Author Archives: hcolt

The Coming Storm

(Clouds over New York City. Photo courtesy C. Lehr)

The COVID-19 pandemic is not over. If that sounds like news, it is. I am not fooled by the hundreds of people walking around my town without masks, nor by the now neglected practice of physical distancing. I am not fooled by the reassurances from Nursing Home directors and hospital administrators who say the virus is controlled, and I am not listening to government officials from any nation who neglect to keep us informed of a possible increase in numbers of deaths.

This is not to say I am not pleased. I am relieved the pandemic has not caused as many deaths as originally predicted. I am delighted that most of the people I know who are over the age of sixty, or those with past medical histories such as heart disease and diabetes are choosing to wait and see, rather than attend public gatherings and eat in restaurants. 

I am glad that some health care personnel have taken responsibility for their own safety and well-being, rather than trust all decisions to an all too often incompetent, hierarchal leadership with different agendas. But I am sad that according to at least one recent report, more than 600 health care workers in the United States have already died from SARS-CoV-21

The US Centers for Disease Control says that in California, where I reside, about 6% of all hospital beds are occupied by patients with COVID-19. Overall, patients with and without COVID-19 occupy only 64% of ICU beds2. This leaves our hospitals with a small safety margin in case a second wave strikes in the next weeks.

SARS-CoV-2 is transmissible by individuals who are ill, presymptomatic, or totally without signs of disease. Viral load depends on frequency, duration, and type of exposure (droplets, respirable aerosols, and fomites). Recent events and the opening of our economies create opportunities for infection. If many medical scientists and public health officials advocate physical distancing and mask-wearing, it is because their concerns for public safety are free from most of the constraints placed on politicians, economists, and social policy-makers responsible for the public good.

As health care professionals, we have a responsibility to do no harm. However, to advocate physical distancing adversely affects the economy. To advocate social isolation adversely affects mental health and puts a strain on family dynamics. To advocate precautionary measures in the workplace and not follow our own advice outside makes us hypocrites.

References

1. https://khn.org/news/exclusive-investigation-nearly-600-and-counting-us-health-workers-have-died-of-covid-19/
2. https://www.cdc.gov/nhsn/covid19/report-patient-impact.html

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Where is the light?

(Photo bruno-van-der-kraan-v2HgNzRDfII-unsplash)

There is an expression that there is light at the end of the tunnel. While this provides hope, the expression also means you are still in the tunnel, and therefore, your problems are not over.

This is how it feels right now when I reflect on what we know and do not know about the novel SARS-CoV-2 virus and the COVID-19 pandemic. Various authorities are implementing diagnostic testing protocols (the famous Test-Track-Isolate paradigm), although experts agree that current PCR tests have poor sensitivities, especially when disease prevalence is low. Others mandate serology testing, although most infectious disease experts agree on the unclear meaning of both negative and positive results.

Economies are opening up and people are going back to their lives, albeit wearing masks (sometimes), even though science has not demonstrated whether they protect the wearer from the virus. Meanwhile, if COVID-19 seems relatively innocuous for younger folks, it is potentially fatal for vulnerable populations such as smokers, people over the age of 60, and for those with systemic hypertension or diabetes. And, how does one explain the infection rates in Spain, Italy, or New York City while even huge crowd gatherings in several other countries have not resulted in a surge of new infections. 

In regard to treatments, there are even more questions.  Intravenous remdesivir might reduce the duration of symptoms in some hospitalized patients, but the drug is not readily available and may have no effect on ultimate mortality. What was purportedly a miracle medicine, Hydroxychloroquine with or without a macrolide, is being flogged even as it is administered to thousands of patients and health care providers around the world. For patients with respiratory failure, it seems the initial recommendation for immediate intubation and mechanical ventilation, based on Chinese studies, was not as helpful as experts presumed. 

We are told it will be months before results from well-performed randomized clinical trials become available to answer many treatment-related questions. Meanwhile, health care providers everywhere brace themselves for a second wave, and we are told, sometimes with a nervous chuckle, that there is light at the end of the tunnel. 

