April 8, 2020

Albert Lamorisse’s Le Ballon Rouge

I apologize for no long post last night. I’ve tried to be disciplined and keep these up every other evening but last night I felt like a balloon after all the air has been let out of it and I crawled into bed by 9 and slept through until the alarm went off at 7 this morning. I feel fine. I think my brain just needed some off time from the toxic stew of life stresses that we’re all marinating in at the moment. At least the new work patterns are becoming slightly predictable and I’ve been able to stay on top of the crises in three different systems: UAB Geriatrics Clinic, Birmingham VA Home Based Primary Care and Comfort Care Hospice. One day, one patient, one problem at a time – although my phone continues to ding regularly with incoming texts from whichever two sites I’m not currently at.

An anecdote from my very distant past involving a balloon. I must have been three or four at the time. My parents gave me a red balloon, fairly strong and sturdy and rubberized that had a cat face on it. I don’t remember where we got it or why and it had no magical properties, unlike the one in the fabulous French short film by Albert Lamorisse. I was playing with it in the alley behind my house when my friend Jay came out of his house across the way and told me it would be great fun to pop it. Jay was a couple years older than I was so I looked up to him as an experienced man of five or six and said sure, that should be fun. He couldn’t find a rock that would puncture it but finally found a stick and convinced me to poke a hole in the balloon. If it had exploded with a satisfying bang, I might have enjoyed the noise – all boys love blowing things up but instead it slowly leaked air and involuted and started to shrink away. My three year old brain hadn’t considered the possibility that my toy might do that and become less usable and fun. I took my wounded balloon inside to my mother who, to her credit, didn’t laugh at me but rather took it as a chance to teach me a lesson in actions have consequences and some decisions, once made, cannot be undone. I kept what remained of that balloon in my room for quite a while as a reminder to be careful with what I chose – and as a reminder to not always follow someone based on seniority. (I’ve taken that last lesson very much too heart and had major problems arise from it at times, but I think I’m happier bucking the system when I know I’m right rather than going along to get along.) It was probably also my introduction to the second law of thermodynamics although I didn’t figure that out until years later.

The number of Facebook friend requests I’m getting and my blog readership are going up astronomically since I’ve started into what I’m calling my plague diaries. Quite frankly, I’d much rather still be doing travel diaries but one writes about what one knows and journaling comes out of the mundane and minutia of everyday life and all of our everyday lives have become about Covid 19 whether we want them to be or not. I did a podcast recording a couple of weeks ago (https://audioboom.com/posts/7547581-season-3-episode-6-one-doctor-s-life-in-the-time-of-coronavirus) where we talk a bit about this blog. Yes, the title is a nod to Douglas Adams. It’s been years since I’ve read his books, but his wonky sense of humor has always appealed to me and it’s very similar to my own. If you doubt me, read the movie columns. Of course, when Mr. Adams was my age, he’d been dead for nearly a decade so he accomplished a lot more with his writings than I have with my own.

In my last long post, I explored – briefly – why the US has health insurance tied to employment while such a system happened nowhere else in the industrialized world. Tonight I want to say a few words about another aspect of the US health care system that’s unique and which causes us a significant amount of trouble. I’m not passing judgment on why this is or the ethics or social trends behind it, I’m just going to lay it out there.

The vast majority of world health systems, especially those of the developed world, are morbidity driven health systems. The aim of the systems is to keep their populations well. They understand that health is much cheaper for a system than disease and resources are deployed to try to keep the majority of the population as healthy as possible. Healthy adults come from healthy children come from healthy infants come from healthy parents so they put enormous resources into making sure all of their population has access to care, that primary care is funded and available, that there is adequate prenatal and child care, that pediatric care will not stress a family unit, and preventive services that will keep people from falling into ill health by catching disease early are easy to come by. What’s the result? Their populations have higher life expectancies than we do, their systems cost much less (usually 9-11% of GDP while ours is something over 17% of GDP), and no one in their populations worries about medical bills and the possibility of bankruptcy from a health condition is so alien as to be unfathomable.

On the contrast, the US health care system is a mortality based system. We worry about why people die and do everything we can to prevent that occurrence. A death is considered a failure of the system to provide adequate care in some way (and our legal system is always looking to find someone at fault). We view life as linear with death as an endpoint and, if our health system is applied properly, we should never actually reach that spot. There are some generational differences in these ideas but it is most clearly seen in the early Boomers, those now in their early 70s who still view themselves as being forever young. There’s a line from a film which paraphrased is something like ‘How can I be old? I was at Woodstock!’

