The cognitive health of a nation’s leader can have far-reaching consequences that extend beyond their term in office. A striking example of this is the case of President Woodrow Wilson, whose impairment during crucial post-World War I negotiations may have indirectly contributed to the conditions that led to World War II.

In 1918, Wilson contracted influenza during the global pandemic. This illness, coupled with a severe stroke in October 1919, left him significantly impaired during the final year of his presidency[1]. This period coincided with critical negotiations for the Treaty of Versailles, which would shape the post-war world order.

Wilson’s diminished capacity meant he was unable to effectively advocate for his “Fourteen Points” plan, which aimed for a more balanced peace[2]. Instead, harsher terms were imposed on Germany, creating economic hardship and national resentment that would later be exploited by extremist political movements[3].

The consequences of these decisions were catastrophic. World War II resulted in an estimated 70-85 million deaths worldwide[4], a scale of loss that might have been preventable had the post-WWI peace process been handled differently.

This historical example underscores the critical importance of a president’s cognitive function. Executive functions such as decision-making, problem-solving, and communication are essential for effective leadership, particularly in times of crisis or complex international negotiations[5].

One aspect of cognitive function that plays a crucial role in leadership is prosody – the rhythm, stress, and intonation of speech. Prosody is not merely about eloquence; it significantly impacts how messages are received and interpreted. Research has shown that prosodic features of speech can influence listeners’ comprehension, emotional response, and even decision-making[6].

In the context of presidential communication, prosody can affect a leader’s ability to motivate a nation, provide hope in times of crisis, and effectively convey complex policy decisions. Presidents who have been noted for their strong oratorical skills, such as Franklin D. Roosevelt and John F. Kennedy, used prosody effectively to rally public support and communicate their vision[7].

The implications of this are significant for the democratic process. When electing a president, voters are not just choosing a set of policies, but also a communicator-in-chief who must be able to lead effectively in times of national and global crisis. The cognitive health of candidates should be a key consideration in the electoral process.

It’s important to note that cognitive health is a complex issue influenced by many factors, and simplistic or discriminatory approaches should be avoided. However, given the potential long-term consequences of presidential decision-making, it is crucial that voters have accurate information about candidates’ cognitive capabilities and that robust systems are in place to ensure continuity of effective governance under all circumstances.

[1] Cooper, J. M. (2009). Woodrow Wilson: A Biography. Knopf.
[2] MacMillan, M. (2001). Paris 1919: Six Months That Changed the World. Random House.
[3] Keynes, J. M. (1920). The Economic Consequences of the Peace. Harcourt, Brace and Howe.
[4] Weinberg, G. L. (2005). A World at Arms: A Global History of World War II. Cambridge University Press.
[5] Goldstein, K. (2015). The Executive Brain: Frontal Lobes and the Civilized Mind. Oxford University Press.
[6] Scherer, K. R., & Bänziger, T. (2004). Emotional Expression in Prosody: A Review and an Agenda for Future Research. Speech Communication, 46(1-2), 180-203.
[7] Leanne, S. (2016). Say It Like Obama and Win!: The Power of Speaking with Purpose and Vision. McGraw Hill Professional.

It is troubling that his closest allies dismissed this as just a “bad night.” This situation is reminiscent of Monty Python’s Black Knight, who, after losing all his limbs after a duel with King Arthur, insists it is “only a flesh wound.” Such deflection ignores the serious implications of what we witnessed.

While I am not a neurologist, but just a humble retired GI doc, I have observed patients and family with neurologic symptoms and signs, taught mental status exams  for 5 years to  medical students and watched 10 seasons of ER. While watching the debate, terms like “abnormal prosody” and “paraphrasing errors” came to mind.. Coupled with a noticeably slowed, narrow gait, vascular Parkinson’s disease may be the disease process we are witnessing. This can mimic neurodegenerative disorders and  often follows a progressive course.

The stakes are too high to ignore these signs. Ensuring that the most powerful position in the world is held by someone who is neurologically and psychologically sound is not just a matter of political strategy—it is a matter of national and global security. If we are to avoid potential tragedy, we must confront these issues with the seriousness they deserve.

