No matter what the project—a business venture, a scientific experiment, government funding of grants or infrastructure, or one’s own family, it is always wise to take a deep breath and look at what our original goals were, and to see if we are marching toward those goals, see what changes need to be made—adopt and adjust if need be, and see if our principles which should be grounded in morality and virtue and should be constant are able to meet the demands of the project.
When well-intentioned people take on a project they oftentimes fail to define the means by which they will effect an end. Failure to define the governance structure of an organization with an eye to what needs to be accomplished, kills many projects before they are even up and running. Failure to define the rules by which the organization will accomplish their goals does the same thing.
The Covid-19 crises gives us two case studies—one successful and one not successful, in how to manage problems. Both stories are filled with drama and intrigue. Both stories in the end are more about people than they are about material. Both were directed by an ethic ingrained in individuals and organizations that predetermined the outcome. In some cases the problems could have been minimized had organizational structures and goals been better defined.
First of all the clinical challenges that doctors and nurses faced at the beginning of the Covid-19 crises when they knew very little about the unique pathophysiology of Covid-19 infected patients, were met by many different approaches to handling the complications, sequels, and post-infection trauma. The early intubation of patients at levels of O2 saturation that traditionally demanded intubation in other patients was not followed by all ICU teams. Early on at the University of Nebraska and at Eastern Virginia Medical School the idea of the “happy hypoxic” was recognized and techniques were deployed that allowed many patients not to be intubated and when the clinical world recognized the successes of these groups treatment guidelines and strategies changed rapidly. This was not done by the rewriting of CLINICAL GUIDELINES, nor were “double blind studies” required to make these changes.
This was done almost exclusively and immediately by word of mouth—word of e-mail and social media would be more accurate. This was a very different approach than what the Academics at Universities or Medical Schools recommended. The use of steroids and monoclonal and convalescent antibodies helped. The early use in the prodrome phase of hydroxychloroquine—yes there are very good studies that show that when this is used in the 1st three days or early-preclinical phase the drug really works. Just like Tamiflu with seasonal flu. Remdesivire the same thing and now the folks at EVMS are showing us how the drug Ivermectin can be used even later in the disease process. Doctors and nurses taking care of patients, communicating across the world in non-traditional ways, not waiting for the “experts” to tell them what to do have saved hundreds of thousands of lives. ICU stays have been cut in 1/3. Hospital stays have been decreased by 35%. In our own community, St. Luke’s is using telemedicine and telemetry to discharge patients earlier from the hospital and monitoring them at home with EKG’s O2 Sat’s, Temperatures and vital signs freeing up beds even faster than what is being done in the ACADEMY.
There are two interesting Idaho connections to this type of on the ground empiricism that we are watching as it is applied to Covid-19 in 2020. The BIRD Respirator was invented by biomedical engineer and pilot Forest Benton Bird in 1956. His factory and production facilities were located in Boundary County. His machines were deployed by Army MASH units during Viet Nam to treat a condition called “Da Nang Lung” first described by Boise surgeon David Ashbaugh in 1964 while he was deployed in Viet Nam. Like Covid-19 issues of oxygen toxicity and barotrauma in ventilator patients were identified and later treated by clinicians and scientists and today the BIRD and BABY BIRD pressure cycled ventilators been replaced by larger volume cycled machines, except in places like Medivac planes, helicopters, and Navy ships. The point of all this is to show what happens when individual innovation is allowed to proceed in an unencumbered fashion, when problems with patients are recognized and when clinicians communicate and collaborate great things can happen. Notice I didn’t mention the CDC or NIH or Central District Health in any of this. The bureaucracy just slows things down and makes things worse. Forest Bird was rumored to have opined that if he had had to undergo FDA approval for his device, it may not have been used.
Now let us next look at the Public Health response to the pandemic. A top down command and control approach has been directed by experts very much divorced from the health care workers and patients on the ground. They originally told us that masks didn’t work—then they told us they did, then only the N-95, but when those ran out all masks worked, and now we find out that really only the N-95 and not the Chinese knock off LN-95 work. TPI—thread counts per inch of cotton or paper masks of less than 600 are useless after a brief period of time or when pore size expands greater than 3.5 microns with humidity or washing. The biggest tragedy is being repeated over and over again and that is those most at risk—the elderly and the immune compromised have not been a priority. If 80% of the deaths come from this group and those over 80 comprise 2.5% of the population and we have already vaccinated 20 million people we should have vaccinated this group of people almost 3 times over and we would have cut fatalities in half in less than 2 weeks.
Health care workers under 55 can wait in line as can teachers under 55 as can politicians who on day 3 have already put themselves at the head of the line. This is the same type of self-centeredness that led to Governor Cuomo ordering his head of Public health to discharge Covid-19 elderly patients back to nursing homes where the infected at risk elderly patients and where at least 40,000 died. If a doctor had done this to an individual patient it would be called malpractice and she would lose her license, but instead the good Governor writes a book and goes on TV morning shows to talk about how good a leader he was—and the media never challenges him.
In our own State, Dr.Hahn has done exactly what has been asked of her, but there are no clinicians on the Governor’s panel. No ICU nurses who could give the governor real-time information about what is going on in their institutions. No virologist-pathologist who could give the Governor a different perspective on the virus and its effects. The Governor is making the same mistake over and over again because of the way he originally designed his team. Governance and operations are extremely important especially if you have people making decisions that do not have skin in the game. How about every government official relinquishing their paycheck when a “shutdown” or quarantine order is made so that they can share in the misery of the small businessman or private entrepreneur. It won’t happen.
So we can readily see in the different responses how outcomes are very different. Time for our Governor and public officials to take a deep breath—change course. Get some new people on the advisory panel instead of hospital administrators and hospital association lobbyists. How about an ICU RN and a Virologist and pathologist to go along with Dr. Haun? How about type 3 Mitigation and identifying those at-risk patients and pairing them up with a doctor or PA, or FNP and a supply chain at the ready should they need attention—meds, monoclonal antibodies readily available etc.
Reflection is good. Self-reflection is hard.