COVID Lessons

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

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

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

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

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

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

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

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

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

My White Privilege

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

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

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

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

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

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

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

A Symbol of Hope

Remembering the Fallen, Honoring the Flag

 

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

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

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

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

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

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

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

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

Black Lives Matter

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

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

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

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

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

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

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

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

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

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

Play Ball

Playing Ball in 1977

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

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

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

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

A Bitter Pill

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

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

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

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

Pandemic Paychecks

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

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

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

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

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