The recent debate should prompt a thorough and transparent evaluation of President Biden’s capacity to fulfill the demands of his office. Anything less risks dooming not just our nation, but the world, to the consequences of impaired leadership. The time for empathy and decisive action is now, for the sake of all our futures.

But wait, as the years stack up like pancakes, so do the struggles at the other end of life’s conveyor belt. Enter the geriatric experience – where once-easy skills now play hide and seek with our memories. Picture me, preparing to enlighten some young medical students about the art of “falls in the elderly.” Little did I know, my own walking escapades would become the star of the show.

“Decreased proprioception,” I declaimed, feeling quite the wise sage. “Ankles that flex like uncooperative door hinges and a big toe clearance that screams ‘trip me if you dare’.” But that wasn’t the end of my aging acrobatics; oh no, there’s more. Numbness, tingling, and muscles that have taken a sabbatical joined the party, making sure my gait resembled a comedy skit more than a dignified strut.

Still, I fancied myself quite the septuagenarian athlete. Treadmill trekking, skiing (albeit a bit more ‘controlled falling’ these days), hiking, and golfing – I had a fitness arsenal that could make even a personal trainer raise an eyebrow. Then came the showdown in the Utah golfing arena. Another septuagenarian, a golfing legend in his own right, launched a golf ball into the stratosphere while mine stuttered like a reluctant rocket. My ball decided to take a scenic route through rocks and pine trees, like it was on a woodland adventure.

“Lost ball,” I mumbled in defeat, dropping another on the fairway. But behold, my fellow septuagenarian turned out to be a real-life action hero. With the agility of a mountain goat and the fearlessness of a squirrel on caffeine, he bounded up the hill, leaping over boulders and obstacles with the grace of a ballet dancer. “How do you stay so spry?” I gasped, amazed. His answer? A casual, “Oh, just thirty years on the search and rescue team in Salt Lake City.” In other words, decades of extreme skiing, hiking to the moon (or at least 10,000 feet), and kayaking through rapids that could give a roller coaster a run for its money.

Ah, let’s talk about the great divide in our mastery levels – I, the illustrious explorer of New York City sidewalks and conqueror of Florida bar stool acrobatics, and he, the daring daredevil of Wasatch Mountain’s icy slopes and altitude-extraordinaire. It’s like comparing a slightly mischievous squirrel to a high-altitude superhero with extra red blood cells for added oomph. Yes, I was grounded at sea level, while he practically lived in the clouds.

So, the big question arose – could practicing the fine art of pedestrianism in quirky situations bring back the glory days? Armed with my trusty hiking poles, I embarked on an epic quest: the Stewart Cascade Trail in Sundance, Utah. A mere 3 ½ miles, you say? A paltry 617-foot elevation gain? Well, let me regale you with tales of fallen Norway Spruce that wanted to trip me, streams that seemed to play tag with my feet, and mud that had a vendetta. Each step was a calculated gamble – like a dance with destiny. Will the limestone rock be a solid partner, can my hip flexors outsmart this tree branch’s sneak attack, should I leap like a gazelle or wade like a water buffalo through that stream?

Three hours later, I emerged – battered, not broken, weary as a sloth on a Monday morning, and feeling like a 21st-century version of Kit Carson (minus the wild frontier, plus the determination to conquer nature’s hurdles). And guess what? A few more trails later, I discovered that maneuvering stairs, sauntering on sidewalks, and even the most mundane urban escapades were suddenly a breeze. I had transformed from pavement pauper to sidewalk swashbuckler!

So here’s the grand revelation: practice, my friends, is the enchanted elixir of youth. Venture to the mountains, ponder each step like it’s a piece of a grand puzzle, and who knows? Someday you might just be the sprightly counterpart to your gravity-defying grandson. Until then, let the sidewalks tremble at the approach of your rejuvenated footsteps!

Prepare yourself for a mind-boggling journey into the world of science, where living with a fluffy animal is the secret to warding off inflammatory bowel disease, autoimmune issues, allergies, and even mental health problems. Get ready for a glimpse into what a health care encounter in the 21st century might just look like. Trust me, it’s going to be a wild ride!

Scene 1: Dr. Barkster’s Office

Dr. Barkster (raising an eyebrow): “Mrs. Paw-some, forget about your traditional prescriptions, because I have a prescription that will blow your mind! Say hello to the furriest remedy out there – a dog!”

