covid19 update

Wednesday, July 22, 2020

Covid 19 Update

  It seems that new stages of reopening are emerging every day. We have no idea how many there will be in total. There are numerous requirements which must be met in order to provide personal care. For the time being and into the future, until full opening is achieved,  most urgent problems will be dealt with virtually and in person as a last resort. At this time we still do not have enough personal protective  equipment to allow full reopening.  Our waiting room is closed.  Under current guidelines  we would have to work anywhere from 12 to 18 hour days in order to meet the same level of service as was in place prior to Covid lockdown. We are attempting to provide urgent care in a minimal contact fashion. This may involve  attending in person to have specific testing along with a follow-up virtual visit. Our virtual counselling services are currently taxed to the limit and extensive wait times can be encountered. Different clinics and specialists are also handling things differently due to the confusion. We will all have to be patient and attempt to adapt.

Please do not call and ask for a referral that is non-urgent. There is no advantage to be placed on a waiting list since they do not exist. Each request is  handled on a case-by-case  basis with urgent  request taking precedent.  If you are looking for results from another physician or clinic, then it is best to call the practitioner who ordered the results or is monitoring that aspect of your care.  We will contact you  for any abnormalities ordered through our clinic.

It is mandatory to wear a mask in all public areas of our medical building.  This also includes inside of clinics. We asked that you do not  come to the medical centre without  a confirmed appointment. There are times specifically set aside  to follow-up  those that have  recovered from Covid and we would appreciate  that this be accomplished in isolation with minimal exposure to other patients.

We highly encourage you to keep track of things like blood pressure, weight, blood sugar  etc. at home and  either email or call in results to us if you have any concerns.

We  will continue to attempt to keep immunization and prenatal appointments on schedule.

It is important that you show up at the time given to you. Maintaining social distancing depends on this.  If you are late, please call ahead  so that we can rebook you into a better more appropriate  appointment time.

Some patients are panicking  with paperwork that  demands medical deadlines.. These cannot be met or accomplished during a coronavirus lockdown. We suggest you contact the  institution or company which issued the paperwork or demand.  Accommodations are being made in most cases.

it is our hope that by early fall we may be in a position to tackle the large volume of  normal and preventative testing that has accumulated. We encourage everyone to follow the current provincial guidelines.

 


Open letter to Prime Minister of Canada from Health Experts

Friday, July 10, 2020

To:  The Right Honourable Justin Trudeau, P.C., M.P., Prime Minister of Canada

Date: July 6, 2020

RE: Dealing with COVID-19: A Balanced Response

The undersigned represent current and past leaders in public health, health care systems and academia.  We are writing to you to with our thoughts regarding a balanced approach to dealing with COVID-19  We strongly believe that population health and equity are important considerations that must be applied to future decisions regarding pandemic management. 

The current approach to dealing with COVID-19 carries significant risks to overall population health and threatens to increase inequities across the country.  Aiming to prevent or contain every case of COVID-19 is simply no longer sustainable at this stage in the pandemic.  We need to accept that COVID-19 will be with us for some time and to find ways to deal with it.  

The current and proposed measures for reopening will continue to disproportionately impact lower income groups, Black and other racialized groups, recent immigrants to Canada, Indigenous peoples and other populations.  And it risks significantly harming our children, particularly the very young, by affecting their development, with life-long consequences in terms of education, skills development, income and overall health. 

Canada must work to minimize the impact of COVID-19 by using measures that are practical, effective and compatible with our values and sense of social justice.  We need to focus on preventing deaths and serious illness by protecting the vulnerable while enabling society to function and thrive.

Elimination of COVID-19 is not a practical objective for Canada until we have a vaccine. While there is hope for a vaccine to be developed soon, we must be realistic about the time it will actually take to develop and evaluate it and then deliver an immunization campaign covering the entire population.  We cannot sustain universal control measures indefinitely. 

We need to accept that there will be cases and outbreaks of COVID-19.  We need localized control measures that are risk-based.  We should consistently reassess quarantine and isolation periods, recommendations for physical distancing and non-medical masks, and travel restrictions based on current best evidence and levels of risk.

At the same time we must improve infection prevention and control in long-term care and congregate living settings.  We should provide support for people living in the community who need to or choose to isolate when the disease is active, as well as those who have been adversely affected by COVID-19, or the consequences of the public health measures. 

Canadians have developed a fear of COVID-19.  Going forward, they have to be supported in understanding their true level of risk, and learning how to deal with this disease, while getting on with their lives – back to work, back to school, and back to healthy lives and vibrant, active communities across this country.

We acknowledge the heroic work that has been done in recent months by many across all levels of government and the public and private sector, and the sacrifices that Canadians have made to get to this stage.  As we look forward, Canada must balance its response to COVID-19.  

Sincerely yours,

Robert Bell, MDCM, MSc, FRCSC, FACS, Former Deputy Minister of Health, Province of Ontario
David Butler-Jones, MD, MHSc LLD(hc), DSc(hc), FRCPC, FACPM, FCFP, CCFP
Canada’s first Chief Public Health Officer and former Deputy Minister for the Public Health Agency of Canada
Jean Clinton, BMus, MD, FRCPC Former President and CEO, University Health Network, Toronto
Janet Davidson, OC, BScN, MHSA, LLD(Hon)Former Deputy Minister, Alberta Health,Former CEO, Trillium Health
Martha Fulford, MA, MD, FRCPC,Infectious Diseases Specialist, McMaster University
Brian Postl, MD, FRCPC,Dean, Rady Faculty of Health Sciences  Univ of Manitoba
Neil Rau, MD, FCPC,Infectious Disease Specialist
Richard Reznick, MD, FRCSC, )Dean Emeritus, Faculty of Health Sciences, Queen’s Univ
Susan Richardson, MDCM, FCRPC,Professor Emerita,  Toronto
Richard Schabas, MD, MHSC, FRCPC,Former Chief Medical Officer of Health,  Ontario
Gregory Taylor, MD, FRCPC, Former Chief Public Health Officer of Canada
David Walker, MD, FRCPC,Former Dean of Health Sciences, Queens Univ Expert Panel on SARS, 2003
Catharine Whiteside, CM, MD, PhD, FRCPS(C), FCAHS,  Former Dean of Medicine, Univ of Tor
Trevor Young, MD, PhD, FRCPC, FCAHS,Dean, Faculty of Medicine  Univ of Tor.  and others.


When to Return to Work After Recovery

Thursday, June 25, 2020

YOU TEST POSITIVE - Public Health will contact all positive cases

-Self isolate at home for 14 days from the onset of your symptoms

-You can come out of isolation 14 days after your symptoms began, if you're feeling better, and don't have a fever (your temperature remains lower than 37.8 degrees Celsius) and can return to work but must maintain physical distancing.  

-Clearance swabs are not required for individuals to return to work.  

 

YOU TESTED NEGATIVE

-If you tested negative for Covid-19 you will still need to stay in self-isolation for a period of time, as you could still be at risk of developing Covid-19 based on your exposure or you may have another illness.

If no known exposures to a Covid -19 case:

-You should remain in self-isolation for 24 hours after your symptoms resolve

If you recently travelled outside of Canada or have been in close contact (eg. in the household or workplace) with a case of Covid -19, you need to:

-Remain in self-isolation for 14 days after your last exposure.

Though you tested negative, if you develop new or worsening symptoms, you may need to get re-tested.

 

YOU ARE AWAITING RESULTS

-Self-isolate at home until your results are received.

-Members of your household should self-isolate with you until your results are received.

 

HOW CAN I OBTAIN MY TEST RESULTS

 -Follow guidance provided by the clinician who test you.

-Check the online portal

-Refer to the website of the institution where you were tested:

  Trillium Health Partner

  William Osler Health System

  Headwaters Health Care Centre

 


covid19 update

Wednesday, June 24, 2020

Covid 19 update June 26

   The provincial government has announced that the lockdown will continue in our area till at least July 19.  We have not as yet received the proper protective equipment to start running regular clinics and opening up. We hope that this will happen in the next few weeks. We have no idea what the world will look like when this happens.  The health Department has prioritized us to the lowest level. We are bound to follow the rules in place. If you have an acute situation please contact us. We are working virtually and off-site. We are assessing our prenatal patients and keeping our pediatric population on schedule with their immunizations. Also patients who require regular injections of medication are being accommodated. We hope to provide you with more information as it comes available.  It is highly recommended and almost mandatory to at least wear a mask before visiting the building complex for all visitors. If you have any symptoms of acute illness please do not enter the building. You should proceed to a covid testing centre or the emergency department. You can also receive advice from our after hours number or by leaving us a message as well.


Covid19 update

Thursday, June 04, 2020

Covid19 Update June 6, 2020

   Well,  it seems the lockdown is now extended till June 30th,2020.  Being on the 5th floor of a large medical center without a direct outside door makes things difficult.  My associate and assistants  are working to make the best of things.  We are able to receive some limited protective equiptment, but currently will not have what is required should the lockdown be lifted and things start to soften up.  We ask that if you have infectious symptoms, get testing done. (see info below)

We are employing medical guidelines in the office to see our pediatric and pregnant population as well as some non infectious but urgent cases.  Social distancing measures are strict in our office, but we have no control over the common spaces in our medical building.  We advise all visitors to wear a mask for everyones safety.  We are working virtually for the most part, and returning most messages in a timely fashion.   We are unable to address routine visits,  paperwork, and non urgent matters until after the lockdown.  

   Waiting room chairs have been removed.  Protective shields installed and we do not allow any visitors apart from the patient and primary caregiver or parent. If you should need to be assessed, we ask that you come on time, wait in the car if you are early.  Our assistant will contact you the day of your appointment and perform a covid screen.  If you are very late, your appt will be rebooked to a time where you can be accomodated safely, and to maintain the safety of those that are being assessed.   We require time between appointments to prepare and clean room, personnel, equiptment and regown if necessary.  This is for the safety of everyone including your physician who hates to admit that he is in the highest risk group to suffer covid side effects. Please do not bring any food, loose items or papers into the office.  Visits are time sensitive, and we will not be able to address long lists of complaints without pre arranging  and screening for appropriate allotment time, as was the case in the past.   Please do not ask our physicians to render advice on behalf of other specialists in your circle of care.  It is best to speak directly with their offices.

   We have been successful at keeping medications prescribed by our physicians flowing.   PLEASE CONTACT THE PRESCRIBING PHYSICIAN IF A MEDICATION WAS NOT PRESCRIBED OR IS BEING SUPERVISED BY YOUR SPECIALIST.  This is important to maintain your treatment goals going.   There are shortages and most pharmacies are dispensing a thirty day supply.  We have a large vulnerable elderly population in our community of care that is a priority at this time.

   We are developing new ways and thinking outside the box on how to best get caught up with the backlog of routine care covid has produced.  If your child needs immunizations. please call us soon.   We are innovating new ideas on how to monitor ongoing health problems.  Home blood pressure machines,  electronic thermometers, scales and even oximeters that measure oxygenation and your pulse are available to the public.  Please consider getting one  for a loved one soon.  This is invaluable for handling phone calls.   Please unblock you home number on appointment days or if you are expecting a call back. This has been a problem ongoing.     This is an excellent time to reach out to your family and elderly shut-ins with a quick call to let them know you are thinking of them.

   It has been a long journey so far, but do not allow fear to predominate your thinking.    It will make other health issues worse. There are many resources available on the internet, see below. We will continue to be here for you!

 


COVID19 update

Saturday, May 23, 2020

Covid19 Update May 25, 2020

    Lockdown continues.  There is no word of getting protective equiptmen, nor of any guidelines of how to re-open a large medical center. We remain hopeful.  More concerning is that a second lockdown will mean that regular appointments  and follow ups will have to be post poned.   It is like sending a well trained army into action, but some general forgot to order bullets.  Whats more the manuals have existed for years, and still seem to have dust on their covers. 

   Some of the most gifted researchers that I have met, have a unique ability.  They rarely are swayed by pre-conceived ideas and unproven notions.  They pick a likely explanantion and start there.  What makes them different is that have a skill to collect observations and more importantly, data vital to their explanation. They refine, and  separate fact from fiction and incorporate this knowledge into their initial assumption.  They are not afraid to refine their predictions based on better facts and data.  We need this to happen on a national if not global scale, to move forward in a positive direction.

    A  "lock down" in the midst of widespread infection has never been substantiated in science.  The outcome should not be measured in how many tests are done???.    So far, the situation has uncovered pre-existing problems in some long term care environments.  Like most viruses,  things spread quickly in confined indoor spaces.  Sadly, many elderly could not cope with aging health conditions and covid.  In other years,  it would be influenza and very few would even notice the mini catastrophies. We have been waiting for a theoretical wave, which has not arrived, nor may it ever arrive.  

    In our area, many people are bewildered by how a lockdown is defined when there seems to be hundreds of thousands of people moving around.   The coronavirus is now part of our environment along with hundreds of other bacteria, viruses and fungi.   No one ever stated, that any of these actions will stop or cure coronavirus.  There have been numerous inferences that somehow we are going to cure this common but more serious cold.   The data for those under 60 certainly now supports that severity of symptoms or death or a rarity, even more so than perhaps influenza.  That group seems to have a better chance of winning a lottery, than suffering severe covid effects.  Media reports continue to sensationalize the rare and should be interpreted in a proper perspective.  The rare results are probably related to unusual pre-existing factors.  To sensationalize that it represents the norm is not helpful.  To assume that you will not encounter the virus when "lockdown" is lifted, is over reaching.  I continue to monitor the results in Sweden and other countries where slightly different approaches were taken, without economic catastrophe and seem to be faring as well as anyone with much less stress and mental health issues escalating.  It seems our approach has cost us worstening of other health issues, depression, anxiety and devastation of numerous relationships.  I hope that it is worth it, and implies that the world will no longer be the same.  In the next few months, we will truly see the  effects  of a devastating economic  pinch.

    The is no science that can guide "re-opening".   Firstly, we were never truly closed.  You may hear about complex modelling, being used.  These mathematical principles make numerous assumptions and use estimates.  In other epidemics, most of them were very far off the mark, and rarely mentioned.   Any science behind these things, is full of estimates and assumptions.   I think our politicians are slowly realizing the differences and it makes it difficult for them to make decisions without ramifications at this point.   


Covid19 update

Sunday, May 10, 2020

Covid19 Update May 11, 2020

Lockdown continues.  There is no word of getting protective equiptmen, nor of any guidelines of how to re-open a large medical center. We remain hopeful.

     You may becoming tired of hiding, sleeping in, experiencing irrational fears and repeatedly  hand washing.  I am becoming paranoid at the number of people who ring my doorbell and run.  Bored of attending webinars, I enjoy calling random numbers in third world countries to sell duct cleaning or reclaim taxes.   A year ago I may have been prescribed therapy and medication.  I am increasingly following the Swedish situation which is accomplishing the same thing in a slightly different way.  They were criticized initially for using sensible distancing vs social isolation, but defended it with scientific basis. People there are worried, take care to minimize spread but schools, and shops remain open.   Lets just take a short reality check.  Viruses and humans have co-existed for eons and it is worth looking at why this relationship has always existed.  Malaria, tuberculosis and flu viruses are still the main problems on this planet.  Swine flu, ebola, west nile, SARS, polio, are all epidemics that many of us have ridden through. One truism is that ALL PANDEMICS fizzle down.   Why we dont take advice from the repeated play books the front line commanders write afterwards is bewildering.  It would be useful to have those experienced frontliners from previous campaigns explain things.  Turning the TV on only brings on a plethora of possibly well intentioned politicians and doctors who oversimplify and have difficulty explaining the situation.  Encouraging people to hide, creates false hope that it will simply go away.

     Good and significant data is emerging, but shared only in limited circles.  A methodical study in a major outbreak center in Germany now suggests that, most people who have had the virus, got through it fine, and further calculate that the rare complication and death rate is much lower than the 10 -14 % estimated at the onset. Their data suggest in the range of 0.02%.  The clinical picture of Covid19 differs and behaves slightly different, but the front line workers have adapted and learned a great deal.  This results in earlier recognition of the rare complications and less intubation.  Any serious lung infection affects the elderly and those who are infirm and bedbound much worse.  An unusual difference with Covid is that the rare person deteriorates very suddenly, a scary sight for all involved.  It also takes a few days longer to develope or notice any symptoms. 

     The curve you hear about, is an idealized concept based on calculated theory and not really science.  Most epidemics dont follow idealized curves, but are lop-sided or have many ripples, so expect the same.  Pushing down a peak to allow for better care makes sense, but how to do it remains a hot discussion topic. Closing borders AFTER your are inundated makes no sense, is was done more for political pressures than anything else. Wuhan was locked down completely with no movement of any kind, arrests, roadblocks and violence, but too late to make any difference according to textbooks.  What border closures have done is to turn a PANDEMIC into dozens of mini Epidemics.  Each will have its own set of problems, poverty, lack of resources, etc and ways of handling things, so comparisons will be hard to make.  Bill Gates gave a TED talk five years ago, and his predictions were spot on and impressivly accurate.  His message was ignored.

      Our immune system is amazing and complex.  Many of us will only need the circulating inate immune system to get through this, while others will manufacture reinforcements such as antibodies to complete the job.  A recent letter to the editor appeared in local papers submitted by a group of medical experts.  It was relegated to the back pages, but stressed that it looks like spread is by droplet fashion.  Droplets are heavy and dont travel far.  The significance is that this implies that it takes a very LARGE viral load, perhaps millions to infect someone to the point of symptoms.  This directly speaks to the fear that a box on your doorstep will not result in infection. Over 90% of people who thought they had covid and went for testing were negative.  This suggests that you may want to worry more about the multitude of other bugs found in the environment around us.  Health workers are prone to being exposed to high doses


Covid19 update

Sunday, May 10, 2020

Covid19 update May 11,2020

for our patients who are calling Peel health and cannot get a test or advice.  Trillium Health partners has put together a virtual assesment center.

You can access it at this link:  trilliumhealthpartners.ca/assessment

If the lockdown is causing anxiety and depression please visit:   https://bouncebackontario.ca/

 A  daily walk in the fresh air has always been advocated for health, and I continue to stand by this advice.   Keep your immune system healthy with fresh vegetables, fruits and meat. No juice or pop.  Supplement with Vit C, and Vit D, since you are not in the sun.  Avoid sugar and reduce carbohydrates. Most importantly, a lockdown is a situation where rights are restricted.  In these situations the effect on other aspects of our mental and physical health is enormous.

TIP OF THE WEEK:  Besides hiding and washing your hands, an obvious ommission has been made by our leaders.  It seems that most Canadians now come with cell phones fused to their hands.  Just try and remove one from a teenager, and you will see my point.   My message to Canadians would be to  CLEAN YOUR CELL PHONE AND DO IT OFTEN.  I was amused to watch a colleague fully gown up, meticulously wash and scrub, and then make a cell phone call followied by tucking the device in a back pocket.  People seem to have cell phones glued to their hands these days, so a lot more attention needs to be paid to this.


     It seems that no one thought this through and set up a protocol for the next step after lockdown.  How do you emerg from a situation when there is no science to guide the way.  Some will simply cook the numbers to support their actions, others will admit to the difficulty and futility. New patterns established in months of isolation do not reverse easily.  How does a society come out of a lockdown that has devastated our economy. I am often at a loss of what to tell family members who have been in isolation for months without any sign of disease, that they cannot touch or hug one another.  When you do emerge from hiding, the streets will be full of  a mix of covid survivors, an occasional sick person,   those with natural or acquired immunity and everyone else.  The fear will be immense.  It will be natural and almost expected that people will try to avoid buildings that perform close examinations of sick people.  We will spend a great deal of time making accusatory glances at all strangers, since all microbes are virtually invisible to us.  There will be covid vigilantism emerging as already happened in some rural towns.   Stay calm, use common sense and try to enjoy the beautiful days when you can. 

 Wearing a mask when going out amongst other humans, is an effective and good way to carry on.  You have many levels of protection that you may not be aware of.   Our skin is designed to be an effective protective barrier.  Virus and bacteria can't penetrate it, unless it is damaged.  Even though you may not of heard this message,  it is possible to overwash your hands, particularly if using strong soaps or any bleach type cleaner.  Strong chemicals can breech the integrity of a well functioning skin layer.


Covid19 update

Sunday, April 26, 2020

Covid19 Update, April 27,2020

We are about four months into the appearance of this virus. Things are starting to slow down a bit. I caution you to not view the numbers as golf scores. We really don't know how many people are infected despite the news people stating otherwise. The numbers they are referring to generally refer to the more serious cases that seek help and get a swab done.  The true recovery rate is unknown, since it depends on knowing how many have the disease at the onset, something we simply make up or estimate.  Currently, even though the greater Toronto area is the hotspot, our hospital resources are not overwhelmed.

Some interesting points that I have picked up by attending frontline medical rounds broadcasts from New York, Italy and London.

We will not need as many intubation machines as first thought. The doctors that give the best advice are those on the very front lines, and not those on the news.  There are emergency doctors in New York and Italy that have had a great deal of experience dealing with the 2 percent of serious cases that newscasters sensationalize.  They found ways to improve initial treatment and outcome. You may have heard that the need to intubate has greatly decreased. Doctors now recognize that the virus causes a inflammation in the chest. It is often not having any symptoms. Initially this finding along with measuring low oxygen blood values resulted in someone needing to be intubated. We can now use a very simple device called an oximeter to measure your blood oxygen and guide early treatment or even help with the diagnosis. We've also discovered that changing positions, which is what non sedated people normally do during sleep improves their oxygen transport and requires less intensive care.

As of yet we still have not received any personal protective equipment in the medical building adjacent to the hospital. This will create a significant problem in how to open up society after the lockdown, and start providing non emergency care.  With the current data, the first assumption will be that everyone is susceptible, except those that had a positive test.   In fact, if you look at the textbooks, they suggest that many had and fought the virus without knowing it.  The numbers will drop, they always do.  We will probably use this tid bit to confirm that lock-downs work, without any good evidence to support.  The danger to the economy is that if we adopt this way of life, and lock down during flu seasons,and subsequent respiratory outbreaks, our way of life will change with a great deal of more poverty.

The vaccine is a long way off. The coronavirus is a common cold virus that we see a lot of, with more severe strains causing SARS and MERS.  Interestingly, work began on vaccine production 15 years ago. Bill Gates gave a Ted talk on YouTube in 2015. It is short and sweet but almost predicts this pandemic to the fine detail. The best vaccines worked really well and were developed 60 years ago:  polio, tetanus, smallpox, diptheria, measles, mumps and rubella.  The other ones tend to not work as well and need repeating such as the annual flu-shot. It make sense that coronavirus vaccine will fall into this less effective class.

In the medical world, we are seriously questioning the numbers coming from China. They are deftly misleading and under calculated. Unfortunately, this creates a legal – political problem more than a medical one. I hope the ramifications from the economic meltdown will not affect us too seriously. There is a tremendous back log of regular work that needs to be done in the medical system that this has created. Even when reopened, the system works close to its maximum so the ability to take up any slack will produce backups and slowdowns for months if not years.

Be safe be healthy


covid19 update

Wednesday, April 08, 2020

Covid19 Update Apr 22,2020

    Lock down and isolation orders have been extended till mid May.  The medical system is awaiting an onslaught of serious cases that I sincerely hope dont materialize.

I have redeployed to hospital responsibilies in the surgical division if  needed.  We continue to monitor and deal with urgent problems by phone and other means.

Most of my specialty colleagues are doing the same.  We have pretty well run out of protective equiptment in the office, and are awaiting new shipments.

We have fho after hours availability for very urgent matters.  You must first call the physicians office to be screened and advised.  An onsite visit may be required.

To help with any potential backlogs, many previous medical scripts are being rewritten.  Prenatal care is being revised to accomodate the current situation, as is pediatric and well baby care.

For those worried about Covid, please take the quiz at covid-19.ontario.ca.       As isolation continues, we expect to see a rise in mood and stress disorders.  You can now access a counsellor for help by calling 289-291-5396 in our region.    Also see www.bouncebackontario.ca   1-866-345-0224  for anxiety and depression.

Sick notes are not required as part of the emergency legislation.

Sick notes – see CMA statement, urging all employers to discontinue requirement for sick notes during COVID-19. The Ontario Government introduced changes to the Employment Standards Amendment Act (Infectious Disease Emergencies), 2020 – the legislation will also make it clear employees cannot be required to show sick notes: https://news.ontario.ca/opo/en/2020/03/ontario-supporting-workers-municipalities-and-retailers-in-response-to-covid-19.html
 
We continue to monitor our phone messages for urgent matters. Please be patient during these times.  We can renew your prescriptions, but the orders suggest that pharmacies limit dispensing to 30 day amounts.   Referrals for routine matters are temporarily on hold.  Routine paperwork and forms will be collected and completed when time and circumstances allow.
 
Please take time to reach out and call anyone that you are aware of in self isolation. It can be a very trying experience to endure this alone.  There are more bright lights appearing in the dark cloudy horizon.  Learn to recognize them and enshrine them.
 
I have posted an editorial piece from today New York Times, that gives great advice from the battle hardened front lines of New York City. See editorial pieces on right column of website.