Category: Medicine

My wife has a good sense of direction. She loves to look at maps and help us figure out the best way to get places. When we travel, she usually navigates, and I drive. 

We were driving to stay at an inn. As we got close I began asking, “Is this the place? Is that the place? What drive do I turn into? Is it this drive? Is it the next one?” Because she is navigating for some reason I expect her to know exactly what everything will look like.

She answered (like she has many times in the past), “Honestly – I don’t know. Neither of us have ever been here before!”

I am now asking myself and being asked by others what I think during the current COVID 19 crisis. What is really going to happen?  How many are going to die? What is this going to look like in West Michigan? Is it really going to get bad here? I find myself saying the same thing, “Honestly – I don’t know. Neither of us have ever been here before!”

We are moving through stages. I know where we have been. I have a good idea of where we are now. But to be honest – I don’t know – nor does anyone really know exactly where we are going. We are relying on our navigators, but even they have never been here before:

• Stage 1: Denial – It was just going to be another one of those China things.
• Stage 2: Wishing – Well, maybe it will be contained and just be sort of a west coast thing.
• Stage 3: Unsettled – Crisis decision making, dramatic changes in life and schedules, constant meetings trying to figure out new things, odd quiet settling over the hospital and day by day things being taken away from my life.
• Stage 4: Preparing for battle – Taking on new challenges. Setting up an improvised home office. Doing my first days of “seeing” patients via video visits and telephone visits. Constant Microsoft Teams meetings. Zoom get togethers to counter the isolation. “Surge” or as I would think about them “doomsday” planning meetings. Hearing horror stories from New York and then Detroit. Bracing myself for the sudden impact of a COVID 19 surge. It was supposed to be here in a week or maybe two or was it three?
• Stage 4 (now): The “Turtle’s Back” – Someone used this analogy and I think it is interesting. Social distancing has worked in West Michigan. The curve has flattened and continues to flatten even more. The modeling still says that we will get a “surge” but now it is getting pushed further out. When it hits it is supposed to be of lower intensity and longer duration. It is no longer a big spike and then drop. Rather than a tidal wave, it may be more of a very large swell that goes over our heads and stays there. We will be treading water and may have to do so for longer than we like. But hopefully we are now strong enough and prepared enough to keep our heads above water until the swell goes away.

It is now like the shape of a turtle’s shell (viewed from the side). We will have an increase and then a sustained high level of cases and then eventually a decline. They are still predicting that it will exceed all standard healthcare capacity. Fortunately, we have had time to prepare and with the flattened curve it will be more manageable. This is wonderful news. And this is terrible news.

It is wonderful that we should be better able to manage it. But the flat curve keeps extending further and further out. This means that this whole thing is going to go on a lot longer than people understand. I am afraid to even write about how long this may go on. But trust me – it is longer than you want.

What does this all mean? 

Two weeks ago, I was in an electronic meeting. I looked at the updated projections for West Michigan. I saw my Michigan summer slipping away. I came downstairs from my home office and sat in the living room with Sarah and felt incredible anxiety inside. I started to doubt if our society really could – or would – sustain this degree of social distancing for as long as we need them to.

The word that came to my mind was “sustainability.” 

We have all been running a sprint. It looks like we need to shift to running a marathon. 

We did this at work. When this started, in the hospital and our medical practice, we rapidly were cancelling things – patient appointments, procedures, etc… Slash, slash, slash. We were putting things off for a few weeks – then maybe 6-8 weeks. That seemed right at the time. It isn’t anymore.

In our lives we were doing the same thing. We locked ourselves inside and hunkered down like we would have for a couple of snow days. Now that it has been a few weeks – that strategy is feeling bankrupt.

Sustainability.  

How can we sustain social distancing for the long hall?

As a society? As an economy? As a business? As a family? As a human being?

We need to start asking strategic and hard questions. 

There are a lot of people that want to jump to either stage 1 (denial) or stage 2 (wishing that this is just a Detroit thing) again.  

