Xenobots are coming: Tiny Blobs of Programmable Tissue (WIRED)

From WIRED.com, the application of DNA engineering not only to the sequencing and reading the DNA and RNA of viruses and organisms, but now to CREATE “tiny blobs of programmable tissue.”

REALLY?

Watch it above, and read it yourself: https://www.wired.com/story/synthetic-biology-plan/

A Good Covid Vaccination Is Like Calligraphy

Join CT on the front line of vaccine clinic at UCHealth!

Hi y’all! I volunteered for a vaccine shift. Me and a couple dozen of my best friends. Here’s the scene: this clinic day was dedicated to second-vaccine doses for nearly 1000 healthcare colleagues, 12 vaccinator stations, and a constant stream of patients down the hallway. Our location can handle 2-3x this number, if we had vaccine supply to do so (and on last Friday, our location and 9 other UCHealth vaccine locations dispensed over 5000 vaccine doses across UCHealth).

Having been a grateful recipient of both my shots, I’m ready to wade in and do my part as well.

Ever wonder what it is like to be a vaccinator at a high-volume vaccine clinic?

On the Vaccine Front Line

First, you receive an email to take your training on EHR documentation requirements ahead of time, and a super quick anatomy refresher on deltoid muscle and intramuscular injections. Easily done, about 10 minutes. Then you report for duty at one of the twice daily 7-hour shifts. You get a quick in-person briefing, some quick hand-holding (ok sounds weird in pandemic times), and off we go!

Here’s my station. Because, as my daughter says, I’m totally into ‘hume-optimizing’ (determining the optimal way for humans to do things – sometimes to the great annoyance of family members or colleagues: sorry y’all) I thought hard and asked lots of questions of my more experienced medical assistants and nurses sitting nearby. Here’s what I learned:

  • Card colors: Green card: hold in air when ready for another patient; Yellow card: running out of any supplies; Red card: medical question (just embarrassing to hold this one up if you’re a physician)
  • Computer: login, find the immunization clinic, filter out discharged patients, sort by time of arrival, click to remove word-wrap to show more patients per screen.
  • The data entry fields pull forward 80% of relevant data to each new patient, as well as the vaccine name, lot#, and details, and I’m down to just confirming patient identity, confirming injection site (6- R deltoid, 7-L deltoid: even the physical mapping makes it easy: when patient facing you, the 6 key is on the same side as the patient’s R arm!), asking the 3 screening Q.
  • Then the shot itself! Vaccine syringe (obvious) but don’t stick yourself or the patient unintentionally. (HOT TIP) And when you insert the needle, do it with a quick pop so that breaking the skin and finishing the motion are in the same moment and the patient’s sensory nerves don’t get a chance to register more than one ‘oh’ of surprise. Specifically, don’t be slow.
  • (HOT TIP from a PA colleague in Interventional Radiology) hold the syringe between your thumb and 3rd and 4th digits, with your index positioned over the plunger. Really? That’s the way? (Sooooo much faster than my jab, then switch hands, try not to be awkward, plunge, untangle my hands and pull back) and the jab+plunge was now less than a second. Level up! (Gamer talk). After my “technique improvement” lots of patients were surprised: “Hey! Didn’t feel that at all!”
https://www.jacksonsart.com/blog/2017/03/28/maggie-cross-chinese-painting/
  • (Irrelevant aside) I notice that this new syringe grasp is reminiscent of the way you are to hold a Chinese Calligraphy brush, like you are cupping an egg and then grasping the brush. Ah, such elegance.
  • (HOT TIP From a brilliant nurse colleague) After the alcohol swab of the deltoid, pre-attach half of the bandaid and let it hang down. That way, you know where to put the shot and you don’t lose track (if no spot of blood) of where it went as you look away to dispose of the syringe. Then flip the bandaid fully on, VOILA! Totally changed my life.
  • Click the needle protector closed with one finger, toss in Sharps container.
  • Mumble sweet nothings to your anxious client while doing the next steps. Answer any questions.
  • Type ‘n’ in the time field to get the time Now. Click Accept to complete the vaccine charting. Their patient portal account is automatically updated, and the State Vaccine Registry is updated (I believe either real-time or at midnight every night)! Add 15 minutes to write onto a sticky note to attach to their vaccine card for them to know when they can leave if feeling okay.
  • Reach for a tiny sticker to put on the vaccine card with vaccine name, lot#, date, location.
  • Smile with your eyes, gesture to the seating area.
  • (HOT TIP from another RN colleague): Wipe down: with gloves on, pull an antiseptic wipe for the desk, chair, relevant surfaces. Whip off gloves, rip and prep an alcohol swab and bandaid —easier with gloves off. New pair of gloves, position a new syringe on desk, check if running low on supplies, raise the green card.
  • NEXT! Cycle time when all was humming, as little as 3 minutes. Less time than it took to read this.

