LETTER TO THE EDITOR

In keeping with Dr. Gaede’s theme of “fun”, I offer this humorous sketch about psychotherapy

A long time ago a young woman was picking herbs in a lovely garden in the Bavarian woods. Unbeknownst to her the garden was the property of a vengeful witch, who upon finding this offense, took the young woman’s daughter as compensation for the pilfered herbs. The witch locked this child away in a tower. With nothing else to do in the long hours of captivity, this child, Rapunzel by name, grew prodigious amounts of hair. Eventually, owing to disrepair the stairs to the tower became unusable and the witch began using Rapunzel’s hair for access to the tower. She would stand at the bottom of the tower and call out “Rapunzel Rapunzel let down your long hair so that I may climb that golden stair.” Soon a cascade of flowing locks would tumble out of the tower window and the witch would climb up. This ritual, as rituals want to do, repeated itself regularly until a prince happened to observe the process and intervened. He rescued the maiden by climbing up her hair, cutting her hair and carrying her from the tower using her hair for a ladder. This couple married and raised children, who had children, etc. Several generations later, a young female descendent of the line was picking herbs in a lovely Bavarian garden. Unbeknownst to her the garden was the property of a descendent of the vengeful witch, who upon finding this offense, took the young woman’s daughter as compensation for the pilfered herbs. It just so happens that this child carried the family moniker of Rapunzel to honor her ancestors. Ever notice how these family dramas seem to recur from generation to generation? This young woman was, as before, locked away in a tower in the woods and with the appropriate family genes, grew some really radically long hair. This latter day witch began using these tresses as a means of egress into the tower and the ritual was brought forth into the current time. “Rapunzel Rapunzel let down your long hair so that I may climb that golden stair.” Again this ritual was repeated daily until one August a psychiatrist on her annual holiday in the Black forest observed the scene. When the witch left, the psychiatrist uttered the magical phrase, “Rapunzel Rapunzel let down your long hair so that I may climb that golden stair.” Sure enough the hair came tumbling down. Rapunzel noting the different voice uttering the phrase invited the psychiatrist to come up and rescue her. At this time the following dialogue took place.

These conversations continued like this each afternoon through that August and several more. Eventually Rapunzel decided to use her own hair to climb out of the tower. She took that asset to Hollywood where she started Hair Club For Men. Thus she began rescuing princes. As for the psychotherapist, she found an absolutely enchanting herb garden deep in the woods near the tower. Countertransference does come to us all.

Some remember the massive effort it took to eradicate polio. Many want to be part of history by helping to end the current pandemic. Others are looking for ways to make a difference or speed the opening of schools and businesses. Whatever the reason, a small army of local healthcare professionals and physicians have voluntarily stepped up to vaccinate against COVID-19. The retired orthopedic surgeon who took on the task of organizing the largest vaccination effort in Fresno County called it “the most complex vaccination project that’s been undertaken in the history of man.” Timothy Brox, M.D., listed all the ways the COVID-19 vaccination effort is complex: “It is a physically friable vaccine that requires special handling. It requires a tremendous amount of participation from the public. It requires a second dose and vaccination requires an observation period. It has irritable side effects.” He leaves out the complexity of politics and misinformation rampant on social media. “This is not like when I was a kid and lined up for my sugar cube for my polio vaccine in school,” he added.

The public health department’s mass vaccination site at the Fresno County Fairgrounds came together quickly. Dr. Brox, who retired from Kaiser Permanente, got a call from the county to “come help on a huge project.” He’d met Rais Vohra M.D., interim health officer for Fresno County Department of Public Health, while sitting on the Global Medicine Committee at UCSF Fresno, and he knew he wanted to help out in the pandemic.

“The system had to build databases on the fly and mass vaccination procedures on the fly. And we had to organize this while starting new clinics,” explained Dr. Brox, adding this came after a year in which Fresno County Public Health’s resources had been severely taxed from handling the coronavirus pandemic and the devastating Creek Fire.

It started slowly but now, with the help of physician and nursing volunteers, the site administers more than 2,000 doses a day.

