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.

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.

Half-fast Fall Ride

In this strange bike racing season, the Tour de France was barely over when the World Championships were held. Now we’re in the midst of the Giro d’Italia, and the Vuelta a España will overlap with that, beginning October 20, while the Giro ends on the 25th.

For those who missed the Tour, it was an exciting race, won in the final time trial by Tadej Pogačar, who also won the King of the Mountains jersey in that same time trial, after easily having sewn up the Best Young Rider competition earlier. Pogačar came back from almost a minute down to win by almost a minute over his Slovenian countryman, but not teammate, Primož Roglič. Not often do you get a time trial on the last day of real racing, with a categorized climb to boot.

A beautiful day for the Half-fast Fall Ride. Low-lying frost greeted us on the way to the meet-up. The usual breakfast place has gone out of business ( a COVID casualty) so we all ate our own breakfast at home. We tried a new morning route, bypassing the ferry crossing in exchange for exploring Sauk Prairie – the former Badger Army Ordnance Works now being restored by 4 owners – the Ho-Chunk Nation, WI Dept of Natural Resources, USDA Dairy Forage Research Center, and Bluffview Sanitary District. Less than half of the land is open to the public, but that leaves >3000 acres to explore via rustic roads and trails. The land formerly produced ammunition for WW II, and the Korean and Vietnam wars. That left a lot to clean up when it was decommissioned. Part of the Badger Army Ordnance Works’ claim to infamy is that at the turn of the new year 1969-70, the New Year’s Gang “borrowed” a plane from a nearby airfield and attempted to bomb the site to stop them from building munitions for the war in Vietnam. While the bombing failed, it is alleged that the same group bombed the Army Mathematics Research Center later in 1970.

Much of the land was and will be prairie, but it runs up into the bluffs just south of Devil’s Lake with some steep climbs up narrow roads, as well as some areas not open to the public. There is a beautiful and lightly-traveled (at least today) bike trail running through it. The climb up through Devil’s Lake was gorgeous as usual and a brisk tailwind pushed us for most of the morning. You know what that means for the afternoon.

We were able to eat lunch outside in Baraboo before our leisurely return to Sauk City. We earned the name half-fast today, this being the slowest 55 miles I’ve ridden in some time.

The ride was a perfect sendoff as I begin my two week tour of duty in the COVID-19 unit. Our Fearless Leader is home from his brief stint. On the way out he tweeted that we should not be afraid of COVID, because “we have developed, under the Trump administration, some great drugs…” What he didn’t mention is that you and I would not receive the treatment or the medication he received. Nor will we discharge to round-the-clock care with a staff of nurses and doctors. And he also neglected to mention that we paid for his treatment, since he paid $750 in taxes for the most recent year we know about, and his care may well have cost that much per hour, not counting his helicopter rides. He has no co-pays, co-insurance, nor worry that one of his care team might have been out of network and not covered at all. Lest we forget, the bulk of his taxes actually go to the War Department (now known, in one of the earliest examples of newspeak, as the Department of Defense) and debt service, so maybe his taxes didn’t pay for a whole hour. And, by the way, it has been reported that Dear Leader holds stock in the company that developed the “COVID-cocktail” and said stock price has gone through the roof since his treatment. So ask Dear Leader if he will pay for your care as you have paid for his. If so, have no fear.

Letters

I have turned into a curmudgeon who writes letters to the editor. They tend not to print them. Here are a few rejects, with context added as needed. Labor Day seems a fitting time to post this.

I used to belong to a union, until Act 10 banned it. Employees were NOT required to join the union or pay dues. They WERE required to pay their “fair share”, a calculated portion of what members paid in dues in order to pay for the cost of negotiating the contract from which they garnered benefits. No one was forced to join the union, despite the propaganda we hear. If “Right to Work” actually meant what it sounds like, I’d be a full supporter. Sure, we should all have the right to a job – but that’s not what it means.

This letter was in response to the myth that workers were forced to join unions and pay dues. Our governor advocated a so-called “Right to Work” law as part of his “divide and conquer” strategy. The letter was rejected because the editorial page editor didn’t realize that Wisconsin Act 10, which restricted bargaining for state employees to wages only (no bargaining of working conditions) and restricted wage bargaining to levels at or below the change in the cost of living, actually banned all union activity at one particular workplace – and named that workplace (University of Wisconsin Hospitals and Clinics).

On this Labor Day, I’d like to revisit the real world results of WI Act 10. Due to changes resulting from Act 10, my take home pay (reflected by the total of the past 8 pay periods) has DECREASED by 6% (adjusted for inflation via the US Dept of Labor Consumer Price Index) from the same period three years ago. I am not a state employee, my wages are not paid by tax dollars, but I was (and am) subject to Act 10.

This letter was rejected because that same editor didn’t realize that Act 10 affected people who are not paid by tax dollars. I sent her the same citations I’d sent previously. She wanted an explanation that would take more than the 200 words allotted for a letter – so I could submit the letter (which would be rejected) or the explanation (which would have no context).

Open Letter to Sen Ron Johnson: Dear Senator Johnson:

Today’s (May 11) Wisconsin State Journal quotes you regarding your meeting with Merrick Garland as referring to President Obama as a “lame duck president”. I do not think this term means what you think it means. A lame duck is a president who continues to serve during the time between the election and inauguration of a new president. It does not refer to a president who is not eligible to run for re-election (as are all second term presidents for their entire second term) or to some arbitrary period of time of your choosing. 

