March 28, 2020

Another Saturday night and I ain’t got nobody. Must be time for the next entry in Andy’s plague diaries. I’ve eaten my gumbo and now I’m finishing up a glass of red wine and eating some cookies that Tommy baked for our last holiday open house together that I found at the back of the freezer. We actually were a tag team in the kitchen when it came to holiday baking. He made the dough; we portioned them out together onto the baking sheets and then I was responsible for rotating them through the oven and getting them out onto the cooling racks. After fifteen of those parties over the years, we had it down to a science and were able to do most of the baking in one long evening, with some favorite music on the stereo and each of us with a glass of wine. Neither of us could foresee that some of those last batches would help sustain me through a viral pandemic after his untimely death. Life’s funny sometimes.

It’s the weekend. I don’t have much in the way of work to do. The few little projects that were left over from the week were completed this morning without difficulty and then I cleaned out all the cabinets in the dining room and felt very accomplished. Most of the first floor has been dejunked and is ready for packing with the exception of the kitchen. A lot of that won’t go. I don’t have the talent to cook for 100 at a time so I don’t see the sense of holding on to huge amounts of cookware. I can cook – I was the cook for me and Steve, but I’ve never been terribly interested in cooking for one. Maybe once I get moved I’ll have a dinner party or two but I doubt I’ll have any of the huge soirees that Tommy and I used to throw.

The number of Covid 19 cases continues to climb, both locally and nationally. We seem to be weathering the surge locally OK from what I can tell. Perhaps the relatively early closing down of things locally is starting to pay some dividends. Fingers crossed and all that. We should know by the middle of April if local health systems will do OK or will be buckling at the strain. I think Birmingham will be OK. I am afraid the combination of poverty and ignorance in more rural parts of the state may lead to some serious issues outside of the urban core.

Today, I’ve been thinking about what comes after. Eventually, even this will pass and we’ll all come out of our isolation and have to confront a lot of changes in our lives: social, political, economic. I read somewhere about the choices that one can make after upheaval. Imagine two tribes on opposite sides of the river after some great calamity. The first tribe, being strong individualists, adopts an every person for his or her self mode of survival with each member trying to hoard as many resources as possible. The second tribe, being more cooperative, come together and share resources and skills to reinforce the group as a whole. Which tribe is likely to position themselves for long term success? I think most of us would agree that the second is more likely to win over time. We have to start laying the ground work of that cooperation and sharing now so we can hit the ground running when society begins to resume.

I threw out an idea today to the local theater community. Once upon a time, there was an uber organization, the Birmingham Area Theater Alliance (BATA) that all the companies supported and which acted as an umbrella. It became nonfunctional in the decline of local theater after 2010 when the 2008-9 crash drove a lot of companies out of business. My thought was that this organization needs to be revived to create a mechanism of cooperation and communication between all the local companies that are likely to emerge from this time in dire financial shape. If everyone hares off in their own direction after funding and resources, things aren’t likely to go well. If there is a large and strong lobbying organization on the behalf of everyone, there’s a greater chance for survival. I am not putting myself forward as organizer or any other such thing. I don’t have the time or energy. But I wanted to get the idea out there because the time to start figuring such things out is now. Not after shelter in place and quarantine orders are lifted.

A lot of people I’ve been talking to have been complaining of excess fatigue and needing a lot of naps, even though they haven’t been doing all that much. There’s a basic biologic reason for that. We’re all marinating in a high stress/high anxiety environment and our sympathetic nervous systems are working overtime getting us ready for fight or flight. However, the current situation is not conducive to fighting (how do you punch out a virus?) or fleeing (where you gonna run? where you gonna hide?). Therefore, it’s switching over to the only other alternative – play dead. We all have to remember, we’ve all got that little lizard brain ticking away deep inside our cerebra and no matter how intelligent or witty we may be, it still holds sway in a very primitive fashion.

I’ve been falling down rabbit holes of reading about new antivirals, large numbers of cell service cancellations in China that belie their official numbers, the conditions of hospitals in NYC, trying to separate wheat from chaff and add to my knowledge base and armamentarium so when I get calls from patients this next week, I can sound somewhat authoritative and reassuring. I may not be able to visit with them face to face easily at the moment, but I remain their doctor and will continue to fight for anything they may need to be as healthy and functional as possible. It’s been my calling for decades now and I’m not backing out.

Stay well.

