Today my HVAC guy taught me how to be a better physician. As you know, it’s stinking hot in Edmonton right now, and though the heat doesn’t bother me much, we are a family of Vikings and it’s my job to help my ginger spawn survive. Cue the ominous silence from our AC unit. I perform my due diligence. Thermostat, on batteries fresh, settings correct. Furnace blower fan, operational. Condenser coil, clean and intact. Exterior unit, not blocked by dead porcupine. Breakers reset and on. Still nothing. Now I’m faced with call the poor HVAC guy.

I get asked a lot about how to fix medicine. There are many people out there who are far better equipped to answer that question, but I think we need to acknowledge some fundamental truths.

Medicine evolved out of our capacity to care for those outside of our immediate family. It required compassion but also an inherent understanding that collective well being is beneficial for us all. In that sense it is indelibly connected with social structure. Disparities in wealth & justice distribution are huge social determinants & drive heath care consumption.

So here’s what you need to know about E. coli, in an easily digestible thread. It a common bacteria, that resides in our guts and those of most animals. We live in harmony with it, but it’s always looking for an advantage. It wants to travel beyond the colon, but fortunately a combination of physical and immunological barriers keep the pickle in the jar.

I get the call from the emergency department.
“He’s was near death, but we stabilized him.”
They start reciting the story. It’s a well worn script we both know all to well.
“Unhoused,
Addictions,
Lost to follow up”
I feel it. That blend of anger & frustration I must control. “He’s pretty unkempt, but his beard is immaculate.”
And at that point my heart softens.
“We don’t have a name yet. We think he had a seizure.”
“Does he have a tattoo over his heart?”
Pause
“Yes”
“Is it a church bell.”
“Y-yes”
Sigh.
“I’ll be right down.”

Some difficult truths when looking at our struggling medical system. We are failing because we are the safety net before the brick wall. When social systems like education, mental health supports, disability services and fair taxation are purposely dismantled this is the fallout. Our hospitals are full of patients with complex medical issues who no longer have the social supports to survive anywhere outside of the hospital environment. Many are homeless, frail or suffering from complications of addiction. These issues have not occurred overnight.

It’s nice to have ⁦@KmarkovCTV⁩ looking into these numbers for us. edmonton.ctvnews.ca/covid-19-in-al… This graph I think is incredibly important. That it shows progressive increases in hospitalization reflects multiple simultaneous stressors. Worsening mental health, addictions, toxic opioids are part of this, but I have been seeing something more concerning.

Many of you are angry at me right now. I think some feel I have turned and betrayed them, but that is not the case. I have gone to a medical conference to learn about Covid and to hone my craft. I’ve done so masked. I have also eaten in restaurants. The vitriol is so sharp. The comment are cruel. I’ve been here before. I’ve weathered this intolerance and absolutism in the past. It was during the delta wave. It was from people who were scared and desperate. We built bridges then and found common ground to share.

I’m in Toronto attending @CCCForum. First live meeting since the pandemic. It’s been thought provoking, but in ways I never expected. I don’t think I’ve ever been so keenly aware of how much I missed in person learning. My mind is a sponge, and we learned a lot from COVID. I find it fascinating the general take on masking. I’d say it’s about
25% of the attendees, and given it’s a highly educated cohort with a lot of first hand experience I think it would be a fascinating impromptu talk.

His chart was litter with brands. The ones that fill the room with the acrid blue smoke of burning flesh. “Alcoholic”, “noncompliance”, “poly substance abuse” “withdrawal”. It was clear that these had been cut and pasted from one admission to the next. But he was dying now. With no one to fill in the blanks I knew nothing more than who was in front of me. Confused, tremulous & lashing out, the sweet sickening smell of acetone on his breath and the impossible balance of finding enough sedation to stop him from biting his tongue but not swallowing it.

Many of you who joined me on this platform did so for an “in the ICU” perspective of #COVID19 during the height of the pandemic. You may have noticed I haven’t been putting much out there on the topic. Much like you, I’m stumbling around in the aftermath just a little disoriented Quite clearly I have thoughts on the future, but my role was always to filter out the extremity of opinions while being hip deep in the extreme. The ICU is a very different place now then it was last year.

