COVID-19: Thoughts from A Primary Care Provider

Eden Family Practice opened only a few weeks before #COVID19 hit the dirt here in the United States, so my clientele is still very small. During the months of the pandemic, I saw no new clients and only maintained the care already established with those who demonstrated necessity, essentially all via telemedicine. I've been seeing entire families rather than just individual clients so I am working with men and women of all ages, and their children. Within that time, I've had three families in which all members were believed to have had COVID-19. The first two had moderate symptoms back when testing was only available to hospitalized patients and the third family was able to get free screening at a drive-up testing site. Ironically, as the primary care provider ordering the screening, never did I receive results or receive any contact by the Indiana State Department of Health even though the client received a text indicating they had positive results. When I called to follow-up and began asking questions, I was repeatedly told, "I don't know, but that's a great question." The state was far less prepared to handle positive results than I ever imagined even weeks into this pandemic.

Each client suffering symptoms within my practice had very similar courses and similar fears. Among my non-infected clients, their concerns have been largely how they might optimize their ability to not suffer the consequences of this virus and they've sought intellectual discussion on the many controversial issues surrounding COVID-19, including the potential risks associated with wearing #masks and potential mandating of the COVID vaccine into the future. These issues are complex and where data is available, often this only muddies the waters further, inviting more questions than clarity.

Certainly if you are a client of mine, we've already had lengthy discussions and I am more than happy to discuss any further concerns with members one-on-one. However, here, I do want to provide some resources and a few thoughts from the more recent data coming across my desk and of course, I'd also like to discuss some of the more controversial points.

Understanding SARS-CoV-2

Briefly, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) mainly causes acute respiratory disease, but it can also cause multiple organ failure. While autopsies were avoided in the early months of the outbreak to protect clinicians, as these have resumed, pathologists are reporting a much broader impact throughout the body than what was previously anticipated. Research has identified that up to 76% of COVID-19 patients have abnormal liver function tests and these patients are those more likely to progress towards severe pneumonia.

Several mechanisms have been suggested as the underlying pathology of COVID-19, one being direct liver toxicity through angiotensin-converting enzyme 2 (ACE-2) receptors and sepsis which promotes cytokine storm or more specifically, that interleukin-6 production which regulates hepatic homeostasis and liver regeneration ultimately leading to COVID-19 specific drugs inducing resulting liver injury. Patients with abnormal liver tests on admission seem to be independent predictive risk factors for poor outcome to SARS-CoV-2 viral load. This data is specific to patients in China however, and there is no real data on European populations, with exception of France.

However, another theory offers strong support for bradykinin storm rather than cytokine storm and this hypothesis does answer some of the questions surrounding the more bizarre symptoms. A supercomputer crunched data on more than 40,000 genes from 17,000 genetic samples to identify this as the potential underlying pathology which also provides more than ten potential treatments, some of which are already FDA approved.

According to this later theory, COVID-19 generally enters the body through ACE2 receptors which is why those who over produce these receptors are at greater risk of disease. These receptors are quite abundant in the nose and from here, they enter the body and spread to the intestines, kidneys, and heart which helps explain the cardiac and GI symptoms associated with COVID-19. Although high expression of ACE2 receptors seems to make people more vulnerable to disease, this doesn't explain the severity of their suffering as the virus can trick the body into up-regulating ACE2 receptors in places where they usually aren't even expressed to any significant degree, such as in the lungs. As bradykinin builds up in the body, it dramatically increases vascular permeability which explains why COVID-19 seems to be more a vascular disease. One in five COVID-19 patients have damage to their hearts and half suffer neurological symptoms such as dizziness, seizures, delirium, and stroke. Bradykinin can also lead to a breakdown of the blood-brain barrier which an otherwise tightly regulated environment to become vulnerable to toxins and pathogens.

A recent study published in Pediatrics supports the role of ACE2 receptors as increasing susceptibility, but not playing significant role in the severity of the disease. Literature published within Circulation speaks more to the coagulopathy which occurs. Each of these studies really demonstrate how very little we know about COVID-19. What we know about preventing its spread is likely even Iess.

Here is a map of the Coronavirus spread and here is a tool for calculating your COVID risk.

