We have reached week 11 of the suspension, by decree, of religion and commerce in the Commonwealth of Pennsylvania. Here in Luzerne County, we are scheduled on 5 June (Friday) to move into the “yellow phase” which means that the Wolf and Levine team will allow a tepid amount of additional business activity.

Whoopee.

This is occurring in the middle of a new crisis, namely the protests/riots in our cities caused by the universal outrage over the apparent murder of George Floyd, a black man, by a Minneapolis policeman who has been subsequently fired, charged, and imprisoned.

Scenes of large crowds of masked and unmasked protesters, provocateurs, and criminals, freely associating in our urban centers, to say the least, has been destructive to the culture of social distancing we have come to know over the past weeks.

Suddenly, coronavirus feels like yesterday’s news. With this new crisis, I suspect the caution and fear people felt about the pandemic will begin to dissipate.

There may be other reasons for this. Certainly, in most areas of the US, the number of new infections and deaths is clearly decreasing. No longer do we wait breathlessly for the state and federal coronavirus broadcasts for the most recent bad news. Drs Birx and Fauci seemed to have faded from the public view.

There was a report this week out of Italy (which appears to be the proximate source of our eastern viral strains) to suggest that the coronavirus there has become significantly less virulent in recent weeks. Based on basic virology, this would make sense.

First, it’s important to remember that this virus comes from a specific species of bat, where it infected large colonies with minimal deleterious effects. This is likely because the bats had a degree of “herd immunity” and the virus had evolved to maximize its spread by minimizing virulence. A virus receives no advantage by killing its host.

Then it spread to humans, whether from freshly slaughtered animals in a Wuhan market or more likely released by accident from the neighborhood virology lab. Humans had little or no immune defenses to this novel agent, and the virus had not yet evolved to avoid excessively sickening the new hosts.

Add in a little globalization and voila… a worldwide pandemic.

Now, if over time, there are multiple mutations of this virus (which there are), it makes sense that some of them will be more aggressive and some less. The strains that make people obviously sick, and/or dead, will tend to be more quickly diagnosed, and the patient isolated, impeding further spread.

Less symptomatic strains will be less likely to attract the attention of the public health system and thus have more opportunity to spread to and replicate in a new host.

At some level, the most successful viruses will be among the mildest ones. The virus has to be aggressive enough to infect the right tissues (respiratory ) to facilitate transmission by coughing and sneezing, but mild enough that the illness will provoke little concern from others and can spread freely.

Now consider a virus such as Ebola, with a horrifying presentation. In modern times an infected patient is quickly recognized and carefully isolated, reducing or hopefully eliminating spread.

In one of Dr. Fauci’s last publicized statements, he feels there is now hope that there will be no recurrence of the virus in the fall. I don’t entirely understand the data that this is based on, but it is undoubtedly good news.

With the good weather, and now obviously with the mayhem, the enthusiasm for social distancing is fading, and I think will eventually become extinct, rules or not. If there is no meaningful bump in cases around the country after all of the mass gatherings that have been occurring, then I suspect the sense of the coronavirus as a threat will reasonably ebb. The practice of masking, and spacing ourselves out, will likely then feel dated and unnecessary.

We are obviously living through extraordinary times. More than anytime in my life, I find myself praying for the welfare of our country and its citizens. I do believe that in God’s good time, there will be recovery and a return to a slightly different, but acceptable baseline.

I just hope this happens before there is more damage to our economy, our infrastructure, and our psyche.

We have now reached week 10 of the Wolf/ Levine “2-week lockdown to flatten the curve”.

For my county, Luzerne, and other counties in eastern Pennsylvania, there is a tiny light at the end of the tunnel. On Friday, we are going to be allowed to exercise a slightly larger sliver of our former civil rights. We are moving into the “yellow” phase.

For many people, this will seem like thin gruel. Though the governor will allow us to open more of our businesses, which will undoubtedly help some to survive, he still refuses to allow restaurants, hair care professionals, athletic facilities, and shockingly, the almighty casinos to reopen. Schools also remained closed, even though children are minimally affected by this virus. Church services are still functionally forbidden.

