Author: Lawrence Hurwitz, MD

Posted on

Gasless in the Carolinas

Fayetville Gas

Roadtrip!” Visions of Chevy Chase in National Lampoon’s Vacation and John Belushi’s scream of “Roadtrip!” in Animal House jumped into my consciousness. The reality was a 1,300 mile car trip up the I-95 to a bat mitzvah in New Jersey. Armed with Google Maps, hotel booking websites,  speed trap detectors,  streaming music services, several bags of M and M’s and 14 gallons of gasoline filling the tank assured me of a well-planned trip that could not be marred with concern or interruption.  I guided the Subaru SUV onto the steaming Florida Highway Interstate and headed North. 

Rumbling past Jacksonville (Named for Andrew Jackson, who knew?) and over the St. Mary’s River into Georgia, the motels and the Loblolly Pines blurred together as we approached the South Carolina state line. A few hundred miles later, my smart car, uttered in a distinguished Bostonian accent, “your fuel levels are low, shall I search for a gas station?” I pushed mute, left the I-95 in Fayetteville and was ready for a quick fill up in the nearest Circle K. Soon enough, a station appeared that was empty of cars but thoughtfully the pump handles were ensconced with plastic. This was a nice Covid protection, I thought. As I squeezed the pump handle with ever increasing pressure, the fuel gauge failed to engage.  My wife stuck her head out of the passenger side of the window, and exclaimed in that know-it-all-tone, “The plastic on the handle means they are out of gas. I reminded you 200 miles ago that a computer hack shut down the Colonial Pipeline and gas would be scare in the Carolinas.”  “It’s a big town, we’ll find gas,” I stammered. Confident that all that fracking, gulf oil reserves and the assurances of Colonial Pipeline execs would lead to a full tank down the road. 

My swagger started to fracture after four empty stations and a “skull and crossbones” emoji appeared near the gas gauge. Limping into a Red Roof Inn on less than one gallon, I anticipated a long layover, minutes from Fort Bragg and the U.S. Army Special Operation Command. Was there a way out? Scrolling down GasBuddy, multiple stations appeared with a slash across the gas tank indicating dead pumps.   Logging off the internet and onto the sidewalk, we hiked a mile up to the nearest 7-11 in search of up-to-date information on gas shipments.  My wife brought a wad of 20s with her in case bribing would be required. “A tanker was spotted five miles away heading toward a Circle K,” the cashier said in a slow Southern drawl. We coasted to our destination and got in line with 50 other cars desperately fighting for fuel. The hour wait was filled with mathematics and history flashbacks. What is the fuel volume delivered by the standard tanker divided by the autos ahead of us?   Memories of the Arab Oil Embargo and waiting for my 1/2 tank of gas with my even license plate was a returning visual in my mind.  Now, 43 years later, I could not think of how I would tell my younger self that I would be gas deficient four decades later due to rogue computer hackers. The moment had arrived, the pump inserted and the sweet distilled hydrocarbon liquid flowed into the tank. I peered to the side and saw a guy in military fatigues pumping gas into his Mustang. Could Special Ops storm Russia and unplug every hacking computer network? Not so easy. Another thought entered my mind from my pumping experience: the leaf controlled the dinosaur kingdom millions of years ago and now oil and gas clearly controlled a trip up the Eastern Coast and dictated our potential absence or presence at a bat mitzvah.

We rolled out of the Carolinas the following morning while tracking the gas gauge every 50 miles and filling up before the fuel gauge got below 3/4. Never take gas for granted!  Shortages of gas delivery and panic buying is a real American response. Perhaps, I thought in a rare moment of self-reflection, i should listen to my wife (who did tell me in December 2019 that a global pandemic was about to occur from a virus found in Wuhan China) regarding human behavior and its defensive responses under pressure and fear. Finally, bring on the electric cars!

Posted on

Traveling In Pandemic Times

My parents provided me with the usual survival tactics in childhood: “don’t put your finger in the electric socket; “don’t play stickball in a busy street;” “look both ways when crossing the street;” “put a jacket on to prevent pneumonia.” But no pandemic advice. My father, born in 1921, had missed out on the Great Influenza pandemic by 3 years. He survived the depression, World War II, the Korean War, The Cold War and Stagflation, but he had no pandemic real world experience. 

Mastering COVID avoidance was easy. I didn’t go out the front door. I wiped down every delivery with Clorox wipes. I interrogated delivery workers at the front door from 6 feet away. I masked up and social distanced with friends who took science and survival seriously. My only brush with the outside world was beamed in with cable news and internet pictures.

With viral mRNA inoculated twice into my arm, the lure of travel beckoned and with it the reality and trepidation of return to the unknown. What would airports, big cities, seeing friends and family be like after a monastic-like life for almost a year?

Armed with an  N95, surgical mask and face shield barrier, I pushed the UBER request on my app for a ride to the airport. “Please roll down the front and back windows for cross ventilation,” I directed the driver, thinking viral kinetics and air exchange. He didn’t blink an eye. At the airport, Homeland Security officers donned face shields and stood behind window barriers. Driver license identity was self-swiped at a distance. The Starbuck’s line imprints on the floor were spaced 6 feet apart and baristas looked like they were part of a surgical OR team. Sipping coffee, a learned skill honed in the past, became a conundrum when faced with two masks blocking the oral route. Should I slip the masks down or up? Should I replace the mask after each sip? Should I take the masks off completely? Should I just gulp the coffee quickly and then replace the mask? Thoughts of Dr. Fauci and the CDC flashed through my head: 10 minutes of exposure, high viral load, ventilation and symptomatic patients. I headed to the far reaches of the airport terminal, separated myself from the unmasked masses, and bolted the coffee down, nearly incurring mouth burns.

