Well, it is week 6 of the coronavirus pandemic. Much like the flowers this spring, my region is sprouting a variety of multicolored facial masks as its citizens browse in the limited number of venues that are open. In my occasional forays into retail space, I see people largely covering their faces and keeping a distance from other people.

I do feel positively like a rube behind my paper and elastic mask (it’s soooo early April) when I see the variety of reusable, fashionable face ware that people are sporting. I did order a rather dashing black mask for myself and my wife, but I’m afraid the delivery date from Amazon will probably be sometime in July.

In most places now the numbers are trending downward. Within our federal framework, some states are beginning to tentatively relax their restrictions. For some states, their numbers support this, while others such as Georgia, are taking a bigger risk.

So as fear and anxiety ebbs, and impatience and annoyance surges, here as some things I noticed this week.

Earlier this week I posted on Facebook, a link to an Epoch Times video on the likely genesis of the pandemic in the Wuhan Virology lab, rather than from the seafood market several hundred yards away. as I wrote earlier this week, Facebook basically disallowed the post claiming the whole premise as false. Turns out there is more and more support for this concept in the press, and many people I have spoken to accept to be true.

After some controversy, our county of Luzerne finally opened a coronavirus testing site. Testing at first was limited to essential workers and the elderly… with symptoms. To heighten the drama and add further inconvenience to our lives, the exit from route 81 was essentially shut down for any other traffic. The road in front of the arena was also blocked off while the testing site was open. This was apparently designed to discourage those getting tested from wandering off into the local Walmart.

The result: In the first week, 556 people were tested. Somewhere between 5% and 7% of these high risk, symptomatic individuals were COVID positive. This made me think. We have been categorizing suspicious cases without testing as COVID 19 deaths. These people were suspicious, having been screened and approved for testing. Perhaps we’re slightly overestimating?

In Europe, Germany has been reopening its economy and relaxing its lockdown. Apparently in the early going, the reproduction rate (the number of people infected by each current infection) has risen from 0.7 to 1.0. This bears watching.

 In Sweden, they continue to pursue a strategy of keeping society largely open with voluntary distancing, and self-isolation. This has led to a significantly higher death rate than the other Scandinavian countries. This is most obvious in comparison to Denmark, which actually has a higher population density.

Sweden’s situation is interesting. We have been told that the lockdown in the United States is all about flattening the curve so as not to overwhelm our medical system. Apparently, Sweden’s medical system is bearing up nicely even with a higher death rate per million population, than the US, Germany, and other Scandinavian countries.

There are those in Sweden that contend that they will likely have nearly the same total of infected patients and death as they would have with our plan. The process (along with herd immunity) will just occur more quickly. By the Swedish theory, the peak of the curve may be flattened in our country, but the total area under the curve (the number of sick people) will not have ultimately changed. Unfortunately, the economy will be devastated by the long-term shutdown.

I’m grateful that the governor opened some obvious, morale-boosting businesses and recreational opportunities. I am also glad to see construction restart once again.  

We do apparently believe that we can safely open certain retail businesses during the lockdown. Given this, the closure of others seems rather arbitrary, and as time goes on, cruel to the business and its workers. Masks and self-distancing work as well at Home Depot, as they would at Target. Warming weather may offer an opportunity for safe outdoor seating at bars and restaurants.

Now is the time for bold but prudent innovation to overcome this pandemic and all of its effects.

The time for fear and anxiety needs to be over.

Those of you who follow this site, know that for the most part, Henrysmithscottage.com is an apolitical site devoted largely to photography and camera gear. I do occasionally swerve off track to talk about other topics. During this coronavirus outbreak, it seemed reasonable to put on my “pulmonary/critical care hat” and offer my perspective.

By the way, I really appreciate the very nice comments I’ve been receiving.

My dealings with social media up to this point have been largely benign. I don’t discuss politics for a variety of reasons: number one, I don’t really care to publicize my affiliations, at least on this platform.  Number two is the essential truth of these times, which is that no one is persuaded by your political postings. When you put up your snarky commentary on Nancy Pelosi or Donald Trump, all you’re doing is annoying a subset of your “friends”. I typically unfollow people that do this persistently.

Of course, in my case, this means my Facebook feed is now dominated by posts on recipes, camera gear, barbecue grills, garden tractors, and people’s pictures and the like. You can’t believe how many people like to post pictures of their new Weber kettles.

Recently I came to realize, that this platform that feeds me all manner of banal content is in no way benign. I personally experienced the manipulation of Facebook algorithms.

Two days ago I risked breaking my apolitical profile by posting a documentary I encountered on YouTube. This was a very intriguing presentation that argued rather persuasively that COVID 19 originated not in a Wuhan “wet market”, but in the Wuhan Institute of Virology, a high-level lab located coincidentally less than a kilometer from the market. It was well done, using actual emails from those in the lab, scientific articles that had been published by their scientists in the lab in well-known peer-reviewed journals. There were multiple interviews of virologists, and China policy experts.

Later in the documentary, it opened up the question of Chinese government involvement. To me, it stopped short of any radical conclusions. I drew from the documentary that most likely the virus very possibly engineered in the lab more as a vanity project than anything else, and was accidentally released. Other than offering some additional embarrassment to China, again there seems to be no political issue.

I posted this with a disclaimer admitting that it was from a conservative source (the Epoch Times) but as the article did not appear to be discussing a political topic I thought it would be interesting.

When I hit the post button, a little window popped up. Apparently my content was rated as “False” by Facebook. And guess what, it wouldn’t post.

The reason: the Facebook fact-checkers have apparently decided that the virus originated in the wet market. So despite the fact that this video makes it a compelling argument, backed up by documents, for origination in the lab, it’s a “no go”. Sorry… Facebook’s already decided the issue for us. How considerate.