For those more interested in management, here is a clinical guideline developed by the Infectious Diseases Society of America (IDSA) for COVID-19. Hydroxychloroquine is only recommended within the context of a clinical trial and IDSA currently recommends against corticosteroids unless the client also suffers ARDS. Convalescent plasma is also only recommended within the context of a clinical trial. However, the IDSA also recommends patients be recruited into clinical trials to evaluate the efficacy and safety of potential therapies.

A consensus statement is offered for utilization of imaging for patients with risk factors for COVID-19 progression and either positive testing or moderate-to-high pre-test probability in the absence of COVID testing. Currently, imaging is not indicated in asymptomatic patients or those with suspected COVID-19 and mild clinical features unless they are at risk for disease progression. It is however, indicated in COVID-19 patients with worsening respiratory status as it helps provide a baseline for pulmonary status and identifies underlying cardiopulmonary abnormalities that may facilitate risk stratification for clinical worsening. Imaging is also appropriate in patients with functional impairment and/or hypoxemia after recovery from COVID-19.

Maternity management has also been some of the more frequent questions I have been asked. The American Academy of Pediatrics (AAP) released an initial clinical practice guideline on the management of infants born to mothers with confirmed or suspected COVID-19. Keep in mind, this is just one organization and all professional organizations have blindspots, agendas, and their main objective is to represent their members, not their consumers. Currently the Academy recommends separating newborns from mothers with known COVID-19 infection; however, if the family opts to keep the infant in the room, they should be educated on the potential risk of COVID-19 for the newborn. Certainly many facilities will not allow mothers to make these decisions. To date, SARS-CoV-2 has not been found in breastmilk. After discharge, it is recommended that she maintain six feet from her newborn or wear a mask when closer, until she is 72 hours without fever and at least 7 days have passed since the initial appearance of symptoms.

Mindset About COVID-19 & Altruistic Providers

The shortage of personal protective gear for healthcare workers who have martyred themselves during this pandemic is one of my greatest concerns as it speaks volumes about the priorities of our country's leadership and puts into question the real motivating factor behind their various mandates, such as the wearing of cloth masks. I'll speak more on that in a moment, but healthcare workers committed to service without reassurance their own healthcare expenses would be covered. They worked without protection for their families as they returned home each evening, many offering the ultimate sacrifice. However, our police were immediately donned in full military gear when facing riots and were armed with weaponry against the masses.

Most of my readers are of the mindset that healthcare in the United States is not about practicing evidence-based medicine; its about risk-based care. That is, the risk posing the clinician, not the inherent risk the client faces. The Patient Bill of Rights has no value in American healthcare. Clinicians don't educate. They don't empower. They strategize based on liability claims. Their risk calculators evaluate for risks not in alignment with the risks of individual consumers. When we include public health risks into these equations, individual freedoms are granted even less priority.

Humor me one moment and consider this. If health really was a priority, why was McDonald's allowed to stay open and serve the public, but gyms were required to close and many remain so today? If #breastfeeding has clear advantages to our babies, why doesn't the government promote, protect, and support women in doing so especially during a national crisis (maybe because large corporations for which the government holds costly contracts would lose profit)? Why has prevention or early management of COVID-19 not been a real priority beyond the recommendation to #quarantine yourself while eating McDonald's and to wear a cotton mask while shopping for your favorite snack foods? Early victims of COVID-19 were told to stay home, essentially until they faced respiratory failure. They were provided warning signs, not a plan for optimizing their outcomes.

In response to the "all hands on deck" mentality that initiated during the initial onset of the pandemic, state health departments began reaching out to their advanced practice nurses, knowing that many are highly skilled in critical care, emergency department management, and in-patient care. I was contacted as well, and having had experience in all these areas, including experience in emergency response. I responded with willingness to volunteer wherever there might be need until it occurred to me that I lacked healthcare coverage myself. If I were to become sick or suffer long-term consequence of my volunteer efforts, I would have no financial means to pay for my own treatment. This was never offered to me by the professional agencies seeking my volunteer efforts, nor was assistance at home offered to care for my children if I were to be exposed or become sick with COVID-19. I am a single mother of three young children but my country asked me to martyr myself knowing that nurses are ultimately very altruistic. Throughout my entire career I have repeated the sentiment that what is asked of us as healthcare providers is great, and what is offered us is little more than hostility and moral injury. Consider too, that during the pandemic, nurse-practitioners and nurse-midwives no longer required #collaboration with a physician because the profession well understands this doesn't improve client outcomes. These requirements only restrict our ability to practice. It only minimizes competition for the physicians, which during a pandemic probably isn't wise. Post-pandemic however, these restrictions will return.

