Life with COVID

“Time is Tissue”

First off, let me start off with some good news.  We hear stories of patients avoiding the emergency room and waiting too long to seek care for important issues such as heart attacks or strokes.  One of my patients woke up this morning at 1:00 AM with chest pain.  He got up to the bathroom and found that he was soaked from perspiration. He woke his wife, they called 911.  EMS arrived quickly, he was given nitroglycerin en route and at the emergency room he was found to have ECG changes consistent with a significant heart attack.  The on call cardiologist was called who took him for urgent cardiac catheterization where an occluded artery was opened up.  The cardiologist sent me a message after he was done at 2:30 AM!  How awesome is that? He suffered minimal damage to his heart and should do just fine long term.  It all happened just right with no wasted time.

I worked at our respiratory clinic today and saw five patients.  I thought it might be interesting to share the process of the decisions that I made, especially in regards to testing.  

The first patient tested positive for COVID-19 early this month.  He had been doing better and has actually been back to work for a week for a transportation company.  In the last week he has felt a lot of his symptoms start to come back.  I was frankly more worried for a secondary infection rather than prolonged COVID.  A chest X-ray did not show pneumonia. A blood count was ordered.  Since he was actively working, I told him to stay at home.  I did repeat the COVID test just to make sure he was not still actively shedding virus while being out in the community.

The next patient had mild symptoms.  He had a slight cough for nearly two months.  He had no other symptoms nor medical issues.  He was retired and staying at home so I did not feel that his symptoms warranted testing.  The time frame certainly did’t fit for COVID. He was reassured but told to call if he got worse.

Later a husband and wife came in together.  He was known to have COVID and had been hospitalized for two days earlier in the month.  He felt like he had been improving but like the other patient, he started having some symptoms of cough, body aches and low grade fever over the last week.  He was scheduled to return to work this next week.  His X-ray showed a hint of “infiltrate” which could mean pneumonia.  I decided to keep him home and treated him with an antibiotic.  He did not want to be retested.  Since we were going to keep him off of work anyway, I did not feel that it was necessary at this time.

His wife was feeling pretty cruddy and was in the thick of it with aches, fever, pain in the chest with breathing and a cough.  Thankfully her lungs were clear and her vital signs look good.  I told her that my suspicion for her was very high in regards to having COVID-19.  I wasn’t convinced that testing would be very useful.  A positive test would confirm the diagnosis but my “pretest probability” was so high that a negative test would likely be a false negative and it would not change the management approach. I put her on the “positive” list so that she would get called every day.  We discussed what symptoms to watch for, about the importance of position changes to keep her lungs aerated, of staying well hydrated and of course, to self-quarantine.

The last individual was young and healthy and had relatively mild symptoms but he did have the distinctive loss of taste.  He had no known contacts.  His father had traveled to Europe in late February but had no symptoms.  He lives at home with younger siblings and both his parents.  I felt that it was important to diagnose him definitively from an infection prevention point of view.  A positive test will allow a more aggressive message to his family to stay at home and possibly get tested. Other contacts could also be informed.  

In all, it was an interesting morning. The staff at the clinic were very helpful, very friendly and we worked well as a team.  I felt very safe, wearing full PPE with a face shield, N-95 mask, gown, gloves and shoe booties.  We cleaned after every patient.  The rooms have been fitted to be negative pressure.  The clinic is well thought out and well executed.  It is the perfect clinic to Make sure that our medical offices are kept safe.  They are not set up to do these kind of visits where it would be impossible to take the same precautions.  As I finished my shift, I took my shower, changed and came home to do a full afternoon of telemedicine visits on Zoom.

We are urgently considering how to open up our offices to usual patient care. The plan is to keep the respiratory clinic going for quite awhile.  This will also help keep the emergency room less crowded and safer for those that need life saving treatment for other conditions such as my patient with the heart attack.  Similar thought needs to happen for all of us.  How do we adapt to an emerging society?  It will still be important to take caution and decide If there are new, safer approaches that will work as well as the older ones.  It will be interesting to see how schools, churches and of course businesses open back up.  Let’s continue to stay safe and let’s be wise.

The Amazing Human Body

The Amazing Human Body

Hearing that an ER physician in New York who had been caring for COVID patients took her own life cut me to the quick Recently.  My heart ached for her and her family.  When someone reaches the point that the only escape they can imagine from the pain that they are experiencing is to take their life, that person has truly descended into a dark place.  I’m not immune to dark somber moods at times but thankfully, I have never had to battle those kinds of thoughts.  I have always had the hope that things will get better.  

For the most part, the human body is too resilient not to have faith in its healing properties.  Just tonight, while doing the dishes I opened up a gash on my finger.  It bled pretty well, but I know that clotting factors were already at work, starting a clot.  Other cells will be recruited to the area that will form scar tissue.  The edges of the wound will grow towards each other, especially if I help them out by getting the edges of the wound close to each other.  I placed a small popsicle stick under the finger and taped it so that I wouldn’t inadvertently bend the knuckle and open up the wound again. White blood cells will course through the area looking to interact with infection causing bacteria.  Cleansing the wound and applying antibacterial ointment will help lessen the load that needs to be cleared.

We do the same with COVID-19 patients.  We don’t have a treatment yet that will definitively treat it.  We do everything we can to support the body until it recovers on its own. Most patients do.  I am seeing an increasing number of patients who have had it or likely have had it.  At least four of the people I spoke to today fall in that category.  One progressed to having inflammation of the eyes.  Several had the typical cough and fever. Some also have diarrhea.  Thankfully, none of my patients have become so sick as to require mechanical ventilation.  Almost all of them have been able to simply stay home and ride it out, allowing their own immune system to fight off the virus.  We can administer extra oxygen for those that need it, give Tylenol for aches, pains and fever, and recommend cough and cold medicine as needed. That is about all that we have to offer.

A vaccine would be great. Hopes of having one any time soon are, as of now, just that, hope.  Such a development would be the ultimate aid to our immune system.  Vaccines prime our immune response so that when the actual disease causing organism is encountered, it is ready to act immediately and clear it from our bodies.  Nothing we have done in medicine to improve the world’s health can compare to vaccinations and cleaning up the world’s water supply.

