Christmas Thoughts

 

"Let's turn to Matthew chapter 1," I told my children.

"But I want to open presents!"  Victoria wailed.

I suppose I am one of those cruel Dads who thinks it is his duty to instill in his children the reason for the Christmas season, but it does seem important.  Victoria was the only one who expressed her frustration with my diabolical plan.  Elise was too young to realize that it even was Christmas Day and the other children were old enough to hide their impatience.

As my children read through the story of Jesus' conception and the visit of the wise men, I thought of the different miracles in the story.  The virgin birth, the star, and the mixture of faith and unbelief demonstrated by the various actors within this account.

"So, what is today?"  I asked my children, when they finished reading.

"It's Jesus' birthday,"  Elliot said.

"No, Elliot," Vince said firmly.  "It is the day we celebrate Jesus' birthday.  We actually don't know what day Jesus was born."

"So, how should we celebrate Jesus' birth?"  I asked.  "Do you think it would be good to have a birthday cake and sing Him "Happy Birthday?"

Elliot nodded.  He likes cake of all kinds, particularly birthday cakes.

"There were two groups of gifts given in this story," I continued.  "There were the gifts the wise men brought and then God gave us the best gift of all -- His Son.  So, what can we give Him in return?"

"We should give him our hearts," Anna said.

"That's right," I said.  "But I think there is something more.  How did Jesus tell us we could do things for Him?"

My children were silent.  This was too much of a "Guess what Dad is thinking" sort of question.  I am good at asking those and typically I am the only one who seems to come up with the answer that I am looking for.

"Jesus said that as we do things to the least of these, we do it to Him.  So, as we see people in need around us and do things for them, we are giving Him gifts."

I continued to ponder on this concept.  The goal I have when I give a gift to someone is not to give them something I want, but something they want.  The same should be true when I approach my Savior.  Often the hardest part is figuring out what that person actually wants, but Jesus was clear about that subject.

Jesus did not say He wanted big celebrations with lights and trees and positive postings on Facebook -- there's nothing wrong with those things, He just didn't ask for them.  He said simply that He wished for His followers to love the world the way He did.  He wanted His people to give until it hurt and then to keep giving until it stopped hurting.  He wanted them to continue the ministry He began so many years ago.

For Him, that would be the greatest gift of all.

Vaccines and Pyrrhic Victories

                             

The year was 279 BC and King Pyrrhus of Epirus decided to invade Italy and challenge the growing Roman Republic for domination.  He mustered his forces and gathered allied troops in southern Italy.

All went well until they came to Asculum.  There the Roman forces had massed and pitched battle ensued.

History tells us that the Greeks won a resounding victory over the Roman forces.  Casualties on the Roman side were at least double those of the Greek forces.

The only thing was that the Romans could (and did) quickly call up more forces to replace their losses while King Pyrrhus could do nothing to replace his casualties.  Many of his commanders died in the battle and his allies started to lose interest in the war.  He is quoted by Plutarch as saying in the aftermath, "If we are victorious in one more battle with the Romans, we shall be utterly ruined."

Thus was born the term Pyrrhic Victory. 

I think we hear of it most often these days in terms of sporting events.  A team wins a close game only to see its star player go down with serious injury.  They have won the battle, but lost the war.

I have heard many people say variations on the statement, "What does not kill me will only make me stronger."  The reality is something different.

"What does not kill me may make me a lot weaker."

The Diseases of the Past

There is a common misconception about the diseases of the past.  People believe that the danger was that they caused death.  Of course, that was some times true, but more often, they just left an individual damaged for the rest of their lives.

Polio weakened muscles, some times to the point that people required external ventilators, called iron lungs.  German Measles caused children to be born with severe birth defects.  Youth carried hearing and vision loss for the rest of their lives from the remnants of H. Flu meningitis.

These little bodies told the tale of Pyrrhic Victories.  Battles won, but damage so severe that life would never be the same.

Many of these infections were viruses and so even modern medicine with its antibiotics has few tools to deal with them.  It is a blessing that we know few younger people who have walked through these infections. 

From this were born vaccines.  The first true vaccine was the rabies vaccine, created by Louis Pasteur (the small pox vaccine was earlier, but it doesn't really count from my standpoint).  Considering that rabies was (and is) 95 percent lethal, this was a real game changer. 

The concept with vaccines is simple.  Give a person a small dose of killed or weakened virus or bacteria and let their body create antibodies to that infectious agent.  The doses are typically kept small and so most vaccines require multiple doses to be certain that there are protective antibody levels present.

