How Do We Get Better?

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It is Week 5 of sheltering in place for many of us.  How are you feeling?  What emotions occur most often?  To where and on whom are they directed?  How do you see the future, and what does that feel like?

Who do we want to be on the other side if this crisis?

For all our sakes, I hope we can be more patient, kind, empathic, open-minded, thoughtful, intentional, and connected.  The COVID-19 pandemic shows us what ultimate paradox really means—trauma and grief on a scale not seen in generations, as well as an opportunity for unprecedented growth, both as individuals and as a society.

I think about the risks and possibilities as both a clinician and citizen.  The experiences overlap, as do the strategies to mitigate suffering.  I am so grateful that physician burnout and well-being has already been addressed in so many institutions, and at so many levels, before this crisis hit.  Programs like physician peer support and Balint Groups show us that our leadership cares for our well-being, or at least recognizes the need for organizational support of it.  Employee Assistance Programs and the like are much more visible now, and hopefully barriers to access are also down.  Everywhere I see offers for formal organizational support and ‘wellness.’

But what will really make the difference in the end?  How will we really grow into our best selves through this, the greatest global challenge of most of our lives so far?

I think it will be in our small, day to day, apparently mundane interactions.

Too often we underestimate the impact of our milieu on our attitudes, thoughts, words, and actions—how we are impacted by our environment, and how we impact it in return.

A wise friend observed two groups of people responding to COVID-19.  One sees the pandemic in terms of ‘what’s happening to me.’  The other experiences it as ‘what’s happening to all of us.’  This is a falsely dichotomous oversimplification, obviously.  But it may be instructive to notice one day this week, if we were to categorize our own thinking/feeling/speaking/acting with regard to COVID, where would we land more of the time?

I’m reminded of the stages of tribal culture described by David Logan and colleagues in their book, Tribal Leadership, and presented eloquently in his TED talk.  I have discussed this idea in previous posts.

The visual above encapsulates Logan et al’s theory of tribal culture.  Their work aims to advance groups from lower to higher levels of culture and performance.  In this framework, the currency of cultural economy is language.  Each tribe member’s dominant cultural stage mindset emanates in their words, and is represented/encapsulated in each stage’s mantra above.

Those who experience COVID-19 as ‘what’s happening to me’ likely live in the lower three stages most of the time—self-absorbed, competing, uninterested in personal or societal connection and growth.  Those able to see how ‘this is happening to us all’ have made the shift toward an Outward Mindset, seeing their node selves as inextricable members of a larger, interconnected system.  For a system to function well, grow, and sustain itself best through crisis after crisis, it must achieve a collective “We’re great” or “Life is Great” mindset.

Whom do you know on your team, among your friends, or in your family, who lives these words (most of the time)?  How do you feel when you’re around them?  What do you hear them saying right now? What energy do they exude?  When I meet people like this in my life, I feel calm, soothed.  They remind me to be humble, and to remember what I can do to help, both myself and others.  I feel connected in their presence; I recall my strengths and potential for contribution, and I’m motivated to act accordingly.  They give me hope.

So what do I hear them saying, what language do they speak that elevates our communal culture?

First, they avoid ad hominem.  They refrain not just from political rhetoric and attacks; they don’t make generalizations about groups based on race, gender, geography, social class, etc.  They also withhold judgment—they entertain various stories about people’s motivation, circumstances, and values, rather than jumping to oversimplified conclusions based on their own biases.

Second, they empathize.  They strive to relate to each person they’re with, as well ‘the others’.  And if they can’t do that, they validate the others’ feelings.  “That’s so hard,” can be the most soothing words a person can hear when they’re struggling and suffering. And “Well, we don’t know what they’re living,” reminds me to be humble.

Third, they offer hope.  But it’s not false hope or superficial, Pollyannish positivity.  They honestly believe in and see the light at the end of the tunnel, and they point to it for our benefit.  They do this by asking, “What do you need?”  “How can I help?” and saying simply, “I’m here.”

