit. 

News of an effective vaccine is like a break in the clouds, the sun shining over our flooded land.  It provides hope that this kind of suffering and these kind of difficult conversations may not be needed, at least for this dreaded virus.  It will take time for the population to get sufficiently vaccinated to provide herd immunity.  May we heed the call of the sirens to head for safety, to continue to watch out for each other as we get vaccinated, mask up, stay apart and keep safe.

The Breath of Life

 For nine months this precious baby grew and developed in her mother's womb receiving all her nutrients and oxygen through the placental "feeding tube."  All that she needed to grow came from her mother.  After hours of being jammed into the bony birth canal and somehow flipped "sunny side up," she exited the warm comfortable fluid of the uterus, entering the cold stark outside world.  As fluid drained out of her lungs and she opened to the surrounding air, her whole circulatory system immediately changed. Oxygen rushed into her lungs causing resistance to blood flow to decrease in the lungs but to increase in the rest of the body. Her skin, at first a bit blue and dusky immediately pinked up.  To me the whole process is a miracle of biology, orchestrated by a loving Heavenly Father.  In the scriptures, the initiation of respiration is referred to as God's "breath of life." 

The idea of life giving breath can be found in the ancient Hawaiian practice of the expression of "ha."  This is a face-to-face greeting, the expelling of one's breath for the other to feel.  It denotes a deep sense of brotherly love and caring. It is ironic that what has at one time been viewed as an expression of good will would now be considered as rude and reckless in today's mask wearing society.  Such action could spread disease and death rather than love and life. COVID has changed everything.  

On the very night that I was able to visit my daughter and her adorable baby at the hospital, I was on my way to the floor above hers to care for patients over night in the ICU. One patient in particular kept our attention for most of the night. His breath was coming fast and shallow, breathing 35-45 times per minute (normal is about 18 breaths per minute). His oxgyen levels were drifting lower but just barely holding steady.  The worry was how long he could keep breathing at that pace. We were doing all we could to keep him off of a ventilator since nearly half of all those with COVID who are put on ventilators never come off. This is due to both the severity of their disease but also results from cascading deleterious affects from the whole process. The patient was transitioned to the highest level critical care unit where he indeed required mechanical ventilation.  The critical care doctor expertly placed the tube and his breath of life was sustained once again.  The whole process is terrifying to the patient and anxiety ridden for the health care team. 

The juxtaposition of new breath and declining breath was a stark reminder to me of the world we now live in.  I am grateful to have a daughter and son-in-law who are willing to start a family in such a world.  Their faith, love and devotion will be a blessing to my granddaughter that she won't learn to appreciate for many years to come.  I am equally grateful for a team of nurses here at the hospital who with faith, love and devotion as they watch over the patients to make sure their current breath is not their last one.  They are being spread thin and can only do so much.  As such, I am even more thankful to all of you who are willing for the time being to cover their mouths with masks, keep their distance from others even when their heart aches to do otherwise.  The pandemic will not last forever. The day will come when we will once again embrace those we love, face-to-face sharing their breath with ours.

The Eyes of COVID

We read so much into facial expressions. Often described as the windows to the soul, the eyes are all we have left in a world of mask wearing.  Now a days one may put on a smile but if it doesn't reach the eyes, no one will ever know that we even tried. Eyes easily convey emotions of fear, stress, exhaustion, hope and joy. Through our eyes we show personal connection, focusing on the person before us, letting them know that what they are saying is important. As grateful as I am to have video conferencing technology, it is hard to look someone square in the eye on Zoom. 

The eyes tell me how sick someone is. Glassed over, easily distracted, drifting eyes tell me that someone is struggling. Wide eyes, showing more of the white, with quick, distracted darting movements tell me someone is anxious and fearful. Often, when following up with a patient, I'll walk in a room and immediately sense that they are doing better. Their body language shows comfort, positive energy but mostly I see it in their eyes.  I thought it might be interesting to share some of the windows into my experience with COVID through the eyes that I have seen. 

His are tired eyes. I can easily tell his energy is low. His chest xray shows viral pneumonia and his oxygen levels are borderline low. He is not sick enough to go to the hospital but he is not far from it. He needs to stay home and rest. When I tell him how long he needs to stay self isolated, the eyes change. The muscles at the edges contract quickly in annoyance, glaring just a bit, followed by a resigned sigh and a hint of rolling. I get it, he doesn't get paid if he doesn't work. He has gone to work not feeling well  many times before. I ask him to stay home not for just his own benefit but for all those with whom he could come in contact. This infection is different.

These eyes showed some irritation and anger. I had just asked her to be tested for COVID due to the persistent cough she has had for over a week. She has been doing everything right. She has not expanded her social bubble, has worked from home,  and has been wearing an N95 mask on the rare occasions when she has left the house. She has even helped design the protocols to keep the children safe at her children's school where there has not been a single case reported. How could I ask her to get tested? And yet her children had coughed a bit and she didn't want it to turn into pneumonia. Of course, I wanted her to get tested. Twenty to forty percent of all those who spread the disease have no idea that they are carrying the virus. Most become symptomatic a few days later but by then it is too late. Still, she refused to get tested. 

Looking into these eyes I find love and acceptance tinged with the regret of just one bad decision. Her and her husband don't declare their faith, they live it. Now in their retirement, they moved far away to be near family but on Tuesdays they are found giving food to the poor.  Being elderly, they know they are vulnerable so they have been careful and cautious. The only social gathering they have been to was the funeral of a family member. "I knew I shouldn't have agreed, but we drove to the cemetery from the church with two cousins." It was a twenty minute drive and though they had on their masks, the cousins did not and were "coughing all over the place." Later, the cousins were hospitalized and one is still on oxygen. My patients thankfully recovered nicely after feeling horrible for a few days.

As I activated  the Zoom call, I couldn't see her eyes at all. She was asleep at the table in front of me. I waved to the screen to no avail so I picked up the phone and called her at home. She wasn't at home. She was at work where she cares for children. She gets this every year, she says. It is just a cold, though she agreed that this one was pretty bad. Could she get a rapid test? You see the fall festival feast was the next day and it was important that she make it. Besides that, she had received an email this last week from her boss telling everyone to not call in sick as there were no backup workers available. I explained that it was important for her to stay home to not only recover but to also protect the children and their families. In her condition, there would not be a test that could rule out COVID. The chance of a false negative result was too high. Her eyes showed understanding but were oh so tired. We agreed to touch base again in a week and she would go get tested the next day. 