Over the years since, there have been many vaccines created to deal with a variety of illnesses.  With the advent of vaccines has come a fear -- fear of the "secret ingredients" in the vaccines and a belief that it is healthier to get these illnesses the "natural way."  As though God intended children to suffer through Measles, Mumps, German Measles, and Diphtheria on their way to an unhealthy adulthood.

I am going to try to wade through some concerns that people have about vaccines and then touch a bit on the recently released COVID vaccines.

History of Vaccines

The very first vaccine was for Small Pox.  Small Pox was an illness that devastated Europe for centuries.  It was said that ten percent of the population died from Small Pox.  There was no treatment.

Then, in 1798, Edward Jenner had a light bulb moment.  Others had noticed that the milk maids in London had the best complexions of anyone around and figured out that it was because they got infected with Variolae Vaccinae (Cow Pox).  Dr. Jenner had the idea of infecting lots of people with Cow Pox and thereby preventing Small Pox infections.

It worked and death rates from Small Pox dropped considerably.  Unfortunately, it was a bit of a dead end as it was mostly happenstance to find a mild disease that provided immunity against a deadly disease.

The first true vaccine was for rabies.  Louis Pasteur was a genius who had already done work to come up with a vaccine against Anthrax for live stock.  He decided to turn his attention to rabies and managed to grow the virus in the brains of rabbits.  He then killed the virus and in 1898 injected some of the material into a boy who had been mauled by a rabid dog.

Amazingly, the boy did not succumb to rabies and the door was opened to begin work on other organisms.

Since that time, there have been hundreds of vaccines worked on.  Some of the projects have been successful and some haven't.

Everyone is Afraid.

As I read posts about vaccines, it is clear to me that there is a large group of people who is more afraid of getting a vaccine than getting the diseases they are designed to prevent.  

This says that vaccines have worked.  We don't see people in iron lungs any more from polio.  We don't have members of our community dying from Lock Jaw.  We haven't seen children with Measles related encephalitis.  This is not because we have treatments for these infections.  We don't.  We just have shots that are remarkably effective at preventing them from happening.

At the same time, we still don't have great treatments for these illnesses.  A six year old boy last year spent 57 days in the hospital after getting Tetanus with treatment costing over 800,000 dollars.  Perhaps the shots would have been better.  https://www.cdc.gov/mmwr/volumes/68/wr/mm6809a3.htm

Secret Ingredients in Vaccines

Vaccines do contain preservatives, they contain tiny amounts of formaldehyde and aluminum.  This all sounds terrible and many have claimed that they are dangerous.  The only thing is that we live in a world that is pretty toxic.  A breast fed baby will get more aluminum in a couple of days than is present in any vaccine on the market.  Fortunately, our bodies break down the tiny amounts of toxins present in our environment and diet very quickly.

Mercury is notably absent from most vaccines at this point -- only present in multi-dose vials.

Vaccines typically contain adjuvants as well.  Adjuvants are designed to deliver an antigen in such a way that it gets the maximum effect from the immune system.  When you feel achy after a vaccination or get a low grade fever, it is typically because the adjuvant is "doing its thing" and revving up your immune system.  Adjuvants: Introduction | British Society for Immunology

All of these ingredients are kept to as tiny an amount as possible and none of them are secret at all.  Vaccine Ingredients .  Vaccine Additives

Vaccines Don't Work?

Many people have the perception that vaccines don't work.  Rates of childhood illnesses fell due to better care of drinking water and better health care.  We have antibiotics and even a few anti-viral agents.  I have seen many post this sort of statement (mostly related to the possibility of COVID vaccine), "We don't have any effective vaccines against viruses." or "We have a flu shot and still have lots of deaths from influenza."

Of course, this ignores the fact that polio, measles, mumps, rubella, Hepatitis A, Hepatitis B and Chicken Pox are all viruses and we have effective vaccines against all of those.  

We are actually pretty good these days at creating vaccines against viruses.

Influenza is an exception.  The issue with influenza is that it is a virus that mutates a lot from season to season.  It lives in poultry and pigs in China and as it transitions back and forth each year, the virus changes quite a bit.  Each year, the CDC makes a judgment about what strains of flu will be most common.  Sometimes they guess right and sometimes they are off, but for a typical year, the flu shot may be anywhere from 20 to 60 percent effective against the common strains.

(I still recommend the flu shot for those who can take it -- it's the best we have and it generally is somewhat effective).