When I come across people like this, I want to be around them more.  I want to emulate them.  I point out their words and actions to others, and show the positive movement they inspire in me and others.  Stage 4 and 5 tribal leaders lead by example.  And make no mistake, they are everywhere.  They often don’t have a title or any designated authority.  But the team/organization/family is always better for their presence.

If you have people like this on your team, consider:  how can you be more like them?  What do they inspire in you?  If you are this person, how can you bring people along in this mindset?  This is how we get better through our current crisis:  We find the leaders who speak the language of We, Together, Growth, and Hope.  We find and follow those who set the example, and we strive to set it ourselves.  We take advantage of the programs and support systems around us.  We get help, get better, and then turn around and help others.

Yes, there is much trauma and grief.  There is also boundless love and connection.  We find the latter easily when we look, and it sustains us.  We can absorb that energy, join that movement, and make a difference in every encounter with our fellow humans.  We can absolutely be better.

 

What Emerges from Crisis:  Connection, Learning, and Contribution

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“What observations/discoveries/learnings have you noticed in these weeks?”

In phone calls, emails, and snail mail to friends, I find myself asking this question repeatedly.  This exercise yields two wins:  1) I’m connecting to my people all across the country; 2) I get to answer for myself, and new insights emerge each time.

How are you connecting with your people in these weeks of physical separation?

What have you had to reframe, create, and experiment with to make life work in our sudden new reality?  How does it feel?  What are you learning?

* * * * * *

 Inconvenient Emotions

Very early in the pandemic, when I realized my clinical volume would drop to practically nothing, I started to feel something akin to survivor’s guilt.  I still feel it—I am not on the front lines; I myself am not in harm’s way, as so many of my colleagues are.  I feel relief for not having to be there (yet).  Then I feel guilty for feeling relieved.  So I try to make myself useful, giving Zoom presentations on wellness to colleagues and firesides on Instagram for the public.  Life has settled into something of a routine.  I do video calls, helping with operations management and team organization from an armchair (standing desk).  Turns out I enjoy working from home!  And I feel guilty for enjoying anything about this time of unprecedented global disruption.  Hello, mental and emotional whiplash, my inescapable human companion.  Thankfully, self-compassion practice keeps me sane.

* * * * * *

Acceptance with Agency

“The first step to changing your circumstances is to accept them.”  Wut?  I have grappled for years to understand this concept; today I think I finally got it (thank you, Donna!).

Today I choose to define acceptance as a state of possibility, rather than of resignation or victimhood.  Sometimes it helps to describe something by pointing to its opposite:  What happens when we refuse to accept what is?  Often we cling to what we think should beWhat should be is a narrow set of unmet expectations that keeps us anchored to the past, or at least to an unreality that simply does not exist.

What happens when we finally accept what is?  We are liberated to ask some important questions:  How do I feel about what is?  What are the best and worst potential outcomes from here?  What do I want to be different?  How can I effect that change?  What is my work here?

Accepting what is brings us over the threshold from the narrowness of what should be to the wide possibility of what could be, where our agency is what we make of it.

* * * * * *

Optimism + Cynicism = Peace

Some days I get so excited, reveling in human ingenuity and resilience!  Look at the transitions we all made, practically on a dime, moving healthcare and education online, organizing COVID testing and creating treatment protocols, constructing hospital wards in convention centers, initiating clinical trials, and sharing experience and data internationally at breakneck speed!  All this learning and application, holy cow, how could we not be smarter, more connected, and better after all of this?

By being human, that’s how.  Despite our great capacity for survival and adaptation, we are creatures of habit and products of our environments and relationships.  We revert more easily than we convert.  On cynical days I think, “Nothing will change.  We will stay the same stupid species we have become, just a couple hundred thousand deaths closer to our own stupid, eventual extinction.  And we will deserve it.”