I am used to seeing fear in the eyes of those I see in the respiratory clinic. Compounding the fear they bring to their visit,  I walk in the room looking like someone out of a horror film. On top of my scrubs, I don the cafeteria worker's hair net, booties over my shoes and a full length protective gown tied in the back. I have gloves that seal the gown at my wrists. Up top, my reading glasses are perched, librarian style on my nose so I can tip my head to look through them to see up close or peer over them to look at the patient. The N-95 has been fit tightly over my face. I test it by exhaling sharply and making sure there are no leaks. It will stay on my face the entire shift. I place a surgical mask over the first, that keeps me from touching the N-95. The face shield straps over all of this and extends past my chin. The stethoscope slides under the shield. It is cleansed after each use and is a dedicated, augmented scope used only in that clinic. The amplified sounds from it are helpful as there are loud blowers in the rooms that suck air out, making sure that there are no air currents that come out to the rest of the clinic. As such, when I come into the room, I am quite the spectacle. 

Last week I saw two patients who already knew they had COVID. They couldn't go to their normal doctor. We keep such patients out of the clinic to protect the others. Both patients continued to cough and were worried about getting worse. Neither one wanted to be in the emergency room. Nearly shouting due to the noise in the room, I explained who I was. I listened to their concerns and examined their lungs. We did chest x-rays, finding their lungs to be clear. I was able to reassure them that their oxygen levels looked good. They both looked me square in the eye with appreciation and gratitude. They were thankful that we have created the Respiratory Care Clinic. Their fear was assuaged. 

For the last few months I have been blessed to have four little eyes follow me around the house. These eyes have no duplicity. Sure, they can show anger and disaapointment but most of the time they show pure love and acceptance. As I leave for work, their little feet run to give me a hug goodbye, "see you later alligator!" cries the older grandchild. "ee-ah-aaga-awawawer," cries the not quite two year old. "After a while crocodile," I return and jump in the car for another day. We have also brought my elderly mother into our bubble recently. Empty nesters a year ago, we now have a four generation home. I am constantly aware of possibly bringing the virus back into my home.   I, like you, look into the mirror each day and see my own eyes and tell myself that I can do this. We must stay focused on the task at hand. The hospitals are filling up. There are many whose eyes will never open again if we don't prevent further infections.  Just waiting for a vaccine is not acceptable. We must stay strong and never ever give up.

COVID Fatigue

Are you as tired of this pandemic as I am? The mask wearing, all day long; dressing in scrubs every morning; doing my temperature check and symptom screen; sanitizing my hands over and over and over again till my skin is dry, rough and raw-I am getting tired of all these things.  I am tired of looking at other countries who have a unified, cohesive approach and are doing so much better than we are.  For goodness sakes there are more cases of COVID-19 in the White House than in the WHOLE country of Taiwan!  I am tired of disinformation, of conspiracy theories and the constant barrage of bickering.  Lately, I am getting tired of seeing 4-5 new patients a day come down with the disease, almost all of which are over 70 years old.  

These are the patients that I worry about the most.  Almost all of them have gotten the disease from family members.  As families have tired of the precautions, the kids and young adults have expanded their circles which fueled the case numbers through late summer and early fall.  Very few of them have gotten critically ill but here is the catch-they all have grandparents.  What we are seeing now is the maturation of this whole process.  Through most of the pandemic, I would only see a few patients in the respiratory clinic who had COVID and were ill. Most, though, were well but needed to be reassured.  The last two weeks has been decidedly different.  Three to four of the patients would already be diagnosed with COVID but were getting worse and needed further evaluation.  Of the remaining, most would have been exposed to someone with a known case of the disease.  Last week, for the first time, I sent a patient to the Emergency Room with shortness of breath, horrible sounding lungs and an oxygen saturation in the low 70's (normal above 90%). 

That night I experienced another form of COVID-19 fatigue-I was simply exhausted.  Caring for such patients takes an emotional toll.  I had a bit of a headache and was feeling a bit achey when I went to bed.  As I slept, I dreamt of being exposed to White House Staffers. They were literally chasing me!  I woke at 1:00 AM convinced that I had come down with the disease. Panicking, I slipped out of bed and went to the other room to be away from my wife.  I was able to calm down and get back to sleep (after terrifying my poor wife) and in the morning, instead of calling my partners to have them cover for me and go in and get tested, I realized that I was fine. I had no fever, no headache.  There was no cough, loss of taste/smell. I just needed some rest.  Certainly, I must be stressing out about this in my subconscious more than I realize when fully awake.  

St. Louis Area Hospitalizations

I understand that the vast majority of people who contract the virus have mild disease and do just fine.  I have literally ridden the tires off of my bike this summer and am in as a good of shape as I have ever been. My chance of severe disease is quite low.  That said, I am not willing to voluntarily take that chance. Hospitalizations in our area, which have been stagnant for many months are on the rise again. Deaths will surely follow.  A man in Nevada who had the virus in April was infected four months later. Analysis showed that the genetic composition of the earlier virus was distinct from the latter.  SARS CoV2 has already started to mutate.  This does not bode well for a successful vaccine. That said, there is a tremendous amount of research being done on this virus by very smart people.  Lessons learned now will not only be of use against COVID, but will transform our ability to fight other diseases as well. This pandemic will pass but it will take some time. 

Now is not the time to let COVID fatigue lower our defenses.  We must stay vigilant and do the simple things that will keep transmission down.  Masks are effective. Social distancing works.  Avoiding enclosed spaces with lots of other people is crucial. We must take the most care around those at higher risk.  They are not an "acceptable casualty" in this war on health.  You and I must keep forging ahead, fatigued or not. 

Good Job

Some days I come home and the mental stress of the day envelopes me like a lead vest, causing me to feel physically heavy which leaves me totally exhausted.  Most of the stress that I feel are the compilations of the many decisions that I must make every day to take care of patients. On top of that is the stress of missing clues, symptoms or lab results that may point to a diagnosis that was previously not considered.  This is the stress that keeps doctors awake at night. This is the stress that drives me to my knees.  Physicians are human too. We make mistakes. We are not perfect. This week has been heavier than others. I have struggled to help diagnose a condition in a patient who is struggling.  He is frustrated and so am I. 