Why There Aren't More Vaccines

So if vaccines are so wonderful, why don't we have more of them?

As with everything, there are multiple reasons.  The most important thing for a vaccine to work is that humans have to be capable of long term immunity to an organism.  So, with infections like Measles and Chicken Pox, people get a single infection and then are immune for life.  This is an ideal scenario.  We only have to simulate this to get the same type of response without the infection.

Unfortunately, our bodies are not able to handle many viruses.  HIV and Hepatitis C are not infections that are typically cleared by our immune systems.  People who have these viruses have chronic infections for years and while those patients do form antibodies to these viruses, the antibodies are not protective.

Then, there are infections that we only form short term immune responses too -- things like RSV.  Vaccines against those sorts of infections are difficult and often require regular boosters to be effective.

Some things, like the common cold are caused by lots and lots of different pathogens and so it becomes difficult to design a vaccine that would cover even 70 percent of the most common causative organisms.

Finally, the disease has to cause enough health issues and be wide enough spread, to make it worthwhile for someone to invest money to come up with a vaccine.  For instance, Ebola causes a lot of death and devastation, but each time there was an outbreak, it was controlled with public health measures before a vaccine was developed and so the matter would be dropped till the next outbreak.  We do have an Ebola vaccine now, but it took many years to develop mainly because Ebola was "controllable" with public health measures.  The common cold, while very contagious and prevalent, doesn't cause serious enough health issues to warrant investment in a vaccination.

Temporality Doesn't Equal Causality

Children are very prone to magical thinking.  They blinked three times quickly and then someone broke a plate immediately afterward and they think they caused it and are careful not to blink again.

Adults are often the same.  They got an injection and immediately thereafter they got sick.  Their child got an injection and developed an illness.

With vaccines, we do large studies with thousands of people to see if there are things that are more common in the vaccinated patients compared to the normal population.  It is really hard to prove a negative, but we can say that in studies of thousands of children who have gotten the MMR vaccine, there is not any increased rate of autism compared to unvaccinated children (actually studies indicate 7 percent lower incidence in vaccinated children).  'No link between MMR and autism,' finds major study - NHS (www.nhs.uk)

The issue is that MMR vaccine is typically given around 15 months of age and that is also the age that most parents begin to notice issues with their children who have autism.  Autism is about 90 percent genetic.  There are some environmental factors that can be identified, but vaccination does not seem to be one of them.  Link Between Genetics and Autism (verywellhealth.com) 

Fetal Cell Lines

One of the biggest ethical issues with vaccines has to do with use of fetal cell lines to make vaccines.  There are a number of cell lines made with cells taken from babies that were aborted in the 1960s through the 1980s.  There are no ongoing abortions done to produce vaccines, and the infants were not aborted for the purpose of making these cell lines, but obviously this taints our view of these particular vaccines.

The vaccines that are commonly used that are grown on these cells are the Rubella (German Measles), Varicella (Chicken Pox), and Hepatitis A vaccines Vaccines Grown on Fetal Cell Lines.  I do still recommend using these vaccines.  To me, it is akin to organ donation from someone who was murdered.  Not using these vaccines will not change the abortion, but perhaps some good can come from the prevention of disease.

Others will differ from me on this and that is understandable.  I think these are two different view points on the subject of Fetal Cell Lines that look at the ethics from a Christian perspective.  This one is by Dr. Amy Givler:  Am I My Brother's Keeper  This one on the Gospel Coalition:  Are Fetal Cells Being Used for COVID Treatments

With the COVID vaccines that are coming, the Charlotte Lozier Institute put together a nice table looking at which of the vaccines were made using fetal cell lines and which not.  Fortunately, most were not made with these.  Charlotte Lozier Institute

Many medicines (including these vaccines) have some testing on these fetal cell lines during development, although they do not continue to use the cell lines to produce the vaccines.  Among the medications tested on these cell lines (at some point) seem to be ivermectin, monoclonal antibodies, and Remdesivir.  It must be understand that while these have been tested with virus made in fetal cells, they are not manufactured using these cells.

Ethically, any time there is an option, I think we would do well to steer away from vaccines made with these cell lines and go to other options.  

Not All Sources of Information are Equal

In today's climate, everybody has an opinion, the problem is that not all of them have facts behind them.  Someone like Robert F. Kennedy Jr. is trained as a lawyer.  I am sure that he is well meaning, but he doesn't have insight or understanding necessary to give an informed opinion.

