• Rosalind Kaplan, MD

How Do We Move Forward?

Five weeks into 'shelter in place'.

There are occasional glimmers of hope- like finding out that the hospital admission rate and death rate from Coved in NYC is decreasing, and from what I can see here in Philly, we are perhaps reaching a plateau. There are also glimmers of hope in the really generous and positive acts of so many people everywhere, and the many articles I read reiterating the need to have big changes in health care, in government, in understanding our interconnectedness and our responsibilities towards each other.

I don't want to diminish the significance of any progress, of any goodness. But there is so much that remains discouraging. While parts of the East Coast may be moving towards the downswing, many other parts of the country and the world are just heating up. The Trump administration continues to abdicate responsibility. Sure, our president now says he's going to ramp up test component manufacturing, but we are many, many weeks late in getting robust testing going, even if he fulfills this promise (which I fear is another empty promise, anyway). And he felt compelled to malign governors who are trying to protect their constituents, at the same time as he grudgingly said he'd get the materials for tests. It's hard not to feel incredibly angry at this country. It's hard to move past that.

And it's really not just the testing, but the continued conflicting messages and harmful communications from our 'leadership', especially the inciting of protests against social distancing and shutdowns. Many of the states who are protesting are just ramping up the number of Covid cases, and will undoubtedly be hit by Covid. The protests themselves will make the situation worse, exposing more vulnerable folks to illness, leading to hospitalizations, deaths and more anguish for medical provider.

The racial and socioeconomic disparities, which this virus is exploiting, are another piece of what makes me feel crazy. I would love for some of the protestors, who have been spared illness and death, to spend a day in the ER at Elmhurst Hospital in Brooklyn, or in the inner-city hospitals in Detroit, or even here in Philadelphia, where we are not technically 'overwhelmed' by Covid. Regardless, Temple Hospital in North Philadelphia has been running an entire Covid hospital in what was an 8-story outpatient building, and has been running a census nearing 200 patients, many of whom are in Intensive Care, on high flow oxygen or on ventilators. Or let the protestors spend a day with one of the funeral directors in a hard-hit city, dealing with bodies piled up inside refrigeration trucks. It might make it a little harder for these people to use their powers of denial if they saw the devastation. Or would these people just look around and say 'well, that's not my city, it's not my community, it's not my peer group (meaning not young and healthy and white)? Will they gloss over the fact that health care workers and other essential employees are getting sick at high rates, and that they are exhausted and scared and that there is STILL a shortage of protective gear? Will they still just blindly believe Trump when he says they should 'liberate' their states?

Over the last couple days, my husband and i have heard from some friends and colleagues, including doctors who have been seeing Covid patients, that they are themselves falling ill. Someone in our closer circle has just moved out of the ICU after a week of intubation, and is suffering continuing symptoms, including confusion after a week of sedation and time in the ICU. How do we move ahead when all these realities jerk us back?

And the plot further thickens- we are finding out more and more about what we DON'T know. Now it appears there may be even more asymptomatic infections and thus spread that has been impossible to predict, than anyone thought. We don't have a clue how many people in any community are going to develop antibodies, nor do we know what antibodies will mean in terms of immunity and the safety of loosening social distancing orders. There is so much to be done before we can get back to moving about freely in our own communities, much less in the country as a whole and, eventually, in the world. It seems daunting, but knowing what we don't know is a good thing- it's the first step in finding out. Still, I can't see a clear path forward.

So, yeah, in some ways, it seems like we're all in a holding pattern. But in reality, things are moving, all the time, hopefully in the right direction, though it's sometimes hard to know. In my own little world, I am seeing a variety of changes in behavior, some that seem positive, and some that really worry me.

I think all of us in medicine have noticed that very few people have been showing up for non-covid-related medical care. For several weeks, Urgent Care was almost silent, except in our sites where Covid testing and care is done. But this past weekend, things picked up a bit. Some of it, from what I can see, is that people have been putting off care, because they were afraid of possible Covid exposure, and are finally realizing that they need to get help. Lots of people called us for advice and many asked for telemedicine. So we are finally, as an Urgent Care Center, going to provide telemedicine. It seems like those who have had access to phone or video visits have been more likely to reach out, so I'm really happy that we are going to do that. It's also safer for us, as doctors and PA's and nurses and other staff- we want to help our patients, but we don't want more exposure than necessary, either. I worry about all the people who are not getting care for acute or chronic problems because of fear. We might not know the consequences of that for a while. I did see several patient in Urgent Care who were out of chronic medications, or who needed routine visits for various reasons- either inability to contact their regular physicians, or in one case, being from another country, and being stuck here because of travel bans. Thanks to internet translations of medication names, I was able to help out.

When I went out to get exercise yesterday, I noticed more people out, walking and riding bikes, than I'd seen in a long time-- even though it was chilly here yesterday. Maybe people are also getting stir-crazy enough to go out, even when they are afraid. Where I live, it looked like everyone was practicing social distancing, but I know that's not true in a lot of places, which worries me...

I personally need to move forward in my own way. I'm so happy when I can do something useful these days. All these weeks into lockdown, a day when I do something that helps others really helps me. I was pleased when a creative essay I'd written about Covid was accepted to a literary journal, as I believe that turning a crisis into art of any kind is helpful both to the person creating the work and to those who appreciate it as an audience. I'm participating in a program to call and just converse with people who are especially isolated because of age or disability and/or living alone. The conversations I've had have been wonderful for me--I've talked with people I otherwise would never have known about literature and movies and history and families. The gratitude I got for making the calls has been incredible- but to be honest, gratitude is just a side effect. The human interaction in its own has been the medicine, both for me and for the person on the other end of the phone. Finally, I'm going to teach a writing workshop for some displaced medical students (they have no clinical rotations because of the risk of Covid) on line, and I feel like its a great opportunity for us to learn from each other. We will definitely experiment with writing about Coronavirus among other topics. If nothing else, I will emerge from lockdown with a strong command of technology for patient care as well as education.

I do have hope that, despite all the loss over the last weeks, we will come out of this with some real changes for the better. One of my favorite quotes, the one I have tattooed on my ankle, says 'Without hope the heart would break.' For me, being useful when I can be is giving me hope. Bad things happen. Bad things have been happening and often it seems like they happen all on their own. I think we all have to keep pushing ourselves to make the good things happen. That's really the only way to get going in the right direction.

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