Sunday, August 9, 2020

New York Attorney General Gunning for the NRA

If the nation were any more divided, then we would be occupying two different planets.  As I have written, and indeed you all know, there is no issue that cannot be politicized.  Would any of us, for example, have ever divined that the wearing of masks during a pandemic would become a fractious political issue and not a simple public health measure?   I’ll bet that if a legislator wanted to offer a proclamation honoring the nation’s mothers, that some quarter of our society would challenge it on some basis.

Earlier this week, the Attorney General of the State of New York (AG) announced that the National Rifle Association (NRA) was so systemically corrupt that it needed to be dismantled entirely.  She levels serious charges of corruption against NRA leadership and has hinted that there may also be violations of the IRS code, which presumably would invite a federal response.

I heard her discussing the charges earlier today on a liberal cable station and to my ear it sounded like political grandstanding.  Keep in mind that her charges are allegations – not yet proven – and the NRA deserves a presumption of innocence.  The AG spoke as if the NRA’s guilt were assured and that future legal proceedings would serve as a formality.  

I think this is highly improper behavior, and even dangerous, particularly for a state’s highest law enforcement official to engage in.   It sets the wrong example for the public suggesting that we regard those who are accused of an offense as if they are guilty prior to due process.  I suggest that a more judicious and proper stance would be for prosecutors to be very measured when discussing charges against individuals and organizations.  This would reinforce to the rest of us that we should keep our minds open and presume innocence as best we can.

I am aware that the presumption of innocence does not apply in civil matters, but as a matter of principle, I believe that the public and the legal community should refrain from making judgements, particularly public pronouncements, at the stage of allegations.

Why, then, would she assume such a public posture?

  • Might we infer that she has animus against the NRA judging by her 2018 statement prior to her election that the NRA are terrorists?
  • Might the AG, who has suspected ambitions for higher office, be making a political play?
  • Might the AG be attempting to taint the jury pool?
  • Would the AG also be calling for the total dismantling of liberal organizations, such as Planned Parenthood or the Sierra Club, if there was alleged corruption in their leaderships?

My own view is that NRA officials who are accused of corruption should be prosecuted, without calling for a total take down.  And, calling an organization ‘terrorists’ at least suggests that her judgment were not made without fear or favor.  And, if she believes in the presumption of innocence and due process, and she wants us to as well, then she should act like it.



Sunday, August 2, 2020

The Coronavirus Pandemic Playbook - A Work in Progress

Life is so much easier when we can rely upon a playbook to guide us over and around obstacles.  Indeed, many professions are devoted to creating policies and procedures to help businesses, individuals and organizations navigate through rough currents.  In general, these prepared plans are created to address challenges that are either known from prior outbreaks or can reasonably be assumed to be potential adverse events.  For example, regions of the country that have suffered from natural disasters would be expected to have contingency plans in place to prepare for the next arrival of Mother Nature. 

Navigating Through Rough Currents

How comfortable it is when facing a dilemma to be able to pull a binder off the shelf for advice.
Of course, as anyone alive knows, we don’t have a binder, an advisor, a parent or a GOOGLE site that can reliably land us safely when confronted with adversity.  So many issues require us to rely upon our experience and judgement and to leap beyond our comfort boundary.  Over time this boundary expands.  This is what is regarded as ‘experience’.  And with experience, fewer challenges are unique, novel and perplexing as it is more likely that we have encountered them.

And then came COVID-19.  Yes, we have addressed pandemics before, but this was a mold breaker.  Health experts, economists, U.S. states, countries, counties, businesses and individuals have all offered differing opinions on how to react to this catastrophe.  And these differences have been brought into sharper relief in recent weeks.

Do you think it would be easy to achieve consensus on the following inquiries?
  • Should we lock down a country or opt instead to achieve herd immunity to protect the population and the economy?   England and Sweden, two western nations, were not following the ‘herd’ on this issue.
  • Who should wear a mask and when? What kind of mask?  Face shield?
  • How much national testing for coronavirus is sufficient?
  • What constitutes adequate scientific evidence for a treatment candidate to be tested in a clinical trial?
  • Should unproven medicines with toxicity be offered to ill patients?
  • Where should finite financial resources be allocated?  Who determines the winners and losers?
  • What is the definition of an essential business?
  • What is the intensity of a potential COVID-19 exposure that should shut down a factory?
  • What is the long and winding road to opening up an economy? 
  • How are disagreements on the pace and process of opening up the economy resolved?
  • What metric of ‘safe’ should be used before the economy begins to open and social distancing can be relaxed?
  • Is there a valid point that the ‘cure can be worse than the disease’?
Much of our response to the pandemic is based on sound public health principles along with sober advice from epidemiologists, scientists and health experts.  But so much of what we need to know is simply not known.  The playbook is incomplete.  A silver lining is that COVID-19 has added many chapters to the Pandemic Playbook, which will leave us much better prepared when another invisible enemy strikes us again.  

Sunday, July 26, 2020

COVID-19 - Lessons for the Next Pandemic

The first case of COVID-19 in the United States was reported on January 20th.   Of course, this is akin to finding one termite in your garage and thinking that there are no others.  Of course, by January 20th there were an unknown number of infected Americans who were silently and efficiently transmitting the virus to others. 