March 26, 2020

Seattle’s Burke-Gilman Trail

And it’s time for number nine in Andy’s continuing saga of life in the time of the Corona Virus. For some reason, I’m hearing Revolution #9 from the White Album in the back of my mind as I’m writing this. For my younger readers, ask your parents… Maybe that was some sort of foreknowledge of events fifty plus years in the future. But enough with the Beatles references, time to plunge into thoughts of today.

The weather has been glorious the last few days so, after work, I have been taking some lengthy walks. My pedometer is happy and glowing green at my number of steps. I like walking. One of my thoughts about the new condo, assuming I ever get to move into it, is that it’s within walking distance of work and more days than not, I can leave the car at home. When I was in medical school, my apartment was about a mile away from campus and a straight shot on the Burke-Gilman trail so I would walk back and forth to class most days and it gave me about half an hour each way to totally clear my head and think about nothing. It was one of the things that helped me make it through medical school. Being a true Seattlite, rain never stopped me, but I did get a bit grumpy during my surgery rotation when I had to leave the house by 4 am to be in time to preround. I have a coffee cup somewhere that says ‘Not a morning person doesn’t even begin to cover it’. The hours were not the only issue on which surgeons and I did not see eye to eye.

I feel slightly like I’m in a state of suspended animation. The reality of the situation with the Covid virus still seems somewhat dreamlike in quality. Because I do not do inpatient work, I have not yet had to come face to face with it in any appreciable way. I know I will have to shortly. My aggressive social distancing is all about keeping myself healthy as a reserve unit so I can spell my colleagues in the hospital later. I hear stories through the usual channels. I have friends who have been diagnosed. I see the mounting statistics. I know what the numbers are for UAB and the Birmingham VA as part of briefings for the medical staff. Health professionals in this country, especially in smaller specialties like mine, are a tight knit group. We all have friends and colleagues all over the country who are telling us exactly what’s going on in New York, Los Angeles, New Orleans, Atlanta and so all of us are taking all of this very seriously, no matter our political leanings. The anger from colleagues at politicians who continue to downplay what we are facing and who do not take the tools we have to fight pandemic illness such as quarantine and social distancing seriously is palpable. We all know that many of us are going to get sick and some of us are going to die because of catastrophic societal and political failures far outside of our control and we want those sacrifices to have some sort of meaning beyond partisan tit for tat. The poem ‘In Flanders Fields’ keeps running through my mind.

A lot of you have reached out to me since I began writing these essays, wondering if I’m doing OK. I’m fine. I’m healthy, I have resources and my life experiences which include a lifetime in geriatric health care, two widowhoods, and surviving a previous viral pandemic have given me a strong and resilient psychic armor which allows me to deal with most crises with a certain level of equanimity. I’m also keenly aware of my own mortality and have been spending the last year or so putting life in order so if I should die prematurely, my family won’t have a huge mess to try and clean up. The last piece of the puzzle was the condo downsizing and I find it very inconsiderate of Covid 19 not to have held off for a few more months while that was finished up. I do appreciate the calls and the texts and such, especially in the evenings which are suddenly empty without rehearsals and performances and nights out to dinner with friends.

The Dance of Death on the old wooden bridge in Lucerne

I would much rather be writing another travel diary or something inoffensive about some silly societal trend but Covid 19 is what we are facing now. It’s real. It affects every one of us. No one is immune. The virus doesn’t care where you live, how much money you have, what your politics are, where you go to church, or what color your skin is. I was talking with a friend on the phone last night about the plague bridge in Lucerne and the moral of those paintings. Death and disease are implacable, cannot be reasoned with, and have no interest in human concerns. If you ever wanted to know what it was like to live in 14th century Europe, you’re finding out. I reread The Masque of the Red Death earlier this week. It’s a short story and easily finished up in half an hour. The wealthy and well connected, busy fleeing to Vail, Nantucket, The Hamptons, and other enclaves seem to be trying to recreate it. I haven’t read Camus’ The Plague yet but I think I ought to.

