Words&Dirt

Hey everyone and hope you’re staying safe out there! Today I’ve got a special edition of my “Notes From a Pandemic” series to share with you. It’s an interview with my father, Terry Raymer. Terry is a diabetes specialist who has worked in the Humboldt medical community for about the last three decades, with the exception of the few years he spent living in Anchorage, Alaska in the late 2000s.

Given our health system’s central role in fighting COVID-19, I thought some of you might be interested in exploring our local situation from Terry’s point of view. Plus I wanted an excuse to feature him and celebrate his amazing brain and compassionate spirit. He’s always struck me as a paragon of the medical profession (I’m biased), and has recently laid claim to the even more impressive accomplishment of having more hair than his own son.

Terry Raymer (TR): Before I start, allow me the disclaimers that I am no expert on this topic, local or otherwise. My perspective is limited in that I am not as integrated into the current medical community as I once was. I also speak as an independent entity, and not as a spokesperson for United Indian Health Services (UIHS). I work there, but these are my personal thoughts and opinions.

Miles Raymer (MR): Of course. So tell me, what does it feel like to be part of the Humboldt medical community in this moment?

TR: Frankly, it feels a bit disorganized and lacking in cohesion. We get wind of things where we should be working actively and explicitly together. Communication is paramount, but largely absent. For example, it appears that Mad River Hospital is turning away anyone who is a COVID-19 suspect provided it is not an emergency (which I believe would be an EMTALA violation, although I’m not an expert on that). They are not doing testing and when a patient of ours who was a COVID-19 suspect showed up for an x-ray, they were asked to leave. That doesn’t sound like the definition of a community-based hospital to me. I have great respect for the people who started and have kept that institution going, but we refer patients there and not once have we had a communication as to what they are doing or why. We found out the “policy” through this incident. Maybe there is a good reason for things that are being done, and a plan worked out by folks with a higher pay grade than us “providers,” but if no one communicates to us, we cannot back it and we are left in the lurch. I realize that in my current position, I may not be in some of the higher loops of communication, but our CEO and Chief Clinical Officer do not seem to have any more information on these issues than I do, and they should. Or if they do, they aren’t sharing it with us.

There used to be a great deal of communication and camaraderie, a kind of “esprit de corps” in the Humboldt medical community. That is mostly gone now. I hate to sound like an old guy lamenting some golden period of the past, but it’s true. Therefore I don’t think we can have a cohesive response to what is staring at us down the gun barrel.

However, there are a couple bright spots. We have some amazing providers up here and I have a lot of confidence in them as clinicians; they are capable and competent. Humboldt County Health Officer Teresa Frankovich has done a good job staying on top of issues: she recommended school closures at an appropriate time (despite that some of us felt it might be too soon since we lacked “inside information”), and she has done well at communicating.  She was on top of recommending community-based masking at the time the information pointed us in that direction. I think the current numbers are bearing out her decision-making in conjunction with the community response.

I belong to the Humboldt Disaster Healthcare Volunteer program and I hope we can pull that program together soon, as the time to do so is now, not when we are in trouble. That would do a lot to assuage my overall concerns here.

MR: How severely do you think the local medical system is likely to be impacted?

TR: Honestly, it is hard to say, but there is potential for it to be pretty severe; we are already stretched thin on specialists and primary care providers. If providers and health care workers get sick, those of us with some competency in areas outside our current scope of work might need to fill in some gaps for a while. This may not sound optimal, but it is better to have people with skills who may not be at the top of their game filling in than no one at all. I say that as a professional who has only wanted to be working at the “top of their game,” but I have done a very good refresher course on ventilators and have worked in the ICU before and would be willing to fill in for a couple weeks if absolutely needed. I’m sure there are others out there who feel the same.

MR: Do you think the local medical system is ready for what’s coming? Why or why not?

TR: I gave some hint of that in the first two questions. While I am not on the forefront of preparations, I honestly worry that we are not completely ready because there are so many unknowns, although individually many of us are doing what we can to get ready.

