Covid Dreams

I'm willing to bet I'm not the only person who's dreams have been hijacked. I don't believe I have had a night of restful innocent sleep in over 2 months, my dreamland constantly recycles the loss of freedom in this new era with ever more stranger dream images. I'm sure we could all combine our dreams into some dystopian dream movie.

As I was talking about my endless restless nights with my wife,  Cynthia, I began to wonder about previous generations. I'm sure that we are not the first to have our blissful sleep disrupted. I even recall several weeks of nightmares after 911. But, I bet my disrupted sleep doesn't compare to when my grandparents woke up on December 7, 1941 to find that Pearl Harbor had been attacked. The life disruption of sending children off to war, nightly black out curtains, rationed food and fuel, must have created intense material for the dream world. The loss of freedom and complete life disruption lasted over 4 years and I imagine many people didn't have restful sleep for years.

I then thought about people who were taken from their homes, loaded in cattle cars, giving up all of their possessions to be transferred to concentration camps. I wonder if their minds could ever comprehend the losses they endured. Did their minds ever relax? Or was the night time just as terrifying as the day?

I completely understand the incredible good fortune of my life, I was raised in a stable, warm, loving household, I have pursued my dream career, I am surrounded by a wonderful spouse and children. I have a beautiful home and good friends. In many ways I am ashamed of this subconscious mind presenting these nightly terrors. I have dealt with greater challenges in my life. During my residency I worked 100 hour or more weeks, cracking chests, doing CPR, placing lines, repairing wounds, in battlefield conditions in inner city Detroit in the midst of the crack cocaine wars and the AID's crisis. This hardly compares, yet nightly my mind returns to it's own battles.

I hope this insanity ends soon, but I fear this is only the beginning of a marathon. I write this hoping for my mind to settle down but more to share with those who read this. If you are having Covid dreams you're not alone and hopefully sweet dreams are nearby.

End of the beginning or Beginning of the end?

 We are now nearly 6 months after someone in China somehow contracted and shared the Covid-19 virus. We have watched as each country has fallen like a domino to this invisible force. Nearly every country has gone through the same stages. Denial that the virus would have much impact, followed by a rapid run-up in cases and a state of uniform fear with progressive reductions in liberty as health systems are strained, followed by anger and depression about the financial toll, and now an attempt to try to return to some degree of normalcy.

What does this mean for the future? Unfortunately, my magic 8 ball tells me the future is uncertain. But, I am going to make a few predictions. I expect within 4 weeks there will be a bump in positive cases. We will see an increase in ER visits but a drop in deaths. By 4 weeks from now we will have at least 1 recommended therapy for treatment and ventilators will not be used very much. I predict that in 6 weeks some states will reverse openings and others will not, creating a confusing array of responses.

I think the public will fight against tightening again and businesses will fight to stay open. I also predict that the rate of infection will begin to fizzle out by the end of July as the number of people already exposed will be large enough to slow the spread. In September we will have a vaccine available to healthcare workers and by December it will be recommended for everyone.

By late fall we will begin to learn that the mortality rate from this virus is .01-.05% of people exposed. The final US mortality rate will reflect this as 30% or 130,000,000 people are infected by the end of the year with a total of 200,000 deaths. I also predict that when the entire number of people who die in this country regardless of cause, which has averaged about 3,000,000 a year the past few years, the number will only have increased by about 50,000 total or statistically insignificant.

Where's My Miracle Drug?

For my entire career and training I have always wanted to do what is best for my patients, I am willing to try new techniques or medications sometimes based on absolute scientific information but usually there is a component of hope and guesswork. There is always great controversy in medicine whether a medication or treatment actually works. I am usually trying to walk that fine line and that is where I believe the art of medicine is practiced.

The recent controversy of treatment for Covid 19 with hydroxychloroquine and azithromycin is a perfect example of art versus fact versus fiction. Many of you have heard the President talk about his hope in these medications while at the same time the doctors around him are skeptical and cautious. This interplay happens nearly all the time in medicine. Anecdotal reports are viewed skeptically, scientists require hard science to be supported but anecdotes can be very useful in practicing the art. In addition,  patient pressure can result in improper treatment and can have bad consequences. I have seen both aspects many times and I would like to share with you some of these as well as my own recent anecdotal experience with treatment for Covid-19.

