The patterns of the flesh

A wrongness beckons when I start walking-

what have I forgotten?

before, it was the opposite, fear striking

after I'd launched unassisted from a chair

the woman I was striding away as I faltered

I learned too well from fear.

the woman I was clings with weak fingers

can I move on again from myself?

Terrifying, Wonderful

 It's been three weeks, and by the grace of God I can still walk.

A Miracle from God

No one tells you this, but it turns out being supernaturally healed is pretty overwhelming. I suppose I might have expected that, but given that I wasn't expecting healing, I hadn't exactly done my research.

February 2021, or, Functionally Speaking

I bought a wheelchair yesterday.

So Here's To Hope

I'm pretty sure I cried straight through the first half of 2020.

In my defense, I was having an objectively tragic year. I left not just my job but my career under the unrelenting pressure of my worsening disability. My husband and I moved, again, this time for a job I knew I needed but wasn't sure I wanted. Two close family members developed devastating chronic illnesses. And I realized that I'm gradually losing my ability to walk and use my hands. All this against the backdrop of, y'know, the raging collective trash fire that has been 2020.

All I was was sad, all the time. I couldn't even talk to anyone about it, really. I just cried every day.

Midway through the year, a close friend sent me a link to a book and informed me we were going to read it together.

I clicked on the link and was greeted by a bright yellow cover with - of all things - an enormous smiley face on it. The Happiness Advantage, the cover screamed. How a Positive Brain Fuels Success in Work and Life. I snorted and texted her back some version of absolutely not. I wasn't about to buy a yellow smiley book on being happy. I don't like yellow. Or being told how to feel. I'm not even sure I like happiness. I find it suspicious a lot of the time, schmaltzy and commoditized, and often exhausting. A forced smile in a toothpaste ad. No. 

When it arrived a mere two days after I ordered it, the book and I stared at each other for a bit. I can't believe I'm reading this stupid book, I texted my friend. Don't ever doubt my love for you. She responded in the cheerfully assumptive manner of someone who never has: we should discuss once a week. Do you want to do one chapter at a time or two?

I truly didn't expect this book to change me so much.

The breakthrough came when we got to the chapter about gratitude. Gratitude: another word I have learned to eye suspiciously, given its cachet with trendy influencers and people who like motivational posters. It conjures up carefully posed social media posts full of product placements - cynicism lacquered in toxic positivity. This was different, though. The author gave a simple hypothesis: maybe the brain can be trained to be more optimistic by marking the good things that are already present in one's life. Invoking the power of accountability, he suggested telling a close friend or loved one three things you are grateful for each day, things that didn't have to be profound but did need to be specific. This appealed to me. It seemed practical and attainable. Maybe we could try it?

So we began. Every day, we would tell each other about a great cup of coffee or a glimpse of beauty, a moment of laughter, a kindness we received. For the most part we kept it small. Almost immediately, we realised that just hearing about the other's happy moments brightened our own day. We didn't anticipate this recursive loop of happiness, but we embraced it, and it became its own self-reinforcing system. We would reach out to each other greedily in the evenings, sometimes simultaneously: tell me about your day! What are you grateful for?

Some days it was a real stretch. It's 2020; a lot of crummy things happened. And nothing about this exercise changed the essential facts of my life. But with practice, we learned that even on the worst days, there was something to feel legitimately grateful for.

This may sound basic, but consider its effects. In the manner of a river slowly changing its bed, my focus has gradually eroded away from the major obstacles I face, instead eddying around bits of happiness. I'm learning to better appreciate small pleasures. And I'm finding that I'm emotionally stronger for it. Far from this change being a distraction or a waste of time, when I turn back to the big challenges they are somehow less overwhelming, because I recognize now that my life will always have a wealth of good things in it. I just have to take the time to notice them.

It's my prayer that in 2021, we would all be able to apply this lesson. There is joy trickling through all the little cracks in our lives, and this next year I hope to settle into that understanding further. It's a small goal, but I'm satisfied with that. A change, no matter how incremental, can gather a curious momentum of its own with time, gradually pressing through the mud to find hope.

So here's to hope.

Happy New Year.

Song of Ascents

"Are you ready to leave clinical medicine?"

His indifferent tone belied the importance of the question, not just to me but to the eight other people currently sitting around the table, waiting for my response with varying degrees of patience and interest. Outside, an unseasonably warm January day coaxed buds from the trees dotting the hospital campus.

I looked over at the chief medical officer of the hospital and blew out a wry breath. A half truth slipped out before I could stop it. "Is anyone really ready to leave clinical medicine?"

Covid-19: Yes, you need to stay home.

I don't know about you guys, but I've been hearing a lot of grumbling lately about how the response to the covid-19 pandemic is "overblown." That's the word they've been using. There seems to be a collective sense that covid-19 is not very serious and because of that, the public health response is an overreaction. We should just live our normal lives, let this little cold run its course, and move on.