This cultural need to prevent death leads us to pour huge resources into individuals who are obviously in a dying process. For most people, death is a process – a very quick process for some (almost instantaneous in some cases) and a very slow process for others. Most health professionals know when someone is in that process but we are taught from early in our training how not to take away hope and the ethics of doing everything in our power to preserve life if that is the wish of a patient and family. But, deep inside, we often recognize when the continued treatments are doing no good. The specialty of palliative care which has arisen over the last few decades is capitalizing on this mismatch and showing that there is another way of not being aggressive with treatments during the dying process and they have shown scientifically that, in a lot of cases, people actually live longer with just having their symptoms treated rather than trying to cure the incurable underlying disease process.

Other systems look at us somewhat amused, ‘Those crazy Americans – they see death rates ticking up from cardiac disease and put everyone on aspirin, everyone on a statin, train more cardiologists. And then the cancer rates start to go up so more cancer centers, new chemo regimens, new biologic tumor annihilators. And now it’s an increase in dementia so more work on new drugs to prevent it (so far unsuccessful). Don’t they realize that the numbers always add up to 100% and all you can do is move people from one category to another?’ The problem is, we really don’t when it comes to how our health system actually operates. I am fond of reminding Medicare insurance executives of the fact that everybody dies in meetings when they’re touting how wonderful their product is at keeping people alive. It has not endeared me to them but I don’t mind.

This issue of morbidity vs mortality is going to play out during the current pandemic. I don’t know how yet but it will be interesting to keep comparing the response in other countries to what we have here. I remain afraid that we’re still in early days with this thing, no matter how tired we all may be of our disrupted lives.

Stay well.

April 5, 2020

For those interested in non-canonical gospels

Last time I wrote an entry in the plague diaries, it was the end of the work week. This time, it’s the end of the weekend. Was it an exciting and action packed weekend? Hardly, those are in abeyance for the duration but I had a few minor triumphs. In the harsh light of day, I decided the cat hair on the rug was not a lived in, but a sloven look so I broke out the vacuum cleaner and the duster and cleaned the main floor of the house. I also finished sorting the DVD collection for discards and entered all the ones I’m keeping into an app database so I’ll know what I’ve got next time I look for a physical copy of something. I played three very long games of Civilization VI on the Xbox and lost every time to my AI opponents. I read a dozen chapters in the book my sister gave me for Christmas (a zombie apocalypse in Seattle told from the point of view of a tame crow and the pets left behind). I took two long neighborhood walks. And I ‘attended’ on line church with a sermon on the non-canonical gospels entitled ‘The Heretic in the Pulpit’ – let it not be said that we UUs have no sense of humor.

On one of my walks I encountered my old friend Angela Forbus Pruitt and we called a few pleasantries to each other across the street. While we were talking I had a brain flash about what to write this evening. One of the themes I’ve seen as friends have been posting about Corona Virus is the common fear of being stranded without health insurance due to job loss. We are the only advanced society that ties health care and employment together. As most of us grow up in this system, it seems normal to us while most of the rest of the world considers it bizarre. How did we get here and why do we do it?

To answer that question, we have to go back to the 1920s and 30s. In the 1920s, the average American family spent a greater portion of their wealth on cosmetics than on health care. For the most part, you didn’t access the system. Doctoring was done by mom or granny and the vast majority of illnesses were handled at home. The doctors, almost exclusively men, were mainly general practitioners who were part of a community that supported them in a symbiotic relationship: this is where all the stories about paying the doctor in chickens came from. If the doctor had an office, it was often part of his home and he spent most of his time making the rounds in the donkey cart or the model T calling on the sick at home, providing advice and succor as he could. There were hospitals, but they were small and generally used for a few specific purposes: surgery, separation of those who might be dangerous to the greater community (the asylum and sanitarium), teaching, and as a carer of last resort for those without intact family structures who were medically ill. They were owned predominantly by public or religious institutions with a charitable mission to provide care for the ill and were non profit in nature.

Health insurance, as we understand it, was invented in 1929 in Dallas, Texas. Baylor University had constructed a large new hospital and was having difficulty filling the beds. The vice president for health services at Baylor, Justin Kimball, had connections with the Dallas school teachers union and hit upon a plan. If the teachers would pay Baylor a fifty cents a month, they would then be eligible, should they require hospital treatment, to enter Baylor’s hospital free of charge for up to twenty one days. This ensured Baylor a steady stream of income, and a steady stream of patients over the next decade or so.