It’s easy to say now what we all should have done then. 

The rapidity of the explosion of worldwide infections has been staggering and humbling.  Compare the known infections and mortality in America today with the state of affairs on January 20th, only 3 months ago. 

Just prior to posting this, the known number of U.S. fatalities to COVID-19 is 150,000.
For some perspective, our country lost over 58,000 individuals in the Vietnam War, but this horrible tragedy was the result of 8 bloody years, not just several months. 

The current diabolical enemy is a merciless adversary.  Like a terrorist, it scares those who have not been infected.  It makes us hide and hunker down.  It kills enough people to make us all feel vulnerable.  And, it has cratered our economy so deeply that it makes the post 9/11 economic damage seem like a modest downturn.

A deadly and invisible enemy.

But we will get through it. I was proud that it seemed that the country had largely come together to get to the other side.  For the first few months, we listened to our public health experts and sacrificed.  We were willing to participate in something that is so much bigger than ourselves.

But as time went on the public's patience waned.  Businesses demanded to be set free.  Masks became a divisive political issue.  Governors opened up their states with the hope of pulling an inside straight.  Many of them were forced to admit defeat and ordered an economic retreat.  And many Americans simply ignored the public health recommendations and filled up beaches and bars putting all of us at greater risk. 

Perhaps, when the next pandemic descends upon us, and it will, we will all recognize that immediate containment and contact tracing is a better pathway than delay followed by collective mitigation.  Will we have the discipline and trust in our leaders to fall in line?   How many shutdowns can the country and the world endure?

I hope and pray that the current experience has been so frightening and traumatic that we will do the right thing when COVID-22 or COVID-24 attacks.   And hopefully, the world’s scientists are learning now how to better design therapeutics and effective vaccines, which may ultimately be our most potent two-pronged weapons against invisible enemies that do not even exist today.

Sunday, July 19, 2020

Do I Have to Wear a Mask?

“I have my rights!”
“Don’t tell me what to do!”
“This is a freedom issue!”

All of us have rights.  Often, one person’s right to do or say something may collide with some else’s right.  One of our courts’ primary roles is to decide in these disputes whose has the better argument. These issues are not scored 100-0 in favor of the winner.  The decisions are nuanced as often both sides have a reasonable claim to argue. That's why the issue ended up in court.  And, as we know, the same set of facts might have led to a different result if a different judge or a different court had heard the case.

I have heard and read about individuals who have refused to wear a mask because they argue it encroaches on their personal freedom.  They have a right to determine their own dress code and the government has no right to impose its will on individual citizens. We’ve heard similar arguments offered by businesses who wish to open up faster than the government or public health officials have advised.

Some folks never leave the house without a mask.

I acknowledge that an individual who is required to wear a mask has a claim that his rights are being violated.  It is a governmental (or corporate) interference with an individual’s personal freedom.  And, this country, unlike many of our global competitors, was founded on individual rights, as chronicled in the first ten amendments to the constitution.   In other words, the guy has a case.

But, society also has rights and there are instances where their rights should prevail over that of an individual.  For example, if a parent decides for whatever reason not to administer recommended vaccinations to their children., should these children be permitted in public schools, recreational facilities, summer camps,  movie theaters, birthday parties or amusement parks?  An unvaccinated child, if given full access to society, could expose thousands of people, -  including the elderly, the very young and immunocompromised –  to the risk of serious illness.  These people also have rights.  In other words, these folks have a case.

Similarly, an unmasked man in the public square might be unknowingly infected with the novel coronavirus and could infect those who are near him.  Keep in mind that COVID-19 has no available vaccine or approved treatment yet.  The people who are in close proximity to the unmasked man also have rights.  They also have a case.

As I see it, both as a medical professional and a citizen, the public health argument triumphs. And, I don’t think that every dispute must be argued or litigated.   Regardless of your presumed legal right, why not simply do what is right?

Sunday, July 12, 2020

Is Coronavirus Different from the 'Flu'?

Early on, when the first coronavirus infections starting springing up in the U.S, I wondered if these infections and the threat they posed were truly qualitatively different from seasonal influenza.  As I became more informed, I recognized that the health experts were correct; this is not the flu.

I was not persuaded, however, by the high mortality rates which were initially quoted.  Even today, we will hear and read that mortality rate for COVID-19 may be 10 times higher than that of seasonal flu, which is in the range of 0.1%.  We simply cannot make such an assertion authoritatively. The truth is that may be grossly overestimating COVID-19 mortality for a simple mathematical reason – we simply don’t know the extent of infected Americans who have mild disease or remain asymptomatic.  With widespread testing, we will likely verify that the percentage of COVID-19 fatalities is much lower than originally thought.  In simple terms, the larger the population segment there is with mild disease, the lower the mortality rate will be.   When the dust clears, we may find that mortality rate to approach that of ‘the flu’.  Let's all hope so.

But even if the mortality rates are similar, the threat of the 2 viruses is quite different. 

The 'Flu' vs Coronavirus!

Experts have pointed out that the novel coronavirus is more contagious than seasonal flu.  An individual infected with seasonal influenza transmits the infection to 1.3 others.  In contrast, those infected with the novel coronavirus at it's peak was believed to be transmitting the infection to multiple people, although its contagiousness has been revised as more data accumulates.  So, coronavirus can reach a larger population more efficiently and deeply than the ‘flu’ can.

