Boreal B[l]og

I remember the dark room, closed door. My eyes ached. I ached. Seventy years later, I can still see the darkness.

Rubeola.

I could have died from it. Hundreds of kids like me did die every year, and that was a normal, usual, childhood disease. Some got encephalitis and survived, brain damaged, others died from…

Measles.

UCD. Usual Childhood Diseases. On medical records, you might still see this term.

When 100 children now die from influenza in a season, the country more than twice as populated as back then, it’s newsworthy. Back then, estimates were 500,000 measles cases annually in children. Virtually everybody got it, for measles is one of the most infectious diseases. The death rate was ten-fold higher per capita than influenza. What we didn’t know then was measles damaged the immune system for an extended period.  I wonder how that manifested with me. I had many strep throats. Could that have been a factor?

The following is my experience with UCD as a child and as a physician. The 6% of Americans my age or older have had similar experiences. We knew these diseases first hand. We all knew those who either died or had complications. These plagues are not extinct. They will return if we ever let down our guard. These diseases are not dichotomies between live or die; there are many in-between permanent complications, such as…

Rubella, a get out of school free card because we usually felt well, despite the rash. My wife was asymptomatic when a classmate diagnosed her. Adults knew, however, that rubella was far worse if a woman were infected while in the first trimester of pregnancy. My wife’s cousin was infected while pregnant during the rubella epidemic in the 1960s; her son was born with congenital rubella syndrome. He was deaf, leading to an obvious speech impediment, and had cataracts. Life is difficult enough when one is healthy; starting life deaf, limited vision, and trouble speaking puts one at a huge permanent disadvantage. His mother became a caregiver because of a disease which can now be prevented. Several lives were affected for every case. Twenty thousand had the syndrome in the early 1960s, but after licensure of the vaccine in 1969, there were about 100 cases per year in the 1970s, single digits annually now. These diseases occurred. UCD. Everybody got rubella, but many of us didn’t see the kids with congenital rubella.

We don’t know the potential lost with congenital rubella and other complications of UCD. It cost the son and his mother an incalculable amount, but we don’t measure or graph “incalculable” in economics. It is ignored. Lost productivity has a dollar sign, but happiness, joy, lack of pain, no disability, or having a child grow into an independent adult are more valuable even if unmeasurable. Had the rubella vaccine existed a decade earlier, the above tragedy never would have occurred. If we stop rubella vaccination, this story can recur, perhaps without a pregnant woman’s even knowing she had the disease.

We all got varicella, chickenpox, too. My wife remembers wearing mittens on her hands to prevent scarring of her face when she scratched. The disease for an individual wasn’t by mid-century standards bad, despite the death rate’s being triple compared to childhood influenza in a bad year today. Chickenpox never made the news. Everybody got it. Chickenpox is now dangerous for the many who are immunosuppressed. It also sets the stage for later infections with herpes virus, leading to zoster or shingles, and post-herpetic neuralgia is a nasty, miserable, difficult to treat condition. Two doses of the vaccine have a very high probability of lifelong protection.

A brother of mine had polio, fortunately not paralytic, but our parents feared summers and going to swimming pools or the beach because of potential spread of the disease. We grew up seeing March of Dimes money collection folders on store counters with pictures of children in iron lungs. I saw real people in them when I was a third year medical student. Unvaccinated young people traveling in the third world today are at risk for paralytic polio, a completely preventable disaster. Polio doesn’t care what color your passport is.

My other brother had mumps meningitis, fortunately not severe, but mumps can cause deafness and orchitis; the latter potentially causing sterility. When I was a Navy doctor, a sailor with a small testicle post-  mumps had his vas deferens, which connects the ejaculatory duct to the urethra, twist and cut off circulation to his testis, a torsion. This causes excruciating pain, like any blocked tube in the body, and especially for the testis. As a doctor right out of internship, I had never seen a testicular torsion, and I never would again, but the diagnosis was obvious. I successfully untwisted the torsion. The sailor was later found to be sterile. We now have a good vaccine for mumps.

When my wife and I were medical students, we went to the Crow Reservation in Montana, where earlier that spring there were three cases of culture proven diphtheria. In 1972. My father-in-law, who practiced ENT, told me that while throat membranes caused by the corynebacterium could lead to death from aspiration, what killed children was diphtheria toxin, a protein causing widespread organ damage including myocarditis, inflammation of the heart. Usual childhood disease. He saw a lot of it.

The first spinal tap I ever did was on a 2 year-old girl with stiff neck and fever. She had H.influenzae (H. flu; Hib) meningitis, which then afflicted 20,000 annually with 1000 deaths. She was treated immediately with antibiotics and eventually went home, but her parents may have wondered for years whether she could have suffered minor brain damage. We had a vaccine for Hib 7 years later that decreased the number of cases 99.5% with no deaths in 2021. Who would deny any vaccination that is so effective and risk Hib?

My mother had both whooping cough and scarlatina, the latter a strep infection with a specific toxin. My father had tuberculosis. We children wore white band-aid patches on our backs for a few days in summer to test for the disease. I have a small scar near my left shoulder where I was vaccinated for smallpox. Finally, I add two more Rs, roseola with its high fever and rash, and RSV, not known as a disorder until 1956. Having a vaccine for RSV is thrilling.

Usual Childhood Diseases became Unusual Childhood Diseases in my lifetime in one of the great triumphs of medicine. One may almost say that nobody gets these any more, a tribute to vaccine efficacy. The Salk Vaccine was so effective that the study was stopped early to start treating people sooner. I was in the first cohort for the Sabin oral vaccine. We must continue them and others.

I know many feel they must experience something in order to believe it. Having had measles, the sickest I’ve ever been in my life, I can confidently say one does not want to experience it. Ever.

Three messages from my generation: first, ignore these diseases at your or your children’s or grandchildren’s peril. Literally. Second, given the cost of treating these illnesses and their complications, vaccines are one of the most cost-effective treatments in existence. Finally, because these diseases didn’t happen doesn’t mean they were never possible, and not having a dollar sign value for something that didn’t occur does not make it any less valuable.

