This Is Real With No Agenda.

It seems to be getting better

It is April 20 th and it seems to be getting better. We have more Personal Protective Equipment (PPE) and here on Long Island the surge is beginning to slow down. We still have a ton of patients but there is a feeling that we at least know a little bit more about what is going on. To that end let me clear up a lot of mis-information that I have seen on the internet.

What is a Bacteria and What is a Virus?

Bacteria

Bacteria are very tiny one – celled plants. When I say that they are plants, I mean that they are individual creatures that have basic characteristics of plants. They eat, they release waste, they reproduce, and they have cell walls (the part that gives vegetables their crunch) and they can alter their environment to make it more comfortable for them.

When we get bacterial infections, it means that these little plants set up housekeeping in a part of your body, such as kidneys, lungs, or throat, then they change the environment by changing the ph (to prevent the body from attacking it) that will allow the group of bacteria to reproduce successfully.

These creatures want to live, and they choose your body as a comfy place to live in. If you live or die does not concern them, but their main purpose is to have a comfortable place to live so they don’t tend to kill you right away.

Viruses

A virus is NOT ALIVE. It is a biological machine whose sole purpose is to reproduce. It consists of a piece of messenger RNA (a tiny strand of chemicals that carries instructions on how to build another virus) with an envelope and a way to inject it into a cell.

When the virus injects the mRNA into one of your cells, it hijacks the reproductive mechanisms of YOUR cells to reproduce itself. It truly doesn’t care to set up shop, or to make a comfy place because it is not alive. It will break into your cells, take over the reproductive machinery, overload and use up the cell to make more of itself and then burst the cells to spread more of itself.

In the picture above, the spikes such through your cell membranes (animals don’t have cell walls – we don’t crunch) and that yellow string of mRNA shoots through.

In COVID – 19 (COrona Virus that was ID‘ed in 2019), the pink spikes attach themselves to certain areas in the lung cells and the kidney cells.

The Disease

When the virus enters into your respiratory tract (through droplets that people cough out or even spew out when they talk) these things attach to the cells of the airsacs, take them over, burst them, and the viruses spread out into the air and into the blood. The viruses that go out into the air spread to people via droplets or land on surfaces to be picked up by people’s hands and transported onto someone else’s mucus membranes then into their lungs. The virus that goes into the blood, makes its way to the kidneys, attaches there and begins to destroy the kidneys as well as making its way back to the lungs.

Viruses don’t set up shop, they attack and destroy as soon as possible and they can kill quickly.

How The Body Fights It

The body has two ways that it destroys attackers.

The first way is the “soldiers“. The body has cells called White Blood Cells (WBC) which travel the blood stream looking for foreign bodies (bacteria and such) which they engulf and kill using little blobs of acid they carry inside of them.

In order to get the soldiers to the area needed, the body releases certain chemicals (histamines and cytokines – like hand grenades that destroy anything even healthy cells ) that cause leaky blood vessels and causes swelling. These cytokines and WBC also cause fevers that are designed to kill these invaders. Arguably, the purpose of this system is to immediately attack bacteria, surround them and kill them.

The second way are the “snipers“. These cells get intel on these invaders (every single abnormal thing in the body), and through their own mechanisms create magic bullets (antibodies) that target all or part of any invader, effectively preventing the bad guys from attaching at all. This system is set up to attack viruses as well as bacteria. Remember you can put thousands of viruses on the surface of a bacteria… they are that small. So the snipers attack big as well as tiny things. These snipers DEPEND ON INTEL! In other words these cells MUST HAVE SEEN THE INVADER BEFORE. Covid – 19 is a “Novel” Corona Virus, meaning that humans have NEVER SEEN IT BEFORE. So our snipers (the guys responsible for preventing virus attacks) have no magic bullets.

So, Covid – 19 enters your airways, attaches to your air sac cells, does its thing and within hours begins to reproduce and destroy your air sacs and kidney cells.

So the body does what it knows how to do… it sends the soldiers.

It has no Magic Bullets, so what does it do?

It sends LOTS OF SOLDIERS to the lungs and kidneys, along with the chemicals that cause swelling (histamines) and the hand grenades (the cytokines).

