The Conversation is running a series of dispatches from clinicians and researchers operating on the front lines of the coronavirus pandemic. You can find all of the stories here.
Even as America begins to reopen, people across city neighborhoods continue to express appreciation for the health care workers braving hospitals to treat COVID-19 patients by clanging pots and cheering nightly. Similar to the firefighters who sacrificed their lives during 9/11, frontline health care workers have become the symbolic heroes of the moment.
But for many American health care providers, this time is unprecedented in terms of the ways in which our lives are threatened. Roughly 77,000 U.S. health care workers have tested positive for COVID-19, according to the Centers for Disease Control and Prevention. More than 400 have died.
These statistics trigger inevitable fear and uncertainty, an uncertainty that is masked by the call to duty that summons providers to carry on despite the novel coronavirus and its risks. This fear can lead doctors and nurses to keep their distance and deprive patients of a potentially comforting presence during this acutely vulnerable time.
At UCLA Health, I’m a hospitalist – a board-certified physician in internal or family medicine whose practice is based in a hospital – as well as an anthropologist in the Center for Social Medicine and Humanities. My interactions in the hospital with a woman suspected of having COVID-19 showed me how fear of contagion could impact my conviction to maintain a compassionate presence in caring for patients.
A need for connection
I was working a shift as a “moonlighter” in mid-March for a hospital that was not my home institution. My job was to ensure the safety of the daytime hospitalists’ patients overnight. At around 9 p.m., I received a page from a nurse in the intensive care unit about a woman I will refer to as Ms. Johnson (not her real name).
Ms. Johnson was a young African American woman with longstanding Type 1 diabetes. She had experienced multiple hospital admissions in the past for diabetic ketoacidosis, a life-threatening condition that can occur when blood sugar levels get too high. Chronic complications from her disease led to kidney failure, and she was in the ICU the night I was called. Over the course of this hospitalization, she had developed fevers and a cough that prompted testing for COVID-19.
Ms. Johnson was placed in “enhanced droplet isolation” while waiting for her test results, which took five to seven days to return from the CDC laboratory. Her enhanced infection control measure mandated that anyone entering her room wear a gown, gloves and eye protection, in addition to a surgical mask.
During this early phase in the U.S. crisis, the CDC recommended that providers wear full protection only with patients who fulfilled the criteria for “persons under investigation.” These patients were perceived to be at elevated risk for COVID-19 infection because they were symptomatic and had traveled from high-prevalence countries, such as China and Italy, or had been in contact with a person infected by COVID-19.
I was uncomfortable with the CDC policy because of media articles questioning the ability of simple face masks to protect health care workers and reports about the possibility of asymptomatic viral transmission. Given conflicting expert opinions, I wanted to be protected by wearing an N-95 mask, but I would have been breaking hospital policy if I wore one to see Ms. Johnson. In the interest of protecting precious supplies of personal protective equipment, N-95 masks were reserved for patients undergoing “aerosolizing” procedures, such as intubation or a breathing treatment. I asked the nurse if it was possible to speak over the phone with Ms. Johnson instead of seeing her in person. The nurse agreed.
Over the phone, Ms. Johnson expressed her frustration that her primary physician was not available and shared that she preferred a higher dose of insulin than she was being given. Due to the risk of dangerously low blood sugar levels, I wanted to avoid an overdose and explained the importance of sticking with the prescribed dose. Throughout the call, Ms. Johnson became increasingly distressed.
“All these doctors are calling me on the phone and saying that they understand, that they hear me and that they’re here to help,” she said. She expressed frustration with her isolation in light of her improbable COVID-19 infection. She expressed feeling locked up and discriminated against because of her race. She also told me of her mother’s visit earlier that day – how she was able to see her only briefly through the glass.
Ultimately, she wanted to be released from her solitude. She wanted to be with her mom. She wanted someone to hold her.
“You’re all afraid to touch me,” she said. “You’re scared and trying to say what you need to say.”
Her words spoke a painful truth. Ms. Johnson’s concerns went beyond the question of insulin. She wanted connection. Under pre-COVID-19 conditions, I would have gone to see her. Even if my presence would not resolve her medication discrepancies, it would have allowed me to express my sympathy better than I could over the phone. But now the risk calculation had changed, and it went beyond personal safety. If I get sick, who will cover my shifts? If COVID-19 cases surge, will I be available? What if I bring the virus home to my family?
