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CMO Covid Blog Orange County- Latest numbers from the Caduceus Covid Treatment Team


Last week, we gave a special bulletin on five items relating to the pandemic. To update this week, we enlisted the help of one of the most famous doctors of all time. He did this by eavesdropping on Annie, a young adult who sported a "good Annie" on one shoulder, and a "bad" Annie on the other. 
 
#1- A new symptom, diarrhea, had taken over as the most common symptom for Caduceus patients. That has not changed in a week, with the proviso that headache has now become the second most common. And those that have diarrhea typically do not have headache, and vice versa. Yes, we still have a lot of respiratory presentations. 
 
The issue is the raw volume. It is very difficult to keep up. The first 12 days of December we accepted 208 new positive patients into our treatment program.  It took four months in the spring to hit 250 cases. Today as I type this, we just assumed an additional 36 new cases.
 
In one day. 
 
A new issue is the challenge hiring new staff and doctors fast enough to take on this volume. So if you interact with our staff, realize many are putting in 12 hour days, 7 days a week with no vacation this year. 

The current spike was predicted by many (including this blog), with the Thanksgiving holiday being the main culprit. But another culprit has emerged- most new cases were due to invalid quarantining.  Far too many patients went back to work, went to gatherings, and went out with friends despite not confirming a negative test after a positive one, or after a close contact. 
 
Let’s ask our guest doctor, Dr. Seuss, about the conversation with Good Annie vs. Bad Annie---Bad Annie has lost her sense of taste and smell...Good Annie advises to quarantine while being tested.
 
BAD ANNIE:   
I do not like Covid 19
I do not want to Quarantine!
 
GOOD ANNIE: 
Would you, could you in your house?
Maybe even with a mouse?
 
BAD ANNIE:
Not in my house
Not with a mouse
I do not like Covid 19
I do not want to Quarantine!
 
GOOD ANNIE:
Would you, could you with a mask?
Maybe if we fill a flask?
 
BAD ANNIE:
Not with a mask, not a flask
I can’t believe you’d even ask
I do not like Covid 19
I do not want to Quarantine!
 
#2- We mentioned that tests were becoming scarce last week. We are pleased that we now have collected enough swabs to resume our usual testing advice.  Many labs are still warning about low supplies, so if you try to find tests close to Christmas at other facilities it may be difficult without symptoms. 

We have more PCR tests than the rapid antigen tests. But we do NOT advise rapid antigen tests in most cases, so try to ask for the more accurate PCR. We still offer same day or overnight results with the expedited test for a fee. We will continue to work hard to always have enough tests for our loyal patients.
 
So bad Annie, while you wait for your result; be sure to quarantine!
 
GOOD ANNIE:
Would you, could you play a game?
Pick up Stix is not that lame
Oh! I know a real fix
Find a series on NetFlix!
 
BAD ANNIE:
I do not play Pick up Stix
I don’t have NetFlix
I do not like Covid 19
I do not want to Quarantine!
 
GOOD ANNIE:
Would you, could you in a car
Maybe you could drive real far
Or better yet on a fancy train
Enjoy the view, out of the rain
Or better yet in a tree
Way up high, where no one can see!
 
#3 We mentioned last week that saliva testing may become available with another choice for a rapid result. We are still researching this. It still isn't ready for prime time.  We will keep you posted on social media and our website. 
 
BAD ANNIE:
Not in a car, not on a train, not in a tree, just let me be
I do not like Covid 19
I do not want to Quarantine!
 
GOOD ANNIE:
Would you, could you wearing socks?
Would you, could you with some Crocs?
 
BAD ANNIE:
Not with socks, not with Crocs
And I don’t want to hear from any docs!
 
GOOD ANNIE:
Here’s an idea, a fancy hotel
With food a plenty – just ring the bell
 
BAD ANNIE:
I cannot taste! I cannot smell!
I don’t want a fancy hotel!
You can keep your food a plenty
I’m so sick of Twenty Twenty!!
 
#4- Vaccine questions---Here is what we know now:
 

  • The Pfizer vaccine is FDA approved for all persons 16 and older to prevent Covid 19 
  • Our Federal government has allocated 6.4 million doses to be shipped now intended for hospitals and government health systems (eg. VA, etc). Their intent is to vaccinate health care workers, high risk seniors, residents of nursing homes, and assisted living residents. 
  • As supplies increase, the wider population will be able to obtain them at no charge at urgent cares, pharmacies, and physician offices. We are told this can optimistically occur in February or March.

We are on it.

 
Only the Pfizer messenger RNA vaccine has been approved. Found to be 95% effective, side effects were uncommon, naming the usual site pain, fatigue, headache, and chills. These were more common after the second dose that is required with the Pfizer vaccine. More traditional antibody vaccines are also asking for approval, and may become available through the spring. Patients could then pick their personal choice. 
 
We DO NOT know the duration of the immunity from the vaccine. An annual vaccine, much like the flu shot should be planned for most likely. 
 
The vaccine does nothing once the virus infects you. 
 
WHAT?  I’M POSITIVE???
Quarantine???
If you make me, if I must
For the better good I trust!
 
I’ll wear a mask, bring on the flask
I will take Covid to task!
 
I’ll take my meds and stay away
And quarantine all night and day!
 
I’ll nest and rest and then re-test
Because Caduceus says it’s best!
 
#5- How to reach us--We mentioned in last blog the issues with our phones. And with the huge spike this last weekend, answering calls timely is a challenge. However, we have hired more staff and will continue to make answering the phones a top priority.

On the positive side, we have seen a much higher volume over our website and app live chat feature and the email feature we call Mousecalls. Those continue to be the fastest way to talk to us.  With hundreds of tests a week, even calling back all the negative tests is challenging. 
 
WHAT?  I’M NEGATIVE???
 
I still don’t like Covid 19
But I survived the quarantine!
 
Hooray, hooray I’m finally free!
 
Now to build  IgG……
 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group

(With special thanks to Mary DeNicola, DNP, and Theodore Seuss "Ted" Geisel helping provide smiles in the midst of the worst part of the pandemic.)

CMO Covid Patient Bulletin Orange County December 2020

Special Bulletin-
 
We want to alert our Caduceus and PDQ patients to new developments regarding Covid ---the usual disclaimer-

These apply ONLY to our patients, other health systems may be experiencing different scenarios, or perhaps not reporting them.
 
1. New presentation of Covid
2. Testing shortage looming
3. New saliva testing update
4. News on vaccinations
5. How to reach us
 
1. New presentation of Covid
 
Like most of the country, we have had an explosion of new cases. So many that we have a difficult time to keep up with the pace. Our aggressive treatment program has been successful in reducing admissions, ventilators, and we are now at 1000 cases treated with no deaths. However, we postulate another mutation has occurred. 
 
For the past two weeks, a large percentage of new cases present with diarrhea as the only symptom. Because they have no fever, or respiratory symptoms, many patients feel it’s a bad burrito and do not seek care. The only other symptom they have is a definite fatigue, even the loss of taste/smell has been rare. Some of these patients do progress on to a full blown Covid picture, so it’s important to get tested if you experience a new onset diarrhea, DESPITE WHAT YOU MAY HAVE RECENTLY EATEN. 
 
 
OUR ADVICE-
 
Contact us for a telehealth visit at the first sign of diarrhea. Do not try to ride it out with some Kaopectate. Isolate immediately. 
 
2. Testing shortage-
 
As we have informed you previously, Caduceus does NOT run the tests ourselves, we swab and send them to a number of different labs to perform that function. The swabs themselves are NOT simply Q-tips , they are specialized swabs provided by the labs.
 
Due to the holiday rush, and the enormous increase in new cases, we have been warned by all labs that there may be a shortage of swabs, both PCR and rapid antigen. Although they cannot give us a time frame, we are hoping this is temporary until the “powers that be” can invest in more testing. 
 
OUR RESPONSE-
 
We will be testing close contacts and symptomatic patients as a first priority. We will not routinely test for every positive antibody. We suggest waiting 10 days in between swabs for patients under active treatment. We ask private companies that have been requiring weekly tests on their staff to temporarily change that to every two weeks.
 
Do not hold off on testing if you need it. We have sufficient swabs currently. But we may have to begin rationing if swabs become harder to come by. This is true for ALL medical centers that are testing. Be prepared to find it more difficult to obtain testing without symptoms. Of course we will give priority to our own loyal patients. 
 
