This article, edited, appeared in The American Thinker on May 16th, 2023

Several weeks ago, on my way to lunch, I stopped at the testing facility in our hospital for my weekly COVID test. This has been a requirement of my employment for at least the last year and a half after I refused vaccination.  The pretty young woman that has been assisting me, collected my sample. She then informed me that the testing facility was closing for good later today.  Subsequently, the hospital administration minimized the requirements for masking within the facility. With these developments, it felt as though the COVID debacle had finally ended.

Reflecting on this, I think back over the 3+ years and cannot escape the profound effect it has had on my life both during the pandemic and now afterward. I have seen death, certainly particularly in older patients and those with comorbid problems. But I have also seen fear and anxiety as a catalyst of social change, and generally not for the good. I have seen factionalism develop over differences in one’s level of vigilance and concern over the disease burden, and later about attitudes towards treatment and vaccination.

I lost friendships. In the beginning it was over the fear of being in contact with me as a caregiver for these patients. Later it was because I invoked natural immunity, and avoided vaccination. I endured their ridicule and even anger about my quaint notions of viral immunity, ideas that would have seemed completely rational, 2 years before.

Now things are changing. Very quietly I think people have grown to accept the notion that this virus was born in the Wuhan lab. It became clear that the draconian lockdowns were of little help, and left a lot of economic, social, and educational damage. They are finally beginning to understand that natural immunity, though not perfect, is likely to be more durable than that provoked by “boosters”.

It is also beginning to sink in, that the vaccines, were untested, minimally helpful and are likely to an extent unsafe, especially for the young. The lack of acceptance of the new bivalent injection I think confirms a new public wariness. Likewise, there has been a pronounced lack of enthusiasm for pediatric inoculation.

But for me, there have been much broader revelations.

As a physician in my 40th year of practice, the events of the past several years have had a profound effect on the way I think of the care I have been rendering.

The CDC, and NIH, manipulated the government, and the willing press, into supporting incredibly corrupt behavior. Prestigious medical journals, such as the Lancet, suspended their usual stringent review processes to publish fraudulent data. The regulatory agencies, and Pharma, acting in concert, punished non-doctrinaire opinions. They manipulated our academic institutions by the issuance and withholding of grant money. Leaders such as the beloved Dr. Fauci promoted phony letters to the editor decrying the lab leak origin story. This was done to protect the NIH and its likely illegal contributions to the Wuhan Institute of Virology for gain-of-function research.

Because of all of this, I looked back and wondered about my entire career. Was everything a lie? Were there medications, perfectly adequate, that I was convinced to discontinue in favor of new patented and expensive medications, with less well-understood safety profiles? How many of the other articles that I had read over the years were corrupt documents, meant to bolster the profits of the pharmaceutical industry? Just how badly have I been manipulated?

As a physician, particularly at my age, I have tried hard to remain current with my specialty. But how much of the latest information I absorbed served only to support the lucrative relationship between academic medicine and their sponsors at the pharmaceutical companies.

I never meant to bring too much drama to this pandemic, which I was fairly sure, even early on, would not be as severe as the doomsayers predicted. But I failed to anticipate the more profound interpersonal, economic, and professional impacts it would have on my life and that of others.

There is a punch line here. Despite being completely asymptomatic, and despite the fact, that months ago, the CDC declared random testing to be useless my last test was… positive.

Feels like a fitting end for this nonsense…at least for now.

I would be honored if you shared this.

Header image: After the Fire (Fujifilm X100V)

It has been 21 months of social upheaval and weirdness since the gift of love from the NIH and the Wuhan Institute of Virology.  In that time period, we have seen a widespread loss of faith in our government health apparatus based on contradictory, illogical, and frankly nefarious behavior.

I’ve divided this article into two parts:

Part number one was intended to be published on 18 November, but frankly, for a variety of reasons, including sloth, I didn’t get around to it.

Part two is being written today. I’m doing this in part because of new developments that are significant, and also as a bit of “I told you so”.

Part one: November 18

Overall U.S. Covid “cases” are falling, particularly in the South, while some isolated northern states are having surges.  We have seen this seasonal pattern before, with the arrival of the outdoor recreation season in some climates, while others seek shelter as temperatures drop.

If you look at recent data, the percentage of hospitalizations and death, as a percentage of the total “cases” has also been falling. This is likely due to multiple factors, including vaccination, increasing natural immunity, and better care particularly in the ICUs.  It may also be due in part to the more benign characteristics of the current “delta” variant which is now dominant in the population.

A virus can be thought of as a small biological machine.  They are not considered as living entities, but more as mechanisms.  The spread and dominance of variants tend to occur when mutations cause a particular set of useful characteristics:

1.  The virus evolves to be more infectious.  This could mean that smaller numbers of viruses are needed to institute an infection, and/or the virus changes characteristics to survive better between hosts.  The virus can also evolve to create symptoms in the host that facilitate spread, such as coughing or diarrhea.

2.  The virus becomes less lethal.  These little mechanisms derive no benefit from killing their host.  Arguably the virus can spread more rapidly if the symptoms are mild, and the host remains in contact with others.  Decreasing lethality will also be caused by an increase in acquired immunity in the population (and perhaps their offspring).  In other words, we and the virus evolve so that we can coexist.

