Omicron is the Grinch That Stole Christmas

The Center for Disease Control (CDC) is reporting that up to 90% of the infections with COVID-19 Sars 2 Coronavirus are the new Omicron strain. It replicates itself 70 times faster than the Delta strain and contact with an infected person within 12 feet for one or more seconds can result in infection. For those who have been vaccinated against COVID-19 with the Moderna or Pfizer Vaccine, and received a third shot or booster, the expectation is that if they become infected with Omicron, they will either have no symptoms or a mild case. By definition “mild COVID” means your respiratory system is not compromised enough to require hospitalization. Despite this, most of the current deaths in countries which are having a COVID surge are in people older than 65 years of age.

In the past, when patients in this area became infected with COVID-19, we arranged for them to go to the local hospitals to receive an infusion of a monoclonal antibody solution made either by Regeneron or by Eli Lilly. The infusion prevented the infection from becoming severe enough to progress to a severe state requiring inpatient hospital respiratory care. These monoclonal antibodies do not work against Omicron. For this reason, the FDA and CDC have removed the Emergency Use Authorization and ended the administration of these drugs nationwide.

There is a third monoclonal antibody made by Glaxo and Var called Sotrovimab which effectively throttles Omicron, but it is in limited supply. As of today, the State of Florida has received 1050 dosages. Production has been accelerated and hopefully the drug will be available in mid to late January for infusion. There are two new antiviral pills which should work as well. The Pfizer product received FDA approval today and, with production acceleration, some should be available by mid-January. Until these drugs are locally available the medical community has no medications to offer patients who contract the COVID-19 Delta or Omicron variant to limit the severity of the disease.

My advice to my patients and loved ones is to reintroduce distancing and masking. Wear a good N95 mask when you will be around others – especially indoors. If you must be indoors with others, make sure the windows and doors are open and the ventilation is excellent. If there is an air filtration system with HEPA Merv 13 level filters and ultraviolet light that adds protection. Distancing with the aggressive Omicron variant will require 12 feet not six feet.

This is a heartbreaking restrictive change in scheduling and behavior we are asking for at a time of the year when families and friends travel to gather to celebrate. Younger and leaner healthier individuals who are vaccinated will survive this. The real questions are who they will transmit this infection to unknowingly, who is too young to be vaccinated or too old to have a robust immune system?

Our office staff will be reassessing the risk to patients and staff daily. With the local testing positivity rate >10% in Palm Beach County, our contacts will be by phone and telehealth. When the Pfizer anti-viral pill Paxlovid is available, and or Sotrovimab for infusion, we will return to regular in-office patient visits.

I apologize for the inconvenience. Stay safe and call if you have questions.

COVID-19 & Public Health Departments

I received an email from the Florida Department of Public Health saying a Federal Judge from Missouri had struck down the necessity for health care workers to be vaccinated against COVID or risk losing their jobs. The suit was brought by several states and, while Florida was not part of this particular lawsuit, was part of other lawsuits which are ongoing.  My immediate thought is that the Florida Department of Public Health should have more important things to do such as providing public health! 

I contrast this with a story told to me by a reliable source – a 66-year-old New Yorker. He lives in the Upper West Side of Manhattan with his 63-year-old wife and spends winters at a home on the West Coast of Florida. 

They packed up their car and, for the first time, hired a professional driver to transport it plus some belongings down to their Florida winter home . They were scheduled to board a flight to Sarasota on December 2nd until the husband received a text message from the NY City Department of Health.  The message said that using cell phone location tracking data they have discovered that the husband was within six feet of an individual who tested positive for COVID-19.  They provided contact information and requested he call the number to receive precautionary recommendations.

When he called, they advised that if he was vaccinated and had no symptoms of COVID he should be tested in four to seven days but remain masked and quarantined until then. The husband stays home most days, except for a daily morning bicycle ride along the Hudson River down to Battery Park where he rents out a gym for a private 90-minute workout with a vaccinated masked trainer who is the only other individual in the facility.  He then bikes home along the Hudson River stopping at a food truck on sunny days to purchase a cup of coffee which he drinks alone on a bench overlooking the river. He and his wife mask, maintain safe distances from others and avoid indoor facilities.

The couple decided to follow the advice of the Health Department. They separated within their home staying masked indoors. They rescheduled their flights for the following week. They have appointments to have nasal PCR tests on day 7 after exposure.

Wouldn’t it be lovely if we had a public health department in Florida that actually practiced public health along with citizens who respected the health of others by following recommendations to prevent transmission of the disease?

