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Coronavirus and the Cancer Patient Coronavirus and the Cancer Patient
(2 days later)
I miss the intimacy, and the innocence, of my visits with patients.I miss the intimacy, and the innocence, of my visits with patients.
The coronavirus pandemic, and the impending tsunami of how it will sicken us, has fundamentally altered how we think about health care.The coronavirus pandemic, and the impending tsunami of how it will sicken us, has fundamentally altered how we think about health care.
I recall fondly the carefree days of just a few weeks ago, when I casually scheduled one patient with leukemia for a follow-up visit to assess her response to therapy, and need for blood. She lived a couple of hours away, east of Cleveland, and was being treated by a doctor close to her home.I recall fondly the carefree days of just a few weeks ago, when I casually scheduled one patient with leukemia for a follow-up visit to assess her response to therapy, and need for blood. She lived a couple of hours away, east of Cleveland, and was being treated by a doctor close to her home.
She asked me to monitor her progress, too, and we saw each other every couple of months. As part of the routine of caring for my cancer patients, back in January, I had checked a couple of boxes on her electronic medical record for an appointment in eight weeks, along with the appropriate labs to be drawn, and for a possible blood transfusion.She asked me to monitor her progress, too, and we saw each other every couple of months. As part of the routine of caring for my cancer patients, back in January, I had checked a couple of boxes on her electronic medical record for an appointment in eight weeks, along with the appropriate labs to be drawn, and for a possible blood transfusion.
But the balance of risks and benefits for all of my patient interactions has now changed.But the balance of risks and benefits for all of my patient interactions has now changed.
She called me the day before her appointment, worried about Covid-19 and whether she should visit our cancer center.She called me the day before her appointment, worried about Covid-19 and whether she should visit our cancer center.
I worried too: about her leaving the house; touching the door handles of a car where the virus could live for 48 or 72 hours; interacting with a parking garage attendant at a distance of less than six feet; passing other patients and family members, who themselves may have the virus, in the hallways on her walk toward our cancer center; interacting with our laboratory technicians, all of whom have themselves been screened, as I have, with a series of questions and a thermometer waved in front of our foreheads on the way into work, but knowing that 25 percent of people may be infected with coronavirus and not have signs or symptoms; and then waiting in an exam room that had been scrubbed to the bone to see me — yet still I’d fret if it was clean enough.I worried too: about her leaving the house; touching the door handles of a car where the virus could live for 48 or 72 hours; interacting with a parking garage attendant at a distance of less than six feet; passing other patients and family members, who themselves may have the virus, in the hallways on her walk toward our cancer center; interacting with our laboratory technicians, all of whom have themselves been screened, as I have, with a series of questions and a thermometer waved in front of our foreheads on the way into work, but knowing that 25 percent of people may be infected with coronavirus and not have signs or symptoms; and then waiting in an exam room that had been scrubbed to the bone to see me — yet still I’d fret if it was clean enough.
Like Paul Monette, who in his poem “The Worrying” described his cleaning rituals while caring for his partner with AIDS as “wiping wiping, crazed as a housewife on Let’s Make a Deal,” I worried.Like Paul Monette, who in his poem “The Worrying” described his cleaning rituals while caring for his partner with AIDS as “wiping wiping, crazed as a housewife on Let’s Make a Deal,” I worried.
For my patients’ immune systems are so exquisitely fragile, because the cancer treatments they need to fight a disease that can be scarier than Covid-19 leave them so immunosuppressed, that it doesn’t take much even without a pandemic for them to catch an infection that could kill them.For my patients’ immune systems are so exquisitely fragile, because the cancer treatments they need to fight a disease that can be scarier than Covid-19 leave them so immunosuppressed, that it doesn’t take much even without a pandemic for them to catch an infection that could kill them.
For some patients, I can schedule a virtual visit. But I can’t draw a patient’s labs to look for leukemia over Skype. Zoom doesn’t have the functionality to transfuse blood.For some patients, I can schedule a virtual visit. But I can’t draw a patient’s labs to look for leukemia over Skype. Zoom doesn’t have the functionality to transfuse blood.
So I advised her to come to Cleveland.So I advised her to come to Cleveland.
When I walked into the exam room, after “foaming in” with hand sanitizer, she was sitting at the far wall, in a chair next to her daughter. Ordinarily we would have hugged, our customary greeting. Instead, I gave her what I have been calling my “corona wave” — placing my hands over my head, in a weak approximation of a crown, the virus’s namesake for the crown-like projections that pierce its surface. She did the same.When I walked into the exam room, after “foaming in” with hand sanitizer, she was sitting at the far wall, in a chair next to her daughter. Ordinarily we would have hugged, our customary greeting. Instead, I gave her what I have been calling my “corona wave” — placing my hands over my head, in a weak approximation of a crown, the virus’s namesake for the crown-like projections that pierce its surface. She did the same.
