#the other half a bunch of antis who say they 'dodged a bullet' before following me | Explore Tumblr Posts and Blogs

sidenotelife · 4 years

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Residency in the time of corona, Follow the science, 201129

I have been struggling to articulate my thoughts on COVID for a while. I feel like I have a few main questions like A. What does it mean to “follow the science” and what exactly is “evidence-based medicine?” B. How important is COVID? What I wonder is, how much of our efforts in biomedicine should be re-routed to COVID from ongoing problems like HIV, drug addiction, diabetes? C. How should societal inequalities play into our response to COVID? And D. COVID fatigue. I will try to put some of these ideas together.

About a year and a half ago I moved to Sioux Falls, South Dakota and I assumed I would live in an anonymous place for a few years. To my surprise, in that year and a half Sioux Falls has made the national news twice. sidenote – Actually now that I think about it there was also this time:

I just googled “meth we’re on it” and I found this and I have to say that I love that someone thought this was such a good idea that it had to be trademarked. Anyways, the first time Sioux Falls was in the news this year was for a COVID superspreading event that happened in a Sioux Falls meat packing plant where a lot of refugees and poor families work. At the time it got a lot of press because it was a concrete example of how the poor were preferentially being killed by COVID. White collar workers with a savings account could afford to stay at home and away from COVID but blue collar workers living paycheck to paycheck had to be out there in the community working. I was worried that this event was just the beginning and it would spread across Sioux Falls. But in fact it didn’t. The outbreak came and went and through the summer COVID was basically a non-issue. In South Dakota we were safe. We didn’t social distance. We never wore masks. And we had no COVID. It gave me a false sense of hope that we were different in South Dakota. Maybe it was the built-in distance of a rural area. Maybe it was the lack of public transportation. Who knows. I didn’t know what it was but I felt like we had dodged a bullet. Turns out I was wrong.

Last month I was on our inpatient team and the hospital is on fire. Obviously I haven’t been a doctor for that long but I’m pretty sure right now is not normal. I think, before last month, I would have been in the camp of people saying that we do not need to be extending excess sympathy to privileged doctors for doing their job but when I was actually in the midst of it was really hard. We had more struggles to send our patients to the ICU because it was so full. We were managing sicker patients with overworked staff. When the hospitals filled up I thought it would hit a plateau but then they started double-rooming patients and then I was going down halls to see patients in rooms I had never been to before. And the patients weren’t only medically complex. I feel like we were ordering more one-to-one babysitters than ever. These are basically staff members that sit in a patient’s room to make sure they behave or at least don’t kill themselves. It’s not an incredibly common occasion to order these one-to-one’s but I swear we had more aggressive and more suicidal patients than I remember seeing. And it’s not even just the extra work or the complex patients that bothers me the most, it’s that there’s this underlying level of stress. It’s keeping up with the constant changes to sick leave policies. It’s those extra couple minutes to put on PPE when I’m already running behind to rounds. It’s when my already quiet voice is further muffled by an N95 and my patients are like what are you even saying. It’s trying to keep up with the latest information when I don’t have the time to know what information to trust. It’s when hospital leadership comes out to tell us that the pandemic is not a big deal. It’s all little things but these are the exact kinds of insidious things that lead to burnout in healthcare professionals. So now Sioux Falls is back in the news for this:

South Dakota is demolishing the hospitalized per capita race. sidenote- My mom told me that South Dakota is even making the news in Japan. My 90 year old grandmother was like wtf is South Dakota doing on the Japan news?? This is probably the first time Japanese people have heard of Sioux Falls. The argument can be made, at least we’re not as bad as New Jersey and New York when they spiked, and certainly that’s not wrong.. but that’s also not right. This probably goes without saying but the size of the hospital infrastructure in South Dakota vs New York City is not the same. When the Sioux Falls hospitals are getting overwhelmed it doesn’t just mean that Sioux Falls suffers. All the complicated patients that typically get transferred in from the surrounding towns are getting backed up into rural community hospitals. I’m trying to get licensed to start moonlighting in one of these rural community hospitals and I can tell you that I would not feel confident taking care of ventilated patients with COVID and PE’s. And sidenote - a couple weeks ago a mask mandate for Sioux Falls got shut down and then approved all in the same week. Everything is happening so fast. I have worries about this mask mandate. I have worries about masks in general because masks has become more than a covering for your face. I do think masks are more or less a good idea and I agree that they probably help prevent COVID but I also think the effect is probably pretty minimal and that the science in support of masks is not exactly a slam dunk. To me the masks thing is representative of a greater problem with this COVID. I know we are supposed to trust the science but I’m just not sure science is made to be used at this sort of pace. Science is cumulative. The way I think about it, science is the kind of thing where one person makes a small discovery, someone else makes another small discovery, then four small discoveries come together to make a medium discovery, but one of those small discoveries turns out not to be reproducible so it takes a while to rethink that medium discovery, and then finally someone in an unrelated field stumbles upon a discovery that gets combined with that medium discovery to create a big discovery like gleevac for CML or reverse transcriptase inhibitors for HIV. If we rush to draw major policy-driving conclusions from one of those small or even medium-level discoveries then we run a major risk of overturning policies, which can get real confusing. I mean think about masks, our public health god Tony Fauci was saying in March that masks are not the end-all and now we are splitting families apart because some people just don’t want to deal with the hassle of wearing a mask. And think of the other aspects of COVID science. We’ve learned that a bunch of stuff doesn’t work (aggressive anti-coagulation, tocilizumab, convalescent plasma), that some stuff actually makes people worse (hydroxychloroquine), and that some stuff that has been shown to work is pretty shaky when attempts have been made to reproduce those findings (decadron, remdesevir). sidenote- should it even be a surprise that steroids may or may not help in a patient with viral ARDS? I sometimes wonder what would have happened if we had just managed these patients as ARDS/sepsis-type patients rather than COVID patients. I think the most unique thing about COVID is its non-effect on kids. That part puzzles me. Anyways, I don’t mean to be a science downer but out of respect for science I just feel we need to be realistic about what it can and cannot do.

See you on the other side,

from ken

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