Post-Thanksgiving Travel Quarantine Guidelines & Other Matters

I hope all in my practice had a safe and enjoyable Thanksgiving. For those of you who travelled out of the area and stayed elsewhere for Thanksgiving, the Center for Disease Control recommends a 14-day quarantine at home before resuming local activities while staying masked and keeping a safe social distance in the community. A seven-day quarantine with a negative PCR test at that point is a less acceptable option but one noted by them as well.

Quarantine means staying home. It doesn’t mean shopping with a mask. It doesn’t mean getting a haircut or hair coloring or nail treatment while wearing a mask.  It doesn’t mean working out with a trainer from a distance in your home with a mask on. It means staying home for 14 days! These are not my rules and recommendations.  They are the recommendations of the CDC.

I was one of the lucky individuals who did get to see most of my children and grandchildren from a distance on Thanksgiving. Thanksgiving is my wife’s favorite holiday. A crowd of 20 or more is the norm in our home.

This year she made a small turkey, baked some breads and we drove down to Palmetto Bay in Dade County for dinner. My California daughter had been there for several weeks helping with the two children and working remotely as have my youngest daughter and son-in-law.

We brought a folding table, chairs, paper plates and disposable forks, knives and cups. My children made stuffing, sweet potatoes, salad and dessert. Since I am the only person in the group going out daily and seeing patients in my office, I am the security risk in this COVID-free bubble. We all wore masks and sat outside at distance.

As much as I wanted to hug and kiss my grandsons, I kept my distance. I stayed outside except for a trip into a poolside cabana bathroom. As different and sterile as it was, I was one of the fortunate ones who got to see and break bread with family.

With vaccines on the horizon, hopefully this will never happen again.

Pediatricians Sending Flu & Upper Respiratory Patients to ERs and Urgent Care Centers

As we head into the post-Thanksgiving and pre-Christmas season with a huge surge in COVID-19 infections and the emergence of the flu , pediatricians, like most primary care physicians , are sending their respiratory patients to be screened at ERs and Urgent Care Centers rather than bringing them into their offices for evaluation. Citing a lack of sufficient personal protective equipment, lack of accurate on site COVID-19 testing ability and concern for healthy individuals being exposed to COVID-19; they are offering telehealth visits only.

The Kaiser Health Foundation Newsletter, in a scathing opinion piece, quoted many academic pediatricians calling this an abandonment of patients. It is easy for those who supervise from a distance and don’t generally see patients to criticize those who do. The truth is, pediatricians are following the initial CDC guidelines.

Those patients tested in an appropriate timeframe after exposure, with an appropriate and accurate test, are being seen by their pediatricians and not referred elsewhere.

The lack of a national program providing guidance and support is the reason this health care situation exists. There are no clear-cut guidelines from our major medical societies, specialty societies, public health departments and major health companies which provide patient care including hospital chains as well as state, local or federal governments. There is no leadership about when practices should stay open and when they should lockdown.

Restrictions of any kind are met by legal challenges from the business and religious sectors. Citizens do whatever they choose to with little thought about how their choices impact others. Within this mix of chaos, Kaiser Permanente has no right to criticize small mom and pop practices trying to provide care and advice to their patients without possessing the resources to keep themselves and their employees safe from COVID-19.

Drug Shortages Exacerbated by the COVID-19 Pandemic

Globalization and overseas outsourcing of manufacturing has resulted in periodic drug and medical supply shortages since 2001. This issue has been brought to the attention of US authorities multiple times with no action on the part of several administrations.

On this blog I have written about the defunding of the FDA so that many of the drug producing factories in China and India have not been inspected by FDA inspectors for quality in decades. Within the last five years the only major producer of intravenous fluids for the United States and Canada, located in Puerto Rico, was shut down after hurricane damage and electrical grid damage. The US Military was impacted by this factory shutdown and tried to purchase fluids from overseas producers, but they were at top capacity and could not meet the demand. There have been critical shortages of morphine for pain control.

The pandemic has further exacerbated this issue. CIDRAP, the Center for Infectious Disease Research and Policy at the University of Minnesota reported on its website that there is a shortage of 29 of 40 drugs crucial for treating COVID-19 patients. The shortage includes the short term anesthetic propofol, the bronchodilator albuterol, hydroxychloroquine (used for rheumatoid arthritis and certain lupus patients), fentanyl and morphine. The Food and Drug Administration has its own critical list of shortages and lists 18 of 40 on their drug shortage list. An additional 67 out of 165 critical acute drugs are listed as in short supply. This list includes acetaminophen (Tylenol), lidocaine, diazepam (valium) and phenobarbital among the most noteworthy.

