Allowing for the intangible...

It started off as a gloomy day. The sky was grey and the clouds weren't breaking. I was without much sleep as I woke up at 3am and couldn't fall back to sleep. It was one of those nights. By 4:30am I've had it with lying in bed awake and decided to ditch the sheets and tried to call up my friend, whom we were going to hang out on a small island daytrip anyway, to see if we should go catch the sunrise together. We did. Although there wasn't much of a sunrise to be had. A slight streak of orange hue peaked through under the layers of the uninviting clouds, among a scene of dull, uninspiring view off the lookout of Cypress. Coffee in hand, the moment was nice, but the scene was slightly disappointing. 

On to breakfast we go. My friend felt the craving for congee, so we grabbed some from the only spot open at that ungodly hour on a Sunday morning. The gloominess loomed at the Steveston Harbour over our warm soupy rice with peanuts and preserved fish and various miscellaneous pork bits and a serving of deliciously tender beef briskets and rice flour wrap. Our tummy was satisfied, but our eyes weren't so much. The clouds seem thick. It doesn't seem like it was going to break. The day destined to be one that would not quite reward our optimistic faith that the iphone weather report could be wrong (it has promised a 30% chance of shower and basically a persistently cloudy day..). 

Should we carry on with the rest of our planned day? We had initially contemplated a leisurely trip to the nearby Bowen Island. Something simple. Something close. Something that could be perfect for a Sunday, on the last official weekend of this unconventional summer. Sure, we decided. Let's go ahead and see what happens. 

Onto the ferry, it was a mixture of uncertainty and slightly upwards optimism. The day seems brighter (which, naturally, would make sense as we were indeed transitioning into the regular daytime hours from our stupidly early start of our day...). The seabreeze proved to be refreshing. If anything, the steady motion of the ferry and the shifting landscape around us brings a sense of promise. Maybe something nice awaits us on the other side. Our adventure, potentially, could still be fun. 

And with that glimpse of optimism the day slowly opened up to us. Un-docking from the ferry, we were greeted with the first few sunshine of the day. We parked our car and roamed around the pier. Ah, there's the cute little lunch place I saw on reviews, Branch and Butter.  With the sun comes a promise for ice cream later. Hey look there's kayak rental place. Again with the sun there's a promise that we could dry up if we get wet (we weren't dressed for the occasion, as both of us were in jeans and not the best kayaking attire...). My friend couldn't swim, but that didn't stop us from signing the waiver and exploring the waving coast along the nearby edges of the island. Blobbing up and down with the waves always seem to freshen up your soul a little. The gentle splashes of the paddles are always a calming influence. 

Two hours later, my butt completely soaked, we once again undocked and enjoyed some delicious tacos under the sun (and ice cream indeed). Onto the dry land we went, and explored a short nearby trail with a speculator lookout to Howe Sound. The clouds had cleared by that time. Blue skies and simmering waters as far as the eyes can see. The day was looking more and more beautiful with each passing hour. Unexpectedly, but welcomed. Now why did I ever doubted coming here in the first place? I'm glad we didn't listen to our guts.

By late afternoon, we decided the best view to soak up the rest of the day was by the west coast of the island, among the various quiet and seemingly private rocky or beachy fronts by the water. The day was ending beautifully, a far cry from the way it has promised at the start. With the stunningly peaceful sunset getting us with its warm rays complemented by the gentle cooling late summer breeze, it was a rewarding end to an unspectacular summer. Still drunken from lack of sleep, we waited until the sun had fully bid farewell, with bugs starting to chase us into our misery. We drove back, in the dark, dodging deers and squirrels and other unseen wildlife creatures. We ended the night on a starry ferry ride back to the mainland coast, even catching several glimpses of passing satellites that we pretended were shooting stars and made wishes anyways. 

 

Why did I write this? Apart from marking an unexpectedly beautiful day, it was to remind me of the many intangible factors in life, often altering the prospects of what we initially could expect from our calculations. For many of us, our intuition and intellect often drives our decision making, but our pride in such decisive thoughts can often rob us of the unexpected. The weather, for one, although highly studied and readily available (so it turned out that my app had been wrong, once again...), still manages to surprise us in good ways and bad, if we give it a chance. So sometimes, despite potentially strong feelings based on the available information at hand, life can still reward us if we give it a shot to serve us the unexpected. Allow some intangible factors into our lives, and they might promise to be rewarding. Let go, and be carried along by the waves, and see what happens on the other side.

