April 3, 2020

Dear Interested Readers,

 

The Acute Presentation Of A Chronic Problem

 

In less than a month after I finished my every other night on call schedule as an intern at the old Peter Bent  Brigham Hospital and began to enjoy the luxury of being on call every third night as junior resident in medicine, I started moonlighting in the emergency room of the Lowell General Hospital. It was 1972. I was married, and had two small sons. My wife wanted to go to graduate school, and I was making about $12,000 a year as a resident. One of the senior residents at the Brigham knew the stress that I was under, and he connected me to the doc who managed the Lowell General emergency room. 

 

Over the next seven years I worked up to thirty six hours a week in the Lowell General emergency room. A typical week would be one weekday 12 hour shift from 7PM to 7AM, and a 24 hour weekend shift. I learned a lot, and we were able to move from a rental, and buy a house in a better section of Newton. I continued the process through my senior residency, my fellowship in cardiology, and my first four years working at Harvard Community Health Plan. Working 80 to 90 hours a week became a habit that persisted until retirement. I spend a lot of time these days replaying in memory my years in practice, but I have never regretted my years in the emergency room. For a brief period of time during my cardiology fellowship, when there was not much night call, I even added a second EW stint at what was then called the Cardinal Cushing Hospital in Brockton, Massachusetts. 

 

By the mid seventies, Lowell and Brockton were both old burned out and dying mill towns with large immigrant populations that were already experiencing the urban decay that is associated with the loss of manufacturing jobs. There was a lot of poverty and substantial racial diversity among the poor who had no other recourse for care than to come to the emergency room. What was also true about both hospitals was that they sat on the interface between urban poverty, and moderately comfortable suburban neighborhoods. At the Lowell General I might have a distressed elderly inner city hispanic woman who spoke no English and was in pulmonary edema from her neglected CHF in one room, and the intoxicated son of a software engineer who worked at Wang Computer, Polaroid, or DEC (Digital Equipment Corporation) who need me to sow up a laceration incurred while doing something inappropriate at a party in the next room. The two separate worlds of poverty and “more than enough” came together in the EW.

 

At night I was the only doctor in the hospital. Nurses would call me to the ICU, to a Med Surg floor, or even OB or pediatrics, to assess a patient before they called the private doctor who might meet their call for direction or change of orders with verbal abuse that was derivative of having their sleep interrupted. I knew that I could make a friend for life if I could assure them that no call was necessary, or better yet, if I made the call for them. I also responded to all the codes in the hospital. I soon developed the philosophy that if a code had been called, the patient was dead and there was no pressure. Anything that I did that brought them back was positive. If they stayed as they were when the code was called, I had done my best. 

 

As time went along, I began to realize that true emergencies and cardiac arrests in people who were doing well were very rare events. There was almost always a prodrome or story, usually a tale of missed opportunity, that preceded the visit to the EW, or foreshadowed the code up in the ICU. I began to conceptualize emergencies as the acute presentation of an unrecognized, neglected or mismanaged chronic process, or at least an unrecognized process that began at some moment when there was still time for a more successful intervention, before the dramatic presentation. The flaw in the system was that clues were ignored. It was hard to garner support for preventative action, even if a concern with a high likelihood for future distress was noted before the “emergency” occurred. 

 

There is abundant evidence now that the depth of loss in lives and the losses in the economy that we have already experienced, or will experience, are not solely attributable to the unavoidable presence of a new and extremely contagious virus. The horrendous depths of our losses of lives and riches will be mostly attributable to the exacerbation by the virus of long standing social and economic inadequacies, and injustices that have been ignored as we have become increasingly isolated from one another in pursuit of personal interests while ignoring what is best for the health of our communities. Our lack of national preparation has been magnified by the personal inadequacies of a president who was elected by a minority to pursue a misguided and cruel agenda for the benefit of the self interested. It is our chronic problems that magnify our collective inadequacies in the face of the current threat. Our hopes now arise from the ability of local and state leadership, coupled with the depleted and damaged resources of the NIH and CDC, and a renewed sense of community, to mitigate the impact of the president’s inadequacies and our collective lack of preparation for what experts told us we should expect.  

 

Part of our current losses will flow from how we have chosen to finance hospital care. Hospital care has been managed as a revenue source and not as a cost center. Many hospital beds across the country are empty at the moment as resources are being accumulated for a tsunami of patients expected in a week, or two weeks, or even longer by cancelling all elective procedures. The only admissions are emergencies from acute trauma, heart attacks, and the other diagnoses that enter the hospital through the emergency room. Across the country, especially in small towns and rural environments, hospitals teeter on the brink of financial collapse because they, like many of the patients they serve, have been living “paycheck to paycheck” and now the paychecks are not coming. 