This original plan morphed over time, as it grew, into Blue Cross: an amalgam of local plans which over the next couple of decades, grew into the organization that those of my generation all remember from my childhood. Blue Shield, which eventually merged with it, had a different origin. It came from a banding together of workers in the logging and mining camps of the Pacific Northwest into fraternal organizations that paid doctors fees if one of their number became ill. Blue Cross and Blue Shield grew piecemeal throughout the 1930s due to the state of the economy.

In the early 1940s, with the United States now at war, many of the heavy construction jobs, especially in the shipyards and airplace factories were taken by women as the men were fighting overseas (the days of Rosie the Riveter). It didn’t take long for the titans of industry to figure out that if these women fell ill, or if their children fell ill, they could not come to work and productivity would be hindered. It started to become the smart business decision for a company to begin thinking about the health of its employees and their families. The leader among the heavy industry types was Charles Kaiser, head of Kaiser alumnium. He led the way in making sure his employees had access to good and timely health care and that the bills would be paid.

In the latter half of the 1940s, after the end of the war and the return of the men to the workforce, heavy industry faced another problem. While the economy was gearing up to meet fifteen years of pent up US consumer demand, not to mention helping the rest of the world rebuild shattered infrastructure, there were still laws on the books left over from the Great Depression, which controlled wages – it wasn’t possible for company A to offer more money than company B for the same job. Corporate America found something else to make up the gap – the benefits package which did not fall under these rules. Health insurance, as it had already taken root in heavy industry quickly became a carrot for getting employees to sign on the dotted line. By the late 1940s, industrial American lobbied congress to change to tax code so that it became advantageous to the owners of industry to offer a health benefit and, before anyone knew it or thought about the consequences, employer tied health insurance was born.

Through the 1950s and 60s, the system worked relatively well. Hospitals were not for profit by both custom and law. Physicians were small independent businesses. There wasn’t much money in the health sector of the economy and, as employment was relatively easy to get in the booming post war economy, everyone was happy. Things started to change with the introduction of Medicare and Medicaid in 1965. They were created to give populations who were not employed or employable access to the health care system – Medicare for the elderly and disabled and Medicaid for the impoverished. But what ended up happening, was a sudden influx of federal dollars into the health care system. Money always catches the eye of the businessperson and this was no exception.

Feasibility grants and low-interest loan programs made available to encourage interested parties to develop and build HMOs. The establishment of procedures through which health plans would become federally qualified HMOs Inclusion of preventative as well as curative health care benefits. Requirements that employers offer federally qualified HMOs to their employees under certain circumstances. USC.

It was Charles Kaiser who went to his old friend Richard Nixon in 1973 and persuaded him to sign a piece of legislation known as the HMO (Health Maintenance Organization) Act. It was in order for him to spin off his health organization into a free standing company (Kaiser Permanente). The unintended consequence was that the language of the act made health care, up to then a not for profit enterprise, into a for profit business. Wall Street took notice and corporate America arrived in health care starting in the late 1970s, determined to remake medicine into a business, one that manufactured hospitalizations and patient encounters, and using the same business principles that had served it well in other sectors of the economy. By the mid 1980s, the field of medicine was very different as we evolved from a health care system, whose goal was to heal the sick and injured, to a health care industry whose goal is to create profit for the owners of industry. These trends have continued over the last four decades (coinciding with my time in medicine – I entered medical school in 1984) and now there is an enormous stress on the system wrought by Covid 19. What will the ultimate outcome be? I don’t know, but I don’t think the health system will look the same or operate the same when we emerge on the other side.

And there you have it. More than you ever wanted to know about the history of American health insurance in seven paragraphs.

Stay well.

April 3, 2020

And so we come to the end of another work week. My patients are as tucked away as I can make them from a distance, the staff are free for another weekend of social distancing, and the reports of more and more cases overwhelming the greater NYC area keep rolling in. Birmingham has stayed fairly stable this past week due to the early adoption of closures and social distancing. The state of Alabama finally followed suit today but I’m afraid it’s going to be too late for a lot of the smaller towns that have assumed they’re safe being outside of an urban core. The numbers for a lot of the rural counties are starting to spike. i figure we will know where we are locally in about another two weeks.