Boarding the plane entered me into a strange world. The cheap seats in the back of the plane got first dibs on boarding to limit contact time. Finally, seated, I breathed a sigh of relief when the hotly debated middle seat vacancy was enforced. Anxiety returned, as the flight attendants distributed the snacks. Was it worth unmasking for a granola bar and a small package of chips? The lure of Pringles was too great and I succumbed to temptation, all the while contemplating my eulogy, “he gave his life for a a few plain potato chips.” 

The plane hovered over LaGuardia Airport awaiting the final approach. Built on a garbage dump used for Brooklyn’s excess waste, I pondered the early Queen’s denizens grappling over their microbe challenge: Salmonella and Shigella. The plane landed, the  gate opened and I marched single file, 6 feet apart, masked and into the terminal where multiple, camouflaged clad military awaited me. Did I take the wrong flight and land in Mogadishu, Somalia? No, New York City, where Andrew Cuomo’s quarantine rules were being enforced against the blasé non-Northeastern states where I was now residing. It seemed surreal to be approached by a military serviceman and servicewoman who were both armed with weapons and asked if I had a Covid 19 PCR test performed in the last 72 hours, and if so, what was the result? Things had changed.

After claiming my luggage, I entered a NYC taxi cab to the final push to Manhattan. As I gazed upon the the facial scowl of our driver, I thought it best not to bring up the cross ventilation directions again. As I entered FDR Drive, I fixated on the credit card swipe. Can COVID exist on the card? Can I Clorox the gap? “What would Dr. Fauci do?”

Walking in Manhattan, I could immediately sense the gravity and public health compliance of the borough. This pandemic was not some abstract chyron endlessly streaming on a CNN telecast. Families and friends had been stricken with serious illness and death at the beginning of the pandemic and this crystallized the importance of public health measures. Multiple restaurants had outdoor seating ensconced within a plastic dome. At night, the yellow and purple lighting from restaurant isolation tables provided an extra-terrestrial feel. 

The ordeal was worth it after ending a year absence from family. Hugging my fully vaccinated son and and elbow bumping my unvaccinated son and daughter-in-law in the social distancing expanse of Prospect Park (thank you ,Frederick Law Olmstead) was priceless.

Many years from now, when my grandchildren gather around me and ask about the Pandemic, I’ll reply, you have to carefully peel off your N-95 mask just like this, and then get the Starbucks lid under the face shield that protects your mask and..…”

  • Fortitude, NY Public Library Lion, Masked
  • Double Masked and Ready
  • Military comes to LaGuardia
  • Outdoor Dining Bubble
  • A bubble for Two
  • Social Distancing in Prospect Park
  • Atlas Masked in Rockefeller Center
  • Unmasked Dog in Upper East Side
Posted on

COVID and Nasal Memories

Pizza in my Olfactory Dreams

The Door Dash delivery was on the top of the steps, delivered from a  pizza service in San Diego that claimed “New York Style Pizza.” After the ritual disinfection of the pizza carton, the lid was lifted and I was delivered into another time and place. Scotty, the owner of a Queens pizza restaurant 60 years ago, was ensconced in my olfactory memory. He was flipping the dough as his octogenarian mother was lovingly molding a veal parmigiana hero that could make a grown man cry. Melted mozzarella, oregano, sausage and mushroom fumes reawakened a gustatory experience that I experienced for the first time, many years ago. With hops entering my nostrils from my Dad’s 1965 Miller High life, I left the COVID virus prison and entered a happier time when New York City  was a palace of gustatory delights and my childhood garden was in full bloom.

Through my nose, to the ethmoid sinuses, onto the olfactory epithelium and 60,000 smell neurons directed my pizza delivery directly to the frontal lobes and limbic system where Scotty’s still lived in vivid memory. This ecstatic experience is being stolen from millions by a renegade virus which has shut down the world for the last year. Expunging the smell and taste in some of the 25 million who have had COVID, which may have long lasting and permanent damage of the olfactory system. Malnutrition, depression and the loss of warning symptoms to natural gas leaks or tainted foods may be the legacy of sufferers of nasal COVID injury.

The least regarded of the five senses, smell and taste have taken a back seat in medical training and in popular culture. Medical school has few lectures on the proper function and diseases of smell and taste. Medical history taking neglects inquiry of one’s nasal and lingual capabilities. Olfaction has been a butt of jokes for generations of comics from the Simpson’s “smell you later”, Hawkeye Pierce’s ridicule on food sniffing in M*A*S*H and  Mel Brooks flatulence scene in “Blazing Saddles.” 

The dismissal of this forsaken sense is belied by its prominent location. The olfactory nerve, the shortest of the cranial nerves, sits in the front of the brain and sends projections to multiple areas including the emotional hub, the limbic system. Our evolutionary ancestors and current mammalian brethren rely on scent to distinguish friend from foe and food from poison. Our beloved canine, Millie, the Jack Russell Terrier from times past would apply the sniff test and rarely made a bad decision on food or domicile choices.

Obscure medical jargon has entered the mainstream with anosmia (lack of smell), parosmia (smell that fails to correctly match the odor) and phantosmia (phantom smells) appearing on long hauler COVID social sites. “Everything smells like burnt coffee” I heard a patient exclaim. “No longer can I taste the citrus in my tea,” another laments. “I ate a hamburger and I miss the onion smell and taste.” Essential oil kits are hawked on Amazon in the hope that olfactory re-education may hasten recovery. While the long term outcomes are not apparent in so recent a disease, it appears that up to 5% of smell sufferers may not  regain perception at 6 months.

