The Wisdom of the Crowd

 

I am not going to write a weather-related piece today, as everyone is likely receiving plenty of information through the usual sources.  As I write this, it is mid-day Wednesday and it the path of Hurricane Laura is becoming more certain.  It appears it will not hit Houston directly, which if forecasts hold would help to mitigate the impact.  However, many are still directly in the path of a very dangerous storm, and our thoughts and/or prayers are with them.  Our support will be needed in the aftermath.

 
Obviously, there is concern about what impact this event could have on our COVID-19 outbreak.  If large numbers of people are displaced, and forced into congregate shelters, this will create a risk of spread of COVID-19.  Public officials have taken steps to limit the size of shelters and incorporate distancing principles into their design and operation, but any significant population displacement will place additional pressure on disease control efforts.
 
So with that brief nod to the issue that is on everyone’s minds today, I will return to an update on COVID-19 issues.  A couple of weeks ago, I posed the question to all of you: “If you were advising one of our presidential candidates, or local leadership, or a company executive on preparation for the next global pandemic, what is your priority?”  You emailed your responses to me, or posted them on Twitter using the hashtag #TheNextPandemicBCM where they are still available for review.  Following a brief review of our COVID-19 numbers, I want to report what you said.
 
The COVID-19 numbers continue to trend well, for the most part.  From prior posts, you know we are focused on three primary metrics: R(t), diagnostic test positivity rates among TMC facilities, and the number of new daily COVID-19 cases in Harris and surrounding counties.  
 
Recall the R(t) calculation is an estimate of viral infectivity, influenced by the properties of the virus and community dynamics.  Simply put, if I am infected with COVID-19, the R(t) is a statistical estimate of how many other people I am likely to infect.  If R(t) is less than 1.0, Houston is winning; greater than 1.0, SARS-CoV-2 is winning.
 
Even with a highly infectious virus (like measles), if we are truly and completely isolated from everyone else – a condition which only exists as a hypothetical – the R(t) would be effectively zero.  Conversely, if we all tend to congregate in crowded spaces with poor air exchange for prolonged periods of time, even a virus which is not inherently very infectious could have a very high R(t).  This is why attention to masking and distancing is so important.  The good news this week is the R(t) has been consistently less than 1.0 for 16 consecutive days.  As of now, we are winning.
 
Our second metric is the rate of positive tests among all tests ordered by Baylor and other TMC affiliate institutions.  This is a rough gauge of viral prevalence, which we would like to see sustainably below 5%.  The TMC positive test percentage is now 6.7%, and has been slowly trending downward.  This is not where it needs to be, but is headed in the right direction.  If you follow the city, county and state numbers, you will note that their percentage positive tends to be a few points higher.  This probably reflects some selection bias on the part of the Baylor and TMC facilities cohort.  Although we test symptomatic people in our ambulatory clinics, much of our testing is asymptomatic employees in surveillance programs, and asymptomatic patients admitted to hospitals, who would be expected to have a low positivity rate.  
 
However, we are very confident in the integrity of the data point we generate, which is why we have chosen this as our metric.
 
Finally, our most problematic metric: new daily COVID-19 cases in the community.  This number is (very) slowly drifting down, and on a 7-day rolling average basis is between 1,400 and 1,500.  This is good news is that in mid-July we were at about 2,400 cases.  However, we are still seeing 5-6 times the number of daily cases compared to May, and for public health officials to have a realistic chance of performing effective contact tracing it needs to be closer to 200.  This metric is the most methodologically flawed, for reasons I have previously reviewed, but should be increasingly reliable as state data issues are resolved.
 
In summary, the trends are encouraging, and hopefully future community stressors like school reopenings, the Labor Day holiday, flu season, etc. will not set us back.
 
Please continue to preach the masking and distancing message to your circles of influence.  
 