The best help we can give our body is to never be exposed to it in the first place. One ounce of prevention truly is worth a pound of cure.  From a societal standpoint there are really only two mechanisms for this to happen.  We can either shut down everyone so that none of us are exposed to those who are ill as we are doing now or we can shut down those that are ill.  For that to happen effectively, early diagnosis is the key.  When a case is detected, if that person’s known contacts can be traced quickly and notified, they can be shut down as well.  This approach allows for society to “cut out” the problem areas while continuing to keep the rest of society operational. The enormity of the pandemic quickly overwhelmed our capacity to do this well.  This is our necessary next step to come out of these depressing days.  I do have hope that we will get there.  Brighter days are ahead.  Standing together, we will give ourselves the best chance to allow the amazing human body to do what it does best, recover and survive.  

Hands

Baby Mara’s Hands

Nothing is quite so precious as the tiny little fingers of a new born baby grasping our own.  Call it a simple neuron reflex but such an action reflexively melts our heart and makes us want to hold this precious little infant in our arms and protect her from all the evils of this life.

A mother’s hands are different. They have matured and are strong and supportive.  If you look closely you will see signs of hard work through the years.  They are also soft and loving. The caress of their touch will make a child feel safe and secure.  These hands have so many purposes. They can work and drive and gesture and love and embrace.  A mother’s hands are blessed.

A father’s hands used to be described as calloused, worn down and tough. That is true of many but other’s of us have occupations that aren’t so hard on our hands anymore.  Ideally, those hands should lift and support.  They stand at the ready to defend his family.  The ring on his finger reminds him of his biggest priorities.  His hands are firm and steadfast.

A doctor’s hands sense, palpate and percuss.   They can certainly illicit pain when they poke and prod too hard.  Those hands may hold instruments of healing.  Now a days those hands have certainly become adept at typing and clicking. Gently placed on a shoulder, they can instill calm and reassurance.

The irony of course is that the same hands that grasp, love, support and soothe can also transmit a virus and cause harm.  They must be constantly washed or gloved. They must not scratch the nose, eyes or mouth.  When clasped or folded they can be melded with the hands of the Savior, those which were pierced for our sake.  They are the hands of the ultimate healer. His hands can guide our hands. We need them now more than ever.

Reassimilation

It is one thing to shut down society, it is another to open it back up.  As you have seen, this is quite the controversial topic these days.  There are lots of opinions to go around but very little data to draw on.  We do have some of the earlier countries to watch and learn from.  So far China, South Korea and Taiwan seem to have a good handle on things.  However, Singapore, which was felt to be a model of how to proceed has had to take a few steps backward as cases of the virus have jumped up after reopening their society.  Without the proper plan in place, disastrous consequences can follow.

This happens on not just a macro scale in relation to our city, state and country but on a micro scale as well.  When I was assigned to work ICU shifts on the COVID floor, I moved to the basement to keep my family safe.  I have had my own bedroom, bathroom and refrigerator.  I have been eating breakfast and lunch down there and coming up for dinner without helping to prepare it.  As my assigned shifts in the ICU was not needed after my initial training, I have not been in that area of the hospital.  It has now been two weeks since I have had any significant exposure so this weekend my wife and I discussed having me more fully rejoin the family.  It is not an easy decision.  I still go to the hospital to see my normal patients.  My risk is low but it is not zero.  It is likely that the virus will not be fully eradicated for many months.  Ultimately, the decision we had to make could not be found in a medical guideline or news report.  We made it a matter of prayer.  As we did so, we felt it safe enough for me to “come upstairs.”  We certainly still clean surfaces every day and our wash our hands all the time.  I made tacos for everyone today and am typing this post upstairs right now (in my designated chair).

Our communities are starting to make such plans as well.  I am glad that there is still a 10 person limit on gatherings and that social distancing is still encouraged.  Our ability to test has opened up a bit more again this week, but there is far more that needs to be done.  Contact tracing is a big concern of mine.  Apple and Google have come together to offer an app which will keep track of everyone around us by “pinging” our device while we are near.  This is done anonymously. If one of those contacts should come down with COVID-19, health officials would be able to download information off of their phone and be able to notify everyone who had been pinged.  There is the obvious concern about privacy infringements but do any of us really believe that Google doesn’t know where we are all the time anyway?  I think that it is a great idea.

For myself, I will be helping out in the “Respiratory Clinic” later this week.  This is a clinic that we set up to keep those with any sort of cough, congestion or fever out of our regular medical offices.  It hopefully will also keep many people out of the Emergency Room as well.  The patients register by phone and wait in their car until their appointment. They are then brought into the clinic through a dedicated door and placed directly in an examination room.  The staff are all in full PPE (personal protective equipment), changing the gown and gloves between rooms.  Not everyone who comes will have COVID but some will. We will be able to not just examine them but test their oxygen levels, do labs (including COVID testing when appropriate) as well as chest X-ray all right there in the clinic.

I suspect that we will need to have this respiratory clinic in place for many months.  I will have to determine what I believe my risk to be once having my turn This week.  Hopefully I will be able to stay “upstairs.”  I am grateful to the many, many people who have taken the “stay at home” order seriously.  The next few weeks will be the key here in our area to see if we can all get back to living a more normal but different life.  Amid the uncertainty, I do feel at peace and will continue to go to my knees when having to navigate the many choices that lay before me.

Help in Recovery

This morning while waking down the hall in the hospital, I passed the physical and occupational therapy offices and  I came across this sign.  It caused me to reflect on the therapists that I see hard at work every day.  We use both physical and occupational therapists a lot to get or patients stronger and more functional so that they can remain at home and be independent for as long as possible.

Most people understand that physical therapists focus on the “getting stronger part” of this process.  They work on stretching, strengthening and mobility in those who have grown weak from their disease.  I, personally, have been benefited significantly through the years by spending time with a physical therapist when rehabbing from an injury.  They are fabulous.

Occupational therapy is a relatively newer field that is not as well understood.  I have frankly learned much more about this field in the last three years because my daughter has just finished her Masters in Occupation Therapy at Washington University.  OT’s focus on functioning.  There is some overlap with physical therapy but they first ascertain what an individual’s level of functioning has been at home.  What things does this person normally do for himself and what is he having a hard time accomplishing now?  They make sure that simple tasks that we may take for granted are not overlooked, such as getting dressed.  If someone has had a stroke or crippling arthritis and can no longer do buttons by themselves, they may suggest something as simple as making sure to use pull over shirts so that they can remain independent.

