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.

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.

Safety for Patients First

In the heat of the ongoing pandemic, my associate and I suspended in-person routine office visits for the safety of our patients. To get to our office, patients walk through a revolving glass door into a common lobby and then take a small elevator up to the second floor. There are stairs which are well hidden and not easily accessible. A sign is posted next to the elevator suggesting facial covering, but not requiring it, despite an executive order in Palm Beach County mandating their use.

This is a multiuse building with numerous offices. Many of the other tenants do not social distance or wear masks routinely. There have been multiple tenants who have tested positive for COVID. For this reason, we participated in telehealth visits exclusively to protect our older, chronically ill and vulnerable patient population. It was safer to keep them in their home than bring them into our practice. We were willing to forego practice revenue and income to do so. Our first priority is the safety of our patients.

The office has been open daily, answering calls, refilling prescriptions, filling out forms and scheduling telehealth visits. The criticism from patients for doing this has been scathing. The worst criticism has been from those requesting blood draws for visits to other doctors. We performed this as a courtesy in Pre- COVID days but believe the risks far outweigh the benefits for non-ill individuals at this time.

The COVID-19 hospitalization rate and percentage positive rate locally have declined to a level that is allowing us to begin safely seeing patients again in our office. The building management still will not enforce the Palm Beach County mask mandate so we urge you to social distance and wear your mask.

Do not enter the elevator unless it is empty. Wait for the next one to ensure safety. Hope to see you soon. Call with any questions.

More Steps Per Day Associated with Milder Irritable Bowel Symptoms

The association between emotions, the brain and the intestines has always been of great interest to me. As a young medical student facing the stress of having to succeed academically, I developed irritable bowel syndrome. I have written previously about my encounters with IBS and discussed how my symptoms diminished as my coping skills improved. I have always loved to aerobically exercise for stress reduction but never really appreciated how that activity may have diminished my irritable bowel discomfort.

Toyohiro Hamaguchi, PhD, of the School of Health Sciences at Saitama Prefectural University reported on a study discussed in Plos One showing that with increased walking irritable bowel symptoms seemed to diminish. The study looked at 100 students, 78 of whom were women with a mean age of 20 years old. They were recruited for the study based on their diagnosis of irritable bowel syndrome between the years 2015-2018.

The participants were not obese based on Body Mass Index (BMI). They answered a GSRS (Gastrointestinal Symptom Rating Scale) document at the start of the study and again while participating in the study. The rating scale evaluates the severity of abdominal pain, indigestion, reflux, diarrhea and constipation. Walking patterns were then tracked using a pedometer.

They found that with increasing daily steps, the severity of the symptoms markedly decreased based on the GSRS rating scale. Based on their findings, the severity of symptoms decreases by 50% when increasing your daily step count from 4000 steps to greater than 9500.

Dr. Hamaguchi explained that “mild physical activity helps clear intestinal gas and reduces bloating. Thirty minutes of daily walking is recommended for increasing colon transit time in adults with chronic constipation. Recent research has found that inflammatory biomarkers were reduced after 24 weeks of moderate -intensity aerobic exercise”.

This is one more study showing that low to moderate intensity exercise, on a regular basis, allows you to feel better. During this Covid19 Pandemic the stress level for all is so much higher. Take a 30-minute walk at your own pace, maintaining social distancing and with a mask available if someone starts to get close . It will reduce your stress and improve your health!

A Perfect Storm Setting the Stage for a COVID-19 Catastrophe

The last week in June always means the recent medical school graduates have just begun their first days as real physicians working in the halls of our nation’s hospitals. With youth comes energy, altruism, enthusiasm and inexperience.

The first year was once called an internship and is now called Post Graduate Year 1. Directors of training programs and their teaching colleagues work overtime to orient, teach and supervise closely so that inexperience does not interfere with excellent patient care. Excellent programs have layer after layer of patient care review to prevent the development of judgement and experience from adversely affecting outcomes in care.

