From the trenches #4 Memorial Day 2020
As we start reopening, what have we learned about living with COVID-19 and how might we think about this? Just my view From the Trenches.
Stay-at-home orders and shuttering businesses are blunt tools. Its a strategy from the Pandemic Playbook, (yes, there really is one) employed when testing and contact tracing are not available. (Still not available… since January…) So stay-at-home effectively flattened the curve - sparing our hospitals from overwhelm, gave us time to learn about the coronavirus, sew masks, and get our testing and contact tracing programs in place. Blew dat last one “bigly” - as one might say.
As businesses start to open and we creep from our homes; how do we assess which activities are high-risk and how or can we make them safer? What kind of information is useful and what should we pay attention to?
Look East (China, S. Korea, Singapore, Hong Kong). The East precede us in the pandemic waves. The first wave hit hard, they locked down to get things under control, started to reopen, and they are now experiencing flare-ups. Secondary to new infections, China recently locked-down another city and closed all movie theaters throughout the country after reopening just 600. We will experience flare-ups too. Watch the East; they are our crystal ball.
Unfortunately, coronavirus will not “go poof” and miraculously disappear. The virulent virus is still alive-and-well amongst us, and we’ve learned that hand-washing, physical distancing and mask wearing will help keep us safe.
Hand-washing (or sanitizing): Well known surgeon and medical author Atul Gawande weighs in on hand washing guidelines. “Behave as if you are the one with the virus,” he says. Yes, 20-seconds and about 10 times a day (if you are not working in a high-risk environment.) Wash before you go into a new place (to insure you are not the vector bringing virus in), wash or sanitize when you leave (in case you picked up virus there) and before you touch your car keys.
My FAVORITE hand-washing PSA from Viet Nam:
https://www.youtube.com/watch?v=Owcdxs_7dWw
Little kids might also really like the Rock hand-washing with his daughter to Moana’s, You’re Welcome.
https://www.youtube.com/watch?v=cvHtcYHy4eI
Physical (social) distancing: notice that it really is PHYSICAL distancing, not social distancing. CA’s Governor Gavin Newsom has also changed his verbiage, swapping physical for social. During the Black Death or Bubonic Plague of the 14th century, doctors prodded patients with a long stick. While they did not know of bacterium spread by fleas, they did learn that keeping their distance increased personal safety. Why? Because their stick kept them beyond the range of jumping fleas. Later, the Pneumonic Plague was spread by respiratory droplets.
With nearly 100,000 dead over a 3-month period, this is hardly a hoax nor similar to our annual flu. Do you really want to tempt fate when simply keeping your distance might save your life?
“I’m healthy,” you say, “I have a strong immune system.” …so did many of our dead.
Gang canny is a departing salutation from Scotland; it means go carefully. One of my patients recently shared it and methinks its apropos. Those in high-risk groups should go carefully. CDC still maintains those most at-risk for death are 65 years and older with a mortality rate of 1.3%. Next most at-risk for death are 50-64 years; mortality of 0.2%. (Flu mortality is ~ 0.1%) Experts believe the common and somewhat reversible diseases of diabetes and obesity - because of systemic inflammation, also put people at increased risk.
Can one golf safely? What about going to parks, rivers, and beaches. Yes, of course! Outside is safer than in; adding physical distancing and hand washing makes it infinitely safer.
Bowling? Movie theater? Churches? Gyms? Not until we figure out how to make them safer. They represent places where people gather or congregate (congregate spaces) with surfaces that are frequently shared and touched.
Masks: to wear or not to wear, that is the question. “The challenge is that our culture, our discussion in American life right now is about freedom versus safety, leave me alone versus keep me safe,” Atul Gawande said. “We overcame this in the healthcare sector by saying, ‘I want to come to work every day never wanting to infect anybody else.’ I never want to cause someone else to be in the morgue.”
We have learned that coronavirus is primarily spread through droplets. We now know that up to 35% of infected people have NO symptoms and can spread the virus. We call them “asymptomatic spreaders”. A simple cloth mask will interrupt most of that.
In our society, it is reflexive to cover a cough or sneeze, most frequently with one’s hand. And that is one way droplets move to surfaces: door knobs, elevator buttons, handrails, etc. A simple cloth mask will interrupt most of that.
“Don’t touch your face,” they say. Touching one’s face is unconscious and reflexive. A simple cloth mask will interrupt most of that.
“I know I’m not sick, so why should I wear a mask?” Because we now know that up to 35% of infected people have NO symptoms and are capable of spreading the virus. That could be you. Wearing a simple cloth mask demonstrates that you care about those around you. Not wearing a mask also sends a message.
