I knew the timing of the cough was going to be trouble.
The world around me had started to close down, at first at the bidding of rumors and assumptions followed by sudden, universal mandates. Businesses sent office workers home with laptops, and in a case of “as above, so below” the schools followed suit with our nation’s youth. Everyone was hungry for information, wrought with uncertainty, and forming the personal opinions that would guide their online interactions for the weeks to follow. Most of all, we were learning that COVID-19 was responsible for the most non-specific symptoms of any virus we’ve encountered. What we did know is that respiratory symptoms were likely and to be suspicious of such.
The last thing anyone wanted was to hear a guy coughing.
I can’t say I fully know what caused the cough, I am assuming some low threat virus or bacteria, maybe a bit of an allergic reaction. We are in Iowa at springtime after all, and my immune system isn’t getting any younger.
The cough was dry and was not accompanied by any sort of secretion or fever. I could feel the specific site of the insult - a tracheal region below my chin and higher than my sternum. I’ve had coughs like these before. They nag. They linger. They flare at inconvenient times and contrary to my prescriber's belief do not respond to benzonatate. And, to the disappointment of the part of me that just wants a diagnosis, I am otherwise fine.
On the last Wednesday of April I made an appointment with my PCP for a check up. He took x-rays during the visit, but no COVID test. He knows my history of any bug I catch eventually settling in my chest, so he was wanting to get a good listen and look. My lungs were clear, and other than my blood pressure and weight being up, I was otherwise grossly healthy. I was given a 2 week sample of an inhaled corticosteroid, Rxs for a methylprednisolone taper pack and benzonatate, and directions to add loratadine or fexofenadine to my daily mix. I was told to hold off on the methylprednisolone and only start it if symptoms didn’t lessen by the weekend.
Fast forward to May 4th, Star Wars day for some, another manic Monday in the world of healthcare. My cough had conspired to be at its worst during my evening shift, and my voice was also failing me. It had been declining in strength since my visit to the doctor, but I talk for a living as well as for recreation so it hadn’t exactly had much chance to rest. After giving my body and the medicine the weekend to improve, I started the methylprednisolone but there was no immediate impact.
Midway through my shift my manager and I made the decision that given the symptoms I was presenting to our work environment, the policies in place, and the example mandated to be set by the Poison Control Center (and all Public Health agencies) that I should be tested and cleared before returning to work.
The next morning I called Employee Health, as the health system that employs me is doing in-house COVID-19 testing. Aside from some frustration with the phone prompts (one sends you to a dead-end voicemail that appears to be misrouted), I soon spoke with a receptionist that was able to transfer me to staff responsible for coordination of testing. They reviewed available times in their schedule and gave me explicit directions for where to go and how to proceed.
The health system had an acute screening site established on the University campus. I was told that there would be a specific path to follow from either east or west ends of the campus, and that they would converge on Lot M, behind the University library. I was told to bring my badge, to leave my windows up until instructed otherwise, and to expect 24 to 48 hours for results. I was to expect a phone call with the results, then an email would be sent to my work email address for the benefit of my department. They needed my name, date of birth, department, and color and make of my vehicle. My appointment would be at 1:15.
I left a little early to make sure I could navigate the University campus in time, assuming I would have spare time to sit and read in peace. The day was sunny but dreadfully windy, and it was appropriately chilly for spring. I was expecting a M*A*S*H style tent in the middle of a parking lot flanked by rows of coughing people in cars.
After a slow orbit of the campus I found the general area of the test, but I will admit I was confused on where to go. I could see folks in PPE waving cars into a parking garage, but there were cones and sawhorse stop signs telling me not to go that direction. It was then that I noticed the first security guard.
The gentleman was part of campus security. Since I lingered too long at the intersection he exited his truck and walked over to me, mask in place. He pointed to a parking lot that I was to head to next. It was a large lot to the west that was filled with long lanes of cones, not unlike you’d see outside of a concert or baseball game that expected large capacity. In fact, it brought to mind cattle chutes, which may have been a side effect of me reading a Louis L'amour novel. There were only a couple cars driving through the lanes, which could have accommodated several dozen cars. For me there would be no such waiting.
There was another round of security, this time a member of the police department. The officer was parked near a pair of long wooden tables. I was approached by a man and woman in PPE who sought to confirm my appointment. The wind whipped across the lot and was brutalizing the pair, who showed no change in demeanor as they professionally carried out their duties.
I, however, was not on the guest list.
Rather than be turned away, they assumed I was a late addition. They stepped away from my car and started coordinating with others via walkie talkie. A car that was ahead of me was waved forward by another staff member in scrubs, and another security vehicle was parked nearby. I do not recall if it was police or campus. The car that had entered previous to me was being flagged to the middle of a lane. A car pulled in behind me but was stalled a good car length behind. One of the pair stepped towards that car to give instruction.
They returned and had verified my vehicle, name, and department as a late addition. I had cracked my window to communicate better, and reached to raise it again. Being me, I of course failed at the most basic task and pushed the lever the wrong direction. The auto lower mode engaged and the man stood back and calmly said, “Yeah, go ahead and raise that back up and leave it there, thank you.”
They waved me across the large lot, where I have my pick of three wide open lanes, again noted by orange cones that by some miracle were not flying away. The wind was relentless, and the woman who flagged me forward too way somehow miraculously spared from taking flight. My vehicle rocked from the gusts.