The fact that they haven’t seen the horror of COVID 19 themselves makes them want to go back to my stage 1 or my stage 2. They want to say that it isn’t as bad as we were told. There are plenty of posts about embracing “herd immunity.” Just get it over and done with. Can’t we just pass through this like we do with influenza every year?  Can’t we just take our lumps and be done? Aren’t we doing equally as much harm with the economic and social destruction of social distancing? 

It is only rational and normal to ask these questions. I see people getting angry and divided over this. We have to ask all these types of questions if we are going to figure our way through this.

I don’t think abandoning social distancing and embracing herd immunity is the right strategy. Let me explain why.

1. There is no denying that this is a bad virus and a bad disease.  We have read the stories. People get really sick.  Even those who do not get hospitalized can go through being scary kind of sick. A lot do get hospitalized. While not everyone gets that sick, a lot of people do. In healthcare we see a lot of different illnesses. This is different. It is not business as usual. It is real. It is scary.
2. There is no question that this can spread so quickly that it can exceed healthcare resources. We have heard about “Ro” and exponential growth. These are not just theoretical concepts. Italy, New York, and Detroit are just 3 strong validations of what can happen with rapid spread. We may not have seen it in West Michigan, but experts really think it is because we were 2 weeks ahead of Detroit in our social distancing. They got hit by a tidal wave with their back turned. We looked and locked down and didn’t get hit.

This disease is bad. It is not speculation. It is not hype. It has happened, with devastating consequences not once but in multiple locations. When healthcare resources are exceeded, then the case fatality rate starts to climb dramatically. 

Will it happen in West Michigan? I don’t know. I hope it doesn’t.

But, I for one expect to have medical care if I need it. 

I have thought about what I will do if I get COVID 19. I will try to tough it out at home. Sarah and I have talked about how we will distance from each other but closely monitor each other if one of us gets ill. And if I get ill – really ill – I expect that there will be a hospital bed, oxygen, someone to monitor me and someone to “prone me”. If I really need it – I expect that there would be a ventilator for me. I would consider it unacceptable if the numbers are so great that I will just be left to fend for myself.

That is why we have done all of this. 

We have done it so that we don’t have to have an eye doctor or an inexperienced medical student trying to run my ventilator. We have done it so we won’t get put on a makeshift cot in the hospital cafeteria or in a convention center hoping for the best. We have done it so that there is a state of the art ventilator available for me if or when I need it. 

But what we are doing right now is not the answer either.  

We need to shift and figure out how to make this sustainable. What things can we do to protect those who do need to work? Frankly I am bothered about the safety of the workers who have to stock the shelves for me. I am bothered by the people who cannot work electronically from home who now have no income. I am bothered by the growing wave of unrest as people struggle to adhere to strict stay at home rules. What can we do to allow more people to work? What parts of our society can we get moving again? Can we learn – and change – and do things smarter – better – safer?  Can we do them for the long haul? How can we survive all of this?

We need to have asked the question: “How can we maximally socially distance and do it in a way that we can sustain it for 4 months or longer?” 

There are two competing messages at the moment. One message is that we must keep it all up and do it even more tightly. Our governor surprised a lot of people when she tightened rather than loosened the restrictions in the state of Michigan. She is hearing the reports from Detroit. She is hearing the cries of healthcare institutions and workers begging for relief. She is hearing of violations of social distancing and experts begging for her to fix it. 

But there is another very valid message.  Let me lay that one out below:

1. Thank you! So many of you have done an amazing job. I have seen the empty roads. I have seen the empty stores and people standing 6 feet apart. I have seen people volunteering to make masks and asking what they can donate. I have seen churches close their doors and remake themselves in new and creative ways that they never dreamed of. I have seen grandparents wave out the window with arms that ache to hold their little grandbabies but staying apart anyhow. I have seen high school seniors give up those most important final few months of their high school life.  Thank you!
2. You have made a huge difference! Our case rates for COVID 19 have remarkably flattened and remained low. Your behavior has changed what was thought to be inevitable. 
3. I am sorry for your losses. The trauma of this has been more than just illness and deaths. The lost jobs and lost income and economic losses are not just about comfort. These are real and meaningful and painful. I know it. I am sorry.
4. Six months is different than six weeks. We need a long-term strategy. We cannot just shut down the world and do nothing. We cannot expect everyone to just stay locked in their homes. We need businesses to manufacture and people to work. We need to think about how to create a “new normal” where we can prevent the spread, keep the curve flat and yet not destroy our society.

