itakecareofsickpeople

[itakecareofsickpeople]

What now?

Ok. So you got COVID.

I have come to believe all of us will get COVID. The reason I am a major advocate for vaccines is because once you show up at my door, it doesn’t matter what you got before you came to me.

I think that Johns Hopkins does the best job at producing real-time, fact-based guidelines. They have always been a major resource for infectious disease management and produce the Hopkins Antibiotic Guide, the essential source for infectious disease management. They have remained a go-to for me to get up-to-date information about current and future COVID therapies. Here is a link to their COVID recommendations. It is much more complete and accurate than I would ever hope to be. You can read this one page and learn more than most people know about COVID. I highly recommend it.

https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540747/all/Coronavirus_COVID_19__SARS_CoV_2_

https://www.hopkinsguides.com/hopkins/ub?cmd=repview&type=479-1206&name=26_538747_PDF

I will not go through all of the symptoms of COVID or the risk factors for severe disease.

If you think you may have COVID, isolate. If you aren’t wearing a mask, put one on until you are in your room at home. Even with a mask, avoid any poorly ventilated areas with other people (like elevators).

If you come to a hospital or doctor's office and think you have COVID, call ahead first. Tell them you think you have COVID, and they will tell you what to do.

Think of all the people with whom you’ve been in contact. Call them now. Don’t wait until you have a test.

In addition to COVID pneumonia, the SARS-Cov2 virus can cause blood clots, pulmonary embolisms, strokes, myocarditis (heart inflammation, both temporary and more severe), heart failure, temporary or more severe cognitive impairment, and other major medical problems. Kids and adults can get Multi-System Inflammatory Syndrome, a disease that could be fatal without treatment.

When you are infected with COVID, you may get a mild disease or a severe disease. That is determined by a few different factors.

First, immunity. If you have antibodies through vaccination or previous infection, your body will recognize the virus and will start making specialized T cells that are covered with antibodies to the virus. They grab it up and keep it from infecting more cells.

Second, inoculation load. If you only inhale a small amount of virus, your body will have more time to respond to the virus before it can replicate. This is true whether you are vaccinated or unvaccinated.

Third, viral replication. The biggest difference between Delta and Alpha is the viral replication. We think Delta makes 1000 times more virus than Alpha. This makes it more infective, and I think that also makes it more deadly.

Fourth, ACE-2 receptor density. The SARS-Cov2 virus attaches to the ACE-2 receptor, and every human has the ACE-2 receptor in their respiratory epithelium, the surface of their lungs, throat and nasal cavity. The more ACE-2 you have, the easier the virus can infect. As you get older, the ACE-2 receptor density in your lungs goes up. Children don’t have as much ACE-2, so they are harder to infect and don’t get as sick. Things like obesity, diabetes, and high blood pressure are associated with higher ACE-2 receptor density. Remember, even if you have less ACE-2 receptor, you can still get sick if you get a big inoculation and Delta is really good at inoculation.

Fourth, immune response. Some people are more likely to develop a big immune response. I personally usually feel terrible when I get a viral infection or a vaccine. I’m sure a lot of you are the same.

Treatment

Treatment for COVID-19 falls into 3 categories: viral suppression, antibody mediation or neutralization, and immune modulation. Everything else is supportive care.

At the beginning of a SARS-Cov2 infection, the goal is to suppress and neutralize the virus. As the infection progresses, the medications for viral suppression become less effective and the goal is to treat the uncontrolled immune response our bodies may have to the SARS-Cov2 virus. This is what results in hospitalization and death.

Monoclonal antibodies are designer antibodies that can mimic your immune system and bind up the virus. If you have risk factors, two regimens have been authorized for early treatment of Covid.

Sotrovimab, a monoclonal antibody, has been shown to reduce risk of hospitalization or death by 85% (7% vs 1%). This medication has the best evidence I have seen at reducing your chance of getting really sick from Covid, but it’s intravenous only and a lot of people do not have access to an infusion site.

Casirivimab/imdevimab (REGN-COV2) is authorized for post-exposure prophylaxis and has been shown to reduce the development of covid by 82% compared to placebo in patients exposed to covid-19. It also appears to reduce the duration of illness in patients diagnosed with Covid.

