Precious Bodily Fluids

One of the most distressing things I am seeing is conspiracy-minded conservatives in the US doubting the mortality numbers from the COVID pandemic. I really get upset as these people try to gas light the nation and convince people that COVID wasn’t that bad. And that people are just inflating the numbers for political gain.

I round at a number of dialysis units. At one unit, I cover the first shift. First shifts are popular. Lots of people want to do their dialysis first thing in the morning and have the rest of their day to themselves. I have 20 odd patients on that shift and every couple of months I’ll get a new patient when a chair opens up. This happens when a patient moves, transfers to another unit, gets transplanted, or unfortunately, passes away. Openings on the first shift are rare and they don’t stay open for long.

I distinctly remember going to round at this unit in late May and almost immediately seeing a new face. So I started my routine, new dialysis patient, spiel, “Hello, my name is Joel Topf and I’m going to be your doctor here…”

And then a few chairs down, I saw another new face, “Hello, my name is Joel Topf and I’m going to be your doctor here…”

And then a bit later, “Hello, my name is Joel Topf and I’m going to be your doctor here…”

And once again, “Hello, my name is Joel Topf and I’m going to be your doctor here…”

I met as many new patients on that one day as I typically get on that shift in a whole year. Each of those new faces represented a patient lost to COVID.

We are not lying about the disease.

We are not exaggerating the dead for political gain.

We are counting them and we can barely keep up.

I lost momentum on the COVID diaries, but today as some people are gas lighting the severity of the COVID-19 pandemic I want to finally publish a couple of posts that I started but never published.

As COVID-19 was raging through Italy one of the storylines that made it back to our shores was the number of docs that were getting sick. The number of doctors who were dying. A scary thought entered my head, in the form of a Twitter poll (it is strange how many of my thoughts are arraigned as tweets)

How many doctors at your hospital will die before you start thinking about heading for the hills?

A. Zero. I’m thinking about bugging out now

B. 4

C. 18

D. Infinity. I ain’t no coward.

I asked the question in a group chat but never on open twitter as it felt too inflammatory. My feeling was that it was less the number and more who got sick. The closer you were to the poor doc on the vent in the ICU the more terrifying it would be. Thankfully Ascension St John didn’t lose any doctors, nurses, or employees. But we did have people get sick. A lot of them.

Early in the epidemic we had an outbreak in the cardiology department. At least 8 of the cardiologists got sick and two of them were hospitalized. I don’t know how the ‘Rona spread through their department, but that gave a sense of how fast the disease could spread without precautions.

The housestaff (residents and interns) were also hit hard. Fully twenty-five percent of the internal medicine residents missed work because of COVID-19.

One in four

Thankfully none of them had to be hospitalized.

Probably another dozen doctors in the department of medicine got sick. A number of them were hospitalized, but no one died. Not because we were good, but because we were lucky.

My father is an oral surgeon and the program director of the oral surgery residency at St John and Beaumont Hospitals. His chief resident got COVID-19 and perished. I was on-call in a hospital full of Covid-19 patients when my dad called to tell me. It was startling and focused the mind. After that I found my self calling old friends just to say “hi.” Kind of getting my personal affairs in order, you know, just in case.

Looking back at the docs that got infected, it is noteworthy that the vast majority of infections were early in the epidemic. They were all in late March and early April. The time when we didn’t know what we were doing. I remember seeing videos on how to take off and safely store your mask between COVID patients.

Those halcion days when we thought we could label patients as COVID and NOT COVID. As soon as that lunacy went away and we just started wearing our mask all the time the infections among the staff melted away. It was a stark before and after experiment, but to my eyes masks worked.

When it became apparent that COVID-19 would not just be a medical event that happened over there but was going to affect everything I started jotting some notes. They have remained in Drafts for over a month, but now I am going to start publishing these diary entries mostly just to document the strangest, most unexpected experiences of my medical career.

I have lost a lot of patients. We all have. A lot of them were people I never knew. Consults in the ICU with a patient intubated and sedated in kidney failure. You don’t get to know these patients. The ICU discouraged going into the room to examine the patient unless it was absolutely necessary both to protect us from infection, and to minimize consumption of personal protective equipment. There was no family at the bedside. No visitors in the waiting room. I have never had thinner connections to my patients. We worked hard to save them. Most of them died. I can only remember a few of them.