Gregory Simpson, M.D., medical director of dermatology at UCSF Fresno, praised the fairground clinic’s organization after volunteering there: “They are incredibly efficient. There’s one warehouse where you do the paperwork, one warehouse where they cycle you through and you get your shots, and one where you wait to make sure you’re not having a reaction to the shots. It’s really on a large scale that’s fantastic.”

That efficiency extends to how carefully doses are measured out to match the number of patients each day, observed volunteer Bonna Rogers-Neufeld M.D., a diagnostic radiologist with Sierra Imaging Associates specializing in breast imaging at WISH Fresno Breast Center. “At the end of the day I am only getting one or two doses at a time. They are absolutely diligent about not wasting each dose.”

Dr. Rogers-Neufeld also appreciated how easy the county health department made the volunteering experience. “There’s no paperwork for me to do,” she said. “All I do is greet people, ask a couple of questions and faster than lightning I have a shot in and half the time patients don’t even know it. I’ve had no problems or seen any reactions. It’s a win-win.”

The county health department also makes sure everyone is comfortable giving shots. “On my very first day volunteering I was taught by a retired nurse from St. Agnes. She had been a nurse for like 40 years and she taught me how to do vaccinations,” said Jessica Martin M.D., a UCSF Fresno resident in emergency medicine. “It makes me chuckle when people say ‘Oh good we got a doctor,’ like it’s going to be so nice to get vaccinated by a doctor. And I’m thinking in my head ‘If only they knew I’d only been doing vaccinations since the clinic.’”

Brand new medical students are getting early experience by volunteering alongside their teachers from California Health Sciences University. “These are first year medical students who typically wouldn’t have these types of clinical experiences until their third or fourth year,” said John Graneto D.O., dean of the university’s College of Osteopathic Medicine. Students become familiar with how to talk to patients and see firsthand how public health disaster relief works.

Of the 79 inaugural students matriculated at the new medical school in Clovis, 55 have signed up to volunteer at

the fairgrounds mass clinic alongside 10 faculty members. “It’s been very positive for them,” said Pamela Kammen M.D., a rheumatologist who is assistant professor of specialty medicine at CHSU. “They have the opportunity to work with patients who have different customs and personalities and learn how to deal with anxious and excited people.”

Dr. Brox boasted that nearly 200 licensed clinical professionals are signed up to volunteer at the fairgrounds and on most days, clinical positions are staffed 65% with volunteers.

“They range the whole gamut from podiatry to dentists to M.D., D.O., through pharmacy to all the different types of nurses,” Dr. Brox said. “Right now I have a nurse 20 feet from here who has a fulltime job at one of the local ICU’s and she’s down here on her precious days off helping. We’ve had a retired nurse anesthesiologist whose license lapsed. He had to do 30 hours of continuing education and he had to pay to get his license reinstated. And he did that so he could come down and help with the vaccination.”

Volunteers include public health professors, retired nurse managers, faculty from UCSF Fresno and CHSU and medical residents from UCSF and Valley Children’s Hospital. “We have doctors in their 70s who came to the clinic before their vaccinations were in effect. That’s a significant risk group willing to serve,” Dr. Brox said. “That’s the kind of response and professionalism we encountered.”

When the call went out for medical volunteers, few hesitated. And just as their professional experiences have been varied, their reasons for volunteering run the gamut.

Dr. Graneto said one of his students told him “I want to be able to tell my grandchildren that I participated in helping in the pandemic in 2021.”

For Dr. Rogers-Neufeld volunteering felt like a natural extension of what she’s been doing since she was a small child and tagged along with her doctor father at a previous epidemic. “My dad went out to schools on the weekends to administer smallpox vaccines and give the polio vaccines, which we put in droplets on a sugar cube. He was a surgeon

Fresno County Department of Public Health Volunteer Coordinator William Timothy Brox, MD

but it didn’t matter. Doctors and nurses banded together because the polio epidemic was just unbelievable.”

