Tag Archives: COVID-19

Despicable

(Image downloaded, Pinterest.com)

Our holiday season is marked by increased cases of COVID-19, more hospitalizations, long waiting lines in front of emergency departments around the country, overworked health care professionals tending to the sick, and too many critically ill patients in overflowing intensive care units. 

Sadly, there is also a significant increase in COVID-related deaths.

Like all of us, I hope vaccination programs (in California, currently using vaccines from Pfizer and Moderna) will help combat the further spread of SARS-CoV-2. But, I am dismayed by what I  hear and see on the streets of my small village.

Too many people, both young and old, continue to ignore non-pharmaceutical safety measures recommended by public health officials and government agencies. Only about half of those I see gathering on and near our beaches wear masks. Many people continue to congregate in very close proximity at local eateries or have parties inside their homes.

Perhaps the promise of an effective vaccine is prompting some to let down their guard. To them, I can only say, please be careful.

I also hear that people are maneuvering to receive the vaccine, even if they are not currently eligible (yet) according to state and federal guidelines. For example, some offer money to pharmacists. Other well-connected folk request vaccinations for their entire families and some feel deserving simply because, after all, they think they should be entitled to it before those at higher risk of severe disease or death.

Like most crises, the pandemic has illustrated what is best in humanity. Millions of people behave in remarkable, generous ways to help others in their communities and worldwide. 

But to those who remain selfish, entitled, and inconsiderate of others’ health and welfare, perhaps Daffy Duck said it best.

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Benefits of standardization

Photo by Markus Winkler on Unsplash

Feared and often misused, the word standardization sometimes causes confusion in the health care setting. By definition, it applies to any process used to develop and implement metrics that specify essential characteristics of something whose control and uniformity are desired. 

In this sense, standardization may apply to almost anything; rules, technologies, services, commercial products, behaviors, and measurements. A common goal of standardization is to reduce what is known as practice variations. By this, I mean how medical acts might be misused; either overused, underused, improperly used, harmfully used, or unsafely used.

In the COVID age, critical examples of standardization are patient and health care worker safety protocols such as the implementing universal precautions to prevent disease spread or using personal protective equipment and hand hygiene properly to prevent health-care-associated infections. When practices such as these are standardized, lives are saved, and accidents are prevented.

Studies demonstrate that standardization improves the portability of expertise, irrespective of the country, the facility, or the health care professionals implementing protocols. But some people resist standardization, not because they dislike being told what to do or how to do it, but because they disagree with the idea of using such methods to incite behavior modification.

Persons of authority can help by teaching and reinforcing the benefits of standardization, which are five-fold. Standardization can (1) simplify or clarify a specific task, process, responsibility, or activity; (2) improve efficiency and diminish the possibility of errors or doing something incompletely; (3) increase productivity, performance, controllability, and consistency; (4) free up time and energy for other tasks; and (5) improve the quality of patient care, customer service, and morale. 

We can also facilitate the universal adoption of standardized safety practices by attaching them to metrics and rewards. After all, everyone likes to know they did a good job.  

References

  1. Schwartz JS. The role of professional medical societies in reducing practice variations. Health affairs 1984.3:2. 90-101. Downloaded from HealthAffairs.org on November 16, 2020.
  2. Lehmann CU and Miller MR. Standardization and the practice of medicine. Journal of Perinatology (2004) 24, 135–136. doi:10.1038/sj.jp.7211060.

A New Era of Professionalism

This image has an empty alt attribute; its file name is sunny-ng-5VjcqRxshtU-unsplash-2.jpg
Photo courtesy of Sunny Ng, Unsplash

In science, technology, and social history individual courage often changes the world. Hannah Arendt, in The Meaning of Revolution, says that a revolutionary spirit is not defined as the action of a people, but rather as the well-sustained thought by individuals that a concept is right [1]. Educating the general public about health-related issues should be inspired by this idea because of two universal concepts; the first is that of the democratization of knowledge. The second is that of the open dissemination of information and technology. Both are made possible as a result of web-based learning, interactive informational systems, affordable access to artificial intelligence, and the widespread use of social media.