There are very strong opinions about the protest in Lansing this week. I am not here to defend or criticize that. I am only here to say that what drove that protest is a cry for help. It is a cry for answers about how we can go forward if COVID 19 is truly going to be a problem for many months. It was anger that we did not hear about the 4 points described above.

What is the path forward?

What is really going to happen?

Honestly – I don’t know. Neither of us have ever been here before. 

But we are going to need to do the best we can to figure this out. We need open dialogue and smart people to re-engineer society. We cannot just judge or yell at each other. We are on the same team and fighting the same enemy. From what I can see now, this is:

• Real. There are people getting really sick and places where healthcare resources are overwhelmed.
• Not going to be over as quickly as you or I would like.

We have some more work to do.  

Yesterday 6 Midwest states (Michigan, Wisconsin, Indiana, Kentucky, Minnesota, and Ohio) announced their plans to work together to figure out how to safely reopen parts of our society. I have seen incredible ingenuity, energy and creativity over the past several weeks. Things that were in the past not possible have become possible. The people in our health system have been amazing. Many of you have been amazing. Can we as a society figure this all out together – responsibly – practically? 

I know we can. We must. We will.

We are fortunate to not yet be in “the surge” of the COVID 19 pandemic. Our hospital has patients with it. The leaders expect or at least are preparing for “the surge” like other cities have experienced. We have been preparing and ramping up for it. As a part of that we have redeployment plans in place. Those of us in cardiology are now doing educational modules to brush up on our critical care skills. 

As I thought about what to write this week it seemed fitting to go back to some memories of being a student. 

ISINLAMIKAMP

For me, this was a very important lecture. If memory serves me correctly it was Dr. Vander. We were in the 2^nd semester of our M2 (2^nd year) of medical school. We were seated in our large lecture hall that was our dwelling place for most of the year. Our professor went up to the board at the front of the lecture hall. He wrote this on the board, “ISINLAMIKAMP.” 

We were all puzzled. 

He told us that he was going to teach us about a very common condition. He said that it often afflicts medical students. He said it commonly comes on sometime about the 2^nd year of medical school and usually lasts for 15 years or longer. He reassured us that it was not terminal. We would survive it even if we didn’t like it.

He went back up to the board and wrote next to each letter:

I’m 

Stupid

I’ll

Never

Learn

All the 

Material and

I’ll

Kill 

All 

My

Patients

We all laughed a nervous laugh. We were all feeling that. None of us had the courage or perhaps the wisdom to admit that we were having those thoughts. That lecture was powerful. It made me realize that I was not alone. It helped me understand how to be a doctor.

That day I learned an important lesson.  There is so much material that it is impossible to learn and remember all of it. It is of course important to study hard and to remain as current as possible. There are some who are just so brilliant that it seems like they know everything. But oddly the ones who seem to know everything don’t always tend to be the best clinicians. More important than knowing everything is knowing that you don’t know everything.  

What do I mean? More important than knowing everything is:

1. Knowing what you don’t know.
2. Being honest and humble enough to admit when you don’t know.
3. Knowing where to go or who to ask.

What’s the Worst Thing that Could Happen?

The next story is a repeated one. It happened almost every time I was on call. 

The story starts the day or night before my call. I would think about being on call and I would feel a pit in my stomach. Even just the anticipation of being on call would bring it on. It was a feeling of anxiety and dread. Was I up to the job? Would I be able to handle everything? Most of the time, I wouldn’t even know specifically what I was so worried about. 

But I would be worried.

Every time.

I learned a technique that helped me a lot. In my efforts to try to figure out what I was so worried about I would ask myself, “What is the worst thing that could happen?” 

The script went something like this:

Me 1: What is the worst thing that could happen tomorrow?

Me 2: …

Me 1: Well?

Me 2: Well – my patient could die! 

Me 1: Yes, they could.  But if they do – then that is ACLS^[1]. And then you know exactly what to do.

Me 2: So, you are saying that if it gets terrible, then I am ok?