Mrs. Paw-some (taken aback): “A dog? But Doctor, won’t our house turn into a hairy chaos zone?”

Dr. Barkster (grinning): “Oh, Mrs. Paw-some, let me tell you, the wonders of fur-therapy are worth every lint roller in existence! Brace yourself for the fur-filled adventure I’m about to unfold.”

Scene 2: The Immune System Superhero

Dr. Barkster (striking a superhero pose): “Imagine a furry dog as your child’s immune system superhero, ready to tackle autoimmune diseases like a true champion! Recent studies show that early exposure to furry dogs can boost the immune system’s resilience, reducing the risk of developing autoimmune issues.”

Mrs. Paw-some (excited): “So, you’re saying a furry dog can be our child’s very own shield?”

Dr. Barkster (nodding): “Exactly! By bringing a dog into your family, we’re empowering your child’s immune system, one wag at a time!”

Scene 3: The Mental Health Marvel

Dr. Barkster (putting on a detective hat): “Hold on tight, because the mental health benefits of furry dogs will blow your mind! They’re like cuddly therapists with wagging tails. They offer unconditional love, endless belly rubs, and they’re the perfect built-in antidepressants!”

Mrs. Paw-some (laughing): “So, our dog will be our very own four-legged therapist?”

Dr. Barkster (smiling): “You got it! Dogs have this incredible ability to reduce stress, anxiety, and even improve social interactions. Plus, they’ll help your child develop empathy and a sense of responsibility.”

Scene 4: Finding the Paw-fect Match

Mrs. Paw-some (curious): “But Doctor, how do we find the right furry companion for our child’s optimal health?”

Dr. Barkster (serious yet humorous): “Ah, the quest for the paw-fect match! It begins with considering your child’s personality, activity level, and your family’s lifestyle. Is your child an energetic explorer or a snuggly bookworm? Are you a family of adventure seekers or more of a cozy homebody bunch?”

Mrs. Paw-some (enthusiastically): “We’re definitely a lively bunch!”

Dr. Barkster (chuckling): “Well then, a playful and energetic breed might be just the ticket! But don’t forget, shelter dogs are often paw-some choices too, so give them a chance to wiggle their way into your hearts!”

Scene 5: The Apocryphal Algorithm for Choosing the Perfect Breed

Dr. Barkster (with a mischievous smile): “Ah, Mrs. Paw-some, I have a little secret algorithm up my sleeve that can help you choose the perfect breed based on your child’s medical needs!”

Mrs. Paw-some (intrigued): “An algorithm? How pawsitively intriguing, Doctor! Do tell!”

Dr. Barkster (clearing his throat dramatically): “Behold, the Apocryphal Algorithm for Choosing the Perfect Breed!”

Allergy Avengers: If allergies are an issue, fear not! Look for hypoallergenic breeds like Poodles, Bichon Frises, or Portuguese Water Dogs. They’ll keep the sniffles at bay while providing endless cuddles.

Anxiety Alleviators: For anxiety relief, consider breeds like Cavalier King Charles Spaniels or Golden Retrievers. Their calm and gentle nature will soothe those frazzled nerves.

ADHD Energizers: If your child has energy to spare, go for breeds like Border Collies or Australian Shepherds. These energetic bundles of fur will keep up with all the endless activities and games.

Depression Defeaters: To combat the blues, breeds like Labradors or Beagles are perfect. Their playful antics and unwavering loyalty will bring smiles and joy to even the gloomiest of days.

Dr. Barkster (waving his hands like a magician): “And voila! The Apocryphal Algorithm presents you with a list of potential breeds to consider, tailored to your child’s medical needs. But remember, this algorithm is purely apocryphal, so be sure to consult with a professional before making any decisions!”

Mrs. Paw-some (laughing): “Doctor, you truly have a flair for the theatrical! Thank you for guiding us through this fur-filled journey.”

Scene 6: The Microbiome Marvels: Dogs, Soil Bacteria, and Healthier Homes

Dr. Barkster (raising an eyebrow): “Mrs. Paw-some, brace yourself for another mind-blowing discovery! Did you know that dogs can actually change the microbiome of humans to a healthier mix?”

Mrs. Paw-some (intrigued): “Dogs and microbiomes? That’s fascinating, Doctor! How does it work?”

