Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

Cape Cod

Easter Sunday musings…4/12/Pandemic

Sunday musings…

1) Indicator. The Sunday paper circulars are interesting. 2, 3, 4 weeks ago the Sunday paper was stuffed with the usual ads from drug stores, Home Depot and the lot. I couldn’t figure out if that was a hopeful sign. Typically there are 15 or more circulars; today there were 3. No mystery here; not hopeful.

The economy has capitulated.

2) Masters. It’s Masters Sunday. Each year I ask that it be ok for me to be allowed to check out from any responsibilities, take command of the TV, and watch the final round of the Masters. Not gonna lie, not having a Masters to follow this year was by far and away the strangest sports non-event for me. Bigger than no Opening Day, no Final Four. CBS has come to my rescue, showing the epic final round of the historic 2019 Masters. It’s almost normal. Beth is doing something useful, I’m bloviating via keyboard, as useless as can be, sitting on my keister watching Tiger.

For the first time in a couple of weeks it feels almost normal.

3) Lockdown. How long can our largest medical institutions in cities not yet “surged” remain at 50% census? I am told that the ophthalmology division at the Cleveland Clinic is down 80% in the clinic and 90% in the OR. In the community taking its lead from CCF it is 90% and 99%. The Clinic (and others such as the Mayo Clinic) are predicting annual losses exceeding $1 Billion at their institutions. Countless patients have seen carefully planned medical care disrupted, further inconveniencing them and their families, and in many cases causing significant financial hardship layered on top of that which everyone else is suffering.

Why the big draw downs in care? So-called “non-essential care” has been shut down, pushed out in order that supplies of equipment (e.g. ventilators) and material (e.g. PPE) be warehoused so that it would be available when the inevitable waves of sick patients are blown in on the winds of COVID. Again, I’m not gonna lie, this particular rationale is a bitter pill to swallow. Enormous institutions with the power to simply float their own loans and cover a loss are complicit in the egregious denial of the coming disaster, failing as fully as the federal government to stockpile what was necessary to be ready. My patients, my staff, and I are direct victims of their lack of vision.

What prevents me from being engulfed by bitterness at this particular aspect of the pandemic is the real reason that “non-essential” care was reasonably shut down and pushed out: medical offices, clinics, and operating rooms working under standard operating procedures are quite simply incompatible with any form of physical distancing. If I go to work and work is normal nearly a hundred patients move through the office in a typical day. Along with them come all manner of family and friends. On my days in the OR 15-20 patients will have surgery, again accompanied by family or friends. It’s not just the patients who are at risk due to the nature of busy offices and OR’s, but all of the staff and doctors as well. And trust me, an eye doctor’s office isn’t the place that all of those missing masks and other layers of PPE have been hiding out. We have been out of masks at our office for weeks. I could protect neither my patients nor my staff.

How long?

4) Compassionate. Again, Twitter is the double-edged sword of my quarantine life. There are some really super smart people hanging out there, and in the spirit of general goodwill most of them have been on their best behavior when “talking” with smart folks who aren’t necessarily smart in their particular area of, you know, smartness. Others, on the other hand, have been just as arrogant and dismissive as ever.

Yesterday I was engaging in one of many discussions of using medications that are either not yet approved for, or whose use for treating COVID-19 would be off-label. Newer medicines without a clear-cut history from which to judge safety pose one very specific problem: can their use in cases of last resort, so-called “compassionate use”, be justified while the option of enrolling randomized, controlled trials (RCT) is available. On the opposite end of the spectrum, is it OK to use older medications with a known track record that includes a very strong safety record in the hope that theoretical benefits will be proven to be actual benefits, again when the option of enrolling patients in an RCT is available.

No less that Dr. Anthony Fauci, the DC biocrat (my term for him coined last week) advocated for what he called the parallel course of doing both, enroll RCT’s and provide medications on a compassionate use basis, when he was faced with another new virus that was killing people at an alarming rate in the 1980’s. When the AIDS crisis was new he realized that waiting for the definitive proof available (though sadly not always forthcoming) from an RCT would mean that people afflicted with HIV and suffering from AIDS would die while the academicians calculated. Safer, older medicines where likewise studied as prophylactic medications in much larger study groups while at the same time being given to large numbers of individuals outside the trials.

When I posted that our present crisis, that includes both the terribly ill at high risk of death as well as the barely afflicted who may or may not end up in the ICU, was analogous to the 1980’s and AIDS I was insulted and belittled by the academicians. Not willing to engage on the ethical and moral grounds of the “parallel course” they instead played king of the hill on the head of the pin of RCT dogmatism. The use of unapproved medications in the most dire circumstances without clear proof that they are not harmful was declared immoral; those willing to even discuss the use of new anti-virals outside of an RCT were labeled naifs without the mental chops to even be given a seat at the table. Likewise the off-label use of an older medication with a sterling safety profile for prophylaxis. There was a barrage of condescending straw man arguments and outright ad hominem.

Why post this here, today? Listen, there were two important conversational threads to be had on this issue yesterday. One on the how and why of RCT’s in both the very ill and those who might become so. The other, no less important, was whether a “parallel course” of compassionate use originally discussed during the AIDS tragedy of the 1980’s by no less than Dr. Fauci, was appropriate. One conversation is cut and dried, ┬ámathematical in nature and wanting only the mechanics to implement. The other is an ethical discussion, one that requires a different vocabulary and one that is open to a wider group of conversant, the insular and dismissive instincts of the academicians notwithstanding.

There will be endless armchair quarterbacking in the months to come. Dismissing people like me, with or without the backslap of insults and derision hitting my backside like the proverbial door as I exited the conversation, will not likely make it any easier for those who demanded the pulpit resting on the head of that pin. It will be hard to offer much in the way of understanding after the fact to those who have extended so little now, in the heat of the battle, to those of us seeking only to understand.

I’ll see you next week…

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