As the election for President concludes, it is far overdue for whomever prevails to dedicate one department to evaluate, plan for and prevent critical drug and supply shortages. It is also long past due that the production and distribution of these key pharmaceuticals and medical supplies return to the United States so we are not subject to the whims of a foreign government or find ourselves trying to outbid our allies for supplies.

Michael Osterholm, MD, the director of CIDRAP, sees the coming increase of COVID-19 cases further challenging the existing supply of medications available to the American public.

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.

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.

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.

Caregivers & Health Care Aides are Underpaid & Underappreciated

It’s been years since I lost my mom and retired as a hands-on personal caregiver. The care I provided her was supervisory, not physical, and it was exhausting.

As a physician caring for my patients who end up in a skilled nursing facility for post hospital rehab, I have always been amazed at how under paid, under trained and overworked these well-meaning caregivers and aides truly are. It’s easy to see why burnout is common amongst them and turnover is ranges from 50% – 100 % annually with these jobs.

The devastation created by COVID-19 at senior care facilities brought this all into sharp focus. These poor employees living in multi-generational homes, and not having the luxury of working remotely, have suffered staggering losses due to this disease. With no quick accurate test for this virus available, they show up at work not knowing if they are infecting their elderly patients inadvertently or being infected and bringing it home to their loved ones. There has certainly been no organized program on a national or state level to protect the patients or the caregivers.

With lockdowns in place at these facilities, these hardworking aides are now functioning to some degree as mental health counselors as well.  But it’s the physical nature of their work that amazes me – routinely lifting and grooming men and women weighing a hundred or more pounds.

My poor little 24-pound rescue pug suffered a neurological catastrophe last weekend with an embolus to her spine leaving her paralyzed in her rear legs. I have a harness and soft belt to support her so she can walk on her front paws and squat to void and defecate. If I don’t hold her up high enough, she scrapes the skin off her knuckled rear paws and they bleed. She hates the booties I tried to protect her with.

The canine neurologist asked that we don’t use the rear rollers you see paralyzed animals use for mobility because she wants her to walk again or at least give her a chance. Once a day I go into the pool with her and support her midsection while she paddles away with her front paws and I move the rear legs through their normal range of motion. Lifting those 24 pounds is exhausting for this 70-year old but she is making progress pushing back now against my hand in those previously flaccid limbs.

I do this out of love. I can’t imagine how difficult it would be to lug a 100+ pound person around all day while risking COVID-19 exposure, all for $15 per hour.  I tip my hat to these health aide angels who are the glue that keeps elder care together in a dreadful profit driven system.  They do it to give their loved ones a roof over their heads, food on the table and a chance at a better future.

As the U.S. population ages, we need to find a way to compensate them fairly and appropriately to show our appreciation for what they do and recognize how difficult and dangerous their essential work is.

Volunteering for the COVID-19 Vaccine Trials

My civic-minded daughter in California asked me what I thought about her volunteering for one of the drug trials or vaccine trials involving COVID-19. She asked me if I knew how they found volunteers for these research studies. I told her I had no idea, but I would investigate it.

The Center for Disease Control and Prevention (CDC) and the National Institute of Health (NIH) websites directed me to a volunteer network formed to find volunteers to test treatments for HIV disease. I was directed to a website being run by the Fred Hutchinson Cancer Institute in the Midwest.

Mr. Hutchinson was a former major league baseball player and the manager of the great Cincinnati Reds baseball team that lost to my beloved New York Yankees in a World Series in the 1960’s. Fred had contracted cancer and been involved in philanthropic works in cancer research. After his death, the center took on his name. It is a first-class extraordinary cancer research and care facility. They are supervising the COVID-19 Trials Prevention Network.

If you access the site at http://www.coronaviruspreventionnetwork.org you have an opportunity to volunteer for prevention and treatment studies. There is a short questionnaire to fill out asking you about your health, height, weight, exposure to COVID-19 and contact information. If you are selected for a trial, you will be contacted and at that point have a chance to review what is being studied and what the risks and benefits are for your participation.

Filling out the form does not obligate you to participate but does put you in the pool of individuals willing to consider participating in a prevention or treatment trial.

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.

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.