When Flesh and Heart Shall Fail

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(Ten years ago this week, this healthy young college student came to our clinic stricken with seasonal influenza complicated by pneumonia.  His family gave permission for his story to be told.)

 

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Nothing was helping.  Everything had been tried for a week of the most intensive critical care possible.  A twenty year old man, completely healthy only two weeks previously, was dying and nothing could stop it.

The battle against a sudden MRSA pneumonia precipitated by a routine seasonal influenza had been lost.   Despite aggressive hemodynamic, antibiotic, antiviral and ventilator management, he was becoming more hypoxic and his renal function was deteriorating.  He had been unresponsive for most of the week.

The intensivist looked weary and defeated. The nurses were staring at their laps, unable to look up, their eyes tearing. The hospital chaplain reached out to hold this young man’s mother’s shaking hands.

After a week of heroic effort and treatment, there was now clarity about the next step.

Two hours later, a group gathered in the waiting room outside the ICU doors. The average age was about 21; they assisted each other in tying on the gowns over their clothing, distributed gloves and masks. Together, holding each other up, they waited for the signal to gather in his room after the ventilator had been removed and he was breathing without assistance. They entered and gathered around his bed.

He was ravaged by this sudden illness, his strong body beaten and giving up. His breathing was now ragged and irregular, sedation preventing response but not necessarily preventing awareness. He was surrounded by silence as each individual who had known and loved him struggled with the knowledge that this was the final goodbye.

His father approached the head of the bed and put his hands on his boy’s forehead and cheek.  He held this young man’s face tenderly, bowing in silent prayer and then murmuring words of comfort:

It is okay to let go. It is okay to leave us now.
We will see you again. We’ll meet again.
We’ll know where you will be.

His mother stood alongside, rubbing her son’s arms, gazing into his face as he slowly slowly slipped away. His father began humming, indistinguishable notes initially, just low sounds coming from a deep well of anguish and loss.

As the son’s breaths spaced farther apart, his dad’s hummed song became recognizable as the hymn of praise by John Newton, Amazing Grace.  The words started to form around the notes. At first his dad was singing alone, giving this gift to his son as he passed, and then his mom joined in as well. His sisters wept. His friends didn’t know all the words but tried to sing through their tears. The chaplain helped when we stumbled, not knowing if we were getting it right, not ever having done anything like this before.

Amazing Grace, how sweet the sound,
That saved a wretch like me.
I once was lost but now am found,
Was blind, but now I see.

Through many dangers, toils and snares
I have already come;
‘Tis Grace that brought me safe thus far
and Grace will lead me home.

Yea, when this flesh and heart shall fail,
And mortal life shall cease,
I shall possess within the veil,
A life of joy and peace.

When we’ve been here ten thousand years
Bright shining as the sun.
We’ve no less days to sing God’s praise
Than when we’ve first begun.

And he left us.

His mom hugged each sobbing person there–the young friends, the nurses, the doctors humbled by powerful pathogens. She thanked each one for being present for his death, for their vigil kept through the week in the hospital.

This young man, now lost to this life, had profoundly touched people in a way he could not have ever predicted or expected. His parents’ grief, so gracious and giving to the young people who had never confronted death before, remains unforgettable.

This was their sacred gift to their son so Grace will lead us home.

 

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Coughing Round the Clock

‘Tis the season to be coughing…

It no longer takes an epidemiologist looking at absenteeism rates in schools to predict the start of influenza season.  For several years now there have been sophisticated models using search engine terms to monitor increasing incidence of febrile cough illness in regions of the world as well as sentinel clinics reporting on influenza-like illnesses.

Or just ask a primary care clinic what its waiting room sounds like these days — a chorus of coughs, high, low, dry, moist, choking, barking, hacking, gagging, wheezing.  In our clinic, every patient is handed a surgical mask at the reception desk, whether coughing or not, with the explanation “for your protection and others’.”   A sea of blue masked faces glances up every time the nurse comes to call a patient back to an exam room.

In reality, it isn’t that clear how effective simple disposable masks are in preventing the spread of viral illness, but they are likely better than using nothing in crowded symptomatic people on public transportation, in a classroom, or a clinic waiting room.  Masks do make it more difficult to touch facial mucus membranes with contaminated hands if you can remember not to rub your eyes.

