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dofficer j

Dofficer J had kind eyes. He smiled as I let out a deep breath; I was about to enter the room of the first patient I cared for with COVID-19. I felt like I did when stepping into the batter’s box in a big softball game long ago: With an increased sense of awareness, I thought, “this is routine. This is important.” J seemed to sense these unspoken feelings.

“You got this doc! Just let me know when you’re ready to come out of the room.”

I laughed at myself, for J is a nurse, therefore spends hours of his day at patients’ besides. Yet he was giving me, someone who spends much less time at the bedside and is therefore at lower risk of contracting COVID-19 at work, a pep talk.

This week, I’m working in a community hospital in Seattle. We have what nowadays seems like a luxury – an adequate supply of masks and gowns. While ever-changing policies on when to wear what add doubt and a significant amount of stress to everyone’s lives, I am grateful that I have not been asked to sacrifice my own safety to care for patients with COVID-19.

Daily operations have changed drastically since I last worked at this hospital a month ago. Some of these changes make work safer but less fun. New workspaces allow providers to maintain more distance from one another, but fewer people are around to bounce ideas off of. The one route I’ve used all year to navigate the hospital has been interrupted by the creation of a COVID unit, meaning I am constantly lost. But one change I’ve enjoyed is the creation of the role of the Dofficer.

A Dofficer is a person, usually a nurse, who has been trained to help providers appropriately don (put on) and doff (take off) PPE when entering and exiting patient rooms. J coached me my first time doffing, but after seeing a few patients the process started to feel routine. Still, the hospital’s policy requires a Dofficer assist with each patient visit, and I quickly came to value these personal interactions as a welcome change in my workday.

Last night, for example, I worked with an operating room nurse who was repurposed to Dofficing when the hospital’s ORs closed to create more beds for patients with COVID. Assisting with glove and mask removal clearly laid outside of his realm of interest. Still, he had a good attitude, and in the minutes bookending my patient visit, he regaled me with stories of surgical cases he’d gotten called into in the middle of the night. Reminiscing on his not-so-long-ago glory days, which felt like a lifetime ago, provided a reprieve for both of us. With other Dofficers I’ve discussed upcoming plans (or mutual lack thereof) and childhood school lunch favorites (conversation sparked by the brown paper bag with my name on it containing my sterilized goggles that I carry around); we’ve done a celebratory dance when a patient’s COVID test came back negative.

Last week, the UW Institute for Health Metrics and Evaluation (IHME) published their COVID-19 pandemic modelling graphics and data. There are always assumptions and limitations to models such as these, but I found them somewhat helpful in trying to imagine what the upcoming months might looks like.

They provided good and bad news. They project that many places will have enough hospital beds and ventilators for all who need them. Not everywhere will. I haven’t figured out how to articulate my thoughts about New York City, except that I think it’s like nowhere else in the world, and that it’s made of millions of resilient, incredible individuals who are New Yorkers to the core, who have come together and survived crisis and hardship in the past and will do so again this time.

Like many, I’m trying to settle in for the long haul. This past weekend, I took a two-day vacation from COVID: I did not read email or news. It took me awhile to catch up on Monday, but it created a kind of freedom. I rode my bike and made cookies whose dough looked alarmingly like poop (but that turned out tasting great and looking…better…once baked!!); my friends made me laugh so hard I cried. These experiences pushed COVID out of the pit of my stomach and created energy within me. I think these breaks, in conjunction with taking note of the daily good, like the decrease in traffic and my interactions with Dofficers, will be key to my resilience in upcoming months.

Two friends recently gave me The Book of Delights, essays by a poet, Ross Gay, on things in life that delighted him. I reread the preface every time I open the book because it makes me so happy, so I’ll share a paragraph from it here:

“It didn’t take me long to learn that the discipline or practice of writing these essays occasioned a kind of delight radar. Or maybe it was more like the development of a delight muscle. Something that implies that the more you study delight, the more delight there is to study. A month or two into this project delights were calling to me: Write about me! Write about me! Because it is rude not to acknowledge your delights, I’d tell them that though they might not become essayettes, they were still important, and I was grateful to them. Which is to say, I felt my life to be more full of delight. Not without sorrow or fear or pain or loss. But more full of delight. I also learned this year that my delight grows—much like love and joy—when I share it.”