Here’s the fascinating thing, though:  I vacillate in this false dichotomy lightly, even though the emotions on both sides can get intense.  We humans are such a complex enigma, capable of profound love and selflessness, and also unfathomable hatred and destruction.  That’s simply what is—we are all of these things, intricately complicated in our nature.  Each one of us possesses an infinite set of potential vectors for connection and/or destruction.  But I still get to choose what to do with my time, energy, and resources in this lifetime.  It’s my call.  So I’m okay; I’ got this.

* * * * * *

Co-Creation:  The New Normal

The last two years I have had the privilege to work with colleagues around our vision, mission, and values.  I have studied various work cultures, observed and interviewed associates and teammates.  LOH taught me the language and framework to synthesize my own, evolving style of relational leadership.  During this downtime—this unearned vacation—I have time and space to consider a bigger picture.  What about our culture best manifests our mission and values?  How did this facilitate our successes in reorganization and mobilization?  What held us back?  What needs to happen (change?) in order for us to emerge from this crisis in learning and growth, rather than in fear and trauma?  These questions apply professionally, personally, and societally.

My strengths lie in relationship and connection.   Throughout this long journey to flatten the curve (and it will be months), I can contribute my insight, observations, and talents at synthesis, creativity and vision, to make our new normal as mindful, intentional, collaborative, and functional as possible.  I can paint a vivid picture of where we could go.  I can embrace dissenting voices and find alignment in apparently divergent interests.  I can help us be better.  This is the contribution I can make.

What will your contribution be?

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The Best Thing That Could Happen

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What do you think is the best thing that could happen out of the COVID-19 pandemic?

I think it’s Connection.

How ironic, as the current best solution to mitigating illness and death is physical (not really social) separation.

Connection won’t come easily, though.  Today I felt all kinds of yuck:  Conflicted.  Unsettled.  Angry, Cynical, Fearful, Guilty, Annoyed, Confined, Enraged.  Not exactly connecting emotions.  The people going about their usual routines, disregarding distancing guidelines, and claiming it as their right to ‘live free’ agitate me the most.  When they get sick, and after they have infected numerous others, some gravely, my colleagues and I will care for them the same as for those who followed the guidelines and acted unselfishly for the greater good.  We will put ourselves in harm’s way, and more of us will pay with our lives for their false freedom.  Because when your ‘right’ to ‘live free’ puts others’ lives at risk, that is not freedom.  That is negligence.

That said, I’ve not lost all hope.  Through Facebook, Zoom, email and snail mail, I am now better connected with some folks than before, and I’m grateful.  They have helped me consider and envision the best possible New Normal on the other side of COVID-19.  I share my wish list below, as well as links to my favorite articles from the past week.

Also, join me this Wednesday, April 8, at 6pm Chicago time for an Instagram live chat.  Owners Tim and Victoria at Ethos Training Systems will host a fireside-style session on COVID-19.  You can join by finding me, chenger91, or Ethos, at the time above.  Please know that I do this public event as a friend of Ethos, and not as a representative of my employer or any medical professional society.  I claim no expertise in infectious disease or epidemiology; I’m just one doctor doing my best to share relevant information and practical advice.

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To Create Our Best Post-COVID Future, Let Us:

Continue to connect earnestly with people near and far.

Advance toward universal healthcare in some form, and shore up our social safety nets.

Reclaim our collective mindset—temper extreme individualism with more altruism and empathy.

Slow down—maintain more flexible work schedules, better childcare options.  Generate less pollution, decrease unnecessary production and consumption.

Live more mindfully and in the present:  Enjoy the good more and dwell less on the bad.  Increase both awareness and appreciation of all that is well in life.

Hold rigorous science and medicine far above opinion and ideology.

Practice Learning, Flexibility, Agility, and Resilience, in all domains, large and small, individually and as a collective.

Recognize our shared humanity, maintain that recognition, and act consistently from that recognition—bake it into our cultural norms henceforth.