3. Saliva testing-
 
Just in the nick of time, it appears there has been improvements of the saliva tests for Covid. Recall we initially did not advise saliva tests due to the lack of good studies and the fact the virus appears to prefer the nasal cavity, leading to many false negatives.

We have kept up with the studies and there may be new saliva tests that are a little more accurate than the rapid antigen test, but not as accurate as the PCR. If it passes our vetting, we will announce it via our website and social media, and begin using them quickly.
 
DO NOT fall for the “do it yourself” saliva tests. There are far too many errors with this. 
 
OUR ADVICE-
 
Consider saliva testing only once we have thoroughly investigated it for efficacy. Follow us on Facebook, Instagram, and check our websites daily for updates. 
 
4. Vaccination questions-
 
Hard to believe but we know about as much as you do from the news media. We have put in for an order, but that is just a formality. We have contacted the manufacturers directly, and their tersely worded responses are a bit disappointing. They basically say “no comment.”
 
Sources at higher levels have shared with us that both seniors and health care workers will come first.
 
But will it be no charge and administered by the government? 
No comment.

Will they sell it to doctors to give in their offices?
No comment.

Will it be the technology of messenger RNA developed by Pfizer and Moderna or will a more typical antibody vaccine being developed by other labs be offered?
No Comment.

Will it be mandatory?
No comment.
 
Will it really get us to herd immunity?
No comment.
 
Did we really ask the authorities all these questions?
No...oops I mean absolutely. Very frustrating.
 
OUR ADVICE-

Any rumors you hear about the vaccine are just that--rumors. Check with our social media and website for updates as we get them. Our past performance on Covid tells you Caduceus been on the cutting edge, and ahead of the game from the beginning. That will continue with the vaccine.
 
DO NOT sign up for, or pay money, or visit an unfamiliar medical office to get in line for the vaccine. There are many hoaxes and scams going around, and NO ONE can or should be taking any money from you at this time for the vaccine or for a waiting list.
 
5. How to reach us-

This last weekend, we had over 2,000 phone calls, mostly about Covid. It obviously overwhelmed our staff, and we apologize if your voice mails were not answered. We are still a local doctor owned small business and would need a staff of dozens of operators to handle what we are experiencing now.
 
Hands down the easiest way to reach is is via email, either the patient portal or Mouse Calls on our website for medical questions. We commit to a same day answer.  Our live chat feature on the websites or apps is a great way to make appointments for testing or any other appointments.
 
OUR ADVICE?
 
If you call and do not get an immediate answer, use the email or live chat options instead of calling again.
 
We would appreciate not leaving negative reviews on Yelp or Google saying we don't answer our phones. This is our first pandemic and we are really using every resource we have to serve our patients. We want to stay in business as much as all other small business owners. 
 
Steve Jobs said this as part of his Apple strategy, but it applies to us now more than ever...
 
Everyone here has the sense that right now is one of those moments when we are influencing the future. 
 
 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group
 

CMO Corner- Orange County Covid Updates for December

Did you know Flintstone Vitamin D is only sold in one city in the United Arab Emirates?

Citizens in other cities refuse to eat them.

But Abu Dhabi Do!
 

As the Covid numbers spike, I feel it may be time for a little humor…yes, I know what you're saying…very little!
 
There are three questions I am continually asked, so feel it’s worth addressing in this blog.
 
1. "Check my Vitamin D level. If it’s low will I have a bad case of Covid?”
 
ANSWER: Yes and No.
 
Yes: some studies, most sources quote one from Spain---show a poorer prognosis in Vitamin D deficient people. Vitamin D may help with macrophage activity to destroy the virus. It may help fight the cytokine storm responsible for many Covid deaths.  It helps "modulate" the immune system, so important in fighting off a bad viral infection. So start taking Vitamin D, right?
 
Well......wait.
 
No: Vitamin D deficiency is more common in older age groups, smokers, obesity, and in those with chronic diseases such as diabetes, hypertension, and also some racial and ethnic groups are more predisposed to deficiencies including African Americans.

The high-risk groups that have more complications and higher mortality rates in COVID-19 coincide with groups that have a high incidence of vitamin D deficiency. So we may just be saying "If you are an older diabetic smoker you will have a poorer prognosis from Covid,” without bothering to check a Vitamin D level.

Will correcting a low Vitamin D level help with Covid? No study shows that, since you should also correct the blood sugar, blood pressure, etc. at the same time.
 
The venerable Mayo Clinic, in a bulletin to physicians, concludes, "To the best of our knowledge, there is no data on the effects of vitamin D in SARS-CoV-2 infection.”  They then opine, “we suggest it would be reasonable to supplement vitamin D in sub-populations at risk of vitamin D deficiency and unfavorable COVID-19 outcomes.” 
 
In other words, those patients we mentioned in the preceding paragraph. I could not find studies controlling for high risk Vitamin D deficient patients.
 
Our interpretation?
 
We do not have good evidence Vitamin D will help, but it’s safe so what the heck; give it to seniors, smokers, diabetics, and any other high risk groups just in case.
 
Another issue is what constitutes Vitamin D deficiency?
 
Most labs list the lower limit as a level of 30. But most experts define true deficiency as under 15. It makes a difference since most articles quote “80% of severe symptoms with Covid are Vitamin D deficient.”

But when we check Vitamin D levels as part of a yearly checkup, I'd estimate 80% of all our patients are under a level of 30, not 15. Despite heavy research, I couldn't find studies on Vitamin D levels under 15 and percentages of a Covid prognosis.
 
Our conclusion?

Taking 2000 units of Vitamin D3 a day will not hurt. If you are a senior, smoker, obese, diabetic, African American, or have hypertension, it may help but be aware evidence is weak.
 
 
What's ultraviolet light’s favorite animal?
 
A lamb, duh!
 

Geesh! Tough crowd!
 
2. Should I use ultraviolet germicidal lighting?
 
If you own a large building, yes. In your home....read on.
 
UVC units look like your mosquito zapper on the patio in the summer, but these rays zap viruses. They have been used to fight viruses since a measles epidemic in Philadelphia in 1937. Numerous studies show when used correctly, UVC produces the same result as replacing the air in a large room 10 times in an hour. It is safe and effective to add a layer of protection against most viruses.
 
Cost? For large buildings, where it is most useful, about $6 a square foot. So for the Yorba Linda packing house at 77,000 square feet, about a half a million dollars. They are already in use in many colleges, as well as certain high traffic areas of LAX.  They definitely add a effective layer of protection.
 
Go on Amazon, you will find portable UVC wands for about $50. You wave it over your body and your friends and family. They have room sanitizing UVC lights for under $100. Perfect right?
 
Well… in fact there are no studies revealing how much or how long to use these devices, or that they even work.
 
The biggest issue is that these zap viruses IN THE AIR floating around, just waiting to zip into your nose and infect you. They have NO effect for viruses already in your body, or if they aren't floating around.
 
Our conclusion?

Installing UVC devices in indoor public spaces would cost a fraction of the budget our elected officials have spent to mitigate the economic impact of this virus. As far as buying a wand or a room unit for your family room? Might be better to open a window....
 
The lab report said I had blood Type A.

But it was a Type-O.

 
Hey, these are the jokes!
 
3. Will knowing my blood type predict the severity of a Covid infection?
 
From a study recently published at Harvard Medical School and Massachusetts General,
"Blood type is not associated with a severe worsening of symptoms in people who have tested positive for COVID-19."
 
When you try to research this in the medical literature, there are two different searches.
 
First, studies that look at IF you have Type O blood. Then perhaps you may have a lower risk of getting infected.  The data is very anecdotal. And weak. Most of it falls into what doctors call the "letter to the editor" category. Interesting to read, but not nearly enough data to substantiate the claim.
 
Then there are the studies that look into IF you have Type O blood.  Then  you're less likely to get very sick and less likely to need a ventilator in the ICU than if you have Type A blood.  Same; interesting theory but the data is just weak.
 
For both categories they are retrospective studies. They look back, and analyze the cases after the fact.  Much preferred would be prospective, randomized clinical trials. Those are lacking, in fact, I could not find even one.
 
Our conclusion?

We are not at the point where we can say, "You have Type O blood so don't wear a mask," or, "even though your oxygen level is low, you don't have to stay in bed with Covid, since you are Type O." It is possible a certain blood type makes better antibodies. We just need more--and better --data.
 
Questions I cannot address yet are the multitude of rumors about the upcoming vaccine.
 