Other than the outlier viruses SARS CoV, MERS Co-V, and SARS-CoV2, there have been four coronavirus types that typically circulate in the population and cause respiratory infections.  These typically cause mild to moderate symptoms though they too can be the cause of pneumonia, and ultimately death, in vulnerable populations.    They are estimated to be responsible for 10 to 30% of viral respiratory infections.

Now here’s the thing. Because they are generally benign, and there has been no therapy identified specifically for these viruses, we generally do not test for them.  And we certainly do not isolate or vaccinate. But we do for Covid.  And at some point, that is going to have to change.

Coronaviruses in general have been endemic in the human population for thousands and thousands of years.  Acquired immunity to them tends to be “relative” in that people tend to be reinfected multiple times in their lives, but typically with modest symptoms.

That may explain the performance of the current vaccines.  At this point, they do not seem to prevent infection and spread but do seem to blunt the severity of the illness that results (though this effect is also waning).  The point is, that SARS-CoV2, will likely become an endemic virus, and any expectation that you will not be reinfected at some point is probably unrealistic.  At some point, we will need to normalize our behavior towards this infection and cease with all the isolation and dramatics.

There is some hope.  As much as I despise Pharma, and their actions regarding hydroxychloroquine and Ivermectin, Merck, and now Pfizer, have introduced oral medications for Covid.  Happily, these drugs are patented, so the pharmaceutical companies will make a lot of money and so happily promote their use.

 Pfizer claims that their medication Paclovid, reduced hospitalization by 89% and death by 100% in their clinical trials.  If this bears out, it would definitely be a significant development, with the potential to change both the epidemiology and psychology of this illness.  Merck claims that their new medication Molnupiravir, was roughly 50/100% effective using the same criteria.

In case you wondered, in several meta-analyses, Ivermectin is about 65% for early treatment, with similar numbers for late treatment. It’s about 87% effective for prophylaxis.

I wonder, given these new medications, and the growing sense that the vaccines seem both relatively risky and ineffective, that Pharma will deemphasize the “jabs” for their new therapeutics.  This may be especially true now that monoclonal antibody cocktails given subcutaneously, have recently been shown to have potential as COVID-19 prophylaxis for as long as eight months.

Part two:

So that was written on November 15-17. It is now 2 weeks later and there have been significant developments since.

The number one development would be the continual deterioration in vaccine performance. We are now seeing significant numbers of fully vaccinated people admitted to ICUs, in some cases never discharged. Both director Walinsky, and Dr. Fauci have been forced to acknowledge this. Their answer: inject patients with even more spike protein mRNA.

There is an abstract published in the Journal Circulation that studied the body’s release of certain biomarkers predictive of cardiac complications after receiving the mRNA vaccine. It concluded:  “that the mRNA vacs dramatically increase inflammation on the endothelium and T cell infiltration of cardiac muscle and may account for the observations of increased thrombosis, cardiomyopathy, and other vascular events following vaccination.”

Now, remember back in 1998. A paper was published by one study group investigating the effect of hormone replacement therapy for postmenopausal females on the heart. It concluded surprisingly, that cardiac outcomes were worse in females who were receiving HRT. In an instant, HRT ceased as an option for women.

Let’s see whether this Circulation article has a similar effect on these vaccines (I doubt it).

Poor Merck. They spent the last year impugning their old drug Ivermectin for the treatment of Covid 19. Shockingly they then released their new oral therapeutic, Molnupiravir which they initially reported as having a 50% reduction in illness and death when used treatment of SARs-CoV2. This made Dr. Fauci very excited.

Fun fact: Molnupiravir works by inserting errors into the viral genetic code. Apparently, during the trials, subjects were required to refrain from heterosexual sexual intercourse, and in the case of females, be using birth control. What could go wrong?

Earlier this week they downgraded that effectiveness number to roughly 30%. This is a problem when Pfizer is reporting 89% effectiveness of their new oral medication Paclovid. If this data bears out I would imagine Molnupiravir will be a bust. Karma is a bitch.

Just so you know, the geniuses in our government have already arranged to buy $1.7 billion worth of this apparent loser. Oops.

  By the way, the much more effective Pfizer drug uses a similar mechanism of action to… You guessed it… Ivermectin.

And now we have the Omicron variant emerging from South Africa. This apparently has the World Health Organization in a tizzy, which the press is dutifully reporting. This variant is said to carry multiple mutations including changes to the spike protein (you know, where the vaccines work). It is said to be more infectious than Delta, but there are indications that symptoms are generally mild. There is obviously great hand wringing that it will be vaccine-resistant (like delta already is?).

Maybe they can lock us down again this Christmas.

To close this up, let me review the facts we need to remember to avoid being manipulated by the hype.

1. SARs-CoV2 is a respiratory virus, much less severe than SARs1, and over time, roughly as deadly as a bad influenza season.
2. We are being pushed to take multiple doses of hastily developed, still investigational monovalent vaccines. We are vaccinating during a pandemic which generally a bad idea. The vaccines over time do not really appear to be very effective.
3. The new variant is  likely doing what viruses are supposed to do; evolving to become more infectious but less virulent. It is frightening to the medical establishment, because its spike protein mutations threaten to completely discredit their entrenched “vaccine only “policies.
4. Given the large percentage the population with pre-existing Coronavirus exposure, and ongoing SARs-CoV2 infections, there is likely a high percentage of the population with broad-based immunity, even to new variants.
5. There are effective IV and now oral medications. Some are repurposed, but there is a new oral med they may actually allow us to use to treat this infection when it occurs.