“Don’t it always seems to go that you don’t know what you’ve got ’til its gone,” Joni Mitchell’s ballad went in the ’60’s.  And so it goes with Scotty’s appetizing, fragrant pies from the same decade. Enjoy your senses and don’t forget to stop and smell the pizza.

Posted on

Media Distortion Syndrome: The Baby Boomer Edition

It was 1963, the Yankees were swept by the Dodgers in the World Series, the Kennedy assassination was to be a month later and the Jetsons were on network TV. My upstairs neighbor, a wise old soul, a year ahead of me in 5th grade, casually predicted the future as he was downing his second Twinkie. “By 2000, all of the Jetsons things will be there for us.” The flying cars, the robot maids, the vacuum transport to Europe and the 2 day work week. 

Fast forward to New Years Eve, 2000 as I anxiously turned on the TV to watch the Times Square Ball drop to usher in the new millennium. Car commercials came on, all terrestrial vehicles, United Airlines ads promising low fares to Europe at subsonic speed and no robots in sight in my Southern California home. How could Joel, my upstairs neighbor, be so wrong?  A case of media distortion syndrome, baby boomer edition, no doubt. 

Social media is replete with opinions and conspiracies that pass as truth and shape our world today.  My generation, spared from the early influence of the internet, was a product of broadcast television. The three networks (CBS, ABC and NBC) and local New York City stations, WNEW channel 5 and WPIX, channel 11, raised us through the ‘50s and 60’s and shaped our proclivities, biases and sense of reality. Through the writer’s scripts, we were raised on the magical, the ingenuity of the white male, the geological time slips, bigotry-lite, and anthropomorphisms. Here is a sampling of television education gone wrong:

  1. The Magical
    1. Bewitched: A corporate advertising executive who marries a witch that can twitch her nose and change reality.
    2. I Dream of Jeannie: An astronaut finds a magic lamp and releases an attractive genie who alters reality and discombobulates authority.
    3. The Flying Nun: Self explanatory.
  2. Ingenuity and Family Glue: The White Male
    1. Family Affair: A wealthy, N.Y.  bachelor engineer becomes surrogate father to two prepubescent 6 year olds and a female teenager, assisted by his English valet. No problem!
    2. Bachelor Father: Bachelor attorney adopts his adolescent niece and live happily ever after. 
    3. Sky King: Rancher and aviator raises his niece and extricates her from all sorts of perils.
    4. My Three Sons: Widowed engineer raises three sons with the help of his father-in-law and later invites his daughter-in-law to live with the extended family. No problem!
  1. Geological Mayhem
    1. The Flintstones: Stone age family lives in Bedrock with their pet sauropod dinosaur. Humans: Pleistocene epoch, Dinosaurs: died in Late Cretaceous: 65 million year gap; a rounding error to the networks.
    2. The Jetsons: Flying cars, humanized robots and push button jobs but no physicists consulting on the show..
  2. Anthropomorphisms
    1. Mister Ed: A debonair horse who only talks to his owner and has an egotistical streak.
    2. The People’s Choice: Politician’s basset hound makes wise cracks about the hi jinx experienced by his owner.
    3. My Mother the Car: Self Explanatory.
  3. Bigotry-Lite
    1. The Real McCoys: An Appalachian grandfather moves with his grandson, and his family to cast aspersions on California natives. Starring  Walter Brennan, a John Birch Society member and avowed racist. 
    2. All in the Family: A Queens cabdriver, Archie
      Bunker, spins prejudice at home but his persona softened by his work ethic and his financial and housing support of his liberal son-in-law.
    3. The Beverly Hillbillies: Appalachian family moves to California where rich, wealthy Californians belittle the rural immigrants. A mirror image of The Real McCoys.

What we digested from those 3 networks and local feeds was entertainment to some and truth and dogma to others. Twitch your nose, rub a lamp, consult your single male engineer/attorney about child rearing or converse with your horse or your loquacious canine and prepare for a blissful life.  As to our current world, with each more outrageous conspiracy theory espoused on cable and social media, the Senate ready to discuss disenfranchisement of  millions of voters I can only shake my head and utter the insightful and comforting words of an equine star of yesteryear, “Oh Wilbur.”

Posted on

Understanding Oxygen and the Apple Watch 6: A Primer on Oxygen Saturation 101

The tech world has had a hold on the imagination and pocketbook of Americans for decades, improving our day to day communication, entertainment and educational options, all contained in the device we hold in our hands. More recently, tech companies have entered the multi-billion dollar health and wellness market, claiming a roseate outlook on life quality by revealing a wealth of “health” data populated on our iPhone or Android phones for us to peruse. For those that majored in business, art, political science or philosophy in college, watched “Keeping Up with the Kardashians” instead of “Mr. Wizard” reruns and did not take a physiology or human biology course, these numbers may be bewildering. It is time to let some “air into this room” and provide a background for understanding tech and health devices.  After 4 decades around EKG’s and pulse oximeters attached to humans and a user of Apple products for almost as long, I will provide the introductory course on the latest Apple foray into health: oxygen saturation and the pulse oximeter.