Please do not fall prey to this misunderstanding.

This infection couldn't be less routine. So why are people wanting business as usual? My hypothesis and hope is that for most people, the important information just hasn't been presented in a way they can easily digest.  Give people the information they need in a way that makes sense, and maybe they will make better decisions. This post is the beginning of my contribution to that effort.

The flu is a convenient point of comparison since right now it feels like the devil we know.  In the United States, flu picks up around October and dies back beginning in March.  You get it primarily from other people sneezing/ coughing around you, or from touching surfaces with virus on them and then touching your face.  There's a lag time of 1-4 days between exposure and getting sick, and each infected person infects another 1-2 people. We all know the symptoms: body aches, fever, runny nose, cough, lasting 5-10 days. Pneumonia is uncommon.  The vast majority of people with the flu feel crummy but are in no danger - only about 1-2% of people with the flu get admitted to the hospital.  And about 0.1% of people with the flu die from it, or 1 in 1000.

So the flu isn't that contagious, and it's not that deadly.  Despite that, when the flu is finally done with our country each spring, healthcare workers are exhausted from the extra workload and tens of thousands are dead. In the 2018-2019 flu season, we saw nearly half a million hospitalizations and 34,000 deaths.

Let's contrast that with what we have so far on covid-19.

Covid-19 is also a virus and it is spread in roughly the same way as the flu.  Mild cases look similar. But there the similarities end.  For starters, the lag time between exposure and illness can be up to two weeks. For people who get sick, the symptoms last anywhere from 7 days to a month, and pneumonia, or lung infection, is much more common.  Early data shows that covid-19 is 2-3x more contagious than the flu, and strongly suggests it is also 10-40x more deadly. It is also about 10x more severe - somewhere between 10% and 20% of people who get sick end up in the hospital (references at the end; I recognise that these numbers are dynamic, but these are the current best estimates). 

That's one out of every ten people who get sick, maybe as high as one out of every five. Very different than one out of 100.

A lot of people focus on the case fatality rate, or how many people who get covid-19 will die from it.  But I think time will show that this is the less important statistic when it comes to making decisions.  Much more important for all of us is the high hospitalization rate, which appears to hold for adults of all ages. A large proportion of people need hospital support to make it through this illness. And the resources for that support - oxygen, IV fluids, respiratory support, not to mention beds to sleep in and staff to give the actual care - are finite.

Do you want access to hospital care if you get seriously ill?  I do.

The high infectiousness and moderate severity of covid-19 combine to threaten our communities with a huge health burden. If the spread of this infection is not controlled, our clinics and hospitals will be overwhelmed by a massive influx of severe illness. The result will be healthcare spread thinly and ragged at the edges.  An article in the New York Times gives a helpful and accurate summary of the situation (article dated March 12th; their cases have tripled since the article was written).  Here's a brief excerpt in case you can't see the article:

"The cautionary tale is Italy.  More than 12,000 people have been infected there; more than 800 have died. A little over 1,000 have recovered. Many of the rest are ill. And a significant number of them need to be hospitalized — right now.

"This has exceeded Italy’s capacity for care. It doesn’t matter what physicians’ specialties are — they’re treating coronavirus. As health care providers fall ill, Italy is having trouble replacing them. Elective procedures have been canceled. People who need care for other reasons are having trouble finding space."

The takeaway here should be that even though many people have a low individual risk, everyone has a huge societal risk.  I want to highlight that resource management is a major concern here, and should be a motivator for all of us.  This is not something Americans have really had to be aware of before. You want to try not to get this infection if possible, but you also want to slow the community spread as much as possible, so that if you do get sick, and you need healthcare, that care is actually available when needed.  

I hope that explains why social distancing on a widespread level is necessary.

So yes, please, wash your hands often and stay home when you're sick.  But also avoid public places, even if you're not under a local mandate to do so. Expect these precautions to be in place for several months, likely through the spring and possibly into summer, although no one can be certain at this point. 

We each have an important role to play in our communities in protecting ourselves and each other.

In the next week I'll post about what it means to be "high-risk" and what additional implications that carries. And let me know if there are any specific questions you have about this infection.

-------------

References for flu severity:

Reed C, Chaves SS, Kirley PD, Emerson R, Aragon D, Hancock EB, Butler L, Baumbach J, Hollick G, Bennett NM, Laidler MR. Estimating influenza disease burden from population-based surveillance data in the United States. PloS one. 2015;10(3). 

 Matias G, Taylor R, Haguinet F, Schuck‐Paim C, Lustig R, Shinde V. Estimates of mortality attributable to influenza and RSV in the United States during 1997–2009 by influenza type or subtype, age, cause of death, and risk status. Influenza and other respiratory viruses. 2014 Sep;8(5):507-15.