I apologize for the length of this. I confess that writing these articles helps me to disperse the toxic degree of cognitive dissonance I experience when ingesting Covid information from the government and the media.

I very much appreciate your interest, your shares, and your comments.

Header image: Deer Camp near Sullivan Falls (Fujifilm X-T10, XF 18-55mm f2.8-4)

It is week 27 of the COVID restrictions in the Commonwealth of Pennsylvania. We are definitely seeing another surge now that fall has arrived.

We’ve actually set a record number of new cases per day with 2200 new Pennsylvania “cases” on 23 October compared to the Spring peak in mid-April at about 1700 cases per day. Happily, at this new peak, hospitalizations are only 37% of their peak in the spring. The death curve remains flat.

Around here we are seeing some activity, including in my own hospital, but so far it is not overwhelming. And we have tons of potential ICU capacity based on our reshuffling of beds earlier this year.

A little perspective however is in order. According to the most recent data on the Pennsylvania COVID 19 dashboard, the test positivity rate for the state is still around 5%, and the overall percentage of ER visits for “COVID like illness” is .8%. There is considerable variation among the counties.

Other states are surging also. States like Minnesota, Wisconsin, and Ohio are having what one might say is their first big peak, with an accompanying admission peak, more commensurate to what we saw in April.

Governor Wolf has so far resisted the temptation to re-impose our Spring restrictions. I’m hoping he realizes that for many businesses, another shutdown would be fatal to their existence. This virus is apparently going to be persistent, at some level we are going to have to figure a “workaround “.

It should be a hopeful sign, that President Trump, and his affected staff, have emerged from their infections essentially unscathed. I do recognize there are people reading this that may have wished for another outcome. I also note that he was by current practice rather aggressively treated. When you compare his disease course to that of Boris Johnson, who became ill in the spring there is a symbolic cause for optimism.

Mr. Johnson is you may recall in early April, contracted the virus. He became rather seriously ill to a point of needing an ICU, and by contemporary accounts required considerable supplemental oxygen. Much like his American counterpart, I am sure he received the maximum therapy available through the National Health Service of Britain at the time. But now we have Remdesivir, antibody cocktails, anticoagulation, and dexamethasone. 5 months later, our head of state, despite being older, had a much milder illness and quickly returned to a rather vigorous schedule.

If I keep writing these articles on a 2-week schedule, the next one will be after the election. It is been fashionable to accuse our Democratic Governors of playing politics with the virus, I myself have been guilty of this. At times, like in mid-July when restrictions were reimposed while cases were still flat, it seemed likely.

There are those who find the current case surges in swing states suspicious. They note that many democrats have already voted by mail, whereas Republicans tend to wait to cast their votes directly. They suggest that these case “surges” are manufactured to discourage Republicans from in-person voting. I might have been open to this concept except as mentioned above, there appears to be real illness associated with the increasing case numbers, at least in our commonwealth. Still, with masks and distancing, I have no fear of the polling stations.

in response to these articles in the past, I have been criticized, particularly on Facebook, for what some people feel is a cavalier approach to this outbreak. I think I’ve been fairly consistent, suggesting that we not react merely to the number of positive tests, but to factors such as hospital utilization, and of course deaths, to decide public policy regarding COVID 19. Given what been going on in the last week, I think it is time to be more careful now. We need to go back to more frequent handwashing, the wearing of masks (for what it’s worth) social distancing, and protection of the vulnerable. We need to carefully balance our understandable desire to socialize, with the risks of gatherings indoors.

There is some reason for cautious optimism. Obviously, with every new case that is either asymptomatic or recovers, that’s one less person who can transmit the virus. With over 5000 positive tests for instance in Luzerne County, if you factor in the asymptomatic’s that were never tested, you may have a lot of immune people in the region.

We also note that the virus is thought to be getting less virulent as time goes on, which is predictable. So far it seems to be the case, that in regions that are having their second or third peak, hospitalizations and death are far lower than when the virus first appeared.

Also, according to Dr. Fauci, we are perhaps 3-4 months from when a vaccine will be available. It is my hope that we can all find safe ways to patronize our small businesses to keep them afloat until the end of the pandemic but still avoid unnecessary spread. We need to come out of this, intact and healthy both as individuals and as a society.

We need to be not fearful, just careful.

As always, I would be honored if you would share this post.

Header image: Witch Hazel (Fujifilm X100V, TCL X100)

We have officially hit week 31 of curve flattening, infection prevention, disease curing, bizarro world. With the weather growing colder here in Pennsylvania there has been an uptick in positive coronavirus “cases”, meaning positive PCR tests. There has been a small increase in hospitalizations, but the death curve is so far flat.

Remember that the New York Times reported that by the current method of PCR testing, up to 90% of people who are PCR positive may be noninfectious. My fear about the rising case numbers is that our governor and health secretary will use the occasion to increase the restrictions upon us. Remember the severe “red phase” lockdowns in spring. All that misery and lots of people still got sick.