When my father was ill with cancer and was having a hard time getting in and out of bed my daughter and his OT were able to recommend a few things that helped significantly.  The first was to simply raise up the bed about 4 inches.  This put him at a better position where he did not have to activate as many muscles in his quadriceps to stand up.  We bought a bed caddy, a bed rail and a trapeze type handle that fastened to the underside of the bed so that he could reach across and grab it. This made rolling him on his side much easier.  We also bought a handle to put in the car door latch to help push off from as well. It amazed me how much my daughter was able to help out with her new found knowledge.

Both physical and occupational therapists in the hospital quietly go about their work.  They continue to have personal interaction with the patients and are thus just as at risk for contracting COVID-19 as are doctors and nurses.  At Missouri Baptist, one wing of the COVID floor is entirely dedicated to rehabilitation.  Those that recover from the virus are often left quite weak.  Here they can work with therapists for at least three hours a day preparing them so that they can return home independently.  Our therapists should not be overlooked and are healthcare heroes just like the other team members.  Hats off to our therapists and a huge thank you for all they do.

COVID Calesthenics

As I have been talking to my patients over the last few weeks, one of the recurring themes is an increase in physical activity.  Due to our “stay at home” orders, combined with an absolutely gorgeous spring, one of the best and safest ways to get outside is to go for a good long walk.  Last Saturday my wife and I ventured into a nearby park, “Phantom Forest” which hooks into another forest area “Bittersweet Woods.”  As we walked around we took an uphill path, figuring that we didn’t have anywhere else we had to be.  The path entered into a neighborhood common area.  We decided to explore, finding a previous unknown neighborhood pond. We skirted around that neighborhood and found a separate entrance to the woods near another pond in the adjoining neighborhood.  We had quite a good time exploring all around our very own area.

Gyms, swimming pools and rec centers are all closed but Mother Nature provides all the recreation we truly need (though I do miss my morning swims).  My son-in-law decided to run his first marathon this year.  He has been training for months.  He literally put down his payment for the race the day before the stay at home order.  Undeterred, he continued his training and mapped out his very own marathon right where he lives.  Last weekend he set off early in the morning before it was fully light.  Using the tracking app on our phones we could see his progress and my wife and daughter criss crossed his route to intercept him with bells and cheers.  I stayed close to home but was able to add my cheers several times as he did two large loops.  He finished what he started and was awarded all the medals we could find!  I am proud of him for sticking with his goals and seeing it to the end.  Now he can say that he ran, finished and WON a marathon!

My daughter is a High Fitness Aerobics instructor at the YMCA.  It was a great job for a young mother as she could drop off the kids at the child center.  Of course, COVID closed the YMCA down so she decided to continue to teach her classes via ZOOM.  She has a good sized following and simply said that “donations are welcome.”  To her surprise she has made more at home than she did at the YMCA.

My youngest son has put up a slack line in our back yard.  If you have never seen one of these before, it is used by rock climbers.  It is a broad band of material anchored between two rocks or trees.  It takes a lot of muscle control and balance to be able to walk on it like a tight rope.  I fear it may be more dangerous to my health so I have not tried it yet.  He is quite good at it.

I pretty much have stuck with biking and running.  About once a week I spend an hour stretching, doing abdominal exercises as well as some strengthening of the core and shoulders.  I use an old gymnastics mat that I put next to my bed and have a foam roller and an exercise ball that I use.  It is a great way to loosen up and work out the knots that build up from tension and bad posture.

Exercise is good for the body but even better for the mind.  One of the best pieces of advice that I have come across is, “don’t go to bed without a plan to exercise the next day.”  There is no better time than now to get into good habits. Most of us make sure that financially we put aside money every month into a retirement plan.  In my mind regular exercise is just as important. If we want to be healthy and active on our retirement years, we need to set aside the time to make good habits right now.

Time for a Little Serenity

Time for a little break.  I feel like I have been banging the COVID drum hard and heavy lately.  For those of you who have been reading this blog every day, you understand that I absolutely feel that this virus deserves our utmost attention and respect.  However, it does not merit unmitigated paranoia. Common sense must still prevail and level headed thinking is a must if we are going to get through and past this ordeal.

Let me illustrate by sharing two examples that I came across today at the hospital.  The first was a specialist that I saw this morning who was just fuming.  He has a patient with a possible abnormality on a CT scan and he wanted to look at it together with a radiologist.  Normally, that would simply entail going down to the radiologist’s office, pulling up the images and looking at them together.  It is something that is traditionally done many times a day.  However, today the radiologist’s door was locked shut.  The specialist was told to leave the films so that they would be downloaded and they could then discuss it over the phone later that day.  I understand the point of wanting to limit exposure whenever possible, but where do you draw the line between careless and cautionary?

The other illustration was told to me when talking to one of the regular ICU doctors.  He said that his family had a refrigerator that was recently installed at his home.  As the technician was wrapping up, the doctor came down in his clean scrubs on his way out the door to go to the hospital.  The technician got a look of abject terror in his eyes and asked if he worked at the hospital.  He answered that he did.  He was then asked, “have you actually been around someone with COVID?”  “Well, yes, I have,” was the reply.  The individual in horror accused the doctor of risking his life saying that he should never have had him come to the house.  He got on his phone and told his boss that he wouldn’t be able to work for two weeks now.

I understand the fear.  I live it when I go to the hospital to see my patients.  I saw three of them today.  I don’t worry much about them.  They have tested negative and it is frankly pretty easy to be careful with them.  What I worry about is everyone else.  Who forgot to wash their hands?  Did they touch the door knobs that I touch?  The telephones, the keyboards?  It is easy to work my mind into a frenzy but I have learned to talk myself down.

Here are the lessons that I tell myself:
1. I am not going to get this from virus floating around in the air. I am not present during any procedure that will aerosolize the virus. If I am, extra PPE will be placed.
2. Coming in contact with the virus on intact skin will not infect me.  It has to get into my mucous membranes, meaning my mouth, eyes or nose.  This is where the basic mask comes in handy.  It keeps our hands out of our face.  If I touch a surface with my hands, I don’t panic.  I do what I need to do and then I go and sanitize my hands.

It is dangerous to be too cavalier and carefree.  Those individuals truly scare me.  Neither is it good to become so crippled with fear that we are not able to help those around us.  In the words of the serenity prayer, “God grant me the serenity to accept the things I cannot change, courage to change the things I can and wisdom to know the difference.”

