Welcome 2021!

Normally we see in the new year with a Lou and Peter Berryman concert. Last year they announced their retirement, so the pandemic did not require a cancellation.

Normally we have a potluck with friends, which includes a listing of everyone’s favorite books, movies, and TV shows for the year. This year was virtual, and we skipped it.

We did welcome the year with home made squash ravioli and closed out 2020 with a 2010 wine that we’d been saving. We’re not wine cellar types, but we do have a root cellar which works equally well for wine and we did lay this bottle down a few years ago with a plan to drink it this year.

Hoarfrost (fog when the temperature is below freezing) came for a visit. (Sorry, but all of the pictures appear darker in WordPress than they did before uploading. I have edited them a second time and re-uploaded them so I hope they look OK this time.)

We live in possibly the weirdest time ever. How many times have you asked yourself if this is really happening? How many times have you thought that this couldn’t be the plot of a novel because it’s too far-fetched to be believable? Here are some excerpts from the transcript of the call from our soon-to-be ex-president and the Georgia Secretary of State (Should we mention that it took 18 tries before they put him through? Maybe somebody knew this was going to go off the rails quickly):

Raffensperger: Mr. President, the problem you have with social media, they — people can say anything.

Trump: Oh this isn’t social media. This is Trump media. It’s not social media. It’s really not; it’s not social media. I don’t care about social media. I couldn’t care less. Social media is Big Tech. Big Tech is on your side, you know. I don’t even know why you have a side because you should want to have an accurate election. And you’re a Republican. 

At first I was just going to pull those first two sentences: “This isn’t social media. This is Trump media.” I thought that was crazy enough. But it just kept getting loonier.

Germany: We’ve been going through each of those as well, and those numbers that we got, that Ms. Mitchell was just saying, they’re not accurate. Every one we’ve been through are people that lived in Georgia, moved to a different state, but then moved back to Georgia legitimately. And in many cases —

Trump: How may people do that? They moved out, and then they said, “Ah, to hell with it, I’ll move back.” You know, it doesn’t sound like a very normal . . . you mean, they moved out, and what, they missed it so much that they wanted to move back in? It’s crazy. 

Germany: They moved back in years ago. This was not like something just before the election. So there’s something about that data that, it’s just not accurate.

I moved out of Wisconsin in the 1980s. I moved back in the 1990s. I voted in Wisconsin in the 2020 election. Does that mean the soon-to-be ex-president thinks I committed fraud, too? Or just that I’m crazy? We’d better hope he never moves back to New York. (Actually, I do kinda hope he moves back there – to serve a prison term.)

He even disagrees with the lawyer he brought in on the call with him. “Disagree” is the polite way of saying that he is just plain wrong (which is a nice way of saying he is either lying or misinformed):

Germany: We chose Cobb County because that was the only county where there’s been any evidence submitted that the signature verification was not properly done.

Trump: No, but I told you. We’re not, we’re not saying that.

Mitchell: We did say that.

Then there’s the flat-out request for fraud to be committed:

Trump: …So what are we going to do here, folks? I only need 11,000 votes. Fellas, I need 11,000 votes. Give me a break. 

Bike Maintenance

I’m in my fourth winter with a belt-drive bike (bought in spring of 2016). So far it has been a godsend. I replaced the belt once and I have a spare on hand. I would have been through a few chains by now and would probably be looking at other parts. The drivetrain has been getting noisy so I just replaced the chainring (or “front pulley” in belt drive parlance). “They don’t make ’em like they used to” does not always mean things are worse. The original pulley was “carbon-reinforced composite”, AKA plastic. The new one is aluminum. The following pictures should show you why I hope aluminum is the better choice. The rear pulley (“cog” in chain drive parlance) was always aluminum.

In case it is not obvious (you can zoom in if needed), the rounded tooth profile (lower pulley in each photo) has been worn down to a sharp edge on the old pulley and the “wings” that extend out to the sides are pretty much gone. In the bottom photo the old pulley is sitting on top of the new pulley. They are staggered so you can see the round vs sharp tooth profiles. The overall diameter is also smaller, as the plastic has worn away. I had to adjust belt tension after the change. Water, salt, and sand did not make that job easier.

I’m hoping for more than four winters from the new pulley.

Coup d’etat

Since the last post there has been an attempted armed coup. As you are all well aware, our deposed leader attempted to stay in office by overthrowing the legislative branch to prevent them from certifying the election result. How is that called a “protest” or “demonstration”? As videos show, they had the assistance of some of the Capitol Police, as well as the tacit assistance of the administration as evidenced by the paltry police presence and complete absence of National Guard presence compared with the presence during Black Lives Matter protests. (By the way, while media reports have referred to deaths from “medical emergencies” during the coup attempt, at least one of said emergencies has been documented as a trampling by the mob. The police officer killed was reported as dying from injuries while “physically engaging with protestors”. The Chicago Tribune reports he was murdered by being struck in the head with a fire extinguisher.)

