My Last Plea

 

India's COVID Crematoriums

As I finished my hospital rounds this morning my path took me by 4 West where my colleagues and I manned the expanded ICU during the winter months.  The lights were off, the rooms were empty and, thankfully, there were no patients needing our care anymore.  “Are you glad to have just one job?,” I was asked earlier by a nurse in the regular ICU attending to one of my patients.  I responded that yes, I was glad. I was especially glad that there was no more need for us to take care of the sick patients but that I did miss working with all of them, the nurses.  There is now a whole group of people that I pass in the hospital who wave to me as I walk by.  We smile remembering our time working together as a team. 

Today marks the end of another milestone for me and our fight against COVID.  For almost a full year, I have left my regular clinic on Thursday afternoons and staffed our respiratory clinic where patients who have symptoms that could be from COVID are sent to be evaluated.  From a risk perspective, it is likely more dangerous than the ICU since I see more patients, most of whom are recently sick and thus more infective.  We have full personal protective equipment on and are constantly cleaning all the surfaces.  Today was my last day in the respiratory clinic.  It remains open but we have hired a full time nurse practitioner to staff it full time.  She has been training with me for the last month and she is fantastic and is ready to go. 

The first patient we saw today already had a diagnosis of COVID but continued with a lingering cough. The chest x-ray showed a slight pneumonia but he looked like he was coming through his illness just fine.  The rest of the patients were all fully vaccinated. Some had colds, others perhaps a sinus infection or an asthma flare. It was frankly nice to see normal conditions once again.  The last patient of the day was a stark reminder that we are not through this yet.  Mid forties with no medical problems, no previous lung disease, on no medications and with a normal weight.  The picture of health except that after starting with COVID symptoms three days earlier, she had to literally crawl into the office because she was so weak.  The oxygen level was low, nearing the point of needing more.  I knew she could go downhill in a hurry.  911 was called and EMS took her around to the emergency room. 

My plea to you and all those you love is simple: please get vaccinated.  This is real. There is no conspiracy.  There is no hoax. At lunch today, the TV at the doctor’s eating area showed India’s “crematoriums.” They are simply open lots with bonfires blazing. COVID has hit India like a California grass fire, ripping through the country.  Many hospitals have run out of oxygen.  The reality is as grim as any situation that I have seen in my lifetime.  The only thing that separates us from them is our access to the vaccines.  In clinical trials they boasted a 95% success rate.  Unheard of. Amazing! Real life experience never quite lives up to the clinical studies. However, a recent post vaccination study showed that they keep elderly patients out of the hospital 94% of the time. 

Isn’t it so nice to open up a bit? For the first time in a year, we had a family dinner with my in-laws at Easter. They had both been vaccinated two weeks prior. What a blessing it is for families to be together.  Recently, one of my fully vaccinated patients reached out to me because he was still hesitant to travel. His mother was dying and he wasn’t sure that he should go.  I told him to go see her.  “Still be careful, but go, you need to be with family,” I said.  He messaged me today saying that he was able to be there for her funeral and to connect with his family. He was so grateful. 

My wife’s family is planning a family reunion in June.  Church meetings are opening up.  Neighbors can be talked to.  This is all good, but remember the two weeks.  Maximum immunity takes two weeks from the second shot.  For my wife, that is in six days, hooray!

It is so tempting to let our collective guard down.  If you have concerns about the vaccine, send me a message. I am more than happy to answer questions and concerns.  In the last year, our country has made a lot of mistakes.  We could have done so much better, but not in this, not the vaccines.  This we did right.  It is the key to our recovery and our hope for the future. 

 

All In

Attending the funeral of a young missionary who was killed in a tragic accident, Elder David A. Bednar, one of our twelve apostles, recalled the courageous faith of the grief-stricken father.  In speaking to those present he admitted that he did not know or understand why his son’s life was taken at such a young age. He concluded with this declaration: “I want you to know that as far as the gospel of Jesus Christ is concerned, our family is all in. We are all in.” About a month ago, Elder Jeremiah Morgan, one of our regional church leaders retold this story at Stake Conference, a biannual meeting of the 9 congregations in our area. With power and a firm conviction he asserted that he and his family were “all in” the gospel of Jesus Christ as well.