On my way home from work I listened to an interview on the radio with Alicia Keys who just released an new album.  One of the songs is entitled, "Good Job."  It struck a strong chord with me today.  It's chorus was a jolt of positive energy that lifted my spirits. 

"You're doing a good job, a good job

You're doing a good job

Don't get too down

The world needs you now

Know that you matter"

Apparently this is the message that I needed to hear today. As I sat down to my computer this morning at work and started going through my messages, I received one from a patient who simply sent me a note thanking me for his life.  Twenty years ago today he came to see me.  As I examined him I detected a lump in his thigh.  It felt pretty much like a lipoma (fatty benign tumor) which I routinely tell patients not to worry about. This one felt just a bit different, more fixed to the deeper layers.  I was so close to telling him it was just fine but decided to scan it.  It turned out to be a lipomyosarcoma, a much more rare and often deadly cancer.  He had a deep resection followed by radiation and has had no recurrence.  He has continued to stay active, running marathons, biking and is now enjoying his four grandchildren.  He expressed gratitude not only for that diagnosis but for the persistent checkups and care through the years.  In a way his praise is terrifying as I know how close I was to not pursuing the testing.  This afternoon, Alicia Keys' song was as if she were singing just to me.  It was music to my ears. 

This time of the COVID-19 pandemic has been stressful for so many people.  We could all use a "good job" now and then.  I am grateful for those that help me do my job.  I have a fantastic team at my office consisting of my nurse practitioner, our assistants and secretary. They always have my back, keep me going and help my smile.  I couldn't do what I do without them. I also have support staff at the respiratory clinic who bravely come to work in the face of certain exposure day after day.  My partners in the office have always been there for me. I will always be grateful that they allowed me time off last year to spend with my father.  

Above all, I would like to nominate my wife for doing a good job.  I have been the source of more than her fair share of worry and stress this year.  She is always there for me and keeps our family together.  We have shared our burdens. We have cried together, laughed together, prayed together and loved each other.  I am more than grateful to her and for all my many blessings.  

I would love to know who you would nominate for doing a "Good Job."  We can all use a little lifting, a little gratitude

COVID Lessons

The pandemic has been with us know for nearly five months.  I thought I would share some of the lessons that I have learned during this time from my perspective as an Internal Medicine physician. I may not be completely on the front lines but I have a pretty good view from the second row seats.  

1. Pandemics require a concerted coordinated response. Our country has great medical care but unfortunately our public health is sorely lacking and not just for the response to this virus.  We do not take great care of all of our citizens, just those with the means to access all that we have to offer. As the pandemic approached, I seriously thought that the CDC would jump to the forefront and direct our efforts throughout the country as a whole.  Instead, we stumbled out of the gate due to a decision not to use the material from the WHO to develop tests.  From the beginning we were hamstrung by an inability to test and curb the disease.  Our ability to track and trace contacts is almost nonexistent depending on local jurisdictions with no federal guidance.  Our president refuses to take a stand, let alone wear a mask.  Countries with strong central government have fared better. 

2. Flattening the curve worked. Initially our hospitals were headed towards the disaster of being over capacity with scarce resources running out.  Shutting down society averted that catastrophe but came at a big price.  Other countries who had a vigorous testing program in place coupled with strict track and tracing procedures were able to do a much better job without complete economic standstill (think South Korea, Singapore, and even China).  In a surgical analogy, they used a scalpel and we tried to make do with a sledge hammer.  

3. Corona is prejudiced.  The virus does not care who it infects, all of us are equally likely to contract the disease.  It will, however, disable and kill the elderly and those with chronic medical conditions at a much higher rate.  Obesity has turned out to be one of the greatest risk factors for more severe lung disease.  There is much more to this infection than dying.  It can be a devastatingly disabling disease. Though I have not had any of my patients due from COVID, many have gotten quite ill.  I recently spoke to a patient in her 50's that was in the hospital for two weeks.  She has now been home for another week and still could not finish a sentence without coughing.  She was excited to be improving to the point where she could almost finish taking a shower without stopping to rest. 

4. My patients eat out too much.  There may be many who have sat home and gained weight during this pandemic but I have encountered a lot of my patients who have finally had time to exercise, cook and eat right since they are not going out to restaurants like before.  They have lost weight, their blood pressure is better and their diabetes is now controlled. Now, if we can just keep that going!

5. Life still happens.  There may have been a momentary pause on health care utilization due to fear of the virus but cancer still raged, hearts were attacked, brains were stroked and kidneys still failed.  I have seen more than the average number of patients die this summer.  Many could not spend their last days with family members due to the virus.  The stress of all of this has been hard on so many people.  That has been hard to watch.  When possible, I have tried to make sure that dying patients can do so at home on hospice so that family can be near.  

6. Zoom is pretty cool.  Most of us are now rather adept at videoconferencing.  It is a great way to stay in touch with family, to attend church meetings and to even conduct business.  I have no doubt that in many forms, this is here to stay.  

7. Faith and Family is my first focus.  When I first learned about working with COVID patients my son gave me a priesthood blessing (pronounced a prayer on my head).  It was a powerful experience for me.  I was promised that angels would watch over me including my father who passed away last September.  Today as I prepared to work in our Respiratory Clinic and would assuredly be exposed to COVID patients again, I thought to myself, "ok, Dad, I need you with me today."  I have faith that his spirit lives on and that he is indeed there by my side.  I know that my faith in God does not keep me from hard times but it has strengthened me so that I can bear them up with ease.  

8. We are in this together. The virus is not going away soon.  I am more than grateful to work with like minded colleagues who will do whatever it takes to care for those that need it.  I have a team at work that shows up day after day knowing they could be in harms way.  My family is at higher risk because I am in their lives but put their trust and love in me without question.  I am grateful to those I see who are clearly being safe by keeping their distance and wearing masks. Pandemics do not last forever.  This too will pass but it may not be for another year or so.  If we all work together, take it seriously and watch out for those around us, we will get through these days just fine. 