We are in the middle of a health care crisis of previously unseen proportion by old timers like me and newly minted physicians. As the coronavirus surged in the state of NY, state officials accelerated the graduation of fourth year medical students and sent them into the fray to care for COVID-19 patients on the front lines. A general call for extra help went out to the medical community nationally to bring back retired physicians but to also reassign specialty doctors to COVID-19 care even though they had little recent experience in infectious disease and respiratory care.

Some news stories talked of dentists and podiatrists being drafted to provide medical care for ailing New Yorkers. The death toll in the NY hospitals was exceptionally high and some critics believe the use of inexperienced clinicians, with minimal supervision, contributed to these extremely high death and complication rates. I believe that while that may be a factor, the real issues were lack of familiarity with a new pathogen, lack of effective medication, lack of personal protective equipment as well as a lack of sleep and rest and mental health counseling all contributing to the inexperience but valiant efforts made by NY health care personnel.

With new medical school graduates on the wards here in Florida, we now face many of the same issues our colleagues in the NY Metropolitan area faced several months ago. What they did not face months ago was a population unwilling to follow the safety measures outlined by Public Health officials, infectious disease specialists and scientists.

The financial hub of the USA, perhaps the world, closed quickly to save lives and slow the spread of disease. Our south Florida hospitals have prepared extensively for the arrival of the new medical graduates. Our best faculty members are out teaching and supervising. Despite this, they are at a disadvantage because there is no governmental leadership by example at the county, state or Federal level.

The number of Florida residents who continue to treat wearing a mask as a civil liberties issue, rather than a deadly public health issue, is astounding. The number of Floridians who do not believe that keeping a safe social distance apart prevents disease spread and fail to observe the recommended guidelines as a protest about loss of freedom is mind boggling.

 Instead of Floridians demanding a comprehensive and organized program to stop COVID-19 while meeting the financial. food, educational, safety, housing, childcare and supply needs of the populace, we have politicians telling us that the increased rate of infectivity is safe in young people. Young people give it to middle aged and old people, and they have a greater chance of getting sicker, ending up hospitalized and dying.

The daily local hospital case load is increasing. The available beds are decreasing. We have not even factored in that we are now in hurricane season which might call for evacuations and mass movements of Floridians for storm related safety.

This is the perfect storm scenario. If you are happy with it then carry on. If you are not then please call, write, text and email your elected officials at all levels of government and tell them in no uncertain terms what your needs are.

What Happened to Honesty & Integrity?

A great deal of time and research was invested in developing a safe plan to resume seeing patients in our office. We prescreen everyone before scheduling an appointment. We screen again the night before the visit and, once again, at the front door. We ask extensively about their contacts and exposure. I expect the answers to be truthful. I have a professional responsibility to keep my patients safe and well cared for. I also have a responsibility to protect my staff and myself.

My first patient back had pushed his way into an expedited visit with a complaint of excessive weight loss. His request for one of the first visits after we reopened was supported by “telehealth” consults recently from two specialists – assigning the evaluation of this problem to me. Of course, they hadn’t bothered to weigh him.

When he arrived at the front door, we gave him a mask. He answered “no” to unmasked close encounters with others and to questions about behavior and visits which might raise his risk of catching COVID-19.

I treat all patients now as if they are contagious so I was masked, face shielded, wearing a gown and feeling safe. After a detailed history he told me he was flying on a commercial airline in two days to his northern home.

On Monday, his “back doctor“ was going to inject him for chronic low back pain. I asked him if his northern physician was aware that he was flying commercially and not maintaining a 14-day self- quarantine as advised. He said “no” and he had no intention of informing him. I told him that was wrong and that with diabetes, hypertension, heart disease and obesity I didn’t think flying on a crowded jet was a great idea.

His exam showed nothing of concern and when we weighed him his weight loss was minimal. He brought blood test results from his other physicians which we discussed. I wished him luck, suggested he quarantine after flying commercially and suggested he drive up instead. He chuckled, removed his facial covering and wished me a safe summer.

