I look around the spaces I work, live, and worship in and I see so many people I love. I believe everyone is my neighbor, but I’m specifically talking about the people I know…the smiling clerk I always choose to check out my groceries, the guy who waves at me every morning when I drive into the garage, my family, the people who share my mission of healing children.
Only ~50% of the country is vaccinated and in some areas it’s only about ~30%. I know this means that some, maybe many, of the people I know and love aren’t vaccinated and, to be honest, it’s breaking my heart.
The Delta variant is dangerous. Every person who is infected with the Delta variant will infect 6-8 people on average (which is more infectious than Ebola or chicken pox)… Unless you are in a group of people like a break room, a church, a gym…. In which case the number will be much higher because of the closed space. Being vaccinated makes it MUCH less likely, but not impossible to infect people around you other because of “breakthrough infections.” These infections after vaccination are rare but expected – it doesn’t mean that the vaccine “didn’t work”.
Masks protect you (some) and everyone around you (a lot) which is why they are so important now – whether or not you are vaccinated.
But back to my friends and neighbors who aren’t vaccinated. The Delta variant is so infectious and spreading so fast that if you aren’t vaccinated, it’s not about IF you get infected, it’s about WHEN.
That’s why when I think about my beloved friends and neighbors I grieve because…
You will almost surely be infected with the Delta variant if you aren’t vaccinated.
You will go on to infect others around you, including people you love.
You will be sick (and probably really sick)… hopefully at home, but maybe not.
You may end up on a ventilator.
You may die.
And if you don’t die, you may be debilitated.
And it breaks my heart. Because these deaths are preventable. And even one of you dying or being debilitated is one too many.
After “WHAT WERE YOU THINKING?????” – which would have probably been my first sentence – I would have been upset, but I also would have realized that these residents were meeting in the way that residents and students have met forever. They were having a goodbye party for people who were leaving. Probably not outside, and probably not socially distanced, judging by the outcome, but I totally get it.
But the consequences of a casual party like this are real and it’s worth thinking about this by asking three questions…
1. What are the chances you’ll get infected at a party?
This one is easy. You have 100% chance of getting infected… unless it’s 0%… and there is no way to know which way it will go.
A recent report of 32,480 nursing home residents and staff showed that “Of the individuals who tested positive, 70.8% of residents and 92.4% of staff lacked symptoms at the time of testing.” The authors also showed that the viral load (which helps predict whether or not the individual is infectious) was the SAME in people who had symptoms and those who didn’t; “In a large cohort of individuals screened for SARS-CoV-2 by qRT-PCR, we found strikingly similar distributions of viral load in patients with or without symptoms at the time of testing.”
What this means in practice is that every single person we encounter has to be considered infectious. And that means every event and every encounter has to be carried out in a way that will prevent transmission of the virus.
2. What are the chances you’ll get really sick or even die if you get COVID19?
Based on data from the CDC, for 20-40 year old people with no underlying medical conditions, here’s the answer to my hypothetical M&M question:
700 of the M&Ms will give you fever, cough, and/or shortness of breath. Lots of patients describe it as having “lungs on fire.”
440 of the M&Ms will give you some pretty awful muscle cramps and aches.
120 of the M&Ms will make you lose you sense of smell and taste. It usually comes back, but not always
3 or 4 of them will put you in the hospital (that goes up to around 20 M&Ms if you have an underlying medical condition)
1 of them will put you in the ICU unless you have an underlying medical condition. In that case, 5 of them will put you in the ICU
It’s unlikely you’ll die unless you have an underlying medical condition, in which case 3 of the M&Ms will kill you. If you carry this home to your 70 year old grandparent with an underlying medical condition, they have a 20% chance of dying (the equivalent of 200 M&Ms for you).
3. If you are in health care, what effect will this have on your patients and your colleagues?
Whenever I struggle with a decision as a doctor, I go back to my “rules”, which serve as the reference point for my moral compass.
Rule 1: Do what’s right for the patient.
Rule 2: Look cool doing it.
Rule 3: Don’t hurt anything that has a name.
If, as a healer, you decide that “just this once” won’t be much of a risk and you end up with COVID19, you break all three rules. You will be infectious for a long time before you get symptoms… which means you will expose patients, friends and colleagues (who all have names) to this potentially deadly disease. And – there is nothing less “cool” than creating a avoidable situation that ends up with colleagues having to cover for you while you are in quarantine and/or recover from COVID19.
We all want this to end… and it will.
We have a special calling – and responsibility – as healers (which includes all healthcare workers since healing takes a team). It’s what makes our work so filled with awe, and so rewarding. It’s also a burden sometimes. But we all took an oath, we all made a promise, and when we are past this point in history and looking back, it will mean something that we held true to that promise.