“Be fearful when others are greedy…”

Warren Buffett once said, “be fearful when others are greedy, be greedy when others are fearful..”. (I think he said this, but cannot be sure, as it had be quoted and re-quoted so many times everywhere…)

Along the same token, is the much more commonly preached investing principle, of buying low, and selling high.

I think there is a lot we can take from these investing mindset into our current evolving precautions against COVID19.

Summer is here. Sun has finally sort of arrived. Restrictions are loosening (although some are tightening again..). People are getting outside. Activities are rising. Socializing back on. Meals with friends. Family gatherings. It’s been too long. We need this reprieve.

And yet, the virus is still here, and still we have no vaccine, or proven therapeutics (not quite there yet anyway..).

Really, nothing has changed.

Other than our mindset.

It is easy, in the midst of the optimism of summer, to let our guards down, and let loose our vigilance.

For, damn it, we needed this. It’s been too long, too taxing, too emotionally straining. And for those who unfortunately also suffered dearly in health or financial hardships, they really, really need more of this loosening of some restrictions.

Because we know that life cannot wait for the solution of COVID. Life needs to evolve to live alongside it. With it.

Yes this is the “dance” that we spoke of so much earlier in this pandemic. The long dance. With a song that seems not likely to end anytime soon.

So I think it is good for our salvation to breathe a little bit, to embrace this slight relaxation we had afforded ourselves from society’s collective difficult effort since the beginning of the crisis.

But yet, the numbers are rising.

Yesterday, I saw a remarkable number of 20-something-year-old patients, some with mild COVID-possible symptoms, some with more convincing versions of the same. They are healthy, and doing well. But that’s likely the beginning of the second wave, if there is such a distinction anyway.

In a few weeks, these healthy younglings can carry the potential virus to their dear families, and the older crowd will show up. And not long after, the even older crowd.

We must remember that everything with this virus takes baby steps in 2-3 week increments. The US has already been seeing a further rise in numbers, some in areas with patterns very suggestive of likely transmissions from their recent national holidays.

So let’s check our minds a little bit.

Just like with the stock market, what you invest in today likely isn’t going to bear fruits until years later. You carry a long term horizon with your finances. We should adapt the same with our social precautions and activities on a personal level.

In finance, it is likely unwise for one to be rushing to purchase all the latest hottest stocks (although this seems to be happening all the time..). Sure, some may carry momentum forward for some further gains, but history has shown us that would not be the sound approach. Instead, buying those that have fallen, and avoiding those that could be too hot, is much more likely to yield better returns over time.

So, likewise, it would be unwise for everyone to relax their social precautions and personal safety vigilance at the same time. Even though that is likely the easiest approach to take. It is easy, when everything looks safer around us, to actually believe that it is so.

In some way, it is precisely this time period, when everyone is coming out, starved of their social activities and all too ready to mingle, that the virus can easily mount a resurgence.

In fact, I think many of us are almost expecting it, in a few weeks time.

I do not mean for us to remain so stressed and anxious about the virus and not take in a bit of emotional reprieve. I think we just have to learn to balance that out with how we choose to live going forward. Humans are social beings. It will remain very important for us to have that available to us.

But perhaps, be a little bit fearful when others are greedy.

Maybe Buffett is good not just in investing after all.

Hope, but do not lose our heads.

I am fed up.

I am disappointed. In people. In us.

Several months into our pandemic, things have stabilized here locally of sorts. Our province had fared remarkably well. Due likely to luck, but also with a lot of good efforts by many good people.

As I mentioned previously, come summer months restrictions are being loosened, and with the threat of the virus fading slightly in our short term memories people are loosening their vigilance.

And people are no longer thinking critically.

As I posted in my facebook rant, I still have a substantial problem with people using gloves. I cringe every time I see one, walking around in the neighbourhood, or working in restaurants and serving food to us, touching multiple surfaces and used dishes with said gloves, then new food, without ever changing or sanitizing them.

They act as if they are doing due diligence. I wonder what is it that they think these dirty gloves are doing for them, and for others.