•   Most insurances will not cover
•   It will be free
•   It will be given to seniors first
•   It will be given to hospitals first
•   It may wear off after three months
•   It will have few side effects
•   It will have many side effects
•    It will only be given to certain assigned centers in each county
•    It will not stop the pandemic
•    It will get things back to normal

 
Those are all possible scenarios. We need a month or two to find the answers.
 
I also have a vaccine joke.
 
But a lot of people won’t get it.
 
I’m here all week.

 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group

CMO Corner- Covid Facts vs. Shiznit


“There was truth and there was untruth, and if you clung to the truth even against the whole world, you were not mad.”
George Orwell
 
 

In the novel 1984 (written in 1949) George Orwell predicted that technology would develop and allow corrupt governments to manipulate and spy on their population. In the book, the dangers of false information were warned of repeatedly. 
 
In an earlier blog we played "Fact or Shiznit?" a true or false exercise regarding Covid myths. There was some constructive criticism of the blog, feeling we were "playing games" with a deadly disease. 
 
Duly noted.
 
So let’s clear up some false information out there; this time, no games.
 
We will tell you the Shiznit and then give you the facts.
 
SHIZNIT #1
 
The CDC and health departments say Covid positive patients are no longer contagious and can stop isolation after 10 days of no symptoms.
 
FACT 
It is true that evidence exists suggesting the virus loses its penetrance after 10 days. No debate there. Yet it takes 7-21 days to re-swab negative once symptoms appear. Negative means no virus is found. Many infectious disease experts are showing evidence it’s safer to release a patient from isolation with a negative swab than just using the 10 days benchmark.
 
Let’s look closer at why the "10 day rule" is Shiznit.
 
Exhibit 1- For starters, the CDC states that there is evidence to release a patient at 10 days with no symptoms. Unfortunately, there has been insufficient time to do a broad scale prospective or double blinded study to show this definitively. That study will not be able to be published for many months. To allow a cessation of isolation in the middle of a pandemic is no time to be using "evidence exists" as your defense. 
 
Exhibit 2- The European version of our CDC has gone on record that there is uncertainty about the requirement of a negative re-swab (also called "test-of-cure") although they also concede a 10 day wait is reasonable. 
 
Exhibit 3- Johns Hopkins -a respected medical source- endorsed the CDC guidelines, yet also points out there is no way to tell if a swab positive test indicates an infectious or non-infectious virus. They also state a large number of Covid cases are spread by asymptomatic people who are swab negative. 
 
So let's try to understand this---if you swab positive without symptoms, you may be able to spread the virus.  But if you are positive 10 days after your last cough, you won’t spread the virus. At least "there is evidence" you won’t. 
 
If this is how our health leaders are planning on stopping the virus, we have trouble. Right here in River City.
 
Fortunately, you have a choice. 
 
TEST. TEST. TEST.
 
Reading the literature, what appears to be the "truth" is that the contagiousness is related to "viral load.”  The higher your viral load when you contract the virus, the longer you are contagious after the infection. Since we have no way to measure viral load, the prudent course is to assume everyone has a high viral load.
 
Hence our advice is to swab negative prior to stopping your quarantine if you are positive.
 
So why are the health departments and CDC sticking with the 10 day advice?
 
In the spring, the CDC admitted the lack of tests in the country played a part in their position. They aren't saying that now. 
 
Yet we know test availability has been a problem in our country, as well as Europe. But if that's the reason, just tell us. We can take it.
 
More facts to dispute the 10 day strategy---cases are raging both in the US and Europe. A large number--up to 40 % in some studies- are coming from asymptomatic people. If the 10 day rule was working, shouldn't we be seeing a DECREASE in new cases? 
 
Would you go to a restaurant where the cook had a fever and swabbed positive 10 days ago, and is now flipping your burger?
 
Would you sit at a table at a wedding where the person next to you swabbed positive 11 days ago but stopped coughing ten days ago but did not re-swab?
 
Would you visit your elderly frail uncle if you had swabbed positive 10 days ago without knowing you are swab negative?
 
Of course not. And I suspect the head of the CDC wouldn't either. 
 
CADUCEUS RECOMMENDS A NEGATIVE SWAB AFTER THE INITIAL POSITIVE SWAB IN A COVID INFECTION.
 
It may be 7 days, or 10, or 20. 
Know if you're contagious.
Don't assume. 
Don't guess.
And don't listen to the health department when they give you Shiznit.
 
SHIZNIT #2
 
If I feel sick between November and February, a Covid swab is sufficient. And a flu shot is optional.
 
FACT-
It is very conceivable to have both the flu and Covid at the same. And if you have only one, it’s important to know which one it is. There is an antiviral medication for the flu.
 
Yet both during the last flu season as well as this one, many of our beloved patients balk at having both. Some say they are really only worried about Covid. They don't want two tests. Although covered by virtually all health plans, they bring up cost. 

Since Covid and flu symptoms are quite similar, and this is the flu season, it is important to see if you have one, or the other, or heaven forbid both. The flu shot is more important this year than ever before. We cannot yet prevent Covid with a vaccine, but we can help prevent the flu and you really don't want to get both this winter.
 
FACT-

CADUCEUS ADVISES BOTH A FLU SWAB AND A COVID SWAB FOR ANY FLU SYMPTOMS THIS FLU SEASON.
 
AND A FLU SHOT FOR ALL ITS PATIENTS. 
 
 
“The best books… are those that tell you what you know already.”
George Orwell, 1984

 

Although this seems counterintuitive, it makes sense when you read Shiznit #3.
 
SHIZNIT #3-
Newer saliva, rapid antigen, and self-administered swabs are accurate.
 
FACT-
 
Yes; some studies do show a five percent false negative and positive rate for the saliva test, which is acceptable. However, those numbers have not been borne out by true randomized peer reviewed studies.
 
In one Yale study, saliva testing was MORE accurate than nasal swabs. Number of patients tested? 76.
 
Yet, another study from South America showed the saliva tests had more false negatives than nasal swabs. It was just published in the journal "The Scientist.” 
 
Sample size? 776 subjects.
 
The fact is for a study to be credible, there must be THOUSANDS of subjects. Different races, ages, and other demographics. Better yet, make that TENS OF THOUSANDS of subjects, with the testing done blinded. 
 
Saliva tests are far from proving themselves.
 
The rapid antigen tests are still running around a 10-20% false negative rate. No real improvement has been seen here, and the data keeps getting more accurate. 
 
Nonetheless, our most popular test to do at a patient’s request is the rapid “while-you-wait” test.  Even if they have to pay for it.
 
Many patients are seeking the test where you do your own swab, mail it in and wait for the result. I am confused as to the logic.
 
First, there is user error. A timid patient will not swab as accurately as a trained professional. Then we are relying on the US mail, whereas a curbside PCR test is no charge - back in a day or two- and very accurate.
 
As Mr. Orwell said...”the best book is the one that tells you what you already know.”
 
You already know the PCR test is the best. Don't fall for the slick sales pitch for rapid tests. Don't be tempted by saliva tests. At least wait until more studies can confirm their accuracy.
 
 
CADUCEUS ADVISES THE CURBSIDE NASAL SWAB VIA PCR TO DETERMINE THE PRESENCE OF COVID. AVOID SALIVA TESTS, RAPID TESTS, AND SELF ADMINISTERED TESTS.
 
This is too important to take a short cut. A possible fatal shortcut.
 
SHIZNIT #4-
Once I recover from Covid, I am out of the woods, just like getting over the flu.
 
FACT-
 
Beware of post-Covid Syndrome, or as we call it-“PCS.” 
 
This is being described in the literature, but the data here is only from our own patients....our sample size is the 600 plus patients we have treated from the start of their infection until turning swab negative.
 
The scenario is becoming more common and more disturbing. You have exposure or a fever. You go curbside for the swab and it does come back positive.
You start in our treatment program. Meds. Pulmonary hygiene. Bedrest. Isolation. 
 
10 days later, you feel better and swab negative. All is great---right?
 
Wrong.
 
A few weeks later, you feel more fatigue. Your cough returns and you can’t walk up the stairs. Your sense of smell, which never totally came back, goes away entirely. 
 
You may actually feel sicker a month after you "recover" than you did while you had Covid.
 
Sounds like a nightmare, right? Welcome to the “Wonderful World of Covid,” the virus that is writing its own rules.
 
For our patients, about 15% of our more recent cases qualify as having “PCS.”
 