Two days later, as we closed up the office, my cell phone rang. The patient had flown up north and as he walked down the concourse he received a call from his friends who told him they were ill, were hospitalized and tested positive for COVID-19. He was calling to ask me what he should do.

He admitted that a few nights before his visit to my office this couple had been to his home for dinner. No masks were worn and no social distancing was practiced. I suggested he go home and self-quarantine for 14 days and seek medical attention if he felt ill.

The patient said he said he did not mention his encounter which occurred before his exam at my office because he wanted to be seen and did not wish to wait 14 days.  What happened to honesty and integrity?

Stay Safe & Stay Home – It’s Still the Best Decision

This past week the number of new Coronavirus cases in the state of Florida has dramatically increased. The percentage of patients having positive results and the number of patients showing up at the emergency rooms locally complaining of flu like symptoms has increased as well.

Due to a continued shortage of testing supplies, patients receive a nasopharyngeal swab and the test is sent out to the reference lab with results back in 48 to 72 hours. The number of hospital admissions with COVID-19 has increased dramatically in the last two weeks. The number of individuals requiring intensive care beds has increased while the availability of ICU beds has decreased. Some hospitals in Jacksonville and Sarasota have no current availability of critical care ICU beds.

Florida’s Governor says it is due to more people being tested so there are more positives. He initially blamed it on migrant farm workers of Hispanic descent but farmers and elected officials from farm districts pointed out they had left the state after harvesting crops weeks ago.

The increase is blamed on young people who will not require hospitalization or develop very many complications from COVID-19 say the elected officials. No need to order masks in public places in Palm Beach County according to the County Commissioners despite numerous studies saying facial coverings are an effective way to slow the spread of the disease. Epidemiologists and virologists from the University of Florida School of Medicine blame the surge on opening businesses too soon and lack of facial coverings as well as social distancing by those people going to restaurants, gyms, shopping and retail stores. The Director of Nursing at the University of Miami Jackson Memorial Program feels the same way as does an infectious disease expert at Florida International University in Miami.

Over the last three weeks I have read, re-read and studied numerous protocols and guidelines designed to safely reopen my small business establishment and internal medicine practice. We spent two weeks training the staff, rearranging traffic patterns, purchasing new equipment for protective purposes. We called our patients and started to bring them in slowly and in small numbers while reviewing and critiquing what we could be doing better to make sure our patients were well protected on the trip from their cars , up the front steps or ramp with a bannister, through a revolving door, into a common lobby and up an elevator to the second floor before reaching my office. It was going very well until the surge of new cases.

This is a very transmissible virus with newly contagious and minimally symptomatic individuals felt to infect 5.7 patients before they discover they are ill. As the surge reached day five on record new cases we met as an office, two experienced physicians, one experienced nurse manager, two medical assistants and one receptionist and decided it would be safest for our patients who were doing well to just stay home and delay a routine visit until the number of new cases and hospital cases declines again.

We phoned and used email as well to contact our patients and try to reschedule them. The negative blow back was both disheartening and surprising. “We need our blood work and are overdue for checking our cholesterol and sugars.” No, you are not. We were accused of being afraid of catching COVID-19.

With the protective gear we have and training and experience I believe seeing a patient in my office is far safer for me than entering and exiting my office building or walking my dog at dinner time. The concern is for my patients’ safety and health in an environment where many have been led by our elected public officials to believe the pandemic is over and scientists, doctors, epidemiologists are blowing COVID-19 out of proportion with the help of the media.

On a personal level these comments are hurtful and simply inappropriate. If younger asymptomatic people have the disease and are roaming the community without face coverings your trip to the supermarket, retail store, hospital emergency room is far more dangerous now then it was a month ago when potential COVID-19 patients were easy to spot and separate from those with other problems.

My hair cutting shop opened up two weeks ago when the Governor gave Palm Beach County an early opening even though the county had not met any of the minimal guidelines set by the Federal agencies including President Trump’s Coronavirus task force. When a client called in sick with COVID-19 two days after a haircut; the owner closed the shop, sanitized the facility and re-examined his protocols to protect his employees and customers. That shop is still closed with no imminent plans for opening

We still have no medical treatment for COVID-19. A vaccine is months away. There is promising news about blocking monoclonal antibodies. Self-distancing, hand washing, and facial coverings is all we have.

