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.