When I was in my residency in downtown Detroit I moonlighted in a local urgent care. A patient came in with an obvious viral upper respiratory infection and requested antibiotics. This same situation plays out millions of times a year. In some countries antibiotics are over the counter and don't require a prescription and are improperly used. I declined the request after explaining to the patient antibiotics don't cure viral infections (This was before Tamiflu and other antivirals). I counseled the patient to wait 7 to 10 days and if the sinus symptoms worsened that would be the time to consider antibiotics. A week later I was called in to the medical directors office. He told me the patient complained and he wanted to know why I didn't prescribe the patient antibiotics. I explained my reasoning and his response was "You should give the patient what they want, that is what they come here for. " I replied that I was going to practice medicine the way I was trained and if he did not want me to follow the standard of care I was willing to resign from his clinic. He decided to have me stay. Unfortunately, his approach to medical care along with many of my colleagues throughout the world has resulted in high rates of antibiotic resistant bacteria. To this day I see patients treated with oral antibiotics repeatedly for allergy symptoms and muscle aches and pains that have been incorrectly diagnosed as infections.

A different story occurred many years ago. During residency we were treating a patient for vertigo, at that time patients were often admitted to the hospital for medication. A new study was published about a treatment using a maneuver to roll the patient that could cure the most common version of vertigo, BPPV. We had a patient we consulted in the hospital that would have been a good candidate. My faculty thought the treatment was absurd and refused to give the treatment a try.  Instead the patient stayed 3 days in the hospital on medication. I waited until I was in practice on my own before I was able to give the Epley maneuver a try and I was very successful. No more hospitalizations for that problem!

I have my own anecdotal treatment. I have seen patients for many years for allergies and I have seen many patients with migraine headaches. Migraine sufferers are usually pretty miserable. About 15 years ago a patient was seen for chronic allergies who also was having migraines twice a week. Her migraine meds only gave modest relief. In addition, her allergy meds barely helped her allergies. We did a workup and she tested positive to grasses, weeds, trees, mold and dust so I placed her on allergy shots. At her 3 month follow up she was starting to notice improvement in her allergies but the remarkable thing was that she was only having a couple of migraines a month. There isn't any great data to show that allergy shots help migraines but it certainly was intriguing. A few months later I saw a patient who's paperwork indicated she had migraines, she was seeing me for something completely unrelated to allergies or migraines. She reported twice weekly migraines while on migraine medicine. I offered to allergy test her even though she swore she didn't have allergies. She tested positive to everything and I put her on allergy shots, last time I saw her she hadn't had a migraine in over a year.

This last story happened recently. A family member texted me she had a horrible sore throat and laryngitis but no shortness of breath, cough or muscle pain. She did have a fever for 1 night. She was in a rural vacation area and couldn't get tested for Covid-19.  She was doing well with sheltering in home but was a guest where she was staying. There was a visitor who was feeling fine but had been exposed to someone that had been recently treated for Covid-19. I decided to prescribe azithromycin since it has been used for Covid-19 and works for Strep. She did ok for a day but then texted me she was having shortness of breath. So, now I was faced with a decision whether to treat a problem that I did not have a positive test for and with medication that is currently a national controversy. I was extremely worried, the woman was young but in a rural location and I decided to prescribe hydroxychloroquine. I was worried about impacting the supply for rheumatoid arthritis patients but when I looked up the dosing she would only need 6 pills. I sent in the medication, warned her of the risk of a cardiac arrhythmia, and made several prayers. Within 24 hours all of her symptoms were improving and by the second day of treatment she felt completely cured.

This is the story of anecdotal medicine. Did my family member have Covid-19? Did the medication make a difference? I obviously used the medication for off label use which is allowed, despite some of the incorrect statements to the contrary. If Dr. Fauci's family member was ill would he do this? If you were my patient how would you want me to treat you?

In the ideal world we wait for double blind placebo controlled studies to prove the efficacy of treatment. Those studies usually take years. What should we do in a pandemic? I don't have the global answer to this, I guess I just have to keep practicing the art.

A Different Quarantine

I bet you're sitting in your house right now. Debating whether going out is both safe and appropriate. Maybe you're saving yourself until you need to stock up on food or deodorant. Maybe your hair is starting to show more gray at the roots. You're probably as stir crazy your kids.

How many times have you thought I'm healthy, strong, the flu hardly ever hits me? Why am I stuck at home? And then you think, I'm doing this for that senior couple two doors down, or maybe the family with the child who is disabled and vulnerable, or maybe the friend who's on chemo for her cancer.