Dr. Barkster (excitedly): “Hold on tight! When dogs dig in the soil, they unwittingly bring soil bacteria into our homes. And here’s the kicker: when they give their human housemates a loving lick, they introduce those beneficial bacteria into our bodies!”

Scene 7: The Soil Spectrum in the Apocryphal Algorithm

Dr. Barkster (adjusting his spectacles): “Now, let’s incorporate the magnificent world of soil into our Apocryphal Algorithm! Different soil types that dogs interact with can bring diverse bacteria, offering unique health benefits.”

Rich Loamy Licks: If your dog enjoys digging in nutrient-rich, loamy soil, they might introduce beneficial bacteria associated with improved digestion and nutrient absorption. Consider breeds like Labrador Retrievers or German Shepherds, known for their earthy explorations.

Sandy Salutations: Sandy soils bring their own set of health benefits. Breeds like Dalmatians or Greyhounds, who enjoy frolicking on sandy beaches or in sandboxes, may introduce bacteria associated with skin health and reduced allergies.

Clay Kisses: If your furry friend loves digging in clay-rich soil, they might bring in bacteria associated with a stronger immune system. Breeds like Airedale Terriers or Staffordshire Bull Terriers, known for their enthusiastic digging skills, might be just the companions for a clay-inspired microbiome boost.

Peaty Pooch Pals: Dogs fond of exploring areas with peat soil can introduce bacteria associated with improved mental health and reduced inflammation. Breeds like Border Terriers or Irish Setters, who enjoy hikes in boggy areas, might be the perfect peaty pooch pals.

Dr. Barkster (with a grin): “Remember, this soil-inspired algorithm is purely fictional but showcases the fascinating connection between dogs, soil bacteria, and our health.”

Mrs. Paw-some (laughing): “Doctor, you never cease to amaze! Our furry friends truly bring the magic of nature into our homes.”

Epilogue:

Dear readers, while the soil-inspired microbiome marvels may be an intriguing concept, the love, companionship, and joy a furry dog brings into our lives are undeniable. So, embrace the pawsitivity, let your child’s health thrive, and embark on an adventure with a four-legged friend who will not only leave paw prints on your hearts but potentially beneficial soil bacteria too! And remember, if you decide to welcome a furry companion into your home, make sure to consult with a healthcare professional to find the best fit for your family and always keep those lint rollers handy!

Too much knowledge can be a dangerous thing, we pondered, as grandparents with 70 lifetime years of pediatric and internal medicine experiences. Lung function, oxygen requirements, surfactant, feeding ability, brain development and infection risk percolated through our collective anxiety. Scientific probability tempered with prayer was the way to dispel these troubling thoughts.

He was born fully formed, loudly screaming and feisty. He entered the Neonatal ICU for warmth, feeding, oxygen and observation time for the next 10 days as we wandered around Washington, D.C. awaiting his discharge and arrival to his parents’ home.

My  anxiety was heightened by the present and past of the U.S.A.  A man with a train conductor’s hat sat in front of the White House blaring music and chanting, “We are on the train of destruction.” Placards in front of the Capitol declared the illegality of vaccination for union workers. We strolled to our grandson’s future home by passing the Garfield Statue (assassinated president) and Ulysses S. Grant on Horseback (Civil War with 600,000 dead). We continued on past well dressed legislative assistants (struggling to pass much needed infrastructure bills) coming out of the Richard Russell Building.  I looked up Richard Russell, who was a former Senator from Georgia who defended Jim Crow and obstructed Civil Rights legislation, and wondered how his name was chosen for an entire building in Washington DC. 

Our grandson was thriving, gaining weight and bonding with his parents. Relieved, we passed the time in our nation’s collective warehouse: the Smithsonian Institution. Endowed by James Smithson, a wealthy Englishman who dabbled in chemistry and mineralogy in 1820, who generously donated his inheritance to a country he never set foot in for the cause to advance science and knowledge.  The Wright Brothers started their research through the museum’s scientific holdings and solved the heavier than air flight conundrum that baffled the world’s best minds. Lieutenant Commander Philip Van Horn Weems, recruited by Charles Lindbergh to perfect a better aviation navigational system led to an era of safer air travel for all. We saw the art of Saul Bellows documenting urban life in the early 20th century and appreciated the genius of the early neoclassical architects such as James Renwick, Charles Bullfinch and William Thornton who shaped our Capitol and early federal buildings.