If this continues, I have no doubt we will see many more careless transmissions, brought on by these brainless servants of the glove-using “contact-less” service industry we seem to be embracing.

And the scientists, bless them for all their hard work in fighting this virus on all fronts. But please tamper your exciting over your discoveries, and do not forget the scientific process and scientific rigour of what made modern day medical science supposingly reliable and trust-worthy. This pattern of rapidly releasing medical “observations” or “findings” in press releases before giving the medical community a thorough review of your work is reckless and potentially dangerous. Indeed, there may be an ethical fine line in pushing positive data early in hope of benefiting more people. But this should be done right, such as releasing the details of your studies at least at the same time as such press releases. Having medical decision makers stand at a podium to answer questions about your work without having the benefit of scrutinizing it themselves is pointless, and misleading to the public. The public need good thoughtful information and education. The public is not a sounding board for all potential medical observations and discoveries. This is why we have a scientific review system in place. That is what defines modern day medicine.

I write this because just this week, we have biotech executives and industry leaders openly speculating that we will have an approved vaccine for COVID19 by November. I know nothing of how likely or unlikely for this to be true. But I do have heavy concerns about the process if it were indeed so.

It will be likely that the process of achieving this will be rushed, pressured, possible flawed, with potentially large oversight, or even an exaggeration of the benefits.  This is because we know this process will be heavily politically and economically motivated. And some may say, myself included, that the November election partly hinges on it.

Large amount of money and attention, as well as the hope of the world, has been put on the search of a vaccine. The world is essentially at a reluctant pause, to some degree, in waiting for it. They are ready for any such promising trend. Forces have already been mobilized and committed to mass production of any such successful candidates. It is as if they are setting the stage for a fully expected success, even though we know in medicine we have no such certainties.

There is a risk, therefore, that in order to fulfill their self-serving prophecies, that any slightest positive signal will be packaged in such a wonderful story to make sure they are able to deliver on their promise. Even if it comes with great oversights or flawed methodologies, or potential harm.

I am not trying to be a pessimist. I do hope today’s cutting edge science can surprise us in something we have not been able to achieve in decades. But I am a realist. And I know some parts of sciences simply cannot be rushed.

I look forward to any potential positive developments from the vaccine front, as well as in all other areas of the fight. But we must remember, with any new information in this COVID fight, that the filters have became very very leaky, and we must approach them with caution, and great thoughtfulness and critique.

Or we risk creating a monster whom we thought would have been a saint.

I know in desperate times everyone is clamouring for good news.

But we must not lose our heads in doing so.

Keep hoping, but keep thinking.

We get into trouble if we do one without the other.

As the world declares open season on China, be sure not to wrongly point the arrow on the Chinese PEOPLE.

There is a distinction. The state is the not people. In the midst of our growing frustrations and anger at the current state of affairs, this distinction can be easily blurred. We have to be careful where to point our fingers, if fingers are to be pointed.

As the world continues to rage war on the new virus, which, along the way, has gathered many unfortunate but often politically-driven and misguided names such as the “Chinese Virus” or the “CCP Virus”, resentment is growing in many parts of the world, including in my own backyard. Many such resentment, sadly, is increasingly placed against the Chinese people in general and, for lack of an obvious distinction, ALL Asians.

Unhappy times breeds anger and resentment. I get that.

People need to vent. They need an outlet. That I am aware.

But we all know that is not an excuse. Luckily, the majority of the good people in our country gets that. I know that for a fact, having lived here for the majority of my life and thoroughly enjoyed how multicultural, for the most part, this city and this country has been.

I am not here to talk about racism. That is the easy tag line towards any optically-racially-related incidents in our society. But tagging such a general and politically-correct label on the topic, and  touting the simple and diplomatic remark of how “racism will not be tolerated in our society”, although noble and needed reminded of, solves little.

I am here to talk about misplaced anger. And how that blurs the lines between poor judgement and racism, and how, if allowed to propagate, can tear our society apart in such a way that a simple political statement of “stopping racism” cannot repair.

For hate and anger, once brewed, only continue to grow on the inside. And even if suppressed, often become a nidus of infection, much like an indolent virus, waiting for the opportunity to resurface and boil over.

