If the Pandemic is War, I guess My Neighbors are Vichy?

The war analogy in regards to the pandemic is a little worn out. Cable News screamed it for too long in the early days for it to resonate much now. Nonetheless, I am going to lean on it in an attempt to convey a few things.

Most of you are probably involved in healthcare and know all to well what I am about to describe. But, it is something I just need to write down. The whole point of this blog is catharsis, after all.

Morale is Low in the Trenches….

From the beginning of this pandemic, those of us working in healthcare have been told we are on the front lines of some epic battle against a deadly foe. It is as good an analogy as any other, I guess.

Like most wars with an aggressor foe, we began underprepared. It was disheartening, but not surprising. Few organizations could have been adequately prepared (though we could have certainly been much better prepared).

Either way, we could deal with the lack of PPE, staffing, etc, as a temporary setback as we struggled to adapt to fighting this new challenge. It was something that would get better, and it did.

For months, we settled into trench warfare. We threw a few salvos of recovered patients out in the world, and the world threw some different ones back. Staff got sick or exposed and had to quarantine, and we had to fight with one hand tied behind out back. It was grueling, but manageable. Most importantly, we had reinforcements, staffing agencies, PRN staff, locums, etc, could be called in.

Unfortunately, we have entered a new phase. Everywhere is surging at once, no reinforcements are available. Hell, urban hospitals are asking us to be reinforcements and surge capacity. We try.

The reality is, for the most part, this is all still manageable (at least where I am). It is stressful, but we signed up to take care of sick of people. Sometimes periods are busier, and then you get slower times to recuperate.

What is becoming unmanageable is a crisis of morale. Burnout has been taking its toll in healthcare for years, so morale wasn’t great to begin with. But now, it is reaching crisis levels.

When Your Neighbors are your Enemy’s Supply Lines

In my corner of the pandemic, I feel like I am resistance in Vichy controlled France. My countrymen, people with whom I should feel a brotherly bond, have decided to capitulate to the Enemy en masse.

When possible, they gather in groups as large as they can get away with. Fully half abhor mask wearing. Which, beyond its well-documented benefit of reducing the spread of the virus, makes me feel like the resistance fighter living among neighbors who provide succor and assistance to an enemy invader.

6 months ago, Paul Revere ran through the countryside yelling the British are coming. In the intervening months, apparently half of us have decided not only refuse to help the Minute Men, but actively feed and clothe the British.

Hell, sometimes they even seem to be setting up a nicely outfitted afternoon tea for them.

Inside the hospital, you never know if enough nurses are going to show up to staff the hospital and/or the nursing home from day to day. At any minute, the Locum Doc or Traveling Nurse you were depending on to give you break may call and say they have tested positive or been exposed and need to quarantine.

Nerves are raw.

Rural healthcare runs a shoestring in the best of the times.

If only 3 docs work in a community responsible for the ED, hospital, Nursing Home, and Primary Care, you are one person away from more than 30% of your medical staff being down.

In the best of times, you live on the brink of disaster.

Now, we are stressed at all times about whether or not we are wearing adequate PPE, our nursing staff is permanently understaffed, and there are no replacement to be found. Add to that, the communities we are supposed to serve seem to view the simple inconvenience of wearing a mask as too steep a price to pay to let us know they have our backs.

We hear the message loud and clear: We are on our own.

The post-modern consumer-patient tells us, “Well, its your job, they pay you, what is it to me?”

Already, I am having to wait half a day to get a person with a Hemoglobin of <4 transferred to somewhere with endoscopy capabilities. That might be you tomorrow, or two weeks from now. It might not, you might be lucky.

At this point, I don’t even care if you don’t think wearing a mask is effective at slowing the spread of the virus.

If you could just do it to send us the message that you have our backs, that you aren’t feeding the Enemy.

Ask the Vichy, capitulation never ages well.

I am not here writing this to descend into politics, culture war, or even evidence based arguments. I am just a tired Doc in a small town asking you to wear a mask to let us know we aren’t alone out here, that someone gives a shit.

Photo: WW2 US Government Propaganda.

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.