Me 1: That is exactly what I am saying. So just calm down and STOP worrying!

Oddly – that made me feel better. I would go and do what I needed to do. As a trainee there were senior residents or fellows or attendings who could help if I didn’t know what to do. And as an attending there were other attendings. The pre-call dread never matched the reality. 

I am not saying that it was never hard. It was. 

I can remember carrying my little green call book and managing 40+ patients on one of my rotations as an intern at the naval hospital. There were lots of times when I was really stressed. There were times when I wanted to throw my pager across the room. 

There were times when I got very tired. One night I really remember. I was so tired I struggled to finish writing an H&P (history and physical). I had to keep waking myself up. I was “falling out of my chair” tired. When I looked at what I had written in the patient chart I was horrified. There in the end of the H&P I had written part of a dream I had just had while asleep. I don’t know how I did that. It was really embarrassing! I got up and walked around to wake myself up. Then I had to throw out the paper and start writing all over again.

But no matter how bad it got, even at its worst, the worst thing that would happen is that the patient would code. And then it was just routine. Then I would know exactly what to do. We would follow the ACLS algorithms.

And even in the very hard times, I was working. I was moving. I was active. 

When I was in medical school I would read novels. Oddly they were like “sorbet for the brain.” In the midst of hours of studying I would treat myself with a few pages of a novel and it would refresh me so that I could go back to studying. One of the books I read was Phil Caputo’s, “A Rumor of War.”^[2] The book tells his story about going to serve as an officer in the Vietnam war. 

At the beginning of the book he was young, just out of college, and a brand-new military officer. He went from worrying about history and literature to worrying about dying. I could not imagine what that was like. While I was reading it, I was the same age and had just graduated college the prior year. That identification with him drew me into the book. Each page carried me with him. I came along as he arrived in Vietnam. I felt myself going when he went on his first patrol. By reading I could feel myself sitting on the helicopter heading to the drop zone. I could feel the intense anxiety and dread. I could feel him pretending to be brave for the sake of the men he was leading. He couldn’t admit it. He had to be strong. The drop zone was visible down below. As the pilot descended I could feel him asking himself if he would be able to do his job once they hit the ground. I wondered. If I was there, could I do the job? And then it happened. They hit the ground. Really without thinking they all jumped out and started charging forward shooting against enemy fire. They were just doing whatever they needed to do.

And so, it would be each time on call. The dread was the anticipation. The riding in the helicopter over the trees and then descending down to the hostile drop zone. Would I be up to the job? When we touched down on the ground would I do what was required of me? 

Then I was on call. I did the job. I handled whatever came.

In the action it was not as bad as the dread of the action.

And that was my second very important lesson: The anticipation is worse than the execution.  At its worst, it is ACLS.

The Person Who Taught Me How to Manage DKA

I was a brand-new intern. I had “MD” written on my lab coat and people called me “doctor” but I still had a lot to learn. 

I had been taught about how to manage diabetic ketoacidosis (DKA) in medical school. I had been a part of managing it several times. But as an intern it was different to be the person who was writing the orders. It was a whole series of things – the fluid – the timing of the insulin – the management of the electrolytes and the anticipation of the rapid shifts in electrolytes, etc. I was anxious when I did my first DKA admission in internship. 

And then I discovered a secret.

The nurses had managed it a gazillion times! As I was writing the admission orders, my patient’s nurse was there. She looked to make sure that I was not missing anything. Then she would conveniently page me every time I needed to make a change. “Doctor, would you like to do xyz?” “Why yes, nurse, I think I would like to do xyz! Can you take a telephone order for that?”

The truth is that the person who really taught me how to manage DKA was an RN.

This was my third important lesson: Healthcare is a team effort.

It is not the all wonderful and all knowledgeable doctor dictating everything that is done. The doctor is not like a puppeteer who has to control all the elements. It is a team. There are multiple layers of professionals. 

In safety we talk about the “swiss cheese” effect. That is the idea that for every error that reaches a patient, it is actually the result of multiple failures. Each failure could have but didn’t catch the error. It is as though you stacked a bunch of slices of swiss cheese and all the holes lined up perfectly to allow the error to pass through and get to the patient.