A new era of professionalism means saying goodbye to antiquated and often coerced acceptance of conventional wisdom. Medical knowledge is no longer only the property of medical practitioners [2], and the divide between doctors and the nonmedical public is increasingly small. In a new era of professionalism, the almost instantaneous and frequently open access to information has the advantage of rapidly enhancing knowledge, initiating change, and inspiring confidence. Codependencies between those who know and those who wish to know are intertwined, such that each may actually learn from the other. Never has this been more important than during the COVID AGE.

Having knowledge, of course, is much more than having access to information. Technology might allow its dissemination to transcend national boundaries, but trust, reliability, and understanding are necessary to change behaviors and implement fresh ideas. These last months, the world has been threatened by an invisible virus and the effects of the SARS-CoV-2 pandemic on preexisting global inequalities. They are financial, intellectual, racial, gender-related, political, class-structured, communication-related, environmental, and cultural. In such instances, when more than individual and public health are threatened, all health care professionals have a responsibility to voice their concerns, to be able to justify their opinions based on the best possible science, and to take on the mantel of leadership when the need arises.

References

  1. Arendt H. On Revolution. Penguin Books, edition (from original Viking Press, 1963). New York, pg 46-47. link
  2. Foucault M. Birth of the clinic: an archeology of medical perception. Vintage Books Edition, 1994, New York, pg54-55. link

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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Credible evidence

Avebury henge. Photo courtesy H. Colt

Here we go again. Just when the general public needs credible scientific evidence regarding COVID-19, another leading journal publishes controversial data, this time from a Noble Prize recipient. After the Proceedings of the National Academy of Sciences (PNAS) published the paper Identifying airborne transmission as the dominant route for the spread of COVID-191, the paper quickly rose to the top 5% in Altmetric’s list of papers being shared and discussed globally2. Meanwhile, a group of more than 50 leading researchers wrote the journal, describing “serious methodological errors that undermine any confidence in its findings”3,4 and requesting that PNAS immediately retract the publication.

Other leading journals, including the New England Journal of Medicine, The Lancet, and the Annals of Internal Medicine are also guilty of publishing papers with conclusions that could not be justified by the evidence5.

Health care professionals and the general public look to the scientific community for leadership and expert advice. It is in the nature of scientific inquiry to bear controversy and generate debate in the search for truth. Therein lies an assumption of responsibility and accountability that is not always equally borne by authors, editorial board members, and reviewers.

Those of us who have published widely know and understand the politics of peer-review. We know the fragility of the process, and how sometimes personal vendettas or reviews done in poor faith may prompt rejections. We recognize the unwillingness of many editors to publish studies with negative findings or papers with conclusions that might justify a contrarian position. We may not always accept the often stern and sometimes unfounded critiques of reviewers who recommend rejection. We revise papers when told that our conclusions are not justified by the results, that results are not addressed by our methods, or when our discussion overstates the study’s objectives.

The purpose of scientific peer review is, among others, to question the validity as well as style of the science presented. It is also to find errors, suggest corrections, and recommend revisions that might improve a paper’s readability. It is not always easy for reviewers to accept as valid, findings that run contrary to one’s predetermined biases, or to accept as valid a well-laid argument that puts in doubt a lifetime of one’s own work. That is, as I mentioned earlier, in the nature of scientific inquiry, and it is partly the responsibility of a diligent peer-review.

This is also a responsibility that ultimately resides with the reader. In my own field of Bronchology and Interventional Pulmonology, I wonder if Train-the-Trainer workshops should include sessions on critical thinking. There could be frank discussions about how to teach students to formulate hypotheses, justify scientific findings without going beyond what an honest analysis of the data provides, and credibly argue opinions. 

Well-informed readers do not need to rely on where an article is published to establish the paper’s credibility or scientific value. They are able to reject poorly designed studies, papers reporting questionable evidence, and authors who overstate their positions. It is one thing to rely on credible evidence, but it is quite another to know whether the evidence is credible.

