Changing Minds in the Missing Year
The following is the second installment of a 2-part contribution. Read part one HERE.
The following interview was transcribed from an audio recording, and lightly edited for clarity by L. Esther Hibbs, Managing Editor.
In-Hospital Transmission
I hear a lot of conversation at work that people are going to weddings, going about their regular lives outside of their hospital jobs, and then coming back and doing what they are supposed to with masks and PPE in the ER. There are a couple studies now that show medical personnel are more likely to catch the virus from one another than from patients, or vice versa. From May, there has been data that hospitals are not places patients catch COVID. In the early days, it was a place where physicians would catch the virus. Since we ramped up PPE, though not enough, the risk has lowered. The risk of patients catching it from physicians has always been low. The risk of doctors catching it from patients was high, and now has tapered off. However, there is now a risk of us catching it from one another. We wear our masks, gloves, etc., religiously when we are around high-risk patients. Even with lower-risk patients like an ankle sprain, we are still wearing our masks and gloves and new scrubs, if not the full suits. However, when people go back to the doctors’ station or nurses’ station, it is back to regular dress. Some people take their masks off and let it hang, or there is a coffee room where people are eating around a table. It is as if it is just five minutes while we eat, but people are behaving like they were before the pandemic. So, there is data supporting that we are catching it from one another. The speculation is that a lot of professionals are not observing precautions in their daily lives, then bringing their asymptomatic or mildly symptomatic selves back into the ER and infecting not the patients, but one another.
The same way you can study someone’s Thanksgiving dinner and do contact tracing, they have done contact tracing to show that nurses are getting it from other nurses or from a respiratory tech or the nurse techs or other healthcare workers who are in the hospital.
An example is a hospital worker who comes in for something like abdominal discomfort, which is low risk. We consider anybody as a possible asymptomatic risk, but this patient would not be a particular risk. So, we would put the patient in isolation because they have GI symptoms, but no other symptoms and a negative workup. On this patient’s way out the door, I happen to walk by and give her a COVID test to follow up in two days because while I have a low degree of suspicion due to the symptoms, it is not zero. Nobody is zero suspicion. So, because she is a hospital worker, we give the test. She came back positive two days later. If I had not sent the test, nobody would have faulted me, because she had no symptoms.
On a given day, of my 20 patients, I am seeing 3-4 known, 2-4 who turn out to be COVID positive. But what about the other 10+? Probably, a good amount of them (25% or so) are asymptomatic positives. This patient is an example of that: someone who had something unrelated but I decided to give her a COVID test as a courtesy because it could be, and it turned out it was. We are probably seeing a lot of those. Because there is COVID fatigue, you can only be on high alert for so long. That is what the stress response is. When you are on high alert for six months, then your body just shifts to that level. Your thermostat is at 90 now, and that becomes your normal. So, some people, when they get home, they relax back to having people over or going shopping.
These are people I have to sit next to for eight hours. That is how we are catching this, us healthcare workers. Some of us are also doing high-risk procedures with prolonged exposures, and potential transmission from patients. If you wear a mask, you are fine for a five minute visit. If you are in there for an intubation though…
Say a patient is 32 weeks pregnant, stroking, and COVID positive. I would have to intubate her and then treat her impending shock so she could be taken to the operating room for a possible emergency C-section. I would be in that patient’s room for an hour and a half. Those are the types of things where doctors and patients get infected from the patient.
Skepticism & Response
I ended up talking to several different groups of workers in the hospital. There was a strong presence of thoughts along the lines of “I am not going to take it,” and I could see it affect others who thought “Maybe let’s just wait and see,” “Let’s just give it a couple months,” et cetera. I ended up pulling together a bunch of articles and sending it to the people in that group. One or two people asked to forward it on, so when I went to the next ER’s, I would talk to people more intentionally and send them that email too. It was a collection of posts, data, studies, CDC reports, Hopkins reports, and articles that addressed the different concerns I had heard people say, such as allergic reactions.
