The Doctors Are Scared

covid doctors are scared

Shared by fellow physician mom and blogger Anne Slater, MD

My friends, it starts.

More and more patients present to emergency departments across the country with viral respiratory syndromes, and now that testing is ramping up, confirmed cases double about every 2.5 days in the US, and deaths about every 3, consistent with the worst international experience.  Coronavirus pneumonia patients can crash quickly, requiring ventilator support within a day or two of getting admitted to the hospital.

Hospital ventilators are increasingly occupied by patients who will require them for weeks, not days like with typical pneumonia patients.  We don’t have enough ventilators for this rapidly increasing and prolonged need.  And these patients remain infectious for the duration of their illness—care teams’ exposure risk escalates with each patient admitted to the unit.  Places like Yale and Vanderbilt have already created overflow wards to care for the flood of patients that New York is already seeing.

Doctors and nurses across the country lack the most basic personal protective equipment (PPE).  Medical teams in China, Italy, and Iran wear hazmat suits like we saw during the Ebola outbreak in 2014.  In the US, we don’t even have enough masks and gowns.  We face a raging wildfire armed with squirt guns.  Our PPE will run out in days unless supplies are replenished now.  My colleagues and I are on the phone with our dentists, contractors, and even our patients themselves, looking for N95 masks, disposable gloves and the like.  This in the country that thinks it’s the best at everything.

I wrote last weekend about my friends on the ‘front lines’, my emergency, hospitalist, and intensivist colleagues.  They are the most qualified to care for the sickest patients.  Their exposure risk is the highest.  In China and Italy, and now in the US, these physicians are the ones falling critically ill and dying.  New grads have already been recruited to stem the tide in Italy.  Retired physicians have returned to bays and wards in New York.

My primary care colleagues and I have been asked whether we will volunteer to work in these high risk areas, for which we have neither the training nor the expertise anymore.  I have not managed ventilated patients in almost 20 years.

If I am called up, I will answer.  But I’m scared.

Both of my kids have asthma.  Though children appear largely spared from coronavirus death, hundreds of children were admitted with severe disease in China.  And my kids’ risk is likely higher than many of their peers’ because my husband and I are both physicians.  We work at different hospitals.  So each of us has a wide and unique exposure circle, both of which we bring home to overlap on our kids every day we see patients.  By the time I’m needed in the high intensity care areas, the situation will be truly catastrophic, and the risk to my family and me will be even greater.  Hubs and I have already agreed that should that happen, we should probably not live at home.  He and I will try to avoid having to answer that call at the same time.

There will be much more death and suffering before this ends.  And the end is still very far off.

You can help.

“We stay at work for you.  You stay home for us.”

I leave you with a personal story that I read tonight.  God bless Dr. Gilman.

https://www.facebook.com/plugins/post.php?href=https%3A%2F%2Fwww.facebook.com%2Fcleavon.gilman%2Fposts%2F10157045636977393&width=500“>From Dr. Cleavon Gilman, emergency physician in New York City, March 20, 2020:

6,211 cases in New York City.

Last night was insane; high volume and high acuity. Sick patients lie on stretchers hooked up to cardiac monitors that beep endlessly throughout the night. At one point I just stood at the nursing station and looked around. I guess this is what the pandemic will look like. There were at least 80 positive coronavirus virus patients in all 4 bays that required admission. Their age ranged from 20-90s, but each age group was represented equally. I’ve never seen so many people with pneumonias with rapid progressions. I try to discharge the younger patients with pneumonias, but when I walked them and check vital signs, their oxygen drops down to 85% and heartrate increases to the 140s. They are so fragile. A few of these patients were otherwise healthy, yet still stricken with pneumonia. A lot of patients had to be intubated for respiratory distress – they crash so quickly.

I’m really happy with the way leadership has responded to the crisis. Last night they deployed an anesthesia intubation team to help us with the vast amount of people being intubated and placed on ventilators. I intubated the prior two nights, so it was great to have others help, because aside from coronavirus patients, we still manage other emergencies such as strokes, brain bleeds, seizures, heart attacks, appendicitis, GI bleeds etc.

