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Tuesday Mar 31, 2020

Taking Care of Each Other in This Time of Crisis

You know that feeling when a huge storm is coming? If you live on the East Coast or Gulf Coast, you likely have prepared for tropical storms or even hurricanes. If you live in the Midwest, you've run to your basement when tornado sirens blare. Folks up north know what it's like to be snowed in for days at a time.

[Kimberly Becher, M.D., and staff]

Here I am (far left) with my colleagues in our new gowns. When our clinic needed protective equipment, community volunteers made us about 20 gowns in roughly 48 hours.

These events have the potential to change the entire trajectory of your life. Your plans are canceled; you don't know when or where you might get stuck if you leave your house. You feel anxious, nervous, your heart rate goes up, you can't sleep well despite feeling exhausted. You know you need to rest, but you can't, even though literally nothing is happening inside your home. You can do nothing but sit and wait.

That's what it feels like to work in health care right now in West Virginia. Honestly, it is probably what it feels like just to live in West Virginia for many people right now.
Since the beginning of March, I've felt a weight on me every time I go into an exam room, and it gets heavier each day.

On March 10, I tweeted advice for people to get their advance directives in order, specifically mechanical ventilation preferences.

March 13 is when my office started a process of triaging patients on arrival into categories of asymptomatic or symptomatic. It also was the day school closures were announced.

It wasn't until March 17 that West Virginia had its first positive COVID-19 test, and I was actually grateful. Someone on social media described it as what winning the Hunger Games would feel like because we were the last state to report a case. I wanted 100 positives to shake people out of their stupors because, from an epidemiology standpoint, it was impossible for our state to have zero cases.

West Virginia is known for being last in so many categories associated with negative outcomes. Closing schools before any positive tests came back was a huge win for public health. Our other big win is being ahead of the curve on mandatory vaccinations for school-aged children. But one of our biggest losses is the overburdening of grandparents (and great-grandparents) with raising grandchildren,(data.census.gov) which could have some dire consequences if we don't aggressively contain this pandemic.

As our governor would say (and there is now a helpful book to help decipher his speech patterns),(wvliving.com) "the $64 question" is why did we go so much longer than other states without a positive test? I think there are quite a few factors at play.

One goes back to what I love most about my patient population. I rarely see the worried well. I see the opposite end of the spectrum. Maybe it goes back to a lack of access to care before West Virginia's community health center network existed, to not trusting physicians or to the scandals of hiding the known risk of black lung until it was too late for too many. I think most people here do not seek care unless they feel they desperately need it. Patients often apologize to me for coming to the office. I always reassure them that this is literally my job to see them, to listen and to help them.

No one came in my office early on asking to be tested for COVID-19. And even now, with positive tests reported in our state, it is rare for someone to ask. Unfortunately, those asking are being forced to by employers, which is an entire blog post in itself. And no, we aren't testing asymptomatic, or mildly symptomatic, patients with our tiny allocation of testing supplies.

People outside West Virginia may assume no one here travels, that we wouldn't have any contact with anyone from another country, etc. That is definitely not the case. Sure, we have fewer international travelers than somewhere like New York or Los Angeles, but West Virginians like beaches, and we have a lot of missionary and military travel. And unfortunately, the few people across the state who did present early on with symptoms or request testing were met with strict guidelines that prohibited testing anyone who didn't meet criteria of being severely symptomatic, at high risk or with known exposure, or all of the above. I'm not saying those criteria were initially right or wrong given how inadequate our testing supplies were and how long it took (and still is taking) to get results. I don't feel those sparse early tests would have changed our trajectory. We had our ducks in a row with business and school closings even before the storm hit.

Now West Virginia is starting to match national data, with an approximate doubling of confirmed cases every 48 hours. My office is still not busy. In fact, it is quiet and empty. Yet I don't feel calm. Every time I see a patient, I think about the guilt I will feel if they end up infected after coming in to see me, if they are somehow exposed on the way to, or in, my office. I unfortunately have the morbid thought of potentially never seeing them again. And that is with a triage system at my office's front door that separates symptomatic from asymptomatic patients, with each group seen in different buildings by different teams, and me working on the asymptomatic side. We have N95 masks, gloves, face shields, and as of yesterday, gowns.

