Category Archives: Health Care

Health care system discussions

Like a Rolling (Gall)Stone – Part Deux

4 Replies

Wednesday

Morning started at 6 a.m. with the Procession of Medications, a pill to prevent reflux, and my nurse noting my lipase level was down to 2,000. A tech took my temperature, blood pressure and pulse oximetry. The day shift nurse, Katrina, brought more meds around 7:30 a.m. which I took with the water I wasn’t supposed to be drinking.

“Uh, didn’t they tell you not to drink?” Nope, this is the first I’ve heard.

She also injected a dose of Lovenox®, an anticoagulant to prevent a deep vein thrombosis (DVT), because it had been ordered, not because I really needed it. I didn’t have the presence of mind to question it because I was tired but it seemed superfluous. My risk for a clot was low since I hadn’t had major surgery, I wasn’t bedridden, I don’t smoke and I’m not pregnant. Yeah, I’m old and fat but so what? (I refused it the next day, which is good because that little sucker was $119!)

An hour later a woman from Respiratory Therapy, who looked and talked like the commandant at a German women’s prison, appeared with one of the newer brand name steroid/long acting bronchodilator inhalers. Remember what I said about hospital meds costing a lot more? This one retails for about $450 and lasts 14 days; the hospital charged $570. My generic version, which lasts a month, is $40 with GoodRx®.

“I have an inhaler for you and I’m going to teach you how to use it. You pull back the cover and it’s very important that you hold it correctly with the vent side up. Then you take a deep breath and hold it.”

I pulled out my albuterol rescue inhaler. “I’m a physician. I’ve been using inhalers for a long time.”

She snapped at me. “You should NOT have your own inhaler! We are responsible for you and must know every medication you are taking! Another respiratory therapist would turn you in.”

Now she reminded me more of General Burkhalter from Hogan’s Heroes. Turn me in? What is this, Stalag 17? Are you going to send me to the Russian Front?

She watched while I inhaled like toking from a bong, then put it in a plastic bag which she placed on the shelf below the TV. “Someone will come back tomorrow for your next dose.” You think I’m so stupid that someone has to watch me? 

No, it’s because the hospital can charge $424 to “administer” the medication and $323 to “demonstrate” how to use it! What the hell do people without insurance do with those kinds of charges?

The Parade of the Grey Coats began around 9 am. Doctors (usually men) in white coats often cause spikes in patients’ blood pressures, so now most wear either grey or blue lab coats to minimize the psychological trauma. Or maybe it’s because white coats are a bitch to keep clean. (I have a royal blue lab coat with a Grateful Dead patch on the pocket.)

The internal medicine hospitalist showed up first. Now, I’m not sure what a hospitalist does other than generating revenue and confusion while making it possible for office-based internists to never set foot in the hospital. I’m sure I’ll get a lot of shit for that but my sister-in-law’s experience with hospitalists, who are usually much younger than the seasoned staff physicians, was exasperating.

He asked me to recount the events that ended with my admission, the third request if you’re keeping count.

“How are you feeling?”
“Better than when I came in.”
“Well, your lipase levels have come down nicely to around 2,000 with the I.V. fluid flushing it out. Do you mind if I examine you?”

He poked my abdomen in a few places. “Does that hurt?”
“Not much but you’re not as rough as the ER doc last night. Do you know Dr. Nell?”

He chuckled, “Yes, I like her, but she can be a little, uh, enthusiastic.” That’s a polite way of putting it.

“Your lipase levels suggest you have pancreatitis. You’re not an alcoholic and you don’t smoke so it’s likely caused by gallstones. That pain you had may have been a stone passing, especially since it didn’t last too long and you’re feeling better. I’m going to order an ultrasound of your gallbladder. We might be able to send you home later today, but we’ll have to wait for the GI guy to see you.”

We interrupt this tale for a moment of education and enlightenment.

THE PATHOPHYSIOLOGY OF BILIARY PANCREATITIS 

The gall bladder is a pear-shaped organ that lies below the liver. It stores and stores bile, which digests fats. Bile leaves the gall bladder through cystic duct. The pancreas also secretes digestive enzymes through the pancreatic duct which joins the cystic duct, forming the common duct. Both empty into the duodenum through the hepatopancreatic ampulla, also known as the Ampulla of Vater (Darth Vater?), which is controlled by the Sphincter of Oddi. Sounds like something out of Norse mythology.

The gall bladder also provides a source of income for general surgeons when it becomes inflamed (cholecystitis), full of stones (cholelithiasis), or both. Stones form when, for unknown reasons, stuff in bile crystalizes and forms gallstones, in much the same way stuff in urine crystalizes to form kidney stones. If a stone gets stuck in the common duct, it blocks secretions from both the gallbladder and pancreas, resulting in gallstone pancreatitis, which is what I had. Pancreatitis can also result from excess alcohol consumption, smoking, prior abdominal surgery, obesity, infections, injuries, and pancreatic cancer.

Abdominal ultrasound is the easiest way of finding gallstones and often cholecystitis, as inflammation thickens the gallbladder wall. Other, and far more expensive, diagnostic methods include nuclear medicine scans, Magnetic Resonance Imaging (MRI), or Endoscopic Retrograde Cholangiopancreatography (ERCP), looking directly into the duct with an endoscope.

A common home test for cholecystitis is consuming a greasy meal which results in excruciating upper abdominal pain; however, this is not medically recommended.

Now, back to the program already in progress

Peg arrived around 9:30am.

Did I ever mention Peg hates hospitals? No, she REALLY hates hospitals. Her mother said, “Hospitals are where you go to die.” If Peg has the big one at home, she wants me to just hold her hand and stroke her arm until she passes. Then, and only then, can I go through her office looking for the lam money.

She also thinks there is a lot of waste and abuse, albeit mostly inadvertently because no one thinks about cost in a hospital. This is largely true. I worked for a staff-model HMO thirty-five years ago. “Managed care” was withholding care from patients for profit and employed physicians weren’t good enough to work with “real doctors.” Forty years later most physicians are employed by heartless entities, and I got the last laugh.

“So, what’s happened so far? I talked to your nurse about 5:30 this morning and she said you had a good night.”

“Yeah, my lipase level has come down to two thousand something. I saw the hospitalist earlier; he thinks I have pancreatitis from passing a gallstone. He ordered an ultrasound and said I might get to go home…depending.”

“Do you have any pain?”
“No, I feel pretty good right now.”

Just then a guy from Patient Transportation appeared in the doorway. He took me down for ultrasound on my bed, reversing the previous night’s course. I stared at the ceiling again as we went left out of my room, into the elevator, down to the first floor, out and a couple of left turns before backing me into a cramped ultrasound exam room. The ultrasound tech introduced herself, squirted warm ultrasound gel on my abdomen and started the exam. About fifteen minutes later she finished.

“And….?”
“You’ve got gall stones, but you didn’t hear that from me.”
“My lips are sealed.”

As the transportation guy wheeled me out someone from nuclear medicine said: “We’re going to see you later.”

Once back in the room I told Peg what we’d both suspected. Then the gastroenterologist showed up – not exactly a fount of wisdom. At his request I repeated the events of the previous 12 hours for the third (or was it the fourth) time. He pushed on my abdomen, and I winced.

