Hurricane

 

What follows is a very long caveat, followed by very short message; it seems to me the caveat is actually more important.

Two weeks ago, I talked about where we were. As difficult as things are now, some things are better than in April (e.g. patients seem to be somewhat younger and less critically ill, we have some emerging treatments). There is a little glimmer of hope.

Last week, I talked about where we are: the fact that our only real weapons against the viral invader are scrupulous attention to physical distancing, masking and staying away from others if you develop symptoms. Please re-read that message and broadly share with others. I still see the occasional mask-less person in the hallway and hear of someone who “didn’t feel well” for a few days at work, and turned out to test positive. I think these exceptions are few, but we need to all push for universal compliance. Mask, distance, don’t come to work sick.

As we are now in an environment where the community presence of the disease is on the rise, the natural question for this week is, “Where are we going?” What’s next?

The most honest answer – and the one that makes this whole situation so difficult – is no one knows.

It is about 6:30 Wednesday morning, and pouring down rain. I look at my weather app and see a large cloud settled over Houston. I am very confident it will be raining in half an hour. It is less clear what will happen this afternoon. I would like to spend some time outdoors on Saturday, and don’t have a clue as to whether it will rain or not.

To me, that is what the COVID-19 pandemic feels like. We can only see what is just around the corner. Everything else is opaque. Will it spontaneously fade like SARS? Become an endemic pathogen, waxing and waning for months or years to come? Mount a major recurrence during flu season? Will a safe and effective vaccine be available this year? Next?

No one knows. Dr. Fauci doesn’t know, nor do the politicians, nor do the media pundits. We have guesses – often well-educated ones – but still guesses.

We use the hurricane analogy a lot, but increasingly it is a poor fit to this situation. In Houston, we are really good at hurricane response. We know when one has the potential to hit. We have context and experience from prior storms to know how bad it might be. It makes landfall, does its damage and passes. Houston can then do what it does best – pick itself up and recover.

This is not a hurricane, though I struggle to find an accurate comparison. Comparisons all seem either trite or overblown. It is like an innocent civilian population caught between warring powers. It is like dealing with the complex physical, emotional and cognitive needs of an aging relative with dementia. It is like losing a job in a down economy and struggling to care for your family. You know it will end, but you do not know when. Part of you knows you have the resilience to get through it, and that you will find strength in a difficult situation. However, in the moment, the uncertainty is the hardest part.

So, with that caveat (nobody knows), here is my view of what to expect in the next couple of weeks:

• The viral numbers in Houston (total new cases, TMC hospital admissions, ICU census) will continue to rise.
• TMC hospitals capacity will begin to be stressed, and hospitals will activate plans for sustainable surge capacity. This will involve adjusting staffing patterns for physicians, nurses and other providers and opening additional ICU beds. The hospitals can function at this level for an extended period of time. As viral numbers continue to climb, there will be increasing planning around emergency surge capacity. It is hoped the more disruptive emergency changes in the delivery system will not be needed, and even in worse case projections right now are at least three weeks off.
• We will all know someone who develops the COVID-19 illness – a family member, friends, neighbors, co-workers. It is inevitable as the virus spreads in the community. Most of the disease in our Baylor community will be imported from the outside. Our internal testing and contact tracing processes will effectively limit the spread of the virus at work.
• The increased viral numbers and associated media focus will get the attention of the citizens of Houston and surrounding communities. For those who have not taken this seriously up to now, we will see virus avoidance behaviors start to improve. More masks, less congregation in crowded bars and beaches. The July 4th holiday weekend will still present challenges, but will be materially better managed by the public at large than Memorial Day.
• State and local officials have already started to stake out a more aggressive posture on virus control. In Harris County, masking is now required in all businesses. Officials will continue to explore effective means of limiting viral spread (through education, regulation and enforcement), while attempting to avoid the economic impact of a broader business “lockdown.”
• Improvements in masking and heightened public awareness will slow the viral spread to a degree. The success of these efforts is a major variable in predicting our peak. My current guess is that our peak will occur in late July. Remember the caveat – I don’t know if it will rain on Saturday.