My view is that communication and cohesion are lacking. I don’t know what St. Joseph’s plan is, and I don’t know what Mad River’s plan is. I have a basic understanding of what the Blood Bank is doing, but I am involved with them as a Board member. The clinicians at UIHS refer patients to these hospitals, so it seems we should at least have an idea of where we are going. I have reached out to Mad River administration as of this interview, but nothing so far. We’ll see.

A positive note in this area is Dr. Roberta Luskin-Hawk’s experience as an infectious disease clinician and her connections. She is the Chief Executive at St. Joseph’s and she recently garnered investigational status for using remdesivir at St. Joe’s. This is a great step for us locally. Problem is, I had to read this in the Lost Coast Outpost––we did not get a professional communication from St. Joe’s.

We also have some preliminary data for medications like hydroxychloroquine (to be used only in the sicker hospitalized patients per current guidelines), as well as using steroids and anti-cytokine meds for the suspected inflammatory components of respiratory decompensation. Sometimes it is the body’s inflammatory response to a virus that causes many of the symptoms and even significant damage in certain cases.  Still, nothing definitive yet. We have to look at hard outcomes––like fewer deaths––in these studies and not markers like viral load.

MR: What is your personal involvement in dealing with COVID-19 likely to be?

TR: I do not know yet, honestly. I have been completely out of hospital medicine for 9 years and haven’t managed a ventilator since 1998. I have taken the refresher course mentioned above, and while there has been great innovation in the machines, the fundamentals of management have only some modest changes. I was surprised that it wasn’t like learning a whole new subject. Having said that, ICU medicine is more than just managing vents, and there are always nuances of experience that can really make a difference. I doubt it will come to that, but I want to be ready if I need to help, even if I am working by phone or telemedicine with a specialist. More likely, as someone in the diabetes field at this time but trained in Family Practice, I might be asked to work in the Humboldt Disaster Healthcare Volunteer program at a triage or urgent care level.

Currently, I am working with the UIHS Diabetes Program to stay current on topics like what is the increased risk with diabetes in COVID-19 disease, what are the ramifications of that, and how we might mitigate and prevent disease in the local American Indian population that I serve. Our program is open for business to work with patients with diabetes and provide them good information. Maintaining target range blood sugars is a good way to mitigate risk, and we have not stopped communicating with our patients, whether in person, or more likely by phone.

Basically, I will do whatever I need to when called upon given the circumstances and my abilities.

MR: What is your greatest fear right now?

TR: I will apologize ahead of time for the answer length here. It is a deceptively simple question. I do not want to operate from a place of fear and feel it is not a useful concept in these circumstances, effectively hindering our actions. But I do have some serious concerns, and these fall into three basic categories

First is the (further) breakdown of civil society. I won’t rail on about how bad it already is with current politics and our divisive Presidential administration, but it could get considerably worse.  While I don’t think it will turn into a kind of “Lord of the Flies” situation, there are already lots of hints that it only takes a handful of knuckleheads to cause significant upheaval. We mostly operate on the premise of an unspoken social contract: I may disagree with everything you stand for, but I stand in line with you at the store, and if you got the last roll of toilet paper, well, so be it. You get the idea. But just as some examples, there was the engineer that derailed the train in southern California in an attempt to stop the USNS Mercy from docking because he thought it was part of a government takeover attempt. Ammon Bundy, (son of Clive) is defying social distancing in Idaho and advocating others do the same. Anthony Fauci is getting death threats because he is advising people of his best understanding of how things are going to play out and what we need to do. I don’t always agree with Fauci, but death threats? Herd mentality can be beneficial in certain circumstances––this is well shown even in humans. You want to be running with the herd when the lion comes and not sit there pondering, “Hmm, I wonder why everyone is moving so quickly?” and end up lion chow. But if you don’t know the landscape of where you’re going you could run off the cliff with everyone else.

