Tag Archives: Coronavirus

578,319….and Silence

The Red Bird by Stasys Eidrigevicius. (Screen capture)

More than 7000 physicians united through more than 40 WhatsApp groups, and suddenly silence. It is as if the global medical community with whom I have connected has become complacent, accepting of disappointment, disease, and death. Such is, perhaps, the effect of six months and more of COVID-19.

Disappointment, because in many countries, medical leaders had failed to prepare satisfactorily for a pandemic that others had predicted. Disappointment because leading medical journals with their shark tank-like editorial boards succumbed to publishing sub-par scientific material. Disappointment because we don’t know if hospitals have the necessary means to satisfactorily protect health care personnel or care for thousands of newly infected patients.

Disease is terrible because when we are ill, we are not the same as when we are healthy. We see the world differently, and for some of us, values change, and priorities are redistributed. Life takes on a different meaning, and may even lose its meaning altogether. The struggle back to a different reality is challenging, but if health is restored, everything can seem “normal” again…until next time.

Death is in the news every day, but not as loudly in the headlines (578,319 COVID-19 related deaths worldwide today, while numerous countries resume partial shutdowns1). Perhaps the medical community accepts this cruel reality, and the general public has perhaps become too complacent. Societies are radically divided, not only into rich and poor, privileged and not, but also into young and old, with the over-60 or those with comorbidities relegating themselves to self-imposed isolation. In contrast, younger generations strive to live as they used to, for life must go on, and they are the future.

With these thoughts in mind, I watched with even greater sensibility than usual, the truthfully realistic virtual exposition of the photographic-film Paris-Vilnius. The Spectacular Silence, by French/Lithuanian artist Yolita René (http://paris-vilnius.fr). Accompanied by a magnificent piano score by Dominykas Digimas and a collection of Pulitzer-prize worthy contemporary photos, the artist/author uses the painting of a masked, red bird named Coronavirus 2020, as a leitmotif that reminds us of the presence of COVID-19 in our lives today, and of the sometimes bleak but always poetic temporality of our existences. 

I am both an observer and a witness as dozens of images from The spectacular silence cross my computer screen. These stills reflect my own feelings about Absence, Solitude, Distance, Resonance, and finally, Masks. These face-covers are of all types and shapes and forms. They remind me of our natural diversity and human fragility, of our ability to love and to unite, and of our desires to connect with others in order to find greater meaning in our lives.

References

  1. https://ourworldindata.org/covid-deaths#what-is-the-total-number-of-confirmed-deaths

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Knowledge first

Rhodes House. Photo courtesy H. Colt

Many say we know little about COVID-19, when in fact we have learned much since the start of the pandemic. 

The abundance of contradictory and often disputed information is consistent with the nature of scientific inquiry. This is because our goals as scientists are to make observations, challenge what might be considered facts, question results, form hypotheses, and validate or reproduce findings with sufficient reliability to qualify them as credible.

Today, there is evidence for us to be hopeful when considering our approach to patients with COVID-19 infection. 

For example, we know most individuals infected with SARS-CoV-2 remain healthy or have only minor illness. There may be no signs or symptoms of excessive viremia, but whether asymptomatic or presymptomatic, people transmit the virus to others via droplets, respiratory particles, and fomites. For those who become ill, symptoms are non-specific and include, among others, fever, headache, rash, fatigue, and loss of taste or smell1

Mask-wearing, physical distancing, frequent hand-washing, and quarantines help mitigate the spread of disease2.

During a much-feared second week, symptoms are related to the immune response. Shortness of breath or hypoxemia may increase, but patients may also present with signs of kidney, heart, neurologic, and skin disorders. The most vulnerable for disease progression are the elderly, the obese, patients with heart or kidney disease, immunocompromised individuals, and those with diabetes or hypertension. A recent report in MMWR states that pregnant women are also at greater risk for severe disease than non-pregnant women3.

Moderate or severe illness may warrant hospitalization. Some patients will need intensive care treatment. For those with increasing respiratory insufficiency, intubation may not be necessary, and alternative ventilation techniques including noninvasive ventilation4 and proning can be beneficial5. Outcomes may be related to the quality of care during this stage, and several diagnostic studies such as chest radiographs, neutrophil/lymphocyte ratios, C-Reactive protein, D-dimers, and Procalcitonin levels may help determine prognosis and signal evolving thromboembolic disease, bacterial co-infection, or cytokine release syndrome6,7. Pharmacologic venous thromboembolism prophylaxis is now routinely recommended for hospitalized patients8, and a significant survival benefit was demonstrated for critically ill patients treated with dexamethasone9 or Tocilizumab10.

We also know that some people have persistent, intermittent, or recurrent symptoms such as low-grade fever, shortness of breath, and fatigue that can last several weeks. Patients discharged from the hospital as well as those recovering from infection-related symptoms warrant prolonged medical supervision, in part because of risks for thromboembolic disease (a reanalysis of the MARINER data suggests that long-term anticoagulation after hospital discharge reduces fatality by 28 percent)11.