Average age of “PCS” is 45.
Male/female -50/50
First and most common of PCS is by far fatigue. Very bad fatigue.
And it’s more likely if they did not practice strict bedrest when they were fighting Covid initially.
 
Most worrisome and bothersome are the symptoms revolves around the lungs-- Shortness of breath. Cough. Air Hunger. Poor exertion. Mucus.
 
For lung symptoms, we use Budesonide, Albuterol, and Decadron if necessary. We follow pulse-ox frequently, and encourage incentive spirometry and pulmonary hygiene. Unfortunately, some cases have not improved even after several months. 
 
We pray it's treatable. 
And prepare for it being permanent. 
For other symptoms, e.g. the lack of taste/smell, muscle and joint aches, headaches and palpitations, TOT (Tincture of Time), bedrest, and plenty of fluids appear to be helping.
 
We have seen new cases of significant hypertension appear shortly after Covid recovery.  These cases require medication and the long term prognosis is unknown.
 
“PCS” is becoming a true disease and deserves more research and alertness on the doctor’s part.
 
Nationally, new diagnoses of  autoimmune diseases post-covid (Hashimoto’s, Lupus, and Sjogren’s) have been noted, but we have not seen that at Caduceus---yet.
 
CADUCEUS ADVISES CONTACTING YOUR COVID DOCTOR IF YOU HAVE NEW OR PERSISTENT SYMPTOMS AFTER YOU TEST NEGATIVE FOR COVID.  TREATMENTS CAN HELP.
 
You all know the drill.
 
- Know if you're contagious---get swabbed before any social gathering and insist the others do the same. 
- Have swabs regularly---every two weeks if you are out and about or working.
- Get regular antibody tests to see if you're immune.
- Wear your masks.
- Stay as far away from others as situations allow.

 
Locally, statewide, nationally, and globally--cases are skyrocketing. One of the solutions is more testing, not less. We are happy to help provide that curbside for you.
 
Still not sold on testing?
 

We offer a complimentary online assessment that is actually kind of fun to take on our website. Go to caduceusmedicalgroup.com or pdqurgentcareandmore.com and hover over the “Individual Covid-19 Testing” button and choose the drop down “Are You Actively Contagious with Covid-19?” It only takes about ten minutes and a staff member will contact you with your results within 24 hours.  

 
Consider taking that test to determine your risk level.
 
Do mandatory masks and testing take away our freedoms? Let’s again look to the novel 1984 and the words of Mr. Orwell.
 
“The choice for mankind lies between freedom and happiness- and for the great bulk of mankind, happiness is better.”
 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group

Orange County Exclusive Caduceus Interview with "Cov"

(The author directs readers to watch the films Blazing SaddlesYoung FrankensteinHigh Anxiety, and The Producers prior to reading this blog. Failure to do so may cause credit-or blame- to be given to the author when it should be directed to Mr. Brooks.)
 
"Life is a play- We're unrehearsed"--Mel Brooks
 
Our loyal patients probably know Caduceus was the first medical group in the area to offer curbside services and flu tests in February, curbside and telehealth Covid testing in March, and higher complexity Covid antibody testing in April.
 
Now we are proud to announce our newest achievement.
 
By taking mucus from a Covid positive patient, isolating the RNA, charging it with 1.21 gigawatts of nuclear power, and putting it through a 3D printer, we have been able to convert a Covid particle into human form! Tweaking the uploading process using Epson microchips, the virus was converted into an exact life-sized replica of Mel Brooks!
 
Best of all, Caduceus has secured exclusive rights to an actual face to face interview with the virus, who has asked to be referred to as "Cov.”  As CMO I am honored to be the interviewer.  FYI-I am no Carl Reiner.
 
CMO: Welcome Cov, full disclosure- I have been trying to destroy you over the past 7 months. So tell me- How are you feeling today?
Cov: (Singing) High anxiety ... it's always the same; high anxiety ... it's you that I blame.
 
CMO: Sorry. Oh I get it!! You're programmed with Mel’s brain. Reminiscent of one of my favorite movies of yours, Young Frankenstein.
Cov: Ummm...remember, I am NOT actually Mel Brooks- I simply took on his form.
CMO: Oh, of course- I should have known...
Cov: Besides it’s pronounced "Fronkensteen."
 
CMO: Let’s get right to what our readers want to know; Did you come through bats in China? Or were you a lab-made conspiracy to affect the US Elections?
Cov: Sorry to disappoint everyone, but we are just an old- fashioned mutation from the plain vanilla Coronavirus that causes the common cold.
 
Our first mutation was in bats, a favorite host of Coronavirus.  But we got tired of hanging upside down all day, plus have you ever had to live right over piles of guano? We wanted a new host, and humans were perfect. Nice big nostrils to invade, and better yet, they flush the toilet.. well most of them anyway.
 
CMO: So was it your plan on taking over the entire planet?
Cov: Hey, we were happy in China. I mean, what’s to not love about Peking Duck? But one day one of the viruses said "let’s get Italian,” so we infected Italian tourists, not realizing all he wanted was a plate of marinara!

It was an honest mistake. So a few Italians get infected, and POW! Next thing you know we are global. We are thinking since Italians won’t keep quiet, always laughing and singing, it kept spreading.
 
CMO: Is it true you live in the nasal and oral cavities?
Cov: Well DUH! We are Coronaviruses. That's our hood. Oh, we produce cytokines that do damage in all parts of the body, but inside the nose for us is like your Malibu beach house.
 
 
CMO: So masks should keep you from infecting other humans then?
Cov: Oh masks are a huge pain. Nothing worse than floating through the air looking for some place to land, and all we see are masks! It’s like you humans using a Club on your new car’s steering wheel. A good thief can get it off, but why not just go to the car next to it without a Club? We see someone without a mask and we say BINGO! If we try, we get through most masks 20% of the time. But then we have to get past the mask of the person nearby so it’s just not worth it.  Especially with so many people anti-maskers. They make our job really easy.
 
CMO: So how does Covid get around? Can you guys fly?
Cov: For a CMO you don't know your virology very well! No we don't have wings. We depend on a good cough or sigh to get us out of one oral cavity and into another.

If God wanted us to fly, he'd have bought us tickets!
 
CMO: And you can only float for about six feet? So the X's on the floor do work?
Cov: Well our best athletes can make it 10 feet with a good breeze. But with us being able to aerosolize, we can actually travel over 40 feet in a small area with good air pushing us. We just look for someone without a mask, naturally. But the closer together humans are the easier our job is.
 
CMO: So will you share what's your "Kryptonite?” Does Plaquenil scare you?
Cov: Ok you seem like a nice guy. I’ll level with you...yes, Plaquenil was a problem for us. See, we survive by replicating in the human host. Plaquenil does inhibit our replication. Thank God Trump praised us, that made everyone hate it.  By the time studies were started we had mutated against it.
Same with Remdesivir. It was killing us off, but now we know a mutation to counteract it.  Fact is, nothing kills us.
 
CMO: So there's nothing you guys fear? You are just going to infect the entire planet?
Cov: Wellll....ummm.
CMO: Come on Co....spill it; just between us.
Cov: (Mumbling) antibodies.
CMO: What was that mumble?  Antibodies? Like IgG?
 
Cov: You didn't hear it from me...But it’s DEVASTATING! We float into a nice warm nose, start replicating and then WHAM! The IgG eats us whole! Its barbaric!
CMO: It’s called Phagocytosis. A well known immunologic mechanism. So it DOES work against Covid! The CDC and WHO are wrong?
Cov: Yeah we cut a deal. They cast doubt that antibodies work and we stay out of their headquarters. They know we don't stand a chance against IgG. It’s like trying to break into a sailboat surrounded by 100 Navy Seals!  Thank Heaven only 10% of the people we try to infect have it.
 
 
CMO: Wait! Was it part of the deal that the CDC not advise repeat swabs on known infections?
Cov: No comment. (Whistling....)
 
CMO: So you must be worried about a vaccine coming soon? After all, a vaccine is simply a lot of antibody in a syringe.
Cov: Naw. We figure there are enough anti-vaxxers to infect to keep us in business for many years. We find them refusing vaccines as showing no respect, right? So those are our first targets.
 
CMO: So why did you infect President Trump?
Cov: The guy with the big hair and red hat? Yeah, we targeted him. He was always dissing us. Saying we are no threat. Not encouraging masks.  Having super spreader events. Viruses have feelings too!
 
CMO: How did you get in? Was the Secret Service a problem?
Cov: Are you kidding me? We just went in the nostrils of a couple of White House interns. A Rose Garden ceremony, and the rest was like taking acorns from a blind squirrel!
 