I hope we as a nation will get to a point soon – we are not even close yet – where we can stop managing the crisis in front of us, and begin to focus on how to be better prepared for the next pandemic.  That was the point of the five word #TheNextPandemicBCM exercise.  Roughly 100 people from the broad Baylor community responded.  Some people responded with tactical concerns, such as the need to stockpile PPE. A few made – mostly respectful – statements favoring one side of the political spectrum or the other.  Most responses addressed broad, fundamental key principles.  Taken individually, none of the principles is particularly surprising; however, there were four major themes when taken together constitute a thoughtful outline for how we can be better prepared next time – the BCM crowd-sourced pandemic preparedness plan:

• Elevate the role of rigorous science in public policy.  Example of five words: Build public confidence in science; Clear communication improves scientific understanding; Trust scientists and not Facebook.  Fully one quarter of respondents reflected this theme in some way.  
• Build reliable data and reporting systems.  Five words:  Worldwide electronic medical interconnectivity; Good data drives good decisions; Reliable information must unite us.  
• Invest in public health infrastructure and education.  Your words: Comprehensive integrated public health network; public health in high school; Public health investment dollar well spent (technically, this last one is six words, but it was too good not to include)
• Effective leadership is critical. Effective leadership: national, regional, local; Good leadership drives action; Clear messaging from leadership unites.

Our limited “Twitter poll” is obviously not a methodologically sound, comprehensive analysis of our current state nor an attempt at meaningful future planning.  However, the Baylor community does represent an interesting collection of researchers, educators, clinicians and learners.  Our exercise does represent a limited snapshot of the mood of this community at a time we were still actively engaged in our struggle with the virus.  Based on this snapshot, we should be advocating for public health curricula across the entire educational landscape: elementary to graduate school.  Our more informed populace will need reliable data presented in an accessible manner.  Our scientific community will continue its long-established commitment to academic integrity.  Leaders need to be able to promote an environment of trust and confidence.  These concepts may seem so obvious as to be trite.  However, if we do not actively work to address these – and no doubt other – issues now, our motivation and sense of urgency will flag as COVID-19 fades into memory.  As a learning health system, we have an obligation to hold our societal feet to the fire.
 
Stay well and 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).

D-Day

This week’s message may be slightly longer than usual, but I hope you will read it to the end.  As the viral dynamics continue to improve in and around Houston, I want to pause to recognize a group that has borne a disproportionate brunt of pandemic-induced pain – our front-line health care providers (HCPs). Theirs is a compelling story.

 
Before I proceed, I will very briefly mention this week’s data.  Our “R(t)” value is less than one (so we are winning).  Hospital COVID-19 related census levels continue to drop steadily.  The rate of new community cases is declining, albeit more slowly than anyone would like.  The percentage of people with positive tests is declining.  This is all favorable news.  If you are not familiar with some of these terms or concepts, please refer to last week’s message for more details.
 
Things are looking up, but I must revisit a persistent theme in these messages:  We must remain vigilant; we cannot become complacent.  Mask, distance, and avoid crowds.  Settle in for the long haul because we will need to live cautiously for months if we are going to be able to open up schools and maintain something that approximates our pre-COVID life.  Again, refer to last week’s message for more details.
 
Now, on to front-line HCPs.
 
Every one of us has suffered, to varying degrees, during this pandemic.  I have two new granddaughters, one born in September, and the other in June.  I consider them both pandemic babies, born in a strange time.  My younger granddaughter is named after her great-great aunt, who was an Army nurse, and part of the mobile medical response team that landed with the D-Day invasion in World War II.  She has since passed away, but in all the years I knew her, I never heard her talk of her experience.  I suspect it was horrific.  Everyone in the United States suffered during WWII.  There was fear of a mainland invasion, rationing of food, coffee and fuel, and shortages of rubber directed to the war effort.  However, given that during D-Day almost 3,000 Americans died, and four times that number were wounded, most would agree that the suffering of the many back home did not compare with the experience of those who stormed the beaches.
 
Have I suffered during the pandemic?  The honest answer is “yes, but…”  
 
Yes.  I have worked a little harder than normal.  In welcoming our pandemic babies to the family, we have cancelled baby showers and missed a large family gathering for a baptism.  We have not been able to jump on a plane for a quick visit.  Everything is a little more complicated, and a little less convenient.  To be sure, we feel fortunate that we have not suffered loss of livelihood, or health, or life – as many have.  
 
