What is the Child?
On most days during the peak of the U.S. covid epidemic, I rode a bike as fast as I could towards the hospital where I worked, filled with a kind of elation borne of sleep deprivation, privilege, and naïveté. One of my privileges was being a doctor, a role that gave me excuse to be out and about in paradoxical compliance with New York City’s Covid-19 quarantine.
If I were working at NYU Children’s Hospital on 34th street, from our 7th floor apartment in Harlem, I could make the journey in 30 minutes flat. Kneeling at the door mat, I would kiss my family goodbye in an emotional scrum, three pairs of lips literally smashed together. I had for sure already thrown my daughter Drew, who is now four years old, many times towards the living room rafters moments prior—“Just one more time, one more time…” The elevator button had been pushed and I tied blindly my Adidas sneakers in a double knot as beads of sweat scattered across my forehead. Across 114th, left on Lennox, down the subway stairs I ran praying against a left ruptured Achilles and an on-time 2/3 train. At Penn station, the obstacle course to the 33rd street exit was half comprised of blood and excrement. It was late April and the subways had yet to close between the hours of 1-5am, a first-ever controversial move by Governor Cuomo rationalising the expulsion of thousands of homeless from NYC’s main transportation hub. It was true: The cars and corridors had become really disgusting and by mid-May were unnaturally shiny and bleach clean but for whom. Pedalling furiously down 32nd Street on Citibike, there was only reflexive need to look in any direction but straight. There weren’t any cars. The traffic lights changed in synchronised quiet. Groaning buses and garbage trucks gave at least a 5 block birth. On the 7 minute cross-town trek I would not see more than 10 pedestrians. I could hear my breath. Faster, faster I challenged myself. I thought about what a 50-year-old man does, the hobbling of a vibrant city and how lucky I was to have a job.
PPE stands for personal protective equipment. I donned and doffed PPE in Liberia for the opening of the first hospital following West Africa’s Ebola crisis, 2014-2015. Not many people know this, but during Ebola, there wasn’t a single public or private hospital or clinic open in Liberia and Sierra Leone for a year. This meant that while Ebola killed 20,000 people thru a truly ghastly process, 20 times more people died of common conditions such as malaria, pneumonia, diarrhoea, even routine child birth— a reality just as ghastly. So it was imperative to open up the hospitals. Everyone knew it. But at the same time no one wanted to responsible for a new outbreak nor did they want to hasten their death trying. To complicate matters, the medical system had already transformed to one of binomial purport: Patients either had Ebola or they didn’t. The actual reason people came in for care was unimportant in the minds of most care-providers, so where was the urgency? Of course, patients thought otherwise, and this here was the rub.
Ebola PPE makes Covid PPE seem like a sexy Speedo. It’s not a competition but imagine the requirement of a N95 mask covering the entire body. Now add a thick rubber apron, a face shield, no less than 2 pairs of surgical gloves, booties and rubber boots designed perfectly to pool human swamp sweat in 95 degree tropical heat. Donning this most impenetrable and scary looking barrier is actually the easy part. Removing or doffing PPE is how you die. At the CDC Ebola camp in Louisiana I attended before shipping off to Liberia, MSF trainers threw fluorescent powder on us prior to us doffing to simulate remnant patient vomit and stool. Having spent 30 minutes caring for hypothetical Ebola patients, the group consisting of soon to be deployed medical and public health personnel, carefully and systematically removed PPE to the cadence of an individual whose only job was to ensure provider safety: “Take off your first pair of gloves, now wash your hands. Take your apron off, now wash your hands. Zip down your suit, now wash your hands…” After completing this arduous 20 minute undressing process, we trainees stood on a red line drawn 4 meters from where the “hot zone” exit. Here the lead trainer ran a black light up and down our bodies in search of shiny sparkling dots. Moving methodically from one individual to the other he declared in a most banal voice: Alive. Alive. You're dead. Alive. Dead. Dead. You're dead. Alive…I found this PPE training most effective.