He is finally allowing much of the Northwest of the state to move into the so-called “green” phase. Even this however is rather restricted with some businesses limited to 75% of capacity, and bars/restaurants limited to 50%. The governor likes to refer to this as “the new normal”.

He now apparently believes, that we cannot return to baseline until there is a vaccine (presumably one that is widely available). Perhaps conveniently for him, this is unlikely to occur before early November.

If I lived for instance in Tioga, Cameron, or Sullivan County each of which has low single-digit numbers of cases, and no deaths, I would be furious. These counties have likely had more influenza cases than COVID cases, yet they are only now being allowed into the “green” phase. Imagine owning a small business in say, Coudersport, and watching it fail, arguably for no good reason.

Germane to this, is new data out of the CDC suggesting that the death rate of this virus, based on the ever-growing number of documented asymptomatic cases, is down to about 0.25%. This is roughly what is seen during a bad influenza year.

,Another fascinating study has found that 40% of random blood samples collected from patients prior to the pandemic have immunologic cross-reactivity with COVID 19. In other words: some of us may have had full or partial immunity to this coronavirus all along. This helps to explain so many infected ended up asymptomatic or with very mild cases.

As I reflect on this, I think most everyone supported a short period of lockdown, especially given circumstances such as those in Italy, and of course in New York City. It was not unreasonable to think that such a dire situation could’ve happened here. It clearly did not, but despite this, the lockdown continues.

In fact, most of the severity of COVID 19 in Pennsylvania occurred because of the Wolf/ Levine decision to insist that infected patients be admitted to nursing care facilities. This of course occurred at the same time Dr. Levine insisted her elderly mother be moved from just such a facility, to a hotel. I don’t really want to fault a decision to protect an aging parent, but the sense of risk to the mother should have absolutely informed the decisions affecting other elders at risk.

If one looks at deaths per 100,000 of the population, Pennsylvania’s number is 40. Florida, early on did the opposite and prohibited COVID patients from admission to nursing facilities. Their death rate that is one quarter as large. As more than 2/3 of deaths in Pennsylvania involved nursing facilities or personal care homes, the numbers make sense. And remember, Florida locked down less severely, and opened earlier, than Pa.

Now to be fair, there was a concern at the beginning of the pandemic that hospital beds would quickly fill, and nursing homes would have to be utilized for convalescing patients. On the other hand, the first outbreaks in the country, occurred in Washington state where it swept in deadly fashion through nursing homes in the Seattle area. This might have been a clue as to what not to do.

At any rate, the disease statistics being used to justify our imprisonment were mostly the result of faulty decisions made at the beginning of this pandemic. And so far as I can tell the governor’s emergency powers have no time limit.

I was curious about what limitations different states place on their executive branch during times of emergency. It turns out that 35 states are like Pennsylvania, in that they allow the governor to change both statutes and regulations under emergency powers. Seven states allow Governors to only change regulations, and 8 states give the governor no explicit power under these circumstances.

While we need to our governors, to have flexibility during times of emergency, this should have limits.

We need to revamp the system. I imagine the law modified so that at some point, perhaps a month, any emergency authority should expire, which would relax all the restrictions that have been imposed. This would occur unless the state legislature voted to extend the time limits. Any extension by statute ought to itself be limited, requiring additional votes. This would force the governor to work with the legislative branch, rather than reject their input as Governor Wolf has done.

I have no wish to disparage fellow public servants who in the beginning, worked very hard to contain this pandemic. Happily they succeeded. As this drags on, it is not hard to believe that other factors are at play.

And they’re likely no longer about us.

We have now reached week 9 of a societal aberration that was supposed to last for 2. The lobster pot is starting to simmer, while we accept completely illogical, and capricious prohibitions, that would’ve been unthinkable 4 months ago.

Some retailers are allowed to be open, while other similar businesses are forced to remain closed because of an arbitrary process of waivers, granted by the state. The practice of religion is suppressed as ruthlessly as it might be in communist China. You can still obtain an abortion, but cannot schedule a procedure to alleviate the severe pain in your arthritic knee.  