References

  1. https://drive.google.com/drive/folders/1qiMWPqo3spLsHNfob_CW0Xbi0_ocKHC4
  2. https://www.microbe.tv/twiv/twiv-621/

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Alone

Photo by camilo jimenez on Unsplash

I’m alone in the patient compartment of our rig, separated from my driver, who’s also an EMT. He can only hear me through the thick glass window.  The ventilator fan is set on high, just like we were told to do after the World Health Organization declared the Coronavirus a pandemic with fatal repercussions. We’ve been out since six this morning. I just chucked the last disposable gown in our emergency kit, and I’ve been wearing the same N95 respirator mask for three days now. Three 12-hour shifts, three days in a row, but I consider myself lucky. Friends of mine just have surgical masks, which we know provide no protection. Funny how some bosses suckered us into thinking they did some good, and besides, they said, what else are we to do? 

The 60-year-old diabetic woman we just picked up is pasty-looking and wheezing. Her daughter claimed it was a bad asthma attack and she was out of inhalers, but when we called it in and said the gal’s got fever too, they told us it’s probably the virus. 

I double-check her oxygen mask. Her breathing is getting worse, and she can’t talk. I take another blood pressure reading—it’s low.

I can’t feel a pulse.

“What did the dispatcher say?” I shout to my driver.

“It’s a forty-five-minute wait at the ER, and we’re still ten miles away!” he yells back to me over his shoulder.

“We’re screwed,” I mutter under my breath, knowing he can’t hear me anyway with the sudden yelp of our siren and the screech of our tires on the road.

“I’m giving her a breathing treatment.” I holler. He needs to know what I’m doing.

“That’s against regulations, remember? No nebulizers in infected patients. It might spread the virus.”

“Well, those were guidelines—we never got a written order. Besides, I don’t know if she’s infected, and she sure as hell doesn’t have COVID-19 positive tattooed across her forehead.”

“You’re gonna get us fired.” 

“Just drive,” I say. 

I break open the nebulizer bag and prop the woman up on the gurney. For a moment, I think she’s looking at me, but then her pupils roll up under her eyelids, and her eyes go white. “Damn, she’s coding.” I jam my fingers over her carotid and can’t feel a beat. A lead from the electrocardiogram monitor falls off. I start chest compressions. The rig lurches forward. I can almost feel my driver leaning on the accelerator.

“Let her go,” he shouts.

“I’m not giving up no matter what the boss might say.” I tear off my fogged-up goggles. “Maybe it’s not the virus, maybe. . .”

She perks up. She opens her eyes. I reconnect the EKG lead and see a waveform. 

She’s alive.

We pull up to a special entrance of the emergency department. The doors swing open. A doctor and two nurses wearing hazmat suits start dragging the gurney out of the rig.

“What happened?” the doc says, not taking her eyes off my patient.

“Just an asthma attack,” I say. “Nothing more.”

“You sure?” she says. I can tell she sees the nebulizer. I can tell she knows. I swallow hard.

“I’m sure.” We’ve got another call. I’ll file the paperwork when we get back.

“Stay safe,” the doctor says, pointing at my goggles before swinging the vehicle door shut, “and…” but the rest of her words drown in the wail of our siren as we take off.

Story by Henri Colt. Originally published April 2020 in CafeLit: https://cafelitcreativecafe.blogspot.com/search?q=colt

Burton Rose MD (1942-2020)

(Screenshot of Burton Rose M.D)

On April 24, 2020, Medicine lost one of its great innovators and educators. Burton Rose passed away at the age of 77, a victim of SARS-CoV-21. A graduate of Princeton University, he went to Medical school at New York University and served on the faculty at Brigham and Women’s Hospital in Boston, Beth Israel Deaconess Medical Center, and Harvard.In 1992, Dr. Rose created UpToDate®, a computer-based online medical resource now including 25 specialties, and used by more than 1.9 million physicians from 197 countries.

