Category: Medicine

I launched my boat on Friday. Last year the boat launches were all delayed due to the COVID 19 restrictions. The water is still very cold, but I am quite happy to have our boat back in the water.

It has been a year. On March 21, 2020 I felt compelled to write a blog post as I struggled to understand whether COVID 19 was a serious reality or was being overblown.^[1] At that time everything was shut down. We were all locked away in our homes but there had been just 12 confirmed cases in Kent County. None of us really knew what to expect or what was going to come. The experts (especially the Imperial College report) predicted 1.1 million deaths in the United States unless we did things like we had never done before. We did them. 

So, a year later where are we?  In the United States we have had documented:

• 31,306,928 cases of COVID 19
• 562,296 deaths attributed to COVID 19

It appears that the Imperial College report was correct. Our country did a lot. And with this we still had almost 600k deaths and we are not yet to the end of this.

This week I read the report from our health system about our current status. This made me feel like I should write something more. Here is what bothered me:

• We are firmly in a 3^rd wave. On Thursday April 15, 2021 Spectrum Health did 2537 COVID PCR tests with 21.1% of the tests being positive. This is one of the highest percent positive reports we have ever had.
• They reported 282 patients hospitalized in a Spectrum Health Hospital.
• In the Grand Rapids area, Spectrum Health had 61 patients with COVID in an ICU.
• The demographic has shifted for this 3^rd wave. It is hitting younger persons and they are seeing an increase in seriously ill pediatric cases.
• Almost 1/3 of the patients who are being seen in the Emergency Department are being seen for COVID or COVID like symptoms.
• At the same time, they have now reached a point where the capacity to give vaccines is more than the demand. That means that people can get a vaccine if they want one (or would be willing to get one).

People don’t seem to be as worried or upset this time.  Maybe we are just used to all of this? Maybe we are putting confidence in the vaccines? 

There is a disconnect and it seems odd to me. A year ago, there were 12 cases in Kent County and Sarah and I were locking ourselves away in our house. We got out the card table and set up a puzzle to pass the time.  We didn’t go anywhere. The 1^st wave fortunately was not too bad for West Michigan. 

The second wave hit, and things were a little bit more open. Nonetheless people seemed to understand how serious it was. By then most of us knew people who had become seriously ill or who had died. Many of us got COVID and the experience even without hospitalization was not something we ever wanted to go through again.

Now the third wave has hit, and people seem to have become a lot more lax. I walk through the store and see variable use of masks. The parking lots at bars and restaurants seem very full. I can remember feeling concerned in November when the test positivity rate was more than 10%. Now it is more than 20%. And yet I am not hearing the alarms ringing like I did before.

At the same time, we have reached a point where the health system has vaccines to give but not people to give them to. 

Last year we dreamed about the hope of having a vaccine available. Maybe then it would make this nightmare go away. We had hopes that if we got enough people vaccinated the rate of infections would drop off. We hoped we would reach “herd immunity.” We just needed the scientists to somehow figure it out and get us all a vaccine.  

They did it.

What about the vaccines? There have been some interesting articles recently about effectiveness.  One report looked at the effectiveness in healthcare and other essential workers.^[2] The volunteers in that study did a nasal swab every single week. The idea was to detect not just symptomatic infection but any evidence of infection. They found an 80% risk reduction (compared to those who were not vaccinated) after the 1^st shot, and a 90% risk reduction after the 2^nd shot. For those who did have a COVID infection detected after having been vaccinated the vast majority had no symptoms or only minimal symptoms. 

Another report looked on a population level at the odds of getting COVID in the US after getting vaccinated.^[3] If you have been vaccinated you have these odds:

• 0.008% chance of getting symptomatic COVID
• 0.00056% chance of getting sick enough to be hospitalized due to COVID
• 0.00001% chance of dying from COVID

Those are really encouraging statistics. 

How does that compare to other things in life?  You have a lifetime risk of:^[4]

• 0.94% of dying in a car accident
• 1.02% of dying due to an opiod overdose
• 0.009% of dying in an aircraft accident
• 0.00055% of dying by being struck by lightning

The vaccines work.

What about harm from the vaccines?  Let’s face it. You might have some symptoms from the vaccine. The CDC reports that about 10-15% of people who get vaccinated have some side effect. These are most commonly arm soreness, fatigue or body aches. A smaller number of people get low grade fevers or nausea. The majority of these symptoms resolve completely within a day or so.  With any vaccine there is a risk of a serious side effect.  Fortunately, the number of people with serious reactions has remained low.  The current rate of experiencing a serious adverse effect from the COVID vaccine is about 0.005%.^[5]  

We are having a third wave of COVID infections and deaths. I wondered how that compares to the 1918/1918 influenza pandemic my grandfather lived through.

This graph shows that they went through three distinct waves. Fortunately, the pandemic eventually resolved and then they were into the “roaring 20s”.  