While personal stories have impact and people who come across very strongly seem like they should have evidence on their side, that may not be the case.  It is useful to look at actual statistics from places like the CDC.

I will do my best to share things are true and researched, but even here, it is wise to check up on me and make sure I have data behind my opinions.

COVID Vaccines

Operation Warp Speed has been in full gear since the beginning of the year.  Three vaccines are in the process of being launched and several more are in line behind them.  I would like to finish by briefly mentioning those.

mRNA Vaccines

Messenger RNA is a hot topic lately.  mRNA is what takes messages from the DNA to the ribosomes, where proteins are manufactured.  The DNA never leaves the nucleus, but it generates mRNA that tell what proteins are to be made.  https://www.modernatx.com/mrna-technology/science-and-fundamentals-mrna-technology 

Till recently, vaccines involved growing a bacteria or virus and then either weakening or killing it and then giving small doses of it to patients to generate antibodies.  

A more recent vaccine, called Shingrix, actually took manufactured surface proteins from the Herpes Zoster virus and administered them to patients.  This turned out to give extremely good immune responses -- better than earlier vaccines for shingles.  Shingrix

mRNA vaccines take this a step farther.  They use mRNA to get the cells in a patient to make proteins that look like surface proteins on the COVID virus.  The body then sees this spike protein as something foreign and begins to generate antibodies to it.  Eventually, the mRNA wears out and the cells stop making the protein.

In the trials, these vaccines were very effective -- between 90 and 95 percent effective at preventing any COVID infection after the second dose and 100 percent effective at preventing serious infections.

Side Effects were mostly things like fevers, muscle aches, and fatigue.  There were four people who got the vaccine who developed Bell's Palsy, although it isn't clear if this was related to the vaccine.  Some people had allergic reactions to them.  Side Effects of Pfizer's COVID Vaccine  

While these vaccines have been rushed along, they have already been tested on thousands of people.  And testing isn't over.  The FDA will be doing post-hoc analysis to see if there are any other things that show up.  The most important thing is clarity -- patients need to know what the side effects of these vaccines are.

Do These Vaccines Change Your DNA?

There is a rumor going on that getting one of the mRNA vaccines will change your DNA and once that happens, "even RKF Jr. won't be able to help you."  I think this misses how mRNA works.  

In the human cells, DNA is the software code that instructs cells how to make the different proteins they need to function.  However proteins are made in a part of the cell called the ribosomes, while the DNA never leaves the nucleus.  mRNA is the go-between that takes messages to the ribosomes telling them what proteins to make and how to make them.

With a vaccine that uses mRNA, the mRNA never makes it to the cell nucleus.  It functions in the ribosomes until it is degraded at which point the cell stops making the protein.

Even if somehow your DNA was changed, the worst case scenario would be that some important protein in the DNA would be damaged and the body would do what it normally does, which is take care of that cell with a process called apoptosis.

For those who question evolution, this should be obvious.  Mutations don't randomly create new species, because they don't stick around if they aren't useful.  (See the book Darwin Devolves for more on this subject).

Traditional-style COVID Vaccines

Astra Zeneca, Janssen, and Merck are all working on vaccines that are developed with a more traditional process.  Basically, they grow COVID virus and then kill it.  The Janssen and Astra Zeneca vaccines use fetal cell lines, while the Merck use monkey cells to grow the virus.

It is a little soon to comment about these except to say that the AZ vaccine had some odd things with their trial.  They made a mistake in the trial and gave a bunch of people half a dose of the vaccine.  Those people got a full dose with their second dose and compared to those who got two full doses, they had better results.  https://www.biopharma-reporter.com/Article/2020/12/10/What-next-for-AstraZeneca-s-half-dose-COVID-19-vaccine  I don't know what this means, but the data for the half dose is less than what maybe we would like.

Other Vaccine Candidates

There are many other vaccines coming down the road.  Some others will be mRNA, some with proteins, and some with killed virus.  It is too soon to say much about them except that each one will need to be studied individually before they are given approval to be used.

Were They Launched Too Fast?

The first COVID vaccines came out with less than a year of development.  This happened because world governments threw billions of dollars at the vaccine development and guaranteed the companies making them that they would buy the vaccines, regardless of their effectiveness.  That is to say, if Moderna's vaccine was completely ineffective, the US government would still have bought a bunch of it (but not administered it to patients).

The point was to get the companies to begin manufacturing millions of doses of these vaccines, even before the testing was done.  By taking away the risk from the vaccine manufacturers, they saved a lot of time and fortunately, some of the early vaccines are much more effective than we had ever hoped.