Of course, GEEZ some patients had the temerity to ask questions. Or we would briefly run low on vaccine as the pharmacy team whipped up another batch in the next room, or someone had to run for sticky notes or wipes or gloves etc. Or maybe I NEEDED A POTTY BREAK, OK? Other times, we would have lulls in the action. Then it was up to our green-card-waving skills as to which of a half dozen vaccinators the lone patient would walk to.

Here’s a counterintuitive tip for non-medical workers.

You might think that having your vaccine done by a person in green scrubs or a white coat (in my case, both) would be ideal: they’re the doctors or providers. In our organization, nurses wear dark blue scrubs, medical assistants wear dark purple (violet?). Almost uniformly, the docs volunteering haven’t given vaccinations since … medical school. In my case, 30+ years ago. My recommendation: go with blue or violet scrubs for technical proficiency and years of practice. Of course, if you want a long medical conversation, by all means stop by my booth!

Here’s my tally. Actually 55 by end of day. I figured out that I could keep my needle caps on the desk until I had a break to make my hash marks and throw out the caps. The system worked. I know many of my RN and MA partners were quicker than me or had better patient-attracting green-card-waving skills or took shorter breaks. Not bad for my first half-day shift.

This was unlike my daily work.

As a physician in an internal medicine clinic I would worry about how to reduce the blood sugar of an overweight, depressed and anxious diabetes patient with high blood pressure, severe arthritis, needing wheelchair repairs, a dozen prescription refills and several prior-authorization meds, and now with several new worrisome symptoms and family pressures. As CMIO I would worry about how to balance the anger of providers spending long hours writing notes and orders versus allowing a sloppy, error-prone verbal-order paper-like system. And how to allocate time and effort between reducing physician burnout and improving predictive algorithms when those projects were sometimes in conflict.

Working in a vaccine clinic by contrast was like playing a fun, fast-paced, team-based video game (not that I would know): clear goals, mutual reinforcement, visible progress, strong team camaraderie, repetitive (and improving) physical skills, opportunities for rapid learning, immediate positive feedback and customer appreciation, excitement over doing a public good. We were IN THE ZONE.

Honestly, on good days, both regular clinic and informatics work is like this too.

What’s not to like?

Oh, here’s one of our physician leaders, Dr. Andy Meacham, even with everything he knows about how docs are the worst vaccinators, willing to be my victim. Thank you for your service, Dr. Meacham.

Gratitude

Honestly, it humbles me to part of such an amazing organization that assembled the people, the process, the tools so that I could drop in as part of a well-oiled machine, only a couple weeks into this brand new process. I’ve noted quite a few physician leader colleagues also taking part. So cool. 

“Covid-19, Yes, Your Days are Numbered! We’ll take back our streets and those jobs you’ve plundered!” — CT Lin & his terrible (My Shot – Covid) ukulele song

If all this talk gets you interested in the vaccine, See my recent blog post on how to get in line for a vaccine at UCHealth

CMIO’s take? Serving as a Covid Vaccine vaccinator was one of the most gratifying things I’ve done. I’m signing up for more shifts. See you soon!