Covid – 19 Disease (called “pneumonia” because that is what it looks like on x-ray but not a traditional pneumonia), has 2 phases: 1) the initial phase in which the lung and kidney cells are destroyed and consists of cough, low oxygen, and kidney failure and 2) the “cytokine storm” in which the body doesn’t know what to do and throws “hand grenades” at the virus and in turn helping to destroy more lung and kidney tissue.

Treatments

Treatments that make sense are those that support the body such as oxygen, Remdisivir (a broad spectrum ant-virus created to combat Ebola) that attacks certain parts of viruses (specific anti-viruses like for AIDS don’t work), plasma (that has the “magic bullets” from people who have survived), and Chemicals that fight the cytokines (IL6 inhibitors) are in place and show good promise.

Hydroxychloroquine doesn’t work. Studies have shown that it doesn’t and frankly there is no reason why it should. Zithromax is a nice antibiotic that doesn’t fight a virus. Both of these can cause sudden cardiac death unless prescribed appropriately by a doctor for appropriate reasons. Covid 19 is not it.

Now, aspirin is an anticoagulant that should be used for heart disease. The finding in autopsies that there are micro emboli is to be expected as there is damage to lungs and the clots form as the body tries to heal.

Doctors do use blood thinners during treatment for the prevention of blood clots and there is evidence for using blood thinners to prevent blood clots in the lungs of people who were really sick and survive. But taking high dose aspirin to prevent blood clots may cause you to bleed into your lungs if you are not carefully monitored.

Bottom Line

There is NO CURE.

Only a vaccine will prevent it which is over a year away.

WASH YOUR HANDS or use hand sanitizer.

Cover your face with a mask or scarf when out in public (remember you need to prevent droplets).

Remember no one knows who gets sickest so its not just old people, it can be young people as well.

Use Social distancing (6 ft is the distance droplets go if you cough).

The Rant

I haven’t written in a few days for three reasons. Firstly I’ve been very tired, the daily work is mentally and physically draining to the point where I sort of just sit and watch life at home flow around me when I’m not at work. Secondly, I’ve had a series of impressive anxiety episodes that I’ve only come to understand now that I’ve come out the other side. I have a Fitbit (I’m not an Apple Watch person yet) and it measures heart rate, exercise, and all that. For the last week, I have had over 45 minutes of “exercise” (heart rate over 100 bpm) and I can assure you I have NOT done any cardio (I wanted to but I fell asleep). I searched the app and found that my heart rate jumped over 100 bpm when I started rounds in the morning and proceeded in fits and starts during the day. That was a bit of an insight that made it easier to realize and control. This results in enough energy to write this post. Thirdly, I have been supremely pissed off.

Idiots

I am not generally critical of fake TV “Doctors” who push diets and therapy and such (everybody needs to make a living) but over the last several days I am astonished at the behavior of two particularly influential peddlers of their own egos.

Dr. Phil (not going to write his whole name because I don’t care) went on TV and in order to gin up his “base”, stated outright that social distancing was not necessary – Jeez what a moron! I read on a popular meme that opening up social distancing because we’ve flattened the curve is like taking off the parachute because we’re slowing down. Dr. Phil, you overinflated egotist, you are a psychologist who used to be a jury profiler and have now peddle stories of nympho 13 year olds… stay in your area of expertise and don’t pretend to be physician.

Dr. Oz (OMG I hate this guy). He went on Fox News and said (he REALLY SAID THIS) that “2% mortality of the total population could die if you open schools, and that is an acceptable outcome to open the economy.” Two percent of the US population is 7 Million people. Think about it… 7 million people!

Both these charlatans went on TV to walk back their BS, likely to try and save what little credibility they have. But, mark my words, they will have shows showing “the horrors of Covid” up close. It’s red meat to these guys.

Finally the President.

OMG

“liberate your state” (?) Seriously?

I fear for my colleagues who will have to dive into the ICU’s in the Mid-West and South when these “patriots” begin filing in and needing intubation. I’m sorry, I’m too old for another round of this (AIDS, SARS, MERS, H1N1, and now Covid), I’m going to sit the next one out thank you very much.

Observations From the Inside

Let me disabuse any of my readers from the mistaken idea that life on the inside has gotten any easier.

We have many more discharges than we used to have (the hospital plays “Here comes the sun” when someone gets discharged who had Covid) but there are still many many admissions. Some of whom we can gingerly nurse along keeping them on high flow oxygen and keeping them prone (face-down) and so far what we’ve been doing seems to help them.

