Thoughts During Self-Quarantine

The CDC produced a research study that documented individuals who tested positive for COVID-19 were out in restaurants and bars within two weeks of detection as compared to a control group who did not develop COVID-19 and stayed away from open bars and restaurants. It’s been a frustrating seven months trying to educate my patients to the fact that they are older, vulnerable and that restaurant workers, hair and nail salon staff, gym employees need a paycheck to survive. If they don’t work they don’t get paid.

They live in homes where others go to work too and spacing does not allow distancing. They are high risk to contract COVID-19 and, because many of these workers are young, they may fortunately be minimally symptomatic but are contagious. Taking their temperature is just a poor screening method for determining if they are asymptomatic and contagious with COVID-19.

So I say, stay home and be safe until we have a treatment for COVID or an available vaccine that works. Having a quick and inexpensive, but accurate, on-location test might help too. The research just proved what we already knew. If you don’t have a mask on, and remain around others who don’t have a mask on to eat and drink, you are more likely to catch a respiratory virus.

I read an interview with the Surgeon General of the US claiming we are ready for a second surge of COVID-19 because we have an additional 119,000 ventilators now. We don’t want to use ventilators, if possible, because the mortality rate for patients requiring ventilators approaches 30 %. He boasted that the Federal government had purchased 150 million quick COVID tests from Abbott Labs and SalivaDirect and they will be distributed at nursing homes and senior facilities by state government.

When I ask my state public health department about the tests they have no idea what I am talking about. My state medical association is unaware of the plan as well. When I contact Abbott Labs, SalivaDirect and several medical supply companies they too have no idea when these tests will be available. They don’t even have a waiting list for those interested.

I would love to have some tests to ensure my staff is healthy and free of COVID and for my patients’ peace of mind as well as being able to closely screen all incoming patients who might need screening.

The Surgeon General mentioned that compiling a national stockpile of PPE, which he says is in abundant supply, may be wasteful because, after all, it may sit and expire. I thought that’s what happens with all stockpiles.

If we were organized those supplies would be distributed worldwide for use before they expired and replaced with up-to-date products. The last time I looked, hospital staff were still limited on how often they received and could replace used PPE. Working parents, with multiple kids, do this well all the time so why can’t the US government? We do it every year here in south Florida with food and water set aside for hurricane supplies.

No “Ouch” Band Aids in Our Future

Last week, at the direction of my physician, I had my blood drawn by my staff to monitor some chronic medication issues. My medical assistant, per usual, placed a band aid over the puncture site before I could object.

I went to work and forgot about it. Nine hours later getting into the shower I saw it and painfully yanked it off and with some of my hair. The next morning, that area looked like it had been punched by Mohammed Ali in his prime.

Ironically, I just read a review from an Israeli magazine of a gel or spray-on transparent polymer bandage. It hardens after application and dissolves with an ice pack or cold water. It stays firm and flexible in warm water so you can shower or bathe with it on. You can examine the healing wound through the transparent bandage.

The development of this new bandage took five years and was the idea of Professor Daniel Cohn, an expert on polymers. With a private investor, they started Inteligels and are in the final stages of receiving FDA and European Union approval. The plan is to first market it for chronic conditions to institutions to treat diabetic ulcers, pressure ulcers and conditions where the injury to the wound surrounding tissue causes skin disruption and pain.

A home bandage version is still several years off but is in the development stages. This is promising.

It’s Hard to Believe

I referred my patient to a surgical specialty office last week for a problem that was out of my area of expertise. The doctor’s office is in a building run and managed by our local hospital.

Upon arrival at the office the patient wore an N95 respirator mask, face shield and gloves to protect himself and others from COVID-19. The multilevel parking lot is a short walk to the office from the garage.

The office door to the suite was open and the staff, sitting in a large open reception area, either had no facial covering or a mask around the neck not covering the mouth or nose. It is a multi-physician office, all in the same specialty, so there were several other patients randomly seated in the waiting room.

When the patient approached the desk to sign in the receptionist recognized him by name and said he did not have to sign in with the logbook. The patient asked the receptionist to please cover her face with her mask citing the Palm Beach County ordinance which mandated masks in indoor facilities. She said, “We believe this COVID-19 pandemic is overblown and its really not necessary at this distance.” When he asked to speak to the office supervisor, he was told the same thing.

The physician came into the waiting room to bring the patient back to an exam room wearing a N95 mask. She too said the response to COVID-19 was overblown. The physician practices an outpatient specialty that is highly reimbursed and does not require going to the hospital. I suspect her office sees no COVID-19 patients although in our area, with the high positivity rate, everyone is a potential contagious patient.