I posted a Washington Post article yesterday about decisions regarding DNR orders in the time of Covid 19. The article got some of its facts wrong when reporting on discussions at Northwestern in Chicago. While the article stated a blanket DNR order for Covid sufferers was on the table, this is in error. What is on the table, is an automatic DNR for those with Covid whose course suggests no hope of recovery and that those who wish to be resuscitated and have the possibility of surviving it will be coded, but only if staff have appropriate PPE on to prevent them from getting infected by blood and body fluids during the procedure. There’s a lot of misunderstanding about CPR and what it can and cannot do. It’s a medical procedure,like any other, although it can be administered by trained laypeople in the community. It was originally invented by the Norwegians to help fishermen who fell off boats in the North Sea and had cold water drownings in sub freezing ocean waters. In these young, healthy men with profound hypothermia as well as cardiac arrest, it was somewhat successful and it simply spread from this very specific use to general use in any sort of cardiac arrest.

Chance of survival by age – cardiac arrest

Currently, if you have sudden cardiac arrest outside of the hospital and you are found down and CPR is started, your chance of survival to leave the hospital is about 4%. If your arrest is witnessed and CPR is started right away, your chances double to about 10% (which is why we train the population. It does make a difference). if a defibrillator is available, and is applied within a couple of minutes, the chances go way up to about 35% which is why defibrillators are now so widespread. If you are in the hospital and arrest with trained medical personnel nearby, your chance of surviving a code blue is about 10% if you’re under 60 (even with the presence of a defibrillator – it’s so much lower because the population arresting in hospitals is so much sicker). It’s about 7% between 60-80 and it’s under 3% if you’re over 80. That’s surviving the procedure. Surviving and returning to baseline health is much, much lower. It doesn’t work anywhere near what the public, raised on a steady diet of television medical dramas, believes. Health care providers know this which is why most of them once they turn sixty or so make their advance directives DNR (Do not resuscitate).

We’re not very honest about death in our society. That’s particularly true of the Baby Boom generation who have spent decades declaring themselves forever young and immortal. Most of the Boom is now over sixty and in a few years, the elder boomers are going to be in their eighties. That’s just the way time works. This is one of the themes of the book I’ve been working on. Going to have to put it on hold until we see just what sort of an effect Corona Virus is going to have on the Boom physically and generationally in regards to their self perceptions. I get death. I’ve seen too much of it over the years. All the gay men of my generation did. And, when the acute phase of that pandemic was over, we came back stronger than ever and much more integrated into society. Here’s hoping that all of our experience with Corona Virus end up with some positive results on the other side. I’m optimistic about the human race. I think it will. I think we’re going to reprioritize what’s actually important in life and that those new priorities are going to launch a new creativity and a new worldview that we, with our inside the box ways of thinking, can’t yet imagine.

Stay well.

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…

March 22, 2020

Avondale Park Villa, around the corner from me

I went for a five mile walk today. It was lovely weather for such. Cloudy, a hint of mist in the air, cool without being cold. The relatively mild and wet winter we’ve had means that the pastel season is in full swing – fresh spring green leaves on the trees, azaleas, forsythia, and red buds in bloom. The daffodils, grape hyacinths, violets, spiderwort are all coming up in profusion. There was also a lot more bird song than I’m used to. I don’t know if that’s due to more birds in the trees, a reduction in ambient noise as we all stay in, or if I, in the current situation, am just more conscious of the simple things. I’ve always been a big walker – from childhood on, and it’s one of the things I can still enjoy in my semi-isolationist state. Just have to be careful to to touch things like park benches.

It’s been an uneventful weekend and today is day eleven of work then home – lather, rinse, repeat and cut all other activities out in an attempt to stay healthy until such time as I am really needed by the medical system. I’m apprehensive, but not particularly worried about myself. I’m far more worried about patients, friends, family. Assuming I don’t get sick and die (small, but real chance), I’ll come through all of this all right but the early retirement with lots of travel is unlikely to happen the way I was planning. Those who enjoy my travel diaries may have to wait for a while. I did get in one piece of theatrical fun: The Politically Incorrect Cabaret has made a PSA about staying home and I provided the tag at the end (they could shoot it from my front lawn without my having to get close to anyone.) It’s due out this evening and I’ll post it when I have it. It’s kind of fun slipping into the Ansager, even for a couple of minutes but I can’t do the makeup anywhere near as well as Tommy could and it’s really hard to do when you’re getting blind as a bat without glasses.