Of course, the big news in the last week was the fact that President Trump and a significant number of White House staff have tested positive for coronavirus. Although there have been allegations, that the president was cavalier about masking, the bottom line was that he has been tested frequently if not every day, along with apparently anyone who was in contact with him in the White House. This clearly was an extraordinary effort to protect him from the virus. Yet it failed. It did so for one reason: this virus is ubiquitous in the environment.

He was admitted to Walter Reed Hospital, not so much because he met the criteria for admission, but because he is the president. Though apparently never requiring oxygen, or getting particularly sick, he was treated with a very aggressive regimen of medications including the antibody preparation from Regeneron which is clearly experimental. After a 2 day admission, he was discharged.

Apparently, he is testing negative for coronavirus now and has been deemed “noncontagious”. The other “infected” staffers, including the first lady, have all done well. As I understand it, no one else was hospitalized.

The Pennsylvania new “case“ numbers are impressive. On October 7 there were roughly 1400 cases reported, roughly the same number, as were reported on April 23 for instance. The difference is that on October 7 there were roughly 700 patients admitted to the hospital with COVID, versus 2700 in April. Whether these patients are actually sick from the virus, or merely PCR positive is anyone’s guess.

It’s also was noting there was far less testing being done in the spring. Clearly, either the tests are oversensitive, or the virus has changed. Maybe it’s a little bit of both.

The search for a vaccine apparently is continuing at a rapid pace. Apparently, the Johnson & Johnson candidate may have provoked some unusual symptoms in one of its test subjects and for now hold has been placed on their efforts.

So now we have increasing cases and so far, God willing, little morbidity. Given the availability of more sophisticated care for those to become ill, I continue to believe that continued numbers of asymptomatic and mildly symptomatic COVID infections is actually good news about our journey to a helpful degree of herd immunity.

Remdesivir is also in the news. On October 8 a study comparing the drug to placebo in ICU patient’s revealed that the median time to recovery, defined by the study as either discharged from the hospital or to a custodial situation was 10 days in the treatment arm and 15 days in the placebo arm. This is a fairly significant result suggesting the drug is a useful part of our growing options for the treatment of COVID 19.

I continue to believe that given the persistence of the virus, it’s declining virulence, the improvements in treatment, that we should relax the regulations killing specific industries and small businesses. We need to react, not to PCR tests, but to actual illness, hospitalizations, and death from COVID, not PCR positives with other acute medical problems.

Finally this week, the World Health Organization seems to change its mind on the advisability of lockdowns. In an interview, Dr. David Nabarro, the WHO’s Special Envoy on Covid-19, warned against using lockdowns as the primary control method for the coronavirus, for fears that global poverty and malnutrition may ultimately result. He expressed concern that for instance, the suppression of the tourist industry has impacted many destination countries severely.

In other words… after eight months of masks and misery, people continue to be exposed to this virus. Time for plan “B”.

Hopefully, Governor Wolf is listening.

As always, I’d be delighted if you’d share this with your friends.

Header image: Maple in the Glen (Fujifilm X100V, TCL X100 II)

It is now 6 months into the dictatorial restriction of our liberties sold to us as “2 weeks to flatten the curve”. There do not appear to be any goalposts being offered to give us hope.

We can surmise, that the availability of an effective vaccine for SARS Cov-2 will liberate us, but this was squelched by the eminent Dr. Fauci, who claims that even with a vaccine, restrictions will need to be maintained until at least the middle of next year. I read that as until June/July 2021.

Meanwhile here in Pennsylvania, the number of new cases per day, after a small late July peak, has once again begun to decline, along with the number of hospitalizations. The average percentage of emergency room visits for COVID-19 type symptoms is 0.6%. The highest percentage comes out of Sullivan County with 3.8% though they still have no documented cases of COVID 19. The average PCR positivity rate is 4.2% throughout the Commonwealth. I’m sorry but this no longer feels like a pandemic.

Meanwhile, we continue, with what is becoming ritualistic behavior vis-à-vis masking. I have made it clear in the past, that I have been compliant up to now, out of courtesy, and out of the desire not to cause problems for businesses I frequent. But as this disease fades, so should we see our precautions fade. Instead, it’s becoming ingrained.

So now I walk into a restaurant. Shortly before entering, I slip my mask on my face. Throughout the summer this is largely been out of doors, and I walk at a distance from other patrons over to a table (no bar seating allowed), either with my wife or to join a group of friends. At the table, we are permitted to unmask. This is despite the fact that we are now sitting much closer to each other (often no further away than we would be at a bar). None of this makes any bloody sense, not only given the minimal incidence of the virus now but by the mechanics of respiratory droplet spread.

Another issue has to do with the persistence of the virus. The experts seem to be preparing us to understand that this particular virus is going to be persistent in the environment. This is really shouldn’t be any great surprise, as it is true of the adenoviruses, rhinoviruses, and other coronaviruses that circulate year-to-year. It’s only by repeated exposure that most of us have at least partial immunity to these common viruses. This means unless you’re very debilitated, you are unlikely to get very sick. Sound familiar?

I hope we have not squandered the opportunity over the summer, through more unfettered social interaction in outdoor spaces, for healthy people to get small exposures to the virus. This would be important in the pursuit of some level of “herd immunity”. I am concerned that as the cold and flu season begins, that we will overreact as respiratory illnesses become more common.

