2020-May/Jun - SSV Medicine

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May/June 2020

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MEDICINE 4

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COVID-19 a Life-Changing Experience for Physicians

COVID Chronicles

PRESIDENT’S MESSAGE

John Wiesenfarth, MD

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EXECUTIVE DIRECTOR’S MESSAGE

Operation Shields Up A Crowdsourcing Success

Aileen Wetzel, Executive Director

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OPINION

Love in the Time of Corona Caroline Giroux, MD

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OPINION

Megan Babb, DO

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POETRY

Healthcare Healers Deepika Goshike, MD

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Breathless: A Brief History of Pulmonary Resuscitation Kent Perryman, PhD

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Board Briefs

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New SSVMS Members

We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below.

Authors will be able to review articles before publication.

Letters may be published in a future issue; send emails to SSVMedicine@ssvms. org.

All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the Sierra Sacramento Valley Medical Society for permission to reprint.

SSVMS Honors Medicine Photos by Scott Duncan

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Mrs. One Arm: An Easter Tale Faith Fitzgerald, MD

Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 p.m.

M–F, except holidays.

INTERVIEW

Vanessa Walker, DO: The Mysteries of COVID-19 Ken Smith, Managing Editor

VOLUME 71/NUMBER 3

Cover photo: An electron microscope image shows the SARS-CoV-2—also known as 209-NCoV, the virus that causes COVID-19—isolated from a patient in the U.S., emerging from the surface of cells cultured in the lab.

Official publication of the Sierra Sacramento Valley Medical Society

5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx

May/June2020

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Sierra Sacramento Valley The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community.

2020 Officers & Board of Directors

John Wiesenfarth, MD, President Carol Kimball, MD, President-Elect Christian Serdahl, MD, Immediate Past President District 1 Jonathan Breslau, MD District 2 Adam Dougherty, MD J. Bianca Roberts, MD Vanessa Walker, DO District 3 Ravinder Khaira, MD District 4 Ranjit Bajwa, MD

District 5 Sean Deane, MD Farzam Gorouhi, MD Paul Reynolds, MD Roderick Vitangcol, MD Angie Yu, MD District 6 Marcia Gollober, MD

2020 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Anand Mehta, MD District 5 Sean Deane, MD District 6 Marcia Gollober, MD

District 1 Alternate Megan Babb, DO District 2 Alternate Rachel Ekraib, MD District 3 Alternate Ronald Chambers, MD District 4 Alternate Vacant District 5 Alternate Mark Drabkin, MD District 6 Alternate Christopher Swales, MD

At-Large Delegates R. Adams Jacobs, MD Barbara Arnold, MD Helen Biren, MD Amber Chadwin, MD Adam Dougherty, MD Gordon Garcia, MD Ann Gerhardt, MD Richard Gray, MD Richard Jones, MD Charles McDonnell, MD Leena Mehta, MD Sandra Mendez, MD

Rajiv Misquitta, MD Sen. Richard Pan, MD Neil Parikh, MD Paul Reynolds, MD Ernesto Rivera, MD J. Bianca Roberts, MD Kuldip Sandhu, MD James Sehr, MD Christian Serdahl, MD Ajay Singh, MD Tom Valdez, MD John Wiesenfarth, MD

At-Large Alternates Natasha Bir, MD Christine Braid, DO Lucy Douglass, MD Karen Hopp, MD

Brian Jones, MD Mohammad Khan, MD Romero Santiago, MD

Margaret Parsons, MD

Sandra Mendez, MD

Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising.

CMA President-Elect Lee Snook, MD

AMA Delegation Barbara Arnold, MD

Editorial Committee Megan Babb, DO Sean Deane, MD Caroline Giroux, MD Robert LaPerriere, MD George Meyer, MD

John Ostrich, MD Karen Poirier-Brode, MD Gerald Rogan, MD Glennah Trochet, MD Lee Welter, MD

Executive Director Managing Editor Webmaster

Aileen Wetzel Ken Smith Melissa Darling

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Listen and subscribe to Joy of Medicine - On Call on your favorite Podcast App or visit joyofmedicine.org

Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests.

CMA Trustees, District XI Douglas Brosnan, MD

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Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Š2020 Sierra Sacramento Valley Medical Society SIERRA SACRAMENTO VALLEY MEDICINE (ISSN 0886 2826) is published bimonthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.

| FEATURED CONTRIBUTORS |

John Wiesenfarth, MD

Caroline Giroux, MD

The daily life of SSVMS President John Wiesenfarth, MD, an emergency physician, has changed dramatically since COVID-19 arrived. He writes about it and why he understands his exile to the guest room.

Dr. Giroux, a UC Davis psychiatrist, writes about how the interruptions in her personal and professional lives in the time of corona have reinforced the need for love and compassion.

Dr. Babb brings us the stunning stories of physicians from across the country who have faced termination, equipment shortages, censorship, salary cuts and the death of colleagues as they fight COVID-19.

Deepika Goshike, MD

Faith T. Fitzgerald, MD

Ken Smith, Managing Editor

Dr. Goshike is a family practice doctor in Folsom and also a new poet. She offers some supporting and inspiring words to her colleagues on the front lines of the fight against COVID-19.

Dr. Fitzgerald remembers a very special Easter and a lesson she learned that has stayed with her to this day. The housekeeper that had been known to her as “Mrs. One-Arm” held an important secret.

Ken talks with pulmonologist Vanessa Walker, DO about treating patients with COVID-19, how doctors are learning on the fly about treatments, and the lasting effects of the pandemic on physicians.

drjohn@winfirst.com

deepika.goshike@kp.org

Kent Perryman, PhD

cgiroux@ucdavis.edu

ftfitzgerald@ucdavis.edu

Megan Babb, DO

mbabb1522@gmail.com

ken@kdscommunications.com

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ssvms.org.

kperryman@suddenlink.net

Ventilators have grabbed a new place in the public consciousness. Dr. Perryman gives us a brief tour of how pulmonary resuscitation has evolved from the days of ancient Egypt to today’s respirators.

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| PRESIDENT’S MESSAGE |

COVID-19 a Life-Changing Experience for Physicians

By John Wiesenfarth, MD drjohn@winfirst.com

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s I write this in mid-April, life as an emergency room physician is a bit like standing on a hilltop and watching the horizon for a tsunami as warning sirens wail. You expect it to come, but even though waves are increasing in their ferocity it’s still unclear when it will hit, how big it will be or—in the scenario we all hope for—if it will hit at all.

Unfortunately, that last scenario is unlikely when it comes to the increasing wave of COVID-19 cases we expect to see between now and when this magazine arrives in your mailbox. The emergency physician community is a pretty tight-knit one, and we are in constant contact with our friends and colleagues across the country. Part of my training was at William Beaumont hospital in the Detroit area, which has been hit hard by the virus, and they recently sent out an email blast asking retired physicians, alumni and other health professionals if they or anyone they knew could come bolster the overwhelmed staff.

A quick response and social distancing seem to be flattening the curve in California, but we are fully aware the number of cases will grow in the coming weeks and possibly months. We have already seen several confirmed or suspected cases of COVID-19 in the area’s hospitals, and it has dramatically changed the lives of almost everyone who works there. For the past few weeks I have been banished to the guest room at home, fortunately not because my wife Kathy is mad at me but in order to keep my family safe.

What continues to amaze me is the resilience of our member physicians and the health care professionals who are taking this virus head on. You see the gamut of emotions from fear to just a conviction to deal with whatever comes, but there is no question that we are all dedicated to providing the best care even if we have to face difficult choices. I don’t remember a similar situation where we literally learn more and sometimes change the course of treatment by the day or even the hour, as we are now.

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Physicians and nurses currently treating COVID-19 patients and expecting more aren’t the only ones under stress these days, however. The focus on having EDs and ICUs ready has meant that almost all elective or less acute treatments have been postponed to keep hospital beds available, and practices ranging from ophthalmology to orthopedics have taken a serious hit or even shut down as patients shelter in place.

