Sunday, April 5, 2020

How I'm Spending the Apocalypse: In a Hospital Bed in Boston (Demographic Doom Podcast #37)

This is the script for my Demographic Doom podcast episode (#37) released on 5 April 2020. It may differ in detail from the final broadcast, which was recorded more spontaneously. This episode is available on major podcast platforms, including PodbeanApple Podcasts and a video version on YouTube. (Only the video version shows you scenes from my hospital bed.) See the description on the YouTube version for annotations, links and corrections. You can also comment on this episode there. (If you leave comments on this blog post, I might not see them.) The main website for this project is DemographicDoom.com



I’m Glenn Campbell. I call myself a demographic philosopher. I’m looking at life and trying to predict the future through the lens of demography, or the study of human populations.

Today is Sunday, April 5, 2020. I had intended to talk about next economic crisis: the collapse of U.S. Federal debt. As bad as things seem right now, they're going to get far worse as the U.S. government progressively becomes insolvent. The simple calculation with this Covid crisis is that U.S. government is gearing up to spend roughly twice as much money as it is taking in, probably on a sustained basis, and this can only end tragically. The government is issuing bonds like there's no tomorrow, and really, truly there is no tomorrow. There's no way to resolve this apart from a currency and sovereign debt crisis on top of all our other crises. The practical effect for you and I is that I'm expecting the return of massive inflation very soon.

But I'm not going to talk about that in this episode. I'm saving that for my next podcast a day or two from now. This episode is a personal one, with only a little demography involved. This is a sort of personal oral history of "Where were you during the shutdown?" Everyone has their own story of how they spent this days when they've been ordered to stay home, and mine is a big exotic and unexpected. For the past 13 days, I have be weathering the Apocalypse is a very comfortable cancer ward at Beth Israel Hospital in Boston.

I'm recording this podcast my hospital gown in the most comfortable possible reclining bed, in nearly perfect health, at least on the surface. I have a blood cancer called lymphoma, which has relapsed since being beaten back in 2018. I'll have to go through about 4 months of chemotherapy, including 30 days in absolute isolation, but I expect the practical discomfort to be mild, and I should be able to type on my computer and work on my podcasts all the way through it. In the short term, my risk of mortality are low—about the same as yours given that I'm protect from Covid epidemic. But in the long term, we all die, sometime before the age of 100, so I'm doing my best to get ready for that.

So to put this moment into historical perspective, we are now in the lockdown phase of the coronavirus epidemic were most U.S. states and European countries have ordered nonessential businesses to close and those workers to stay home. Schools, offices and most stores are closed. Apart from essential things like food and alcohol, the economy has all but stopped, and the streets are nearly empty. I know they're empty because I can see them from my seventh floor window. I spent a lot of time in this hospital ward in 2018, so I know this view, and the intersection below me, in front of the hospital, is a eerie void. This main road, Brookline Avenue, is carrying only tiny fraction of the cars that it normally does, even for a Saturday.

The empty streets are my only visual indication of anything wrong in the world, because I've never personally experiences the lockdowns. I came into the hospital about 13 days ago just as they were getting started. I came into the Emergency Room is Boston on March 23, which was the day before a statewide stay-at-home order in Massachusetts, so I've spent the whole lockdown right here, in the luxury of a private, in a cancer ward I know well. I'm in a bubble right now. The only way I know what's going on is through the media, and there's so much news, so many things collapsing all at once, that is difficult to keep track of it all.

So in this podcast I'm going to focus on my own microscopic issues, not the big picture, I want to talk about my two things: First, own medical condition, because folks like me just love talking about the medical conditions. I also want to talk about how this big-city hospital is dealing with the Covid epidemic, as seen from the inside. Spoiler alert: Things are pretty damn calm from my viewpoint, with none of the chaos you would expect. A hospital is a very compartmentalized place, and much of it continues to operate unchanged.

