Beware, Narcissus!

By now we have all seen the images. Carousers on beaches, partiers in bars, etc. The exuberance and perceived invincibility of youth which the government and media boosted with poor messaging. Modern incarnations of narcissus, so in love with their own beauty and youth they can see no other truths.

Sure, on a population scale, statistics are near destiny. However, on an individual scale, statistics are a poor substitute for adequate personal protective equipment.

Trust me, I know something about being the 1 in thousands. So does my wife and our first daughter. We were young, healthy, with access to good medical care. Statistically, we were destined for a healthy and uneventful pregnancy and healthy child.

Here is the thing about statistics, someone is that 1 in 100, 1 in 1,000, 1 in 10,000. And all the statistics in the world will not stop you from being that one.

At 3 weeks old we had to sit and hold our baby while she took her first and last breaths without a machine to breath for her. Statistics didn’t help me sleep. Statistics didn’t comfort my wife. Statistics didn’t soak up our tears in the middle of night.

Some of us young, otherwise healthy people will die from this. And the more people who get sick at once, the more of us and others will die.

The other side of those statistics is this: we all know 100 people, including people who are compromised or elderly. At the rate we are going, we will ALL know multiple people who will die from this virus. It will touch us all, one way or another.

As someone who knows about grief, do what you can to limit how many people you will have grieve over the next year. You may not be able to spend time with the people you love in their last hours because of restrictive hospital quarantines.

Someone you know, and in all likelihood, someone you love, will die alone in a hospital bed in the next year.

Why do anything which means this will happen more than has to?

Because it is inconvenient? Because it will cost money? Because it is boring? Because it isn’t necessary?

Because I don’t want to sacrifice for something which may not directly benefit me?

The Individual will No Longer Be King

We are at a deflection point in our nation’s soul. For the last 60 years, the role of the individual has increased in our nation’s psyche. Society and the good of all have occupied a smaller and smaller place in our national priorities.

This must change. This will change. The only way for as many people as possible to emerge from this alive is for all of humanity, but in our case, Americans, to remember we are part of something greater than ourselves.

Our petty desires and whims pale in contrast the great struggle humanity is embarking on. This is terrifying, but also an opportunity. Our dependence on one another, the bonds which keep families and communities functioning will grow clearer than they have been in a long time.

We are part of a whole. A mass of humanity, connected now more than ever. We must find where those connections can be nurtured, strengthened, and where each of our own gifts will contribute most.

Specifically, this is a calling to my generation, often known as Millennials to stand up and make our contribution. We must show up, we must act. This is the beginning of a great test as a nation and a generation. It has been decades since humanity has been called to such an epic task.

For some of us, it will be 3D printing of needed parts, sewing of masks, running to the front lines in hospitals, caring for elderly or high risk neighbors, getting groceries.

For others, this will simply be staying home. We will contribute to breaking the chain of infection.

We must not underestimate the courage of staying of home.

The act of staying home is no simple feat. Staying home makes real the fear of the threat we face. It would be much easier to pretend no threat exists, because no fear could torture us.

By staying home we sacrifice the sweet delusion of the absence of fear. It is worthy sacrifice, as we cannot be courageous until we have first felt fear.

Courage is resistance of fear, mastery of fear – not absence of fear.

-Mark Twain

So, I call on all of us to act courageously, to allow ourselves to feel afraid. We can only begin to know the depths of our collective courage once we have touched that fear collectively.

We cannot continue to hide our fear behind paper tiger statistics. We will not have truly entered the fray until we have allowed ourselves to feel at risk. We must show up and give of ourselves.

This means giving not what one wishes to give, but what others need. We must give what is so desperately needed, not something easily dispensed.

History has given us a moment to rise to the occasion. It is terrifying. Yet, it is an opportunity for us all to be our best.

Beware Narcissus, my fellow Millennials, live your best life, feel afraid, act courageously, stay home.

Image: Narcissus, by Michaelangelo Da Caravaggio, circa 1597 – 1599. Galleria Nazionale d’Arte Antica.

The Tide Went Way Out

When a disaster comes to the High Plains, the sky holds the warning. It has always been this way. The sky dominates the land on the plains. Of course it where the warning first appears.

When wildfire rushes across the plains smoke clouding the sky announces its imminent arrival. When the “black blizzards” rolled across the plains in the Dust Bowl their towering clouds of dust blocked out the sun on the horizon. The sky lets you know ahead of time.

Except this time it doesn’t. The sky is serene and blue as far as the eye can see.

The pace in clinic and the Emergency Department is slow. I have only been on staff here for about a month, but I know this is slow even for here. Physicals have been cancelled, colonoscopies postponed, the usual minor urgent care visit in the ED have effectively ceased.

I think of stories from the islands of the Pacific during Tsunamis. First, the tide goes way out suddenly, then the wave builds in the distance and it just keeps coming. As I stand on the edge of town, looking West at the setting sun, I feel like I am watching the tide rapidly recede.