Sign up for COVID Vaccine at UCHealth. (The EHR is our superpower).

UCHealth, like all health systems across the state of Colorado, are following the guidance of the Colorado Department of Public Health and Environment (CDPHE). As the guidelines change (sometimes daily!) we follow the guidelines. Our supply of COVID-19 Vaccine is closely tracked, and each next shipment depends on our adherence to guidelines.

The change

We are now opening up vaccination signups to segments of the general public beyond health care workers. See the CDPHE guidelines here: https://covid19.colorado.gov/for-coloradans/vaccine/vaccine-for-coloradans. Based on the state’s plan, UCHealth is focusing efforts on vaccinations for people 70 years old and older. You do not need to be a UCHealth patient in order to get vaccinated.  

Here is how it works

Keep in mind that most health systems in Colorado are working on vaccine distribution. Please first check with your primary care provider or primary health system. For those over 70 with interest in getting their vaccine from UCHealth,

  1. We will use My Health Connection, the patient portal for UCHealth’s electronic health record, to communicate with people. If you have an active My Health Connection account, you will automatically receive updates regarding the vaccine. If you do not have an active My Health Connection account, please create one to receive these updates. To learn more and create an account, go to www.uchealth.org/covidvaccine.
  1. Over 80% of patients at UCHealth have a MHC account, and we’ll be using our Electronic Health Record (EHR) to determine our patients who meet the criteria for vaccine (currently, using date-of-birth to calculate age 70+).
  2. You DON’T have to be an existing UCHealth patient or be seeing a UCHealth provider to create an MHC account and to indicate your interest in the COVID-19 Vaccine.
  3. You WILL need to have an email address and be able to access the patient portal yourself. You may have a proxy (trusted designee) sign up for you; keep in mind that this proxy would also potentially have access to your UCHealth electronic health records as well.
  4. At this time, we do not have enough vaccine doses to offer it to everyone. As UCHealth receives shipments of the vaccine, we are providing it as quickly as possible, according to the state’s plan. As we receive additional quantities of vaccine, we will send vaccination invitations through our randomized selection process to give everyone the same chance of receiving a vaccine.
  5. When vaccine becomes available to your phase of distribution, you will receive an invitation from My Health Connection with instructions about how to schedule your vaccine appointments. Please be patient until you see the message titled “Urgent: Schedule your COVID-19 vaccine”. When you receive this message, you will be able to schedule both vaccine doses. You will have 48 hours to get your appointments scheduled. If you miss the 48-hour time frame, you will receive a new opportunity to schedule in a future distribution phase. 
  6. An appointment is required to receive the COVID-19 vaccine; walk-ins cannot be accommodated.
  7. For the most current information regarding COVID-19 vaccines, go to the COVID-19 vaccine page on the UCHealth website.

The EHR is our superpower

This process has worked well for our first 37,000 COVID-19 vaccinations, and we plan on scaling up further, as vaccine availability improves.

Some may criticize us for using an electronic patient portal and perhaps leaving out those without access to the internet. (I have even heard the term “digitalism.” However, looking that up, it seems to mean “being poisoned by digitalis from the foxglove plant.” Hmm. But we digress.)

At the same time, we’re putting plans in place to ensure that those without access to a computer or smartphone also have access to the vaccine. Through phone hotlines, clinics that target low-income areas of the state, and outreach to underserved communities, we aim to provide the vaccine fairly to everyone. Some of these efforts have already begun.

Our main point from using our patient portal was that, using our existing infrastructure where we already have nearly 1 million patients, we could move quickly, filter our patients by age, and create and send invitations thousands at a time. This contrasts with those who might have to postal-mail invitations or make phone calls and set up (and staff-up!) a phone bank, that could take days and weeks. 