 

The reality in hospital management is that the bulk of revenue comes from elective procedures. It’s all about volume. The catch phrase in hospital finance is that it is the “hip, hearts, and knees” that pay the rent. I would also add that most hospitals have a financial dependency on the failure of the outpatient management of chronic disease. At least a quarter, if not a third, of all hospitalizations are from avoidable failures in the management of “ambulatory care sensitive conditions.“If a hospital stops doing the elective hips, hearts, and knees, and the associated income from lab and imaging for those admissions comes off the table, the margin is gone. The residual revenue from trauma management, obstetrical services, and the medical floors where one finds all the patients who are failures of ambulatory care management being hospitalized, is not enough to keep the ship financially afloat. The loss of usual hospital revenue is why the 2 trillion dollar CARES Act gives $153 billion to “public health.” I don’t know how much of that $153 billion will go to your local hospital, or for that matter to any hospital, but some of it is supposed to help with the red ink that hospitals will experience. 

 

We are right to worry about the future of small businesses because they employ more than 50% of the workforce. We allow many of those people who are employed to work at wages that do not support them and their families. We make up the difference between their meager wages and the cost of subsistence living by committing the social crime of offering them an inadequate safety net that is hard for anyone to navigate. As we look forward to the day when the storm has passed and we will emerge from our confinement hoping to return to normal, we should also worry about the economic impact of a failing healthcare system since healthcare employs 11% of the workforce, and in many small towns the local hospital is the largest employer. 

 

There is more to process now than most of us can manage emotionally or intellectually. Most of us, except for conspiracy theorists, accept the reality that the emergence of the coronavirus is nobody’s fault. With more than a quarter of a million Americans already infected, with over six thousand deaths, and with the concern coming from Dr. Fauci that perhaps as many as 240,000 may die before the pandemic subsides, the legitimate question is whether or not we will be able to mitigate what lies ahead. History does not give us much hope as Jill Lepore points out in a recent article in The New Yorker entitled, What Our Contagion Fables Are Really About: In the literature of pestilence, the great threat isn’t the loss of human life but the loss of what makes us human.” She writes:

 

The literature of contagion is vile. A plague is like a lobotomy. It cuts away the higher realms, the loftiest capacities of humanity, and leaves only the animal. “Farewell to the giant powers of man,” Mary Shelley wrote in “The Last Man,” in 1826, after a disease has ravaged the world. “Farewell to the arts,—to eloquence.” Every story of epidemic is a story of illiteracy, language made powerless, man made brute.

 

Lepore’s article is an impressive review of the immense literature of contagion that is often followed by mankind’s descent from its collective wealth and achievement to its unenlightened and brutish origins:

 

Death by death, country by country, the human race descends, rung by rung, down a ladder it had once built, and climbed.

 

That image is not a big stretch when we think about the scenes we have seen coming from Italy, the birthplace of much art and human achievement, or as we view the empty streets of New York where less than a month ago the sidewalks and subways were packed with people of all colors and backgrounds with their heads down as they hurried along to the next place on their agenda. Lepore’s extraction form the literature makes T.S. Eliot sound like an optimist when he says:

 

We shall not cease from exploration, and the end of all our exploring will be to arrive where we started and know the place for the first time.

 

Lepore’s review of literature would suggest that when our trip ends we may be wearing loin cloths and defending ourselves from our neighbors with clubs. Others seem to anticipate a need for self defense. We are buying a lot of toilet paper, but more ominously, gun sales are also up, a lot. Lepore spends a lot of time with Edgar Allan Poe’s, The Red Death set in medieval times. In contrast Mary Shelley’s The Last Man, and Jack London’s The Scarlet Plague are both set in the future near the end of the twenty first century. London writing in 1912 with chilling prescience seen from our vantage point of over a hundred years, writes a story of a pandemic in 2013 that is described by a survivor in 2073. London borrows heavily from the themes of Shelley and Poe. The survivor has saved a telegraph message describing the aftermath of the pandemic that was the last report coming out of New York sent some sixty before:

 

New York City and Chicago were in chaos. . . . A third of the New York police were dead. Their chief was also dead, likewise the mayor. All law and order had ceased. The bodies were lying in the streets un-buried. All railroads and vessels carrying food and such things into the great city had ceased running, and mobs of the hungry poor were pillaging the stores and warehouses. Murder and robbery and drunkenness were everywhere. Already the people had fled from the city by millions—at first the rich, in their private motor-cars and dirigibles, and then the great mass of the population, on foot, carrying the plague with them, themselves starving and pillaging the farmers and all the towns and villages on the way.