I talked to my father this afternoon. He was very interested in the concept of ‘flattening the curve’ and just what did I think of that. He has, quite rightly, noticed that the area under the two curves in the standard diagram that is being shared around is roughly the same (meaning the same number of people become ill in both trajectories) and that the flatter curve means that the disease is present over a longer period of time. This led to a discussion of lies, damned lies and statistics. I had two take home points for him: First, the flatter curve may last longer but is less likely to overwhelm the medical system meaning that those who can be saved will have the resources to save them. Plus, all the usual medical issues we cope with are going to happen whether Covid 19 is here or not and, if the system is swamped, there’s no way to care for them leading to excess all cause mortality. Therefore, the flatter the curve, the better, at least as far as my brothers and sisters in health care are concerned. The second is that those curves suppose normal distribution and, with a new disease process, it’s impossible to say if that will hold up or not. There are a whole lot of variables, mainly unknown.

If you have any of these, take them to the closest hospital – STAT

The people I am most worried about at the moment are the health care providers. The health system, with its just in time ordering mantra and financial disincentives against stockpiling is incredibly low on protective equipment and, as most of these products come from outside the US, N-95 masks, gloves, clean protective gowns and the like are in short supply. Within days, they are going to be sent in to care for the ill without the necessary protective gear and they will catch it and fall ill and some will die, completely unnecessarily and on the altar of short term profit for the owners of the system. It’s the moral equivalent of the World War I commanders ordering the young men of Europe out of the trenches and into charges against machine gun emplacements. It makes me incredibly angry and incredibly sad to know I will soon be hearing about the deaths of cherished colleagues, done in by the complete political and economic failure of the system that should have been there to protect them.

It’s back to work in the morning. No clue what the day will bring. Two weeks ago, there were no cases in Alabama, I had just finished successful performances of the Mozart Requiem and was looking forward to opera staging rehearsals. A lot has changed. A lot more is going to change. Where do we end up? I just don’t know. Looking at the history of various disasters, usually societies end up transforming themselves for the better after something cataclysmic. Perhaps this is nature’s way of reminding us not to get too fossilized in our thinking or institutions.
I’ll continue writing every other day or so. If you have something you want me to address in these plague diaries, drop me a note and let me know.

March 20, 2020

Waterhouse – The Decameron

In a different life, I’d be on stage, roughly half way through the opening night of Massenet’s Cendrillion at Samford University’s Wright Center. But a burgeoning viral pandemic had other ideas and that process came to a crashing and premature halt about ten days ago. I’ve now spent more than a week either at work or sequestered away from the world in hopes that I don’t get infected with Covid 19 at a time when I might either become a disease vector for the frail elders for whom I care, or may have to serve as part of a reserve unit for the hospital doctors that are more than likely to fall ill from their front line duties. Those of us who normally do ambulatory care are transferring the majority of our work to telephonic, trying to minimize our contact with others, and stay healthy for the time we will be needed.

When I began these long posts at the time of a tragedy of a more personal nature, I had no idea I was going to end up as some sort of 21st century plague diarist. While I think I write rather well, I have nothing on Boccaccio or on Camus (although his plague was fictitious in nature). I tend to use more words than are needed and my syntax is sometimes arcane, at best. But these essays are essentially brain dumps written in a single pass without rewriting other than to fix glaring spelling mistakes and not massaged and edited into something that they are not. Like the rest of the world, I’ve had a lot of my assumptions about life come crashing down around me in the last few weeks. I feel relatively optimistic about the ultimate outcome (history shows we tend to do rather well after a major crisis passes), I am quite concerned about the more short term issues of how we hold our institutions together under incredible strain, especially in this country when half the country seems to be living in one reality and the other half in another.

Alabama entered the triple digits of diagnosed cases today (that’s up from single digits last weekend) and they’re starting to turn up at the hospitals A lot of planning by a whole lot of very bright people has happened over the last two weeks so we should weather the initial surge well. The biggest immediate issue is shortages of PPE (personal protective equipment) for the front line doctors, nurses, techs, respiratory therapists etc. who are going to be exposed over and over again. Our societal decision to treat health care as an industry like any other (one which manufactures patient/provider ‘encounters’) had led to a business model where you keep no excess inventory and order ‘just in time’ so you don’t have to pay to store, discard outdated supplies, or staff unneeded hospital beds. The side effect of this, of course, is that when there’s an instantaneous nationwide demand, it’s not possible to ramp up quickly. The beds don’t exist. The supply chain buckles. There’s a shortage of trained staff. Some of my craftier friends who sew have already started on making cloth masks to donate when the stocks are depleted. It’s better than nothing.