PPE Doffing process in Ebola care
Baby Girl Ramirez is 12 days old. She is 4.1 kg or 9 pounds and comes into NYU Brooklyn’s emergency room where I am attending overnight. Her mother describes her baby as refusing to to breast feed for 8 hours. The previous afternoon she measured a temperature of 100.5 Celsius. 100.4 is the definition of fever. Otherwise, Baby Girl Ramirez has not had difficulty breathing, rash, or abnormal movements. She has frequent wet diapers— a sign of good hydration. When I ask Ms. Ramirez if her child has vomited, she looks at me as if I am not listening, “Ella no tombaba,” -- “I said, my baby won’t drink.”
Baby Girl Ramirez’s father has been sick and likely the source of Baby Girl Ramirez’s fever. He hasn’t been tested for covid because he doesn’t know where to go, but he has a dry cough, some sore throat and incapacitating chest wall and back pain. Like a good citizen, Mr. Ramirez has stayed home and isolated himself. Like a good patriarch, he’s kept away from his family as best he can but there are realities associated with three grand parents, two small children and spouse living in a 2 bedroom apartment in South Brooklyn. “Es muy difícil la situación,” Ms. Ramirez says, “It’s a really hard right now.”
The medical workup of a newborn with fever is straightforward. The doctor searches for sources of infection that cannot be excluded by physical exam. This means microscopic analysis of urine, blood, and spinal fluid. Some doctors add a chest x-ray to the diagnostic work-up but then they would be wrong. A pneumonia on X-ray would be seen clinically as an increase in breathing rate, the flaring of nostrils, or a whistle of the lungs. So no need to irradiate developing cells. Neonatal infection of urine, blood, or the central nervous system on the other hand is nondescript. BG Ramirez’s fever and irritability could be from Covid, but more likely from Influenza A & B, parainfluenza, rhinovirus, enterovirus, adenovirus and corona viruses OC43, HKU1, 229E and NL63. The viral list goes on…More dangerous is that she is infected by Staphylococcus, Streptococcus or Haemophilus— bacteria common to all age groups but which can devastate the neonate. So, despite the context, it would be better in my mind if Baby Girl Ramirez had covid instead of bacterial infection, though Ms. Ramirez in her mind fears covid and isn’t even thinking about bacteria. To compound the disparity, Ms. Ramirez is worried that her daughter is going to die while I know she is going to be fine. Baby Girl Ramirez is sleeping now. Flits of dreamy sequences lead to brief erratic smiles on her face. As I hold her, I think back to my 20 years of being a doctor across six countries and three continents. I’ve only had one baby look normal while suffering from life-threatening meningitis or sepsis. And this was in the moments before it seized.
The fragile neonate. Sick or not sick?
I complete the tests with Ms. Ramirez in the room— my practice style. I hide the elation of getting the spinal fluid in one try. The secret: I anaesthetise the skin midline at L3-L4 before directing the spinal needle between the spinous processes. This prevents the baby from startling right at the moment I push the needle 1 1/4 inches cephalad into the subdural space. I show Ms. Ramirez the clear fluid collected in one of the three plastic capped tubes that will be sent stat to the laboratory. I tell her that the sample clarity is a great sign but we must still analyse for microscopic white cells and bacteria to be sure. She nods silently in miraculous awe at the 3 cc’s of translucent fluid extracted from her baby daughters back.
I swab for corona-19. This is a requirement for any patient being admitted to the hospital but part of Baby Girl Ramirez’s primary diagnostic workup. We are after all in a pandemic. Because of baby girl Ramirez’s fever and age, she will be admitted whatever the result. I glide the swab low along the floor of one of her left nostril respecting its convex contour so as to not hit the fragile boney concha. To prevent Baby Girl Ramirez from moving during the test, Ms. Ramirez holds her daughter’s head still: She lifts her baby’s arms up per my instruction and pushes the back of both elbows in towards the ears. I twirl the hub twice. Baby girl Ramirez still sleeping first grimaces as if given a lemon. She then sneezes twice and at this, both Ms. Romario and I close our eyes, hold our breaths, and turn.
At this particular Emergency Room, there aren’t medical residents assigned from 11pm to 7am, which makes me appreciate the hard work of doctors in training. So I proceed with catheterisation of Ramirez’s bladder, which I don’t care to describe, writing the medical note, documenting all procedures, and cleaning up the mess from the many supplies I’ve used. I am wearing surgical mask, cap, plastic gown and gloves. In a different time, I would dress this way only for the lumbar puncture. But this being the time of covid, I wear full PPE for the entirety of the case. Full PPE in my case does not include N-95 mask, defined as protection against 95% of aerosolised particles. My colleagues ask (through N-95 masks), “Why risk it?” I reply, “I’m not,” and shrug: Covid is personal. There is no right and wrong, just ideology. Nothing I say will change what you believe.