The stress that comes from facing a pandemic unlike anything we’ve seen in over 100 years is enormous for anyone, and it doesn’t help when you are at risk at losing your livelihood and not knowing when some degree of “normal” might return. Physicians are human, and no matter whether it’s the overwhelming load of an emergency room or having to furlough staff, it’s often

What continues to amaze me is the resilience of our member physicians and the health care professionals who are taking this virus head on. hard for our families to understand exactly what we’re going through. That’s why SSVMS’s Joy of Medicine program is so valuable and why you should tap into it now more than ever.

Joy of Medicine’s peer groups are invaluable toward helping you face whatever professional or personal challenge has come your way, and you also have access to six free resiliency teleconferences with experts who can offer guidance. Whatever you may be going through, you will find that you are not alone and that you can get through it.

I’m very proud that as California and our counties have worked to flatten the curve, SSVMS has worked hard to stay ahead of it. Through Operation Shields Up, your medical society has mustered a grassroots moment to create and deliver face shields that are an essential element of protection as we treat COVID-19 patients.

They are also working closely with the counties and

physicians to offer support in any way possible.

If there is any silver lining from the iniquity of this pandemic, it is the public awareness and appreciation physicians, nurses and others in the health care community have received around the country and around the world. From nurses working extra shifts to the cleaning staffs to my fellow physicians who have all stepped up, even though I know you’ll say you’re just doing your job I want to thank you for all you do. But we also couldn’t do it without the support of our families, friends and neighbors who have come together to help out and understand that life just won’t be normal for a while.

By the time you read this, it’s very possible that the wave may be

Woodland Memorial, like many local hospitals, set up a temporary intake area for patients showing symptoms of COVID-19. hitting at full force. Whether or not it arrives as expected, I know that our incredible membership and our colleagues throughout the health

care community will be ready. You can also be sure that SSVMS will be there by your side every step of the way.

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| EXEC UTIVE DIRECTOR’S MESSAGE |

Operation Shields Up A Crowdsourcing Success

From an Idea to Delivery in Just Three Weeks

R

emarkable times call for remarkable actions. That’s why in a space of just over three weeks SSVMS was able to launch a new, innovative program dedicated to getting health care professionals the personal protective equipment (PPE) they need.

Operation Shields Up is a grassroots collaboration of SSVMS, local businesses, community members, and engineers with the 3-D printing capacity and design skills needed to produce plastic face shields. We are raising money for supplies, working with vendors from across the country, coordinating volunteers locally, and distributing thousands of face shields to health care professionals throughout the region. Our goal is to have 15,000 new face shields in the hands of local providers by the time you read this.

This whirlwind of an operation began after many of our members told us they didn’t have the PPE they needed. SSVMS was determined to answer the call to make sure our physicians were equipped to practice safely as the number of COVID-19 cases started to grow.

Traditional approaches just weren’t available due to the immediate need and the demand for products elsewhere in the country. That led to the novel idea of crowdsourcing shields.

The community response was incredible and the results were greater than we could have expected.

We’ve received shields using a CDC-approved design from a diverse range of sources that include members of a computer lab co-op, volunteers who were out of a job as a result of all the shutdowns, and even a 10-year-old boy who printed 30 shields on his own. By the first week of April almost 8,000 shields had already been printed, assembled and delivered.

SSVMS has gone beyond face shields, however. We’ve also distributed 3,000 fabric masks, many of which were sewn by volunteers, to nursing homes and medical practices to help protect patients and staff.

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Sierra Sacramento Valley Medicine

By Aileen Wetzel awetzel@ssvms.org

This has all been on top of business as usual at your Medical Society. The staff has been working long hours and has done a fantastic job. I can’t thank them, along with all the volunteers and sponsors, enough for their hard work and dedication.

Building a manufacturing and distribution operation in three weeks without any cost to our members or added staff is not without challenges. But we’ve been able to learn on the fly and SSVMS is committed to getting you the resources you need for as long as it’s needed.

Shields have come from diverse sources, including a 10-year-old boy who printed 30 on his own.

These are stressful times for many of our members, whether it is because they are treating patients with COVID-19 or because they are suffering financial losses due to a falloff of their practices or the postponement of elective procedures. SSVMS has been here for you and will continue to provide resources, guidelines, and information so that your practice of medicine can remain viable during and after the pandemic.

It’s important, now more than ever, to pull together as a medical community. SSVMS has expanded Joy of Medicine, and at the end of April we hosted our Virtual Town Hall. Even though it’s always better to meet in person, we set up Zoom events with virtual physician meetups in which our members could check in and talk about what they’re facing. We plan to hold more of these as long as social distancing restrictions are in place.

These are unprecedented times, but I’m proud to say that SSVMS and our members have risen to the challenge. We all hope to return to something that’s closer to normal sooner rather than later. In the meantime, though, thank you to everyone on the front lines fighting COVID-19 and please stay safe.

THANK YOU SSVMS would like to thank local community members and businesses for answering the call for help, donating much needed Personal Protective Equipment (PPE) to protect our medical personnel on the front lines of this crisis.

Special thanks to: Volunteers, donors, and creators of Operation Shields Up! Community members donating hundreds of masks, gloves and other PPE materials Sewing groups and individuals sewing hundreds of fabric masks Joann Fabric - Folsom

May/June 2020

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| OPINION |

Love in the Time of Corona T

he day after a non-celebrated St. Patrick’s Day, I’m walking to my fourth-grader’s class to pick up his books per his teacher’s email instructions. Forgotten lunchboxes and shirts are strewn all over the playground. There is no laughter.

This desolate, post-cataclysmal sight makes me sad. I walk into my son’s class and am suddenly thankful to see his warm, friendly teacher.

I congratulate my presence of mind to have grabbed a bag from my car since my son’s pile of stuff is heavy. As I take his books one by one, the grief sensation is exacerbated, similar to the bereaved parent’s gathering of a deceased child’s belongings. This feeling was so disturbing and the previous weeks have been so draining mentally that when the teacher asked me, sincerely, how I was doing, I let myself cry, and accepted a very much needed hug, thinking this would be the last in a long time.

Various dimensions of our lives have been affected by the pandemic: the way we provide care to patients (who will I prioritize if there is a medication shortage and when everyone asks for a 90-day supply of their pharmacotherapy?), the way we raise our children (especially how we structure a new routine as they must stay home), the way we integrate domesticity while 8

Sierra Sacramento Valley Medicine

doing clinical supervision over the phone, the way we travel, the way we shop and consume resources, the timeframe for a pregnancy, the way we greet each other, and so much more.

Most of us went through an unexpected crescendo of microgriefs: Vacation: canceled. Lacrosse practice: canceled. Meeting or in-person appointments: canceled.

Book club: canceled. Dinner parties: not until further notice. Ski season:

By Caroline Giroux, MD cgiroux@ucdavis.edu

ums (this ubiquitous fixation on bathroom procedures seems like an interesting displacement of fear of death). Our minds and hearts feel threatened in unimaginable ways. It seems like the world is at any given time on a fight, flight, freeze or faint mode (“the four Fs”). And the response in us is all those reactions at the same time: pupil dilation, fast heart rate, digestive upset to rally the blood troops to the muscles, and general hyperarousal when some-

Our minds and hearts feel threatened in unimaginable ways.

It seems like the world is at any given time on a fight, flight, freeze or faint mode. prematurely terminated. Grocery stores: depleted. Movie theaters, restaurants or museums: forget it.

My daily dose of hugs: canceled. It even affects how we dream.

We all felt the rise of a collective panic, alternating with disconcerting nonchalance. Avoidance, xenophobia, conflicting information, lies, chaos… it is hard not to tense up, freeze, feel like crying or burst into laughter. We are glued to our screens, we toss and turn at night.

We are witnessing an almost comical dystopian version of a gold rush, now with N95 masks and hand sanitizer. Some households have turned into toilet paper muse-

one coughs.