While the ‘flu shot’ is not an ideal vaccine, it does offer us some protection.  There is no vaccine against coronavirus.  And, many of us have some partial natural immunity against the ‘flu’, as we have been exposed to various 'flu' strains that descend upon us each year.  The novel coronavirus is new on the scene, so our immune systems are more vulnerable and less equipped to battle it.
And, finally, there are effective treatments for the ‘flu’ and very few therapeutic options for coronavirus, despite the false claims that chloroquine andhydroxychloroquine were gamechangers. 

What does all this mean?   Well, without natural immunity, a vaccine or any effective treatment, it becomes imperative to avoid infection.  Are you familiar with the phrase, social distancing?  It has been dismaying to see so many of us mingling closely in bars and restaurants without a mask in sight.  And, just this week, case rates in the majority of U.S. states are increasing raising fears of more illness, hospitalizations, deaths, economic lockdowns and fear.   Is wearing a mask and keeping one's distance really too much to expect?

Sunday, July 5, 2020

Independence Day 2020

This Independence Day is different from all others that I have experienced.
We are so bitterly divided.
We face the fury of a resurgent pandemic.
We cannot even agree if wearing a face mask is the right thing to do.
Tens of millions of Americans have been thrown out of work.
Our politics is increasingly poisonous. 
Anger and frustration over racial injustice has erupted.
How do we move forward?

Will we be able to celebrate the day with the 'bonfires and illuminations' that John Adams forecast?

The Whistleblower

”I am apt to believe that it will be celebrated, by succeeding Generations, as the great anniversary Festival. It ought to be commemorated, as the Day of Deliverance by solemn Acts of Devotion to God Almighty. It ought to be solemnized with Pomp and Parade, with Shews, Games, Sports, Guns, Bells, Bonfires and Illuminations from one End of this Continent to the other from this Time forward forever more.”

John Adams

Sunday, June 28, 2020

'Face Masks Violate my Rights!

Several decades ago, Thomas ‘Tip’ O’Neill, who was Speaker of the House is associated with the adage, all politics is local.  In other words, caring for the needs of one’s constituents is the best strategy to preserve one’s political viability.  Of course, those were also the days when Democrats and Republicans – despite their philosophical differences – could argue and thrash out a deal.  Indeed, it has become political lore how Speaker O’Neill and President Ronald Reagan could capitalize on their personal chemistry to make progress for the nation.

Those were the days.

There is a different type of chemistry today that exists between Speaker Pelosi and President Donald Trump.  When they are mixed together, they form an unstable compound that is highly volatile and may explode.

Instead of all politics is local, we now have all things are politics, a sad bastardization of O’Neill’s principle.  Now, as we are all so painfully aware, anything can be politicized, which serves only to frustrate and divide us. 

We all know that many issues are highly political, as expected.  For example, if 2 congressmen argue if income taxes for certain Americans should be raised, this falls well within the realm of politics.  If the president proposes a change in our immigration policy, then we expect that various constituents will do their best to exploit the issue to serve their political interests.  In a perfect world, of course, there would be no political tainting of the issues as all good people would strive to serve the greater good and not their parochial interests.  Have you noticed that our world is slightly less than perfect?

Yet, one might have thought that certain issues transcend politics.  But, that naive notion is pure fantasy.  There is no issue today that can escape the predatory tentacles of the political machine.

Is this guy making a political statement?

Readers might be aware that we are in the midst of a pandemic and that our nation’s progress has been halting.  As I write this, nearly 30 states report that their COVID-19 cases are on the rise.  Every public health expert has advised us to wear masks, among other sensible recommendations.   Wearing a mask, as I do, is not a political statement; it is a public health measure.  I do it to protect those around me in case I am unknowingly infected.  And, it is possible that it might also afford me some protection.

Yet, there is a vocal movement of anti-maskers out there who vociferously argue that a mask infringes on their rights.  I reject this.  Their right to mingle near others barefaced is outweighed by the community’s right to avoid infection.  How such a simple act could become a political issue may seem baffling, but it is standard operating procedure today.  Earlier this week I watched citizens in Palm Beach County Florida decrying the mask and those who advocate its use.   One watching this venomous display might have thought that the government was poised to seize their homes.  Alas, it was only about a cloth mask to protect their neighbors, not quite a 'grab your pitchfork' moment.  

I challenge you to identify any issue that is immune to politics.  Apple pie, baseball, Mother’s Day, Sesame Street, stuffed animals,  petting zoos, Halloween, Thanksgiving…  

Stumped yet?

Sunday, June 21, 2020

Ohio City to Remove Christopher Columbus Statue

Progress is a messy business.  The pathways that have led, and are leading, and will lead to societal change have not been straight shots.  The nation is now tightly focused on pursuing racial justice, which has entered the 401st year of a journey that has yet to meet its destination.  You can site your own examples of necessary reforms that were the result of years or decades of struggles that have been wrenching, frustrating and even violent.  None of these successes and ongoing works in progress are easily accomplished.  It’s hard for folks to feel they must give up something, particularly if they do not feel personally responsible for the injustice that is being legitimately targeted. 

