COVID-19
I agree with the following, written by cardiologist James Stein 5/7/20, and another by Jesse Charles 5/1/20. I would add that attempts by the government and fellow citizens to force people to do things will not produce good results—at least not politically. The problem is that bad behavior is mostly informed by bad media, not by science.
A SCIENTIFIC PERSPECTIVE IS A SANE PERSPECTIVE
COVID-19 UPDATE AS WE START TO LEAVE OUR COCOONS
The purpose of this post is to provide a perspective on the intense but expected anxiety so many people are experiencing as they prepare to leave the shelter of their homes. My opinions are not those of my employers and are not meant to invalidate anyone else’s – they simply are my perspective on managing risk.
In March, we did not know much about COVID-19 other than the incredibly scary news reports from overrun hospitals in China, Italy, and other parts of Europe. The media was filled with scary pictures of chest CT scans, personal stories of people who decompensated quickly with shortness of breath, overwhelmed health care systems, and deaths. We heard confusing and widely varying estimates for risk of getting infected and of dying – some estimates were quite high.
Courtesy: CDC
Key point #1:
The COVID-19 we are facing now is the same disease it was 2 months ago. The “shelter at home” orders were the right step from a public health standpoint to make sure we flattened the curve and didn’t overrun the health care system which would have led to excess preventable deaths. It also bought us time to learn about the disease’s dynamics, preventive measures, and best treatment strategies – and we did. For hospitalized patients, we have learned to avoid early intubation, to use prone ventilation, and that remdesivir probably reduces time to recovery. We have learned how to best use and preserve PPE. We also know that several therapies suggested early on probably don’t do much and may even cause harm (ie, azithromycin, chloroquine, hydroxychloroquine, lopinavir/ritonavir). But all of our social distancing did not change the disease. Take home: We flattened the curve and with it our economy and psyches, but the disease itself is still here.
Key point #2:
COVID-19 is more deadly than seasonal influenza (about 5-10x so), but not nearly as deadly as Ebola, Rabies, or Marburg Hemorrhagic Fever where 25-90% of people who get infected die. COVID-19’s case fatality rate is about 0.8-1.5% overall, but much higher if you are 60-69 years old (3-4%), 70-79 years old (7-9%), and especially so if you are over 80 years old (CFR 13-17%). It is much lower if you are under 50 years old (<0.6%). The infection fatality rate is about half of these numbers. Take home: COVID-19 is dangerous, but the vast majority of people who get it, survive it. About 15% of people get very ill and could stay ill for a long time. We are going to be dealing with it for a long time.
Key point #3:
SARS-CoV-2 is very contagious, but not as contagious as Measles, Mumps, or even certain strains of pandemic Influenza. It is spread by respiratory droplets and aerosols, not food and incidental contact. Take home: social distancing, not touching our faces, and good hand hygiene are the key weapons to stop the spread. Masks could make a difference, too, especially in public places where people congregate. Incidental contact is not really an issue, nor is food.
What does this all mean as we return to work and public life?
COVID-19 is not going away anytime soon. It may not go away for a year or two and may not be eradicated for many years, so we have to learn to live with it and do what we can to mitigate (reduce) risk. That means being willing to accept *some* level of risk to live our lives as we desire. I can’t decide that level of risk for you – only you can make that decision. There are few certainties in pandemic risk management other than that fact that some people will die, some people in low risk groups will die, and some people in high risk groups will survive. It’s about probability.
Here is some guidance – my point of view, not judging yours:
1. People over 60 years old are at higher risk of severe disease – people over 70 years old, even more so. They should be willing to tolerate less risk than people under 50 years old and should be extra careful. Some chronic diseases like heart disease and COPD increase risk, but it is not clear if other diseases like obesity, asthma, immune disorders, etc. increase risk appreciably. It looks like asthma and inflammatory bowel disease might not be as high risk as we thought, but we are not sure - their risks might be too small to pick up, or they might be associated with things that put them at higher risk.
People over 60-70 years old probably should continue to be very vigilant about limiting exposures if they can. However, not seeing family – especially children and grandchildren – can take a serious emotional toll, so I encourage people to be creative and flexible. For example, in-person visits are not crazy – consider one, especially if you have been isolated and have no symptoms. They are especially safe in the early days after restrictions are lifted in places like Madison or parts of major cities where there is very little community transmission. Families can decide how much mingling they are comfortable with - if they want to hug and eat together, distance together with masks, or just stay apart and continue using video-conferencing and the telephone to stay in contact. If you choose to intermingle, remember to practice good hand hygiene, don’t share plates/forks/spoons/cups, don’t share towels, and don’t sleep together.
