What’s pandemic preparation like for a healthcare worker and a physician family?

California is officially on lock-down for the international pandemic that is COVID-19. According to the Wall Street Journal on 3/19,

“California ordered its 40 million residents to stay at home except for essential activities beginning Thursday night in the largest such lockdown in the U.S., as the nation’s total coronavirus cases rose to more than 14,000 and an intensifying outbreak in Europe pushed State Department officials to advise citizens not to travel abroad.”

We have been bracing for the outbreak, and social distancing since 3/8, the day after my birthday. At a combined birthday party, we learned of our first case of community-acquired COVID in our area. Between having a toddler at school, a musician playing out every night, and a healthcare worker in the family, we will have our share of potential exposures. This is about pandemic preparation as a physician family.

It’s felt like bracing for disaster. My two year old touches everything, and touches his face. He rubs his eyes, and throws food on the floor. Having a toddler makes one feel vulnerable to infectious disease. My husband and I were both saddened and relieved when our son’s school closed last week. While we rely on the care and education he’s getting there, we know it also puts us at risk of catching anything in the community. So my husband is the de facto caregiver while I’m at work.

This is possible since as a freelance musician and music teacher, my husband is essentially jobless for the foreseeable future, while I am the breadwinner, on the front lines of a microbial war. No pressure.

Mentally preparing as the hospital locks down

In the meantime, my hospital has restricted all visitors. The vast majority of patients have no visitors, while those facing death can have up to two dedicated visitors (no rotating). There is a fraction, maybe a tenth of the people walking through the halls, compared to a normal day. Temporary shelters stand outside the ED and cafeteria to prepare for a potential surge of patients. Military style tents can become ad hoc hospital wards when the hospital is overwhelmed.

Sheltering in place as a physician family

As a family, we have been self-isolating ahead of the mandate, hunkered down at home for over a week. My son, whose daycare has closed for several weeks, started coughing, without his usual runny nose. He bordered on a true fever. Then my husband began to cough. While I felt subjectively warm and had viremic prickling of my skin, I measured just a degree and a half above my baseline. I wasn’t coughing, but I wondered whether I could be harboring the coronavirus. Although I have no known exposure so far, it’s spread by asymptomatic individuals, so we really don’t know who’s been exposed.  

Prepping family for the pandemic

My dad’s across the country, isolating himself in his apartment in New Jersey. At the age of 70, he’s someone who might not make it, should healthcare rationing come to pass. He’s healthy, but aging. And I’m worried. Meanwhile, he’s worried about me, and likens my clinical duty to being on the front lines in Vietnam. And he’s not the only one making such war-time comparisons. Many physicians communicating online express this grave parallel. I’ve had a lingering sense of dread, that we will not be able to handle the influx of patients. I’m worried about a relentless stream of patients gasping for air. We will run out of time and resources. And rationing is not part of the American health system. The cultural clash will be devastating. To keep my mind off the grim, I can focus on what I can do right now. 

A couple weeks ago, burned out physicians were talking about feeling like a cog in a wheel, but now, that idea is mildly comforting to me. Being able to do my little part in my little silo gives me some sense of agency in this impending crisis. It helps keep me focused on the things I can actually control. But that illusion of control can be shattered in a moment. Again, I’m worried. 

Fear of PPE shortages

I’m concerned about running out of masks and other personal protective equipment, or “PPE,” for us healthcare workers. Just like the toilet paper hoarding, some people have hoarded masks. It’s upsetting to think about experiencing a shortage of PPE for front line workers, who expose themselves and their families to this deadly pathogen to help others. In some places, healthcare workers are already fashioning their own PPE, and re-sterilizing disposable masks. Manufacturers like Tesla are working to pick up the slack, to make PPE and ventilators so we can save as many people as we can, while staying healthy ourselves.

Preparing my department

As head of my section, I pray we can be prepared to care for patients through this time. The SIR put on a webinar called, “Is your IR Lab Prepared for COVID-19?” It featured voices from the front lines in Singapore, but it was overwhelming. We are so unprepared. There’s also a new resource accessible online, the Covid Toolkit, providing information on proper cleaning protocols and protection for IR staff which can be found here.

Resident education in a time of uncertainty

In the meantime, I have a resident rotating with me. He is an internal medicine resident planning to go into interventional cardiology. I am teaching him about imaging, access, and the care of patients in this crazy time. Together, we are continuing to take care of patients who can’t wait 4-6 weeks for their procedure. This is our current guideline for postponing routine care.

That means we are still doing cases like liver ablation and select uterine artery embolizations (UAE), for example. Some UAE cases would normally be elective, but this patient is bleeding so much, that she can’t make it to the bathroom at work before soaking her pants with blood and clots. She’s even needed transfusion. So she can’t wait until this pandemic is over, especially when we don’t know how long it’ll last. We simply don’t have a timeline, so we forge on, taking care of patients, while knowing there are risks in doing so. 

I even checked myself into the ER to get tested the other day, once the work was done. I wasn’t coughing, but the guys in my house were, and I’d had a low grade headache all day. Running a degree and a half over normal for me, I’d been self-monitoring to ensure I didn’t hit a true fever of 100.4 F. Finally, concerned I could unwittingly spread COVID-19 while seeing patients, I pulled the trigger and got tested. Thankfully, for now, I’m negative. I can have some confidence what I have is just a cold, and I can soldier on. Meanwhile, my husband is sick, and solely responsible for childcare while I work. We don’t want to risk passing the coronavirus to our nanny, who may be more vulnerable.

Calm before the storm

It’s eerie to walk down an empty hallway, but comforting too. Less than a tenth the number of people pass through the corridor. The volunteers, most of whom are seniors, are home, sheltering in place. Most patients can have no visitors, unless they’re imminently facing death. In our department, a family member or friend would usually accompany each patient; now, these patients wait alone. It’s a sad consequence of the social distancing protocol we are forced to impose. 

