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