Tough Choices

Diane is a very good friend of ours.  She happens to have Multiple Sclerosis and has been wheel chair bound and dependent on care givers for almost twenty years now.  She has a quick wit, a beautiful smile and a determined will.  Not content to spend the rest of her days in a nursing home, she now resides in her own apartment with some help.  I am amazed by her positive attitude and perseverance.  She is one of my heroes.

She recently forwarded me a document reminding physicians that rationing resources away from those with disabilities is a crime as outlined in the Americans with Disability Act.  It was a good reminder for me given the current pandemic.  It is illegal to deny care to anyone due to disability. Corona virus may preferentially kill those who are more debilitated to start with but we as humanity must never do that.  These are lessons learned from the Nazi regime during World War II.  Recently I listened to a podcast discussing the possibilities of rationing care in the face of resource shortage.  At face value, it seemed to fly in the face of protecting the vulnerable.  The underlying premise was to bring care to the most number of people possible.  That too is an honorable goal but how and who makes the decision in regards to who receives care and who doesn’t when there are not enough resources for all? These are tough choices.

In truth, we ration care right now.  Accessing our amazing health system is difficult for those who are uninsured or underinsured.  Costs are high.  Yes, there is a safety net for the very poor but there are millions of people who are above that level economically but still cannot afford to cover their families.  Our system never has been fair. If there are only so many resources, in this case ventilators.  How do you decide who gets the ventilator and who doesn’t?  That is not a decision that I ever want to make.  New York and Italy have had to make these decisions. They have been gut wrenching for those in the front lines. Here are some of the things we should be doing now to make sure we never get to that point.

The first order of business is to do everything in our power to make sure we have access to every ventilator possible.  The BJC system has a central repository of medical equipment and supples to distribute among the various hospitals according to need.  They have taken them from operating rooms that are not currently being used due to the cessation of elective surgeries.  There are ventilators that had been used at home for patients who have expired.  Novel ways of trying to maintain two patients on one ventilator have been devised. Some of our factories have now been repurposed to make more ventilators as well.

The second order of business is to make sure that mechanical ventilation is used appropriately.  The mindset for COVID-19 has shifted from the earlier days of the pandemic.  Because the virus is so infectious and causes a precipitous drop on oxygenation, it was felt that early intubation was ideal.  That practice has been questioned as those on ventilators seem to do worse.  This is hard to truly ascertain as the sickest patients are the ones put on ventilators, so it is expected that they do worse, but what is being seen seems to be out of proportion to what is expected. If someone is in a stable environment where rapid intubation can be done if needed, such as in the ICU, the approach now is to wait as long as possible.  It has been found that often times using alternate oxygen flow devices and prompting the frequent movement of the awake patient the need for ventilation is less.

Lastly, it is imperative that patients and their doctors communicate clearly what their wishes would be for ventilation if their health deteriorated to the point that would be considered.  I have talked to several patients with emphysema, some of whom are on oxygen at home, and then asked them what exactly they would want us to do if they were in this position.  Such patients have a less than 5% chance of meaningful recovery.  If it were due to COVID-19 that number is likely even smaller.  I also explain that being comfortable in your last days and being on the ventilator are not compatible statements.  It is a very uncomfortable process, usually requiring high levels of sedation and sometimes even paralytic agents to be able to keep the lungs going.  Most patients indicate that they do not want such treatment.  I mark their chart indicating their wishes not to be resuscitated so that others can clearly see. This eliminates the unnecessary use of such resources.

Going back to Diane, what of those with disabilities?  The guidelines are clear, they are not to be discriminated against.  Guidelines in New York and in Switzerland indicate that in the face of scarce resources the guiding principle is to determine who has the higher likelihood of survival regardless of the underlying diagnosis or age of the patient.  If a patient is expected to only live 5 more years of life, a healthier patient would take precedence over them.  These are hard choices to make.

The great news is that here in St. Louis, you all have been flattening the curve.  Just last night I was shown a graph of the predicted number of cases in the hospital here in our area.  There was a line for a “bad case scenario” and another for the best case scenario.  We are currently slightly under the best case line.  I am so grateful to a community who have taken social distancing seriously.  You are helping the rest of us so that we will never have to choose between two patients as to who will live and who will die.  Keep up the fight. Stay safe, stay strong!

COVID Coping

Stress is all around us. The current pandemic adds to and magnifies the stress that we already feel.  There is the stress of becoming infected. The worry that it could progress to a critical stage and even death. There is the stress that I could infect my family. Luckily, my job security is solid as opposed to the patient I saw today who was notified that his research position is being furloughed till the end of July.  I listened to a report recently forecasting that divorces would be going up due to the stress of couples spending more time together.  I certainly don’t have that problem.  I welcome any time that I can get to be with my sweetheart.

Today reminded me of the stress that I and most of my colleagues feel in primary care on a daily basis.  We are quite good at second guessing ourselves.  It is not uncommon after a phone call in the middle of the night from the Emergency Room, like I received last night, to have a hard time going back to sleep.  My mind will circle and wonder if the diagnosis is correct.  Did I remember to give the appropriate orders?

On a typical day, most conditions that I come across are pretty straightforward.  The human body has an amazing capacity to regenerate and recover so my job often is to educate and reassure that things are going to get better.  What we all worry about is that patient who doesn’t quite fit into the normal categories.  More than anything we worry about missing an important diagnosis.  If this anxiety goes to far, unnecessary tests will be performed for common conditions just so “nothing is missed.”  On the other hand, the right test done at the right time will lead to the correct diagnosis and is crucial to taking care of the problem.  The right balance is key.  I try to always give my patients an expectation for recovery and resolution.  If they continue to have symptoms, I tell them to come back so that I can consider other possibilities.

A different stress that we have is having the difficult conversations with patients and their families.  I will never get used to having to tell someone that they have cancer or other life threatening conditions.  Discussing someone’s wishes at the end of their life is also stressful.  Most people don’t want to spend their last days on life support.  However, how does one determine which days are the last days?  It is not always clear. That is part of our job, and it is stressful.  To sit a patient and family down and tell them it is time to pull back and make sure the patient is comfortable is hard.  Am I right?  Is now the time?  I am almost always right but there is no crystal ball.

Now there is the added stress of families, scared out of their mind with worry about their loved one in the hospital but they are not allowed to be with them.  It is easy for them to worry and assume the worst.  I have been making an extra effort to reach out and call them each day.  They are so relieved and seem to appreciate the effort.