And for that, I am getting increasingly concerned about the potentially unintended consequences as politicians, especially in America, upon stabilizing their internal affairs, begin broadcasting their anger towards China, the nation. All the while, many of their avid listeners, keenly holding on to their every word, might widely interpret their messages simply, as anger towards Chinese, the people.

Sadly, for in America, while still in the midst of a raging infectious disease war, is also in the escalating stages of a raging political war. At the helm, a politically-insensitive president who is prepared to do and say whatever he needs to be re-elected. And one of his current playing cards, perhaps as part of his potentially winning hand, is to direct the suffering of the American people towards an easily identifiable target: China. He is a master of the political arena, and of the vulnerable American people’s emotions. I suspect that he is all too ready to turn his people’s despair into an emotional rally cry towards a potentially triumphant campaign. 

But sadly, it would appear, that even his opponent, Mr. Biden, whom I would have normally expected a more diplomatic approach, have equally identified this to be the correct angle to wage his political battle. For he, too, has clearly expressed his desire to unleash his diplomatic fury at the Chinese government.

So, deserving or not, in the next few months, we will be hearing a lot of strongly worded rhetorics against the Chinese nation. From both sides, among many other smaller voices.

To be clear, I, too, am angry at how this whole thing unfolded. As a front line health worker, I am perhaps at the most deserving spot of being angry at this outbreak. I also want accountability. I also want transparency.

But in the midst of all these rhetorics, I am afraid it will be the Chinese people who will suffer most.

For again, while there is a clear distinction, I am afraid that the general public will simply not be able to differentiate when we are raging a war on a government, and not instead against the people.

Very easily, therefore, if we are not careful, those very people, would become the mislabeled image of the enemy.

We can not allow that to happen.

We have to be smart in reading the messages carefully. We have to be smart in not letting their rhetorics drive our emotions. The speakers may not all be polished and crafted. Us, the listeners, will have to be held to a higher standard.

We have to remember what our values are, in our society, and of the people who helped built this society.

We have to control the outlet of our sadness, our suffering, and our anger.

Indeed, we all hate the virus. We hate the situation we are in.

But none of us, ever, should hate the people who this virus is here to infect, no matter where such infection happened.

The Covid Years. A glimmer of hope.

No, it’s not been years.

That’s a gross exaggeration. Although I’m sure to most, it may have felt like so.

It’s been approximately 2 months since our local province had declared a State of Emergency over the COVID affairs, mirroring what’s been going on in much of our “top of mind” developed worlds, give or take a few weeks.

Here, Spring is looming. April was one of the driest, sunniest months on record. We were blessed with such fortunate timing amidst our social distancing orders. With the sun comes hope. With flowers come happiness. Green leafs bring a sense of calmness. Dry pavements brings an invitation to get out and play.

Us humans have a short memory. Both a blessing and a curse. I find even myself, who stay glued to the television set for daily news of the world pandemic, slowly losing sight of the nasty images of overwhelmed hospitals and mass mortalities during some of the “televised” peaks in our worlds. My mind gradually shifted to a level of normalcy. My attention towards the new focus of reopening, of reintegration, of our society and livelihoods.

“I worry that people are going to forget about the risks…”, said my mom.

“Let them forget a little.”, I said. For the time being. Let them have some emotional relieve. Daily stern reminders to be vigilant will mean diluting the key message when we need them to listen again.

And we will need them to listen again real soon. The second wave will come. It’s just biology. Nothing has drastically changed in our fight against the virus. It is still here. It is still circulating. We are still susceptible. Many will still get sick and die.

But perhaps, something HAS changed. It isn’t all the same, is it?

In warp speed, more impressive than I have ever witnessed in medicine, is our increasing knowledge-base of the virus and its complications.

In fact, that is where I’ve heard the term “Covid Years”. In our current battle against COVID, enhanced by an unprecedented scale of international collaboration and experience-sharing via easily accessible social medial channels, one week feels like a year of progress.

The shear volume of data, of observations, of thoughts and novel ideas, have been staggering to date. Overwhelming to be sure. For many of us clinicians, passively surfing through volumes of online updates, podcasts, video conferences, have unfortunately became a favourite pastime in our non-clinical hours. Some might even call it an obsession, or addiction. For we have no sports; what else do we have to distract ourselves with other than, well, more COVID news.

