Musings on Medicine and Life

“I am a surgeon. It is what I do.”

It is early Sunday morning, traditionally a day of rest for everyone. I am up and about, soon to head to the hospital to amputate a gangrenous finger on the hand of an unfortunate individual with end-stage kidney failure due to diabetes that is poorly controlled. This is not the scenario most people envision when they think of plastic surgery. I am surprised to feel mildly excited, looking forward to surgery. On reflection, I think, this is weird. Am I abnormal? How can I revel in such a sad situation?

I make my living performing surgery, so one could rightly say that I have a vested interest in people getting sick and needing surgery, or simply wanting surgery for some other reason, so that I can make a living. This particular accusation has been leveled at doctors and the entire medical profession by those who believe there is a financial incentive in all that doctors do. Many are advocates of alternative medical therapies. They fail to see the hypocrisy of claiming that traditional doctors have a profit motive as their primary imperative when they profit from their own alternative/non-traditional therapies as well.

Medical practice is not simply caring for simple, common problems.

There has been a strong and largely successful push by advanced practice nurse practitioners (NPs) and physicians assistant (PAs) to practice autonomously as primary care providers. The Florida legislature recently granted advance practice nurse practitioners license to practice independently https://www.usnews.com/news/best-states/florida/articles/2020-03-11/florida-oks-independent-practice-for-nurse-practitioners. That term, “provider”, has replaced the original, which was “physician”. NPs and PAs have now been elevated from their original designation as mid-level providers of care to acknowledge their more limited education and clinical experience, while primary care physicians have been demoted so that they are now lumped in with mid-levels as “providers.” Many patients do not know the difference and commonly refer to NPs and PAs as their “doctor”.

“Absent an effective treatment or vaccine, and knowing that we cannot stay locked down indefinitely, our only hope for dealing with this virus is to turn to the most effective anti-virus agent known to man: a healthy immune system.”

I have no illusions about the Wuhan Virus, aka SARS-CoV-2. It is a dangerous beast to be taken seriously. What does that mean, exactly? When we speak of containment, mitigation, flattening the curve, what are we really referring to?

Let me say up front that it is a terrible thing and too many have died. For them and those they have left behind, we can only offer our prayers and condolences, and a promise to try to do better. With that said, how do we do better? As a physician, admittedly not an expert in public health, an epidemiologist, or an expert on viral pandemics, I have some observations and opinions. Take them from someone who has been in medicine for over 40 years. I am a plastic surgeon, yes, but first and foremost, I am a medical doctor.

A transplant patient enters the hospital for a problem unrelated to the Wuhan virus. While there, he develops a complication and is wisked to the transplant unit. Because of Covid-19, his wife and family are not permitted to visit him even though none of them is ill. All encounters are electronic. They never see, touch, or hug him again as he passes away in total isolation because he had the bad luck of getting sick during the Wuhan virus hysteria and the hospital’s no visitation policy in response to prevent spread of the Wuhan virus. No exceptions, even for a dying man.

An elderly pastor has a terrible motorcycle accident and is airlifted to the neurosurgical ICU at Level 1 trauma center. The weeks pass and he shows slow, but steady improvement. He is transferred to a specialty care outpatient facility to continue his recovery. While in the hospital, although he is critically injured, only one person, his elderly wife, can visit him briefly. His daughter must stay outside the hospital. At the outpatient specialty facility, no one can visit him. They must peer in through an outside window or communicate via a nurse holding a cell phone or tablet. The family watches a steady stream of staff, workers, delivery people, maintenance personnel, and other enter and leave the building every day, while they cannot see their husband/father/grandfather.

At my office and going around town, I see a lot of people wearing masks. A lot of confusion exists about whether and how to wear a mask. As someone who has worn surgical masks for over 40 years, I guess I have some authority to comment on this “new normal” (I hate that term!).

In normal use, surgical masks are supposed to protect the patient from bacterial contamination by the surgical team. Masks are only worn by patients when it is known they carry a highly communicable disease. In practice, mask wear is all over the place. I wear mine snugly, in part because, if I don’t, my glasses fog up. Anesthetists/anesthesiologists and nurses on the surgical wards are especially bad at mask wear. They wear them too loose, improperly tied, under versus over the nose, etc. Although I have worn masks for forty years, I don’t like them and take mine off as soon as I can.

