In the Northeast, the rate of Covid-19 transmission and infection is dropping down to the point where I only have two Covid patients left on my service.
Both of them are relatively young and strong men who will likely need oxygen for the rest of their lives.
Be that as it may, the focus of life as we emerge from isolation, is now on prevention of spread and trying to keep the horror of March / April / May from happening again.
(We all know it’s going to come back in the fall, but for our own sanity, we’re “whistling past the graveyard” and trying to pretend it didn’t happen)
But it did.
I’m Sorry
When I unilaterally declared on a previous blog post that it was over, I was only thinking about it for us… here where I live. Not for the rest of the country.
For that I am sorry.
It isn’t over.
I will not go into politics, but I will go into the discussion of willful ignorance and stupidity.
I would have thought that when the New York area was going through three months of death and upheaval, the rest of the country would have paid attention. When every outlet (official and unofficial) was advising us all on how to stop the spread of this virus, society as a whole would have listened.
Really?
But no.
The medical professionals have listened and are now using the best practices that we developed while we were in hell, to attempt to salvage life. But the populations in the Southeast and Southwest do not honor their healthcare workers, they do not honor their elderly, and most of all do not honor themselves, and do not take measures to protect themselves.
I’m not saying that everyone is doing it, but enough people are blinded by selfish desires couched in the finest rationalizations, to cause spread of Covid and invite death into their midst. The way to stop the spread is well known.
It’s easy.
Grow up, wear a damn mask. Wash your hands. Social distance.
It’s not political, it is human.
In this season of exposed lies, of exposed fear, and exposed hatred… be that spark that exposes love for one another.
In the spaces between seeing patients, calling families, and writing notes come thoughts. Psychologists would call them “invasive”, and yes I know that left unexamined, these things can be dangerous. Luckily, we have our social worker who regularly (and insightfully) does an informal debrief on us.
She probably thinks we don’t notice but we do and we’re thankful.
When did it really start?
The gift shop has St. Patrick’s Day stuff.
When we come into work in the mornings, we are temperature checked and then need to swipe our ID cards into a card reader. What this does, is to document that we’ve been checked and presumably that we are aware of the danger of going to work.
When we were talking about when it really started, an image from this morning came to mind. The card reader is right outside of the Gift Shop. When you look into the gift shop , it’s still full of St. Patrick’s Day cards, green hats, St. Patty Cards, and the very beginning of Easter Chocolate Bunnies.
The gift shop was closed in early March, when all the volunteers were sent home and now sits like a clock frozen at the time of a disaster, it’s cheerful Trinkets heralding holidays that were just days of anxiety and fear in the hospital in which it lives.
The days after that came almost unnoticed, the hours of terror turning us all into zombies, lumbering on under increasingly heavy loads until after two weeks it became normal.
Like Monuments To The Lost
This morning on rounds my team and I had to walk by the security holding closet. This is the closet that hospital security uses to keep an admitted patient’s belongings until they are being discharged or until family comes to retrieve them.
Now normally this isn’t even an after-thought and I’d be hard pressed to even tell you were it is.
I know where it is now.
Like monuments to those lost
Security was emptying the closet of unclaimed bags of personal effects and getting them ready for long-term storage. Hundreds of bags all stacked neatly along the hallway; generic hospital issue clear bags, shopping bags, backpacks with decorative patches, and large inter office envelopes all being labeled with the names of those lost to Covid, awaiting some future relative who would claim them.
As we walked away from that sight, it reminded me of headstones, marking the life of someone who came to us and never left, their lives remembered in a small pile of clothing and shoes.
Images that stoke a memory.
Hope?
Recently, there have been reports of the possible effectiveness of a drug by the name of dexamethasone in treating Covid-19.
Dexamethasone
Dexamethasone is a steroid and what steroids do is suppress the immune response. If you recall, the danger of Covid is the way it stimulates the immune response into destroying the body’s lungs and kidneys. A drug (like Remdisivir and dexamethasone ) that decreases the immune response should help this phase of the disease.
The preliminary reports show that when given at the right time, it improves short term survival by five percent. There is no data about quality of life or long term survival.
So it’s a good thing. Better would be that you wear a mask and don’t get sick in the first place.
I live and work in New York (Long Island specifically) and things have pretty much settled down at our hospitals.
