Monthly Archives: March 2020

There are two milestones in the US today. We crossed 10,000 total cases and also had more than 5000 new cases in a single day. Granted, some of this might be because we are finally doing some testing, however, there was a reason we should have been testing extensively long ago and should have instituted some form of lockdowns. Now we pay the price.

The orange line represents cumulative cases in China. The yellow line is cumulative cases in the rest of the world. I don’t think I even need to give commentary on what is transpiring. Look at it for yourself.

Just weeks ago, China dwarfed everything else. Now, everything else is going to dwarf China. Think about that.

I’ve asked another friend of mine to contribute from one of her areas of expertise on a topic that we should all should get into place whether or not there is a pandemic.

It’s more important than ever to have an Advance Directive/Health Care Directive/Living Will prepared. It doesn’t take a long time to fill the form out and have it notarized.  These are best done with the help of a healthcare provider, not a lawyer.  Yes, these are legal documents but lawyers do not have the education or background to educate the public like nurses and doctors do. It is needed to explain what various lifesaving methods entail and chances of recovery from trauma or diseases.

A well written Advance Directive will have three components:

1) It will identify a Healthcare Agent (your advocate) if something were to happen to your health. I strongly encourage individuals to choose two Agents, a primary and an alternate.  Choose someone who knows you well and cares about your wellbeing that will follow your healthcare wishes and speak up when you can no longer do that for yourself.  Normally people select their spouse as their primary Healthcare Agent. The other should be someone who is younger than yourself or spouse.

2) It will document your wishes for medical care. This is the largest section of the Advance Directive.  There are free forms from the Minnesota Advance Directives, including their worksheet.  The Mayo Clinic Advance Directive instructions document and Advanced Directive Form are the best I’ve ever seen in my career. The University of Minnesota Extension service also has a PDF form that can be filled in online. One does NOT need to be a Mayo Clinic patient to utilize their form.  In fact, Minnesota is one state where Advance Directives are accepted from any organization and can be drafted anywhere. Please check the rules for your own state or country and if particular forms are needed.

3) It will document your wishes for after you die. Your choices for burial or cremation can be documented here, including if a burial plot and funeral home expenses have been identified and paid.  Information about a service can also be outlined in this area.  Once a person has died, Minnesota regulations state that unless being investigated, the body needs to be processed through embalming or cremation within 72 hours. Again, check the rules for your state or country.

Once an Advance Directive is completed, it is essential to have multiple copies made and have them notarized.  Minnesota legally allows this paperwork to be witnessed by two individuals, but if traveling domestically, many states require Advance Directives to be notarized.  Several copies are needed, one for yourself, for each of your physicians if they are with different medical organizations, one for each Healthcare Agent, and a spare copy.

Paula Johns, RN and Death Investigator

Educator on Advance Directives and The Final Checklist: Final Act of Love (Death Workbook) and teaches privately and at several Community Education programs in the Minneapolis/St. Paul metropolitan area.

I had developed a model to estimate the global and US death burdens from COVID-19 and wrote about it on March 13th. I had used the data from South Korea to develop my best case scenario at that time. In that model, in the US would have 506,896 deaths and globally we could expect 11,844,853. I had mid-range and high estimates too based on how close we were to the actions of other countries.

Unfortunately, I never really thought we would get by that easily for a number of reasons. My friend Bob Bierman wrote a piece today that addressed those societal issues far better than I could so I asked him if I could have permission to share here. Graciously, he agreed.

“To the US, a mere 60 years ago, the Republic of Korea (South Korea) was little more than a scarred up battlefield where the west had fought a proxy war against the Soviet Union.

It was a time of starvation for the country, with North Korea’s leader, Kim Il Sung (Kim Jung Un’s grandpappy) looking like an economic genius as his citizens enjoyed a higher standard of living than the South.

In 1963, Park Chung-hee, the military ruler of South Korea instituted a program of industrial reform.

In 1979, Park was assassinated after seven years of near-dictator status following a series of constitutional changes.

It wasn’t until 1986 (with a new constitution adopted in the meantime) that the constitution was amended to allow for direct election of the prime minister.

During the 1997/98 Asian financial crisis, South Korea was on the verge of economic collapse. Citizens stood in long lines, waiting for hours … not for food … but rather to donate gold to the government to help keep the country solvent, independent, democratic.

They impeached their prime minister in 2017 over a bizarre corruption scandal.

By the way, Inchon Airport didn’t open til 2001.

Today, South Korea, population +/-52M, land mass 1/99th the size of the US, is the 12th largest economy in the world. 81.5% of the population is on the Internet.

We watch shows born in Korea (Masked Singer!), use Korean high tech products (Samsung, LG), drive Korean cars (Hyundai, Kia), cheer for Korean music (Psy; BTS – or I can suggest a few actually good bands, if you like), increasingly, eat Korean food.

This is the country that dealt with the Corona virus quickly. Immediately implementing testing. Educating the public. Facing the pain quickly, completely and – from the looks of it – getting it over with fast so life can go on.

Without sheltering in place. Or martial law.

They immediately began testing. At a rate of 10,000 per day. They cared for the sick to the extent they could be cared for. They mobilized every resource of the nation, whether real estate for public health centers or public funds to implement their plan.

My 300M American brothers and sisters, as you gripe about your freedoms being taken away, whine about inconvenience … dwell on conspiracy theories about this virus, accuse the entire world – from China to Italy to South Korea of conspiring to destroy the global economy, bring the world to a halt and sicken thousands, simply to make the US president lose an election … flaunt how ruggedly-individual you are by defying the advice of public health specialists, consider this —

There are people in South Korea who still remember the dark days before democracy was a way of life, who remember starvation, who value and cherish democracy and enjoy economic prosperity.