As a member of our stake presidency, I have stewardship over 5 of our 9 congregations.  Each week, I prayerfully consider which congregation to attend, hoping that I can be an instrument to bless someone’s life.  A few weeks ago, I had the unmistakable impression to go to one ward in particular.  In our Sunday worship meetings, the sermons are given by members who have been asked to speak by their bishop.  On that week, the assigned theme was to discuss what it means to be “all in.”  This member admitted to being intimidated by the assignment.  She has had a difficult year with a trial that caused her faith to waver.  As she compared herself to the father of the stricken missionary or to Elder Morgan and his family, she felt lacking. She didn’t think she could say that she was “all in.” She did feel like she had hope that she would get to that point and was on the path towards it, trying the best she could for now.  She then courageously shared her struggles, doubts and fears with the congregation.

Tears came to my eyes as I listened to this good, pure young woman with righteous desires. As she spoke, my mind recalled the scriptural account of a young man whose spirit was willing but whose flesh was weak, the apostle Peter.  Early in his ministry he and the other apostles witnessed Jesus heal the sick and miraculously feed thousands. On the night of that miracle, they were sent across the sea of Galilee while Jesus went off alone to pray.  The wind picked up, the waves tossed and Peter and the others, many of whom were experienced seamen, were afraid.  In the distance a man appeared, walking towards them on the water. It was Jesus, of course, and he asked them to take courage and be not afraid.  Peter called out, “Lord, if it be thou, bid me come unto thee on the water.”  The Lord simply said, “come” and Peter with faith took the steps out of the boat and walked on the water. As the wind blew and the waves lapped on his legs his focus wavered, his faith faltered and he began to sink.  “He cried, saying, Lord, save me. And immediately Jesus stretched forth his hand, and caught him” (Matthew 14:28-30).  

When the the young woman’s sermon was over, I rose to share a few remarks.  I recounted this story of Peter and then asked the question, “when was Peter all in? Was it when he stepped out of the boat and was walking on top of the water? Or was it when he was sinking and his faith was wavering and he was reaching out toward Jesus asking to be saved? He was literally “all in” at his low point, not his high point.  With all the feeling in my heart, I looked at the woman who spoke and told her that I knew that she was “all in.”  Her faith may not yet be perfect but she had the faith to step out of the boat. Even amidst her personal waves of trial, she had the faith and courage to reach out to him by coming to church and sharing her story with others.

All of us will find ourselves lacking when we compare other’s best to our worst qualities.  Jesus, the one who is actually our judge, doesn’t do that.  He sees us as we are and more importantly he sees us as we can become.  He simply asks us to “come.”  As we reach out to him, he is immediately there to catch us.  Our journey out of the water will not be easy. In fact Jesus later taught his apostles that it is impossible with men, “but with God all things are possible” (Matthew 19:26). 

For Christmas this year my daughter gave us a print of this, her favorite picture of Jesus. On the back she wrote, “we love this picture of Christ. It reminds us that when you feel sad or feel like you’re drowning, He is there for us. He is there to help lift us up. We love you and hope you feel Christ’s love always, but especially when you’re ‘drowning’ and need Him most.” Indeed, we need him most when we are “all in” the troubled waters of this life.  May we all feel of his love and saving power this Easter and all year.  I invite you to worship with us this Easter weekend as we listen to our prophets and apostles teach and testify of Him, our Savior and Redeemer at our General Conference.  The link can be found at www.churchofjesuschrist.org. 