In addition, technology has come a long way.  We know how to grow viruses and kill them.  We know how to make basic vaccines.  The whole genome of the COVID virus was sequenced in March.  These are the sorts of things we can do today that would have been very difficult to do ten or fifteen years ago.

At the same time, there is more testing to do.  As vaccines are given we will be watching for anything concerning.  This watching never stops.  If I see a significant reaction to a tetanus shot, I still report it to the CDC who will track it, even though tetanus immunizations have been on the market for decades.

Take Home Message

I am a big believer in vaccines and vaccination programs.  Some, like the flu shot, are not terribly effective and some that have been tested have caused serious issues (RSV in the 1960s, Rotavirus in the 1990s).  Every one that is released needs testing prior to release and then continued analysis after release to be certain that they are safe and doing what they are supposed to to prevent disease.

The COVID vaccines have been tested on thousands of people so far.  We know that they are very effective at preventing serious COVID infections and hospitalizations.  They have had some allergic reactions and otherwise minimal issues.  Certainly, as we give these vaccines to millions of patients, other things will show up.  There will be more allergic reactions.  Perhaps other side effects or groups of patients that shouldn't get it.

I do plan to get a COVID vaccination.  The issue to me is not my personal risk from COVID -- it is probably small (although we don't know all of the long term implications of COVID infections).  The issue to me is that I could be the conduit whereby someone else gets COVID who does worse than I would.  I have seen all too many situations where a younger person gave COVID to someone older.  The younger person sailed through unscathed, while the older individual ended up in the hospital and came out weakened.

More than anything, I believe in vaccines to prevent Pyrrhic Victories and am glad that we live in an age where we have the option to protect our children from illnesses that could have maimed them in another era.

Outpatient COVID 19 Care

 

 

I picked up the phone.  It was the third time that day that I was making this sort of call.  “Ms. Nellie?”  I asked when someone picked up on the other end.

“Dr. Waldron,” the voice on the other end said, the words pouring out.  “I don’t know if you know, but I tested positive for COVID.  I guess my daughter gave it to me after Thanksgiving.  I’m so worried.  Some folks have told me at my age that it is a death sentence!  What should I do?”

Over the next several minutes, I talked to my distraught patient about her diagnosis and some things to do and some things not to do.  Most of all, I tried to instill in her a sense of hope.  Things would be OK.

What we know at this point is that most people with COVID will have mild illnesses.  At least 90 percent will be able to take care of themselves at home without requiring hospitalization.  The younger you are, the less likely you would need anything more than supportive care.

When to Get Tested

It is often difficult to know if you should go get tested for COVID.  You have a little tickle in your throat and maybe your nose is stopped up a little.  Maybe your neighbor stopped by for a quick chat and then called you a couple of days later to let you know that he tested positive for COVID.  There are a myriad of symptoms that we can experience and it is sometimes hard to know when to go get a test.

Common COVID symptoms are cough, fever, and muscle aches.  Loss of sense of smell is an obvious one that we associate with COVID infections, but to be honest, only about 60 percent of symptomatic people will have this symptom and so I wouldn’t put too much stock in the fact that you can still smell.  If you have the other symptoms you should probably get tested.

There are a lot of people who have other symptoms – GI (diarrhea, nausea) or simply confusion when their infection starts

If you have these symptoms and you need to be around other people, it is important to get tested.

If you have no symptoms but a possible exposure, it is probably best to wait.  Testing early is very prone to false negative tests.  Remember that you must have a certain level of virus in your system for the test to detect it.  Running out to get tested the day after an exposure may make you feel better, but it won’t really tell you if you are infected.

Dealing with a Negative Test

One of the hardest things is to figure out what to do with a negative test result.  Quite simply, a lot depends on your level of suspicion.  If your symptoms all fit COVID-19 and you had a known exposure, I wouldn’t trust a negative test.  Too often it is a false negative – either the swab wasn’t good enough, or some other factor made the test negative.

Of note is that Rapid COVID tests seem more prone to false negatives and so should be trusted a bit less than the standard PCR tests.

But if the test is positive, what should you do?

Isolation

Probably the hardest thing if you test positive for COVID is staying away from other people.  Many individuals don’t feel too bad and they want to get back to normal as quickly as possible.  The current recommendation is that you stay home for at least ten days.  At that point, as long as your symptoms have resolved for 24 hours, you can get back to normal.