The local authorities have gotten more serious as the week has gone on. We’re not on full lockdown but most shops are closed. All food establishments are carry out only. Gatherings of more than ten people are strongly discouraged. I have a couple of friends working as grocery clerks who are just about to call it quits on the human race as they try to deal with panic buying. Fortunately, my local Piggly Wiggly has been sane and relatively well stocked. For those of my friends who have suddenly found themselves unemployed, most groceries are hiring. Not the most glamorous of jobs but essential and likely to provide steady employment for the duration. I personally shouldn’t need to go to the store for about a week. I’m pretty well stocked and, as one person, I don’t eat that much. I did have a major score today when I found a liter jug of hand sanitizer in Tommy’s wig studio, so now I’m stocked up on that.

I’ve been looking at the differences between Western and Asian societies and their approach to containment. China has nearly stamped it’s original epidemic out. South Korea’s is beginning to come under control. It never really took off in most of the other Asian countries despite early transmission through travel routes. Meanwhile, we and Western Europe continue to rocket along. I think at least part of this comes from a fundamental difference in our conceptions of who we are. Western thought, starting in the post Renaissance period with Cartesian dualism and then expanded by the Enlightenment thinkers, places all emphasis on the self. I am who I am, you are who you are. We are individualists at heart. We will come together for the common good, but we do it as individuals. Many Asian cultures, which developed without those changes in philosophy still use the community, the tribe, the family as the unit of existence rather than the individual. If one conceives of oneself as being a part of a larger collective, collective action for the good of the larger group is easier. I think they understood the need for individual behavior change in a deeper and more logical way than we can with our ‘no one can tell me what to do’ ethos. I hate making these kinds of generalizations because I’m always afraid I’ll end up stereotyping people and if I’ve offended anyone, it’s unintentional, it’s just me trying to process big ideas in inadequate words.

I figure our next big hot spot will be Florida, thanks to young people refusing to give up the beach and crowded theme parks that were relatively late to close. It takes about two weeks from the introduction of the virus in an area for the rate of cases to become majorly noticeable so I’m thinking next weekend should see a surge in the sunshine state. I saw an interesting article earlier today on the manufacturers of a smart Bluetooth thermometer that can upload your temperature to your home computer or to a hospital information system. Apparently, all those temperature readings, stripped of any identifying data, go to a central data bank and the company can look for trends. They usually see a hot spot of increased temps a couple of days before a flu or other viral outbreak and are better at predicting where flu is circulating than the CDC – another use of big data systems. According to this report, Florida is starting to light up like crazy, far more than most of the rest of the country.

I wonder what Steve or Tommy would have made of all this. Steve would likely have alternated between mild hysteria and laughing over YouTube videos of middle america emulating WWF smackdown in the toilet paper aisle. Tommy would have been miffed at the shutting down of the music and theater world, and then gotten out some new music to learn, gone to work in the garden, and gotten out the sewing machine and a mask pattern and gotten to work, all the while with a big ‘I told you so’ on his lips. Tommy had a keen eye for the fissures and fallacies of American society and was very much a realist about the rot at the top. If Tommy were still alive, we’d be arguing about the politics of it all, but after that was done, we’d still love each other and head off to bed to watch Star Trek with a bowl of ice cream. That’s the hardest thing at the moment for me. Just having to be on soft lockdown by myself. I’d go stir crazy if it wasn’t for the age of social media which allow me to feel somewhat connected to my communities.

I’ll try to keep this up roughly every other day and post interesting or informative news pieces in between. If anyone has a topic they’d like me to ruminate on, feel free to let me know. Going to have that bowl of ice cream now.

March 18, 2020

Life finds a way – Ian Malcom

It certainly seems that we’ve all been slapped upside the head these last few weeks with two basic truths. First, humans aren’t special. We’re just one of many species struggling to exist on this blue ball teeming with life and mother nature is in charge. We may like to think we’re exempt from the natural processes that govern the way the world works but we’re not. Second, Americans aren’t special among humans. As the stress of the pandemic and societal shut down grinds inexorably on, we’re starting to recognize that forty years of hollowing out public good for private profit might not have been the best of ideas and that our tools for responding to this situation aren’t anywhere near as robust as they are elsewhere in the world. The last week or so may have seemed surreal to many of us, but it’s only the beginning. This is not something that’s just going to go away in a week or two. We’ll survive. We always do. Humans are a hardy species and pretty darn ingenious when we put our minds to it and this isn’t the first nor will it be the last tough spot we’ve been in. I read somewhere that sometime during the Cro-Magnon era, the human race was down to eight breeding females (determined from sequencing mitochondrial DNA) and we made it out of that tight spot.

