One Man, One Vote

“I don’t want to die.”

My 80-something patient appeared less frail than either her words or medical history would suggest. Her short and graying hair held a remembrance of a raven past. A mask concealed her mouth and nose, into which oxygen flowed, the tubing disappearing beneath the face covering.

In the hospital, where everyone is masked, one’s attention is drawn to another’s eyes. Hers were brown, from which frown lines radiated like spokes on a wheel. I saw fear in her eyes, but they were also resolute.

Outside the door of room 12 in our emergency department, before walking in to see her, I’d removed my yellow surgical mask, replaced it with an N95 and layered the surgical mask on top of the N95. Next I put on gloves, slipped into a gown, tying it behind my neck—challenging for a person with limited dexterity, one reason I didn’t choose a career in surgery—before finally donning my transparent face shield, securing it around my noggin’ like a hockey goalie’s mask.

She lay on a gurney, head propped up at 45 degrees, and I pulled up a stool at her side. My new patient was my old neighbor, I discovered; she lives in an apartment complex mere blocks from my house. “Mary” tested positive for the virus one week earlier. Enrolled in Mayo’s COVID home monitoring program, she was keeping an eye on her oxygen levels, which had stayed stable, thanks to O2 that flowed 24/7 into her nose, needed because of longstanding COPD.

That morning at 4, she’d awakened struggling to breathe. After dialing 911, an ambulance took her to the hospital.

A friend in the apartment building tested positive three days after Mary did. Though the two of them were careful otherwise, when they drove to get groceries together, neither wore a mask. Mary wasn’t sure who’d infected whom. Perhaps one of them got the virus from another resident in their complex who’d also come down with the disease. Mary had every COVID symptom: chills, sweats, cough, head and body aches, fatigue, shortness of breath, loss of taste and smell. At the onset of her symptoms, she had diarrhea, which is also common.

Mary took me in, paused for a moment before saying, “My son had nice curly hair, just like you.”

I heard “had,” past tense, but didn’t want to assume. “He had curly hair?”

“He’s no longer here.”

“I’m sorry. What happened?”

“He was killed in a motorcycle accident. He and his brother-in-law, my daughter’s husband.”

“I’m so sorry. Do you have other children?”

“I had four. There’s only one left. Delores is 62. She’s my rock.”

I gave her time.

“My other son committed suicide, at 23. And my first child was stillborn at full term,” she added, hinting at obstetrical complications, perhaps malpractice.

I waited, again. “You’ve had a hard life. Did you work outside of the home?”

“I stayed home when my children were young. When they went to school, I became a crossing guard. My husband died at 47. Cirrhosis of the liver. He was an alcoholic. Not a nice man.” She paused for a moment. “After he died, I cleaned houses.” Her words were matter-of-fact, expression emotionless. “I never married again. Once was enough for me.”

“I understand.”

She took a breath and asked, “What are my chances?”

Her age and emphysema put her at high risk of death. But her vital signs were stable, and her chest x-ray looked okay. Her lungs, though, when I listened with my scope, wheezed musically when she exhaled, and she gasped for breath whenever she coughed.

“You probably have a 25 percent chance of dying,” I said, sensing she’d take the news with equanimity, which she did. “But that means you have a 75 percent chance of surviving,” I quickly added. “And we’ll do everything possible to take good care of you.”

“Thank you for trying to help me,” she said.

I took off and threw away my gloves, removed my gown, placed it in the hamper, washed my hands and walked out of the room. At the face-shield cleaning station, I put on a new pair of gloves—to protect my hands from bleach in the wipes—and swabbed my shield clean. Next I tossed my surgical mask before removing my N95 and, holding my breath, quickly slipped on a new surgical one. After sanitizing my hands, I was ready for the next patient.

The week before last, in morning huddle, one of my Republican colleagues said it wasn’t clear what was causing Wisconsin’s surge of infections.

“I don’t think it’s too hard to sort out,” I said. “College students are back and partying; the weather’s getting colder, moving everybody inside; there are Trump signs everywhere, especially in the countryside, and science deniers who won’t wear masks; the Wisconsin Tavern League will keep bars open regardless, no matter the cost in human lives; and conservatives on the state Supreme Court won’t let Governor Evers shut them down, something that, facing this situation, any sane society would do. Plus,” I added, trying to keep my heart rate down (that all of the above is happening really bothers me) “people are sick and tired of keeping their distance and wearing masks.”