As a longtime customer of your dealership, a physician, and a concerned citizen I wanted to reach out to you to talk about the experience I had today when I picked up my car. Please know that this is not an attempt to complain – it’s an attempt to explain – and hopefully make you, your family, your employees and your customers a little safer.
I woke up this morning excited I’d be getting my car back today! Since I realized I didn’t want to expose or be exposed to anyone that wasn’t necessary, I called ahead to pay online (thank you for making that possible!). But, once I got to the dealership… well, it just wasn’t safe.
I stood outside while someone went inside to start the process of checking me out … and here’s what happened – which is what prompted me to write you this letter:
I watched as one of your customers, who was clearly in at least two, if not more, high-risk groups walked up the ramp. She was passed by an employee coming down the ramp, who passed her shoulder-to-shoulder. The employee’s mask was on their face, but below their nose.
I watched as the service folks checked in two people who both had masks on properly (as did your employees). But they walked up to them and held out their hand to take keys, which meant they were within 2-3 feet of each other.
The service employee who checked me out came out with papers and then handed me a pen – which I suspect they had been using all day – and stood right next to me. When I shook my head and asked if there was another way to do this, they said “I can get you hand sanitizer”… and then “We know it’s coming again.”
When my car was returned to me, the employee who drove it up to me had a mask on – around their neck. The windows were up and there was no smell or sign of any disinfectant. They walked up to me (2 feet away) and reached out to hand me my key (which I put into a ziplock bag I had brought for this purpose).
As I was leaving, an employee walked by with their valved mask on… around their neck. Two strikes! These valved masks are being sold because it’s “easier to breathe” but that’s because all the air you breath out escapes… with the virus. So, they have no benefit at all.
Let’s break this down… and I hope this will help you and other businesses to think about this in a way that makes sense. We all want businesses to open – and stay open! So working together to prevent more spread of this deadly virus just makes sense. What’s making this hard for some people is how politicized this has become. But, it’s important to know that this virus doesn’t care how you vote or what you think. This is just medicine, science and common sense.
The official CDC recommendations can be found here, but here’s how I would translate them for your employees i.e. what I would post somewhere if I were in your shoes:
Assume everyone you meet has COVID19
Unlike other viruses, you can be infected for up to 6 days before you feel sick. During that time, you can infect other people. Which means that everyone you meet could be infected… whether or not they are ill. If there is nothing else your employees remember, they should remember this.
If anyone with COVID 19 coughs on their hands, touches something and then you touch it (followed by touching your face), you can become infected.
This is not the primary way this virus spreads but it can spread this way. (This is why it was so upsetting to be handed a pen.) I also wish the person who returned my car had a spray bottle of disinfectant with them. I sure would have felt better if they got out of the car, sprayed down the seat and steering wheel and then wiped it off. Oh, by the way, once COVID19 is on a surface (depending on what the surface is made of) it can last for up to three days. That’s why it’s so important to disinfect surfaces frequently and wash our hands after we touch anything that hasn’t just been disinfected.
If anyone with COVI9 talks, yells, speaks, coughs or sneezes in a closed space, the virus can hang in the air for up to 3 hours. If you walk into that space during that time, you can become infected.
I can’t think of a worse closed space for COVID19 than inside a car! It’s true for any room, including your office space, but this is why I was perplexed when the person who returned my car didn’t have their facemask on. This is also why there is a “6 foot” rule and why we wear masks. (By the way, it’s not either-or, it’s both). We wear masks to protect others, not us… which means if we all do it, we’re are all protecting each other. (That’s also why you shouldn’t let any employee wear a valved mask) We stand at least 6 feet away from each other because the viral load will be much lower if we are talking to someone who is infected. By the way, the aerosol an infected person produces when they sneeze can travel up to 20 feet … and, remember, those viral particles can remain in the air up to three hours.
Most of us will probably be infected eventually, but that’s not relevant.
I understand that in the face of such a terrible disease there is a tendency to just throw up your hands. I’m sure that’s why your employee told me “We know there’s another wave coming”.
But here’s the deal – every day we postpone any one of us getting COVID19 (or preventing it, if all goes well!) is one day closer to a vaccine.
With every day that goes by, we also understand more about COVID19 and how to treat it… so the odds of not needing the hospital, ICU, or morgue goes up.
For every case we prevent, we are actually preventing many, many more cases because of how this spreads.
There’s also the part about just being a good person; You don’t want to be the person who bends the rules, gets sick and then infects family, friends or customers.