A recent article in a peer reviewed journal pointed out that people recovered from COVID-19 only had protective IgG antibodies for sixty to 90 days calling into question whether we ever can achieve “herd immunity” by keeping everything open and allowing the young less vulnerable to get sick, recover and develop antibodies.

How many more people must die in the name of economic well-being? How many people will get so ill that even if they recover the rehabilitation process will be so long and so partial that the price is too steep to pay?

I cannot say it enough – stay home, keep your distance and wear a facial covering in public. That is not an imposition on your civil rights. It’s being caring and compassionate for others.

Testing in Pharmacies, Another “Duh” Moment for Florida’s Governor DeSantis

At his coronavirus pandemic news conference, the Governor of Florida, who last week defined professional wrestling as an essential business, announced that testing for COVID-19 will be expanded by using pharmacies as test sites. He indicated the details still need to be worked out.

In the absence of a Federal plan for testing, states like Florida, which are desperately trying to reopen for tourism and business, are attempting to figure it out themselves. I just raise these simple questions:

  1. Who will be performing the testing? Will it be the same pharmacy techs that take 30 minutes to give a vaccination that can be administered in five minutes or less elsewhere? Will they hire nurses? Medical assistants? Moonlighting EMS personnel?
  2. Which test for COVID-19 will they be using? If it requires a nasopharyngeal swab will the personnel have adequate personal protective gear? Will it be sent to a lab? Will it be a quick on site test? If 100 people with COVID-19 took the test how many would test positive? If 100 people not infected with COVID-19 took the test, how many would falsely test positive?
  3. Who will train the pharmacy personnel on how to correctly take a deep nasal sample?
  4. Who will train the pharmacy personnel on how to dress in the personal protective gear and sanitize between test subjects so that they do not expose the non-infected, or next test subject in line, to COVID-19 or expose themselves?
  5. Where in the pharmacy will this be done? Will it be a drive thru in the parking lot? If it is in the pharmacy how will you protect healthy shoppers from potentially sick patients? How often will each store need to be disinfected and how will they do it?
  6. Who will pay for the cost of testing?
  7. For those who test positive, who will be responsible for reporting it to Public Health? Who will be available and responsible for tracking down contacts of infected patients?
  8. Will the testing only be done by appointment at specified times?
  9. Will the pharmacies have the same limited test supplies that has prevented appropriate recipients from being vaccinated for shingles with the Shingrix vaccine?

The State of Florida, through decimation of its Public Health system due to inadequate funding under former Governor, now Senator Rick Scott, is reeling from an inability to respond, test and treat the poor and underinsured of Florida. They once again turn to an inexperienced and untrained private sector to assume their responsibility.

Distancing, N95 Masks and Eye Covering Protect Against Respiratory Illness

To wear a facial covering or mask, or not, has been turned into a political affiliation and machismo issue in the United States instead of a scientific, medical and public health issue. A publication in the British medical journal Lancet clearly brought the issue into a medical public health category.  The “cliff notes” summary of the study is that for each meter (2.2 meters = one foot) you distance from a contagious individual, the less likelihood you have of becoming infected with that illness.  Facial coverings diminish your risk of catching the disease by about 15% and N95 or KN95 respirator masks work better than surgical masks, bandanas or cloth masks.

The study was a systemic review and meta-analysis of 172 observational studies involving SARS, MERS and COVID-19 spanning six continents with almost 26,000 participants.  Daniel Chu, MD, PhD made it clear, “The risk for infection is highly dependent on the distance to the individual infected and the type of face mask and eye protections worn. Six feet or more away is the optimal distance to maintain. While N95 masks scored best in terms of protection for health care workers, facial coverings of any type reduced the chance of infections from 17.4% to 3.1%. Eye protection reduced the risk of infection from 16% to 5.5%.”