It is not OK to continue with normal activities, even if you wear a mask and aren't really sick.  Quite simply, you may have gotten a mild illness, but you could easily infect someone else who might give it to someone else and eventually, one of those folks could get really sick with it.  The goal is to break that chain of transmission.

While you are isolating, it is a kind thing to notify the people you have been around for the last several days of your positive test.  Some states are doing "contact tracing," but it is probably taken better if you let your friends know yourself.

Don't Feel Guilty

I think all of us know that we could "do a little better" at social distancing and wearing masks.  If you come down with COVID-19 there is a tendency to blame yourself or, others for your infection.  Those sorts of feelings aren't helpful and could lead to destructive emotions like anger and bitterness.

As Scarlett said, "Tomorrow is another day."

Rest

Much of what we do for COVID is “supportive care.”  These are things like pushing fluids, resting, and deep breathing exercises.  The whole point of this is to give your body the care it needs in order to fight the infection off and avoid a superimposed bacterial infection.  We know that this can happen with influenza and it can happen as well with COVID.

Some have suggested using a device called an incentive spirometer.  This is something that people use after surgery to make sure they are taking deep enough breaths and while there is not testing showing it prevents more serious lung infections with COVID, it would make sense that it would help.

Fever Control

I have met some people who believe that it is important to “sweat out” their fevers and they avoid medications like ibuprofen and Tylenol.  There is no particular benefit to letting your temperature go way up and certainly you will feel a lot worse if you do.  My experience is that it is easier to keep your fever down than to get it down once it shoots up.

It is probably better to keep the temperature under 100 with either Tylenol or ibuprofen.

Vitamin D Supplementation

We know that people who have low Vitamin D levels seem to get worse cases of COVID than those who have normal levels.  That said, it doesn’t seem to help very much to start taking it once you get sick. 

My recommendation would be that if you are planning to get COVID down the road you should go ahead and start on a Vitamin D 2000 unit a day now.  If you aren’t sure if you plan to get it, it wouldn’t hurt to take it anyway.  https://www.covid19treatmentguidelines.nih.gov/adjunctive-therapy/vitamin-d/

Zinc

A lot of people think that Zinc is the wonder supplement when it comes it respiratory infections.  There is some indication that low zinc levels can increase risk of bad COVID infections.  There is no indication that taking zinc if you aren’t deficient does much.

I still generally recommend folks take 25 mg of Zinc a day while they are combating COVID.

Vitamin C

Vitamin C is another vitamin that is a "wonder vitamin."  It is the sort of thing that most of us take more of when we come down with colds.  There have been studies done looking at mega doses of Vitamin C (6000 mg) with COVID and did not indicate any benefit.

On the other hand, there was a study that showed that taking between 1000 and 2000 mg at the first onset of cold symptoms seemed to shorten colds duration by a little bit.  This is the dosage that I recommend people to start on.  It is safe and may help a little bit.

Other Over the Counter Medicines

Some people complain of stomach upset with COVID-19 and it can be helpful to take some Pepcid as this is pretty effective at calming that down.  Typically the cough with COVID is a dry cough, but if you have much mucus production, Guaifenesin (Mucinex/Robitussin) can be helpful to thin that out so that it doesn’t gum things up as much and is easier to cough out.

I do not recommend the “D” versions, as the pseudoephedrine in them tends to raise blood pressure and heart rates without a whole lot of benefit.

Monitoring

Hopefully you have a thermometer and can keep track of your temperature curve.  I am surprised how many moms think they can tell someone's temperature by a hand on the forehead.  "Feels like about 101, Honey."  Even if you have this skill, it is nice to have a calibrated instrument capable of giving an accurate reading.

The handiest thing to have if you are dealing with a COVID infection is a pulse oximeter.  A pulse oximeter used to be a very expensive piece of equipment that only medical offices and clinics could afford to have, but the prices have come down a lot.  It is a little device that goes on the end of a finger (or a toe) and gives you an oxygen saturation and pulse reading.  These are two important things.

Typically, even if you feel bad and are working a little harder to breathe, your oxygen level should stay up.  Three reasons to consider heading to the hospital for further evaluations are (1) decreased oxygen level (less than 95 percent for someone without chronic lung disease), (2) fast pulse rate (over 100), or fever that stays elevated despite medications to bring it down.