“Well, at least it’s in the right place. Your ultrasound showed you’ve got gallstones. We’re going to get a CT (Computed Tomography) scan to confirm the diagnosis and a general surgeon will see you later today.”

“Ok, how about not giving me another liter of fluid? I’ve had three in the past ten hours, and I’ve been peeing every two hours.”
“Yeah, that’s probably a good idea. We’ll also try you on clear liquids.”

Peg and had a discussion after he left.

“You told me it didn’t hurt, and you told him it did.”
“It didn’t hurt when you asked me. It hurt after he reefed on it because it’s inflamed, not because I’m lying to you.”
“Getting a CT scan to confirm what we already know is a waste of money! The ultrasound showed you have gallstones; a CT scan is redundant. It’s not going to give any better information. And THIS is why healthcare is so expensive!”

Peg had a point. If you’ve already made the diagnosis with a $1,000 ultrasound scan, why tack on another $3,000 for a CT scan to tell you the same thing? If an ultrasound might be difficult because of extreme obesity, then just do a CT. (Side note: Later that day the general surgeon told me the CT scan was used because ultrasound can’t evaluate the pancreas very well for things like fluid collections or tumors, which is important when considering surgery.)

We saw the cardiologist next and recited my history for the fifth time. I recognized his name; he is the “electrician” who did my sister-in-law’s cardiac ablation. She absolutely loves him, and his partner is my cardiologist, so I trusted whatever he had to say.

“Your EKG and troponin levels were normal. You haven’t had a recent stress test and we’ll have to clear you if you’re going to have surgery.”

I had a stress test in 2017 because I’ve no reliable family history and I was going to start work as a hospitalist. Unfortunately, a normal stress test doesn’t mean you won’t drop dead a few weeks later like Tim Russert.

There are two ways to do a stress test. The time-honored tradition is to hook a patient up to a 12-lead EKG, run him or her on a treadmill until the pulse is at least 130, and see what happens. ST segment changes suggest coronary artery blockage. (So does grabbing one’s chest and having the big one.) The test runs a few hundred bucks.

The other way is a cardiolite stress test, injecting the subject with a radioactive tracer and scanning the heart before and after the treadmill. A decrease in uptake after exercise suggests blockage and may indicate which artery/arteries are affected. The tracer and scan add several thousand bucks to the procedure, even though it is of questionable benefit in someone who has no history of coronary artery disease. Coronary angiography, injecting dye through the coronary arteries, is still the definitive test for detecting blockages.

The charge for an outpatient study is considerably less than doing the same thing in a hospital:

Itemoutpatientinpatient
Treadmill$325.00$1,200.00
Tracer$720.00$918.00
Scan$1,634.00$5,532.00
Interpretation$300.00$300.00
TOTAL$2,979.00$7,950.00
Cardiolite Stress Test: Comparing outpatient and inpatient charges

A nuclear med technician came in with a syringe containing the isotope in a shielded container and transportation took me down in a wheelchair instead of a gurney. This time I could at least see where I was going. The cardiac evaluation unit was below the first floor and reminiscent of the Batcave.

One of the women in the scanning room explained the procedure, then had me lay on the slightly uncomfortable scanner bed.  The initial images took about six minutes, then they wheeled me across the hall to the treadmill room. Another tech applied twelve more EKG leads on my chest and abdomen, on top of the six leads I had for the portable monitor. The woman running the test explained what was about to happen.

“You’ll be on an incline on the treadmill. It will start out slowly for a few minutes, and then I’ll increase the speed until your heart rate gets to 130. You’ll have to keep that pace for at least a minute. Try to go as long as you can. When you need to stop, I’ll slow the treadmill for a one-minute cool down phase.  I see you have exercise-induced asthma. Do you have an inhaler?”
“Yes, I do but the respiratory Nazi told me I shouldn’t have it in the hospital.”
“Well, she’s wrong; we like treadmill patients to have their inhalers on hand.”

Left hand, have you met right hand?

The incline was fairly steep, more than I’ve ever tried at home. I held onto the bar across the front of the treadmill to keep from falling backwards. The pace was manageable despite feeling I was hiking up a mountain.

Then, to quote Emeril Lagasse, she “kicked it up a notch.” Actually, several notches. It didn’t take long for me to hit the target heart rate. I managed two minutes at that speed before I told her I had to stop.

“Are you having any pain or trouble breathing?”
“No, I’m just way out of shape and too old for this shit.”

I went back into the scanner for about three minutes before being wheeled back upstairs. I napped for a while, while Peg sat in the corner playing with her Kindle and looking at the news feed on her phone. I figured no news was good news.

The day nurse came in a little after 1pm to tell me the CT scan was scheduled for around 4pm and I’ll get oral contrast to drink around 3pm. The guy from transportation arrived a little before 4, followed by the nurse.

“Wasn’t I supposed to drink some contrast?”
“Uh, you didn’t get it?” Would I be asking you if I had?

She sputtered a bit and disappeared, possibly to give someone an ass-chewing, and to get the CT scan rescheduled. Peg rolled her eyes.

“If you were just a regular patient, you would have gone for your scan without asking any questions. They would have done the CT, discovered you didn’t have the oral contrast, and sent you back upstairs, and repeated it later. And you wonder why I hate hospitals.”

I saw the surgeon around 6:30, after Peg had gone home to feed Baxter. We hit it off immediately. He extolled the virtues of removing gallbladders with a laparoscope and I told him about assisting on an open cholecystectomy when I was an intern. Back then they made an autopsy incision from the breastbone along the right rib margin, then pried the muscles apart to get to the gallbladder. The guy I helped with was fat and needed a very large retractor called a Joe’s Hoe for exposure. Yeah, it looked like one could till soil with it.

“There are two options. The first is to have the surgery since you are already in the hospital, and you’ve gotten cardiac clearance. The other option is letting you go home and scheduling this as an outpatient. I’d recommend doing it now because we know you have gallstones and you’re likely to have another attack within three months. It’s better to take care of it now, because I’ve seen people wait and then come in with a necrotic gallbladder. They end up in ICU on I.V. antibiotics and sometimes a ventilator because they are really sick.”
“My wife works long hours. I need to talk to her and make arrangements. What is the chance of passing another stone in the next two weeks?”
“It’s likely pretty low but not zero. You might want to just get it over with.”

Well, that sounded good to me; I wouldn’t have a lot of time to think about going under again. We talked about my prostatectomy; he said taking out my gallbladder wouldn’t take as long, and I could probably go home a few hours later.

“I know your surgeon. We’re actually very good friends, even if he did go to Ohio State.”
Oh God, he’s a Wolverine. They can be sooo insufferable! But he seems like a decent guy.

“In the meantime, you can have a clear liquid diet tonight. Don’t have anything after midnight in case you decide on surgery. I have one case in the afternoon.”

I called Peg.

“He said we can do it now or do it later. I told him you had to work and could we do it in a couple of weeks. He said we could but there was a chance of another attack before surgery.”
“Well, what do you want to do?”
“He’s coming back in the morning and you’ll probably be here before him, so you can ask him any questions. If I do it tomorrow, I won’t have a lot of time to think about it.”
“I’ll go along with whatever you want.”

Katarina brought me two cups of contrast just before 7pm.

“Drink these now and I promise you’ll be downstairs for your CT scan around 8pm.” Well, this better happen!