My most important prediction: Our Baylor community will be stressed by the disease burden in our community, but will continue to work together effectively to meet our organizational mission. We will continue in challenging circumstances to take care of a population that needs quality healthcare more than ever, pursue new discoveries and educate future providers and scientists. Most importantly, we will keep each other safe. Thank you all.

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

Control

 

Today I want to talk about control – specifically, frustration over those things we cannot control, and the importance of recognizing and maximizing those things we can.

For a phenomenon that has been with us for a relatively short period of time, it may seem strange to speak in terms of “epochs,” but it does feel like we have lived through some very distinct phases in this pandemic. April was categorized by a long list of unknowns, rapid community viral spread and an overall mood of fear and anxiety.

May seemed different. We regained a little more of a sense of routine. The virus, though not in retreat, seemed to have reached a point of community equilibrium. We breathed a small but tentative sigh of relief, and even had some optimism that we could simultaneously re-engage our regional economy and hold the infectious invader at the gate.

By June, we started to see the impact of the loosening of distancing in the community. If you have followed the recent numbers, community cases are sharply increasing, and hospital capacity is feeling the strain. Political polarization has accelerated and become personalized – “you can’t make me wear a mask” vs “I am offended by your reckless behavior.” Some of April’s anxiety has returned, but this time tinged with fatigue. When will this all end?

One of the hardest parts of dealing with the impact of the pandemic is that so much is out of our control. City, county and state officials will make decisions regarding how our community will respond. Leadership of Baylor and other TMC facilities are engaged on a daily basis in encouraging appropriate action. We can recommend, promote, cajole, provide data, and we have substantial influence. But at the end of the day, these decisions are out of our control.

The reality of the situation is obvious, but bears stating. We will be working and living our lives outside of work in the midst of a significant – and at this point, growing – viral presence in our community. Given this reality, let’s focus on those things we can control:

• Mask/maintain distancing/don’t come to work sick. This is our armor, unequivocally the best things we can do to keep the virus out of our Baylor work environment.
• Adopt a “universal precautions” mindset. In the hospital environment, providers are at risk for exposure to blood-borne pathogens (e.g. HIV, Hepatitis B & C). As a consequence, if a provider is at risk of coming into contact with any bodily fluid, it is universally assumed that the patient has a blood-borne disease, and appropriate protocols followed. We need to adopt this same mind-set around COVID-19. You should assume everyone with whom you come into contact is infected and actively shedding virus – even if you know they had a negative test yesterday. If you mask and maintain distancing, you are relatively safe.
• Hold each other accountable. Masking is required at Baylor. To keep our environment as safe as possible, we need to point out to each other when we are falling short. If I am not wearing a mask, or if I am not maintaining appropriate physical distancing, I want you to point this out to me. This needs to be not in the spirit of “tattling,” but as a collective act of compassion to our work community.
• Carry your armor outside of Baylor. Most of our time is not spent at work. I strongly encourage you to maintain scrupulous attention to masking and distancing outside of work. Frankly, your risk of exposure from a store clerk, waiter or the person on the next treadmill is probably greater than anything you will encounter at work. Wearing your armor and maintaining universal precautions outside of the walls of Baylor helps to protect you and your family. It also provides positive role models in our community. We will win converts not by preaching or scaring people into compliance, but by serving as an example.

A word of warning. We will see more infections of members of the Baylor community. This is not a failure, but an expected consequence of living in the middle of a pandemic. Baylor leadership and the ICC will also continue to do whatever is necessary to keep our community as safe possible. We have a rational approach to workplace testing (symptomatic employees and learners, surveillance testing of high exposure areas, random voluntary sentinel testing, internal contact tracing).

I have asked our Testing Advisory Committee to reconvene to review our internal testing guidelines in light of the increase in community spread. We are refreshing our surge planning efforts from earlier in the outbreak. We have passed all our internal social distancing audits with flying colors, and are making good progress in an a appropriately paced recovery across all mission areas.

We seem to say this a lot – this is far from over. I share in your concern, anxiety and fatigue in dealing with the situation thrust upon us. However, I remain extremely confident that our community will work together to see us through this ongoing crisis.

Stay safe.

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).