But, them you look out the window and there goes seven or eight teenagers, boys and girls, aiming for the path in the forest, all within inches, giggling, bumping, swatting each other. The first thought, I bet, is those kids are not socially distancing, second thought, their parents will be so pissed if they all get sick, probably serves them right. Maybe your next thought is China and Singapore know how to do this. Those kids would be in deep s#$t there.

Well I believe you might be thinking wrong. Maybe these kids kind of have the right idea. Albeit, they're kids so they don't have it completely right. But they walk like they own the world and no badness can befall them. They are partly correct. This virus doesn't really harm most of them. This virus has a predilection for the old, the infirm.

So, "What's the point Dan?" you ask. The point is we are using the blunted weapon to fight this virus. We're going to use a 16 penny nail to hold this soap bubble to the wall. Well, how well is that going to work. My point is, we created a global stay at home order. Everyone, all ages needs to follow the very simple rules, Don't leave home except for absolutely essential reasons. You can go out for food, doctor visits, gasoline, a visit to the hardware store but beware if you want a hair cut, a new shirt, maybe a car wash, you better not or you'll get Corona and infect us all.

Is it just me or is there something wrong here? You can be 80 and go to the store to buy milk but if your 18 beware of a walk with your friends. I am probably a fool but I just don't see how this works. Sure, right now we isolate the virus maby five percent of us gets the virus, fifteen million, one percent of those die, one hundred fifty thousand. But, the virus isn't gone and we are nowhere close to the ninety-five percent herd immunity. So what's your reading list for November when this thing takes a second swing at us?

The real answer is to shoot for about the same mortality risk, one hundred fifty thousand, but a much higher rate of exposure to the population so when those elderly or frail individuals leave their homes they're safe. The only way to achieve this is smart quarantining. We aggressively isolate the high risk groups. We put our vast government resources into bringing food and healthcare to them. We have our younger healthy population out interacting, getting the corona virus and going nowhere near the vulnerable population. Society kind of moves forward.

Perhaps we institute some harsh terms. No children see grandparents for a while, at least until either the virus stops circling in our community or we have a viable vaccine. Most of us go to work. Yes, some of us who shouldn't die do. But right now there is no guarantee against this anyway.

I expect most everyone will disagree with me. I'm not saying it's a great idea. But good luck corraling a bunch of teenage to twenty somethings. Until you do every time a senior or someone immune compromised walks into a grocery store it's like Russian roulette.

CORONAGEDDON vs CORONA CONSPIRACY

I hope I'm not the only person skeptical and confused about what is happening. As I mentioned last week my first thoughts on this virus was there was some sort of manipulation occurring but as I did more research I began to buy in to the concept that this is a highly dangerous disease. As last week progressed my anxietycontinued to rise. I read about a surgery in China in the nose to remove a tumor of the brain that infected every healthcare worker in the room with Corona virus. This was followed by the revelation that the two groups of doctors in Italy and China most infected by the virus were ENT, which I am, and Ophthalmology. I have spoken with colleagues in San Francisco and at Stanford and have dramatically curtailed visits in my office, stopped all elective surgery, and begun wearing a mask full time in the office.

Those of you who know me are aware I usually look at Facebook about once a month but as I have exhausted news outlets, cdc website, university postings I have turned to Facebook to see how all of my friends are doing and to get a feel on perspective. I have learned a lot! Although none of it has really answered my questions. So now I go back to the tried and true, my own logical analysis of what is happening. I am not going to provide references for the information I am going to share but if you have caught some of my shared reports and if you are willing to check out the main purveyors of statistics you will see that I am doing my best not to share false information.

The first item on my list is whether this virus is apocalyptic and by that I mean likely to infect 50% of the US population with deaths in the millions. Let's look at the numbers. As of today the world total confirmed infections is about 330,000 with about 15,000 deaths. Of course we don't know how many deaths are being missed and we don't know how many people have had the virus but not tested. The overall mortality rate claimed is about 1% with transmission rate or Ro of 2.5-3. Ro means that each infected person will infect 2.5 to 3 other people. By the way one of the articles I reposted claimed this was the rate per group encounter which is not correct.

Let's focus on the US. As of today about 400 deaths with 33,000 confirmed cases. We also know that we have done at least 275,000 tests. We know the testing has been restricted to people who are suspicious to have the virus. So, based upon this if you feel pretty sick in the US you have about 1 in 6 chances of being positive. We know the virus has been here at least since late January.