COVID-19: Bringing Back Precautions & Restrictions

We recently spoke with our Friday night Shabbat Dinner friends of 40 years and cancelled our dinner plans because of the aggressive resurgence of the COVID-19 Delta Pandemic. I remember our last dinner eating outside in early February 2020 on a beautiful evening wondering if we should all be together one last time before suspending our weekly meals together. We were joined by a physician friend and his wife visiting from Cleveland and they were poking fun at my concerns and over reaction to the “Wuhan Flu.” The proverbial “shit hit the fan” the next week and we went into lockdown.

One year later we were all excited lining up for the Pfizer and Moderna vaccine. We really thought that would be the solution. We really thought our leaders at the federal and state levels would stand up and promote vaccinations. We really expected community leaders, respected by people of color, including church leaders, community activists, respected community members would be out there championing the vaccine, helping at vaccination sites and getting the shot into the arms of the most vulnerable.

Several months ago, when things began to calm down, we started having dinner together again in our homes. The rate of positivity in the spring of 2021 was low and our friends masked and kept distance when indoors shopping for supplies. We felt comfortable enjoying our friends’ company once again outdoors at a few restaurants and in our homes. Then came the Delta surge and with it the relaxation of restrictions.

It reminds me of pictures of the start of the Oklahoma Land Rush. A gun was fired, and everyone rode off to stake their claim. In 2021 they made their plane flight reservations, bought their concert tickets, made their hotel reservations and resumed everything they did prior to the pandemic. They stopped tracking cases, and, in many states, they stopped looking for new genetic mutations and variants of the virus. They forgot to get the vaccine to poorer nations but left the air and ship travel paths open to anyone and everyone. They underestimated the ability of the virus to find a way to survive by changing once inside the bodies of the vaccinated and unvaccinated.

Yes, it’s true that if you are vaccinated and get infected with the virus you most likely will not require inpatient hospitalization and die but according to those who went through this you will feel miserable for quite awhile. Yes, it’s true that you probably can transmit it to others even though the data on that is still new and quite controversial including passing it to unvaccinated children and the immunosuppressed.

To make matters worse, our Governor thinks he’s Bob Barker screaming; “Come on Down” as he invites foreign and out of state residents to come visit our beautiful state, spend money, pick up the virus and bring it home to your locale. I bet Florida is the leading exporter of sickness, death and chronic illness in the world over the last 12 months and no one in our state capitol seems to care.

We are returning to a bunker mentality in our household. No more dinners out. No more social engagements with friends whose activities and travels we are unsure of. If our grandson is sent to his preschool my wife will stop being his nanny because she does not want to risk catching the virus.

As college and NFL football season approach, it is unlikely I will sit in a stadium with thousands of unmasked individuals to see my teams play. The same goes for the theater and for travel. It’s really disheartening and depressing but we will do what is necessary to stay healthy and we hope you will too.

Put on a Mask and Just Stay Home!

I listened to the Governor of my home state, Florida, declare our state the freedom state because all the businesses are open and running full tilt.  He cited his success in keeping deaths from coronavirus low while keeping the economy running and jobs available.

I bring this up because on my way to visit my fully vaccinated adult children last weekend I passed by at least 20 overhead electronic road signs proclaiming, “Miami Beach Curfew 8PM – 6 AM Causeways Closed!”  Yes, here it was springtime with Passover and Easter on the horizon and the famed Miami Beach was closing at night.  We are at a critical point in the fight against the Sars2 COVID-19 coronavirus. We are trying to vaccinate enough people quickly so that the virus does not enter a vulnerable host and mutate to a form that the vaccine is less effective against.   We are so close to controlling this pathogen but human nature and failure to be able to delay gratification, and put off travel and group activities, is leading to a potential fourth surge of COVID-19 related illness and death.

My cell phone rang twice with patient calls on the 60-minute trip southward. The first was from a patient whose adult children came to visit him. His unvaccinated eighteen-year-old grandson was with them. After spending four days together they received a phone call that the grandson’s girlfriend was sick and tested positive for COVID-9. The next two calls were from patients who had been to two different Passover seders. One was outdoors, the other indoors with 20 plus guests. Both had been exposed to a person who called the next day to say they were COVID-19 positive.

I watched the director of the Center for Disease Control and Prevention (CDC), an experienced infectious disease and critical care physician, beg Americans to wear a mask and social distance while she was brought to tears by the thought of another wave of illness, death and prolonged restrictions. I listened to the President of the United States plead with state governments to maintain mask restrictions a bit longer to save lives and control the disease. I listened to the Vatican public relations division discuss not holding an Easter Service in St. Peters Square this coming weekend and wondered what it will take to convince people that we just are not ready to resume full activities.