References

  1. www.pnas.org/cgi/doi/10.1073/pnas.2009637117.
  2. https://pnas.altmetric.com/details/83863073/news.
  3. https://www.buzzfeednews.com/article/peteraldhous/mario-molina-coronavirus-face-masks-pnas.
  4. https://metrics.stanford.edu/sites/g/files/sbiybj13936/f/files/pnas_loe_061820_v3.pdf.
  5. https://retractionwatch.com/retracted-coronavirus-covid-19-papers/.

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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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The ritual of hand washing

(Photo courtesy H.Colt)

In religion, the arts, and many forms of symbolic gesturalisation, rituals represent the values of a community. In medicine too, there are rituals: solemn moments deep with meaning, significance, and tradition. 

For most societies, rituals are transformative; a time for bonding, enhanced communication, and even gift-giving. It is during rituals that members of a community renew their trust in one another. Some rituals instill confidence, others reward positive actions. 

Rituals are also used to gain strength in the face of challenges. They are crucial in times of mourning, and in times of loss. They help relieve anxiety, and they reduce feelings of uncertainty. Often, they help gain a sense of control over what might appear to be uncontrollable1.

If some rituals are staged, others seem almost natural, as if they were genetically hardwired into our DNA. They can be learned, adopted, or created. They can also be neglected and forgotten.

In 1847, the Hungarian physician, Ignaz Semmelweis, was ridiculed when he proposed hand washing with chlorinated lime solution to reduce the spread of Puerperal fever in the obstetric ward of the Vienna General Hospital2. Eventually, hand-washing was adopted by the surgical community. The scrubbing ritual became a solemn act that protected patients and professionals from infection around the world.

Hand-washing was less practiced on medical wards, however, and it took decades before soap, hand-sanitizers, and sinks were installed in front of and within every patient room, as well as in the hallways, nurses’ stations, waiting areas, and examination rooms. Still, I have often witnessed health care personnel neglect one or more of The World Health Organization’s Five Moments of Hand Hygiene (before touching a patient, before performing an aseptic or clean procedure, after potential exposure to body fluids, after touching a patient, and after touching a patient’s surroundings)3.

Wet, Lather, Scrub, Rinse, and Dry. These five steps to proper hand-washing are advocated by infection control experts everywhere4. But I have had physicians and nurses lay their hands on me without first using sanitizer or soap. I have seen doctors wipe their hands on their hospital coats and scrubs. I have watched professors avoid the hands-free dispensers, and I have cringed when junior doctors ran their fingers under cold water, forgetting that soap was an obligation. 

Hand hygiene is the least expensive way to reduce the rate of transmissible infections from health care personnel to patients. Yet, even with the use of alcohol-based handrub compliance is low, and there are many disparities in global practice5. Perhaps, this is why the United States Joint Commission advocates hand hygiene programs with “surveyors” to help ensure compliance6.

It seems there are problems related to the duration, frequency, locations, and techniques of hand hygiene protocols regardless if one uses soap and water, the CDC 3-step protocol (apply alcohol-based handrub to the palm of one hand and rub hands together, cover all surfaces, and continue rubbing until hands are dry), or the WHO six-step technique (apply a palmful of alcohol-based handrub in a cupped hand, cover all surfaces, and rub 6 different aspects of the hands)7.

Before going into the operating room, surgeons discuss operative techniques and engage in casual conversation during the scrubbing ritual. The favorable impact of similar ritualistic compliance with hand hygiene protocols in nonsurgical settings during the era of COVID-19 is undeniable.

References

  1. https://www.scientificamerican.com/article/why-rituals-work/
  2. https://www.ncbi.nlm.nih.gov/books/NBK144018/
  3. https://www.who.int/gpsc/5may/tools/9789241597906/en/
  4. https://www.cdc.gov/handwashing/when-how-handwashing.html 
  5. https://www.beckershospitalreview.com/quality/why-does-low-hand-hygiene-compliance-still-plague-healthcare-4-reasons.html
  6. https://www.infectioncontroltoday.com/hand-hygiene/behavior-modification-key-boosting-hand-hygiene-compliance-avoiding-survey-deficiencies
  7. https://pubmed.ncbi.nlm.nih.gov/27050843/

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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