Tuesday, July 14, 2020

Thought I Had The Answer, Now I'm Not So Sure

Like most parents right now, I'm grappling with the decisions that need to be made about the upcoming school year. Our School District will be sending us a questionnaire about choosing either a continuing virtual model or some form of in-person learning. I have two high schoolers and upon our initial discussion, they, without hesitation want to go back into the classroom. And I want that for them as well. But is it the right decision?  I'm just not sure. And I've been hearing more & more concerns from teachers about the risks that they're expected to be exposed to & I don't think it's fair to them as well.   I'm truly conflicted as the date draws closer.  And honestly, a good chunk of whatever our final decision will be, will be doused in prayer. Because right now, I'm absolutely sure of nothing. The following is a pretty good compilation of concerns, discussions & opinions regarding the "Back to School" topic. Although these are not taken from our School District the thoughts are similar and could easily have come from ours. It's not an easy decision & I envy any parent that is completely confident with whatever they choose. As for me, uncertainty is where I live.
**As of the time of this post, certain School Districts have made the decision that the start of the Fall Schedule will be full-time distance learning.

**Update: A few hours after I posted, our School District announced that it will go to full-time online instruction at the start of the Fall School year, up until at least October 5th. I've been released of the choice & I feel relieved, concerned & sad for the kids. I can only hope & pray that there is an end in sight of this dreaded Covid-19. 