It’s time to weed-whack the bushes of irrationality to see more clearly through such a large-scale impasse. We have to think fast, but also pause and respond in a way that honors deep, humanistic values. This is an unprecedented opportunity to observe and reflect about the human condition. I wish I had already read Love in The Time of Cholera… maybe literature, if not my medical degree, could have prepared me for this.

Questions abounded as we saw our individual freedoms shrink for the greater good. We will stay home and avoid human contact, but how

long can we all stand such confinement? I am so scattered that I can’t absorb my 12-year-old son’s dismay (and my deep shame) at my inability to double-check his resolution of a quadratic equation.

As a psychiatrist, I have been bombarded with questions as I was trying on my end to switch patients over to video visits and continue to provide group therapy despite the recommendation to cancel all group activities (we discussed a possibility using Zoom and it was a success).

I also had my own questions: No more playdates? Should I move out of the bedroom since my spouse is an emergency physician? I also had my own fears… What if one of us gets sick?

My father, two aunts and various people I know from my native Quebec were vacationing in Florida. My crusade to convince them to leave was all consuming.

Thankfully, they drove back before a border closure was announced. I don’t know whether I will be able to visit them as planned this summer.

How will technology compensate for the needed social connections?

I feel increasingly trapped in my home, in this country, in my head.

This crisis affects many details of our existence we had not anticipated or were prepared for. My children have been through countless fire drills and lockdowns in case of an active shooter. We obsess about earthquakes and forest fires. But epidemics have been blind spots.

Shouldn’t all children learn basic principles to prevent disease spread from kindergarten to enhance lifesaving health literacy? Because in the midst of a crisis, we could save precious times and lives not having

to teach how to wash hands like a surgeon, or the cough etiquette, or when to not go to a doctor.

As we try to process all the incoming information and the magnitude of this global catastrophe, there is a war within our autonomic nervous systems. The only response and solution that can defeat this has just four letters: love.

But social distancing is interfering with attaining our deepest of needs at the moment. A pandemic also triggers existential angst, and the remedy is reassurance, the one found in the appeasing presence of others. How can we heal if we are told to stay away from each other?

Love is still the answer, in whichever form, and love is what aches for me at this time as a mother, daughter, doctor, writer. It aches as I am relieved that my relatives are back in Canada but I am filled with yearning for them. It aches because I know too well that soon doctors— like my spouse—will have to decide who will be given a chance to live and who will die. It aches as I don’t know what the future holds for any

of us. It aches because I don’t have a template to help me find the words to explain this to our children, other than, “I have never been through anything like this.”

There is no magic pill, no religion, no wealth that will solve this pandemic and the angst it creates overnight. And even love cannot be manufactured. But it has a precursor: compassion. This is a luminous force that is felt, genuine, not scripted during press conferences. It is action towards a common cause, which is the well-being of humanity. Compassion is our common denominator. With compassion will come many fruitful collaborations, co-creations that can be life-saving as long as they leave the ego battles aside.

If we all work together, if we are all prepared to help each other rather than just fend for our own, we can survive and maybe even learn an important lesson. This is not about a country, a nation, or a specific socio-economic group. It is happening to many people, regardless of social status, age, gender,

May/June 2020

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nationality or race. It could be any of us. Maybe it is an ironic reminder of justice or a call for equality. The contagion is a tragic reminder of our interdependency. If we don’t strive for it, nature will find its way.

The “Us vs. Them” paradigm is preposterous. If medical institutions and corporations don’t let fear of lawsuits guide their actions, we will realize that concrete solutions are within reach, and that it’s pervasive greed that might have led us here in the first place. Rather than address social inequities and poor access to care, people have invested in illusions (financial assets, which can disappear in seconds) rather than values such as compassion. There is never a shortage of compassion, and only man-made barriers can prevent accessing it.

The only prayer that matters, the unifying principle, the eternal equalizer, is love. We all deserve it, and we all have it inside. It is time to unleash it by practicing compassionate decision-making. Time to be ready to inspire it, receive it, and let it grow. Fear is as contagious as any virus, but pausing through mindfulness will help you access love and compassion, which in turn will be the compass guiding you towards the right thing to do, calming the overactive stress response systems and its cacophony of the four Fs. Even more so than showing off our quadratic equation skills to our teens, this pandemic is a great test for our egos and our attitudes toward others. It is also an equally great opportunity for our humanistic core values to triumph and create a more compassionate, loving society ready to face the next challenge.

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| PANDEMIC |

The Mysteries of COVID-19

Pulmonologist Vanessa Walker, DO on Why This Disease Is Different and How it Can Destroy Practices

V

anessa Walker, DO was born and raised in Folsom, and always wanted to return to her hometown to practice medicine there and be with her family.

She earned a college softball scholarship as a pitcher and then moved to Kansas City for medical school before completing her internal medicine residency at University of Nevada, Reno and her pulmonary and critical care fellowship at Duke University.

She joined Pulmonary Medicine Associates, an independent practice, in Sacramento in 2014 and is a member of the SSVMS Board of Directors. An active participant in the Joy of Medicine program and medical director of Sutter Health’s Valley Area electronic ICU, covering an area that ranges from Los Banos to Crescent City, she has found herself on the front lines at Sutter Roseville Medical Center treating COVID-19 patients and learning more each day about the disease. SSV Medicine asked her about her experiences with the pandemic in Northern California.

Editor’s note: This interview was conducted on April 8, 2020, and it’s very possible conditions have changed significantly since then. The following has been edited for clarity and length.

Have you seen a surge of COVID-19 patients yet?

What’s it like on the front line?

It’s very interesting because we’ve closed off all elective services right now. Normally the hospitals are filled with patients there for elective services—knee replacements and various things—that’s all gone. There’s nobody there electively anymore, so hospital volume is actually down quite a bit. ERs are down, they’re only seeing about 50 to 60 percent of their normal volume.

However, the acuity in the hospital is pretty high.

That’s because the only people that are coming are really sick. People are sick for a variety of reasons, and just because COVID is here it doesn’t mean people stop 12

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By Ken Smith, Managing Editor ken@kdscommunications.com

having heart attacks or strokes or sepsis or the flu.

[At Sutter Roseville] we have started to see the tick up in coronavirus over the past three weeks. Two or three weeks ago we had one patient with COVID in the ICU, we had six as of Sunday. I think we have four now, not because they died but because we were able to improve them and downgrade them to the floor.

What makes COVID-19 different from other viruses?

It’s interesting, this coronavirus is definitely a unique virus. With all the other viruses that we’ve taken care of, the disease itself is very similar to other diseases. We all know how to take care of influenza. Most of the other viruses that we get cause inflammation, they all convey similar symptoms and they’re all managed the same way. This virus is manifesting very differently, and we have to manage patients in a completely different way.

“COVID-19 is causing ischemia on a scale that we would liken more to somebody getting carbon monoxide poisoning.”

Some people think it’s just a run-of-the-mill bad viral pneumonia, and that’s not the case. It’s doing something physiologically to the blood itself and changing the structures of the hemoglobin and making it so people’s oxygen levels are profoundly low. It’s causing ischemia on a scale that we would liken more to, say, somebody getting carbon monoxide poisoning.

We’ve been avoiding bronchoscopies because it will spread aerosols in the air. But we had to do a bronch today and my partner sent photos to us. The stuff coming out of the lungs was just... I mean, it’s almost like we’ve never seen this before. We were just shocked. It’s like dark, black, bloody material.

We’re having to do things a lot differently than the

Do you think this is going to become more of a practice in the short term? One of the big issues, both medically and politically, has been the ventilator supply.

This is going to be helpful because initially we were saying, get everybody on a vent, if you’re above six liters of oxygen you need to be on a vent because it’s going to help contain the virus. We started doing that and we were causing more damage to their lungs than was necessary; the high-pressure treatment that we were using for ARDS patients was actually causing

Photos courtesy Vanessa Walker, DO

ways we’re used to doing them.

