The following tracts my observations volunteering to give Covid Vaccines through a local hospital system. Both Kernie and I, for this work, have been vaccinated twice each. The effect is psychologically liberating even though our public behaviors (masking, social distancing) remain unchanged. Rumors are flying with both pro and anti-vaccine sources about side effects. We had only trivial side effects none of which changed our day-to-day one bit.
I was introduced to the local Medical Reserve Corps (MRC) while I still worked as an administrative doctor. Its role was made apparent when at a conference with the local Health Department, we studied the following scenario:
“A graduate student from the local college spends the summer in Egypt on an archeological dig. He is exposed to smallpox by a terrorist two days before flying home. He presents to the local Emergency Room in the early stages of his condition. He is is not hospitalized as no one recognizes the disease in its early phase. A week later, the diagnosis is made, and his living in a dormitory at the college is the focus of today’s exercise.”
Anticipating a plague long before our current one, the role of volunteers doing contact tracing was outlined as well as (in that setting) draconian limitations on the freedoms we all take for granted—like using a grocery store and being allowed past road blocks. Smallpox in an unvaccinated population is devastating and very infectious. Resistance to masking, social distancing, or even isolating— even with young adults— would have faded quickly as age is is not a barrier to the mutilation (facial scars) and death caused by a smallpox epidemic; in my opinion, the vanity issue for the young would trump the risk of death…..and therefore reinforce these measures. On the other hand, at the beginning of the twentieth century, there were virulent anti-vaccers demonstrating against mandatory smallpox vaccination campaigns the end result of which, in 1977, was eradicated smallpox world-wide.
Up front: The Covid pandemic has negatively affected the use of vaccinations across the board: people are not going to doctors as much; the childhood vaccination programs are behind and in this State, they are required to attend in-person, public schools. My MRC routinely administers hundreds of vaccinations to children going to school and who do not have regular pediatric contacts prior to the school year. Given the need for social distancing, there were no mass events for the efficient administration of vaccines. Our numbers were down easily by 80% this year.
Our MRC was invited to support the local hospital system to provide its staff with Covid vaccinations quickly the week they arrived. We accepted. We would be offered the vaccine our first day of work.
I was on the fence in September when the possibility of the vaccine being available this winter first seemed real. My personality and temperament find me waiting for the first wave of people to try a new treatment (or car or computer) before jumping in myself. However, a year of isolation and modified behaviors, all of which are slipping with time, as well as nightly visuals on the news of what can go wrong, I reconsidered this hesitation. I looked into he new technology of mRNA vaccines and on reflection, decided that the pros outweigh the cons with the information we have today even given the newness of this technology. In theory, when compared to the traditional vaccine, the mRNA (messenger RNA) generated vaccines are far “cleaner” than what’s expected with a more traditional vaccine. By this I mean your immune system specifically makes antibodies to the spike proteins of the virus and that is all. In the polio vaccine or tetanus, for example, you have the whole (inactivated) virus to react to immunologically ie there is more “stuff” to react to. In preparation, one of the contraindications to the virus was, “a previous reaction to any of the components of the vaccine.” I don’t know one doctor prior to this epidemic who if asked, could tell you what the components of any vaccine were. In the case of Pfizer’s product, there is mRNA, salt water, and few fat molecules presumably used to help keep the RNA soluble in water. I looked to see if the fats are in other vaccines; I could not find that they were.
TRAINING DAY: This took place at the community hospital. I felt a bit like I was coming home after being gone for years. This hospital was a center to my working world for decades. I have until training day, been a stranger to the hospital for nearly a decade. I noted in the training group of thirty people, I was one of two males. There was a brief prayer suggested; it was not brief. There was hope and a sense of magic or more appropriately, something spiritual about the opportunity within which we were involved. The magic disappeared quickly: Most the speakers used hospital acronyms unknown to those of us who don’t work at the hospital. Kernie called the speaker out on that point. He apologized, made a joke about it, and within minutes fell back into acronyms and administrative-speak. Neither Kernie nor I could sign into the computer app through which all the vaccine documentation would take place. There was no one from IT in the room so we were stuck and left the training with only a paper guide ie no hands on experience. The final step was to document ones competency and for the hospitals outside providers were a problem. Doctors don’t typically give vaccinations. I asserted my competence, cited my work at the “catch up” vaccine clinics and in the end, a very competent floor nurse looked me up and signed off that I was competent to do this. I offered to demonstrate and she turned me down; she signed off—even after my story about Amber dropping off a flu vaccine for Kernie years ago from her work place. I administered the vaccine and as the plunger went all the way in, there was a click; on taking the syringe away, there was not needle. I freaked out thinking I had somehow left a needle sticking inside Kernie’s arm. We quickly sorted out that technology had moved on (and that I am something of a dinosaur) and there were now retracting needle ie they disappear when you push the plunger all the way in. That story marked me as a greenhorn but it turned out, many nurses present had similar stories so my credibility for fessing up was honored.
