Category: Medicine

Posts that are specifically tailored around the practice of medicine.

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Being human Medicine Reflections on Life, Being Human, and Medicine Reflections on the Christian Life

A Medicine That All of Us Need

My blog today is about a very powerful and effective therapy. I have written about it before but there is a strong need for it now. I needed to take a strong dose this morning. I suspect you do too.

There are just some things in medicine that for certain conditions really work. These are really satisfying to be the one to prescribe. It is like being the one who gets to put the last piece into a 1000-piece jigsaw puzzle. Or perhaps the perfect tennis lob coming at you that you know you can just crush and then you really do it. Or when your golf swing is “on” and you swing the massive driver and it hits in the perfect center of the club and the ball flies with grace and beauty way down the center of the fairway. Such a good feeling!

  • Ibuprofen: It may sound silly now but when aspirin and then ibuprofen were invented they were wonder drugs. I remember my mother and how much her shoulder problems were helped by the new Upjohn wonder drug called Motrin. Even now for the right thing a strong ibuprofen is remarkably effective.
  • Antibiotics: It goes without saying that these have been miraculous and for a bacterial infection it is fun to be the hero who prescribes the antibiotic and have the patient get better.
  • Lasix: For a heart failure doctor, when I see elevated neck vein pulsations (a sign of volume overload) I know I can make patients feel better by giving them Lasix. I am not doing anything special but they are amazed at how much better they feel. This is remarkably satisfying to be the one to help them.
  • Cardiac resynchronization (CRT) for a heart failure patient with a left bundle branch block and a QRS duration of 180 ms. This is for my medical friends who will understand. For the rest, just trust me it is fun to be the one to prescribe this therapy in the right setting that can be like a miracle to a patient.
  • Hope.

Hope is one of the most potent medicines that I know.

Hope is a medicine that if effectively applied brings amazing strength and power.

I have discovered that it is also a fundamental part of what it means to be human.

And like ibuprofen, antibiotics, Lasix, or CRT, it can be really fun to be the one who has the honor of prescribing it. And if you don’t know what I mean I am really hoping (no pun intended) that you will read on for a bit with me.

What is hope?

Hope is not, “I wish, I wish, I wish, I wish!”

Hope is not a delusional state or forcing yourself to believe something that you don’t believe to be true.  That is cheap mimicker of hope that I call wishful thinking. That is not hope.

Hope is patiently looking beyond the current troubles to better things to come.

What do I mean by this? 

Years ago, I read an article about the CHiPs (California Highway Patrol motorcycle division). Most of us remember Eric Estrada and the television show that made everyone know the CHiPs. The article was specifically about how the CHiPs were trained for driving safety. One of the parts of their training was how to handle an obstruction in the road. The natural inclination is to swerve to try to miss the obstruction. But experience had taught them that when the officers swerved, they frequently would lose control of their motorcycles. Often the obstruction (such as an animal) would move out of the way. The majority of the time they were better off not to swerve. So, they trained the officers not to swerve. Instead they were to look beyond the obstruction and pick an area where they would be after passing through the obstruction. They could then pass through it but their focus would be on confidently controlling their motorcycle to their target point. And right before they hit the obstruction they would even goose the throttle a little bit to extend their front forks.

That is HOPE.

What do I mean? 

Whatever is going on now, look beyond it.  Stop for a minute now and do that. Can you see the other side? More than that – can you see something pleasant on the other side? Once you do – I want you to stop trying to swerve away from your current troubles. Go ahead and “take them” – go through them – but don’t focus on them – instead focus on where you are headed on the other side.

Do you have the imagery? See whatever it is that you are facing and aim beyond it. Keep your focus on what is beyond. In fact – pick a specific point after it and use that to guide you as you go through it. And then right before you hit it – go ahead and goose the throttle a little bit. 

Practically how does this work?  Well – first off, I would say – very well. But let me share some examples.  I do have a prior LinkedIn post that has some stories about this that might prove helpful. I will share one personal one. 

Ann, my mother in law, was an amazing woman. She had polio as a child and survived. But she had to live with the consequences. She went through a LOT in her life and she will forever have our respect for the amazing dignity and grace in which she did that. But she had one illness and it really knocked her down. I am honored that I was one of the people that helped to carry her home from the hospital. In the midst of this and the pain medications, for the first time that I had known her, she lost her HOPE. It was scary. It was not her. 

My wife and I talked and I told her about my clinical experiences of prescribing HOPE. We talked about what we could do. We talked about what Ann loved. We knew that more than anything she loved her family. We also knew that she loved to be a part of what people were doing and she loved to travel. But that was going to be really hard in her new debilitated state. So, we started problem solving. We decided that if we could rent a big motor home, we could all travel and go visit other family members. And then we asked Ann what she thought about it.  