So who would be harmed by circulating this article? Well, again I don’t think this is a political topic. The only entity that would appear affected by this would be the Chinese communist government. Why would Facebook run cover for them?

So let’s talk about the accuracy of these “fact-checkers”. Several days ago I posted a video of a physician from the midwest discussing how different states score coronavirus deaths and how it can be misleading. Again I viewed it as apolitical. As I said at the time, being familiar with death certificates, a lot of what was said rang true. Again the fact-checkers at Facebook rated this as “mostly false” and let it post with a disclaimer.

Lo and behold, several days later, Pennsylvania is forced to remove 200 deaths from the coronavirus column, largely because of the exact things discussed by the physician in the video.

So I think beyond charcoal grills and garden tractors, Facebook is manipulating us. I would argue that this platform is best used for “happy talk”. Post birthdays, your pets, your children’s or grandchildren’s pictures. Have a ball. But don’t trust this platform for anything more important because it does not appear to allow a true exchange of ideas.

So-called “fact checkers” do not have a monopoly on the truth.

Now let’s see what happens with this post.

It is now roughly 5 weeks since the spread of the novel coronavirus forced us to shut down the vast majority of our commerce and personal interaction. It’s been a long period with a very unnatural but necessary restriction of our freedoms. At this point, enough time has passed that we are starting to see the trajectory of this pandemic.

In most places, even in New York, the number of new diagnoses, as well as deaths, have either plateaued or are on the downslope. This is not to say that the numbers are small. As I write this, it appears that another 20 people died in my county in the last 24 hours (50 deaths of 1800 total cases).

By all accounts, outside of New York City, hospital systems have not been overwhelmed. Our facility continues to see sporadic cases, none of them particularly severe. Many of these people come from nursing facilities. An emerging problem is the understandable reluctance of those facilities to receive these residents back once they no longer require hospitalization.

I want to discuss several topics related to COVID 19. The first is the topic of ventilators. When the pandemic started there was enough hype to suggest that these devices were going to be essential for the survival of the species. We all watched the great efforts that were made to procure large numbers in anticipation of a respiratory disaster.

There was also talk in the popular press that severely compromised patients should be kept on a ventilator for at least 14 days prior to “weaning” them. I looked around the pulmonary literature but could find no support for this. Still, I kept seeing this in medical chat rooms and the like. My partner, who is also very experienced in critical care, was equally befuddled.

Roughly a week ago I began to hear a different theme. Suddenly, there arose the theory that ventilators are actually the problem, and that mechanical ventilation is causing damage to the patient’s lungs. Therefore, only oxygen should be given.

Given my career in critical care, none of this has any bearing on reality. Ventilators are used in situations where either the patient’s oxygenation cannot be maintained by the lesser means, and/or when the patient’s own respiratory system can no longer maintain ventilation without fatigue and ultimately respiratory arrest. Beyond this, there is no therapeutic benefit. Actual harm to the lungs can result if ventilator settings are inappropriate. We do think we have learned over the years how to minimize this problem.

We also have intermediate modalities, including oxygen supplementation, “high flow oxygen” and “noninvasive ventilation as “that are delivered by mask, and generally offered long before intubation is considered.

The problem is, these less invasive respiratory modalities have a bad tendency to create aerosols of the patient’s secretions, which, in a small ICU room, puts the staff at risk.  

Also, the actual act of intubation (placing the breathing tube in the trachea) exposes the operator to a high risk of infection. This is even more true when done emergently. Thus, I think there has been a general sense that when the patient is deteriorating, that “securing the airway” in a deliberate fashion, before the crisis, is safer for all concerned than intubating a “crashing” patient.

In ventilated patients, once there is no other factor to prevent it, patients are tested daily to see whether they can breathe on their own once again. If so they are extubated. This is important as endotracheal tubes provide a significant risk of secondary infection, and the enforced inactivity in ventilated patients creates other complications.

The sooner you can get them extubated, out of bed and ambulatory, the better they do. So far as I can tell, other than some interesting nuances about the patient’s lung physiology, there is nothing really truly different about ventilating these patients versus those with other similar critical illnesses.

On other fronts, as antibody testing proceeds, we are started to get a sense that many more in the population have been infected then we ever expected. In some ways, this is good news as it suggests there may be many more recovered people about, and we are closer to herd immunity. it also drops the case fatality rate, perhaps significantly.

Unfortunately, this is a little comfort to the roughly 47,000 people have died. Even if the death rate approaches that of the flu, the denominator for the flu is always based on symptomatic patients, who are the only people we test. There is little sense in the literature that influenza, unlike coronavirus, can be asymptomatic.

There is evidence that in the first quarter of 2020 the overall death rate in the United States is not particularly high. This is curious. Some of this may be due to the “cause of death substitution”. It may also be due to decreased opportunities for auto accidents and other trauma, given the social isolation.

I don’t think however it diminishes the extraordinary number of deaths in unique situations like New York City where reliance on public transportation and population density seems to have affected them exponentially. I have no desire to downplay the severity of this pandemic.

Nonetheless, I continue to believe if we are to prevent a severe economic recession if not depression, we need to adapt to current reality, and reopen commerce in a thoughtful way. I look at vast states like Wyoming and Montana where there are less than a quarter of the cases than in my little county. Is it fair to ask them to remain “locked down”?

 There is probably no way to do this without some risk, and we have to know that some degree of increased spread will occur. We need to steel ourselves for this and not panic when it happens.

This can only occur if the political factions in this country stop attacking each other for political gain, every time there is bad news. That must stop. This is too serious now.

I hope you and your loved ones, are safe and well.

Let’s see what this next week brings