Drowning in air

Last week I wrote about my experience of working in the COVID-19 unit. My experience is nothing compared to the experience of my patients.

One described the disease to me in simple terms – “It’s like drowning in air.”

I shopped at Costco today. Only one person in the store was unmasked but an appalling number wore their masks fashionably below the nose. Come on folks! I know you can breathe more easily with your nose free. Why do you think you’re supposed to cover your nose? (Hint: it’s not for your benefit.)

I stayed with another patient while she ate orange slices. (The anonymous pronouns for today are she and hers). Even through an N95 mask and face shield I could smell that orange. She savored each thin slice as though it would be her last. I wanted an orange so badly. She followed the orange with coffee and aspirated (choked on) the coffee. A minute (that seemed like hours) of coughing ensued. She cleared her lungs but it took minutes before she was breathing freely again, with acceptable oxygen saturation. By the way, those orange slices were her last. Three days later, she was dead.

The emergency field hospital in Milwaukee is now taking patients. It was not long ago that Wisconsin crossed the threshold of 1000 new patients per day and we thought that was outrageous. The daily new case average has now passed 4000. PS: It’s not just because we test more. For those with the IQ of the president (or those to whom he speaks) nobody gets the disease from testing. Testing is not a pain in the ass. It is how we identify the Typhoid Marys of our time – the people who are not sick but spread the disease.

Our new COVID-19 ICU opened today. It has been under construction for a couple of years, slated to open as an expansion to the neuro unit. As I reported last week, I expected that plan to be changed at the last minute, despite assurances even then that the plan remained in place to open next month as a neuro unit. Yesterday it was announced that it would be a COVID-19 unit and today it was announced that it would open as an ICU this afternoon. The first patients have been admitted. The old ICU is full.

The university’s new star quarterback, who had a breakout game last weekend and was named Big 10 Player of the Week, is now sidelined for 3 weeks after testing positive. Will people now take this seriously? I mean, come on, it has now affected football. While football is not worshiped quite as seriously here as in Texas, this could make a difference (though sadly, probably only if he gets really sick – otherwise it will be seen as overkill as well as sacrilege).

We lost another great musician this month. Jerry Jeff Walker is dead at 78. I haven’t worn cowboy boots since I was about ten, but when I first heard this song I wanted to hitchhike to Austin to buy a pair. If there is an afterlife, Jerry Jeff is still wearing his Charlie Dunn boots.

We also lost Spencer Davis this month – for those too young to remember, he’s the bandleader who brought us a teenage Steve (then Stevie) Winwood.

Winwood on piano and vocals, his brother Muff on bass, Spencer Davis on guitar, Pete York on drums.

September saw the death of Toots Hibbert, leader of Toots and the Maytals. While they had an album out four years earlier, they were introduced to the US in Jimmy Cliff’s 1972 film “The Harder They Come.” Toots died from COVID-19.

Also lost to us in September was Diana Rigg, The Avengers’ Emma Peel (no, not the Marvel comic book, but the British TV show). As Emma Peel, she was witty, tough, and drove a Lotus Elan. What was not to like? Later she was the host of PBS’ “Mystery”, with this intro drawn by Edward Gorey.

Sorry for all this death in one entry. I started a post about Toots and Diana in September. I realized others had more to say about them (and more eloquently) than I, so it sat in my “drafts” folder. Losing two more icons of my youth was more than I could take.

What’s wrong with this bike?

Image from Competitivecyclist.com

How about this one? Maybe a closeup will help.

Image from Competitivecyclist.com

If you said “nothing”, you’re right. There is nothing wrong with these bikes…as long as you have about $6000 to spend.