As a physician and cultural anthropologist, I am trained to interrogate the ways in which standardized protocols, cumbersome electronic medical records and time pressures can serve as dehumanizing forces in the doctor-patient relationship. These constraints are only amplified during this time of uncertainty and vulnerability.
A new normal
Now, three months later, conditions have changed. With a well-vetted PPE protocol and the example of coworkers traversing COVID-19 units with unbroken professionalism, I feel more comfortable working in the new normal. But there are unmistakable differences compared to the practice of medicine pre-pandemic: increased monitoring of patients by robots, curtailed physical examinations and the palpable absence of family members.
In addition to these distancing measures in the hospital, there has been a dramatic shift toward telemedicine. As leaders in digital health and health care delivery call for a greater push toward nonvisit care and imagine a future where “in-person visits are the second, third or even last option,” my lingering remorse about Ms. Johnson tells me that Zoom visits and telephone calls cannot substitute the therapeutic power of presence.
I feel ambivalence as my neighbors cheer from their windows for the seemingly fearless and unflappable frontline provider. What dangers lie behind a hospitalist’s bravery, and what are we losing in the process of tempering our risks?
As anthropologist Jason Throop has argued, empathy, or the ability to understand another and be understood, is affirmed through touch. Touch is central to empathic communication because the person being touched is also touching back.
Ms. Johnson’s COVID-19 test was negative, and she ultimately transferred out of the ICU. Unfortunately, she may have lasting memories of her isolating hospitalization during the pandemic. As COVID-19 ushers in a new era of medicine, will this disconnect further impair doctor-patient interactions? Or will we find a way to maintain the essential give-and-take between patient and provider that is so powerful and core to our profession’s healing craft? My hope is for the latter.
Liza Buchbinder does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
In this specific predicament, U.S. officials have to choose a strategy to deliver the aid without the perception of benefiting Hamas, a group the U.S. and Israel both classify as a terrorist organization.
Logistics
When aiding people in war zones, you can’t just send money, a development strategy called “cash transfers” that has become increasingly popular due to its efficiency. Sending money can boost the supply of locally produced goods and services and help people on the ground pay for what they need most. But injecting cash into an economy so completely cut off from the world would only stoke inflation.
So the aid must consist of goods that have to be brought into Gaza, and services provided by people working as part of an aid mission. Humanitarian aid can include food and water; health, sanitation and hygiene supplies and services; and tents and other materials for shelter and settlement.
Due to the closure of the border with Israel, aid can arrive in Gaza only via the Rafah crossing on the Egyptian border.
The U.S. Agency for International Development, or USAID, will likely turn to its longtime partner on the ground, the United Nations Relief and Works Agency, or UNRWA, to serve as supply depots and distribute goods. That agency, originally founded in 1949 as a temporary measure until a two-state solution could be found, serves in effect as a parallel yet unelected government for Palestinian refugees.
USAID will likely want to tap into UNRWA’s network of 284 schools – many of which are now transformed into humanitarian shelters housing two-thirds of the estimated 1 million people displaced by Israeli airstrikes – and 22 hospitals to expedite distribution.
Gaza is a self-governing Palestinian territory. The narrow piece of land is located on the coast of the Mediterranean Sea, bordered by Israel and Egypt.PeterHermesFurian/iStock via Getty Images Plus
Since Biden took office, total yearly U.S. assistance for the Palestinian territories has totaled around $150 million, restored from just $8 million in 2020 under the Trump administration. During the Obama administration, however, the U.S. was providing more aid to the territories than it is now, with $1 billion disbursed in the 2013 fiscal year.
But the White House needs Congress to approve this assistance – a process that requires the House of Representatives to elect a new speaker and then for lawmakers to approve aid to Gaza once that happens.
Ethics
The United Nations Relief and Works Agency is a U.N. organization. It’s not run by Hamas, unlike, for instance, the Gaza Ministry of Health. However, Hamas has frequently undermined UNRWA’s efforts and diverted international aid for military purposes.