To our fellow FCPS (Fairfax County Public Schools) families, this is it gang, 5 days until the 2 days in school vs. 100% virtual decision. Let’s talk it out, in my traditional mammoth TL/DR form.
Like all of you, I’ve seen my feed become a flood of anxiety and faux expertise. You’ll get no presumption of expertise here. This is how I am looking at and considering this issue and the positions people have taken in my feed and in the hundred or so FCPS discussion groups that have popped up. The lead comments in quotes are taken directly from my feed and those boards. Sometimes I try to rationalize them. Sometimes I’m just punching back at the void.
Full disclosure, we initially chose the 2 days option and are now having serious reservations. As I consider the positions and arguments I see in my feed, these are where my mind goes. Of note, when I started working on this piece at 12:19 PM today the COVID death tally in the United States stood at 133,420.
“My kids want to go back to school.”
I challenge that position. I believe what the kids desire is more abstract. I believe what they want is a return to normalcy. They want their idea of yesterday. And yesterday isn’t on the menu.
“I want my child in school so they can socialize.”
This was the principle reason for our 2 days decision. As I think more on it though, what do we think ‘social’ will look like? There aren’t going to be any lunch table groups, any lockers, any recess games, any study halls, any sitting next to friends, any talking to people in the hallway, any dances. All of that is off the menu. So, when we say that we want the kids to benefit from the social experience, what are we deluding ourselves into thinking in-building socialization will actually look like in the Fall?
“My kid is going to be left behind.”
Left behind who? The entire country is grappling with the same issue, leaving all children in the same quagmire. Who exactly would they be behind? I believe the rhetorical answer to that is “They’ll be behind where they should be,” to which I’ll counter that “where they should be” is a fictional goal post that we as a society have taken as gospel because it maps to standardized tests which are used to grade schools and counties as they chase funding.
“Classrooms are safe.”
At the current distancing guidelines from FCPS middle and high schools would have no more than 12 people (teachers + students) in a classroom (I acknowledge this number may change as FCPS considers the Commonwealth’s 3 ft with a mask vs. 6 ft position, noting that FCPS is all mask regardless of the distance). For the purpose of this discussion we’ll say classes run 45 minutes.
I posed the following question to 40 people today, representing professional and management roles in corporations, government agencies, and military commands: “Would your company or command have a 12 person, 45 minute meeting in a conference room?”
100% of them said no, they would not. These are some of their answers:
“No. Until further notice we are on Zoom.”
“(Our company) doesn’t allow us in (company space).”
“Oh hell no.”
“No absolutely not.”
“Is there a percentage lower than zero?”
“Something of that size would be virtual.”
We do not even consider putting our office employees into the same situation we are contemplating putting our children into. And let’s drive this point home: there are instances here when commanding officers will not put soldiers, ACTUAL SOLDIERS, into the kind of indoor environment we’re contemplating for our children. For me this is as close to a ‘kill shot’ argument as there is in this entire debate. How do we work from home because buildings with recycled air are not safe, because we don’t trust other people to not spread the virus, and then with the same breath send our children into buildings?
“Children only die .0016 of the time.”
First, conceding we’re an increasingly morally bankrupt society, but when did we start talking about children’s lives, or anyone’s lives, like this? This how the villain in movies talks about mortality, usually 10-15 minutes before the good guy kills him.
If you’re in this camp, and I acknowledge that many, many people are, I’m asking you to consider that number from a slightly different angle.
FCPS has 189,000 children. .0016 of that is 302. 302 dead children are the Calvary Hill you’re erecting your argument on. So, let’s agree to do this: stop presenting this as a data point. If this is your argument, I challenge you to have courage equal to your conviction. Go ahead, plant a flag on the internet and say, “Only 302 children will die.” No one will. That’s the kind action on social media that gets you fired from your job. And I trust our social media enclave isn’t so careless and irresponsible with life that it would even, for even a millisecond, enter any of your minds to make such an argument.
Considered another way: You’re presented with a bag with 189,000 $1 bills. You’re told that in the bag are 302 random bills, they look and feel just like all the others, but each one of those bills will kill you. Do you take the money out of the bag?
Same argument, applied to the 12,487 teachers in FCPS (per Wikipedia), using the ‘children’s multiplier’ of .0016 (all of us understanding the adult mortality rate is higher). That’s 20 teachers. That’s the number you’re talking about. It’s very easy to sit behind a keyboard and diminish and dismiss the risk you’re advocating other people assume. Take a breath and think about that.
If you want to advocate for 2 days a week, look, I’m looking for someone to convince me. But please, for the love of God, drop things like this from your argument. Because the people I know who’ve said things like this, I know they’re better people than this. They’re good people under incredible stress who let things slip out as their frustration boils over. So, please do the right thing and move on from this, because one potential outcome is that one day, you’re going to have to stand in front of St. Peter and answer for this, and that’s not going to be conversation you enjoy.
“Hardly any kids get COVID.”
(Deep sigh) Yes, that is statistically true as of this writing. But it is a cherry-picked argument because you’re leaving out an important piece.
One can reasonably argue that, due to the school closures in March, children have had the least EXPOSURE to COVID. In other words, closing schools was the one pandemic mitigation action we took that worked. There can be no discussion of the rate of diagnosis within children without also acknowledging they were among our fastest and most quarantined people. Put another way, you cannot cite the effect without acknowledging the cause.
“The flu kills more people every year.”
(Deep sigh). First of all, no, it doesn’t. Per the CDC, United States flu deaths average 20,000 annually. COVID, when I start writing here today, has killed 133,420 in six months.
And when you mention the flu, do you mean the disease that, if you’re suspected of having it, everyone, literally everyone in the country tells you stay the f- away from other people? You mean the one where parents are pretty sure their kids have it but send them to school anyway because they have a meeting that day, the one that every year causes massive f-ing outbreaks in schools because schools are petri dishes and it causes kids to miss weeks of school and leaves them out of sports and band for a month? That one? Because you’re right - the flu kills people every year. It does, but you’re ignoring the why. It’s because there are people who are a--holes who don’t care about infecting other people. In that regard it’s a perfect comparison to COVID.
“Almost everyone recovers.”
You’re confusing “release from the hospital” and “no longer infected” with “recovered.” I’m fortunate to only know two people who have had COVID. One my age and one my dad’s age. The one my age described it as “absolute hell” and although no longer infected cannot breathe right. The one my dad’s age was in the hospital for 13 weeks, had to have a trach ring put in because she could no longer be on a ventilator, and upon finally getting home and being faced with incalculable time in rehab told my mother, “I wish I had died.”