We’ve each already had sorrow, fear, pain, and loss. There will be more to come. But perhaps by uncovering and sharing with each other the hidden good we will get through this, slightly more full of delight.

the uncounted deaths of covid

I had vacation scheduled for this week. I’ve been at home, doing chores and enjoying being in the presence of my thriving house plants. While trying not to spend too much energy on COVID-19 while not at work, the physical distance from the hospital has provided me room to think about it differently.

I love to tell stories, so I’ll start with that of one of my dearest patients from residency. I’ll change his name and call him James. A veteran in his mid-80s, he reminded me a little bit of the old man from the movie “Up.” Stubborn and distrustful of almost all, when I eventually cracked his shell, he was warm and delightful to be around. Even when I knew he would intermittently disagree with my medical advice in a way that made me want to pull my hair out, I looked forward to our visits together.

Alone in the world, James had been unstably housed or homeless intermittently for many years, and as an older adult had gotten a small subsidized apartment. He had no friends or family members: Near the end of his life he’d asked me, as his primary care provider, to be his power of attorney, citing me as his closest contact. On most days, he stayed in his room, used an exercise machine that he’d somehow purchased, drank Coca Cola, and watched YouTube videos of scenes of street life from countries he’d never visited.

He had several chronic medical problems for which he came to see me about once every six weeks. He had no phone. If I wanted to reach him, I’d either wait until his next appointment, which we set up prior to his departure each visit, or I’d send him a letter in the mail. He had strong opinions about his medical care, but when we reached an agreement, he took his medications precisely as prescribed. We made small, incremental changes, as I knew that I would not have the chance to monitor his lab tests or symptoms for six weeks. Once, after falling and breaking his arm outside of his apartment building, he took three connecting buses to get to our hospital’s emergency department. When I asked him, a man in his mid-80s with heart failure and difficulties balancing, why he didn’t ask someone to call an ambulance for him, he said, “Because those are for emergencies! This was just a broken arm!”

That day, in the emergency department, James’ arm was splinted, and he was asked to come back in a few days, after the swelling went down, to get reevaluated. The message to return early was somehow lost, and while in the coming weeks many people went to great efforts to contact James, he came back at his next regularly scheduled primary care appointment, over a month later. He still wore the same splint. By that point he’d permanently lost almost all mobility in his dominant hand and wrist.

James died a few months ago, of a complication of one of his chronic diseases. He maintained his stubborn dignity to the end of his life. I felt lucky to be still living in Seattle when this happened, and that his inpatient provider contacted me when he was admitted to the hospital so I could visit him in the days before he died. In what felt like an important moment in my young medical career, James and I watched one final YouTube street scene video together.

There are many people like James across the country, whose chronic diseases maintain a precarious balance even with a strong medical system to support them. Despite optimal conditions, sometimes communication breaks down and complications occur.

Studies have shown that in the setting of crisis, the death toll often is much higher than is officially reported. In 2017, Hurricane Maria caused massive damage to infrastructure in Puerto Rico. While the official death toll was set at 64, public health experts estimate thousands more died from interrupted or delayed health care for their chronic illnesses.

In speaking with nurse and doctor friends who work in different Washington clinics and hospitals, they describe work this week as “eerily quiet,” with the “usual patients,” people with heart failure exacerbations, diabetic ketoacidosis, cirrhosis, and other chronic diseases, not coming in as usual. These patients are likely trying not to be exposed to SARS-CoV2, the virus that causes COVID-19, which could be especially dangerous for them. But I’m also worried that they will come to the hospital in a week or two, when their illnesses have further decompensated, when it will be even harder to right the scales back to that delicate balance of health.

The people who have always been the most vulnerable – those experiencing homelessness, who do not speak English as a first language, with mental illness, who do not have a disposable income, who lack cell phones or computers to easily communicate – will undoubtedly suffer by social distancing from their providers. Telehealth is a helpful tool for many and is probably the best option for most right now. But some will fall through the cracks that COVID-19 has created in our health care system. They’ll become uncounted deaths of this pandemic.