But in my mind, that will became our main salvation going forward.

The light at the end of this dark tunnel isn’t going to be a proven vaccine, or a widespread availability of a successful therapeutic. Not yet. Those would take too long, and if they do come this year, would be prone to such a high degree of “bad science” that I’m not even sure if I should support that notion.

The ongoing angle to fight this battle, to gain and keep an upper hand, will come down to knowledge and preparation.

And our numbers are reflecting that success.

Locally, despite somewhat persistent case numbers, admissions rates and ICU numbers are declining.

Are we humans becoming less vulnerable to the virus? No. We are simply adapting as a population to know how to fight it better.

Perhaps one of the earliest “lessons” in this pandemic, stemming from observations in Wuhan and Italy and early New York, was a call to “intubate early” for severe cases. They crash quickly, we were told.

Suddenly, many COVID patients around the world ended up on ventilators. Just like that, hospital capacities grind to a halt. Death rates rose for those who needed but lacked an ICU bed.

On top of that, widespread worries about aerosolizing the virus into open space forced many clinicians to avoid previously useful “bridging or temporizing” methods, such as high flow oxygen, or BIPAP or CPAP, that has been invaluable in the past for other respiratory struggles. As such, even many “non-COVID” patients who might have benefited from these therapies were denied such interventions, perhaps leading to progression of their non-COVID illnesses. This might be hard to prove, but logically plausible.

But within weeks, the medical field has turned the corner. Progressive observations from NY and other hot spots described a changing of attitudes, that perhaps such “early intubations” were not, in fact, protective, or possibly even detrimental. A new observation, of many “happy hypoxic” patients, dumbfounded clinicians, as they stared at patients with numbers that should not normally be compatible with life but instead lying prone “happily” tapping on their iPhones.

Suddenly, we aren’t rushing to jam tubes down all these people’s throats “to keep them alive” anymore. From a hospital resource point of view, this would have profound positive influences.

Meanwhile, week by week, we are discovering new and unsettling complications of this virus, from unexpected thrombotic events to neurological complications to, for heaven’s sake, serious atypical inflammatory conditions in kids. These unexpected events are truly what makes this virus awful to deal with, in my opinion.

But week by week, we are pulling together as a human race to discover new insights in how to detect and counteract these complications.

As for our collective livelihood, our economy, and our social needs, our path towards reopening and reintegration will not yet be solved by a viable vaccine, but instead be guided by our improving knowledge on the determinants of prevention, identification, and separation of this virus from our society.

There, too, it will be knowledge and preparation that will enable us to get as close to, although no yet to the same level, to our previous normal.  

In popular social media circle, a lot of fuss has been made about the virus “mutating” or “evolving”.

But nobody is talking about the “evolution” of the human race. We, as a whole, integrated by modern technology which allows our collective wisdom to be shared and utilized instantly, has an edge to fight this thing. (Indeed, cloud computing and networking companies aren’t just helping us stay afloat in the stock market, they are also allowing us to keep winning in this fight).

For throughout the summer and come next fall, we are going to need all of this knowledge and preparation to keep fighting.

And for that, together with the sunshine and booming flowers, I am starting to develop a small hint of optimism, that we might just be able to pull it off, vaccine or not.

Where is the light?

As days of social distancing grows and the astonishingly abnormal patterns of our lives started to become the “new normal”, my sense of hopelessness and depression about the distance future continues to blossom.

It is no question that my mind, despite the battle we are facing and continue to brace for ahead of us, has been more bogged down by our lack of endgame, universally across our planet. I have eluted to this fact numerous times before.

Last night, in a rare “social” encounter with friends on Google’s video chat platform to celebrate a friend’s birthday (poor girl had to eat her cake by herself in front of the camera), my friends asked me whether I truly believe this would stretch into the summer.

Why the hell would it not? Do you see a breakthrough coming before then. I don’t.

The fact of the matter is, all these extensive efforts in city-wide shut down and social distancing (a necessary evil, despite the profound affect on our economy and way of lives), is purely to buy us some time. Effectively, it stretches the trajectory of the disease in the population down a line, in an effort to keep our current needs at bay. A necessary evil, but nothing to celebrate on.