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Pieces that helped me the past week:

An excellent review of the evolution of and rationale for universal masking:  https://www.vox.com/2020/3/31/21198132/coronavirus-covid-face-masks-n95-respirator-ppe-shortage?fbclid=IwAR237JXMUy94AcI_4uigdP3ZZUfoNd1c_4tyRDi-A8u2BYm7YZmSJ0f3ii8

A summary of current knowledge of SARS-CoV-2 and COVID-19, written accessibly and with practical recommendations, by my teacher and colleague, Dr. Alex Lickerman:  https://imaginemd.net/blog/coronavirus-april-2020-part-5/?fbclid=IwAR20m7QfOSUlZlAZuTaytKDaw210j_wWuqd6xgGBeTbIHAEfZeASfDnYTac

Dr. Lickerman doing a similar review as a guest on a podcast, also excellent: https://www.larryweeks.com/ep-36-coronavirus-qa-with-dr-alex-lickerman-m-d/?fbclid=IwAR077iOtNkCGcyjJdjVWZWKW6RWgtNhVgdN7cYvrnd2bQcbaStrRvTjdqAE

From Maria Shriver’s Sunday PaperBut today is Palm Sunday, and Easter Sunday is a week away. This week is the beginning of Holy Week, a time of spiritual renewal and rebirth. So, I’m taking that as a sign that we aren’t meant to go back to what was. We are meant to go forward both individually and collectively. Each of us will come out of this time a different person, a changed human being. How could we not?
What a double tragedy it would be if we went back to the way we were. To a time when we didn’t care for our planet. To a time when we were so mean to one another. To a time when we were so divided in every way. To a time when we didn’t know our neighbors. To a time when so many only cared about themselves and saw others as the “other.”

A diagram shared on social media of our human responses to the crisis (I don’t know who created it—if you do, please give credit in the comments and tell them thank you).  I think it’s normal that we should find ourselves doing things in each of the nested circles every day.  We can exercise compassion for ourselves and others at the same time:

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Finally, a poem, also from Maria Shriver’s Sunday Paper, shared by her niece, who died with her 8 year-old son the very same day:

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Things will likely feel worse for at least a few weeks before they feel better, my friends.  Hold tight to those you love and who love you.  Count your blessings.  Take perspective.  Consider deeply our inextricable and undeniable interconnectedness.  Be kind.

Finding Peace in the Morass

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Friends, how are you feeling and doing today?

Three weeks ago workouts and bedtime went to hell for me, as it became clear that coronavirus would soon turn our lives upside down and inside out.  I could not read fast or widely enough.  At the end of that week I posted three times in four days, discharging all that I was learning, attempting to convince anybody I could that the tidal wave was coming.  I felt like Chicken Little.

The last two weeks saw myriad conference calls, reorganizations, virtual team huddles, sleepless nights, workflow changes, text threads, mood swings, mass emails, sporadic workouts, and also moments of connection, both personal and professional.  In an effort to stay informed, I put Facebook back on my phone, to keep up with the medical COVID groups sharing information and experience.  It’s exhausting.  As of this moment that app is once again deleted.  I need a better new normal.

I’m not doing my usual in-depth, in person interviews and exams with patients.  I really miss it.  But my phone conversations have been no less meaningful.  I hear about my patients’ cough, fatigue, fevers, headaches, and sore throats.  Some have diarrhea.  Some can get tested for coronavirus, others cannot.  We work through it day by day.  I also hear anxiety, confusion, frustration, fear, and uncertainty.  I do my best to be objective and evidence-based, as well as compassionate and empathetic.  I always wish I could do more.

I think it’s uncertainty that people fear the most.  When we don’t know what will happen, especially when the possibilities are as divergent as COVID-19 outcomes, everything is nebulous and scary.  What can we expect?  How should we prepare?  If we choose one path, what if it turns out differently, and we did the wrong thing?  How will we cope?  All this social distancing and sheltering in place—it’s decimating the economy.  Those voicing concern over this must not be dismissed.  Meanwhile, what do we do?