Few people today can truly understand, she said, how scary it was when science was not as advanced and little was known about transmission. Parents forbade children from swimming in streams or playing with other children. “It was crippling,” Dr. Rogers-Neufeld remembered. “We just had no information. And now we have a world of information – probably too much information – but we knew how immediately it spreads.”

Vaccines that are routine for children now weren’t for Dr. Rogers-Neufeld. “In the world I grew up in we got the measles, we got chicken pox and there was no vaccine,” she said. “And my precious cousin Debbie died from measles at age 8. She died of measles caused encephalitis, which is a horrible way to see a child go. When you see the personal devastation of something that subsequently becomes completely preventable by a vaccine, it changes your whole world. And then you see your father helping to be part of the solution.”

Dr. Martin’s motivation was to learn more. “My family has been really wanting to get vaccinated, but nobody was in tier and no one really knew where to go. So, I thought it would be nice to get better information on vaccinations and help out as well,” she explained.

“There is no minimum requirement that they’re asking of me which is really, really kind,” said Dr. Martin,

a second year resident with long days and often overnight shifts. The county health department has a sign up portal for volunteers that makes it easy to see which shifts are open, she added.

Third-year UCSF Fresno resident Catheryn Salibay M.D. also had to figure out how to work volunteering in between long rotations working in family medicine clinics, studying for her medical boards and being a wife and mom. “I had a career in public health for eight years at the California Department of Public Health’s immunization branch,” Dr. Salibay said about what led her to medical school. “I was pretty much interested in everything and anything to help out the community. My time on weekends is precious, but I told my husband I really want to volunteer and I really want to give vaccines.”

For Dr. Simpson, it was a matter helping to lighten the load he’s seen his colleagues carrying. His University

Dermatology Associates office is right next to Community Regional. “For the entire year, I’ve been watching the hospital really, really just be overrun with COVID,” he said. “The internal medicine residents who rotate with us in dermatology had just been through ICU rotations with just a day of rest between. They just looked pretty rough because of how much work and how much death and destruction they’d seen.”

He added, “I just wanted to figure out what in the world I could do to help out. What can a dermatologist to do to help out against COVID?”

Volunteering to vaccinate gave him the perfect chance to make a difference.

Physicians are hardwired to make a difference observed Mark Alson, M.D., a diagnostic radiologist with Sierra Imaging. “Most people that are physicians went into medicine because they want to take care of people. So here’s an opportunity to take care of people,” he said. “My whole feeling is this needs to be done and I’ve got some free time, so I’ll do it ... I think most of the physicians are doing it because it is an easy way for us to help the community.”

Helping his own community is what prompted Albert

Wilburn M.D. to come out of retirement to work at the vaccine clinic at Gaston Middle School in West Fresno. “I’m a black physician and I’ve worked with underserved populations most of the time,” explained the retired Kaiser Permanente hospitalist. Before coming to Fresno in 1991, Dr. Wilbun worked in public health clinics in Columbus, Ohio, and in the Watts neighborhood in Los Angeles. “I’ve seen that inequity in healthcare and this pandemic just threw that in your face. The groups who were dying the most got the least amount of vaccines first.”

SPOC’s Drive-Through Vaccination Clinic administers 1000 doses per day, four days per week.

He added, “I think one of the few positive things that have come out of the pandemic is people can see now how unequal the whole medical system is.”

Fresno County has been trying to rectify those inequities. “We’re trying to run clinics both geographically and from a cultural perspective,” Dr. Brox said. “We’ve have one of our county nurses who is Hmong running a specialty clinic with Hmong volunteers. And Gaston Middle School is run with the African-American Coalition and the Economic Opportunities Commission for people of color to be vaccinated by those with the same personal experiences.”

Dr. Wilburn knows many in the Black community are reluctant to trust doctors – and especially government doctors – after past medical research used them as unknowing participants. “But when people decide to come

to the clinic they’ve already jumped that hurdle. I’m in a position where I don’t see that hesitancy. I’m not out in the community recruiting people,” he said.