Someone arrived just before 8pm and took me down to the CT room. It was cold, probably to protect the equipment which can become very warm. The tech who met me was a scruffy guy who reminded me of the dude that drove the school bus down to the water when a bunch of us went canoeing at Turkey Run State Park in Indiana during college. (His “mandatory safety instructions” were “If the brakes go out on this bus, put your head between your legs and kiss your ass goodbye!”)

“Marian will help you lay on this skinny bed while I get everything set up. I’ll let you know when I push the I.V. contrast because your head will start to feel warm and then you’ll think you’ve peed your pants. You’ll have to hold your breath a few times but that doesn’t last long. Do you have any questions?”
“Nope, let’s just get this done.”

The scan was as he described. I held my breath a few times while the scanner did its thing. The I.V. contrast created a brief sensation of warmth in my head and nether regions, passing quickly. I was back upstairs by 8:30 and I called home to say goodnight to Peg and to Baxter, who wasn’t taking this very well at all. He paced Tuesday night until 2am and this promised to be another fitful night.

Maybe tomorrow would bring a reprieve from all this fun and excitement.

JOIN US NEXT TIME FOR THE SERIES FINALE!

Illustration Credits: All © Can Stock Photo
Pancreas: Blambs
Pancreatitis: alila
Pear: yayayoyo
Burger and Liver: FabioBerti

Like a Rolling (Gall)Stone – Part 1

12 Replies

Tuesday

One minute I’m sitting on the couch watching 911: Lone Star and the next we’re hauling ass down 22nd Street on our way to Our Lady of the Suburbs Hospital thinking I’m gonna die from a heart attack.

I’ve had one hell of a case of reflux from three decades of stress, heavy caffeine intake and being fat, so occasional epigastric “discomfort” doesn’t set off alarms. But this time the slight ache turned into a constant squeezing pressure just below my xiphoid, that triangular bone below your sternum (breastbone) and pain that ran up to my right jaw. I went to the dining room table and sat for about 10 minutes and, like every other guy facing the prospect of a life-altering illness, hoped it would go away.

It got worse.

Peg was on the phone with her sister when I said, “I need to go to the hospital right now!” I was clutching my chest and had that I’m-not-pulling-your-leg look.

“Oh, shit, I gotta go!” She hung up and asked, “Do you want me to call 9-1-1?”

Hell, no. My first and hopefully last ambulance trip cost about fifteen hundred bucks and we could get there faster by driving. We got into the car and for once Peg didn’t drive like my grandmother. We were at Highland Avenue in about five minutes; the hospital was another five minutes south.

I thought back to the time Peg’s mom Gloria took Michele’s husband to the same hospital with his second heart attack. She didn’t like the maniacal drivers on Highland and took the back way through Finley Square Mall. Despite being potentially on death’s door, Dave still had the presence of mind to backseat drive.

“This isn’t the way to go.”

Gloria snapped, “Well this is the way I go!”

Best not to piss off the woman who has your life in her hands.

Peg pulled into the circular drive at the Emergency Department entrance. I got out and slowly walked into the reception area, still clutching my chest. The pain wasn’t as bad, but it hadn’t gone away. Peg said, “Possible MI here!” which impressed no one behind the glass.

“Have you been here before?”
Does it fucking matter right now?

Peg whipped out the all-important insurance card while I grabbed the nearest wheelchair. A few minutes later someone came out to reception and wheeled me through the ED double doors. The desk clerk, whose duties include traffic control, said, “They’re just finishing cleaning up nine. You can take him in there in a couple of minutes.”

Even though I’ve done it a couple of times, I’m still not used to being the one being wheeled into an exam room. Usually, I’m the one strolling in after all the folderol is over and the patient is prepped. Now I’m the one climbing onto the gurney while a couple of people swarm around me like worker bees around the queen. 

My shirt came off and someone put EKG leads on my chest, a blood pressure cuff on my left arm, a pulse oximeter on my left index finger, a thermometer under my tongue and an IV catheter in my right antecubital space (elbow joint), one of the worst places to put it. A lab tech took several tubes of blood before the nurse ran heparinized saline through the catheter before plugging the end. I put my gown on sometime during this onslaught. Someone else came in for a nasal swab for a COVID test.

A tech did an EKG and I figured I wasn’t having a cardiac issue since he didn’t go running down the hall for the crash cart team. Modern EKG machines print out a preliminary reading; mine was normal sinus rhythm. A radiology tech pulled a portable x-ray machine into the room, put a plate behind me and said, “Deep breath and hold it.” Imaging is all digital now; no more 55-gallon drums full of used x-ray film. The image appears on a computer monitor and the ability to zoom in and out means the radiologist doesn’t have to squint nearly as much.

The nurse started taking a history of my episode; this would be the first time of many that I’d recite the same story. This is not surprising since patients will tell nurses one thing and doctors something else. My story went like this:

“So, tell me what brought you to the hospital / what happened / what’s been going on?”
“I was sitting on the couch about a half hour after dinner and started to feel this pain right here (points to mid-epigastric area) that felt like someone was squeezing me really hard. I waited about ten minutes thinking it was going to get better, but it only got worse, so we came here.”
“When did it start?”
(Looking at the clock) “About 30 minutes ago.”
“Did the pain go anywhere else?” This is important because cardiac pain generally radiates to the left jaw and/or the left arm.
“It went up into my right jaw.”
“Any nausea, vomiting, sweating?”  The first heart attack admission I saw when I was a 17-year-old hospital orderly was sweating like a pig*. Some have nausea and/or vomiting, making them think “it’s just a little indigestion.”
“How do you feel now?”
“Better than I did before I came here but it still hurts!”

*Before someone says, “Pigs don’t sweat,” that phrase came from iron smelting. Molten iron poured onto sand forms “pig iron” which resembles a sow and piglets. Moisture from the ambient air condenses onto the “pigs” as they cool, which looks like sweat. I didn’t know that before, and now you know it as well.

The nurse left and the ED physician, Dr. Nell, walked through the privacy curtain covering the exam room doorway. She was short and stocky with short blond hair peeking out from under her surgical cap; her last name suggested she was of Eastern European descent. She asked me “So, what happened?” (Go up two paragraphs for the recap.)

Before I answered I made a point of telling her I was a retired physician. Normally, I don’t advertise but I’ve found it comes in handy since physicians don’t treat their brethren with the same dismissive attitudes and skepticism reserved for the great unwashed.

She began her examination by listening to my heart and lungs, then pushed on my abdomen REALLY hard, like one of the old Soviet Union’s female weightlifters.

“AAAAAH!”
“Does this hurt?”  Well, now it does!

She was quiet for a few minutes.

“You don’t have any of the classic heart attack signs like sweating or nausea and your EKG is normal, so it might be GI. I’m going to try nitroglycerine to see if it makes any difference while we’re waiting for your labs to come back.”

She left and a few minutes later the nurse returned with a small oval pill in a medicine cup.

“Put this under your tongue.”

Nitroglycerin is a vasodilator, a substance that relaxes smooth muscle and blood vessels, increasing blood flow to coronary arteries and is absorbed more rapidly from the mucous membrane under the tongue. The tablet itself irritating if left in one place too long and tastes like crap after disintegrating.

A few minutes passed and I didn’t feel any different. The pain had been slowly ebbing since I’d arrived, and my blood pressure dropped slightly. Dr. Nell returned.