Due to a shortage of personal protective equipment (PPE), the CDC downgraded its requirements for health care workers treating sick infected individuals  to surgical masks, cloth masks or bandanas.  Professor Raina MacIntyre, MBBS, PhD at the Kirby Institute University of New South Wales in Sydney went on to say that recommending anything less than an N95 mask for health care workers is like sending troops into battle “ unarmed or with bows and arrows against a fully armed enemy.”

Many wonder what the difference is between an N95 respirator mask and a KN95 respirator mask. They both are supposed to prevent 95% of the particles of a certain size from penetrating. If the masks are reviewed and approved and certified by USA agencies such as OSHA or the CDC, they are labeled N95.  If they are reviewed by similar agencies in China, they are labeled KN95. In most cases the product is made outside the USA even if the company is an American firm.

Key points to remember are:

  • Distancing works with over six feet best for preventing person to person transmission of respiratory illnesses like Covid-19.
  • Facial coverings reduce the risk of infection.
  • N95 and KN95 are the gold standard for health care workers.
  • Eye covering reduces infections even further. 

This is not a macho or political issue. It’s an infectious disease public health issue.  Be smart and considerate of others. Cover your mouth, cover your eyes and keep six feet or more apart.

Sacrificing Citizens to COVID-19. Where is the True Grit?

My dad fought through the Pacific Theater in WWII with the 11th Airborne Division.  He returned to the USA and started a manufacturing business with his brother, also a veteran of WWII, that was in a ghetto in Brooklyn, NY.

The business took off until a suspicious nighttime fire burned the plant to the ground.  You could not get property insurance for a business located in the ghetto, so he lost everything.  The two brothers reorganized, got financing and reopened nearby – building a manufacturing business again.  Nighttime burglars set fire to this plant five years into operation. Being uninsured, they lost everything once again.

They started over again and built a new successful business that lasted for years.  I was aware of the differences at home after the loss of the second business but always had a safe home, food on the table and clothes on my back. They were different times with few living paycheck to paycheck but mom going back to work and grandma watching us when we got home from school until my parents got home. My college fund was used to live on so when I became a junior in high school I was told I was going to a state school if I could get a scholarship or to a city university living at home if not. I started working part time at age 15 to help at home. I never felt scarred or deprived by these changes. My parents and aunt and uncle showed true grit and resolve rebuilding their firms, raising four children and providing an education and home for us all.

I say that with the utmost respect and awe while I read about all of the small business men and women complaining about the possibility of losing their small businesses if the state and county governments do not open up businesses in the midst of the Covid-19 epidemic.

We still have no treatment other than supportive care. A vaccine to prevent Covid-19  is months off as well. Personal protective gear for health care workers is still in short supply and much of the advertised products are either inferior or being sold by scam artists.  Testing for asymptomatic but contagious COVID-19 patients is still inaccurate at best and takes days to get results.  Antibody tests to see who had the disease and has some level of immunity are still full of statistical and procedural problems. 

Despite this, the Palm Beach County Commission is voting on June 5th to move ahead and relax restrictions in restaurants and stores and open bars and lounges and theaters.  They have not adequately addressed the staffing and equipment shortages at senior independent, assisted and skilled nursing facilities. 

The number of new reported Covid-19 cases has increased each day last week. First this was rationalized away by claiming several days data was included in Wednesday’s numbers. When Thursday’s numbers were even higher, they said it was due to more testing access, but all was well because only 7% of those tested were positive.  Well 7% of more cases will mean more sickness, more potential complications and more potential hospitalizations and deaths. I guess seniors, the young and the disabled and infirm are expendable in the eyes of the Governor and Palm Beach County Commissioners if the rate of new hospitalizations doesn’t overwhelm the system. They caved to the business interests before and continue to do it again now.           I keep wondering how my dad and my Uncle Harry and their generation would have handled this situation.  I bet they would have pulled together, protected their loved ones and friends first and lost their businesses only to rebuild again when it is safe. Where is the true grit that greatest generation proudly earned?