The Governor of Florida is correct. Deaths are down due to vaccinations and the elderly staying home. I suspect if he tracks the cell phones of the tourists and spring breakers to their home states and countries three weeks from now, he will see an increase in hospitalizations and deaths.  Florida’s economy may boom but we certainly are maintaining it at the cost of illness and death elsewhere.

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.

There is Still a Pandemic in Florida Folks!

I opened the local newspaper to headlines that the Palm Beach County Commission has opened county facilities but is not requiring visitors to wear masks, facial coverings or observe social distancing rules.  A county commissioner was quoted as believing that it was not within their authority to require facial coverings.  Strange opinion when they have closed businesses , facilities and services due to COVID-19 and then reopened them independent of Public Health, CDC or even White House guiding rules and regulations and published the conditions under which these facilities will open and operate.  I imagine, or hope, the County civil servants have union representation that will address the issue of their employees being called back to work with their health and safety being taken for granted.

Recently, I spoke to a patient who believes COVID-19 is overblown. They are closer to 80 years old than 70, continues to smoke tobacco regularly despite having documented coronary artery disease and is incensed that the free flow of patients has not restarted in our medical practice.

I keep coming back to the same question.  Despite our Governor opening the state up again, what has changed medically or scientifically?

  1. We still do not have an onsite quick accurate test to determine if a patient has COVID-19 and is a contagious asymptomatic carrier. Yes, testing sites have increased but most test results come from a lab with a 48-hour wait delay.  Our local medical center, Boca Raton Regional Hospital Baptist Health system has on the physician website a request to only perform quick in-house COVID-19 testing one time on admitted patients only because they do not have enough supplies on hand.  Patient’s presenting to the Emergency Department still receive a nasal swab which is sent to an outside reference lab and results take 48 hours.
  2. We don’t have enough personal protective equipment for hospital staff to change masks, capes, face shields and gloves according to their own guidelines for treating an infectious patient and preventing transmission of the pathogen to others, including you! In view of the shortage of equipment, the CDC and hospital infectious disease departments have relaxed their own guidelines several times to ensure their guidelines agree with the way equipment is being used.
  3. We still do not have a treatment other than supportive care. Yes, there is some evidence that remdesevir early in the course helps and that a triple drug regimen in more severe cases helps.
  4. We are still months away from having a vaccine.

In Palm Beach County, civic leaders admit they bowed to the pressure of struggling businesses, distressed parents out of work, and home with school age children, and political pressure from Washington and Tallahassee in deciding to open the economy back up.  With Palm Beach County opening May 11th and Dade and Broward County on May 18th, we should begin to see an increased infection rate over the next two weeks based on the incubation period of COVID-19 and its complication rate developing around Day 8 or 9.  

I sincerely hope I am wrong about this, but my infectious disease colleagues, critical care colleagues and Emergency Department colleagues have shared this professional opinion with me.  This disease infects and kills youngsters, young adults, teenagers as well as senior citizens.  Asymptomatic carriers of the COVID-19 bug infect 5.7 individuals before they discover they are sick. 

Despite this, we ask county employees and restaurant servers to spend time up close with no requirement to wear a facial covering.  Tell me, what has changed other than the level of patience of our elected officials and their overwhelming desire to gain public favor and get re-elected regardless of the health care costs and carnage from COVID-19?

Changes in Florida’s Prescribing Medication Laws

In their ultimate wisdom, the Florida Legislature has decided that all medication prescribing shall be done electronically by computer beginning in January 2020.  As of November 1st, the Florida Medical Association has not informed its members of this but it was discussed briefly at a hospital staff meeting.

We were told that most pharmacies will no longer honor paper written prescriptions.  My office electronic health record system, which slows down seeing patients remarkably, has had electronic prescribing software which we have used for several years now.  The big change is that we will now be required to order controlled substances online electronically when in the past it was not permitted.

Since the opioid crisis struck Florida, physicians have been required to create an account with the State’s narcotics hotline named E-Forsce and check out the recipient prior to prescribing controlled substances for pain.  We then issued a written prescription.

It never made sense to me why if one is trying to track narcotic prescribing it wasn’t being done on computers from the beginning?  Nonetheless, this is a change which will require prescribers to download additional software and use two methods of identification as the legitimate prescriber before you can actually prescribe for your patients.