Most still fall into catagories of a rapid crash and intubation and mechanical ventilation or long indolent courses that may or may not improve – we don’t really know yet (it’s still developing).

The plateau is like scraping along a bumpy road in a car with no shock absorbers, it’s bumpy, uncomfortable, and potentially dangerous. Every day more and more nursing home patients just die, and our fellow health care workers are taken off the board as they get Covid.

PPE is adequate but NOT what we all learned about in school… and we make all kinds of compromises.

Everyone is tired, and the first line of expert health care workers are being burnt to a crisp. I fear what our souls and hearts will look like when this is all over. I also fear for those who have been “rushed” to graduate into this environment. They will forever know medical care as Covid, and likely suffer intellectual myopia like I did when AIDS swept through the world and Polio was still a major player.

There is too much food being donated to the hospitals (in my opinion) maybe some can go to a food bank or outreach programs to feed those who have lost work.

I truly appreciate the applause and fire trucks, but please… just take care of yourselves and stop calling us heroes and yet make more work for us.

Information

So here is what we know about drugs for Covid so far:

Hydroxychloroquine

Useless and dangerous. Just don’t.

Azithromicin

Might help to address any co-infections with bacteria. May have some immunosuppressive effect. Has the same problem of lengthening the QT interval and causing sudden cardiac death. Don’t.

Remdisivir

Works by inhibiting the enzyme that allows a virus to do its thing and attach to cellular DNA. Developed originally for Ebola. Shows really good promise in very early studies. Trials happening now. Once safe dosing worked out, will need to scale up production. Promising.

Ritonivir and Lopinavir

Ant-virals devloped for AIDS. Doesn’t work at all.

Immune System Inhibitors

Mainly IL-6 or Interleukin 6.

Trials ongoing and shows some promise. Hard to get but very promising.

Convalescent Plasma

Being given now, has to be obtained from blood of those who had disease.

Shows Promise.

Bottom Line

Until a vaccine comes along, a combination of medications may be effective, but as of now There are NO CURES and precious little in the way of treatment.

Reference:

Here’s What We Know about the Most Touted Drugs Tested for COVID-19: Scientific American Medicine 2020 by Tanya Lewis

Today felt a little different.

It isn’t like there were fewer patients who were sick on my service, in fact there were close to a record number.

But it felt different.

It didn’t feel like we were being overrun, like we would drown in a sea of Covid patients. There were a lot of them, old folks coming in and quickly dying, younger folks coming in and lingering with fevers and shortness of breath, and younger people – wide eyed and frightened as we walked around them in hazmat suits and unavoidably stand away from them as they cough and puff for air praying they wouldn’t end up like that guy over there on a ventilator.

I think it has to do with knowing what to do, what to expect. Sure, we’re making it up as we go along, but hell, so is Fauci and the NIH. it’s just that we’re doing pure battle against a foe that we now know a little about, we see some patterns emerging and feel we have some idea how the bastard operates.

We are all still scared out of our minds, but we have a plan and as long as you have a plan you can do anything.

Morale is surprisingly good on the inside. Where a year ago, there was education done to “teach everyone to be nice”, the staff bends over backwards to be kind, informative, and loving to patients and their families. The families, in turn, are the most grateful I’ve seen in over thirty years. Where in the past no one acknowledged each other in the halls or pretended to look at their phones, we’re all looking into each other’s eyes (all we can see with the masks on) as we pass each other in the halls, saying each other’s names aloud almost like an acknowledgment that we are still together, still ok, still alive.

I will praise our Hospital Administration (not something that folks often do), as throughout this catastrophe they have been transparent , communicative, and responsive. Most of all, they were THERE with us. It is easier to forgive silly oversights when we all realize that we are all just trying to get something right that has never needed to be done before.

Finally for today, I want to thank Chris Brennan MD for gifting me a Tyvex “bunny suit”. Our team (Palliative Care) usually spends enormous amounts of time with our patients, holding hands, talking, and being present to them In this time of patient and staff isolation families ask us to be with their dying relatives, but we can’t. There are only four of us for the whole hospital and that would mean long term exposure to Covid patients with only the barest minimum PPE. So we use what PPE we have and run in and run out. This suit will allow me to sit with our sickest patients and witness their struggles with them. Thanks Chris.