 

Lepore continues on to Albert Camus’ “The Plague” to make her points about how contagion reveals the dark side of humanity. As I read, I kept hoping that she would extract something other than existential angst from her review of the literature of contagion. She did not. She finished with a mention of Jose Saramago’s 1995 novel Blindness. Again she writes:

 

Camus’s observation about “the utter incapacity of every man truly to share in suffering that he cannot see” is the subject of José Saramago’s brilliant and devastating reimagining of the plague tale, “Blindness,” from 1995, in which the Defoe-like doctor is an ophthalmologist and the disease that reduces humans to animals is the inability to see. As historical parable, “Blindness” indicts the twentieth-century authoritarian state: the institutionalization of the vulnerable, the ruthlessness of military rulers. When the disease strikes, the government rounds up all the blind and locks them up in a mental asylum, where, blindly, they go to war with one another. They steal, they rape. “The blind are always at war, always have been at war,” Saramago writes, in the novel’s darkest observation.

But “Blindness” is far darker than any history lesson. For Saramago, blindness isn’t a disease; blindness is the human condition…

 

I was disappointed, but not surprised, by Lepore’s sudden end without resolution or a “feel good moment,” so I had to event one for myself from my own skimpy knowledge of literature. In my mind I went back to 1963 when I took an advanced placement literature class from the most impactful teacher I ever had, Jack Russell. I have described him before in a piece late last summer about critical thinking. In that article I also mention that I had discovered that my friend, Eve Shapiro, had been equally impressed by him a few decades later when she took his classes at the University of Maryland. Dr. Russell was attempting to lead a group of freshmen, me included, through the discussion of Stephen Crane’s semi autobiographical short story, “The Open Boat.” If you don’t know the story, it is based on Crane’s own experience of being in a lifeboat for over thirty hours after the ship he was on going to Cuba sank after hitting a sandbar. The story is told by one of the survivors from the open boat who is a “correspondent” or journalist. I will let the excellent review in Wikipedia pick up the most important part of the story:

 

…the moods of the men fluctuate from anger at their desperate situation, to a growing empathy for one another and the sudden realization that nature is indifferent to their fates. The men become fatigued and bicker with one another; nevertheless, the oiler and the correspondent take turns rowing toward shore, while the cook bails water to keep the boat afloat. When they see a lighthouse on the horizon, their hope is tempered with the realization of the danger of trying to reach it. Their hopes dwindle further when, after seeing a man waving from shore, and what may or may not be another boat, they fail to make contact. The correspondent and the oiler continue to take turns rowing, while the others sleep fitfully during the night. The correspondent then notices a shark swimming near the boat, but he does not seem to be bothered by it as one would expect. In the penultimate chapter, the correspondent wearily recalls a verse from the poem “Bingen on the Rhine” by Caroline Norton, in which a “soldier of the Legion” dies far from home.

 

Our class met in the early afternoon, and many of its members were sluggish or would doze with an early afternoon post prandial siesta during class. On the day we were discussing the “Open Boat,” the discussion that Dr. Russell was trying to lead probably felt like a struggle for him. He was trying to emphasize the concept of a thematic climax to a bunch of sleepy heads, and was pushing us for our impression of when the thematic climax had occurred in Crane’s story. I was a little reluctant to answer because as usual much of the class had been a conversation between me and Dr. Russell. I knew that many of my classmates thought I was obnoxious, and speaking again would just increase their animosity toward me. After what seemed like ten minutes of silence with no response to his question, Dr. Russell was looking frustrated. In a response to his appearance of frustration, and to prevent some imagined catastrophe if the question went unanswered, I blurted out, “When the correspondent felt sorry for the soldier dying far from home.” Dr. Russell’s appearance changed immediately. He drew himself up to his full six foot five inch height from which he had slumped during the period of silence. He peered down at me over the frame of his glasses, and looked me straight in the eye while I sat terrified in the front row of desks, embarrassed about my outburst, and waiting to hear that I was wrong. To my surprise he smiled an insider’s smile, and said in a muffled voice that few could hear but me, “Damned good!” It was the highlight of my academic career. 

 

I wish Lepore had found some reference in the literature of contagion that expressed the ability of people to find comfort and salvation in the care and concern for their neighbors. There is no empathy in the stories that she tells. They are a warning. Our story for this moment is not the number of dead, or the number that might die, but the efforts being extended by healthcare professionals, local leaders, and ordinary people to mitigate the potential disasters to which we are vulnerable because of our pre existing inequities and our headlong pursuit of individual, business, and institutional interests over the needs of our most vulnerable citizens. Those social sins were then magnified by a leadership that distrusted science and had no moral compass. Our current “emergency” is in many ways the acute presentation of many of our chronic problems. 