The make-shift ICUs have been dismantled, COVID patients on vents relegated to a small area in the back of the MICU (Medical ICU). The non-intubated people housed in three hallways of the unit that had always been designated for infectious diseases. Those areas still have the COVID look to them, bags taped to walls and blue plastic gowns hung from hooks, but there is less desperation than there was.
The patients that were going to die in the ICUs are slowly dying, regardless of what the families want and what any doctor could ever do. Those not on vents are going home (with oxygen and forever damaged lungs -pulmonary cripples) or still short of breath on high concentration of oxygen and clearly going nowhere.
At least the families can come to the windows and see their relatives from outside the buildings. And we’re beginning to let some families come visit those near death.
Everywhere else in the hospital it’s different. We still all wear masks (a habit that will probably live on for a good long time) but the rooms are now immaculate, the floors shiny and the walls all freshly painted. All hint of the horror covered in bright white with earth-tone trim.
I was rounding with my team this week when our social worker (a brilliant woman who was “parachuted” into the hospital from our hospice affiliate on a grant to help us – she arrived as the “tide” was washing out) noted the look in our eyes and the blank eyes of the nurses on the floors and asked us, “but how did it feel?”
It Was Dark
The lights weren’t bright enough
As a group, including some floor and ICU staff, we all had similar recollections.
It was dark. Not literally, but no matter how many lights were on – the hallways, rooms, and offices felt darker than they should have been. The atmosphere inside was “heavy”, hard to breath.
We all agreed that we actually couldn’t remember what it was like… more like we didn’t want to remember it, but we all had individual “moments” we remembered. One nurse said that she couldn’t remember anything about those weeks, but vividly described an incident in which two young patients coded in the same room and they had to choose which one to intubate first and which one to let die.
A social worker recalls helping a group of nurses communicate with a patient who spoke Greek and was isolated and scared, they didn’t have to care so much, she said, but it was the act of caring so hard that maintained their sanity.
I recall the surreal nature of one of our make-shift ICUs towards the end of the first wave, messy, music from phones in the background, “bunny suits” tied around everyone’s waist (they are hot to wear all day).
When these snippets of shared memories are recalled, everyone looks the same, they get glassy eyed, as if peering into a dark distant place, then everyone says the same things.
“I can’t remember much about it.”
“It’s too soon-I don’t want to think about it.”
“I had no one to talk about this with anyway. “
“It pisses me off that everyone outside is bitching and moaning about being BORED!”
“I’m scared, I don’t think I could do it again. But I’m scared that we’re gonna have to, no one is paying attention!”
I don’t know how I’ll be able to do it again, but I will… as will everyone else, no matter how scared they are. It’s what we do.
Covid Update
So, I don’t care what you think of New York or it’s governor, New York and the Northeast (except Vermont) has done an amazing job in decreasing cases of Covid.
I fear for all those states that thought we were joking or that we were over dramatic “snowflakes” ( I invite you to see the refrigerated trucks behind the hospital). You are now being hit with it worse than we were.
Wear all the PPE.
I address the new Covid Warriors (healthcare workers) :
Patients should get high flow O2 and lay them prone. All of the meds we have now DON’T WORK!
Isolation is important as is hand hygiene.
Eat well, sleep, wear your mask it’s not political, it’s reality, exercise. Keep relative isolation from vulnerable family members.
Scrubs, head covers with buttons on the sides for the mask straps (look on Etsy) and “Covid sneakers” that you change out of outside your house and throw in the wash before walking in.
Be good to yourself, it’s gonna suck and you’ll likely end up as damaged as we are in the NE. We’ll be here when you need help like you helped us.
New Mask
On a not serious note, I got a new mask.
Base Camp Mask
Since we’re all going to need masks for the foreseeable future, I ordered a very cool looking and comfortable mask. It is super comfortable with a Velcro strap around the back of the neck (takes the strain off the ears) very breathable with replaceable filters inside.
Called Base Camp masks, it’s good quality, solid shipping and less than 40 dollars.
You’ll spend more on boxes of cheap masks of poor quality that don’t look near as cool. Btw, I’m not getting paid to show you the mask, I just think it’s cool.
As always, wash ya hands, wear a mask, social distance, and love each other… we are all we have.
In 1854 in London, there was an outbreak of a disease that was fairly common in the world at the time. The name of the disease was Cholera. Cholera is a disease (that still exists) caused by a bacteria called Vibrio Cholerae.