Ultimately, until there is a breakthrough, nothing will have changed. Having globally infiltrated every country on the planet, there is zero chance of us getting as lucky as we did in SARS, when the disease just vanished, before any of us arrived at a long term solution.

We cannot count on such luck. Even if it goes on a hiatus during the summer, this will be back, next fall, again and again. Like the flu. But deadlier.

Of the three paths to victory: diagnostics, vaccination, and therapeutics; I see the latter two obviously too long to wait on, as there is little chance of them becoming of widespread use within a year (without us being recklessly in doing so). Diagnostic holds the most promise to reality in our current year, but even then, I have yet to see something promising on the horizon. What we need, is something as cheap and simple, and as sensitive and timely, as a test like a home pregnancy test. But it cannot be antibody based, because the we still miss the window period of the infection. There lies the technical challenge. Currently, the most sensitive tests requires PCR machines to amply the RNA of the virus, dependent on a good acquisition of the sample (a step that is prone to failure, thereby drastically limiting the sensitivity of such test, a measure of utmost importance in a screening assay). To me, that is the closest thing I can think of in order to drastically gain an upper hand on this battle. Something that is cheap and foolproof enough that can be used in all parts of the globe, including the slumps of India, and the favelas of Brazil.

Short of such a breakthrough, all we can do is social distance, and continue to erode our lives.

Realistically, I gave our society one to two months maximum, before message fatigue kicks in, and people, despite their good conscience, starts breaking the rules even if they remain in place. Policies makers know this too, I believe, and will strategically loosen their measures, only to allow some slack so they can tighten them again in the next cycle.

So summer we should be looking at a relaxation of the measures, if only by necessity, for our salvation, and to allow the economy a needed dose of relieve.

Come next fall, I told my friends, I don’t see us being a very different position globally. The virus will likely still be with us. We will likely still be afraid. And measures will likely still have to take place.

But likely, we will know much more about this virus, and how to track it, and how to handle the infected. That would allow us to implement less stringent policies, and use better diagnostic tests and tracking measures, to maintain a tighter but much more accepted way of life as we enter into next flu season. Hospital capacities will have evolved, based on the vast adjustments and improvements we are currently doing, and together with our increased understanding of management and therapeutics, would be in a much better position to handle a surge.

As for myself as a health care provide, that is where the light stops burning. We will still be on the front line. We will still be at high risk of exposure. We will still need a massive load of PPE to do our daily clinical duties. And unless we all acquire immunity through our work, assuming that such immunity is effective and lasting, we will still be afraid to see our families.

For the masses, it is likely that life will be “a little more” normal after the next few months, with an asterix. For the rest of us, we will continue to run this marathon.

Until a breakthrough is found.

Fearful brainstorming.

There’s been a lot of gratitude lately towards us front line health workers.

I don’t quite feel like we deserve it.

Not yet, anyway.

With all the social distancing measures and the mass panic over the coronavirus, people have now became scared silly to even get near the ER. In a way, it goes to show how many “unnecessary ER visits” there were in the past. But some of us do fear that people aren’t coming when they should come, and when they do, they may be gravely ill. It’s all a fine balance. But for the time being, we will take the “calm before the storm”.

And since none of us are used to any sort of calm at work, it feels, somewhat, undeserved.

Especially when you see footages of the hardest hit places, and what our colleagues go through there.

But then I realize, maybe we do deserve some of this gratitude. For being here, for standing guard, for treating those who come, and for risking ourselves at the front line of this long battle.

Just yesterday, I realized that one of my most believed teacher at my old teaching hospital ER, fell ill from the COVID virus. Thankfully, it seems he should do okay. But the news almost brought tears to my eyes. In fact, I think it did a little.

Much of our struggle at the current stage is mental. I’m sure it’s on all my colleagues minds when they come to work, and when they go home to their family (those who don’t have the option of staying away for months, as I am doing). We know we are high risk in contracting it. We know not all “healthy young people” would do well routinely. I myself have mild asthma, so I do have some worries. We do the best we can, donning personal protection equipment. But every time you put on the equipment, it is a reminder of the risk that you are taking. And for that, yes perhaps the gratitude is deserved.

We are also frantically using this time to plan ahead. We have the benefit of seeing what other places go through when a surge hits. We have, fortunately, appeared to have acted in time to allow ourselves to try to prevent that same surge, while at the same time plan meticulously for it.