My White Privilege

He felt a pop in his chest as he put extra torque on the screw driver lever putting on the trampoline mat for my grandson's visit. Dad and Jack had a special relationship, even separated by 78 years of age. They read books together, took walks together, went on boat rides and shared ice cream.  Dad had a way of making all his grandchildren feel special because he took time with them when it counted.  He himself was raised in a broken family.  His parents divorced when he was about 9 years old.  He missed his dad fiercely and craved to have that paternal influence in his life.  My grandparents were eventually remarried but there were critical years when my father needed him most and he wasn't there.  Dad vowed to be there for his children, grandchildren and great-grandchildren and he was until the very end.  That pop turned out to be a fractured sternum riddled with metastatic melanoma skin cancer. It was right about a year ago and progressed to his death in September. 

This is my first Father's Day without my dad, my hero.  Was he perfect? Of course not and he would be the first one to tell you that. He was a master of self-deprecation, sarcasm and humor but it was done in such a way that no one ever felt that they were inferior in his presence.  He was a master at making friends and breaking down barriers.  On my knees last night as I said my nightly prayers and thinking of my father, it occurred to me that I have now have two fathers in heaven, my earthly father and my Heavenly Father.  Dad is gone from this world but he is not gone from my life.

This week I watched "The Color Purple."  I hadn't watched this movie for many years.  The acting was phenomenal but it left me feeling quite unsettled.  Set in the generation after slavery, it depicted one of the most shackling legacies that continued past emancipation; that of the cruelty with which men treated women and the children in their lives. Men learned the horrible lessons of aggression taught by the example of the slave owners. Arguments were settled with beatings. Children were raped and their children were ripped from their arms and given to others. In contrast to the home I grew up in where my mother and father may have had their share of disagreements, we children always new that they would work things out peacefully and that no matter what we were loved and prized above anything else. 

The root of this certainty comes from our doctrine that we are all children of Heavenly Parents. That our God, Heavenly Father, has an eternal partner who raised us as spirit children in a heavenly home and that we were sent to this earth to learn how to return.  His is our Eternal King and she our Queen.  The family unit is divinely appointed and critical in our ability to learn those lessons.

In our church we worship in chapels each Sunday but we also have temples where we make promises to God on how we live our life.  We are taught God's plan for our happiness and learn about our first parents, Adam and Eve.  It is very clear that Eve was the first one to understand that in order to have children according to this plan, they would need to leave the garden and so she partook of the fruit. Adam was slower to understand this concept but chose to be with her through thick and thin.  Said Eve of the experience, "Were it not for our transgression we never should have had seed, and the joy of our redemption" (Moses 5:11). We believe that our salvation has everything to do with what kind of family member we are.  We also believe that since we are all children of Heavenly Parents, we are literally brothers and sisters, "black and white, male and female...all are alike unto God" (2 Nephi 26:33).

In our temples everyone wears white clothing.  This is a symbol of purity, of being washed clean through the blood of Jesus Christ. It has nothing to do with race. In fact, as all who enter the temple wear this same clothing. Distinctions of race and economic station dissolve into a state of equality.  It is a beautiful place to be, truly heaven on earth. During the pandemic and time of quarantine, we have not been able to gather and worship together in our chapels or our temples.  Though this has left a void in our hearts, we have had the sacred experience of worshiping together in our homes. 

So in these days of unrest, confusion and fear, I can still feel peace.  When I consider how fortunate I am for the privileges that I enjoy, I recognize that being Caucasian, I have access to privileges that others of color do not. My greatest privilege, though, is free to all, that of being washed white by the blood of the Lamb of God, Jesus Christ.  This most important of my "white" privileges enables me to one day return to my heavenly home.  There I long to be embraced by both my Heavenly Fathers who I miss so much. 

A Symbol of Hope

Remembering the Fallen, Honoring the Flag

 

On June 14, 1885 a small town school teacher in Wisconsin by the name of Bernard Cigrand, felt inspired to organize his school in paying respect to the American Flag. The day was chosen to commemorate the day when the second continental congress convened in 1777 and decreed that the flag for our country would be composed of 13 stripes, red alternating with white and that the union would be represented by a new constellation of 13 stars on a blue background. The official day was established in 1916.

Amidst the current state of national turmoil and upheaval, I would like to share some of my thoughts about the flag, our country and my hope for the future.

At the time of the revolution the American states were anything but united. Each had its own culture, set of laws and geographic boundaries. They did share the goal of self governance and so came together to fight the common enemy, the English Empire. Many of our Founding Fathers felt driven by a higher power to establish this land. Our pledge of allegiance references “One nation under God.”

In less than 100 years our nation grew to include 34 states. There was, however, one tenet of society that was not based on freedom, equality, “liberty and justice for all.” It was the practice of slavery and it threatened to tear apart the seams of the nation and our flag. At its root, slavery was born on economic greed, first from the slave traders and also from the land owners who bought the slaves. Many of them were "church going, God fearing” people. I can only imagine the mental gymnastics that had to occur to appease their souls. We know that many convinced themselves that their black slaves were less than human or that they had been cursed by God. These beliefs were fiercely held onto because to recognize the humanity of a black person was an open admission of guilt, it would require serious introspection and change. It was a declaration that they personally had desecrated a child of heaven and were living under the condemnation of God. Roots to such ideas permeate the history of my own religious tradition. It is “the nature and disposition of almost all men,” as our own cannon of scripture declares, “as soon as [almost all men] get a little authority, as they suppose, they will immediately begin to exercise unrighteous dominion.” At its core, I believe that racist thinking is a misguided form of self justification, an attempt to cover our sins.

The Civil War ensued and stands as a starting point towards true equality among the citizens of our country. The abolition of slavery was a huge step in the right direction but it was only just the beginning. I take heart that this land has always been a land of fresh starts for those willing to try again. Just as the flag has changed to incorporate new states in the heavenly constellation, the deep seeded feelings of bigotry can change as well.  

My church for a time did not allow black members to hold priesthood authority. This was thankfully changed in June of 1978, perhaps a bit late but it was for us another step in the right direction.  In December of 2013 the following was released: "the Church disavows the theories advanced in the past that black skin is a sign of divine disfavor or curse or that it reflects unrighteous actions in a premortal life; that mixed-race marriages are a sin; or that blacks or people of any other race or ethnicity are inferior in any way to anyone else. Church leaders today unequivocally condemn all racism, past and present, in any form." I take hope in seeing that not only can policies be changed but that hearts can be softened. We are coming closer to our doctrine that "The Lord denieth none that cometh unto him, black and white, bond and free, male and female;...all are alike unto God." It is well past the time when all are alike unto man as well. 

