Heaven Help Us

Each day brings a new turn of events. Today started with a text informing us that Missouri Baptist Hospital was being asked to double the amount of ICU beds to 80.  This will require turning an entire floor of rooms into ICU rooms.  Smaller, outlying hospitals with limited ICU capability and essentially no ICU physicians will be sending their sick patients up to us.  Staffing all these beds will put into action the back up plan we had previously made, much faster than anticipated.  Our ICU doctors will now take on a supervisory role with teams.  On each team there will be an Internal Medicine physician such as myself and an anesthesiologist. We will adjust medicines, write orders, notes, talk to the families, arrange for discharges.  The anesthesiologists will do the procedures to intubate (insert the breathing tube in the airway) and putting in central lines. They will also manage the ventilator settings.  Each team is to take care of 15 patients. This will start next week.
I have never been involved in going to war but I imagine there are some similar feelings.  Sure it is scary, but this is what I do.  I take care of people and I wouldn’t have it any other way.  We will take every precaution that we can to be safe but there is certainly risk involved.  I did not look forward to coming home and telling my wife.  I have put a lot of stress on her.

Tonight I decided I needed some extra help from on high.  In our church we do not have a paid ministry.  Every worthy male who desires, can be ordained to the priesthood. This is how we can function at home without going to our church buildings and not miss a beat.  I asked my son, who returned from a two year mission for our church, to give me a priesthood blessing.  We video conferenced our other children. It was a sacred experience for me.  During the blessing he told me that angels would be sent to watch over me.  For the first time since my father passed, I felt his presence during the blessing and knew that God would allow him to be with me.

I don’t know exactly what lay in store in the days to come, but I have faith to move forward calling on Heaven to help on the way.

Party Time

I once listened to a motivational speech by a cancer patient who was going through chemotherapy and advised, “It’s ok to have a pity party, just don’t invite everyone to it.”  Today just feels “heavy.”  There isn’t one thing that happened to feel more weight than other days.  I think it is just cumulative. I had no idea it was “doctor’s day” until a patient sent me a message wishing me a good one.

I now have three patients that have tested positive for the disease.  I haven’t been around any of them.  One we spoke to on Friday and she ended up going to the ER and was admitted with pneumonia.  She turned around real quick and was actually discharged home before her COVID test came back positive.  Another is in her 80’s and has cancer. Thankfully, she is getting better, but finding the best way for her to be taken care out of the hospital is looking to be a challenge.

We met as a practice via zoom tonight to get an update on setting up the “respiratory clinic.”  That will be ready to go by the end of the week.  It will help take some of the load off of the ER and keep sick people out of our offices to reduce further transmission.  It seems that testing is starting to open up but now we are being told that there are not enough swabs to go around.  This frightens me more than anything.  If we can’t test medium risk individuals I fear that we won’t be able to head off the virus.  We’ll have to continue mass isolation strategies.  It is like doing surgery with a sledge hammer instead of a scalpel.

What keeps me going is the love and support of my wife and family.  My faith keeps me strong and I make sure to spend time in the scriptures everyday.  I also just had to get outside this evening so I jumped on my bike and did my short loop which includes Marshall Road-a nice steady long hill that always takes it out of you.  That may have been my best therapy yet.  Lastly, patient after patient has reached out in gratitude and always ends by saying, “we are praying for you.”  The sustaining strength of those prayers is the best gift I could ever receive on this day set apart to honor physicians.

Mind the Gap

When the ER called this weekend and let me know that the next new admission had metastatic cancer and was being admitted for diverticulitis, I immediately felt a pit in my stomach.  Over the years, I have seen time and time again where a patient with cancer presents to the ER who is clearly declining.  What often happens, is that the ER sees that they are sick and then will find something on imaging that will allow them to admit the patient to the hospital.  Usually it is “pneumonia.”  It is never pneumonia. It is cancer and it is time to have “the talk.”  This time there was a little bit of inflammation around the colon, but there was cancer everywhere.

