In forty-eight hours, I went from thinking SARS-CoV2 might skip over my county to wondering if I just got SARS-CoV2 in my dick. The case report writes itself: Novel mode of transmission of SARS-COV2: a case report of penile acquired disease transmission in a health care worker following exposure in an aerosolized environment.
It is easy to imagine the atmosphere is alien and deadly; full of aerosolized poison spraying out of the ET tube in the patient’s room. I remind myself that this is just a virus and it must follow the rules of transmission, the trusty old PAPR and Tyvek suit will keep me safe, right up until the moment it doesn’t. I squat down to move the catheter bag, and the crotch of the Tyvek suit blows out into an eight-inch gash.
I immediately begin to rethink my decision to not wear much under the suit to stay cool. What level of PPE do Fruit of The Loom Cool-Mesh briefs offer? Intact skin is not an exposure, but what about genitalia in an aerosolized environment? My partner should be awarded partner of the year – she tapes up my blown-out undercarriage with Gorilla Tape and as nurses look through the glass and wonder what the fuck is happening there. The patient is unaware of my exposure (double-entendre) thanks to propofol.
Two and a half days later I wake up at 02:30 with a pounding headache. I am going to vomit, not right away, but it is inevitable. It is going to happen. All future light timelines lead to emesis. I tell my wife I am going to isolate in the guest bedroom. The sweating commences. Maybe I can make it to the bathroom before vomiting. I can’t. I exit to the kitchen sink; the bathroom is too far away. Trying to vomit quietly, while not waking a sleeping two-year-old is no easy task.
The doubt creeps in—few people have spent 4 hours with a patient on a ventilator with SARS-CoV2 in the back of a metal box at this point; how good is a ten-year-old PAPR? Are the filters expired? Do filters expire? The rest of the night is a fever dream of alternating shivering and sweating, thinking how I do not want to end up on a ventilator and wondering who I trust to intubate me. It is light outside before the headache abates, allowing me to sleep a few hours.
A New Paradigm. With the outbreak of SARS-CoV2, the healthcare paradigm is evolving. Those who are locked into black and white thinking and rigid structures are going to have a bad time, a really bad time. I’m not saying we need to fabricate trash bag intubating bubble helmets for our healthcare workers, or form death squads, but we have to be agile. We must be able to adapt and to evolve. We must be able to intake new information and update our beliefs. A constant, endless, ever-moving OODA feedback loop. Waiting on multiple levels of bureaucracy to impart changes is no longer going to work. Clinging tighter to “the rules” when you are shown that “the rules” are not working is slow suicide or at best some kind of sanctioned Russian Roulette leading to an evolutionary dead end.
Healthcare has left the linear, ordered world and entered the VUCA world.
“Things Done Changed.” – The Notorious B.I.G.
What is VUCA? It is an acronym for volatility, uncertainty, complexity, and ambiguity.
It is making hard decisions on the fly, deciding on course of action with nothing more than some fuzzy details and weighing risks versus benefits, deciding just how hypoxic a patient can be, and of course, there is the incident where I exposed myself to several nurses in a med-surg room converted to an ICU room and maybe got SARS-CoV2 in and around my penis.
VUCA is the forecast for the next few weeks or months ahead. The sooner we realize where we are, in a world dominated by VUCA, the sooner we can begin to acclimate and to operate in these conditions.
If you are in a leadership position be aware that this VUCA world is an uncomfortable place not just for you but for many of your employees. In addition to the discomfort you feel (or at times—straight-up horror) you need to watch for the people in your charge as well. They are going to be anxious, irrational, mad, confused, frustrated and depressed about having the black and white rug of cause and effect thinking pulled out from under them. There are only shades of gray now.
Full disclosure: what follows is a disjointed mess where I tried to put down some thoughts. It may be futile to try and pigeon-hole concepts into one letter of VUCA, there is so much overlap between all the domains. It might be futile to try and read what I wrote as well. Combatting VUCA is not nearly as important as being okay with it, not being overwhelmed by it and learning how to operate in these conditions.