In opening up Redemption Hospital following the West African Ebola epidemic, my teams employed inconvenient yet calculated concepts of risk and protection. With regards to testing, WHO protocols devised at the beginning of the epidemic mandated that any patient with fever and one sick symptom be tested for Ebola because patients had the virus 10% of the time. But at the tail end of the Ebola epidemic when Ebola prevalence was less than 1%, there simply weren’t enough tests to adhere to this protection standard (sound familiar?). Results took days to come back while patients deteriorated before our eyes at the hospital door (sound familiar?) So I worked with Liberia’s Chief Medical Officer to develop a new Ebola recovery testing strategy because the WHO never would. This protocol was as follows: Patients could come into the hospital without Ebola testing if they exhibited classic clinical presentations for known diseases. But patients could not have abnormal bleeding or a family member who was sick or recently died. Medical staff would wear modified PPE consisting of plastic aprons tied over a plastic gown, N95 grade mask, face-shield, and one pair of surgical gloves.
Modified PPE at the opening of Redemption at the tail-end of the Ebola epidemic in Liberia
To bring this back to covid in America, we doctors must use logic while science continues to develop on this most egregious virus. We must always respect but never heed fear. Care-providers have dealt with Coronaviruses for a long time: Most strains cause only mild respiratory illness. Viruses are non-living mechanical microbes which act in predictable ways. Just like members of the Wang-Chun family don’t wake up suddenly one morning to fly away like sparrows. Coronaviruses don’t suddenly become aerosolised cluster bombs in the respiratory tracts of humans. Seven months of epidemic in the U.S. has shown that Covid-19 does spread beyond the typical three feet of respiratory droplets— Surprise! — but only in highly specific contexts: In emergency rooms with patients experiencing severe respiratory distress; in churches holding robust choir practice; during aggressive Trump MAGA and Chief Justice ramming events; and in boisterous vociferous restaurants and bars. Outside of these contexts, a surgical or cloth mask is enough.
As a paediatrician, I am further protected. Out of 212,000 U.S deaths from Covid, there have been only 100 deaths in children 18 years and under. In contrast, there are 2,400 gun violence deaths in this cohort every year. Turns out Coronavirus is not spread readily by children under eleven years of age, who because of stature don’t cough hard enough to aerosolise droplets. We know this from tuberculosis. This has been shown in genomic studies in Iceland where children to adult transmission was documented only three times. Danish, Greek, Austrian and Swiss elementary schools and the Chinese primary educational experience of 200 million are all showing similar results.
I remember my first patient on the day we opened Redemption Hospital. It was December 14, 2014. A bloody newborn was run over to me from labor and delivery. The baby wasn’t breathing and was limp. I first thought, please baby don’t kill me. I am not Liberian and as such, this is not my battle. I then thought, bloody baby, you are not actually bleeding, you just aren’t breathing. At that time, my PPE was literally melting off my body from hours of continuous sweat. My arms and face were had become exposed, a no-no in Ebola care but this is the key: This was not Ebola care. I paused only for a moment to selfishly pray to a god I inconsistently believed in. I took that baby and resuscitated it like any blue wet floppy baby and it survived. The family subsequently named him Wilson.
Baby Girl Ramirez’s test comes back covid (+). No matter what I say, I can’t get Ms. Ramirez to stop crying. This is what it is to be a parent. Ms. Ramirez feels guilty that she didn’t protect her baby from a virus even though there is nothing else she could have done. Sure, the risk of death of Covid in children is minuscule, but for a parent no risk is too small. But for the medical professional, the numbers behind risk are important just like the type of masks we wear. Science and logic must prevail over fear if we are to recover from this stubborn horrible disease. I try to reassure Ms. Ramirez once directly then indirectly by sharing with her the processes she will encounter in-hospital and by getting her some breakfast to eat. At 7 a.m., before I leave for home, I go upstairs to the ward to visit Baby Girl Ramirez and her mother. The following day, Baby Girl Ramirez is discharged before I have chance at the start of next shift to say goodbye.
We will win.