As I came to see him we talked about the diagnosis but then I asked him what kind of care he wanted as things got worse and the cancer progressed.  He tearfully confessed that he was tired of seeing doctors. He was tired of feeling sick, of having no appetite, of having no energy.  He just wanted to go home and be with his family.  You see, with the COVID craze we are all in, he is not allowed to have any visitors.  He asked me to call his wife so we got on speaker phone together.  She was rather upset that he was considering stopping the treatments but as we discussed everything together, she started to see things from his eyes and softened quite a bit.

It broke my heart to not just have these conversations with them but that they couldn’t do this together.  This time of isolation can tear us apart if we are not careful.  At the hospital, I am trying to take the extra time to call the families that would otherwise be there.

In stark contrast, we met all together as a family today to discuss scriptures as our Sunday worship.  It is rare to have all of us together, but we could do it thanks to technology.  I was finishing at the hospital, everyone else was at the home and we included a good friend and my in-laws as well.  We had such a good discussion together.  How blessed I felt to feel so close to each of them despite our separation.

Later today I connected with my mother and my son on a three way call to wish him a happy birthday.  I also called my cousin to catch up.  It had been too long since I took the time to call.  Sometimes when we strip our lives down to the bare necessities, we remember what is the most important.  Let’s not let this time of isolation to distance the gaps with those we love.  With some effort, we can reconnect and grow even close.  It is time to mind the gap.

The Crowned Prince of Peace

 Being on call, I cover 10 doctors for the weekend.  Last night there was a flurry of activity with six people being admitted to the hospital. Two for possible COVID. The dedicated floor is getting more and more patients on it but thankfully we still have capacity.  I am on the other floors and am grateful for those that are willing to work with the COVID patients.

The day went smoothly. The mood in the hospital is somber but cordial.  A smile goes a long way. There is a sense that we are all in this together. The unspoken truth is that we know that there are some among us who will get sick and there may be some that succumb to the illness.  A part of me wishes that I could just get a mild form so that I could become immune.  That is a very small part because even routine colds tend to linger due to a history of childhood asthma.  I like to think I am quite healthy and have stayed in good shape. Though that is true, but I am closer to 60 than many of my colleagues.  I would love to just get the vaccine some day.

Seeing the news is sobering. We all see what is happening in the big cities across America.  I feel a thud in the pit of my stomach. So much of this could have been avoided.  We missed a huge opportunity to reign this in. I don’t know what happened that our ability to test is so much worse than other countries.  I assumed since South Korea and China could test so many people that as soon as we saw cases here, we would be able to do the same. I was dismayed that we had access to so few tests. Now our country is paying the price for this huge mistake.

I still have faith that bright days will come again but it will be after much tribulation.  A welcome package was left on my door step today, a box full of isolation gowns. There are so many good people in this world.  My faith remains intact. We start our fast for this Corona stricken world tonight.  The virus may have been given this royal name of Corona, but I will place my faith in He who wears the Father’s crown, the Prince of Peace, the King of Kings, the Great Emmanuel. He sits on the right hand of our Father.  He is our Advocate, our Redeemer, our Deliverer, our All.

Tumultuous Times

Friday March 27, 2020
My mind has not been quiet.  I was up at 4:00 AM just because it wouldn’t stop spinning. Listening to a lecture from George Handley, a BYU Literature Professor who I went to high school with, helped distract my mind.  I have been reading the Book of Mormon in spanish the last few months and finished it today.  How I love that second witness of Jesus Christ.  Gina describes her disquiet as being in her heart, as in “my heart was not good today.”  For sure these are unsettled times.

I kept my mind distracted for most of the day, busy with talking to patients about the rest of their lives that still matter.  “Yes, you can still exercise. Go outside and go for a walk.  Just keep your distance.”  We talked of diabetes and high blood pressure.  We talked about limiting alcohol intake.  One patient stopped going to his AA meetings because they were cancelled.  He agreed to sign up for the virtual one.