So we are in the thick of it now, with patient volumes up 30% over the usual load with extra staffing needed to manage the increased phone calls and electronic messaging.   We do rapid flu tests for those patients who fit criteria for Tamiflu treatment, otherwise, we are primarily looking for those at risk for flu complications, all the while trying to make the miserable a little less miserable.  Otherwise the usual self-treatment advice applies, especially stay home, stay home, stay home.

Once the fever and body aches subside,  one little residual symptom is usually left behind: a post-viral cough serves as a humbling reminder of the persistence of influenza inflammation and irritation in the respiratory tract.  Although no longer infectious by ten days after onset of illness, the cough can last up to three weeks or more, no matter what the patient does or takes.  It can be round the clock, interrupting everyone’s sleep from a constant tickling pressure in the trachea and a sensation of heaviness in the chest.   Although this cough is unlikely a risk to spread infection to others, it certainly sounds to others like a potential threat, so wearing a mask is advised as a courtesy and a reminder to protect others at all costs.

Has modern medicine found an answer to the plague of post-viral cough, other than preventing the whole illness to begin with by vaccinating for influenza?  Dropping out of polite society for three weeks isn’t possible for most people. Post-influenza patients must allow their bodies time to heal from a major insult that required a significant immune system response but most of us do need to get back to work and school.

What’s a doctor to do?

Antibiotics certainly aren’t the solution and never have been, but historically they (and a narcotic cough suppressant) were the easiest prescription for physicians to write for a tired and frustrated patient.  The aisle in local pharmacies for “Cold/Flu Remedies” seems to lengthen annually with new combination over-the-counter products.  Heavily marketed items vanish quickly off the shelves as people search in vain for relief.   Every imaginable combination of menthol, eucalyptus, and honey-lemon has been tried and tried again.   Probably chicken soup is still just as effective as anything else.

This is a time for tried and true wisdom:  this too shall pass.

Just please don’t pass it to others.

Being Led Home

photo by Josh Scholten
photo by Josh Scholten

Nothing was helping.  Everything had been tried for a week of the most intensive critical care possible.  A twenty year old man, completely healthy only two weeks previously, was holding on to life by a mere thread and nothing and no one could stop his dying.

His battle against MRSA pneumonia precipitated by a brief influenza-like illness had been lost.   Despite aggressive hemodynamic, antibiotic and ventilator management, he was becoming more hypoxic, his lungs collapsing and his renal function deteriorating.   He had remained unresponsive during the ordeal due to intentional sedation for his time in the ICU.

The intensivist looked weary and defeated. The nurses were staring at their laps, unable to look up, their eyes tearing. The hospital chaplain reached out to hold this young man’s mother’s hands.

After almost a week of heroic effort and treatment, there was now clarity about the next step.

Two hours later, a group of family and friends gathered in the waiting room outside the ICU doors. Most were the age of their friend; they assisted each other in tying on the gowns over their clothing, helped distribute gloves and masks. Together, holding each other up, they waited for the signal to come in after the ventilator had been removed and he was barely breathing without assistance. They entered his room and gathered around his bed.

He was ravaged by this sudden illness, his strong young body beaten and giving up. His breathing was now ragged and irregular, the sedation preventing response but not necessarily preventing awareness. He was surrounded by silence as each individual who had known and loved him struggled with the knowledge that this was the final goodbye.

His father approached the head of the bed and put his hands on his boy’s forehead and cheek.  He held his son’s face tenderly, bowing in silent prayer and then murmuring words of comfort. It was okay to let go. It was okay to leave us now. We will see you again. We’ll meet again.  We’ll know where you can be found.

His mother stood alongside, rubbing her son’s arms, gazing into his face as he slowly slowly slipped away. His father began humming, indistinguishable notes initially, just low sounds coming from a deep well of anguish and loss.

As the son’s breaths spaced farther apart, his dad’s hummed song became recognizable as the hymn of praise by John Newton, Amazing Grace.  The words started to form around the notes. At first his dad was singing alone, giving this gift to his son as he passed, and then his mom joined in as well. His sisters wept and sang. His friends didn’t know all the words but tried to sing through their tears. The chaplain helped when we stumbled, not knowing if we were getting it right, not ever having done anything like this before.

Amazing Grace, how sweet the sound,
That saved a wretch like me.
I once was lost but now am found,
Was blind, but now I see.