Clearly as the recent events surrounding the death of George Floyd attest, there is more work to be done. I believe that in this land of "equal opportunity" we need to do more of just that, make opportunity equal.  Our ability to get a good education should not be dependent upon our zip code. Educational excellence will serve to the caste system of economic desparity. I think that many of those in need would benefit more from a paycheck than a payout.  I recently listened to a TED talk by Bryan Stevenson, an attorney who has dedicated his life to those living on death row.  In it he said, "ultimately, you judge the character of a society, not by how they treat their rich and the powerful and the privileged, but by how they treat the poor, the condemned, the incarcerated" (and I add, the sick and the afflicted).

That resonates with me. Only when we create opportunity for all races will we stand united. "Give me your tired, your poor, your huddled masses yearning to breathe free," says the inscription on the Statue of Liberty. This image of free and easy breathing is particularly poignant in reflecting a man suffocated to death by a knee on his neck. So amidst all the uncertainties and mountains yet to climb, on this flag day, I will fly my flag in honor of freedom.  Freedoms that have been fought for and freedoms yet to be fully implemented in all sectors of our society.  I respect those who choose to kneel in front of that flag in honor of those who have fallen, to keep their memory alive.  I will chose to raise my flag with the optimism that all segments of our society can stand united, that divisions can be healed and our nation will become even greater in the days to come.  God bless America, God bless us all. 

Black Lives Matter

Like being rocked to sleep by the gentle oscillations of lapping water in the center of a lake on a summer's day, declining COVID numbers have given the impression perhaps that this pandemic is behind us and all is well.  I was surprised last week when looking at my news feed that of the five featured stories, not one of them mentioned anything about the pandemic.  I, myself, fall into the same category having not posted for a few weeks now.  Society is opening up, my patients are no longer more afraid of seeing me in the office and so my life has gotten increasingly more busy.

In a conversation that I had with our hospital's Chief Medical Officer at the peak of the pandemic he told me, "what I fear the most is complacency."  It is when we decide that wearing our mask is not that important, when washing my hands after everything I touch in the hospital is not really needed, that we will get ourselves into trouble.  It is even harder at home and away from work.  However, like my grandchild in a game of peek a boo, the SARS CoV2 virus lurks in the shadows ready to jump out and cry, "hear I am!"

Here are the latest numbers of patients hospitalized in the St. Louis area as of June 6th:

I like looking at hospitalizations because this is a number that is the most significant from a societal point of view.  If everyone who was ill had mild disease and could stay home, there would be very little disruption to normal society.  We could in essence vaccinate ourselves and develop herd immunity.  It is when the hospitals are overrun with extremely sick patients and our resources are exhausted that drastic measures need to be taken.  At first glance, the graph looks reassuring.  Following the blue line we see a steady decline across the weeks. Looking at the last few days, though, we see that there is a considerable uptick in two of those three days.  Should that trend continue, the blue line will start climbing once again.

In my own experience, I have seen more patients with positive results in the last week than in the few weeks prior.  My sample is small, but every single case has been in the African American community. I find it interesting that in the very week when we are rightly reminded that "Black Lives Matter," there has been very little news reporting on the elevated risk that the SARS CoV2 virus poses to this community right now. I think that the movement that we have seen across the country of solidarity between people of all races has been great. I applaud those who show support while continuing to practice safe guidelines.  A life snuffed out by over aggressive law enforcement is a tragedy.  It is a wrong that cannot be tolerated. I would like to stand up to say that "All Black Lives Matter," not just the ones taken in violence.

My professional life is dedicated to improving the lives of my patients.  I am passionate about preventing disease. I constantly encourage them to eat healthy and get more exercise.  Vaccines have been shown to save lives and the advances in therapeutics have helped to treat many diseases and better manage many chronic ones.  In my experience there are some in the African American community that can be very suspicious of drugs, vaccines and hospitals, and for very good reasons.

In the 1930's The U.S. Public Health System began an experiment in African American men to treat Syphilis called the Tuskegee Study.  In the 1940's penicillin became available and was quickly shown to be an excellent treatment for the disease. However, the trial continued and withheld that treatment in one arm of the study.  The researchers eventually were soundly criticized for not disclosing this information and the community rightly came to feel that they were being treated as experimental lab animals. This well deserved sentiment of mistrust has persisted in some circles for generations.

In 1976 the government pushed a new "Swine Flu" vaccine to prevent an epidemic that year that never materialized.  The vaccine which was used had a higher than average risk of a potentially deadly condition called the "Guillain-Barre" syndrome. Many citizens became leery of government sponsored health campaigns which feeling persists today.

In recent times, it has been well documented that African Americans receive inferior care for similar conditions than their white counterparts.  This is less likely to occur when their doctor is African American but with only 5% of doctors being African American, few have that option.  I would like to believe that these statistics do not apply to myself, but I cannot guarantee that I do not have subconscious racial biases. It is important that I understand this trend so as to maintain a vigilant attitude to prevent it from becoming a reality in my own practice.

Ultimately, if we truly believe that "Black Lives Matter," then we must all work together to make sure that all of them do.  Patients need to trust the doctors that are responsible for their care and heed their advice.  They must chose to adopt healthy habits.  Right now that includes social distancing and the wearing of masks in public. Is there a way to raise our voices without endangering lives during a pandemic?  Gatherings are a powerful symbol of unity but they do carry extra risk. Doctors, for our part, must earn our patient's trust every day by treating each individual with the utmost respect, truly listening to his/her concerns and tirelessly being an advocate in a system that, historically, has not had his/her best interests at heart. We must all be the solution. We are all in this together.

Play Ball

Playing Ball in 1977

Kids love to play.  Growing up, I would spend hours in the hills near our house with our neighbor friends creating all sorts of fictional worlds to conquer.  We made lean-to forts.  We had our own "Sherwood Forrest" in a lot next to our home.  We played soldiers constantly. Every pine cone was a grenade.  Tree branches became machine guns.  Our favorite was when we created our very own backyard Olympics complete with weight lifting, wrestling, high jump, races and more.  We made our own medals and sang the National Anthem. We played all the sports, all the time.