If health care providers do not buy into the science of wearing a mask during a pandemic to lessen the transmission of the coronavirus, what hope is there for getting the rest of the public to buy into the idea? We are getting a breather now. The number of patients presenting to ERs with respiratory symptoms are down. Hospital admissions for COVID-19 are down. ICU occupancy is down.

The onslaught of seasonal visitors will soon begin to arrive, bringing with them all the pathogens circulating through their home communities. With them come the tourists from Europe, Canada and Latin America. Our Governor is desperate to restore tourism and the economy.

These out-of-state visitors bring the flu and COVID-19 and; they want to go to the beaches, restaurants, bars, theaters and “party hearty” as vacationers should. With politicians politicizing COVID-19, and now physicians in the community feeling the same way, it looks like a long dark dangerous fall and winter season here in Florida.

Good News on Treatment & Prevention of COVID-19

A study in the New England Journal of Medicine (NEJM) examined the effects of a new vaccine which uses mRNA injections to stimulate an immune antibody response against the coronavirus. The published study looked at two potential dosages while looking at younger patients and those over 65 years old.

Both doses of the injection vaccine produced an antibody response in the younger patients and senior adults. Side effects were minimal – mostly injection site irritation and soreness. Some patients ran low grade fevers and had myalgias. The vaccine is now in a larger Phase 3 trial.

This vaccine and another mRNA product in testing and production both have the drawback of requiring storage at -40 to -80 centigrade which most pharmacies and physician facilities do not routinely provide. It is hoped this vaccine will be available by the end of year 2020. There have been no challenge tests with this vaccine, meaning vaccinated individuals who develop antibodies have not been directly exposed to the coronavirus to see if those levels of immunity are protective.

On the same day of the publication of the NEJM study on the mRNA vaccine, the pharmaceutical company Regeneron released a shareholder report on its Phase1 and 2 IV anti COVID-19 monoclonal antibody. They took antibodies from recovered COVID-19 patients, identified the most important ones and then synthetically created duplicates of two of the more important antibodies in a form that is infused by IV administration. This product blocks the P spike on the coronavirus from working, preventing the coronavirus from attaching to and entering human cells.

They enrolled COVID-19 infected patients with symptoms but not severe enough to require hospitalization. They found that those with a low viral load of the disease developed an immune response with IgG antibodies to COVID-19. Those who had few or no antibodies were overwhelmed by the virus and had high viral loads measured. They found that the Regeneron product worked best in those with a high viral load and few or absent antibodies to COVID-19 virus and more symptoms. These patients cleared the virus quicker with the monoclonal antibody product than non-medicated patients receiving standard care. They had alleviation of symptoms quicker and tolerated the infusion and product well.

In addition to this trial on non-hospitalized patients there is currently an ongoing trial in hospitalized patients in Phase 2 and 3.There is additionally a trial in family members of COVID-19 positive patients to see if the Regeneron monoclonal antibodies can prevent them from acquiring the virus in close household contact.

There is light at the end of the tunnel. We just need to continue to social distance, wear masks in public settings, hand wash frequently and remain patient because these products are very close to release.

Honey Reduces Upper Respiratory Symptoms

The British Medical Journal published a thorough review of the medical literature reviewing the beneficial effects of honey in reducing the intensity and severity of coughs in viral upper respiratory tract infections. The study was performed at Oxford University by Abuelgasm, Albury, Lee and associates. They reviewed fourteen published studies on the subject and then ran that data through their own stringent tests to assure the hypothesis was accurate. We are heading into the fall-winter cold and flu season with cold weather forcing individuals to remain indoors. We can add to this the ongoing Covid-19 respiratory pandemic as a source of coughing. For years now doctors, scientists and public health officials have tried to convince their colleagues and the public that antibiotics do not lessen the course or duration of a viral upper respiratory tract infection. There are dozens of over the counter non- prescription cough preparations sold in pharmacies and groceries. We read regularly about these products causing severe illness, deaths and adverse effects in children and the elderly. Honey solves these issues.

In an online review accompanying the article experts suggest mixing 1.5tablespoons of honey with 6-8 ounces of oolong tea. Let it cool down so it isn’t too hot and it is a great cough suppressant and source of hydration for children one to five years old. The darker the tea the more nutrient rich antioxidants the patient gets from the tea leaves along with caffeine. They suggest later in the day switching to a chamomile tea to avoid all that caffeine. Younger children will benefit from 2-3 servings per day providing hydration plus cough suppression. Adults and older kids can use two tablespoons of honey and consume a larger volume of warm fluids.