You have a wonderful dealership and I will continue to be an enthusiastic customer. Your service is incredible, your employees are kind. Stay safe, stay well, and thanks for giving me an opportunity to share this information with you and for others.
It’s so important, and so very hard, to care for yourself
when times are tough. When routines are disrupted and fear and anxiety are
present, our usual ways of caring for ourselves seem to (appropriately) fly out
the window. So, here are some ways to
think about caring for yourself in the time of COVID19, whether you are working
(at home or in the hospital) or isolated at home.
Connect with nature. Long after this pandemic is
over, the earth will still be here and spring will continue to happen every
year. Make sure you get a good dose of the smell of grass, the sight of a blue
sky, the feeling of a cool breeze on your face at least once a day (but hopefully
more).
Move. It’s normal that workout schedules are disrupted right now, but it’s not a good time to completely give up on your physical wellbeing. There is nothing good about being sedentary – not only does it make you feel physically bad, it also contributes to sadness and anxiety. A good, brisk walk outside may be the best “workout” right now since it combines movement and getting a dose of nature… but please make sure you practice social distancing and stay six feet away from everyone.
Eat well and enjoy good chocolate. You may be limited
in your choices and your ability to get real food, but do your best. This is
not a good time to succumb to the junk food as comfort food diet. Nor is it a
good time to be overly restrictive. Splurge on small doses of the foods that
make you feel comforted, but make sure it’s the best version of that food
possible! Now is not the time for cheap chocolate… just sayin’.
Keep your spaces clean. Our homes need to be a safe sanctuary
now more than ever, and that means we need to know they are clean. In addition
to creating
a ritual to enter your home, come up with a plan to keep your home neat and
cleaner than usual. If it helps, what we’ve done is set a mindfulness timer to ring
3 random bells an hour when we are home. Every time it rings, we do one small
bit of cleaning (or one set of an exercise) e.g. vacuum one room, clean the
countertops, wipe off all door handles or do some pushups. What you lose in
efficiency is made up for by breaking up an otherwise boring task and by the “surprise”
of the random “request”.
Dose your news. We need to know what’s happening, but
we don’t need to know it all the time. The human brain doesn’t like being continually
bombarded with potentially dangerous information. It promotes the physiologic
stress response and pushes us towards fight, flight or freeze… none of which
are helpful in this time. I love Twitter, but I have to be careful right now…
it can be an echo chamber of sadness and stress. The news I’ve found that is
the most informative, most accurate and least stressful is the PBS News Hour.
Guard your spirit. Find a place and a way to keep your heart full, your #EyesOpen and your compassion alive. This is not a sprint… it’s clear we are in this new world of COVID for a while. #WeNeedYou so please protect yourself in body, mind and soul.
The following is an “unrolled” Twitter feed from Mark Reid, MD on depression. It’s solid, important advice that I thought should be shared. Dr. Reid is an internist from Denver, who is very active on Twitter as @medicalaxioms. He is also the author of Medical Axioms, a delightful book of medical wisdom
If you are starting the think you might be depressed, or that your brain is out to kill you, here’s what you do:
1. Find or call your primary care IM of family MD. When you call for an appointment and they ask what for, say “depression.” Notice how the scheduler doesn’t flinch. They get this call 4 times a day!
2. When you get to the doctor, and they ask what’s wrong, just say, “I want you to do those screening tools on me to see if I’m depressed.” Let them do their thing. If they say you’ve got it, let them tell you how meds and counseling work. Let them tell you what they know about pills and which one might help you. Decide together if pills are worth a shot. Tablets really work for some people.
3. You also need a counselor. Ask the MD for a referral. That might work. If not,
4. Go to your insurance and find out their preferred providers for counseling. I suggest you pick someone your same gender. Counterintuitive for some but works better for many.
5. If that doesn’t work, go in the internet and type in counselor or therapist and the name of your town or city. Read ratings and reviews. Cross reference them with yelp. Look for someone nearby who writes a bio that sounds okay. Figure you’ll see them once a week and it will cost $100. Give them 4 tries. If you don’t feel like you are getting anywhere, ditch them and try again. I’ve seen 3 people in the last 10 years and in retrospect I can rank them.
6. With tablets and shrinks, the trick is resolve. If they aren’t working or give side effects, don’t just quit. Try again. Different shrink. Go back and try a different tablet with your MD.
You can feel better and you are worth it. You deserve it.
There’s lots of other stuff that helps some people: support groups, sobriety, exercise, sleep hygiene, self help books, spiritual practice, ALANON. If your shrink is any good they will recommend this stuff and know something about it.