Through many dangers, toils and snares
I have already come;
‘Tis Grace that brought me safe thus far
and Grace will lead me home.

Yea, when this flesh and heart shall fail,
And mortal life shall cease,
I shall possess within the veil,
A life of joy and peace.

When we’ve been here ten thousand years
Bright shining as the sun.
We’ve no less days to sing God’s praise
Than when we’ve first begun.

And then he left us, his flesh and heart having failed, to enter into a new life of joy and peace.

His mom hugged each sobbing person there–the young friends, the nurses, the doctors humbled by a powerful pathogen. She thanked each one for being present for his death, for their vigil kept through the week in the hospital.

This young man, stricken by a common virus followed by a devastating bacterial pneumonia, was now lost to this mortal life, having profoundly touched so many people in his dying. His parents’ grief in their loss, so gracious and giving to the young people who had never confronted death before, remains, even now a few years later,  unforgettable.

This was their promise to their son as they let him go, as he was lost to them: that he would be found, that he was deeply loved.
This was their sacred gift to us who witnessed this love in the letting go: such Grace will lead us all home.

 

Forgetting About the Killers

It’s only been a little over fifty years since vaccinations became routine for the childhood killers like polio, measles, mumps and whooping cough.  People my age and older had no choice but to suffer through childhood infectious diseases given how effectively and quickly they spread through a community.   Most of us survived, subsequently blessed with life long natural immunity.  Some did not survive.  And I think we’ve forgotten that.

As a physician, I help enforce vaccination requirements for a state university.  A day doesn’t go by without my having a discussion with a prospective student (or more likely the student’s parent) about the necessity for our requirement for proof of  mumps, measles, rubella vaccination immunity.  I have been labeled a Nazi, a Communist, a pawn of the pharmaceutical industry and many more unprintable names because I happen to believe in the efficacy of modern vaccine to help keep a community free of infectious disease outbreaks that will kill people.

We have forgotten these are honest to goodness killers of healthy human beings.  We forget that unvaccinated children continue to die in developing countries for lack of access to vaccine.   Yet educated and well-meaning American parents make the decision daily to leave their children unvaccinated, believing they are doing the best thing for their children by protecting them from potentially rare and often unproven vaccine side effects.    I’ve had caring loving parents tell me that God will provide the needed immunity if their child gets sick so taking the risk of a vaccine is unnecessary.    Actually they are banking that everyone else will be vaccinated.  The problem is:  guess again.  There are now too many deciding that they are the ones who can remain vaccine-free.   Babies died in California this past year from becoming infected with whooping cough–in the year 2010– when this is a completely preventable illness.

 

I tell these parents  God does provide  immunity–after suffering through a life threatening disease which threatens those who are unfortunately exposed.  He also provides immunity in the form of a vial of vaccine, a needle and syringe.  I don’t think any one of these parents would deny the life saving miracle of injectable insulin for their child diagnosed with diabetes, nor would they fail to strap their child into a car seat.  Vaccines are miracles and instruments of prevention too, but the rub is that we have to give them to healthy youngsters in order to keep them healthy.

 

As a society, or as clinicians, we simply don’t think about immunizations in the same way as we did in the fifties.  When I received my first DPT vaccination at the age of 4 months, my mother wrote in my baby book:

“Up most of the night with fever 104.5 degrees,  considered a good ‘take’ for the vaccine.”  She truly was relieved that it had made me sick,  as it meant that I would be safe if exposed to those killer diseases that were so common in the 1950s.  Now a febrile reaction like that would almost be considered grounds for a law suit.

 

I’m an old enough physician to have seen deaths from these diseases as well as the ravages of post polio paralysis, the sterility from mumps and deafness from congenital rubella.   My father nearly died from the mumps that I brought home from school when I was eight and he was in his early forties.   My sister-in-law almost didn’t pull through when she was an infant and contracted pertussis.  I’ve seen healthy people develop  encephalitis and pneumonia from chicken pox.    I’ve seen a healthy college student die of influenza within a week of getting ill.   There is an epidemic of fear in our society that is unwarranted: as Seth Mnookin, a journalist covering science topics wrote in Newsweek and his upcoming book “The Panic Virus”, “If only there were a shot for irrational fears.”

 

I wish vaccines were perfect but they aren’t.   Nothing is.  I wish medications that are developed for treatment of some of these illnesses were perfect but we can’t depend on a guarantee of cure once sickened.   I wish our immune systems were perfect, but they too fail and people do die.