He loves the diversity of those working at the Gaston clinic. “A lot of people working there were raised in that area. I’ll hear them talking with patients telling them ‘I was born four blocks this way’ or ‘five blocks that way.’ They are eager to give back to the community and very assertive in encouraging people to get the vaccination.”

Getting appointments set up without computers or internet access or familiarity with online registration is difficult, so many are showing up without appointments, Dr. Wilburn said.

“We had a couple of older people who came in with the son who had an appointment,” he described. “We asked them to come back about 30 minutes before the clinic closed when we knew we might have extra doses. These people were both pushing walkers. Everybody was worried about them.”

They got in and got vaccinated. And they felt the same as most at the clinic, he said. “People seem much more relieved. A burden has been lifted.”

Fresno Mayor, Jerry Dyer received his vaccine from Rick Lembo at SPOC

Dr. Brox ticked off the categories of who has been vaccinated: “So far we’re doing 65 years and up. We’ve done all healthcare. We’ve offered to all in education.

We’ve offered to all food and ag workers. We’ve offered to all emergency workers who are not healthcare.” He continued, “So the big change effective

Monday, March 15, is we’re going to offer to everyone, age 16 to 64, who has a pre-existing condition. We’re asking for a note from your doctor attesting that you have that condition, but we’re also accepting selfattestations.” Parceling out vaccinations this way is an imperfect attempt to get to those who would be most affected if they got sick. “But the disease has not really fit nicely into these categories and people who have not fit in these categories have had some of the most severe forms of the disease,” observed Dr. Brox. Private practices and clinics have begun to step up to help expand the county’s efforts as more vaccine doses become available and more people become eligible for shots.

“There needs to be a great shout out to dentists or pediatricians or other small providers who have taken

on the work to become an authorized vaccine provider,” praised Dr. Brox. “The hoops that those people went through is a testament to their dedication. The work to become an authorized receiver of vaccines and then injectors of vaccinations was not for the faint of heart. People like Dr. Nicole Bahn and her pediatric group and the people at SPOC (Sierra Pacific Orthopedic Clinic) need huge kudos.”

Rick Lembo, director of sports medicine and patient care at SPOC, joked to Jeremy Ealand, COO that he was just trying to find a way to stay essential through the pandemic after school and college sports closed down and elective surgeries came to a halt. They worked at getting people screened, setting up SPOC for social distancing, telemedicine and then on the logistics of surveillance testing their staff. When vaccines were approved for use, they turned their attention to that.

SPOC was the first private clinic to get approved in the area on Dec. 29 and took delivery of vaccine doses on Dec. 30 and 31 to vaccinate their staff. “On New Year’s Day we were on a Zoom with the county and they asked if we would help vaccinate other healthcare providers. So we said sure,” Lembo described.

When the county opened up vaccines to those 75 and older, SPOC was ready to help again. Ealand and Lembo had a model for drive through COVID-19 testing but were told the county didn’t need that help in their area. The logistics for that were easily transitioned for drive through vaccinations, said Lembo. “We just flipped it to delivering vaccines to people who have been in the house for 10 months and they want it. But we caused complete gridlock in northeast Fresno for three days.”

“There was really no hesitation,” SPOC’s CEO Joe Clark said of the decision to turn their orthopedic clinic into a mass vaccination site. “My feeling is that we needed to do everything we could to get the county back open, get our schools back open and our kids playing sports again.”

The effort has also helped SPOC avoid potential furloughs. “We wanted to find a way to keep our employees working,” explained Lembo. “Our employees bought in from day one. They have never worked harder in 8 hours vaccinating and they ask to come do it again. They are proud to be part of it.”

Eye Q Vision and Sante employees and physicians have also come to help with SPOC’s drive through vaccinations, which are now delivering 1,000 doses a day, four days a week. “People aren’t waiting more than 30 minutes now. It’s like clockwork,” Clark praised Lembo’s set up.

Dr. Simpson said he’s still working out some of his office’s vaccination logistics. The paperwork, he said, is nothing compared to the scramble that happens in his dermatology office to use up all the doses opened that day. “There is serious mayhem at the end of the day trying to get shots into arms,” he joked.