It seems if we work in the healthcare field it is assumed we will endure risks without sufficient protection. This is not dissimilar from when nurses are assaulted by patients yet officers refuse to file charges and judges refuse to award damages because the opinion is that this is part of the role we accept. Ironically this isn't the case for police. In fact, assault an officer and your consequences advance exponentially. Not providing protective equipment to healthcare professionals during a pandemic is the epitome of proof to support the utter apathy of our government towards our healthcare infrastructure and its providers.

Offering police immunity but allowing unprecedented legal claims on healthcare providers to the point that the profession now prioritizes minimizing liability to improving patient outcomes. This shortage of personal protective equipment and basic medical supplies is anticipated to persist for years without strategic government intervention. The American Medical Association offered a "deal" to clinicians in Indiana for obtaining protective equipment, none of which were approved for healthcare providers. Were we being deceived or was the AMA's leadership ignorant to the lack of protection these "deals" offered healthcare providers?

There isn't even a long-term strategic plan for the manufacture, acquisition, and distribution of PPE for the immediate future, or into the future for preparing for our next pandemic. The supply chain needs to be strengthened dramatically if there is a real concern for the health of the masses and certainly, its clinicians. Not only has the need within healthcare increased, but distributors are also being called upon to meet the needs of first responders, schools, clinics, and even retail businesses.

A study conducted at Penn University by researchers at the Perelman School of Medicine reported that more than half of the reported deaths among healthcare workers globally were physicians. Notably, family physicians appeared to be affected more often than frontline, hospital-based physicians. This outcome is thought to be based on the fact that frontline providers had better access to personal protective equipment such as #masks, face shields, and gloves. This smaller study seems to support that when PPE is available, it is safe and improves outcomes, but sadly, a significant number of clinicians and support staff were denied protection.

As of May 13th, 2020, an online database of healthcare deaths worldwide, requiring confirming documentation, found 1,004 deaths and nearly 55% of the COVID-19 deaths were physicians. The average age among physicians who suffered demise was 62 years, and among non-physicians, the average age was 52 years. Twenty-seven percent were general practitioners, or family practice doctors in primary care. Front-line physicians, such as critical care specialists, anesthesiologists, and emergency room physicians represented only 7.4% of deaths within this cohort.

General practitioners are more likely to see clients with more early-stage symptoms, even asymptomatic, but still thought to be contagious and of course, they often donned no personal protective equipment. Males seemed to be more impacted than female providers. Certainly this is a single cohort which creates some weaknesses in the study, but the data identifying the bradykinin storm supports the gender preference of COVID-19 towards males.

There are significantly more deaths globally within healthcare than these 1004, as more than 600 nurses alone have demised of COVID-19. Reporting deaths and assigning cause of deaths differs from country to country and case to case. If you are aware of deaths within the healthcare profession from COVID-19, Medscape is asking for your help to keep the list up to date. However, labeling deaths as COVID-19 related is another complex controversial topic in itself.

Hand Sanitizers & Toxic Sanitary Procedures

The FDA shared a warning list about dangerous hand sanitizers that either contained toxic methanol or insufficient ingredient to actually kill the pathogens it claimed. One hundred and sixty different hand sanitizers were identified as dangerous or misleading, but this isn't the only concern. People are drinking hand sanitizers to get high and after some short-sided statements by our leadership, others have ingested hand sanitizer with belief it would disinfect their bodies. More than 1,500 cases of methanol poisoning have been reported since May of this year, per the American Association of Poison Control Centers. Eight hundred people have died after drinking methanol, another sixty developed complete blindness, and about 5,900 have been hospitalized.

The CDC recommends the use of alcohol-based hand sanitizers that contain at least 60% ethyl alcohol (ethanol) or 70% isopropyl alcohol (isopropanol), the agency emphasizes that methanol (methyl alcohol) is not an acceptable ingredient and must not be used due to its toxic effects. Some sanitizers are marked "FDA approved," which is a fraudulent claim as known are approved by the FDA. They simply stipulate which ingredients are allowed in over-the-counter hand sanitizers.