Oxygen is a key to human health. Before it’s atmospheric debut, we had bacteria for a billion years with few tech inventions during this period, save for the flagella, a whip like structure that could take you a few inches across a scum filled pond. Queue the plants (algae and other photo-synthesizers) and oxygen enters the atmosphere allowing for multicellular organisms and ultimately us (now is the time to hug your house plant out of gratitude). What did oxygen do for us? It unlocked the ability to generate much more energy from food sources that allowed us to dig a ditch, launch a satellite or use your TV remote. As any biochemistry or medical  student knows, ATP, the powerhouse chemical we use to store and release energy, is manufactured 16 fold in the presence of oxygen (for the curious, see oxidative phosphorylation and electron transport chain for more details).

The engineering dilemma that evolution was faced with for us multicellular beings was a supply and distribution problem. How to get oxygen from the air to each of our cells?  To move a substance, you need a pressure gradient to drive the work and the atmosphere pressurizes oxygen to move from high to low pressure zones. But this does not get the prized element to deeper tissues. For that obstacle, we evolved the lungs, blood vessels, blood and heart to circulate oxygenated blood to tissues to bypass this problem. 

Yes, blood, that substance thicker than water. Oxygen can dissolve in blood but at very low concentrations. To improve on the quantity of oxygen, we inherited the red blood cell and its key constituent, hemoglobin. Hemoglobin is the main oxygen carrier in the blood and allows pick up and delivery of 02 to the tissues. Oxygenated blood is bright red (usually arterial) and less oxygenated blood (usually venous) is blue. We can exploit this light absorbing property to determine how much oxygen is bound to hemoglobin at a particular moment by shining a frequency of light at a blood vessel and checking how much is absorbed and reflected at one time in the heart beat cycle.  The ratio of oxygenated to  de-oxygenated hemoglobin is measured, and reported as  oxygen saturation.

Do you need a device that warns you of oxygen shortage? Shouldn’t you feel short of breath, breathe faster and get yourself into an emergency room in time? Not always, as your brain, highly dependent on oxygen, can go haywire with  confusion, lethargy and poor judgement as a consequence. This is why the flight attendant always directs you to put your oxygen mask on first before your children. What about turning blue (cyanosis) from low oxygen? Unfortunately, this is a late occurring sign which occurs when fully ⅓ of the hemoglobin is devoid of oxygen.

Is there an early warning device to warn us of oxygen deprivation?Cue the pulse oximeter:  oxygen saturation can be measured by a pulse oximeter, or more recently with tech watches that have similar technology. Healthy lungs at sea level usually allow for oxygen saturation over 95%. As with all technologies, certain pitfalls apply. If your hemoglobin is abnormal it may not be measured properly. Carbon monoxide poisoning, for instance, renders hemoglobin incapable of binding to oxygen but is not registered by the pulse oximeter. Yes, you can asphyxiate with a normal pulse oximeter reading. The sensors must be close to the skin and not moving or else a faulty reading could result. Even expensive devices can be subject to error. Many a time in the surgery center, a reading of 60% could appear in an awake, non sedated patient. Repositioning the sensor, recalibrating the device or wheeling a new machine into the OR solved the false reading.

So what can you glean from the result? High altitude can lower oxygen saturation due to lower oxygen pressures. Altitude sickness can result with headaches, shortness of breath and in extreme circumstances, flooding of the lungs with fluid. Severe pneumonia can lower oxygen saturation and in the case of COVID 19, may not result in air hunger which would normally warn you of severe lung infection. Severe asthma could also cause a drop in oxygen saturation. Apple has started a research trial examining the usefulness of the Apple Watch 6 in this circumstance.

 The most important use of this technology may be in screening for obstructive sleep apnea. This condition is quite common in the U.S with a prevalence up to 30% of males and 15% of females).  Celebrities such as Rosie O’Donnell, Shaquille O’Neal,  William Shatner, (aka Captain Kirk of Star Trek fame), Quincy Jones, Randy Jackson (of American Idol fame) are afflicted. Luminaries whose death may have been influenced by sleep apnea include William Howard Taft (former 27th President), Jerry Garcia (of the Greatful Dead), Justice Antonin Scalia, Carrie Fisher (of Star Wars fame) and James Gandolfini (of Sopranos fame). Sleep apnea has severe health consequences and has acceptable, effective therapy. With the increase in risk factors such as adult obesity and sedentary nature of the population, obstructive sleep apnea is becoming epidemic, resulting in upper airway obstruction at night with snoring, interruption of breathing and dangerous reduction in oxygen saturation. This condition often results in headaches, daytime fatigue, hypertension, acceleration of cardiac disease and premature death. A continuous positive pressure mask can ameliorate this condition. A convenient, readily available screening tool such as a reliable pulse oximeter for nighttime use could potentially save multiple lives by directing those into the office of sleep specialists for definitive diagnosis and treatment.

So should you climb on board the day and night pulse oximetry tech train?  With certain caveats (a device that has reproducible results and matched to gold standard testing, FDA approval and  that works for night-time monitoring) this metric may benefit you when hitting the ski slopes and when your significant other has had it with your snoring and asks you to “do something about it.” Take a deep breath and ponder that.

Posted on

The Battle Against Fake Science

The fates of Dr. Li Wenliang and Dr. Anthony Fauci will be irrevocably linked in our current times. Both physicians were muted by their respective political overlords:  Dr Wenliang sacrificed his life in the pursuit of warning the world of a deadly airborne virus originating in Wuhan, China and Dr Fauci, by the Trump Administration in thwarting his public health efforts in limiting morbidity and mortality. In these unsettling times, the assault on medicine and public health is not only lethal, but tolerated by industry, public opinion and political factions. 