I do not watch the executive branch daily news conferences. From what I can tell, they consist mainly of contradictions and word salad. The election of someone who promised to take a wrecking ball to government institutions means those institutions are non functional or non existent when you need them. It’s going to be pretty much every state for itself in terms of pandemic response – some have been more proactive than others and you can see that in the numbers. The west coast grows, but at a much slower proportional rate than the deep south. I’m hoping we’re all learning a painful, but necessary lesson in the role of the federal government in times of crisis that effect the whole country equally.

My housekeeper is on furlough with four children suddenly out of school. I came home from work fully intending to vacuum and dust and make the house presentable but the only person that sees it is me and so what if there’s cat hair on the living room rug. It just adds to that lived in look. I played Xbox for a few hours instead, then made myself a gourmet meal of Kraft macaroni and cheese, hot dogs, and salad in a bag. I found some of Tommy’s famous chili and some butternut squash soup he made in the freezer so I’ve put that in the fridge to thaw for dinners this weekend. I am continuing my slow sort and clean out of junk. I still have to tackle the kitchen and the closet in the spare bedroom. Then I’ll have made a first pass on the main living areas. The basement and the garage are being left for later as they are the big bad boys.

I’m trying to think what to write about tonight and absolutely nothing is coming to mind. Perhaps it’s the glass of wine with the mac and cheese robbing me of creative thought. Perhaps I’m just carrying too much psychic weight. Perhaps I’ve told all my good stories already over the last two years. For some reason, I’ve been thinking a bit about early childhood today and I flashed on my first day of kindergarten. The neighborhood I grew up in in Seattle was faculty ghetto for the University of Washington back in the mid 1960s when we moved into the house in which I grew up. I started kindergarten in the fall of 1967, right after the summer of love. It was a half day program and I was in the morning class with Mrs. Easterwood. We were all taught to walk to school, about twelve blocks for me each way but on that first day, my mother brought me. I had been in pre-K so going to school was nothing new and I came in, marched around the room and read all the signs on the walls aloud. Mrs. Easterwood looked at my mother and said something like ‘So, he can read’ and my mother looked somewhat abashed. My parents hadn’t really formally taught me, I more or less taught myself from picture books, being read to and marching up to my parents with book in hand and demanding to be told what this or that word was. It was decided that I would be sent next door to the first grade classroom during reading time as I would be bored silly by the elementary exercises happening in the kindergarten room. I loved school – still do, although my mother chuckled for years about the time I came home, stomped in the house, and started complaining about how Celia Hanley told me what color to color my balloons and I definitely remember Lisa Hurd being much better at cutting circles than I was. And if I remember correctly, Celia was a nurse and Lisa an angel for Halloween that year. I was a pirate.

My first years of elementary school were run on the precepts of the 1940s and 50s. Boys and girls had recess on separate playgrounds. Everything was very formal. Seattle public schools didn’t have its act together on arts education so big black and white televisions were brought in for broadcasting music and visual art class from the local PBS studio. (This is before it was actually PBS). I still remember chanting tah tah tee tee tah along with a lot of other five year olds. Mrs. Easterwood seemed incredibly ancient to me, but was in her mid 40s. I googled her and found her obituary. She made it well into the new century before dying at the ripe old age of 98 having taught several generations of kindergarteners over her life. It’s more than fifty years later and I can still distinctly recall her voice. I seem to have a good ear for voices even after many years. At a public lecture I gave in Seattle a few years ago, a lovely older woman came up to me to thank me and asked me if I remembered her. I didn’t recognize her at all but as she spoke, I knew exactly who she was, Audrey Palmer, my fourth grade teacher (and the only elementary teacher inflicted with all three of the Duxbury children). I don’t run into too many people from my distant past these days but if I do, the voice will tell me who it is.

Today’s children will have a vastly different growing up. One thing I am hoping happens with the current crisis is that families will spend more time together as they stay home and focus on each other. I hope the kids, when they are my age, look back on this time as one full of memories of family togetherness, silliness in the backyard, family games, projects with siblings, and a break from the overly scheduled lives we’ve tended to foist on the young in our quest to mold them into competent and competitive adults. Take the small joys that this time can offer and treasure them.

In the meantime, be well.

April 1, 2020

It’s hump day evening, I’ve had my leftover chicken masaman from the local Nepalese take out accompanied by a glass of Cotes du Rhone (Tommy’s favorite) and I finished sorting the movie collection and pulling the obvious discards. Must be time to sit down and write again. I’ve never been one to drink alone but as day drags on into day by myself in the house, I’m opening a bottle of wine a week and treating myself to the occasional glass. One less thing to have to eventually move. I still haven’t quite figured out how I’m going to do that in the middle of a societal lock down but that’s a problem for another day.