So take care of yourselves! If you do or do not have chronic illness, do what you can to stay well. Check in on those who you know are vulnerable. If you can help them adapt to communicating via telemedicine appointments, or grocery shop or pick up their medications for them, you may be saving a life from COVID-19.

protecting providers’ health and wellness

This weekend, our first medical resident tested positive for SARS-CoV2, the virus that causes COVID-19. Most importantly, they’re doing ok. They stayed home since the first hint of symptoms, are now asymptomatic, and will return to work later this week per our employee health guidelines. Despite this, the news was jarring.

It’s impossible to know whether this resident was exposed to the virus in the community or at work. They cared for a patient with COVID-19, but the timing of their symptoms would be unusual for this to have been the exposure. The resident wore the proper personal protective equipment (PPE), but the patient was hospitalized before the implementation of strict training and protocols for donning (putting on) and doffing (taking off) PPE.

I’m extremely thankful for the resident’s return to good health. But their illness reinforces the importance of rigorous and thoughtful workplace training and protocols to protect those who work in the hospital, from housekeepers to phlebotomists to physicians. For my provider friends, here are a few lessons I have learned:

If you work in a hospital and might go into a patient’s room, shave your beard. We use two categories of masks in medical settings: surgical masks and N95 masks. Based on CDC recommendations, we are using contact and droplet precautions (surgical masks + other PPE) to care for patients with suspected or confirmed COVID-19. We are using airborne isolation (N95s + other PPE) for patients undergoing aerosolizing procedures including, among others, airway suctioning and noninvasive ventilation.

N95s provide a tight seal around the nose and mouth. For people who cannot use N95s, or for the very highest risk procedures including intubation, a machine called a powered air-purifying respirator (PAPR) can be used. In incident command meetings a few weeks ago, I was amazed with the amount of time spent discussing the exact number of N95s and PAPR hoods available, how more could be procured, and how to protect the current stock. Mask shortages have been in the news. We’re very worried about running out of N95s, but our hospitals’ single-use PAPR hood stocks are critically low.

Facial hair precludes the use of an N95 by preventing the mask from providing a tight seal. So, barring religious or medical reasons, please temporarily say goodbye to your beard to preserve the PAPR hoods for those intubating patients and those who cannot use N95s for nonmodifiable reasons.

Get N95 Fit tested ASAP. This test to determine the effective type of N95 mask should happen once per year, but many hospitals do not require this. Assuring the effectiveness of the most important piece of equipment for hundreds of people, all at once, significantly slowed us down in expanding who could safely care for patients with COVID-19. This could have been mitigated through regular testing protocols. Also, save the N95 mask used for your Fit test (it hasn’t been used with a patient so is not contaminated). I’ve been using mine to practice taking it off, which can be tricky without contaminating yourself.

Push your leadership to provide proper PPE training. If your leadership is too overwhelmed to develop PPE training and protocols, develop it yourself. Personal Protective Equipment including gowns, gloves, masks, and face shields is the stalwart of protecting yourself. When properly donned and doffed, the rate of virus transmission between patient and provider is thought to be very low.

At my hospital, we have four steps providers must complete before caring for patients with suspected or confirmed COVID-19: 1) watching a video on hand hygiene/PPE donning and doffing; 2) FIT testing; 3) an online PAPR module, and; 4) in-person donning/doffing training. Doffing in particular is complex and time-consuming; it requires patience, practice, and is best done in a buddy system. This sounds intense, but I really think it’s the best way to protect ourselves.

A few of my colleagues adapted PPE protocols to something that would work at our hospital. Check out the resources page of this blog for UW’s protocols. UW incorporates trained observers, which our hospital did not have the staffing to do. If you want to see our slightly simplified protocols, send me a message and I can show you the checklists my colleagues developed.

Provide a unified message. With rapidly changing protocols, lack of clear communication and mixed messages have led to tensions between groups of providers, as well as wasted PPE (for example, an entire unit’s staff thinking they needed to wear N95s at all times in and out of patient rooms). Most importantly, when any hospital employee does not properly don and doff their PPE, everyone is at increased risk of infection. We have trained “PPE Champions” in each service line in our hospital who train their division and disseminate information.