I first met Dr. Rose in the early 1990s, shortly after he decided to expand his novel UpToDate® computer-based educational programs to include topics on Pulmonary Medicine. At first, the program was available on 3.5-inch floppy disks. If I recall, back in 1995, having a PC with a 1-gigabyte hard drive was cause for celebration, and a Mac LC-500 was an educator’s dream, with its all-in-one desktop design, 14-inch CRT display, and built-in CD-ROM. 

Dr. Rose’s colleague in Boston, Professor Steven Weinberger (former Executive Vice-President and CEO of the American College of Physicians), served as Editor-In-Chief of UpToDate®’s new Pulmonology and Critical Care Medicine (a position currently held by Peter Barnes, Talmadge King, and Polly Parsons). I had the honor of authoring several chapters and serving as an editor with my friend, Praveen Mathur, who sadly passed away a few years ago. We were delighted when the leadership team approved our request to start an Interventional Pulmonology Section, and it is with pleasure and pride that I continue to serve UpToDate® as an author and section editor, sharing the IP editorial role now with Professor David Feller-Kopman.

Burton Rose was amazing. In addition to being a brilliant physician, medical writer, and dedicated teacher, he had the entrepreneurial instinct to recognize that physicians thrive on evidence-based medicine. By creating UpToDate®, he designed an easy-to-access program that allowed health care professionals to query the text with questions as well as by disease. Beginning with a proof-of-concept using his own specialty, Nephrology, he moved on to Primary care Medicine and all subspecialties. UpToDate® quickly became a leading resource for point-of-care medical practitioners and students everywhere.

According to a short video on the UpToDate® website, the program is accessed more than 1 million times and contributes to 300,000 medical decisions each day. This makes it an essential element of health care practice3. Subscriptions are available to individuals as well as institutions, and UpToDate® generously provided affordable subscriptions to trainees and hospitals in countries with low financial resources. 

The greatest key to the program’s success, of course, is the accuracy and timeliness of its content. Material is constantly reviewed and updated by a team of professional editors, deputy-editors, writers, contributors, and peer-reviewers4. Quality is of the utmost importance. This has not changed since UpToDate® was bought by the global provider of professional information and software solutions, Wolters Kluwer in 2008.

Doctor Burton Rose was a true believer in the democratization of knowledge. He did all he could to provide information to medical practitioners around the world, and he assembled a team of dedicated individuals who made his mission their own. He will not be forgotten. 

References

  1. https://www.legacy.com/obituaries/BostonGlobe/obituary.aspx?page=lifestory&pid=196075793
  2. https://www.statnews.com/2020/04/25/remembering-uptodate-creator-burton-bud-rose/
  3. https://www.uptodate.com/home/uptodate-story
  4. https://www.uptodate.com/home

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Reader Beware

(Photo Research Hub, Winona University)

With the number of scientific articles about COVID-19 increasing, it seems we have entered a new era where our mantra must be “Reader Beware.” For reasons known only to their editorial boards, even reputed medical journals are falling prey to the temptation of publishing studies plagued with poor methodology, incomplete information, or conclusions that are not always justified by a careful analysis of the data.

Many classification schemes offer scientists help in judging the reliability and generalizability of study findings, as well as the value of conclusions authors draw from their study results1. Different types of research questions are answered by different types of research studies. Various levels of evidence, also known as a hierarchy of evidence, are assigned to studies based on their design, validity, and applicability to specific experimental or clinical scenarios.

In philosophy, the study of knowledge is called epistemology, which most agree requires three conditions: truth, beliefs, and justification. Even published statements, guidelines, and recommendations are rendered epistemologically more reliable when authors explicitly identify how both facts and opinions contribute to their conclusions. Evidence can be graded, and opinions themselves can be described, for example, as evidence-based, personal preference, as a result of consensus or compromise, or as grounded in conventional wisdom or moral convictions.

The value we attribute to such opinions often depends on their generalizability, as well as on whether they reflect feelings intrinsically shared with others. In this regard, they may be considered secure, vulnerable, or debatable. They may be based on graded factual claims, reasonable projections, or erroneous assumptions. They will also be viewed through the lens of culturally diverse populations, biases, presumptions, and experiences.