I headed to the hospital in the afternoon and ended up seeing patients needing admission for non COVID reasons, kidney failure, kidney infection and a heart attack.  The ER was tense and busy.  Everyone had masks on.  It was a busier than it has been for awhile.  I know that the COVID floors took more admissions today.

The nurses on the floor were awesome.  No one is allowed to have a visitor now unless they are in the last stages of dying.  I saw first hand how the nurses were making sure to reach out to families.  I am often given thanks for “being on the front lines” but I am not alone.  There are nurses and transport workers and the janitorial staff.  We all carry risk of contracting this virus.  I am grateful to all of them. Their courage is quiet but firm, even palpable.

This evening I received notice that a “respiratory clinic” has been approved at Missouri Baptist.  This will be available so that those not sick enough for the hospital can be tested and treated all in a situation where exposure will be minimized and the protective equipment can be used the most efficiently.  This was pioneered at Vanderbilt and should help save lives and keep staff safe.

President Nelson, our prophet and leader of our church has asked that all members fast and pray for the world this coming Sunday in regards to the virus.  We typically fast once a month and as part of our worship, we donate money to help care for the poor and the needy.  Even if you are not a member of my church, I invite you to join with us in asking Heaven’s blessing be upon us all.  Consider donating to your favorite food pantry or charity.  Together with the Lord’s help we will make it through these tumultuous times, of that I am certain.

Bamboo in a Typhoon

Thursday March 26, 2020

I woke up this morning and after reading my usual chapter in the scriptures, turned to see the latest news.  It was like watching a newscast of a typhoon tearing into a coastal city as I read of New York’s skyrocketing case load and death rate.  As feared, the cases have completely overcome the health department’s ability to search out contacts, isolate them and snuff out the epidemic.  They are bracing for the worst which is still to come.  Projections of being out of protective equipment and ventilators within two weeks is chilling.

I feel like we in St. Louis are like those inland cities which will get hit hard by the storm but have some time to prepare.  We can button down the hatches, put plywood on our windows and hunker down hard. The more we socially isolate, the better chance we have of the virus petering out and going away.  If we don’t, we will suffer the same consequences of those cities being hard hit right now.  The severity of our storm will be commensurate with our preparation.

Certainly there will be a wave of those who will get sick and require hospitalization and ICU care.  Tonight I participated in a conference call for all the doctors on staff at Missouri Baptist Hospital, where I work.  Two weeks ago our administration gathered together the physician leaders across medicine, surgery, anesthesia, ICU, ER and nursing.  They have met daily and have been putting together a plan to weather this storm.

As we primary care physicians have moved to telemedicine in order to touch base with our patients, the surgeons and other specialists have cancelled all routine procedures.  The ER has reformulated how patients are seen so that anyone who might have COVID virus is sent to a different entrance and fast tracked to appropriate care. There is one doctor and one nurse in charge of all such patients that need hospital admission and they work closely with the ICU team and the ER.  There is a dedicated elevator for these patients and their own floor of the hospital.  Assuming demand becomes excessive there are plans for mobilizing physician such as myself to take over the non COVID patients that need care or even help in the ICU.  Our anesthesiologists have all agreed to assist in the ICU as have our pulmonologists.

Tonight in the call, each physician/nurse leader described their part in the plan.  I was filled with emotion to be part of a team of dedicated professionals who are willing to do what it takes to care for the ill and maximize the safety of all those around them.  When the ICU physician was asked to report he said, “The ICU is like bamboo in a typhoon, we may bend but we won’t break!”

We likewise need to stand strong where we stand. Planted on the rock of Jesus Christ, we become a team of believers, willing to do whatever is asked to help those who have lost their way. Teaching his sons this very lesson, the prophet Helaman declared, “And now my sons, remember, remember that it is upon the rock of our Redeemer, who is Christ, the Son of God, that ye must build your foundation; that when the devil shall send forth his mighty winds, yea his shafts in the whirlwind, yea when all his hail and his mighty storm shall beat upon you, it shall have no power over you to drag you down to the gulf of misery and endless wo, because of the rock upon which ye are built, which is a sure foundation, a foundation where on if men build they cannot fall.”