So we have suffered, but not to the extent of our front-line HCPs.  In this SARS-COV-2 war, they are the soldiers, and our ICUs are the beaches of Normandy.
 
In preparation for this piece, I spoke to about a dozen inpatient front-line HCPs in several Baylor affiliates: Baylor St Luke’s Medical Center, Ben Taub Hospital, and Texas Children’s hospital.  I spoke to intensivists and hospitalists; nurses and residents.  I wish I could have spoken to them all, as they all had an important story to tell.  What follows are a few of my questions to them.  The responses are their words, not mine.
 
We have been dealing with this crisis now for six months.  Tell me about your hardest day during that time, and what made it hard?

• My hardest day was when I worked my first shift in a newly-designated “all-COVID” unit.  All the patients were incredibly sick.  There were multiple codes.  I couldn’t leave one patient’s bedside long enough to attend to the next one.  I went home and cried.  I had to let it out.  It was one of the worse days of my life.
• Watching a young patient deteriorate before my eyes; seeing families devastated by the disease affecting multiple people.
• We are a people called to care.  In the early days, there was nothing we could do that seemed to help.  It is hard when you can’t see a path forward.
• I always try and take care of my people.  I couldn’t help them.
• I was worried about my family – that they would contract the disease.
• It was physically grueling work.  At any given time, 70% of our ICU patients were on a proning protocol.
• It is very hard to take care of sick kids when both parents can’t visit, they can’t see my face though my mask, and I can’t sit on the edge of the bed.

What single word best describes your feeling on that day? 

• Draining (multiple responses)
• Helplessness
• Overwhelmed
• Numb
• Anger (at the lack of resources in the early days, at the community at large for not taking this seriously)
• Despair

What did your team of health care providers do well?

• We had a shared spirit, and collaborated broadly.  It was one of the most rewarding experiences of my life.
• I was proud of our new faculty.  They were fearless.
• Everyone was committed.  Everyone sacrificed family responsibilities, vacation time.  We all worked long hours.
• We really rose to support each other. I was incredibly impressed and proud. Teamwork.
• We adapted rapidly, and learned quickly.  We became masters of data-driven micro-innovation.  We are better for this experience.
• Even though everyone was already incredibly busy, we held frequent Zoom meetings with regional hospitals to review cases and treatment protocols.  We felt an obligation to help build capacity and improve quality across the region, just not in our hospital.

Imagine a time when COVID-19 is truly behind us.  What is the single biggest lesson we should have learned from this experience?

• Our health care community is incredibly valuable.
• I cannot function without a great team around me.  I have an overwhelming sense of humility, and gratitude for my colleagues.
• We need to be ready next time. 
• Stockpile PPE.
• Enhance our public health systems – earlier control, more effective contact tracing.
• We have a leadership responsibility for the region.
• Life is precious, but uncertain and fragile.
• Putting others first is the best way to take care of yourself.

I hope we learn these lessons.  I hope our front-line health care providers differ from the survivors of the Normandy invasion in one important way – I hope we continue to talk about these experiences.  Experiences that have been incredibly hard, but at the same time affirming and formative.  As one person commented, “talking about this has been very therapeutic.”
 
In closing, I want to express my admiration and gratitude to everyone in our professional community who has been on the front lines sacrificing to provide extraordinary care in extraordinary times to our families, friends and neighbors.  May we never forget.
 
What would you like to communicate to a front-line health care provider?  Using exactly five words, post to Twitter using the hashtag #COVIDThanksBCM, or send your five words to svpclinical@bcm.edu, and I will post some of your responses.  Also, as many have asked, feel free to share this message broadly. You can copy and paste this link to email messages or social media: https://bit.ly/3277mrt.

So what are your five words of thanks?  I will start, with apologies to Winston Churchill:
 
This was their finest hour.

(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).

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.

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).

