Mindset & Principles
Lead With Vision
History is filled with arguments about how to handle pandemics - see Dr. Joanne Liu of MSF pleading with the WHO to act faster for Ebola in 2014. Dr. Liu saw firsthand what was happening, what was to come and acted decisively.
This guide was borne out of the fact that most people do not react like Dr. Liu. It was therefore written to provide a concise, concrete and rapid action plan with immediate implementation for any facility.
I would advocate thinking in an Emergency Medicine or Crisis mindset.
My vision: Organize the best care for the most people as quickly as possible, with the utmost security of healthcare workers in mind.
When you have a clear, strong vision - you will lead with energy and positivie conviction.
Making the Vision Happen
Unlike a Code Orange Mass Casualty Incident (MCI), a Pandemic is a Long Term Event. Things do not change for a few hours and then return to normal. The infectious component necessitates urgency and being Proactive.
"If you are Reacting in a Pandemic - you are too slow, and too slow is dead" Canadian MD
"Speed Trumps Perfection in Pandemics" (Mike Ryan WHO)
If you do any kind of acute medicine or are exposed to high risk situations with time pressure, then you have been:
Scared, Out of Control and Unsure what to do.
This feeling is terrible. You either wilt or you decide you don’t want it to happen again. You fix it by:
Planning - Practicing - Doing - Analyzing - Repeating
Anticipate like Gretzky
Wayne Gretzky was a great hockey player because he saw the game 5 steps ahead of everyone else. Hockey is about where the puck is going, not where it is.
You need to be the Wayne for your Community.
Plan for the worst
It is easier to scale back to something simpler, than to scale up to something worse, especially with time pressure.
Speed Trumps Perfection. Get things started mostly OK and then Fix Them on the Fly.
Your institution's normal speed may be 40km/hr. People around you may ramp up to the speed of sound - Mach1: 1200km/hr. Maybe even Mach 5. They will be happy with this.
My Advice: Do Not listen to them. They do Not understand that Covid is moving at Mach 10 or Mach 100.
Your only hope is to go at some fraction of the speed of light: c
You have no choice because the implementation of ideas, procedures and the physical setup will be Exponentially slower, and then will require even more time to perfect.
This is mountain biking, not a flat ride nor a bunny run. You have rocks, trees, cliffs and rivers as you are biking. The solution is to look ahead, be flexible and maintain your cool to maintain your balance. You will be tossed and pushed. That’s OK.
Needless complexity is slower, prone to errors and dangerous. Avoid it. Be efficient.
Look at the Big Picture
You have to keep everything in mind. You will be Overwhelmed with information. Prioritize, Get Help, Keep your focus.
Keep Things in Perspective
The coming days will be harder than you imagined. You will feel lost, anxious and overwhelmed. Take a moment to spare a thought for your colleagues in Syria or Sudan. They are dealing with all of this while enduring shelling, measles, political strife and starvation. It could be worse…
You cannot do this alone. Ask for help.
Advocate for your patients and colleagues.
Decrease the Source
What does Jon Snow have to do with helping you in a pandemic? More than you think.
OK... GoT's Jon Snow may or may not have had much experience with a pandemic, but if he had, you can bet he would have taken decisive action.
So let's consider another leader, Dr. John Snow...
A British physician and one of the founders of epidemiology helped stop an 1850’s cholera outbreak in London’s Broad Street by stopping use of contaminated water.
His weapon? Not a sword, but a handle.
By removing the handle of a water pump, the contaminated water source for cholera was Eliminated!
Mitigation, The Usual Strategy vs Elimination
A diagram of the usual response routine is presented below.
“With mitigation, the response is increased as the pandemic progresses, and more intensive interventions such as school closures are often held in reserve to “flatten the peak”. By contrast, disease elimination partly reverses the sequence by using vigorous interventions early to interrupt disease transmission….
...in western countries...apparent that the mitigation strategy of “flattening the curve” was failing, as health services were being overwhelmed across Europe.”
Contact tracing, quarantine and self isolation are legit hallmarks of epidemic control. But - what is easier - contact tracing and isolating 100 people or 5 people? If you have ever been involved in this - you know how much work it is to contact trace just ONE person.
COVID is not the flu: 59000 vs 14
Incubation is 5-6 days, not 1-3.
Asymptomatic spread and identification of cases is harder.
From Hugh Montgomery, University College London
"Normal flu...I'm going to infect on average 1.3 people ... by the time it's happened 10 times, I've been responsible for about 14 cases of flu. (This figure comes from calculating (1.3)10... which yields 13.786)
"...coronavirus is very, very infectious, so every person passes to it three, now that doesn't sound like much of a difference, but if each of those three pass it to three and that happens in 10 layers, I have been responsible for infecting 59,000 people." (This figure comes from (3)10 which yields 59,049.)
Ramp up quickly, scale back if needed. You will NOT be able to gain back the time lost by going too slow at the beginning.
Elimination & the Hierarchy of Infection Control
Prevention and decreasing the source early on can pay dividends very quickly: this gives you time to get ready.
Look at where you live, see if you can get help to have Early Elimination going on. This applies to countries but if you live rurally, you are a slightly separated area in your country. Apply this to your Facility and Home as well. Decrease the source.
For more on this please see section: Lessons Not Learned, Lessons Being Learned, The Ugly Social Truth
You need to make it through all this. You need to stay healthy. You need to stay on top of more info than you can handle.
I am going to tell you to sleep even though I have been sleeping 4-5 hours/night for a month. But make sure you eat well (not junk food), sleep and exercise.
Sleep will increase the more organized you get early on.
Have a system to Keep Track of everything. I have simply taken the headings of each section of this guide and have a daily/weekly standard list that I review each day with key people: Nursing head, admin, colleagues. You cannot do it all so get help from your colleagues.
Prioritize information and goals
You will be pushed and pulled off course several times a day. You need to focus on your vision: what's important now and will become important in the future. The morgue needs to be addressed. But don't address it if you don't have Pre-Triage figured out.
Have time frames in mind with deadlines. You may need to enforce those deadlines. Be nice, collaborative, but firm about it.
You are not here to be popular, you are here to be effective. People’s lives depend on it.