 

There will always be a new plague–history has demonstrated that over and over with the appearance of  HIV, SARS, Avian flu, or multidrug resistant tuberculosis.   There is plenty to keep our immune systems at the ready because we don’t yet have effective vaccines widely available.

 

There is simply no good reason to invite the old plagues back into our homes, our schools,  our blood streams, and onto our death certificates.   They deserve to be considered the killers of yesteryear now overcome by modern medicine–merely a footnote in the epidemiology history books.

 

Listen to a child with whooping cough on this link:

Portrait of baby

A Febrile Ceasefire

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Flu viruses rank up there with mosquitoes, rats, and slugs as creatures of questionable value to the Planet Earth.    I realize there is a reason for all things at all times, but how I managed to invite one of these little RNA stuffed darlings  into my nasopharynx is a mystery.  I was washing my hands to the point of being red and raw and wearing a N100 mask when in contact with hundreds of coughing feverish patients.  It still happened.  It outsmarted sanitizer, respiratory barriers, and social distancing.  So now on day three of fever and general misery, I bow in homage to the virus that lays millions low.  Misery does not love company.

Viruses do tend to have an equalizing effect on society.  They are no respecters of social status –one nose and set of lungs is as good as another.  However, the fact that thousands of deaths occur annually due to these little creatures is significant.  You’d think a virus would know better than to kill its own host, but some hosts can’t take the onslaught of cytokines and inflammatory response.   It is still pre-H1N1 vaccine in most parts of the world, and some of the antiviral medications have little effect, so it becomes an outright virus vs. host battle.  That’s what it feels like: a Lord of the Rings-Orks against the Elves and the Dwarves-onslaught happening in every muscle of my body.  I’d forgotten about some of those muscles.  Some haven’t made themselves known for decades, probably not since my last influenza, or when I tried taking a yoga class in my twenties.

So my only physiological response is fever.  This isn’t necessarily a bad response, as some studies suggest that a hot host is not a hospitable host to many viruses.  We’re not nearly as tolerant of fevers as we used to be.  A recent study has shown that giving a dose of Tylenol to children before or after their routine immunizations, to help decrease pain and fever, actually blunts the immune response so they don’t make as much antibody, which is the whole point of the vaccination to begin with.  So there may actually be need for fever in certain circumstances.  In my lovely 50’s era baby book, my mother noted in 1955 that my 6 month shot was a “good take” because I spiked a 104 degree fever, signaling a good immune response to the vaccine.  That was one way the doctors calmed down nervous mothers about brand new vaccines.  Fever is a “good” sign.  Nowadays, that kind of fever after a vaccination would be enough for a trip to the ER and potentially a law suit.

If there is anything I’ve learned in 30 years of doctoring, it’s that the pathogens continue to be smarter than modern medicine no matter what weapons, chemical or otherwise, we come up with next to arm ourselves.  Thankfully, we have immune systems that are remarkably effective for most things, but the fight required to win the war with a virus is not for the faint hearted.  It is a down and dirty trench and barbed wire battle field.

Just right now, it feels like time for a ceasefire…

First Frost

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written initially Sept. 23, 2005/updated Sept. 30, 2009

There needs to be a warning system in place for the first frost. Today caught me completely unaware, as I woke in a bedroom with windows flung open as they’ve been for over 4 months. I sensed immediately that autumn on the calendar meant business. It was freezing, both inside and out. I wanted nothing more than to stay under the covers, hiding my head from the reality outside. The wood floors were cold, the furnace sputtered itself to life as I closed windows and gazed out at frost on the grass and leaves, sparkling in bright morning sunshine. How can this be, a month earlier than typical? I am not ready for this. No one prepared me for summer to be over, literally overnight.

It was, to be entirely fair, a very transient frost. It wasn’t crunchy underfoot and merely put a little glaze on everything. As the sun rose higher, in only a matter of minutes, the frost softened and melted, leaving no trace behind. The only hint of cold air was the puffs of steam from the horses’ nostrils as they raced in the pastures to warm their muscles, as they do not yet have their full winter coats, and they too were startled by this early cold.

