Better Living Through Our Shared COVID Experience

Habits.

In general, it takes about three months of regular performance of a new behavior to develop a habit – to incorporate actions into your life that becomes largely unconscious and effortless, like brushing your teeth. In my mind, the crisis in Houston became real with the closure of the Houston Rodeo on March 11. Since that date, we have all been dealing with change on an unprecedented scale. Work changed, the economy slowed, schools closed, we experienced two disease surges (or as some would contend, one long continual surge). Using the Rodeo as a marker, we are now in our 5th month of the crisis – plenty of time to have developed new habits. Today I would like to briefly review the improving data from the past week, while pausing to contemplate what positive lessons we have learned so far. How are we going to be better for having lived through this historic crisis?

We are clearly in a transitional period. The numbers this week are encouraging. For the past two weeks, the R(t) – the measure of community viral infectivity – has been at or below 1.0 due to community masking and distancing efforts. It now appears we achieved our peak of new viral infections during the 2nd week of July. New community cases in Harris and eight surrounding counties, on a rolling average basis, have decreased from about 2,400 daily at peak to around 1,800 (but keep in mind, for most of April and May we were seeing fewer than 400 cases per day, so we are still seeing a lot of new disease). New community cases reflect all positive tests, including people who are asymptomatic or minimally symptomatic.

The decrease in community disease burden in showing up in slackening hospital demand. Across TMC institutions at peak, daily admissions were above 350; we are now below 250. The daily census of patients in non-critical medical/surgical beds is dropping, and ICU patient census – which is expected to lag these other indicators – is starting to drop. In short, all the metrics are headed in the right direction.

To be clear, this does not mean things are easy. Providers in hospitals are still managing high numbers of very sick patients. Faculty, providers and residents in ICUs are fatigued. All tertiary/quaternary hospitals are providing extracorporeal membrane oxygenation (ECMO) to record numbers of patients. There are parts of Texas, particularly in the Rio Grande Valley, that are still squarely in crisis mode. So again, this is not over – just better. Vigilance around masking and physical distancing must continue. When the time is right, we must continue to encourage thoughtful, data-driven reopening decisions.

So, as we ride the backside of the current wave, I would like to reflect briefly on lessons learned – societal, organizational and personal. What new habits, skills and strengths have we developed during this crisis?
On the broadest societal level, I think this is a difficult question to answer. This will no doubt be the subject of many books to come. One lesson learned should be that the U.S. deserves a less fragmented, better-coordinated public health system. I hope this is my only global pandemic, but if we are ever unfortunate enough to experience something like this again, as a nation we must be better prepared.

In terms of institutional lessons, we have had a glimpse of what it means to be a learning health system. The AHRQ describes an learning health system as a system where “internal data and experience are systematically integrated with external evidence, and that knowledge is put into practice. As a result, patients get higher quality, safer, more efficient care, and health care delivery organizations become better places to work.”

I think that summarizes our last five months remarkably well. We have proven that if we have focus and organizational commitment, we can do big things quickly and do them well to improve the health and well-being of our community. The Baylor collection site just “swabbed” patient 10,000 this week. While other labs are challenged to provide timely results, Baylor labs continue to provide region-leading turnaround time for high reliability testing. Our researchers continue to manage productive labs and submit COVID and non-COVID related grants. Telehealth services enable us to provide necessary services to patients, and in a challenging environment, we are ahead of pace to recover all of our pre-COVID patient volume. Psychiatry in particular is performing the majority of their services virtually – including direct services in support of many in the Baylor community – and are on pace to exceed their pre-COVID levels of patient care. Curricula have been redesigned, and new students, residents and fellows smoothly onboarded. I hope a residual Baylor habit is recognizing we can accomplish important things quickly and well.

On a personal level, all of our lives are different than they were. We have faced a ton of disruption and much negative and difficult change. I think it is useful to stop and reflect for a moment on what is better, however small those things might be. What new routines have we established that we find meaningful and valuable? How would you finish this sentence?  “In the post-pandemic world, I will continue to…” These habits can be small or large, but pause to think about what they might be. For me personally, two come to mind. In the post-pandemic world, I will continue to…

• Limit my professional travel. Like most of you, I have not been on a plane since February, and have discovered I really do not miss it. I have more time at home, and seem to have been able to fulfill professional obligations fairly well remotely. To be sure, when travel becomes routine again, some face-to-face interactions will and should resume. However, I like being at home with my family and will be more selective about future trips.
• Have Sunday lunch with family. We have a new tradition of sitting down to mid-day Sunday for a family meal (within our household). Although we typically do take-out rather than cook, this feels like a throwback to a less hurried era. Pre-COVID-19, we had limited opportunity for unstructured, leisurely conversation; somehow now it seems to be more important.

In the post-COVID world, what positive thing will you continue to do? Take time to reflect. If you are inclined to share, email me your (brief) sentence, or if you are on Twitter, post using the hashtag #COVIDHabitsBCM.

Stay well.

(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).

A Cautionary Tale

My message today is a little different.  Generally, my comments are directed to the Baylor Community, and I hope they may have broader applicability.  Today’s message is squarely directed outside of Baylor.  Please share it widely, and share it today.

You do not need me to tell you the SARS-CoV-2 situation has substantially worsened over the past week – every media outlet in the nation is covering that story.  We are in the midst of a major surge.  Our affiliate hospitals are working hard to make sure there will be beds available to meet the demand, staffed by qualified healthcare providers.  We are prepared, but clearly are in for a challenging couple of weeks.  As we manage increasing volumes of patients, and especially as we enter the holiday weekend, the most important thing we can do is work to slow the spread of COVID-19.  That is why I think the story of Frank and his family is so important.