I saw the man standing alone in the long line of idling vehicles, between an F-150 and a Ram.  

Waiting to get vaccinated.

Wow, did that look weird. That was a new one for me. I walked towards him and got his attention, signaling for him to follow me to the other side of the first tent, where I kept my personal gear, and to the chairs nearby, where he could sit down.  As he left, the Ram pulled forward.

Once I had him there, I told him to fill out the vaccine administration record (VAR) on the clipboard he carried, and I would return in a few minutes.  I walked back ten vehicles to one I hadn’t yet checked, a blue Camry, behind the Ram. As I walked towards it, I saw two hash marks on the upper windshield. Two people for vaccination.  I approached the vehicle and said good morning, asking for the clipboards where each of the two had filled out information for the vaccination.  I then checked the spelling of the name, confirmed the date of birth, scanned quickly to the bottom to make sure we had a contact number, then turned the paper over.

One person had forgotten to sign and date, so I had him do that; the other had signed it and the seven medical yes-no questions were all answered no.  I filled out two small white CDC vaccination cards with their names, dates of birth, the vaccine (Pfizer) and the lot number, handing the cards back to them.  

“Hand these two pieces of paper (VAR and card) to the vaccinator, and they will keep the big piece and hand the card back to you. Keep the card, bring it to you next time, at least 3 weeks or later, and make the appointment the way you made this one.”  They nodded.

“The vaccinator will give you the shot, and they will write the time on the side of the vehicle when you can leave the observation area, 15 minutes after the shot.  If you have any problem, honk the horn, blink the lights, scream, make yourself noticed.

“Go ahead and pull forward. Thanks for coming out.”

I took the clipboard and the pen we gave them, then turned around to walk back and talk to the person whom had walked in. 

Multiply this by about 100, and that is a day at the max/vax site as a registration person.  There are 14 lanes of traffic, formed after people drive in and are first separated into four lanes, getting a clipboard, a lane assignment, and a mark on the vehicle for how many people need to be vaccinated.  Others direct them to the lane, where they drive up as far as they can. We were told to wait until each vehicle reached the tent before the vaccinator, then screen them.  We’d have gone stir crazy if we did that, and the vaccinators would have been upset as well. They needed to have a steady flow of work.

So, we worked our way back to the last vehicle, checking information, making a new card if it were the first shot, updating their current card if it were their second.  If problems—no clipboard, somebody else in the car wanted to see if they could get a shot—we had to check with one of the staff who floated among the 14 lanes.  For the most part, people were polite and happy to be there.  A few were grumpy, and I mostly ignored them. Occasionally, a dog present was nasty, and I tried to stand clear, but the of the dogs were generally well behaved.  While we screened a vehicle, other vehicles in front of them often moved forward, opening a gap. Sometimes, the staff told us to close the gap.  I didn’t like that. During the screening process, there are natural breaks, and out of the corner of my eye I am aware of the situation. If there are backed up vehicles out to the lane confluence, I will have the vehicle move forward and talk to the driver later, closer to the vaccinator. Otherwise, I waited until I had finished.  I don’t know the overall situation at the vaccination center, but I knew my lane and my situation.  I will work for 2 hours without stopping to even look at my watch.

When lunch time came, we were spelled by staff or others. We could move to other lines easily, in order to help others on break.  While we were told to take breaks frequently, we were short staffed and couldn’t do that. Lunch was a half hour where I could leave, cross the street, and sit by a log in the nearby park and take off my double mask.  Once the half hour was up, I was back in the line again.

We saw all sorts of people and vehicles. We didn’t screen in the traffic line for appropriateness; our job was to move them along and finish the paperwork, including making sure the name was clearly spelled and the birthdate was correct. We now use iPads for confirmation, and at first it was cumbersome, but other than for the vaccinators, it is working out better, and each one of those is one less transcription someone else has to make. I think I convinced the leads that we could write the lot number of the vaccine on the vaccination card. I did that, and the vaccinators loved it. They did not have to handle the card, write anything on it, and hand it back. This sped them up, and they are the rate-limiting process to the whole system.

I make a comment when someone was born in the same month or year as I.  I have seen three with my birthday so far. Some complain about their age; almost invariably, I tell them I have a few years on them.  One woman propositioned me.  A couple of others asked about hiking in town, since I am wearing my Cascade Volunteers name tag.  One vaccinator I knew from past hikes, and I have seen two other people I knew in line.  

Many have thanked me for volunteering.  I tell them that I felt guilty for sitting out the pandemic and not helping out, although what I would have done wasn’t clear.  I wanted to be one less problem for medical personnel, and I succeeded in that.  This job is part of medical treatment, and while it isn’t exciting or life saving, it is needed, and it needs to be done right. I get pleasure out of contributing the eight times so far that I have been out there, seven at Autzen Stadium in the parking lot, and the other at the community college.  It’s a great system, and I have long wanted to be part of a good system of work flow.

I’m fast at checking registration, either paper or iPad. That’s good. We are short handed this weekend, and my wife may be pulled to be a vaccinator.  I could be, too, but I think I am better where I am.  I may be handling a line by myself this weekend, and I know I can. 

We are in a race.

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I’m not sure why I did it, last Sunday afternoon.  I was tired of doing zooniverse inputting, I had answered 16 algebra problems online, and I didn’t feel like doing any more of them either, so I googled my pediatrician from 60 years ago, Frank Disney.  I wasn’t sure what I’d find, so I added, “rochester ny” and hit return. 

I had remembered Frank Disney as the elderly man (he was two years older than my father) who visited me at home when I had strep and lay febrile and miserable in my bedroom.  When I got my well-child exams, I went to the pediatric practice about 2 miles from home, and saw Disney or his partner Burtis Burr Breese.  My mother once told me that when Disney treated my brother, he told her, “I can’t make him half well for you, so if he gives you any trouble, just have him go out and play along Route 20.”  She loved that line and it became part of our family lore.  Later, Drs. Breese saw me at home; they each had their own style, and I liked both of them.

