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.

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.