On our FAQ page, we asked and answered the question “Is it cheating to ride an e-bike?” The world of e-bikes is changing. Some are 75 pound behemoths that drive themselves – until the battery dies. The two pictured above weigh around 26 pounds – about the same as my Bruce Gordon touring bike. Even when the battery dies, pedaling these bikes is no big deal. Where is the motor? you ask. Nearly invisible, in the rear hub, I answer. A close look between the cogset and the brake rotor and you might see the hub diameter looks a bit large – sort of like the 3 speed hub on my Spot Brand bike – but small enough to be virtually invisible.

the Bruce Gordon

E-bikes are now a lot like other bikes – available as commuters, cruisers, mountain, gravel, and road bikes. They can be pedal-assist, or can have a throttle like a motorcycle. Top speed is governed in multiple classes – you get to pick. With the motor not assisting, you can go as fast as you want (or can). Possibly the ultimate niche for them is the cargo bike. I was going to include some images, but there are too many variants – just search the term.

Would I ride an e-bike? No. It might be like a jet ski or a snowmobile or crack cocaine. Once you try it, you don’t want to give it up. Or so I’ve heard; never having tried any of them. Though the e-bike doesn’t have the societal costs of the others. A half-fast friend recently went bike shopping. His partner wanted an e-bike and bought one. He tried one and almost did it – but the Colnago won out and he couldn’t afford both. (But, as you see below, it was a false dichotomy – don’t tell him.)

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  Images from Colnago.com

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  Which is the e-bike?

This might qualify as bike porn – pictures of $5000+ bikes that most readers can’t afford and maybe have no business riding even if they can. We’ve all seen the stereotypical e-bike. Today, we just wanted to say the market has expanded. There are lots of choices. Just get out and ride; or do whatever it is that you love and will get you off the couch. (And no, I don’t have links for you to click to buy these and get me a commission. If you want to buy a bike, you’re on your own.)

As we said in the FAQ – if e-bikes get people riding who wouldn’t otherwise, we’re all for them. If they’ll get you out more, more power to you. If it’s just another expensive toy, don’t you have enough already?

Tales from the front

I learned a lot from a two week tour of duty in the COVID-19 unit. First is the unpredictability of this disease.

Details will be obscured so that no patients can be identified. Pronouns will be “they”, “them”, or “the patient”. I am not a doctor, but I play one on TV. A few numbers will make things make more sense. “Oxygen saturation” or “SpO2” is the amount of oxygen in the blood expressed as a percentage, with 100% being the ideal state in healthy lungs. Over 90% is generally not a problem. “FiO2” is the percentage of oxygen in the air being supplied to a patient. Air is about 21% oxygen. 100% FiO2 means pure oxygen. The flow rate of oxygen is measure in liters per minute. Home oxygen concentrators can supply about 5 liters per minute (some up to 10). Normal resting heart rate is around 75. Normal respiratory rate is about 12-20 breaths per minute. There will be a quiz later.

In my world, I am asked to make a discharge recommendation the first time I see someone. (Can they go home? Do they need to go to rehab? Do they need extra help?) If I think they can go home I am to “clear” them for discharge home when I think they are safe to go home.

One patient looked great when the Physical Therapist saw them. She told me she had cleared them to go home and I didn’t need to see them. She thought they might leave that day. The next day the nurse called to say they looked worse, and could we see them? On day 3, they could sit up at the edge of the bed (with two of us helping) long enough to eat a snack. Two days later they were dead.

Another patient was up independently in their room; able to wash, dress, go to the bathroom independently . Two days later, they were on 50 liters per minute of supplemental oxygen (at 50% FiO2), with a respiratory rate of 35, heart rate of 115, and oxygen saturation of 82% – at rest. What happens next, I don’t know. I have a prediction. I will not speak it here.

A third was cleared by another therapist and I was asked to monitor them (look at the medical record each day, see if there were any significant changes that might require our intervention). I decided to go see the patient when I read that they might go home soon. SpO2 was 90+% on 6 liters of O2. Getting up from a chair and standing for 1 minute caused the patient to feel the need to sit down. Half a minute after sitting, SpO2 dipped to 75%. Flow rate had to be increased from 6 to 15 liters/minute and it took 15 minutes of rest to recover and get back to over 90%. I rescinded the “cleared for discharge home” designation. They went home the next day.