“Did the nitro do anything?”
“No.”
“I didn’t think it would.”
“Yeah, neither did I.”
“Well, your troponin levels are stone cold negative, so I don’t think you’re having a heart attack.”

Troponins are proteins released into the blood when heart muscle is damaged. During my internship forty-some years ago we used to measure blood levels of lactate dehydrogenase (LDH) and creatine kinase (CK) when evaluating heart patients, but levels can be elevated with damage to other tissues. Troponins are much more specific.

She continued: “If it’s not cardiac, we start thinking of other causes, specifically gastrointestinal. Esophageal spasms (painful contractions of the esophagus) can mimic cardiac pain. We’ll have a GI evaluate you, but I want to try something else in the meantime. I’m going to give you a solution to drink.”

My nurse returned with a little turquoise container resembling a salad dressing packet, containing a solution of antacid and viscous lidocaine, a topical anesthetic. “We call this Magic Milk.”

I’m probably not going to like this, am I?

“It’s a combination of lidocaine and an antacid. You’re probably not going to like it.”

I’m used to downing Bicitra, something we gave to women before doing an emergency Cesarean section after a long, fruitless labor. It’s a solution of sodium citrate and citric acid with a fluorescent yellow-green appearance and tastes like thick, unsweetened Mountain Dew®. A friend of mine compared it to battery acid, but it cooled the burn expeditiously. It would probably be even better over ice with a little gin or vodka.

I tossed it back like a tequila shot, grimaced, and then roared, causing Peg to immediately panic.

“Are you OK??? Is something wrong???”
“Yeah, this stuff is really awful!”

Dr. Nell returned about 15 minutes later.

“Your labs are normal. Your EKG and chest x-ray are normal. I don’t know what’s causing the pain but it’s not likely cardiac. We’re going to keep you overnight and get consults in the morning.”

A woman from Admitting came in with a tablet and had me sign several forms, including “You’re responsible for any charges not covered by insurance. Don’t be a deadbeat or Vinnie will come visit you.” My nurse hooked me up to a telemetry EKG monitor. I got another wrist band and someone from transportation started pushing me down the hall.

I’ve seen friends and family in this hospital, so I knew my way around a bit, but that was walking upright. It’s almost impossible to know where you are looking at the ceiling, passing under fluorescent lights and acoustic tiles. Left, then right. Down one hallway, right and down another. A bell announced the elevator’s arrival; two bumps as the cart rode over the entrance.

A short trip up and I was on the 5th floor. The transportation dude wheeled me into the observation room.

“Can you make it to the bed?” Yeah, I’m not dead yet and I’m not as old as you think.

After I got settled I looked around at the luxury that was the observation room. I’d bet the Cook County jail had better holding cells.

There was a single hospital bed in what used to be a double room, a bedside table next to the bed, and a single utilitarian vinyl-upholstered recliner in the corner. A laptop was bolted to a mobile desktop between my bed and the bathroom wall. I think there was an unremarkable print on the wall, the kind whose eventual familiarity drives one insane. The walls were painted in either celery or baby diarrhea brown which, combined with the yellow tint of the fluorescent lighting, made the room even more dismal. The mattress was lumpy and about two inches thick; it alternately inflated and deflated in different spots, probably to prevent bedsores or blood clots in skinny, immobile old people. One could probably die from despair in here.

My nurse, Meghan, came in shortly to get me settled. She was tall with dark brown hair, grey eyes, not much of a butt and yes, I could be her father or grandfather. Just because I’m on a diet doesn’t mean I can’t look at the menu. What the hell else am I gonna do at 11:00 pm after thinking I was going to go to the Great Beyond?

We chatted a bit between the obligatory nursing documentation questions, including going through my medication list for the third or fourth time. Here’s a hint: if there are any meds you can do without for a few days before you get back home, don’t mention them. The hospital will give them to you while charging outlandish rates.

About 1am she came in and said, “Your lipase level came back 30,000 and the doctor thinks it might be pancreatitis, so we’re going to start I.V. fluids.” (Lipase is an enzyme the pancreas secretes to break down fats in one’s diet; an elevated level indicates inflammation from a number of causes, including alcoholism, gallstones or tumors.)

Pancreatitis? The only person I ever saw with pancreatitis was when I was a resident. She’d been deposited in our Labor Unit because some genius in the emergency room figured the woman in triage was (a) female and (b) in pain, so she must be in labor. She was actually 49 and had acute pancreatitis; and our nurse manager reamed someone a new one. I wasn’t in that much pain, but even I realized 30,000 was, if not an error, something terribly wrong.

Whoever gave the order also wanted me NPO, nil per os, meaning nothing to eat or drink. However, no one passed that on to me, so I kept drinking all night. And, not wanting to be a bother, I’d unplug the I.V. pump when I needed to urinate, wheel it to the bathroom, do my thing and hook it back up before getting back into bed, after figuring out how not to get tangle in the I.V. tubing. Two days passed and NO ONE asked why the bedside urinal was never used.

The bathroom was another disappointment. Commercial toilets are wall-mounted and, if done more than ten or twenty years ago, were lower to the ground than today’s “comfort height” toilets. Hospital toilets also have a rod connected to the plumbing that pulls down to spray out bedpans. Whoever does maintenance put in a six-inch lift between the bowl and the seat to raise the height but neglected to caulk the lower part of the lift. Anyone peeing sitting down (including me because it’s easier since my prostatectomy), ends up drenching the floor. It took a few trips to figure out why my feet were wet.

The lab took blood sometime during the night, but I wasn’t aware of it and figured they’d taken it out of the I.V. port.  I wondered what fresh hell daylight would bring.

TO BE CONTINUED…

Featured image: Chest Pain.  © Can Stock Photo / yekophotostudio

Smallpox

VACCINATION CONSTERNATION

2 Replies

On February 4, 1976, a nineteen-year-old army recruit at Fort Dix died of what the CDC determined was an influenza strain genetically similar to the 1918 H1N1 swine flu virus that caused a worldwide pandemic. Fearing another pandemic, CDC pushed for mass vaccination Then-President Gerald Ford (who facing re-election) figured mass American deaths would be politically unforgivable if nothing was done, agreed and fast-tracked a vaccine.

A few months later the pharmaceutical industry demanded federal indemnification against liability for any adverse reactions before releasing the vaccine. Then, as now, such a move created public suspicion and distrust of both the government and the vaccine. That skepticism was furthered after several reports linked the vaccine to recipients developing Guillain-Barre syndrome,  a rare disorder in which the body’s immune system attacks nerves causing weakness and sometimes paralysis severe enough to require ventilator support.

The pandemic never materialized as that flu strain was far less dangerous than initially thought. But the damage to the idea of vaccines being lifesaving miracles had been done.

That fall I had the dubious honor of being interviewed on camera by one of the local TV stations in Rockford, IL after getting a swine flu shot. When asked why I wasn’t hesitant to get the vaccine, I said something stupid like, “I should know about these things; I’m a medical student!”

But the real reason I got that vaccination and continue to do so was because I grew up during the 1950s and 1960s. Our parents lived through the times of no vaccines and witnessed the devastation. Immunizations were miracles of science and our parents were determined we would have a better (and healthier) life than they did.  