The Corona Virus counter I check every evening shows that we’re now at roughly a million cases reported world wide (likely a huge under count as the statistics from a number of places are not to be trusted), roughly double the number of cases in the USA than in Italy, and the Alabama number entering four figure territory for the first time. We continue to be able to cope at UAB and at the Birmingham VA with the local needs so far but, two weeks in, there’s a feeling of fatigue and that this is going to get a whole lot worse before it gets better. I figure we’re going to have a better sense of the local parameters of the pandemic in about two more weeks when we see what the behaviors of today are doing in terms of controlling spread. I tend to hang out with relatively intelligent people so we’re all practicing our social distancing and isolation with reasonable success but I can tell from friends social media feeds that there’s a longing for a return to a world of rehearsals, neighborhood restaurant nights, theater parties, and just the plain joy of hanging out with your usual crowd not feeling a need to do much of anything. A friend of mine is trying to work out an on line version of Cards Against Humanity but it’s just not going to be the same.

Today’s musings have to do with trying to battle instinctual behaviors. We all have them. They’re buried deep in the limbic system and tend to make themselves known at times of stress. One of the chief among them, as social animals, is finding solace in the group in times of fear and uncertainty. I absolutely understand why some communities are still trying to come together in religious ritual. It’s a deep and innate longing and need in unsettling times. Unfortunately, our intellectual selves, having mastered an understanding of biology and basic virology, know that this is one of the worst things we can do from an epidemiologic point of view. This leads to a really primitive conflict which we’re seeing played out, especially in the south, between militant church goers and other members of society who recognize that this behavior will endanger others and should not happen. Where do I stand on this? I believe that god will understand is church is in abeyance for a while and god is helping me through this – he/she gave me a brain smart enough to not put myself in a position of danger.

Andy hanging from the fly bar

I think I learned the most about battling my own instincts when I took trapeze lessons for about a year a couple decades ago. I’m not going back to it – at my age I’d likely dislocate my shoulder or fracture my hip or some such. I started at a resort in Mexico. Steve and I had booked a vacation there in the spring of 1998 and, the week before we left, UC Davis decided to disband its clinical geriatrics program and handed me a sixty day pink slip. Needless to say, by the time we arrived at Blue Bay Los Angeles Locos, I was fit to be tied and needed something to make me feel like I still had some mettle left in me. They were offering beginner trapeze lessons so I signed up thinking if I could face my acrophobia and do that, I could take on the upcoming work challenges.

Flying trapeze is all about physics. At the peaks of the arc, you’re basically weightless and can do your maneuvering relatively easily. Some of the tricks that look spectacular from the ground are relatively easy. The hardest part is, after being caught, returning back to the original fly bar. I never did quite get the hang of that. When you’re standing on the platform with the fly bar in your hands, everything in your brain is trying to make your body thrust its center of gravity backwards onto the platform so you won’t fall twenty five feet or so. However, to successfully launch, you must do the opposite and puff out your chest, draw your hips in and keep your center of gravity forward towards the bar. It’s difficult to get yourself to do that and requires a sort of zen tranquility to over ride the lizard brain that’s in full flight or fight mode. I took several series of lessons at that resort the next few years, and then continued with a flying school in Atlanta for a time. I stopped when I met Tommy and got interested in other sorts of performing. Joining the circus just wasn’t in the cards.

The apprehensiveness that I feel, that we probably all feel, as we experience this global event has me feeling like I’m standing on a trapeze platform. I want to bend backwards and hold myself in a completely wrong position as it feels like a place of safety. Instead, I know I have to stand tall, stick my chest out, and launch myself into a new and unknown world -it’s scary as hell but I’ve done it before in all sorts of ways. I have to trust that the safety lines and net of my intelligence, my education, my family, my friends, my career, my performing instincts, and all the rest will lead to a successful trick and dismount. And, even if I fall, I have learned how to do it safely and gracefully; it’s the first thing you learn in trapeze as you’re going to do it again and again.

March 30, 2020

According to the handy dandy little Corona Virus counter maintained by Johns Hopkins, we’re up to nearly 1,000 cases in Alabama. About half of those are in the greater Birmingham area. UAB continues to weather the storm but folk are getting tired and we’re all still on the upswing. My professional life is fairly peripheral to the main hospital where the majority of cases are being treated. Currently, it’s my job to look after my patient population and try to keep them healthy enough so that they don’t need to come into the emergency department or the hospital for any reason. Lots of phone calls checking on medications and refills, making sure people aren’t falling, that fluid status is OK, and nipping UTIs and bronchitis in the bud. Anything I and my colleagues can do to reduce pressure on the hospital system the next few weeks, the better.