Another patient looked great the first day. I cleared them for discharge home. The next day they were placed on a mechanical ventilator – a machine to breathe for them. After extubation (removal of the breathing tube down their throat, removal of the ventilator), the nurse and I helped them to a chair. They were on 6 liters per minute of O2 via nasal cannula. Up in the chair we added 15 liters more via a non-rebreather (a mask with bag attached that looks sorta like what you see on an airplane) in order to keep their saturation level acceptable. Two more days and they are making a great recovery on 3 liters/minute while up in a chair.

This virus also messes with your blood clotting system. A person came in with COVID-19 and a blood clot (thrombus) in the leg. Part of it broke off and settled in the lungs (an embolus), where it became immediately life-threatening. The treatment for this is a heparin drip (a steady release of an anti-clotting agent into the bloodstream). This resulted in bleeding into the muscles of the butt/torso (a hematoma). Now we had a dilemma – stop the heparin to stop the bleeding so they don’t bleed to death, or continue the heparin to break up the clot in the lungs so they don’t suffocate? That’s why doctors make the big bucks, not me. While this person was afraid to get out of bed, then afraid to walk to the bathroom, ultimately they recovered and went home.

That’s only five people – half a day’s work -but you get the idea. So what did I learn? I can’t make a reliable prediction from seeing someone once. I’ve come to write “To be determined” for my discharge recommendation on the first day, and revise it daily. While it is important to be up and moving if possible to help recruit healthy lung tissue, we need to monitor vital signs closely and adjust our expectations minute by minute. One patient talked with their child and the child said they were taking it, not “one day at a time” like AA, but “one hour at a time.”

Usually I scribble quick notes to myself as I go, then transcribe that into the electronic medical record (EMR) when I leave the room. Since every patient on this unit is in isolation, I can’t bring a pen and paper in the room and take it back out, so I memorize all of these numbers and try to write them as soon as I leave the room. After seeing 8 or more patients, I shower, change clothes, and write all of the notes into the EMR at once.

Each patient is isolated from each other patient and the entire unit is isolated from the rest of the hospital (meaning doors are closed unless someone is passing through them – all automatic door openers are disabled – and the unit is negatively pressurized so air does not escape). We wear hospital-issued scrubs (usually reserved for operating room personnel). For each patient we don fresh gowns and gloves that we remove before we leave the room. We disinfect our face shield and hands before we enter a room and when we leave it. We disinfect our hands and the keyboard before and after touching computers. If in doubt, we disinfect our hands before and after touching anything. As such, everything takes longer than usual. The nurses use a PAPR (Powered Air Purifying Respirator – sort of above-water SCUBA). They remove and disinfect it after every patient. Our N95 mask (formerly used once, with one patient, and discarded) is to be used for 7 days. (Image from workersafety.3M.com)

The caseload is going up. The hospital is full. A month ago it was full of non-COVID patients. Now the COVID units are filling up. A newly-remodeled unit will open soon. I suspect it will be diverted from its planned use to being a COVID-19 unit. Elective surgeries are being postponed again (as they were last spring). A 500 bed field hospital has been opened on the State Fairgrounds. A lawsuit has just resulted in an injunction against the Governor’s order limiting crowd sizes. At least the mask order was upheld (different suit, different county). So you can go into a crowded bar and take off your mask to drink, but you need to keep it on to shop for groceries. And of course, everyone in bars stays 6 feet apart, no one talks loudly, and everyone controls all bodily secretions (“say it, don’t spray it”).

I know our president still thinks it is no big deal. Among the things I wish for him, is that he could follow me for a day – change in and out of isolation gear 8-10 times, run from room to room, and then remember what you did 8-10 different times to write it all down later. Mostly I want him to see the people who aren’t him, who didn’t recover and get back to work in a few days; watch them struggle to breathe, to get out of bed, to do the things we take for granted every day. I want him to see that not everyone has a personal team of doctors and nurses who have only a single patient to care for. I want death to not be an abstraction.

Friends

…and I don’t mean the TV show and I don’t mean Quakers.

A blogger I follow recently referred to me as a friend (and I agree). That got me to thinking. That, and a visit out of the blue last night.

My daughter has “Internet friends” all over the world; people they have never met in the flesh, but many they have met face-to-face via FaceTime, so we know they are who they say they are (as much as we know that about anybody, but that’s another story).