There are still a lot of people that come to the emergency room and want coronavirus testing, but we cannot test everyone, because there are not a lot tests. The coronavirus test is limited for patients being admitted because patients have to be cohorted with patients that have or don’t have coronavirus. Our main criteria for admission are shortness of breath and hypoxia, which have to be monitored closely.

What is shortness of breath? Imagine running full speed on a treadmill at an incline of 8 then stopping immediately and trying to speak to someone. That is what respiratory distress from coronavirus does to you. Patients cannot breathe at a rate of 40 times per minute for too long before they tire out.

Young patients usually do well on supplemental oxygen, but a portion of them desaturate on the floor and ultimately end up intubated.

I was fortunate to spend the night with our ED director Dr. Betty Chang, and residents Taylor Walsh and Marc Tarsillo (pictured below). Till next time.

#CleavonMDjournal

covid fb cleavon gilman nyc 3-20-2020

Standing By

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UGH. The tsunami is coming, my friends. The alarms have sounded for so long already.

And we KNOW what to do!  We can brace the shore for it and decrease loss of life.

I just spent all weekend working on operations reorg and mobilization–so proud of the teams who worked around the clock to prepare for the worst.  While we wind down non-essential practice functions, we ramp up in crisis mode.  We will redistribute clinical staff to where they are most needed.

But we need EVERYBODY to pitch in and help out.

Please please please do your part.  LEAD BY EXAMPLE.

I’m already wondering which of my friends will get sick. So many people I admire, dedicated professionals and teachers, people who make the world better, work in our emergency departments and on the hospital floors. They care for the sickest of the sick.

Please do your part to NOT put them in harm’s way.

I am a vector. You are a vector. We are all vectors. That is why we need to keep physically separate right now.

This kind of separation is temporary.

Let us tolerate it and help minimize the kind of separation that is permanent.

***

From Jennifer Leung, MD:
Takeaways from the UCSF COVID-19 town hall [this week]:

1. If you’re exposed to COVID, you’re likely to see symptoms in about 2-9 days, with median of 5 days.

2. The common symptoms are acute respiratory distress and fever, often high, which may be intermittent but can be persistent and last over 10 days.

3. Breakdown of cases: About 80% of those who contract COVID only get mildly ill; 14% get hospital-ill, 6-8% critically ill. The mortality rate seems to be between 1-3%, but that needs to be adjusted for age. Mortality is 10-15% over 80, and drops lower for younger cohorts.

4. The bulk of those who fall ill are aged 40-55, with 50 being the median. But being young and healthy (zero medical problems) does NOT rule out serious illness or death; it may just delay the time course to developing significant respiratory illness by about a week or longer.

5. Findings [suggest] that COVID-19 is spread simply through breathing, even without coughing [edit 3/17: I am still looking for primary source evidence for this; one experimental/model study showed the virus staying aerosolized for three hours; it is unclear what this means in real life]. It seems unlikely that contact with contaminated surfaces is a primary means of spread: “Don’t forget about hand washing, but if you don’t want to get infected, you can’t be in crowds.”

6. The virus spreads by air and in droplets (sneezing and coughing), but also via fecal-oral transmission. This is where hand washing with soap is key. And try to eat only cooked foods if you didn’t prepare them yourself.

7. COVID likely originated in bats. But for those sharing rumors that COVID came from Chinese people eating them, researchers now believe it went from bats to another animal species before jumping to humans, and that fecal-oral transmission was the likely vector. WASH YOUR HANDS.

8. There are no real treatments for COVID yet. Remdesivir has shown signs of reducing mortality but it is still in tests, is in short supply and only available under restriction. Steroids, a common treatment for respiratory illness, may make things worse.

9. The terminal phase of COVID is acute respiratory distress, treated by putting patients on a ventilator. We have 160K ventilators in the US. About 1M will need ventilators. Half will die in the first week; survivors stay on for 4 weeks. “We don’t have enough ventilators.”

10. …Italy is already overwhelmed. Many countries are just days behind Italy on the case curve. The US is actually breaking the curve–[due to severely limited availability of widespread testing].