Fortunately, we’ve learned so much from what they did in China, Italy, what they did in New York, what they did up in Seattle. I think that is the benefit that we have in our state is that we’re kind of seeing what they did that didn’t work, what did work, and now we’re able to implement that right upfront instead of trying all these things and failing before we get it right. We’re kind of able to hit the ground running and starting by doing things in the right way, then we’re making adjustments on the fly.

Two weeks ago, I was working with a group responsible for creating guidelines for the Sutter system for how to manage respiratory failure. We were telling everybody: Intubate! Intubate! Two weeks later, now it’s the complete opposite: No, don’t put them on a ventilator, avoid it as long as possible and manage them with high flow oxygen long as you can. That is a 180 that goes against everything we’ve ever done to manage respiratory failure before.

Vanessa Walker, DO says COVID-19 is manifesting itself in very different ways than other viruses and doctors are learning on the fly. more damage.

Once we totally changed our mindset and stopped intubating the people that we would have intubated last week or a week and a half ago, they have been getting better and moving out to the floor. I think if we had intubated them they’d still be on the ventilator and doing poorly.

I’ve heard it said that once you got on a ventilator with COVID19, your chances of coming off it weren’t good. Is that potentially part of the reason?

That was probably a huge part of the reason. Never mind that once you get on a ventilator you’re pretty sick. Once you get on a vent, over

80% of the people on ventilators don’t come off. That’s data coming from China, and we know that data is flawed. China is not going to put an 85-year-old obese person with diabetes and coronary artery disease on a ventilator. They’re a communist society, and they are not like the U.S. where we are like, “Come one, come all.”

If we practice the way we normally practice here, I guarantee you even less people would come off the ventilator, because often we are putting people on a ventilator who truly have no business being on one. Before we even had coronavirus, we had been putting people inappropriately on ventilators for years simply because the pendulum May/June 2020

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has totally swung from this paternalistic style of medicine to a free-for-all in which a patient has all the say.

We put out this smorgasbord of options, and you decide what you want without taking into account the physician’s recommendations. I don’t know how many times I’ve literally had to put a 95-year-old person on a vent.

How does information about changes in treatment get spread and implemented?

Social media is huge. We have groups on Facebook that are filled with critical care providers in various places, all over the world, sharing information, sharing literature. I’d say that’s probably one of the more readily available sources for getting information out there.

Dr. Imran Mohammed, who is our medical director for [Sutter Roseville’s] ICU, has been very, very proactive in conferences with doctors from China and Italy. Every day, I think there are probably five or six articles coming out to our group on our email chains.

We’re having robust discussions and trying to find best practices.

We’re constantly in communication with doctors from New York and they’re giving us their advice. It was the doctors in New York, actually, who were the

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ones to start saying, “Hey, I don’t think this is ARDS the way we all think of it. I think this is something else.” In Italy now, a big group is putting out research confirming that they think this is a different thing. However, we still need ventilators. New York has a huge shortfall of ventilators, New York has a huge shortfall of critical care beds. We’re fortunate, I don’t think that we’re going to be in that position.

Could there may be a genetic proclivity that affects why some people are affected by the virus and others aren’t?

I think so. They don’t know exactly what it is yet, but for example we’ve had in our local region a family that was affected. There were three or four brothers and sisters, they were all incredibly sick in various ICUs across our region because they went to a family wedding while they were sick.

As far as I know, few—if any—others got sick. So, it makes me wonder if there was something that was genetic in the family that made them more susceptible to the virus than other people who were at that wedding.

How do you think this has changed, or will change, health care delivery and planning?

I think the big thing we’ve learned from this, and this is not political in any way, shape or form, is that the United States cannot be as reliant on outside countries as we have made ourselves. While it is wonderful to be a globalist and that kind of thinking helps our society in many ways, I think it has been a huge detriment to our ability to respond to this pandemic because we simply did not have enough supplies. We are so reliant on other countries in order to provide basic products for our health care delivery that we are already at a distinct disadvantage.

The other thing I think, unfortunately, is that this is going to be the kiss of death for many of our independent practices. A big organization might take a hit money-wise, and they’ll be able to try to recoup from the government. They can withstand that [financial hit] better than a two- or three-doc shop.

You’ve got family practice docs that only have two or three physicians, a handful of MAs and very little resources. If suddenly because of this pandemic nobody is coming in to do their well-child visits or their annual

What Dr. Walker now wears to treat patients, above, is much different than before COVID-19 (opposite page). exams, things like that, they have a huge drop in their income. Independent practice is already at high risk because the big shops are taking us over.

Fortunately, PMA is a very big group and the majority of our money comes from intensive care unit practices so we’re good. But our colleagues that have predominantly outpatient practices, like rheumatology or podiatry, where people are kind of electively showing up for visits, they’re going to be hurting and possibly closing up shop or having to join these big groups.

That sets up really nicely for the concept of a complete takeover of health care by large corporations, completely getting rid of independent practice and then eventually moving to something like a single-payer system and completely altering the face of health care.

So I do think that wherever you stand on the politics of universal health care, this is definitely going to nudge us in that direction.

By Jon Davids, MD jdavids@shrinenet.org

There are potentially two groups of doctors now going through some very stressful times, aren’t there? There are those who have to be ready even if they aren’t

seeing patients yet, and also doctors who aren’t part of that but are under tremendous stress for financial or business reasons.

Absolutely. It’s like you’re either in the thick of things and fighting on the front lines and terrified every day you go to work that you’re going to get a virus that you might take back to your family or pass the disease on to others or get yourself sick… versus, say, I’m home and not able to go to work or I wasn’t able to adapt to a telemedicine profile because the majority of my patients are elderly and don’t know how to use a smartphone.

I can’t even imagine the stress of potentially losing your practice, your livelihood, and not being able to pay your bills. Add in to that fear that when you do go to work, if you keep your practice open, you are also exposing yourself to people who could be infected so there’s a double whammy there. It’s hard, whatever side you’re on.

That’s where Joy of Medicine comes in. There are free consultations and we’re trying to make sure that every doctor knows that they are available to them. The Joy of Medicine peer groups are another great program. The Medical Society provides food and we alternate bringing bottles of wine. We all have a nice glass of wine, we just sit down, relax at my house and do a check in. We ask members to share something they’re struggling with or something they’re super excited about that just made their day.

Do you have a prediction for any surprises or what we might learn as we come out of this?

I don’t know that it’s necessarily a surprise, but I think the health care team member who is going to shine out of this that will—I’m hoping—get a lot of respect is the respiratory therapist. It is a job function that for far too long has been totally under-appreciated. When you hear people say, “Thank God for those brave doctors and nurses,” very rarely do they also say respiratory therapists. Respiratory therapists are just as important as nurses and physicians. They have a huge responsibility: they’re the ones who run these complex ventilators all the time and help us make decisions on appropriate management and care.

So I hope they get the respect that is due them, because it has been eluding them forever. My father is a respiratory therapist and he’s been in this situation his whole life.

May/June 2020

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| OPINION |

COVID Chronicles Threats, Pay Cuts, Broken Promises Show Not Everyone Is Cheering for Physicians During the Pandemic

I

remember the first day of medical school as if it was yesterday. “Look to your right. Look to your left. Now, look at me,” the dean of our college said. “Statistically, one of you three will not graduate.”

I suppose the purpose of this was to provoke a drive in us all, however it did nothing more than drive in me a fear of failing--a fear I had never had before. Fortunately, I was able to endure but these three sentences left a permanent mark on me.

I often wonder if the obstacles physicians struggle to overcome are self-made due to the competitive nature of our profession that begins in its infancy. We are often left to survive in an environment that encourages unhealthy competition, one where the cornerstone of thriving is driven by selfish tendencies. Encouraging the survival of the self, without consideration for the pack, can make it nearly impossible to recognize when our own are struggling.

The COVID crisis has highlighted the need, more than ever, to start focusing our efforts on how we can protect and support those colleagues who need us. In an effort to allow physicians from across the nation to have a voice, an email account was created where physicians and other health care workers could anonymously voice concerns as they pertain to COVID and injustices they have faced. The emails are vetted to the fullest extent they can be to ensure accuracy.