Today's kids still love to play. Their fictional worlds are more virtual. The violence that we hinted at In our games is laid out in graphic detail on the screens of today.  What saves our children is their interaction with other kids through athletics. There is a huge void in that regard right now.  It is not healthy to keep our children locked up too long. Their bodies need to move, their hearts need to pump fast and their lungs need to be expanded. It is well documented that our children are the least affected by the virus and are not likely to even become severely affected by COVID-19, let alone die from it.  Why must we restrict them so severely?

The answer of course is that they all have grandparents whose risk is so much higher.  Children are incredibly efficient germ spreaders.  They are not good hand washers.  They are still learning how to cough into their elbows and the little ones put everything into their mouths.  One of my patients came in a few years back coughing, hacking and with a fever.  I simply asked, "when did you get back from Kansas City?"  She was dumbfounded. How did I know that she had been to Kansas City?  I responded that she always got sick after visiting her grand kids.  We called it the "Kansas City Crud" from then on.

Our numbers here in St. Louis have looked pretty good, overall.  Our community quickly banded together and took the social distancing requirements seriously. Our  COVID-19 curve was absolutely flattened.  The number of the sickest patients in the hospital has been decreasing and society is starting to open back up.  One of the questions on people's mind is, "how and when do we let the kids back to play?"  In regards to the type of activities that I described above, I hope that families have been kicking their kids off the screen and out of the house to play outside all along.  I love seeing siblings out throwing a ball or just horsing around.  In regard to youth sports, I do feel that it can be done but precautions should be taken.  None of us really know the best way to do this. We have never been through such a pandemic before. The Washington University Orthopedics Department has released guidelines for resuming youth sports. (Click here to be linked.)  I feel that they are well thought out.  Some key take away messages are to stress the importance that all of us should stay at home if we have any concerning symptoms.  Sanitizing hands after contact is important.  Lastly, crowd control is key.  Spectators are much more likely to spread the disease than the participants. If we are smart we can let the kids loose and “play ball.”

A Bitter Pill

Today I went through fit testing.  No, I didn’t have to run a mile for time.  The fit test is to make sure that the N95 medical grade mask is working for my particular face.  My wife thought I was having a mask formulated just for me.  Nope, not that either.  It is to make sure the masks that we are using work for me.  Let me explain the process.

I first don this lovely head shield without a mask.  A canister is attached and a saccharine aerosol is injected inside.  Apparently, my taste buds don’t light up with this substance so instead of detecting a sweet substance, I received the alternate, bitter canister.  After determining that, yes I do taste/smell the aerosol, I cleansed my mouth and the process was repeated again but this time after donning the N-95 mask.  A larger dose of aerosol was injected into the hood and I was asked to nod up and down, then move my head side to side.  Lastly, I was asked to read a page of prose.  No bitter taste! I passed.

The aerosol is manufactured to be between 5-20 microns in diameter which matches the size of the tuberculosis bacillus as well as the SARS CoV2 virus.  If it fits well enough to keep out the bitter, it will keep out the nasty Coronavirus as well.  I felt comfortable using this mask before but now even more so.  Perhaps this was something that should have been done two months ago, but I am happy that I was able to do it now.

This whole shut down his been a bitter fit test for all of us.  Sometimes we have to go through the bitter to appreciate the sweet.  Because there have been so many who have been careful, we are now able to carefully open up.  Like a N-95 mask that protects a health care worker, our societal guidelines are protecting everyone.  May we all be fit and ready to move on to the next phase of opening back up.

Pandemic Paychecks

I read today of man in Florida who posted on Facebook that his God was stronger than any virus and there was no reason to fear.  He changed his tune when both he and his wife came down with COVID-19. He was hospitalized for two weeks. His wife is still on a ventilator and has made no improvement.  They were both self employed but the loss of their income seems insignificant to the very real struggle to just survive one more day.  The road to recovery before him is long and will be hard.  My heart aches for him and his wife.

I know of two people who showed up to work with cough, fever and shortness of breath.  The first was detected quickly and found to have COVID-19.  That person was able to be sent home rapidly but there was a very real risk of infecting many others.  The other works at a large box store.  Initially the person refused testing for COVID-19 saying that it was just a sinus infection.  Thankfully a fever was present and the employer wouldn't allow the person to come back to work until there was an evaluation. That COVID-19 test is pending but I would be surprised if it were negative.  In both instances, these two individuals needed their next paycheck to stay afloat.  Missing work, even with sick days was too big of a risk financially.

In my own office we have 20% of our staff that have been sent home, "furloughed."  We are now being encouraged to open up to seeing more patients but have fewer staff with which to do it.  As we see more patients, we actually may need more support staff to make sure we maintain appropriate distancing, keep the waiting room to a minimum number of people and screen those that come in for symptoms.  There is a tricky balance of always doing the right thing for the patient and still staying financially sound.  At the hospital, nurses are being used to cover the duties of med techs and phlebotomists who have been furloughed.  They are also being asked to care for more patients than before due to the cutbacks. 

Obviously, I am concerned about how financial stress will affect our ability to keep our patients and community safe.  That said, I am not immune to financial pressures myself.  Amidst these cut backs it was announced that the doctor's compensation system would remain unchanged.  This may sound good on the surface but we get paid according to how much we do.  If our productivity drops by 40%, our pay will drop by the same amount.  There is a lot of pressure to do more and see more, especially right now.  I am grateful that in my office the other providers and myself have agreed that we will not see older adults for routine visits during this first phase of opening up.  Acting responsibly now will pay bigger dividends than chasing a higher paycheck.

I think as a society we all are making similar choices as the economy is allowed to resume.  The financial strain cannot be oversimplified.  There are many who are hurting badly. The old saying about being penny wise and pound foolish seems to apply here.  We will all do better and be healthier by making the right decisions for all of us.  Let us cautiously move into our next phase, never being too hasty.  We all have our part and we need to play it together.

Antibody Testing

Wouldn't you love to know that you are immune to COVID-19?  For me and my colleagues this would be very valuable information. It wouldn't make me careless in my approach to taking care of patients, but it would take a lot of the fear and anxiety out of it.  I would be more apt to volunteer to work in our respiratory clinic to help spare other providers who are not immune.  I asked my partner how it would change his life.  He quickly responded that if he knew that he and his family were immune, his kids would be allowed to throw their arms around Grandma and Grandpa and give them a big hug.  Our public service workers could do their jobs easier, more safe and with less restrictions if we knew for sure that they were immune. 