From our local leadership two days ago: “The trends over the past week have been alarming both in our communities and within our hospitals. Daily we are seeing new records for Covid-19 testing, confirmed positives, percent of positive tests, and hospitalizations.”

Today we have 31 COVID patients in our region’s five hospitals, most of them in Eau Claire, where four are in intensive care, three of these on ventilators.

The dreaded and long-planned-for surge has come to pass; last week, I was deployed to the hospital, a gig I’ve volunteered to do often in the coming weeks. My new colleagues in hospital medicine, the vast majority immigrants, have been awesome: helpful, welcoming, and patient with my EHR incompetence. Together with nurses and pharmacists, often joined by social workers and therapists, I’m part of a team that coordinates each patient’s care.

All patients admitted with COVID get e-consults from infectious disease doctors in Rochester, who relay treatment recommendations remotely within an hour. In the 28 years since it began, the benefits of the merger with Mayo have never been more apparent.

The virus maims and kills through a combination of three basic mechanisms: direct tissue damage, an over-robust immune response to infection, and blood clots. Each patient is treated with prophylactic blood thinners, and blood CRP and d-dimer levels—markers for systemic inflammation and clotting, respectively—are closely followed.

This past week, each of my three new COVID admissions, upon Rochester’s recommendation, received the antiviral Remdesivir. (It will be interesting to see if this advice continues, considering the WHO’s 11,000-patient study, published online two days ago, that concluded Remdesivir provided no clinical benefit.) None of my patients received dexamethasone—the potent anti-inflammatory steroid given to POTUS, which may have disinhibited his atrophied pre-frontal cortex yet more—because they were clinically stable and their CRPs were only modestly up. Two days ago, I discharged a lady in her late 80’s to her daughter’s care after she’d completed the five-day intravenous antiviral course. She did well in the hospital, and her prognosis is good.

Earlier in the week, I pulled into the parking lot of a busy intersection on the south side of Eau Claire, a hotbed of pro-POTUS activity, festooned by placards and flags. From the beds of each of two big black pickups flew a trio of Trump flags. I hopped out of my Subaru, on top of which sat my sleek and flashy pink and blue paddleboard, and approached a 60s-ish couple. The man was short, with a plus-size paunch, his bushy beard a graying red. He wore faded jeans, his black leather vest inscribed Bikers for Trump. I’d come from work, dressed in slacks and a button-down.

The man was retired. He’d run a salvage yard and an auto repair shop before switching to installing HVAC systems, mostly for clinics and hospitals, the last seventeen years of his career. He and the lady gazed up at the roof of the building next to the lot, where young men erected mammoth POTUS signs.

“I was hoping to talk with one of the men who own one of those trucks,” I said with a nod at a vehicle.

“I own one,” the man said.

“Great!” I said. “Can I talk with you?”

“What about?”

“What do you like about Trump?”

“My freedoms,” he said. “And we gotta clean the swamp.”

“Drain the swamp,” echoed the woman, nodding.

“How about the virus,” I said. “What are your thoughts?”

“It’s a silent world war.” When I gave him a quizzical look, he added, “It’s been proven that the Chinese made this virus. They did it to pay back Trump for what he’s done to them. And you can’t trust Biden. What’s he done in 47 years?”

“Do you think Biden is more liberal than other Democrats?”

“Biden’s just a puppet. He’s just there to have Ka-MA-la Harris take over. He’ll be there three months before he turns it over to her. President Ka-MA-la and Vice President Nancy Pelosi. How you gonna live with that? Americans won’t stand for socialism. I mean, we won’t take it.

All you need is 51 percent.”

“What if it’s 55-45?” I asked.

“Ain’t no way. Something’s crooked if that’s how it comes out. Everyone I talk to is for Trump.”

At this stage of our conversation, it might not have been clear to him that everyone he’d talked to didn’t include me, but pointing this out seemed superfluous.

“What about masks?” I asked.

“What about them?”

“To prevent the virus from spreading.” Neither he nor I had one on. But we were outside, and the wind was blowing.

He shook his head. “Ain’t gonna help. You telling me someone can spread it without any symptoms?”

“Yes,” I said. “And I’m a doctor.”

He threw his head back and laughed. “Ain’t no way! I done my research.”

Something on which we both could agree: on November 3, he and I get one vote.