Humanitarian aid professionals regularly have to contend with these trade-offs when deciding to what extent they can work with governments and local authorities that commit violent acts. They need to do so in exchange for the access required to help civilians under their control.
Similarly, Biden has had to make concessions to Israel while brokering for the freedom to send humanitarian aid to Gaza. For example, he has assured Israel that if any of the aid is diverted by Hamas, the operation will cease.
This promise may have been politically necessary. But if Biden already believes Hamas to be uncaring about civilian welfare, he may not expect the group to refrain from taking what they can.
Security best practices
What can be done to protect the security of humanitarian aid operations that take place in the midst of dangerous conflicts?
Under International Humanitarian Law, local authorities have the primary responsibility for ensuring the delivery of aid – even when they aren’t carrying out that task. To increase the chances that the local authorities will not attack them, aid groups can give “humanitarian notification” and voluntarily alert the local government as to where they will be operating.
Hamas has repeatedly flouted international norms and laws. So the question of if and how the aid convoy will be protected looms large.
Under the current agreement between the U.S., Israel and Egypt, the convoy will raise the U.N. flag. International inspectors will make sure no weapons are on board the vehicles before crossing over from Arish, Egypt, to Rafah, a city located on the Gaza Strip’s border with Egypt.
The aid convoy will likely cross without militarized security. This puts it at some danger of diversion once inside Gaza. But whether the aid convoy is attacked, seized or left alone, the Biden administration will have demonstrated its willingness to attempt a humanitarian relief operation. In this sense, a relatively small first convoy bearing water, medical supplies and food, among other items, serves as a test balloon for a sustained operation to follow soon after.
In that case, the presence of U.S. armed forces might provoke attacks on Gaza-bound aid convoys by Hamas and Islamic jihad fighters that otherwise would not have occurred. Combined with the mobilization of two U.S. Navy carrier groups in the eastern Mediterranean Sea, I’d be concerned that such a move might also stoke regional anger. It would undermine the Biden administration’s attempts to cool the situation.
On U.N.-approved missions, aid delivery may be secured by third-party peacekeepers – meaning, in this case, personnel who are neither Israeli nor Palestinian – with the U.N. Security Council’s blessing. In this case, tragically, it’s unlikely that such a resolution could conceivably pass such a vote, much less quickly enough to make a difference.
Topher L. McDougal does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
Diagnosis and management of postoperative wound infections in the head and neck region
“The majority of wound infections often manifest themselves immediately postoperatively, so close followup should take place […]” Credit: 2023 Barbarewicz…
“The majority of wound infections often manifest themselves immediately postoperatively, so close followup should take place […]”
Credit: 2023 Barbarewicz et al.
“The majority of wound infections often manifest themselves immediately postoperatively, so close followup should take place […]”
BUFFALO, NY- October 20, 2023 – A new research perspective was published in Oncoscience (Volume 10) on October 4, 2023, entitled, “Diagnosis and management of postoperative wound infections in the head and neck region.”
In everyday clinical practice at a department for oral and maxillofacial surgery, a large number of surgical procedures in the head and neck region take place under both outpatient and inpatient conditions. The basis of every surgical intervention is the patient’s consent to the respective procedure. Particular attention is drawn to the general and operation-specific risks.
Particularly in the case of soft tissue procedures in the facial region, bleeding, secondary bleeding, scarring and infection of the surgical area are among the most common complications/risks, depending on the respective procedure. In their new perspective, researchers Filip Barbarewicz, Kai-Olaf Henkel and Florian Dudde from Army Hospital Hamburg in Germany discuss the diagnosis and management of postoperative infections in the head and neck region.
“In order to minimize the wound infections/surgical site infections, aseptic operating conditions with maximum sterility are required.”
Furthermore, depending on the extent of the surgical procedure and the patient‘s previous illnesses, peri- and/or postoperative antibiotics should be considered in order to avoid postoperative surgical site infection. Abscesses, cellulitis, phlegmone and (depending on the location of the procedure) empyema are among the most common postoperative infections in the respective surgical area. The main pathogens of these infections are staphylococci, although mixed (germ) patterns are also possible.
“Risk factors for the development of a postoperative surgical site infection include, in particular, increased age, smoking, multiple comorbidities and/or systemic diseases (e.g., diabetes mellitus type II) as well as congenital and/ or acquired immune deficiency [10, 11].”