Outside vs Inside: Virus is dispersed into the air. Outside, the virus dissipates quickly, sunlight kills it, and inhaling a large concentration of virus becomes less likely. In an enclosed space, say a choir loft or doctor’s exam room, the concentration of virus builds up over time - making time in an enclosed space more risky.
Think of Easter egg dye in water. If you put 20-drops of red dye (represents virus) into a coffee cup filled with water (represents small, enclosed space), you will concentrate the dye and have red water (= lots of virus in small space). If you put 20-drops of red dye into a 5-gallon bucket of water, the dye dissipates and the water will look clear. And that is what makes outside safer than inside.
Want to visit with friends? Do it outside. There has been plenty internet shaming of people having cocktails in their front yards with friends and family. But evidence shows - that’s the way to do it. My own cul-de-sac hosts 6 sets of grandparents visiting their grandkids in similar fashion. BYOF picnics: bring your own food and set up 6 feet apart.
Haircuts? Last week, a Springfield Missouri hairstylist, working sick X 8 days, exposed 91 known people - and they in turn, exposed hundreds. Haircutting is a recipe for close physical contact and lots of conversation. Wear masks. Minimize talking. Hold your mask to your face when the elastic around your head must be removed for haircutting. No talking when shampooing; a time when a gabbing hairstylist towering over an upturned face can literally be a viral shower. Make it even safer by having a dry cut outside.
Time: short vs long. Time = exposure. How long are you going to be exposed to others? A longer time increases the possibility of viral spread.
If someone jogs by - breathing heavy - holding one’s breath is a reasonable strategy while they jog away. What about singing or loud, slobbery talkers? Move away, add physical distance as all three activities are known to produce more droplets.
My own ukulele group KaBang! is back to in-person rehearsals - we are outside and spaced 6-8 feet apart.
What should we pay attention to?
I remember asking one of my ED physician mentors about using a drug “off label,” that is - using it for an unapproved, often unproven purpose. Kinda like using a drug for Lupus to prevent coronavirus… . What my mentor said has been with me for 20-years. He said, “I never presume that I am smarter than the team of experts who read all the studies and created the guideline.” All that to say - follow the science from vetted sources.
Watch local stats: Keep tabs on the number of local confirmed infections and deaths. If numbers increase; up your game. Stay-at-home, decrease activities involving others, use more caution. Instead of continuing to open up, reverse direction and start closing down - like China is doing right now. We KNOW these starts and stops are coming. For us to survive a virus for which there is no vaccine and no natural immunity, ignore science at your own peril.
Where do we get good information? Find your local stats.
- Sacramento Coronavirus Stats (website below). California currently has 2405 cases/1M (million) = 2.4 cases/1000. These are cautious-open-up stats. If cases rise - pull back in your activities and lifestyle. Don’t wait for Gov Newsom’s announcement.
- Watch for the impact that opening up on Memorial Day weekend has on our area. New cases will increase in 7-14 days if we have not been sufficiently careful.
US Coronavirus Stats
Navigating the website:
See upper right corner dialogue box: Case Overview.
At the bottom middle of that box, go to: 
more locations and statistics.
Choose: United States then look for California, then Sacramento. It currently reads 2405 cases/1M (million) = 2.4 cases/1000
Sacramento Epidemiology maps - search by zip code
https://sac-epidemiology.maps.arcgis.com/apps/webappviewer/index.html?id=ad477bb955dc49e78d0a19b78bbd09dd
3) CDC Coronavirus (COVID-19) site: While I personally think the CDC has been sidelined, muzzled, and their website scrubbed, I am not confident that they would actually publish false data. So while their website is not as thorough and complete as in years of yore, I still believe that the information posted is accurate. Methinks you can use them as a reliable source of accurate data.
https://www.cdc.gov/coronavirus/2019-ncov/index.html
On 5/25, CDC did post their long awaited detailed plan for opening businesses, churches, schools, etc.
4) Other useful articles:
We are not yet done with COVID-19
https://www.jonbarron.org/
https://www.jonbarron.org/
From Camping To Dining Out: Here's How Experts Rate The Risks Of 14 Summer Activities
The Coronavirus in America: The Year Ahead
Social Distancing is not Enough: The Atlantic 5/22/2020
https://www.theatlantic.com/ideas/archive/2020/05/how-will-we-ever-be-safe-inside/611953/
Atul Gawande on Handwashing
Much love and aloha to you all and Gang canny = go carefully. ~ Lorin
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