“He’s awake!”
“There’s no damn way!” I called back, instantly regretting my tone when I realized who I was speaking too.
They had let his sister into the room because they think he’s going to die.
I must have missed that given the sheer bedlam in the room. “We need more access, and all blood needs to go through the warmer.”
“He’s squeezing my hand”
I glance at the arterial tracing. Barely enough pressure for a pulse, but she’s holding his hand and she’s completely composed.
“Seth, give me a thumbs up please.”
And he does.
“Shit.”

I tell my residents that when they are done with their ICU rotation they will be able to smell death when they walk into the room. I temper it with doing my best to give them the skills to navigate that precipice, & tether lifelines. Today I crossed that threshold - unexpectedly. It was the smell that disoriented me. The juxtaposition of youth and rotting flesh. My clinical mind knew instantly what was happening, I subconsciously was making lists of diseases and aetiologies , but none of them would materialize, because she was nearly a child.

Many out there are about to discover how marginalized those with fibromyalgia and chronic fatigue are. Long COVID will be a significant medical and social issue that will likely be largely and purposely ignored. Living with COVID may not be the life we expected. I have often wondered if there was a way to prevent these diseases that have profound effects on people would we employ them. I’ve wished for cures. Now to wait and see the repercussions of unchecked spread really concerns me.

I sat down with him and his wife to speak of what comes next. I’ve done this so often that the words just come out of me. I know where to pause to intercept the sadness or bolster against the rage, but today in that space came …. Nothing. So I waited. I looked into his eyes and saw confusion. Perhaps it was the vespers of oxygen past his ears, so I spoke up, looking into those eyes, willing him to pay attention to what came next.

I would like to thank everyone out there for the outpouring of support. I am not leaving medicine, and will continue in critical care, but after two and a half years of working harder than I ever imagined possible I clearly needed to make a choice if I was going to survive. Leaving nephrology is hard. It’s filled with regret. It’s part of who I am, and there are these horrible feelings that I am abandoning my patients. Though I know I am handing them over to exceptional colleagues, the guilt is crushing.

The current provincial #COVID19 strategy is to normalize this disease by removing data and hoping it just fades into the background like the common cold. This is predicated on the beliefs that the virus attenuates and infection provide enduring immunity. This is untrue. I want to believe this on a personal level, but I have several reservations. Of course I worry about more virulent variants, and waning immunity, but what bothers me most is how profoundly the after effects of repeated infections may shape our overall health.

This story starts yesterday, when our family was riding home together. Aidan decides to make his break from the “peloton” and goes full green jersey. I’m caught unaware and he gets the jump and several gears on me. It breaks me out of my head, and I drop the hammer. Clearly, I still have images of my 19 y/o son riding training wheels, because the shock of his brutal acceleration has dropped my jaw almost as far as he has dropped me. My stomach is uncomfortably full but I have no choice but to pursue. I know this is going to hurt.

Don’t like this, because I don’t. Don’t fear this, because I don’t either. Let’s lay down facts.

To prevent another wave we must MAINTAIN our vaccination rate. Given that immunity wanes over time, that means boosters every 6 months. I see no policy to accomplish this. There is a false narrative being put out there that viruses attenuate over time. There is no scientific background behind this. Beneficial viral mutations increase infectivity and speed reproduction. As long as lethality is delayed this doesn’t effect variant selection.

I have this ability to sense impending doom. It’s been refined over the years from ridiculous hours, hospital cafeteria food, and a keen fascination of the finer points of dying. In no small part it is distilled from those moments I have been in the room just as it is happening. It has taken the form of Rorschasch blood splatter upon the ceilings and sudden outbursts of sloughing and liquified the bowel spilled out onto bedsheets. It can rend bone during a seizure or interrupt a man in mid sentence. Unapologetic asystole.

I take pride in my ability to work with families through the worst times of their lives. It requires honesty & trust. This week has been so demoralizing. It’s so hard to connect with people who are in the ICU because they fundamentally distrust the foundations of medicine. I have been threatened for disclosing bad news, bullied for not using disproven therapies, and had complaints lodged against me when I discuss prognosis and palliative care. I know it’s part of my job, but I have never seen such anger. The weight of it bears down.

Though there is good evidence that omicron will be mild for those vaxed and boosted it remains an incredible challenge for the medical system. We will eventually get through this but must appreciate the need for long term management of burgeoning chronic health conditions. We are at a tenuous crossroads here. The chaos has destabilized an already troubled health care system. There is a drive to buffer it with private initiatives. All of which historically have been short term solutions which eventually fail and become expensive public liabilities.