My department is smaller compared to some of the others in the city, meaning that we have less resources, and less physical space, to handle a surge of respiratory patients. We also have less staffing, should any number of us take a hit and have to be off work for weeks, to be able to absorb such blow. That bit really worries me.

And that is one of the biggest challenge of this outbreak, as I explain to my friends. Hospitals and ERs are not built for this. We have limited space, and limited staff, on good days. We cluster patients routinely, and we do not have the physical infrastructure to allow proper “social distancing” of our patients when they all come at the same time. My department has one negative pressure room. Upstairs, our ICU has 8 beds. They are always full.

There is also lots of planning from the personle side. We know this is essentially an ICU disease. So that means, the ER docs, the ICU docs, and all the nurses, have to have a game plan to all work seamlessly together. We’ve also spent a lot of time working out the kinks in our team-oriented attack, involving as well our anesthesiologists, as they are the usual del facto airway experts. When you bring a lot of bright people together, all capable of doing things their own way, you need to make a lot of rules so that we are all, when the chaos hits, doing things the SAME way.

So that’s what the last couple of weeks has been like. All of us, brainstorming and discussing and planning, on how we can literally transform our department on the spot to account for these expected needs. My best friend in the department, another Dr. T, has been taking this task to heart, and spent weeks mulling over options and physical space limitations and led the charge on this endeavour. I offered my usual critical eye and the occasional idea. Piece by piece, we are transforming our ED, for something that hopefully we would never need the full extend of.

Lots of anticipation. Lots of planning. Lots of fear. Lots of hoping.

And in all likelihood, this will be the new normal, for months to come, if we are lucky.

If not, for years.

For as stated in my last post, I am not aware that we have arrived at any endgame yet.

And so, the stalling tactics continues.

What is our Endgame?

What is our endgame?

I feel like we are not fighting in the right area. Or at least not talking too much about it, in addition to everything else.

It’s been over a week since the world’s sports stage has shut down. It was a turning point for global sentiment, in my opinion. Until then, the world sees this as “other people’s problem”. I was shocked to see thousands of fans still filling packed stadiums to cheer loudly for their favourite pastime. Don’t get me wrong. I NEED sports. Background hockey games is the only thing that fills the air in my empty condo when I’m home. The void created by the lack of sports is eerie. But it was a wake up call. And hopefully it came in time, although I’m sure already a little late.

Worldwide, everything is being shut down. The earth, at least in the parts that dominates our headspace, is closed. This is perhaps the single biggest event most of us will ever see in our lifetime. I sincerely hope it is. Social distancing is the number catch phase on planet earth. Flatten the curve closely second. But all this is to buy us time. Time for what? What is our endgame?

We know we cannot fight this by social distance. And I do not believe as a globe we have the stamina to social distance for 1-2 years, which is probably the least amount of time required for a widespread vaccine to be rolled out even if a successful candidate were to be identified TODAY. Same for therapeutic treatment. We cannot wait for those, it would take too long.

I think the real fight needs to be in diagnostics and isolation. Currently, suspected cases have to be swabbed by a provider, and the swabs takes anywhere to hours (in other parts of the world) to up to 7 days here in Canada in the past week. Plus there’s a high risk of false negative. Furthermore, lack of supplies and inability to keep up with the pace of testing is forcing us to shut down widespread screening programs, thus essentially shoving our heads in the sand and making all of us fly blind for the next few weeks as we head into the heat of the battle.

As vaccines and therapies are likely months and years away, our only chance to end this might be to efficiently identify those transmitting disease, treat them while isolating effectively, then let the virus starve off, globally. Everything hinges on effective, cheap, rapid turn-around, and hopefully point of care testing.

I don’t feel that there’s enough international discussion and collaboration on this front. I started the discussion in our Canada physician facebook’s COVID19 focused group, and seems we are reliant on scattered companies and individuals around the world to make this happen. We need to bring them together (conceptually, online of course) to create something that can change the way we fight this battle.

The beginning.

It looked like a war zone.

