March 24, 2020

Welcome to the 8th edition of Andy’s plague diaries. I have no idea how many there are going to be before it’s all over. I’m just going to trust that it remains in double digits. I remain healthy. My social isolation/soft quarantine to work and home only continues and trepidation mounts as Birmingham alternates between thunder storm and warm and steamy. It’s as if it were late May already. The weeds in the garden are having a field day but it’s been too wet to go out and do anything about them. Maybe it will dry off some by the weekend. My yard people are still showing up but I have told them if they need to be off to take care of kids out of school, it’s OK. Same with my housekeeper. And I am continuing to pay them both. I’m not that guy…

The first lappings of the tsunami of Covid 19 are starting to hit the foundations of UAB. On Friday, there were three cases in the hospital. Today there are 45 with more coming in. If the social distancing and other measures that have been put in place locally are effective we should start to see a leveling off in another week or so. What’s happening today reflects the social behaviors of roughly two weeks ago, just as it was recognized that the virus was here and starting to spread in the community. The city of Birmingham and Jefferson County have been fairly proactive. The state has not. What I fear most locally is that the exurbs and rural areas, filled with people who get all of their news from ‘conservative’ media outlets, have no idea what’s waiting for them and when things get rough they’ll turn to the Birmingham medical system for help. Alabama, for political reasons, did not take the Medicaid expansion offered by the PPACA and over the last decade, a number of rural hospitals have closed and services outside the urban cores are tight, at best. I’m already starting to hear stories that the emergency departments in the rural hospitals are starting to look like war zones and will soon be overrun.

I cannot save the world nor can I save people from the macro forces of politics and economics. I learned that lesson a long time ago. All I can do is work as best I can to try and protect my patient population in any way I know how. My whole career has been about saving one person, the one in front of me, at a time. That’s all I’ve ever been able to do. At the moment, that’s been through shifting most of our work to telephonic in order to keep people with the chronic disease burdens of age away from a hospital or clinic building where the acutely ill will also be. It’s working so far and we can temporize in this way for a month or so, but eventually we’re going to have to work out a way to see and examine people safely. We have some ideas, but one major set of problems at a time. It’s a good thing I’m relatively creative and used to thinking outside of the box at moments like this.

I asked at the end of the last entry for people to send me ideas for things to tackle as I write. One friend asked me to talk about how to deal with the very frail and demented elders in this current situation. Many of them live in senior living and the managers of such institutions, have quite rightly locked the buildings down to keep traffic in and out to a minimum to try to keep the virus from spreading within their vulnerable populations. When such measures are not taken, you get what happened at Lifecare of Kirkland, outside of Seattle, which rapidly became one of the ground zero centers of the outbreak. The approach to ones elders depends on their cognition. Those over the age of 80 or so who are relatively intact are going to have living memories of the Depression and World War II period and will have an innate understanding of what bad is and the kinds of rapid changes a society must sometimes undergo in order to protect itself. My father is 87, born in the depths of the Depression and World War II was the background of his childhood. Germany invaded Poland when he was six, Pearl Harbor was the week of his ninth birthday, and the war ended when he was twelve. He’s quite philosophical about where things are. He’s a bit bored being stuck in his apartment in his senior living facility in Seattle as he’s a naturally gregarious sort but he gets it. His generation has a few things to teach us all about surviving bad times. Ask and listen. (And I’m sure he’ll chime in in the comments if he feels the urge).

If you have a cognitively intact parent or grandparent stuck in senior living, call them. Get them to tell you stories of their lives. The role of the elder is the role of the storyteller and the keeper of collective wisdom – let them pass it on. If they have problems hearing, try FaceTime or Skype. If they don’t have a smartphone, see if one of the staff will lend his or her phone for a conversation. Many older people don’t do well on the phone because they need the visual cues from the shape of the face for the brain to process language correctly and video chat can really help. Working with the cognitively impaired is harder. They can’t process all of the rapid changes happening around us. All they will know is that spouses or children have suddenly stopped visiting. Their realities and brains are different than ours and they don’t have to be made to inhabit a world they don’t understand. If you’re talking to them on the phone, ask them to explain what’s going on. Their brains will create a narrative that makes sense to them, even if it’s far from reality. It’s OK to go with it. It’s OK to tell white lies. It’s OK to shine them on and change the subject. The best thing to do if they start perseverating and getting repetitive is to get a different brain pattern going, king of like pushing the needle on a stuck record (a metaphor that’s going to go right over the heads of everyone under thirty five). If they have a snack nearby, tell them to eat it (taste bud stimulation). Have them turn on the TV (visual stimulation). Start singing something or reciting a familiar hymn or childhood poem – lyric and song are stored differently in the brain and can sometimes push people into a new pattern quickly.

I’ve seen some heartwarming and heartwrenching displays of love around these lockdowns. Spouses of decades visiting by coming up to the window of a room. Children singing in the garden to their great grandmother. Just don’t forget your friends and family members, just as frightened as you, just as unable to move freely as you, but with a much bigger concern regarding mortality than you likely have.

As for the suggestions of the lieutenant governor of Texas that were published yesterday, I have a modest proposal for him…