When capitalism and profit intersect with human health, the American experience has often been in the favor of the former. American medicine in the 19th century was profit driven, fueled by several hundred medical schools that had no legitimate science curricula, no formal training programs and no criteria for competent professors. US medical students, desiring a top flight education, would journey to Paris to get state of the art instruction. Snake oil salesmen who peddled dangerous potions for multiple ailments thrived in the 19th century. 

The 20th Century provided some sanity and sanctity in the pursuit of science and healthcare. Abraham Flexner, an American educator, at the request of the Carnegie Foundation, reported in 1910 on quack medical training that resulted in the closure of multiple schools and began the scientific basis of medical education in the U.S. The Food and Drug Administration, established in 1906,  provided an oversight of drug therapy and provided a safety net to the general public.

Greed and the pursuit of profit in healthcare today still cannot be denied.  Popular entertainment reinforces the profit motive. Mr. Wonderful, on Shark Tank, when reviewing a vitamin and herbal supplement, gleefully queried the proprietor, “I don’t care if it works, what are your yearly sales?” Gordon Gecko, in the 1980’s movie “Wall Street”, uttered “Greed is good.”  Even in the 1950’s, Jim Anderson,  the iconic principled father in “Father Knows Best” sitcom during  the Eisenhower era, readily endorsed the Springfield snake oil salesman’s request for a business license because he was good to his dog and family. 

Congress got into the act of greed and greenbacks in response to a potential flood of pharmaceutical lobbyist money, further sacrificing the principles of science and public safety. Utah Senator Orin Hatch orchestrated potential legislative medical malpractice with The Dietary Supplement and Health Education Act of 1994 (DSHEA) which decreed that over the counter supplements and herbal products did not need to prove safety data prior to their release to the public and any complications would only need to be voluntarily reported. The supplement companies could not claim to treat a “disease” but misleading euphemistic claims such as “supporting health, “wellness,” or supporting a biologic system could be used in advertising without any scientific data to confirm the claim. What was the result? The OTC industry money profits increased from $9 billion to $50 billion,  Salt Lake City, Utah became a destination for the supplement companies. Hatch’s family became lobbyists for the industry and he and other members of Congress had a reliable flow of campaign donations.  What did the consumer get? The answer is clear: A flood of products that resulted in liver injury, life threatening drug interactions and occasional cardiovascular deaths. Product labeling was often misleading or wrong. Probiotics, living bacteria that can contribute to health, were often non viable or absent when analyzed by microbiologist/scientist scrutiny (R. Knight, UC San Diego). Families put themselves into financial jeopardy by spending hundreds of dollars per month on bogus supplements hawked by salesmen and health providers. This was a legislative fiat that legally supported medical quackery.

Now the technology industry is attempting to expand their profits by tapping into our health obsession and circumventing health law. Products that evaluate sleep hygiene, pulse and heart rhythm and oxygenation are entering watches, phones and bracelets. When developing a new technology, the rational response is to compare your experimental device to a gold standard that accurately measures the outcome you are looking at. For sleep analysis this is polysomnography, a medical test that looks at EEG, respiratory rates, eye movements among other data; oxygenation gold standard is the transmission pulse oximeter. Tech companies, such as Fit Bit and Apple, for instance, bypass the gold standard test and support their device results with an opaque “secret artificial algorithm.”  In the few studies that compare products to their gold standard, they are often shown to be inaccurate. The companies, unable to get FDA approval, then take guidance from the supplement industry by using “wellness” as the reason for the biometric. With no reproducibility and no public direction on the meaning and actionable explanation for the results, we are left with tech company advertising babble to encourage their purchase. 

It has been the pandemic of 2020 that has shown the stark reality of science deniers. Trump’s effort to undermine science and mask wearing and the infiltration and destruction of our beloved NIH, CDC and FDA autonomy has been an armageddon moment in healthcare. Pushing hydroxychlorquine, megavitamins and experimental medications that have not been fully vetted in randomized controlled studies as effective cures is unacceptable to the medical community and cannot be recommended as treatments to the public at large. Furthermore,  anti-vaxers, and proponents of the deadly “Herd Immunity” strategy are further evidence of our dilemma.

I am reminded of Dr. John Snow, a British obstetrician in the mid 19th century, who observed his London patient washing her infant’s diapers in a common water pump in town that spread cholera throughout the community. Snow’s work established the water-borne source of cholera and his urging of removing water pump handles. His pleas went unheeded by the public and scientists of his time leading to the death of thousands of additional victims in the cities around the globe. Accepting well designed investigations and their conclusions are our only way to avoid a “Dark Ages” outcome of health goals.

Our hope for the future lies in the investment of science teachers, high quality training of physicians and allied health providers, debunking and removing dangerous healthcare products on our social networks and providing the public with political leaders who want to move away from the past and into the evidenced based medical world of the present. 

Posted on

How Did Trump Happen?

As the key engaged the heavy deadbolt, a loud clank was emitted and the solid steel doors opened the locked ward of the LA County Psychiatric Hospital. That sound and the antiseptic smell of the unit still linger 35 years later, as I walked across the threshold, as a third year medical student, ensconced in my newly pressed white coat and brand new Washington Therapeutics manual.  A large muscular man was leaning on a table brooding and muttering to himself. The psychiatry resident pointed to him and asked me to take a psychiatric history. “He took a bus from Illinois and was arrested on the 405 Freeway while attacking cars on the off ramp with a crowbar.” After eliciting some grunting responses and “God directed me” responses to my clinical questions, I abandoned my medical questioning. “Send him to my office and I’ll demonstrate how to perform a psychiatric history,” my instructor demanded. Summoning the patient into the small office, I sensed a catastrophe in the making. Turning over the psychiatrist’s desk and chairs and uttering a string of expletives in rapid fashion, he stormed out of the room.  The resident paused for a minute and then observed, “That guy is dangerous. F**k the history. Double his haloperidol dose.”