2. Social distancing, not touching your face, and washing/sanitizing your hands are the key prevention interventions. They are vastly more important than anything else you do. Wearing a fabric mask is a good idea in crowded public place like a grocery store or public transportation, but you absolutely must distance, practice good hand hygiene, and don’t touch your face. Wearing gloves is not helpful (the virus does not get in through the skin) and may increase your risk because you likely won’t washing or sanitize your hands when they are on, you will drop things, and touch your face.
3. Be a good citizen. If you think you might be sick, stay home. If you are going to cough or sneeze, turn away from people, block it, and sanitize your hands immediately after.
4. Use common sense. Dial down the anxiety. If you are out taking a walk and someone walks past you, that brief (near) contact is so low risk that it doesn’t make sense to get scared. Smile at them as they approach, turn your head away as they pass, move on. The smile will be more therapeutic than the passing is dangerous. Similarly, if someone bumps into you at the grocery store or reaches past you for a loaf of bread, don’t stress - it is a very low risk encounter, also - as long as they didn’t cough or sneeze in your face (one reason we wear cloth masks in public!).
5. Use common sense, part II. Dial down the obsessiveness. There really is no reason to go crazy sanitizing items that come into your house from outside, like groceries and packages. For it to be a risk, the delivery person would need to be infectious, cough or sneeze some droplets on your package, you touch the droplet, then touch your face, and then it invades your respiratory epithelium. There would need to be enough viral load and the virions would need to survive long enough for you to get infected. It could happen, but it’s pretty unlikely. If you want to have a staging station for 1-2 days before you put things away, sure, no problem. You also can simply wipe things off before they come in to your house - that is fine is fine too. For an isolated family, it makes no sense to obsessively wipe down every surface every day (or several times a day). Door knobs, toilet handles, commonly trafficked light switches could get a wipe off each day, but it takes a lot of time and emotional energy to do all those things and they have marginal benefits. We don’t need to create a sterile operating room-like living space. Compared to keeping your hands out of your mouth, good hand hygiene, and cleaning food before serving it, these behaviors might be more maladaptive than protective.
6. There are few absolutes, so please get comfortable accepting some calculated risks, otherwise you might be isolating yourself for a really, really long time. Figure out how you can be in public and interact with people without fear.
We are social creatures.
We need each other. We will survive with and because of each other. Social distancing just means that we connect differently. Being afraid makes us contract and shut each other out. I hope we can fill that space created by fear and contraction with meaningful connections and learn to be less afraid of each of other.
AN INTENSELY PERSONAL DOCTOR’S PERSPECTIVE
Courtesy Jesse Charles (Facebook)
Copied below is an update I wrote to my family and friends about my time serving in Brooklyn [Dr. Charles is from Missoula, MT].
I was hesitant to post this. It is an intensely personal reflection on my experiences. But then an ER doc in NY committed suicide, and I couldn’t stop thinking about her suffering and the suffering that her family now has to endure.
We call health care workers heroes, and then put them in impossible positions. These experiences are traumatic, and in her case, the trauma was complete.
***
Hello all,
I’m writing to give an update and to share some of my experiences and reflections on my time serving here in Brooklyn. I struggled to find the words to capture my experience, and so I just started writing my memories.
The following is mostly a stream of consciousness, so I apologize if it runs on. Where there are names, they are made up for privacy.
Mr. Pullman is a 78 year old man. I met him when I switched from serving in the ED to the 'gen med floors' caring for patients admitted to the hospital with COVID. On rounds that first morning, he seemed unconscious, but could raise his eyebrows and almost whisper, indicating that he was in there somewhere. It was clear from his sunken eyes that he was wasting away. Through his oxygen mask I could see that his mouth was dry, his teeth were caked in some sort of yellowish resin, his tongue cracked.
I placed my hand on his face, and leaned in close and spoke his name, in the hopes that he would come to. He moved his eyebrows, attempted to whisper, but could not manage. I learned later that day that he and his wife had contracted the virus at church. They were both admitted at the same time. He had been doing well at the time, on oxygen but breathing easily. Shortly after his wife died. After that he stopped eating and drinking.
I was told that he had no other family.