We launched the invitation and scheduling process over one weekend (thank you and sorry to our IT and project leaders who built this) and offered vaccines the next weekday after receipt of our first batch. I’m so grateful to work with such amazing colleagues and their amazing teams, and grateful that we have an existing information technology infrastructure that allows this. The EHR is our superpower.

News items

Fox31 news (patients 70+): https://kdvr.com/news/coronavirus/covid-19-vaccine/uchealth-patients-over-70-start-getting-vaccinated/

The Coloradoan: https://www.coloradoan.com/story/news/2021/01/05/covid-19-colorado-next-up-vaccine-heres-what-know/4127958001/

9news (mass vaccination): https://www.9news.com/article/news/health/coronavirus/vaccine/colorado-hospital-systems-get-ready-for-mass-vaccinations/73-3f1a2fbb-df90-4007-8f1d-35c372c71414

KOAA news (mobile clinic):
https://www.koaa.com/news/covering-colorado/uc-health-goes-mobile-with-covid-19-vaccine-in-colorado-springs

UCHealth mobile vaccine clinic: https://www.uchealth.org/today/older-adults-receive-covid-19-vaccine-at-home-through-mobile-clinic/

UCHealth older adult vaccine news: https://www.uchealth.org/today/older-adults-rejoice-as-they-begin-getting-coronavirus-vaccines/

CMIO’s take? We are excited to be part of the solution for our community throughout Colorado and the Rocky Mountain region!

AI-cameraman mistakes bald ref’s head for soccer ball (sbnation)

from IndianXpress.com

https://www-sbnation-com.cdn.ampproject.org/c/s/www.sbnation.com/platform/amp/soccer/2020/10/30/21541962/soccer-match-ai-camera-bald-head-ball

Because there are no cameramen allowed to capture video of live soccer matches, an AI cameraman tracks the action by following the round ball around the soccer pitch. Well, a referee’s bald head is very attractive to the AI cameraman; this ruins the day of many soccer fans. So sorry.

This is priceless and also reassuring that we are not yet all out of a job.

Transporting patients in the Covid Bag (guest post: Gary Breen MD)

Despite N95’s and protective gear, the entire Life Flight Crew came down with COVID the last time they transported your patient on a ventilator to a higher level of care. Now what?!

The Problem

How are intubated and ventilated Covid-19 patients transported?  As a hospitalist located at Yampa Valley Medical Center in Steamboat Springs, I have had to intubate and initial mechanical ventilation on a number of patients infected with Covid-19. 

Initially, following the onset of this pandemic, these critically ill patients were being transported via rotor or fixed wing aircraft to our larger UCHealth facilities on the Front Range for optimal care by flight crews donning PPE which included N95 masks, goggles or face shields, gowns and gloves. 

Despite this protective gear, many of the flight crews contracted Covid, which resulted in some emergency transport services becoming grounded until crews could recover.  A better, safer option for transporting these patients was needed.

The ISO-POD

Originally developed to transport patients infected with the Ebola virus, The ISO-POD is negative-pressure patient isolation and transport system which allows us to safely transport critically ill Covid-19 patients, while simultaneously providing protection to our emergency personnel.  The device has a port which allows for ventilator tubing, IV lines, and monitoring lines to pass, as well as 12 gloved iris openings to allow the flight crew staff access to the patient from head to toe. 

Packaging the patient

The patient is placed into the ISO-POD, and the bag is closed and sealed, then sterilized over the exterior surface to allow for transport.  Air movement into and out of the device passes through filters to remove viral pathogens, ensuring that flight crews remain safe during transport, which can only occur in a fixed-wing aircraft. 

Packaging patients up in the ISO-POD is a logistic challenge, often requiring 1-2 hours for crews to safely prepare patients for transfer.  The majority of our transfers from Steamboat are via Classic Air, who maintain three reusable ISO-POD devices, and a flight crew of over 300 people.  The ISO-POD has allowed Classic to transport numerous Covid patients without any crew infections.