This moment in my medical training recurs in my mind as I watched for the past 3 ½ years at the news correspondents’ quizzical looks as they tried to respond to Donald Trump’s ever increasing disjointed communication.  While my patient in the county psych ward communicated with violent behavior, he nonetheless was unable to express a coherent on-topic conversation that mirrors reality like Donald Trump.  As the evidence mounts of Trump’s psychopathology,  supported by Ivy League and family embedded mental health specialists, the parallel becomes more realistic.

How can you account for the election and sustained authority of a man that has no appreciation for reality, no empathy and no problem solving ability? Three concepts are critical, in my opinion: 1) The firewall of falsehoods that support politics and insulate the economic, profit motive for governance; 2) the pseudo-reality of 7 decades of television watching; 3) the inability of rational people to respond to a psychotic dialogue.

The political firewall of falsehood is particularly thick in our early education. We learn that Thomas Jefferson, the author of the Declaration of Independence and the third president of the United States is a great American, however educators skim over his ownership of slaves.  Andrew Jackson, our “people’s president” and victor over the British in New Orleans during the War of 1812, was also the architect of the forced removal and slaughter of the Cherokee from Georgia despite two Supreme Court rulings against its legality.  Various wars fought in the name of preserving the American way of life were often a subterfuge for economic gain. The latter was particularly relevant for me during the Vietnam War, as my generation was drafted and conducted the war at the bequest of past presidents, including the corrupt Richard Nixon. The firewall called the war effort to “prevent the spread of communism” and contain China and Russia from world domination.  These pseudo-facts were debunked by Southeast Asian historical scholars and disseminated in political science courses during my college years and validated by the subsequent arc of history.  Profits and employment opportunities in the U.S. were the nested reasons for this conflict. Lobbyists dominate political decision making and mask the true reason for congressional and presidential decision making. When one does break the firewall of mendacity and falls on the other side, the lure of profiteering can steer you back to the wrong side. No wonder, during my one Vietnam era protest in Washington, I was warned by relatives that this could harm my future employment in Wall Street financial firms. It was hard to contest the Trump supporter’s claim that “all politicians lie.”

Television was the final coup de grace that catapulted Trump into the White House. The lack of critical thinking is pervasive in our society and television has obliterated the lines of news and entertainment. Early television could still cling to morality and group cooperation (think Father Knows Best and Gilligan’s Island). “Reality” shows that masquerade as truth created a fictional narrative that viewers accepted without reservation. Without The Apprentice, Donald wouldn’t have had the political on-ramp he enjoyed.  While all who worked with Trump in the real world of construction and media declared him a fraud, he was on television and they must be mistaken.

In summary, rational people brought up on falsehoods, ensconced in Reality TV  for a number of years combined with protective self-talk when confronted with uncomfortable behavior from elected leaders, begin to accept and adapt to irrational discourse and actions. Consequently, they excuse or ignore it.

So the narrative goes as follows: Yes, he tells lies, but don’t all politicians do the same (the firewall of falsehood) and he’s a competent businessman, it says so on television. The psychosis element is dismissed by either: 1) not dealing with it (think of how many people avoid the homeless);  2) he couldn’t be in his position with a diagnosis of mental illness.

Mental illness that erupts into violent and dangerous behavior is easy to discern and react to swiftly with isolating the perpetrator from society.  That was easy to understand in my early days of training. Like the frog slowly boiled in hot water,  we have as a society built a firewall from truth, televised abnormal behavior into entertainment and have been trained to look away and excuse or normalize statements of question or actions by leaders when confronted with uncomfortable behaviors.  My Uncle Jack use to respond to all inexplicable government driven situations with, “It’s Fixed.”  I think he is correct, but it is up to us to fix the fix.

Posted on

Gut Punch Against COVID-19

“You are what you eat.”Jean Anthelme Brillant-Savarin, a French lawyer, epicurean and father of the low carbohydrate diet, penned these words in the 18th century. As we struggle through the COVID-19 pandemic, we search for personal ways to influence our health and our immune system to combat this pestilence. Food choices are an overlooked variable that may alter our fate.

Our human engagement with infections is played out daily through our immune system. Ironically, we are dependent upon our commensal microbes that happily reside in our bodies to assist in the fight against environmental, viral and bacterial invaders.  Over one hundred trillion bacteria and untold fungi, archaea and microscopic multicellular microbes take up residence in the gut after birth.  These microbes are a virtual army responsible for innate immunity and the initial fighting response to pathogenic agents. Furthermore, these bacteria contribute forty times more genes in the gut than human genes in the entire body. The exact role of these genes is uncertain, but they may produce proteins that may influence the bodies fighting power.  It is believed this gut bacterial diversity and their metabolites protect us by establishing an intact mechanical barrier, facilitating the release of bacterial and human antimicrobial chemicals and competing with pathogens for nutrients. They trigger the inflammasome, a coordinated release of immune stimulating chemicals (cytokines) that arm the lymphocytes, macrophages, neutrophils, dendritic and plasma cells that produce the coordinated inflammatory response.  A delayed innate response can result in a virus that gains a foothold that cannot be stopped. Similar to friendly fire, an over exuberant immune response can injure tissue from toxic inflammatory chemicals long after the pathogen has been vanquished.