Disney and Breese founded the practice after the war.  Disney had been working at the blood bank in Rochester early in the war, shipping hundreds of pints to New York City every week, and then was himself sent to the South Pacific from 1943-6.  He was discharged as a Captain, and that is all he listed on his CV.  I have read much about that particular theater of war, and I wonder exactly what Disney did there and where exactly he was, knowing that it was a difficult place not to become ill, let alone die in war, and he was still in the area several months after hostilities ended with Japan.  Not a word, which was typical with the Greatest Generation.  

Disney and Breese practiced at a time when they made house calls every evening, hoping they could get useful information by phone, assuming they could get the operator.  That’s where I intersected the practice. I remember more than one house call, when I was sick, got a shot, and the next morning awoke feeling well.  And while I didn’t learn this until today, I did not form antibodies to that particular strain of strep, and there are many strains of Group A.

At least 35 articles came out of their practice in the 1950s and 60s. The physicians were interested in Group A Streptococcal disease. I am part of multiple data sets. Carriers of streptococcus were uncommon, about 4% of people, but my brother was one, and from the information they learned, he was treated, which perhaps finally ended my long history of periodic strep throats, one more of which would have led to a T & A.  They sampled their patient records every 15 days to randomly study their practice, a superb approach today—simple, not difficult, and effective.  They did this with pen and paper, no computers, just good minds. They were doctor-scientists-humanists, words of honor. 

I now realize how lucky I was to have my strep throats treated by experts, so my risk of complications of rheumatic fever and acute glomerulonephritis was minimized.

Disney knew that house calls were not efficient, but from the interview I read, he learned much about the family dynamics and the child from being in the house and seeing the interactions. I made house calls occasionally as a neurologist, and I agree completely.  When he and his partners realized that white counts and cultures were important to diagnose and treat strep, they had the children come to the practice.  Still, somewhere in the recesses of my mind there was one of their ancillary workers who came over and cultured the recesses of my throat.  I can’t swear to it, but I think it happened.

Disney thought it would be a great idea to charge parents an annual fee for unlimited visits. He was only about 50 years ahead of his time. The other pediatricians in town were not at all interested. 

He was interviewed in 1996 about his life and practice. Disney remembered when he was a young boy, in the early 1920s, when a child could not go to a store without a doctor’s note saying s/he was not infected with poliovirus.  In short, the country was more sensible in the 1920s than it is in the 2020s.

When the Salk vaccine came out for polio, the practice was besieged by parents wanting the vaccine, wanting to know when they could get it.  When the Sabin vaccine appeared, I was in the first cohort to get it, and I remember where I ate the coated sugar cube in the southeast corner of the junior high school by Twelve Corners, which still stood, when I drove by there in 2013. 

The same occurred with measles vaccine:  the parents wanted it immediately. They did, after all, know what these diseases could do.  There were measles epidemics about every 3 years in most cities, which I did not know.  Apparently, an epidemic was enough to give temporary herd immunity until it dropped low enough, probably below 80%, for it to again infect anyone who hadn’t had it.  I remember having measles; it was the sickest I have ever been.

I sure wish we had Frank Disney around today to tell us that pay per visit is not an efficient way to practice, although it certainly may be more lucrative. Or to show us that good science can come out of a working medical practice in Brighton, something I tried to do years later and thousands of miles further away, with not at fault injuries and chronic pain, with right hemispheric stroke patients, who were awake but kept their eyes closed, and with the fact that female spouses came into the exam room when their husband was being examined three times more often than men did for when their wives were the patient, and that depression was—and is—a major concern of the practicing neurologist.

I really wish Disney could tell people about measles and polio, that having a note from the physician to go to the store was once thought by Americans as necessary, was considered neither a hardship nor a violation their constitutional rights, because you didn’t want a family member to get polio.  

That’s up to me to say for him in the Age of Covid to all of those who are alive because of people like Frank Disney. 

Last week, the Cascade Volunteers scheduled a volunteer appreciation day outside at a ramada in a nearby park.  I was a bit concerned even being outdoors, even limiting to 100 people, that this event was unsafe in the Age of Covid. When I heard that beer would be served, I was convinced it was a bad idea. Fortunately, the governor the day before limited all gatherings to 6, and that plus the first major storm of the fall changed the event to virtual.

Some still don’t get it. We are talking about having an overnight Board retreat in February. Not me.  Even on hikes and Crew outings, some still carpool. It’s dangerous.  We have to be careful in the woods, even though there are fewer of us.  Halloween parties and people having friends over lately, and this and that… and well, our cases have exploded in Oregon and there is frank community spread. We rank 40th nationally in case number, lower for deaths per capita.  It’s generally worse, elsewhere.  The Dakotas just blew right by us, but our 7-day average has doubled here, and deaths, while still low, are a lot higher. It’s hospital capacity—and that means working, well, rested individuals who have enough PPE, not number of beds—that concerns me.  I hope not to get Covid; I also hope not to have some other medical condition or be injured during this time.

Each day, I open Worldometer and look at the worldwide Covid stats.  For awhile, it looked like India might eventually pass the US in numbers of patients, but that trend reversed, not necessarily that India is doing better, for I have been told, through a responsible journalist I know in New Delhi, that many cases are going uncounted. Still, we’ve solidified our hold on first place. I now know what America First really means.  The other countries in the list are changing places. Even Germany moved up from 22nd to 13th.

I then look at the US data, the top 10, now having Wisconsin at 7, and that and a few other states in detail; Texas, Florida, the Dakotas, and lately Illinois, before looking at Oregon.  Some days, I check Idaho and Montana, and pretty soon, I will probably look at Michigan and Ohio.