While I’m making every effort to reach objectivity, on this particular point, you don’t know what the f- you’re talking about.
“If people get sick, they get sick.”
First, you mistyped. What you intended to say was “If OTHER people get sick, they get sick.” And shame on you.
“I’m not going to live my life in fear.”
You already live your life in fear. For your health, your family’s health, your job, your retirement, terrorists, extremists, one political party or the other being in power, the new neighbors, an unexpected home repair, the next sunrise. What you meant to say was, “I’m not prepared to add ANOTHER fear,” and I’ve got news for you: that ship has sailed. It’s too late. There are two kinds of people, and only two: those that admit they’re afraid, and those that are lying to themselves about it.
As to the fear argument, fear is the reason you wait up when your kids stay out late, it’s the reason you tell your kids not to dive in the shallow water, to look both ways before crossing the road. Fear is the respect for the wide world that we teach our children. Except in this instance, for reasons no one has been able to explain to me yet.
“FCPS leadership sucks.”
I will summarize my view of the School Board thusly: if the 12 of you aren’t getting into a room together because it represents a risk, don’t tell me it’s OK for our kids. I understand your arguments, that we need the 2 days option for parents who can’t work from home, kids who don’t have internet or computer access, kids who needs meals from the school system, kids who need extra support to learn, and most tragically for kids who are at greater risk of abuse by being home. All very serious, all very real issues, all heartbreaking. No argument.
But you must first lead by example. Because you’re failing when it comes to optics. All your meetings are online. What our children see is all of you on a Zoom telling them it’s OK for them to be exactly where you aren’t. I understand you’re not PR people, but you really should think about hiring some.
“I talked it over with my kids.”
Let’s put aside for a moment the concept of adults effectively deferring this decision to children, the same children who will continue to stuff things into a full trash can rather than change it out. Yes, those hygienic children.
Listen, my 15 year old daughter wants a sport car, which she’s not getting next year because it would be dangerous to her and to others. Those kinds of decisions are our job. We step in and decide as parents, we don’t let them expose themselves to risks because their still developing and screen addicted brains narrow their understanding of cause and effect.
We as parents and adults serve to make difficult decisions. Sometimes those are in the form of lessons, where we try to steer kids towards the right answer and are willing to let them make a mistake in the hopes of teaching better decision making the next time around. This is not one of those moments. The stakes are too high for that. This is a “the adults are talking” moment. Kids are not mature enough for this moment. That is not an attack on your child. It is a broad statement about all children. It is true of your children and it was true when we were children. We need to be doing that thinking here, and “Johnny wants to see Bobby at school” cannot be the prevailing element in the equation.
“The teachers need to do their job.”
How is it that the same society which abruptly shifted to virtual students only three months ago, and offered glowing endorsements of teachers stating, “we finally understand how difficult your job is,” has now shifted to “screw you, do your job.” There are myriad problems with that position but for the purposes of this piece let’s simply go with, “You’re not looking for a teacher, you’re looking for the babysitter you feel your property tax payment entitles you to.”
“Teachers have a greater chance to being killed by a car than they do of dying from COVID.”
(Eye roll) Per the Insurance Institute for Highway Safety (IIHS), the U.S. see approximately 36,000 auto fatalities a year. Again, there have been 133,420 COVID deaths in the United States through 12:09 July 10, 2020. So no, they do not have a great chance of being killed in a car accident.
And, if you want to take the actual environment into consideration, the odds of a teacher being killed in a car accident in their classroom, you know, the environment we’re actually talking about, that’s right around 0%.
“If the grocery store workers can be onsite what are the teachers afraid of?”
(Deep breath) A grocery store worker, who absolutely risks exposure, has either six feet of space or a plexiglass shield between them and individual adult customers who can grasp their own mortality whose transactions can be completed in moments, in a 40,000 SF space.
A teacher is with 11 ‘customers’ who have not an inkling what mortality is, for 45 minutes, in a 675 SF space, six times a day.
Just stop.
“Teachers are choosing remote because they don’t want to work.”
(Deep breaths) Many teachers are opting to be remote. That is not a vacation. They’re requesting to do their job at a safer site. Just like many, many people who work in buildings with recycled air have done. And likely the building you’re not going into has a newer and better serviced air system than our schools.
Of greater interest to me is the number of teachers choosing the 100% virtual option for their children. The people who spend the most time in the buildings are the same ones electing not to send their children into those buildings. That’s something I pay attention to.
“I wasn’t prepared to be a parent 24/7” and “I just need a break.”
I truly, deeply respect that honesty. Truth be told, both arguments have crossed my mind. Pre COVID, I routinely worked from home 1 – 2 days a week. The solace was nice. When I was in the office, I had an actual office, a room with a door I could close, where I could focus. During the quarantine that hasn’t always been the case. I’ve been frustrated, I’ve been short, I’ve gone to just take a drive and get the hell away for a moment and been disgusted when one of the kids sees me and asks me to come for a ride, robbing me of those minutes of silence. You want to hear silence. I get it. I really, really do.
Here’s another version of that, admittedly extreme. What if one of our kids becomes one of the 302? What’s that silence going to sound like? What if you have one of those matted frames where you add the kid’s school picture every year? What if you don’t get to finish the pictures?
“What does your gut tell you to do?”
Shawn and I have talked ad infinitum about all of these and other points. Two days ago, at mid-discussion I said, “Stop, right now, gut answer, what is it,” and we both said, “virtual.”
A lot of the arguments I hear people making for the 2 days sound like we’re trying to talk ourselves into ignoring our instincts, they are almost exclusively, “We’re doing 2 days, but…”. There’s a fantastic book by Gavin de Becker, The Gift of Fear, which I’ll minimize for you thusly: your gut instinct is a hardwired part of your brain and you should listen to it. In the introduction he talks about elevators, and how, of all living things, humans are the only ones that would voluntarily get into a soundproof steel box with a potential predator just so they could skip a flight of stairs.
I keep thinking that the 2 days option is the soundproof steel box. I welcome, damn, beg, anyone to convince me otherwise.
At the time I started writing at 12:09 PM, 133,420 Americans had died from COVID. Upon completing this draft at 7:04 PM, that number rose to 133,940.
520 Americans died of COVID while I was working on this. In seven hours.
The length of a school day.