It will give you the freedom to prescribe from your phone or tablet when out of your office which is a convenience not available in the last few years. It will however mean more time in front of the computer screen, more user names and passwords to remember and less time actually listening, talking and communicating with patients.

Joint Commission Inspection and Data Entry Duty for the Doctors

I received an email from our hospital Accreditation Coordinator/Quality Coordinator in a manner that wasn’t clear if it was directed to me personally or if it was sent to the entire medical staff.  It said that she was reviewing the Joint Commission Accreditation of Hospitals recent survey which found that the charts did a poor job of reflecting the patient’s “Code Status”.  The institution only received a 40% rating.

Some patients were listed as “Do Not Resuscitate” (DNR) but did not have the yellow State of Florida DNR Form on the chart.  Some charts had the DNR form but the physician, in a progress note, had incorrectly indicated that if the patient’s heart stopped beating, or they stopped breathing, that the patient was in fact a “Full Code.”   Of the 25 charts reviewed only ten were in full compliance.

For some reason I took this email very personally.  In my practice I take the time to discuss end of life issues with all my patients who are at an age, or have issues, that make one believe they may face a catastrophic cardio- respiratory arrest in the future.  When I have the discussion with the patient and family, I present them with a large yellow State of Florida DNR form. The large top half and small detachable bottom half are identical. The patient is supposed to fill both out, with the physician signing both.  We photo copy the form and scan it into the patient chart while listing DNR Status on the electronic health record face sheet for all to see.  The patient is supposed to place the large yellow upper half on their refrigerator while carrying the smaller wallet sized version in their wallet or purse.

Most of my patients get to the hospital through the emergency department by self-referral. Sometimes they call us first but most times they call 911 or go themselves.  Most situations involve unexpected falls and trauma or pain from a chronic source.

When I am called by the ER staff the patient has been registered in, insurance has been checked, medications have been reviewed, as have allergies to medication, and the patient has been evaluated by nurses and physicians.  The patient’s record is a mix of paper documents and electronic health records.  The hospital recently instituted a new electronic health record system with inadequate staff training and support (in my opinion) with decisions for financial reasons.  The result is that most clinicians are constantly searching for information and not quite sure where all of it is.  There is still a loose leaf binder type shell for some daily paper information such as the EKG rhythm strips created on the telemetry monitors.  Where a State of Florida DNR form is kept is anyone’s guess.  I took the electronic health record training course on line and the two in person events. At no time did they discuss entering a code status or show us how to enter this data.

It seems to me that the question of a patients “Code status” is something that should be asked at registration in the ER and at elective pre admission. All patients should be considered a full and complete code unless they say otherwise and can produce the documentation needed. If they are not carrying the documents with them then the document should be re-executed and signed at the registration desk by the patient or their legal health care surrogate. When their physician shows up to admit them the document should be on the chart, filled out for us to see.  I can access my office patient files at the emergency department from my iPad but, due to lack of interoperability between electronic health records in the office and in the hospital, I have no way to print out the document from my office electronic health record while I am at the hospital.

If end of life issues have not been discussed with the patient prior to hospitalization, I have no problem beginning the conversation when the medical condition they are there with has been addressed and stabilized.

It turns out that the email was addressed to the entire medical staff and not directed at me alone.  None of the 25 charts reviewed by JCAHO were mine.  If administration wishes to fix the problem it needs to make sure its employed clerical staff are trained to ask the right questions and list the answers where the doctors and nurses can easily see them and interpret them and act on them if necessary. Don’t ask caregivers to be data entry clerks for JCAHO or anyone else.

Leave us free to provide health care.

The Florida Legislature and Florida Medical Association Making Docs the Fall Guys

I wrote and mailed my annual $250 check to the Newborn Injury Compensation Act (NICA) fund today. In 1982-83, when there was a medical malpractice crisis and no physician could get insurance to practice, the Florida Medical Association (FMA) cut a deal with the trial lawyers and our elected officials to form NICA. Every physician, regardless of specialty, is required to pay $250 annually into this fund to cover the cost of injuries to newborns. Obstetricians pay $5,000 annually.

In exchange for making the social problems of the state the responsibility of Florida physicians alone, the legislature passed some changes to the medical malpractice laws which encouraged insurers to return to and start writing policies in Florida. Isn’t it time for the State of Florida and its citizens to assume their responsibility for providing reproductive education and prenatal opportunities to women of child bearing age nearly 40 years later? Why does it remain my responsibility as a physician to continue to fund this entity? The FMA thinks it is still a good deal and will not discuss lobbying for a change.