CMO: Looks like you got the whole White House staff?
Cov: Once we had Trump, we figured why not settle down in the White House? The West Wing is totally cool, and the Situation Room is a trip! We even got a few top secret passwords I can share with you later!
 
CMO: But did he really have a pretty mild case like he claimed?
Cov: Yeah, we didn’t send out the Big Boys. I mean he is the President after all. Just some of our lower level guys to scare him a bit.
 
CMO: Would you say you are political?
Cov: Don't be stupid; be a smarty! Come and join the Democratic party!
CMO: I think you mean NAZI Party?  In the...
Cov: Whoa! Be careful! We are in a blue state! You'll get boycotted!
CMO: No, No - I mean in The Producers that line went...oh never mind.
 
CMO: You realize Covid has caused over a million deaths globally? Don't you feel just a little guilty?
Cov: Does a bear feel guilty when he catches a salmon swimming upstream? Does a shark feel guilty swallowing a seal whole? It’s what we do. If it bothers you so much, invent an antiviral agent to combat us like you did with HIV.
CMO: Well perhaps Caduceus is in its lab every day doing just that?
Cov: Don't make me laugh---we are Covid and we will just mutate away from anything you invent.
 
CMO: Well, Co, Thanks for the interview. I learned a lot. Say, since we have kind of bonded here, before you turn back into 125 nanometers, want to hang out awhile? What do you like to do?
Cov: Sure. 2 things. I like chess.
 
 
CMO: A virus knows how to play chess?
Cov: Yeah - it was uploaded from one of our mutations--I think when we visited Magnus Carlsen.
 
CMO: Chess sounds kind of dull. What's the other thing you like to do?
Cov: Kill people.
CMO: Let’s play chess.
 
 
Gregg DeNicola MD
Caduceus Medical Group
Chief Medical Officer
 
-KNOW IF YOU'RE CONTAGIOUS.
-KNOW IF YOU'RE IMMUNE.
-SET UP A REGULAR TESTING PROGRAM FOR SWABS AND ANTIBODY TESTS. 
-STAY HUNKERED DOWN FOR NON-ESSENTIAL ACTIVITIES. 

Top Five Covid FAQ's- Just the Facts for Orange County

Mark Twain once said there were three types of lies... “Lies, Damned Lies, and Statistics”...meaning we can bend statistics into verifying wrong conclusions. 

Mr. Twain actually modified a quote by T.H. Huxley---"There are three types of liars- Liars, Damned Liars, and Experts.”  

The more I research Covid and its physiology and treatment, this quote takes on great meaning--and accuracy. For once, as a previous blog pointed out---even our experts are usually flat out wrong.

An example is the fact that our new Covid cases from testing at our three centers shows a significant spike, as we reported two weeks ago. They have not yet come down. This is despite reports from the OC Health Department showing new cases are flat. 

Explanation?

Clearly either Caduceus encourages more testing, giving us more cases- or –

Caduceus patients really know how to party. 

I’m going with the former.  I pray a third possibility, cases through the health department are being under reported, is out of the question.

We are in the midst of a SURGE in cases. 

We are NOT near a safe level of positive cases. 

As tired of this as we all are, we cannot let down our guard and assume the worst is over.

Using the tenet that “you can only believe what your eyes see,” let’s use actual scientific data to answer the five most common FAQ’s we are receiving.

1. If masks and distancing work, why get tested?
2. Is it now safe to eat at restaurants?  Bars? To fly?
3. How long will my antibodies last?
4. When I hear I should quarantine, what exactly does that entail?
5. With all the cases Caduceus has treated, what are the most effective therapies?

1.  If masks and distancing work, why get tested?

Even the N95 masks fail 5% of the time. Typical cloth masks seen everywhere are 85% effective in blocking the virus, meaning if you are near someone Covid positive there is a 15% chance the virus gets past the masks.

Masks work. Just not 100%.

Many studies confirm that while social distancing at six feet apart prevents transmission of 80% of the virus, the combination of a sneeze, a cough, singing, or a slight breeze in the air can aerosolize the virus and allow it to travel 40 feet or more. 

So the X’s on the floor six feet apart do work. Just not 100%.

Hence the need for regular testing- preferably a PCR nasal swab. It adds one more layer of protection. It's arguably safer to be at a Sunday BBQ with ten people who all tested negative that week, than at a restaurant table with three people untested. 

KNOW IF YOU ARE CONTAGIOUS.

Wear masks, distance six feet apart and avoid super-spreader events. Regular frequent testing is literally a life-saving strategy.

In the past three weeks 40% of our positive cases had no symptoms. That’s right. They were spreading the virus and did not know they were contagious.  

We cannot assume people with no symptoms are not contagious.

2.  Is it now safe to eat at restaurants?  Bars? To fly?

No.

Not the answer you wanted to hear right? 

A study recently published in Morbidity and Mortality Weekly Report, a respected journal, found adults with positive SARS-CoV-2 test results were twice as likely to have reported dining at a restaurant as those with negative SARS-CoV-2 test results. That went for indoor OR outdoor dining. 

The reason? When eating at a restaurant, patrons take off their masks. They sit closer than six feet apart. And most diners do not know if they are carrying Covid. Fortunately, the restaurants that have contracted with Caduceus for testing do test their chefs and wait staff on a regular basis. When they do test positive, it’s almost always from an infected diner; remember the statistic 40 % of our positive cases are with NO symptoms. A diner with Covid that has not yet shown symptoms will infect the waiters- despite the mask worn by the waiter -15 % of the time.  This applies to bars as well.

The same science applies to air travel. Despite filtered air, and meticulous cleaning, there are just too many people in a confined area. Some flights do require a negative PCR nasal swab, which is reassuring. Until that is standard procedure, “ix-nay on anes-play.”

3.  How long will my antibodies last?

If you are one of the lucky ones to test positive for the Holy Grail of antibodies -IgG-it is likely you are immune from Covid 19. But how long does that immunity last?

We have had 2 patients where it only lasted four weeks. We have had many patients where it is still showing up after six months (which is as long as we have been able to test for it). In Asia and Europe, data tells us to expect IgG to stay active for 2-12 months--a huge variance. 

That's why we advise a monthly antibody test if you are antibody positive. If you are immune, you still need to wear a mask, social distance, and avoid super-spreader events. But you can breathe a little easier knowing you're IgG positive. 

For example, we have had ZERO cases of Covid in people IgG positive. And this comprises a sample of hundreds of patients. IgG appears to be performing as advertised.

Another Mark Twain quote is “If you don’t read the newspaper, you’re uninformed. If you read the newspaper, you’re misinformed.”

Never has a century-old saying been more accurate. Our team spends hours a day reading, researching, and surfing dozens of publications, and are incredulous at the misinformation floating out there. 

For example, let’s look at #4…

When I hear I should quarantine, what exactly does that entail?

There are two times to quarantine:
-When you test positive
-When you are tested because you had close contact 

In both cases, you need to quarantine until you swab negative. Yes, we are aware the local health department and the CDC do not require a test of cure. That is the misinformation we are talking about. 

The evidence for that advice is weak.

Let’s look at the White House saga. The President was "cleared" of Covid using CDC guidelines of 10 days without symptoms. But many infectious disease centers advocate for a 20 day quarantine. Other academic centers match our advice, insisting on weekly swabs until negative.

Our experience tells us the average time to swab negative after a positive swab is three weeks, confirming the 20 day recommendation. The weekly swabs until negative rule is valid and should be the standard.

Why does the CDC stick with the 10 day rule? Admittedly there is data suggesting the virus is most contagious the first week of the infection. And that only a small number of patients stay infectious longer.  Yet they also admit they stopped advising the test-of-cure (re-swab) due to a shortage of tests.

At Caduceus, we have no shortage of tests. We want our patients to be SURE they are not contagious .A positive swab means there is active virus and that virus should be quarantined until gone.

What's the saying about “the proof being in the pudding?” Under the CDC guidance, numbers are spiking across the country. Clearly we need a more aggressive pudding...I mean strategy.

A larger problem is how people are quarantining. Very reasonable people are balking at standard quarantine protocol. This is one of the biggest issues comparing the flat curve of Asia and Italy. We simply aren't being smart about our quarantine protocol.

Pushing aside the patients that shockingly refuse to stay home and even go to work after a positive swab, we need better education on how to quarantine. 

