Dear Community,
We hope you are all safe at home if you can be. We know many of you need to still be working outside of the home (big appreciation to health care workers, grocery store workers, food preparers for take out, delivery people and others) thank you for all that you are doing.
Below is a new dispatch from the frontlines from my brother, Dr. Jordan Shlain. This is Dispatch #5. We will continue to send these as long as they’re needed.
And a few updates from us:
NEW GLOBAL CLOUD FILM: We are loving the videos you are sending in! So great that many teachers here are having their students participate. This is a perfect thing to do while you are home. You can do it through zoom, your phone, or with any recording object near you individually or in digital groups on screen. We welcome voices of all ages and from all over the world. Watch our 4-min film A Declaration of Interdependence and SUBMIT a video of yourself answering some questionsand reading the poem "Lockdown" for our new cloud film. Deadline is this Friday.
FRIDAY ZOOM CHALLAH BAKING MORNING & DISCUSSION W/RESEARCHER
*10am PT Friday: The Zoom Challah Baking class last friday was so much fun that we are doing it again this Friday 10am PT. All info and ingredients here.
*I’ll also be doing an online discussion with researcher Dr. Tracy Dennis-Tiwary about creating boundaries around screen use while we are in this quarantine period. National Day of Unplugging is hosting this conversation on Friday at 11:30 am PT. All info here.
To seeing humanity shine during this crisis in many new ways,
Tiffany, Sawyer & The Let it Ripple Film Team
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A New Reality: The Stillness of Action
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Welcome to dispatch #5, insights from the front lines, where I hope to bring you an honest and sobering account of our new reality. My goal is to provide best understandings of the truth as well as pearls of clinical insight and practical considerations for you and your family.
We are at an existential crossroads. Each decision we make starting today will have a profound impact on the future. Please decide wisely.
I’m not panicking.
I’m preparing. This time it’s mental preparation.
We have now fully entered the psychological phase of this pandemic.
I think of the stages we are going through akin to Elisabeth Kubler Ross’s Five Stages of Grieving (denial, anger, bargaining, depression and acceptance) I believe ours are:
Denial
Disbelief & helplessness
Action
Grief/sadness
A new day -- rebirth
We have gone through the first two phases of denial and disbelief and now entering phase three: action.
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The Medical and Mathematical Truth
We are entering the exponential phase of viral activity all around the world. Our inability to understand the speed of parabolic growth is not surprising given that we’re equipped with a 150,000-year-old brain. Our blind spot is our cognitive deficiency in contextualizing exponential growth in the context of linear time. We are at an inflection point in this pandemic and every single action we take now will have outsized implications for our future.
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Finally, the CDC Reports on Americans
The CDC’s Morbidity and Mortality Weekly Report, March 18th
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The US finally has its own data on over 4200 Americans. While the Italy and China data can teach us something, it’s important to recognize that each country has unique statistical characteristics. The CDC published the first US study of what COVID-19 is doing to us here in America. The key takeaways are that adults over 65 years old represent 31% of all cases, 45% of all hospitalizations, 53% of ICU admissions, and 80% of the deaths.
Regarding the reports of young people getting sick: it’s very hard to interpret this early data given the dearth of detailed reporting. Were they vaping? Are they metabolically sick with diabetes? Were they the ones who were immunocompromised? Bottom line: young folks should adhere to the same physical distancing that adults are for the time being.
Facts
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Young people are also getting hospitalized, but they seem to recover.
Kids under the age of one are also vulnerable.
People with high blood pressure and diabetes are high risk.
According to a Lancet Study, 50% of nonsurvivors in this series had “secondary infection”—compared with 1% of survivors—a difference that was highly statistically significant. A secondary infection is an infection that occurs during or after treatment for another infection. It may be caused by the first treatment or by changes in the immune system
Surfaces Matter
We also know that coronavirus likes to stick on surfaces, as evidenced by this study, which found that coronavirus sticks to all sorts of materials, including cardboard. Good handwashing is crucial.
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Are We Asking the Right Questions?
As a person who studies philosophy, I’m more interested in getting the question than the answer right. Getting the right answer to the wrong question can be catastrophic...especially right now.
So, what questions should we be asking, right now?
Here are a few that I think are most proximal to getting us out of this situation:
- What should I do?
- Who can I help?
- Who can I trust?
- What is true?
- What does courage look like?
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Take Action
First, recognize that you can help. Staying at home and staying away from others is the most impactful; especially those over 60 years old.
Help older and immunocompromised people get food and assistance (specifics below). Check in on your loved ones—do it frequently. Be smart about how you share information.