Banished to the Basement?

March 25, 2020
I awoke this morning with that little tickle in the back of the throat.  Did I sniffle? Was there drainage? I am paranoid?  The answer was yes, yes and yes.  After still not being quite sure what my status was, I decided to stay at home and work here.  My partner was good enough to see my one patient in the hospital and I let my office and my wife know.

So what does that mean for my family? This does not help the anxiety level in the house.  I am on call for 10 doctors this weekend and was thinking that this would be the time when I needed to just sleep downstairs and stay away as much as I can.  Given this sore throat, I did it today, bringing down my essentials.  I set up a card table in our bedroom, fired up the lap top and started doing all my telemedicine visits.

Half way through the day I called my mother, who is not happy with me and my siblings.  Due to her age and conditions we told her that she can’t be driving to town and doing her errands.  Unfortunately she does not really understand the scope of this virus and the risks to those in her age group.  I think that I finally was able to assure her that we weren’t picking on her, that everyone in her situation is being told the same thing.  Hopefully, she’ll still talk to me tomorrow.

My wife is a saint to put up with all of this.  It is taking a toll on her.  By the end of the day, I still felt pretty good so I decided to take a walk around the neighborhood.  The sun had come out, people were walking the streets, working in the yard-all at a safe distance. The smaller trees and underbrush had all started to sprout their new leaves almost over night.  I don’t know what the pollen count was but I am sure it was high.  By the time I got home I was convinced that I simply had allergies.

My partners reached out to me and asked how I was doing, I responded: “I am fine. Pretty sure I have seasonal allergic rhinitis compounded by paranoia without psychotic features (yet)!” They all got a kick out of that.  I’ll be back at it tomorrow.  Sometimes it is just good to laugh at yourself.

On a lighter, happier note, my wife’s niece was married today in our church’s temple in Payson, Utah.  We certainly would have loved to have been there but due to the virus, only eight people are being allowed to participate and even then, some areas aren’t allowed to hold the ceremony at all.  They decided to move ahead being married for “time and all eternity.”  I am proud of them for not letting fear of an uncertain future derail their commitment to each other and to God.  When all is said and done, Our Heavenly Father’s only wish is to exalt us and bring us back home.  We may go through trials and times of discouragement, but he won’t banish us to the basement, he will bring us up back home to Him.

Social Connecting

Social distancing is the new buzz word.  Flattening the curve for the virus will save our health care system and by so doing, save lives.  I hope that most of you truly understand how critically important this process is. My wife came across an idea in our neighborhood where each family was invited to put a stuffed bear in one of their windows so that when kids went on a walk they could go on a “bear hunt.”  What a fun idea. My daughter discovered a post from someone who found herself rushing to her front window every time she saw someone walk by so that she could wave to them.  “Now I know why dogs act the way they do!,” she exclaimed.

At the office we started using video in more earnest this week and especially today.  For some people-the younger ones, this is quite natural and easy. Now mind you, many of my patients grew up in a different generation.  The idea of video conferencing is like teaching an old dog new tricks.  Today when asking one of my patients if her phone could do that she said, “I am 87 years old, my phone may do that but I don’t!”  We decided to stick with just voice and it worked fine.

Today I had a patient with a bad sore throat.  Of course it would have been best to see and examine him in person but I managed to have him tilt his camera just right so I could see back there and determine that his tonsils were indeed, not enlarged and less likely to be from strep.  Another patient was able to show me a boil that required an antibiotic. I was event sent some pictures of a rash and could determine that indeed this individual had shingles as diagnosed in the urgent care.  There are limits, though.  One woman described a lump to me that was “down there.”  Smiling, I said, “I am not going to ask you to stick your phone down there to show me.”  She laughed and said, “Oh, no, my booty is much too big for that!”  We both had a good laugh.

Tonight I met over Zoom with our Stake President and we planned how to adapt our “Come, Ask, See” meeting for technology. It is geared for those interested in learning more about our church and was planned for this Sunday.  We are going to try and do a large Zoom meeting which will allow everyone to stay put and stay safe.  If you are interested, I’ll post the information once it has been finalized.