So how do we deal with the stress in our lives?   What is the best way to cope? Here are some of mine:
Keep my mind occupied.  When I am at work, I am all in.  When I am with a patient, I have to be with them in that moment.  As soon as I walk out of a room, I have to be able to turn that off and reset for the next one.  Similarly at home it helps to turn off the day by my hobbies.  When I am involved in my wood carving, it forces me to think of nothing else.  Regular exercise also keeps me sane.  When gasping for breath, it is hard to worry about anything else.

One of my friends sent me a picture of her new project: backyard bucket gardening.  She doesn’t even cook but now she is growing potatoes, tomatoes and herbs!  What a great way to take the stress out of life.  Helping something grow, bringing something to life is the perfect activity during the current pandemic.  She plans to share her produce with friends and neighbors.  I am inspired by her great idea.

My partner has been building a new shelving unit in his house.  Like our bunk bed project, building is a great antidote to dealing with the stress of this disease.  I know many who are involved in making masks and donating them.

My son has been playing music.  We love to hear him play his violin. He has jumped back on the piano and is learning when of my favorite songs, Billy Joel’s “New York State of Mind.”  There may need to be a new verse written by the time we are through with COVID-19.

Last but certainly not least is prayer, meditation and scripture study.  “Peace I leave with you,” says Jesus. “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” (John 14:27). He does not make our life easy but he can strengthen us in him.  I am grateful for the peace that I feel despite all that is going on around me. May we all have the strength to manage our stress. We will get through this together.

Guatemalan Dreams

Guatemalan Trip 2017

It was a beautiful bright sunny day. The sun was out, the birds were singing. I had just finished attending church and was standing to the side, taking it all in.  As familiar as much of this sounds, this was my first week attending church as a young 19 year old missionary in Guatemala.  I had taken Spanish for two years in middle school and all four years in high school.  The lessons came rather easily to me in the two month preparation courses that I just completed but being placed in a community in a foreign country was something else entirely.  Even when words were spoken that I knew, I didn't understand them for the cadence and the accent.  It was all a bit overwhelming.

As missionaries we were always paired with a companion.  Mine was Guatemalan and knew absolutely no English.  While he spoke to the bishop of the congregation, there I stood feeling rather unneeded and overwhelmed.  I felt a tug on my hand and looked down to see the darling face of a four year old girl who noticed my predicament.  She pointed to a flower and said, "flor" to a blade of grass and said, "hierba" and to an ant, "hormiga."  She would wait after each one for me to say it and then give me a warm smile.  I was smitten.  That little girl instilled in me a love for the people of Guatemala that is hard to explain.  I was there to help and bless the lives of those around me.  I left feeling like I was the one who had been helped and blessed, having received far more than I gave.

The two years of being a missionary changed me for the better.  Not a day goes by when I don't think of that experience.  Helping others feel closer to their Savior Jesus Christ had an even greater effect on me personally.  When I finished my missionary term I returned to college and prepared for medical school.  My major was Spanish.  I was able to do both my prerequisite classes in medicine as well as dive into the hispanic culture, their art and literature.

After I finished my Internal Medicine Residency, I longed to do more for that community.  I thought of returning to Guatemala but as a Primary Care physician, my skills did not lend themselves well to appearing in the country for a few days and then leaving.  I found a Spanish speaking medical clinic here in St. Louis (La Accion Clinica) and started volunteering once a month in the evening.  It was not a huge time commitment but I persisted month after month.  When the recession hit in 2007, the clinic folded but within a year a new one started up sponsored by St. Louis University, "La Casa de Salud."  I scheduled my first Thursday of the month evening shifts and have continued ever since.  It has now been 22 years total. Though I feel like my steady contribution has been significant, I continue to feel that I have received more from the Hispanic community than I have received.

Through the years, my best friend from childhood has been going and organizing an eye center in a remote Guatemalan village, Nuevo Progreso.  He and others have done an amazing job of bringing high quality vision services to an area that would otherwise not have them.  Above and beyond the operations they have performed, they have set up a facility and been able to hire and train local physicians to continue to provide care on their own.  For the last few years, I have been invited to come along and this year I said, "yes."

I was to be in Guatemala starting last Thursday night.  The pandemic had other ideas. Our excursion has been indefinitely postponed.  In addition to helping the surgeons, I was very much looking forward to meeting with the primary care doctors there.  I am sure they would help me learn so much and hopefully I would be able to help teach them from my experience as well.  I look forward to making this happen in the future when it is safe to do so.

The foundation is called "Hospital de la Familia."  A link to its website is here.  There are many ways to help if you are interested.

To the Rescue

My four year old grandson has been following a You Tube channel at home that is geared to teaching kids how to draw pictures.  This week the subject was Spider-Man.  I’d say he did a pretty amazing job! After the superhero was completed, the kids were invited to draw something in the background. Jack drew a building and two corona viruses because “Spider-Man kills the Corona virus,” he exclaimed to me.

I think he has it right. We need superheroes if we are going to have any chance against this virus.  Thankfully we have plenty of them.  I have previously talked about our ER and ICU staff and the job they are doing each and every day in the face of personal danger and uncertainty.  We have other superheroes as well that are not as easily seen.  They may not even interact directly with patients but the effects of their work will be crucial to how we move past this pandemic and recover. They are our scientists and researchers.  Many are working long hours in the hopes to develop a vaccine or to find a medication that can treat COVID-19 and lessen the disease burden on all of society.

In a recent post I discussed the trial using convalescent plasma that we are a part of at Missouri Baptist hospital.  Yesterday I received an email from researchers at Washington University that are looking at fluvoxamine.  This medicine has been used for decades in the treatment of bipolar disorder but it also has something called sigma-1 receptor binding which may help to decrease the “cytokine storm” that is so prevalent in those with severe disease.  As such it is hoped that those patients won’t become critically ill and can be managed at home.

You likely have heard of the malaria drug chloroquine and its close cousin hydroxychloroquine (used in rheumatic disease). These two have been around for a long time. They are being looked at in COVID-19 due to possible effects of inhibiting viral entry through a cellular structure called an endosome.  The medicine has a known effect of raising the pH within the endosome which is thought  to inactivate the virus.  Elon Musk tweeted that it would be worth considering and off the shelves it started to fly. We all know that President Trump is all for it.  Scientist insist on doing formal studies both to make sure it works as well as to demonstrate its safety. Just this week I received notice that patients who have been treated are at a higher risk of developing potentially deadly arrhythmias while taking these medicines. As such, when used they should either be on a heart monitor or have an ECG pretreatment and also while on treatment to screen for this tendency.  Careful consideration of the facts is always preferable to brash hyperbole.