So let me talk about my medical condition, because I love all its intricacies. Honestly, if you're more interested in the collapse of human civilization as we know it, you should move on to the next pdcast, which will be out in a couple of days. I do have cancer, a blood cancer called lymphoma, but my state is not particularly fragile. In fact, I look and feel perfectly fine on the surface. For the past 9 or 10 days, I would call myself a "malinger." I'm a healthy guy lying in a hospital bed who is only pretending to be sick. To prove how healthy I am, I put in over 10,000 steps on my FitBit on a closed hospital floor, three days in a row. They've since hooked me up to an IV, which slows me down a bit, This means that when I walk the halls, I've got to haul a noisy wheeled stand with me, so it's hard to pick up 10,000. If I didn't have the stand, I certainly could. I could do 20,000 or 40,000 steps, except that I've got better things to do on my computer.

Things were different two weeks ago when I came into the Emergency Room. At that point, things were pretty dicey. Clearly I would have died had I not received prompt medical intervention. I had a fluid build up around my heart, which was restricting its activity, moving in the direction of a complete and fatal shutdown. The problem was quickly diagnosed and easily solved.  The day after I came into the E.R., they inserted a catheter in the middle of my chest to drain the fluid. I was awake for the procedure, because I really love that stuff. Honestly, if I could stay away for open heart surgery because I love participating.

So they put this catheter in my pericardium, drained all the fluid, and almost immediately my symptoms were relieved. The main systems were fatigue, a racing heartrate and a bunch of other minor symptoms relating to my poor circulation. They sucks about a liter of fluid out of my chest in two big glass syringes. It looked to me like blood, but when the fluid was analyzed, is was found to contain lymphoma cancer cells, consistent with my old cancer in 2018.

So back in July of 2018, I came into Beth Israel in pretty sorry shape. PET scans showed tumors everywhere in my body, from my head to my toes. I appeared that the cancer had metastasized and that I would surely die, but they pulled out all the stops with a very aggressive chemotherapy program, and within about two months all the visible tumors had been cleared from my body. It turns out blood cancers like this tend to be widely distributed, and "metastasis" didn't really apply. It took another 3 months of chemo to complete treatment, and in December 2018, I was officially declared "in remission".

I then spent all of 2019 cancer-free. I was physically weak in January from the effects of chemotherapy, and by December, I had regained full strength. This healthy state persisted until around March 18, when I was driving in New Mexico and I began experiencing some unusual symptoms: Fatigue, fast heart rate and a sense that my lungs weren't working like they should. So what was my first self-diagnosis? Why COVID-19 of course. It must be in its early stages. Over the next few days, however, I eliminated that possibility, and reverted to the more logical alternative: My cancer had returned and was causing some kind of anemia.

So on Monday, March 23, I stumbled into the E.R. at Beth Israel. The next day they inserted the catheter, and the day after that I recorded my first in-hospital podcast. It was the last one about Japan and Italy, and it was written, recorded and edited inside the cardiac ICU while I had a tube coming out of my chest and a bunch of wires attached to my body. Now that's dedication!

For the my first 36 hours in the ICU, I was being cleared for COVID 19. Unlike most of you, I've actually been tested for it, twice, and I know definitely that I don't have it. Furthermore, I'm in a cancer ward that's COVID-sterile, so the chances of my getting it here are extremely slim.

So I spent three nights in the ICU getting my cardiac problem resolved and getting cleared for COVID, then I was moved to my favorite cancer ward, Feldberg 7, where I have been in nearly perfect health ever since. It was only yesterday, Day 12, when I actually received my first dose of chemotherapy. It's all on Instagram and Facebook, if you care to check it out. I record everything on social media, in excruciating detail. If you want to find the links you should go to the description in the video version of this podcast.

My treatment is likely to proceed in two phases. In Phase One, lasting about 2-1/2 months, I'll go through 2-week cycles of what I anticipate to be the the most painless, non-intrusive chemotherapy I've ever experienced. The drug is called methotrexate, and in combination with other drugs it's intended to kill cancer cells without killing everything else in my body that divides, like blood and hair cells.