Depression is a disease, not a failing. You wouldn’t judge yourself for a sprained ankle. This is the same…. except for one thing. The disease of depression includes not being able to objectively see what’s going on. That’s why it’s so important to get started on treatment.
If you are a medical student or resident, counseling is available for you and it’s free. The same rules hold, though. If the first person you see isn’t helping after 3 or 4 visits, it’s ok to make an appointment with someone else. This is not personal and you don’t have to worry about “hurting their feelings” any other consequences.
The National Suicide hotline is 1-800-273-8255. You are loved. You matter. This is a disease not a failure. Please seek help.
Around the world, Ebola and other infectious diseases take the lives of mothers, fathers, sons and daughters … and place at risk those who care for them. This risk is known to all who choose medicine as their career. It is part of caring for the ill, and always has been.
“A healthcare provider has an ethical and professional duty to address a patient’s needs, as long as the patient’s diagnosis – or when the patient’s initial complaint, on the face of it – falls within the provider’s scope of practice.Refusing to do so is not consistent with the ethical principle of beneficence. “ Twardowski, et. al. RI Med Jl October, 2014
Around the world, physicians, nurses, and all healthcare workers willingly fulfill their duty to care for patients who are or might be ill with Ebola and other dangerous diseases, reflecting the altruism and compassion of those who choose medicine for their career.
However, the duty to care for these patients does not automatically extend to those who are learning medicine. Without the experience, context and well developed skills of established providers, trainees are potentially at greater personal risk.
When I operate on patients with HIV, Hepatitis, or any blood-borne pathogen, I take every precaution possible for myself and the staff who are scrubbed. I also take advantage of the “teachable moment” to discuss ethics and universal precautions with my trainees…. but I don’t allow medical students or junior residents to directly participate in the case. Likewise, I am sure that learners will not be allowed to provide direct care for patients known to be infected with Ebola or other dangerous diseases… or to travel to West Africa for clinical experiences while the epidemic is still present.
All of us in medicine honor those who provide care to the ill despite the risk …and we thank you for the example you are setting for those learning to heal. We hold our colleagues in Dallas, Atlanta, Africa and around the world in our thoughts as they work tirelessly to heal the sick and contain this terrible disease.
Like our residents (but not nearly as frequently), my group has started taking “in house” call. For every one who is currently or has been a resident, this is an experience we all know…. and one that’s hard to describe to those that haven’t experienced it. Spending 24 hours on call in the hospital can be emotionally and physically draining, but it has moments that make it a special experience, too.
There are ways to make the experience easier. Here are my top 10 ways to survive (and maybe even enjoy) being on call:
1. Drink water. Put a water bottle in the lounge refrigerator, drink from every water fountain, put your water bottle next to your computer, or come up with other ways to stay hydrated. If you want more flavor, bring a zip-lock with cut up lemons or limes to put in your water or add a splash of fruit juice.
2. Be kind. No matter how stressed or busy you are, knock on every patient’s door and enter their room with the intention to help. Sit down or put a hand on their arm when you are talking to them. Smile.
3. Take breaks. On purpose. No one really expects you to work non-stop for 24 hours and it’s not good for your patients. Deliberately stop to do something else every few hours, even if it’s just for 5 minutes. Go outside for a few minutes for a short walk to catch some natural light and breathe some fresh air. Get a good cup of coffee or tea, listen to some music or just sit. If you want something more active, climb a few flights of stairs, stretch, or even do a light workout.
4. Eat well and eat often. Do not rely on fast food or the hospital cafeteria. By far the best plan is to bring really good food from home. You need to have “comfort” food on call. If you don’t cook, buy really good prepared food that you can look forward to. Make sure you have “plan B” ready if your call day gets completely out of control by having an energy bar (my favorite is Kind bars), peanut butter sandwich or other “quick” food in your white coat pocket.
5. Be part of the team. Notice and encourage the unique camaraderie you share with everyone else who is on call. It’s a small “band of brothers” who find themselves in the hospital at 3am. Be kind to each other, help each other, and use this unique opportunity to get to know someone you might otherwise not get to know.
6. Wear good shoes. If you are in house for 24 hours, bring a second pair that’s completely different (clogs and running shoes for example). Ditto socks. Buy really good socks and change them after 12 hours if you can.
7. Use caffeine wisely. It’s practically essential for many of us at the beginning of the day, but beware trying to “wake up” with caffeine after 2pm. Not to mention that if you “caffeinate” all night, you’ll have that sickly post-call-too-much-caffeine feeling in the morning.
8. Take naps. Any sleep is good sleep on call. If it’s possible, 20 minutes will make you more alert and effective in your work.