Note: I changed the name of the main person in this story to Frank Wilson and left out some details, not at his request, but to allow this story to be told without intruding on the privacy of anyone involved in this story. The story is real, the people are real, the impact on their lives is real.

Frank Wilson and his extended family have lived in the same town for more than 40 years – three generations.  They are a close-knit family in a close-knit community.  They enjoy a pace of life that is at least a half step slower than a city like Houston.  This is the story of SARS-CoV-2 in a place far removed from the intensity and complexity of the Texas Medical Center.  It is a story of good people in a safe place.

The Wilsons planned to spend their Memorial Day the way they spend most holidays and many weekends – enjoying a family gathering at their favorite picnic spot.  This celebration took on a little more significance, as they were coming out of the coronavirus induced lock-down.  As regional leaders mandated a partial shutdown of the economy, they suffered along with the rest of the state and the country – lost shifts at work, cancelled family events.  Now public officials were reopening the economy, and life was trying to regain its normal rhythm.  There was nothing more normal for Frank than a family picnic.

What did he think of all the coronavirus warnings?  “I thought it was all a big hoax – the government trying to take control of things”.  He knew people in other parts of the country had the virus, but he did not personally know anyone who had it.  He didn’t even know anyone who knew anyone who had it.  The response of media and civic leaders seemed overblown.  “It was a big nothing.”  Thankfully, it seemed now it was behind us.  We were opening back up.  We had beaten the virus.

This Memorial Day was like countless other similar holidays – an opportunity to unwind and relax with family.  It would become a day – that would lead to a week – that would change their lives forever.

The first warning sign.  Frank’s mother became short of breath.  Her symptoms were severe enough they felt compelled to get her checked at a local emergency room.  She was evaluated and told that she was suffering from a “broken heart.”  She was still mourning the recent death of her husband – Frank’s father – and it seemed reasonable that her symptoms were anxiety related.  All were relieved it was not the virus.

Memorial Day was Monday, May 25.  Tuesday passed and was uneventful.  

Wednesday, Frank went to help a friend tune up the engine of his car.  Towards the end of the day he didn’t feel well.  That night his temperature went up and he called his boss to say he would not be at work.  He went to the hospital and got the COVID-19 test.  Results the next day – positive.  He had the virus.

Thursday, Frank’s wife developed similar symptoms.  She went to the hospital, and was sick enough to be admitted.

Also on Thursday, Frank’s mother-in-law became ill.  In retrospect, she had not felt right since mid-May, but had already had a negative test for COVID-19.  She went to the hospital, and was admitted.

Friday, Frank’s sister became ill. Like his wife, she went to the hospital and was admitted.

By Friday evening, his mother’s condition had worsened to the point he sat at her bedside all night.  He did not realize it at the time, but this would prove to be the last night she would spend in her home.  On Saturday, he took her to the hospital, and she was admitted.

Thus ended a week from which the family is still struggling to recover.

Frank was lucky.  He did not need to spend time in the hospital.  However, he tells me it was the worst thing he has ever had.  “It was ten times worse than the worst flu.  I had terrible stomach pain, and couldn’t get my breath.  It felt like a bomb was going off in my chest.”

His wife’s condition was severe enough that it looked like she would need to go on a ventilator.  Fortunately, with a combination of regular proning (face-down positioning that improves air exchange in COVID-19 patients) and high levels of supplemental oxygen, she avoided the ventilator and was discharged after about a week.

His mother-in-law’s condition deteriorated, resulting in a prolonged ICU stay.  She is profoundly weak and continues to undergo intensive rehabilitation.

Frank’s sister also wound up in the ICU, and required extracorporeal membrane oxygenation (ECMO).  This is used in patients whose lungs are so badly involved that they cannot effectively exchange oxygen between the airways of the lungs and blood, which is much like slowly drowning.  The patient’s blood is drained out of the body, infused with oxygen and replaced.  Thankfully, she recently improved to the point that she is off ECMO, although she remains hospitalized.

Frank’s mother was the most critical of all.  She was admitted to the ICU and received the best and most aggressive treatment possible, at the finest medical center in the world.  She participated in the convalescent serum trial, receiving antibodies from another patient who had recovered from COVID-19.  Despite heroic efforts, she passed away. 

This is a true story, as told to me by Frank – real people, real events. After seeing the devastation the virus brought to people he loves, his instinct is to do all he can to help others.  He wants to donate his plasma so someone might benefit from his antibodies.  Most importantly, he wants people to know the threat is real, and that everyone must act responsibly to protect each other – to protect people like his wife and sister and mother.

Our most important weapon to control the viral invader is our own safe behavior.  Mask when in public places and when exposed to others.  Practice physical distancing all of the time.  If you have any symptoms, do not go to work or places where you could infect others.  Assume everyone you meet has the virus and is infectious, even if they had a negative test.  

Importantly, for the upcoming July 4th holiday, celebrate with your immediate household – not with your extended family, and certainly not as part of a public crowd.  Celebrate at home if at all possible.

Please share this message broadly.  The following link can be used in any social media posting: https://bit.ly/2Zoadec.  The Wilson story is tragic, but will at least have some meaning if others learn from it.

I wish you all a safe, happy and healthy July 4th holiday.

Thank you all.