The rhythms of my work week are all out of whack. It doesn’t feel right to be a doctor and not be able to see my patients other than the occasional video chat. When you’ve done this job as long as I have (32 years now since I graduated from medical school…), you get this spidey sense about who is sick and who is not and what is normal and what can be safely ignored and what needs to be investigated further and it just doesn’t work without the physical presence of the patient. I’m pretty good at what I do and I’m afraid that the current straitened circumstances are going to lead me into missing something significant. We can still see people in the office, we’re just trying to avoid it as much as possible as we are just down the hall from the emergency department and we want to minimize the risk of exposure to Covid 19 in my patient population.

I’ve been thinking about what to write this evening for a while. This is always a mistake. When I overthink one of these long posts, they get stilted and anodyne and don’t come from the heart the way the ones I write half asleep as pure stream of consciousness do. Good, bad, or indifferent, I really couldn’t think of much that I felt I had to touch on. We’ve all seen the news. We all know that it’s going to be a while before any of this lets up and we’re all in this together. Not just as Americans, but as members of the human species world wide. In this age of globalization and international travel, Covid 19 is going to make its way to pretty much every human population within the next year or so. I imagine even the isolated tribes of Highland New Guinea have some contact with others and it doesn’t seem to take much for it to leap from one person to the next.

For various reasons, I’ve had to cancel my time off in April/May that I was going to use to move. It’s just as well. I still haven’t figured out how to move furniture when one lives alone in a time of quarantine and social distancing. If Tommy were still here, we could make it work (aside from the piano) but he’s not and I am not as young as I once was and even when I was in my prime I could not move a couch by myself. Steve and I moved ourselves a number of times over the years. We were young and energetic and we were always moving within the same neighborhood so a pickup truck and some boxes usually sufficed. He moved in with me towards the end of my internship year. I didn’t ask him to. I just came home one day to find his living room set in my apartment. When I said we should really talk about this first, he got upset and, when I came home from my next call night, the furniture was gone again. I think he drove his living room furniture up and down Highway 99 between Sacramento and Lodi three or four times. It became a standing joke between us. I could tell if he was mad at me if the couch disappeared.

Our Victorian Condo – 2414 G street Sacramento

Our first move was upstairs in the same apartment building – the units were slightly bigger. About a year and a half later, we found a condo, the upper story of an old Victorian a few blocks away, so we hauled everything over there for the next few years. Timothy Busfield’s brother, Buck, and his family lived next door and he and Tim were in the process of starting the B street theater in Sacramento at the time so I got a little vicarious theater interaction when we would run into them but, for the most part, it was buckle down and finish residency and fellowship and get the career underway. Our last self move was to a lovely craftsman bungalow a few blocks further uptown once I finished all my training and finally started making a real paycheck. Steve had gotten a deal on some furniture through a friend and we had stashed it in various neighbors basements until we took possession and had a long weekend in which we could retrieve it all.

The house, as a craftsman bungalow style from 1912, had been designed for one level living with an unfinished second floor. A previous owner had finished out the second floor and then Allan Owen had redone it with a grand master suite (including a shower to die for) but the interior stairwell remained small as it had only ever really been intended to be attic stairs. One of the pieces of furniture we had bought was a large white wood desk. Steve had picked it out as he thought a doctor should have an impressive desk in the home office (the old sleeping porch). The sucker weighed a ton and was large enough to be impractical. Steve and I got it into the house and into the stairwell where we managed to get it wedged tightly between wall and bannister. We couldn’t get it up, we couldn’t get it down, we couldn’t back it out. We asked one of our body building neighbors for help. He couldn’t budge it. We finally had to get out a skill saw and cut the legs off of it to free it. We then reassembled it in the office with a little wood glue. It was so heavy, it didn’t budge. When it came time to move to Alabama, we left it in the house. We weren’t about to have a repeat of the prior incident. For all I know, it’s still there.

I’ll figure out the move thing eventually. It’s really not that high up on my list of worries at the moment. But I remain amazed at my long track record of poor timing in real estate transactions. If Covid had hit six weeks earlier, I wouldn’t have been out looking. If it hit six week later, I would already have moved.

Everybody stay well.

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.