It is week 24 of “two weeks to flatten the curve”. Pennsylvania’s recent bump in cases, mainly in Western Pennsylvania has subsided with a minimal increase in hospitalizations and no real increase in the rate of death which was already quite low.

There are a few counties said to be “problematic” because their PCR positivity rate is greater than 5% (the overall rate in the state is 3.4%). Most counties report that the percentage of their emergency room visits for COVID-like symptoms are less than 1%.

In the southern states, almost without exception, their rates of infection have peaked and are now decreasing. As I have said before, there was definite morbidity and mortality as a consequence of these surges. Those numbers too are either flat or improving. You can see this most easily on the Atlantic’s COVID project page where each state’s data is numerically and graphically displayed.

 Almost without exception, all of the recent trouble spots were in essence experiencing their first onslaught, much like the Northeast experienced in April. One gets the impression that the virus is moving through the country like a wave that started in the Northeast and moved south and west. Interestingly the Dakotas seem like the next hot spot, but although their numbers are rising, they are rather low compared to other states.

To me, it seems that the virus’s behavior in the Northeast over the summer months has been similar to the seasonal behavior of other respiratory viruses. We remain aware of its presence because uniquely among respiratory viruses, we are continuing to test for it in the population. Given the burden of disease suggested by the emergency room and admissions data, it would otherwise likely go unnoticed.

Some would say that it is through our masking and social distancing, that we have controlled the pandemic. I would argue that this virus is observing its own timeline, with a minimal impact from our suppressive efforts. Like most viral infections once it enters the population it spreads, peaks, and declines. That is happening all over the country, we’re just several months ahead.

I still wear a mask and respect people’s space. But after the onslaught, this spring and the many months since only 1% of Pennsylvania’s population has been documented to have an infection. Maybe we need to relax a bit.

There is certainly reasonable concern about opening schools and colleges. This has already happened in much of Europe and Asia with generally good success. Middle school and younger children have a low amount of the ACE2 viral receptor and generally are thought not to be contagious. Older children are “spreaders” but usually with fewer, milder symptoms. Teachers of course are older and a concern, but are exposed much the same as anyone who deals with the public. The good news is we can watch other countries as they move forward.

I do want to speak to another virus that infects us and is far worse than coronavirus. I speak of the rampant disrespect and intolerance online and in the community, at large. As a baby boomer, I would be tempted to ascribe it mainly to younger people, but I know that isn’t true. Somehow, we got to a point where people have no regard for others, especially if they hold views that they find disagreeable.

The incubator and breeding ground for this is social media. Facebook and Twitter have provided an arena for arguments in the “ether” where people feel unbridled from the courtesies we generally employ when arguing in person. This is extremely pernicious in our increasingly selfish, areligious, and amoral society.

As many of you are aware I’ve seen this first hand. I spend a lot of time researching these articles before they’re published and I genuinely hope to convey what I believe is truthful information, even if it flies against what is being said in the media. I have been guilty of some snark when it comes to the governor and the secretary of health. I only began to be critical of them in mid-May, after we passed our infection peak, and there was no sign that they had any interest in listening to voices in the legislature, or those of small business owners being driven out of business. I have tried to keep my criticisms based on their actions, and not their political party.

For several weeks now, I have had rather persistent, and militant, commenters on my Facebook page. These aren’t people that are pointing out specific errors they feel I’ve made. They prefer to condemn my viewpoint without evidence, and quickly go “Ad hominem” when rebutted. They accuse me of lying and are arrogant enough to report a post to Facebook for removal. They’re vicious and very persistent. The last person was posting under an account that appeared brand-new and had very little personal information. When pressed, the person admitted that the account was anonymous to avoid facing responsibility for their comments.

If I read something on Facebook for instance that I disagree with, I may post a retort. Usually, I reserve this attention for friends. I try to use irony rather than sarcasm as the latter tends to come off as mean. And I don’t persist. Friendships are worth more than winning an argument.