It’s awful. The Dakotas have had remarkable case numbers; North Dakota had over 2000 a day before a mask mandate. That is 1 in 300 people being diagnosed, every day. Nurses in North Dakota finally got a mask mandate after protesting the WTF policy of being allowed to work if they tested positive without symptoms. Wearing a mask, even in North Dakota, shouldn’t be considered an unreasonable burden. It protects the wearer, this Duh moment finally being recognized by the people in power.  That’s how it should have been rolled out in the first place.  Do governors not see what happened in New York?  Or Arizona?  And what happened when the governors got serious?  Should we wait until the hospitals are closed for patient care?  Where do they go, Minnesota?  That’s where North Dakotans who wanted testing went. Minnesota hospitals are filling up, too. 

I worry that much of the country is unaware of what is happening to nurses and physicians.  I practiced medicine where some days I literally ran from patient to patient, the times I had to work, when I was occasionally sicker than my patients—with pneumonia one time—and eventually burned out. What I went through is nothing like hoping to have PPE, putting it on for hours at a time, working extra hours, seeing no end in sight, dealing with patients that often linger for days before too often dying, and dying alone, and seeing people outside complain that they can’t go to a bar and have to wear a mask. Poor things.

When does it stop, Gov. Noem?  When hospitals literally have no staff and people dead on the street? That’s what epidemiologist Mike Osterholm is worried about. This Mike has thought about dead on the streets for quite some time. Who is going to care for those of us who need medical care for other conditions, elective surgery, which may be elective, but improve life?  Three more doublings of cases will be a million a day, with 3000 deaths—a daily 9/11—by Biden’s inauguration at the current rate of doubling every 19 days.

We knew how to deal with this, even after Mr. Trump didn’t read the pandemic plan that George W. Bush had put together. We just had to follow what Gov. Cuomo did.  He offered it to states, but apparently the fact that Cuomo wasn’t perfect got in the way of what he did right  Even while New York’s cases are rising, their deaths are still much smaller, but as many of us know, there is a lag time, and even with improvement of care, deaths will rise should the sheer numbers, of course, and from the fact that the beds, staff, meds, proning, or ECMO simply won’t be available. 

Wisconsin has a governor who wants to control this, but the legislature won’t meet and any time the governor tries to do something, the Courts say he can’t. Nothing like judges practicing medicine.  I still remember last May the picture of a happy, overweight man walking into a bar in the state. Yep, bars and indoor dining matter. Education, not so much, and a quarter million Americans, no longer alive to comment.

Idaho had a hospital that was 99% full, and the county acted by revoking the county’s mask mandate. One of the board members said she didn’t believe coronavirus was making people sick. Another had given up. Now, Gov. Inslee of Washington is telling Idaho’s governor to get his act together since Spokane’s hospitals have come under the gun.

I know, Covid has been hard on our mental health. So is reading the last paragraph. So has been Mr. Trump.  But the Brits dealt with the Blitz, being bombed night after night, couldn’t have indoor dining and bars open, and weren’t forever scarred as a people. The world even dealt with the loss of a generation of young men in World War I and then had the 1918 pandemic.  The people born back then became part of the Greatest Generation. My parents.  The people born today may never know their grandparents. We are losing another generation.

Ninety per cent of the deaths are those over 70, so I have a vested interest in seeing this pandemic over.  But, when we reach half million deaths in this country, which we are on track to do by the first anniversary of Covid, that means 50,000 deaths in people under 70, a full year’s worth of auto deaths, and they won’t all be over 60. That’s a lot of premature deaths, and we aren’t discussing long term sequelae of the lung, heart, kidney, blood clotting ability, chronic Covid, and the possibility of being re-infected. Those with chronic Covid, or long haul, are not the elderly but previously healthy, productive members of society. We don’t know how they will do, whether this is treatable, goes away, or hangs on indefinitely. It is cavalier to treat this disease as a live-die dichotomy.  It isn’t. 

We don’t get it. If the hospitals get overwhelmed, medical care stops in this country, and that will be catastrophic. 

We have since had problems with Halloween parties, Covid fatigue, people just getting together in groups. I know. I hike with a group, and people like getting together. The Club has a “arrange your own transportation” policy on out of town hikes, and plenty carpool. I’m leading a hike Saturday, and I won’t carpool.

We now have vaccines that work, but it will be the 2nd and 3rd quarter 2021 before they will be widespread. Still, there’s hope.  But we need to wear masks, shut down if necessary, and support those displaced through at least the first half of 2021. We need to fine those who congregate in groups.  Where’s the money coming from?  We don’t need to have an active military at the moment, and we had a trillion dollar tax break given to people who aren’t going to trickle it down. Some money can come from there. 

The rest becomes our national debt. At least we will be alive to deal with it and so far, the dollar is still a good currency world-wide.  For now.

Social distancing, called safety, in the age of Covid. The person in the middle is a little close to the sawyer, but he is looking up at the top of the log to make sure it isn’t going to cause problems. Right now, we are clearing the trail. Fixing the bridge will come later. There are about 200 trees down and at least 3 bridges. North Fork of the Middle Fork Trail, about 15 miles from Oakridge, Oregon.

Author, 3 April 2020, with a balaclava mask. I was an early adopter.

A recent article in the medical section of the Times told the story of a man with chronic buttock pain who ended up with being diagnosed with Crohn’s disease with sacroiliac arthritis. 

It only took 10 years. The cause was discovered by accident when the man had a colonoscopy and an alert GI doc noted that the ilieocecal valve was scarred. He passed the scope further into the distal ileum and found inflammatory changes consistent with Crohn’s disease. The patient has since done well with strong anti-inflammatory agents. He had never had overt symptoms of Crohn’s. So many of the things I once learned in medicine have been shown not to be true, or to be different from what I originally had learned. So many of the conditions that were once untreatable now are. 