It began to dawn on me that with the controlled schedule they were able to distance everyone, be it on foot or in car, to maximize buffer zones. I was impressed. This did not change throughout the process. I was waved forward again to exit, without stopping, and pull back out onto the road, back to the intersection that I had originally tried to enter incorrectly. The security man nodded, walkie talkie in hand, and pointed me onward. Everyone had walkie talkies.
The next lot presented more cones and a longer wait. I saw two women in scrubs, windbreakers, and masks walking towards me. I assumed they bore instructions, but it turns out they were just walking laps. They passed me several times before I departed, and it seemed like a curious area to use to get your steps in. It was probably a pair of workers on break and they were sort of married to the site, “dirtied” perhaps by the exposure and not able to leave the area.
Eventually I was waved into a parking garage, no tent to be seen. A tent may not have survived the punishing winds. There were outdoor blast heaters and patio warmers set around, but none were running. It was cold, and would have been more so in a prolonged exposure. At least outside you had the sun. At least within the garage you were free from the wind. No one looked tremendously comfortable but you would have never been able to tell by their professional manner.
A single nurse with a mask and walkie talkie was in command of the lot feeding into the garage. She walked the length of it several times to coordinate with the two yellow robed nurses within. A car was ahead of me and I wouldn’t be allowed into the garage until they were swabbed and released. HIPPA was being maintained to the fullest ability afforded.
When I was finally instructed to pull into a stall, the two nurses approached and motioned to roll down the window. They had full PPE; hair, face, mask, gown, gloves. It all had a very science fiction feel to it. My SUV sits as high as any SUV or truck, and once of the nurses was short. I inquired how best to accommodate her and she said just lean my head back against the headrest, turn towards her, and breathe normally.
Before I knew it, without much fanfare, a long probe was pointing through my window. I had heard it was a swab, and to be honest I expected a rigid Q-Tip style contraption. Instead this was a semi-floppy plastic swizzle stick with the tip covered in little plastic cilia. I wondered how they would navigate it without any rigidity. I found out exactly how no sooner than I had formed the thought.
The nurse asked me to once again confirm my name and date of birth. The swab was inserted into my nostril up to the nurse’s fingertips. It was inserted slowly, and frankly didn’t really irritate the lining of my nose as much as I feared. I could feel the spikey end of the swab bobbing against the interior of my oropharynx. I didn't care for that but it wouldn’t stay there long. I was told to continue breathing normally, and I realized I had started to hold my breath. With that the swap was retracted and drug against the lining of my sinus areas.
It tickled, but not in a funny way. It was a non-painful irritation that left a streak of hyperstimulated nerve endings in its wake. I wanted to crawl out of my skin in the moment. It was very uncomfortable, but before I could make a fool of myself it was over. A dull shadow of that sensation lingered for hours, the surface of my nose’s interior unaccustomed to visitors and not happy with the disturbance. Still, it was not abrasive. It did not scrape or hurt. It brushed. It tickled.
The probe was packaged and I was told to roll up my window and exit through the garage. I emerged in a different part of the campus, an area where no one seeing my car would know that I had been anywhere but on campus. It was very organized and very smooth.
I was called at 8:45 AM the next day with my results. I was COVID-19 negative and a letter was to be emailed to me shortly. The Employee Health nurse reviewed my symptoms with me, and shared that even with a negative result that they are asking folks to not return until they are asymptomatic. We discussed the nature of my symptoms and my prior appointment, and she agreed that I should be allowed to return, if my managers concur.
And that, as they say, was that. I immediately contacted my workplace and confirmed that I could return to action. I thought that I would type up a little but about the process since, mercifully, not many of us will experience it first hand. Not everyone will be sent to the University site. Others will be routed to stations within their clinics, or to public sites arranged by state or private labs. But the process, so long as it does not become overwhelmed, is quick and painless.
I could see them being able to ramp up productivity to impressive volume with few changes to what I experienced. Very little actual medical equipment was needed - nothing that couldn’t be performed with a card table, cooler, and a totes. It could be done anywhere. The key is to protect the process by finding that sweet spot - that magic number of where we can expose the least workers, test the most patients, and avoid overwhelming the material and human resources involved.
I imagined the same site but with the cattle chute lanes full of cars. Maybe someone pulled in the wrong way. Maybe someone honks, impatient beyond reason. Maybe someone cuts in line, has a vasovagal response, shows up without a slot, or has a car full of agitated kids they couldn’t just leave at home. Maybe there would be emesis or sneezing or SOB (or a plain old S.O.B.).
So many things could happen in this setting. It could have been miserable. By the grace of G-d, it wasn’t. And that was at least somewhat due to planning, vision, training, and execution. No one woke up April 1st an expert on COVID-19 and the management of public test sites.
Lastly, I wanted to commend the staff for their professional service in what had to be uncomfortable conditions. It could just have easily been raining, freezing, snowing, or searing heat. These nurses were out there serving both people and the public, putting themselves in a position of exposure in a low visibility, low glamour, low reward setting.
Healthcare professionals of all walks are being called to go above and beyond. It really put into perspective the orchestration, demands, and our individual roles in this time. So kudos to all of the teams orchestrating the response to the COVID-19 pandemic, and bless you for your efforts. I hope you (we) all stay encouraged, healthy, and content in knowing that we are making a tremendous difference, even when it isn’t easy or welcome.