Now I am faced with two diverging issues. Either we are vastly undercounting the number of people who have been exposed or overcounting the mortality rate. Working backwards if we have 400 deaths with a 1% mortality rate and we allow 2 weeks for a death to occur after infection we should have had about 40,000 people positive 2 weeks ago and if everyone did their job infecting 3 others we would have 120,000 people positive today. We know 80% show mild to moderate symptoms and that we have not tested nearly enough people to capture all the positives. But our current count of 33,000 positive means miraculously we caught everyone of that 20% group plus a few more. That makes no sense to me. The other thing to keep in mind is that the tests are for active virus shedding. If your negative it neither answers whether you were infected in the past or whether you will be in the future. My only logical conclusion is that far more people have been infected than we assume and therefore the mortality rate is much less than 1%.

What can we say to support this? The highest rate of mortality has been in China, Italy, and Iran. I don't know anything about the healthcare systems but I can draw some conclusions about lifestyle. Wuhan has a population of 1200 per square mile with a male smoking rate of 52% and I fear to guess the level of air pollution especially prior to the start of the endemic. Regarding Italy even though the Lombardy region is not densely populated Italy has one of the highest densities at 200 per square kilometer. Italians do tend to live in tightly clustered towns with multiple generations in the same household. Regarding Iran, the country is known for high density religious gathering as well as less than optimal sanitation.

The next question is what is the correct Ro? This is much more difficult to assess. I think this may be more related to how healthy an individual is and how many close contacts with an infected individual occur. This is supported by reports that most transmission in China was among family members. And don't forget density. In the US the density in our cities is around 615 per square kilometer and outside cities a remarkably low 13 per square kilometer. This explains why the US hotspot is New York City with a density of 10,000 people per square kilometer. Based upon these facts I believe the Corona virus will most severely impact the large cities with high density, aging population, and high rates of smoking, lower density populations that are healthy will likely have small clusters of severe infections like nursing homes.

Now that I have convinced myself the virus won't be the end of the world what about all of the conspiracy theories? I shared a pretty long winded one the other day that tied Bill Gates, University of North Carolina, the Chinese and some undescribed cabal as the creators and manipulators of this pandemic for world dominance. Based upon the level of convolution I vote that one down, on the other hand it would make a great novel. I am more concerned regarding the massive power grab governors and the President are taking to subvert free will and democracy. Every day there are threats of martial law and increasing activation of the National Guard. I am concerned about the massive impact this is having on our world economy and I am not convinced based upon the first part of this post that this is a response that is relative to the threat.

When all is said and done and the forensics of this are complete in a couple of years I suspect that if this sizzles out leaders will claim it was only a success due to their difficult decisions in difficult times. If it ends up that the virus runs rapid destroying the world they will say they did their best in a horrible situation. In the mean time what constitutional rights will we have forfeited?

Regardless of the outcome the economic damage is done. We will just have to hunker down in our homes, keep our six foot distance, and of course crack open a bottle of fine wine or your preferred beverage.

CoronAgeddon

Are you starting to feel like the world is ending?

If you are you're not alone.  The Covid-19 Corona virus information feels like a classic Hollywood movie, a common virus mutates in a different continent and rapidly spreads around the world shutting down the economy as it quickly spreads destroying lives. In fact, some of you might recall a few years ago I started to write a story with a similar idea based on the Influenza outbreak from 1918. I still need to finish the story. I actually think Covid-19 and the handling will give me some great material to work with.

Ironically, as I started to write this post I was beginning to suspect there was some underlying nefarious plan to take down the world economy but as I researched more and more information I have come to understand why the government is reacting so aggressively. I still wonder if we may be over reacting but I can understand how the progress of the virus in Italy has scared everybody. Seems every day the Italians have worse news.

Here in Santa Cruz we have a shelter in place order. Our schools are closed, most businesses are closed, ironically the recreational marijuana distributors are open. In my office we have cut volume by over 50% I'm walking around with a mask on and send each patient home with the wise words "stay healthy". I still wonder if there is an antihero like Dr. No hiding behind this but then I look at Italy, Iran, South Korea and I nod in agreement with the grand plan.

Of course, everything you read says if you get the virus your risk is low to moderate but no one really has any idea what that might mean. Realistically when we have 200,000 people infected in a population of billions and 8,000 deaths it seems hard to understand why everyone is so frightened. But, then I look at predictions of 100 million American infections and 1-2 million deaths predicted and that does look super frightening.

I wish there was more and better information from experts aside from stay indoors for 15 days and reassess. I saw a great article on how that made a huge difference in the Spanish flu in 1918 but one would hope we had made progress in the past 100 years. I also wonder why there hasn't been an accelerated review of the drug Ritonavir which the Chinese have tried but without any info on if it works. We all know it will take ages for a vaccine but if we might have a drug that works early maybe it could be used like Tamiflu to slow the spread.