The N95 mask that everyone talks about, because it is so effective in filtering out viruses, is awful. It is claustrophobic, stifling, and difficult to breathe through. I wore one in surgery, once. Never again. I also found that I could not understand people wearing these. Their words came out muffled. It made me concerned about what would happen in an emergency, when clear communication is crucial.

Coming soon to a medical office near you…….

Dr. Mayo: “Mr. Smith, I am afraid I have some bad news.”

Smith: “Oh, no, doc. Is it about my blood tests?”

Dr. Mayo: “’Fraid so. Your blood test shows you have colon cancer.”

Smith (with trembling lips): “Doc, are you sure?”

Dr. Mayo: “Well, there is a 30% false positive rate.”

Smith (hopefully): “Gosh, doc. That’s good, right? It could be wrong. What happens now? Will you repeat the test?”

Dr. Mayo: “No. I have you scheduled for colon surgery.”

Smith (in disbelief): “But, doc. Why not repeat it first?”

Dr. Mayo: “Well, it won’t be any more accurate than the first one. And, besides, we just can’t go around repeating tests on everyone. There aren’t enough to go around, and they’re expensive. Hey, remember, you have a 70% chance that the test is right. Those are pretty good odds.”

Smith: “How can you expect me to do something this radical based on a 70% chance of being right?”

Dr. Mayo: “Hey, nothing in medicine is 100%.”

Smith: “I can’t believe this. You said I had no risk factors. I don’t have any symptoms. This was supposed to be just a screening. How will you know what part of my colon to remove?”

Dr. Mayo: “That’s just it. We don’t, so we’ll just have to take the whole thing out. Don’t worry, people live perfectly normal lives with colostomies.”

Smith: “No! Doc, this is crazy. I can’t turn my life upside down like this. I have a business, employees, a family. They depend on me.”

Dr. Mayo: “Mr. Smith, that is a very selfish, irresponsible attitude. I am only acting in your best interest. Think of all the people who will be negatively impacted if we don’t do this- the operating room nurses, the laboratory personnel, the pathologist, the hospital administrators, the housekeeping crew, and many others. Think of the ripple effect.”

Smith (sheepishly): “When you put it that way, doc, let’s do it!”

Dr. Mayo: “Great! Now, let’s look at your insurance coverage. By the way, do you have any friends who want to be screened for colon cancer?”

(Current tests for the SARS-CoV-2 virus are currently giving a 30% false positive results. Turnaround times for screening are as long as two weeks, which is about as long as most authorities allow that this valid to show someone might not be infectious. Someone needs to tell the virus it is not allowed to infect anyone during that two week window)

“Social distancing and shelter-in-place must end immediately, not tomorrow or next week.. Now. Not phased in. Fully and immediately.”

The discussion is endless and contentious. The questions are many, and and so are the answers. Has social distancing helped the cause in fighting SARS-Cov-19, hereafter referred to as CV-19 for simplicity? Does shelter-in-place work? When can we lift these restrictions? Should they be  lifted right away or gradually and, if the latter, over what time frame? How many people have been infected? Do we develop immunity by being infected? How long does immunity last? What is the true death rate? The list of questions goes on.

There are some points of agreement even among those divided by a wide gulf of opinion. The virus came out of Wuhan, China and spread so rapidly because the Chinese communist government deliberately misled the WHO and the world; on this there is remarkable unanimity of agreement worldwide. It is as contagious, if not more so, than seasonal flu. It hits the respiratory system particularly severely. It is mild to asymptomatic in close to 100 percent of children and young adults, and over 95% of most adults under 60, with infection fatality rates falling almost daily. Even in the most vulnerable age group, those over 80 years, the case fatality rate (deaths among those who are actually ill) is a relatively low 15% at most. We do not yet know the most important number, the infection fatality rate (deaths among those who have been infected with the virus).  This will tell us how bad CV-19 is compared to seasonal flu, the virus it is most often compared to in terms of danger.