The current anti-vaccine movement started in the 1980s and has only grown since then, thanks to the Internet, anti-science politicians and Andrew Wakefield’s thoroughly discredited claim that vaccines caused autism. Most of those people either didn’t experience or chose to forget what life was like prior to vaccines, which calls for a review of pre-vaccine devastation.

In 1892 Canadian physician Sir William Osler called pneumonia “the old man’s friend” because it often claimed the elderly already suffering from debilitating disease. (Osler died of pneumonia in 1919.) Thirty to 40 percent of people who developed pneumonia died before widespread use of antibiotics. Even now, antibiotic resistance among the more than 90 serotypes of Streptococcus pneumoniae can make treatment difficult.

A polysaccharide vaccine against 23 streptococcal serotypes, PPSV-23 (Pneumovax ® Merck), was released in 1983. A pneumococcal conjugate vaccine (PCV7) was released in 2000; it was replaced in 2013 by PCV13 (Prevnar13 ® Pfizer). So now us old people can die of slower, more expensive diseases like Alzheimer’s, chronic congestive heart failure and cancer.

Smallpox, a contagious disease caused by the variola virus, produced fever, vomiting, generalized body aches and a characteristic pustular rash that frequently resulted in terrible scarring. Sometimes smallpox infections left the victim blind or dead. A vaccine became available in 1961 and was given until 1972 when it was declared eradicated in the United States. In 1978 Janet Parker, a 40-year-old photographer, was the last smallpox fatality.  The WHO declared smallpox eradicated in 1980.

All of us who received a smallpox vaccination have a cratered scar on our upper arms. Mine has all but faded but I wore it like a badge of honor.

Polio, caused by the poliovirus, is a disease whose symptoms range from none (75%), through common viral symptoms such as fever, headache, nausea and stomach pain (20%) to progressive, devastating neurological damage (5%). Many victims suffered weakened and deformed limbs or outright paralysis. (President Franklin Roosevelt was 39 when he contracted polio in 1921 and became unable to walk, but he hid it well from the public.) Sometimes the virus affected the ability to breathe, requiring patients to spend a good deal of their lives in an iron lung, long before the invention of modern ventilators.

Our parents were terrified because everyone knew someone who had contracted polio. People blamed cats, dogs, public drinking fountains, swimming pools and beaches for spreading polio before its fecal mode of transmission was identified. One of my high school classmates, born in 1954, contracted polio which weakened one leg. Sixty some years later he still wears a heavy leg brace.

Jonas Salk is remembered for created the inactivated polio vaccine (IPV) which was released in 1955. Albert Sabin created an oral polio vaccine (OPV), released in 1961. Kids my age got the OPV on a sugar cube that had been dosed with the vaccine. Currently IPV is the only vaccine available in the US but OPV is still used in other countries.

Diphtheria, a bacterial illness caused by the Corynebacterium diphtheriae, creates a toxin that destroys respiratory tract tissue. The resulting grey “pseudomembrane” makes breathing and swallowing difficult and gives the breath an odor described as a “wet mouse.” The toxin can wreck the heart, kidneys, and nervous system if it circulates in the blood. About 10% of victims died from diphtheria before a vaccine was developed.

Pertussis, also known as whooping cough, is a contagious bacterial respiratory disease caused by Bordetella pertussis. Infection produces a severe hacking cough that can last for 10 weeks, accompanied by a “whoop” sound with inhalation. Severe coughing fits can lead to fractured ribs. It was sometimes fatal in infants prior to a vaccine; it is still common in underdeveloped countries.

Tetanus, once commonly known as “lockjaw,” is caused by the bacterium Clostridium tetani, found mainly in damp soil. (My mother always told me one developed tetanus from stepping on a rusty nail, which never made sense. It was due to bacteria in the soil around old, rusty nails.) It produces a toxin that causes painful muscle contractions (tetany), often affecting jaw and mouth muscles.

DPT, a vaccine for diphtheria, pertussis and tetanus was developed in 1949, combining diphtheria and tetanus toxoids (inactivated forms of toxins) with killed pertussis cells. I got vaccinated when I was five years old and spent a couple of nights in the hospital after developing hives. I never got a tetanus booster after that, but the hives were more likely a reaction to the pertussis component. A newer vaccine, TDaP, which used pertussis antigens rather than killed bacteria (aP = acellular Pertussis) was released in 1981 and replaced DPT in 1997.

Measles is a very contagious viral illness caused by the rubeola virus which has gone by many other names: red measles; English measles; hard measles; seven-, eight- or ten-day measles. Infected people, mostly children, develop cough, fever, runny nose and itchy eyes followed by a generalized flat rash 3-5 days later. While most recover without any problems, measles complications include ear infections, bronchitis, pneumonia and encephalitis. (Adults often do poorly with childhood diseases, especially measles.) About 100,000 people around the world, mostly children under 5, die from measles every year. Measles was declared eliminated in the United States in 2000 but there were 1,282 cases in 2019, largely due to people lacking vaccination.

Mumps is a viral illness that causes parotitis (swelling of the salivary glands) but can also affect the breasts, pancreas, meninges (the tissue covering the brain and spinal cord), ovaries and testicles. Mumps used to be a common cause of aseptic (non-bacterial) meningitis and hearing loss in children before widespread vaccination. Death from mumps is rare.

Rubella, also known as German measles or three-day measles, is a viral disease that causes fever, headache, runny nose and a distinctive fine rash that spreads from the face to the trunk and then arms and legs. The infection is usually mild, and most children recover quickly, but complications include pneumonia leading to death, encephalitis causing deafness or intellectual disability, or a ruptured spleen. Up to 70% of women with rubella develop arthritis.

Congenital rubella syndrome (CRS), characterized by cataracts, congenital heart disease, intellectual impairment or hearing deficits, can occur in babies whose mothers contracted rubella during pregnancy. There were 12.5 million cases of rubella in the United States during the 1964-1965 rubella epidemic with a staggering toll.  Women lost 11,000 pregnancies from miscarriage, stillbirth, or abortion and 2,100 babies died after birth. Of the 20,000 cases of CRS identified, 11,000 were born deaf, 3,500 were blind and about 1,800 suffered intellectual disabilities.

Varicella (chickenpox), another annoying but potentially dangerous childhood infection, is caused by the varicella zoster virus (VZV). It produces small blisters that eventually turn into scabs. Complications include skin infections from open blisters, pneumonia, encephalitis, bleeding and sepsis. There were over four million infections and around 100 deaths annually before a vaccine was released in 1995. Shingles (postherpetic neuralgia) is a painful re-activation of VZV along nerve paths.

MMR/MMRV: In 1963 inactivated and live attenuated measles vaccines were released in the US.  The inactivated vaccine didn’t offer sufficient protection and was discontinued in 1967. The live attenuated vaccine caused fever and rash in recipients and was withdrawn in 1975. A combined measles, mumps, and rubella vaccine (MMR) was released in 1971; varicella was added (MMRV) in 2005.

Zostavax, a live, attenuated vaccine to prevent shingles, was released in 2006. Shingrix, a recombinant, adjuvanted zoster vaccine, was released in 2017, replacing Zostavax in November, 2020.

I had chickenpox, because DPT, polio and smallpox were the only available vaccines at the time. When a neighborhood kid developed chickenpox, other mothers would send their kids to a “chickenpox party.” We’d pass around a contaminated drinking glass to contract chickenpox and “get it over with.” Some parents still engage in the practice despite having a vaccine, thinking “natural” immunity is preferable.