If you live with roommate or family that IS infected:

-Stay in your own room.
-Use a dedicated bathroom.
-Food delivery contact-less is left at door.
-To move about the house or go into the yard, the house should be empty, or the residents should be out of sight of the infected person. That means NOT watching TV in the same room as the family, NOT eating at the same dinner table, NOT "hanging around" other household members. 

I know it is very difficult. Do NOT be misinformed. Quarantine correctly.

It’s only three weeks.

We desperately need to get the number of new cases down to lower the death and hospitalization rate until a vaccine is available.

5.  With all the cases Caduceus has treated, what are the most effective therapies?

This is straightforward, having used dozens of different therapies on our 500 cases we have actively treated. 

Five stand out as being especially effective:

-REST; yes it’s that simple. People who stay in bed, on the couch, or recliner and rest get better faster than those that get about and try to exercise. This is a great time to binge The Sopranos complete series.

-Pulmonary hygiene---ideally buy a pulse ox (drugstore/Amazon), nebulizer, spirometer, and find a partner with a mask to pound your chest.  Mucous is our nemesis; we are aggressive in getting the mucous out of your chest. It has kept many of our patients out of the hospital.

-Budesonide (Pulmicort) daily as a preventive med to keep airways open, and Albuterol as an abortive inhaler when cough or shortness of breath hits. It has worked in nearly everyone with lung symptoms.

-Decadron orally in patients who are not improving or worsening despite best practices. Initially meant for inpatient use, we have found excellent results safely to help prevent the hospital in the first place.

-For those few patients who have needed to be admitted to hospital, both Remdesivir and convalescent plasma have been very effective to neutralize the virus.

In Summary:

-Test. Test. Test.
-Know if you're contagious (get swabbed regularly).
-Know if you're immune (get antibody tested regularly).
-If you have been exposed or are positive, self-quarantine by the book.
-Read the newspapers, but be skeptical.

Mr. Twain had another saying worth modifying---
“The two most important days in your life are the day you are born and the day you find out why.”

We can take some poetic license and say:
The two most important days in 2020 are the day you test Covid positive...and the day you test negative.

Gregg DeNicola MD 
Chief Medical Officer
Caduceus Medical Group

Now Offering Covid Rapid Antigen Testing Orange County

There's something happening here…
What it is ain't exactly clear…

Stephen Stills had it right in the 80's. We’ve been dealing with Covid for over six months now, and how do we deal with it? Well- it’s not exactly clear.

We will address these issues today:

• The newer trends and what Covid has told us
• Announcing new testing policy at Caduceus
• A call to action to our patients and the public on how to curb the spread

If there is one thing we have learned this year is that we have run out of patience.

At first, we all were united. We saw the horror of China. The devastation of Europe. The ambulances lined up with bodies in New York.

So we quarantined. Locked down. Hunkered.

And the numbers in California dropped from April through late May.

So we reopened. But not smartly. We were ready for returning to some type of normalcy. Going out to restaurants. Memorial Day gatherings. Protests. But Covid plays by ITS rules, not ours and the June, July, and August numbers skyrocketed.

We became divided. Maskers vs. Anti-maskers. Social distancers vs. life as normal. Sadly, it became political. Even Right vs. Left managed to somehow arm wrestle over what should have been a unifying crisis.

Fortunately, as masks and distancing became the "new normal,” the numbers began to fall in the first half of September. So much that in Orange County we were allowed to open back up- restaurants, theatres, gyms, and churches. And at the same time, here came the Labor Day weekend.

We warned our patients about gatherings, parties, and BBQ’s. About frequenting restaurants and hanging out downtown instead of our living rooms.

We've all heard Albert Einstein's famous line, "Insanity is doing the same thing over and over again and expecting different results.”

You guessed it; we are seeing another spike in cases- apparently learning little from our Memorial Day experience.

We shouldn't be surprised. Covid has now told us exactly how it works.

• It has a two week incubation period where it is spreads even if no symptoms.
• It can spread by micro droplets, far beyond our arbitrary six foot boundary.
• It has a high penetrance rate---i.e. it doesn't take a lot of Covid to spread; it’s very "catchy."
• It doesn't care about the age of its victims.

At Caduceus we have been tenacious on our position.

As CSNY would say,

We, who have a Covid load
Must have a code
That we can live by…

And here is ours….

Know if you’re contagious.
Know if you’re immune.

In Europe, the caseloads are also rising quickly. Where they had been using universal testing with good results and lowering the numbers, they took their eye off the ball when the numbers fell. The European view is shifting toward individual responsibility, and not government action. Instead of locking down and pushing for universal testing, European governments note that many Europeans are tired of the whole thing. Testing, masks, and distancing are less common now, and the rising European numbers are proof that as tired as we all may be, we will not start to see blue skies until we know who is contagious, and who is immune.

Caduceus and PDQ Urgent Care and More are now offering improved PCR swab testing for Covid. At this time, we are no longer using LabCorp or Quest for our testing. (Except on patient request).

This was not punitive or political. We simply could not rely on the results being timely, and our calls to check on the results on behalf of our patients went unanswered.

We have made arrangements with smaller labs that have the same machines, but can meet our needs regarding turnaround time.

We now offer our patients with insurance NO OUT OF POCKET PCR Covid testing with a 2-3 day turnaround.

This allows us to further advise our patients to set up a REGULAR testing schedule without worrying about out of pocket payments.

If you need a 24 hour turnaround,
We can offer you an expedited test for a cash price of $189.

In addition, I recall an old ad campaign for Toyota that said, "You asked for it, you got it.”

If you have no insurance, we can offer you the antigen test with a physician’s order for $66. Results while you wait or we will follow up with you same day if you prefer not to wait curbside.

That’s the deal with swabs for presence of virus. How about immunity?

We continue to use "moderate complexity,” a more sensitive antibody test to help determine if you are immune. We alert you that some insurance plans are not covering antibody testing, so in that case we offer a cash rate of $85 for moderate complexity and $75 for low complexity antibody testing.

One example of how testing may help bring down the numbers…

A family we are caring for wanted to have a family gathering of 10 people over the Labor Day weekend. Of course, I discouraged it, but there were mitigating circumstances that made it essential. The ages ranged from 20 to 80 and many had jobs serving the public.

We ordered PCR testing the day before the gathering. Results were back the next day. All 10 were PCR swab negative. (Antibodies were also negative so no immunity.) They still practiced precautions, but it was reassuring all 10 were Covid free at the same time. It has been over 14 days, and no Covid came from that gathering.

Testing works.

Let’s look at a gathering without testing---

65 people attended an August 7th reception at the Big Moose Inn Cabins in Maine. By August 25th, 53 cases were tied to the wedding. A week later, 147 people who attended the wedding or got the virus second-hand as a result of someone who attended the wedding tested positive for Covid.

Even worse?

Three of those people have died. None of the fatalities had even attended the wedding.

Testing works.

In addition to offering improved testing choices, I also encourage setting up a regular testing schedule for ALL of our patients.

If you serve the public (health care, restaurants, retail workers),
Test every two weeks (Caduceus and PDQ test their staff at least every two weeks.)

If you are usually home or in a small office, but do go out and about,
Test monthly.

If you hunker down at home and rarely go out,
Test quarterly and on demand when you must go to a gathering or meeting.

All patients should consider an antibody test every 1-3 months to detect immunity. If it is negative, take extra precautions.

And as always, all of our testing is done by video from your phone and curbside so you never leave the security of your home or car.

For both swabs and antibody tests, you do not need a physician's order if you have had a telehealth visit (or office visit) in the previous 12 weeks and were negative.

In summary:
• Learn from this summer… Mask. Distance. Avoid gatherings. Don’t give in to impatience.
• Get tested regularly. If you are contagious, self-quarantine. and if you are not immune, take extra precautions.
• Don’t succumb to peer pressure or your own impatience to socialize unnecessarily or go without a mask. Covid has told us its rules. Listen to them.

If David Crosby could write a song about Covid now, it might go…

Must be because I’m worried I'll get Covid at Christmas
And I'm not feelin' up to par
It increases my paranoia
Like not wearing my mask then seein’ a police car
But I'm not givin' in an inch to fear
‘Cause I promised myself this year
I feel like I owe it to someone
To be tested
Hoping my Covid swab shows none

Gregg DeNicola MD, Chief Medical Officer

CMO Covid Corner

URGENT ALERT-

As CMO I want to report to our patients a dramatic upswing in POSITIVE Covid19 PCR cases.

