• Navigating Paper Walls, Digital Windows in Pandemic

    This is not your typical COVID-19 physician diary. My new physician colleagues have done a remarkable job sharing their stories of patient deaths and emotional trauma in busy city hospitals, but I want to provide you a glimpse of my life as a rural family physician during this pandemic.

    In the small Missouri towns where I live and work, we have not yet had evidence of significant community spread of the virus, so my experience of preparing for COVID-19 has been less dramatic than what my colleagues are facing in New York, where I completed my residency.

    Now -- no stereotyping, please -- but for context, you should know that I am a New Yorker of Italian descent. I've been told I have the gift of gab, but wearing masks all day has necessitated the development of new communication skills. I was already good at talking with my hands, but lately, I've become an expert at expressing myself with my eyes. To overcome my muffled voice, I find I'm speaking even louder than before. I have to, especially with my elderly patients, who often have hearing impairment. I find myself having to choose between sitting six feet away from patients and speaking with my mask off so my voice is clear and they can read my lips, or keeping my mask on and leaning in close so they can hear me. I wonder which is safer.

    Not only am I naturally gregarious, I'm also a hugger. I don't often hug my patients, but I do believe in the importance of physical contact while also respecting personal space as a family physician. Typically, I like to shake my patients' hands, often finishing in a warm, two-handed clasp. At the least, I'd sometimes opt for a friendly pat on the shoulder. Now, at least for the foreseeable future, those days are over. Our once-comfortable, barrier-free, face-to-face encounters have been interrupted by paper walls (masks) and digital windows (telemedicine).

    It took a while to get used to these changes, which seemed designed for higher-risk areas. What makes it even stranger is that the COVID-19 crisis has not yet had a significant impact on our community, except for the changes we ourselves have made in preparation. I feel I am living in a surreal, paradoxical reality, like something out of The Twilight Zone. I do what I am supposed to do, attending COVID-19 preparedness Webex meetings, following all the protocols and testing patients who meet criteria. But, as I am writing this, our COVID-19 numbers are almost nonexistent, and my nursing home patients remain unaffected. So, I cross my fingers, say a grateful prayer and continue going through the motions, knowing I am doing everything in my power to stay safe and protect my patients and staff.

    I find myself standing in a hallway talking to a co-worker and trying to stay focused as I watch my colleague's soft, foldable N95 mask get sucked in and form a mouth, which moves up and down like a napkin puppet, and wonder what a strange world this has become. In another instance, I might be sitting in my office talking to a staff member who asks if it's OK to take their mask off for a moment to catch a breath and relieve the feeling of hyperventilating.

    Meanwhile, most of us in my community have not yet treated a patient with a known diagnosis of COVID-19, and many have not even been in contact with someone reported to have had it. In our local reality, the biggest impact this pandemic has had on our daily lives is in the adjustments we have made as a community. We have seen it in the closed or severely restricted businesses and churches, the bare shelves at stores, and the budgetary restrictions at our hospital, clinics and other places of work that have led to furloughs. Here, our pain from this virus seems self-induced.

    Yet, we continue going about our day, masks on, breathing in our own CO2 and smelling our own breath, like health care workers in the rest of the world, many of whom are simultaneously dealing with critically ill and dying patients. The harsh reality of this pandemic is not lost on us. We feel the weight. I remind myself of what others, some not very far away, are going through. I consider the people I know, some of whom will read this blog, who have lost loved ones to this scourge.

    I think of my sister, who is only a year out of nursing school and is now on a COVID-19 floor in a New York hospital. Having lived with me in Missouri during her training, she knows what life is like in this quaint, peaceful little town. Now she tells me stories of how her face shield fogs up and the foam band where it encircles her head disintegrates due to a combination of sweat and spray sanitizer treatments.

    I hear stories from my colleagues in metropolitan areas about overrun ERs and maxed-out ICUs. I am not surprised. I remember what it was like admitting patients from the ER and managing them in the med-surg and telemetry units of my hospital in the Bronx. Even on a good, slow day, it was never easy. I can only imagine, with a twinge of survivor's guilt, what it must be like for those brave souls who are battling it out in the inner city day and night.

    I don't regret the decision I made to become a rural doc. I feel fortunate and blessed. I have the privilege of providing routine, full-spectrum care for my patients and educating them about COVID-19 -- how to prevent contracting it, and what to expect if they do. I have come to really enjoy and be efficient in conducting telemedicine visits. Patients have learned to wait in their cars before labs and appointments. My higher-risk patients now use a back entrance to the hall where my exam rooms are. Most wear masks. We've got this down.

    Our hospital has had a big head start on this pandemic, and we are ready. I feel prepared mentally, but not emotionally. My community is preparing for Phase 2 of loosening quarantine restrictions. Having completed six weeks of stay-at-home orders, I know there is no good reason to expect that the virus numbers won't now begin to steeply rise. I don't want to become complacent, but like many in my community, I have this irrational hope that maybe the strange lingering chest colds many of us saw and experienced from December through February were the feared coronavirus. Maybe the plague passed through before we had the tools to test for it, and we have already achieved some level of herd immunity. I know it's too much to hope for, and we have a ways to go until a vaccine is ready. Not that it would matter. There are many people in my community who are vaccine-resistant. Nationally, one-fourth of Americans say they will refuse the vaccine whenever it becomes available.

    Just thinking about the possibility of a flood of COVID-19 cases inundating my small, 72-bed hospital gives me anxiety. I don't think these wonderful, independent-minded country folk will put up with another quarantine as well as they did the first time. Many here are already wondering if it was worth it this time around, and I don't think our rural community or health care system could sustain the economic impact of further sequestration.

    So, I grimace under my mask just a little, with my fingers crossed, and I pray even more earnestly than before.

    Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in rural southwest Missouri.

    Read other posts by this blogger.


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