These are their stories. These are our stories.

Nephrologist, Dallas, TX: The hospital system I work just sent an email to all the employed health care workers mandating we sign a document that removes all responsibility if a worker becomes ill due to not wearing appropriate PPE. An email sent ten minutes prior stated: “We are granting permission for our employees to wear cloth masks on their shifts.” Hmmm…

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By Megan Babb, DO mbabb1522@gmail.com

Critical Care Physician, Orlando, FL: In an email sent to our physician group which consisted of five sentences, all of the following were used at least once: mandatory, termination, inappropriate, under no circumstances, we will not tolerate.

I was forced to drop my clinical hours due to COVID and our institution’s lack of response to institute telehealth visits. I just received notification that as a result of my dropped hours, I no longer qualify for the loan forgiveness program I have been on for six years and two months.

I had ten months left to go.

Family Practice Physician, Atlanta, GA Resident Physician, Boston, MA: This was just distributed to every fourth-year medical student in the greater Boston area: “We are reaching out to you with the opportunity to sign up for the ultimate capstone before internships start due to your unique position as graduating medical students who have the skills and experience of 1st year residents. While most residencies, including those affiliated with [the medical school], will not be starting early internship programs, there are ways that your expertise will be very valuable.

This request is being sent to graduating medical students from all medical schools in Boston and we know that all [our] students have always been leaders and risen to

the occasion. As part of our community, we invite you to play a vital role in caring for our community members afflicted by COVID-19 at the experience level of a Sub-I. The COVID-19 pandemic is a once-in-a-lifetime challenge…”

The students are being asked to volunteer… for free.

My mentor just died. He was one of the greatest physicians I have ever known.

Yesterday he was alive.

Today he is not.

Hepatology Fellow, NYC, NY

Neurologist, Denver, CO: I was asked to do an interview with CNN. When the reporter called my hospital to comment in response to my interview (prior to it being aired), I immediately received from them a threat for termination.

Neonatologist, Los Angeles, CA: The parent of one of our NICU babies who has been coming in and out of the NICU seeing his newborn was just admitted to the ICU with positive COVID testing. When I brought this to the attention of the hospital president, I was specifically told not to inform other patients’ parents of the possible exposure.

Internist, Detroit, MI: Our entire medical group was just informed that ALL social media accounts will be monitored and if there are any inappropriate posts that highlight the hospital negatively, we will be terminated.

General Surgeon, Seattle, WA: Two days ago I received notification that my salary would be cut by 30%.

The following day I received a follow-up email requesting I volunteer on the front lines without compensation.

Emergency Room Physician, Tacoma, WA: I was in the ICU for six days, intubated for four of them, positive for COVID-19. I was discharged on a Monday. The $137,562 bill for this hospitalization arrived at my house on Friday along with a letter from Employee Health stating my workman’s comp case (which I had yet to file) was already denied.

Hospitalist, Miami, FL: I am the medical director for my group’s hospitalist program, and our contract just got terminated.

They stated our demands for PPE did not promote a collegial relationship.

OB-GYN, Los Angeles, CA: I was in a perinatal safety meeting last week. I asked when our supplies for N-95 masks will be replenished since we had just run out. I was told by our Labor and Delivery manager that we were last on the list to receive because our unit has the lowest risk in the entire hospital. This was followed up with, “You should be grateful that they are giving us any.”

Critical Care Pulmonologist, Bethesda, MD: I was just terminated because I refused to see patients positive with COVID without a gown or N95 mask.

I was told that this was insubordination. Security walked me out.

Internal Medicine Resident, Brooklyn, NY: Last night was my seventeenth (and last) night sleeping in a local hotel. The hospital made reservations for a swanky hotel and said, “Don’t worry about who will cover the bill, we’ll take care of it.” When I walked out today with my bags, thanking the staff for their help, the manager said, “We still need you to check out. The hospital responded and unfortunately, will not be Editor’s note: Responses have been edited for length and clarity.

May/June 2020

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I lost my job today. Told they are only keeping on essential employees. I thought I was essential.

Pediatrics, New Orleans, LA covering your hotel stay.” I cried when my total bill was $5,780. Lucky me, they threw in a 10% off discount. This was the last of my savings.

Hospitalist, Minneapolis, MN: The academic institution I am employed by plans to cut physician salaries by 25%, including frontline hospitalists and intensivists. They have also declined our request for hazard pay. We are expected, however, to remain whole with our 16 shifts per month.

General Surgery, Memphis, TN: It has been two weeks since the American Surgeon General recommended cessation of all non-essential elective cases. Our hospital refuses to cancel. The rhinoplasty which is on the board for tomorrow is apparently essential and non-elective.

Infectious Disease Specialist, Las Vegas, NV: Physicians were put on suspension unless they agreed to sign the following, “I agree to undertake best practices to avoid infection and further risk of infecting others. Any harm or loss to any other party as a result

of an infection caused by my actions shall be my sole responsibility, which I accept and assume. I expressly agree to indemnify and hold harmless the company, its clients, and its contractors against any and all claims, demands, damages, rights of action, or causes of action, and any person or entity, that may arise from such infection caused by my actions.” The irony is, we don’t have any N95 masks.

Cardiologist, Miami, FL: Our hospital CEO accidentally replied all to an email stating, “If you could just deal with the physicians, and keep me from having to deal with them, I would really appreciate that, Margaret.” Foot. In. Mouth.

The ability to practice medicine is a privilege. We will never be anything more than we are today if we only do the things we have in the past which have contributed to what we struggle with now. We must support one another. We must pop the bubble which surrounds us, shatter the ceiling that restricts us, and break apart the boxes that silence us.

I choose medicine. I choose patients. I choose physicians.

Healthcare Healers

A Poem Dedicated to All of You in These Unprecedented Times

You are an awakener, a warrior and a healer in your soul.

Ingrained in your DNA are healers of all times.

Let the sun in your soul shine bright that destroys the darkness.

Keep every part of YOU intact so that it terrorizes the disease and the virus.

Remember you are a HEALER and a WARRIOR with supreme intelligence.

The rays of the SUN are as infinite as your abilities and responsibilities.

Remember you have everything it takes And that is your DNA as a healer.

— Deepika Goshike, MD

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Sierra Sacramento Valley Medicine

— Deepika Goshike, MD deepika.goshike@kp.org

Contact SSVMS to Access Your

M e m b e r O n ly B e n e f i t s

info@ssvms.org | (916) 452-2671 BENEFIT

RESOURCE

Reimbursement Helpline FREE assistance with contracting or reimbursement.

CMA’s Center for Economic Services (CES) www.cmadocs.org/reimbursement-assistance | (888) 401-5911

Legal Services CMA On-Call, Legal Handbook (CPLH) and more…

CMA’s Center for Legal Affairs www.cmadocs.org/legal-resources | (800) 786-4262

Insurance Services Life, Disability, Long Term Care, Medical/Dental, Mercer Health & Benefits Insurance Services LLC www.countycmamemberinsurance.com | (800) 842-3761 Workers’ Comp, Cyber Liability etc.

Career Center Member groups receive free basic job postings and access to the Career Center resume bank.

California Physician ™ Career Center www.careers.cmadocs.org

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MAYACO Marketing & Internet www.mayaco.com/physicians

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Mercury Insurance Group www.mercuryinsurance.com/cma

Car Rental Save up to 25% - Members-only coupon codes required.

Avis or Hertz

CME Certification Services Discounted CME Certification for members.

Institute for Medical Quality (IMQ) www.imq.org

Student Loan Refinancing Members receive a rate discount of 0.25% off the approved loan rate.

SoFi www.sofi.com/rate-discount-25

Healthcare Messaging Free secure messaging application

DocBookMD www.docbookmd.com/physicians

HIPAA Compliance Solutions Members receive a discount on the Toolkit.