This is not your grandfather's chemotherapy which killed everything that moved and made the patient miserable. It is conceivable I could get through this with little of the weakness or pain associate with traditional chemotherapy. At the beginning of each two-week cycle, I will have to come into the hospital for about four days. This isn't because I'll be sick but because this treatment requires very close monitoring in its early stages. There is always opportunity for things to go wrong, and past performance is no guarantee of future results, but there's a good chance I'll get through the first 2-1/2 months with little pain or weakness.

The main aim of all chemotherapy is to stop cell division. Cancer cells, by definition, are rapidly dividing, so if you can interfere with the biological processes of division, the cancer cells die. Traditional chemo stops all cells in the body from dividing, including blood cells, immune cells and hair follicles, which is why people lose their hair during chemo. This methotrexate method, along with some other chemicals like leucovorin, ought to stop the cancer cells from dividing without interfering much with good dividing cells like red blood cells.

So after 2-1/2 months of this low-impact chemo, sometime around June I'll probably move to Phase Two, which is the radical part. It is called an "autologous stem cell transplant", and if it happens as planned, I'll be locked in a room for 30 days while my immune and blood systems are wiped out and rebooted from scratch. This involves removing stem cells from my own blood and putting them in the fridge. Stem cells, as I understand it, look like blood but they're not. They are the primitive cells from which all other blood cells are made. Once they have a supply of them in the fridge, they will use heavy-duty, scorched-earth chemotherapy that essentially kills everything that divides. This includes my entire bone marrow, where all my blood cells come from.

For a few days, I will be a "boy in the bubble" with absolutely no immune system, which is why I have to be locked in a room for 30 days. After this massive kill-off, they give me back my own stem cells, hopefully without any cancer cells. The stem cells are given intravenously, and they know what to do. They automatically head for the bone marrow and start repopulating it with new blood cells. Hopefully, after this reboot, I get a whole new blood and immune system, minus the cancer.

At this moment, I happen to be assigned to one of those transplant rooms. It's just like any other private hospital room, except that I have my own shower. The main difference is that I'm never allowed to leave during the roughly 30 day period. Staff can come and go from the room, but only in full gowns, gloves, masks and visors. This isn't dehumanizing, because I know all the staff so well. Even behind the masks I know who they are.

Wiping out and reconstructing my immune system sounds terrible, but I'm not too worried. It turns out that most cells in the body do not divide. Brain cells, muscle cells and heart cells never divide once you reach adult, so they are not affected by those scorched-earth chemicals. I expect that my brain and typing fingers will continue to function as normal throughout the 30-day quarantine. This would seem like a prison cell except that I will have my computer and wifi, which makes all the difference in the world. I can still eat regular food, so long as it is cooked. I'm probably going to need a few blood transfusions along the way, until my bone marrow repopulates. Risk of mortality is quite low, but not trivial. Whenever you compromise someone's immune system, there's a risk of an opportunistic infection, which is the main threat here.

In all, I'm not terribly worried. Like everyone else on the planet, I'm going through a period of great uncertainty, but at least I know where I'm going to physically be for the next four months: either in my favorite hospital or out on bail for 10-day stretches. I just need the medical system to hold together for the next four months, to possibly give me a few more years of life.

So is the medical system going to hold together for the next four months? From my standpoint, yes. In spite of the COVID crisis, I see no chaos here. A hospital is a very compartmentalized place. Everyone continues to do their job with various accommodations for the virus.

There are only a couple of obvious differences in my hospital ward between today and the 79 nights I spent here in  2018. The biggest is that no more visitors are allowed in the hospital. None. Only patients and staff, and they all have to pass through a screening checkpoint to get in. It used to be that an average hospital was an open place. Anyone could walk in and go just about anywhere on campus. There was essentially no security two months ago, but now there is. I am told that the hospital entrances looks like Fort Knox now.