As many of you know, I have been using the Atlantic magazine’s COVID Project among other resources, for some of the data in these articles. As a left of center publication, one would hardly think they would shave the data in a conservative way.

I looked at South Dakota, now 4 weeks from the Sturgis motorcycle rally. South Dakota, it is one of the few states that does not have a mask mandate. The event was accused of being inappropriate, and later of being a “super spreader”. On the website, there are multiple graphs documenting a number of parameters including new cases, number of tests, number of hospitalizations, and number of deaths.

At first glance, the numbers are concerning. South Dakota had had very few cases of COVID, with small peaks in April and May. The curve was then flat until roughly August 16 (right around the end of the rally) when an upward spike began, peaking in early September. Hospitalizations, also peaked, interesting to roughly the same level seen in May with a much smaller number of total cases. The graph of deaths also had a small peak.

All of this looks discouraging except for something I initially overlooked. The graphs used by the Atlantic, have a different scale for each state. This makes it easier to track smaller numbers but also makes small changes look much more dramatic. For instance, the second large peak of hospitalizations post-Sturgis looks impressive, but the number was only 83 admissions for the state. The death peak was 2. Sturgis hardly appears to have been a “super spreader”.

There is more encouraging news. We talked about the CDC reports of “excess deaths ” several weeks ago. This is a comparison of the agency keeps between the actual number of deaths throughout the US for a particular time of year, versus the expected number of deaths. For the first time since April, in the third week of August, there were no excess deaths, and in the fourth week of August, we’re actually 14% below the expected death rate for the week. This certainly seems consistent with our impression that although there are significant numbers of positive PCR tests, the morbidity and mortality associated with this are very low. This may be due in part to the over sensitivity of the PCR test, and possibly a better understanding of how to treat the smaller numbers of those who become critically ill. If we remain below the expected death rate, it might rightfully be said that this outbreak is over.

At any rate, in Pennsylvania, there appears to be no end in sight. A federal judge ruled that a portion of the Wolf/ Levine unilateral restrictions are unconstitutional. I’m not well versed in law but I understand this suit was brought by plaintiffs in a variety of businesses, whose complaints have been largely dealt with as the state partially reopened. Members of the hospitality industry were not a party to this, thus their issues were not addressed in the ruling. The main effect of this may be to relax the restrictions on public gatherings. The Wolf administration is expected to ask for a stay, while they appeal.

I’m uncomfortable with the idea of becoming a militant “antimasker”. The extreme viewpoints on either side of an issue tend to be wrong. Then again, I think we need to find a way to cut through the unwarranted fear, both for our health and for legal liability, the politics, and the religion-like virtue signaling that has become a part of the public reaction to the pandemic. If the virus is here to stay, we’re gonna have to learn to live with it. To me that means moving back towards a normal state of existence.

People keep saying “follow the science”. I completely agree.

As always, I would be honored if you would share this.

Header image: Old Trail near Ray Brook (Fujifilm XE3, XF 18-55 f2.8-4)

We are now in week 25 of the two-week effort to flatten what has become the flattest curve that can still be a curve. Pennsylvania seems to be over a slight bump in cases we had in July and August. The number of new deaths remains flat.

Nationwide statistics are interesting. I’m looking at the curves on the Atlantic’s COVID Project. Overall, in the US were clearly two peaks of new cases: 1 in early April and a second peak this summer. The latter produced roughly double the number of new cases per day as the peak in April. Of course, the number of tests performed during the summer surge was significantly higher than those performed in April.

 Interestingly the number of hospitalizations for both of the peaks was roughly the same, but the number of deaths was significantly lower in the summer (April peak daily deaths were around 1800, in early August around 1200. This tends to confirm the impression on multiple fronts that the virus has become less virulent, or we have figured out better therapies. Or… maybe our testing is a problem. More on this below.

Despite the favorable Pennsylvania numbers, our governor has thoughtfully extended his emergency powers for another 90 days, thus, of course, past election day. He can get away with this and continue this virtual dictatorship because his fellow Democrats control the Pennsylvania Supreme Court. I’m not sure I can see an end to this. Though he touts the various benefits the state receives from this emergency declaration, the fact remains that we probably wouldn’t need the benefits if he didn’t insist on the restrictions on businesses and churches.

There has been some news from the CDC on the characteristics of patients who have died carrying COVID as a diagnosis. Turns out that only 6% of the patient’s died of the virus without the contribution of comorbid conditions. Yes, this coronavirus is dangerous and potentially lethal. However with the overall death rate of COVID per Dr. Fauci currently at 0.6%, the death rate for healthy people who contract the virus is thus 0.0036%.

Now I have written before about death certificates. If the patient denies of respiratory failure secondary to congestive heart failure but has COVID as a contributing factor on the death certificate, is that counted as a COVID death? Remember a diagnosis of CoV-2 infection was financially advantageous for hospitals that were struggling because of the cancellation of all of their elective procedures. In light of this, here is another interesting guideline from the CDC website regarding the coding of COVID deaths:

COVID-19 deaths are identified using a new ICD–10 code. When COVID-19 is reported as a cause of death – or when it is listed as a “probable” or “presumed” cause — the death is coded as U07.1. This can include cases with or without laboratory confirmation (italics mine).