I remembered from medical school being told that a barium enema (which is how we imaged the colon back then) had to reflux into the ilium or the appendix to be able to say it was complete. It’s not enough to say the cecum—the beginning of the large bowel— was viewed.  What looked like the wall of the cecum in one instance was a large tumor. Had one not looked for the appendix, which was impossible in that situation, or the ileocecal valve, which was very difficult to find, the tumor itself might not have been appreciated.  Cecal tumors themselves are difficult to pick up.  I learned that lesson.

I thought of the good specialists who told us medical students about conditions in their field we didn’t want to miss. That bailed me out in my internship the night I examined a scrub nurse in the ED with a scalpel wound to the palm of her hand.  Everything looked fine; she could move everything and feel everything, and there was minimal bleeding.

I called the hand surgeon anyway. I had learned that puncture wounds of the palm were dangerous.  He came in, thanking me for calling him.  A few weeks later, I happened by the nurse, who took me aside and thanked me for saving her hand.  I was surprised and asked her what happened.

“I had a significant hematoma drained,” she said. “Had nothing been done quickly, I could have lost significant function and might not be able to work. Thank you.”  I had forgotten about that day.

Or the patient who complained of something in his eye where nothing was found. I either had to find the object, find a corneal scar, or call an ophthalmologist.  Something was wrong until proven otherwise when a person complains of a sensation that something is in his eye.

Or the Fireman 1/c on board my ship, who had a red eye that might have passed for conjunctivitis, except the inflammation encircled the iris. He had acute iritis, and I had to treat him with steroid eye drops. Iritis is not something one wants to miss. I would never see another case. But I found that one.

Or the patient with progressive loss of vision that was felt to need glasses.  The only problem was that the pupil had a very poor reaction to light on that side, but reacted briskly when light was shone into the other eye.  This meant the optic nerve was compromised, called an afferent pupillary defect, since the afferent pathway is involved.  In this instance, the patient had a meningioma compressing the optic nerve. Another trick to screen for optic nerve disease is to look for red desaturation, have the patient compare the degree of redness with each eye. The afflicted eye will not see the red nearly as bright.

It can also work in reverse.  Many with poor visual acuity may have remarkable improvement looking through a pinhole, which can be easily made. When such improvement occurs, the visual problem is always refractive, for visual defects of optic nerve origin do not improve by looking through a pinhole.

Or the man I saw in the Morenci, Arizona clinic, 3 hours’ drive from Tucson, whose neurological exam was fine, but he had a soft lump on his cheek. These look like sebaceous cysts that should be drained, but I was taught well about parotid gland tumor presentation, and the one thing one never does with parotid tumors is stick a needle into them, for it will enhance spread. He was sent to Tucson where a surgeon cured him.

Hoarseness?  The patient has two weeks to get better before one must do a laryngoscopy looking for vocal cord paralysis due to recurrent nerve injury perhaps due to a condition like a malignant lung tumor.

Possible pneumothorax?  Get an inspiration-expiration film, where the difference is sufficient to show air where it does not belong. I can still remember what room I was in at Denver General Hospital when I saw a case on a Saturday morning, the second month of my internship, 46 years ago.

When I was in practice, a patient with a cerebellar infarct was admitted to the floor. I put in a call to a neurosurgeon, because while at the time the patient was in no distress, the affected brain can swell and compromise the lower brain stem quickly, leading to death.  Potentially enlarging cerebellar lesions are dangerous and deserve respect.  I asked the nurses to “check frequently,” without needing to take vital signs, which saved them time and underscored the need to watch the patient often. The next day, I found the patient post-op in the ICU, awake. The swelling had become significant, the brain stem was becoming compromised, and the swollen, infarcted cerebellum was removed. He made an excellent recovery.

My wife had two cases where there was a clearcut breast malignancy on the mammogram but nothing found by either the surgeon or pathologist.  In the former, missing the malignancy led to a second mammogram—uncomfortable to go through post-operatively—and a subsequent change in the hospital system, so that X-Rays were required to be taken of the specimen before closure, to ensure that the lesion was in the specimen and not still in the patient. In the latter instance, the pathologist was told he had to go back and find the cancer, because it was in the specimen, and it was cancer. It was found.

On the psychiatry rotation I learned never to be shy about asking about suicidal ideation, and I asked about it scores of times in practice, to evaluate depression. Not one person was ever angry with me for asking. Virtually all had thought about suicide; very few had gone to the next step, which was determining how they would do it.

Or, the routine physical exam which I did on a sailor before he left the Navy. I felt his abdomen, something I had done hundreds of times, and the large mass I felt surprised me. The sailor had been unaware of it. He would turn out to have lymphoma.

While I have long forgotten the details, I remember calling in consults to orthopedic surgeons using words like “valgus” and “varus,” rotational deformity, distracted or overriding, and discussing vessels, skin, nerve, tendon, joint, and muscle, for that was how I was taught. 

I learned that when I argued with myself about whether I should do a spinal tap, just do it. More than once, I discovered something that was useful. Sometimes, one had to get the spinal fluid a different way. I had an obese diabetic with a stiff neck at 2 am in the ED one night. A spinal needle could not reach her meninges through the back, so I punctured the skin just below the base of the skull, “walking” the needle down the occipital bone, until I reached the cisterna magna, finding white fluid indicative of a bacterial meningitis. She did survive.

I hope along the way some of my teachings may have been useful, like checking level of consciousness by “What does it take to arouse them?” “What do they do when they are aroused?” and “Are they getting better or worse?”  The last was an attempt to remind people that being medically stable requires at least two observations, not one. I don’t know if the same approach is used today in teaching medical students, but I hope they do finish training knowing not only the potential pitfalls in their specialty but many of the ones in other specialties, too.

The other day, a woman called in to Doctor Radio wondering when there was going to be a cure for Covid-19.  Her voice was peremptory, as if this were something we should all be expecting by now.  Americans are impatient, and while I am impatient, I have inhaled a dose of reality.  I know there are many drug trials, at least a dozen, with results due anywhere from next week to late September. That’s good. What isn’t so good is that if we had any trial stopping event—like polio vaccine, which was so powerful the drug trial was halted and the vaccine being given—we might know that by now. Something that pulls someone off a ventilator overnight, or ECMO, or empties an ICU is a big deal, and I haven’t heard of that yet.  I don’t expect to.  