11. 40-70% of the US is likely to get the virus. Around 150 million is the UCSF estimate, with a 1% rate of mortality. Which means 1.5 million Americans will likely die of this disease in the next 12-18 months.
To put this in context: In 2019, 606,880 Americans died of cancer.

12. We are “past containment” at this point, experts say. The [lack of early unified intervention made] it impossible to stop the spread—we can only slow it so healthcare can catch up. And no matter what anyone says: We won’t have a vaccine for at least 12 months.

Shrink and Separate for the Greater Good

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For every person you contact, you are indirectly contacting every other person they contact.

This is what I’m calling your ‘exposure circle.’ The more people you contact, the more your circle grows–exponentially.

The fundamental goal of social distancing is to
1) shrink each of our exposure circles and
2) minimize overlap of different exposure circles (and unless we only see people who only see us, every circle is different).

At this point we should assume community spread of SARS-CoV-2, the virus that causes COVID-19 illness. Travel to and from ‘hotbed’ areas is likely no longer the main source of new infections.

Each infected person is thought to infect, on average, 2 additional people (the basic reproduction number, or R0=2), so spread is exponential.

If you have a hard time picturing what this looks like, go to the last page of One Grain of Rice A Mathematical Folktake by Demi.  You can see the grid on Amazon by clicking the “Look Inside” icon.  Doubling one grain of rice every day yields over 536 million grains of rice on day 30, and over 1 billion total grains accumulated over all 30 days.

Because we have not been able to test widely in the United States, we cannot know who is infected and who is not. So targeted isolation is not feasible.

It may very well be that young healthy people are infected and don’t show symptoms, so they spread to many others out in community without knowing.

This is why school closures should NOT be seen as vacation, license to go shopping, eating out, seeing movies, partying, etc.

THIS is why we need to keep our distance from one another–all of us.

I know it sucks. I know it’s incredibly disruptive and feels like overkill. If it works, nothing will be that bad and we will think, why did we do all of that?

And that is, of course, the goal.

If we succeed, we may never know how bad it could have been.

If we fail, we will see all too soon and it will be too late to regret.

Why the Drastic Measures?

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On COVID-19 (Coronavirus Disease 2019), caused by the SARS-CoV-2 virus.

For up to date information:  https://www.cdc.gov/coronavirus/2019-ncov/summary.html

 

My friends, it’s been such a strange and surreal week.

I’m feeling so much more tense and agitated than I ever would have expected.

What keeps me really hopeful, though, is connection.

My colleagues and I have dug deep, cancelled our own spring break plans, and stood up in solidarity, ready to do what is needed to help one another take care of all of our patients.

Patients express empathy and patience for us their docs, which is so heartwarming.

They listen to my explanations for decisions to cancel gatherings and close schools. They understand when I describe what’s happening in Italy, and the difference between St. Louis and Philly during the 1918 Spanish flu pandemic.

Many are living the economic consequences of these decisions much more concretely and acutely than I, and their perspectives moderate my own.

I think the best thing we can all remember in the next several weeks is that we are all doing the best we can.  We are all in it together.

It’s stressful and scary for everybody, and sometimes we will lose our cool.

Now is the perfect time to call forth our best efforts at calm, compassion, empathy, and forgiveness.

And then wash our hands.

I share below a compilation of the media pieces that have helped me most in my communication with patients, with the most salient quotes below each respective link.  Maybe they will help you, too.

Onward.

 

https://www.wbur.org/news/2020/03/10/coronavirus-covid-19-massachusetts-hospital-capacity-ashish-jha?fbclid=IwAR3I0HXO028IGmJeyXV2ZhvEmUW56WO_EvE5ToOcjSsaeHkEGZxlS1vZQMg

“Some of the best epidemiologists in the world are estimating that between 40 and 70% of adults will end up getting an infection. Even if we begin with that low end of 40% of adults in Massachusetts, that’s 2 million people getting infected. If we take data from China that says 20% of people needed hospitalizations, that’s 400,000 hospitalizations. Even if we said ‘No, that’s too many, we can cut that in half,’ that’s 200,000 hospitalizations. At any given time in Massachusetts, we think there are [3,000 to] 4,000 hospital beds open at most … And so, if you start doing the numbers, you very quickly realize we do not have anywhere near capacity to take care of tens of thousands of people with [COVID-19] who might need hospitalization … But if we can spread that out over many, many, many months — ideally a year — then I think we have a shot of being able to take care of everybody who will need the care.”