There are no excess allergic reactions with these. The vaccines were developed on time, they were not rushed, they were not pushed through, there was no compromise. The reason they were able to be done so quickly was because there is a raging pandemic out there. Because so many people have the disease, they were able to run the trials much faster than rare diseases where you have to wait for people to catch it. So, in the US, phase three happened in three months instead of a year and a half because they did not have to wait for 30,000 people to get the disease.
I sent these around knowing that people do not make choices based on facts and information. They make their mind up, then go looking for facts and information that supports the decision they make. They make their decision for other reasons: political affiliations, self affirmation, confirmation bias, selection bias, and all kinds of other mistakes we have with our thinking. What I did was put the opening paragraph, the basic bottom line, then I provided all the data knowing that 90% of the people were just going to look at the volume of the data and not the studies, article, or data itself.
If you give someone a textbook or 25 articles to say “this is the supporting evidence” and throw it on their desk, that might be enough to convince them and they might not even need to read it. I once participated in doing this for a fellow physician. His hospital decided not to make the emergency department a full department. He said “Send me all your articles that say all the reasons Emergency Medicine should be a full department.” We sent him around 60-70 articles, which he printed and put on the CMO’s desk, and the CMO changed his mind. You know he did not read a foot-high stack of papers. So, the data has value in quantity.
This is something I knew before, something I was teaching-- we do not make rational decisions, mostly, but I haven’t been deeply involved in a situation that was also affecting my health, job, and income like this before. It was not surprising to me that people are making irrational decisions, but I had not been up to my neck in irrational decision-making day after day in a way that is life threatening until this. So, I got the vaccine so I could feel good. What the studies show is within 3 weeks you have 95% protection against getting severe disease. You have about a 90% protection of not catching the disease, and early data show about 70-80% protection against spreading the disease. That data is getting better: it will probably be up in the 90’s. That is after one dose after three weeks, so after the second dose it all goes up into the mid-90’s. I feel good that I will not get sick like this.
Personal Context
This all started in the end of February/end of March 2020 and I have been seeing patients in the COVID ward since early March 2020. I have been tested around six times and have always been negative, so whatever we were doing for PPE was working. I felt good about it. I am not super unhealthy, but I am not a spring chicken. I certainly did not want to get the disease-- I did not want to spread it to my family. I have been living in my basement since March. From March-September, I did not go upstairs once. I was not in their living space, they were not coming down here. We have a back porch-- I would occasionally sit and eat dinner on the porch when they were sitting inside through the screen door. We went on a few hikes in a park near the house, we would walk the dog with one person on the street and one person on the side… I was trying to walk the walk. I did not want to bend the rules at all, because my own teaching was that doing so is as if you are in a dry barn of hay and saying “I am just going to drop this one match-- I am not throwing gasoline, it is just one match.” But one match is all you need, so I did not break protocol for nine months. Then, in September or October, we started having me go upstairs briefly with a mask on once or twice a week, but we’re not in the living room or hanging out. I have not changed that now that I have the vaccine. My second vaccine is in the beginning of February, and until the data comes in about spreading, I am still going to be down here. That will be 12+ months separated from my family.
I would not have moved to Europe for 12 months. I would not have taken a job in another country or state for 12 months, but that is what I had to do. I do not want to be away from my family for 12 months. I am living in the basement and we do talk. Before this, I did a lot of travelling-- 3 or 4 months of the year, a week or two at a time. So, I would see the kids and talk to them over the phone or Skype. I was still feeling like I would not, before COVID, take a job somewhere for six months and be away from my family for six months, but this job has made me be away from my family for a year. My kids are school-aged. This is a time when they actually need me, not just a person. They need the higher level interactions and model that you only get by observing. They missed out on school and sports and they also missed out on one of their parents.
How Does Understanding Happen?
There is a lot of reluctance. However, I noticed through these conversations that there is a window of opportunity. Because most have not firmly decided, there is still a skeptical window. This is where the nudging and the messaging and the PR, backed with and informed by good data goes a long way. The same way in social media we have these influencers, you can also have that effect especially in this early stage to get people to understand (even health professionals who you would think would all be for it). So the point of this is, if health professionals are reluctant, what do you think the public is like? They are probably much more reluctant. They are susceptible to this nudging, or even more so because of the authority gradient of recommendations. Anyway, I think there is a huge opportunity for us to inform each other. I have made the mistake of thinking everybody knows the science behind it.
