I have repeatedly said that to understand the numbers in discussing the Wuhan virus, you have to understand the context. What this means is that just giving out total numbers of cases, hospitalizations, and even deaths must be clearly understood in their proper context to be meaningful.

I have long felt that that the numbers have been misused and inflated/deflated depending on the agenda of whoever is reporting them. We have used them to justify the national lock down, promote unheard of policies like shutting down businesses, universal social distancing, and mask wearing for all. Never has an entire population of healthy individuals been quarantined or an economy shutdown to this degree for a viral epidemic. This did not happen with H1N1 in 2009, which infected between 700,000 and 1.4 billion people and killed between 150,000 and 575,000 people worldwide over 9 months. The wide range reflects the difficulty in getting good numbers, just as with Covid-19, because these depend on the reporting criteria, testing, etc.

 The latest “bombshell” is the CDC statement that only 6% of deaths have been purely from Covid-19, or around 9500 persons. All of the rest have listed co-morbidities in the cause of death. These are other medical conditions in addition to Covid that contributed to death. On the surface, this might be seen as cause for celebration and people like me, who have feel we have overreacted to this virus, should be declaring “I told you so”, but you have to understand this number before you jump with glee.

Daniel Mintz, Chair of the Department of Information Technology at the University of Maryland Global Campus posted on Facebook a very interesting thought experiment. Mintz openly acknowledged that he suffers from TDS (Trump Derangement Syndrome). He describes the lead up to a Trump victory in November based on his speculation that Trump decides to control the election. The text of his post is below.

What would he (Trump) do? Among other things:

• Has learned that undoing executive authority, even if unconstitutional, takes a lot of time (I think Mr. Mintz needs to read Defender in Chief: Donald Trump’s Fight for Presidential Power by John Yoo)
• Say the election was going to be stolen by Democrats
• Disparage the use of mail-in ballots
• Attempt to establish that the opposing candidate is senile and outside of normal behavior (hates God for example) – opposing candidate helps make the case
• Ignore the involvement of Russia and China in their attempts to manipulate the US election and insert misinformation since that adds to the chaos
• At the same time put strong supporters in charge of the US Postal Service to control the flow of mail-in ballots, including replacing all career operational leadership (in August so that this is not in the news in October/November)
• Keep up a drumbeat that local and state governments, especially with Democrat leadership are in favor of violent extremists
• Establish that it is ‘okay’ to send in federal representatives to ‘support’ local legal authorities
• Attempt to encourage local violence so that he can use those federal representatives to manage election polling locations, perhaps put such representatives in place to act as election judges (since there is an enormous shortage of polling judges across the country made much worse because of COVID-19)
• And thus control all aspects of the vote count

When I was a boy, I lived in a wonderful neighborhood filled with kids my age. One of these was Skipper Jaffe, who lived two doors down. When I was around 7, Skipper came down with measles. When the news got out in the neighborhood that the Jaffe house had measles, all the other moms did what most moms did in those pre-vaccine days: they sent their kids over there to play. Within days, every kid in the neighborhood had measles. In a week our neighborhood “epidemic” was over.

I doubt these mothers knew the statistics on measles, that the mortality for measles was around 0.1%, about the same as seasonal flu now, and that most of those were in children under 5. I doubt it would have made much difference. They knew that, absent a vaccine, their children were almost certainly going to be exposed to measles and the sooner they were exposed the better to establish future immunity. They did the same for chicken pox.

In 2018, even with an effective vaccine, 140,000 people died of measles worldwide and, again, most of these were children under 5. Measles is a terrible disease in the few who develop a severe infection with sometimes lifelong consequences. There has not been a measles death in the US since 2015 thanks to an effective public health campaign to vaccinate children, but the anti-vaccination movement is producing a population of vulnerable people that will be at risk for measles in the future (unapologetic vaccine plug). https://www.cdc.gov/mmwr/volumes/68/wr/mm6840e2.htm.  

In the ongoing, seemingly never-ending crisis due to the Wuhan virus, SARS-CoV-2, which causes the illness Covid-19, the new battleground has become the issue of opening up the schools in the fall. Social media is rife with heated arguments for and against returning children to school, from elementary to college. In the elementary area, this has become especially contentious because of the critical nature of this period in a child’s life, both in obtaining a fundamental base of education on which to build and in developing social skills that will be crucial to their later role as socially competent, functioning adults. On the importance of this there is no real debate.

My children are grown and you could say I don’t have a dog in this particular fight, but I do have grandchildren that I love and have a great interest in. For them and their parents, this is an issue of major import.

The question of if and when to open the schools to children 15 years of age and under can be broken up into several component parts.

“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)