The reform process is not clean and many friendly fire casualties often result.  We saw this when the nation become revolted after learning about the horrible and pervasive culture of sexual harassment that permeated many businesses and industries.  I felt that in this instance, and elsewhere, that the net being wielded to snatch up the perpetrators became too wide in another example of zero tolerance.  Whenever zero tolerance is invoked, brace yourself for unfair and absurd outcomes. Do we really think, for example, that Al Franken had to be thrown out of the U.S. Senate for irreverent actions and speech he committed prior to public service when he was a comedian?  And, in our zeal to come to the assistance of harassed women, we were counseled to ‘believe the women’, as if any allegation should be assumed to be true. These examples of overshoot make me uncomfortable.    I endorse our current system when the accused is presumed innocent and the burden of proof is on the accuser.

This past week, I came across an example of overshoot that merited Whistleblower attention.  A city in my own state of Ohio plans to remove a statue of Christopher Columbus, a figure who many  believe to be a dishonorable person who should be removed from the public square.  The city has taken this act to promote diversity and tolerance.   The statue has stood watch over the City Hall since 1955.

The Flag of the City of Columbus Still Waves

There are many Americans who oppose efforts to scrub out Columbus Day and to dismantle statues honoring him.  However, I can understand why a city, particularly in the current political and social climate we are now in, might feel that a Columbus statue is improper.  Here’s what I don’t understand.  Explain to me how a city named Columbus takes down a statue of Columbus but still keeps its name?

If the leadership and citizenry of Columbus aim to remove a statue of the explorer because it is deemed too offensive for public display, then shouldn’t they enthusiastically jettison the city’s name for the same reason?  And if they opt to keep the city’s name, what is their explanation?

Sunday, June 14, 2020

Breaking News! Black Lives Matter vs COVID19 vs Election 2020!

Protests for racial justice continued throughout the country.

Businesses are racing to announce their corporate policies for justice and equality.

New polling reports that a majority of American support the protests and the Black Lives Matter movement.

Even military brass support renaming military installations named after Confederate generals. 

New York City opened up showing bold determination to aim toward normalcy

Over a dozen states are reporting increased cases of COVID-19.

President Trump expressed that policy brutality is committed by a few bad apples.

Attorney General William Barr and others denied that systemic racism exists in law enforcement. 

Over 40 million Americans have lost their jobs. 

Over 150 COVID-19 vaccine efforts are underway.

Major League Baseball still has no agreement between owners and players because of the usual obstacle.

HBO Max pulled Gone with the Wind because of its sanitized portrayal of slavery in the antebellum south.

Polling shows that presumed Democratic presidential candidate Joe Biden continues to gain strength.


All of these items occurred just within the past week.  The news cycle is exploding.  Every item is a Page 1 ‘above the fold’ story, but only 1 or 2 can be accommodated. There is simply an avalanche of real breaking news these days.  This is in contrast to CNN, where Breaking News, with it’s bold red font, is used to introduce every newscast, and is often sprinkled throughout their programs.  Of course, if every report is Breaking News or is a Crisis or is Unprecedented then these terms have no meaning.  Fox News has it’s own Fox News Alert designation, but in their defense it is utilized much more sparingly.

But, in the past week and months, we are all struggling to follow so many truly monumental and evolving stories simultaneously.  And we and the media may not have the bandwidth or the attention span to absorb them all.  Since the George Floyd murder and the subsequent protests, the coronavirus pandemic was pushed aside, even though it is still a page 1 story here and abroad. And soon I expect that the protests, even if still present, will be edged out by an event or a controversy that hasn’t yet occurred. 

There’s a whirlwind of information bombarding us in real time   How do we prioritize the news?  How closely should we follow the stories?  How do we know that our news sources are trustworthy?  Do we have the skill and the desire to separate out the static and the noise?  (One man’s static is another man's...)  

When every story is ‘breaking news’ does it mean that the news business itself might be broken?

Sunday, June 7, 2020

A Nation Reels from Police Brutality

In medical terms, the nation has been in status epilepticus – an unrelenting seizure - since the cruel and cowardly killing of George Floyd, an act of evil that we have all witnessed on tape repeatedly.
First, there was the brazen killing of an unarmed man who was already lying face down in handcuffs while a police officer pressed his neck into the pavement.  All the while the officer’s hand was comfortably planted in his pocket, a casual pose that one might expect from an officer ambling down the street greeting folks passing by.  Three of the officer’s confederates hovered over the scene.  Was Mr. Floyd a flight risk?  While I am not a law enforcement professional, Mr. Floyd did not appear to be combative or resisting?

This violence was perpetrated by one who was sworn to protect and serve all of us, including Mr. Floyd.

Protests erupted throughout the nation and beyond our borders.  While Mr. Floyd's passing may have been the spark, the story started hundreds of years ago.

And, there was also violence and looting.

And, there was a reaction to the violence and looting.

And, yes, there was a reaction to the reaction to the violence and looting.

And, so it goes.

How will we find a way out?

Through it all, the nation is headed by one who gives voice and space to the darker angels of our nature.

Astonishingly, for a week or so, COVID-19 was pushed to the back pages of our attention.

