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.

Time to Vaccinate

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

How the vaccines work: 

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

Activating the Immune Response 

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

Cell Delivery 

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

Foreign Material 

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

Side Effects 

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

Safety 

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

Bottom Line 

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

Staring Death in the Face

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

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

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

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

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

The Breath of Life

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

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

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

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

The Eyes of COVID

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

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

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

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

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

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

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

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

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

COVID Fatigue

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

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

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

St. Louis Area Hospitalizations

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

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

Good Job

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

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

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

You're doing a good job

Don't get too down

The world needs you now

Know that you matter"

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

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

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

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

COVID Lessons

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

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

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

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

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

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

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

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

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

My White Privilege

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

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

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

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

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

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

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

A Symbol of Hope

Remembering the Fallen, Honoring the Flag

 

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

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

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

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

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

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

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

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