Remdesivir has shown promise. It was researched previously for the SARS virus but was not found to be efficacious.  There are several studies that are ongoing for its use in COVID-19.  An oral drug called EIDD-2801 which proportedly introduces genetic mutation into the virus’s RNA making it incapable of infecting cells is showing some promise. There are literally hundreds of other trials going on at present as well.  The knowledge that will be accumulated by our scientists will reap benefit society for years to come. Our understanding of all viral infections will be augmented.  Our scientists are working hard in our behalf.  Thank goodness for superheroes!

Stay Strong!

I see signs that the lock down is starting to wear at the edges of our resiliency.  As I jumped out of my car to go into the office today, I didn’t realize that I wasn’t wearing my mask till I arrived at the front door.  After having my temperature checked and answering the appropriate questions, I was given a new mask and I went up stairs.  In a recent conversation with our Chief Medical Office at the hospital he told me what he worries about more than anything is one thing, “complacency.”

On social media I have seen posts declaring that it is time to stop hunkering in our corners and face life’s challenges head on.  I understand the sentiment, I feel it too.  One in particular quoted an elderly man decrying what a weak society we now have.  When he grew up there were cases of Polio, Measles and other diseases which took a toll on his community but “we never shut down society,” he concluded.  It made me gasp a bit and wish that I could shout from the roof tops (blogging will have to do) that if this gentleman were just a little older he may have recalled the last pandemic to hit the world, the 1918 Influenza.  In the end, 500 million people were infected taking the lives of about 40 million people.  It took more lives than World War I. Society was indeed shut down at the time but perhaps not soon enough.

Our numbers at the start of our pandemic were mirroring those of the 1918 one, but as communities have come together and shut down and isolated, those projections have not been realized.  That said, the numbers continue to rise, especially here in St. Louis. We have not hit any kind of plateau yet.  It is not time to brazenly open our doors.  Twenty percent of infected individuals have no symptoms and yet are capable of passing the virus to others. Until we have universal testing, our only option is to continue to mitigate as we have been.

There is an excellent article written about Dr. Osborn at Washington University who is on the front lines pleading the same point. I was dismayed to see reports just today of more than 3000 people gathered to protest the shut down as well as our very own executive leader advocating promoting such demonstrations with encouragement to open up our society.

My partner, Dr. Voss. Stay strong so we don't have to!

The economy has been shaken to its core. I understand that makes a lot of us nervous. Our health systems are rightly concerned about our financials but I will not allow an elderly person in my office for a routine wellness exam while the numbers in our community continue to rise.  I took an oath to first “do no harm” and I intend to keep that oath.

Being brave and strong is fighting the impulse to “go back to normal.”  As health care workers, we can handle what is coming right now if everyone helps out.  We cannot let up. We must continue to stay strong!

New Blood

One of the questions that researches are actively working to get an answer to is whether or not those who have been infected with and recovered from COVID-19 have active immunity. We suspect that they do, but if so, for how long?  Will this virus mutate and change year to year as does the influenza virus necessitating yearly vaccination (assuming a vaccine can be made)?  We certainly hope not and that for those who have recovered, they are now "one and done."

Antibody in blue; Corona Virus in Green

Our bodies have an amazing immune response which is able to recognize when foreign material, like this virus, is introduced into our system, and then select our immune "B" cells to preferentially make antibody proteins that essentially tag the virus so it may be attacked or removed from our body.  This process takes a few weeks to occur. As such, it is not too helpful in the first instance but it gives one immunity for future exposures.

The BJC Health System, of which I am a part, is actively recruiting recovered patients and asking them to donate their plasma (a blood donation without red blood cells).  The plasma is then being infused into critically ill patients in a study to determine whether that helps boost the patient's own immune response and enhance recovery.  The study is currently underway and preliminary results should be available within a few weeks to months.  If you are in St. Louis and know of anyone who has recovered from the virus, please ask them if they would be interested in donating plasma.

Contact information: Interested candidates in the St. Louis area may email IDCRU@wustl.edu    or call 314-454-0058.

We also have "new blood" to announce in my family.  Losing my father to cancer last fall was truly one of the hardest experiences of my life.  I like to think that my new granddaughter who was born early this morning was able to be with and know him.  What a joy it is to add her precious spirit to our family. She and her mother are doing well.  It is a relief to have her come, especially at this time of pandemic.  She is blessed to have two wonderful parents. I am sure they have no idea what they have gotten themselves in to but they will all learn together.  I don't know when we will be able to go and safely visit them but look forward to doing so when we can.  Thank goodness for video conferencing.  It was so fun to see them today. 

Masking Up

Masking Up

New dad look :)

I have had a request to discuss masks as there is a lot of conflicting information floating around out there right now.  To begin, let’s discuss a little basic virology.  

Most viral infections are spread by contact or droplet. The virus is shed in our secretions (snot, tears, mucous, etc) and can be expelled into the environment by a cough or sneeze or it can be wiped or touched with a hand and then transferred from another surface, such as door knobs, eating utensils, keyboards, telephones, etc.  Typically, when expelled via a cough the particles can be found 2-3 feet from the source.  A six foot radius, therefore, provides adequate protection from those around you.  A person infected with a virus who is merely breathing will not appreciably expel any infectious particles.  

Some viral particles or bacteria are so small that they can be carried longer distances in air currents such as the chicken pox virus, tuberculosis or measles.  The COVID-19 virus is actually quite a large virus. It is not felt to be an airborne virus.  As such, is there really any need to wear a mask at all?  The answer is “yes”, but for two different reasons.  

The first scenario is for health care workers who are present within that 3-4 foot parameter of the patient during an episode of aerosolization.  This is a term denoting the virus being incorporated into a fine mist. A cough is a crude form of that process. There are procedures in the hospital that initiate this process such as high flow oxygen, non invasive ventilation (air flow through a mask), intubation (when the breathing tube is placed in the airway), nebulizer treatments and bronchoscopy (scope down the air tubes down into the lungs).  These scenarios have been shown to carry a very high risk of spreading the virus.