Much of the nation who are not black are accepting the existence of structural racism whose roots sprouted here over 400 years ago.  The issue is longer, wider and deeper than we can fathom. And, we have made real progress over the past several decades.  Let’s acknowledge this as we also accept the challenge to pursue fairness and justice.  Making progress will take strength, pain, perseverance, frustration, understanding, protests, compromise, reform, disappointment, fairness, tolerance and, perhaps most importantly,  the ability and willingness to consider an issue from another’s point of view. 

The task is beyond the abilities of any one person to accomplish.  And, we may not personally witness its completion.  

As written in the Jewish Talmud, it is not incumbent upon you to complete the work, but neither are you at liberty to desist from it.


Sunday, May 31, 2020

Telemedicine Surges during the Coronavirus Pandemic

Not long ago, Telemedicine was something that I read about.  Now, it’s something I do.  Over the past weeks I have been evaluating patients over the phone from home.  It has been an adjustment, but it has been smoother than expected.  First, I have always thought that the physical examination is overrated.  Yes, I recognize that such a declaration constitutes medical blasphemy, but I stand by it.  Don’t extrapolate beyond my actual meaning.  I am not suggesting that the physical exam is superfluous.  Indeed, there are many circumstances when the exam is absolutely critical.  However, for a good bulk of the routine gastroenterology patients I see, particularly for those who are returning to my office for a follow up visit, the exam contributes little value.

Here is a sampling of patient visits where the history alone is largely sufficient.
  • A patient with years of chronic constipation returns to see me for a 6 month follow up visit.
  • A new patient sees me to evaluate frequent heartburn.
  • A college student returning from a spring break camping trip in Central America sees me for diarrhea.
  • A 35-year-old new patient is referred to me for abdominal cramps that occur after eating dairy products.
  • A 65-year-old asymptomatic patient is sent to me with occult blood in the stool.
For cases similar to those I listed above, it is highly likely that I could obtain sufficient information simply from the patient interview – a hands free encounter.   This is why telemedicine can be a highly functional modality for treating patients.  And, while it is beyond the scope of this post, technology exists and will be further developed that will allow for many aspects of the physical examination to be performed remotely.  Even without futuristic technology, we can evaluate a patient’s appearance skin, pharynx, speech, joint mobility, respiratory effort and ambulation through the miracle of video transmission.  And, a patient can palpate their own abdomen and report if it is tender.

Do you think you could canoe up a waterfall?

My telemedicine encounters have been nearly all conducted by phone, and they have gone well.  At times,  patients have needed to have their expectations revised.  For example, if I have a phone visit with a patient whom I have never seen, who has years of unexplained abdominal distress and has seen digestive specialists and had emergency room visits, it would seem unlikely that a new physician will crack the case on the phone.  

As I have written throughout this blog, I lament how technology has exacted a cost on the doctor-patient relationship, much as it has eroded humanity and intimacy writ large.  To reclaim what has been lost would require canoeing up a steep waterfall.  It can’t be done.

After the pandemic has passed, I hope that I can return to my conventional office practice, which for me is the ideal setting to practice medicine.  But who knows what the new normal will be. 

Sunday, May 24, 2020

Memorial Day 2020 - A Plea to Remember.

Tomorrow will be a Memorial Day worth remembering.  Of course, its core meaning – to remember and honor those we have lost in the service of this nation – remains paramount.  I have thought over the years that the day’s essence has become blurred as the day has become one of family picnics and barbecues.  I confess that I have not sufficiently paused and meditated on the day's meaning in year's past as I think I should have.  I placed a small American flag on our front lawn today, the smallest of gestures to honor a very solemn remembrance.   

But this Memorial Day is different.  To those of us like me who have never served, this may feel as close to a war atmosphere that we will hopefully ever know.  Lockdown.  Shelter in place.  Commerce shuttered.  Empty streets and concert halls.  Fear.  Desperation. Hope.  Propaganda.  Supply chain disruption. Heroes.  Victims.  Agony and death.  

We are battling an invisible and cunning enemy who knows no borders.  Thusfar, he is bulletproof.  Yes, we are winning, but it has a been a tortured grind leaving a staggering wake of destruction.  We are not even sure what winning will look like.  We will get to the other side, holding a collective fantasy that life as we knew it will await us. But that destination is yet unseen and unknown.

Let’s remember those we have lost in the current war, and the loved ones who still grieve, and the ordinary folks who became extraordinary heroes as they ran straight into the fire.

Sunday, May 17, 2020

A Primer on the N95 Mask

A few months ago, most of us had never heard of an N95 respirator or mask.  I had never heard of it. It is an essential element of Personal Protective Equipment, or PPE, which we have all heard so much about.

The N refers to ‘non-oil’, meaning that the mask should not be used in the presence of oil-based substances.  The 95 means that 95% of airborne particles are screened out if the mask is worn properly.  Keep in mind that 95% is less than perfect.  It means that the mask will fail 5% of the time.  And, if the mask is not worn with a tight seal, the efficiency percentage will drop further.  And, the mask wearer is instructed not to adjust the mask during use which will break the seal.  So, the 95% standard is likely under idealized circumstances. 

As of this writing, I have only worn the N95 mask on two occasions.  My initial experience donning the mask was for a fit testing by an occupational health specialist to verify my proper mask size.  The objective, I learned later, was not comfort, but to obtain a tight seal.  The fitting took less than 5 minutes.