That was my first impression, when I walked in for my night shift. Not so much patients, they seem the expected amount for the night. But the setup. Make-shift dividers turning hallways into “spaced out assessment areas” as our ER’s best effort to keep anyone with respiratory symptoms separate from each other. The so-called “social distancing” phenomenon. It’s a compromise, of course. Physically our department only has one negative pressure room, and another so called “decontamination” room which I’m not sure what criteria qualified for the title. It’s likely still early in the Pandemic in our city. Globally sports leagues just cancelled their seasons. Sending a final wake up blow to the causal observers who up until that point had view this as a “China virus”, or just something from afar, or something that’s purely associated with travel. It is not. It is here. Likely circulating undetected for weeks to months. I welcome the shock wave to bring some senses to all people and all levels of government. I’ve seen efforts being stepped up to prepare. Too late, in my opinion, and not enough. Widespread recommendations that sounds nice on paper but likely written by people who has no clue how feasible it would be to carry out, especially at smaller sites like ours. So, the call was to attempt to isolate anyone who presents with respiratory symptoms. Impossible. So this military looking department is what we came up with at the very moment until the next, better idea.

These are stressful times indeed. I haven’t seen my parents in weeks, and actually didn’t even meet my brother who flew in to pick up his two daughters who had stayed in town longer due to the school closures in Hong Kong. I debated a lot over that decision. To my 4 year old niece, and to some extend my 9 year old one, this would seem harsh and suggest disinterest on my part to be with them. It is not. But being at the high risk position that I am, as front line medical staff, and with the elusive but highly contagious nature of this thing, I couldn’t risk it. I fear I am looking at many more weeks to possibly months of staying away from my parents in person. Thank goodness for FaceTime.

People are stressed at work too, as you can imagine. Which is ironic, because stress decreases our immune system, making us all more susceptible to fall ill. And that is what I am most fearful of. The incapacity of our health care system, and in particularly, our doctor group, with withstand anyone missing any work for any duration of time.

I’ve personally be recovered from a cold, which I’m quite over by now, but some persistent sinusitis symptoms and slight stirring of my post viral asthma kept me self-conscious with an occasional cough. I don’t believe I’ve been exposed yet to any positive Covid 19 patient, but of course one can never be sure. I’ve swabbed many, and fortunately all so far came back negative and most were consistent with the flu. I’ve always kept a mask on and almost never touches a patient without a pair of gloves. But what troubled me, and it’s something that’s plagued me for some time now in this profession, is the inability to “call in sick”.

My friends would ask, shockingly, “you can’t call in sick??”

My reply, usually, unimpressed, was that “well who’s going to replace me?”

Few other profession has this concept, I find. Most people have sick days, or even if they don’t, they lose earnings, but they just don’t show up. In the era of heightened awareness of communicable diseases, that is commendable. It should be encouraged. It should be the norm.

But doctors, particular smaller groups like those of us in our ER department, has never had the luxury of that. To miss a shift, we have to find our replacement. That you cannot obviously just find ANY replacement, because only those within your group are qualified to work on behalf of you. So, you only chance is to draw from your existing pool of colleagues, most are already overworked, stressed, or just unable to help because of their own scheduling obligations. It is a very unsettling feel. Knowing that no one is ever really there to save you. For such an intensely demanding job, when really you should always be top of your game, this is extremely ironic. If you need to miss a shift, you post it on your group’s schedule calendar, and hope that someone can do it. Very often, if given enough time, that does happen, thanks to my beautiful colleagues. But most of us who fall ill need to cancel in the last minute. And that, unfortunately, does not happen.

At the time of writing, I’ve just came off a night shift and is due for another one tonight, and I’ve posted these two shifts in hope that someone would relieve me so I can continue to nurse my asthmatic cough in peace. I don’t expect myself to be relieved.

I hope this virus change that culture. We have to have a new systems. For far too long, doctors come out of this difficult and harsh medical school journey and feel an obligation to be “toughened” enough to motor through most adversities. The very notion that “doctors get sick too” has actually gotten some interesting following on social media as if this is someone a foreign concept. But as we preach for the masses to no longer try to “be a hero and work through your sickness”, we should create ways to adhere to such similar advice. It is not yet possible, due to the way the employment structure is set up. But if there is anything this viral outbreak has taught us, is that there are lots of ways we are going to have to change in how we live. We have been too relaxed for too long. We should have seen this coming, and we did not prepare adequately for it.