In the hospital, such events are avoided whenever possible, and when it is unavoidable, highly filtered masks and other protective equipment are used to avoid viral spread.  These are the “N-95” masks you may have heard of.  They are currently in short supply and are life saving for the medical community.  

The second scenario when a mask is useful is to simply help remind an individual to keep their hands away from their face.  Over the last month, I have been on many “Zoom” meetings and I can tell you that we all touch our faces more than we realize.  I see it all the time on the screen.  The likelihood that we will contract the COVID-19 virus by breathing it in the air is almost negligible if we are not in the hospital.  The most likely way to contract the virus is by touching something that is contaminated and then touching our face and introducing it into our body.  This virus has been shown to be highly contagious, it only takes a very small amount of virus can cause infection.

A basic masked I used on the night shift

As such, home made masks out of fabric or other material are very helpful.  In fact, many health care workers are using these masks during their shift.  If they need to enter a room, the N-95 mask will be put on and then the other mask can be placed on top of it. This keeps our fingers off of the N-95 mask, so it can be worn again.  We currently are using a brown paper bag to place the N-95 in so it can be reused.  This is not ideal, but sufficient until more masks are available. 

When using a mask, take care to hold it by the elastic or tie strings, so as to avoid touching the mask itself with your fingers.  This is important both when putting it on as well as taking it off.  Make sure to wash your hands just prior to handling it. Once it is safely taken off and stored, wash your hands again. 

 Those with medical conditions that would lend themselves to getting more severe disease have an even greater reason to wear a mask. These include patients with chronic lung, kidney or heart disease, cancer or any conditions that weakens the immune system, which includes pregnancy.  Just today my daughter-in-law has been admitted to the hospital to deliver her baby.  She was appropriately given a mask to wear through the whole process as was my son.  We trust that all will go well and this precious little baby girl will be with us soon.  As always, be careful and stay safe!

Of Rainbows, Hope and Sunny Days

In a previous post, I spoke of how proud I was to work with a group of amazing people.  The whole staff have gone the extra mile to make sure we take care of patients and do so in the safest possible way for them, for us and for those around us.  It is an honor to be part of them.  One of our nurse practitioners put this video together.  The images and music express my emotions better than I can with mere words.  The video recognizes the stress we are all under but in a light of positivity and hope.  I hope you enjoy it.

Day Shift

There is just a different feeling when there are windows in the rooms and the sun is out. I was assigned a day shift in the ICU today. I got up extra early as I had a patient of mine own to see in the hospital before my shift started.  After making sure that the patient was taken care of and a plan was in place, I headed over to the unit.

I am starting to get in a routine for the hospital at this point.  There is a side entrance for staff that we enter. Our temperature is taken, we are asked if we have had a cough or loss of taste.  They have stopped asking if I have been exposed to anyone with known COVID-19 infection. The answer is for just about all of us in the hospital, “yes.”  Our exposure is much different, though, than someone in the community given the protective measures that we take.

I come dressed in clean scrubs and carry my old ones in a plastic bag. After entering the hospital I first go to the scrub machine and deposit the old ones to be cleaned. This give me a “credit” so that when I am done I return to pick up a new clean pair to take home with me.  I wear a mask from the time that I leave my car to the time I get back into it.  This is to keep my hands away from my face.  Every time I touch a door knob, telephone, keyboard, etc I then go and sanitize my hands.

I didn’t actually go into a patient’s room today, but if it were necessary I would don “full PPE.”  This consists of a baseline pair of gloves followed by a gown, booties on my shoes, covering for my head. Another pair of gloves goes on over the sleeves of the gown, followed by an N-95 mask, goggles or face shield.  It is quite the process to go into a room, so everything is geared to minimize unnecessary use of the protective equipment given the shortage around the world.

At the end of my time in the hospital, I go collect a clean pair of scrubs, go to my car and get a bag of clean regular clothes and a new towel. I then head over to my office where we have a shower.  I put my dirty scrubs in a bag for the next day and take a nice, hot shower.  Letting the water run over my head and down my body can be very relaxing. I take a few deep breaths which helps to “wash out” not only the germs but the stress that has built up as well.

Today I was paired with an anesthesiologist. We joked that together we hope to come close to making one whole critical care physician but really we are still probably about 85% of that.  He clearly has experience and expertise in doing procedures (IV lines, intubation, etc) and I have more experience in putting in orders, managing medications and writing notes.  Together we went around and talked with the nurses with all of our assigned patients and then got to work writing their notes and putting in the necessary orders.  Later we reported to the supervising ICU physician and we again went around to each patient and their nurse.  It was a good time to report on what we knew but also to ask questions.  Together we formulated plans.

A few of the patients are clearly getting better and are about ready to come off of the ventilator. A few are not doing well at all and the rest are in a holding pattern.  We called family members of each of the patients and discussed their care and progress.  I found that I was even more comfortable with this aspect than even the ICU doctors.  Communicating to patients and their families is at the core of pretty much everything that I do.

In all, today felt much more upbeat.  It is easy to focus on those patients who are doing poorly but it was so great to call family members on those who are improving and be able to give them hope and good news.  It is an incredibly stressful time for these families who cannot be here to visit their loved ones and show them support.  Given the nature of the disease, some families are dealing with multiple members who are sick at the same time.

So now I am “on call.”  Our tiered level of care is in place and ready to expand should the need arise. The rest of my colleagues will be finishing up their training shifts this week.  I truly enjoyed my shift today.  It is nice, frankly, to be needed and have the skills to be able to help.  That said, wouldn’t it be great for all of us if my skills were not required, that the demand from our community was low enough that our expansion plans are never put into action.

Deliverance

Happy Easter to you all.  It is one of my favorite holidays as it commemorates the most important series of events that have ever happened on the earth. Its very roots started before the world was created, when we existed as spirit children of our Heavenly Father and a plan was made for us to have a mortal experience.  The earth was created by our brother and first begotten son of God, Jesus Christ.  We chose to come to earth in this plan, born in families to our earthly parents.

This earth is a precious gift to all of us.  The beauty and majesty of nature point to her divine creator. It also comes with "thorns and thistles" and yes, even viruses, sickness and death.  It has been so since Adam and Eve. I do not believe that God has purposely cursed the earth with the COVID-19 virus. I believe it is the process of natural consequences.  We knew before coming to earth that there would be challenges, that we would be tested.  It was part of the plan.  The test for us is whether we will allow our Father to bless our lives as we seek for deliverance.