After weeks of performing telemedicine from home, I was called into the workplace for the first time this past week to perform a day long marathon of procedures.  I hadn’t touched a scope in over a month, the longest I had been separated from my flexible friends since they first let me loose 3 decades ago.  Hopefully, performing colonoscopy is like riding a bicycle.  Along with my amazing team of medical professionals, I performed 17 procedures without incident.

PPE in place

Scope doctors like me are prone to various aches and pains.  We can be standing for hours which can be tiring.  Our necks can become stiff.  And, we do all sorts of repetitive twisting maneuvers with  both hands which can give rise to various ailments.  There is an actual condition called colonoscopist’s thumb.

But, during this scope jamboree, I became very sorely acquainted with a new malady.  My nose was crying out for relief.  A great contest of Man vs Mask commenced, and it was not a fair fight.  I now know that the N, which I had thought mean ‘non-oil’ really stood for Nasal torture. The N95 mask was burrowing into the bridge of my nose hour after hour.  For those who have not donned the N95, here is some guided imagery to assist you.  

Imagine you are seated cross legged in a pastoral meadow. The sounds and aromas of spring abound.  A sunbeam pierces the clouds as a gentle breeze laps against you. Now imagine that your head is encircled tightly with sharp barbed wire that crosses your nasal bridge.  Now, imagine that every few minutes that the circle tightens...

By the end of the day, my proboscis looked like I either needed plastic surgery or I had just had it performed.  I queried my colleagues and learned that my experience was not unique.  We’ve all seen the photographs of medical personnel whose faces at the end of their shifts are marked with deep grooves and crevices.  

I realize, of course, that my nasal assault is but an inconvenience compared to the suffering of front-line medical professionals and afflicted patients.  But, I was not prepared for the slow grind of a nasal buzz saw.  I have 2 other endoscopy session this month.   I think I know who will prevail in the N95 vs Nose competition.  

Sunday, May 10, 2020

Do Masks Protect Us?

Prior to the pandemic, patients who entered my office building were greeted by 2 staff professionals who would assist patients in checking in and performing the usual logistical tasks that occur prior to a medical appointment.  Shortly after the pandemic commenced, I would arrive to work to witness these 2 ladies in rather different garb. They were now fully gowned, masked, gloved and goggled.  Each carried a bottle of hand sanitizer.  If not for their voices, I would not have recognized either of them.  Patients and medical personnel passing by would extend one an open palm to receive a squirt of the precious cleansing elixir. 

While I acknowledge the necessity for staff interfacing with the public to don protection, it was an eerie site for me to witness, even as a medical professional. It is simply a scene that is foreign to most Americans.

I recall when I traveled to Israel for the first time, I was struck at the site of uniformed and armed soldiers ambling everywhere.  Of course, Israelis paid them no mind, similar to how we might react to police or security guards on patrol in our cities.  But, as a first time tourist, it felt as if I were on a movie set.  

I also recall when I was traveling in Asia years ago, that it was very common to see ordinary folks wearing surgical masks everywhere.  Was I in the midst of an epidemic?   Was the mask to protect the mask wearer or the community from disease?  Or, might it be an effort to filter out impurities in the air?  Might there be a different cultural basis for shielding the mouth and nose?

Folks wear masks for many reasons.

In the coming days and weeks, we will see more masks in public.  In Ohio, our governor announced that he will set an example by wearing a cloth mask when in public, and has urged Ohioans to do the same.  

Experts have advised us that these masks are not to protect us, but are to protect others from us in the event that we are silently infected.   Nevertheless, I suspect that many will be masking up with the belief that the cloth will prevent coronavirus from reaching them.

Masks will soon take on a normal appearance if they are widely used over the coming months.  Most of what we now take for granted appeared odd and novel when we first encountered it.  What was our reaction the first time we saw a cigarette smoker, sushi or a tattoo?

Sunday, May 3, 2020

COVID-19 and Chloroquine and Hydroxychloroquine: First, Do No Harm

In a recent post, I presented why I believe that the fragmentary and anecdotal medical evidence supporting the use of chloroquine and hydroxychloroquine for COVID-19 does not justify its use. Certainly, if I become infected with the coronavirus, I would be reluctant to accept a recommendation to take either of these 2 medications, based on what is currently known.

Ordinary people, especially when they or loved ones are afflicted with a disease, will readily accept unproven remedies, especially when conventional medicine has no effective treatment.  We all understand this.  But the lack of a treatment, in my view, does not justify abandoning our usual standards that physicians rely upon when we make treatment recommendations.  
Shouldn't Physicians Weigh the Risks and Benefits?