We are blessed to live in an age where we can socially connect with others even as we keep our distance.  How are you keeping in touch with the ones you love?

Faith Over Fear

The day really begins late in the night as my phone rings indicating there is a call from the hospital.  This time the fear of COVID-19 is real and the person is admitted to the “COVID” floor.

We are fortunate to have a floor of almost completely unused rooms that were vacated a few years back when the new wing of the hospital was built.  I know that there are eventual plans for these rooms but for now it is being put to good use for the pandemic.  It would be great if the affected patients could always be put there but I fear it won’t be enough before too long.  Procedures are now in place so that anyone suspected to have the COVID-19 virus will be taken care of by a dedicated team on a dedicated floor thus minimizing exposure to other staff and patients.

My patient had family members who had traveled to Italy and they had recently been to visit them. The patient presented with severe abdominal pain and now needs surgery to take out the gall bladder.  Thankfully, testing for the virus turned out to be negative. Patients still get ill with all the problems that we had before but now everything lays on a blanket of pandemic fear.

I am grateful to work in a hospital with proactive leaders who are not waiting to react but preparing the best we can.  My partner is the Chief Medical Officer for the hospital and is tirelessly working with the hospital committee to organize and prepare.  He has spoken to all of us internists who could step up and help if the demand gets as high as we think.  The response has been heartening. Repeatedly the answer has been, “sure, whatever it takes.”

I remember my own moment when I realized what I would do if faced with a dangerous exposure. It was about two summers ago when the Ebola virus was feared to come from Africa to our lands. Patients were being screened as to their travel and one of mine came with the report that he had just come from Sierra Leon, Africa. This was one of the “hotspots.”  I had him stay in the hall. I donned a mask, swallowed hard and went to talk to him. It turns out he had gone to Sri Lanka, not Sierra Leon and it was a false alarm. I knew from that experience, though, that I would be willing to care for my patients regardless of the risk.

I stand proud with so many others who may be looked over who are equally courageous.  I am first and foremost grateful for my family who are willing to still take me home at night.  My staff at the office have not blinked twice about doing what is needed.  As I left the office today, I passed the cleaning crew getting ready to wipe everything down for the next day.  I am sure that many of them do not earn large wages and yet they are crucial to our effort.

Ultimately it is faith that keeps us going. Faith that this too will pass. Faith that the sun will shine again.  Faith that like the spring that is starting to sprout and bud around us, human life will conquer.  It is my faith that there is a God who knows and loves each one of us. I do not believe he is vengeful and sending a scourge to punish his children. Some things just happen in this life we call mortality.  I do know that if we reach out to him he can comfort anyone of us.

Yesterday I posted on Facebook a simple song sung by faith filled missionaries who serve here in St. Louis.  Tonight a friend told me of the struggle one of their children is having with anxiety. The child has not been able to sleep well and is panicked about the safety and health of the parents.  My friend brought their family together and played this song for them.  Last night brought comfort and peace where before there was despair.  The child was able to feel calm and sleep through the night. That is the power of love and faith.

Peace in Turmoil

Sunday is a day of rest, but not apparently for the COVID-19 virus.  We woke to the news of record level of the virus. Most chilling to me are the reports out of Italy because I feel that our country is following along its trajectory more so than the Asian countries.

I have been texting with my siblings through the day.  We have shared with each other articles. Some are more factual than others.  We discussed how we sift through information.  I was asked which sources that I trust the most.  I stick with the usual news sources for data.  I don't have access to the data any better than the rest of society. I have been trained to pick out what is meaningful and what to discard.  I stay away from social media sources.

I was also asked about masks. I continue to see many who are confused about how they work in preventing spread.  Thankfully from everything that I have read that this corona virus is spread like the common cold or influenza, by droplets and not by being aerosolized like chicken pox or measles.  As such, the masks are most important to put on patients who are actively coughing.  They are good for health care workers who could be within three feet of the individual should the patient cough on them.  Other than that, it is all about good hand washing.