My second concern is for the future and is more nebulous, but I think anyone can envision what I’m referring to generally. I worry we will not learn the lessons we need to as we have not learned from them in the past. One example is that we know that communities that practiced social distancing and restricting the economy in the short run during the 1918 Flu Pandemic did better in the long run than communities that did not prioritize social distancing and tried to keep their economies open. This was demonstrated in community after community, large and small. Opening the economy prematurely as our illustrious leader has proposed might be foolish. We didn’t fully learn from that remote history by implementing these practices early and completely in a targeted fashion, and we didn’t immediately run with the recent lessons of South Korea. Look what is happening with our numbers and growth curves. I don’t care what the administration says about how many tests we have run now; we did not run enough tests early enough in the right locations and do effective contact tracing and isolation. We are now paying dearly for that.

Third is a personal concern, but not of getting sick. Not to be cliché, but life is inherently risky. However, I am anxious about unwittingly passing along the virus to my patients or the ones I love. Causing serious illness in people you are trying to help is antithetical to everything a medical provider is trained to do.

MR: What is your greatest hope right now?

TR: First and foremost, that what we are doing is working and that we will get through this less battered than previously predicted. If you look at the current Humboldt numbers and some other signs, it seems to be a little encouraging, but overall the US is #1 in cases––not a place we should aspire to as you have pointed out on your blog. And we just passed Italy to become #1 in deaths in the world, which are still doubling every 6 days or so.

Selfishly, one hope is that people will finally see the ineptitude and disorganization of our current Presidential administration and vote him out of office. Let’s take one example: in 2016, the Obama administration created “a 69-page National Security Council playbook on fighting pandemics.” In short, Trump’s administration shelved the report and said it was useless, even prior to the pandemic. This article on the Pentagon Report further details their incompetence. The administration had also let many of the international disease surveillance staff go, a very short-sighted “money saving” tactic. Public Health personnel have taken a hit inside the country as well. They lied about the National Stockpile, pure and simple, called it “empty shelves.” I have already mentioned how we did not learn from and adopt South Korea’s actions to stem the pandemic––look at their numbers. The administration knew things we had no way of knowing (witness Richard Burr’s insider trading). The ambiguity and even mendacity of Trump’s initial messages and the inaction of the administration was unethical and abhorrent at best. Yet my hope of administration change based on this matter is a little short-sighted and polemic. And unfortunately it is a bit unlikely. He may even try to cancel the election; I would not put it past him.

Mainly, as opposed to my concern above, I would hope we learn a tremendous amount from this global experience, which we are, and then apply it to face the next pandemic, because history has shown us it is always when, not if.  We also need to learn to be nimble and versatile in our responses because the next one will have its own personality and behavior. It will not be ventilators we need, but dialysis machines or something of the like.

I also have hope (and maybe even a little trust – egads, optimism from your father!) that “cooler heads will prevail.”  I have to believe that love of our fellow man and the better angels of our nature will continue to throw light on the shadows. Victor Frankl said, “what is to give light must endure burning.” Looking around so far, we seem to be doing okay in this regard, but then I listen to NPR and don’t watch Fox or MSNBC.

MR: Globally speaking, what do you think this moment represents for people who’ve dedicated themselves to the medical profession?

TR: A chance to do what they are trained to do.  As you know, Albert Camus, via his character Dr. Bernard Rieux in The Plague, said (paraphrasing) that “doctors aren’t really heroes; they are just doing their job.” When firefighters, police officers, PG&E line workers, teachers, custodians and all manner of workers put themselves in harm’s way of one sort or another, they are heroes, and just doing their jobs. Think of the hospital cleaning staff in a busy New York hospital ICU––yikes! So I guess we all get to be heroes when the time comes, as long as we suit up and show up. It’s not a matter of your profession, but doing your job when it’s time to do it, even in the worst of circumstances. The cowards are the folks who don’t “show up,” or worse yet try to make some opportunity and/or money out of a situation like this. I don’t suppose that is a very glamorous answer, but that’s all I got.

MR: Anything else you’d like to share?

TR: Yeah, these were hard questions! But they helped me frame my thinking and brought some clarity regarding the entirety of the matter.

Otherwise I think that’s more than enough. One final thing for everyone: take care of yourself, because you are no good to others if you don’t. Try to do what your heart tells you is the right thing. Listen to people who seem to be advocating for the greater good. Approach everyone as if they are your loved one. That’s often a hard one for me to remember.