So in other words, if the patient presented let’s say in early spring with a respiratory syndrome, perhaps with a fever and URI symptoms, and ultimately died, the patient can be coded as a COVID death even in the absence of a positive test. And the coding in that way would benefit the hospital with an increase in reimbursement.

When you look at the CDC’s COVID mortality numbers, they are in a category known as “deaths involving COVID”. Not deaths “from COVID” or “caused by COVID”. This is the roughly 160,000+ US deaths being reported secondary to the virus. This apparently includes deaths from other causes when COVID 19 is listed on the death certificate. Even George Floyd may have qualified in this way.

As we have discussed before, death certificates typically have two or three lines where the causes of death would be entered. An in-hospital death would likely be filled out by an intensivist, or a hospitalist often employed by the facility. The first line is for the “disease state that caused the death”. The second and third lines are for “significant conditions contributing to death that did not contribute to the underlying cause of death”( per Pa’s Death Certificate Manual). Once filled out, it ultimately goes to the county coroner where it is reported to the state Health Department. Depending on the motivations of the state government, these numbers could certainly be subject to some “sleight of hand” if one wished to increase the numbers of Deaths related to COVID.

Before I get accused of being a COVID denier, let me say that on the same CDC website there is a graph showing monthly US death rates as far back as 2017, with a line just above the graft showing the point of so-called “excess deaths”. In every month since March, we have been above that line, so clearly there has been illness and death beyond the norm. It’s just that for many of us, the wave has passed.

The PCR test (deep nasal swab) for the coronavirus has recently come under scrutiny. A recent article in the New York Times does a nice job of explaining the methodology of the PCR test, and the likelihood of false-positive results.

PCR testing, also known as gene amplification testing, becomes more or less sensitive depending on the number of amplification cycles the lab specifies. It is thought that most labs have made the test so sensitive that it detects tiny amounts of virus or viral fragments that would not lead to clinical illness or disease spread. In the article, it is suggested that 85-90% of positive tests would be negative if testing were conducted more appropriately.

 The risk of false positives in PCR testing has been recognized before. In previous viral epidemics such as SARS-CoV-1, Zika, Ebola, or MERS-CoV, the CDC and WHO recommended that tests should only be performed on patients who either were symptomatic or were known exposures. It was also recommended that a positive test be followed with a second confirmatory test before assigning a diagnosis.

For some reason with the current virus (SARS-CoV-2), testing until recently was not limited to symptomatic patients, and still, no confirmatory tests are necessary. One positive PCR is enough.

There have been a variety of testing errors that have come to light. Most notably the 77 NFL players tested positive for the virus in late August in preparation for training camp. The players were all then retested and came out negative. Apparently, there was contamination at the testing lab. I think of other labs in Florida the reported having 80-100% positive results. Then there are the anecdotes of patients who registered to be tested, but never actually had a sample taken, but still received positive results. I continue to be concerned that our current testing regimen is deeply flawed.

All of the above is why I continue to believe and have stated multiple times, that the best marker for disease activity in the community is hospitalizations and deaths actually caused by SARS-CoV-2. It is these parameters that should be used to determine the government and public response.

So we in the “early states” where the actual COVID illness has come and gone, remain stuck with business and worship suppressed, following illogical regulations with no end in sight. Oh, maybe there will be a rushed vaccine of questionable efficacy and safety that many will refuse.

The curve is officially flattened.

Now we’d like our lives back.

I would be honored if you’d share this.

Image: Summer evening at Fountain Lake (Samsung Galaxy S8)

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, 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.

 

Today, I learned that I have completed a ritual that I have been participating in for the better part of 30 years. I am somewhat hopeful that it will be the last time it is necessary. I’m talking about recertifying in one of my medical specialties: Sleep Medicine, through the American Board of Internal Medicine.

Board certification has been a mainly voluntary way that physicians validate their expertise in whatever specialty they choose to pursue. In my case, over the years I have been “board certified” in four specialties: Internal Medicine, Pulmonary Medicine, Sleep Medicine, and Critical Care Medicine. For 3 of the specialties, I am required to sit for a day-long exam, every 10 years. If you are an older physician, you may be “grandfathered” into some specialties (which is why I don’t need to recertify in internal medicine).  :  If for instance,  I had trained one year earlier, I wouldn’t have had to recertify in pulmonary medicine 3 times during my career.  This fact alone brings the whole business into doubt.

Meanwhile, the boards keep subdividing care by inventing new specialties.  For instance (and there are many) as an internal medicine resident, I was trained to care for hospitalized adults, who naturally tend towards being geriatric.  That’s what internists did. Now there are boards in geriatrics. Cardiologists now sit for boards in echocardiography, nuclear, and electrophysiology.

 Pity the poor surgeons. They finish an arduous 5-year residency only to discover they’re essentially not qualified to anything without a fellowship.  For instance: abdominal surgery is the “bread and butter” of general surgery residents work. In 2018 this means colectomies for colon carcinoma. But the American Board of Surgery has created a specialty of Colo-rectal surgery. This means that you may have to be an underpaid servant for an academic colorectal surgeon, for two more years, before you go into practice. And the ABS will be able to extract more money from you, over your career, to keep you fully certified.