When the medical literature provides us repeatedly with questionable studies, it forces us to doubt the reliability of future publications. It mandates that we apply critical thinking, and not rely only on abstracts or potentially sensational sentences written into a well-composed conclusion. It reminds us also that complementing clinical training with learning elements of scientific writing, critical reading, and ethical research publication should be an essential part of professional training2.  

In times of crisis, however, critical thinking may be neglected because of a rush to hope. Sometimes, experience suggests that what is best for a population of patients may not be what is in the best interests for a specific patient3.  Furthermore, in a hierarchy built on tradition, some medical readers and practitioners may not share their doubts in the written word. Journals may not publish critical commentaries or provide explanatory retractions, and a herd mentality can prompt practices that potentially harm rather than help colleagues and patients alike.    

References

  1. Lokker C. et al. A scoping review of classification schemes of interventions to promote and integrate evidence in to practice in healthcare. Implementation Science 2015;10:27.
  2. Eastwood S. Ethical Scientific Reporting and Publication: Training the Trainees. In, Ethical Issues in Biomedical Publication (Jones AH and McLellan F eds). Johns Hopkins University Press, NY, 2000, pgs 250-275.
  3. Brody H. Patient ethics and evidence-based medicine-the Good Healthcare Citizen. Cambridge Quarterly of Healthcare Ethics 2005;14:141.

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Truth and Responsibility

Photo by The Climate Reality Project on Unsplash

Medical professionals are traditionally identified as purveyors of truth. In fact, truth-telling has become a cornerstone of doctor-patient relationships. In recent years, the patient’s right to autonomy seems to have trumped the doctor’s ethical obligations to beneficence and nonmaleficence1

In a recent Gallup poll2, nurses were considered the most trustworthy and ethical of all professionals for the 18th year in a row (followed by engineers, doctors, and pharmacists). It seems that patients expect the truth, and it is because health care workers such as nurses and doctors usually comply with this demand, that the profession garners the general public’s respect and admiration.

The COVID-19 pandemic, however, has thrust many health care professionals into a role that is different from that taken in the doctor-patient dyad. Many, by the nature of their profession, are called upon to provide “expert” commentary on news outlets and social media. They are asked to educate, inform, and sometimes convince a trusting public with their opinions on widely different issues such as triage policies for patients needing ventilators, best medical treatments, population-based testing for signs of SARS-CoV-2, and potentially coercive public health interventions such as quarantine or social distancing.

The potential dilemma is obvious. Cognizant of having the public’s trust, yet soulfully aware they may not possess the communication skills or critical expertise necessary for a truly informed opinion, “medical experts” on the public stage must negotiate a minefield. Frequently, there is a lack of evidence to justify their positions convincingly. Furthermore, there is a wealth of misinformation, contradiction, and uncertainty circulating in scientific as well as mainstream and social media. Scientific backgrounds are diverse, and not everyone can be everything: a competent patient care provider, a well-published intensivist, a knowledgeable public health official, credible virologist, and judicious medical ethicist. 

Thrust onto the stage of public deliberations, colleagues who, whether by choice or obligation must comment on such diverse issues have a responsibility to tell the truth. Of course, relevant factual information includes evidence-based arguments as well as judgments based on an assessment of likelihoods and societal values. Ideally, there should also be discussions about guidelines and peer-reviewed evidence complemented by remarks about critical thinking and considerations about the ways and means of medical science3.

But many truths are ever-changing. Therein lies the challenge in the pursuit of truth itself. Each time we learn more about COVID-19, we may need to refute or revise what was considered truth in the earlier days of the pandemic. Such is the nature of the scientific endeavor. “Truth is made,” wrote 20th-century philosopher and psychologist, William James, “just as health, wealth, and strength are made, in the course of experience.”4

References

  1. Swaminath G. Indian J Psychiatry. 2008 Apr-Jun; 50(2): 83–84.
  2. https://news.gallup.com/poll/274673/nurses-continue-rate-highest-honesty-ethics.aspx
  3. www.ama-assn.org/delivering-care/ethics/ethical-physician-conduct-media.
  4. William James, Pragmatism’s conception of truth. In Pragmatism: a new name for some old ways of thinking (Longmans, 1907), 197-236.

