“Sentence first – verdict afterwards.”

And so the Red Queen announced the sentence, “Off with her head!” in Alice’s Adventures in Wonderland by Lewis Carroll. I thought this was absurdity or satire, not news, when I read it.

Illustration by John Tenniel

The news is at least as absurd. On Tuesday night, our only president announced his victory in the election before the votes were counted. He tweeted “Votes cannot be cast after the Polls are closed” – not that anyone was trying to cast ballots after the polls had closed, but they were attempting to count ballots after the polls are closed – that’s sorta the way it works. It appears that he considers counting the votes to be STEALing the election. He announced that his leads were “magically” disappearing as “surprise ballot dumps were counted”; which appears to mean that he didn’t want the absentee ballots to be counted, or maybe there were just certain counties whose ballots he didn’t want counted.

I’ve never really understood election results watching as a spectator sport. It seems like watching a sporting event in which all you can see is the scoreboard. The excitement, such as it is, is to watch the numbers change, not to watch the athletes at work. Co-workers stayed up late, or woke up in the middle of the night due to anxiety, turning on the TV to see what was happening.

As this is being written, the score is either 248-214 or 253-214, depending on which scoreboard you’re looking at. (One of them just changed – during proofreading – to 264-214; the other is still at 248-214.) It appears to be the ninth inning, the 4th quarter, or the third period if you’re a hockey fan. The trouble with this sport is that after the game is over the score could still change. Points could be transferred from one to the other because the final score isn’t really final for over a month, even though we all want to wake up to a final score on Wednesday morning, or stay up to see it Tuesday night. We could go into overtime, only to have the Supreme Court suddenly declare Game Over. The way it looks right now, if each wins all of the states in which he is considered to be leading, it is a Biden victory 270-268. The trouble with that is that Biden’s leads are slim and Trump’s leads (particularly in PA, the biggest prize remaining) are larger. Not to mention that there will certainly be demands for a recount, especially if Mr. Trump loses – he is already demanding recounts and hasn’t lost yet.

I see three possible scenarios: 1) Trump wins and we have 4 more years of this madness; 2) Trump loses and has almost 12 weeks in which to metaphorically torch everything on his way out (or, for another metaphor, the Trump administration is like a rock band that has already been paid and trashes the hotel suite on the last night); or 3) the Supreme Court hands him the election in a replay of 2000. I’m not really sure which is worst.

My fantasy is that he loses and refuses to abdicate. Biden is sworn in and the Secret Service forcefully evicts the former president on January 21. Maybe the sheriff could toss his belongings to the curb. Maybe we could see a perp walk to a waiting squad car, hands cuffed behind his back. The charges? Criminal trespass, impersonating the President. (18 U.S. Code § 912)

Then the indictments begin. The RICO (Racketeering Influenced and Corrupt Organizations) Act seems ideally suited for this. Then we have tax evasion (like Al Capone), fraud charges for the funds he diverted from his charitable organization, the Emoluments Clause, and various state charges. Who gets to extradite him first? Or can we pronounce the “sentence first – verdict later”?

As spectator sports go, I gotta admit I’m enjoying the NBC Extended Highlights of La Vuelta a España much more than this presidential race. They don’t go online until late afternoon but they’re worth waiting for.

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.)

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.