How how does that happen, that it becomes spread out?

“So, what we know is that this idea that people talk about social distancing — this is why Harvard University today just canceled classes. In-person classes; we’re going online. In our offices, were now encouraging everybody to work remotely … Certainly all large gatherings should close.”

 

https://www.theatlantic.com/ideas/archive/2020/03/coronavirus-cancel-everything/607675/

When the influenza epidemic of 1918 infected a quarter of the U.S. population, killing hundreds of thousands nationally and millions across the globe, seemingly small choices made the difference between life and death.

As the disease was spreading, Wilmer Krusen, Philadelphia’s health commissioner, allowed a huge parade to take place on September 28; some 200,000 people marched. In the following days and weeks, the bodies piled up in the city’s morgues. By the end of the season, 12,000 residents had died.

In St. Louis, a public-health commissioner named Max Starkloff decided to shut the city down. Ignoring the objections of influential businessmen, he closed the city’s schools, bars, cinemas, and sporting events. Thanks to his bold and unpopular actions, the per capita fatality rate in St. Louis was half that of Philadelphia. (In total, roughly 1,700 people died from influenza in St Louis.)

In the coming days, thousands of people across the country will face the choice between becoming a Wilmer Krusen or a Max Starkloff.

In the moment, it will seem easier to follow Krusen’s example. For a few days, while none of your peers are taking the same steps, moving classes online or canceling campaign events will seem profoundly odd. People are going to get angry. You will be ridiculed as an extremist or an alarmist. But it is still the right thing to do.

 

https://www.sciencemag.org/news/2020/03/does-closing-schools-slow-spread-novel-coronavirus?fbclid=IwAR0DZmornmQrYZJdgnz6ELAIl4cNocAl1nC6UExyZ4dIGByhaXrYV4PEcwo

When we engage in social distancing, it’s not so much that you don’t get infected yourself. The real advantage is that by removing yourself from circulation, you stop all the paths of this virus through you. You are doing a social service, you are helping the community. Employees who want to work from home [and are able to] can work from home.

 

Italy’s experience:

https://www.theatlantic.com/ideas/archive/2020/03/who-gets-hospital-bed/607807/

Two weeks ago, Italy had 322 confirmed cases of the coronavirus. At that point, doctors in the country’s hospitals could lavish significant attention on each stricken patient.

One week ago, Italy had 2,502 cases of the virus, which causes the disease known as COVID-19. At that point, doctors in the country’s hospitals could still perform the most lifesaving functions by artificially ventilating patients who experienced acute breathing difficulties.

Today, Italy has 10,149 cases of the coronavirus. There are now simply too many patients for each one of them to receive adequate care. Doctors and nurses are unable to tend to everybody. They lack machines to ventilate all those gasping for air.

Now the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has published guidelines for the criteria that doctors and nurses should follow in these extraordinary circumstances. The document begins by likening the moral choices facing Italian doctors to the forms of wartime triage that are required in the field of “catastrophe medicine.” Instead of providing intensive care to all patients who need it, its authors suggest, it may become necessary to follow “the most widely shared criteria regarding distributive justice and the appropriate allocation of limited health resources.”

The principle they settle upon is utilitarian. “Informed by the principle of maximizing benefits for the largest number,” they suggest that “the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care.”

 

On taking the larger, community-centered view:

https://grownandflown.com/finest-hour-covid-19/?fbclid=IwAR34zisTQM3zb6JzF3u3obqL9EfkNEOwo7-x8R4QOciwJ36c8QA1ibCNeVY

Your losses are real. Your disappointments are real. Your hardships are real. I don’t mean to make light or to minimize the difficulty ahead for you, your family or community.

