March 23rd Bulletin

Greetings on the start of the week!  

The weekend saw a lot of new cases in the area and around the world. Columbia County had its first several positive tests to report, and Berkshire County edged to 23 confirmed cases. Testing in Pittsfield has expanded; the question is whether they will be able to keep up with the demand.  The nurse triage line at BMC (855) BMC-LINK remains the central resource for testing info and general questions.

We continue to test at the office and will do so as long as we are able to obtain tests. We can report that we are seeing the vast majority of the sniffles come back as negative for Corona. But COVID-19 is here. I hear the ICU at BMC is currently at capacity.  Expanding capacity in the county is needed and is a challenge for a community that has seen an influx of its part time population this month.  We have often relied on transferring our patients to Springfield or Albany when we are overtaxed. This will likely still be an avenue but having more resources here will be critical. 
Business not as usual

We remain open, but like many offices we are limiting our in person traffic for everyone’s protection. Routine visits will be postponed, and visitors will be screened for any symptoms or high risk exposure. Please call before stopping by.  Doctors across the country have been conducting visits over the phone and insurance companies have indicated they will pay for services rendered in this fashion during this emergency. This follows the government passing a bill to allow Medicare to temporarily reimburse in this way. We don’t want to pass on any extra financial burden to you, and we will mindful of that as we navigate our procedures around this.
Public Health Partners

Worldwide cases are near 1/3 of a million, per one source.  China is holding steady at 80K plus.  Italy has climbed to near 60K and the US has 30K positives tests.  These are the three countries with the highest case counts. Stories from Pakistan and Iran, in particular, highlight the challenges countries have when the first wave isn’t met with good public health measures. For all of the regrets we may have as a country about our preparedness and response, we still can be very proud of how hard the public health sector is working for our well being!
Can’t smell?

Clinicians are noticing loss of smell and/or taste can be a sign of the Coronavirus, even in the absence of other symptoms.  It doesn’t happen all the time, but it can be a clue when it does. People are encouraged to consider themselves contagious if they suddenly can’t smell their morning coffee and to isolate themselves and pursue testing.
Cytokine Storm

This is an important part of the novel Coronavirus syndrome. There is a initial phase which can often have some combination of fever, muscle ache, sore throat, cough and even diarrhea followed by a mild recovery. Often this leads into a second phase where a robust immune response called a cytokine storm is experienced. Worsening of symptoms, including shortness of breath, can be a part of this phase. This is not unknown in the infectious disease world, and it is the target of proposed interventions. You might have seen how a combination of a Z Pack (azithromycin) and a course of Plaquenil (hydroxychloroquine) has been shown to reduce the viral load in a small study from abroad. This is very promising.

There is also the concern that boosting the immune system indiscriminantly could worsen the cytokine immune response.  When people ask what they can take to boost the immune system, we can’t respond with any evidence to back us up.  Recently higher doses of vitamin D have sparked a little theoretical concern for up regulating the Coronavirus virulence.  It’s only speculation but now some doctors are recommending not exceeding 1000U daily.  One thing that we as a global community have used a lot with good results with COVID infections is Chinese Herbs. They should be considered. We have several great acupuncturists in our community. I have been in recent contact with Allyson at Good Chi Acupuncture in Sudbury, a college classmate, who tells me she has a supply of good quality herbs and has been in connection with contacts in China as to what protocols they are using.  She is offering Skype/phone visits to individualize a regimen.
Lock it down harder?

The UK recently came out and is strongly suggesting the the vulnerable population stay put and not even go out for groceries but rather rely on family and community to do it. This is something we should be considering. Granted we aren’t the big city, but the idea is we are best off thinking that the medical world might not be able to help if we get so sick that we need advanced hospital level attention. We are safest at home. Contact us if you need help with finding resources for shopping.


And how long?

Most people are have been pretty insulated for close to a couple weeks now and wonder what to expect. There is some speculation that it be a long time BUT it may only need to be several weeks (rather than months), according to models put forward in the article, The Hammer and the Dance.  Basically we are in the “Hammer” stage where we need to be very strict with our distancing and isolation policies to weather the initial surge. This doesn’t need to be excessively long; it just needs to get us through this first surge.  Then we can enter the “Dance” stage where we can loosen up (ie, return to life) and be selective as to which communities need to be extra cautious based on testing and new case data.  There is good information coming through that tells a reassuring enough of a story to have a lot of hope, in my opinion. The population will rapidly get to the point where the virus can’t find new people to infect and will peak.
Cautiously optimistic

Most of what we hear now is strategy based on the real worst case scenario of overwhelmed medical systems.  We want to spread the serious case load out over time. Strict isolation in certain populations is imperative.  Social distancing in all is critical. The numbers used are grim but speculative. It’s valid to think along these lines, and helpful to be as aggressive as possible during this first wave…. but the numbers are not finely tuned.  What I’ve consistently been able to find behind the scenes is the story emerging from the quiet, super smart calculations of the numbers guys. I like the smart numbers guys and what they have to tell. And the story that’s there when the situation is carefully deliberated is reassuring.  For example, Korea’s data is really relevant because they have, by far, tested most widely.  They were prepared to do so because previous SARS outbreaks hit home.  Their population is older, and despite this fact, the case fatality rate there is less than one percent, in the optimistic range.

It’s tough now and it’s going to be tougher, but while the worst case scenarios (3% and possible re-infection) get a lot of air time it’s way more likely that we will be spared from the worst, if we hold the line with our social distancing.  I make this point because we can use this knowledge to help ourselves to take on the task I describe next.
Confronting Fear
Emotions influence health and the immune system. Calmness is a important entry point to important territories. Florence Nightengale marveled at “how very little can be done under the spirit of fear.” In other words, a daily practice in peeling back the layers of the onion of what we are holding on to in this regard opens the door to immeasurable Goodness. Overcoming fear will guide you in all paths of life. That is my opinion. What does that look like? Start by listening to how you talk to yourself. Develop the habit of complimenting yourself regularly. Be inquisuitive and compassionate if you notice negative thinking patterns. I think the real secret is to realize that you are not alone. You have helpers willing to give aid if you ask for it. You’re worth it! Don’t forget it.

Don’t hesitate to reach out.

In Solidarity,

Dr Cooney