Cholera
This disease is spread by drinking water that is contaminated by the bacterium and the bacterium is passed by the fecal-oral route ( yeah gross) from dumping sewage into the water source that you then drink from.
It gives you a severe diarrhea that leaves you dehydrated and was a major cause of death as cities grew all over the world.
The normal distribution of this disease (as you would figure) is in those areas around a river that is contaminated with sewage. London (being on the Thames River) at that time was having it’s fair share of problems with that. The thing is, they didn’t KNOW about Vibrio Cholera. This was before the confirmation of the Germ Theory so they didn’t know what caused Cholera.
There were many throries. From “miasmas” or clouds of invisible toxic gasses, to sinfulness and being a bad person.
The idea was that the wealthier you were, it meant that you were a good person and that you were somehow protected from getting the disease. Similarly, the holier you were, or the higher station you were, prevented you from getting it. What was happening in London at the time however, was baffling to the physicians of the time.
It didn’t matter what station in life or how much money you had or even if you had the best doctors, people were still getting it. Not by the river but smack in the middle of the city.
A controversial doctor by the name of John Snow had a suspicion that there was more to it than that.
What he did was to plot the known cases of Cholera on a map with the names and addresses of the victims. By doing this, he found that every sngle infection had a common point, a water pump on Broad Street in Central London.
In the mid 1800’s there was no routine indoor plumbing and water had to be obtained from pumps that drew their water from the local water source or resevoir. Either the family drew water from this pump or the servants for the family did, and it was this pump that was the common denominator.
There was no “boiling the water” as there was no reason that anyone would want to do that. No one knew about bacteria or parasites, or even viruses.
Dr. Snow figured that something had to be in the water or on the pump that caused the disease.
In a very controversial move, he caused that pump to be put off limits.
He then followed it up by plotting the illness once that pump was shut down. Finding the cases almost stopped, he went on to investigate just what the heck was in that water that caused the disease and became a great researcher into “anti-sepsis” and cleanliness in the field of anesthesiology (as it was practiced at the time).
Cool Story Bro…
So what does this have to do with anything?
What Dr. Snow did was essentially invent the field of epidemiology which is the study of how diseases spread. Lately, with Covid, we’ve all been exposed to a little bit of that, and we are smart enough to know about bacteria and viruses and the like. However, the major diseases that have been around before Covid, and will be around long after, have a similar pattern but with a twist.
They aren’t caused by a bacteria or virus, but by a lifestyle.
When people died of bacterial infection, sepsis, “childbirth”, viral infections like measles, mumps, rubella, polio, and yes even the flu, there was no need to worry about “lifestyle” diseases.
Even when Type I Diabetes (juvenile or insulin requiring) was first described as a disease and subsequently treated (NOT CURED), people died young and the lifespan of the average human was very short.
What is a major problem that is correlated with lifestyle are the diseases that are considered chronic and non-infectious: smoking, substance abuse, Diabetes Type II, Coronary heart Disease, and obesity.
Eventually we’ll get to all of them, but today I want to make the correlation between obesity and relative poverty.
Now Come The Inequities
Now true poverty leads to many self perpetuating issues and we will discuss these in the future, but I want to bring in the subject of obesity in children leading to Diabetes in youg adults. This has been found to be directly related (by the method that Dr. Snow invented) with what is I like to think about as second world poverty in our own country.
For example: A family makes just enough (in whatever community that may be in) to provide food for their children. This food however, is as inexpensive as can be, as the family does not have extra to pay for the more expensive food items. We have all experienced that the least expensive food items are the high carb, high fat, high sugar items that are usually “generic” when found in a supermarket. This keeps the family fed and happy. It does not keep them healthy though, salads and fresh fruits and vegetables are not cheap, so families in these types of situations avoid them when they can. [as an aside, in Dr. Snow’s times an apple or an orange was considered such a treat that it was given as a christmas gift]
This same family may live a fair distance from a supermarket and live in a “Food Desert” (an area that has little access to healthy food), in which there may be many convenience stores (of the 7-11, gas station, or bodega variety) or fast food restaurants with their one dollar chicken nugget deals.
Plenty of food, little nutrition
This same family may not have a car or only one car that the principle breadwinner needs for work, so the family will have access to a supermarket infrequently using the car or they would have to use public transportation.