Of interest, I learned on the web that anti-vaccine news fronts had surveyed videos of people getting this vaccine and proclaimed the whole thing a hoax because it was clear that as the syringes were pulled from the vaccinated arm, no needle could be seen. “They were pretending to vaccinate people without even using needles…….”
VACCINE DAY: As with the training day, there was another call to prayer; this one was sweet, a bit long, and edited a bit like an e.e. cummings poem. There was an air of excitement as this was the first day of vaccinating in our region. The press was observing as we prepared. For both of these reasons, there were an extraordinary number of managers in the vaccinating room. As the morning ran, I decided there were too many chiefs and not enough Indians doing the work.
Kernie could not get access to the I pads used to document the work so was assigned to be a “preparer.” Under the guidance of a pharmacist who was husbanding the resource, she with direction, cleaned the vial, injected .3 cc’s of air and then aspirated .3cc’s of vaccine. She tapped out the bubbles in the syringe, made sure the full amount was present, and capped the needle. Done! And a photo was taken. And the photo was available in our local paper by 5PM that day. What a coup! The hospital’s moment in the sun and a volunteer was front and center.
When I was a manager, we studied Lean management systems and had an organizational philosophy of standard work. My comment about too many chiefs comes into play here. The pharmacy manager outlined the standard work for filling the syringe, but was gone as the other managers variable gave advice: Kernie will tell you someone suggested a correction: a counter-clockwise rub of alcohol on the vial prior to aspiration. I observed concerns about how to track doses per vial: was it an error to mark that you drew a dose before you had actually done it or should you wait until afterwards, in case it was contaminated or otherwise not used? The appropriate fit of gloves, whether to walk the vaccination syringe to the nurses or have someone else do it, etc. all came under view of the nurse managers. Of interest, Kernie had been able to pull six full doses of the vaccine (that is like striking gold when you don’t expect it) out of vials that were identified as a source for five doses. A manager, replacing Kernie could not match that and later in the day, the pharmacy manager, having returned had Kernie resume this role.
Later Dates—observations and concerns.
1) Distribution: If a battle plan is an analogy, the fog of war messed things up. The first few days were easy—the majority of scheduled employees came in and were vaccinated. Given the fragility of the Pfizer vaccine, one had to manage the thawing carefully to avoid wastage; once thawed, the vials had to be used within 6 hours. The routine at the end of the shifts became more and more interesting with time: the extra doses not yet used found ready volunteers from staff as the word went out. With time, the appeals expanded to people who were not hospital staff, but staff for businesses that did business with the hospital. The state distributed the vaccine to the hospital with a general purpose guideline which to avoid wastage, could easily find loopholes and those are a slippery slope. I saw little wastage of the vaccine.
2) Regulations: I think it is becoming clear that having a militant distribution to those prioritized on the list slowed down vaccination access considerably. Nurses on the floors of the hospital reported that there were staff that would not get the vaccine, even after the last year, and waiting for them to show up for their held dose proved inefficient. The State and on the scene managers are going to have to adjust (it is better to ask forgiveness than ask for permission) and in the case of managers, I wish they would develop a plan together and not make up necessary adjustments individually as they go, day by day.
3) Observation: Patients who have no risks for complications are asked to be observed for fifteen minutes. This is new; when doing mass influenza vaccine programs, you are moving patients on ASAP. With the need to socially distance, and then wait fifteen minutes post vaccine, the logistics for wide application of vaccinating the population has some hurdles. Is it necessary to have people wait: on Kernie’s first shift doing this two people at about twenty minutes identified not feeling well and were found to have very high blood pressures (200/120) and rapid pulses. Both felt, “weird” but there was no passing out or other problems. Both were transferred to the Emergency room for further observation. Happily, this auspicious start was not repeated over the following weeks. I elicited laughs from doctors and nurses alike when I suggested that being who they were, they would never tell anyone they felt poorly short of the moment prior to total collapse and that we would appreciate just a little more warning than that. My hope? After ten million vaccinations, data should allow a rational decision to eliminate the waiting period as necessary or make it optional or focussed to some criteria of higher risk patients.