V = Volatility: Liability to change rapidly and unpredictably, especially for the worse.
I’ve been shooting at moving targets for weeks now. Two weeks ago, I knew nothing about the dangers of aerosol generation and viral infections, now I am worried if auto-asphyxiation (of the non-erotic kind) will be covered by our worker’s comp insurance because someone tries to intubate wearing a plastic bag.
The guidance from organizations is fluid and ever-changing. Social media is in constant flux. Is ibuprofen bad for SAR-COV2? Probably not. Should we be intubating people in trash bags? Beats me. Should the patient be in the bag or should the intubator be in the bag? Maybe both? Does a Z-pack and Plaquenil cure this disease? In just two days this went from looking like the cure to SARS-CoV2 to looking like dog shit wrapped in cat shit with some real academic fuckery occurring.
A lack of understanding of exponential growth may be to blame for some of the volatility. The human mind operates in the linear world, not the exponential one. The famous lily pad problems nicely explains this. One lily pad, doubling in size every day, covers a pond in 30 days. On what day is the pond a quarter covered? On what day does the healthcare system become overwhelmed? What day is the day, two days before there aren’t enough ventilators or N95’s?
Understanding that we are running in The Red Queen’s Race is helpful. Being willing to change our minds as new evidence emerges is needed – a sort of cognitive flexibility must be practiced, and the ability to quickly abandon our ideas and practices when shown to not work or be harmful is imperative. If this whole aerosol generation turns out to be more of a healthcare worker mass hysteria than an actual threat I wouldn’t be surprised. In the past emergency medicine changed practice in timeframes measured in years (think: backboards, high flow oxygen for everyone), we need to be able to change practices in days or even hours as new information becomes available.
Avoid the sunk-cost fallacy. Half of what I have done in the past two weeks has now ended up in the trashcan.
“If you are going to eat shit, don’t nibble.” – Ben Horowitz
Once something is no longer relevant, cut your losses and move on. As much as you want to be right, the confirmation bias can land you on a ventilator pretty quickly these days.
Operating in a high volatility environment
Avoid the sunk cost fallacy
Avoid premature closure
Cognitive flexibility—update your beliefs when new information arrives.
Know what domain we are in (The Red Queen’s Race)
U = Uncertainty: the lack of predictability, the prospects for surprise, and the sense of awareness and understanding of issues and events.
Events must be carefully examined. Correlations abound, causations are few. Two elderly patients passed away within twenty-four hours of each other in our county, both have had symptoms of SARS-CoV2 and both have been tested for it with results still pending at the time of their deaths. Two employees were exposed to one of these patients during a resuscitation. banished to exile in the Super 8, for the good of the kingdom. A sweeping wave of death for the elderly and the infirm is starting in your rural mountain community. Except that it isn’t here yet, both patients tested negative. The employees were exiled for nothing but there is no way to know, instead of real-time results there is only uncertainty and the ability to look days into the past.
As the infection prevention “officer” at my agency, I am writing protocols daily. When I took a 2-3 day class on this topic, twelve years ago, I never imagined we would have an actual pandemic. There are days where I will tell you I don’t know what the fuck I am doing. Now I am self-teaching myself to become an expert in 3m industrial respiratory protection products and trying to understand things like mJ/CM2 UVGI exposures.
I wake up anxious. It is 4 a.m. and something isn’t sitting well with me about the bleach sprayers we made three days ago. What did that girl ask me yesterday when I got the cattle obstetrical gloves from her (as part of a makeshift gown if we ever run out) at the vets office—something about bleach and hot water. I get up, sleep is not going to happen at this point. I stagger out to the bay and stare at the bleach, the lights humming overhead. Something is wrong. Something, but what?