In some ways, the economic catastrophe looming over us all is worse than the health catastrophe. And that’s probably what got the federal government to finally wake up. They weren’t terribly concerned about the safety of ordinary citizens (a failure of the first magnitude as that’s the most basic job of government) but they’re awfully concerned about the preservation of wealth, especially in the hands of those who run our institutions. I foresee a lot of changes coming because of this particular dynamic but whether those will be in the direction of an authoritarian cracking down by the power holders or a more equitable future for ordinary citizens is difficult to discern at this point. Maybe both. Maybe neither. Maybe some unknowable third way. I read a meme somewhere that we’re back in the roaring 20s, starting off with a pandemic, the bars are closed, and Wall Street is crashing.

If nothing else, I think we’re starting to recognize who’s really important in our society. As a doctor, I signed up for a job that I knew might include a time like this and where I might have to take on personal risk to benefit patients. It doesn’t bother me. It’s part of the calling. If you don’t have that ethos, you don’t belong in medicine. But people like grocery store clerks didn’t sign up for what they’re doing at the moment in terms of keeping shelves stocked for a populace that seems to have lost its collective mind over toilet paper. And they’re not the best compensated of individuals. Think of those that are really helping us get through theses days: Everyone involved in the supply chain – clerks, truckers, railroaders, port workers, warehouse workers. The people we turn to if we’re cooped up at home are the artists: the writers who provide us with books. The actors, directors, and myriad technicians that create movies and television. The musicians that lighten are hearts with song. We’ve been underfunding the arts and culture for decades in our society and it’s time we stop that because collectively, they are our soul but we only seem to understand that in times of trouble. And don’t get me started on the teachers – underpaid for years. With most of the country being thrust into home schooling, when the schools do reopen, I can see mobs of angry PTA parents marching on the local school district demanding better salaries and working conditions now that they’ve figured out what teachers actually do.

At my job, the people I’m saluting are the behind the scenes folk. The cooks and serving line people that make sure there’s a hot lunch in the cafeteria so I can keep going. The custodial staff who are doing double duty disinfecting. The IT people who make sure the computer systems work the way they need to. My receptionists who are fielding calls from frightened and confused people with a smile. My nursing staff who give a damn on a very personal level about the well being of our patients. It’s easy to elevate a doctor up on a pedestal but there’s a whole team of unsung heroes around him or her that allow the job to be done.

With three days of work, we’ve managed to get ambulatory care in geriatrics shifted away from bringing people into a clinic in a hospital environment to a telephonic based system where we can still provide care. We’re open for business. We will see people in person to keep them away from the emergency department but most routine care will be done through either phone or video chat for the next few months to try and keep our patients safe and out of harms way. I can’t say I like it because I’m a toucher and a hugger with patients (sometimes it does more good than any pill I can come up with) but desperate times call for desperate measures. Anything we can do to keep my peeps from falling seriously ill is OK in my book.

I’m pretty fried when I get home in the evening. It would be nice to have someone to unwind with other than the cats but I’m still being pretty rigorous with my social distancing and will likely be so for a while as I don’t want to be a vector carrying disease to vulnerable populations. I had my first outing other than work in nearly a week this evening when I stopped by the Piggly Wiggly on my way home to pick up a couple of things for the fridge. Sanitize hands before going in. Don’t touch face. Try not to touch anything other than products I’m buying and the basket. Most things were well stocked other than bread and I wanted a loaf. The bread aisle was completely cleaned out but I wandered over to the deli and found a few loaves of specialized brioche bread in an out of the way corner that had been overlooked. Score! And I happen to like brioche. Sanitize hands again in the car. Get home and scrub. My current wash hands song is The Ladies Who Lunch – last verse. May Elaine Stritch forgive me.

Spoke to the mortgage people today. Everything is in place to close on the new condo in a month as was planned. I told them I was fine if force maejure caused a delay. Even if I close on time, I foresee certain issues in the practicalities of moving so I may have possession but it may be a while before I can move and occupy it. We shall see. I can use more time to sort and downsize but that’s not a task I really want to do alone and at the moment, I’m a little leery of having a lot of people traipse in and out and undo the work I’ve put into keeping myself semi isolated.

Everybody continue to be well. I’m going to try and write like this every couple of days for a while, touching on the age of Corvid 19. I thought about going back to the chapters I’m working on for my book about the aging Baby Boom but I’m thinking that may need to wait until new realities take shape. I will try to get some new movie columns written though. MNM’s voice gets stronger in my head when the chips are down.