It’s now over a month into the New World and I realize that I’ve only been on the outside six days. I go into the hospital, do my thing, then come home.

The evenings are lost to me as I go through “stages” ( as my daughter has observed). I go from obsessively washing and disinfecting everything I come into contact with, to staring at dinner, to walking around the house looking out of the windows, and finally staring blankly at TV until I lay in bed and stare at my phone in the dark, trying to avoid doing research on Covid (and usually failing) until I pass out.

So it’s safe to say that I’ve only been on the “outside” for 6 days. Just enough time on the weekends to begin to forget what it’s like inside.

This makes reentry difficult.

On the first day back, muscles are tight beyond all as my body tenses in an involuntary cramp all day, the soreness as I relax interpreted to surely be Covid. Any cough from allergies are also Covid, as is the panic when you are too cold or too hot… Covid Covid Covid.

Finally, there’s the ritual of the twice a day temperature checks, the fear as you wait with the stupid thing in your mouth waiting for it to beep… and give you a reprieve for another twelve hours. Another chance to update the instructions in that pended email I have ready to send to my family in case I get sick, one more time.

I think… everyone inside ( on the frontlines or however you want to say it ) feels a similar existential fear.

As far as what it’s like inside :

– Everyone is tired. Maybe not the fatigue of staying up all night, but the dull blankness in the eyes that only lights up when gearing up to go into a room. The fog that only abates when trying to save that life.

– Everyone knows a horror story. A patient whose family won’t give a DNR on an obvious lost cause because three other family members have just died, of the daughter who now lies in the same bed with Covid as her mother who just died of it last night, or of the entire grandparent generation of a family who died on your unit this week.

– Everyone is getting fat. We’re all eating too much, drinking too much coffee, and ignoring ourselves. Maybe if this goes on for another month we’ll all flip to being health nuts, but health food stores don’t deliver to the hospital (for now anyway).

– We’re not crying. I can make that observation but can’t really dissect it, because I’m not crying either.

– In our hearts, we don’t think this will ever be over and for some of us, when it is… it will never be.

A good friend of mine posted on Facebook today (you know who you are), about how there are going to be many cases of PTSD when this is all over. That off-hand observation had me thinking all day long as I donned PPE, saw patients, removed PPE, cloroxed everything around me, and spoke to my colleagues on the “inside”.

PTSD (Post Traumatic Stress Disorder) is defined by the Mayo Clinic as “a mental health condition that’s triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event.”

Moral Injury is defined by the Syracuse University Moral Injury Project as “disruption in an individual’s confidence and expectations about one’s own or others’ motivation or capacity to behave in a just and ethical manner”.

This Pandemic is an ongoing terrifying event for those of us on the “inside”. We see and experience things that on a normal day would horrify any reasonable health worker and we shrug it off with “I’m good”, spray Virex (carcinogenic by the way) over our one -gown-a-day, and move on.

Much like in war, we are suffering Moral injury as well. The things we tolerate, the actions we take for the “greater good”, and the small acts we do to let us know we are still human are causing damage on a daily basis.

We strip outside and wash everything before setting foot at home, we don’t hug anyone anymore (loss of human contact), we obsessively disinfect everything… and death becomes just another thing, something in which you cannot invest.

Much like in war, this is not going to be over for years. When the media has moved on to the next shiny object, Health Care Workers will still see the horrors of random deaths by suffocation and kidney failure as a normal thing. We’ll still be wearing masks, shoving gloves in our pockets, and having a severe mistrust of human touch.

So yeah, “when this is over” there will be a lot of us who will leave the field, and a lot of us who won’t, but will be forever scarred and will carry the burden that our military now carries of Anger, Depression, Anxiety, Substance abuse, Insomnia, and Nightmares. I hope we will learn, because the Medical Community is much worse than any other in taking care of itself, I fear we won’t.

If not, we’ll see the same incredible suicide rate that we see in our military among those of us who “gear up and go in” on the “inside”.

It has been my experience, that when you are tired (I mean tired to the soul), memories are imprinted in a series of “snapshots” that expand into full movies, kind of like thumbnails of movies on YouTube.

This was the case today.