Our graph for the state of Michigan is here:^[6]

It looks very similar. We are not however through our 3^rd wave yet.  I sincerely hope that our third wave deaths don’t go as high or higher than the other waves. 

What am I saying?

1. COVID is real and continues to be a big problem.
2. It is disturbing to see a very large 3^rd wave hitting Michigan.
3. It bothers me to think of children becoming seriously ill. I sincerely hope and pray that COVID does not become a big issue in children.
4. Vaccinations are available.  They work. 
5. The vaccines create real hope that we can get past this.
6. If you have not yet been vaccinated, please do so. They are available. They work. 
7. Continue to be careful. There is a LOT of COVID in our community. The risk now is as high or higher than ever. Please be careful.

I really hope that our COVID graph tails off. I hope that with mass vaccination and time we will get past this. Maybe then we can move into our own “roaring 20’s.” I am so ready to move on. I am ready to be able to be together in groups again. I am ready to go linger in a coffee shop. I am ready for our own version of the 20’s to start. One hundred years ago it was fast cars, jazz music and flapper dresses? Anyone up for that now?

---

^[1] https://manmedicineandmike.com/is-it-really-worth-all-the-fuss/

^[2] https://www.cdc.gov/media/releases/2021/p0329-COVID-19-Vaccines.html

^[3] https://www.cnn.com/2021/04/09/health/covid-vaccines-adverse-reaction-rare-trnd/index.html

^[4] https://www.iii.org/fact-statistic/facts-statistics-mortality-risk

^[5] https://www.latimes.com/projects/covid-19-vaccine-safety-side-effects-risks-reactions/

^[6] https://www.michigan.gov/coronavirus/0,9753,7-406-98163_98173—,00.html

I met him when I was a 4^th year medical student. My military scholarship allowed me to do an elective each year at a military hospital. I had chosen to do pulmonary medicine at the Naval Medical Center Portsmouth, VA. 

I met him on my first day in the pulmonary medicine clinic. Dr. C was a Captain in the U.S. Navy. He was a specialist in pulmonary medicine. He was a southerner, complete with the soft, lazy sounding accent. I was a young medical student. We both wore the working uniform of the day which were Navy Khakis made of CNT (Certified Navy Twill). He was a Captain. I wore the single bar of an Ensign. 

We went to see a patient with asthma. Perhaps it was the pollen or the flowers in the Virginia area that were causing her problems. They always had such beautiful Azaleas each year in Virginia Beach. Regardless of the cause she had been having multiple flares of her asthma. Each episode brought her to sick call or to the medical urgent care clinic. With the flares she would get a brief course of prednisone and would improve. She had accumulated enough of these that she was in danger of being pushed out of the military.

In order to serve in the United States Navy, everyone had to have a physical examination each year. The primary reason for the physical examination is to determine if you are, “fit for all duty at sea and on foreign shores.” That is the standard for the Navy. Unlike some of the other branches of the military, the Navy feels that based on their mission, if you cannot be fit to do everything, then you are not fit for service.  If you are not fit for service then you receive a “medical board”. A medical board removes you from the military. 

Our asthma patient was being sent to us to see if she should have a medical board. She was 16 years into her Navy career. She could retire in 4 years. With the 20 years, she would have lifelong medical benefits and a lifelong pension. A medical board before that time might give her some disability payment or not depending on whether the board determined if her condition “existed prior to enlistment (EPTE).” Either way she would lose her pension.

Captain C listened to her and examined her. He asked her if she wanted to remain in the Navy. She shook her head yes vigorously. She had committed 16 years of her life to her career. She really wanted to at least get to the 20 years to get her pension. 

Captain C took me out to the charting area. We looked through her record. Charts were paper then. They travelled with every sailor from duty station to duty station. We could see every medical interaction she had ever had. We could see her initial entry into the military, every physical examination, and every clinic visit. He pointed out that she did not have any hospitalizations. Each of her asthma flares had improved with outpatient treatment. 

“Do you know what she needs?” he asked me.

“What does she need sir?” I replied.

“She needs a big jar of prednisone and to be taught how to stay away from us.”  

I can still hear his southern drawl as he said it and that expression, “a big jar…” 

Captain C took a blank consult sheet and started writing on it. His writing wasn’t neat or pretty but it was legible. On one side of the paper, he drew a picture of her chest x-ray. That was his trademark. He always did that. When he was finished writing, we went back into our patient’s room.

“I am going to try to help you finish your career. But you need to promise me that you will work with me.” He then went through a process of teaching her how to use occasional courses of prednisone to counter her asthma flares. He made her promise to not use them too frequently and to call him if the flares became too frequent. He then wrote a prescription for a “big jar of prednisone” and gave it to her.  He set her up for a follow up visit to monitor her progress.

I learned a lot in that first hour in clinic. I don’t know whether he realized it but he was teaching me in ways that went far beyond just lung disease.  