She loved the idea. She had something to look forward to. She had HOPE. And in that small thing, the spark came back. Ann, the woman who taught us all about HOPE – not just on this earth – but eternal HOPE through an abiding faith in Christ and a firm confidence in the good things to come after this life – was back.  I got to drive a large motor home. It had a built-in generator. It had wings that slid out to make a larger living area. We could stop anywhere and be home. But more than that, Ann was Ann again. Just by looking ahead at the idea of what was coming (the trip in the motor home) she was better.

And so, one of my favorite medicines to prescribe is HOPE. In medicine I encourage clinicians to prescribe it regularly.  To do this – you need to get a chair and sit down and talk to your patients. Find out about them. Find out what is important to them. Find out what is ‘on the other side’ that is worth living for. Like Miracle Max on the Princess Bride, do some detective work to find what they have to live for. “Hey! Hello in there! Hey! What’s so important? What you got here that’s worth living for?” Help them to find it. And then prescribe HOPE. Talk with them about focusing on that rather than the current struggles. Every day pull out more details and help them paint a richer and richer picture of the other side.

I wrote this last year when I was going through radiation therapy. The radiation with the complicated breath hold equipment and then the associated nausea and fatigue were no fun.  The staff were kind and wonderful and amazing. But I felt crummy – queasy and fatigued. I could have stared at it – focused on it – and thereby made it a torture for me. Or I could do something else. And my wife is just so kind she planned a LOT for me on the other side.

  • Beach vacation planned. (We went and had a great time!)
  • Visit to my daughter in London planned. (That also was an amazing trip. We even went to Loch Ness!)
  • New parts for my sailboat ordered. (Installed and working well thank you!)

That is HOPE. 

I didn’t post this when I wrote it. But now I see that our entire world needs it. We are in the logarithmic phase of growth of the number of cases. Many of us have read excerpts or summaries of the Imperial College report and the predictions of a massive wave of deaths to overtake the United States. Even if these do not occur, we have the impact of the social distancing on our economy and how we will recover from that. We have a large obstacle in our path. Regardless of what happens or how severe the outbreak ends up being it is not good. We don’t have a choice. We are going to have to go through it. How are we to do it and successfully make it to the other side?

Hope.

What is important to you on the other side? 

See the obstacle. Look beyond it. Pick on spot on the other side. Focus on that spot and aim for it.

What can you see on the other side? What can you focus on? There is nothing wrong with looking at that and using that for strength if or when you feel anxious or stressed in the current circumstances. That is how human beings function. We were designed to function based on hope. What can you see?

Sarah and I drove by the sailboat yesterday. A few days ago, I made sure I had some supplies that I needed to make minor repairs on it before this year’s sailing season. I am going to be out sailing on a beautiful warm and sunny day. We will be beyond COVID 19 and we will invite friends to come with us. We will relax and not worry. We will smell the water. We will wait and try to see the green flash and then the amazing colors of the sunset. We will blow on our conch shell to welcome the sunset and we will all laugh at the sound. And then we’ll sail back and dock and then maybe stop for ice cream on our way back home.

Yesterday China had no new cases of COVID 19 reported. All the Apple stores in China reopened. There is a place on the other side of this.

What is your spot on the other side?

Categories
Being human Medicine Reflections on Life, Being Human, and Medicine

Is It Really Worth All the Fuss?

There are currently 12 confirmed COVID 19 cases in Kent County.

There are ONLY 12 confirmed COVID 19 cases in Kent County.  And yet we have shut down everything. Restaurants closed. People being laid off. The streets quiet. All of us obsessively washing our hands and filled with anxiety.

Did we act too early?  Couldn’t we have waited until it really hit here hard? I mean, shouldn’t we have waited until we had a big portion of our city sick and reports of lots of deaths? These changes have been extreme. Shouldn’t we have waited until the extent of the people who were ill and dying was that extreme?

I obsessively check the statistics each night. It is an odd and somewhat morbid thing. Of course, I don’t want the numbers to climb. I don’t want people to be ill and certainly don’t want people to die. I don’t want our ICU to become overwhelmed. I don’t want to hear about our teams having to make extreme choices of who gets treated and who doesn’t. I don’t want to hear about not having enough ventilators, or isolation masks, or anything. I want it to remain at only 12 cases. 

But a part of me is anxious to see the numbers rise. Part of me wants to see that all of this upset of our routines and our economy and our society is worth it. Part of me wants to have the numbers jump in our area and then confirm inside of me that this is all worth it. “See. It IS really bad. I am SO GLAD that we acted. I am SO GLAD that we are doing everything we can to control this and counter this monster.”

That is the strange circumstance in which most of us find ourselves. Don’t get me wrong, 12,955 deaths around the world is bad. But in the 2018-2019 influenza season in the United States, the CDC estimates that 34,200 people died of the flu. In the grand scheme of things, it seems that we are accustomed to a LOT of deaths from influenza and it doesn’t seem to phase us too much. We don’t stop our entire culture and destroy our economy each year for the sake of the 34,000 who die. What is so different here? 