COVID-19, Phase III Reopening & Influenza Vaccine

Watched the Presidential debate last evening which resembled a sequel to the movie Animal House with Chris Wallace of Fox News doing his best Dean Wermer impression. The moderator had the right and duty to allow each participant to answer the question in their allotted time and could have turned off the microphone of the offending participant but chose not to. The American Public was cheated by his ineffective leadership.

This occurred on the same day columnist Fabio Santiago, of the Miami Herald accused Florida Governor Ron DeSantis of threatening public safety by opening the state completely before the state has met any of the recommended safety benchmark goals of the CDC.

An article in the Jerusalem Times forwarded to me discussed a large series of Israeli COVID-19 survivors who developed antibodies to COVID-19 and then became ill with it within the three-month recovery period. Their presumed second round of COVID was far more serious and complicated than the first bout raising questions about whether they ever cleared the disease or not. It underscores the tremendous lack of knowledge we have about this pathogen.

I understand the frustration of small business owners, stay at home working parents who now have to supervise their kid’s education while working remotely and; the unemployed who cannot break through the inefficient computer systems to obtain the benefits they deserve and need to survive. In my mind these issues just highlight the need for a national program to fight the spread of COVID-19, protect the most vulnerable, support those out of work as well as the businesses who need to pay rent and salaries to survive while we wait for a vaccine or medication. To say that its fine to come to Florida, and safe for tourism purposes, is a lie exposing Floridians to the COVID-19 they bring from their homes and exposing their friends and neighbors to the COVID-19 of the Sunshine State.

Which brings me to the influenza vaccine. Do yourself a favor and get your influenza shot. No, the vaccine does not make you more susceptible to coronavirus as one Midwest couple read on a disinformation website. No, it is not 100% effective, but it will reduce the intensity and the severity of the disease if you are exposed to it.

We are currently experimenting with the safest way to immunize our patient population. The tenants in our building, with the support of building ownership and management, did not enforce the indoor mask mandate when we were in Stages I and II. Now the younger, more casual tenants, are even less likely to observe social distancing CDC guidelines. We are experimenting with three different ways of administering the vaccine on site, which I believe is still far safer than the exposure in a commercial pharmacy.

My advice to my patients remains:

1. Stay out of restaurants and country club dining rooms despite the efforts of management and the board to keep these places spotless. CDC studies show restaurant attendance is associated with catching the disease.

2. Stay out of gyms – both public gyms and gyms in your apartment complex. Take walks outside. Use a chlorine pool. Walk at the beach. Bicycle ride.

3. Stay out of hair salons and nail salons.

4. Cook and prepare your own food. Restaurant workers, who must come to work to get paid, are often asymptomatic spreaders of COVID.

5. Suppress the urge to use commercial air travel to visit your relatives. Airport terminals and inconsiderate and uncaring passengers are your biggest threat. If you do go, you will need to quarantine for 14 days before you see your vulnerable loved ones or; wait at least four days after arriving before being tested for the COVID-19 antigen indicating an ongoing infection.

Stay home. Wear masks when in public. Wash your hands frequently and stay 12 feet or more away from others. That is our best option for staying healthy and alive until a treatment or vaccine is available. Get your flu shot. Listen to science not politicians.

Another Anti-Vaccination Myth Put to Rest. Pregnant Women Can Safely Take the Flu Shot

Vaccinations have been blamed for causing autism in children and used as an excuse to permit school age children to opt out of receiving vaccinations and immunizations but still attend school. The result has been a reemergence of measles and other preventable childhood illnesses in multiple areas of the world.

Anti-vaccination advocates have extended their arguments to claim pregnant women receiving the flu shot are increasing their off springs’ chance of developing a disease on the autism spectrum. To study this question Jonas F. Ludviggson, MD, PhD of the Karolinka Institute in Stockholm, Sweden explored this question. They followed large numbers of pregnant women in Sweden during the 2009-2010 influenza season and then followed their newborns for almost seven more years. Over 39,000 pregnant moms were vaccinated with the standard inactivated flu vaccine that season. Only 1% of their children, 394, had developed illnesses on the autism spectrum by 2016. Conversely, over 29,000 moms did not receive the flu shot that season and 394, or 1.1%, of their offspring developed diseases on the autism spectrum. There was NO statistical difference in the groups. Their research paper was published in the Annals of Internal Medicine Journal.

As we head into influenza immunization season; the voices of scientists, public health experts and physicians will be encouraging everyone to take a flu shot. The voices of those who believe these vaccinations will cause harm will also be loud.

Look at the data and scientific evidence and please take your flu shot this season. It certainly is not a perfect preventive treatment but it reduces symptoms and severity in those unfortunate enough to catch it. Call your doctor and make an appointment to receive your flu shot.

