How to Do the Holidays Safely This Year

“Wear a condom!”

Asking loved ones not to be together for the holidays is like asking teens not to have sex.  People will do it no matter what we say, so we should help them do it as safely as possible.  Let’s talk about COVID condom-equivalents!  Below are my thoughts, here at the end of August, about how we can make holiday gatherings hotbeds for communion and connection, rather than infection and transmission. These are my own recommendations and do not represent the advice or policies of my employer:

Talk About It Now

If your family is anything like mine, people have varying degrees of comfort and anxiety about COVID, and these levels may themselves oscillate and evolve over time.  Before we even talk about gathering for the holidays, we need to know how people feel and what they think about it all, as much as possible.  Talk to your nuclear family.  How important is it for each of you to be with extended family?  What trade-offs are people willing and not willing to make in order to do so?  What are the deal breakers?  What are the must-haves?  Starting these conversations today gives everybody time to reconcile differing opinions and make the most accommodating and collaborative plans.

Contact your extended families.  What’s everybody thinking?   Who’s on the same page?  For those who are not, what will need to happen?  How can we all work it out so that these holidays bring joy and connection, however we can get it, rather than more separation and loneliness?

Isolate for 14 days in advance

The most effective method for preventing infection and transmission is isolation. The incubation period for SARS-CoV-2 is 2 to 14 days. If we have no contacts outside of our household in that time, the chances of us getting infected, and then passing the virus onto others, is very low. I know this is not possible for many, but if we really want to be together safely, this is what we should aim for. Everybody who will be together in the extended family needs to minimize contact with people who will not be with us, in order for us not to spread the virus rapidly between us.

Merge Bubbles SAFELY

Once we have decided to gather, we should follow precautions obsessively:

  1. DO NO PARTICIPATE IF WE HAVE SYMPTOMS.
  2. Check temperature daily; stay away/isolate if over 100.0 degrees Fahrenheit.
  3. Wash hands and sanitize surfaces like our lives depend on it—20 seconds with soap and water, or enough 60+% ethanol-based hand sanitizer to take many seconds to dry, no exceptions, early and often.
  4. DO NOT share anything: utensils, drinking vessels, implements, etc.  When it doubt, throw it out and get a new/clean one.
  5. Minimize close contact–consider masks if close contact is prolonged.
  6. Optimize ventilation.
  7. Spread out whenever possible.
  8. Mask up if it helps us feel safer—especially if anyone was not able to isolate.  Respect one another’s decisions on this—be kind and generous.  Nothing ruins a gathering, holiday or otherwise, faster than snide comments and passive-aggression.

Know the Risks

So many statistics abound, and depending on our particular perspective on the pandemic, we will focus on certain facts more than others.  The bottom line is this:  Populational statistics are not easily applied to individuals.  Nothing can predict your or your family’s outcome if exposed.  Some things to keep in mind:

  1. None of us, not even veteran infectious diseases and public health expert Dr. Anthony Fauci, have seen a disease with such a spectacularly wide spectrum of illness—from asymptomatic to rapid multisystem organ failure and death, and everything in between.
  2. Any person, regardless of demographic, could have any course.
  3. There is no way to predict what any given individual will have, and virtually no way to influence it, other than preventing infection in the first place.  Maybe you can increase your vitamin D level and decrease your risk (talk to your doctor about it).  But unless you’re in the hospital (which means you are very sick), where remdesivir and dexamethasone may shorten your hospital course, there is nothing you can take or do to make you better.  You could be ill for many weeks with symptoms that involve your lungs, gut, brain/nervous system, heart, and blood vessels.  And all you will be able to do is wait it out.
  4. If you get infected, even if you recover, we still don’t know whether and what long term effects the virus and the disease will have on your body and/or your immune system.  It’s simply too new.
  5. The local positivity rate where we are can help us assess the risk we pose to others.  Where are we and our relatives coming from, and what does the pandemic look like t/here?  Find out here

Stay vigilant

Let’s say Thanksgiving goes well and nobody gets (too) sick in the weeks following.  Are we getting together again in December or over the New Year?  If so, we will all need to follow the same preparations and precautions before and during all gatherings to make it into 2021 unscathed.  The good news is, if we have already merged bubbles and we all steer clear of contacts outside of this new cohort, we may continue to commune safely all through the season.