Both of these therapies work better if given earlier in the course of the disease.

In order to get REGN-COV2 or Sotrovimab, you will have to find an infusion clinic. Here is a link to the HHS website that provides infusion clinic locations: https://protect-public.hhs.gov/pages/therapeutics-distribution

No other outpatient therapies have been shown to reduce progression of hospitalization or death in well-designed clinical trials.

Nutrition is very important in our patients and we round with a nutritionist every day. I generally give vitamins to all of my patients, but my patients have high degrees of malnutrition and I only use standard dosing. Vitamin D deficiencies are very common, so I check vitamin D levels and replace if needed. I am not aware of any well done studies showing vitamin supplementation reduces progression of disease in patients without vitamin deficiencies.

Inpatient therapies.

Remdisivir is the only antiviral authorized by the FDA for use, and it has been shown to reduce length of hospital stay in hospitalized patients who needed oxygen or were breathing fast. It appears that Remdisivir is more effective the sooner it is given.

Dexamethasone is a steroid that has been shown to reduce mortality in patients who need oxygen. It is likely that other corticosteriods have similar benefit, and I do not think the ideal dosage or length of therapy has been determined. Steroids are the mainstay of therapy for patients admitted to the hospital. If they are given before patients need oxygen, they are associated with a worse outcome. In mechanically ventilated patients, they were shown to have a 35% reduction in mortality.

Tociluzimab is an immune modulator that is used to treat a reaction to lymphoma therapy. It has been shown to have a 3% reduction in mortality in patients who progress despite steroids.

Everything else we do in the hospital is supportive care and prevention of complications. Supportive care would include therapies as simple as oxygen or as complex as a ventilator. Patients can develop clots and we use blood thinners to prevent them. Sometimes, a patient can develop a secondary bacterial infection and require antibiotics. It is very important not to use antibiotics if you don’t have a bacterial infection as they promote bacterial resistance and can create drug-resistant bacteria.

PS: I take care of sick people. I am a critical care pulmonologist.

I appreciate all the feedback support for my posts. Thank you to all of you who got vaccinated because of my words.

I am starting a blog that will be focused on providing easy-to-understand explanations for complex medical problems. The medical system is complex and hard to navigate. Hopefully I can make that a little easier for people.

Eventually, I would like to have other doctors provide similar articles for patients in areas that they understand.

Please share and check out my blog.

https://itakecareofsickpeople.tumblr.com/

#itakecareofsickpeople #covidsucks #covid

Thanks to Stacey Jemison Torgerson and Denise Larrabee Adams for all the help and support.

[itakecareofsickpeople]

Why Do I Hate Ivermectin?

I was asked to do an article on ivermectin and I feel that it is important to understand the science behind ivermectin (and HCQ).  I think if you know the science, you will be as skeptical as I am.

I was once being quizzed by an Attending Physician when I was a resident.  I stuttered as I was answering and said, “I think…”  He stopped me mid-sentence and said, “Son, you are a second year internal medicine resident, I don’t give a shit what you think.  What do you know?”

You see, it really isn’t relevant to all of you what I think. You aren’t interested in my opinion.   You are reading this post because you are interested in what I know.  I don’t take anything at face value and I always read all of the studies that people are using as a reference to prove a point. The thing is, most “studies” aren’t worth the paper they are printed on and don’t actually “study” anything.  Worst thing is, sometimes it’s a fake.  

We all know about the faked anti-vaccine trial by Andrew Wakefield, the completely discredited, former doctor, who started the anti-vaccine movement by faking data on autism and vaccines. In case you didn’t, he faked the original anti-vaccine study and In 2010, the British General medical council found that Wakefield “had been dishonest in his research, had acted against his patients' best interests and mistreated developmentally delayed children.”  That’s right anti-vaxxers. That’s your start, one giant lie. 

I have read all of the studies that I will make reference to in this post and regrettably, every study I can find on ivermectin. As of now, I do not see any evidence that supports the use of ivermectin for Covid in humans outside of a clinical trial. Hey! That’s what the cdc says too….odd. 