Bracing for emotional trauma

In some cases, the policy, which I agree with, can have devastating consequences for the individual patient. A friend and colleague had to deliver a terminal diagnosis yesterday, and the patient broke down, just wanting to be with his girlfriend. My friend felt so powerless. With the devastating news, the patient was essentially alone. 

I think also of the people in Italy, gasping for air, without enough healthcare workers to attend to them. They may be in pain, or air-hunger, which seems potentially worse, with someone attending to them who can’t hear them as well, and who is overwhelmed by a high patient load. Surrounded by other victims, with no family nearby, you could die alone. Some people aren’t even making it to the hospital. A pathologist pleaded for the ability to test the dead, so we could get a more accurate idea of coronavirus’s mortality. This information is important for those that remain in the fight. 

How rapidly things have changed

A couple of weeks ago, I would’ve been driving to Los Angeles for laser hair removal. I cancelled the moment I heard LA had its first confirmed case of community spread of coronavirus. I didn’t want to risk spreading the disease for this reason. But I think of all the businesses, large and small, and how they’ll suffer. I wonder how many will be forced to close. Those without a cushion for such a disaster will have no choice. And the same is true for individuals: those without an emergency fund are headed for hardship.  

As a family that has financial reserves, I worry: how much is enough? Even if we have money, what good is it if we can’t find basic supplies due to supply disruption and hoarding behavior? In some ways, there is no true preparation for a pandemic as a physician family; we must do the best we can and hope it’s enough. And I worry about everyone else, and the potential for societal break-down. The lengthening lines at gun and ammunition stores make me shudder. 

The daily routine as a physician preparing for COVID-19

Because I change back to street clothes before leaving the hospital, then shower on entering the home, by the time I see my son, it’s 7 pm or later. I don’t know of any specific viral exposure, but assume there are contaminants everywhere. So I come home, shower, and wash my clothes. We do a lot more laundry these days.

There was an SIR webinar sharing strategy from Singapore the other day, and I saw how well prepared and regimented the hospitals were in protecting their workers. They had UV cases with dedicated goggles, and enough for 15 people. Plastic sheets covered every piece of equipment. It probably took an hour to prepare the room for a Covid patient, and over 1.5 hours to clean the room afterward.

Our national preparation for the pandemic

In our ‘developed’ country, we are nowhere near as sophisticated. We like to think we are, because usually, we throw more money at our weaknesses. But in this pandemic, I worry it won’t be enough. Habit related pathologies from diabetes, to lung disease and nonalcoholic fatty liver cost us all hundreds of thousands per patient. Our lack of social responsibility shows. While many have listened to the warnings and sheltered in place, others have continued to travel, enjoy spring break, and minimize the problem we face as “similar to the flu.” These actions will harm us all.  

To make things worse, the public has been getting mixed messages. While all non essential businesses are closed, “leaders” are still saying gatherings are OK, if they involve 10 people or less. How arbitrary! When an asymptomatic carrier of the virus goes to a gathering, up to 9 people can be infected, and those 9 in turn can each infect an average of 2.5 people. That’s the harm of mixed messages.

A vulnerable system

In any case, I will certainly be surrounded by virus soon. I’m not on the front lines, but just behind them. Our newly renovated emergency department is still inadequate to handle our normal patient load at times. Patients spill into the radiology department, taking over IR holding, and one of our ultrasound rooms.

Being just behind the front lines, I’m glad I have an estate plan in place, in case something happens to me or my husband. Although it was expensive and time consuming to set up, we have our living wills and a family revocable trust. This means we formed a legal entity that holds all of our assets. In a revocable trust, my husband and I still control the assets. We can still sell our house, though it belongs to the family trust. But if we pass, there is a plan for Wesley and for our belongings. If we died without a plan in place, the state would decide who raises Wesley, and what to do with our assets. If you don’t have a living will, guardianship for your kids, and an estate plan in place, now is the time.

Should I freak out about the stock market plunge?

Probably not. For those of you early in your career, you may see big losses in your portfolio. It may seem your hard-earned dollars have disappeared. I’ve seen my investment balance drop by $100k. But unless you’re selling, these should not be thought of as losses: they are unrealized losses. You don’t “realize,” or solidify the loss until you sell a security in your portfolio. In a tax-deferred retirement account, there is no reason to sell right now. If you did, you would only solidify those losses, the worst thing you could do. So even though my balances have taken a hit, I won’t sell. I’ll wait for recovery. As long as society doesn’t collapse, those numbers will rebound, as we’ve seen historically.

The one exception to “don’t sell”

On the other hand, if you have a taxable account, you might consider tax-loss harvesting. It took some time for me to understand this concept, and it can be a huge benefit to certain investors. If you have money in a taxable investment account, you could benefit from selling say, an index fund at a loss, and purchasing something similar. This strategy seizes the realized loss, which you can deduct from gains on your tax return, while retaining the lower price of the similar security. You buy the new fund at the bear market rate, and if history is any indication, it’ll likely rebound in value. 

And some good news: if you’re just getting started investing- everything is on sale, and will continue to be for a while. We are headed for recession. So if you are blessed enough to still have a paycheck coming in, it is time to invest. This recession will be a head start in your investing journey, as we recover over the next several years. As the White Coat Investor says: 

Forget to invest the last 4+ years? You can now buy stocks at Dec 2016 prices.

— White Coat Investor (@WCInvestor) March 20, 2020

This is what pandemic preparation looks like for a physician family, including those like me who can’t stay safe at home.

What are you doing to prepare for the novel coronavirus arriving in your neighborhood? 

Wishing your health and good hand hygiene,

Tired Superheroine