I also had all the other childhood viral illnesses – measles, rubella and mumps. When I developed mumps, my mother chastised me for any activity, saying “You’ll be sorry if it goes down on you!” She was talking about mumps orchitis (painful testicular swelling from the mumps virus that can lead to shrunken testicles and, rarely, infertility) but I had no idea what she was talking about and she didn’t bother to explain. That I have three kids indicates no apparent gonadal damage.

MORBIDITY AND MORTALITY
BEFORE AND AFTER
VACCINE DEVELOPMENT

Other communicable diseases and vaccines

Hepatitis A, formerly “infectious hepatitis,” is an acute liver infection caused by the Hepatitis A virus (HAV). It is acquired by ingesting virus passed through feces, usually from contaminated food or water. It causes fever, nausea, abdominal pain, jaundice, and dark urine. Complications are rare but infection can lead to acute kidney failure as well as hemolytic and aplastic anemias. Fulminant hepatitis, which leads to liver tissue destruction, is rare and has a death rate of up to 80%.

A vaccine against HAV was released in 1996 and infection rates declined until 2016. The US has struggled with a Hepatitis A outbreak which began in 2016 and was linked to person-to person contact (drug use and homelessness) rather than contamination. There have been 37,121 cases reported across 35 states with 348 deaths as of December 18, 2020.

Hepatitis B, formerly “serum hepatitis,”is an acute liver infection caused by the Hepatitis B virus (HBV). It is acquired through

  • unprotected sex with an infected individual
  • sharing drug paraphernalia or personal items
  • tattooing with unsterile equipment
  • passed from pregnant mother to fetus
  • human bites

Signs and symptoms are the same as for HAV; however, about 50% of infected people may have no symptoms. Complications are similar to those of HAV; about 200-300 people die of fulminant hepatitis each year. A vaccine was released in 1986. It is recommended for all newborns and anyone not previously vaccinated.

There are about 800,000 to 1.4 million people in the US with chronic hepatitis with and additional ,5000-8,000 becoming chronically infected every year. Most annual deaths linked to HBV are due to the consequences of chronic infection: cirrhosis (3,000-4,000) and liver cancer (1,000-1500).

Hepatitis C, D and E are forms of viral hepatitis caused by Hepatitis C (HCV), Hepatitis D (HDV)and Hepatitis E (EV) viruses. There are no vaccines for these three viruses. HCV can be treated (the Hep C medication for which its creators incessantly run commercials costs $94,000) but there are none for HDV and HEV. HEV infection usually resolves spontaneously.

Employers often require healthcare workers to provide evidence of immunity to HBV and other communicable diseases prior to employment. I got the HBV vaccine in the early 1990s

Haemophilus Influenza type b (Hib) is a bacterium, not a virus. It primarily infects infants and children under 5 years, and can cause meningitis, pneumonia, bacteremia (bacteria in the blood), and epiglottitis, a potentially life-threatening swelling of the epiglottis. There were about 20,000 cases of Hib and 1,000 deaths annually before a vaccine was released. The polysaccharide vaccine released in 1985 did not work well in children under 2 years and was replaced with conjugate vaccines in 1987.

I recently got my first COVID vaccination; I’m a healthcare worker who still has contact with mostly older people. I expect there will be more adverse reactions reported as there’s a big difference between several thousand people in a vaccine trial and tens of millions of people being vaccinated.

None of us should want to live in a world in which easily preventable diseases with significant morbidity and mortality run rampant because we no longer have sufficient herd immunity.

Featured Image © Can Stock Photo / joloei

The Prostate Saga – Rehab

7 Replies

WARNING: This post contains material of a sensitive and sexual nature. If you are easily embarrassed or squeamish, you might want to sit this one out.

I saw the Urology Department Physician Assistant the week after my surgery to take out my catheter. She gave me a prescription for 50mg sildenafil (generic Viagra) tablets and told me to take a half tablet every night “to keep the blood flowing” – a prophylactic Roto-Rooter®. I made an appointment with her and the Vacuum Erection Device Clinic for January as “the December clinic had already passed.” I was supposed to talk with the clinic about acquiring a “medically approved” vacuum erection device in January, but I pushed to get it ordered in December since they run upwards of three hundred bucks and I’d met my deductible for the year.

I got a mysterious text message from FedEx alerting me to a delivery from upcrx.com that required my signature. Often “signature required” means either someone is sending alcohol, or the IRS wants to do an audit. Google helped me find University Compounding Pharmacy in San Diego but did nothing to alleviate my confusion.

The package arrived the following week. I scrawled my name on the driver’s tablet and I now possessed my very own prescription “Austin Powers Swedish Penis Enlarger.” I wasn’t supposed to use it until after my postoperative appointment in January, and then only “under medical supervision,” lest I somehow injure myself.

I had an appointment in January with Dr. Fine for a postoperative visit. The PSA level I’d had drawn the previous week was undetectable; I’d get a PSA level done every three months for a year, then every six months if all went well.

He asked about my recovery.

“It’s going fine. The big incision burned every time I moved but that went away in a week and I used the Norco maybe three times. I got by on Tylenol. And I’m back to my pre-surgical level of incontinence.”

His eyes lit up!

“You should really see one of the pelvic physical therapists. There are a couple of people who specialize in male incontinence therapy.”

“I’m fine.”

“You really should consider it; nip it in the bud right now.”

(Like I have the time or inclination to have some dude teach me Kegel exercises, which I’d taught women for decades.)

“Ok, I’ll give them a call.” (No, I won’t.)

Many physicians are hardwired to offer as many labs, procedures, and referrals as possible. That is probably why sleep studies have been such a standard for anyone who is fat, diabetic, hypertensive, and/or chronically tired. He gave me the phone number which I tossed into the trash on my way to the car.

It’s been seven months since surgery; I don’t wear underwear shields anymore and the urgency is almost nonexistent. I may not be able to write my name in the snow but it no longer feels like I’m trying to urinate through a urethra in a death grip.

The following week I saw the P.A.  She had asked me to come in early because she had to go somewhere. Today she was a little frantic and hurried through her instructions.

“You’ll be talking to Jonathan about the vacuum. Stop taking the Viagra while you are using it. Try the Viagra after a couple of weeks. If you don’t see any results after several tries, it’s time to open this little white bag and take the pill that’s in there. If you’re still not getting any results after 2 months, you need to come see me. Here’s an instruction sheet. Now I have to go…”

My next stop was the pretentiously named Vacuum Erection Device Clinic. I figured I’d be in a classroom with several other men discussing our surgical recovery, led by a physician in the requisite white coat giving us a talk on the mechanism of tumescence and how our recent surgery had interfered with function.

Instead, I went to another room and met with the “physician liaison” (read: equipment rep).

“I’ll need to order your device and when it comes in, we can talk about how to use it.”

“Uh, I got it last month.”

“Ok, then. Here’s what you do. Put it over your penis. Pump the vacuum for five or ten seconds, then wait forty-five seconds. Release the vacuum, wait a minute, and then pump it again for five to ten seconds and wait forty-five seconds. Do that for 10 minutes a day. If you have any questions, here’s my card.”

I wasted an afternoon for this?

How an erection works.