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Be Measured
There is no asymmetry of information as this unfolds—we all have access to the same media. There is, however, an asymmetry of curation based on the nuances of science.
The “everyone is an expert” mentality often promotes the latest “news” but does not respect the clinical concept of the “risk/benefit” ratio. This is a tool all doctors use when deciding on an intervention: diagnostics or therapeutics. Real scientists understand the concept of pessimistic meta-induction and are very careful in how they interpret and discuss scientific studies. Non-scientific people propagate medical information that usually highlights the benefit (consumerism) without acknowledging the risks (public health).
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Stone-Cold Reality / Physical Distancing / Distant Socializing
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Let’s stop calling it social distancing
As the WHO just announced. It’s too vague and candidly a misnomer. What we need is “physical distancing” (@adamgazz) to flatten the curve sooner, so we can get back to a semblance of normal life.
The only way to slow this down is to stay physically away from each other. Just look at the math—it doesn’t lie.
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If you’re confused about what "social distancing" means, take a cue from the Beatles.
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It works—just look at the last pandemic.
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The Good News
Every top scientist, in every country in the world worth their salt is working on a treatment.
China has closed down its last coronavirus hospital; there aren’t enough new cases to require them.
Apple is reopening all 42 China stores.
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South Korea: the number of new cases is declining.
There are more drive-thru testing clinics now.
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The Bad News
- Italy, Spain, Iran are having a very tough time.
- The US has a (totally unnecessary) severe shortage of masks, tests, and protective gear for doctors. I have on good authority that many hospitals are completely out of masks.
- We are bad at physical distancing
- Fake masks, fake tests (dang, really)
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Covid-19 Symptoms
Some are asymptomatic and some have fever, cough, shortness of breath, loss of smell, or diarrhea. There is no “one set of symptoms” that everyone gets. What we do know is that if you have symptoms, you should get tested and if you have shortness of breath, you should seek medical attention. Emory University had developed a best practice symptom checker based on best clinical practices, CDC guidelines, illness severity and risk factors like age and pre-existing conditions.
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What To Do if You’re at Risk or Feel Sick
- Have a plan: Go to the website of your local Public Department of Health or hospital for local information on testing and access to medical careCall your doctor and know their protocol.
- Cancel any routine physicals/annual wellness visits.
- Cancel any non-urgent follow ups for stable chronic problems.
- Postpone mammograms, colonoscopies, elective procedures/surgeries for the next month at least; they will likely get cancelled anyway.
- Call your doctor for any new fever, cough, or shortness of breath.
- Call for any worsening of chronic illness or new nonrespiratory issues for which you need to be evaluated.
- Postpone non-urgent laboratory testing.
- Reduce risk profile: if you’re over 60 or have specific underlying medical problems, consider the Pneumococcal polysaccharide vaccine (PPSV23).
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How Can Cities Help? Part I
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States are starting to shut down elective hospital procedures and contemplating repurposing ambulatory surgery centers into ICU beds. There are alot of ventilators sitting in the 5000+ ambulatory surgery centers that dot the country. It could be a godsend to free up all that capacity for those in need.
State and local officials are starting to take over hotels, stadiums, and dorms to create quarantine zones and overflow clinics. Finally.
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Optimize Your Immune System
Eat real foods as much as possible. Processed and ultra-processed foods are not good for your immune system.
Get sleep. Remember that the last hour of sleep is the most immune-boosting time; set your alarm clock to go to bed!
Alcohol is an immunosuppressant. Try to limit alcohol or at least drink lots of water.
Get exercise; it’s a great way to mitigate anxiety.
Support your local restaurant with take-out. Be sure to transfer food to your own dishes and carefully wash hands when getting take-out.
Have Zoom, FaceTime or Hangout meetings; they’re super fun and good for mental health.
“Live in rooms full of light. Avoid heavy food. Be moderate in drinking of wine. Take massage, baths, exercise and gymnastics. Fight insomnia with gentle rocking or the sound of running water. Change surroundings and take long journeys. Strictly avoid frightening ideas. Indulge in cheerful conversation and amusements. Listen to music.” —De Medicina, Aulus Cornelius Celsus, c. 25 BCE–50 CE
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Engage/Protect the Children
There’s a lot of news coverage about the outbreak of COVID-19, and it can be overwhelming for parents and frightening to kids. The American Academy of Pediatrics encourages parents and others who work closely with children to filter information and talk about it in a way that their child can understand. These tips can help:
- Offer simple reassurance. Remind children that researchers and doctors are learning as much as they can, as quickly as they can, about the virus and are taking steps to keep everyone safe.