We talked to each other at a distance of eight feet. She was feeling well, and fortunately her labs were stable. Not normal, and not even that great, but not worse, meaning the chemotherapy was still holding her leukemia at bay, and not so low that she needed a transfusion. We spent a few minutes discussing Covid-19, the precautions she was already taking, and what measures she could put in place to protect her further.We talked to each other at a distance of eight feet. She was feeling well, and fortunately her labs were stable. Not normal, and not even that great, but not worse, meaning the chemotherapy was still holding her leukemia at bay, and not so low that she needed a transfusion. We spent a few minutes discussing Covid-19, the precautions she was already taking, and what measures she could put in place to protect her further.
Then I washed my hands and began a weak approximation of a physical examination, to minimize the amount of time I had direct contact with her.Then I washed my hands and began a weak approximation of a physical examination, to minimize the amount of time I had direct contact with her.
Whereas normally I cradle my patients’ arms and walk them to the exam table to make sure they don’t lose their balance along the way, I left her to her own devices.Whereas normally I cradle my patients’ arms and walk them to the exam table to make sure they don’t lose their balance along the way, I left her to her own devices.
Whereas normally I palpate a person’s neck, searching for lymph nodes, I tried to do this instead by “visual inspection”: look, don’t touch.Whereas normally I palpate a person’s neck, searching for lymph nodes, I tried to do this instead by “visual inspection”: look, don’t touch.
Updated June 1, 2020 Updated June 2, 2020
Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.
Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.
States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
More than 40 million people — the equivalent of 1 in 4 U.S. workers — have filed for unemployment benefits since the pandemic took hold. One in five who were working in February reported losing a job or being furloughed in March or the beginning of April, data from a Federal Reserve survey released on May 14 showed, and that pain was highly concentrated among low earners. Fully 39 percent of former workers living in a household earning $40,000 or less lost work, compared with 13 percent in those making more than $100,000, a Fed official said.More than 40 million people — the equivalent of 1 in 4 U.S. workers — have filed for unemployment benefits since the pandemic took hold. One in five who were working in February reported losing a job or being furloughed in March or the beginning of April, data from a Federal Reserve survey released on May 14 showed, and that pain was highly concentrated among low earners. Fully 39 percent of former workers living in a household earning $40,000 or less lost work, compared with 13 percent in those making more than $100,000, a Fed official said.
Yes, but make sure you keep six feet of distance between you and people who don’t live in your home. Even if you just hang out in a park, rather than go for a jog or a walk, getting some fresh air, and hopefully sunshine, is a good idea.
Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications.Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications.
The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.
Charity Navigator, which evaluates charities using a numbers-based system, has a running list of nonprofits working in communities affected by the outbreak. You can give blood through the American Red Cross, and World Central Kitchen has stepped in to distribute meals in major cities.
Whereas normally I gently grasp a person’s shoulder as I listen to her lungs and heart with my stethoscope, both to hold her steady and to let her know “I’m here for you, I’m on this cancer journey with you,” I didn’t.Whereas normally I gently grasp a person’s shoulder as I listen to her lungs and heart with my stethoscope, both to hold her steady and to let her know “I’m here for you, I’m on this cancer journey with you,” I didn’t.
I did ask her to open her mouth so I could shine a light in it and look for thrush or signs of bleeding; and I asked her to lower her shirt enough so I could visually examine the permanent catheter that we used both to draw her blood and to administer chemotherapy, checking for any signs of infection. Both looked fine.I did ask her to open her mouth so I could shine a light in it and look for thrush or signs of bleeding; and I asked her to lower her shirt enough so I could visually examine the permanent catheter that we used both to draw her blood and to administer chemotherapy, checking for any signs of infection. Both looked fine.
She returned to the chair next to her daughter. I washed my hands again and sat eight feet away. We chatted a bit, even lingering, perhaps, so that our words, the eye contact that we made, our ability to laugh at each other’s jokes, would compensate for the lack of physical contact. We sat in silence a while longer, the three of us.She returned to the chair next to her daughter. I washed my hands again and sat eight feet away. We chatted a bit, even lingering, perhaps, so that our words, the eye contact that we made, our ability to laugh at each other’s jokes, would compensate for the lack of physical contact. We sat in silence a while longer, the three of us.
“I’m glad I came,” she said. “I feel better now.”“I’m glad I came,” she said. “I feel better now.”
So did I.So did I.
Dr. Mikkael Sekeres (@MikkaelSekeres) is director of the leukemia program at the Cleveland Clinic and author of the book “When Blood Breaks Down: Life Lessons From Leukemia.”Dr. Mikkael Sekeres (@MikkaelSekeres) is director of the leukemia program at the Cleveland Clinic and author of the book “When Blood Breaks Down: Life Lessons From Leukemia.”