We talk about the swiss cheese effect, because the vast majority of the time, the swiss cheese effect works to our advantage. We end up doing the right thing because of the integrity of the entire team.  Gaps in one of our actions are compensated for by the others.

In training there are multiple layers. As a medical student there is the intern. As an intern there is a resident and the other interns. As a resident there is the attending and the other residents and the interns. 

But there were also nurses. The nurses trained me in ways that I couldn’t learn in books. There were respiratory therapists. They taught me about ventilators. The unit secretaries taught me how to handle the paperwork and what orders to write to get things done.  The pharmacists taught me about drug interactions and drug dosing and pharmacokinetics. The list goes on and on.

The point is that if we are smart we treasure the integrity of the entire team.  It doesn’t mean I don’t take ownership for my responsibility and my actions. I push myself to know as much as I can and to always always always do the right thing. But I do that in the context of being a human being. That means that I am fallible and will make mistakes. When I inevitably make a mistake, it is the integrity of the team that catches the mistake and stops it. It is easily corrected. It does no harm.

 The dangerous physician is the one who is arrogant and thinks that he has to do it on his own. The wise and safe clinician is the one who values and empowers the team. 

What about now?

I am so sorry for everything that is happening in Italy and New York and now on the southeast side of Michigan (and multiple other areas). They are living through very challenging times. 

The data suggests that it is coming to us too. We have been given the blessing of some extra time. It doesn’t seem especially fair that we get this and they didn’t. But who ever said that everything in life is fair? And who ever said that anything about this COVID 19 pandemic is fair? 

But we have been given time to prepare. It feels a little bit like we were given 2 extra weeks to study for final exams. In that studying it makes us feel anxious. Part of us just wants to put away our books and march in and demand our chance to take the exam. But wisdom tells us that these extra days are a precious commodity. Our colleagues in other areas would have loved to have had this time and more of a chance to prepare and plan.

And so, we prepare. We plan for redeployment. We brush up on clinical skills that we have not used in years. And we remember lessons we learned early in training:

1. ISINLAMIKAMP: It is ok to not know everything. As long as you know that you don’t know and are wiling to ask.
2. The anticipation is worse than the execution. When the time comes we can do the jobs that we are needed to do.
3. The team: We are not going into this alone. We have a lot of talented people around us. We will be going through this together.

How about for those of you non-medical readers?

1. ISINKEIWTKIDKWTB  (I’m Stupid, I’ll Never Know Everything I Want To Know and I Don’t Know What To Believe): We all feel like that sometimes. We don’t have to know everything. We just have to use our best judgment to find experts that we think are credible. At the moment,  smart people are telling us to stay home, wash our hands, and to slow the spread. That is enough.
2. Sitting and doing nothing is hard. That is human and natural. I hope it helps just a little bit to know that? Anticipation is hard to handle because you can’t just “do”. Many are going to get this illness. Some of us will just go through it without problems. Some will feel awful and then recover. We may lose some people we love. That is the essence of the dread that many of us feel. I am in no way looking forward to any of that. Maybe I should be telling everyone that the frustrated feelings they have inside at the moment are not valid? Maybe I should be telling all of you to just be happy and that you have things “good” sitting safely home at the moment? But honestly I find myself feeling the “pre-call dread.” I am back to figuring out how to deal with that. Please know this: In the worst of it, human beings – you – have a deep strength. That strength comes out when you need it. Are you up to what is going to be required of you? When the doors open and the helicopter hits the ground and the bullets are flying around you, you can and will jump out and charge forward and do whatever job is required of you. You might not like it. But within you is the strength to do it.
3. The Team: Remember that in medical education the learning comes from all directions. It is never just “top down.” Maybe in this time also we can take encouragement and support from all directions? If you have children in your life, maybe this is the time for them to teach you (to remind you) how to play? We are all in this game of life together. None of us are perfect. Fortunately, we do not have to be. Even if we are physically separated we are still going through this together. Together we are strong.

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^[1] ACLS = Advanced Cardiac Life Support

^[2] Caputo, P. (1977) A Rumor of War. Holt and Company, Henry.