 

COVID Letdown

 

I am not sure what just hit me. By all rights, I should be flying high right now.  COVID numbers have steadily decreased over the last few months.  The extra ICU has remained close.  I am well vaccinated. The vaccine efficacy data so far has shown an excellent response.  Most of my elderly patients have at least received their first vaccine.  My in-laws and my mother have now received both their shots.  I took a few days that had been slated to work in the ICU to go see my mother and had a nice visit.  To top it off, I was recently honored to receive the Joe Ansty Award for clinical excellence for 2020 at my hospital, Missouri Baptist.  Knowing that my peers at the hospital saw and recognized the efforts of me and my supporting team this last year was very emotional for me.  Yes, on all fronts, I should be in the very best of spirits.

The reality is that I have been more physically, mentally and emotionally exhausted than at any other time of my career these last two weeks.  Work at the office was busier than normal.  I had twice usual the number of patients in the hospital to take care of.  It seemed that I was having end of life discussions every single day.  Most of these patients I have known for more than 20 years.  It was disheartening to navigate through the stormy seas of COVID to then tell a patient that they were dying of cancer, a stroke or of heart disease.  At the office, it seemed that I was being pulled from all directions. On leaving a patient room there were times when my secretary had the ER on the phone, my assistant had a question and my nurse practitioner needed help with a patient she was seeing.  From the second I entered the hospital in the morning, I felt that I had to be totally engaged and “on my game.”  It wouldn’t let up till late in the evening.  Even then, the hospital would call, sometimes all through the night. 

“How,” I asked myself, “could I go go go all year long only to struggle now that life was getting back to normal?”  In my moments of reflection, I recognize some of the reasons for this.  First, when the adrenaline is running high and the stress levels are increased, I tend to function pretty well.  It is when I let down my guard that I am prone to a letdown. I don’t think I realized how tired my body truly was from the year long stress.  Secondly, I am truly just busier than normal at work.  Some of that was a back log of issues that were building from having to cancel clinic days to work in the hospital.  Some of it is from patients who have been keeping issues on the back burner and they are now feeling comfortable coming to the doctor to be evaluated.  My patient panel is getting older. My many 70-year olds are now 90.  As much as we as doctors try to prevent disease, all of us are mortal.

I frankly have hesitated to share what I have been feeling. After my blog on COVID Fatigue, one of my former patients, a retired psychiatrist, reached out concerned that I was headed for a mental breakdown.  I have decided to go ahead and post this, suspecting that I am certainly not alone in having stress this last year.  Taking the time to describe my feelings is a step towards healing. The last two days at work have been decidedly better: busy, but normal busy.  It has been such a blessing to come home to a supportive wife who has always been there for me.  My faith has certainly been sustaining. I am buoyed by prayers in my behalf. Focusing on my blessings helps.  Making time to exercise is my therapy time. It is therapeutic both mentally and physically. Lastly, as much as it wears me down, I truly do love my job.  What a privilege it is to be a partner in a patient’s life journey. The truth is that you and I can allow external forces to determine our demeanor or we can look past the darkness and allow the light of God to prevail in our lives. All of us have been beaten down this last year.  Let’s focus on what will keep us on the path to brighter days. 

Lessons from the ICU

Today the 4West ICU at Missouri Baptist Hospital is being closed down.  Hospital numbers are on the decline and our emergency service is no longer required.  It is a joyful day for all of us who have worked here over the last four months.  It is a beacon of hope that we as a community are on the path to returning to normal life.  These are days not soon to be forgotten.  Here are some of the lessons I have learned from working in the ICU:

COVID is Tough:

By now, I assume that all of you know someone who has had COVID or you may have had it yourself.  Chances are, the disease may have made the individual feel real bad for a few days but that was about it.  Most feel tired and worn out for a few weeks but get back to normal pretty quick.  Some of you, unfortunately, know people who were hospitalized and have even succumbed to the disease.  Unless you work in the hospital, it is hard to explain how bad COVID can get. With no visitors allowed family members have a hard time understanding how a love one could look and act so well just a few weeks prior and be at the brink of death a short time later.  When COVID hits hard, it hits really hard.  Most commonly it hits the lungs. Once its intense inflammatory reaction sets up in the lungs, it is very hard to recover.  We have learned better how to care for such patients but there is only so much that can be done.  When days turn into weeks, the inflammation causes scar tissue. Mechanical ventilation is now put off for as long as possible. Very few of those who are intubated survive the hospitalization.