This is a long post and I don’t want to make it longer than necessary. Dr. Williams is a family practitioner in Bessemer, AL. Below is his follow to his original post. You can find that post at: https://coronavirustruths.godaddysites.com/ . I encourage you to read this through. Do your own research. Make up your own mind. What we are doing does not make sense with this continued lockdown of our nation.

By David Williams, MD

On April 19, 2020 I authored a paper titled, “The Truth (and Lies) about Coronavirus.”  It was revised to a final version on April 23.  If you have not read it, it is readily available through a link from the Tide Wellness Facebook page or on Rock 103’s website in Memphis.  If you read the original, please go back and read the revision and addendum.

I referenced coauthors in the original, but there are no coauthors on this paper.  It is simply too personal.  In almost 25 years of clinical practice I have treated thousands of patients with infectious diseases.  I have worked in primary care, urgent care clinics, and emergency rooms.  I have cared for the elderly and immunocompromised in nursing homes and at the VA.  I have provided for the disadvantaged while supervising a rural health clinic.  However, this could have been written by a journalist, football coach, or hairdresser and it would not affect the truth.  If this becomes Dr. Williams vs Fauci vs CNN vs Trump no one wins.  American citizens have historically been smart enough to reach their own conclusions without relying on what I say or anyone else says.  We don’t have to live in a society that bases its belief system on what someone else says, what network they are on, or what party they are affiliated with.  We are better than that.  This doesn’t need to be a war between talking heads where people take sides.  The fact this debate has been politicized and sensationalized is not helping us.  In fact, that’s exactly why we are in this situation now.  I am merely attempting to present the basic facts. 

It is very easy to compare COVID-19 and influenza.  Anyone can do that.  It is easy to see how the number of deaths attributed to a disease can and will be impacted by directives to modify what goes on a death certificate.  It doesn’t take a rocket scientist or immunologist to understand our current policies are leading to both a greater negative health impact than the virus ever will, but also an economic depression we shouldn’t have to face.

This is my imperfect attempt to put into words my current thoughts and feelings regarding this entire Covid-19 situation. Today, after more than five weeks of sheltering-in-place, social distancing, and being prohibited by the powers-that-be from practicing my profession, I thought I would be delighted at the welcome news that the governor has given the go ahead to resume elective surgery on May 4. Instead, I find myself angry and sick at heart. Having no better appropriate outlet for my anger- going into a quiet corner somewhere and shouting obscenities at nobody doesn’t seem productive- I am sitting here writing down some thoughts. I will go over this later and see if any of it is worth sharing otherwise it will never see the light of day.

I see a world I no longer recognize. It is a world in which there appears to be a deliberate campaign of disinformation and misinformation the purpose of which, more than anything else, seems to be to instill and maintain an atmosphere of unreasonable fear. The underlying purpose of this is still unclear. I think we have long passed the point where we can justify the current situation on the basis of public health. The American people have accepted almost without question a degree of government encroachment of their personal liberties which would have been impossible without the fear factor. We have permitted the Federal, state, and even local city governments to tell us we cannot leave our homes, we cannot keep our businesses open, and we cannot gather in other than tiny groups. A population of 300 million people has allowed itself to be quarantined and a trillion dollar economy has been shutdown, without a timetable or any inkling of the possible repercussions, for the first time in our history. All this because of fear. Fear of a virus about which we admittedly do not know everything, which is not to say that we do not know a lot about it.  

It is stating the obvious to describe that many, if not most, of the population of the US are in a state of anxiety, some in fear, and a few even panicked regarding Covid-19. I think that much of this is due to a misunderstanding that we are defenseless against SARS-CoV-2, the virus that causes the illness we call Covid-19, and some still refer to by its place of origin, China. We are not and here is why.

It is critical to understand that we live in a world invisible to our senses that is teeming with bacteria, viruses, and fungi. Some of these are beneficial, in fact essential, to our health and well-being. Others are actually or potentially pathogenic (disease-causing). The fact that most of us do not succumb to these early in life is ample confirmation that we are not defenseless. The reason is our immune system.

The cells, organs, and processes that, in sum, make up are immune system are arguably the least understood aspect of the human body. The complexity is staggering. I will attempt a very basic explanation of how it works in the case of SARS-CoV-2. Hopefully, this will help to understand how you can protect yourself and reduce some of the fear this epidemic has created.