But, we have something now. One Remdesiver trial showed the time for half the patients to recover was 11 days with the drug and 15 days without. The death rate was 8% in the control group vs. 11.6% in the treated group.  That is a 31% difference with a p-value of 0.059. The time to recover was significantly shorter; the death rate statistically not significant (want p-value under 0.05, which is the probability if chance were operating and nothing else, we could have seen this result or one more striking), but with a larger study, I suspect we would see a value under 0.05, which is an artificial construct but generally used.  Study two compared length of time efficacy; 5 days’ treatment is as good as 10 days, good news. 

From Oxford, a genetically modified MERS virus vaccine stopped Covid in macaques, a control group of whom did not survive similar doses of the virus without the vaccine. This study needs to be watched. 

But for the moment, let’s look at reality: how quickly we are going to return to whatever will be normal.  And those last four words to me are key. Sports, concerts, flying, cruise ships, restaurants, road trips, and schools aren’t going to be normal for some time, in my view, a lot longer time than many think. I have cancelled two trips this spring; I don’t expect to canoe in September, and I am not expecting to see the eclipse in December. 

Certainly not on a cruise ship.

Some wonder whether it is worth getting the virus and getting it over with.  Given the number of anecdotal cases of young and middle aged people having severe disease, I don’t think that is a wise choice, especially if one has diabetes, is obese or smokes, which are not rare in society today.  I correspond with people overseas, and one in Asia told me the whole family just got clinical Covid.  Two have anosmia, mild in the scheme of life, but people complain bitterly about it.

There are additional issues with the virus either causing a coagulopathy, where the blood doesn’t clot, or attacks the blood vessels directly.  Coronavirus myocardial damage is known; coronavirus encephalopathy and involvement of the thalamus in the brain is known, and the virus been found in the kidneys.  One third on ventilators have significant kidney disease. That should bother anyone.  I sure don’t want that at my age.

We also don’t know whether there will be after effects of pulmonary scarring, congestive heart failure, or chronic renal failure. Again, I don’t want to get this virus. 

I look at a lot of numbers and have noted from the beginning that Washington State never had a big problem after the initial attack in the nursing homes.  I expected California to explode with cases like New York, but it didn’t. Florida had people on beaches, and it had cases, but not like New York’s. I have wondered whether the population density of susceptible people mattered, and I think it does. The media does mention that “cases are rising xx per cent,” but they are rising from a smaller number.  What is clear is the numbers of cases in the mid-continent haven’t yet started to fall, whereas they have on the east and west coasts.  That concerns me, but to say the numbers are rising at 10% a day means a doubling time of 7 days, and NYC started with doubling at 3 days and continued that way for awhile.  Oregon is going to allow elective surgery.  That makes sense, because elective surgery is often biopsies and fixing things that we all have come to expect with surgery.  I think social distancing worked; we need to remember that there is a two week delay when people start moving about before we will know if there are new infections.

For those who are saying we never had to do anything, that this virus wasn’t all that bad, keep in mind that the purpose of public health workers is to prevent things. We don’t have many cases of measles; if people vaccinated, we wouldn’t have any.  It’s not that measles is gone; it just doesn’t have a home here. We social distanced and we cut the number of Covid-19 cases.  Not enough, and the numbers are well past the number of deaths from influenza that people quote every year.  I suspect they will be more than 100,000, the low end of the original estimate. We are already 11,000 over the estimate for 1 May that I read two weeks ago.

The other issue is testing, an important catchword, and we need to also know how good tests are,  Recently several were checked; three were good.  It turns out, (proof below),  a test that is 90% specific (one has the disease, test is positive) and 95% sensitive (one doesn’t have the disease, test is negative) and the disease is relatively uncommon (5% of people), a positive test has a 50% chance of being false positive.  It is the difference between “if I have the disease what is my test?” and “I test positive, do I have the disease?”  The more common the disease in the underlying population, the more likely a positive test is true.  It’s why public health people did not require AIDS testing for wedding licenses. The disease was uncommon enough that a third of the positives were true and the other false. 

5% prevalence of disease

	Test Positive	Test Negative	Total
Disease positive (has it)	45	5	50
Disease negative	47.5	902.5	950
Total	92.5	907.5	1000

This is sensitivity of 90% (45/50) and specificity of 95% (902.5/950).  Positive test has (45/92.5) or 49% chance of being a true positive, even when the specificity and sensitivity are both 90% or more.

Same with a 20% prevalence in the community would make false positives only 18%.

So, I wear my mask, take my walks, and wait. 

Maybe next year we will do a lot more, but not soon.  We don’t yet know for sure whether people are immune to the virus after having had it or can get it again. There is a bit of national denial in thinking that sports will start soon. They won’t until or unless there is a vaccine or an anti-viral better than Remdesivir. Additionally, we don’t know what it will take to get a vaccine, or whether a vaccine will even be effective, let alone for how long and what side effects are present. People want something, but vaccines can backfire and overstimulate the immune system, which is a huge problem with this virus.  Indeed, many medicines are in trials to see if they can turn down the immune system.  In the meantime, beware of those who are pushing strengthening our immune systems.  Stay in good health and let your immune system take care of you.

We are finally doing random sampling in various cities to get a sense of how many asymptomatic infections are present.  The evidence we had from China was that few were asymptomatic.  That is not true. We need more information about relative risk, not that 2/3s of the deaths are over 70 but what the risk of a 70 year-old or more, without chronic disease, surviving. That’s a different question.  We need to give the risk to people in various decades of life with and without chronic disease as to what their risks are—to be asymptomatic, to avoid hospitalization, to avoid ventilators, and to avoid death.  

If public health professionals are doing their job, people will complain that they were too strict. 

It’s nice to be still alive to complain.