The cross-section of the penis looks like a cartoon monkey face. The shaft of the penis contains two spongy cylinders, the corpus cavernosum; a sizeable artery runs through each. A vein flanked on each side by an artery and a nerve runs above the corpus cavernosum. All this is surrounded by a layer of fascia, like a hot dog casing. A third spongy tube, the corpus spongiosum, surrounds the urethra and runs the length of the shaft below the corpus cavernosum while the dorsal penile vein runs the length of the shaft on top. All this is enclosed in loose tissue and covered by thin, flexible skin.

The arteries in the corpus cavernosum normally aren’t fully open, which is why men don’t have permanent erections. When the brain is stimulated, a combination of nerve impulses and chemical signals open the arteries which fill the corpus cavernosum with blood. The engorged tissue presses on the veins, blocking return blood flow and, voilà, an erection is born.

It’s been suggested that men hit their sexual peaks at 18 and it’s downhill after that. Research, however, shows men’s testosterone levels peak in their 30s before gradually declining. Getting an embarrassing, spontaneous erection for no apparent reason disappeared by my late teens.  Sexual function can decline as early as one’s 40s; I started noticing a difference in my late 40s. Other things can affect sexual drive and function besides purely aging:

The nerve bundles required for achieving an erection are often damaged during a radical prostatectomy. Scarring around my prostate required taking out the neurovascular bundle on the right side. The left side was spared but the trauma from surgery is enough to keep the remaining nerves from doing their job. It may take up to two years before being able to achieve an erection with or without ED drugs. If that doesn’t work, the alternatives are injections into the penis or penile implants.

This is my device. It has both battery-operated and manual vacuum pumps which attach to an acrylic cylinder. There are five silicone rings (sizes 5 to 9); the cone is used to slip a ring onto the other end of the cylinder. The ring ejector twists to push the ring onto the penis before removing the cylinder to maintain the erection. The body shield is that circular thing resembling a old-fashioned floppy disk drive and provides a barrier to prevent scrotal skin from being sucked into the pump. The gel is used to form a seal around the base of the pump and to lubricate the penis; without it the penis will drag along the cylinder wall like an anchor on concrete.

Note to self: make sure to grab the correct white squeeze tube: the lubricating gel tube, not the menthol gel I use on sore muscles.

The Vacuum Erection Device, aka the “Austin Powers Swedish Penis Enlarger”

The caveats in the instruction manual were disturbing.

“Vacuum therapy may cause a small “blood blister” on the head of your penis. This is normal and not harmful.”

“The rings may bruise the base of your penis. Some bruising is normal and should not be cause for alarm.”

Wait, what? In what alternative universe is a bruised and blistered penis “normal?”

“If you wear a ring for more than 30 minutes, you may severely bruise or damage your penis.”

So, if that happens, do I just get a new one from Amazon with 2-day Prime delivery?

I looked over the instruction sheet I’d gotten from the P.A.

You were given samples of ED medication to try at your leisure. Please use the paper form you were given (to) track your response and side effects of each medication. The goal is for you to try one tablet every 3rd day followed by (significant) stimulation.

  • Tablets work better on an empty stomach
  • Tablets take one hour to become effective
  • Space out your trials by 2-3 days at the minimum

If tablets do not work, you may still have intercourse with the vacuum rubber bands.

Common side effects – headache, facial flushing, nasal congestion

If you are on Cialis and are experiencing leg cramps – Please stop Cialis immediately as Cialis can sometimes be linked to tendon inflammation, possible rupture.

Oh, goody!

I discovered the vacuum doesn’t work immediately, which was disappointing. One cannot hope to instantly inflate the penis like a balloon that a clown twists into animal shapes for kids at a party. At first it took fifteen minutes to achieve anything resembling an erection, which decreased to around five minutes after three months. The least they could do is make pumps entertaining with indicator lights and an alarm that goes off when one has reached maximum height (or is it length?).

Anyone who played with a vacuum cleaner hose as a kid knows it can inflict some pain if left on a body part for too long. Moving blood into a penis with negative pressure is an uncomfortable process and certainly not erotic. And few things are worse than having a large chunk of scrotal tissue suddenly sucked into the cylinder along with a testicle. The barrier did not help at all; it was too flexible and got drawn in as well.

It didn’t take long for one of the rings to break and the replacements cost twenty bucks each. I ordered a different kind of ring that looked like a flat, silicone bagel (the penis goes through the hole and the surrounding material blocks wandering skin, but it was for a rival brand and didn’t fit my pump. I found another type that looked more like a foam-lined chip clip (or a cigar cutter). I settled on a silicone loop I bought from Amazon.

The battery pump died after a month. The company said they’d send a replacement which never arrived, and I don’t feel like calling them again. The manual pump is equally effective but using it leads to spasms in my right thumb and pain in my right wrist, caused by old nerve damage from two separate lacerations. The recommended forty-five seconds on, one minute off did nothing, even after multiple attempts over three weeks. I finally just pumped and left the vacuum on for several minutes while amusing myself with my Kindle game. (I may not have sexual function, but at least I’m doing my part to delay age-related dementia!) My erections promptly deflated as soon as I released the vacuum, despite the ring. There was never sufficient rigidity to close off the penile veins.

I then tried using 100mg sildenafil without the pump or any kind of stimulation. I got a slight flush but nothing. A few days later I made another attempt. I got distracted doing other things but applied the pump three hours after I took it. I got a reasonable erection which again deflated after taking off the pump and using the loop. I tried the pump again and then manual stimulation which made it last a little longer but still wasn’t anything to write home about. And all this took about 25 minutes, not including the minimum one hour wait for the drug to take effect.

George Burns said, ““Sex at age 90 is like trying to shoot pool with a rope.”

But all is not lost. Men can have orgasms without an erection, although it may take some mental adjustment. If you’re a New Ager into Tantra (and you have a lot of patience), you can have an orgasm using just your mind. Radical prostatectomy removes the prostate and seminal vesicles, meaning there’s no more semen, along with the sphincter between the urethra and the prostate, which normally prevents retrograde ejaculation (semen going into the bladder instead of out the penis). The result is climacturia, the release of urine with orgasm and a common side effect of the surgery. One can prevent this with an adjustable loop around the penis, muscle training or surgery, but emptying the bladder beforehand is the simplest.

More information than you ever wanted to know, eh?

Finally, nothing is more important during post-prostatectomy rehabilitation than a loving and supportive partner. Peg says she would rather have me alive and annoying than six feet under, and for that I am grateful.

Monkey illustration © Can Stock Photo / yayayoyo

(ALMOST) EVERYTHING YOU SHOULD KNOW ABOUT COVID-19

6 Replies

There is a lot of misinformation and bad advice circulating regarding the COVID-19 pandemic. I’ve tried to provide pertinent and useful information in this blog post. But before I begin, I want you to do two things:

DON’T PANIC
DON’T BE STUPID

Panicking in a crisis does no one any earthly good and often makes things worse. This is not the zombie apocalypse, Outbreak, The Stand, Contagion or The Walking Dead. It’s not even The Hot Zone, a book and miniseries based on the discovery of an non-human primate Ebola virus in Reston, VA in 1989.

We can get through this by helping each other, not by being a selfish asshole hoarding toilet paper, or going out to restaurants because Devin Nunes told you to. Follow current recommendations and guidelines to minimize the risk of getting it or giving it to someone who is at greater risk of dying.