This angry self-righteousness in our citizens is far more dangerous than COVID. Because, as we see in places like Portland, Kenosha, Seattle, and Minneapolis, this pandemic has the potential to literally tear apart our society if it is not stopped. If anyone should be “quarantined”, it is the vicious purveyors of hatred and mayhem who infect and highjack peaceful protests.

I remain extremely grateful to those of you who share these posts and offer support and encouragement. I feel the same for those of you who disagree politely, either with a critique, or your silence.

It’s only with kindness and respect that we will cure this virus.

Image: Ligularia in August (Samsung Galaxy S8)

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

 

 This is an Editorial from the fall 0f 2009 as published in the Wilkes Barre Times Leader, on a diagnosis , that from the veiwpoint of a Pulmonary/Critical Care/ Sleep physician, is starting to overwhelm medical services in the United States.

It was written for a local Northeastern Pennsylvania perspective, but I think it applies to most of the US if not the bulk of of the developed world.

Although it is often mentioned as a cause of rising health care costs, I’m not sure that the average person understands the true impact of the epidemic of obesity on the healthcare system.  The statistics on obesity are available and sobering; 2/3^rd of US adults are considered to be overweight.  33% of adults in the US are categorized as obese (Body mass index greater than 30 kg/m2), up from roughly 12% in 1962. Twenty years ago, when I started my practice, perhaps twice a year a patient would present that was too heavy for my 350 pound capacity scale. Now it would easily be twice a week; the scale in my office now accommodates 750 pound patients.  I have personally cared for folks as heavy as 650 pounds.

Our affluent society has given us extraordinary access to high caloric foods. Fast food makes up an increasing percentage of our diets, and purveyors, keep inventing larger and more caloric offerings to entice us.  Foods high in sugars and carbohydrates tend also to be the least expensive which partly explains why obesity rates in the US are higher among the poor.  People are often just not aware of what they’re eating. A dozen chicken wings can actually equal a person’s total recommended caloric intake for the day. “All you can eat” buffets encourage a pattern of eating that can be potentially lethal to the wrong person.

We also lack perspective. When all your friends weight around 300 pounds, it may not seem terribly alarming to be approaching 400. I encounter this denial issue all the time. We sometimes have to confront people with the extraordinary degree of their obesity problem. It is not uncommon to have to remind a patient that they are three times their ideal body weight. Young people can be the most difficult to convince. When you are young man, you can manage a 300-400lb body without too much trouble. It is only later in life that such patients will develop the respiratory, back, hip, and knee issues that can be devastating.

It is well recognized that obesity leads to increased rates of diabetes, heart disease, malignancy, arthritis, and other health issues. A problem that is specific to my specialty (Pulmonary and Sleep Medicine) in the obese patient is Obstructive Sleep Apnea, a condition where breathing is interrupted during sleep by collapse of the patient’s airway. Treatment usually requires the purchase of a CPAP device, a small ventilator that pressurizes a patient’s airway during sleep, preventing this. This is expensive technology.

More expensive yet are the power chair and “scooters” increasingly provided to those whose weight, along with the inevitable arthritis of the knees and hips, makes them unable to walk.

At their “end stage”, patients become essentially immobile, unable to walk because of the orthopedic and respiratory problems. And because of their extreme weight, and complex medical problems they are often not considered to be a candidate for elective surgery such as joint replacement, because of the multiple risks associated with surgery in this population.

The respiratory system is affected by obesity in other ways. First, excess weight is an additional inescapable burden that must be carried about, increasing symptoms in anyone with an impaired cardiopulmonary status. Obesity tends to increase the severity of Asthma by both mechanical and metabolic effects.