Be well, to the best of your ability. Some of our residents have found caring for patients with COVID-19 to be particularly emotionally challenging. There are no easy patient deaths, but it is especially distressing when a person dies alone. Stable patients with COVID-19, such as an elderly man we recently cared for, are lonely: They’re not allowed to have visitors and are seen as infrequently as is safe to minimize infection risk and conserve PPE. Hospitals are taking steps to get patients digitally connected with their families, but this means of communication is new for some. I mentioned the concept of “crisis standards of care” in my last post, about the emotional challenges that will arise if we have to compromise our usual practice of medicine during this pandemic.

All this comes at a time when, as a society, we’ve been stripped of many of the activities we usually use to get our minds off of work. Just when I was getting strong, my rock climbing gym closed; when I could finally use the subjunctive, my Spanish class moved online; the book club, concert, and ladies night were cancelled.

It’s nerve-wracking to work on the front line, in a building full of infected patients, but I’m grateful to interact with people in the flesh every day. I’ve tried to adapt my usual exercise routine by doing home video yoga and getting back into running. I heard the concept of “forest bathing” last year, the improvement of health that comes with being in nature. I take the opportunity to be outside, greater than six feet away from people, as often as possible.

For other chiefs – to support residents’ health, we’re moving toward schedules that provide prolonged rest between periods of work. I’ve tried to maintain the educational atmosphere of residency by continuing in-person morning report. With medical students off their rotations, our numbers are very small, and these conferences provide learning and a brief respite from the thick atmosphere that COVID-19 has created. On Wednesday we’ll hold our first weekly “Soul Food” meeting. While eating take-out from local businesses, one of our chaplains will lead a discussion among small groups of residents to help process all that’s going on. These meetings, like everything else, might change soon, but for now, I think they are safe and helpful.

Finally, if this is your thing, Headspace, a meditation app, is offering a free membership to healthcare professionals through the end of 2020. Just register with your NPI! I haven’t done it yet but likely will.

Eventually, and probably soon, we’ll all know people who are affected by this disease. The news gives the impression that things are spinning out of control, but I think of provider wellness and PPE protocols in the hospital like I think of public health measures outside of the hospital. They’re things we can act upon to protect ourselves and slow the course of this pandemic.

face your fear friday

During my fourth year of medical school, I took improv and comedy writing classes at the Second City (when social distancing ends, I highly recommend this). My writing teacher introduced us to an idea called Face Your Fear Friday (known henceforth as FYFF). He encouraged his students to do something that terrified us once per week. Through this challenge he’d convinced past students to take risks such as doing stand-up comedy for the first time.

In the past few years, I’ve intermittently revisited FYFF, thinking about what scared me and attempting to face it straight on. This typically led to some degree of embarrassment, for example the time I drove a carful of friends up one of the steepest hills in Seattle in heavy traffic. New to driving manual transmission, I figured facing this fear in a high stakes environment was the best way to learn. This exercise ended in deeply concerned friends and a police officer asking the several cars behind me to back up, as I’d rolled dangerously close to them while stalling out multiple times (of note, I can now drive up any hill without stalling, so maybe this worked after all!!).

In the past few weeks, when faced with a virus I cannot see rather than a hill I can conquer, I’ve thought about fear differently. Not as something to face straight on, but something to reckon with. To cope, I’ve thought about the following things: What scares me the most, what allays these fears, and what actions can I take to address them that won’t hurt other people?

Of course, like everyone, I worry about many things (for example, the mental health of society right now, whether I’ll be ostracized for blowing my nose one time after biking to work in the cold). But here are two things that scare me most:

1. The sickness and death of my loved ones. I think this is on everyone’s list of greatest fears. I worry about many, including my dad, one of my heroes, a doctor who could get exposed at work, and who is in a higher risk group because of his age (although anyone who knows him would agree that he’s young at heart). It’s unbearable to think about him getting sick and being unable to visit him.

To deal with possibilities that make my stomach turn, I quickly focus on reassuring things and those that I can act upon. My dad will do everything recommended to prevent the spread of illness, staying at home when possible and using the right equipment at work. I can teach him what I’ve learned about COVID-19, which might help him. I can continue to draw strength from his calm demeanor, analytical mind, his lightness and humor.