9. Make your beeper a “Zen bell”. Use your pager or phone as a tool for mindfulness. When it goes off, take a deep breath, relax the muscles in your face and shoulders and be present. This is a proven practice to decrease stress – try it, it works!
10. Learn. Take advantage of the unique educational opportunity of being on call. The fact that there are fewer people around at night and on the weekends has a real impact on how and what you learn on call. If you are a student or junior resident, you are more likely to be the first person evaluating new consults and admissions. You are also more likely to have one on one time with your senior resident or faculty as you care for patients together. If you are further along in your training, the “down time” on call (if there is any!) is a great time to catch up on reading.
I recently spent the night in the hospital with a friend who underwent a minor procedure. It was a fascinating experience to watch the hospital “from the other side”. Overall, I was very impressed – the nurses, patient assistants, technicians, clerks and food service personnel were universally professional and kind.
But then we went to sleep…. or tried to. Vital signs, meds, and necessary events were more or less over for the day by 10pm. The unavoidable noise in the hall, unfamiliar bed, and the events of the day made it difficult to get to sleep, but we both drifted off around midnight.
At 4am there was a cheery “Sorry to bother you, but I’m here to get your weight”. She couldn’t have been nicer but when I asked why my friend had to be awakened at 4am (!) for a weight (!) she responded, “We have to have the weights, labs, x-rays and vitals all completed before the day shift starts at 6am.”
Not too long after this experience, I admitted a long-term (and adored) patient of mine for an elective procedure. Her parents reminded me that last time she was admitted I wrote an order to forgo the middle of the night vital signs so their daughter (and they) could sleep. Coming on the heels of the night I spent with my friend, it made me think about how we manage sleep in the hospital.
1) To distribute work to the less burdened night-time staff from the day time shifts
2) To have the data available for morning rounds.
3) Because of pressure to get the patient out of the hospital at a certain time
Is there really no way to off load the busy day time shift without waking up patients? Would it really change things if stable patients (particularly if they are on monitors!) were allowed to sleep through the night? Would it change therapy if the daily weights were at 10 in the morning instead of 4 in the morning?
There’s no question it’s nice to have data for morning rounds – but is it really essential? How much of this is a holdover from the paper chart era? In the era of the electronic medical record, access to data- at any time of the day or night – is easier than it used to be. Granted, morning report or rounds would be different, but I think it’s something we could figure out.
There is financial (and other) pressure to get patients out of the hospital. But have we looked at ways to manage this that don’t involve waking up patients? For example, there are hospitals that count the “day” in the hospital by the patient census at midnight. As long as you are out of the bed at midnight you don’t get charged for the day.
Sleep is important for recovery from illness or injury.
There are numerous studies that suggest that the immune system in particular is affected by disruption of sleep. The data are not conclusive, but many physicians, nurses and scientists have published work suggesting that protecting sleep for ill or injured patients might be important:
In babies with necrotizing enterocolitis, we order abdominal x-rays every 8 hours for at least a day or two (to look for air in the abdomen.). If the x-ray shows “free air” (like the one below), it means they need emergency surgery to deal with the perforated bowel.
The standard schedule in our hospital for q8 (every 8 hours) x-rays is 6am, 2pm and 10pm. Here’s the problem with that schedule as far as hospital efficiency goes:
The 6am xray, if it shows a problem, will result in action around 7. If the baby needs surgery, the operating room is already set up for the 7:30 cases. Because the OR schedules is usually very full at the beginning of the day, we often then have to “bump” (postpone) a patient to do this emergency case.
The 2pm x-ray will result in the surgery being posted around 3, a complicated time in the OR since day time nursing staff is leaving and the remaining cases are being juggled.
The 10pm xray will start the process rolling at 11 or so – putting the surgeon in the OR in the middle of the night.
Since the timing of the x-ray has a big effect on the timing of the surgery, it becomes a variable that really affects what happens. Here’s what happens if you change the schedule to 3am, 10am, and 8pm
The 3am xray, if it shows a problem, will result in action around 4. Surgeons are the early-birds of the hospital. Since they will be waking up early anyway, the case can easily be started at 5 or 6, which helps with the OR schedule and keeps the surgeon from being up all night.
The 10am x-ray will result in the surgery being posted around 11 – this is a time when “holes” in the OR schedule are easier to find, and getting the baby into the operating room will be easier.
The 8pm xray will start the process rolling at 9 or so – which means the surgeon is more likely to get some sleep.
What’s the bottom line? We don’t think about some of the unintended consequences of our orders. Sleep is important – for both patients and the people taking care of them. It’s worth thinking about.