Some obese patients will develop Restrictive Chest Wall Syndrome, which occurs when excessive soft tissue envelops the chest and inhibits the patient from utilizing their total lung volumes. An extreme form of the latter problem is referred to as Obesity Hypoventilation Syndrome. Also called “Pickwickian Syndrome” (named for a character in the Dickens novel The Pickwick Papers), the condition is usually linked to Obstructive Sleep Apnea, and in  occurs when chest wall restriction is extreme, and the patient hypoventilates to a degree that they retain carbon dioxide in the bloodstream and can literally be “smothered” by their  own adipose tissue. They will often respond to positive pressure therapy at night (similar to CPAP), and of course, significant weight loss.

Obesity has profoundly altered healthcare in hospitals. The obesity epidemic has forced healthcare facilities to purchase new, so-called “big boy” beds, chairs, lifts, and other equipment to deal with the burgeoning dimensions of our patients. Nursing staff bear s much of the burden of the epidemic. It is increasingly difficult for a single 150 pound female nurse to provide care to patients who are often more than double her weight.

Simple procedures such as even intravenous lines become difficult. Procedures such as central venous lines are even more problematic. These larger intravenous lines, often used in emergency situations, are placed using anatomic landmarks for guidance. As those landmarks are obscured in the obese patient, ultrasound imaging is now often necessary for successful placement. Even more troubling is that at some point, patients can become too heavy to undergo diagnostic test such as CT scans, for fear of breaking the scanner’s gantry, which could delay care for other patients.

Recently at John Heinz, morbidly obese patients were noted to be an increasing percentage of our inpatient and outpatient Pulmonary Rehabilitation Programs. This prompted us to create a unique Bariatric Respiratory program, utilizing our resources in Physical, Occupational and Respiratory Therapy, Respiratory Nursing   Pool Therapy, and Dietetics. It is available to obese patients who have respiratory diagnoses such as those mentioned earlier in the article. Patients can be enrolled as inpatients, usually in transfer from an acute care hospital, or attend as outpatients. The program consists of special joint-sparing exercise training, education, occupational therapy and an intensive program of dietary counseling with the goal of improving the patients cardiovascular fitness, increasing muscle mass, and thus metabolic rate, and planning a diet for slow, healthy weight loss.

  At Mercy Special Care Hospital, a Long Term Acute Care Hospital in Nanticoke, Pennsylvania, we have run a successful  ventilator-weaning program for the last twelve years. There too, we have seen a  shift from patients with diagnoses such as Acute Lung Injury, or end stage lung diseases such as COPD, to increasing numbers of patients whose ventilator dependence is due to Obesity Hypoventilation Syndrome.  Over the last several years, we have had great success treating obese, ventilator dependent patients by using a rather simple protocol. We carefully control their caloric intake, using precise metabolic monitoring, and begin aggressive physical therapy to make these bedridden patients ambulatory once again. Generally, once they lose 15-20% of their body weight, and begin to walk, they can generally be liberated from the ventilator.  Once liberated, they can be transitioned to home, or to the programs at John Heinz.  Such patients, if they participate fully, can have literally life altering results.

If you are struggling with weight issues, there is help available. Besides the programs mentioned above, there are numerous resources on the web including sites such as Web MD and freedieting .com.  The latter site has a calculator to establish your Body Mass Index, a rough guide to determine the need for weight reduction. Your physician can arrange a consult with a dietician to help you plan an appropriate weight reduction diet. Commercial programs such as Weight Watchers, Jenny Craig, and Nutrasystem can be very successful for the right individual. Finally, bariatric surgery is increasingly seen as a useful tool, offering long term health benefits to properly chosen patient’s that undergo it.

If we are truly control health care costs in this country, then recognizing obesity as a serious epidemic and effectively addressing it will be an important component of the solution. Recognition and treatment of the problem for individual patients can help them avert their own personal health care crisis.

Sadly, after January 2010, Medicare, in their infinite wisdom, restructured reembursement for pulmonary rehabilitation to  only those patients who carry the diagnosis of Chronic Obstructive Pulmonary Disease (cigarette-related airways disease), essentially eliminating outpatient rehab for obesity-related respiratory problems.  We continue to try to find ways to help this burgeoning patient population.