At the Library of Congress we saw a portion of the over 800 miles of library stacks and more than 25,000,000 volumes that are available to all Americans that wish to research any topic and can participate in a plethora of summer programs for kids to introduce them to learning and research. This spectacularly beautiful building was full of historical treasures and important information. For example, we learned of the accountability of a democracy, embodied by the Presidential Recovery Act of 1978 that transfers Presidential papers to the public domain after office. This Federal Act was prompted by the willful burning of presidential records by Grover Cleveland, Millard Fillmore and numerous other Commanders-in-Chief.  

Throughout our stay in DC we continued our US historical scavenger hunt: we saw the documents of Lincoln establishing agricultural/land grant colleges in the 19th century that created American engineering superiority, the bravery of Harriet Tubman guiding slaves to their freedom through the Underground Railroad and the bigger than life statue of Albert Einstein in front of the National Science Administration accompanied by his proclamation of free thought in his new country and safe harbor away from fascism.

Opportunity, American ingenuity, hard work and the limitless resources of art, science, politics and jurisprudence documented in our nation’s capitol left us truly humbled. The presence of such endless possibility that is freely bestowed upon every American Citizen— in the backdrop of our grandson’s birth— left us in awe and rendered us speechless.

 Our grandson graduated from the Neonatal ICU into his home now several ounces heavier, with healthy lungs and an animated disposition. We, as grandparents, are now in the grandstand joyfully watching every moment of his wonderful life. Just knowing that opportunity and choice are around the corner as he grows and prospers in our great country brings us comfort as US citizens and hope for a brighter future for our newest patriot and family member.

While learning about truth, honesty, civility and camaraderie in school, the real world of hidden agendas creeped in. New and improved Fruit Loops tasted  exactly the same as the old Fruit Loops. Two box tops and $2.00 did not get you “life sized action figures” but ant sized plastic toy soldiers. Reality only accelerated with age. “This VCR  is state of the art and will remain a standard for years,” the Circuit City salesman told me with a straight face in 1982 as I drained my bank account of $1,200.  Obviously, the advertising on cereal boxes and a stereo salesman suffered from hidden agendas or conflicts of interest.

The world of medicine brought its own litany of hidden agendas. Pharmaceutical representatives extolling the virtue of their brand name products when a generic and a lower cost substitute achieved the same goals. I entered the profession during the era of drug sponsored free Caribbean vacations, five star restaurant outings,  and “free” basketball playoff tickets. Was there a potential for bias in prescribing habits when you’re cutting into a filet mignon paid for by an acid reducer you haven’t used before? One would have to think so.

Transparency in medicine became clearer when government edicts regulated Pharma’s gifts to the medical profession. The trips, five star restaurants, and  sporting event tickets disappeared.  Finally, even complementary pens and trackpads were forbidden. Quite rightly, transparency in prescribing was demanded by consumers. Today, the consumer can check on their provider’s lunch reimbursements, Medicare payments, and Big Pharma consultant fees. A simple internet search will quickly reveal the truth regarding your doctors financial ties—if any— to pharmaceutical companies and the like.

Regretfully, most of the world operates with hidden agendas and conflicts of interest unbeknownst to the consumer or general public. However, to the world of medicine’s credit, regulatory agents have collectively required physicians to publicly reveal conflicts of interest.  For example, if you are a physician presenting a paper at a meeting regarding your research on a drug, you must disclose any conflict you have with the company making or marketing said drug.  Furthermore, your research paper must cite any conflict you have as well.

Certain areas of the field of medicine have escaped transparency and issues of reporting conflicts of interest.  Lobbying has produced the DSHEA Act of 1994 which stripped regulation and FDA oversight from over-the-counter pharmaceuticals. Many over-the-counter medicines have not been subjected to vigorous oversight or proof of efficacy.  Billions of dollars of products are bought that may have little or no assurance that they help or improve what it professes to do on the package information. Fortunes have been made from this lack of transparency to the patient slash consumer.  It would seem, in the public’s interest, that a warning indicating that a product that has not been rigorously tested and proven in its stated efficacy, should be placed on the product packaging.