I may update this post as the holidays get closer. Maybe everything will get better and we will have much less to worry about… I seriously doubt it. The best thing that could happen is that we all draw closer, physically and/or otherwise, to take care of each other and appreciate all that we have; that we live more mindfully, kindly, and inclusively in all domains; that we pull together in every way and keep each other safe and healthy.

What will be your COVID condom-equivalents this holiday season?  How willing are you to wear them every time, no question, without fail, to protect yourself and your loved ones?

***

Coda:  On Testing

Below is a draft of information I have written for patients.  It reviews what constitutes an exposure, and guides decision making about testing.  Bottom line:  Negative testing does NOT guarantee the absence of infection or risk of transmission.  Know what the information means and how to use it before getting tested.  These are also my own recommendations and do not represent the advice or policies of my employer:

Definition and Degree of Exposure

Known exposure

–You spent more than 15 minutes within 6 feet of someone who was symptomatic with COVID-19 illness and/or tested positive ​within the two weeks prior or 48 hours after the time you were with them.

Possible exposure

–Same situation as above, but you and/or the other person were masked​.  ​Some would still consider this an exposure​, others would not.  If you were both masked for the entire encounter, the risk of transmission ​is significantly lower.

— You spent less than 15 minutes unmasked with someone who was symptomatic or tested positive within the two weeks prior to or 48 hours after the time you were with them.

–You attended a large gathering, flew on an airplane, rode a train, etc. where someone in the vicinity recently or subsequently tested positive. The risk in this situation is higher if anyone was unmasked and/or if it was indoors and/or in a small, poorly ventilated space. Avoid these activities if possible.

–Prolonged outdoor contact, unmasked, inconsistently distanced at 6 feet or more, eg outdoor dining.

Not an exposure

–Outdoors, consistently masked and/or distanced from other people at least 6 feet apart

Statistics of Infection

–Incubation period is 2-14 days

–Average time to symptom onset is 5 days

–By 10-11 days, 90% of infected people will have developed symptoms

–Viral load peaks 1-2 days before and after symptom onset—this is when the test is most likely to be accurate

Reasons for Testing

–Required for return to work/school, participation in structured activity, etc.

–Known exposure

–Symptoms:

  • fever
  • cough
  • any new shortness of breath or difficulty breathing
  • chills
  • shaking with chills
  • muscle pain or body aches
  • headache
  • sore throat
  • new loss of taste or smell
  • diarrhea
  • nausea or vomiting
  • congestion or runny nose
  • fatigue

–I do not recommend testing in the absence of symptoms, exposures, or a requirement. 

Timing of Testing

–After a known or possible exposure, the best thing to do is self-isolate ​for 14 days.

–If you develop symptoms, seek testing.

–If you do not develop symptoms, consider testing around day 5-10 and continue to isolate

–Check the turnaround time at your designated testing site.  Results can take anywhere from hours to weeks.  Note that if a result is reported many days after the test date, that result may not reflect real time infection status.  Thus testing may not be useful and 14 day self-isolation is the best course of action.

​-A negative test does NOT ‘clear’ you. Testing can be negative in up to 30% of people who have symptoms, and may be higher in those who are asymptomatic or early in infection. Therefore, you MUST continue to isolate for a full 14 days after a known exposure, even if you test negative. 

Amplify the Important Stories

This weekend we lost another selfless leader, Dr. Joseph Costa of Baltimore.  Chief of his hospital’s intensive care division, he continuously led his team on the front lines of pandemic patient care, despite his own high risk medical condition.  He succumbed to COVID-19, in his husband’s arms, surrounded by colleagues turned caregivers. 

My friends, are you exhausted like I am?  4.2 million American COVID cases (about a quarter of total global cases).  At the current rate we will likely cross 150,000 deaths by the end of this week.  And it won’t stop there.  We will lose many, many more mothers, fathers, sisters, brothers, grandparents, sons and daughters in the coming months.  This, all while PPE shortages still put healthcare workers at risk across the country, caring for those who follow prevention guidelines the same as for those who do not.

Read Dr. Costa’s story.  Remember him.

Then honor his memory and those of the almost 600 healthcare workers who have died of COVID-19 by wearing your mask and protecting the people around you.

***

“Oh, are you from Maryland?”

Her name is Odette Harris, MD. 

She is a neurosurgeon and the director of brain injury care at Stanford Medicine.  She is a Black woman.  “Something as absurd as putting the initials of your state next to your name seems more plausible than the fact that ‘MD’ stands for doctor.  I can’t even tell you how many people ask that.”