Other Medicines

It is hard to know what to say about other medications.  If you have asthma, certainly COVID can worsen your control and increasing inhalers and even adding steroids would be in order.  As far as steroids and COVID in patients without asthma exacerbations, they don’t help, unless people need to be hospitalized and placed on supplemental oxygen.  I have tried nebulized budesonide and despite reports to the contrary it really didn't seem to make much difference in how my patients did (they generally did fine, but there was no sudden turn around with this).

Hydroxychloroquine really doesn’t seem to be effective and isn’t recommended, despite some doctors claiming that it is helpful.  I know this has become very political, but if Dr. Zelenko's treatment regimen has any benefit it is from the Zinc.  I can't find any studies that replicate his retrospective study findings.  Hydroxychloroquine to treat COVID-19: Evidence can’t seem to kill it | Science-Based Medicine (sciencebasedmedicine.org) 

Antibiotics are not generally helpful unless someone begins to show sign of a bacterial infection on top of their COVID.  This will typically either be in a patient who requires hospitalization or someone who thought they were getting better and then a few days later begins to have recurrent infectious symptoms.

I will mention Ivermectin only to say that I don’t know about it.  Some are recommending it now, at various stages of COVID infection.  It may help, but it probably needs some formalized testing.  This is a summary of the issues with studies dealing with ivermectin.  Ivermectin is the new hydroxychloroquine, take 4: Bret Weinstein misrepresents meta-analyses | Science-Based Medicine (sciencebasedmedicine.org)  The studies all seem to include lots of other medicines including lactoferrin, hydroxychloroquine, doxycycline, steroids and Zithromax making it difficult to sort out what benefit is really from ivermectin and what is from other things.  Further, one of the biggest studies that showed benefit from ivermectin has recently been withdrawn due to some issue with plagiarism and fraudulent data.  Flawed ivermectin preprint highlights challenges of COVID drug studies (nature.com) If your health care provider is comfortable prescribing it, it probably wouldn't hurt, but I have not found it be helpful in my practice.

Monoclonal Antibodies

The number one thing that we know helps people avoid hospitalization are infusions of monoclonal antibodies.  These are infusions of antibodies that are targeted at the COVID virus, basically to help our immune systems fight of COVID more effectively.

The studies that looked at REGEN-COV antibodies found an 81 percent reduction in "events" (deaths or hospitalizations) between the antibody group and the placebo group.  1.5 percent of those who got antibodies required hospitalization, while 7.8 percent of those who got placebo ended up in the hospital.  Phase 3 Prevention Trial Showed 81% Reduced Risk of Symptomatic SARS-CoV-2 Infections with Subcutaneous Administration of REGEN-COV™ (casirivimab with imdevimab) | Regeneron Pharmaceuticals Inc.

It is important to note that these antibodies are most helpful if given early -- they are not approved for people requiring hospitalization and oxygen therapy.  They probably show the most benefit in patients who are at high risk for developing complications from COVID -- people over 55 years of age or those with risk factors.  They are not approved for people under 18 years of age.

Many states require a referral from a medical provider to give these infusions, but some states have set up infusion sites where people can self refer upon receipt of a positive COVID test.

Antiviral Agents

There are a couple of antiviral agents that are likely to be available soon in the United States.  The first one, from Merck, is called molnupiravir.  It is moderately effective for those who have mild to moderate COVID and cut people with those symptoms need for hospitalization by 30 percent.  The benefit of this is that it will probably be cheaper than an antibody infusion and of course, it is a pill, so it doesn't require a visit to a specialty pharmacy.  At this point, if someone is high risk for developing severe COVID, I would still do an antibody infusion as it seems more effective than this antiviral medication.  9 Things You Need To Know About the New COVID-19 Pill > News > Yale Medicine

Pfizer is releasing a protease inhibitor called Paxlovid.  Early data suggests that it is about 90 percent effective at preventing progression to severe COVID.  This pill is a little farther away from release, but my guess is that the benefit of this will replace monoclonal antibodies for the majority of people.

Obviously, there are many scientists working on specific agents against COVID and there will be more things coming out that will be quite effective.

Primary Care Provider

I know a lot of folks get their routine care from places like Urgent Cares, but it is really helpful to be established with a primary care provider.  Even if you get your COVID swab at an Immediate Care, the follow up will be done by a primary care provider.

Our office has been calling patients daily to check up on them after a COVID positive test, until they seem to have turned the corner.  If there are issues that develop, we are able to treat or help them sort out what the next step is.

I think it is important, even in a quarantine period, that people realize they are not alone.