Each week, our knowledge of COVID-19 increases, but there is still much to learn. Also, we must spread the word about all we already know. 

Not everyone has the time to peruse the medical literature or judge the quality and consistency of published evidence. I want to thank everyone who generously helps me select relevant papers for the COVIDBRONCH-LIT repository12, as well as several thousand health care professionals around the world who use this knowledge to benefit their patients.

References

  1. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html.
  2. https://jamanetwork.com/journals/jama/fullarticle/2765665?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jama.2020.7878.
  3. https://www.cdc.gov/mmwr/volumes/69/wr/mm6925a1.htm?s_cid=mm6925a1_w.
  4. https://www.acpjournals.org/doi/pdf/10.7326/M20-2306.
  5. https://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600(20)30268-X.pdf.
  6. https://labtestsonline.org/diagnosing-covid-19-testing-essential.
  7. https://responsebio.com/procalcitonin-and-d-dimer-in-patients-with-covid-19/
  8. https://www.acc.org/latest-in-cardiology/articles/2020/04/17/14/42/thrombosis-and-coronavirus-disease-2019-covid-19-faqs-for-current-practice.
  9. https://www.medrxiv.org/content/10.1101/2020.06.22.20137273v1.
  10. 10.https://journal.chestnet.org/article/S0012-3692(20)31670-6/pdf.
  11. Post-Discharge Prophylaxis With Rivaroxaban Reduces Fatal and Major Thromboembolic Events in Medically Ill Patients. J Am Coll Cardiol 2020;75:3140-3147.

12. https://drive.google.com/drive/folders/17adnJE8G0V9hKZZebq82h5m98LmRpnT9.

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We need to wear masks

Photo, H. Colt

The curve flattened across California. Many stores and restaurants reopened. Folks who had been trapped indoors for months flocked to the beach with their families. But now in Orange County, where I live, the number of people infected with SARS-CoV-2, the respiratory virus responsible for the COVID-19 pandemic, is increasing, hospital beds are being filled, and public health officials (those who are courageous enough) are sounding the alarm. 

It’s a second wave, but it’s one we can prepare for, with common sense.

While the situation is fluid, we have a greater understanding of Coronavirus than we had at the start of the pandemic. We know transmission occurs mostly by large droplets, like ones that can be stopped by wearing a mask. We also know transmission occurs from fine aerosols, which is why health care personnel use special N95 masks and other protective gear. Transmission occurs from contact with contaminated surfaces, which is why we use disinfectants, alcohol-based hand sanitizers, and practice physical distancing.   

So, with all we know about spreading the virus, I was surprised to see that most people in my town, both locals and visiting tourists, are not wearing masks. I wrote a brief letter that was published in our local paper1. In it, I shared the following story:

“My mask protects you, and your mask protects me,” I said to one young couple standing next to me by the ice cream shop. 

“Chill,” they said, not in a mean way as they pulled their masks up from below their chins to cover their faces.

I thanked them and explained how older people like myself were at a higher risk of becoming severely ill if we catch Coronavirus. I share this statistic with Blacks, Native Americans, and Hispanics, as well as with those who have heart disease, chronic kidney disease, or diabetes. In fact, care fatality rates increase with age and number of comorbidities2.

The last thing we want is to see our health care facilities overburdened with a surge of critically ill patients.

Wearing a mask3 when we are near others is a generous act of kindness that might be the most effective way to protect against COVID-19 infection. 

An increasing number of scientific studies help support this proposition. Both the CDC and WHO now recommend face-masks to the general public4. The WHO reversed its position regarding mask-wearing based on a meta-analysis of 172 papers by Chu et al4. Mitze et al.5 concluded that masks might reduce daily growth rate in the number of infection by more than 40%, and Stutt et al., in their mathematical models, note that when masks are used by the public all the time, the effective reproductive number, Re, can be decreased below 1, leading to mitigation of epidemic spread6.

‘My mask protects you, your mask protects me,’ may be the secret to surfing the second wave of this pandemic safely.

Addendum: Since this writing, the Governor of California and the California Department of Public Health issued guidelines mandating face coverings in “high-risk” situations (https://www.cdph.ca.gov/Programs/OPA/Pages/NR20-128.aspx).

References

  1. Colt HG. Stu News, Laguna Beach, June 17, 2020
  2. https://bestpractice.bmj.com/topics/en-gb/3000168/prognosis 
  3. https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-respirators-surgical-masks-and-face-masks
  4. Chu DK., et al. Physical distancing, facemasks, and eye protection to prevent person-to-person transmission of SARs-CoV-2 and COVID-19: a systematic review and meta-analysis. The Lancet. June 1, https://doi.org/10.1016/S0140-6736(20)31142-9.
  5. Mitze T et al. Face masks considerably reduce COVID-19 cases in Germany: A synthetic control method approach. Institute of Labor Economics, June 2020. ZA DP No. 13319.
  6. Stutt ROJH et al. A modeling framework to assess the likely effectiveness of facemasks in combination with “lock-down” in managing the COVID-19 pandemic. The Royal Society Publishing, May 2020. ROJHS, 0000-0002-1765-2633.

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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

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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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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