Easter hearkens back to Ancient Israel, to the passover when the children of Israel we spared from a desolating scourge by spreading the blood of a sacrificed lamb on the doors of their homes.  Perhaps in the days to come, we may also be spared through protective vaccination.  Certainly, the homes that are adhering to strict social distancing can greatly enhance their ability to be "passed by." Not being able to return to our heavenly home would be an even greater desolation than anything COVID-19 could ever extract. Ultimately it is the effects of poor choices or sin that distance ourselves from God.  Jesus became the sacrificial lamb.  As we symbolically apply his blood, his life saving sacrifice, to the doorways of our heart, we will conquer even death itself.  To me, that is the power of watching EMS personal, police, nurses and families who offer assistance to others. They are offering a sacred gift so that others' suffering may be alleviated.  There is no greater christlike service than this.

The glory of Easter, though is not about blood, gloom and death. The glory of Easter is that Christ rose from the grave on the third day and conquered death.  He was resurrected and opened the doors so that we all may be as well.  The easter egg symbolizes this new birth. It is the season of spring when new growth, blossoms and leaves come out in all their wonder after the dark and cold winter.  As families, cities, states and nations of the world, we too will come out of the winter pandemic that is COVID-19 and life will come again.  In my own family, my grandsons keep us real. They don't dwell on the negative. The four year old just says, "when the sickness is over, you can come to my house and we will play cars."  It is impossible to see their bright smiling faces and not smile yourself.  My daughter-in-law is due to deliver her baby any day now. We are so excited for them. Our granddaughter may be coming into an uncertain world, but what a wonderful world it will be.

Facing Fear with Courage

“I am going to go for a walk,” said one of the ICU nurses to her supervisor. “OK, just so long as you come back!,” he replied with a twinkle in his eye. I have many thoughts about my first over night hospital shift in 22 years, but above all else I hope to describe the courage that I felt from those around me.  Nelson Mandela famously said, “ I learned that courage was not the absence of fear, but the triumph over it. The brave man is not he who does not feel afraid, but he who conquers that fear.” 

In the COVID ICU no one is worried that they might be exposed to virus, for there is an absolute certainty that they will.  The constant mindset is how can I take care of these patients without contracting the virus myself?  IV poles are hung outside of rooms, the tubing extended and draped from a hook in the ceiling as if creating some macabre maypole. This allows manipulation of flow rates, medicine administration and alarm evaluations to be done without donning the scarce PPE (personal protective equipment) which is so vital to the health of the workers.  One of the nurses is not even assigned to take care of patients. That nurse’s sole job is to make sure that when someone enters a room, they have appropriately applied their PPE and are safe to proceed.  They then act as a runner to bring anything to that person if needed.  The ICU has video monitors so that the critical care doctor can look at the patient. The ventilator and its monitors can also be seen this way without entering the room.  

Last night I was assigned to cover a certain portion of the ICU. After completing a note on a new admission, I went down to talk to the nurses and ask them to tell me about the patients that they were taking care of.  There were elderly people on ventilators as we would be expected but the 25 year old fighting for his life, slowly getting worse was a chilling reminder of how serious this illness can be.  

After telling me of her patients, I looked oen nurse in the eyes and asked how she was doing.  She responded that there is not a day that goes by that she doesn’t think about how she can get out of her job and not come to work. She was still struggling with the death of a patient earlier this week. She then steadied her chin and said, “it is my faith that gets me through.”  She said that she does not understand God’s plan for her in all of this, at least not yet.  She keeps in memory and constantly recites to herself the 91st Psalm which reads:

1 He that dwelleth in the secret place of the most High shall abide under the shadow of the Almighty.

2 I will say of the Lord, He is my refuge and my fortress: my God; in him will I trust.

3 Surely he shall deliver thee from the snare of the fowler, and from the noisome pestilence.

4 He shall cover thee with his feathers, and under his wings shalt thou trust: his truth shall be thy shield and buckler.

5 Thou shalt not be afraid for the terror by night; nor for the arrow that flieth by day;

6 Nor for the pestilence that walketh in darkness; nor for the destruction that wasteth at noonday.

7 A thousand shall fall at thy side, and ten thousand at thy right hand; but it shall not come nigh thee.

8 Only with thine eyes shalt thou behold and see the reward of the wicked.

9 Because thou hast made the Lord, which is my refuge, even the most High, thy habitation;

10 There shall no evil befall thee, neither shall any plague come nigh thy dwelling.

11 For he shall give his angels charge over thee, to keep thee in all thy ways.

I stood, awed by her faith in the face of terror. I asked if I could pray for her and she accepted.  In a quiet moment we shared something very personal and intimate.  I am mindful that it was Good Friday.  I am grateful to know that Jesus suffered the pain and sicknesses of his people and the bands of death that he may know how to succor his people (See Alma 7:11-12). I am also grateful for members of my faith and many others who chose to fast yesterday to petition God that he may end this pandemic, protect healthcare workers, bless the economy and strengthen us all.  I indeed know that angels have charge over us.

This morning as I checked in on the unit, one of the nurses was pumping milk from the patient with the new baby.  It was asked if there was a way to medically cause her milk to dry up.  The ICU doctor responded to keep up the pumping because her milk may contain precious antibodies that could prevent infection.  There are studies just now underway testing “convalescent serum” or fluid containing antibodies from survivors, to see if that could mitigate the course of the disease in the critically ill.

I am mindful of X-ray technicians, phlebotomists, ER workers, sanitation staff who may not have as much personal interaction as caregivers but nonetheless are in harms way and courageously come to work each and every day.  As I drove into the hospital last night, there was a sign that read, “Heroes Work Here.” I teared up a bit then but even more so now after witnessing first hand the heroes at work last night.  I had just remarked to my wife prior to going into the hospital how we live in such a bubble, surrounded by the beauty of spring and even in the relatively low numbers of COVID here in St. Louis compared to much of the country.  Is it really worth the damage to the economy and our nation to stay locked down for so long?  I ask you to consider looking into the eyes of these courageous workers and ask them.  To let this virus run unchecked will completely overwhelm our capacity as a health care system.  We have got to buy time and flatten the curve so that we can put in place aggressive testing which we do not at the moment have the capacity to do.  That is the only way out of this pandemic safely.  So for all of you who are staying home, you are my heroes too.