Older age, diabetes and obesity are clearly risk factors for severe adverse outcomes with COVID-19. The common metric of these risks are a dysfunctional immune response. A slow initial response or an unregulated and injurious inflammatory reaction can result in devastating consequences for the infected host.  The gut microbes and their genes, the so called microbiome, are fundamental for a proper defense to infectious agents. A healthy microbiota is still being defined, but with new molecular biological techniques, a diverse population of organisms is critical to drive down the middle lane of life–away from infectious disease and autoimmune/allergic disorders. Altered microbiota or dysbiosis, is the hallmark of obesity and diabetes. And our country is flush with these risks. Over 40% of the U.S. is obese, representating a four-fold increase in prevalence since the 1960’s.

The microbiota can be malleable and is dictated by food for good or bad. And, food choices in our country may have steered us into more fatal outcomes with COVID-19. Processed food, hydrogenated and trans fats, high fructose corn syrup, larger portion size with higher calories and antibiotic tainted meats have assaulted the beneficial microbes in us. Could this be one of the reasons we are the leading country in COVID-19 cases and deaths?

Social distancing and masks are first line defenses against the Coronavirus fight.  Food choices MAY be another volitional pathway to maintain health. Fermented foods can select for beneficial commensal bacteria that make-up one’s microbiota. Greek yogurt, sauerkraut, tempeh, kimchi, and miso can favor the growth of Lactobacilli and Bifidobacter genera, both known to be healthy members of the microbiome.  Germany, Korea and Japan have low per capita rates of disease, attributed to timely public health measures and widespread COVID-19 testing. Might these differences be partly explained by eating sauerkraut in Germany, kimchi in Korea and miso in Japan?  Do some long standing cultural food preferences select for a healthier microbiome that is protective for Coronavirus infection or helps to modulate an appropriate immune response?  It seems to this clinician that it’s worth a clinical study as we, the people of every culture and nation, come together to collectively look to each other for any possible clue to mitigate the ravages of this virus.

Posted on

Uncertainty to Despair to Hope and Redemption: My Professional Life Battling an RNA Virus

I feel  like I am reliving a bad dream. The race to find a treatment and/or cure to SARS-CoV-2 is reminiscent of decades of practicing gastroenterology while hepatitis C roamed the hospital wards as a death sentence for many. I found myself recently recalling a patient whose story ends with science finding a cure.  The story begins in a community hospital’s ICU.

 As I peered around the ICU curtain, I could see the outline of a motionless ill man. I was visually greeted by a panoply of colors not usually seen in human health. Yellow skin and eyes, violaceous bumps on his extremities and blue hued fingertips. As I entered the room, I recognized him as the car salesman I had spoken to several months ago discussing the pros and cons of  an SUV versus a minivan. His labs and physical exam delivered the bad news that his liver and kidneys were not working and he had vasculitis, an inflammation of the blood vessels. While he had a case that medical students study intently, private doctors rarely see in decades of practice: essential mixed cryoglobulinemia secondary to Hepatitis C. In an attempt to curtail the virus, antibodies bind to viral proteins. Excess antibody-protein complexes, instead of being  cleared from the blood circulation, get deposited in the blood vessel walls causing inflammation and sometimes closure of the vessel. He was in danger of losing his kidneys, his liver and his life. A National Institute of Health study had shown a few years earlier that the immune stimulating natural agent interferon could have a beneficial effect on Hepatitis C. Interferon was started and miraculously the bumps disappeared, the kidneys started to make urine, dialysis was stopped and the jaundice receded. He left the hospital and completed 12 months of interferon, combating fatigue, low white blood counts and depression due to drug side effects. He had been cured of Hepatitis C and had dodged a fatal complication of the virus using a toxic biologic agent.  

This early success had been a rare gold nugget amidst multiple disappointing and tragic events in my experience with the RNA virus, hepatitis C. The lessons learned from this virus are worth retelling as this is a story that parallels our current ordeal with another RNA virus, SARS-CoV-2. 

The biologic veil of Hepatitis C was heavy and was only lifted in fits and starts. In the alphabet soup of hepatitis viruses, A and B were discovered early but “C” was undetectable and given the placeholder non-A-non-B for years until special techniques were devised to recognize its presence. Infection was through blood transmission, usually through blood transfusion, sharing of needles or instruments that were contaminated with the virus and inadvertently inoculated through the skin. In contrast to SARS-CoV-2, which has a presymptomatic stage of a few days, Hepatitis C’s silent period was years or decades before disaster would take hold. Cirrhosis, or significant scar tissue in the liver could impair the sieve like blood circulation within the liver shunting blood to places it normally wouldn’t go resulting in gastrointestinal bleeding, ascites and encephalopathy. Years of infection can lead to liver cancer with a dismal prognosis. 

My early encounters with hepatitis C felt like bailing water from the Titanic while it was taking on water. I could band bleeding blood vessels, start water pills and limit salt in those with fluid overload and give antibiotics to reduce the toxin burden and reduce hepatic coma risks. But without specific treatment for the virus, we were on a slowly sinking ship. Then the drug interferon came along. It was a mixed blessing. It was toxic, causing fatigue in most and depression in a significant minority. It could lower white blood counts and damage the nervous system. It worked in only 10% of patients with the most common genotype of the virus. Most diabolically, those who needed it most were cirrhotics, and for patients with this condition, it was the most toxic and had the lowest response rate. I saw harsh drug side effects that included suicidal thoughts, absenteeism from work on the drug and plummeting white blood counts in countless patients. I questioned whether it was worth the one in ten chance that the drug would work. Slow progress (too slow for patients on the liver transplant waiting list) was the rule of the day. Ribavirin, an oral drug, used with interferon, raised the response rate to over 40% at the expense of the new side effects of anemia and potential birth defects. Most of my discussions with afflicted patients were often discouraging treatment, waiting for “some breakthrough in the future.”