Our soon-to-be ex-president has been banned from Twitter after Twitter found credible evidence of a planned second coup attempt, spurred on by his posts. Attacks on Washington and state capitols are planned for next weekend and Inauguration Day. I am hoping for a much more robust response from police and troops. While Twitter is finally taking some responsibility, there are multiple other online fora actively promoting the coup.

COVID-19 and health

I just had the second dose of the Pfizer COVID-19 vaccine. While several of my co-workers suffered miserably from side effects, I feel fine. Even my arm ache is less than the first go-round. My hope is that we will be back to public events in 2022 and I can go on a big ride with others again (Cycle America, here we come!). Death Ride 2021 is off the table for me, though it is still scheduled as of this writing.

It has been a year since my surgery (chronicled here) and 20 months since the original injury. Post-op pain has made me question the value of the surgery (pre-op it only hurt to walk; post-op it hurt to ride a bike and sometimes just to sit) and whether, if I had to do it over again, I would have lived with a hernia instead of having it “fixed”. After several rounds of acupuncture which helped for a while, I opted for a nerve block and corticosteroid injection (a mixture of an anesthetic for short-term relief and an anti-inflammatory for longer-term relief). The anesthetic worked great for a day. For the next two days it was like I’d never had the injection, then the following day the pain was reduced (not gone). So far, the injection seems like a winner. We’ll see how long it lasts. The way it works is a 3.5″ long needle is guided via ultrasound through the abdominal wall and to the nerves that are the source of the pain (two nerves, in this case). The injection surrounds the nerve with one medication (bupivacaine – trade name Marcaine) to block transmission of pain signals and a second medication (Kenalog, generic name triamcinolone acetonide) to reduce inflammation around the nerve. The plan is to calm the area down to reduce irritation to the nerve. With luck, this is curative. With less luck, it lasts a few months and then I face the question of more steroids or putting up with pain for the rest of my life. Not to mention the question of whether it is worth it to continue working, since that seems to exacerbate the pain. Since this is (allegedly) an on-the-job injury for which the job accepts no responsibility, retirement may be the best option if the injection doesn’t work long-term. I’d rather not retire until the pandemic is over, so I can have a party.

Why is it…

that the only people trying to steal the election are campaigning under the banner “Stop the steal”? Is it just me, or is that the ultimate in irony?

I did it. The first injection of the novel coronavirus vaccine from Pfizer went into my arm Saturday afternoon. My arm did not freeze and fall off. With a substance stored at -70 degrees C (-94 F) I was hoping they’d warm it up a bit. They did. Nothing like frostbite from the inside out. While there are supposed to be only mild side effects (like the pain at injection site you get with the flu vaccine), my employer isn’t taking any chances – I was required to get the vaccine at the end of my Saturday shift so, if I get sick, I’ll be sick on my own time and won’t miss work unless it lasts 3 days. Kinesiotape at the injection site works for the flu vaccine. We’ll see how it works for this.

Twenty four hours after injection I have an achy arm, a lot like after a flu shot. I have a vague sense of dis-ease – slight disequilibrium, subtle visual changes, very mild nausea, and a slight headache – nothing that would have kept me from working if today were a workday. In three weeks I’ll let you know how the second injection goes.

We received our new shipment of PAPRs (Powered Air-Purifying Respirators) so I can dispense with the N-95 mask and patients can see my face for the first time this year (except for a week or two in February when I worked maskless). I still need a mask for the non-COVID patients and when I am doing anything else at work, but that is just a simple mask, not an N-95. They can hear me better, too. (Photo: What the well-dressed therapist is wearing these days. Isolation gown not shown.)

I’m thinking a PAPR could come in handy for the Death Ride. Nothing like extra air delivered under pressure for the thin air at higher elevations while climbing mountains. Not to mention that I don’t expect to be ready to share air at close quarters with a couple thousand other people in July.

We added a new member to the family this week. He was a street dog from Oklahoma and came to us via a rescue organization and a foster home. He seems to like it here so far. He got a little close for this selfie but, lacking thumbs, he did pretty well I think. Especially since he was drifting off to sleep. When our daughter moves out, he goes too, so I can’t get too attached. Maybe he’ll come for sleepovers. (Then again, I got pretty attached to the kids but it was OK for them to move out on their own.)

We had our first real snow and the lake is starting to freeze. Time for the studded tires. For now, I try to avoid the icy spots and ride slowly when there is no choice.

Rumor has it people have started skating on the shallow bay – the first place to freeze and attract ice fishers, who are on the ice before any sane creature.

A couple of days after that last paragraph, it warmed up; and the newspaper included a story about the number of ice rescues performed that day. None were from that bay, but skating will wait, as it has been above freezing for >24 hours.

In our culture, this season is often associated with conspicuous consumption – the TV ads encouraging us to surprise each other with new cars, telling us the only way you can show your love is via diamonds, helping us convince ourselves that joy comes from stuff. Delbert McClinton and friends tell us otherwise:

Check the sky tonight – Jupiter and Saturn will appear very close together, and just in time for the solstice. They will appear in the southwest sky shortly after sunset as long as, in your home on the range, the skies are not cloudy all day.

Photo by Jim Peacock, Bayfield WI, 12/14/2020. From EarthSky.org

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.