Electronic Apostasy: Why I Have Re-embraced the Paper Book

As I write this, I am on an airplane at 30,000 feet, and it strikes me as an ideal time to confess a digital heresy: I have entirely abandoned electronic books.

When the first e-readers burst onto the scene, I was an early adopter; initially on a single function reader, later on a tablet.  The appeal of the technology was immediately obvious.  My entire library was at my fingertips.  I could carry hundreds of books with me everywhere (even at 30,000 feet).  It was quick and easy – virtually instantaneous – to buy a book on line.  Clearly, this was a life-enhancing technological innovation.

After several years, you can now place me firmly in the anti-e-reader camp.  Here are my top nine reasons I have sworn off e-books:

1. I miss the tactile experience.  This is probably the most obvious reason on everyone’s list of a certain generation.  Anyone who was raised (and likely, developed neurologically) reading physical books, probably misses the sensation of turning pages – the weight of the paper, the new-book and old-book aroma, the palpable crack of the spine upon completing the ritual of properly opening a new book for the first time. That ritual, incidentally, came to me courtesy of my outstanding third grade English teacher, Mrs. Walton.  I never think of Mrs. Walton when I fire up my iPad.
2. Thickness of the remaining pages is part of the experience.  E-readers all have some sort of “percent completion” feature to let you know how much of the book you have plowed through.  I need the feel of the remaining pages.  Beyond the purely tactile experience, a thick book, with lots of unread pages, motivates me (“you have a lot to read…better get to it”).  For a cliffhanger, it gives me a sense of how much time the author has to wrap things up. It helps to manage my expectations.
3. My nightstand is a major motivator.  I always have a half-dozen or so books on my nightstand in various stages of completion.  They are a constant reminder of commitments I have made, but have not yet met.  My “stack” in my e-reader probably has dozens of waiting commitments.  I have no memory of many of the books I downloaded on a whim.  I never look at my queue.  My lost books float in cyberspace, like a sailor cast adrift on a life raft hoping to be discovered.
4. The thrill is the hunt.  I love to go to the bookstore, wander around and stumble upon an unexpected treasure.  As I carry my latest acquisition around the store, I have a sense of anticipatory excitement I never experience with an electronic download.
5. Written margin notes help me learn.  As I read, I make occasional notes in the margin.  Frequently, particularly when reading non-fiction, I will flip back to my earlier notes.  Years later, when I pick up a book I previously enjoyed, I review my old notes to jog my memory of the book.  Electronic highlighting does not have the same impact.
6. I like maps.  When I read history, I love books with maps.  I like to dog-ear the pages with interesting maps, and flip back frequently as I am reading.  The ability to casually flip back to a certain page does not work well with an e-reader.
7. I enjoy looking at my bookshelf.  At home, my desk is surrounded by bookshelves.  I enjoy glancing at the spines, reminded of great books I have read.  I feel pangs of guilt for the few volumes I was never able to make it through (but will someday).  I am surrounded by friends.  I never spontaneously flip through my electronic queue, nor does it evoke any real affection.
8. My memory is flawed.  When I read a physical book, every time I pick it up, I see the title…the author’s name…the cover art.  Subsequently, I remember the details, in part due to repetition. When I read an electronic book, I am frequently in the position of enthusiastically attempting to recommend it to a friend, while struggling to remember the author’s name, and sometimes even the title.
9. I am distractible.   Reading is sometimes an effortless pleasure.  Reading is sometimes a painful slog.  Part of the benefit that comes from reading a great book is the investment you have to make of yourself in the experience.  I love to read John le Carré. The early chapters of his books are always challenging.  He drops you into the middle of a confusing story, with incomplete information. The motivation of his characters and the complexity of their situations are revealed very slowly.  It requires patience and commitment.  If the first few chapters of The Spy Who Came In From the Cold had to compete with my email, text messages, Facebook, Instagram, LinkedIn, Solitaire, Pandora, etc., I might not have ever made it through one of my favorite books.

For these reasons, and others, I am declaring my liberation from e-books.  Now, back to my reading, as soon as I finish labeling the Kodachromes in my photo albums.