Methanol, also called wood alcohol, can be toxic when absorbed through the skin or ingested. This is rare per the CDC, but the FDA warned the public in July that "methanol is not an acceptable ingredient for hand sanitizers and must not be used due to its toxic effects." These products should be disposed as hazardous waste, per the FDA. Prior to this pandemic, poisonings from methanol-containing products were largely windshield washer fluid. Unfortunately, even if methanol is used, it isn't always on the label.

Masks Have Revealed Our Ignorance

Lockdowns and social distancing measures introduced around the world to try and curb the COVID-19 pandemic are reshaping lives, challenging everyday freedoms, and creating new social norms. Interestingly, behaviorists argue that our individualist culture means we think more for the needs of ourselves rather than collectively for the best of our community. In societies with more political division, people are less likely to trust advice from one side or the other, and also tend to form pro- and anti-camps. Yet, we are social animals. We were made to be in relationships with others. The pandemic goes against our natural instincts to connect. Our cellular history is cognizant that presence within the tribe is life-saving and excommunication means death. People have a hard time resisting that tendency for social and group connection.

The mask controversy isn't nearly as simple as the lay community likes to argue - that either one wears the mask and is therefore a compassionate citizen or one refuses out of selfishness, placing everyone else at risk. The infamous meme demonstrating the man urinating onto the other, with only one, neither, or both wearing pants and how that demonstrates why one should wear a mask is incredibly short-sided.

According to the World Health Organization's guidance on face mask use, made available on June 5th, 2020, there is no direct evidence that universal masking of healthy people is an effective intervention against respiratory illnesses. It is known that masks do not prevent viral infections, including COVID-19, yet the WHO still makes a case for universal mask-wearing. Their position is that mandating the community to wear masks can help reduce stigmatization of people caring for COVID-19 patients in nonclinical settings and making people feel like they're doing something to help, as well as serving as a reminder to be compliant with other measures, and of course, they even site the economic benefits for people who can sew homemade masks.

Despite the fact that cloth masks are far less effective for blocking potentially infectious respiratory droplets, the WHO recommends cloth masks should be worn by infected persons in community settings. A policy review paper published in the CDC's journal Emerging Infectious Diseases found that masks did not protect against influenza in non-healthcare settings. They conform to absolutely no quality standards. SARS-CoV-2 is a beta-coronavirus with a diameter between 60 nonometers and 140 nanometers, or 0.06 to 0.14 microns. This is about half the size of most viruses, which tend to measure between 0.02 microns to 0.3 microns. Virus-laden saliva or respiratory droplets expelled when talking or coughing measure between 5 and 10 microns, and it is these droplets that surgical masks and respirators can block.

N95 masks can filter particles as small as 0.3 microns, so they may prevent a majority of respiratory droplets from escaping. They cannot block aerosolized viruses that are in the air itself. Additionally, many N95 masks only protect the wearer, as they have exhalation ports that allow you to exhale unfiltered air. The 3M surgical masks can block up to 75% of particles measuring between 0.02 microns and 1 micron, while cloth masks block between 30% and 60% or respiratory particles of this size.

What the literature has shown us is that the effectiveness of face masks in reducing laboratory-confirmed influenza virus infections in the community is nil. In fact, there was no evidence of benefit. A systematic review found no significant effect for face masks on transmission of laboratory-confirmed influenza.

Harms and risks of mask-wearing include health effects associated with poor air quality and toxic ingredients in the mask, self-contamination caused by manipulation of the mask by contaminated hands, general discomfort, facial skin lesions, irritant dermatitis or worsening acne, and a false sense of security that may reduce adherence to other preventative measures such as hand hygiene. Respiratory infections are reported to be increasing in frequency and the impact to our immune system is still in question.

These points don't even touch on the greater issue of cross contamination. When wearing a mask or gown or any protective equipment, there is a very clear protocol one must follow or you'll nullify what little protection you are offered. For example, these items are ineffective when wet or damp, when soiled or damaged, and when not properly fitted. These items should remain untouched. They can not be adjusted or displaced for any reason. If touched inadvertently, the mask should be replaced and hand hygiene performed. Gowns, masks and gloves should be discarded and changed after caring for any patient on contact/droplet precautions in the immediate vicinity of exposure.