That is the basis of the emotional disconnect. 

I am not challenging the decisions have been made. I am not going to say that this is a big socialist conspiracy to deprive of us of our liberties. I am not going to say that this is some colossal election year trick or manipulation. I know that those things are not true. 

But what I am saying is that it is okay to acknowledge the question. Asking the hard question is the first step to a better understanding of what is going on. It is important that we go through this process so that we can go from head knowledge to knowledge that makes sense to us. We need to really understand. We need this so that we have the strength we need to face the challenges ahead of us.

I looked at a picture of my grandfather as a young man. He is standing with his brothers. His mother is seated with her boys around her. My mother captioned the picture, “Alonzo died on 3/24/1919. Mary was left to raise 5 sons.”  

My grandfather’s family was traumatized by the Spanish flu epidemic (the 1st major H1N1 outbreak). At the age of 11 he saw his family become ill and his father die. Overnight he had to take responsibility for running the family farm. I cannot imagine that. 

In 2019 the CDC collected a series of stories to remember what happened in that epidemic. The stories are riveting.[1]One person told how she was baptized at the same time as her father’s funeral because then the minister only had to come to the house once. No one else was allowed to attend. Another tells of how the leaders pulled a wagon down the street each day. Families would bring out their dead relatives and load them on the wagon to be taken away (without caskets). Outrageous. Awful.

One morning this week I found myself looking up numbers about that time. I was hoping it might help me understand what is going on now. What I learned was that in that epidemic, 500 million people contracted the flu. Around the world there were 50 million deaths. In the US there were 29 million cases (about 28% of the population). Somewhere between 500,000 to 675,000 persons died. That is enormous. By comparison, in all the years of World War 2, the US lost 235,000 in battle. The Spanish flu was horrible. It shook the world.

To get control of and end the epidemic the authorities implemented “mitigation” strategies. This included efforts to slow the spread and protect at risk individuals.  The strategies worked and eventually the epidemic ended. 

With the H1N1 outbreak of 2009, these same strategies were implemented. This resulted in 60.8 million cases with about 12,469 deaths. With modern healthcare and mitigation, the strategies appeared to work.

What is so different with COVID 19? Why is this such a big deal that leaders in both political parties are willing to throw our country into chaos?

My best way of explaining this is to reference the Imperial College report.  Who is the Imperial College? They are a team of 50 scientists with close ties to the World Health Organization.[2] They really are the “gurus” of public health policy. They are the ones that everyone trusts. They are considered the “gold standard”. What they say usually becomes public policy.

Early on, they were recommending the same “mitigation” strategies and talking about how “herd immunity” would be the best approach for the novel coronavirus. But then they saw what happened with the disease when it spread outside of China (where strict suppression was implemented). They did a detailed analysis. They came up with some scary predictions.  

Like 2.2 million deaths in the US if we just let the disease run its course.

If we do what we did with H1N1 in 2009 (mitigation) we should expect 1.1 to 1.2 million deaths.[3]  Also we should expect that we will have such a terrific spread of the disease that we will overwhelm the US healthcare system. They predict that we will exceed the ICU and ventilator capacity in the US by 8-fold. We will literally have people dying without the ability to care for them.

They ran the figures again if we implement the strict suppression strategies that were put in place in China. If we do this, they anticipate that we might be overwhelmed at first but then over the course of a few weeks we could slow the spread down to a pace where the healthcare system would have more of a chance to keep up. Even with this they recommend that we take drastic actions to increase capacity. This includes cancelling all elective procedures and finding ways to increase ICU capacity. 

Is this real?

In short: yes. 

It is real enough to scare Boris Johnson and Donald Trump into doing things that none of us ever thought we would see. 

It is real enough that we are daily hearing horror stories out of Italy, and now New York and Washington State and California.

This disease is unlike anything we have ever had to deal with. If you get COVID-19, you are 21 times more likely to die than if you get influenza. It is real and it is that bad.

The thing is the only way to manage this is to act aggressively and act early to prevent the spread. We just don’t have anything else we can do. I just hope we have acted soon enough.

Only 12 cases in Kent County. That should make us happy that so far there have only been 12.  I sincerely hope that we are so ahead with “suppression” in West Michigan that we won’t have to live through the horror that is currently happening elsewhere.  

Not able to go to a movie or go out to eat at a restaurant? Not able to go to church? Not able to get together with friends? Obsessively washing my hands?

I am ok with that. 

My grandfather. He was an amazing man. I miss him. He lived through the horror in 1918/1919. I hope that we don’t have to see it get that bad.

[1] You can read the Spanish flu stories here: https://www.cdc.gov/publications/panflu/stories/index.html

[2] [2] https://www.nytimes.com/2020/03/17/world/europe/coronavirus-imperial-college-johnson.html

[3] https://ftalphaville.ft.com/2020/03/17/1584439125000/That-Imperial-coronavirus-report–in-detail-/