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Infodemics

We are deluged with information these days. A simple PubMed search of COVID-19 reveals 4806 articles published since January 1, 2020. Every medical society publishes guidelines, many of which contain information that is not evidence-based. Networks pummel us with supposedly expert commentary. Journalists become opinion leaders overnight, and a multitude of physicians educate us about the effects of coronavirus on everything from health to economics.

It is a strange world when politicians opine about medical treatments, and physicians preach about economic policies and political science. When radiologists suddenly become pandemic experts, and talking heads, regardless of experience, project their expertise without a track record of academic publications.

In addition to this bombardment of information, not all of which is trustworthy or helpful, there are editorials and journal articles presenting biased arguments, complex data, contradictory positions, or erroneous information. In the midst of it all, preprint literature has become popular, and hundreds of non-peer-reviewed papers are disseminated using social media.

I neither critique nor commend those who share their data using preprints. Servers such as bioRxiv and Xiv were designed so authors can communicate their research results speedily and avoid the delays and politics of peer-review haunting many journals. In a way, these vehicles are reminiscent of the way email and fax machines were used in the 1970s and 1980s; communication vehicles for investigators wanting to share information in order to advance the greater good. 

 A novel aspect of preprints is that of Final Preprints. Authors publish their paper as a preprint, then again as a “Final Preprint” after revising their manuscript based on comments and critiques from a broad readership rather than from individual reviewers designated by a journal’s editor. Some investigators chose to never submit their paper to an “official” journal for publication, especially if recognition or CV-building is not crucial to academic promotion. 

I think the future of preprints is exciting. Interesting questions will be raised by editorial board members of many scientific journals. After all, a degree of acceptability is already evident within the scientific community: Many already disseminate preprints using social media. A search engine exists for preprints called PrePubMed2, and even the National Institute of Health has, with its iSearch portfolio, an updated registry of preprints about COVID-193.

References

  1. https://www.nature.com/news/when-a-preprint-becomes-the-final-paper-1.21333
  2. http://www.prepubmed.org
  3. https://icite.od.nih.gov/covid19/search/

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Children and COVID-19

Screen shot cover IASC

Honesty, Respect, and Reassurance. These three cardinal rules for sharing bad news with children are worth remembering. 

Thankfully, kids don’t often get COVID-19. Less than 2.5% of cases are reported worldwide. When children are infected, they usually become only mildly ill, though asymptomatic infections are not uncommon1. In one study from the Wuhan Children’s Hospital, only 171 of 1391 children (12.3%) assessed and tested for SARS CoV-2 were confirmed to be infected with SARS CoV 2 (median age 6.7 years), with 3 requiring intensive care support and mechanical ventilation and 1 death (all three had numerous comorbidities)2.

Of course, telling a child they are ill is one of the most difficult tasks a health care provider, social worker, parent, or family member might be asked to do. We are fortunate that such a task is only rarely required in today’s COVID-19 pandemic. Teaching all children about the effects and potential impact of COVID-19, on the other hand, is for many of us an almost daily responsibility.

Sometimes, it may be necessary to talk about why a family member or friend was rushed to the hospital. Other times, we may need to explain what is seen or heard on the news or the internet. Children also communicate with each other via social media. Like us, they share stories and are readily exposed to fake news, scary headlines, and other information that may cause fear, panic, or misunderstanding.

In order to address the psychosocial and mental health needs of children everywhere during the COVID-19 pandemic, the Inter-Agency-Standing Committee of the United Nations (IASC) consulted with more than 1700 teachers, caregivers, parents, and children from around the world. Their goal was to write a story created for and by children. This story was published by the IASC under a Creative Commons Attribution so that all users could reproduce, translate and adapt the Work for non-commercial purposes, provided the Work is appropriately cited. 