Tuesday, July 7, 2020

A Covid-19 Update from Dr. Rick Loftus, MD

Mom with Baby in Navy Blue Wrap
Last year, 2019, around this time, both The Huz and I were in the midst of worry and stress over our mothers. The Huz' Mom was in the hospital awaiting surgery to remove (what we were relieved to be told was a non-cancerous) tumor. My Mom had to go to the Emergency Room for low blood pressure, developed gout which caused her so much pain and issues with her kidneys.  I remember praying so hard for the both of them and just wanting them to be healthy & pain free. It was a tough season but with God's Grace, they both recovered slowly from their different illnesses. Fast forward to March of 2020 and the breaking news of the Covid-19 Virus spreading globally. I remember waiting anxiously for news from the School District about closures and feeling both worried not just for the health of my sons but also for their thriving progress in their education. As expected, their school announced a closure mid-March & we, as a family, went into First-world lockdown--distance learning & working from home, only going out to pick up take-out or go grocery shopping. There was a pretty high level of anxiety all around.
It's been about 5 months now of quarantine--going out for essentials, wearing face masks when out doing errands, and visiting our mothers---all from a relatively safe distance with masks on. We have been taking all the necessary precautions for the sake of our own health and for our extended loved ones because I'm so thankful for life and I want to make sure we do everything we can to preserve it and have opportunities in the near future to enjoy all the fun things we enjoyed before this virus took over the world.  I'm also very aware that many people don't believe in the validity of this virus--that it's just a regular flu virus and people are being too paranoid.  It's also become very political--with the left believing shut-downs are necessary & face masks lower the spread of the virus and the right believing in the opposite.  As for me, I believe that it's definitely better to be safe than sorry. Because I've heard some first-hand accounts form health frontliners who've seen it all and THEY take this very seriously. There are a lot of asymptomatic people who contract the virus and never feel one day of suffering from it--how blessed & fortunate are they!  But those same people have the ability to spread it and the person they give it to may not be so lucky.  And I don't want to risk my family because I don't know if we would be the ones that don't show symptoms or recover quickly.  Just the chance that we could be part of the smaller percentage that doesn't fair well is enough for me to take this virus seriously and practice all the necessary precautions to minimize contacting and/or spreading it.  And to all those that have died from the Virus & their mourning families--I see you.  I hurt for you.



There are multiple frontliner accounts of Covid-19 out there, ones online & ones from friends in the health care field. Here's one I saw online passed on from a friend in health care. It's from Dr Rick Loftus, MD:  