It seems that physicians and some areas of medicine are leaders in self-reporting conflicts of interest and public available transparency of these conflicts should be the standard applied to all businesses that interface with the public at large.  For example, politics operates in the world of dark money facilitated by Citizen’s United and the death of campaign reform.  So when a politician publicly espouses a certain political opinion, why do they not have to disclose any influence or conflicts of interest they might have that would benefit from their political stance on an issue?  Doesn’t the American citizen need this transparency to be an educated voter?

Furthering this argument, Journalists in a variety of communication forums report information in the public’s best interest.  Under their by-line in a newspaper or in a chyron on the bottom your television screen there should be a clear statement of any conflict of interest the journalist might have.  If you own stock in a company that spilled oil into the ocean, I’d like to know that when you present information on the oil-spill.  

A rational world should apply the rules that govern conflicts of interest or hidden agendas in a schoolyard playground the same as they should in the world of medicine, politics and journalism to name a few.  Self-reporting, fairness, and truthfulness should be a minimal requirement for all who interface with the public who are purportedly looking out for your best interest.  

Let’s level the playing field. 

My mechanical sleep alarms were left home when my family and I traveled to Southeast Asia. Off to Chiang Mai, where we met a guide and hiked through jungle terrain to the self-subsistence rice farming Karen Tribe² in Northern Thailand near the Myanmar border. After 4 hours of a grueling uphill journey, replete with mosquitoes, leeches and excessive sweat, we arrived at the encampment. My sense of accomplishment was dampened quickly when the Guide informed me, my wife and our teenage boys that the school children in the tribe make the same trip twice daily. With the livestock huddled under the stilt supported wooden abodes, our ‘farm to table’ chicken meal had a short transportation impact. Exhausted, we slept on the dirt floor in a tree house with paper thin mats.  We were fast asleep in seconds with our melatonin levels peaking from heat, food and altitude. 

The horizon was barely illuminated when a 110 decibel sound emitted from multiple moving sources around our elevated bedroom. I bolted upright, needing this noxious sound to cease to restore tranquility. Peering out the open window, I saw the parade of roosters crowing at unimaginable volume. This was no Loony Tubes Foghorn Leghorn^3. “Could the rooster’s head comb serve as a snooze button?” I was fully awake within moments with multiple thoughts racing through my head. “Could this natural alarm clock be more effective than an Apple product?”

Many circadian driven mornings have since come and gone from that fateful trip to Thailand. The kids have moved on and now reside in a different time zone. My now retired self no longer has to get up in the morning and go to work.  My wife and I find ourselves traveling from place to place. During one recent trip to Utah, I was reminded of the roosters from our Thailand expedition.  Finding refuge in the Wasatch mountains,  one morning I awoke to the cacophonous chirping of Magpies foraging in the front yard. This scene was repeated each morning. To my surprise, the Magpies packed their bellies and beaks by 1 PM each day like clockwork and were replaced by an equally vocal group of Robins. Pecking and browsing for grubs and earthworms, this group departed in the gloaming and were followed by an aquatic band of mallards, Canadian geese and the occasional surprise appearance of Wild Turkeys (not the drink but the bird).  Nature’s circadian rhythm was outside my window and all I needed to do was listen and observe.

The light is dimming as I write these words from our home in San Diego.  I cannot fight the escalating melatonin levels impacting my hypothalamus and finding my eyelids growing heavy with the urge to sleep. I search frantically for the iPhone sound effects for the Magpies and come up empty handed.  I quietly crawl into bed with a glimmer of hope and a sense of confidence that I will be awakened by the sound’s of nature emerging for the new day.  I set the iPhone to “Do not disturb.”

¹ Plastic dish-ware  popular in the 1950’s and ‘60s, manufactured by a now defunct company,  American Cyanamid Corporation.

² The Karen reside predominantly in Myanmar and Northern Thailand and are linked by a Sino-Tibetan language heritage. They have practiced crop rotation agriculture for centuries.

³ A Warner Brothers Cartoon Rooster, appearing in Looney Tunes and patterned after a fictitious bombastic Southern Senator, Beauregard Claghorn. Foghorn often strolled though the chicken coop, humming Camptown Races.

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..…”

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.

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.