I have spent the last 48 hours running around the hospital checking for what supplies we have, asking pharmacy techs to order more vecuronium (on backorder), steroids, duo-nebs, and morphine, oh God, please make sure we have enough morphine. I verbally underline the need to stay stocked with morphine to the pharmacy tech.

I repeat Dr. Edward Trudeau’s mantra in my mind, “To cure sometimes, to relieve often, to comfort always.” In a preparation meeting, I remind my colleagues Rural America looks demographically a lot like Italy. Mostly older, and in our case, very chronically ill.

We unfortunately have even fewer doctors and hospital beds per capita than Italy. This will swamp us, I emphasize to my colleagues. And our typically release valve, “transfer to higher level of care,” is going to stop working pretty soon, because it will hit transfer centers before it hits us.

I am preparing to practice mass casualty, battlefield medicine. I fully anticipate we will run out of IV fluid, IV tubing, etc at some point. I insisted we order 3% saline so we can mix it with D5 or Sterile water to make more normal saline than we otherwise would be able to order.

I made our pharmacy tech other oral rehydration solutions, feeding bags, and NG tubes. Once we realize we are getting low on IV supplies, hydration will have to be done orally, with NG tubes if necessary for the weakest.

Just like everyone else, we have started rationing PPE. Hopefully the supply lines catch up by the time it really reaches us. We will probably have a 1-2 week lag compared to urban centers.

When I get home, I completely strip, all my clothes go into the wash – on sanitize. I shower more thoroughly than I ever have. Only then do I get to kiss and hold my wife and daughter.

Like everyone else is saying, please stay home for us and our families.

20% percent of Italian healthcare workers have contracted the virus, when one out of every five healthcare workers is out and cannot work, more people than need to will die.

This is what I dread is coming….I hope I am wrong….but I don’t think so.

The Wave is Building

We all take comfort in our founding myths and narratives. The physical and social isolation of the High Plains from the coasts and cities allows people to act as though the problems of those places exist in another world. This time has been no different. People have reacted slowly and still aren’t sure whether or not to take it seriously.

I have been trying to create a sense of urgency without panic. A narrow balance beam to walk. I don’t know if I am succeeding.

I can feel the shocks of the formative earthquake rippling through my body, even if the wave is still not visible. It is corporeal. The wave is building, rising. I survey the horizon, there is no high ground. No where to run to. We are it out here.

The state has already told us not to expect extra equipment any time soon. The strategic stockpile is already spoken for.

Already, we are accepting low acuity patient’s from the nearest large urban hospitals in an attempt to free up bed space for them. Our normal Critical Access bed cap of 25 has been lifted to 35 beds.

The wave is building.

We really normally only function with 5 acute inpatient beds which normally hold the lowest acuity patients who would ever be in the hospital. We have one ventilator, and it is transfer vent. No bipaps, our nursing home is physically attached to our hospital – a disaster in the waiting.

We won’t be keeping anyone alive on ventilators out here. To try and do so would utilize valuable resources in the hands of physicians and staff who are not well suited to maximize that person’s survival.

The role I anticipate we will play is three-fold. Surge capacity for low acuity cases who simply need oxygen, hydration, and nursing care. We will likely provide convalescent care for people who are weakened after serious illness and sent out here to take the load off of urban referral centers. And, finally, hospice and palliative care.

We will comfort the dying. Comfort always. At some point this will be the greatest gift we can offer.

Death will Walk with Us

In a moment between meetings, I sit dumbfounded in my chair in front my computer. The photo is an Italian military convoy hauling trucks full of bodies out of Bergamo. This is different.

The wave is building.

As a physician, we have all interacted with death before. This will be different. Italy is showing us this now. I learn the next day, we don’t even have a funeral home in town. Our options are 20 miles in either directions.

I ask our emergency preparedness director what the plan for moving bodies out of the hospital is. She tells me the mass casualty plan includes a plan for bodies to stored in the community center until refrigerated trucks or another location can be identified.

Well, that’s at least something, I think and take walk to the edge of town to watch the sun go down.

It seems fitting that the edge of town is also the edge of the cemetery. I estimate the space left in the cemetery, probably insufficient. I guess it doesn’t matter much anyway. People’s bodies who die in a pandemic are supposed to be cremated anyway.

This is rural medicine in the age of the pandemic. A family medicine doctor is running around helping to creatively order supplies for the entire hospital. I am urging administration to build a list of somewhat medically trained people in the community to use as an auxiliary nursing force.

Trying to think of anything and everything we can do to keep people out of the hospital – I plead with our leadership to start building a framework of phone trees and community health volunteers to check on the vulnerable and elderly.

We need to compile and update a list of recovered people in the community, because in 1 month, they will be like gold.

I worry about where the dead will go.

This is our life now and for the foreseeable future. Acceptance will be key to maximizing survival, not only of individuals, but of communities and our way of life. We must not stick our heads in the sand.

Comfort always.

Photo: The Great Wave Off Kanagawa, c. 1829-1833. in Metropolitan Museum of Art by Katsushika Hokusai.