Here are some reasons why I object to coronavirus patients taking chloroquine and hydroxychloroquine for COVID-19.   The principles outlined below certainly extend beyond the coronavirus issue.
  • The medical profession should not be prescribing treatments that have no reasonable evidence of efficacy.  Patients should have confidence that our therapeutic recommendations are based on sound science, professional experience and sound judgment.
  • Chloroquine and hydroxychloroquine efficacy against COVID-19, like any treatment, should be tested in well-designed clinical trials.
  • Clinical trials may have difficulty recruiting a sufficient number of patients if coronavirus patients are opting instead to take the medicines being tested on their own outside of a trial.  A clinical trial’s conclusions are more reliable when it contains more patients.
  • It may be true that chloroquine and hydroxychloroquine worsen the condition of COVID-19 patients.  Medicines do not always behave predictably.   Should we be condoning the use of medicines when we have no proof of either benefit or harm?   The safety record of the 2 medicines being discussed here with regard to their established medical indications may not be true for coronavirus patients, particularly when higher dosing is being advised. This is why scientific study of medicines is absolutely necessary. 
  • Prescribing medicines irresponsibly consumes resources that should have been devoted to more worthy endeavors. 
Consider who is publicly promoting chloroquine and hydroxychloroquine use for COVID-19.  Are they our public health experts or politicians and administrative officials?   Whom would you trust more for medical advice? 

Sunday, April 26, 2020

Coronvirus - Test Your Knowledge!

Folks love quizzes and puzzles, especially now when most of us are spending most of our time hunkered down at home.  I had attempted to send one my kids a jigsaw puzzle that I ordered on line, only to discover a few weeks later that the item was out of stock.  Apparently, like hand sanitizer and foster dogs, jigsaw puzzles are in very high demand.

Scarcer than toilet paper.

In an earlier phase of my life, I prepared ‘quizzes’ that were passed around on holidays and family dinners when guests competed for valuable prizes such as stickers, packs of gum and other treasures that are sold at dollar stores.   Not only were these experiences ‘fun for the whole family’, but they were effective educational tools.   Ask a Kirsch kid even today whose portrait is on the $50 bill or how many neck bones are inside a giraffe’s neck, and he or she (I hope) will nail it.

So today, I will offer readers a lighter fare.  Here’s a coronavirus quiz based on recent news reports.  Rely upon your knowledge and judgment.  To relieve your performance anxiety, I have made this a True-False examination.   I could have constructed a multiple choice and even included an essay question, but my generous nature prevailed.  Good luck!
  • Coronavirus takes its name from Corona beer as the virus was first isolated in brewer’s yeast.
  • Coronavirus is named after Rosie, the Queen of Corona, who refused to practice social distancing and contracted the virus.  Julio, who wore a mask, escaped infection.
  • Gargling with Lysol. and followed by a Mr. Clean chaser. kills the coronavirus and also rids the body of various harmful germs and toxins.
  • Anthony Fauci takes a dose of valium before and after the daily Coronavirus Task Force press conferences.
  • Vice-president Mike Pence has shown America that he has a spine of steel.  He is his own man.   
  • Deborah Birx’s scarves are impregnated with a potent antiviral agent, which is the main ingredient in Ty-D- Bol toilet bowl cleaner.
  • President Trump’s scientific knowledge has been credited for the sudden spike in applications to college engineering programs.
  • Masks are for sissies.
  • 4 out of five dermatologists surveyed no longer recommend any sunscreen.  UV light wipes out coronavirus even better than Chlorox.
  • It has been inspiring to witness the seamless and harmonious cooperation between the state and federal governments.  

So, how did you do?  Scores of 80% or higher are prize worthy.  Of course, since we are in the midst of pandemic, you will have to settle for virtual trophy. 

Sunday, April 19, 2020

When Should We Open the Economy after Coronavirus?

In the weeks ahead, there will be growing tension between forces wanting to open up the economy and those who demand that we hold the line.  And no one can tell us now when it will be okay to pull the trigger.  It is so much easier to endure a challenge if there is a firm end date to focus on.   In this case, not only is there no clear trigger-date, but there will never be agreement on when it will be acceptable to pull back.  I’m no expert, but here’s a brief list outlining the complexities of this conundrum.
  • Public health experts will disagree on the economic relaxation date.
  • Corporate leaders will likely favor a sooner and broader opening of the economy.
  • Governors will have diverging views from national leaders about what actions their state should take.
  • Businesses who are not permitted to open may howl and protest as competitors are given a pass.
  • Can schools, for example, be reopened while we are still urged to maintain social distancing?
  • Will the nation accept being told that we are opening up the country when in reality only scattered pockets are being permitted a gradual loosening of restrictions?
  • What happens when COVID-19 rates rise as the economy is revived?   Will we have the tools and the will to do what is necessary?
  • As difficult as it has been to shut down the economy, it will be a much harder and longer process to bring it back to life. 
  • Will we be told, and will we accept, that we will not be able to return to the status quo ante?
The decision of when and how to open the economy will always involve risk.  Doctors and medical professionals understand this reality.   We may advise a patient that there is a choice of surgery or continued medical treatment, and both options have risks.  If we open up the country too soon, we risk a resurgence of the virus and a squandering of what we have accomplished.  If we wait too long until the last remnant of the virus has been vanquished, then we may have no economy left to resurrect.

A Cure for Termites?

If a house has termites, we can cure the infestation by burning the house to the ground, but would the homeowner celebrate this victory?

We will have to balance serious risks in an evolving situation with endless moving parts with no playbook to refer to and disagreements on how to proceed among experts.  Would you like to be making the decision? 

Sunday, April 12, 2020

Chloroquine and Hydroxychloroquine for COVID-19?