It was really all my fault: it was I who suggested to my cardiologist about a year ago that maybe I should be screened for abdominal aortic aneurysm.  I didn’t think I had one, but I’m old, male, and have a waist size that is borderline large for my height.  I don’t think the cardiologist agreed that I had any risk factors, but he scheduled me for a CT Angiogram in a year. He was in no hurry.  He  first wanted to get a CT of my heart, looking for calcium in the vessels, 

That exam showed almost no calcium, good news, but a small hiatal hernia, a fairly common finding, but which I could have done without.  A year passed, I had the angiogram, and the aorta was normal.  That was the good news.  The bad news was that I had diffuse esophageal thickening, which is always abnormal, and which required evaluation. The likely possibility was reflux esophagitis;  maybe I had Barrett’s esophagus, where the lower esophageal lining changes and appears more like the stomach’s, Esophageal carcinoma was a fortunately more remote possibility.  

I initially didn’t think I had significant reflux, but three years earlier, I had a nagging cough that went away dramatically when I started an H2-blocker for acid reflux, again confirming what we know about one cause of chronic cough: reflux.  And when I started thinking about it, I did have some symptoms of reflux, especially if I did some bending over activity when working trail.  I had such reflux up the Aufderheide last August in the Waldo Lake Wilderness that I upchucked, fortunately with nobody else on the crew’s noticing.  Barfing on the crosscut saw would have upset everybody.  Anyway, It’s like my body is trying to tell me that my heart Is doing OK, deal with my esophagus.  

So that is how I found myself one dark morning in the GI lab, about to get an upper endoscopy (EGD), at least with half my clothes still on me, including my shoes.  I was hoping I would only have to ditch the shirt for the study. Given what was going to happen later, I could have walked out of the hospital nude and not been aware of it.

The nurse told me what medicines I would be given, and I heard something I wasn’t sure I heard right, and I didn’t really want to hear it, but I asked her to repeat what she said.

“Versed.”

“Oh,” I replied. “I did have that in 2001 for a colonoscopy, and afterwards, the nurse asked me how I felt, and I said fine, so they let me leave the lab.  Unfortunately, they didn’t ask me if I knew where I was, because the next thing I knew, I was wandering around the hospital parking lot, fortunate enough that my wife, in the car, found me before someone ran me over.” I had no recollection of walking out of the GI Lab, leaving the hospital, and ending up in the parking lot. The hospital later heard about my experience and promptly changed the system to require all patients to leave in a wheelchair, accompanied by a staff member.  The next two colonoscopies I had were done with Propofol, and I did just fine. I actually woke up in the GI lab, rather than leaving the hospital without a clue as to what county I was in. Such a relief.

Just sayin’ be careful with that stuff with me, and don’t believe much I say when I come out of it.  The nurse laughed.  I was serious.

The last thing I remember before the procedure was telling the Indian-born doctor that I really liked the birding at Bhartapur in India, when I was there in 1995.  Incredible place.  Saw 30 species that day.

The next thing I vaguely remember was trying to read the report and understand the pictures from my study, but as I tried to turn the pages, I couldn’t do it. The feeling was like one has in a dream where simple things just can’t be done, and words don’t quite make sense.  The next thing I remember in this induced dream/reality was making my breakfast at home, hearing my wife saying that the bag of blueberries I had picked and frozen last summer had a hole in it. I then remember eating, reading the paper online, and doing some writing.  I even read my report.  I looked at the clock and was surprised it was 1050. The last time I had seen was 0800. Nothing else surprising happened for the next hour, when I had lunch and then let the heater service man in the house to take care of the annual servicing. The gap in my morning was still a gap, and I still wasn’t aware of it.

That afternoon, 5 hours after I got Versed, I took a walk.  I felt fine, but only then did I realize I hadn’t a clue what happened earlier that day.  There were four parts to this particular day, and so far, I had only been aware of two: right now, and before I had the procedure and acting normal at home.  The third part was being at home, eating two meals, and having lunch, but not being aware I had had a deficit. That deficit itself was part four, when I was able to remember anything.  I did not remember the doctor’s talking to me after the procedure, my getting dressed, walking out of the hospital, to the car, riding home, getting out of the car, and going inside.  None of it.  

I walked for nearly an hour, came home, to where my wife had some concern that my note “Took a walk” didn’t include the needed comment, “I really know who I am now.”

This loss of memory is known with Midazolam (Versed), and a friend of mine had a similar problem after a colonoscopy, although hers was more like Transient Global Amnesia, a disorder of unknown cause, that typically lasts about 12 hours, or Global Amnestic Syndrome, which typically follows a significant head injury.  The way I would test for these two disorders was to tell the patient my name, then leave the room, and come back in a minute later (or even after 30 seconds) and ask if they knew me.  With the above conditions, they would not know me.  

Once again, we are fortunate in our house to have medical knowledge. I don’t know what an older couple would do if they suddenly heard their partner ask over and over again where they were.  My wife knew that I would eventually return to the world of memory, but she didn’t know exactly when. 

I didn’t turn in my smiley evaluation to the GI lab, because I when I left the lab, didn’t know who I was, let alone where the box was to turn in the evaluation. I felt like the man in Blazing Saddles, who woke up in jail, so maybe I need an “in jail” smiley. My review will be the one of my favorite lines in response to the black sheriff’s asking, “Are we awake?”

“We are not sure. Are we black?”

“Yes, we are.”

“Then we are awake.  But we are very puzzled.”

I stood up as a very tall young man walked into the examining room, didn’t introduce himself, shook my hand, and as he sat down, his booming voice uttered one word:

“Questions?”

Interrogative.

It reminded me of the time in 2006 I was in Grand Marais, Minnesota, the night before I went to Isle Royale National Park.  I was at the casino eating dinner, since that was the only place open, and the waiter walked up and uttered one word.

“Walleye.”

Declarative.   

I remember repeating the fish’s name, interrogative, and he replied that it was the special. I’m not sure if I decided to have it, but I do remember his introduction.  