I have the privilege of working all over the hospital, not just with “my people”, but going from ER to the OR and everywhere in-between. So I see so many things that they “store “ as snapshots or moments in time that I can touch and replay at will ( and sometimes they replay against my will). I’ll share some of them with you.

– The barely controlled frenetic energy of the emergency room, hazmat suited doctors and nurses contrasting with the aides trying to choose a good food tray for that “patient in 8 who is really hungry”.

– The zush zush zush sound of the nurses and aides as they walk through the halls in their tyvek “bunny suits“ going from room to room taking care of the dying and the not dying yet.

– The eerie subdued lighting and oppressive quiet of what was once a holding room for elective procedures that is now a “fishbowl” of Covid patients all in a circle. Those of us working inside quietly desperate as we can almost “feel” the virus in the air.

– The frightened look in the eyes of the nurse caring for the Covid patient in the recovery room isolation area, her unseen smile and insouciant attitude covering up her fear.

– Half heard conversations on the new temporary ICUs among nurses who have never met before, declaring bravely that “we’re the cool kids now” as they gear up.

– And finally the seemingly endless phone calls I made to Spanish speaking families (I’m native born Spanish speaker in case you didn’t know) about how their Mom/Dad/Son/Daughter/Grandmother/Grandfather is NOT going to get better and that yes, I will pray with them.

Hey, stay safe, get some rest, so we can do it again tomorrow.

Since this has all started there have been several waves here in the hospital.

First there were the old nursing home patients, then there are the younger folks with co-morbidity.

Now we are seeing the lower socioeconomic community, the Hispanic and African American community. I work in a fairly well off Hospital in a fairly well of suburb of New York, but there has always been this “service” class that has existed if not unofficially, certainly not counted in the minds of those who plan for these things.

This will change in the future I hope as the second wave of COVID is exposing the system for never seeing them.

On the bright side, we are discharging many more people safely to home and every time someone who has survived Covid goes home they play “Here comes the sun” overhead. It makes you smile to know not all is about death.

The next weeks are a marathon as we keep sweeping against the tide. We can only hope to have enough left in our own tanks to get us through.

I love all my nurse colleagues at Good Samaritan Hospital. I could not be more proud of everyone.

Morale is good, in that tired, “we’re in this for each other “ kind of way.
My feeling is that those who “show their faces” in the trenches NOW will be respected in the future.
If you don’t, that respect will not be given freely.

“We few, we happy few, we band of brothers;
For he to-day that sheds his blood with me
Shall be my brother; be he ne’er so vile,
This day shall gentle his condition:
And gentlemen in England now a-bed
Shall think themselves accursed they were not here,
And hold their manhoods cheap whiles any speaks
That fought with us upon Saint Crispin’s day”

• Henry V

We don’t operate on how you feel. We operate on what evidence is, and data is…

Anthony Fauci, MD April 3, 2020

So here it is, my take on what Covid – 19 otherwise known as Corona virus (or just “‘Rohna” by those of us on “the inside” of those hospitals you hear about on TV), is about as of this writing. I fully anticipate that in the future we’ll all look back on these Covid blog posts and rightly say “well that was bullshit”.

To our knowledge, the Corona virus which is in the family of viruses that include the common cold and SARS, started in or around Wuhan China. I don’t know (nor care) whether a guy ate a bat, 5 G towers for your cell phones caused it, a secret CIA research facility released it, or some guy from Massachussetts sold it to the Chinese for pocket money. Most of that is all garbage and, other than adding to the general mis-information around the disease, does nothing but fill your Facebook feed with click-bait fake articles.

It is clear that this virus started some time in late October and the extent of this spread was somehow suppressed until the Chinese government took the extraordinary step of closing down the city of Wuhan and the surrounding area (everybody noticed it then). The spread proceeded from China through traditional routes around the world to the Middle East, across the Mediterranean to Europe, to Britain, to South Amenica, to the West Coast of US and (because of international travel) to New York City. Once it got to NYC all bets are off and now it’s everywhere.

I want to emphaze, that this was NOT an attack on the US by any means but rather a predictable spread of a virus from its origins in Asia and spread throughout the world much in the same manner as the yearly influenza. So comparisons to Flu, in this VERY LIMITED sense, are valid. However, so was the predictability of it’s spread (we knew this was coming).