Despite the improvement in your statistics, if you live in the wrong city or county, there is no end in sight.  Businesses both large and small are running out of money and calling it quits. And because of this, jobs are disappearing.

And in most cases where these restrictions are imposed, they are edicts of the executive, who dismiss any action, even at this late date, from the state representative bodies. In Pennsylvania this means that a lame-duck governor, and his ethically dubious health secretary, are acting without any voter accountability. They have rejected any input from the legislature (formerly called laws). They are overseeing the destruction of the state economy, perhaps with an eye towards the upcoming presidential election.

Let’s talk about masks. There is no consistent data on the use of masks. There are a lot of statistics bandied about, but little hard science, particularly in the face of the vast variety of face ware people are using.

Some justifications I have read include the idea that since countries like Taiwan and South Korea, have widespread usage, and they have done relatively well during this outbreak, then masks must be useful. Not really hard data from my point of view.

According to the CDC, on one hand, if a sick and a well person both have masks on, the transmission of virus will be very low. One study from the University of Hong Kong, studied this in hamsters.

Before you indulge yourself with the unbearably cute image of hamsters with teeny -tiny masks, it turns out that the study involved covering the hamster cages with mask-like fabrics. It did show that transmission of coronavirus was the lowest with both infected and uninfected hamster cages covered,

This is interesting I suppose, but it is not really directly comparable to our situation.

I wear a surgical-type mask in places where it is requested, mainly as a courtesy to others. The right mask can protect those that you encounter. Unless you’re wearing an N95 mask or better, it is unlikely to protect you. Many of the facial adornments I see in public are probably useless.

I can’t find any data to suggest wearing a mask in the out-of-doors protects anybody if people keep a reasonable separation.

I suspect we are all much too cavalier about these masks anyway for them to be useful. According to the WHO, we need to avoid touching them (yea right), and each time we do, we need to wash our hands once again. I’m sure we’re all doing that. They also worry that wearing a mask may cause some people to ignore social distancing. By observation, this seems to be true.

 I finally received the fancy masks I had ordered so many weeks ago through Amazon. This was a 5 pack of black masks said to be washable. It turns that these are made of a rubberlike plastic, with the mask itself composed of a foam-type material. Now the foam seems fairly dense, but I suspect not enough to filter micron-level droplets.

Unfortunately, the manufacturer included a button-like one-way exhalation valve on the right side of the mask. This conveniently allows me to share my potentially viral-laden droplets with others. I have relegated these masks for workshop duty, but I still see people wearing them.

I guess the message here, is that I hope we don’t get too hung up on facial coverings, as I suspect they are of limited value.

We continue to be told that this virus is likely to be persistent in the environment. In fact it is this theory that is being used to prolong our isolation.

It can be argued that the fact of viral persistence should lead to the opposite conclusion. If we are stuck with this coronavirus, we will not be able to avoid it forever by staying at home and keeping businesses and schools closed. The long-term cultural and psychological effects of this would be devastating.

Oh yea, and it will destroy the economy.

We are going to have to protect our most vulnerable, but the rest of us will need to swallow hard and understand that as the denominator increases with increased testing, that the mortality rate in most locales for relatively healthy people younger than 65, is quite low. The overall case fatality rate in Luzerne County for instance is about half a percent. At one point, two-thirds of those came out of nursing facilities.

I don’t want anyone else to die. But the state, national, and global economy has to survive if we’re to avoid a civilization level disaster.

I say this with the knowledge that in the event of a second wave, given my profession, I may be drawn into the middle of it.

We have endured a difficult spring, caused by both the pandemic and some persistently cold, crappy weather that made things even less pleasant. This weekend however is Memorial Day, our traditional beginning of summer. In the Northeastern US it is predicted to finally be warm and dry. I suspect people may find that the joys of the season may beguile them from their isolation.

I will likely be one of them.

Come see my new mask.

Well, here we are in week 8 of the coronavirus shutdown. For those of us in Luzerne County, there is essentially no end in sight. Clearly, we had been a hot spot in the state.   But our numbers have stabilized or decreased despite the vastly increased testing available.