I went to the urologist’s lab a week prior to get my annual PSA test.  I am more concerned about my PSA than I should be, but I remember the adage that the probability in percent  of a man’s having at least microscopic prostate cancer is equal to his age.  In addition, my father had it, and he took an expensive medication to control it.  My only biological brother doesn’t write me often and may not have been checked in years, so I don’t know anything there. 

I arrived at the office for my appointment 20 minutes early to check-in, the check-in line out the door, and only one person working.  I joined a few old people there, and while waiting, I heard a daughter ask her mother-patient questions that the latter needed to have repeated and wasn’t sure of the answer.  The receptionist had a problem couple she was helping, and explaining the iPad check-in took time.  Life is sometimes difficult for those of us digital non-natives.

Eventually, it was my turn, and fortunately, I was checked in quickly and given two pieces of real paper on which to write down my medications.  Before I even got to the third line, I was called: “Michael?”  

While I usually introduce myself to younger people by my first name, I don’t like being called it in public by people who are a third to half my age and don’t know me.  It wasn’t worth saying anything, but whatever happened to basic formality? Perhaps if we were more formal in our speech and treatment of each other, we Americans might be less polarized.  Or not.  Just sayin.’

The nurse told me that “James” would be seeing me.  I didn’t know a James, and I started running through my head my doctor’s first name.  On my way to the inner sanctum, I had to get weighed, so I took my phone and wallet out of my pocket, stepped out of my shoes and got on the scale.  I lost 13 pounds two years ago, kept it off, and am proud of it.

I was put in a room to wait for “James,” saw my doctor’s first name (David) on a business card, and within a couple minutes, the tall man entered.

I was so stunned by the start, I couldn’t think of anything to reply to  “Questions?”  

I should have asked, “Who are you?” But, I read the “PA” on his badge.  I could have then asked, “Where’s David?” But obviously I was going to be seeing a PA.  I stammered, much like Ralphie does in the movie “A Christmas Story,” near the end, on Santa, he clams up and finally says, “A football?”  with my version of the pigskin:  “What was my PSA?”  

Tappety tap, mouse clicks.  Then, “When was it done?” Answer—with plenty of time for it to have been sent here and written on a piece of paper that you could have taken in your large hands in here and given me the result immediately instead of tappety, tap.  I stared at the wall and finally learned it was a good 1.8.  

I liked my physician, David. He’s a major player in the local and state medical community plus being a principal investigator for the practice.  I was once a player in my local and state medical community but never a principal investigator, although I tried to get my colleagues to investigate errors, but that didn’t work out.  

I have called the office and been on hold, where I heard about the great cutting edge, literally and figuratively, care is given.  It’s truly impressive, as is the information given to patients, hearing, “Knowing is better than not knowing.”  But, I didn’t know why I wasn’t seeing David but a PA.  I realized that being a retired physician counts for little these days, either in a medical office or outside of one, where first responders, nurses, and therapists carry the day and docs are good for ….well, let’s face it—being donors, bashed as a group, or occasionally being asked to give a curbside or trailside diagnosis. I had several questions, and while some were answered, it wasn’t the same.  I got my exam and some recommendations.  David told me a lot more.

The next thing I knew, I was walking out of the office, aided by a sign pointing to the exit, which was needed, because I needed to be in the left lane or else walk into somebody’s office. I remember thinking that the sign needed to be permanent, because it was necessary and the temporary one looked tacky in this 21st century office.

I had been looking forward to telling my urologist that I was off diazepam, that I had both discovered and used it successfully for a nasty condition. I tapered it myself, after one internist suggested as I got older I had more of a fall risk taking it, which was true. I tapered it faster when my next internist ignored my refill order. Don’t get severe pain today, because physicians are scared of the feds coming down on them for opioids and other controlled substances scripts, even when diazepam is not an opioid.  We went from pain as a 5th vital sign to don’t ever give opioids. I’ve been on this pendulum before.

I never got to talk to my urologist about the fact that some of my issues arise from other medications I am now taking.  This stuff happens at 70. I wanted to talk to him, because “Knowing is better than not knowing,” unless one is an old man with a stable condition and can be put off on a mid-level practitioner, rather than the physician.  I never did that when I was in practice.  I saw people, I returned their calls myself, I gave mountains of free advice and care, and I was a chump in another era.  But I was available, for better or for worse; for worse, if I were sleep-deprived, which was often. My office didn’t require people to make more than two 90 degree turns or walk more than 10 meters from the waiting room.  We didn’t need signs showing how to leave the sanctum sanctorum.  

It’s a different world.  

I wrote David and said I had missed him and had looked forward to seeing him.  I never got a reply.  That hurt.  It takes 24 seconds to send a polite blow off email.  I timed it once.  I sent an email to James deciding to take the medication we discussed, and several days later screwed up logging in to my patient portal, getting my account locked.  I waited and sent a couple of emails, and nothing happened.  A call finally settled everything, and I was told an email for me was on the portal, except it wasn’t.  Three days later, I got a three emails giving me a password to my account. Not being a digital native, I just thought it was a bad system, but digital is always better.

I thought that the bill would be less because I saw the midlevel and didn’t have a urinalysis, which I wanted to have.  It is, after all, a urology office.  One colleague told me that my bill would be the same. We were both wrong. It was $150 more than the prior year, when I saw the physician AND had not only a urinalysis but an ultrasound. My followup care charges in 1992 were $35. By medical inflation, they should now be $90. It was $350 for what I described above. We’ve lost something in 21st century medical care.  We are arguing as a nation as to who should and should not have care and how it is paid for.  Fair enough.  We need to do more, in my opinion.

But how the care is delivered is not unimportant. Knowing is better than not knowing.  And there is still important magic given by physicians who actually take time to see patients. That time matters.  Knowing matters. Laying on the hands matters.  I didn’t fully understand that when I was in practice.  I do fully understand it now.

And we have yet to fully address quality of care.  That’s for the 22nd century.