PrivaPlan Associates, Inc www.privaplan.com

Magazine Subscriptions Members get up to 89% off the cover price of popular magazines.

Subscription Services, Inc www.buymags.com/cma

Confidential Physician Wellness Resources 24-hour confidential assistance hotline is free and will not result in any disciplinary action. Additional Physician wellbeing resources also available through SSVMS’ Joy of Medicine.

Physicians’ Confidential Line (650) 756-7787 www.cmadocs.org/confidential-line www.joyofmedicine.org

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SSVMS Vetted Vendor Partners Maloof Law Group Nicholas Maloof, Esq. Estate planning, business transactions. Physician members receive a 10% discount on all services.

Cooperative of American Physicians (CAP) Medical professional liability protection to over 12,000 of California’s finest physicians.

NORCAL Group Medical professional liability insurance, risk management solutions and provider wellness resources.

Sotheby’s International Realty Mela Fratarcangeli is consistently ranked in the top 5% of all real estate agents in the Sacramento Valley serving the buyers and sellers at all levels in the Sacramento Region.

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www.ssvms.org/physician-resources/vendor-partners. Questions: dbrooks@ssvms.org

May/June 2020

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SSVMS

Honors Medicine On Saturday, February 29th 2020, more than 250 physicians and guests attended the SSVMS Honors Medicine event to enjoy delicious food, wine tasting from local vintners and the musical stylings of big band entertainer Peter Petty.

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1) From left to right: SSVMS President John Wiesenfarth, MD, Medical Honor recipient Andrew Hudnut, MD, Ruenell Adams Jacobs, MD, and Awards Committee Chair Margaret Parsons, MD. 2) Andres Sciolla, MD (second from right) with medical students from UC Davis and California Northstate University.

3) SSVMS Board Member Bianca Roberts, MD takes a selfie with her colleagues.

4) Margaret Parsons, MD and John Wiesenfarth, MD join Golden Stethoscope recipient David Kissinger, MD. 5) David Caretto, MD and Pal Minickam, MD.

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6) Josephine Williams and Eric Williams, MD. 7) Medical students from UC Davis and CNSU. 8) Liza Vitangcol, Karly Kaplan, MD, Renuka Nandan, MD.

10) The SSVMS Board of Directors, from left:, Paul Reynolds, MD, Rick Vitangcol, MD, Sean Deane, MD, Adam Dougherty, MD, MPH, Farzam Gorouhi, MD, John Wiesenfarth, MD, Carol Kimball, MD, Vanessa Walker, DO, Christian Serdahl, MD, and Bianca Roberts, MD.

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Sierra Sacramento Valley Medicine

Photos by Scott Duncan

9) Entertainer Peter Petty rocks the crowd.

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May/June 2020

21

| ESSAY |

Mrs. One-Arm An Easter Tale M

y maternal grandparents had lived in China, as had numerous upper-class Tsarist Russians in the early years of the 20th Century. But after the Bolshevik Revolution in 1918 they justly feared the Communist regime, so could not return to their homes in the newly-created Soviet Union—or indeed go anywhere else since their Tsarist passports were no longer valid and they were stuck in Shanghai (which was then an “international settlement” run by the French) during the Japanese occupation of that city in World War II from 1941-1945.

My mother had come to the United States in the 1930’s, however, and so was out of danger. As my grandparents were non-combatants and had Finnish passports, they, too, came to America after the Japanese surrender, joining my mother, older brother, and me in Berkeley, California. My grandfather had made quite a lot of money in China as a dealer in the paper business, second in value only to arms and ammunition in wartime, so my family was well off when they arrived in America but were deeply concerned about their many friends still in Shanghai as the Chinese Communists were becoming more active there.

These Russian friends were merchants or Imperial Russian ex-soldiers or old Russian aristocracy and were Russian Orthodox Christians. When the then-newly formed United Nations issued “displaced persons passports” allowing men and women whose passports were no longer valid to come to the United States if they had a sponsor who would guarantee that they would not go “on the dole,” my grandparents provided some of that sponsorship. This was the major reason that Russians would come en masse to San Francisco after the war, where they would ultimately build the Russian Orthodox cathedral on Geary Boulevard as well as establish an orphanage for Russian children from China.

Of the many Russians who came to the Bay Area, my brother and I, then both less than 10 years old, met a 22

Sierra Sacramento Valley Medicine

By Faith T. Fitzgerald, MD ftfitzgerald@ucdavis.edu

large number. They were always coming to our house and we to theirs. We also met many who were working as gardeners, elevator operators, store helpers, taxi drivers, manual laborers, and maids in order to support themselves and their families.

One such maid worked as a housekeeper for my family and was fascinating to us children because she could, even as an older woman, navigate an extremely heavy Hoover vacuum cleaner over the rugs in every room, in spite of the fact that she had no left forearm, a condition she hid by stuffing her remaining upper arm under the bib of her apron. I can not remember her name, but we kids secretly called her “Mrs. One-Arm.” On the Saturday night preceding Russian Orthodox Easter there is a traditional midnight service at the church and my brother and I were allowed, for the first time, to come with our grandparents and mother to that event. When we arrived at the church and went in, it was darker inside than I had ever seen it. Black cloths covered the icons, fewer candles were lit, and the choir was singing Russian baritone laments. There was, in the middle of the church, a small coffin on the table, a table also covered in black cloth.

As midnight approached, the choir lined up and headed for the exit door, all carrying unlit candles.

Candles were also distributed among the worshippers who followed them out of church. When the priest emerged to lead the choir and worshippers fell in line behind the choir, we all walked three times around the church. It was cold! It was dark!

When we, after three walk-arounds, came at last to the front door again the priest stood in full regalia on the porch. The crowd began to light their candles, passing the flames from the front to the back of the line. The doors swung open; the light inside was now brilliant.

The priest shouted, “Christ is risen!” and the congregation shouted back, “He is risen indeed!” Then the priest and the choir re-entered the church and all following

them began to sing in triumph. The icons were glistening; the casket gone. The walk around had signified the three days the crucified Jesus was in the tomb described in the Christian Bible.

After a fairly long sermon the ritual was over. It was time to eat Easter breakfast. Many did so in the church basement dining hall but we went home as my grandparents had invited close friends to the Easter feast at our house. When we arrived home, the big dining room table was fully set and the food laid out before us, as Mrs. One-Arm had stayed behind to prepare the places and put the food on the table.

Everybody sat down and my brother and I took our usual seat, but I was confused. The chair at the head of the table, where my Grandpa always sat, was empty.

I looked around and found him sitting two chairs away from us on the opposite side of the big table. I’d never seen him do that before.

Within several minutes after we all arrived, but not yet begun to eat, Mrs. One-Arm came out of the kitchen dressed in a silver gown with a tiara on her head, and sat down in Grandpa’s chair. She was, we discovered that night, a Russian baroness and so was the highest ranking aristocrat in the room.

Though she had lost everything in Russia, she had not lost her social status.

I was reminded of Mrs. One-Arm (and the lesson she, and others, taught to my brother and me on that Easter Day long ago) when the salaries of physicians and other faculty in the University of California Medical Schools and Colleges were made publicly available on the internet. A distinguished faculty

Photo: Yuval Helfman

San Francisco’s Russian Orthodox Holy Virgin Cathedral on Geary Boulevard in San Francisco, also known as Joy of All Who Sorrow. colleague came to my office, angry and distraught. He had reviewed the sums given to our UC Davis School of Medicine doctors and was irate when he found that radiology faculty much junior to him in rank and length of service had much larger salaries than he did.

“Are you in need of money?” I asked him.

“No, but these guys are making more than I am to sit in the dark and read films, while I see patients in clinic, attend on the wards, teach students, administer programs, do research, publish, and do major management tasks,” he said. “Hell, football coaches make more than I do.”

“Do you want to be a radiologist or a football coach?”

“Of course not! I love my work but it is unappreciated and that makes me angry.”