 

Our hope lies in our ability to forget self long enough to embrace community. We need to continue our current communitarian attitudes and actions when we emerge into the “new normal.” Game theory, the history of our species, and most religions suggest that the best strategy to protect and improve one’s lot is to save others. The devastating end to Poe’s tale occurs when the rich and powerful withdraw from community and are followed by the “red death” into their castles. The correspondent in the boat survived after he expressed empathy and saw that he shared a common humanity with a man he never knew who died on the other side of the world far from home. 

 

One can hope that the observations we make now about what has made us vulnerable will be remembered when we emerge from our experience of “social distancing.” All of Lepore’s stories suggest that we will forget, and that it will happen again. The opportunity for us now is to collectively resolve that this time we will write a new conclusion to the old, old story of humankind versus contagion. The challenge will be that we not forget what we have learned when the storm ends and the rainbow appears. 

 

Someday Over The Rainbow/ What A Wonderful World!

 

I thought that I would leave you with a positive image. The picture in today’s header is once again the product of my neighbor, Peter Bloch, who started out making beautiful wooden lamp shades, and has expanded his interests to include unique aerial photography projects. You should check out his work by clicking on the links.

 

The first time I saw this picture it was framed. Peter presented it as part of an exhibit at the Sunapee library. Over the past two weeks, Peter has been sending out a video each day from his collection to help people deal with the “confinement.” He has not yet sent out “The Big Picture~3 Panorama Photos” which is the video from which I took the screen shot, but it is one of my favorites.  I get a lift everytime I watch it. It is a minute and a half of pure pleasure. The video begins with the rainbow over Sunapee Harbor on a summer afternoon, moves on to a beautiful local pond that has several islands, and then finishes with a moonset over Little Lake Sunapee, my lake, that was shot in winter. The lake is frozen and the sky is a mix of blues and purples. I live at the far end of the lake toward Mount Sunapee on the right which you can identify if you look closely for its ski trails. To the left on the horizon is Mount Kearsarge. 

 

Rainbows are about hope. In Genesis we are told that a rainbow is God’s promise after the flood that it won’t happen again which leads some people to think that history will be punctuated by fire the next time the world needs to be restarted. Little children are told that there is a pot of gold at the end of the rainbow, but it’s rare that we can see where it ends. One of the things that makes this picture unique is that you can see that the rainbow ends amid the multimillion dollar homes on Lake Avenue, almost exactly where Steven Tyler of Aerosmith lives in a unique house that I have been told has a retractable roof! 

 

What is uplifting for me about the picture is its amazing color, and the way it congers up wonderful memories for me of summer days in this part of New Hampshire that I hope will be repeated again and again over the coming years after we get past the trials of the COVID-19 pandemic. 

 

It is a reflex, but every time I see a rainbow or even the picture of a rainbow, the wonderful song written by Harold Arlen and Yip Harburg,  and first sung by Judy Garland in the Wizard of Oz, pops into my head. You know the words:

 

Somewhere over the rainbow way up high

There’s a land that I heard of once in a lullaby

Somewhere over the rainbow skies are blue

And the dreams that you dare to dream really do come true

 

Someday I’ll wish upon a star

And wake up where the clouds are far

Behind me

Where troubles melt like lemon drops

Away above the chimney tops

That’s where you’ll find me…

 

Years later, the wonderful Hawaiian artist, Israel Kamakawiwoʻole, sang the original version, but then extended the melody and the rainbow image in a way that made the song even better and brought it to a sharper vision for a better world with greater diversity and depth by writing “What A Wonderful World.”

 

Well, I see trees of green and red roses too

I’ll watch them bloom for me and you

And I think to myself

What a wonderful world

Well, I see skies of blue and I see clouds of white

And the brightness of day

I like the dark

And I think to myself what a wonderful world

The colors of the rainbow so pretty in the sky

And also on the faces of people passing by

I see friends shaking hands saying

How do you do?

They’re really saying I, I love you

I hear babies cry and I watch them grow

They’ll learn much more then we’ll know

And I think to myself what a wonderful world

World

 

In the movie Dorothy first sings the song while still in Kansas when she asks herself if there is someplace where there is no trouble:

 

“Some place where there isn’t any trouble. Do you suppose there is such a place, Toto? There must be.”

 

I do not think there will ever be a world without the challenges of trouble and uninvited change, but I do believe that our world is capable of continuous improvement that could bring us all the universal equivalent of a pot at the end of the rainbow, or better yet a wonderful world when we use our wisdom to avoid more and more trouble.

 

Be well! Practice social distancing. Wash your hands frequently. Don’t touch your face. Cover your cough. Stay home unless you are an essential provider. Follow the advice of our experts. Assist your neighbor when there is a need you can meet. Demand leadership that is thoughtful, truthful, capable, and inclusive. Let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,  

 

Gene