It has been easy to get sucked into the vortex of the news cycle.  We are all feeling anxious. I am grateful for the peace I find from our Lord Jesus Christ who promised, "peace  I leave with you, my peace I give unto you; not as the world giveth, give I unto you. Let not your heart be troubled, neither let it be afraid." Even when our heart is pounding and worry is all around, he can provide peace. Gina while studying the scriptures today felt this as she read of Enos who after receiving an answer to his prayer said, "I knew it would be according to the covenant which he had made; wherefore my soul did rest."  I love that, rest to the soul. Now, how do we maintain this peace?  It is not easy and in the days ahead there will be struggles to come.  We can do it together.

And So it Begins

I've decided to jot down some thoughts, hopefully each day as there seems to be some interest in my perspective on the Corona Virus situation since I am a primary care physician.  I truly don't have an agenda other than sharing. Feel free to ask questions and I'll answer them as I am able.

As I talked with my partner yesterday I said that I feel like we are sitting in the eye of a hurricane, the calm before the storm. Living in a "flyover" state has its advantages given the situation in New York, California and the Chicago area. That said, our turn is coming.

Two weeks ago I felt tremendous anxiety in regards to my situation as both a leader in my church and our policies in the office.  At church we had discussions about when to shut down our weekly sacrament meeting.  We met a few days later and decided that if schools shut down or the health department declared no gatherings that we would keep people at home. The very next day I felt even more uncomfortable and called the Stake President (our regional leader that I work with) and we decided that I would call our Area Authority, Elder Hintze who is also a doctor.  I immediately called and as we were talking on the phone, the general leaders of our church released the announcement that all in person meetings would be cancelled for the foreseeable future in the whole world.  That was a huge relief and an answer to prayer.

The next day, Friday March 13, my anxiety turned to my office. After talking to all my partners and our regional managers we met together that evening. Specifically, we discussed what to do with our patients who were coming for routine visits that were not ill.  We decided unanimously to suspend those visits and do everything that we could over the phone to limit exposure to our vulnerable patients, our staff and ourselves.  We put in place procedures this week that I believe has served as well but still kept us in touch with our patients.  There are many more details of the last week but I will now skip to my specific thoughts from yesterday and today.

Thoughts of Corona are never far away.  A dear 96 year old who was recently treated for pneumonia in January requiring an extended stay at a skilled nursing facility awoke with a cough, weakness and confusion.  Her daughter called and we discussed how aggressive they wanted to be. Even without the threat of Corona looming, she did not want to take her mother back to the hospital. Together we decided that we would try an antibiotic but would have our hospice nurses see her so that she could stay home for her last days.

Another patient called having had chest pains the day before.  She had been quite anxious due to stress in her life, augmented by concerns for the virus.  Likely this was the cause.  She is 57, smokes and has a family history of heart disease.  A normal stress test two years ago is reassuring but not definitive. Together we talked of doing further testing but agreed that it might be more risky in the current environment to bring her into our health care system. She promised to call if things got worse and we will wait and see.  These are some of the discussions that I have, every day.

At home I worry about bringing anything home. My exposure has been quite limited but as the hospital becomes full, we primary care doctors who still see our own patients in the hospital will step up and essentially become hospitalists. The current ones  will be on the front line for COVID patients and we will take over the care for the other patients.

Do I need to essentially self-quarantine when at home?  Do I sleep in another room? We have not been told the answer to these question but it is likely, "yes". Already I have taken to wearing scrubs at work, changing back into clothes at the end of the day after showering at the office.

My faith has been an anchor to my soul.  Yes, I feel stress and I worry but "I know in whom I have trusted. God will be my support."  I am grateful to be of service to others and will "trust in him with all my heart."  To keep my mind distracted at home, Gina and I have been working on a few projects. We have been painting rooms, creating a grand kid room in the basement and I have started a new puzzle.  I may have to start up a new wood carving as well.  I continue to read from the scriptures daily and prayer is never far from my mind. What do you do to keep sane?