If I feel sick, am I infected or not?  Am I contagious or not?  I can’t get a test.  What should I do?

*****

Over the holidays I read Being Mortal by Atul Gawande, my favorite physician writer.  His eloquent and accessible writing on aging, illness, and the American end of life experience should be required reading for every physician, and really every adult.   After finishing the book, I decided that in order to die at peace, we must live in peace.  And peace must be cultivated.  It’s not something you can invoke in the midst of crisis, unless you have practiced.

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Let Your Breath Lead You

I learned about box breathing at the International Conference on Physician Health in 2016.  It resonated because I had already attempted a mindfulness meditation practice for some years, with varying success.  Inhale, hold, exhale, and rest, each for a count of four.  This is not a normal breathing pattern.  So it’s both a mental (attention) and a physical (parasympathetic stimulus) practice.  It lowers blood pressure and heart rate, and eventually cortisol levels.  It is also known as tactical breathing, as soldiers train for combat with this very practice.  The objective is focus and calm at the same time.  I have practiced since 2016, also with varying consistency and success.  These three weeks I have pulled on this technique as a matter of course, and it has saved me.  When the mind is full and chaotic, we can call on the body to lead us to peace.

Accept and Embrace Paradox

Human nature is to overgeneralize and oversimplify.  We seek simple, compartmentalized solutions to complex problems, often in binary form:  black or white, open or closed, good or bad.  But much of life is simply the opposite of simple (ha!), especially during a pandemic of a novel virus.  What we need is a way to tolerate the inherent ambiguity and uncertainty that life will always bring.  Here I must credit “The Big Bang Theory” for teaching me about Schroedinger’s Cat.  It’s a physics thought experiment in which a cat inside a box with a toxic radioactive substance can be thought of as, paradoxically, simultaneously alive and dead until the box is opened and its true state revealed.  In the case of coronavirus:  If you have had an exposure and you feel fine, or if you feel sick but it’s not that bad, and you cannot be tested, your true state is either infected or not infected.  But since we cannot know, we can consider you to be both.  So what should you do?

  1. Be grateful that you are not gravely ill.
  2. Act like you’re healthy, and live your life.
  3. Act like you’re infected, and don’t do things that will infect others.
  4. Practice, with deep, box-like breaths, the skill of accepting and embracing paradox.

Make a Choice

Even as I advocate vociferously for people to stay home, I understand the economic consequences of this intervention.  Rock, meet hard place.  For a while I asked myself  which I would regret more:  Executing defensible drastic measures in response to those who warned us for months, and then having it be ‘not that bad’ (because we all already know it will be some version of BAD), or doing less than was recommended and having it be unfathomably bad, like it has been in Italy, and what New York City already is?  Lives will be ruined either way, and deaths will escalate, directly from the virus and indirectly from all kinds of other things.  But I could not live in good conscience if we knowingly chose the latter path; I personally would regret that more, and I think our leaders and my profession would be crucified.  Because there are very few ways to prevent the direct deaths now—we missed the boat of containment.  Now our only hope is to slow the spread so as not to overwhelm our hospitals.  But there are myriad options to prevent and mitigate the indirect suffering and death, economic and otherwise.  That is where we can still exercise agency, creativity, collaboration, and innovation.

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Nobody knows what lies on the other side of this morass.  Life will never be like it was before—but that has always been the case.  Make no mistake though: we are all in it together, like it or not, know it or not, want it or not.  At no other time have we seen more clearly how the actions of one affect the outcomes of the many.  In another example of paradox, each of us is both victim and agent at the same time.

So how can we achieve peace?  Look for the helpers, as Mr. Rogers’s mom advised.  Be a helper, as much as you can.  Breathe through the anxiety; connect with those who help you.  Let go false dichotomies and breathe some more.  Plan and execute your small and significant contribution to maintaining and rebuilding the economy.

And please, please—for now—stay home.

 

The Doctors Are Scared

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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.