Things happen daily in our lives that we feel unprepared for. No matter how much schooling we pursue, how much news and information we absorb, or how many tales of advice we’ve heard from our wise grandparents, there will always be a surprise around the corner, and usually not as harmless as an early frost. Perhaps it is a hurricane that shifts direction picking up speed and ferocity, or a virus that mutates in a way that makes its transmission more deadly, or the “big one” earthquake that has been predicted for years finally lets loose. These threats hang over our collective heads and we cower and hide our heads under the covers, as it can be too overwhelming to contemplate.

I have been taking part in Disaster Planning work preparing for the H1N1 influenza outbreak, as well as participating in “tabletop exercises” that help prepare first responders and health care personnel for a variety of horrible scenarios, and I found that I’m not cut from the same cloth as many emergency workers who seem to enjoy thinking up the worst possible cases. I end up in a state of tabletop anxiety as we walk through the handling of chemical spills, dirty bombs, and deadly pathogen release into the community. No matter what we discuss, a positive outcome was to contain inevitable destruction to a localized area, and prevent spread, not only of the deadly agent, but of the immobilizing and contagious fear that can bring society to its knees. It is hard for me to think in those terms, as even one death in my clinical practice is unthinkable and rare. As I’ve read the stories of the health care professionals who worked days on end to help in the Katrina disaster, I realize they too were unprepared and undoubtedly scared. Yet they were there, doing their best helping people despite overwhelming need and limited supplies, because giving up one’s own comfort in the service of others is the good and right thing to do.  So my long work days seeing many H1N1 influenza-afflicted college students seems very minor in comparison.

We are called to get up and get going even on the “coldest” of mornings, when throwing the covers back over our head and staying warm and comfortable is far more appealing. It is such a small sacrifice, as insignificant as a first frost, compared to the monumental gift, earth shaking and heart rending, that has been given to each of us, unselfishly,  out of Love. In response, we must leap willingly out of our warm beds and stand ready to go wherever and whenever we may be needed most.

Don’t Wanna Hold Your Hand

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Ross MacDonald illustration for the New York Times

Suffice to say, I’m not germ phobic.  If I were, I wouldn’t live on a farm handling manure everyday, and I wouldn’t work as a health care provider in the “culture media” otherwise referred to as a university student health center.  I’ve learned to live in harmony with all the pathogens I come in contact with, and, for the most part, we leave each other alone.

Yet there comes a time (and this is it!) when a little paranoia about viruses is warranted.  This current early influenza season has the potential to be a real humdinger because the virus people are passing between them is unfamiliar to the majority of the younger (under age 50) population, so their immune systems are not readily primed for the antibody fight.  So there may be good reason for social rituals to adapt to protect the unprotected.

There is reasonable evidence that H1N1 influenza really takes hold in environments where people are doing a great deal of “meet and greet” activities, such as sorority and fraternity “rush” week at universities.  That means that hand shakes and hugs, or the seemingly benign cheek kiss, confer more than good will.  They become the vectors of a viral gift, ready to transfer to our mucus membranes with an innocent rub of an itchy eye, or licking of our lips after touching the outside of our mouths, or running the back of our hand across our noses.

In other words, we inadvertently share and receive more than we intend with a simple greeting ritual.  This becomes important during a time when potentially fatal viruses are circulating widely, especially as a certain percentage of the population will tend to be “carriers” without having obvious symptoms,  effectively becoming unwitting transmitters.

So this fall, the time has come to stop greeting with hand shakes, particularly in “high volume” situations like political rallies, wedding and funeral receptions, church lobbies and school orientation activities.  The options to replace the hand shake are plenty, but ideally should minimize physical contact.   I prefer a simple nod, leaning forward, hands behind my back, and actually using my vocal cords to do the work:  “good to see you”  or some other gracious few words.

I’m not being unfriendly, nor am I rebuffing your friendly extended hand.  I just don’t want to share what I may have just been exposed to a few minutes earlier without having had a chance to adequately wash my hands, as I would if I were working in the barn or the clinic.  Just like the classic classroom exercise illustrating how many sexual partners you exponentially end up with when you consider all the partners of the partner’s partners, etc. —when you shake my hand, you are shaking the hand of everyone I’ve touched since the last time I washed my hands.  In certain social situations, that can be an overwhelming number of contacts.  So let’s just take handshaking out of the equation and make it a little tougher for this virus to find its way from me to you.

So it’s good to see you looking so well. And I really want you to stay that way.