They sacrifice when needed for the greater good.

They are your example.

Sure. The young there are farther from the level of commitment the older generation possesses, but still far more committed to their shared society than the best of us.

Too many of us have forgotten, never understood or just plain don’t care about our neighbors to act like children of the same nation.

Yet somehow we call that patriotism.”

I have to add a postscript. What exactly does it look like when you are selfish and don’t give a damn if you kill other people? Well, it’s something like this.

I heard a really good idea from a friend of mine a few days ago and after thinking about it, decided to share.

It would be a good idea to get into the habit of taking temperatures twice daily at 12-hour intervals. Temperature monitoring for responders was part of the practice at the initial quarantine sites for the evacuees from China and for the 14 days after working in that environment.

The benefit of this is that if those temperatures are taken roughly at the same time each day, it provides a baseline range of temperatures for comparison if one subsequently becomes elevated.

Ideally, each household member would have their own thermometer for the checks. If there was a temperature that fell outside of the normal range, then it would be best to keep that family member in a separate bedroom if possible as well as limiting to a single bathroom that only they would use until the source of the elevated temperature had been determined. This would be the trigger to call your primary care provider to discuss what steps to take.

Of course, many homes may not have the option of a guest bedroom that becomes an in-home isolation room. Even partitioning off a room somehow might help reduce the spread of droplets to other family members. If that’s not possible, then at least maintain a 3-6 foot distance. from the person with the elevated temperature and/or exhibiting symptoms.

During this time, also be especially aware of surface disinfection. This should be part of the norm at this time but be especially vigilant about this practice for surfaces that the potentially sick person touches.

This sounds like something from a Civil War history book, doesn’t it? Unfortunately, this was a tweet by the mayor of Bergamo, Italy on March 10th. If this doesn’t send chills down your spine, I honestly don’t know what would.

Twelve hours ago on Facebook I linked to a news story. I indicated that there were six big events that I expect to happen in the hospitals in the Seattle, Washington area. I had described five, but didn’t specify number six. I specifically said “There will be one more step taken at some point nobody is prepared to think could happen.”

These were the first five:
1. Cancelling elective surgery
2. Running out of personal protective equipment
3. Healthcare workers becoming infected
4. No beds available in the hospital
5. Healthcare workers walking off the job because of fear that they will get infected and the stress of the environment as the problem escalates.

The final stage is resorting to what is essentially battlefield triage.

The mayor took a lot of heat for that statement. Later, he says “If in some hospitals there are no places available, the regional system intervenes and the choice is made on who to intubate first and who to move and intubate in another hospital.” What happens when all of the hospitals in a particular region are out of space?

That is the reality that looms on the horizon. We need to face up to the prospect that this may become a new normal for part of this year.

Do you think that’s a stretch? The Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care has published guidelines on this. They are for ALL patients. “The criteria apply to all intensive patients, not only to patients infected with Covid-19 infection.”

One telling guideline is “All accesses to intensive care must however be considered and communicated as an ‘ICU trial.'” This recommendation is essentially that if there aren’t some indicators for improvement in a short time span, that bed should be made available for someone else and that patient should be given palliative care, which is not meant to be curative, but to mitigate suffering.

Yascha Mounk writes about this in The Atlantic. The last three paragraphs mirror what I’ve been trying to emphasize.

“But if Italy is in an impossible position, the obligation facing the United States is very clear: To arrest the crisis before the impossible becomes necessary.

This means that our political leaders, the heads of business and private associations, and every one of us need to work together to accomplish two things: Radically expand the capacity of the country’s intensive-care units. And start engaging in extreme forms of social distancing.

Cancel everything. Now.“

Can we now close the lid on that argument? It’s obviously not the case and I’m not going to bring this topic up anymore.

This topic has been on my mind for a few days. Over the weekend, I began modeling the impact of COVID-19 on US hospitals by state. I also broke it down for the metropolitan area where I reside. I knew what to expect, but even with having studied this for so many years, I am still feeling in shock from the numbers. I’ve felt paralyzed much of the afternoon because I can’t get the reality out of my head.

I don’t know if I’m going to share that data, but what I will say is that you should do EVERYTHING you can to stay healthy and avoid needing ANY care in the hospital. They are all going to be on track to run out of beds at some point. You may not be able to get admitted if you need one. NPIs will offset that, but in my estimation we are doing too little too late. The longer we wait to institute a massive lockdown, the more likely that my model will come to full fruition, and I’ve only modeled it on middle of the road data.

That leads me to my point. We are going to experience major behavioral health problems as well. Some of the expected symptoms and reactions are

• Emotional symptoms such as irritability or excessive sadness.
• Cognitive dysfunction such as difficulty making decisions or following directions.
• Physical symptoms such as headache, stomach pain, or difficulty breathing.
• Behavioral reactions such as consuming more alcohol or interpersonal conflict.
• Failure to adhere to needed physical or psychiatric medication needs.

One thing you can do to help those in your circles is to take a Psychological First Aid course. According to the National Child Traumatic Stress Network, “PFA is designed to reduce the initial distress caused by traumatic events and to foster short- and long-term adaptive functioning and coping. PFA does not assume that all survivors will develop severe mental health problems or long-term difficulties in recovery. Instead, it is based on an understanding that disaster survivors and others affected by such events will experience a broad range of early reactions (e.g., physical, psychological, behavioral, spiritual). Some of these reactions will cause enough distress to interfere with adaptive coping, and recovery may be helped by support from compassionate and caring disaster responders.”

An online course is available if you would like to learn these skills.

I will close with a final thought. There is a mantra in emergency communications that is Be First, Be Right, Be Credible. I want to start changing the thinking of the public to Be Home, Be Informed, Be Healthy. Will you do that?