This sounds bad for the patients, who lose the in-person support of their family members, but it's a huge boon to the staff and to the relative calm of the ward. Back in 2018, many of the patient rooms would have 3 or 4 people in them. There would be the patient themselves and 2 or 3 family members. Family members can be a management problem for the staff, and now they don't have to deal with them anymore. It's wonderful for them, and it's wonderful for me, because I get more attention from the staff. The corridors are emptier and things are much more relaxed.

They have also banned all the volunteers who used to, quote, help, unquote lift the spirits of the patients. For example, there's no more Reiki program, where volunteer practitioners would provide some kind of New Age energy therapy but gently touching key parts of the body. It did it once, and it was relaxing in the sense that I had to lie still for 15 minutes, but I didn't care to repeat the experience because I had better things to do. Nonetheless, they kept return every time I was readmitted to the hospital, and I had to shoo them away. Now there's no more Reiki, no more visitors, no more unnecessary noise. Everyone on the staff can now be focused on the core medical issues at hand.

They've also eliminated shared hospital rooms. Every patient gets their own private room, which I love. While I adore the staff here, I'm not particularly fond of the patients, who tend to be old and watch a lot of TV. I never relished the times in 2018 when I had to share a room with someone, and now that curse has been eliminated. Since room doors remain closed, I have the illusion that I'm only patient here. It's just me and the staff and a few old patients watching TV who I only see from the distance. Occasionally, I pass another patient walking in the halls. I get to know their names and stories, but I don't particularly connect with them. In most cases, I can't relate to their attitude toward cancer. They think they are prisoners here, while I treat this as a wonderful pleasure cruise.

Another difference with Covid-19 is that all the staff wear facemasks all day long. You're issued one facemask per day, and are supposed to make it last, because there is still a facemask shortage. There is no shortage of rubber gloves, hand sanitizer or any of the other usual supplies, just facemasks, and presumably American industry will rise to challenge of supplying that that. I don't wear a facemask while I'm inside my room, but I do wear it whenever I step out. During the past couple of days, the staff has been required to put on full protective gear whenever they enter a patient's room: mask, gloves, gown, visor. This strikes me as overkill, and it may not last.

The facemasks mean you hardly ever see a staff member's face. This isn't a problem for me, because I know most of these people well and can usually identify them from the top of their head. Smiles and jokes still happen as they used to, but now the smiles are conveyed in tone of voice.

In all, I don't sense a lot of tension in the ward. The Covid restrictions are annoying and time consuming, but at least the staff doesn't have to deal with all those annoying visitors, which I think more than makes up for it.

All elective surgery has been cancelled at this hospital and probably every hospital in America. There are no more hip replacements or shoulder surgeries. Any medical procedure that can be put off, will be, which frees up all those rooms for Covid patients. There's all sorts of construction and reallocation of hospital resources, includes a noisy renovation in the floor above mine. It said the hospital is preparing dedicated floors just for Covid patients, although frankly no one here really knows. If you work in a hospital, you know about your floor and your specialty, but you don't know what's going on in other buildings or on other floors.

What's it like at the Emergency Room of the hospital. Pandemonium? I don't think so, based on my own visit there 13 days ago. I was dreading going to the E.R. because I thought it would be overwhelmed with Covid patients. It wasn't. There was no one waiting at the E.R. at all. I had explicit instructions from my doctor to go there, and I didn't have Covid, so I was waved right in without waiting for even a minute.

They had a really simple system for dealing with Covid cases. When you got to the E.R., you first came to a Covid screening desk. Here a staff member quickly ran through all the symptoms and signs of Covid-19. Since I didn't have any, I was waived immediately into the regular Emergency Room, where there were no lines, no waiting.

If someone answered "Yes" to any of the Covid-19 symptoms, but they weren't in respiratory distress, they would have been sent home to self-isolate. Essentially, they are saying, "We don't want you here." Presumably if someone did have signs of both Covid and respiratory distress, they would be shunted off into a special path for these patients. They would not be allowed into the main E.R. where they might infect other patients. I didn't see what that other avenue looks like, but I assume they have whole floors dedicated to Covid patients, where they are not going to contaminate anyone else.