We hired (elected) you to do a job. Please do it. “With the advice and consent of the Senate” in regard to Supreme Court nominations does not mean “advise the president not to make any nominations because we are going to withhold our consent no matter what.” Please follow your Constitutional duty by moving forward with this nomination. Otherwise, I hope we, the voters, send you back to your wife’s family company and make you a lame duck.

This newspaper doesn’t tell you why they reject your letters. I choose not to speculate. Re: the last sentence – Sen Johnson married his boss’s sister and became CEO of a plastic manufacturing company, thus becoming a millionaire. He claimed to be a “citizen legislator” who would serve for one term and return to the private sector. Surprise! That didn’t happen.

“Breaking news” is stretching it a bit. How many times has this been front page, above-the-fold news? Today, when he announces, yesterday that he was going to announce, last week when he accidentally announced and then deleted it, the week before when he filed with the Federal Elections Commission, and countless other times when he announced when he would announce and/or announced that he was not currently a candidate. Then there were the times that he formed a PAC to not be a candidate and when he formed another PAC to be a pre-candidate.

Contrast that with your below-the-fold treatment of Bernie Sanders’ rally in Madison which drew a larger crowd than any rally by any candidate anywhere in the country – and that encompasses a lot of rallies by a lot of candidates. That was news for one day. 

Now tell me again how editorial decisions and news decisions are completely separate and one does not influence the other.

This was in response to an e-mailed “news alert” to subscribers headed “Breaking News”, telling us that our governor had announced his candidacy for president. (For those not familiar with newspaper jargon, “above the fold” refers to the top half of the front page of a newspaper – the part that is visible in a stack of papers on a newsstand or in a vending machine.)

Governor Walker’s proposed budget includes “self-insurance” for state employees and others covered by the state insurance contract. Is this single payer/socialized medicine good for Wisconsin? It might save or cost the state money, we’re not sure. I’m confused, Governor. Do we want the state in or out of the health care business? This proposal would decrease competition in the marketplace and clearly hurt smaller HMOs, and we know small business is the chief engine for employment. The Governor proposes to let the big three HMOs split the administration of the program and cut out the smaller ones. This would include GHC, a health care cooperative and an HMO that is consistently ranked as one of the top in the country, not just in Wisconsin. Is this the way to improve health care, to hurt the best HMO in the state?

This was in response to the governor’s attempt to find a way to stop paying for health insurance for state workers, at the same time that he was opposing state supports for health care, including Medicaid expansion, for others. I thought it ironic that he opposed the “socialism” of a single-payer plan except when it was convenient and provided another opportunity to screw state employees. He had no cost figures to demonstrate that it would save the state money; but we knew it would decimate a small cooperative HMO. He also tried to privatize the state pension fund. He appointed a task force to study the notion. Of course it was dominated by big business interests. They rejected his idea, telling him that it was among the best-run pension plans (and investment systems of any kind) in the country and he’d be a fool to mess with it. His response was to appoint another task force. They also told him he was an idiot.

Pay no attention to the man behind the curtain! I once thought Donald Trump was an idiot, unfit for the presidency. I have come to realize that he’s smarter than we think. While we agonize over his latest outrageous tweet, he puts the fox in charge of the henhouse and destroys our government. Every two-bit magician knows that misdirection is the key and they don’t call it illusion instead of magic for nothing. While Trump and complicit media focus on tweets, his Secretary of Labor formerly represented Walmart and UPS to fight worker rights. His Secretary of the Interior used to represent mining and oil companies. The head of the Bureau of Land Management used to sue that agency regularly. OSHA has cut staffing to where it would take 150 years to inspect all workplaces under its jurisdiction. The Secretary of Education funds (and supports government funding of) private schools. The EPA has rolled back pollution standards to the extent that even the auto industry opposes it. And, of course, the USPS is headed by someone who gave a lot of money to the president and knows that one way to keep the president in office is to destroy the Postal Service to prevent safe voting. While he is still clearly unfit for the office, who are the idiots?

I don’t think that one requires any further context or explanation, but it could have been a lot longer. It merely scratched the surface and didn’t even get to the outright corruption, felony convictions, and high turnover in the inner circle. 200 words can only do so much.

My most recent reject seems to have vanished – I don’t even have the receipt from them that I sent it. I will set the context and summarize instead. The State Supreme Court last spring rejected an extension of the public health emergency, ruling that the Department of Public Health lacked the authority to extend the order. The Governor, recognizing the likelihood that the court would strike down an order from him as well, took no action until the situation was out of control (and the day before a new Supreme Court justice would take her seat, so a new decision might be different). That’s when he finally issued a mandatory mask order in response to rising COVID-19 infections and deaths. The Majority Leader of our State Senate, Scott Fitzgerald, opposed the mandatory order.

Fitzgerald was quoted as saying, “I think things are going well right now. People are complying if they want to.” I noted wryly that he seemed to be advocating for an end to his own job; arguing that laws are unnecessary and people will “comply if they want to”. I ended by saying “Scott Fitzgerald, anarchist – who knew?” I guess they didn’t like my calling a Republican leader an anarchist.

Tweet Storm

It scares me that our national attention span has been reduced to 240 characters. If we want to say anything longer than that, we divide it into 240 character bites to make it digestible. I know that’s the limit to our president’s attention, but it scares me that that is becoming the norm for the rest of us. It made sense in the era of the Burma Shave sign. For those too young to remember, Burma Shave was a shaving cream that marketed with roadside signs composed as quatrains, one line to a sign, so you could read them as you raced past at highway speed. The fifth sign just held the brand. They worked like this:

If ya got no food


Don’t just bitch


Take up the fork


And eat the rich.


Burma Shave

Or, my personal philosophy: