Commander Alice Fike Oral History 2021

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Read a paper:
Risk Factors for COVID-19 and Rheumatic Disease Flare in a US Cohort of Latino Patients, Arthritis Rheumatology, 2021 Jul; 73(7): 1129-1134.  doi: 10.1002/art.41656. Epub 2021 May 28

Alice Fike

Behind the Mask

April 16, 2021

Barr: Good morning. Today is April 16, 2021. My name is Gabrielle Barr. I am the archivist for the Office of NIH History and Stetten Museum, and today I have the pleasure of speaking to the Commander Alice Fike. Commander Fike is a nurse practitioner with the National Institute of Arthritis and Muscular Skeletal and Skin Diseases, and today she is going to speak about some of her COVID experiences, and I want to thank you for being with me.

Fike: Thank you for having me.

Barr: Yes, so I think we are going to begin with some of your [NIH] Clinical Center activities. So, how and when did you decide to volunteer to help screen for COVID 19?

Fike: I think, if I am remembering correctly, it would have been in the beginning of March 2020, somewhere around there. A call was put out by the Chief Nursing Officer, Dr. [Gwenyth] Wallen, and so, because of that, I volunteered.

Barr: What did your training entail?

Fike: Training was just, you know, the epidemiology questions that we need to ask people as they are entering, and then the flow for how to deal with folks who screened positive, and that was different depending on if it is a patient or an employee, and how to bring them through the building to minimize exposure, and then also just reviewing the appropriate PPE that we needed to be wearing because at the beginning of the pandemic, we were not doing universal masking, so it was just only us who really had PPE.

Barr: Was your training held mostly online or was there like an in-person component?

Fike: It was in person. Yes, because this was it.  I started before everything shut down.

Barr: Yes, it is interesting. As a nurse practitioner, did you have any role in shaping how NIH conducted its COVID screening?

Fike: I think all of us, who were on the core group of people who were screening, you know, we gave our input and things evolved as we were learning more about the virus, and so, I would like to think that we had some impact.

Barr: That is good. Can you speak a little bit about some of your responsibilities in daily routine screening patients, staff, and visitors who enter the Clinical Center?

Fike: Sure. So, it was divided up into, let's see, one two three, three main entrances: the south entrance, north entrance, and the parking entrance which included the ramp that started a little later (the ramp and then the P1 area, where patients would enter). So, we had folks stationed at those different areas, and then we would, each person that came in, we have them do their hand hygiene, and go over the questions about symptoms with them, and then just remind them about, once we moved to universal masking, we then had to give them masks and make sure that they are wearing it correctly, and then talk to them about what to do with it when they are leaving, where to throw it away, that type of thing, and then, depending if you have any positive screens then we would need to take care of those appropriately depending on whether it was a patient or an employee. I think a lot of it also, dealing with supplies, making sure we had enough PPE to distribute, and then also a lot of times patients would come with their loved ones, visitors. When we moved to a 100% “no visitors” policy that was a difficult transition.

Barr: Must have been really hard.

Fike: It was very hard. I do remember that…

Barr: You had to turn people away?

Fike: We had to turn people away and, you know, the decision was made kind of quickly, and so, the information did not necessarily flow out to all of [the] patients because the change was made kind of from one day to the next. I think that was a big theme, just a lot of change and transition that was happening quickly, and that, I think, uncertainty was really difficult for a lot of patients, families, and staff so, yes, I remember that day when patients were coming with their families and we had to turn them away and people were very upset. It was hard. Yes.

Barr: I am sure. Can you talk a little bit, you spoke some, about the evolution of your process, but can you speak a little bit more about how the process has changed as the pandemic has kind of shifted?

Fike: Well, I think we started off where only the screeners were in PPE, and initially, a lot of us were wearing PAPRs, that is the purified air kind, like a motorized system with a helmet, similar to what is used in the SCSU during the Ebola epidemic. So, we kind of started off with that level of PPE, whereas everybody else, because you know it was the beginning of the pandemic and the guidance was that people do not need to be wearing masks, so, patients and visitors were not wearing masks, and then within maybe a week or two, we shifted to screening patients for where they are coming from because NIH is an international center.

Barr: Yes.

Fike: People come from all over the world, and all over the United States, so, we added—Epidemiology added—questions about where people are coming from. And then, depending on where the epidemic was, or the pandemic was, at that time—it was a pandemic already at that time, but I guess there were hot spots as opposed to now—so, based on that we were told to tell people coming from certain areas that they needed to mask. So then, we started distributing masks to those folks who would need to be masked while they are in the Clinical Center, and then, it evolved from there to then having all patients masked. That came next, if my memory serves me correctly. And then, after that, we went to universal masking but this whole process probably evolved over, I want to say, four to six weeks…

Barr: Wow!

Fike: …going from only the screeners being masked to universal masking. And then, I think it was becoming more evident to the general population that masking is probably a good idea. I started seeing people coming in, especially patients coming in with [them], and there were not [commercial] masks available at that time…

Barr: Right, yes.

Fike: …so, people started to come in with very rudimentary, homemade, very pitiful looking, masks and you know, I just really remember that making me sad that these cancer patients are coming in and they are so vulnerable, and they are coming in with their very homemade looking masks but, yes.

Barr: You give them extras? I mean, like that is just so, I mean, I am sure you provide them with materials for the whole time they are at NIH?

Fike: That was before we were distributing, [before] we had moved to universal masking, or we had moved to even patient masking at that point, so, we were not, and that was, I think, at the beginning of the pandemic. There was such a fear that we would not have enough PPE for healthcare workers taking care of these patients so our strict instructions were, you cannot give any PPE away. It is absolutely no! So, people would ask us for masks. They would—before we had gone to distributing masks to everyone coming in the building—patients would say, “Can I please have a mask?” and you had to say, “No.” Thinking back now to how we do it now, it is like, really, that is what we had to do, that is what we were told to do.

Barr: Yes, that is so hard. Has it [mask wearing] gotten any more flexible with more people being vaccinated, or it is still at a very stringent level?

Fike: Still the same stringent level. I think, probably, because it is a healthcare setting, there is not going, I do not think, in any time soon we are going to see any relaxing of that, but we are still 100% universal masking, we are still “no visitors”, unless the visitors are pre-approved for specific reasons. What else? Yes, those are the main things, I think.

Barr: About how many individuals did you screen in a shift, just on average, and was there a particular time in the pandemic that was really busy for you all?

Fike: I think I remember the average number for the entire building, and it would usually be for the 24-hour period, usually we would screen about 2500 people, and then depending on which entrance is more busy. The south entrance where most of employees come through, that tends to be one of the busier entrances, so they would do high numbers; so in a shift, they would screen anywhere from 400 to as much as 700 people in a [shift]. Usually, we were doing 12-hour shifts, so, in a 12-hour shift.

Barr: Did you ever have to contend with individuals who did not want to be compliant to your regulations or your questions?

Fike: Yes, definitely. I think for varying reasons too, for sure, that came up. A lot of times, people did not want to sanitize their hands; they wanted to use their own hand sanitizer, or they would, for whatever reason, they wanted to evade the hand sanitizing stations. I am not sure what that [was] about. So, that came up a lot, and then also with the particular mask. People were [double masking], now it has changed a bit, now they are allowing people to double mask. Again, as the science evolves, then things have shifted, but when I was doing it which was March through the end of June of 2020, we were not allowing double masking at all, and people would get very upset with that because they wanted to wear their N95 underneath or, really, in general, it was more people wanting to wear an N95 underneath their NIH provided mask, so that came up a lot; or people would have masks that have like exhalation valves on them, which obviously, in a healthcare setting, you do not want people walking around with those. So, we had to fight the people in that fight, but we had to try to get them to listen to us and people [would] get very upset. I think, anxiety levels are just so high during this, so any little thing like that where it maybe would not have been such a big deal if a pandemic was not going on, but people's anxiety levels were just really high. Yes, so, they were not maybe as patient as they normally would be.

Barr: Yes.  Did you ever have situations where you had to turn people away because they presented COVID symptoms?

Fike: Yes, definitely, and that would be with staff, NIH staff. Then, we would give them instructions on how to access testing through Occupational Medical Services. We had a handout and gave that to them. For patients, it would depend on other several factors as to whether we would still bring the patient in and test them or figure out an alternative for them.

Barr: Yes. Did you all [report]? Well, I guess it was on the staff to report it, but for like contact tracing?  I am sure you were, probably, a little nervous, you know, if staff came in with symptoms.

Fike: So, the contact tracing efforts were all managed through Occupational Medical Services, so we did not have a role in that.

Barr: Was there a particular memorable incident for you on while you were screening whether it be good, or bad, or funny, or just stuck in your mind?

Fike: I remember a family who came in at the very beginning. We had really just opened up the booths, maybe like the first week, and they were coming from internationally, and it was a family with mom, dad, and several children, and they [came to] NIH. One of their children was very ill, and NIH was just kind of like their last hope. They made it to NIH, I think like the day before travel restrictions would have prevented them from coming.

Barr:  Wow!

Fike: And if I remember correctly, they also arrived, and they had symptoms. So, I remember a lot of stories like that, where people, through all of the uncertainty, people showing up and being in bad shape and making it in, and hopefully get help.

Barr: Were people very emotional with you all as screeners, and did you ever have to do any kind of like reassurance work with them?

Fike: Oh, definitely. I think the anxiety levels were so high. So sometimes patients who wanted to double mask, they sometimes would get really upset and just trying to talk them through it and provide as much reassurance as you could and to let them know that we are trying to keep a safe environment for them.

Barr: For sure. Definitely. Yes, it is very hard. So, I think now, we are going to move on, because in addition to your COVID screening, you have also been volunteering, administering the vaccine. So how did you get involved with this endeavor, and what has this experience been like for you?

Fike: That again, the Clinical Center Nursing Department put out a call for volunteers, so I volunteered through my institute and this has been much more gratifying than screening. I much prefer this because I think at the beginning of the pandemic, everyone wanted to do something so that is why we said, “Oh, how can we help?” There was not much that we could do at the beginning…

Barr: Yes.

Fike: …besides the very important public health tools which people don't like, so you get a lot of people [who] are not happy, or grateful that you are doing that. They are, in general—not in general—but a lot of people are annoyed or fight you on it, like we were talking about, so, [the] vaccination clinic is great. People are so happy. They come in; they are a mixture of so excited and happy to be getting their chance to get vaccinated, mixed with others who are just so anxious, like they are just so afraid that they are going to miss their appointment, or, you know, that something is going to mess it up so they will not get vaccinated, and the anxiety levels are very high.  And then, you have your occasional person who comes in, who even though they have made the appointment, they are not like 100% sure that they want to go ahead and get vaccinated, so then with that you get to sit with them, and talk to them about it, and help them feel comfortable, before going forward, so that is nice.

Barr: Yes, that was going to be one of my questions: “How do you assure people who are just really, really nervous?”  I mean, a lot of people are just—I did not even realize—they are so nervous about needles, and some people are really upset about, in particular, about what type of vaccines they should get. How do you tell assure people that it is going to be okay?

Fike: Yes, so, I think you know the fear of needles thing, that is nothing new for nurses, nurse practitioners. We know how to help folks out with that, so, that is nice in this pandemic, to have something that you can say, “Oh, I know how to take care of that!” and you can help them and that is not usually a big problem. Because these are new vaccines, I think the group of people that I have found that are struggling most with the decision to get vaccinated, are people who have underlying illnesses, generally like autoimmune illnesses, those types of things, and they are just concerned about side effects down the road, and that is understandable. Usually, we just talk through it, and you know if they have made it, I think, if they have made it into the vaccine clinic, they want to be vaccinated, but they still want to be reassured before they are vaccinated.

Barr:  So, yes. Have you ever had anyone request it be Moderna, or Pfizer, or something like that?

Fike: Yes, people do, people do, definitely. I think that happens on a daily basis. Because we just can only administer the vaccine that we are given by the State of Maryland, it is already handled through the state so, we cannot really know until that day, that week, what vaccine someone is getting, so, we might have more supply one day of Pfizer, and more supply another day of Moderna. That is usually handled by the folks who check people in, so, by the time they get to us, they understand that the vaccine they are going to get, is what they are going to get. We do not get a lot of—the vaccinators do not really hear a lot about that, but I do hear them having the discussion in the check-in area, and you know they just say, “This is all we have.” And just try to give people solutions, but, generally, nobody turns around and leaves. They all just say okay, and they can get them.

Barr:  Okay. Have you witnessed anyone who has had an adverse reaction?

Fike: Nobody that I vaccinated has had, but definitely, it has happened while I have been in clinic. It happens here and there but, I think, they have a very good system set up for monitoring folks.

Barr:  Yes. What have you found to be like most rewarding about vaccinating people and you were saying that earlier?

Fike: Yes, I think just that you feel like you are actually doing something to help fight COVID, to help try to bring an end to the pandemic. You can actually give a number, like I vaccinated x number of people. You know what I mean? That feels like you are really doing something concrete so that is gratifying to me. And then I love when people come in and they want to do a vaccine selfie, and they are like, “Oh, is it okay if I take it? Do you mind?”  And I am like, “I do not mind. Please do it and post it.” Yes, that is gratifying.

Barr: That is really nice. So, I think now I am going to move on to your work with NIAMS, and so, how has COVID impacted your work with rheumatology patients at NIH?

Fike: So within NIAMS, I work, my main work is for continuity patients, patients who we follow through what we call the Community Health Clinic, which used to be in the community, that is now the clinic located in building 10. We serve patients who generally have less limited access to health care; they are uninsured, or they are underinsured, and they have rheumatic diseases, varied rheumatic diseases. A lot of these patients do not have access [to technology]. During the pandemic everyone has gone virtual whether it be in the workspace or healthcare and so we really have shifted to virtual in terms of delivering health care to natural history patients like these patients, but what we found is that our patients, they have limited technology some of them and so it is hard for them to navigate the different applications to have a telehealth visit. So that has been a barrier to providing telehealth care to that population; so then you have to shift to a phone visit which is not ideal because now you do not have any type of physical exam that you can in a virtual exam. Yes, so that is a project that we are working on.

Barr: Can you shed light on a study that you were a part of that examined risk factors for COVID-19 and rheumatic flare in a U.S. cohort of Latino patients, and what drew your attention to this particular population, and how did you conduct this study or observation?

Fike: Yes, so within that clinic, the community health clinic, it is a majority—most of the patients are Latino, probably 70 percent. And we noticed as the pandemic was going on that a really large number of our patients, or a large proportion of our patients, were telling us that they were getting COVID, which makes sense because our patients are in essential worker positions—so they are child care workers, they are food service workers, construction workers, they all tend to work in jobs where you cannot move, you cannot work from home right though [the pandemic]. They really were at risk for getting COVID and they, a lot of them did get COVID. What we found was interesting was that our patients, most of them are on immunosuppressive medications, but they all did pretty well with their COVID. There was a subset of patients, a small number of patients, who needed to be hospitalized, but, thankfully, none of them had bad outcomes; none of them had to be admitted to the ICU, so for us, that was informative.

Barr: Yes, so how did you have the chance to integrate your interest in applied epidemiology and rheumatic manifestations of infectious disease in this study and in some of your other work?

Fike:  I think through just following this population and looking. I think this COVID-19 is really a good example of looking at the incidences in this population, and risk factors, and trying to come up with real solutions to the problem, so that is what we tried to propose in our article. We observed this increased incidence, and actually increased incidence in our patient population, as opposed to the general population of Latinos in the in the DC area. So, something about patients with rheumatic disease, whether it be the medications that they are on or their dysregulated immune system, makes them more susceptible to getting COVID. We definitely saw that. And we saw that patients in our cohort that were obese tended to get COVID more than patients who were not obese. So, we published our findings and the main points of our findings whereas that rheumatologist should if they, if patients are telling them that they have had COVID, that they should follow those patients more closely. I did not mention, we also observed in our patient population that our patients had increased incidence of flares, rheumatic disease flares, after having COVID.

Barr: That was going to be one of my questions.

Fike: Yes, so, that was one of our applications of the data. [It] was that if your patient tells you that they have had COVID, then you should follow them more closely in anticipation that they might have a flare of their rheumatic disease. That was one. And then also to be mindful that your patients who you know cannot work from home, that they really need to be reminded about public health measures and doing the best that they can do under the circumstances to avoid getting COVID because there seems to be increased susceptibility in these patients, in addition to their increased risk by virtue of their occupation.