Where is the percentage on the bleach bottle? What have I made—are sure or are you just pretty sure? The bleach does not list the amount of active ingredients anywhere. Days ago when I got the last four gallons of bleach at Walmart I felt like a successful scavenger, now I’m wondering how bad I fucked up—potentially exposing multiple members of the staff by doing a faulty decontamination of the ambulance. The internet provides you the answers, the ones you did not want. Splash-less bleach is bullshit. I have been disinfecting with a homeopathic bleach solution. Fuck.
Put redundant systems in place. Have a plan A, B, C, and D. Embrace negative visualization and think of all the ways tired and scared employees deep in system 1 thinking might operate. Remember what Sir Mix-a-Lot says, “Uh, double-up, uh,uh.”
Thinking in future counterfactuals (aka a range of outcomes) is required here. Do not make singular predictions unless they are for the worst-case scenario. While I am pretty sure someone isn’t exposed to SARS-CoV2, what if I am wrong? Even if the chances of it being an exposure are less than 5%, if one of the possible outcomes is catastrophic, follow the safest course of action if staffing allows for this.
Invert. Think about what you want to avoid rather than what you want to accomplish. (insert counterfactual diagram)
Set tripwires. There are going to be very few scenarios where things are 100% certain for the next few months. Set a tripwire to act when you are 80-90% certain and try to do it in safe to fail experiments. When you hit X number of N95’s left you will start to re-use them. When you have lost x% of staff you will let asymptomatic exposures work.
Being comfortable with cognitive dissonance is needed. Holding two opposing ideas and trying to not be ripped apart by the tidal forces is not easy. I want to do what is right for the patient, but I also want to keep myself safe. I must keep myself safe. This may go beyond just a touch of cognitive dissonance going all the way to terminal, paralyzing, goal-conflict.
Taking a page from Decisive, run a vanishing options test – ask what you would do if option A is no longer an option. For example, a nebulizer might be a COVID death-mister at this point, rather than spend hours working out how to jury rig some piece of shit contraption, can you just get an MDI? How about over the counter Primatene Mist MDIs from Walmart? Maybe terbutaline IV or even a few micrograms of IM or IV epi could work.
Operating with uncertainty.
Avoid premature closure (it said Bleach on the bottle).
Thinking in a range
Understanding risk (black swans and catastrophe)
Goal conflict – run a vanishing options test
C = Complexity: the multiplex of forces, the confounding of issues, no cause-and-effect chain and confusion that surrounds organization.
I am on board with the paradigm of nothing more than six liters of oxygen per minute or intubation for my own selfish reasons (note: in the time since I wrote this draft and the publication date, I am leaning towards changing my mind on this. Remember: Update beliefs, call it Bayesian or OODA, whatever). But what if we are wrong? We are going to see an uptick in peri-intubation arrests because of the protocols we are implementing, make no mistake about this. I have already heard of an intubation of one of these patients reaching an spo2 of 48%. I am going to hurt patients to protect myself. At least I can tell you that here and now, we’ll see how that plays out in the messiness of being in the shit. Can I sit on my hands?
Synergy is a real bitch, where 1 + 1 =3, not 2; beyond synergy, we need to understand something known as emergence—this is where 1 + 1 = (WTF), something that is not even a number. Emergence is when two separate things combine to form one entirely new thing; think rogue waves, pandemics and a guy eating a bat in china causing a global depression and making my small grocery store sell out of toilet paper.
Systems thinking is cognitively harder than remaining in system 1 thinking where cause and an effect explain the world. Even ‘groking’ the difference between linear and exponential thinking may not be enough—the difference between linear and self-amplifying feedback loops must be understood. What if the vector pool for this disease wasn’t the nursing home patients, but the healthcare workers?
Consider a primer on systems thinking. Look for ways to interrupt the feedback loops before it is too late. Get the healthy people out of the nursing homes now, if you can.