We Americans (with notable exceptions for descendants of upper-class families in some Southern states or on the East Coast) rise in “rank” by how much money we make rather than a social hierarchy based on old family status. We admire success but to use salary or accumulated wealth as evidence of

our societal status is just wrong and truly problematic in physicians— who should have their “rank” determined more by patient and colleague trust in them rather than wealth—as it now contributes to the rising cost of health care, which is especially damaging to those who have little money to pay for it. Now some physicians, disquieted by the increasing demand to prove their worth by how much revenue they generate, have left their practices and academia to care for people, here and abroad, for far less remuneration… and are happier.

I am, as an American, not desirous in any way of a return to any hereditary aristocracy. Moreover it seems to me that doctors, no matter what their lineage, are granted high social status in our country simply by being good doctors who are trusted and, if deserving, admired by their patients. Mrs. One-Arm and the other Russian emigres we met taught my brother and me a wonderful and enduring lesson: people can be highly valued socially for how they adapt and how they behave, rather than for their wealth, and I have been grateful to them for that insight all of my life.

May/June 2020

23

| HISTORY |

Breathless A Brief History of Pulmonary Resuscitation

U

ntil recently, ventilators were not part of the public consciousness. But with the advent of the coronavirus pandemic, they have become a daily focus in the news and in fighting advanced cases of the virus.

Whether a ventilator is available to help the patient breathe can often be the deciding factor between life and death.

The coronavirus backdrop makes this a good time to take a look at the evolution and applications of the ventilators and other forms of pulmonary resuscitation that are in use today.

At the height of the Second Industrial Revolution, in the late 19th and early 20th centuries, an increased occurrence of coal mining asphyxiations, high-voltage shocks from the expansion of our electrical infrastructure, and the introduction of anesthesia all made the need for artificial respiration more critical. Today, drug overdoses and approaches for conditions such as cardiac arrest have led to new developments in life-saving technology.

During the time of the Roman Empire, animal dissections by the Greek physician Aelius Galen suggested a link between respiration and the lungs, but it wasn’t until the 17th century that Robert Hook—a biologist, astronomer and philosopher who was literally a Renaissance man—confirmed Galen’s hypothesis through a series of animal experiments.

During resuscitation, air can either be pulled into the lungs (negative pressure ventilation) or pushed into the lungs (positive pressure ventilation). Both methods have evolved over time.

The Beginning: Mouth to Mouth

Mouth-to-mouth resuscitation, one of the earliest forms of positive pressure ventilation, likely dates back as far as ancient Egypt. In 1472, Paolo Bagellardus,

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By Kent Perryman, PhD kperryman@suddenlink.net

an Italian physician and professor of medicine at the University of Padua, encouraged midwives to employ mouth-to-mouth resuscitation to revive newborns and infants. However, it was not until 1732 that the first documented use of mouth-to-mouth was reported.

Depictions on two slabs associated with ancient kings has led to the contention that the life-saving procedure of tracheostomy dates back over 4,000 years to ancient Egypt. However, it’s very possible, according to Patric Blomstedt of Umeå University in Sweden, that because ancient Egyptians had limited surgical skills these depictions may actually have been of human sacrifices.

More reliable evidence of an actual tracheostomy is seen in artifacts and carvings from about 3,500 years ago in Egypt. Alexander the Great was even said to have saved the life of a soldier by using the tip of his sword to open the trachea. In the 16th century, Flemish physician Andreas Vesalius used a cane or reed tube inserted in the trachea. The next step, intubation by inserting a tube through the nose or throat, was introduced in 1788 by Charles Kite to resuscitate drowning victims.

Manual and Negative Pressure Resuscitation

The 19th century introduced more interest in negative pressure ventilation and the development of several techniques that were also used primarily to resuscitate those pulled from water. The Silvester method required the victim to lie on his back while the rescuer rhythmically lifted both arms. Schafer’s procedure required that the victim be placed face down while the rescuer applied rhythmic pressure on the lower ribs, compressing the abdominal viscera. Both these methods, which had varying degrees of success, pulled air into the lungs.

In 1832, the Scottish physician John Dalziel developed one of the first mechanical methods of resuscitation,

Science Museum, London/Creative Commons

A European resuscitation kit from the early 1800s. The bellows could be adapted to inflate the lungs with fresh air or tobacco smoke, which some physicians at that time thought would be more stimulating, in an attempt to revive the patient. The kit includes tubes, nozzles and syringes to inject stimulants into the lungs, nostrils and rectum. a prototype breathing apparatus made from an airtight wooden box with a hand operated bellows.

Similar devices were later developed that were initially used to assist in coal mining asphyxiation and, as early as 1918, to aid victims of polio.

The best-known outgrowth of these early negative pressure ventilators came in 1928, when engineer Phillip Drinker created a motor-driven bellows unit used at Boston Children’s Hospital for an eight-year-old child with respiratory failure. Like today’s ventilators, the Drinker respirator became part of the public consciousness in the 1940s and 1950s when it was used to treat polio patients and known as the Iron Lung. It was not unusual to see wards with dozens of these respirators; more fortunate patients had to spend only a few weeks within the confinement of an Iron Lung, but some remained in them for years or even their entire lives.

During the mid-20th century, portable negative pressure ventilators that were less confining for the patient and provided easier access for caregivers were invented. As early as 1904, the Biomotor, a cuirass-style ventilator (named for the style of armor that included a breastplate and backplate but left the limbs free), used a plastic shell that fit over the upper torso and applied alternate positive and negative pressure. It was used extensively throughout Europe for mine rescues as well as polio.

During the height of the polio epidemic, new and less-expensive negative pressure ventilators such as the Tunnicliffe jacket (1958) and pneumobelt wrap-style breathing jackets had widespread use. They consisted of inflatable bladders that supplied abdominal pressure to assist breathing. Another invention was the “rocking bed” that used a tilting motion that used the weight of abdominal organs to

move the diaphragm. More modern versions of wearable negative pressure systems, such as the biphasic cuirass ventilation (BVC), control both the inspiratory and expiratory phases and are in use today.

Positive Pressure Resuscitation

Positive pressure systems had a similar evolutionary path to those using negative pressure. With drowning a significant concern in Europe during the 18th century, the French Academy of Sciences recommended mouth-to-mouth respiration as the primary method of resuscitation. The first mechanical positive pressure ventilator was a 17th century fireside bellows, a very effective method, and bellows became the recommended method.

Unlike the Dalziel version, which used a bellows to create negative pressure within a box, these versions used positive pressure to Continued on Page 28 May/June 2020

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| BOARD BRIEFS |

Board Briefs March 9, 2020 THE BOARD: Received a report from Dustin Corcoran, CEO, California Medical Association, regarding the Medical Injury Compensation Reform Act and the proposed initiative to change the MICRA cap slated for the November Ballot.

Approved contributing to the defeat of the 2020 MICRA Ballot Initiative.

Approved the appointment of Jonathan Breslau, MD to the Board of Directors to fill the vacancy created in District 1, Office 1 by the resignation of Ashutosh Raina, MD. Approved endorsing the CMA resolution, Volunteer Physician Malpractice Coverage, by SSVMS Delegate Ann Gerhardt, MD. Approved the 4th Quarter Financial Statements, Investment Reports and Recommendations.

Approved the appointment of Christine Braid, DO to CMA Alternate-Delegate and accepted the resignations of Russell Jacoby, MD and Don Wreden, MD as delegates due to retirement.