And with the still relatively small numbers it is very hard to keep focused on maintaining distance. I understand how China essentially locked down Wuhan and now they have very few new cases. This has given rise to optimism that controlling contact can control spread of the disease and we are seeing dozens of countries essentially asking people to stay in their homes. The question we all have is how easy is it to get? I am unable to find any data on what percent of close contacts of positive individuals get the virus and I cannot figure out what percent of people tested are positive. These are the numbers necessary to help us decide how scary this really is.

Yet, news reports suggest this is one of the most contagious viruses ever, which makes sense since the Corona virus is also the typical cold virus. Current analysis indicates each infected person should infect two to three others, but is this accurate? We may not know until the end when someone goes back and analyses the data but I suspect it is overestimated. I recently read that in China most of the healthcare workers who contracted the disease were traced back to family contact transmission and not from patients in the hospital. If this is true then the contact time with an infected person needs to be longer.

The information we do have is that people are most contagious early before they know they have a serious problem, this is similar to how the flu virus behaves. The CDC estimates 2019 influenza has infected 36 million people with 22,000 deaths over 25 weeks. The infection rate peaked around week 18. If Covid-19 is more contagious then we are going to see some seriously large numbers in the next few weeks unless everyone isolates. I suspect we already have more cases out there and either the mortality rate is lower than advertised or we a due for a big shocker real soon. In the US Washington State is going to be our canary and if Washington starts to go down the drain we know we are in big trouble. But if they start to turn around then that will probably also tell us what to anticipate.

Either way, we are right now stuck in the unknown so uncork a bottle of wine, sit back, binge watch some end of the world movies and relax.

I'm going to college...again

I graduated with an undergraduate degree in Biology about 32 years ago. Since then I've accomplished a lot, I went to medical school, did a residency, and built up a respected and successful medical practice. And in that time I've forgotten all I learned those many years ago.

I ended up becoming a physician because I had a deep love of the elegance of science. Everything I learned had this incredible logic and my passion that drove me was to explore and learn. Somehow as the years have gone by I have forgotten all that great knowledge.

Have you ever wondered if you went to school now would it feel different? I was so goal oriented in school sometimes I worry that I missed something about the magic of learning. I even have feared that trying to learn again would be so difficult at this point in life that I might become discouraged or frustrated.

I also worry about my mind becoming stale and unwelcoming to new ideas. I know that studies show that if we don't keep our minds stimulated there is a much greater risk of dementia. I read a lot but passive thinking is not nearly as effective at mental simulation as an active task. Puzzles and mind games have been proven to decrease the pace and even reverse cognitive decline. Unfortunately, mind games bore me. About the only time I can tolerate them is on an airplane. I listen to stimulating radio shows like TED talks, Freakonomics, and others but I still feel I need to do more.

One thought I had was to see if I could remember my old science education. I tried to remember everything I could about biology, physics, chemistry, and math. I realized I just couldn't recall chemistry or any of my higher mathematics. So, I decided to explore what was available on the Web.

Many of you probably know this, but I was not aware that the Khan Academy has essentially all of the lectures for college courses including all of the basic sciences. So about 2 weeks ago I went back to college and began studying chemistry again.

Fortunately, I discovered I haven't lost my knowledge I have only misplaced it in some dark corner of my mind. Each lecture brings back that knowledge and as it does I feel a sense of accomplishment and satisfaction. I find it ironic that I am so excited to relearn concepts like ionic and covalent bonds or how the elements interact or how to solve a stoichiometric equation.

In a very short time I have already completed about 6 weeks of learning. Obviously, I am at a distinct advantage, I did learn this all before. But, the rememory process is highly stimulating. I am convinced I will keep going until I have repeated all of those courses. I will probably toss in a few I never experienced before as well.

I would probably repeat my medical school course as well if they are available. Am I crazy? I don't think so. The second time around I get to see how this knowledge I am using on a daily basis fits. The first time learning I was so focused on cramming the knowledge in to my head so I could excel on exams but this second time I get to see the true practicality of it.

My mom asked me today if I see how chemistry fits into the practice of medicine. What I notice is that I don't think directly about the science but I realized that the problem solving process is similar. All those years of studying S and P orbitals actually makes a difference.

So while all of you are frolicking this weekend there is a very good chance my mind will be buried in a lecture on chemical equations. We'll see who had more fun!