In general, American doctors are snobby.  We want studies from Europe, Israel, Australia, Canada and the good ole USA.  We don’t want studies from countries with dictatorships or totalitarian regimes.  These countries have a long track record of producing fake studies and bad studies.  Countries such as China, Egypt, Iran, Iraq, Brazil, Venezuela, etc.  You know, the same governments that hack us and steel info from us, those ones.  It is in their governments interest to make all of their people think they have a treatment for covid, otherwise there would be revolts.  American doctors generally would never consider a study from Egypt as high quality, unless it was published in a very well respected journal.  There just isn’t any quality control.

The science behind HCQ is basically the same, except with ivermectin, a large clinical trial showing it helped, was all fake.  HCQ just didn’t work.  Lots of us used HCQ at the beginning of covid until real studies were done showing it didn’t work and may actually worsen outcomes.

Remember, most drugs are safe in normal doses, but toxic in doses outside of the “therapeutic window” that is the dose that both will have the desired effect, but also is safe and well tolerated.  Too little drug, it doesn’t work, too much drug, it causes toxicity. 

First, It is very important to test all drugs that are easily available for activity in covid.  This starts in a test tube. Ivermectin was approved in 1996 for the treatment of  strongyloides and hookworms.  In animal studies, it is lethal in overdose and causes toxicity at 10x the approved dose.  It also was found to be a teratogen (birth defects) and is not approved for use in pregnant women.  Otherwise, it is quite safe and effective in comparison to approved treatments of the time and was approved after being studied in about 1700 patients (half given ivermectin, half given old treatments).  It is widely available and is pretty safe (Except in pregnancy).

Ivermectin was found to have in vitro (test tube) activity against the SARS COV2 virus.  I know that sounds great, but remember what we said about the therapeutic window. It was shown, in the test tube, to inhibit activity of covid by 50% at a concentration of 2 μM (1,750 ng/mL), which is > 35× higher than the maximum plasma concentration (Cmax) of 0.05 µM (46.6 ng/mL) after oral administration of the approved dose (~ 200 μg/kg) and ivermectin showed little to no activity at 1 μM in vitro. 

Wait, so that means you would need 35 times the approved dose to inhibit covid and ivermectin is toxic at 10x the dose.  It also causes birth defects?  Count me out.

As you might imagine, based on this knowledge it is very hard for me to believe that you can safely dosed ivermectin could have any benefit for covid.  Now, on to the bad studies. 

Remember what I said about studies from certain countries?  

In November, an article from Egypt was published without review in an online site called Research Square.  Never heard of it? Me either?  It showed a 99% reduction in mortality.  Holy crap, that’s amazing, right?  Of course.  Despite it having such a completely unrealistic outcome, many doctors picked this up and ran with it.  In America, a group of doctors that named themselves the FLCCC, led by two guys named Paul Marik and Pierre Kory, latched on to this and started spouting its effects. I personally have a lot knowledge and not a lot of respect for Marik’s work predating covid. His FLCCC “treatment guidelines” have never been evidence based and in general he has never been able to publish studies that prove his claims.

So after this first study from Egypt comes out, a bunch of studies follow and are picked up by Marik’s group.  They did a “review” of them and included the Egyptian study. Most of the studies aren’t even reviewed and are published online as “preprint.” They are from Egypt, India, Iraq, Bangladesh, Pakistan, Peru, Nigeria, Mexico, and Argentina.  None of these places are exactly known for being in the 1st world and none of the other studies showed the massive effect as the Egyptian study.  

Then, a medical student in the UK is assigned the Egyptian study for a report. He actually reads the study.  It doesn’t make sense.  He then requests more information from the authors and they sent him the “patient data.”  It was clearly faked and he got some journalists involved.  After they involved an expert on faked studies, the study was then taken down from Research Square over “ethical concerns.”  Too bad Marik didn’t bother to do what the med student did.

Unfortunately, this has led to a massive amount of confusion.  If you think that there is a treatment for covid, you might not take the vaccine.  Even If it worked, we would be taking about a minimal effect.   Heck, it could even be toxic if you give it to that many people.  The other big problem is we have to do a bunch of American studies to see if it does work.  Studies that could have been done with another treatment.  What a waste of time and lives. 