But this isn’t like other illnesses and we don’t get to act like it is. It’s more contagious, it’s more fatal—and most importantly, even if it can be managed. It can’t be managed at a massive scale—anywhere. We need this thing to move slowly enough for our collective national and worldwide medical systems to hold the very ill so that all of the very ill can get taken care of.

So what is our work? Yes, you need to wash your hands and stay home if you are sick. But the biggest work you can do is expand your heart and your mind to see yourself and see your family as part of a much bigger community that can have a massive—hugely massive—impact on the lives of other people.

You can help by canceling anything that requires a group gathering. You can help by not using the medical system unless it is urgent. You can help by staying home if you are sick. You can help by cooking or shopping or doing errands for a friend who needs to stay home. You can help by watching someone’s kid if they need to cover for someone else at work. You can help by ordering take-out from your local restaurants. Eat the food yourself or find someone who needs it. You can help by offering to help bring someone’s college student home or house out-of-town students if you have extra rooms. You can help by asking yourself, “What can I and my family do to help?” “What can we offer?” You can help by seeing yourself as part of something bigger than yourself.

 

Dr. Anthony Fauci on how to counsel patients, 13 min New England Journal of  Medicine podcast with transcript:

https://podcasts.jwatch.org/index.php/podcast-256-anthony-fauci-talking-with-patients-about-covid-19/2020/03/10/?query=RPF&fbclid=IwAR0gIzU7M5WOyC4964CbKnglcNw_wlSODvT6-KAYodWdKCMyrQWou2jyAK0

 

 

Sexism and Apologies 2020

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“If you say, ‘Yeah, there was sexism in this race,’ everyone says, ‘Whiner!’ If you say, ‘No, there was no sexism, about a bazillion women think, ‘What planet do you live on?’”

That is how Senator Elizabeth Warren answered a reporter when asked whether she thought gender played a role in her suspending her presidential campaign.  I recommend watching the whole video clip.  In case anyone wonders: if the question even needs to be asked, then yes, gender played a role.  But Senator Warren rightly called out the question for what it is: a trap for any woman running for high elected office.  Her statement summarizes it succinctly; she knows what’s what, and she names it without apology.

I was more upset than I expected when Aunt Eliz Crusader ended her campaign.   Megan Garber expressed the story of my profound disappointment eloquently in her piece for The Atlantic:  “America Punished Elizabeth Warren for her Competence”.  Basically she elaborates the apparently inevitable social equation for women:

Competent  +  Vocal  +  Unapologetic   =   “Strident”  +  “Shrill” +  “Condescending”

The past two weeks I have had a series of encounters wherein I find myself voicing opinions and positions more firmly than I might have in the past.  I feel confident and grounded in my knowledge and expertise.  I am professional and respectful.  I apologized for writing a long email, even though the words were necessary and clear.  My strong woman mentor reminded me to save apologies for when I actually commit a transgression.

What I have learned (perhaps again) in this time, however, is that relationship discord, even just the possibility of it, is what distresses me the most.  How will I be perceived for voicing my concerns, for advocating for my peers and teams?  How will a negative perception undermine my effectiveness?  Will it cost me my seat at this table or others?

Does any man ask himself these questions?

Given that I was already knee deep in vulnerability and self-doubt around these encounters, the Atlantic piece poked my fears and prodded them to the surface.  It shook me.  It also made me angry that here we still are, in 2020, unable to accept, let alone embrace, competent, vocal, and unapologetic women in leadership.  And it’s not just men; countless women also disavow their sisters.

I vented my disappointment on Facebook (of course):

“So it is down to three Old White Men.  Very disappointing.”

A friend tried to make light of the situation, pointing out that Donald Trump is the youngest of the three.  This attempt at levity (from the Right) felt like a nemesis rubbing salt in my fresh wound.  Twice I rebuffed; twice he persisted.  Finally I (voiced):  “I feel ignored and dismissed when I express distress and you make light of it.  Perhaps my distress is not clear to you, because you only know me through social media [we were friendly acquaintances in high school]; you may not know how upset I am.  But after two replies by me rejecting your attempt at humor, to have you schooling me [that humor is a ‘primary’ way] of dealing with [politics] just makes me more angry.”