Kindly refer to the article linked below explaining my great concern over the massive hype over these 2 medicines that many are perpetuating.    MK

Sunday, April 5, 2020

CDC Advises Cloth Masks for Everyone. Why Now?

I haven’t seen so many masks since I was a Trick or Treater.  Even as a physician, I have worn surgical masks very rarely as it was uncommon for me to be in an operating room, where masks and gowns are part of the dress code.  Until I embarked upon a transition to telemedicine recently, many of the patients coming to see me in the office were masked.

The official dogma on wearing masks during the pandemic is evolving. Experts at the Center for Disease Control and Prevention (CDC) the World Health Organization (WHO), the Surgeon General as well as many prominent public health officials had advised just recently that masks were not an effective barrier against coronavirus.  This is why asymptomatic individuals were not advised to mask up.  In contrast, we were told that these masks should be worn by symptomatic individuals who were coughing or sneezing as masks may reduce the risk that others will become infected.

Just days ago, there was a sudden change in policy.  Now the CDC and many of the president's advisors and others are recommending widespread cloth mask use to keep those who are silently infected from transmitting the germ to others. The WHO has not signed on to these revised recommendations. While it is still true that cloth face coverings are not likely to protect a healthy individual from infection, the hope is that such a barrier may prevent a asymptomatic infected individual from spreading the virus.  It's not clear to me why the revision was issued now as we have known for months that asymptomatic individuals can spread the infection.  The explanation for the policy change has been murky  

Could there be a downside?

It is confusing when an important safety recommendation undergoes dramatic and abrupt revision, particularly when there is already endemic anxiety.  The public needs consistent messaging.  It is unsettling when organizations, experts and government officials have different opinions on what precautions we should take.

Here are some of my concerns about widespread use of cloth face coverings:
  • Frequent adjusting of the cloth covering by new users will increase hand to face contact, which is a sure method of coronavirus infection
  • Individuals, despite CDC advice, may use medical grade masks which should be reserved for medical professionals
  • False sense of security of masked folks who may relax their social distancing practices, which every expert maintains is our paramount strategy to flatten the curve and save lives
  • Symptomatic individuals who should be at home might feel that a mask will allow them to enter out into the community risking transmission as they may believe that they are less infectious
  • Will mask wears know how to carefully remove the mask when they return home, clean it after every use and wash hands well when placing and removing the mask?
Don't misunderstand me.  I'm not qualified to opine on the wisdom of the policy.  I do think that the abrupt policy change and mixed messaging is confusing.   And, I don't think it's quite as simple as slap on a mask and all will be well.  I offered above a listing of some of my concerns that I do not think have been sufficiently considered or publicized.  .  
I worry that the expanded attention and use of masks may distract us from two measures that every expert unwavering insists upon.   Keep your distance consistently  And wash your hands often and thoroughly as if you have just touched the virus. 

Sunday, March 29, 2020

Do Doctors Wash Their Hands Properly?

There is no person unaffected by the coronavirus pandemic.  It does seem that the public and the government are responding belatedly in a manner commensurate with the threat.  I write this knowing that less than a week ago from the time I am composing this, Florida beaches were teeming with vacationers.  A memorable quote from one of these selfless and enlightened partiers was:

“If I get corona, I get corona. At the end of the day, I’m not gonna let it stop me from partying.”

This individual, from my own state of Ohio, did apologize for his remarks.  I would suggest that his mouth be mandated to take a 14 day quarantine from all speech. 

Look, we’ve all said dumb stuff.  I know I have.  My advice?  If you sense some dumb words about to erupt, and there are cameras rolling, sprint in the opposite direction as if the coronavirus is on your tail and gaining ground.

Right now, Ohio and many other states are in a ‘shelter-in-place’ status, in an effort to enforce social distancing.   I’m trying to do my part.  I’ve learned about curbside grocery pick up.  I haven’t shaken hands in weeks.  I try to keep my distance from others as best as I can. And, I am practicing telemedecine.  I watched a video that demonstrated ideal hand washing technique.  I’m in a profession that should be model hand scrubbers.  I’ve washed my hands probably hundreds of thousands of times and I’ve seen many colleagues lather up.  But I’ve never seen hand washing as depicted in the training video. This was no mere soap & water exercise.  It was a performance, a veritable choreography of cleanliness.   In other words, I think my own profession could use a hand hygiene refresher course, as could the rest of us.

Scrub Vigorously
(You Don't Have to Get This Deep.)

Interestingly, when the president and his medical minions are giving their frequent news conferences, they all seem huddled together, much closer than 6 feet apart. 

But, at most I’ve been inconvenienced during the pandemic.  For so many, this pandemic has been devastating medically and economically.  The job losses and company closures are horrifying.  I am more sanguine about prevailing over the virus than I am over recovering our economy.   And, there is tension between public health experts and many in the business world about when to permit economic activity to resume.  

As I write this, the U.S. Senate has still not agreed on the zillion dollar recovery package, which I anticipate will occur shortly.   If there was a legislative bill that was against cancer, would it be able to pass the House and Senate easily? I wonder.

We will get to the other side.  And, we will recover eventually.  But we will not be the same. We and the world will have learned about the ferocity and tenacity of an invading microbe and the strategy and tactics necessary to defeat a wily and stealth enemy.   And, we will surely need these battle skills again and again. 

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