Barr: Yes. It seems like there is a correlation. It is very interesting what you are just saying, that COVID may make the rheumatic disease worse.

Fike: Yes, it seems to be that they have, and we are seeing this, but it is also with vaccination, that patients after they are vaccinated, that they seem to have an increase in disease activity. There is actually a study that is ongoing right now, that is led by Dr. Mariana Kaplan, where they are looking specifically in a prospective manner at patients with rheumatic diseases and whether getting a lot of, looking at a lot of variables prior to vaccination, or prior to infection, and following them over time and seeing whether or not they have increase in disease activity based on one of those areas.

Barr: That is really interesting. Can you envision subsequent research or studies based on the study you did of this Latino population?

Fike: Well, I think you know Dr. Kaplan's study looking at it prospectively.

Barr: Yes.

Fike: She is, particularly, interested in vascular inflammation. Part of COVID disease is that there is this vascular inflammation that gets [you] into trouble, and there is, with systemic autoimmunity, there is also vascular inflammation, so she wants to look at the interplay of those two things,

Barr: Are you working with her in her team?

Fike: Yes, we are.  I am working with her and I am on the Rheumatoid Arthritis team, and we are recruiting mainly from that Community Health Clinic.

Barr: Yes, that is really interesting. Well, best of luck with that study as well.  So, what perspective did your participation in the PREVAIL partnership (for research on Ebola vaccines in Liberia) trial provide at how you look at, or approach, COVID?

Fike: Parallels between the two, definitely, when I was in Liberia.  I think similarities that I see are just that kind of population level of anxiety, where people are…just the general population's anxiety Level is so elevated, and I definitely observed that when I was in Liberia. Now I feel like I am seeing the same thing during this, where people are just really on edge, and people's societal behavior kind of shifts. So I definitely have observed that, I think. Yes.

Barr: So, we are going to transition to you as a person during the pandemic. Have there been personal opportunities and challenges that COVID has presented for you?

FIKE: Absolutely. Challenges: I think probably as you are doing interviews with NIH folks during this, I am sure this is a huge theme particularly for women, and that is, juggling—having kids at home while you are trying to take care of patients or do research—and our kids’ anxiety levels are super high, their routines are completely disrupted, they are at home doing virtual learning—is very challenging. So, I think that is probably the biggest challenge: helping your kids learn during this.

Barr: Yes. Have there been any opportunities that COVID has afforded you?

Fike: Thinking back to PREVAIL and Liberia, and then also when we had Ebola patients in the Clinical Center, I think one thing that I have always loved about working at the NIH is that there is this opportunity to volunteer and interact with different people from different institutes that maybe you never would have crossed paths with because the NIH is so huge, and we are so usually focused on our own work, so, I think that has been [an opportunity].  I have definitely met people that I did not know and bonded with them during the screening process, sometimes working nights. So, yes, I think that has probably been the silver lining, yes.

Barr: What hobbies or things that you enjoy have helped make the pandemic a little bit more manageable—definitely [it has] not been enjoyable—but [manageable].

Fike: Probably, I would say gardening, working on the garden and trying to any time that we have been able to, especially now that the weather is [nice]. I think it was just really hard while the weather was cold and gray, but now that we are getting some good weather again, I think that helps everyone just getting out into green spaces; it helps.

Barr: Yes, definitely. So, this is a fun question. When the pandemic is over what is one really fun thing that you would like to do that you have not been able to do during the pandemic because of public health concerns?

Fike: Travel. 100% travel.

Barr: Really! Where is first on your list?

Fike: Travel, will probably go back and visit family and overseas.

Barr: That is very nice. Well, is there anything else that you would like to add as an NIH clinician, but also as a person who is living through this pandemic?

Fike: I think it is really a privilege to work at the NIH and be able to participate even in this. These are small things that I have been able to participate in—screening people, or vaccinating—just to feel like you are part of the NIH effort which has been huge in the pandemic and in terms of developing a vaccine, I think that is something that is really cool.

Barr: Definitely, definitely. Well I wish you the best with all of your endeavors, and I hope that you and your family continue to stay safe.

Fike: Thank you so much.