I'm in a hotspot hospital in a hotspot region (Coachella Valley, Inland Empire, CA). We just converted the entire 2nd floor of our hospital to COVID-19 care yesterday, July 1. We have 65 inpatients with COVID-19 in a hospital with 368 beds. It is the same at our other 2 hospitals in the Valley. We spent yesterday deciding the ethical way to divide up limited remdesivir (30 patients' worth) for the hospital patients. My 20 incoming interns for our IM resident were exposed to COVID 2 weeks ago during their computer chart training; apparently 100% of our computer trainers had COVID19. One intern tested positive 7 days later and I insisted we re-test them all again, as there are almost certainly other cases with minimal symptoms. I raided my household and took my entire supply of face shields to the hospital for the residents to wear on their first day, and I paid $1,000 of my own money to equip all of my residents with medical-grade face shields. I require all residents to wear a surgical mask or N95 with face shield if they are within 6 feet of another human, patient, or coworker. Roughly 20% of our inpatients die. Only 30% of our ventilated patients survive. (We try to avoid ventilation at all costs. Some people insist on being full code and decompensate despite high flow with face mask, proning, dexamethasone, antibiotics, and a cocktail of famotidine, zinc, Vitamin D, Vitamin C, NAC, and melatonin—we throw everything we can at each case, so long as it won't hurt them.) My administrative assistant, who sits adjacent to the interns, just went home with COVID symptoms. Her test is pending. In the Southwest, we are experiencing catastrophic exponential growth. I have had multiple families—siblings, parent-child, spouses—admitted with COVID-19. I had a 31 year old come in satting 78% on room air; he had been sequestering himself in his bedroom for a week to avoid infecting his elderly parents, with whom he lived. His sister, the only person he saw outside his immediate household in the 10 days prior to onset of fever, cough, and dyspnea, had also had fevers but had tested "negative" at our other large hospital so he thought it was safe to visit her. (Sigh. The Quest PCR test is about 80% sensitive, we think—it had emergency approval, so sensitivity data was not required. The Cepheid rapid COVID PCR test is 98.5% sensitive but is in short supply due to limited reagent availability.) I'm glad some of you are sheltered from what unbridled COVID-19 looks like. It's a hell show. This is *July*. What do you think my hospital will look like in winter…? This is real. Doctors in places with proper public health responses will see few cases in their hospitals—like UCSF—but let me tell you something: The laws of physics and biology don't change. If you're in an unaffected region, an introduction and poor governance and low use of physical distancing and masks will give you an exponential increase in no time flat (i.e. 2-4 weeks). That's pandemic math. And 20% of the population infected needs a hospital. You *will* run out of beds with an unbridled pandemic. There is almost ZERO pre-existing immunity to SARS-CoV-2. There may be some "priming" of T-cell responses due to exposure to other "benign" beta-coronaviruses, but we have no idea if that explains the 20-40% of people who seem to get minimal symptoms. Asymptomatic infected persons, however, can, and do, spread COVID to those who die from it. By the way: I've seen scary looking CT scans of the lungs that look like terrible interstitial pneumonia in a patient who had ZERO symptoms and SaO2 94% on room air. She came in for palpitations and the intern overnight got a chest CT for cardiac reasons. We didn't know it was COVID until her test came back 36 hours later. So "asymptomatic" does NOT mean "no biological activity." The virus replicates furiously in people who feel fine. Kids can spread this as easily as grown ups, even if they feel okay. Related: I've talked to two previously healthy patients ages 32 and 44 who are 3 and 4 months, respectively, post their acute COVID. They continue to have cough, night sweats, fever, fatigue. How many survivors have "post-COVID syndrome"? We don't know. Less than 20% but we're not sure. I've asked my hospital to allow me to establish a post-COVID clinic to care for and study survivors. Both NIH and UW are planning similar efforts based on my dialogues with them. Autopsies show anoxic brain injury in many patients who died of COVID, not to mention microthrombi throughout the lungs and megakaryocytes in massive infiltrations in their hearts and other organs. People get heart failure, lung fibrosis, and permanent kidney injury from COVID-19. This is a disease of the vascular systems, and it can affect any organ, with lungs and kidneys being especially at risk. In early May, thanks to lockdown, our census of 55 came down to 10 COVID cases, and for a brief moment, I actually had hope that the worst nightmares I had about COVID, as a biohazard virology-trained hospitalist, would not come to pass. Then we re-opened, without test/trace/isolate systems anywhere close to adequate. Eight weeks ago my county decided to make masks "optional," despite 125 doctors begging them not to do that. Now we're worse than we were in April. And it's getting worse every day. You wanna see if COVID is real? Come walk on my COVID ward with me. It's real. Hearing people talk about it as if it's an exaggeration is, well, rage-inducing, honestly. Denial is the most common reaction to a pandemic. Denial is how the US will wind up with 1.1 million deaths instead of 30,000. I saw AIDS denialists get killed by their belief that HIV "isn't real, it's a pharma conspiracy of the medical industrial complex." Yeah, right, if you say so. I watched patients with those beliefs die. The hardest part about this is, every new case I treat exposes me. I have assiduous hot zone technique. But no technique is bulletproof. If you keep exposing me to case after case, eventually, the virus will get through my defenses. I'm a 50 year old hypertensive. I don't expect to do well if I get infected. For now, I keep going to work. I'm one of the few pushing forward on COVID clinical trials, basic science, public health messaging, and diagnostic studies at my hospital. I feel a responsibility to keep going. I wake up with nightmares every morning at 4am. But I'm going to keep going for now. I feel very alone a lot of the time. People are not taking this seriously, and it's costing lives. -R

We're still in the middle of this Pandemic. And there is still so much uncertainty out there. I'm still praying & hoping this ends sooner rather than later so we can all go on with our carefree lives. Please be safe out there. Whether or not you believe this Virus to be a threat or not, try to understand that many people are concerned. Many have lost their loved ones.  Wear a Mask. Be kind.