This feels promising compared to the situation where testing was less scarce but our growth in cases was exponential. Something is happening. It’s likely not all because of mitigation.

It is worth noting however that here, in Luzerne County, 82 of 112 deaths have come out of nursing facilities. Sad, but these vulnerable souls are not representative of the working public.

In Pennsylvania, there are now 3 phases of existence. Until recently most of our state, no matter how few cases there were, was in the red phase. We are ordered by fiat to stay home. We can actually be questioned and cited for “nonessential travel”. So-called “essential” businesses are open. We have been permitted to visit our grocery stores, beer distributors, hardware stores, big-box stores, and gas stations. With masks and social distancing, we seem to have been able to control the spread of this virus.

If we are deemed to be worthy, we may someday get to the yellow phase where we can open other retailers, but still cannot gather in a group larger than 25, or visit bars or restaurants. It appears that this viral purgatory will be denied to us until at least June 1.

Does this mean that churches will still not be able to open? What happened to freedom of religion?

Green phase, where things return to basically normal almost seems like a dream.

The problem is, I remember what we were told at the beginning of this. Remember: “two weeks to flatten the curve”? Well, we damn well flattened the curve. So much so in fact, that hospitals who have been curtailing other services, threaten to lay off workers because of low volume. Only modest percentages of hospital beds have been needed for coronavirus patients. There are plenty of ventilators. Yet two months later we remain locked down.

Looking at the number of new cases in Pennsylvania, the curve is noisy but is clearly trending downward.

Even more disturbing to me is the attitude of the state government. It appears for the Wolfe administration, the new default position for our commonwealth is “closed for business”. We only get to open if we are properly respectful and deserving. He seems little inclined to relieve our misery.

This feels unconstitutional. Given the crisis, we gave our state government some leeway and submitted ourselves to rules (not laws) that go against the basic freedoms of society. This was done for one purpose, which was realized. Now as others have pointed out, Gov. Wolfe has moved the goalposts from the field to an undisclosed location. And he does this without explanation.

The administration might want to study data from states that have reopened. Georgia is a case in point. Their numbers prior to late April were not the most favorable, yet since opening their new cases are declining. Hopefully, this is because to an extent, this virus is running its course as the season progresses.

We are now living in a society where state agencies in the state police are being used to suppress our freedoms and our commerce in a way that will damage our economy for months if not years.

Warren County in northwestern Pennsylvania is an example. As of this date, they have had exactly one case of coronavirus with no deaths, yet they were under severe lockdown for 2 months. How lovely for them that they will now be permitted to move to a slightly less damaging state of existence? And much of the rest of the state, many counties with single- and double-digit case numbers are similarly oppressed. This is ridiculous.

I have been uncomfortable thinking about this idea, but I now have to wonder whether this is political. As a swing state, a damaged economy might be helpful in moving Pennsylvania towards a democratic challenger. And yes, politics is that ruthless.

I think at this point Gov. Wolfe has jumped the shark. What started as a reasonable response to a bad situation has morphed into tyranny. An increasing number of counties are declaring that they no longer will submit. This rebellion includes a lot of South-Central Pennsylvania including Dauphin County, where Harrisburg is located.

In answer to this development, the Governor has doubled down. He referred to counties and businesses threatening to open as “cowards” and “deserters”. He threatens to use weapons such as state licensure, access to federal funds, and business insurance as retaliation for this behavior. His words suggest he has no compassion for those who are struggling financially in these times.

To quote him: “in the end, the ultimate goal is to defeat this virus”. Except that we can’t defeat it by hiding. The goal should be to get through this pandemic with the least amount of medical and psychological morbidity, and economic damage.

At this point, we have all the tools for dealing with the pandemic. We wear our masks, wash our hands, and observe social distancing. We’ve been practicing for 2 months.

Governor Wolfe has a perverse concept of cowardice. He believes that a small business owner, who desperately needs to reopen to avoid insolvency is a coward. He considers that people who are in dire straits and are willing to face exposure to feed their families as cowards.