In addition to the severe lung disease, respiratory (breathing) failure usually cascades into damage into other organ systems.  Such patients are more prone to blood clots which commonly travel to the lungs (pulmonary embolism) or less frequently to the brain (strokes).  The kidneys are often the first to be affected due to decreased oxygen deliver. Powerful steroids which are used to tamp down the inflammatory response commonly result in the acquisition of diabetes requiring every increasing doses of insulin to control.  The heart can be strained. Arrhythmias are common (atrial fibrillation) which can then trigger heart failure and low blood pressure. Each blow contributes to overall fatigue and even outright delirium.  Such patients are as complex as any we ever see in the hospital.

ICU Nurses are Tougher:

My colleagues and I have been in awe of our battle hardened ICU nurses.  They have literally been in the trenches from day one.  Coming into the ICU was a scary experience for us.  From my first shift, I could see that these nurses had their "game face on."  Their attention to detail was stellar and they were always on point. Despite their clearly superior level of experience in patient care, I never felt anything but support.  They were never condescending.  We quickly learned to work as a team.  What I lacked in knowing the intimate details of how to care for each problem, I was able to help them in understanding the overall disease process and why such problems were occurring.  When I was asked what I would miss most about working in the ICU by one of the nurses, I simply and easily replied, "working with all of you."

Power in Partners:

Though the idea of working in the ICU was a bit terrifying, we quickly learned and remembered that we know how to care for complex patients. We do it all the time in the office, they just aren't critically ill.  It really was like reliving my days as a resident physician in training.  I did learn that I am getting much too old to do 12 hour night shifts.  Luckily, I found younger colleagues who were willing to trade those for day shifts with me.  Even though we never worked side by side with each other, we worked as a team.  We scoured each other's notes, gleaming as much information from the chart as we could as we quickly got up to speed when coming on service.  Handing off the patients well to the one coming on for the next shift was crucial to providing excellent care. Those conversations were laced with an emotional understanding of what the next one would be dealing with.  It was a comfort to never feel uneasy about the physician coming on. When we would see each other in the doctor's lounge, we now had so much more in common.  We were all in this together.  When we started, our physician leader texted, "We got this!"  We still do.

Compassion is Key:

Every patient has a story.  Every patient has a family.  At the beginning of the pandemic, doctors would rely on nurses to examine the patients and use telemedicine to communicate with the patients to minimize risk.  As time went on and we could see that our personal protective equipment (PPE) was truly effective, we were able to spend more time with patients.  Despite the constant hum of the negative pressure fans, speaking through thick N95 masks and face shields, the patients truly appreciated a quick conversation.  Families who were desperate to know details of their loved one's condition were so appreciative of each phone conversation.  The nurses were excellent in giving daily updates.  Part of compassion is understanding when we have done all that we can do and having the difficult conversation to provide comfort rather than prolonging the dying experience.  I am passionate about allowing family to have time to say goodbye and ensuring that a patient is comfortable in their last moments. Any dignity that can be found in death is worth the stress of seeing one pass on.

Staying Strong:

Resiliency is measured one bite at a time, hour by hour and day by day.  Working in the ICU was no vacation from our usual practice. My patients still required ongoing daily care.  Thanks to my awesome team (see previous blog), we were able to do this together.  I couldn't allow myself to look too far ahead.  It was too overwhelming. By taking it one shift at a time, one patient at a time, I was able to keep going.  It is the same as my professional life has ever been but on a much higher scale.  As we come out of this pandemic we all need to pay attention to detail.  It will literally happen one mask and one vaccine at a time.  It requires persistent vigilance so that we never have to open up another emergency ICU again.  We are all in this together. "We got this!"