So why do I hate ivermectin?  Well, I don’t.  I hate the waste of time I have spent writing this article to discuss a drug that could only be effective for covid if you took enough to kill you.  I hate the people that faked the study, they have cost lives.  I don’t hate Marik, but I definitely think he is crazy and I’m not interested in what he thinks and that isn’t new.  Unfortunately he has a big microphone and I just have this little one.

My biggest recommendation is ask your doctor if you should have the vaccine.  If you trust YOUR doctor, listen to HIM or HER.  Not some YAHOO online like ME. Remember, you trust your doctors to take care of your babies, born and unborn, cut you open, give us anesthesia and put cameras in all our holes. You trust them to help you make major medical decisions about your life. Keep doing that, they care about you. We care about you. 

Please, don’t post any articles in support of ivermectin. I read them and found them lacking. Also, don’t post another doctors opinion of ivermectin. I don’t care what they think, just what they know.

PS: I am a Critical Care Pulmonologist, I take care of sick people. Hopefully that won’t be you.

Oh yeah. Feel free to share. I should really charge for these.

[itakecareofsickpeople]

The Parable

I take care of sick people.  I am a critical care pulmonologist. 

2 years ago, if I said that, you would have no clue what I do.  It used to make me mad. Now, it’s sad that I don’t have to explain it anymore. 

There is a parable I heard while in Louisiana and I always liked it. 

There was a good and pious priest in his parish church when a man banged on the door. The priest opened the door and it was a man with a truck. The man said, “father, there is a hurricane coming and you have to come with me. The priest, he said, “do not worry, my son. I will be ok, God will save me.”  The man said, “have it your way father, but I can only stay till the rain starts.”  

The man, he waited in his truck until the rain came and he left.  The streets began to flood and the church began to fill with water. The priest had to climb to the roof. 

After a time, a boat came along filled with people. The captain shouted to the priest and called for him to get on, “Father,”he said, ”I have come to save you. Please come with me.”  The priest, knowing he was a good and pious man, said, “No my son, I will be ok, God will save me.”  

The boat left and the rains kept coming and the water rose till the priest was on top of the steeple. A helicopter saw the priest scrambling up the steeple and called down over the microphone, “Father, take the ladder, you are going to die.”  The priest said again with  all the faith in the world, “no my son, God will save me, save someone else.”

The helicopter then left and the water rose. The priest was drowned. 

When the priest got to heaven and met God, he said to God, “God, am I not a good and pious man?” God said, “Of course you are, that is why you are here at my side.”  The priest said, “But God, my work was not done. Why did you not save me?”  

God said, “I tried my child, I sent a truck and a boat and a helicopter, but you refused them all.”

The vaccine, it’s the truck, but it’s leaving once the rain starts. The boats, I’m one of their captains and we are taking on water and the bilge pump is out. We are all hands on deck and I will get out and swim if I have to, but we may not get there in time and we can’t get everyone. The helicopter, it’s grounded. The storm is just too bad. 

My advice. Get in the truck. Don’t drown. Go to heaven when your work is done.

[itakecareofsickpeople]

mRNA and mRNA vaccines.

I was asked to post something about mRNA and the vaccines. 

My general stance as a critical care doctor who has taken care of severe covid on a daily basis is that it doesn’t matter what the risk is, covid is worse. Your risk is worse, the disease is worse, everything is worse than the vaccine ever could be. 

That being said, I get it. Most of us have never heard of mRNA and all the sudden I want to inject some into your arm. Fair enough. So I will give it a shot. Before I get to mRNA, I would like to say one thing. 

The value of a treatment isn’t based solely on the risk of the medicine, it’s based on the difference between the outcome with the treatment and the outcome without the treatment. Half of the medicines we take do not prevent death, yet the also carry some risk of side effects, sometimes serious side effects. My job, as a doctor, is to try to learn both about the disease and it’s risk and learn about the medicine and it’s risk and benefit. If a disease is very deadly (eg cancer) we accept a lot of risk of treatment because the outcome is so bad->death. The thing is, covid, unchecked, will kill more people than cancer and all you need is this little shot. Our women sometimes have to cut off both of their breasts to prevent breast cancer if they have a bad gene. Seems like a shot isn’t that bad. 

Now on to mRNA and vaccines. 

In order to explain mRNA, I have to do a little background in basic cell biology. I will try not to get too detailed and may over simplify. 