After rounds I went in his room to clean his mouth out and try to get him to drink. I spoon fed him sips of water and protein shake, but he was too weak, and couldn't stop from choking on the water.
He tried to tell me something, but I could not make it out. My heart suspected he wanted to fight no longer.
That night I lost sleep thinking of him, edging towards a death that would end in a mass unmarked grave in Potter's Field, where for centuries they have buried the bodies of the vast unclaimed in this city.
When I saw him the next morning, his mouth was wet, but he was unresponsive.
I asked around and discovered that he did in fact have children.
I called and learned to my dismay that no one had contacted them in over a week.
At that time, their mother had just died. They didn't get to see her or talk to her before she passed. They could not mourn as a family. Their mother was dead, their father was in the hospital, on oxygen and doing well, but alone. For a while they kept in touch through the phone. But then he stopped answering. A man of few words, they presumed he was just sick of talking. They tried to get through but couldn't get any answers.
The next they heard was from me, saying that he was very weak, and likely to die. They did not know that he had lost his spirit when his wife died.
I talked to his daughter and two sons, one after the other delivering the news. Each conversation included the same desperate plea:
Can I see him? No. That would put you and the community at risk.
We agreed that we needed to put a feeding tube in to get him nutrition and hydration.
Somewhere in that lost week he had become severely dehydrated, his blood excessively salty, and his kidneys had gone into failure.
The only hope was to feed him through a tube into his stomach, and continue to give him fluid through an IV.
The next morning he could raise his eyebrows and open his eyes slightly, but could not focus them. He was more responsive than he had been in days. I took the opportunity to arrange a video chat with his children. Not knowing if this would be the last. Each time giving them the same warning:
"I want to prepare you for what you're about to see. Your father looks very different than the last time you saw him. There is a tube in his nose, that is what feeds him, the mask is what is delivering his oxygen. He may not focus his eyes but I think he can hear you."
His daughter cried freely in this moment, but when I told his son, he broke down sobbing. I watched him shake his head to fight the tears to show a stoic face to his father. I watched as the son, not wanting his father to see his tears through the phone, buried his emotions deeper. It is a cruel fate that as men are raised, they are stripped of the capacity to freely show their pain.
Each time I showed them their father, there was a pause, and then 'hi papi'.
Each time Mr. Pullman raised his eyebrows, but did not focus his eyes. He tried to speak when he heard his daughter.
Each moment felt so inadequate to me. So unjust.
But his daughter told me that she had been praying for this opportunity all week.
His son, crying, said that he couldn't find the words to thank me. I told him my father was near the same age, and that I couldn't imagine being in his position, my mother dead, and my father inaccessible. At this he broke down again. In my time here I hadn’t cried until now, writing these words, remembering this moment.
There are over ten thousand of these stories in this city. And more to come. Ten thousand lives lost because a viral particle jumped from a bat to a human.
The woman who we coded the other day, whose mother died of COVID, whose sister died of COVID, whose other sister received a call that day informing her that now most of her family died in 2 weeks. All of them taken by a virus that started in a place she'll probably never even have the opportunity to travel to.
She was 53. I was the second person to do chest compressions, and the last; interrupted by a person I've never met telling me that she was dead and not coming back.
It felt so sudden and cold the way he said it.
Who knows what he's been through...
There are 78 bodies in a refrigerated truck outside, I wonder how many he has seen pass. On average 15 people dying a day in this hospital for weeks.
I think of the nurse standing at the end of the bed, tears welling in her eyes as she said: "She was just talking to me, we thought she was going home, and then she just...died." She walked out and locked herself in the bathroom.
I closed the woman’s eyes and covered her with a sheet.
The hospital staff are not immune. 5 have died. Family members too.
And yet, there are still moments of happiness. The pregnant woman intubated in the ICU, forced to deliver early, who is now off oxygen, her baby alive, but premature. The sound of 'three little birds' playing over the hospital loudspeaker, when a patient who had been intubated, walks out of the hospital breathing free air.
For me personally, it has been the patients who I first saw while working in the ER. They came in like all the others: feverish, coughing, and short of breath; each one of them afraid, each one of them alone. I evaluated them, made sure they had water and blankets; anything that could provide them some measure of comfort. I arrived the following days to find them still in the ER because the hospital was so full. Alarms sounding all night, and patients coding around them.
Sleep, that most essential of medicines, is completely inaccessible.