Meanwhile, Wolfe, and his vast state executive, are paid biweekly and doing fine, thank you.

Lockdown was sold to us as a temporary strategy for extraordinary circumstances. It has worked.

But now if we are to avoid economic devastation, it needs to end.

Despite the atmosphere’s reluctance, spring is insistent on emerging here in Northeastern Pennsylvania. As I write this, the trees in the valley are leafing out. Up higher the forest canopy has erupted in fluffy light green as the stubborn oak trees cautiously bloom.

We were teased with several warm days over the weekend. Unfortunately, predictions for the week are cool to cold, and unbelievably there is snow predicted for Friday. It seems somewhat cruel of nature to provide us with an unusually cold spring, in the same year it has gifted us with this wonderful Chinese coronavirus.

Time in lockdown rolls on. At the VA Hospital in Wilkes-Barre, we see sporadic cases, most of whom are modestly sick. Around our state, infections and deaths continue to rise, but far more slowly than before.  Overall from the standpoint of coronavirus, Pennsylvania appears to have stabilized.

Regarding drug treatments, Gilead’s antiviral drug remdesivir, underwent a phase 3 trial, that was featured rather prominently in the news as supporting the drug’s effectiveness. As I read the trial, it seemed to be more about establishing whether a 5 versus a 10-day course of the drug was appropriate for treatment. Efficacy did not seem to be an endpoint in this study. The drug was used to treat hospitalized, hypoxic but not ventilated COVID-19 patients. The mortality rate of these patients in both arms of the studies (5 versus 10 days) was 7%.

By comparison, a study in JAMA looking at hospitalized patients with COVID 19 in New York City had a mortality rate of 21%. These studies are completely unmatched however in terms of age or disease severity, and again the Gilead study did not include ventilated patients (at the start). The New York study had a mean age of 63 years old, with patients apparently as old as 107. This clearly might hint that remdesivir is helpful in these patients.

 Interestingly, 553 people died in the New York study, but only 373 were admitted to an ICU, and roughly 330 were placed on ventilators. This means that at least 223 of the dead, did not receive ICU care or mechanical ventilation in a premorbid state.

Given the age range reported, I suspect a percentage of these people were not aggressively treated due to age, or multiple comorbid conditions. This suggests that there were many patients, even without the pandemic, with the potential to die in the next several months. This would tend to lower the practical mortality rate of this illness.

Let’s talk about masks. First rule: No mask short of an N95-type will protect you for instance from an aerosol containing viral particles. However, there is some conflicting data to suggest that an infected person, projects less infectious material by using facemasks. The problem has been that supplies of medical type masks, which are more effective are inadequate, forcing people into homemade alternatives.

So, when I’m in the grocery store, I see all manner of masks from 3M particulate masks, to surgical type masks, to homemade cloth masks and even bandannas pulled up over the nose. If you’re an asymptomatic carrier, the homemade cloth masks and particularly the cowboy chic, probably does little to contain your little viral hitchhikers from visiting other folks. Surgical masks when available, test better in this regard.

Then there those people who wear them while solo running or driving in their cars alone. I fear it’s becoming another form of virtual signaling. According to CDC’s newest guidelines when you’re asymptomatic, masks should be worn only when conditions preclude social distancing. They are in no way a replacement for adequate separation and are probably unnecessary when that is achieved. All this, of course, changes if you’re coughing. In that case, wear a mask and stay the hell away from others. I would say however that wearing a non-occlusive bandanna is useless. Stores should probably not accept this as being compliant with the state guidelines.

At week 7, the economic consequences of this lockdown are becoming apparent. Corporations as diverse as Norwegian Cruise Lines, Lord and Taylor, and J Crew have filed for bankruptcy. More are likely to follow. Businesses are closing prematurely. I worry greatly that the ultimate morbidity (and even mortality) resulting from a severe economic downturn, will be every bit as significant as that from the virus itself.