The initial breakthrough came: direct acting antiviral drugs were available in 2011. They were protease inhibitors, drugs that blocked the assembly of viral proteins within the cell. The first generation protease inhibitors had novel side effects including disabling rash, headaches and mouth sores.

I came to dread the newly diagnosed hepatitis C consult. It felt like a “pick your poison” option.  I could offer an imperfect and potentially toxic mix of therapy, not unlike the oncologist administering chemotherapy to a cancer victim. 

This all changed with the synthesis of the drug sofosbuvir, an RNA polymerase inhibitor not unlike Remdesivir, an encouraging agent for SARS-CoV-2. Sofosbuvir, coupled with new protease inhibitors was the miracle I had not witnessed in my four decades rendering care to my patients. It’s side effect profile was no different than placebo and amazingly the cure rate would climb to over 98%. It worked equally well in patients with cirrhosis and the course of therapy was “weeks” rather than “years.” And, it was a cure! Patients who would have been candidates for liver transplantation saw improvement and were removed from the transplant lists. Liver cancer risks were reduced. Other non-liver conditions like heart disease, immune function and cognitive function improved with eradication of the virus. I felt my office was the equivalent of a Lourdes destination for the hepatitis C patient.

Science rendered a disease that afflicted 3.5 million Americans and killed up to 20,000 people a year to an affliction that most likely will be eradicated from the planet in our lifetime. The success of the treatment for hepatitis C can be looked upon as a template for our next RNA viral battle: SARS-CoV-2.  Hopefully, we can build from the success of the hepatitis C RNA polymerase inhibitor and extrapolate to a drug combination that can treat the disease as we wait for a definitive cure and vaccine.  Covid-19’s fate must be one that someday, when I reminisce about this time, I write another science driven medical success story.

Posted on

The Art and Science of Barriers

“Good Fences make good neighbors” is a memorable and salient line from Robert Frost’s poem, “Mending Walls.”  While the context of its meaning is a plea for the importance of privacy, it is a useful phrase for the COVID-19 pandemic as we all try social distancing as our physical defense and protective barrier from the Coronavirus. Six feet away from one another and swathed with a nose and face covering mask seems to be the barrier du jour. It has been that throughout life we must deal with barriers that represent either obstacles, as in the poetic verse of Robert Frost, or provide succor to our existence. In our current COVID-19 world, our imposed barrier, a protective mask, will be critical to manage our “new normal” prior to a transformative drug or vaccine. In essence, we need a science driven mask that is effective, comfortable and re-wearable.

Biologic barriers are present from conception. Surrounded by the amniotic membrane, we are protected from most pathogens. Upon its rupture and our ride down the birth canal we start the self versus society struggle.  Hepatitis B, polio, rotavirus, diphtheria, tetanus and pneumococcal vaccinations are our initial immune barrier. Child proofing mechanical barriers (plug locks, stair locks, edge protectors) are present during our formative years. Car seats and later seat belts protect us from motor vehicle morbidity. Science has driven these medical protections and public health measures have orchestrated their distribution to the public and their acceptances as standards of care.

Societal barriers have protected humans for eons from human aggression, accidents and microbes. The Caves of Lascaux  protected Paleolithic man, The Great Wall of China retarded invasion by the Mongols. The Roman emperor Hadrian built his namesake “wall” in Northern England to keep out the “barbarians.” Ramparts and moats around European castles in the Middle Ages slowed the devastation wrought by the Vikings. In our lifetime we put up with anti-terrorist barriers at TSA checkpoints at all U.S. airports. Physical barriers and screening techniques have been shown over time to decrease disease and death from outside threats to our well-being.

Our protection from COVID-19 now demands a barrier to our nasopharynx. We are now safely surrounded by our homes’ four walls and limited “world” contact through our UPS and Amazon delivery services. In order to integrate into society we need extra protection from the virus. A mask or “facial condom” could provide us with the protection and turn human interaction into an acceptable risk. We are now familiar with the N95, surgical, and home-made masks. We have YouTube videos of media celebrities constructing masks. Now,  “mask science” is the next logical step to assure that our efforts are working to prevent Covid-19 transmission. What we really need is some evidence based guidelines developed from a controlled study.

 The geometry is well known: N95 keeps out 95% of particles that are as small as 0.3 microns; droplets containing COVID-19 are 50 microns or less. Droplet spread is 6 feet, more if sneezing or aerosol transmission is involved from the contact. What we don’t know is what materials and layering are most effective against virus spread when used in a real world scenario.

Compliance and comfort are inextricably linked. When I donned a mask in the OR, my face felt like I was in the microclimate of Miami during the summer and my eyeglasses fogged up like winter in London. We have designers and aerosol engineers that can overcome “wearability” issues that could lead to improved compliance. We have industry and universities that have the capability of testing combinations of fabric under simulated and actual environmental conditions.  Distribution capabilities are available to send masks to every household in the United States utilizing the Postal Service.

Americans have internalized the use of seatbelts and TSA screenings in my lifetime. Introducing and complying with  a “new fence” is easier when the alternative may be a painful respiratory death. Wearing a fashionable, comfortable and effective face mask should become the “new normal.”  The design, efficacy and distribution is simply just one more barrier for science to overcome.