Someone handed her their car keys outside of the venue where she gave a keynote address, thinking she was the car valet.  [Michael Welp mentions this in Four Days to Change—it is a common occurrence for our Black sisters and brothers.]

During an all-day meeting, after she stood up from the conference table to stretch her legs, her own colleague asked if she was going to set up for lunch.

Nobody has ever asked me if I’m from Maryland because ‘MD’ comes after my name.  I have never been mistaken for a car valet or wait staff at a professional meeting.  And I am not the chief neurosurgeon who runs traumatic brain injury care at my hospital.  Let us white and white-adjacent folks meditate on Dr. Harris’s experiences for a moment.  Because that’s all we have to do—consider them for a minute or two.  Our Black colleagues and peers live such denigration their whole lives.

***

The Wall of Misogyny

It started with, “Your hair smells incredible.” Followed by, “My hands may touch you. They are hard to control.” It even went as far as, “You were in my dream last night. Did I mention it was wet?” He made my skin crawl. I spent more time focused on trying to be where he wasn’t that I had no space left to focus on why I was there in the first place, and that was to learn. The awkward stares from OR staff looking upon me with pity made me want to vomit. And the number of male physician on-lookers who seemed to watch this behavior for sport did nothing but enable his behavior (when one brought his daughter to work with him, it was all I could do but hope she never had to experience from a man what I was experiencing from him). The lack of shock of such behavior from everyone aware in the system confirmed its normalcy.

Read this stark essay by Dr. Megan Babb, a fellow physician mom.  Inspired by Alexandria Ocasio-Cortez’s incisive speech on the floor of the House of Representatives this week, Dr. Babb published her own story and those of many other physician women.  They recount the everyday misogyny that for too long we have blithely accepted as ‘the way things are’ in medical culture.  Peruse them slowly (a few choice samples below).  Imagine they are your mother, your sister, your daughter, your friend, your colleague.  How would you upstand for them? 

I was asked by a male patient if I needed to practice my prostate exam technique because he was happy to allow me to do so on him. When I asked the administrative team to move him to the service of any one of my many male colleagues I was told, “These are the sort of things that build character. I think we need to thicken your skin. The patient will remain on your service.”

I recently gave a presentation at grand rounds in my hospital. When I walked to the podium, I overheard a male physician say to a group of others, “Isn’t the lecture today supposed to be given by an orthopedic surgeon?” I am the orthopedic surgeon he speaks of.

 As a medical student I was on a surgical rotation with a male urologist. While assisting him with a TURP [trans-urethral resection of the prostate] he asked me, “Would you like to see what a well-endowed penis looks like?”

***

And There Is Still Hope

A specialist physician and woman of color consulted on a patient in the hospital, a white man.  He was frustrated at having to see so many doctors and answer so many questions.  So he demanded that she sit in silence until he was good and ready to talk.  After the 25 minute hospital visit, she rightly documented his behavior in the chart, as she had done for so many episodes of patients’ abusive behavior in the past, especially since these patients often levy complaints against her for treating them badly.  To her surprise, the white male attending hospitalist paged her later to discuss the occurrence.  He had read the chart and apologized for the patient’s behavior.  He also called the patient out, asserting that if our colleague had been a white male herself, the patient would never have treated her like that.

An authentic white male ally, wow. 

…White men are more likely to listen to and follow other white men, I thought.

So I wrote her, “Can his actions be amplified so that he feels empowered and inspired to do this more?  So that other white men can see his example more easily and feel safe to follow?  Can someone mention his actions on rounds, share them in a newsletter, make them as visible as possible?  Examples like this can go such a long way to recruit white men to the cause—so many men sit on the fence, and just need to see one of their own lead the way, and then they get off on the side of doing what’s right.”

She agreed to highlight his actions in an upcoming community spotlight, noting that now he would likely be the target of any patient complaint.  We agreed that he would then need the support he gave her, given back to him, and then some.  We reflected on this great opportunity for colleagues to unite in solidarity for one another, standing up to cultural norms that oppress us all.

***

Stories like these humanize ‘others’ to us.  If we are honest, we may recognize that the ideas of ‘healthcare workers’ and ‘women of color’, among others, too often float on the surface of our consciousness as abstractions.  It does not occur to us to try to relate or empathize, to see them as real, flesh and blood people like ourselves. 

But that is what the world needs the most right at this minute—for us all to relate and empathize with each and every other human who suffers, who lives a different life from our own.  Our connections are the only thing that will heal us.