After seeing a drifting downward of new cases between late August and early September, we are experiencing large numbers of new cases similar to our dark days of April.  We are in the middle of another surge.

I cannot speak for numbers put out for LA or Orange County now. This alert is based on OUR swab results in the last week.  About 33% of our new cases are without symptoms. Those with symptoms have become very ill, very fast. Average age is 35, with most cases between 20-40.

We have noted good response to Budesonide and Decadron given early, so I encourage being tested immediately for ANY Covid symptoms, especially:

-Fever
-Fatigue
-Loss of taste/smell
-Nausea/diarrhea
-Muscle aches
-Upper or lower respiratory symptoms including sinus pain and sore throat

We want to keep our patients out of the hospital and prevent the horror stories that have become common with Covid infections, even in younger patients.

The current siege started on September 21st, exactly 14 days after the Labor Day activities we were concerned about. Recall the incubation period for Covid is 14 days. Many of our new cases trace their contact to that weekend, others to the recently reopened restaurants, gyms, and salons. One common denominator--none of our new cases suspected their contacts were contagious.  Because no one knew they were.

We DO NOT advocate more closures.
We DO advocate more testing.

CADUCEUS and PDQ URGENT CARE AND MORE NOW OFFER NO OUT OF POCKET COST PCR SWAB COVID TESTING WITH A 48 HOUR RESULT TIME (with valid insurance).

Of course the physician order is via a telehealth video visit from your home, and the swab is curbside from your car. We have reasonable cash prices if you are uninsured.

We have worked hard to arrange this service for you, please consider taking advantage of it.

If you test PCR positive -STAY HOME AND QUARANTINE!
If you are antibody negative, STAY HOME AS MUCH AS POSSIBLE.

Understandably, the new siege has stressed our systems, and we are adapting. You can help us by--

-Avoid the phones, use email or LIVE CHAT instead, available from the home page of our website or app.
-Use our telehealth platform, if appropriate, in lieu of office visits or walking in.
-Keep your appointments, and let us know if you must cancel or no show. This makes room for more patients.

We are all weary of the masks, the X's on the floor, the elbow bumps, and the binge watching on the couch.

We will beat this.

But it requires you to:

KNOW IF YOU'RE CONTAGIOUS
KNOW IF YOU'RE IMMUNE

Our lifestyles, and lives, depend on it.

Gregg DeNicola MD
Chief Medical Officer

Covid 19 Coronavirus September Updates- The Hard Facts on Our Progress in Orange County

CMO Covid Corner


A quick visit to the archives for a new take on an old TV show…
 
Who can you trust for Covid-19 advice?
 
Not WHO
Nor FDA
Nor even the CDC blog...
 
Just little ol' us...
We're UNDERDOG!
 
At Caduceus, we are used to being an underdog. Our entire annual revenue would possibly fit in Kaiser’s petty cash fund.  Mammoth health "systems" in Orange County, like Providence and Memorial, are comparable to Costco’s size next to our little boutique practice.  And the government agencies in the above rhyme have billion dollar budgets with some of the greatest health care minds in the world.
 
Yet here we are in month nine of the worst pandemic in our lifetime, and no end in sight. Perhaps it’s time to listen to the “Underdog.”
 
Let’s look at what our prodigious health agencies have told us so far. FYI, all the data we publish forth comes from their own websites or newsletters.
 
WHO-
The World Health Organization is an agency of the United Nations. It is funded by its members. The top three financial contributors?

-The USA
-Bill Gates
-The UK

Despite it ravaging Asia and then Europe, the WHO did not proclaim Covid-19 a pandemic until March 11. We started curbside testing for flu and strep in February, and added Covid-19 tests on March 12.
 
They have not advised universal testing, only those with symptoms or close contacts.
They advise stopping a quarantine on a swab-positive case once symptoms have resolved.
They determined a positive swab without symptoms can be due to "prolonged viral shedding.”
They have told employers they "may" want to require a negative test before people return to work after infection. 

On April 24, they told the public that antibody tests showed no evidence of immunity. They now have reversed course on that position.

On June 7, they did not advise routine mask wearing. On June 8, they changed their position.

And what has their advice accomplished? Almost 300.000 NEW cases a day worldwide now, compared with fewer than 100,000 at the end of May. Perhaps tighter controls are in order?
 
FDA-
The Food and Drug Administration is a truly bipartisan part of the Federal Government, yet empowered through Congress. So, they both have their fingerprints on the crime scene here.

Let’s see…Plaquenil. It was given emergency approval for Covid-19 in March. In June, they revoked it. Now they say they won’t approve it, but a doctor is approved to use it in the hospital or a clinical trial setting. Keep in mind that once the FDA approves any drug for ANY condition, ANY doctor may use that drug for another indication "off label,” it’s done daily on thousands of drugs. It is not "illegal" to use Plaquenil for Covid-19. But trying to follow the FDA advice is like playing Whac-A-Mole.  
 
Let’s look at the Abbott "rapid test" for Covid-19...it was given emergency use authorization in the spring.  Then several academic centers found "adverse events” (translation-bad mistakes) with the test informing thousands of patients they were Covid negative when they were actually positive.Yet the FDA approval stood. They simply put out a "warning" of the high degree of false negatives.

And now, they have just approved a new "quickie" Abbott test, coming out in October with a better false negative rate. Ummm…according to Abbott....no academic center has tested it yet.  And the FDA still approved it. 

And the result?  Only PCR swab tests have data with acceptable false negative rates. FDA approval of "antigen" tests (i.e. quickie tests) have exposed thousands of Americans to Covid-19 unknowingly.

On the flip side, thousands of Covid-19 patients have improved with drugs such as Decadron, with no FDA approval
At least right now, FDA approval--or lack of it---appears to be of little importance.
 
CDC-
The Centers for Disease Control is a federal agency. If you want to trace how Covid-19 became out of control in the US, we can start here. The first confirmed case in the US was January 20.  Yet the CDC delayed widespread testing for over a month. Worse, CDC tests were found to be faulty, and investigations show the CDC did not follow their own protocols regarding pandemics. 

And although Caduceus was the first to start testing for Covid-19 in Orange County, we had to wait until March 12 because the CDC had not made tests available to the health care community until that date. It would be April before the testing was available to the general public. And even then, everyone was running out of tests. This debacle lay in the hands of the CDC.

This was definitely a pandemic prior to March 11. 

A US Department of Health and Human Services (HHS) investigation into the COVID-19 testing crisis is under way.
But that isn’t all; the CDC admitted they inflated results by combining IgM antibody results with positive PCR swabs. 
Even now, they admit they were wrong to not advise testing close contacts of known Covid-19 patients with no symptoms, and now do advise it...four months too late.

They also discourage a test of cure (re-swab) after a Covid-19 infection. It is easier to have a Michelin restaurant allow substitutions than have the CDC advise us to test.  And we shouldn't forget the CDC website told us in the spring to only wear masks if social distancing was not possible.

And what has our federal agency designed to protect us accomplished? 
New cases in US March 30-19,000 
New cases in US August 30- 44,000. 

How is minimizing universal testing working out for you?
 
How about the White House Task Force---headed by Dr Fauci, under President Trump?
 
On February 29, WE WERE TOLD "NO NEED TO CHANGE WHAT WE ARE DOING" in regards to the large wave approaching. He has also flip flopped on the travel ban (first against it, then for it). He first spoke of masks being optional, and then changed his mind. The lockdown? First for it, then against it.  More flip flops than Labor Day in Laguna Beach. 
But this is truly a bipartisan gaffe; both Nancy Pelosi and Joe Biden downplayed the upcoming carnage in February when we needed a strong push to test from all of our leaders. 
 
We must mention our own Orange County Health Department leader Nichole Quick was forced to resign after death threats when she put out a mandatory mask order.  Her replacement understandably reversed the order. The job doesn’t pay enough to risk an execution.

When the state also passed a mandatory mask order, the Orange County Sheriff said he would refuse to enforce it.
Our own OC Health Department is calling our patients telling them no need to retest after an infection. As recently as last week, other health departments through the state are doing the same thing.

And Governor Newsom locking down, reopening, and then locking down again-without advising mandatory testing? 

How effective are our state leaders in getting this under control?
New cases in California March 25- 471
New cases August 25- 6,004

More testing anyone?
 
At Caduceus, we have been consistent with our message from Day One.