Consider then the mass cross contamination occurring among the lay population who isn't wearing a gown to cover their clothing while traveling in their car to their local shopping center. They are coughing, sneezing, talking, and breathing all over their shirt, which is then worn into the shopping center which is likely to be touched by their hands and pathogens transferred, if the clothing doesn't touch product directly. If we consider purses in which used masks are stored, even credit cards which are handed back and forth among retail workers and consumers, the cross contamination risk is significant especially if we take into consideration that bio-hazard bins are not available for mask disposable. Rather, many are dropped directly on the ground on left on the seats of bleachers. Masks are now posing one of the greatest environmental hazards due to improper disposal. The real benefit of mask wearing is offering the lay community a sense, albeit false sense, of security.

Antibodies: Immune Response & COVID Vaccine

While the argument surrounding masks certainly riles up many, I suspect into the future, my clients will be most alarmed by the issues and mandates surrounding the COVID vaccine. Already we are seeing requirements for the flu vaccine, such as with Purdue University and Indiana University both requiring the flu vaccine at the onset of this fall semester.

Once antibody testing became available, a significant number of my clients requested testing, yet none have demonstrated positive response in spite of presumed COVID infection based on known exposure and overwhelming signs and symptoms. This seems to be supported by early reports that antibody response is in fact, short-lived. Will vaccines be protective then against the virus? Expert immunologists claim that other aspects of the immune system still remembers the virus and can mount a robust and protective response.

Johnson & Johnson aims to test its experimental coronavirus vaccine in up to 60,00 volunteers in a late-stage trial scheduled to start in September, according to a U.S. government database of clinical trails. They are already recruiting and anticipate initiating first injections in late September, with first vaccines becoming available in 2021. Their rival vaccine makers such as Moderna Inc and Pfizer are targeting recruitment of up to 30,000 volunteers for their late-stage studies.

There are many unanswered questions about a vaccine that without which greater than 99% would survive the infection. Will it be effective? How can we create an effective vaccine for a virus we don't fully understand? We haven't even an effective vaccine for the flu yet. What are the risks and are those insignificant enough to endure them when COVID-19 poses a risk of mortality in fewer than one in every one hundred of us. The morbidity seems to be growing in significance however. This may be the greater risks/benefits discussion, again, only if we have a vaccine that is even effective.

Vitamin D Deficiency

Vitamin D has been a priority in my clinical practice for more than a decade. Most all clients I evaluate, which is greater than 90%, are deficient. This largely reflects on lifestyle behaviors, but conventional medicine has the goal of identifying only those levels insufficient enough that they fall into a range associated with increased incidence of disease. Optimal levels however, are nearly, if not more than doubled, these levels, per functional medicine clinicians. Each pandemic seems to recognize the role of vitamin D in minimizing the impact of these viruses, yet priority has not been given to altering our lifestyle to better allow sun more regularly into our daily activities.

Nature in fact hasn't any real priority in our culture. Physicians aren't prescribing grounding or earthing as frequently as the health of consumers necessitates. We aren't protecting Mother Earth. We aren't connecting ourselves to the Earth or teaching our children to honor this vital connection. Our modern world is very misguided about what optimal health looks like and how to attain it; rather, our focus is on minimizing the suffering of dis-ease. Self-care is vital for enduring not just this pandemic, but for optimizing our outcomes into future pandemics.

Other Interesting Tidbits

• Humidity seems to be a consistent factor contributing to the spread of SARS-COVID-19. This may cause the infectious material to remain airborne for longer or it could be a more direct effect on the survivability of the virus in the environment.

• The overlap between mental health and the pandemic finally took center stage this week. Mental Health America (MHA) has found a dramatic increase in depression, anxiety, psychosis, and suicidality. The biggest problems were seen among adults younger than 25 years. This is thought to be related to penetration of the CNS by the novel coronavirus.

• The elderly do not often present with the typical COVID-19 symptoms of fever and cough, but may present with delirium and diarrhea. They more typically have lymphopenia and elevated cRP, or even increased procalcitonin levels. In severe cases, troponin I, D-dimer, and lactate dehydrogenase are raised.