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

https://www.cleveland.com/opinion/2020/04/chloroquine-for-covid-19-not-for-this-doctor-michael-kirsch.html

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.