Public transportation is usually very poor in areas where this income level family lives, so it is easier (and cheaper) to shop at the local bodega or 7-11 – yes, this really happens. So the cheapest and most convenient thing is what gets bought.
Now, in these areas (growing up as a hispanic NYC kid in the 70’s we thought of them as “those places”, but now living in a suburb, what are food deserts to a poor family are just “drive through” neighborhoods to me), there are usually schools that are considered “Bad Schools” whose kids don’t usually graduate and whose budgets are small compared to wealthier neighborhoods. These schools don’t usually have any afterschool activities, so (as in my case as a kid-until I joined the Cub Scouts), those kids are kept indoors, away from the “bad kids”. In my case, it was reading encyclopedias borrowed from the library, today it is video games. These bookish kids don’t do any exercise, get fat, and tend to develop pre-diabetes and diabetes at an early age since they don’t get healthy food, develop habits of eating unhealthy food, and don’t get much exercise.
The only other alternative in some neighborhoods is joining a gang.
Bodega style food
I know of many Moms locally who make their kids study and exercise at home and sign early waivers for their kids to join the military, to get them away from the gangs. A much safer plan and considered a win for the family who now has more money to spend on the others and that child is now considered safe.
So… Inequities?
This correlation is strong. “second world” poverty in the US is a preventable source of Diabetes in children which leads to Diabetes in adults which then leads to Heart Disease, frequent illness and a strain on the medical system. So ensuring things like good Public Transportation, and incentives for supermarkets to locate in areas most needed, can inexpensively decrease the amount of heart disease in the working poor, thus decreasing the strain on the medical system (such as it is).
But What About Covid?
Things are opening up, that’s good.
The virus is NOT GONE, there is NO MAGIC CURE.
You are NOT Immune.
In New York, the cases are down as are the deaths, this means we have plenty of room in our ICUs so you can do dumb stuff and get infected. We are used to face-timing family of dying patients now. So, go ahead, we have this down. You’ll still be running the risk of death or chronic disability as a “Chronic Lung Patient”, but hell, it’s YOUR choice.
In other parts of the country (outside the Northeast), your numbers are going up. You may end up sick without facilities to care for you, but it IS YOUR CHOICE.
Please: wash your hands, don’t touch your face, social distance, and wear the masks.
Please love each other, we are all we have.
Remember that everyone is of value, but we need to see that too many people of color have been discriminated against and mercilessly abused by a system in which (amazingly) most of its members don’t even realize that it is doing it. So at this time it is important that we recognize and fight for the recognition that Black Lives Matter.
In the months of March and April, I noticed a curious thing. Whenever I would be outside at night (usually to take out the trash), I would stop and stand very still and listen.
It was dead silent.
There is always a background hum to what we call civilization. Back in High School, our Social Studies teacher took us to the roof of the school and had us listen to it. When I was young I used to love to go up to the roof of the apartment building and listen to it… the hum of the cars, airplanes, ambulances, whatever, it was always there.
Even after 9 11, when all the air traffic was down, the hum was still there.
But during these last two months it was gone. Replaced by an introspective quiet, the absence of useless motion, almost a protective blanket of quiet lest the virus come and get you.
Over the last few days, starting with the slow reopening of Long Island, the growing realization that there is Spring in the air, and the tragic murder of George Floyd with the ensuing protests and completely unaffiliated opportunistic looters, the quiet is gone.
I stood outside and the hum was back.
Gone was the introspection.
Gone was the protective blanket of silence, replaced with white hot anger and the realization that no matter what Nature throws at us, the worst enemy humanity has is itself.
The diseases of Racism, Hatred, Opportunism, and Cruelty have pushed Covid almost to the background.
The mask a mere part of the uniform we all wear to be out in the world.
Covid is still here
I fear that we will see another mini surge in cases with all the protests. I hope not.
There are stillno effective treatments.
We are sending ventilators to Russia (as well as useless Hydroxychloroquine).
And there is the injection of the “culture war” into the basic public health measure of wearing masks.
This Blog is Evolving
I will continue to bring the latest in news of Covid to this blog, but I will also be bringing news of general health, disease specific self care, health and public policy, and a larger perspective to the idea of health writ large.
As Always…
Wash your hands, do not touch your face, social distance, wear the masks! Eat Right, Exercise, and most of all… practice loving each other.
Toleration is NOT the goal, valuing and celebration of each other is the goal.
Life, Health, and Policy. 