Those patients were eventually moved to the general medicine floor. Sick enough to need oxygen, but not sick enough to be intubated. As the outbreak plateaued the ER slowed down, and I transitioned to caring for admitted patients. I discovered that these same two patients were on my service, and requested to care for them.
Over the following days we became close.
I would sit in head-to-toe PPE, asking them about their lives, their families, their questions. We were advised to minimize patient contact, but that felt like the only true medicine I could provide.
Each morning the same routine:
Good morning Mrs. Y, Good morning Mr. Z, Let’s check your Oxygen. Check the saturation on oxygen, and off oxygen; and if they were strong enough, sitting and walking.
In the free time of the afternoon, returning to re check on them, lingering to hear their stories.
Day by day they slowly improved. Yesterday I discharged one of them, and today the other.
When I first met him he would say very little to me. I presumed it was the justified mistrust that some black men have of the medical establishment, or just the barriers between us.
On the morning he walked out of the hospital, he took me by surprise by breaking into tears and hugging me. My face shield pressed against my face. My body slumped as though I was in the arms of my father.
He's the only person I've hugged other than my partner in over a month. I needed it just as much as he did.
We agreed that some day, 'when the world is right again', I would come back to New York, and we would get coffee. We could have a real conversation, one where neither of our faces were hidden.
Set against it all is the pandemic of poverty and crushing racial inequality.
You read the statistics in the news,
“In Louisiana, blacks account for 70 percent of the deaths but 33 percent of the population.”
These numbers are repeated all over the country. Scrolling through your phone, they are just digits.
But each day it is laid out in the flesh. I walk through the park in this largely gentrified neighborhood. The people I pass are mostly white, and mostly young. But when I enter the hospital, nearly all of my patients are black. Those that aren't are from other vulnerable populations, the disabled, the mentally ill...
This virus has laid bare what we already know to be true:
That health and well being is a luxury in this country, that sickness is a burden we do not share equally.
That even without the virus, each year 245,000 people die because of poverty, 175,000 because of racial inequity.
How would we react if poverty was new, if racism was mysterious? If each day we kept a running tally on the nightly news of those whose lives were cut short by the systems they were born into, and could not escape?
Would we shut down our world, put our lives on hold, forego physical intimacy with our loved ones until we had a more just and equitable society?
It occurred to me today that the era in which we live is largely a digital, pick your own reality world; that we have so few shared experiences. This crisis, in ways both minuscule and devastating, is a shared experience for us all. On some level we are all losing something: our hopes for the future, our family, the physical comfort of friends and loved ones.
The morning after I wrote these thoughts, Mr. Pullman was struggling to breathe. Suspecting that he might not last the day, I offered to bring his children in to say goodbye. Two said yes, the other was too distraught to come. I helped them get dressed in protective equipment and brought them up to the room. His eyes lit up when he saw them. He tried to speak but could not. I left them to have a private moment with their father. I don’t know what happened in those moments. But on her way out, his daughter wept, and told me that her father had kissed her hand.
He passed later that evening.
It is possible that his death was avoidable. In a just world, the fact that he was black would not have meant that he was more likely to get the virus. It would not have meant that he was more likely to die from the virus. And it would not have meant that his hospital lacked the resources to give him the best chance of living.
This hospital is filled with some of the most dedicated, hard working people I've had the privilege of working with. Unfortunately it is underfunded and understaffed on a good day. With the surge of COVID patients, that only became more true. I have seen tragic lapses in care and communication that might not have happened at a hospital that was better staffed and funded. These were not human failings. They were the failings of a system. This is not the fault of the staff, who are overworked on a good day. No amount of heroism on the part of healthcare workers can overcome a system which distributes resources so unjustly.
I knew that I would come out of this experience with a great deal of sorrow. What I did not expect was the anger. I grew up poor. But for the color of my skin I could be that young man whose father is dying.
I hope I can channel it.
I hope that America can channel it.
I hope that this is the start of a new era in our lives.
I hope we can take this experience, and let it forge us into a stronger people, into a society that remembers that our origins are communal, that we are strongest when we stand for each other, rather than ourselves.
That is all I have for you.
Other than this Rilke quote I was reminded of the other day:
“Let everything happen to you
Beauty and terror
Just keep going
No feeling is final”
With Love,
Jesse
If you are only going to read one article about what these families are experiencing, read this:
https://www.newyorker.com/…/texts-from-my-father-in-elmhurs…