Recently I attended one of many continuing education courses mandated by the elected officials in Tallahassee. It was on prevention of medical errors. It’s the same course I took two years ago and two years before that. Most of the errors are surgical and do not apply to me. The others are communication issues.

I have proposed over and over to my hospital’s chief medical officer and medical staff that we form a medical staff communication committee to facilitate doctor to doctor, and doctor to staff, communication to improve patient safety and care. Time after time they turn a deaf ear to the suggestion yet they host the medical error meeting yearly.

They also host the Domestic Violence lecture yearly. It too is mandatory for license renewal in Florida. The same message is delivered every year. “If the assault is made with a knife or gun call the police because they can do something. If a weapon is not involved your only option is to recommend counseling and safe shelters.” The Legislature has done nothing to toughen domestic abuse laws but they make us sit through the lecture every two years.

I have the same message for the legislature, the FMA and the Florida Board of Medicine, “You can kiss my grits!”

Dealing with Pain Physicians Should not be so Painful

The State of Florida is trying to eliminate medical practitioners and facilities which prescribe narcotics freely without doing the proper evaluations. These pill mills sell drugs for cash and the resulting overprescribing of oral narcotics has flooded the streets of Florida and nearby states with oral pills leading to increased opioid related deaths and trips to the emergency departments for drug overdoses. The frenzy has been fueled by “blue ribbon physician panels” discouraging the use of nonsteroidal anti-inflammatory drugs for pain in favor of narcotics. The Florida Legislature responded by passing draconian legislation that separated opioid pain prescribing into acute prescriptions which all physicians may prescribe and chronic prescribing. For chronic prescribing health care providers must take a course and check a special box on their licensing reapplication form every two years. Pharmacies are coming under scrutiny for providing refills of short acting narcotics for pain when they have been refilled well past the 8 week suggested limit on these medications, even if the prescription is appropriately written by a legitimate physician. The pressure on the pharmacies by the state and law enforcement has led to a policy of not stocking narcotics or filling narcotic prescriptions at many Florida pharmacies. Sick patients with well documented sources of pain and legal prescriptions search endlessly for a pharmacy to fill their pain medications.

The Florida pain law encouraged the growth of pain specialist doctors especially anesthesiologists, rheumatologists and psychiatrists. I treat an elderly population of chronically ill patients many with severe long term chronic back, hip and joint problems. They arrive at my practice with a history of long term use of nonsteroidal anti-inflammatory medications for pain relief and many are using opioid narcotics for years. When referred to many of the pain specialists they are integrated into a conveyor belt type operation using injections of medications into joints, physical therapy with very little attention paid to the patient’s medical history. Most of the pain doctors prefer using injection techniques rather than working with oral or injectable medications, physical therapy, counseling or any of the alternative therapies.. The patients receive their series usually of three shots into an area of the body and then are expected to be able to tolerate their pain. The problem is that during the series of injections and after the series of injections, if the pain relief has been incomplete or inadequate, there is little time set aside to discuss what to do when it really still hurts. The result is that the patients call a doctor who actually answers the phones and returns calls promptly even if that physician does not have a degree in pain management or a large volume practice injecting joints for pain relief. That doctor is left with the option of prescribing the very oral medications we are being advised not to use, or chasing down the pain doctor to discuss exactly how they wish to address the problem? Usually the pain doctors are very willing to take ownership of the situation and they make suggestions of oral medications for that particular instance. The problem then usually recurs before the next round of injections or shortly after. There are very few pain practices actually talking to patients, examining them and working with oral medications or transdermal medications to relieve pain. They just do not have the time to discuss the situation especially with the procedures being so much more profitable. It is much like the situation in psychiatry where so many of the practitioners see patients briefly to adjust or regulate medications but spend little time engaging in counseling or psychotherapy any more.

There are however, several local pain doctors, who have answered my calls for assistance regarding patients having multiple cognitive and behavioral problems due to chronic use of opioid medications for legitimate pain. They have spent time analyzing the situation and helped the patients successfully withdraw from ineffective treatment regimens and resume a productive life. These clinicians are few and overwhelmed with chronic pain patients. The solution to the problem is an updating or retraining of our health care provider population so that more practitioners are comfortable treating chronic pain. At the same time our elected officials and law enforcement need to establish a system which prevents prescribers of pain medications from profiting from the dispensing or distribution of these products. Until that occurs I will continue to get phone calls from patients saying, “I had my third shot three days ago and I am still in excruciating pain. I cannot reach my pain doctor but their PA says I cannot get another shot for another three months. What should I do about the terrible pain?”