Pandemic Cabin Fever and Risk Tolerance

It’s Labor Day and I am so grateful to be alive and have my family tell me they are healthy and well. As part of the COVID-19 pandemic, my wife and I have been isolating since February.

Our major risk of disease transmission is I go to work and see patients face to face. I dread the thought of being the one to pick up the coronavirus and sicken my loved ones. I often feel like a quick change artist changing into special scrubs, masks, gloves, face shield and gown or lab coat to see patients . My pants, shirt, tie and belt get hung up and my shoes and socks get put into a plastic bag. My sneakers never leave the office. In between patients, while my staff clean the exam room, I am shedding one outfit and changing into another. The used one goes into a netted laundry bag which gets washed on the hot cycle each evening.

My wife and I have not been to restaurants. We pay for shoppers picking up supplies and bringing them to our front door. We have a receiving decontamination process by our front door. We bring in no prepared meals. Trips for haircuts, nail and toe trimming and even some non-critical physician visits have been put on hold. The goal is to stay alive until a vaccine or treatment makes the risk less.

We miss our friends greatly. We are all over 65 years old and considered high risk for COVID complications. There have been no socially distanced meals or gatherings. We talk on FaceTime or Skype. Our regular Friday night dinner with family friends for 30 plus years is on hold for now. Our schedule is structured and revolves around work responsibilities, pet care responsibilities, exercise to keep the mind and body fit and home cleaning responsibilities. We speak to our adult kids and their kids daily.

We are more fortunate than most having a daughter and her family an hour away south of Miami in the “ 305.” She has been pregnant during the pandemic, preparing to deliver shortly so she is high risk too. We respect her protective bubble and when we drive down we stay more than socially distant, all with N95 masks on surpressing the urge to pick up our toddler grandson, hug him and smother him in love and kisses. In the pandemic with his brother or sister in utero, being able to visibly see him, smell him and see his growth is enough to refill our tanks and maintain our COVID plan.

Many of my friends and patients believe we are crazy for being so isolated. I see the wives go out to lunch with the girls, go for hair coloring and cuts. They tell me how safe and clean it is at the site they are visiting until I get the phone call about the fever spike, the dry cough, the headache, the diarrhea. Then the frantic quest for accurate and reliable testing begins for individuals.

At times it is the golf game, or tennis and a meal “ at the club.” I always get a lecture from them on just how many precautions “the board“ put in place to protect them. That is, until it doesn’t and they too are sick with COVID.

Other times it is the younger adult families with school age kids traveling out of state to the mountains with “safe and responsible friends” only to end up COVID positive, survive and be dragging six weeks later with new EKG changes a health conscious 40-year old did not have pre-COVID. When I get the patient call from the high-risk individual now positive with COVID 19 there is little I can do other than pray and root for them. Knowing the multi system diseases these individuals must overcome I suppress the urge to just cry. Yes fluids, Tylenol, rest and cough syrup are available but not much else unless they get much sicker and hopefully that won’t occur.

When they get worse it’s off to the hospital where the COVID team armed with not much more (steroids, convalescent plasma, remdesevir for some) does the same. When the patient thankfully does not get worse, and should be grateful, instead they complain foolishly about “why am I here if you are not doing anything for me?”

A vaccine is closer than further. Treatments with monoclonal antibodies and possibly prevention are closer than further. With the opening of in-person schools, in-person college attendance and our Governor pushing safe air travel and tourism, I expect the infection numbers to climb in late September early October.

Putting our lives on hold may be extreme and overreacting. I will continue that plan and advise you to suck it up, tough it out and do the same. I pray that my efforts and family’s efforts continue to keep them well and healthy. Even with their efforts there are no guarantees – just our prayers.

Conversations Overcome Concerns & Strengthen Relationships

When I organized my medical practice, I tried to find individuals with great customer service skills plus the medical knowledge to work in an internal medicine practice. We all do our best to meet the needs of our patients but sometimes, even with the best of efforts, we fall short.

For example, a patient requested a large quantity of a medication as a refill early one morning. I saw the fax as I walked in the door, picked it up, signed it and returned it to the pharmacy for the refill. It only took about five minutes to send it to the pharmacy.

When the pharmacy received the refill authorization, they did not have the quantity of the medication the patient requested. When the patient went to pick up the medication, they were given a 90-day supple, not requested 180 days.

The pharmacy incorrectly told the patient we only ordered 90 tablets. Angry, the patient called the office and was abrasive – not giving my staff a chance to investigate the matter to see if it could be settled to her expectations. Unfortunately, the pharmacy never told the patient their supply of that medicine was short.

