Be Like A Tree during the COVID-19 Cytokine Storm
March 28, 2020
The COVID-19 pandemic has definitely proven how powerful Facebook physician groups are. There are three main COVID-19 MD-only Facebook groups, and the clinical discussions, mutual assistance and advice is phenomenal. These are doctors helping other doctors, because we are all trying to save our communities. I was Zoom chatting with engineers from Hewlett Packard yesterday, and they were asking for information on what designs and equipment the medical community needed. I honestly told them, everything is on these Facebook groups. CNN is at least 48 hours behind these groups.
But one of the primary COVID-19 MD Facebook groups has 21,000 members! It can be a whirlwind of journal articles, posts, tutorial videos on how to make PPE and comments. There are journalist on the fringes, friends or spouses of members, and suddenly a post will receive a few comments and is then featured on a major news outlet. This is usually with permission of the commenters of course. You can see the pandemic coming toward you, as MDs from the current hot spots give us a preview of what is to come. One post that has been shared and copied multiple times has mentioned that on “Day 10 of illness Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours,” wrote the internist.
That evening I read that detailed post of the typical course of a bad COVID-19 case and that sentence about Cytokine storm on Day 10, there was also an unusual hail storm in Southern California. Hail storm, cytokine storm, dense ice hitting our windows at an oblique angle, deluge of proinflammatory interleukons and T cells overwhelming the alveolar cells, city storm drains being flooded, lungs losing their surface area that performs vital gas-exchange. The imagery is horrifying yet hauntingly powerful.
The odds are good that most of us will not have a cytokine storm on Day 10 of illness. Yet as more and more get sick, and statistically more and more stories are spread about human lungs succumbing to the cytokine storm – all of us will start becoming afraid. I have put my demographic and health status information in a COVID-19 epidemiologic calculator and my risk relative relative to a 65 year old man is 0.11. Yes Dr. Plastic Picker is still afraid. The children’s relative risk is less than 0.03 or something. But even that epidemiologic calculator is not enough to take all my worries away. It’s human nature to worry.
But I have decided that during this time I’m theoretically worrying about the remote possibility of the COVID-19 Cytokine Storm, living through a real hail storm, and getting through this difficult time being a medicine and worrying about the world, my patients and my own family – I should be like a tree. This is what I tell children when I counsel them about possible childhood abductions by strangers. I know this is not a likely threat, but it is something that parents ask about. I don’t remember where I heard this, but I recount this advice. Be like a tree. A tree is rooted to the ground. Don’t let them move you. You can sway like a tree but keep your feet on the ground. I have had a few children in my practice that this has happened to them. Someone tried to abduct them and they escaped. One was at a local mall. My own daughter was approached by a strange older man at Walmart while sitting in the shopping cart and I was 2 feet away. My heart pounding when I saw him approach her, I snatched her away and after that unable to walk into that Walmart for the next 5 years.
So during these stormy days, Dr. Plastic Picker will seek to be like a Tree. I am more helpful to the world if I stick with my roots. I want to be like everyone, and brush up on my ICU skills and dive into the ED or ICU to help. But it’s unlikely that an outpatient pediatrician who does not see adult patients and is 14 years from my last ICU rotation will get called to intubate anyone. I’m more likely to intubate their esophagus than their trachea, and I’d probably use too small of a tube anyway and spread COVID-19 everywhere. So what are my roots? Here are five things I can do mostly to help. Yes dear reader, I love blog posts with list of FIVE! Short and sweet.
- I am a general outpatient pediatrician. So I will continue to practice outpatient pediatrics, since ear infections, asthma and appendicitis are still going to happen during this time. I will show up to work every day and wash my hands, including my thumbs. I will deliver sound pediatric care as much as I can, and I will care for the caregivers children. I am the pediatrician for a lot of nurses, pharmacists, health secretaries and medical technologists. They are all stressed. So I can help them be more helpful, by taking care of their children, and keeping kids out of the emergency room.
- I am a middle-manager. I am still a middle manager, so I need to continue to help run my department. Again rather than diving into the ED, I need to continue to smartly staff our clinics and helping with medical building workflows, keeping staff informed and reassured that we are as ready as we will be. Having a clear-headed clinic lead is more important to reassure staff, and reduce their own stress.
- Decrease Infection Spread in the Four Clinics I have Control Over: I also have partial or complete MD oversight over several clinics. These are physical spaces that can become a foci of COVID-19 spread. So I have partially shut down the lunch room and coffee pots. I have limited only 2-3 in the lunch room, and we have stopped communal food. This is important to keep our staff healthy so things don’t spread among our health care staff. I am trying to set a good example and telling folks to come to work, and go straight home and not hang out unncessarily in clinic. The more we social distance at work, that is important as well.
- Gather PPE Supplies and Donations: I am gathering PPE Supplies and Donations for our organization. I have had interesting high-level discussions with groups like Hewlett Packard, but honestly I think they are too late. We needed PPE supplies like 2 weeks ago. They are pitching in 50 faceshields. I had our secretary make 50 faceshields in an afternoon, following an Ob-Gyn YouTube video tutorial that utilized self laminating plastic sheets and foam I had at home already. Amazingly easy and good enough for outpatient if we completely run out of supplies. No one has approved these. I’m just keeping them at home just in case. When we have nothing, I’m sure someone will want these. Faceshields are just pieces of plastic anyway hanging over your face. At the most, we are just examining kids and doing swabs.
- Coordinate Per Diem Staff: I recruited and hired a robust group of per diem pediatricians. They actually want to work. So it makes sense to continue to coordinate and support them, so they can periodically relieve our full time staff. There is a downtrend in pediatric outpatient needs, but as our inpatient staff get pulled to take care of older patients maybe into the mid 20s – we will probably need to tap them for virtual or outpatient clinics.
So during this continued COVID-19 pandemic, possible Cytokine storm for some, and chaos for all – Dr. Plastic Picker realizes that I am most helpful just doing my job. I have to be like a tree, and stick with my roots. Rather than diving in to do medical work I am not trained to do, I need to continue to be an outpatient pediatrician, HMO middle manager, work to ensure health care worker safety through workplace infection control and increase PPE supplies, and also coordinate how our per diem staff can help. But I’ll continue to check those COVID-19 Facebook groups and follow along at the amazing things that ED and ICU doctors and internist are doing. I cry for them and I want to help them. But I will be most helpful if I let them do their job, and do mine to my utmost ability.
Apolgoies for all the mixed metaphors. As you can see from the trash art below, Dr. Plastic Picker is a bit mixed up in my brain these days. Thanks for following along, and this helped me organize my thoughts quite a bit!
I also had trees on my mind, click here to read about when our Girl Scout Troop earned their Trees Badge https://drplasticpicker.com/everyone-should-earn-their-trees-badge/