Category: General

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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.

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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.

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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.

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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.

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Soup Saviors: Chicken and Matzo Ball Soup Stories

Chicken soup has long been an off-label medicinal treatment for the common cold and flu as long as most of us can remember. So, it seems in these troubled times of COVID-19, we are hearing of its use in both healthy and coronavirus inflicted patients. An elixir from antiquity, chicken soup and its Passover-inspired cousin, matzo ball soup, are the “magic potions” from yesteryear that have been a proven adjuvant to analgesics and cough suppressants. However an Amazon search for chicken soup brings up a dizzying array of “out of stock” and “delayed delivery” for dozens of pre-made poultry influenced self-prescribed potions.  Chicken noodle, chicken and stars, old-fashioned chicken noodle, low sodium, healthy request, chunky, cream of chicken and every conceivable form of soup on a grocery shelf is starkly absent. In fact, chicken soup is one of two most requested items on Amazon. When I took a moment to ponder why, my memory was flooded with memories of my grandmother, aunt and mother serving up large bowls of chicken soup for every childhood illness that befell me. And, to be quite frank, I almost instantly felt better after its consumption.

My maternal grandmother, Nan, unveiled her divine Matzo Ball Soup at the start of each Passover Seder. Even a “soup skeptic” like my father, devoured the contents of the bowl. I can still hear the clanking of his soup spoon on the bottom of the porcelain dish. My nuclear family had matzo ball soup anticipation throughout the year, and not unlike McDonald’s McRibs strategy, Nan would bring it out during random Erev Shabbat gatherings. While there were many proponents of Nan’s soup credentials there was not unanimous agreement. Aunt Rose’s Matzo Ball Soup was touted as the gold standard by my relatives north of the Bronx. The debate on the best soup went on for decades.

Chickens can incubate avian influenza but they can provide sustenance through their soup derivatives. The 12th century Jewish physician and rabbi, Maimonides declared the medicinal properties of chicken soup back in the 12th century. Modern science has weighed in on its medicinal values. Chicken soup can slow  the entry of white cells into the nasal cavity, explaining the improvement in airflow. Medical researchers at Mt. Sinai in Miami Beach ascertaned chicken soup challenge in humans showed an improvement in nasal mucus flow, a marker of viral clearance. Chicken soup can also improve cilia function, the hair-like projections on naso-respiratory cells that “clean up” the nasal and respiratory passages, The soup additives, onions and garlic can have antiviral effects.

As Jews celebrate Passover and recall the 10 plagues of antiquity while living through a 21st Century pandemic, let us remember the benefits and memories that our loved ones provided: the humble Matzo ball/chicken soup miracle.

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Now What? The Retired Doc Manifesto


My thoughts wandered back to my first year in college, afflicted with infectious mononucleosis during my first semester. After spending 3 days in a University infirmary, my dad flew me back to NYC for a second opinion with his company doctor. “So you’re majoring in political science. You know there’s not a real world job out there,” declared Dr. Sussman behind his mahogany desk on Park Avenue. “You should try for medicine,” he counseled. Fifty years later, mentally replete with the teachings of Hans Krebs, Bert Vogelstein, Sidney Winawer and a host of others, I walked out of the endoscopy center, bid adieu to colleagues, staff and my endoscopes and entered the world of the “retired doc.” Now what? Travel the world, sleep in and watch “Get Smart” reruns, volunteer in indigent clinics, hangout in hospital dining rooms and talk about the good old days? Turning to the internet, I found a plethora of sites advising me on finances, providing lists of post-doc duties but no voices of the retired physician community describing the journey of the medical retiree. In this blog, I hope to stimulate discussion of meaningful and whimsical topics of value to the retired physician community. Let’s go!