March 16, 2020

OK stream of consciousness time. This is my first world wide viral pandemic so I really am not sure how I’m supposed to feel or to react. If anyone knows, please send me a message and in the meantime, we’ll continue to all muddle through together and make it up as we go along. Our society, which has escaped most bad things for about 75 years, is learning what bad is very very quickly and it’s coming thicker and faster than I think most of us can actually absorb which might explain some of the stranger posts I’ve been seeing on social media over the last couple of days. I have great faith in America and Americans. When tested, we usually rise to the occasion. I have a lot of hope for the Millennials in particular – if you believe in the four generation cycle of American history, they occupy the same place as the World War II generation and we’ve had the Depression and Pearl Harbor rolled into one over the last two weeks.

I feel, at age 57, like I’ve been drafted and am preparing to ship off to war. The enemy is coming, implacably and inexorably. It is microscopically tiny, impervious to usual weaponry, and no amount of drilling or stripping of field rifles is going to help. The weapons are going to be maintained supply chains, good hygiene, availability of medical care, and necessary equipment. The home front can contribute by staying home. This will all rip a giant hole in our economic lives but we’re all in this together and on the other side, we may need to rethink our social priorities a bit. I don’t trust the gerontocracy of the federal government to handle post pandemic life terribly well. They’re not the kind of flexible thinkers who adapt to new norms. I think, as communities, we’re going to be a bit more on our own than we’re used to and have to be prepared for that.

Today, work was mainly about planning. How do we switch most of our clinic work from face to face visits to telephonic visits? Who can be pulled from outpatient to inpatient duty to cover all the usual medical issues if the inpatient docs are all either busy with Covid 19, under quarantine, or ill themselves? I last did inpatient ward duty in a previous millennium, so i hope I’m pretty low on the list. We’re all stepping up to do our part without complaining. It’s what we signed up for when we decided to go to medical school. It’s just a particular bill that’s coming due. Same thing tomorrow with the VA part of my job. And then, on Wednesday, we’ll figure out the hospice piece. One of the most interesting problems to surmount is how to deal with the myriad rules from the medico-legal-financial complex such as Medicare or HIPPA. They aren’t suspended until they’re suspended and working within those constraints makes things a bit more difficult than they might be otherwise.

My much older patients, those over 90 who survived the Depression and World War II and have clear memories of them, are fairly philosophical about the whole thing. They’ve seen a lot and they know that death lies in wait for them, just outside their field of vision. It’s my younger patients, the cusp of the boom who still believe in eternal youth and immortality that are struggling the most with the reality that this is not something they can wish away and that affluence or influence are not protective. For the most part, they’re taking my basic advice of good hygiene and staying home but, no matter how vigilant, I’m pretty sure I’m going to lose some of the familiar faces I’ve been taking care of for decades. I have a number of people I’ve had since I first arrived in Alabama – in their 70s then and in their 90s now and together we’ve seen social changes, health catastrophes, major improvments in function, widowhoods, and all the other little triumphs and tragedies that make up life. I learned how to say good bye in the 80s with HIV. I’ll make it through this.

We’re roughly ten to eleven days behind Italy in terms of the population disease curves which means we’re about three or four days away from the time when they locked the country down. From my latest news reports, they basically have started to do that to the SF Bay area and the Seattle area and I expect most urban areas will be that way by this coming weekend. How long? I don’t know. I have enough food in the house for me and the cats for about a month if it comes to that. I’m writing to my mortgage people this week to tell them that if closing needs to be delayed on the new condo, fine with me. I’ve never tried to complete a real estate transaction during a pandemic. I can’t imagine they have either. All of this has made me in no hurry to get to work sorting and packing. I came home from work after a not overly busy day and immediately fell asleep on the couch trying to play Words with Friends.

Everybody be well – use your downtime to clear your heads and practice a little zen or tao of letting the times carry you along instead of fighting against them. And keep a vigilant eye on your politicians. Some of them are itching to use this as their Reichstag fire moment to rush new policies through while we’re all distracted and prevented from protesting en masse. Watch out for your neighbors, your friends, your communities. We’re going to need them in coming months. I’ll try to keep these musings up every couple of days. If you’re a latecomer to my circle and being at home makes you bored enough to want to explore all these posts of mine, they’re archived at