APPROVED THE FOLLOWING MEMBERSHIP REPORTS January 27, 2020 For Active Membership — Archana Anantharaman, MD; Pamela Apolaya, MD; Apurva Bhatt, MD; Hans Bueff, MD; Charlotte Burke, MD; Barak Davis, MD; Bethany Fleming, MD; Muhammad Azam Gill, MD; Angelique Goodhue, MD; Pritika Gupta, MD; Terrence Horan, MD; Anne Hsii, MD; Dong Lee, MD; Tim Lee, MD; Esther Manolarakis, MD; Donald Matthews, MD; Matthew Mermer, MD; Maja Mircic, MD; Phi Nguyen, MD; Amir Obbehat, MD; Akhila Pamula, MD; Claudia Ruiz, MD; Manu Saini, MD; Philip Sinatra, MD; Prabhbir Singh, MD; Shawn Skaife, MD; Roberto Solis, MD; Xiannan Tang, MD; Holly Thompson, MD; Ranni Vatti, MD; Catherine Watson, MD. For Reinstatement to Active Membership — Michael Flaningam, MD. For Retired Membership —David L. Evans, MD; Ulrich Hacker, MD; Philip Levy, MD; Pankaj Patel, MD; Kevin Walsh, MD. 26

Sierra Sacramento Valley Medicine

For Transfer of Membership to Placer-Nevada Medical Society — Megan Anderson, MD; Jon Buchanan, MD; Sarah Dehaybi, MD; Samjot Dhillon, MD; Vishal Doctor, MD, Yusheng Han, MD; Deann Hoelscher, MD; Sirisha Kari, MD; Derrick Koo, MD; Allen Lue, MD; Hai Luong, DO; Christina Mora, MD; Anna Peter, MD; Syed Safdar, MD; Antoine Sayegh, MD; Anna Siao, MD; Gurtej Singh, MD; Brian Snyder, MD; Yan Wang, MD. For Transfer of Membership to Santa Clara Medical Society — Arlene Burton, MD; Tammy Chen, MD; Taresh Taneja, MD. For Transfer of Membership to San Francisco Medical Society — Melissa Mariano, MD. For Transfer of Membership to Solano Medical Society — Daniel Martineau, MD. For Resident Active Physician Transfer of Membership — David Barba, MD (San Diego); Lindsay Boothy, MD (Alameda-Contra Costa); Jacob Fennessy, MD (San Diego); Robert Haughton, MD (San Diego); Seema Shah, MD (Alameda-Contra Costa); Jocelyn Young, MD (San Diego).

February 24, 2020 For Active Membership — David Sorour, MD. See New Members for a link to the list of 455 Sutter Medical Group physicians for Active Membership.

For Reinstatement to Active Membership — Dave Auluck, MD; Richard Lynton, MD. For Retired Membership — Douglas Hershey, MD; Andrew Klonecke, MD; Don Wreden, MD. For Resignation — Anil Jasti, MD; Monica Kasrazadeh MD (left area); Richard Meister, MD; Sarada Mylavarapu, MD (left area); Judy Nguyen, MD (left area); Alison Semrad, DO (left area); Inder Singh, MD (left area); Malathi Srinivasan, MD (left area); Kasandra White, MD. For Transfer of Membership — Melissa Johnson, MD (to Placer-Nevada); Harison Tong, DO (to Placer-Nevada).

For Transfer of Resident Active Membership — James Liao, MD (to Santa Clara); Shilpa Lingala, MD (to PlacerNevada).

March 9, 2020 For Active Membership — Mark Cabanne, DO; Anna Juern, MD; Neal Mehra, MD. For Retired Membership — Carolyn Bahl, MD; Suzanne Gibbons, MD.

| NEW MEMBERS |

For Resignation — Dave Auluck, MD (left area); Kaye Cunningham, MD (left area); Christopher Neubuerger, MD; Paul Perry, MD (left area); Murphy Steiner, MD; Sage Wexner, MD (left area).

For Termination of Membership Due to Expired License — Richard Atkinson, MD. For Termination of Membership — 107 members for nonpayment of 2020 dues.

New SSVMS Members

The following applications have been approved by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. — J. Bianca Roberts, MD, Secretary.

New Active Members

Specialty abbreviated following name

Dave S. Auluck, MD, P, The Permanente Medical Group Marc B. Cabanne, DO, OSS, Northern California Neurospine Institute Anna M. Juern, MD, PDD, Mercy Medical Group

Richard C. Lynton, MD, IM, Solo Practice Neal Mehra, MD, N, Solo Practice Shaun P. Rafael, DO, P, Mercy Medical Group David N. Sorour, MD, IM, Methodist Hospital of Sacramento

Over 450 new members have joined from Sutter Medical Group.

To see the list, visit http://tiny.cc/Welcome-SMG-Members.

Are You Interested in Shaping Health Policy?

T

he Sierra Sacramento Valley Medical Society has vacancies to fill in our delegation to the California Medical Association (CMA) House of Delegates. The CMA House of Delegates convenes annually to establish broad policy of the organization on current major issues affecting the practice of medicine and public health.

Policies adopted by the House of Delegates are implemented by the CMA Board of Trustees either at the state level or referred for national action or legislation.

As a delegate, you will help shape policies and goals for health care delivery in California. Delegates and

alternate delegates are responsible for representing their colleagues in the House of Delegates and are required to attend, and actively participate in, all sessions of the House of Delegates as well as quarterly delegation conference calls held during the year.

In 2020, the House of Delegates is scheduled to meet in Los Angeles October 24-25 at the Marriott LA Live. Delegation members must stay for the entire meeting (SaturdaySunday) to be eligible for reimbursement.

To learn more, contact Chris Stincelli, Associate Director at (916) 452-2671 or cstincelli@ssvms.org.

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Breathless force air into the lungs.

With the discovery of carbon dioxide and oxygen in the mid 1700s, positive pressure ventilation became more rational. The medical profession was beginning to appreciate the importance of blood oxygenation to survival and recovery. Early piston-cylinder ventilators assisted expiration and venous return, but there were many concerns with these early devices including over-inflation and rupturing of the lungs. Their use was also complicated by the lack of technology to monitor carbon dioxide levels.

In the beginning of the 20th century, the pulmotor time-cycle ventilator was developed for coal miners. It consisted of a face mask attached to a pressure regulated oxygen cylinder that cycled every five seconds. The rescuer would remove the mask to allow for expiration. It was a reliable first-aid device that was available in mines, some public facilities and later in many hospitals.

Technological progress with positive pressure ventilators slowed until the mid 20th century, when the increased use of tracheotomies contributed to a decreased mortality rate. The medical profession was also beginning to gain a better understanding of oxygen saturation through the monitoring of blood gases to identify acute respiratory failure. Also, there were many new technical innovations including micro-processors and pressure support ventilation that greatly improved flow delivery and responded better to the patient’s 28

Sierra Sacramento Valley Medicine

Photo by Lindsay Coate

From Page 25

The Bird 7 respirator is on display at the SSVMS Museum of Medical History. needs. Positive pressure ventilators became much safer due to an increased emphasis on the patient’s contribution to ventilation.

A significant achievement was the introduction of the Ambu bag in 1953. This hand-held bag valve mask, also known as a manual resuscitator or self-inflating bag, is still widely used today in emergency situations.

English hospitals began using the popular Roger Manley ventilator (Manley Mark II) in 1952 that was gas driven and independent of any power source. Gas flow raised a weighted bellows which collapsed under gravity allowing adjustable gas volume into the lungs. In the U.S., Forrest Bird’s “Bird Universal Medical Respirator” was released in 1955 as the “Bird Mark 7.” The Bird was a pneumatic ventilator that did not required a power source.

Advances in circuitry led to the introduction in 1971 of the compact and fully electronic Servo 900 series manufactured by Siemens-Elema.

This was a ventilator that proved

to be highly reliable and safe. The Servo 300 ventilator, introduced in 1991 by Siemens, had the added benefit that it could be used to provide treatment for infants in addition to adult patients.

Modern ventilators generally can be programmed to provide intermittent mandatory ventilation, allowing the patient to breath spontaneously between ventilator cycles. They can be either pressure mode, which stop inhalation at a set pressure, or volume mode, that can be set to deliver a certain volume regardless of pressure and have safety back-up controls to ensure safe pressure and volume.

Today’s ventilators are the result of centuries of experience in resuscitating victims of asphyxiation, technological advancements, medical discoveries and an increased knowledge of physiology. As these ventilators and other techniques to keep people breathing have improved, going back to the first use of mouth-to-mouth, so have the outcomes for patients.

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