2. Practicing “crisis standards of care.” Crisis standards of care means we are forced, by a pandemic or natural disaster, to change how we would usually practice medicine. If we didn’t adopt these less ideal care standards, it would likely result in more illness and death.

For example, the usual standards of care are to dispose of gloves after each use. However, in a disaster, there might be a shortage of gloves, and the crisis standards of care might be to wash gloves and use them again. While washing gloves is far from ideal, once the last pair of gloves is used, providers would be forced to wear no gloves, or to not touch their patients or the equipment in the room such as IVs. This would lead to more harm to patients and providers. In a crisis, perfect is the enemy of good.

This concept is a nightmare for providers. I appreciate the necessity of these measures when there is no other choice. However, physicians, nurses, and other health care providers are not trained to do “ok.” The thought of providing suboptimal care, even if compelled to do so to avoid further illness and death, is morally distressing.

But, “hope is the only thing stronger than fear,” said my boss, the director of our residency program, in an email a few days ago. He’s not quite sure where this quote came from, but I like it so I’m sticking with it.

And there’s a lot of hope that allays my fear. I’m encouraged by people bearing social distancing to slow viral spread and decrease the surge of sick patients that we’re expecting in Seattle in the next few weeks. At a meeting yesterday, our program leadership laid out a plan for upstaffing our hospital in a way that took provider rest and recovery into account. We’re conserving materials in a way that maintains protection of providers and prevents spread of illness.

The enemy here is invisible, and there are many things we cannot control. There is a lot to worry about these days. But there are things we can change, too, so I try to spend my energy on these things, and trust that others are doing the same. With this collective action, being conscious that viruses don’t discriminate and we’re all in this together, I’m able to move forward with my day and not be crippled by fear.

love in the time of covid

Let me start by acknowledging that this pandemic is hard for everyone. We all have the pit of anxiety in our stomachs. Many face major financial insecurity with stock market losses, business and school closures. I know people whose weddings, family members’ funerals, and dream vacations have been cancelled. My friend’s grandma recently enrolled in hospice and cannot have visitors. It hurts differently for everyone, but almost all are suffering to some degree.

These pain points push us. They drive us to doubt the reality of the threat or to overreact to it. My goal in writing is to help those I love (and anyone interested) walk that line, promoting understanding of the COVID-19 pandemic’s power without allowing it to cripple us with fear.

In Seattle, we’re a week or two ahead of much of the United States in terms of COVID-19, both in number of infections and deaths, but also in our response to it. I hope that Seattle is not a week or two behind Italy, which recently surpassed China as the country with the most COVID-19 related deaths, and that the rest of the U.S. and the less affected parts of the world are learning from mistakes and successes of those who have been hit hard early.

One of our neighboring hospitals in the Seattle area has a full ICU with no remaining ventilators. A young, previously healthy doctor infected with COVID-19 is in critical condition. For me, these realities shattered the illusion that this pandemic would not be important. The fear and anxiety are well-founded.

And yet, I’ve found love to be the predominant sentiment throughout all of this. When talking about potential virus exposure with several medical residents, their unanimous first concern was of unknowingly transmitting the infection to frail patients. Several people in our community have donated meals or transportation to and from work to our residents in a time when public transport is not recommended. Not even on my most adventurous travels – hitchhiking through the Middle East solo during the Arab Spring – have I had so many loved ones reach out and tell me to stay safe as I have in the past few weeks.

My advice is to follow your local public health department’s guidelines, even if only begrudgingly. These guidelines differ in every part of the country, and they’re changing rapidly, so tune into your local news frequently. If your public health department recommends you stay home, try to do it. The goal of these measures is to slow the transmission of the virus so that everyone who needs mechanical ventilation for respiratory support will be able to have it.

Most importantly, think about your community. If you can see how this hurts those you love, try to help them. For me, Seattle has never felt so remote, knowing that my Midwest-based family is no longer a simple plane ride away. Before I get out of bed each morning and head into the hospital, I take solace in scrolling through photos and videos that my family and friends have sent. Little acts of love go a long way in the time of covid.

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