 If we believe this disease is going to be persistent in the environment, then at some point were going to have either be immunized, or to “face it down “. As the most optimistic timeline for a vaccine is sometime in the late fall or early winter, we have little choice but to open things up in a judicious way, and deal maturely with the bump in diagnoses and deaths that may occur.

So let the snow come on Friday. I know its inevitable that true spring must come, likely soon. Have hope, it’s almost here.

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

I’m writing this article on 21 March 2020. I am ensconced in my mountain enclave, in a state of semi-isolation because of the coronavirus situation. I say “semi-isolation” because although I mainly write about photography issues on this little website, my living is made as a pulmonary physician for the Veteran’s Administration and I have to go to work. I think it is likely that I am going to have an “interesting” next several weeks.

Things are already somewhat tense in our facility. We have made great efforts to reschedule nonessential physician visits, handling things over the phone. We have shut down routine testing. I undergo a brief medical history and have my temperature taken on arriving for work in the morning. All of this seems very prudent to me. The hospital is actually very quiet right now, with a very much reduced risk for exposure. This, however, may change.

More ominously I have been conducting seminars to update my colleagues on the management of mechanical ventilators for the types of problems seen in a SARS-type infection. We have begun to convert our short procedure unit into an adjunct ICU/negative pressure room. All of this is a little scary for a hospital not typically engaged in the care for very high acuity patients. Hopefully, this will all be overkill, but it’s clearly necessary to plan for the worst.

It’s very likely that my pleasant part-time pulmonary/sleep medicine career is about to revert to my former life as a critical care physician.

In terms of the disease, I am somewhat hopeful about several recent developments. Number one would be the possibility that several medications (hydroxychloroquine, azithromycin, and remdesivir) already available or nearly available, may have activity against the virus. Number two: hopefully the infectivity and/or virulence of this bug will fade over time much as do many of the seasonal viruses. It would be hoped that if there is a summertime pause, a vaccine can be developed to be available for the next season.

Like many people, I watched yesterday’s press conference where Dr. Fauci seemed to downplay the president’s enthusiasm for the proposed medications. This is inevitable for a man deeply involved in research, a culture where a treatment is only endorsed after multiple double-blind studies prove its efficacy. Unfortunately, we don’t have time for such perfection. He is right when he says that if we are to try these medications, then we need to keep the data so we can draw appropriate conclusions regarding their efficacy.

Meanwhile, I have two children in Seattle Washington. Both are healthy, and working from home, and report to me that all is well. Hopefully, that will continue.

On the other hand, I have a 93-year-old physician father sequestered at his home. I do visit but stay at least 6 feet away from him. From his point of view, as he doesn’t drive, things aren’t that much different than normal. These visits may have to stop at some point, which is sad.

I pray for my friends whose jobs and thus their income has been interrupted by this mess. Hopefully, we can find ways to help.

My advice to all would be to lay low, wash your hands frequently. Perhaps a shower after a trip to the grocery store, or other public spaces would be prudent. Disinfect work surfaces obsessively. By all means, get outdoors for exercise if you can.

I would ask your physician about hydroxychloroquine/azithromycin. The doses are readily available on the web and at least around here, they are still available in the pharmacies.

It would be really smart to stop smoking at this point.

And for God’s sake, don’t be a martyr. If you’re sick don’t go to public places, and don’t go to work. Even if you are a healthcare worker, stay home. You’ll do more harm than good.

I fervently hope, and cautiously believe that in a month or so, if all of the efforts in place are effective, the curves will flatten, and things will begin to normalize.

Then I can go back to writing about cameras.

I’ve been distracted of late.

Every ten years, I am required by the American Board of Medical Specialties to recertify in the  medical specialties in which I am Board Certified. For me this means Pulmonary Medicine , Sleep Medicine, and Critical Care, which occur on different cycles. I am currently in the final stages of study for the Pulmonary Exam, so the blog has been relatively quiet. I will have to take the Critical Care exam in November.

I am thrilled however with the continuing interest in the content that is currently available.

Once I’m done with the current exam (May 4th), I will have some breathing room.  I have several things I’d like to explore in writing here.

Until them, wish me luck.