We’re inching up on forty million confirmed cases of Covid-19 in the US since the pandemic began about 18 months ago. Over the last four weeks, there have about 4 million new infections and about 27,000 deaths. We’re not quite where we were last winter when no one was protected by vaccines but we’re rapidly approaching it, and have certainly surpassed it in the Republican states that have decided basic public health measures are somehow un-American. Florida, of course, continues to lead the way with numbers blowing last winter out of the water and Texas isn’t far behind. Alabama is not doing well, but at least our governor is taking a laissez-faire attitude towards tried and true means of spreading infectious disease rather than actively campaigning against them. The 7 day average for cases in Alabama is now about 15% higher than it was at the peak of the winter surge. How that’s going to translate into hospitalizations and mortality in a month or so remains to be seen as it’s unclear to me how many of those cases are in at risk for serious complication populations and how many are breakthrough cases in the fully vaccinated.
The resident I took on my rural house calls rotation today just came off the medical intensive care service and had a couple of interesting things to say about it. Last year, the residents did not work with Covid cases. Before the vaccine, we were not about to risk the health and lives of young people just beginning their careers. Now that health care workers are vaccinated, the risks are much lower and the house staff are working with those patients on those floors. This young woman mentioned that all she took care of during her month of ICU was Covid. She felt good about handling those individuals but feels that maybe she was cheated out of learning about other medical conditions that require intensive care, everything else having been crowded out. She also was very interested in the family dynamics of the people she treated. The majority were in their forties and fifties, previously healthy, and, therefore, had not given thought to their mortality and prepared no advance directives and had no discussions with their families about such things as code status, CPR, or final wishes. Time and again she found herself in the waiting room with their children, mainly high school age to mid-20s asking them what should be done and these young people not really being able to comprehend what was being asked of them. They almost always said ‘Do Everything’ because it’s their understanding that they should have their parents until they themselves are comfortably middle aged and they can’t imagine being young without them. They don’t really comprehend that ‘Do Everything’ in an ICU situation with a disease that destroys the lungs rarely turns out well for anyone concerned.
I was wondering what I should write about this evening when I ran across yet another news story about ivermectin, the antiparasitic drug that has caught on as a treatment for Covid-19. In this particular column, the author was talking about people getting the veterinary version as a topical paste, diluting it with water, and then injecting it. The trained physician in me just shivered as there’s so many things wrong with that approach that I don’t know where to begin. Perhaps they’ll start rubbing it into their eyeballs next. As I believe I wrote earlier, there is good scientific evidence that ivermectin blocked replication of the virus in the laboratory. Experiments to show what dose might be appropriate in a living human and whether it has that same effect in living tissue rather than in cell culture have begun but have not yet produced any data that would allow the FDA or any other regulatory body to approve the drug for use in the treatment of Covid. These experiments are in process and, if they show promise, I’ll certainly write about it at that time. In the meantime, ingesting topical horse paste or injecting dewormer mixed with tap water is a really bad idea. There are a number of people in ICUs nationwide with liver failure from ivermectin toxicity, taking up those few beds not occupied by Covid patients. And take it from a physician, dying from liver failure is not a pleasant way to go.
Physicians, with our ceremonial robes of the white coat, descend from the priesthood. We are the intercessors with the gods and with fate who miraculously restore the balance of the world through the healing of the individual. As George R. R. Martin put it, ‘What do we say to the god of death? Not today…’ As these age old archetypes have come down to modern America, a little of the idea of healing magic has continued to cling around the edges. We’re a very literal people so we like our magic to take physical form so we embody it in the prescription. Most healthy people, when they have need of medicine, have developed an acute illness or complaint that has some sort of reliable cure or amelioration. If we’re going to take a day off work, drive downtown, spend twenty minutes trying to find a parking space in the over full deck, wait while the doctor is running an hour or more late thumbing through an old Golf Digest, and then sit in a too cold exam room in our underwear, we figure we better get something for all that inconvenience or we’ve wasted our time. The prescription in part of the deal and its implicitly understood on both sides of healer and patient. We therefore tend to imbue the prescription with supernatural powers for good and we carry that idea of medicine is a good thing with us throughout our lives. When this gets mixed in with our cultural ideal of the quick fix, we lose track of what medications actually are. Medications are controlled doses of poisons.
What is a poison? A poison is a substance, which when taken into the body, alters that body’s balance and physiology to a negative end result. A medication is a carefully measured and tested substance, which when taken into the body, alters that body’s balance and physiology. It’s more or less the same thing, only with medicine you trust you aren’t going to get that bad thing happening. Some medications are literally poisons. The most famous example is the drug warfarin (brand name Coumadin) which is used as a blood thinner. It’s called warfarin because it was developed at the Wisconsin Army Research Facility (WARF) – it’s intended use when first invented? Rat poison. In the 19th century when medications were not regulated, people were poisoned and died from them all the time. The public outcry during the progressive era is what led to the creation of the FDA to begin with. It coincided with the Flexner report that helped to standardize medical education and society accepted that only trained individuals should handle and dispense medications as they could be dangerous in untrained hands which is why physicians, nurses, pharmacists and the like all have to go to school for a very long time and pass innumerable exams to get licensed. Every state in the union has a vested interest in making sure that even controlled doses of poisons are used judiciously with appropriate understanding – something one does not find in social media groups of people hawking outlandish cures.
The biggest issue I have with medications as a geriatrician is in convincing older people that sometimes deprescribing is better than prescribing. Older people, as they sail through life, collect up various ailments and disease processes. It’s inevitable. With access to Medicare and an almost unlimited number of specialists, they also collect up any number of medicines to treat these, or the side effects of the original medications (controlled doses of poison, remember…) Sometimes you need to put the ship in drydock and scrape a few of the barnacles off. Geriatricians are comfortable with this. Patients, their families, and most other doctors are not. There was a great experiment done a few decades ago using family practice residents. The residents sent their older patients to a geriatrician who would then make recommendations for care and send them back to the resident for implementation. Residents are young, impressionable, want to be the best they can be, and take their elders ideas and ideals as gospel as they prepare to move up in the world. You could see this in this experiment. If the geriatrician suggested that the resident start a new medication, they did this more than 95% of the time. However, if the expert recommendation was to stop a medication, the resident would only do this about 30% of the time. They would not deprescribe. Deprescribing is antithetical to how we are trained to think as doctors and it’s a concept that’s difficult for a brain, trained to hone down through a differential diagnosis to find just what the problem is an just the right medication to fix it, to wrap itself around.
As the baby boom, with its generational love of substances of all types, continues to age, becoming more and more geriatric by the year, it’s going to become even harder for I and my colleagues to keep people out of trouble. Not only do we have to worry about medications, we have to worry about substance use, over the counter medicines, herbal and other natural remedies, things hawked on late night infomercials, and stuff they borrowed from the neighbor which may or may not be appropriate for who they are. The average older person takes seven medications daily (four prescribed, three over the counter). There has never been a controlled study published in any language on a human body with more than three drugs circulating in their system at the same time. It’s too hard. We have no clue from a scientific point of view what’s going on in someone with 7…9…16…22…37 medications entering the blood stream daily. That’s the art of medicine and it’s more medicine Jackson Pollock than medical Rembrandt.
It’s late. I have an early morning meeting. You know what comes next. Wash your hands. Wear your mask. Keep your distance. Get your vaccine.
Life, The Universe, and Everything 