4) Consent: I was fascinating when reviewing the consents and then vaccinating, at how casually people take the consent process. The 6 page official informed consent document was trimmed to 9 basic questions; the hospital employees had been asked to review these prior to coming in so as to be ready to simply sign off on the form. Most who said they had read it lied ie gladly welcomed the chance to review it, “just to be sure.” Some actually had a positive responses that required some thought. One woman on “blood thinners” could not tell me the name of her medication and had not consulted her doctor about whether it mattered with respect to getting vaccinated. Another had Addison’s disease, treated, and asked me if he needed to adjust his medication after getting his vaccine. When asked if he had consulted his doctor, his answer was, “not yet.” One woman who was breast feeding got the advice from her doctor to acknowledge that and take the vaccine anyway. One person had asked their doctor for advice on their medical condition and the doctor responded, “I don’t know; use your best judgement……”
6) Different Vaccines: This makes things complex; the Pfizer vaccine (first to be distributed) has such requirements that only medical systems are going to be able to effectively use it. This is not the vaccine to be used at your local pharmacy. The Moderna vaccine is more versatile; of interest, the Moderna syringes are a cruder quality than the Pfizer vaccine’s and there is no retracting needle; rather there is a somewhat cumbersome needle cover you slide into place after the needle is withdrawn. The effect is rather like being trained on an automatic transmission and suddenly being asked to use a manual. Actually, after two or three tries, it is like riding a bicycle…..
7) Process: our clinics became very efficient with time. At one point, I had done 6 or 7 vaccinations with consents and some schmoozing in half an hour. That success does not change some challenges. I kept thinking the arrival of the vaccine was like a miracle, just like the short Iraq War I was not excited to see happen—but it did happen quickly and with few American casualties. Success? Nationally, the distribution plan was not well developed and is evolving daily state by state. There are a lot of variables, a lot of Governors, the transition from a hands off Federal approach to one that will take on more responsibility with all the good and bad that will flow from that.
A related topic for a group that is in 1A category and the problems of distributing vaccine to people, “on the list."
https://www.nbcnews.com/news/us-news/there-was-no-plan-private-health-care-workers-shafted-over-n1252842
8) The anti vaccination movement is heterogenous; there are religious issues, conspiracy issues, fear of the unknown, fear of the new technology, fear of the “politics” of having it out so quickly, and just not feeling right about foreign substances being injected into one’s body. My goal is to be as clear as possible about risk and benefits. I accepted long ago that not everyone is going to get this (or other vaccines). If not enough get it, and the added population of those already infected in the population does not rise to a high enough level, the herd immunity will not take hold and sporadic disruptions to all our communities will continue. Should vaccine for Covid be obligatory in some work places?I think so. Is there precedent for making it mandatory? It has always been controversial but yes. In recent years, a nurse in the hospital system could get the flu vaccine or be asked to “gown up” when providing patient care—until this year, that was the exception and not the rule.
I am thinking that the surges post Thanksgiving and Christmas will give a broader portion of the population personal experience with someone who died or made seriously ill. Risk taking will be modified by this, hopefully, and the Spring should show declining numbers of those actively infected and we should be able to have liberalized access to the lives we took for granted for so long. Kernie and I did receive our booster shot January 8 and to date, can report no significant side effects. The rumors that the second dose is associated with fever and aches are rampant—-we did not suffer from these. Again, the psychological relief that the end is within sight is very real to us.
PS: a funny story. Nurses are notorious, in my experience, for having a visceral dislike of vaccination; no specific reason required. They just are. My wife was one of those. She only accepted flu vaccines when Amber, my daughter, extorted her to do so: no vaccine, no babysitting the grandchild. When we got our marriage license in California, one had to get a VDRL and a rubella titre. Kernie’s rubella titre was borderline. She managed to get pregnant and deliver babies multiple times over many years with many different doctors without ever getting the rubella vaccination. I did mention this need the day she was discharged from the delivery of Darby. The Doctor who made it happen—despite the fact that I had already made sure there was no chance of her ever having my baby again. Kernie is a vaccine advocate now, thank you very much.
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