As anyone who is been through the board certification process will tell you, the process is arduous and expensive. Yesterday’s test for me was the culmination of 10 months’ worth of effort. For much of this I have been studying 2-3 hours a day, this despite the fact that I actively practice sleep medicine, teach residents, and run a sleep lab.

 When I was a young man, and first took my Internal Medicine boards, I insisted upon being a purist. I studied the major internal medicine textbooks, and some physiology books, and felt really good about my knowledge base. I know several others that took this approach. By and large, we all flunked. I then I got wise and bought the review materials (at some expense) from the American Board of Internal Medicine. Using these materials I subsequently passed.  But I didn’t know at as much internal medicine as I knew for the first exam.

Since that time, given the restraints of time allotted in a busy pulmonary/critical care practice, I have always attended the conferences sponsored by my specialty’s society and purchased their educational materials. And I have never flunked again.

For this recertification, I enroll at no small expense in the “maintenance of certification” process run by the Board of Internal Medicine I then purchased from the American College of Chest Physicians their online review course which was very done but also very pricey. I also purchased collections of review questions from the ACCP and a variety of sources which are extremely useful for testing practice.  Then you have to pay for the testing center. All of this costs me multiple thousands of dollars.

What is frustrating, given all of the effort involved, is that rather than ending up a review of good clinical practice, the review materials basically offer you a standardized medical dogma. Because the nature of multiple-choice testing is inadequate to the complexities of medical care, the board has needed to come up with a solution so that test grading can be precise.

Thus, a lecturer will say: “X” what I do in clinical practice, but for the Board exam the answer is “Y”. This blunts the clinical utility of the entire process. Shouldn’t the reason for recertifying be to ensure clinical competence? Instead, it becomes a measure of one’s ability to memorize facts that often questionably relevant to treating patients.

Another issue in this particular board exam (sleep medicine) is the addition of material that traditionally I would not be expected to master. As I understand it, the American Board of Internal Medicine in its infinite wisdom has chosen to partner with the American Board of Family Practice for this exam. I’m an internal medicine physician at my core, which is the specialty of adult medicine, I am not in any way, trained in pediatrics and like most people who are internal medicine based, I don’t practice pediatrics. Despite this, we have been required to learn pediatric sleep medicine which is rather distinct from the adult version.

Failing this exam would have significant financial consequences to me. It makes me wonder whether an internal med based sleep doc that flunks the test, particularly on the basis of the pediatrics material would have a legal course of action against the Board.  As this is a computerized exam, It would seem easy enough to delete the pediatric questions from the tests of those who are internists and add more material on adults.

It used to be even worse. For some reason, the physicians in charge of the especially boards seem to delight in making things even more arduous than they had been. 10-15 years ago they instituted a policy where we had to do “practice improvement” modules in our office. This involved, for instance, studying some process in our office, and then instituting some improvement, restudying the results, and reporting it to the ABIM. Given the already difficult nature of private practice, this was an absolutely over-the-top requirement. Most every practice I knew ended up in some way faking the results. A major pushback from medical societies finally caused this nonsense to be suspended.

So now it’s  time for the final exam. You’ve purchased all of the review materials and spent months and months reviewing, learning all of the official answers required of the Board.

November 20 of last year I went to a test center. Happily, one is located within the half hour of my home which means I no longer have to travel to a major city and pay for a hotel room in order to take the exam. I suspect however that many other physicians still have that expense.

In my particular center, the staff was extremely courteous. I suspect for them this is an adaptive strategy given the indignities they are forced to impose on those being tested. The security involved is over-the-top and was frankly demeaning and insulting. First, you need two forms of picture ID. For many people, this will mean a passport as well as a driver’s license. You can take nothing into the testing area except your clothing. Your watch, bracelets, wallet, obviously your cell phone, any coins or even tissues are not allowed in the testing room. They confirm this by making you turn out your pockets. All of your belongings are placed in a locker. You’re not allowed to drink coffee or chew gum. There are cameras that watch your every move. Your palm is scanned multiple times during the process, both to enter the room, and then every time you exit. Just going to the restroom is like being released and then readmitted to prison. The whole thing takes 6 hours, and frankly, at the end, you are grateful to be done

It’s so discouraging that at my age unless I am compelled, I doubt in 2021 I will recertify for my pulmonary boards again.  In another world where the process was more reasonable, I would out of pride, continue to recertify in all of my specialties.  But this has clearly become a racket. So I may have to retire early. And there aren’t many young pulmonologists to take my place.

As a senior physician, multiple boarded, who has been a 30-year “diplomat” of the ABIM I know this could be different. I certainly understand the importance of ensuring that physicians of all specialties remain competent. And I think it’s reasonable for first-time candidates to be put through a rigorous procedure for board certification. On the other hand, I think that having achieved board certification in a specialty, you have earned the right to some dignity and dare I say economy, in the maintenance of your credentials.

Currently, the ABIM provides so-called self-assessment modules, that we are required to do between board exams. They are open-book tests that can be done at home. There is, of course, a charge for participating. They seem to be targeted to force the review of the new literature, and developments, that are significant to clinical practice. They take time but they seem far more valuable clinically than the rote memorization of useless facts required to pass the 10-year exam. I certainly think they would be an adequate way to assess physicians for recertification.