Turns out he had mistyped; he’d meant to write that humor is one of his primary ways of coping with the absurdity of politics.  He apologized to me.  It felt sincere.  I was consoled, and I thanked him.

Competent and vocal.  Confident and unapologetic.  Respectful and humble.

We need all of these qualities and more to be true leaders.  Women, arguably, must work harder than our male counterparts to prove that we possess all of them.  Then we get punished when the proof proves irrefutable.  How sadly ironic.  The truth is we need many more of our leaders, men and women alike, to own, exude, and model these virtues.  The last two are not weak, though they may feel profoundly vulnerable, which is not the same thing.

I feel urgent impatience at the state of sexism in America.  But I know how to soothe and manage myself; I can reclaim the patient urgency of fierce optimism at my core.

I will persist.

Aunt Eliz has shown me how.

Caring for One Another

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Last Saturday a patient cared about me.

He had severe abdominal pain that had kept him up all night and he needed advice.  By the time we agreed on a plan he had apologized, at least three times, for ‘bugging’ me on the weekend.

I explained that it’s okay to ask for help on weekends. I’m happy to help if I can, and the relationship is the most meaningful part of my work.  I also thanked him for not abusing that relationship—for not taking me for granted, for seeing me not as a transactional service provider, but as a person with a life outside of work.

When we feel seen and appreciated, life is easier to take and we function better.

* * * * *

Recently I’m thinking about organizational values and mission statements.

For the most part I find them superficial and unhelpful, wordy and convoluted.

As I consider the team I have led the past two years, I feel proud that although we have not formally written mission or values statements, we are nonetheless clear on both.  We define them in succinct language, gauge how we manifest them through action, and reconcile behaviors, conflicts, and initiatives against them regularly.

Our values, collectively adopted one year ago:

  1. Fun, joy, creativity
  2. Collaboration and Connection
  3. Accountability
  4. Kindness and Compassion

Reviewing the list, I see that caring for one another serves as the foundation for this house.  This applies both to the team’s inner work, as well as anything facing outward toward patients.

It is of course our responsibility as professional caregivers to manage ourselves and show up our best for our patients.  I expect patients to treat our team with respect, but we should not necessarily feel entitled to their caring about us, per se.  It is our job to care for them; the relationship is inherently imbalanced in that way.  In order to do that well, we the team must also care for and support one another in service of our vocation.

So every once in a while, when a patient expresses genuine caring for me or a member of the team, in addition to appreciation for a job well done, it really brightens our day.  It keeps us going.  It makes all the unappreciative, and even abusive, encounters worth it.

Thus, we march on.  We remember why we do this work and we hold each other up.

* * * * *

Please know how much your expressions of affirmation matter to your medical team.

We’re all here caring for each other in this life.  The more we can remember that and act on it, the better off we will all be, no?

What Makes You a Leader?

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Is it your title?  Your reputation?
Is it your status?  Your paycheck?

“If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”

This quote is attributed to John Quincy Adams, but there is apparently no evidence that he actually said it.  Dolly Parton, on the other hand, said,

“If your actions create a legacy that inspires others to dream more, learn more, do more and become more, then, you are an excellent leader.”

Your actions make you a leader.
Anybody can lead, as long as people are willing to follow.
So what makes people follow?

I think it’s actions grounded in:
Conviction
Authenticity
Openness
Inclusion
Transparency

Accountability
Resonance
Collaboration
Belonging
Integrity
Honesty
Humility
Consistency            …what else?

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So:  How do you lead others?  How aware are you of your leadership, day to day, moment to moment?  How intentional are you about it?
What do you lead others to and for?
What is your purpose in leading?
What is your goal for those you lead?

What is your goal for your cause?

What do you want from your followers?
What do they need from you?
How will you make it so that your cause outlives and continues to flourish without you?

Great leaders do not always know the answers to all of these questions.

But they ask and consider them, regularly, honestly, and humbly.