Your DNA encodes for all of the proteins and enzymes that make up our body. Each 3 nucleotides code for an amino acid.  Those amino acids are put together to make us. Each cell has an exact copy, but different cells only use certain parts, that’s what makes them different. Your body doesn’t want to touch drag your dna around the cell, it might get messed up and cause cancer or a genetic defect. But it needs the code to make the proteins and enzymes. In order to do that, it makes mRNA. 

I won’t go into all the names of the enzymes, but the cell turns on the gene (lots of ways it does this, think steroids) and the cell starts making copies of mRNA. Those mRNA pieces are then taken out of the nucleus and to the ribosome. The ribosome is like the factory for your cell. The ribosome reads the code and sticks each amino acid together until it makes a protein. The mRNA is degraded in the process and the pieces are recycled. It’s made unstable on purpose so the cell can turn off the gene and the protein stops being made. That protein is then either used in the cell or it’s carried out of the cell and into the body to be used outside of the cell. 

Coronavirus is an RNA virus and it injects RNA and some proteins that hijack the ribosome and make copies of itself. It’s kind of how they got the idea for mRNA. mRNA is not the same as RNA. The biggest difference is that it’s unstable. It’s just made for that one purpose. 

An mRNA vaccine is when we take the code for a protein from the outside of a virus and make a bunch of mRNA copies and inject into your cell. Then, your ribosome will make the proteins and kick them out of the cell. The mRNA then is degraded and gets recycled like normal. Then, your body recognizes the protein is foreign and makes antibodies against it. Because it thinks your are infected, you feel sick.  The thing is, because you can make any sequence, you can theoretically make a vaccine against anything and you can make it fast if you have the code. 

The biggest problem with developing these vaccines over was getting the mRNA into the cell.  About 15 years ago, they started to figure out how to get it into the cells and the technology was led by this company called Biogen. They made the first monoclonal antibody (basically the biggest development in cancer and autoimmune treatment ever, no joke they cured a lot of cancer).  It even got good enough that a company called moderna was formed in 2010 by some venture capitalist and they both started making vaccines. They were already testing the mRNA vaccines for Zika, flu, rabies and were even being tested at my hospital for cancers. 

Historically, vaccines have either been a different virus/bacteria (cow pox for small pox was the first vaccine) or altered/dead versions of the virus/bacteria or proteins from the virus/bacteria and some of the vaccines in other countries are more traditional versions and that’s why they took longer to come out. They are slow and harder to make than just churning out a bunch of mRNA. They literally had the vaccine, in its current version, made in February of 2020. They just had to show it was safe and it worked and make a bunch of it. 

The biggest reason we didn’t have any other mRNA vaccines already approved is that we haven’t really needed them. Zika and flu were being tested, but normally, it takes a long time to get people to sign up to take a new medicine. Enrollment is usually the hold up with any clinical trial. You have to get people to do the study to have a study. With covid, massive numbers of people signed up quickly and were enrolled in the trial. 80,000 people enrolled and half of them got the vaccine. Then, they waited till people got covid and it didn’t take that long. I was in that trial. 

They had already decided that when 170 people got covid, they would look at the trial.  When they hit that number,  it turned out that 94% of the people who got covid and 90% of the people who got severe covid were unvaccinated. Bam, emergent authorization. We continue to see roughly those same numbers in vaccinated vs unvaccinated. 

I would like to point out at this time that I joined in the clinical trial without all of the safety data you have. There was a fair amount, I read it. There is a lot more now. I am not a lemming or a plant. I am very cautious in medicine and have much more doubt about these miracle drugs than vaccines. Mostly, we just needed the vaccine and I knew that more than anyone. I was also pretty dang scared till that shot went in. I got the placebo and yes, it was obvious, soI didn’t feel better till I got the real one. Ps. I am a critical care pulmonologist, I take care of sick people. Hopefully that won’t be you.

[itakecareofsickpeople]

It’s Heartbreaking

I look around our ICU and it’s heartbreaking. Our COVID unit is full again.  We are on diversion again. Not enough ECMO again. People are dying again, all from a preventable disease.

Lost a previously healthy 41 yo after 2 Months.  Sweetest and most wonderful wife. His kids were my kids age. 