- Give them control. It's also a great time to remind your children of what they can do to help—washing their hands often, coughing into a tissue or their sleeves, and getting enough sleep.
- Watch for signs of anxiety. Children may not have the words to express their worry, but you may see signs of it. They may get cranky, be more clingy, have trouble sleeping, or seem distracted. Keep the reassurance going and try to stick to your normal routines.
- Monitor their media. Keep young children away from frightening images they may see on TV, social media, computers, etc. For older children, talk together about what they are hearing on the news and correct any misinformation or rumors you may hear.
- Be a good role model. COVID-19 doesn’t discriminate and neither should we. While COVID-19 started in Wuhan, China, it doesn't mean that having Asian ancestry—or any other ancestry—makes someone more susceptible to the virus or more contagious. Stigma and discrimination hurt everyone by creating fear or anger towards others. When you show empathy and support to those who are ill, your children will too.
- Give them other things to think about. Google Arts & Culture has partnered with over 500 museums and galleries to feature virtual tours and online exhibits from the most famous museums around the world.
- Common Sense Media has a number of online events.
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On Testing
The short version is everyone should get tested. The longer version is that we were woefully unprepared and we are currently only able to test those with symptoms. Furthermore, the best tests we have to confirm infection of COVID-19 are only 75-80% sensitive using Polymerase Chain Reaction (PCR). We need to do better.
The world of ELISA testing is the next frontier. These tests tell you if you have had infection with COVID-19 and if you are immune. The FDA is fast tracking many of these tests, yet leading virologists are skeptical given the lack of peer-review and quality control.
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On Treatment: The Search for Coronacillin
There is lots of noise in this space, and to be clear—it is mostly noise. The great hope for chloroquine and hydroxychloroquine are still very anecdotal. There have been no large scale studies and certainly nothing rigorously examined and peer reviewed (the gold standard) but they are underway.
Furthermore, these medications are toxic to your heart and can kill you if you take too much or mix it with other medications. It would really suck to die taking something that was supposed to prevent you from getting something that has a low probability of killing you, right?
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On Immunity
It is reasonable to expect that there will be partial immunity for some period of time while people get infected. This is similar to how you can get a common cold one year and still get the common cold the next year. They mutate slightly every year.
It’s worth framing this coronavirus in the context of the other, more common, four coronaviruses that make up the twenty plus viruses that constitute the common cold.
When each of those viruses first appeared, hundreds or thousands of years ago, they would have been devastating to the humans alive at that time because they, too, would not have had immunity to them.
Over the years, humans have acquired more and more immunity to them which is why they are relatively minor illnesses.
One scenario is that this coronavirus becomes the fifth regularly circulating coronavirus. If this is the case, we would expect that with each successive year, humans would get more and more immunity.
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On Courage
Courage is the quality of mind or spirit that enables a person to face difficulty, danger, pain, etc., with the appropriate attitude towards fear. We all need to embody our inner courage. This is an innate quality of being human. Demonstrate your concern for the fears and anxieties that you and those around you are feeling. Emphasize empathy; no one has the “right” answer. Share your concerns and spend more time on the right questions. This is where humility lives. Over-communicate and be purposeful.
I strongly encourage you to step out of your comfort zone and be bold. Now is the time when the courageous are separated from the cowards.
Again, in the words of Churchill, “Never, never, never give up.”
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Celebrate/Acknowledge the Heroes
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Big shout-out to all my colleagues and peers on the front lines. Huge shout-out to the medical guild who pride themselves of selfless compassion and risk their lives everyday in the service of their fellow citizens. To all the physicians, nurses, respiratory therapists and all clinical and non-clinical staff helping out in the emergency rooms and intensive care units: you are the heroes of 2020.
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A new Lancet study suggests that the quantity of viral load might be a useful market for assessing disease severity and prognosis.
Covid Ready Communication Skills: A playbook of tips on how to about to talk about difficult topics — in almost every language.
If you’re a doctor on the front lines looking to join a chat group and share experiences, please message me on LinkedIn.
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I hope this was helpful.
For all of you who got to the end, thank you for taking your precious time to read. Please share this dispatch if you feel compelled. My aim here is to make a small difference by giving you the tools on how to think about how to think and act.
Meanwhile, I’m going to practice some metaphysical distancing :)
Jordan
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Dr. Jordan Shlain is a practicing internist who manages a team of doctors and nurses in SF, Silicon Valley, NYC, and LA. Follow him on LinkedIn and Twitter. This whole dispatch is also on Tincture and you can sign up for updates directly from Dr. Shlain there.
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Trusted Resources
Great Articles & Presentations
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