The easy response is, "well let's get the antibody test done on everyone."  It sure sounds good on the surface but it is not as cut and dry as it may seem. Here are some points to consider:

1. Quality of the tests: The FDA has loosened the usual quality assessment requirements for labs to develop the test.  Those control measures have not yet all been validated. They are starting to be done now, but we are not yet sure who has the most accurate results.  

2. False negative tests: No one is advocating using this test as a means to diagnose active infection with the SARS CoV2 virus. Antibodies are developed by our immune system to fight future infections but the process takes 3-6 weeks to occur.  If blood is drawn within that time, the test may be negative but the infection may be present.  For example, if I see a patient who was stuck by a bloody needle at the hospital, I will order antibody tests for hepatitis and HIV. The reason to do so is to document whether or not that patient already has those diseases to begin with.  I will then order another test in six weeks to see if that exposure resulted in infection. Therefore, a negative test has three possible interpretations. It can indicate a new infection, an inadequate immune response or someone who has never been exposed to the virus in question. 

3. False positive tests: This is the more concerning of the scenarios.  If some has a positive test and feels that they are immune but are not, they may put themselves in higher risk situations.  In our current situation, there is concern that there could be cross reactivity to the other corona viruses that have been in the community for many years but cause mild disease.  More studies need to be done to determine the specificity of the new tests for our current strain. Until those studies are done, it does not do much good to perform the test. 

4. Experimental application. The one scenario that is currently being studied where the test will be useful is in individuals who were known to have COVID-19 and have recovered. If they have a positive antibody test, their serum might be used as a treatment for others with severe disease.  Studies are ongoing at Washington University. If anyone would like to participate, here is the contact information:

Email: IDCRU@wustl.edu or call 314-454-0058.

As much as we would all love to know our immune status to this virus, it is best to wait till more information is available. In the meantime, I protect you be being careful, just as you protect me. We are in this together. 

Influenza vs COVID

I am seeing repeated claims that the death rate for our SARS CoV2 virus is not so bad, that we have been mislead. "Really, it is no worse than influenza." “What is the big deal?” “Did we really need to shut down society?” I have been trying to think about this critically and have dug into some of the published numbers. Here are some of my thoughts on the matter.

1. Influenza comparisons. I understand the desire to compare these two viruses. Influenza is the virus with which we are more familiar and with which we have a history of pandemics. The 1918 pandemic had a far higher mortality than what we are seeing now. These is no comparison. It was felt that 40 million people died world wide from that disease. Historians looking back on that pandemic theorize that the vast majority of deaths occured due to secondary bacterial infections. It was in the days before antibiotics. Likely, if that same disease were to strike again, much fewer would die due to our enhanced ability to fight those secondary infections effectively.

That said, the comparisons being made now are not with the pandemic years but with influenza from recent years. Overall, the mortality rate from influenza has improved markedly through the 1900's due to the factors stated above. Widespread use of the influenza vaccine began in the 1980's. Repeatedly, studies have consistently shown that the vaccines save lives. I spend a considerable amount of energy every year encouraging my patients to get vaccinated.

Three years ago, the vaccine that was developed was not a good match for the strain of influenza that hit our communities. It was a busy year. Our hospitals were full. I lost at least 10 patients that year, all of which were elderly. My colleagues had similar experiences. It was not usually a direct effect of the influenza but if someone was weak from other chronic conditions such as heart disease, lung disease, etc they weren't able to have enough reserves to recover. It was a hard year. My point is that influenza should be taken seriously also.

The COVID-19 disease is not the same disease. The potential for secondary infections is present but has not been seen nearly as much. The respiratory failure that we see comes as a toxic effects from the virus itself as well as an overactive immune response that is generated. Decompensation can be precipitous.

2. Death Rates. Yes, the published death rate from COVID-19 is decreasing. This comes as no surprise at all. In the beginning of our surge in this country our testing capability was extremely limited. Only the sickest patients were being checked. As such the death rate will appear artificially high. It is now estimated that up to 20% of those infected have no symptoms at all. The more we test, the larger the denominator and the lower the mortality rate will go. This does not diminish the number of patients that flooded the hospitals in New York and nearly overwhelmed their capacity. Death rate is not the same as total number of deaths. 

Our current mortality (death) rate in the US is 25.7/100,000 people. Belgium is the worse at 77/100,00. Two countries with some of the lowest rates are South Korea and Taiwan. Their rates are 0.5/100,00 and 0.03/100,000 respectively. That is a huge difference. It is interesting that neither country completely locked down their societies. What they did do was to aggressively test, contact trace and enforce strict isolation on positive results. China too has been aggressive.  Just yesterday it was reported that Wuhan had an “outbreak” of six new cases. The government response is to test 4 million people in that region. These countries show us the way out of our mess. Unfortunately, I fear that our inferior infrastructure and our unwillingness to give up civil liberties will hinder our ability to do so.

3. "Only the good die young." Death rates vary by age. In Italy, those above 90 years old with COVID had a 10% chance of dying. Those younger than 50 have a much lower rate of death. The number of deaths reflects how heavily a certain population is infected as well. In Bergamo Italy it is estimated that 66% of the entire population has been infected with the virus. It has taken a huge toll on their elderly population. Since such a large proportion of their population has been affected they are starting to develop "herd immunity" which protects those who have yet to be exposed. In New York City, by contrast, there have been many more infections in younger people. The reason is that their population is younger. Even with a low death rate the number is high because of the high number of people in that cohort. If New York’s population were older, their situation would be even worse. Both New York and Italy stand in stark contrast to other cities, such as Los Angeles, which is estimated to only have 2% of the population infected.

It does look like the death rate for COVID-19 is higher than influenza. It certainly has a higher capacity to cause critical illness.  Even if younger people live through their illness, they may need to be hospitalized and ventilated for weeks. Personally, though I am concerned for both influenza and COVID-19, if it is left to run rampant in high risk populations, SARS CoV2 has the potential to overrun our health care systems, overwhelm our public health workers and max out the morgues. Influenza hasn't done that for a very long time.