All this is preventable and we have chosen to kill ourselves to prove some unclear point.  It’s like we are shaking our fist and saying, “you can’t kill me, I will do it my own dang self.”

I have to say I am confused at why we would look at vaccines as anything other than a medication with risks and benefits. 

Take high blood pressure for example. I have high blood pressure. Lots of people have high blood pressure. It causes strokes and heart attacks and peripheral vascular disease. I don’t want any of those things (they really suck), so I take two medicines to keep it low. The high blood pressure didn’t make me feel bad, but the meds do. I just don’t want to be all stroked out, eating tube feeds through a tube in my stomach, so I take the meds and don’t have a stroke. 

Medicines are meant to prevent diseases and they have risks and benefits. The vaccine risks are very small and in line with other medications we take like tic tacs. Heck. We love Percocet and it kills people all the time. If you are unvaccinated, and you don’t have a terminal disease, you are more likely to die of covid than anything else. The vaccine mostly prevents that and if everyone got it, covid would be mostly gone.

Take your medicines and your vaccine. Trust me, everyone wishes they could go back and get it in the end.

PS. I am a critical care pulmonologist.

[itakecareofsickpeople]

All these people talking got me scared, I don’t know why I listened to them. I am really scared now.

patient in the ICU with covid when asked why she didn’t get the vaccine Aug. 2021

[itakecareofsickpeople]

I Take Care of Sick People...

I take care of sick people. I am a critical care pulmonologist in one of the biggest and busiest ICUs in Nashville.

The Monday before July 4th I stood and looked at the last active covid case in our hospital. I raised my hands in victory and said to all the staff, “we won!!”  We hugged each other. We gave real high fives.

That was a little over a month ago, a week ago we had 20, now we can barely take patients again. We have never gone up so fast. Not ever. We have it better than a lot of places. My heart goes out to all my friends in Baton Rouge and my people at Our Lady of the Lake.

We have PPE, we have vents, we have medicine. We have support from our staff. We are short on nurses big time and we are maxed on ECMO, but that’s not the point.

It is very clear to me if one thing.

The virus has changed. Delta is worse. Much worse.

I used to think I was a viral pneumonia expert. Flu is my wheelhouse. ARDS is what I do. COVID is different and Delta is a gremlin that was fed after midnight and jumped into your pool.

I don’t tell you this for sympathy. I don’t need sympathy or support. I’m going to be fine. I got my shot. So did my family. I am good. I say all this so you can be as afraid as I am.

Heck. Covid has been phenomenal for my career. I have never felt so important at my hospital or so respected by my colleagues and let me tell you, business is booming.  In truth. A part of me loves covid. The rest of me is terrified of it.

If you are scared of the vaccine, be more scared if delta. If you think that we can save you, you are wrong. It won’t be because we won’t try, it’s because we aren’t enough. We are doing our best and we will continue to do our best, but our best is not good enough.

My people, all of you, are dying for no reason.

The medicines suck. Trust me, I have given them all. Other than steroids, they barely do a thing. We are arguing about 1-2% mortality reductions. The vaccine gives a 90% reduction in severe cases of covid.

You may have done some math in your head and feel you are low risk. Your math is wrong.

I am not seeing older people or unhealthy people. I  am seeing people that look like me. Healthy men and women in their 30’s and 40’s that are as sick as the 60 year olds at the beginning. 50 year olds act like 70 year olds and 60 year olds act like 80 year olds.

If you aren’t vaccinated, you are a blindfolded pedestrian crossing I24 at rush hour.

If you aren’t vaccinated, run to the nearest CVS or Walgreens and get the shot. If it’s over principles, abandon them. It’s not worth it.

If you know and love someone that isn’t vaccinated, beg them. That’s what I am doing. That’s what this is about. I am begging you.

I don’t do these posts to start a war or debate. I don’t do them for your sympathy. I do them because we are your last line of defense and we are not enough.

I do these posts because we can’t let the people who don’t have a clue be the loudest voice. We can’t let people who have never watched someone die over months, tell you it’s fine.

We can’t keep losing our friends and our family.We can’t lose you.

Please feel free to share. Normally I charge for medical advice. This one is free.