At some point those floors might get filled up, and the hospital won't be able to take them in. I have no idea what that capacity is, but I don't think they're close to reach it yet. Once they get there, the hospital will have no choice but to stop admitting Covid patients. In theory, they can do this by refusing ambulances with Covid cases or not letting Covid cases come in from the street. No matter how you slice it, it's ugly, but all the ugliness takes place outside the hospital. The inside of the hospital remains an orderly place. In a crunch, they are going to admit as many cases as they have the capacity for, and no more.

There is conflict in medicine that I've touched on in previous podcasts and videos. That's "best practices" medicine and "triage" medicine. In best practices medicine, you pull out all the stops to save one patient. You give him the best of everything, and you try not to expose him to any kind of risk. That's how medicine is practiced in the developed world, and it is backed up in America by our lawsuit system. If a doctor were to every fail to give one patient the best of all possible care, and something bad happened, the patient or his family would sue the doctor. Our whole medical system is geared for this best-practices model, and it works so long as there are plenty of resources to go around. As long as there are plenty of hospital beds and treatment systems and the financing to support them, the best-practices model prevails.

Triage medicine is when you don't have enough medical resources to go around, and you've got to parcel them in such a way as to maximize the number of survivors. The classic case is the wartime field hospital. If a hundred wounded soldiers come it, and you've got facilities for only a dozen.  In that case, you're deliberately not trying to give each patient perfect care. You're giving them "good enough" care, good enough to improve their odds, then you move onto the next patient.

For example, best practices for Covid-19 would be one patient per room, because you don't want one patient to infect another. In a triage treatment for Covid-19, you might be willing to house several patients of similar condition in the same room. There's greater risk there but also great economy of scale.

One of the things that makes Covid such a crisis in the West is that modern medicine doesn't know how to do triage. They can only do best practices, and they are going to keep doing best practices even as the number of patients rise. Each Covid patient will get his or her own room, and no compromises will be made. When the hospital's capacity is reach, no more patients are let in, and all those outside patients aren't the hospital's. This method is going to maximize the survival chances the people who did get into the hospital, but it may result in greater death overall because so many people can't get in.

I brought up this topic with my doctor today, because I am annoyed by my current status. As of this moment, I am in an isolation room 48 hours being "Covid cleared". This is when they keep you in isolation for a couple of days while they run two Covid-19 tests on you, 12 hours apart. I already went through this when I first came into the hospital, and I passed. I don't have Covid-19.

Last night, however, they put me back into isolation to test me again. The only reason? I had a very slight fever last night—101.3—following my chemotherapy regime. I had no other symptoms, just the fever, and my temperature quickly went back to normal. Nonetheless, they felt they needed to test me for Covid-19 all over again. The chances of my having it are close to nil, but best-practices dictate that you've got to cover all the bases and obey all the rules. I understand why they would test me the first time, 12 days ago, because they were bringing me in a cancer ward with a lot of immuno-compromised people, but the second time seems silly. The hospital could have used the last two tests for someone with actual symptoms.

All of these state and community lockdowns are an expression of the Best-Practices model. We're going to protect every citizen from every possible source of infection, which is why we're even shutting down the beaches and other activities that have virtually no chance of spreading the virus. The trouble with the Best-Practices model is that it is frightfully expensive, in this case absolutely devastating the economy. Yes, you've protected the patient from every possible source of medical infection, but you've stolen his job, killed any chance of making a living, and sooner or later these costs become more deadly than the infection itself.

Philosophically, the solution to the coronavirus crisis is shifting gears to the triage model. We are no longer going to try to protect everyone from everything. Instead we're going to focus on the few vectors that are the main source of infection, thing like shaking hands and touching door knows. Everyone can learn to manage these vectors without completely shutting down all economic activity.

Note: The second half of the final podcast deviates significantly from this script. For a better transcript of the last few minutes, see Podcast #42, Best Practices Medicine vs. Triage Medicine, which includes a 6-minute excerpt of this episode.


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For annotations, links and corrections, see the description on the video version of this podcast. You can also leave comments there.