I do agree that we can’t stay in lock down forever. The bottom line is that we can and should relax restrictions safely. Ideally it should be done in the manner we have seen in Taiwan and South Korea. We must protect the most vulnerable. Nursing homes are especially dangerous places and we will need strict guidelines for isolation for a very long time. Multigenerational homes are another potential hazard. How families act that have children and grandparents living in the same place will be crucial. As we lift restrictions we must protect ourselves and all those around us by continuing to maintain a six foot radius, liberally cleansing our hands and using masks. These measures will help regardless of which infection we are dealing with.

Coming Out of COVID

Good news from the COVID count this morning. The St. Louis task force released the latest numbers and they are continuing to come down. After an initial plateau, seeing a definite decrease last week has been good to see. If this trend continues for the current week, society will likely start to open up more fully next week. "Life as we knew it" is not likely to ever be completely the same again. Our long term success in maintain the health of both our bodies and our economy will depend on the decisions that we make in the next few weeks. Here are some of my thoughts.

1. When and how should I access the health care system? In my office, we are seeing patients with acute problems that are best served by an evaluation in the office. In order to keep our office as safe as possible for the patients who come, anyone with respiratory symptoms are seen in an affiliated, "respiratory clinic." We are not yet seeing routine visits but will start next week by seeing those under 65 without serious medical issues. If the numbers in the community continue to come down, we'll start seeing more.
We, like other industries, are trying to rethink our usual operating policies. How do we limit the number of patients in the waiting room? How do we space out visits to reduce too many people coming together at the same time? What is the best way to draw labs? perform X-rays and other tests? We are finally figuring out how to check patients in remotely. Labs are being done by a "drive by process" at the hospital.
2. What is the best way to shop? Now those of you that know me well may laugh that I am being audacious enough to offer any such opinion. Certainly on line sales will remain robust. Curb side pick up will likely be here to stay as well. It cuts out those that like to simply browse while they shop which sounds good to me! (Sorry Mom). The bottom line is to find ways to reduce groups while still allowing commerce to happen.
3. Will we ever be able to gather again in large groups? Of course we will, but not in the short term. If 50,000 people gather in a stadium to watch a baseball game, there will be asymptomatic carriers of the virus who touch the same door knobs, use the same bathrooms as all the others. Touch-less doors will help as well as similar towel and soap dispensers. The risk will never be zero, but I can foresee it being low enough to make such events possible.
4. Can we ever expect children to truly self isolate as they go back to school? Not really, no. This is perhaps the more difficult scenario to control. It is not the kids we worry about, or even their parents, it is their grandparents. To me, the only way to move forward is to have good community testing. If we can quickly identify a hot spot, schools can be shut down quickly in the area that has been identified. We have learned that on line studies can be continued. Even better is to have such good tracking so that discrete exposed families can be isolated without shutting down the whole school.

Above all else, we need to develop a culture of personal accountability and honesty. We had a patient show up to our office yesterday without an appointment who had cough, fever and shortness of breath. There is a high chance this person was infected with the virus. The patient was asked the appropriate screening questions at the front door but must not have been completely honest. Thankfully, there was no one else in the waiting room at the time and was quickly given a mask and sent to our respiratory clinic. If individuals do not stay away from gatherings when ill, our system will be overrun again. We can and should get out of this lock down but we need to do things a bit different. Let's all be strong, let's all be safe.

Mothers

While we may think that the SARS-Cov2 is the "mother of all viruses," it will have its day and life will go on.  A day like today is a good time to take a break from all things COVID and step back and remember the good things in this life and for the rich blessings we have received. Of those nothing is bigger than the love and sacrificed bestowed upon us by our mothers.  Every single one of us arrived in this life via a mother.  I will never know what it is like to carry an infant in my body, to have that living soul grow and develop inside of you.  From two cells that merge into one, it grows and develops into millions of differentiated units. Our development may be programmed by DNA but it is dependent on the environment in which we are raised at our mother's hand.

My arrival came one month earlier than planned.  This is not a big deal with today's medicine and technology but in 1966, I spent a few extra days in the hospital struggling for each breath.  My mother was not sure that I would survive.  She poured her heart out in prayer to God and has always instilled in me that my life was spared for a purpose, that my life was a gift from God.  Mom and I had the typical ups and downs that is typical but deep down, I retained that lesson instilled from my infancy.  I don't ever question her love. She has always made me feel special.

I am one of the fortunate ones to also have the loving influence of my mother-in-law. I met my wife in my first year of college.  I left for two years to serve as a missionary for my church and on returning, I planned a trip to St. Louis to meet this cute girl and her family.  Another boy who was interested in her caught wind of my trip and sent a dozen roses to her home the day before I arrived.  Gina's mother promptly took those roses and threw them away even before Gina saw them! If that wasn't a clear sign that this was a family I wanted to be a part of, I don't know what was.  She has accepted me as one of her one from day one.  We have been fortunate to live so close to Gina's parents through the years when we raised our children.  She taught all of them the piano.  Music has been a loving gift that will continue to live on in our family.

Thirty years ago this week, Gina and I became parents for the first time.  We were young parents for sure but we have never regretted starting our family early.  Karalee has been and continues to be such a blessing to us as have each of our children.  Watching my wife become a mother is a sacred experience.  She is a fierce protector of her brood.  She watches over them without hovering, cares for them without enabling.  All of our children learned to do their own wash, make their own lunch.  She delivers just the right mixture of self reliance while maintaining unquestionable love and devotion.  Now, seeing her as a grandma is the best.  She may have been able to say "no" to her kids but not those grand babies.  Right now we are not able to travel to see them and it is killing her.

I also would like to give a shout out to our Mother Earth.  The same world which delivers earthquakes, famines, death and disease also give us birth, blossoms, mountains, and beaches.  Sunrises and sunsets still take my breath away.  I love being outside.  I love learning about nature, biology and especially the human body.  It is all a miracle to me.  Just as I preach taking care of our human body, we also have a stewardship to care for our mother earth.

Lastly, in our theology we believe that God is our Eternal Father and that we are his children.  As such, the pattern we know on earth is mirrored in heaven.  We believe that we also have an Eternal Mother.  We know very little about her, but I am sure that she embodies all that is good, loving and caring.  I have faith that she knows about the details of our lives. My we honor all the mothers in our lives and be grateful to them all.