The angry patient left our receptionist in tears and our office manager flustered. It takes a great deal to fluster our office manager, given her background. I tried to call the patient, but she did not take the call.

Having a personal conversation is the preferred way to understand and overcome concerns, issues or complaints. Email is too impersonal and rarely conveys the tone properly and a handwritten letter is less personal than a face-to-face meeting.

The same applies to those unexpected release of records forms you receive from patients requesting their records be sent to another internal medicine or family practice. You never want to learn your patient has left your practice without knowing why. How do you fix a problem and prevent it from happening in the future if you were never made aware of it in the first place?

I encourage my patients to contact me if they are unhappy with me, my staff or the way I provide care so we can address their concerns. Better communication makes for better care – even if the original message is unpleasant.

Give us a chance to hear your point of view and address the issue. That is what relationships are all about.

Although this article is based on my patient experiences, I encourage everyone to have a conversation with their doctor to share their concerns.

A Perfect Storm Brewing: Flu Season Plus A COVID-19 Resurgence

I was asked by a colleague what I thought influenza seasonal infections coupled with a predicted second wave of COVID-19 would look like locally? Influenza A arrives locally around Thanksgiving and peaks the last two weeks in January and first two weeks in February. I suspect it is fueled by seasonal visitors coming to Florida bringing the disease from their home locales. We see a low level of influenza B year- round in our pediatric population.

A full-page ad appeared in all Florida newspapers today sponsored by every major health system in the state including Baptist, Tenet, HCA, Cleveland Clinic, Broward Health, Jackson, U M Health, Memorial Health and others. It stressed wearing masks, social distancing and frequent hand washing.

If you get sick with mild symptoms, they encourage remote telehealth care. If you have moderate symptoms, they suggest going to their urgent care facilities. For severe symptoms call 911 or go to the ER. At no time did they suggest calling one of their employed physician offices or visiting your private doctor which is all consistent with CDC recommendations. Private independent and employed physicians just don’t have the ventilation systems, sanitizing systems, personal protective equipment or trained staff to see potential COVID patients in their offices. If a patient is positive, or a staff member converts, what is their responsibility to the next patient or to the other tenants of their building? Is a 14-day quarantine in order?

Much depends on unknown factors. How effective will this year’s flu shot be? In my area, the chain pharmacies already received their supply of influenza vaccine and have shamelessly been pushing it on customers since July. Scientific research shows that in senior citizens the flu shot immunity begins to subside 90 days after you receive the shot. Given that, if your pharmacy tech gives you the flu shot in September, then how much immunity will you have by the time the flu arrives around Thanksgiving?

Quick, accurate and inexpensive testing availability for flu and COVID 19 is an important factor as well. We have had a quick influenza test for years requiring a nasopharyngeal swab. A similar test for COVID -19 has just been released by Abbott Labs and received Emergency Utilization Authorization from the FDA. That means Abbot Labs researchers say it works and the FDA takes them at their word. This test, called “a game changer” by many, will be available in October.

When $15 per hour medical assistants start performing the test rapidly, in volume, I hope the accuracy results are similar to Abbots claims. Our health and lives depend on that. At the same time a finger stick blood drop test is heading to market to quickly detect flu and COVID -19 on the same test card. Finnish scientists and Israeli researchers have quick breathalyzer tests coming soon as well. I hope they work and get here soon. I will test everyone at the door as will restaurants, theaters, sports arenas and most businesses.

All of this information really skirts the issue. With no treatment and vaccines available yet, I expect this flu COVID-19 season to be a human health disaster. With no national plan in place and no close coordination with state and local elected and public health officials, I see the fall and winter as a time of continued disease surges and deaths while the political influence on disease treatment supersedes scientific research and public health realities. Without a coordinated program of PPE and medication distribution, coordination of testing availability and results with contact tracing and specific shutdowns of hot spots without challenges related to loss of freedoms the outlook is grim.

Protecting senior facilities without a coordinated program and funding for it will not work for residents or employees. Opening schools and day care without similar precautions, training and funding for materials and tracing will lead to hotspots as well. There are members of the student population such as special needs children who need to return too, in person, learning safely and creatively. Others need to learn remotely or be given a chance to catch up later when safe return to in person learning is possible.

Without a plan to assist renters, homeowners, landlords, small business owners, farmers, restaurateurs, etc.; any shutdown for disease will be met with overwhelming resistance. I see a bleak and dangerous health picture developing in the fall/winter creating a perfect influenza/COVID storm.  I hope I am wrong but, if right, the disease surge will overwhelm ERs and hospitals.