Hospitalization

Probably only about ten percent of people with COVID will end up in the hospital.  Obviously at this point, you are in the hands of someone else and will need to rely on the doctors at the hospital for good care.  Typically now, depending on how sick you are, hospitalized patients are being treated with dexamethasone (a steroid that has the best data for reduction of COVID mortality), oxygen, and low molecular weight heparin (for prevention of blood clots). 

Remdesivir is a medication that is used in some ICU settings.  It has gotten a bad reputation due to some doctors (who don't work in ICUs) claiming that it causes kidney failure in a high number of patients.  Studies do not show that when Remdesivir is used to treat COVID pneumonia that increases the risk of kidney failure.  I will say that some pretty major trials have shown minimal benefit to using Remdesivir.  The Cochrane Review analyzed data from multiple trials and indicated that it is pretty ineffective at reducing length of hospital stays or deaths.  Remdesivir for the treatment of COVID-19 | Cochrane  There is no indication that Remdesivir makes anything worse (the same Cochrane Review says that there are "fewer side effects with Remdesivir than other treatments"), but it may not be beneficial in the way that we hoped.  

Some patients will require ventilation.  ICUs are trying to position patients on their stomachs (prone positioning) to try to keep fluids from collecting at the back of the lung.  Obviously, this isn't the easiest position to care for someone in, but it does make a difference in survival rates.

We are doing much better at taking care of patients who are admitted to the hospital.  Even for people who require ICU admission, at least 70 percent will survive, although it will probably be a long road to get out of the hospital.

Hope

The most important thing to me with any diagnosis is not to lose hope.  This is true with COVID-19 as well.  Regardless of the things that you have read about how terrible things “can” get with COVID-19, chances are good that you won’t ever need to cross that bridge.  Worry does not change a thing about the future, but it certainly makes the present less enjoyable.

I have made lots of these sorts of calls to inform people of positive COVID test results.  The most important thing for me in those calls is to remove the sense of despair that many, particularly the elderly, experience with this news.

As I think about it and what to do with the time you have while isolating, I would encourage you to pray – not just for your own healing, but also for those who are experiencing it first hand, the health care workers who are stressed out, and just for general healing in this nation.

Real good can come out of any experience.  Even wading through the waters of a COVID-19 diagnosis.

“When I am afraid, I put my trust in you.”  Psalms 56:3

The Mind of Vince

 

"Vince," my wife, Elaine, said.  "I'm looking for the CD that Elliot needs to play along with for his piano practice.  Do you know where it is?"

"Of course," Vince answered, looking at the stack of CDs he had been sorting through earlier in the day.

Our household is one of the few south of the Mason Dixon line that still listens to CDs.  I think, everyone else uses Pandora or Spotify or has reverted to vinyl.  I don't know if these silvery discs are better than MP3s, but since we own them, we still listen to them.

"Well, where is it?"  Elaine asked Vince, with a touch of frustration in her voice.

"It should be easy to find," Vince said.  "I just finished organizing them."

Elaine studied the CD boxes for a several seconds.  "How did you organize them?  They don't seem to be organized either by style of music, or alphabetically."

"Oh, I didn't organize them that way," he replied.  "I organized them by copyright date.  It makes more sense than any of the ways you mentioned."

He went over to the stack and thumbed through them.  "Here it is," he said, offering the CD to his mother.

Vince's mind works differently from mine.  It may be an obvious way to organize literature, but I can't imagine trying to find something in a library where all of the books were arranged by copyright date.

"Ah, yes sir, The Lord of the Rings you say?  That would be over here in 1954.  Right beside Wheel on the School and Horton Hears a Who!  A very good year if I might say so..."

I may not understand how my son's mind works, but I fathom even less of the mind of God.  Isaiah 55:8,9 say, "For my thoughts are not your thoughts, neither are your ways my ways, declares the Lord.  For as the heavens are higher than the earth so are my ways higher than your ways and my thoughts than your thoughts."

William Cowper wrote words to a song many years ago:

    God moves in a mysterious way

      His wonders to perform.

    He plants His footsteps in the sea

      And rides upon the storm.

The problem isn't that God's ways don't have purpose.  The issue is that their purpose is far beyond my feeble ability to fathom.  It is easy to think that God doesn't know what He is doing, or worse, that He is a capricious God, vindictive, and only looking for our destruction.

Nothing could be further from the truth.

When we don't understand God's purposes in our lives, it is mainly that we don't really understand God's mind or His ways.  The best course is to trust Him and wait.

We will see that our Heavenly Father has our best purposes at heart, even when His ways are mysterious beyond our understanding.