CDC report on influenza disease burden for the 2018-2019 season.

References for COVID-19 severity:

CDC weekly update on covid-19, dated 18 March.  Important because this is our first look at statistics from America.

Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, Azman AS, Reich NG, Lessler J. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Annals of Internal Medicine. 2020 Mar 10.

Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DS, Du B. Clinical characteristics of coronavirus disease 2019 in China. New England Journal of Medicine. 2020 Feb 28. 

Xu Z, Li S, Tian S, Li H, Kong LQ. Full spectrum of COVID-19 severity still being depicted. The Lancet. 2020 Feb 14.

Lancet article on the current situation in Italy. It's a good summary of that country's demographics, infectiousness, severity, and public health considerations.

Like air

I fought for her as she held
her diamond breath in her
hands, close
close to her chest
finite and precious
saving it carefully, losing it
every other word

When I returned
heavy-laden from long hours
she smiled
took my hand and prayed
and I felt
the breath I had given her
being returned

Healing

"Your kidneys have shut down.
There's nothing I can do.
I'm so sorry."
Her husband held her as she cried.
Later, I came back.
We talked of the power
of The Great Physician.
I prayed for her.
She clutched my hands in thanks
And I realized
That in my helplessness

I had offered true medicine.

55 words

I fell down a little narrative medicine hole today, and in so doing, I found a writing mechanism called the 55-word story.  There is an excellent discussion of this mechanism in this JAMA article from 2017.  Writing is a tool for processing, reflection, entertainment, teaching, and so much more.  But sometimes you just don't have any bloody time.  Enter this tiny sliver of writing!  It's almost a game - 55 words exactly, no more, no less, but in any format you'd like - and completing one is terribly satisfying.

I am going to start doing this, and I hope it will be a regular event.  Here is today's story.

Perspective

My boss leaned back and put her hands on her hips.  "Well, you know what?  I think we kicked ass today.  Well done."

I didn't lift my eyes from the transfer paperwork I was filling out at top speed.  "Do you think so?  I just feel like I got my ass handed to me all day."

She was unfazed.  I saw her shrug out of the corner of my eye.  "No, I think we did a good job.  It was tough today but we took care of patients."

I grunted.  "I guess."

--------

Her words came back to me several hours later, when I was driving home berating myself.  It's something I do often.  Over the years my commute has naturally become an opportunity for me to take stock of the day.  I like to take stock of things, sum them up.  This is especially true of work, where I don't have the time or space to emotionally process during the shift.  I do a kind of final evaluation, sorting my experiences and trying to put them away before I get home. 

The trouble is, I'm never satisfied with my own performance.

Is it a win that I stabilized a transplant patient enough to make it to her critically important transplant meeting tomorrow?  Or is it a sign that I can't manage patients efficiently, since it meant she was with me for nine hours?  Does it mean something that she and her husband thanked me when I checked in with them one last time before I left, two hours after the end of my shift?  Or should I focus on the mother of the child with an earache who had to wait two hours to be seen while her son cried in pain?  She told me off pretty soundly when I finally got in the room.  I couldn't tell her that I had been prepping and transferring a patient with intracranial bleeding and coordinating care for my first ever case of acute angle closure glaucoma, and I didn't mention that we were short a doctor that day.  My instinct isn't to defend myself in those situations.  I just apologized.

I saw so many sick patients today.  Bowel obstructions, cancer complications, my transplant patient.  Two patients with heart rates sprinting away, their owners pale and panting for breath.  I reassured a post-stroke patient that their recovery was just beginning.  I kept someone out of a nursing home by helping to arrange for assistive devices at home.  I made two little kids laugh during their exams!  My boss is right.  She did a good job today and so did I, damn it.  So why don't I feel like I did?

Maybe it's because we were so busy.  My charts aren't finished.  Wait times were long.  That kid with the earache?  He wasn't the only one who had to wait a long time, and people were annoyed about it.  When my night colleague came on, there were patients who had been waiting for hours already queued up for her.  She was nice about it, but I know that's a lousy situation to walk into.

Or maybe there's no external reason.  I know one of my strongest traits is perfectionism; it's a double-edged blade that medicine has sharpened and hardened over time.  I don't know what today would have had to look like for me to feel like I did well.  I just know that I always feel like I'm not disciplined enough, not knowledgeable enough, not efficient enough, not fast enough.  Not kind enough.  Not consistent enough.  Not enough.

I still don't feel like I'm enough.

The Importance Of The Physical

My charge nurse stepped out of a room and waved to get my attention.  "We need a doctor in here, please," she said in a level voice.  In non-ED-charge-nurse speak, this roughly translates to, "GET IN HERE RIGHT FREAKING NOW THIS PERSON IS DYING."  I dropped everything and headed in.