Continue reading the paper: DOI:https://doi.org/10.18632/oncoscience.589
Correspondence to: Florian Dudde
Email: floriandudde@gmx.de
Keywords: surgical site infection, head and neck surgery
AboutOncoscience:
Oncoscience is a peer-reviewed, open-access, traditional journal covering the rapidly growing field of cancer research, especially emergent topics not currently covered by other journals. This journal has a special mission: Freeing oncology from publication cost. It is free for the readers and the authors.
To learn more about Oncoscience, visit Oncoscience.us and connect with us on social media:
A year after the Supreme Court struck down President Biden’s student loan forgiveness plan, he presented a new scheme to the Department of Education on Tuesday. While it is less aggressive than the prior plan, this proposal would cost hundreds of billions of taxpayer dollars, doing more harm than good.
As the legendary economist Milton Friedman noted, “One of the great mistakes is to judge policies and programs by their intentions rather than their results.”
Higher education in America is costly, and this “forgiveness” would make it worse.
Signing up for potentially life-long student loans at a young age is too normalized. At the same time, not enough borrowers can secure jobs that offer adequate financial support to pay off these massive loans upon graduation or leaving college. These issues demand serious attention. But “erasing” student loans, as well-intentioned as it may be, is not the panacea Americans have been led to believe.
Upon closer examination, the President’s forgiveness plan creates winners and losers, ultimately benefiting higher-income earners the most. In reality, this plan amounts to wealth redistribution. To quote another top economist, Thomas Sowell described this clearly: “There are no solutions, only trade-offs.”
Forgiving student loans is not the end of the road but the beginning of a trade-off for a rising federal fiscal crisis and soaring college tuition.
When the federal government uses taxpayer funds to give student loans, it charges an interest rate to account for the cost of the loan. To say that all borrowers no longer have to pay would mean taxpayers lose along with those who pay for it and those who have been paying or have paid off their student loans.
Let’s consider that there will be 168 million tax returns filed this year. A simple calculation suggests that student loan forgiveness could add around $2,000 yearly in taxes per taxpayer, based on the CRFB’s central estimate.
Clearly, nothing is free, and the burden of student loan forgiveness will be shifted to taxpayers.
One notable feature of this plan is that forgiveness is unavailable to individuals earning over $125,000 annually. In practice, this means that six-figure earners could have their debts partially paid off by lower-income tax filers who might not have even pursued higher education. This skewed allocation of resources is a sharp departure from progressive policy.
Data show that half of Americans are already frustrated with “Bidenomics.”
Inflation remains high, affordable housing is a distant dream, and wages fail to keep up with soaring inflation. Introducing the potential of an additional $2,000 annual tax burden at least for those already struggling, mainly to subsidize high-income earners, adds insult to injury.
Furthermore, it’s vital to recognize that the burden of unpaid student loans should not fall on low-income earners or Americans who did not attend college. Incentives play a crucial role in influencing markets.
By removing the incentive for student loan borrowers to repay their debts, we may encourage more individuals to pursue higher education and accumulate debt without the intention of paying it back. After all, why would they when it can be written off through higher taxes for everyone?
The ripple effect of this plan could be far-reaching.
It may make college more accessible for some, opening the floodgates for students and the need for universities to expand and hire more staff, leading to even higher college tuition. This perverse incentive will set a precedent that will create a cycle of soaring tuition, which would counteract the original goal of making higher education more affordable.
While the intention behind President Biden’s student loan forgiveness may appear noble (in likelihood, it is a rent-seeking move), the results may prove detrimental to our nation’s economic stability and fairness. And if the debt is monetized, more inflation will result.
Forgiving student loans will exacerbate existing problems, with the brunt of the burden falling on lower-income Americans. Instead of improving the situation, it will likely create an intricate web of financial consequences, indirectly affecting the very people it aims to help. But that is the result of most government programs with good intentions.
Vance Ginn, Ph.D., is president of Ginn Economic Consulting, chief economist or senior fellow at multiple state thinks across the country, host of the Let People Prosper Show, and previously the associate director for economic policy of the White House’s Office of Management and Budget, 2019-20. Follow him on X.com @VanceGinn.
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