But there are patients I do remember.

The first patient that I Iost was a dialysis patient. She was an older lady that had been taking care of for a few years. I remember the last time I saw her. I was rounding in the dialysis unit and she was sitting in her chair, mask on, and I told her that I was seeing patients with COVID and that it was really bad. I told her not to believe Fox News telling people it was just like the flu. She nodded her head. She was in total agreement. he last thing she told me was to be careful. She lived in a nursing home. Nursing homes are COVID tinder boxes. A week later she was gone. 😥

Another dialysis patient was a young (my current definition for young is anyone born after 1969) man. He was a rabid Michigan fan. Every time I saw him he would be hot about the latest U of M athletics story. Satellite camps, Louisville forfeiting the championship over Michigan, trips to the Vatican, sleep overs in tree houses, Beilein leaving for the NBA, it didn’t matter how minor the issue he would get completely worked about it. I loved his passion. He was one of only a handful of my patients that still worked and he was an essential worker at a grocery store. And then one day…he stopped coming to dialysis. We sent the police to his house and he was gone. 😥

Not all of the hospital patients were so isolated. I remember an older gentleman who came in because he fell. He was tested in the ER because we are testing everybody. He tested positive. He had just a small oxygen requirement but he was otherwise nearly asymptomatic. I saw him the day after admission for some mild acute kidney injury. After my evaluation I asked him he needed anything and he asked if I could get him some grapes. One of the strangest asks I have received. I couldn’t. The next day he was moved to the ICU for intubation and a week later he was gone. 😥

I lost a few patients from my advanced CKD clinic. These are patients that I see every four weeks to fight for every milliliter of clearance as we try to hold off on dialysis. The mantra of that clinic comes from the first season of Game of Thrones, paraphrased.

What do we say to the God of Dialysis? Not today.

One that I lost was a patient I had been working with for years. I helped him lose weight after learning about weight loss medications on The Curbsiders. I think it was the first time I consciously changed my practice based on a podcast.

He used to come to clinic with his wife and sometimes with his school-aged kid. He was kind and gentle. A good guy taken too soon. 😥

Another long time patient was a woman who would come to clinic with her sister. I always saw them together. In my clinic. I the hospital. Always together. She had terrible heart disease and we were forever adjusting her anti-angina medications and diuretics. Sometimes winning, sometimes losing. She had tough disease but she was a fighter.

One of my favorite memories of her was she used to wear an iPod nano as a wrist watch for years before finally getting an Apple Watch. loved that look.

Another one taken too soon. 😥

Another patient was not a clinic patient, or a dialysis patient, but a patient with pretty bad CKD that our group knew from frequent admissions. He would repeatedly come in with decompensated CKD and we would nurse him back to health and not see him for a few months until he came in again. Then he came in with COVID-19. 😥

Then there was the man who was shot in the bely. We see too much of that in Detroit. He required all the resources of St John’s trauma center. He was going to make it. He was recovering , still sick, but recovering. Then COVID was everywhere. And he no longer was recovering. Nothing feels more like a failure than a lethal nosocomial infection. 😥

The transplant patient who came to the ER because they thought they had COVID. They didn’t. Sent home. Patient returns days later convinced they had COVID. They didn’t. Sent home. Returns a third time convinced they had COVID. This time they did. I don’t know where they got infected, but I think the ER waiting room was a possibility. Another lethal nosocomial infection. 😥

I already wrote about patients that we thought were wins but we ended up losing. Those hurt. 😥

Then there was another long-term patient of mine. Another one in the advanced CKD clinic. One we were fighting for every milliliter of clearance. Like Al Pacino in Any Given Sunday fighting for every inch.

That patient was admitted with a viral illness at the end of February. The swab was positive for influenza. We didn’t have much capacity to test for COVID-19 and the protocol said that a positive influenza test meant no test for COVID. But I wonder. I haven’t lost a patient to influenza for years. I know it happens, but I wonder if this patient was actually the first patient I lost to COVID-19. 😥

There have been others. Too many other. The numbers are still piling up. Just last week I lost six patients. Six patients. One week.

As the US death toll spirals past the total from Vietnam, I keep thinking about how my medschool roommate, Tim Lamb, described the Vietnam memorial

You start walking and there are just a few names and as you walk, step by step, the names pile up until you are surrounded by names. Drowning in death.