“We’d open up 10 shots because you have 15 on the schedule who qualified (by being over 65, etc.) and then you find out 12 of them have had the vaccine,” he said. “The last thing you want to do is waste shots. So the last two hours we’re calling in patients who meet the criteria and are already interested to see if they can come in. Or we call people who may not be patients yet. They’re new patients without all their paperwork in yet. And then my staff has got to register all that paperwork.”

But the work has been worth it to see how grateful older patients have been when offered a vaccination at their dermatology appointment.

And when vaccination criteria opened up, Dr. Simpson said the requests poured in. “I’ve kind of felt like one of those old-timey telephone operators with the amount of calls I’ve been getting. My cell phone has been getting texts from teachers and just random people the minute they qualify. They’re texting me ‘Can I get a shot? Can I get a shot?’”

He’s happy to have his phone blow up if that means vaccine hesitancy is waning and more people are getting protected.

Volunteers universally remark on how cheery patients are when they’re rolling up their sleeves to be vaccinated. “In healthcare typically a new patient comes to us frustrated or in pain or not happy with the insurance process,” said Dr. Graneto, who was an emergency department physician for years before joining CHSU. “Even the words we use to start a visit with are negative words. We ask people ‘What’s your chief complaint today?’ But these encounters are really pleasant and these patients say ‘please’ and ‘thank you.’”

CHSU’s Dr. Kammen has appreciated how patients encouraged their students, “A number of them say ‘Oh this student did very well.’ Or they’ll say ‘I didn’t feel a thing.’ This kind of positive feedback helps the students a lot.”

Those encounters have definitely increased the new medical students’ poise, said Dr. Graneto. “Every single student shows up a four-hour shift petrified and they leave with self-confidence having had a very pleasant experience and having participated, in a tiny way, in the cure.”

UCSF Fresno resident Dr. Martin has had multiple patients want to take photos or videotape their vaccination. She gets just excited about the possibilities that open up for people after vaccination “On Thursday I finally had more second dose vaccinations than first doses. I had one guy tell me ‘I have not seen my grandchildren

Fresno Physicians (above) Don Gaede, MD, Pamela Kammen, MD, Kenny Bahn, MD, Bonna Rogers-Neufeld, MD, (below) Christina Maser, MD and Greg Simpson, MD volunteer at the Fresno County Department of Public Health Vaccination Clinics.

in over a year and now I finally feel like I can!’ Because Thursday was his second shot. That’s always sweet to hear.”

Lembo loves how enthusiastically grateful people have been: “I had a little grandma get out of her 10-yearold Mercedes and give me a huge hug because she got her vaccine and she can see her grandchildren now.”

Volunteer vaccinators all have a story of a patient that reaffirmed their choice to be involved. “The best story for me,” said Dr. Simpson, “is about a patient I’ve been seeing for years who is 78 and has been in a wheelchair since 3 or 4 because he had polio. He got polio before the vaccine was widespread. He was so incredibly happy that we were able to give him the vaccine for COVID. He was well aware of the affects because he’s had people close to him die of COVID.”

“It helps me recharge,” explained Marina Roytman M.D., an internal medicine physician specializing in liver disease. She’s a UCSF professor of clinical medicine and has been treating COVID-19 patients at Community Regional. “I’m probably at the vaccine clinic most Saturdays. It helps me recharge to see healthy people. And these are people who now aren’t going to come die in the hospital.”

She continued, “If I can do 100 shots, these are 100 more people who won’t get sick. And people are so delighted. They are so ecstatic and taking pictures. I’m probably in hundreds of pictures giving shots.”

Dr. Bonna-Neufeld agreed, “This is very refreshing. My regular job is hunting for breast cancer. You actually do save a lot of lives because you find early breast cancer. But patients are not very happy with you that you’re delivering bad news … Here people are happy to see you.”

“So as long as there are people lining up for vaccines, I’ll be there to give them,” she said.