Now, back to our previously scheduled PSA

What is Coronavirus?
Coronavirus is a family of RNA viruses – chunks of genetic material in a protein capsule – that infect human respiratory tracts. Coronavirus, like the more well-known rhinovirus, respiratory syncytial virus (RSV) and parainfluenza, often cause nothing more than a common cold.  It is so named because there are spikes on the surface that make it look like a solar corona. Click here to see an electron micrograph.

Where did it come from?
Coronaviruses are “zoonotic” – transferred from animals to humans. Bats provide a reservoir for coronaviruses and spread them to other animals. SARS was thought to come from civet cats in Guangdong, China, while MERS was transmitted by dromedary camels in the Arabian peninsula before spreading to other countries. (MERS resurfaced in Saudi Arabia in October 2019.) SARS-CoV-2 might have originated from an outdoor wet market in Wuhan, China. Neither the Chinese nor the United States developed it as a bioweapon.

How is it spread?
Coronavirus, like other respiratory viruses, spreads among people through droplets from coughing or sneezing which are then inhaled. It can also spread when hands contaminated with virus touch eyes or nose, or someone else’s hands.

The incubation period (time from contact to developing symptoms) is 5-7 days but can be as long as 14 days, the rationale for a 2-week quarantine. People who carry the virus can spread it even though they feel fine. Health officials estimated a lawyer with COVID-19 in New Rochelle, NY, had contact with 50 people before becoming ill.

No one is sure how long the virus survives on surfaces like countertops, handrails and boxes, although study results published in the New England Journal of Medicine on March 17, 2020 found coronavirus lasts longer on plastic and stainless steel than on copper and cardboard. When in doubt, wear gloves and wipe it off!

VIDEO: Amanpour & Co. Infectious Disease Expert Dr. W. Ian Lipkin Discusses How Coronavirus Spreads

If coronavirus is common, why should I worry?
Viruses, like bacteria, can mutate into more deadly forms. The virus causing the current disease, COVID-19, is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Yes SARS (Severe Acute Respiratory Syndrome 2003) and MERS (Middle Eastern Respiratory Syndrome (2012) were both “novel human coronaviruses,” meaning they hadn’t been seen in humans.  The difference between coronavirus causing a cold and SARS-CoV-2 is like the difference between the E. coli in your intestine and E. coli O157:H7. The former keeps your digestive tract healthy while the latter caused severe illnesses and deaths in people eating contaminated hamburger (1993), “organic” spinach (2006) and Romaine lettuce (2019).

Isn’t it just like getting influenza?
There have been an estimated 34 million influenza infections in the United States over the six-month 2019-2020 season with 375,000 hospitalizations and 22,000 deaths. But we have a vaccine and herd immunity for influenza, so the death rate is about 0.06%. There is no vaccine for COVID-19 and there won’t be one for 18 months or more. COVID-19 is more likely to kill people over 60, those with chronic illnesses (diabetes, asthma/COPD, heart or chronic kidney disease), and anyone with compromised immune systems (cancer, HIV, genetic disorders), regardless of age. The youngest death was a 21-year-old Spanish soccer player with undiagnosed leukemia and coronavirus.

As of March 17, 2020, there have been 197,320 cases of coronavirus and 7,950 deaths around the world. (Source: Worldometer Live Update-Coronavirus) That doesn’t sound like much until you do the math, which gives you a death rate of 4%. The New York Times reported C.D.C.’s worst case scenario:

“…Between 160 million and 214 million people in the United States could be infected over the course of the epidemic, according to a projection that encompasses the range of the four scenarios. That could last months or even over a year, with infections concentrated in shorter periods, staggered across time in different communities, experts said. As many as 200,000 to 1.7 million people could die….”

Take a deep breath and don’t panic. England got through WWII with “Keep Calm and Carry On,” not, “OMG, it’s the apocalypse and I’m going to run out of toilet paper!”

Related: USA Today What does the coronavirus do to your body?

How do I keep from getting COVID-19?

  1. Wash your hands, often! Wash them for 20 seconds, the time it takes to sing “Happy Birthday” twice or recite the Star Trek intro. Hot water isn’t more effective than cold or warm water, so don’t scald yourself.
  2. Use hand sanitizer if you’re out and don’t have soap. Antibacterial wipes are good for public surfaces (shopping carts, handrails).
  3. Don’t touch your face. That is going to be really hard for most people. Cajun hand sanitizer will make you remember not to touch your face!
  4. Although it’s better than using your hand, I don’t think coughing or sneezing into your elbow is a great idea. Get a small pack of tissues or stuff some in a zip-lock bag and keep them handy when out. Use them and toss them in the trash. And use hand sanitizer afterwards.
  5. Stay away from crowded places like subways, commuter trains and airplanes unless absolutely necessary. Many businesses are making their employees work from home.

If you need catchy music to grab your attention, then watch this Vietnamese PSA.

Should I wear a mask?
In general, no. Regular surgical masks stop droplets, which is helpful but won’t filter out viruses. If you are healthy and out in public, you don’t need one. N 95 respirators, masks that can block 95% of particles down to 0.3 microns, are used by people exposed to dust and other small particles. Health care N-95 respirators are a subset, specifically for health care workers. They need to be fitted to be effective and are a bitch to breathe through.

You should wear a mask if:

  • You are a health care worker.
  • You are coughing or sneezing.
  • You are sick and need to leave the house
  • You are sick and can’t isolate yourself from healthy housemates

Why should we practice “social distancing?”
Because health officials want to avoid an exponential increase in coronavirus cases by “flattening the curve.”  (If you don’t understand exponents, you weren’t paying attention in algebra class and I don’t have time to explain them! Just think “increasing really fast.”) We don’t want a lot of people getting sick in a short period of time and overwhelming the health care system. It is better to spread out those illnesses over many weeks or months.

Protecting the vulnerable – those who are elderly or have compromised immune systems – is the single best reason for keeping your distance from other people.

How is COVID-19 treated?
Like any other viral illness there is NO cure. One treats the symptoms whether cough, fever or full-blown respiratory failure requiring mechanical ventilation. Influenza is often treated with oseltamivir, which shortens recovery by 1 to 2 days. Remdesivir, created from a molecule developed ten years ago, may be the best drug to treat COVID-19, but it’s only in the testing stage and it isn’t a cure.

Eating garlic, drinking bleach or colloidal silver, breathing hot air from your hair dryer, taking Vitamin C or zinc, snorting cocaine or masturbating will not protect you from COVID-19.

Related: Buzzfeed News list of coronavirus hoaxes

What should I do if I feel sick?
If you just feel crappy with mild to moderate viral symptoms – cough, fever, aching – call your healthcare provider. DO NOT go to the Emergency Room without being told to!  They don’t want to see your sorry ass for something that is not life-threatening and will just have to run its course.

However, if you are having chest pain or enough difficulty breathing that your lips are turning blue, or you feel as if you are drowning, GO TO THE EMERGENCY ROOM IMMEDIATELY!

Should I be tested?
Not unless a qualified healthcare worker thinks you need to be tested. There aren’t enough tests right now.

Where should I go for information?

  1. The Centers for Disease Control
  2. Your state’s Departments of Public Health
  3. Harvard Medical School’s Coronavirus Resource Center

DON’T PANIC. DON’T BE STUPID. BE CAREFUL.

Coronavirus illustration © Can Stock Photo / feelartphoto