That reality had always been foreign to me until I started blogging. Now I have people all over the country whom I would call friends, or at least friendly acquaintances, though we have never been face-to-face even on FaceTime.

My best friend R from my ten years in California appeared out of the blue last night. I got a FaceTime request from an unknown number. I declined it and said “Who are you?” He was an hour and a half away and passing through. We had a great walk and talk in the park a few blocks from my house. We stayed several feet apart. He got back in the RV and disappeared. I walked home for dinner.

Three of us (R and F and I) used to get in hot water together regularly in the Bay Area. I mean that literally. We would go to a hot tub place, sit in the tub together and talk, then continue the talk over dinner. (Truth be told, I’m more of a sauna guy, but hey, this was California;) We asked each other the kinds of questions that made us think and feel and know each other and ourselves more deeply than usual.

R and I once drove 50 miles to a jazz concert. We argued economics (or discussed passionately) for most of the drive and part of dinner. We heard and saw a great concert, then continued the discussion on the drive home and sitting parked in front of my house for too long. As I walked into the house I realized I had just learned something about love. I had spent my formative years (18 to 30) in a close-knit community, where we agreed on most things and our disagreements were, in the grand scheme of things, pretty small. Now I was having a disagreement that was pretty big; but I realized that I could disagree about an idea and love the person speaking it.

This is a friend to whom, when I am gone, I think I may be invisible. We have had no contact in over ten years. But when we are together, he is here 100%. He is fully present – so I don’t begrudge him the fact that he is fully present somewhere else with someone else when I am 2000 miles away.

Those years from 18-30 were present in our talk. The park contains a memorial to an old friend. We had a community of interlocking organizations and friendships. (See previous post and reference to the New Nation – building a new society in the shell of the old.) I initially knew Orly through an organization I worked for, People’s Office. We were a community center providing some of the services that the internet provides now. If you needed someone to fix your plumbing, Orly was the guy, and we had his number at our fingertips. Need to get bailed out of jail? Find out what’s happening in town tonight? Need to get your car fixed at the Co-op Garage? Having a bad acid trip? We could help you. If you had a problem we hadn’t run across before, we’d find a way to help you. Several organizations got their start that way.

Later Orly apprenticed to the electrician who wired the co-op when we got a new building. That electrician happened to have a PhD, but he’d put himself through school as an electrician and liked it. It was only years later that he worked as a psychotherapist, using that degree. Working at the neighborhood grocery co-op, I knew pretty much everybody (and what they ate), and they knew me. S liked to work Sunday mornings so she could see who came in together to pick up bagels and the New York Times. She thus knew the neighborhood gossip first. It was that kind of town.

Moving back after ten years in California, my re-introduction to the community was Orly’s funeral. He died during a heat wave just after I moved back. We had a canoe funeral procession down the river. His flower-filled canoe was towed between two others. We rounded the bend out of the river and into the lake, pulled up on shore at the park, and had a big potluck. It seems that everyone I knew was there. I was home. Orly and the canoe are memorialized on a plaque on a park bench right where the river flows into the lake (where we took the walk back at the beginning of this post). That park is also home to the Marquette Waterfront Festival, with which we welcome each summer (the weekend that school gets out).

So there are that kind of friends, too. Those whose lives weave in and out of our own for years. Those we may never know well, but who make our lives richer anyway. Those we have a deep connection with somewhere along the way, but not forever, but they are still part of that fabric. Then there are friends like the half-fast cycling club, folks I’ve ridden with for 10-45 years. Sometimes a bike ride is the best place to talk.

A song from the Women’s Movement of the 1970s. I couldn’t find a recording by the writer, Ginni Clemmens (without buying the whole album). She was a Chicago folksinger in the 60s and a stalwart of women’s music in the 70s. She died in 2003 on Maui.

You may have noticed that I refer to living people only by an initial and dead people by name. I guess dead people can’t defend themselves and living people may not want to be identified here, so I don’t name them without consent, and I don’t tend to contact them to ask for consent.