Keeping our flight crews safe, and allowing hospitals to fight this thing together

The “Covid bag” has become an invaluable, and all too familiar tool, allowing us to transfer our critical Covid patients to larger UCHealth facilities in order to receive optimal care, while still keeping our flight crews safe.  As a physician caring for these patients, I am incredibly thankful to our dedicated flight crews for job they do, and appreciative of innovative technology such as the ISO-POD.

Gary Breen MD
Physician Informaticist
Hospitalist, Internal Medicine
Yampa Valley Medical Center, UCHealth

I am NOT Throwin’ Away My Shot – Covid Vaccine (ukulele)

I wondered what Lin-Manuel meant when he wrote this song. Turns out, it was for THIS moment.

While my colleagues are working hard delivering vaccine doses to healthcare workers as fast as we can (15,000 doses given in the last 5 days! Woo!), I’m hard at work at the Ukulele Parody Studios.

Here it is: the world premiere of a song that seems titled for this moment in time: I am not throwin’ away MY SHOT.

Thanks to Lin-Manuel Miranda for the original, and the overall miracle of the Hamilton musical. No thanks to him, on how hard this song is to sing.

Happy holidays, y’all.

This is the best Covid-19 graph I’ve ever seen

Perhaps the image of the year. Control group vs Vaccine group in the Pfizer trial: see the red line COMPLETELY FLATTEN at 10 days.

The Pfizer vaccine flat-out works. Read the New England Journal of Medicine article yourself; open access:

https://www.nejm.org/doi/10.1056/NEJMoa2034577

But, what’s the TL;DR?

  1. The control group (blue line measuring cumulative, or total number of infections of Covid-19 in the control group) grows at a constant rate, as expected.
  2. The vaccine group (red line) rises in parallel for the first 9 days, and then by day 10, BAM the red line is almost completely flat, indicating almost NO infections in the vaccine group. This makes sense, as it takes the body awhile to detect the vaccine antigen (spike protein), then manufacture antibodies in great volume

SO COOL. As Michelle Barron MD, our infection prevention specialist states: “I would have been happy with a vaccine that is 50% effective, like the flu shot some years. This one is 95% effective.”

Wow. Hang in there everybody.

I am NOT throwing away my Shot (I got mine today!)

Covid-19 Vaccine! I got mine! And University of Colorado Hospital is set up to give over 1000 doses per day just at our hospital.

As you know, Covid-19 vaccine is out in the wild. Colorado received the first shipment earlier this week, and we at UCHealth received the first 17,000 doses. We set up an infrastructure to schedule vaccinations through My Health Connection, our patient portal. We sent out over 10,000 invitations this week, and already 5000 health care workers have already booked their appointment. IN 48 HOURS! Never have I ever heard of something moving this fast. 97% of physicians/providers state their willingness and intent to be vaccinated.

Among my colleagues, many of us were hitting “refresh” waiting for our invite to schedule the vaccine. Last night, I was super excited receive my invite. Woo! So organized the portal ensures you book both appointments at the same time. Super simple!

Then, super easy on arrival; we use our patient portal to e-check in, verify my demographics, read the consent form for the vaccine, so that my check in can be super simple and super quick. Yes!

And here we are! 8 check-in stations humming smoothly. Everyone masked up, smiling, everyone so excited to be part of DOING SOMETHING to fight back against the pandemic. Bam!

Here we are in our auditorium. Sixteen vaccination stations, with appointments every 10 minutes, and vaccine service hours from 5am through 9pm. I calculate our capacity to vaccinate about 1000 people a day. This just at UCH; we have 9 other vaccine locations throughout UCHealth’s hospitals in Steamboat, Fort Collins, Colorado Springs, Pikes Peak, also actively vaccinating. Our goal: to administer our entire received batch before Christmas day. Zowie!