For example, one of the things I told a group of nurses was “We have two vaccines. One comes in two weeks, one comes in four weeks. They are safe. I would not have taken this if it were pushed as a tool for the election, but it just happened that the date this became available-- I have taken a point of making sure it is safe. I am not a rubber stamp but I am going to take it, and take it to my kids.” Saying things like that, one of the nurses said “This is the first time anybody has told us any of this. What they all usually say is ‘here is what you are going to do,’ the bosses lay down the law and say ‘here is what you are going to take,’ like the flu vaccine.” You do not have to take the flu vaccine, pre-COVID, but if you do not you can’t come to work. What they used to say was that you would have to wear a mask all day, which actually does not protect you from giving or getting the flu because flu is almost all droplets. It is not airborne or from cough, it is from touching, so the mask does not help for the flu. The hospital was still saying “If you decide not to take the flu vaccine, you cannot come to work or you have to wear a mask all day.” It is like a punishment, so nurses are used to a top-down hierarchy and nobody thought to explain it to them. All they needed was a little bit of information.
Some people had some legitimate concerns: “What do I do if I am pregnant, or want to be?,” “What do I do if I have an autoimmune disorder?” There are also all these ideas that keep coming back like zombies-- they won’t die. One is anaphylaxis. There is a baseline side effect on everything. There is a baseline side effect with Tylenol, with Ibuprofen. There was this article just a few days ago: some doctor had an anaphylactic or severe allergic reaction after he got the vaccination, so he gave himself his epipen. To me, this should say, “Hold on a second. You’re someone who carries around an Epipen. You have had severe reactions before, so you are kind of susceptible to severe reactions, so you are the guy who should have been high-risk and worried to begin with.” To put the article out there without saying it is very rare and the instance is no higher for anaphylaxis then for anything else is dangerous.
When we used to give out penicillin shots, we would keep the person there for a half hour because one in a thousand would have an allergic reaction. We do not want them to have an allergic reaction when he is driving home in his car. Well, the instance of a reaction to vaccination is the same as anything else: it is low, but it does happen, and if it does, we know how to treat allergic reactions. We do not know how to treat runaway pandemics.
When you really get into the weeds of the science behind it, you are leaving most people behind. What they want is somebody who has done that work of digging through the risks, side effects, and likelihoods, who they then believe and trust to give the one sentences responses: “Yes,” “You’re right,” “We don’t know, but I believe based on this that it is okay.”
Final Thoughts
We should not underestimate the healthy skepticism that even health professionals have about this, particularly our colleagues who may not have training or access to find out answers. In our jobs, we are trained to go find out the answer. If you do not have that training, how do you find out the answer? We could use our positions in our hospitals, emergency departments, etc., to address that. I do not think we should underestimate the degree of healthy skepticism and unfortunate unhealthy skepticism (planted by social media and news outlets) that people have about the vaccine.
Fortunately, this virus is pretty easy to make a vaccine to. The mRNA science is not new, it is just newly applied to this circumstance. It works better than anyone thought, and your body can make a good immune-response. Some viruses are very hard to make antibodies to. It is just a fluke that this pandemic turned out to be one you can make a really good vaccine to. I think if you give people the data that has convinced you and given you confidence, they then read your confidence and they will use that to change their opinions. Like with any relationship, once someone makes their mind up, it is very hard to unmake their mind. So, before people have made their mind up about the vaccine, this is our time to influence their thinking, while they are in a window period and could go either way. This is where we should be advocating. We can take that lesson to the public also. They are not yet being given the option of taking the vaccination or not. They very shortly will be-- it is estimated that probably in February, it will be opening up. We will have three or four vaccines by then, which should start going through the pharmacies. Anybody will be able to just go and make their appointment. Before that happens, we need to have public communication about what this is. It needs to be out there.