You could always recognize one of Captain C’s notes. On every note he would draw a picture of the chest x-ray. A picture is worth a thousand words. From Captain C I learned that there is a lot more that you can communicate than just the words you write. You should create a full picture of who the patient is and what you thought was going on. For a chest physician looking at the chest x-ray is key. It often means so much more than just reading a sentence about what someone thought the x-ray showed. 

In future years I found myself looking in the charts for Captain C’s notes. I would flip through the pages looking for the rough drawing of the patient’s chest x-ray. A quick look at his note would tell me a lot.  The sketch was always valuable, but I looked for his notes for reasons that went beyond the sketch.

Captain C’s words themselves were about creating a picture of who the patient was and what was going on. His words were honest and plain and to the point. They were important. When you finished reading his note, you could see in your mind and really understand what was going on.  Reading his notes, I could always hear his southern accent in my mind. He wrote exactly like he spoke which was exactly like he thought. He would even put, “I think” in the notes. 

These notes had immense value. They were not some generic worthless writing of the same stuff over and over again. The notes gave you a valuable opinion, insights and a plan for each patient. They contained the thoughts of an expert. 

We get lost today in the world of electronic notes. It is easy to use the computer to generate enormous and lengthy notes that say nothing. I get so frustrated when I see notes that require several minutes to scroll through only to find no expression of human thought anywhere in the note. I would rather have only 1 sentence that showed what the physician thought than 20 pages of computer-generated meaningless data.

We get lost in our communication with each other also. Whenever I blog I find that I write too many words. I have to go back and simplify. I delete words. I shorten sentences. I delete entire sentences or paragraphs that do not add value. The goal is to communicate. If we do that well we create a picture that others can see and understand. 

Often I fill my interactions with others with a flurry of words but only narrowly communicate. Oddly, I am worse at this when it is really important. It feels safer to bury what is really important under too many unimportant words.  I think I fear being blunt, open and honest. 

But from Captain C I learned to say what I think.  In medicine, and in life, when someone is able to do that, as humans we hungrily gravitate toward it. It is like digging through the chart looking for the rough sketch of the chest x-ray that will indicate a Captain C note. We seek it out because there we find reality and truth.

That afternoon we went to the lung cancer tumor board. This is where a group of experts get together to review cases of patients diagnosed with or suspected of having lung cancer. We talk about options and what would be the best care of the patient. 

One patient’s case was presented. He had advanced lung cancer.  Captain C spoke up, 

 “Do you know what this man needs?” He paused for effect and looked around the room.  “He needs a big jar of morphine and a fishing pole.” It truly was the best option for that patient. At that time there was really no effective treatment for him. Any attempts to treat him would just make him feel worse and were not going to help to improve his survival.

I hear people talk about their mentors. Sometimes I feel left out. 

When I hear about a mentor I imagine someone selecting me and then investing hours and hours of focused attention on me. I can’t say that I have ever really had that.

If I am honest, however, I realize that while I haven’t had one specific mentor, I have had dozens. I cherish all of them and what I learned from them. Most of them never realized how they were teaching and molding me. They likely had no idea what a dramatic impact they would have on my life and who I am.

To this day I can still hear Captain C’s voice in my head. Late at night when I am sitting at my computer trying to finish my day’s notes it comes back to me. What should we do for this patient? Should we put in an LVAD? Should we try to push to get him to transplant? Is there anything else? I read the written interpretations of the echocardiograms and the heart catheterizations. The words are empty and lack enough substance to guide my decision making. 

I open up the software and start viewing all of the images myself. As I do I start to get a feeling for what I really think is best. I could have just typed the quick note. Press F2 and select the standard language. Maybe type, “Continue current inotropes. Evaluation in progress.” 

Instead, my memory of Captain C pushes me. I push myself to put a real opinion. I hope that I can be the expert that guides the care to the best options. I start writing what I really think. I hope that will help me the next time I see the patient. Maybe it will help others who also will see the patient?

I saw another patient in the office. He was elderly and frail. He was failing. His heart failure was causing more and more problems for him. The easy path would be to put him in the hospital. I worried that if I did so he would never go home. Being in the hospital is hard on people. We do all sorts of tests on them. With each test we make them “npo” (not able to eat). They come back from the tests exhausted. As hard as we try to keep the wards quiet, there are noises in the night. They never sleep well in the hospital. I have seen so many patients get admitted and then not go home or go home just a shadow of who they were before.

“Do you know what you need? You need to not let me hurt you by putting you in the hospital.” The patient doesn’t know but in the back of my head I can hear a familiar voice complete with his southern accent,  “Let’s come up with a plan to keep you away from the emergency room and the hospital.” 

After we come out the exam room, I explain to the student who is with me that there is some data showing improved survival duration with hospice. “What this patient needs is a big jar of torsemide (a diuretic) and to be home with their family!” 

I try not to say it with an accent, but in my head is Captain C’s voice, southern accent and all. 

I hope he would be proud of me.