What makes Covid – 19 dangerous is that it is a “Novel Coronavirus” meaning that people have never been exposed to it before and therefore have no natural herd immunity (everyone else being immune gives you protection – kind of like not getting wet in the rain because everyone around you has very tall umbrellas). So, because of this, this little booger does what all viruses do, it hijacks the mechanisms in the cells of your body for the express sole purpose of reproducing copies of itself and spreading them around. This one in particular seems to like the cells in the lungs and kidneys (Angiotensin Converting Enzyme receptors).

So How Does Rohna Get You and How Do We Treat It?

The problem comes mainly with the body’s response to attack. The immune system is set up in two layers, an immediate army of soldiers (white blood cells that engulf and destroy foreign bodies) and the second line of immune cells designed to make antibodies (magic bullets) against viruses. If you’ve had exposure to a virus (or one similar) in the past your body has a template for the the virus, looks it up on “body – google” and manufactures the antibodies that destroy the virus.

If it has never seen it before, it goes into “oh my god what are we going to do?!” mode and begins to unleash primitive methods to kill proteins such as turning up the heat (fever), making cells “leaky” so that all the immune cells can take a shot at the virus (massive swelling and lung damage), and releasing all kinds of toxic chemicals to try to kill the virus (cytokine storm).

Unfortunately, this has the nasty side effect of killing the person.

So the main way to treat this Novel Coronavirus is supportive, we keep the breathing going, we keep the kidneys going, and we try whatever we can to reduce the inflammation while trying to outwait the virus and allow the body to heal.

Chloroquine is an anti-malarial drug that is sometimes used to treat immune disorders (as a second or third line drug) and has hellacious side effects. No one who has ever taken it, likes it. It has been used to try to prevent some of the early viral shedding and to slow down some of the immune response. There are NO STUDIES ABOUT THIS!!! this is all heresay reports from the Chinese (suspect), the Italians and the French (both groups desparate to do something) and unfortunately, the Italians and French stopped giving it to people when they got “too sick” so we don’t know how it works on sick people.

Azithromycin is a nice friendly antibiotic that the Doc gives you when you get a bad bronchitis or sinus infection. It is usually for 5 days and is related to erythromicin (without the nasty stomach upset). It is good to attack any bacterial infections that happen when Covid patient begin to get worse, and it may have some (very little) ability to reduce inflammation.

These are used in combination. However, they both have the nasty effect of increasing the QT interval on the EKG, which means that these two drugs do some slap-dash re-wiring of the conduction systen of the heart that could potentially cause irreversable sudden cardiac death.

So what can we do?

Stay inside among those who you are exposed to all the time. You can be pretty sure that if you’re all together for more than a week, you are either negative or all of you are positive and didn’t even notice it (yeah that can happen). WASH YA DAMN HANDS! and do it well like on all those interminable TV demonstrations. THIS WILL SAVE YOUR LIFE.

Don’t go out in large groups for now until my guy Tony Fauci (not Dr. Oz) says it’s ok. Wear a personal facemask that covers mouth and nose when in a position that you will be around other people (yuk). If you are by yourself on a run or a walk, then don’t (I carry mine in a pocket when I go running- ya never know). Wear gloves (this is my thing), not necessarily medical gloves (geez don’t throw them on the ground that is disgusting), but regular gloves when you are touching high frequency items outside like doorknobs and such (who knew formal gloves would make a comeback?).

Take a good multi-vitamin with Vitamin C, Zinc, eat right, exercise , and keep up your spirits. Just be a good, healthy adult human.

It’s all going to be OK one day.

I had a nightmare last night.

In it I was at work (yeah that kind of dream) and we were all dealing with a horrible illness. It attacked seemingly at random and we were all running around trying to cure a disease that we didn’t understand.

Some young people did great, but some others crashed horribly and were put on ventilators. Some old people died quickly, but some smiled at us and asked for more ice cream. I felt like the hospital I was in, was like a rock in a river being overtaken by a flood, we were drowning.

But, I was able to hold hands with the dying and comfort them. I hugged the spouse of the young man on the vent who died. I got to be the object of hatred for the old man whose wife just died in front of him… that’s ok though.

Families asked why.

The country was afraid but united.

Then I woke up… and I remembered it’s worse than my nightmare.