Category: Medicine

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 1^st 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. 

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^[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-/

I meant well. My patient called and had a recurrence of her medical problem.^[1] In the past I had sent her to a specialist. He had made some recommendations if the problem recurred. I could have made her call or go back to the specialist. In hindsight I wish I would have. I wanted to help her and everyone. I meant well. I was trying to make things easier. I looked at the recommendations from the specialist. I prescribed one of the medications that he suggested could help with her problem.

She developed a horrible complication from the medicine.  It was a rare complication. But it had been reported with the medicine I had prescribed.

I acted quickly. I immediately saw her. I called specialists and asked for help. I did whatever I could find to help her recover from the complication.  All the king’s horses and all the king’s men…

She got worse. A lot worse. ICU type worse.

And then every day, sometimes twice per day, I walked to the ICU to see her. I carefully monitored her condition. I looked at everything. I spoke with the ICU team and all the specialists. Together we worked hard to do the best we could to help her get better.

It was hard. It was hardest on her. I wish that I could go back in time. I wish I could do anything possible to prevent her from having the complication. I have replayed the events over and over again in my mind so many times since then. 

It was also really hard to continue to be her physician in the midst of all of this. I had prescribed the medicine. And every day, sometimes twice a day, I would walk down the hall and climb the stairs to go to her room. It felt so heavy. My heart was a lead weight as I climbed the stairs every time. I wouldn’t take the elevator. It didn’t seem right. I climbed the stairs. I would swallow hard and go in to see her. Be the best physician that I could be. She deserved the best. 

I kept doing the walk. Every day. Sometimes 2 or 3 times a day. I had to. She deserved physicians who would do that. 

And I needed to do it. The word that comes up now as I think about it years later is “penance.” It was for me like something that I needed to do. I am sorry. I am really sorry.

I wish I could tell you that everything worked out fine. It didn’t. She survived but ended up with complications. It left her injured. There was nothing that I or anyone could do to fix it. Unlike in childhood when there would seem to be someone to rescue you, in real life there are times when there are no fixes or rescues. She had to learn how to live with the complications. I had to learn to live with the guilt that a decision I made in treating her caused those complications.

I had to learn to go on living and making decisions. I had to learn that this life is not a fairy tale. Sometimes things go wrong. And sometimes you cannot fix them. What do you do when that happens? You must put one foot in front of the other and you keep walking. Even if your heart is heavy and you feel sick inside, you just keep putting one foot in front of the other. 

That is what so many of you have had to do. We all wish that Mom or Dad would come in and clean up the mess. But that is not the way it works in real life. And when you become Mom or Dad you want to be the one who fixes everything for your kids. But you know that in your own life not everything can be fixed. You know that you have to just keep walking. It gets even harder when you begin to worry that you cannot or should not fix everything for your kids too.

The pain has shaped me and molded me and taught me. I am not going to say that I am thankful for it. That would not be honest. To this day I would do whatever necessary to spin time backwards and not to have prescribed that drug. But I did learn.

I learned that bad things happen. I learned to think more whenever I make a decision in medicine. Just because there seems to be a clear action, we have to think again about what “could” go wrong. Even if it is not frequent, we still are obligated to think what could go wrong. 

I learned about sharing the decision making with my patients. The risk was small. But I read about the obligation that doctors have to disclose risks to their patients. This is not always done in medicine. Doctors are trained to balance risks and make the “best” decision. We are told to be objective. We may not want to worry our patients. But we also have an obligation to involve our patients in the decision making as much as possible. Often we don’t go through the discussion with the patient. We should.

I learned about guilt. Penance doesn’t help by the way. It doesn’t make things better. It really doesn’t fix anything. It doesn’t even make you feel better. 

In retrospect I am thankful that I did the walk every day. But it has nothing to do with penance. What is important is to accept the reality and still do the right thing regardless of your feelings of guilt. Do the right thing regardless of whether it is easy or hard. Just do it anyway.

Just keep walking. Everyday. Sometimes 2 or 3 times a day.

This too shall pass. That is the expression. I say it to encourage me and others. This too shall pass. Not completely however.  When things are hard you can keep putting one foot in front of the other. Over time it gets a little bit better. It doesn’t just go away. It didn’t go away for her. I still feel it too. My heart isn’t as heavy now. But it is still with me. I will always think about it. I will always think about her.

Bad things do happen in medicine. Complications are going to occur. When I switched to cardiology and was doing procedures the burden would weigh heavy on me. Every time my pager would go off, I would jump and worry that something bad had happened. Most of the time everything was fine. But sometimes complications would occur. 

Somehow in medicine we have to learn to deal with this. Patients will have bad outcomes even if we do everything perfectly. Patients will have complications from procedures even if we are skillful and careful. Sometimes we will make mistakes. That too is a certainty because we are all human.

So, what do you do when there is a complication?

1. Be the best physician you can be regardless of how you feel. Continue to do the right thing for the patient. Do it even if it is hard.
2. Objectively look to see if there are lessons that you can learn. Was it preventable? If you had it to do all over again would you do anything differently? No fair changing your mind because you know the outcome. You don’t have a crystal ball. Based on what you knew at the time would you still do the same thing again? From a safety perspective there are ALWAYS lessons to learn. What are they? Learn them.
3. This too shall pass – or at least – we can continue to move forward in spite of the complications that have occurred. We owe it to the next patient that needs us. Complications are going to happen. We must learn and go on. Just keep walking.

I see this happen to our surgeons and proceduralists. They all have had to learn how to deal with complications. Some handle it better than others. But if you expect to never have a patient have a complication you will never be able to take care of any patients. You have to keep moving forward. Learn what you can. Be objective. Not about guilt or not guilt. What can you learn? Is there any better way? There may not be. But ask the question. And do the right thing. Even if it is hard. Be objective. Penance doesn’t help by the way. It is not about penance. Just do the right thing. That is what helps. 

What about for those who read this who are not doctors?

1. Life is hard sometimes. You WILL have times that you will not be able to fix things. That is just the way it is.
2. When life is hard, just keep walking forward. One foot in front of the other. Even if your heart is heavy, go ahead and walk. Every day. Sometimes twice a day.
3. This too shall pass. Or sort of. It does get easier with time.
4. Penance doesn’t really help. Even thought you might want to submit yourself to some penance to help with your guilt, it doesn’t really help. Don’t try to hide it. Don’t try to “make up for it.” Stop. Think. Just do the right thing. Even if it is hard. Just do it anyway. In the long run you will be happy that you did.

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^[1] For purposes of patient privacy, I am nondescript intentionally. The exact circumstances don’t matter. They do not change the reality of what I am trying to communicate.