I got mine! 15 minutes socially distanced in the auditorium to observe for immediate reaction, and then done! In and out in about 30 minutes! Woo!

As you know, the FDA and CDC guidance is: Healthcare workers and long term care residents and staff first (winter), then high risk general public (spring) and then general public (summer). We are getting started, and have infrastructure now to deliver shots just a quickly as possible. We anticipate vaccinating up to 20% of all people of the State of Colorado. Hope to see you here soon!

CMIO’s take? I am NOT throwin’ away MY SHOT! (could it be there is a new ukulele song/rap? … stay tuned!)

Podcast alert: Alphafold and the Future of Physicians

First, go listen to the story. It is only 10 minutes and worth it.

Then

Here

Are

My

Observations.

There. Just wanted to give you some space to listen and then come back. Here’s my take. I did this originally on twitter, but it turns out, I need lessons on creating an easily connectable twitter thread (yikes, another thing to learn and master).

This Podcast is excellent.

@Doctor_V is spot on. Agree: industrialization of docs means there is no time for most docs to tinker with test tubes in the back office of their busy clinic. Even academic medical centers find the legendary ‘triple threat’ docs (clinician, teacher, researcher) increasingly rare. 1/

And then, information transparency means medical literature is widely and instantly disseminated: the myth of the all-knowing doc is eroding. Some patients with rarer diseases can study enough to be nearly as expert and up to date, albeit without the broad clinical experience of years of medical practice. 2/

Furthermore, the explosion of new information and knowledge is too fast for ANY human to keep up with. This is due in part to the technology acceleration, due to growth in globalization and ability to communicate and connect many minds with many ideas. Only purpose-built AI’s have a chance to digest such a deluge. 3/

The bad news: human minds will not keep up, from here on out. The good news: we can become centaurs: half human, half horse (or AI-assisted). Chess, for example, in unlimited tournaments, is most often won by human-computer hybrid teams. I think this is our foreseeable model in healthcare, and in a growing number of fields. 4/

And in the long run, perhaps we are all out of a job? I don’t agree with that either. TV did not knock out radio. Cable did not knock out broadcast TV. Internet did not knock out cable. The landscape just looks different. 5/

Finally, I agree with Dr. Vartebedian’s point: we need to look up more from our grindstones and see what is on the horizon. If the technology acceleration continues, it will come at us faster. And we need to prepare ourselves and educate our patients, our communities. Thanks for reminding us. Amazing things ahead. 6/end.

Covid Vaccine education: THIS is how you do it (Denver Health Grand Rounds)

Want to know how to teach science that makes sense to scientists as well as the general public? And, it is about Covid vaccine effectiveness and safety. Watch and learn. So proud of our Denver Health Colleagues.

I am unhappy that many physicians and scientists are so bad at educating colleagues and the general public on important topics. We get too much into the weeds, we lose sight of the forest when describing the trees too-up-close.

Dr. Anuj Mehta, a physician at Denver Health held a grand rounds that blows these low expectations out of the water. In 40 minutes, he tells us:

  • How vaccines work in general
  • Why and how the new Covid mRNA vaccines work
  • The actual safety data from the Pfizer, Moderna and AstraZeneca trials
  • How vaccine approval works in the US, and what the FDA and CDC are saying
  • He then summarizes “COVID-19 Vaccine: Reasons Why NOT To Be Scared”

Finally, in our recent surveys of physicians and staff at my organization, over 97% of physicians state they plan to get the vaccine, while only about 65% of medical assistants state this. This speaks to both physician confidence in the science, and also to the concerning gap that we are not teaching our non-physician colleagues adequately about the science and how important this is.

CMIO’s take? 1. This is a tour-de-force, folks. Watch it. Learn. There are brighter days ahead. 2. Please spread the word. Vaccinations will save lives. AND, continue to wear masks and social distance. It all works together.