I have written previously about our state's food insecurity, and specifically about my own county. We still have no grocery store. One of our two dollar stores is closed for renovations. So, in an era of people being afraid to travel far to a large, crowded Walmart in another town, there is one Family Dollar store in town where people can buy food. There are kids staying home, missing being fed two, or even three, meals at school. For adults, there is the frightening reality of being off work due to isolation protocols and business closures to prevent further spread of the virus.

So, we carried on with one of our food distributions, which are a combined effort of the Mountaineer Foodbank and the United Way. We typically provide food to more than 300 families -- more than 1,000 people -- at one of these monthly events. They are much like the drive-through COVID-19 testing sites. People drive up, we put food in their cars, and they leave. Efficient. This week we provided food to somewhere between 450 and 500 families. We did everything we could to decrease any potential exposures. I was double-gloved, wore an N95, and primarily was a box opener and milk organizer. But I didn't feel this was a service we could put on hold or cancel. I felt canceling would cause more risk, not less.

And it was at that food distribution that patients called out from vehicles asking what I needed. Some of these people I knew to be talented seamstresses, bakers and craftspeople. So I went big and asked for gowns. We had seven gowns at the onset of this pandemic. Technically we should be changing gowns between patients, but instead, if we wore one at all we wore it all day, or for one particularly sick patient being swabbed for the flu or COVID-19. My request for gowns was made at 8 a.m. on Saturday. By Monday morning, I had about 20 amazingly constructed gowns at my office. It really did feel like Christmas, and I felt like Santa passing them out to as many people as possible, although some still don't have gowns.

Masks soon followed, and we are using them to cover our precious N95s. Someone also brought us a box of N95s. It was a good day.

I have seen advertisements on social media for T-shirts that say, "I survived COVID-19, you stay in your holler and I'll stay in mine" with an outline of our state. Sure, they are funny, but I, unfortunately, would say, "Y'all ain't survived nothing yet."

We aren't even in the storm yet. We can just see the clouds rolling in. And we might miss the first wave that our friends in New York are trying to survive, but we won't escape unscathed. And even if we in West Virginia -- where people in some counties can stay isolated without really trying -- suffer fewer lives lost than our more populated states, we won't escape the economic impact.

For outpatient medicine, the telehealth boom has hit. We all scrambled across the entire country to find ways to care for patients without putting them or us at risk of exposure by coming into a brick-and-mortar building. Some offices will thrive on this model. Patients who have the ability to do video visits from their own homes or offices will never want to go back to the old ways of waiting rooms. But in rural West Virginia, this will not be my saving grace. Large portions of my state have no cell phone service and no internet. And do not be swayed by those satellite internet offers. I couldn't even check my email on it when I had it at my house.

We are trying -- calling and coaching patients using cell phones, tablets and laptops -- but for the majority it is not a hurdle, it is an impossibility.

We initially thought all those kids living with grandparents could help them, but you can't connect a tablet to a service that doesn't exist. I have had patients drive to my office and do telehealth visits from the parking lot because there is cell service in town. We also have patients pulling up and borrowing a tablet, which we sanitize, to do a visit from their vehicle.

But this will not be enough to save rural family medicine practices from financial ruin. Still, we need to be here now. And we will need to be here to help patients on the other side of this pandemic. People will grieve, they will have depression, they will have uncontrolled diabetes from eating ramen noodles for weeks, they will have heart attacks that go untreated, with resulting heart failure. It isn't just the thought of losing lives now that feels too heavy, it is the long-term fallout and uncertainty that I think is leading to something called anticipatory grief.(hbr.org)

And, I'm sorry, you can't treat all that over the phone, even if you are getting paid for it. Rural family doctors need help keeping their doors open, because people are definitely going to need to walk through them in masses months from now.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va. You can follow her on Twitter @BecherKimberly.(twitter.com)

Read other posts by this blogger.

Posted at 04:27PM Mar 31, 2020 by Kimberly Becher, M.D.

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