Consider the second and third-order effects of actions. We gave a few people N95 masks to take home to their spouses. That probably sounds crazy right now, but when you realize their spouses are in healthcare, working at a facility that could run out of N95 masks and if their spouse gets sick and our employees will have to take work off to watch their children, the cost of a few N95s is far outweighed by not losing an employee.
Watch out for buggy knowledge, also known as chauffer knowledge—if you think every hypotensive SARS-CoV2 patient should get a big ole’ bolus of saline, or worse the standard 30ml/kg all-inclusive deal, you may be harming patients. If you are one of the people who was posting memes comparing this to the flu a month ago—you can go fuck yourself.
Understand Emergence and synergy
Systems thinking (fatigue – lowering of the immune system – sick workers – fewer workers – more fatigue)
A = Ambiguity: the haziness of reality, the potential for misreads, and the mixed meanings of conditions; cause-and-effect confusion.
An elderly nursing home patient who hasn’t left the residence and has had no visitors becomes the first positive case of SAR-CoV2 in our county. How did this happen? Perhaps this disease has been floating around our communities for some time and we did not know it?
Who should be allowed to work and who shouldn’t? The CDC issued guidance that people exposed to positive SARS-COV2 patients should not work, unless the workforce is exhausted and then it is fine to have asymptomatic people work because we don’t actually know when someone can transmit the disease—is it only when they are symptomatic or days before that? Most cases are mild or even asymptomatic and it seems to be a reasonable assumption that asymptomatic people can spread this disease.
Many people will test positive days before their symptoms begin. Some people will test negative while having the disease. Maybe it is time to trust Reverend Bayes instead of the rayon swab?
While some people ran out to the aquarium store, bought some chloroquine and then died, the right approach would have been to really look at the data in the study. Fox News is not a substitute for medical knowledge.
Invert – what is the right thing to do here with these employees? I know what I want to avoid.
Remember Hickam’s Dictum
Chauffer knowledge will kill you (aquarium meds).
Thriving in the VUCA world
What is needed to thrive in the VUCA world we are facing? Healthcare workers will have to embrace agility, change, and uncertainty. Multiple levels of bureaucratic red tape will ensure a controlled flight into terrain where the regulations were followed all the way to the point of impact. A year from now the “black boxes” may be very hard to listen to. Organizations will have to trust their employees to do the right thing, even when it means coloring outside of the lines—the lines which were never made for deciding which patient gets a ventilator and which patient dies, or which provider gets enough PPE and which one doesn’t.
I’m outside my house jamming a rayon swab four inches into my nose. It comes out with a bit of blood on it. I snap it off and put it in the media. It gets dropped off at the lab and I come terms with waiting for days to find out if I have SARS-Cov2. There are just a few moments when the anxiety grips me tightly. I start to reexamine my outlook on life – am I really okay with dying? (Answer: fuck no I am not, at least not yet. Looks like there is more work to be done there). For the most part, I keep it together apart from one 5-minute melt-down.
I tell my wife that this is fucking bullshit and I shouldn’t have to do this shit anymore and it isn’t my fucking problem. A few moments later I get my shit together. It is my problem—I took this shit on and need to remember that. It is big-boy pants time. “What stands in the way becomes the way.” People asking for hazard pay should shut the hell up. This is what we signed up for.
The next day get a phone call with my results. Until now it had been taking five to seven days to get results, mine as done in less than twenty-four hours; it seems the state lab has prioritized health care providers. My results are negative—just in time for me to go back to work after spending my four days off being sick. I’m not saying I wanted SARS-CoV2 but I could have used a few more days of isolation (AKA not work) even with the side order existential dread that accompanied it.
In The Obstacle is The Way, Ryan Holiday says: “Don’t worry about the “right” way, worry about the right way. This is how we get things done.” I hope that goes for my butchering of the English language in this blog post as well. I wish there was more time to really tune this up a bit, but I need to run in place as fast as I can right now.