My Hero Helpers

 The days all roll together, one after another in a seemingly never-ending succession. My professional life ping pongs from keeping my practice of patients cared for to twelve hour shifts in the Intensive Care Unit.  Sprinkled in the cracks are weekly shifts in the Respiratory Care Clinic, teaching responsibilities with medical students and resident physicians from the Washington University School of Medicine and my usual monthly volunteer visits to Casa de Salud, a Spanish Speaking medical clinic. I have never been so busy. The demand has never been so great. As tired as I sometimes get, I have never felt that my skills have been so needed.  It has been invigorating and yet I realize that I can't keep up this pace long term. One truth stands clear and tall above all others: I could not fulfill any of these responsibilities without amazing people that support me and my colleagues during this intense time. They are my hero helpers.

First and foremost, I pay tribute to my wife and family.  She has been by my side in this journey since before medical school.  We married when I still had two more years of undergraduate school to complete.  I distinctly remember being told that I would never make it to Medical School having married so young.  Our first child was born before I finished college. We welcomed our other three in the years that followed. In medical school, I was able to focus completely on my studies because my home life was always taken care of.  My wife and I always considered that "we" graduated from medical school.  It was truly a team effort. It has been no different in the years that followed. During these busy days of the COVID pandemic she has been my rock and my support.

My nurse practitioner has been crucial for me to be able to work away from the office. The heavy load that I normally carry has landed squarely on her shoulders.  I am grateful for the trust that she has developed with my patients and her "can do" attitude.  We both feel so fortunate to work with our assistants who anticipate what we need, take care of the details and keep us smiling even when we may want to cry.  Our secretary makes sure things get done.  She can sweet talk her way into referrals, tests or anything we throw her way. It is truly a team effort.

At the end of each day, I make my way to the back of the office to change out of scrubs and clean up before going home.  Every single night, our cleaning team is there sanitizing the office so we can do it all again the next day.  I am greeted with smiles and wished a good night. They too have to live with the threat of exposure to this unseen virus.  Their position is not as visible as mine and certainly not as frequently praised.  Let me raise my voice to say, "God bless all of our house keeping staff both at the office and at the hospital."

Just as I have support staff at the office, those that work day after day in the Respiratory Care Clinic (RCC) make my heart swell with emotion and pride.  More dangerous than even the ICU where most patients have been in the hospital long enough that they are frankly not likely to be contagious anymore, those that come to the

RCC are often at the height of their ability to infect others.  Many of the patients are in pain, they are scared and feeling poorly.  Our do-it-all secretary greets them on the phone, when they come in the door, and calms their fears with persistent cheerfulness.  Our medical assistants efficiently take my orders as I come out of the exam room, process the labs and x-rays and keep things running smoothly.  Without this clinic the only real option would be the emergency room.

My colleagues and I who have worked in the Intensive Care Units these last few months have been impressed beyond measure by the nurses who work with us.  The critical care doctors will give us back up if we need it, but the nurses are the ones by our side day by day, hour by hour and minute by

minute.  It is hard to explain to others how sick COVID patients can get.  These nurses have been in the thick of this pandemic from day one.  We rejoice over those who recover but they have to face death on a nearly daily basis. These nurses are awesome.  They have been battle tested, are resilient and deserve all the adulation that we can give them.  When they come to me and say, "Dr. Fuller, do you think it would be good if..." the answer is pretty much always, "of course, what do you think is best?"  When a patient can't breath, they are the first ones to their side. When families call, they are the ones to answer the phone.  The nurses make sure that medicines are given on time, the monitors are working correctly, and that the patients are fed, cleaned and bathed.  They are heroes indeed!

Lastly, I pay tribute to my fellow physicians who have repeatedly stepped up, pitched in and gone the extra mile.  I am more than proud to be numbered among them. I have never felt a greater sense of camaraderie and togetherness.  We are living through an experience that has been unlike any other.  Our vocation is no longer just a career, it is truly a profession.

All of us are in this fight together.  We in the health care system are more than tired of this virus.  This pandemic will end but not anytime soon. In the meantime please wear your mask, keep your distance, be careful and get vaccinated when you are able.  Above all else, know that my heroes will be here to care for you and your loved ones.