As a physician, we are under ever-increasing demands from the hospitals, the health insurance companies, the plaintiff’s bar, and the federal government.

We certainly do not need to be harassed by our own specialty boards.

I have just returned from a trip to Baltimore, Maryland.

Often in June, depending where it is held, I attend the American Academy Of Sleep Medicine meetings.  This year they were scheduled for Baltimore, which is a surprisingly short drive from my Northern Pennsylvania home.

I’ve had many pleasant trips to the city in the past.  Though I initially hoped that my wife would accompany me on the trip, her work schedule prevented her from joining me, and I was forced to go alone. Thus I would need something to do with my free time.

Early June is a pretty good time to visit the Chesapeake region, as often the temperatures and humidity have not risen to uncomfortable levels.  Such was the case on my trip.  I arrived Sunday, shortly before a cold front came through, which on the back side yielded bright blue skies and temperatures in the seventies.  It was cool enough, at least on the water, for a light jacket.

Though this was not purely a photographic trip, I knew that I would want some gear along to occupy my off hours.  I decided on the Fuji X Pro 1 with multiple lenses for more deliberative photography, and the Fujifilm X100s, as my companion for street shooting.

I pretty much carried the X100s everywhere, including into the conference.  I took a lot of images even in the product exhibition hall, before discovering there was a strict rule against this, to the point where they would threaten to eject you, and confiscate your “film”.  The problem with enforcing this is that everyone had a camera in the form of their cell phone, and I saw many people photographing new products, that perhaps they wanted to remember, or even included a presentation.  Hell, one of the exhibitors had a Nikon DSLR in hand, and appeared to be shooting a lot of images.  The X100s was wonderful in this setting because of its stealth and its low light capabilities.

I have noticed, that compared to its predecessor the X 100, the X100s appears to have a decreased battery life.  This had been annoying to me before the trip, but I learned that if you keep the camera off (and not rely on the auto shut off feature), that the battery life was quite tolerable.  I did not need to change a battery over the three days of the trip (probably shooting 150 frames).

Anyone remotely interested photography who sees the Fuji X cameras, is fascinated by them.  They often assume that I am shooting film.

I took the opportunity to travel about.  Part of this was in search of meals, as the locals I encountered would generally send me out of the “Inner Harbor” neighborhood for the best restaurants.  Perhaps they are “seafood snobs” as I did have several good meals in restaurants overlooking the Harbor, including perhaps the best mussels I’ve eaten my life.  I don’t believe I’ve never had a bad seafood meal in the Chesapeake region.

It was a modest walk from my hotel, to the Federal Hill neighborhood of the city.  There, a large park occupies a flat-topped hill overlooking the Harbor, once used as a vantage point for cannons, which would have been the final defense for the city from the British in 1812.  The neighborhood features brick row homes, of an early 19th century vintage, quite similar to my old neighborhood in the Society Hill section of Philadelphia.

The neighborhood was positively festooned with quaint cafes and public houses (which is never a bad thing). Having stopped in a restaurant in the neighborhood,  I was reminded by my server  that in the Chesapeake region, they were having a particularly good soft-shell crab season.  She served me an appetizer that deliciously proved her point.

The above image was shot inadvertently at ISO 1250 which required a shutter speed of 1/10th with the lens at f2.8.  This points out some good and bad features of the X Pro 1.  The good: that the combination of lens stabilization, and the lack of a mirror, allowed me to shoot a sharp image, at relatively slow shutter speeds.  The bad: the lack of an effective auto iso control on the X Pro 1 (as opposed to the feature on the X100s) means that I have to pay attention when switching cameras, remembering to alter the iso setting manually on the X Pro 1 as the lighting changes.

On another day, I made use of the water taxi service, both to gain another photographic vantage on the harbor, but also to visit Fort McHenry, which is preserved by the National Park System, for its role in the war of 1812.  As you may well remember, the fort served as the primary, outer perimeter defense of Baltimore Harbor.  It was the sight of the American flag being raised over the fort, after the British Fleet was sent packing that inspired Francis Scott Key, to write the Star Spangled Banner.  The fort served many purposes since that battle, including as a hospital for wounded in World War One.  Sometime in the early part of the 20^th century, it was restored to a condition near to that, when the famous battle occurred.

In order to get to the fort, you have to stop to change boats at Fells Point, a neighborhood of Baltimore famous in the early 1800’s for privateers: civilian ships and crews, who were sanctioned by our government to raid British shipping. This is another quaint historic neighborhood that if anything, looks a little older than that at Federal Hill.

It was also quite gentrified, again with bars, B+B’s art galleries, and quite honestly more bars.  Your water taxi ticket gives you two-for-one beer coupons for many of the establishments.  This makes it extremely important to remember that there are no “facilities” on the boat for the ride home.

As a whole , this city is a wonderful location for photography.  It is obvious that it has been developed in such a way that it is pleasant to view from the water, in a much more intimate way than for instance, New York.  There is a varied architectural themes throughout the city, all of which makes it visually stimulating, and quite interesting to photograph.  And the people are very friendly and proud of where they live.

Baltimore is a lovely place to visit.  I think the best months for a trip, might be mid to late May, and for September/October, all months when the schools are still in session, the crowds reasonable, and the temperatures moderate.

And, best of all, it’s soft-shell season.