The story is, My Hero Is You: How Kids Can Fight COVID-19.3 This illustrated storybook is meant to be either read to or read with children by an adult. The book can be downloaded for free from the IASC website (see reference 3) as well as from the UNICEF website at https://www.unicef.org/coronavirus/my-hero-you. The UNICEF website also contains helpful links to sections such as “what teenagers need to know,” or “what parents might want to share with their children”.

Numerous translations are already available and downloadable from the above-named websites. I am very proud to say that others are in progress from contributors to our COVIDBRONCH initiative.

Stay well, and stay safe.

References

  1. Ong JSM et al. Coronavirus Disease 2019 in Critically ill children: A narrative review of the literature. Pediatric Crit Care Med prep 2020. DOI: 10.1097/PCC.0000000000002376.
  2. Lu X et al.. SARS C New Engl J Med, March 18, 2020. DOI: 10.1056/NEJMc2005073.
  3. My hero is you. How kids can fight COVID-19. IASC publication. Helen Patuck (story and illustrations). https://interagencystandingcommittee.org/system/files/2020-04/My%20Hero%20is%20You%2C%20Storybook%20for%20Children%20on%20COVID-19.pdf

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A Celebration for Change

(Photo, H. Colt)

In Judeo-Christian tradition, this is a time for joy and celebration, whether to honor the resurrection of Jesus Christ or the liberation of the Hebrew people from bonds of oppression in ancient Egypt.  

Some say the word Easter comes from the Old English word ēostre. While the etymology is debated, some scholars associate this word with the month of April, a time when pagan Anglo-Saxons may have celebrated the coming of Spring and the powers of a fertility goddess.

Easter is also known as Pâques, which stems from the word Paschal, and the Hebrew word for Passover, Pesaḥ.  The origin of this cherished holiday most likely comes from pre-Israelite celebrations of Spring and the first grain harvest.

This year, the COVID-19 pandemic brings a new significance to celebratory words. We celebrate doctors, nurses, first responders, and all those who are not health care providers but who do their share to bring this pandemic to an early end.

Most people stay home, self-isolate, and practice social distancing. Meanwhile, health care providers around the world toil each and every day to save and prolong lives. Scientists labor through 24-hour shifts in their quest for a cure and a possible vaccine. Countless professionals spend time away from their families to assure us food and other comforts. At the same time, government officials grapple with responsibilities to design and implement policies that keep us safe.

Our lives are changing and will continue to change. Hospital administrators must honor requests for negative pressure procedure suites and antechambers. Critical Care units will need more isolation rooms. Infectious disease specialists must share knowledge about infection control and personal protective equipment. Medical directors will practice disaster management skills. Outpatient clinics will embrace innovative Telehealth services. 

Most importantly, we will be less complacent about warnings regarding global health.

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Short Circuit

As I write this note, my mother is dying in a hospital room in Southern France. She is alone. 

Visitors are not allowed. My elderly father is quarantined in his home, an ancient four-story stone house that dates almost from the Middle Ages. In two months they would have celebrated their 65th wedding anniversary. 

But that is not to be.

There are no doctors or nurses huddled around my mother’s bed. No family or friends, no palliative care specialists or counselors who know what to say when it’s the end, when no one can really say goodbye, and the last communication is a final “I love you” from my father transmitted to her, maybe, through the medical ward’s secretary.

Decades of my own experience with death and dying taught me many things, not the least of which is to live in the now; to cherish each and every moment because you never know if it may be your last. I try to imagine that somewhere, there is a nurse, or maybe a young Intern, who will go to my mother’s bedside, just to be there. I remember sitting with teenagers at the end of their lives, and with grandmothers who prayed for death to release them from the pain of metastatic cancer. I remember saying, “I’ll see you in the morning,” to that favorite patient of mine, and being called after midnight with the news he didn’t make it. 

Medicine is, I think, the most noble of all professions. It is a profession based on trust, and love, and generosity, and grace. It is most noble when the ego is removed from all considerations; when one person sits with another and waits…and waits…until transition occurs…and a tear flows, even though one may barely know the patient’s name.

I hope my mother has someone like that when the moment comes; behind closed doors, with masks, and gowns, and whatever else they need to wear. 

I know she will. In fact, I am sure of it.

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