*Know if your contagious (PCR Swab) 
*Know if your immune (Antibody blood test)
*If your positive strictly quarantine until PCR swab is negative (Average 14 days) 
*Get tested bimonthly, or monthly depending on your risk and activity level

 
-Keep in mind the main three methods of transmission:
 1. Respiratory secretions (Wear a mask)
 2. Close contact with the virus (Social distance)
 3. Crowds (Hunker at home, avoid gatherings)
 
If our leaders had put forth--and enforced--such measures, our transmission rate would have plunged and lockdowns would have been unnecessary.

A few other facts...
Would reviewing Avian Flu help us with Covid-19?
This influenza is spread from infected birds, not bats. And does not wreak the havoc Covid-19 does. No help here.
 
How have airlines dealt with Covid-19?
Some block middle seats. Most require masks. Some upgraded their disinfecting policy. Most stopped serving meals. So far, little effect on the rate of Covid-19 spread has been noted. Nothing here to assist us either.
 
Is there an association between frogs and Covid-19? According to Ethos, a famed vet blog, It is neither considered likely that Covid-19 will be found in frogs nor as a cause of disease, nor that frogs function as a reservoir that allows spread to humans.

So, for extra credit, can we actually use Wally Cox's monologue from the famed cartoon to adjourn?
 
Sure, easy:
Where can we best find Covid-19 advice?
 
Not bird
Nor plane
Nor even frog

Just little ol' us
Heh Heh 
Underdog.
 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group

Now Offering Covid-19 Coronavirus Diagnostic Nasal Swab Results in 48 Hours or Less


(With apologies to Messrs, Chandler, Hammett, Spade and Marlowe...)
 
THE BIG SLEEPY SWAB 
 
A novella in 5 acts
 
Act 1- The Wife
 
I have two rules. First, I don't follow any rules. Second, rules are for suckers. 
 
It was a balmy August morning, the early morning fog hovering over my beach town - so thick it made pea soup look like Evian. The town is an artist colony, and has the personality of a eucalyptus tree swaying in a Santa Ana wind. My name is Diamond. You can call me Samme. 
 
My rent for the summer was overdue, more than a high school senior’s library book. I was sitting in my office wondering where the rent money would come from when she knocked. She walked through my door the way a princess walks into a dive bar. She sported strawberry blonde hair and wore that dress. A dress so tight it looked like it had been tattooed on. Not the expensive tattoos. More like the kind the sailors get at the docks.
She looked like she jumped from the USS Gorgeous and didn't wear a life vest.  She had bad news written on her like it was 9-11-01.
 
"Mr. Diamond?" she cooed.
"Samme. What can I do for you Angel?" I snapped back. 
"You’re the best diagnostician in town, and I need to find out what is killing my husband Frank.  Can you help?"
I was intrigued. "Tell me more," I instructed.
She shared, "You know the drill. Headache. Cough. Low grade fever. Going downhill." 
"Doesn't sound so fatal to me," I chimed back.
"I took him to a specialist. Told me he had 48 hours to get on treatment. But he couldn't pin it down. I figure you’re our last chance."
I knew this would take some legwork. 
"Your name Angel?"
Frances Frackle. You can call me Fanny," She said with a purr. 
“I better get started Fanny. Oh, speaking of coughing, you'll need to cough up my fees,” I reminded her.
"Of course Samme. Name it,” she declared.
 "$89 for an office visit. $69 for video visit from your phone," I said.
"Sure Samme; anything," Frances responded.
 "That's not all Angel---plus expenses,” I told her.
 
She agreed so I went on…
"Get Frank down here now. Pull up curbside. Keep him in the car. Have him lay low. My people will take care of the rest.”
I knew the clock was my enemy.  I also knew what I needed - a beach house and a vacation. What I had was a white coat, a straw hat and -for protection- a #10 blade scalpel. 
 
Act 2- The Masks
 
My first stop was downtown. A little boutique on Main Beach. The owner was a little blonde number named Heidi. She was so petite a 20 MPH offshore wind would take her to Catalina. I went there because Heidi  makes the masks she sells by hand. And everyone in town gets their masks from Heidi. I knew she could help.  She knows everyone in town and everything that's happening too. 
 
"Hi Princess," I greeted her.
"Samme, don't call me that! You know that's sexist!"
"Sorry Heidi. Just being true to the genre."
"Oh why didn't you say so? Sorry- I wasn't around in 1947,” Heidi reminded me. 
"So Heidi,” I asked, “have you seen Frank Frackle lately?”
"Are you kidding? Everyone knows he won’t wear a mask. He’s been walking all over town sans mask. I saw him on the street and I offered him free masks; he just said the whole thing was a hoax," Heidi retorted with the roll of her eyes.
 
I knew it.  Frank Frackle--an Anti-Masker.
I threw 1,000 bits on the counter and took my favorite mask--jet black with nuthin’ on it. I knew there was more to this caper than I was bargaining for.  There was a killer out there and it was my job to find him...or it.
 
 
Act 3---The Mechanic
 
After a quick club sandwich from Penguin's, I decided to drop in across the street at the local mechanic. Mechanics always bugged me. That’s the trouble with mechanics. You get all set to hate them and then you meet one that goes human on you.
 
Jim was a happy Pollyanna type of fellow that you couldn't miss due to his thick Scottish brogue .When he spoke you expected to see him wearing a kilt with bagpipes and eating a meat pudding. His hands were big. As big as plates of spareribs, and twice as greasy- grease from a '47 Hudson.
 
Jim tuned up every car in town, and knew every car owner and when he saw me he said, "Hey Mr. Diamond, its ty-em  fer yer old jaloopy to get 'er oil changed.”
Jim was right. Of course it was.
"Next week, my friend. I'm checking on Frank Frackle; has he been in the shop lately?" I inquired.
"Matter of fact, 'e was just 'ere loost week. Broot 'is Rolls in,” he remarked.
"Notice anything unusual?" I inquired.
"Yes indeed. He refooosed to use our hand sanitizer--we poot it out here on the counter and ask the coostumers to use it. He said it was all a cone-spiracy!” Jim sighed.
Figures. No mask. No Purell. I was getting the picture crystal clear and it wasn’t pretty. Or as Jim would say "purty."
"Ok Jim, thanks for the dope. And better add a loob n’ filta to the jaloopy toon up next week, eh?" I quipped trying to impress with my new accent.
"Worst Scottish brogue imitation I’ve eva heard mista Diamond,” said Jim with a broad smile, “and stay oot of trouble."
 
A little trouble I don't mind. It’s big trouble I have a problem with. 
 
Act 4- The Restaurant
It was 6:54 PM -the time for most guys to go home and get in their slippers, and light a thick Cuban cigar.  But for me it was suppertime and time to go to my regular hangout next to my office, a little Creole place. The residents of my beach town will eat anything that is plant-based, gluten free, and held loosely with toothpicks. Me, I needed a steak. 
 
Michael, the owner, sported a full head of hair whiter than a salesman’s teeth after his dental appointment.  He was as smooth and strong as a garlic milkshake.  He quickly escorted me to my regular table, #4, in the corner where open windows gave a breeze as welcome as a slice of bacon at Zinc. His wife Cindy came to take my order. A tall drink of water, Cindy was as sweet as a baby's smile and her eyes revealed a brutal honesty. 
 
"The usual Samme?" she asked.
"No, Cindy, I’ll take a steak."
She was shocked.."But Samme you always have gumbo?"
"Trying to be true to the genre Cindy," I said.
"Ohh…gotcha," she said yelling over to Robert the chef, "one 1855 steak for Mr. Diamond, Robert!"
 
I asked Cindy and Michael if they have seen the Frackle’s lately.  "Oh how can I forget Samme. They were here last week, no social distancing and walking around hugging and kissing everyone. We had to ask them to leave. He said we were infringing on their human rights.”  No surprise there. Frank Frackle touched all three bases, but there would be no home run...no mask, no hand washing, no social distancing. A blind man on a galloping horse could see this picture. 
 
I finished my steak. Robert had cooked it exactly to order, matching how I was feeling. Burnt on the outside. Cool on the inside. 
 
Part 5 -The Reveal
 
The following day, Fanny reappeared in my office.  She looked as inconspicuous as a rattlesnake on a white tile floor. "Mr. Diamond, I must say you are stupid. A stupid person. In a stupid business. On a stupid mission!” she cajoled.
"I get it," I agreed. "And now I must make a stupid diagnosis. Because you see, Fanny your husband is suffering from Covid."

"Good guess Mr. Diamond. But you can’t prove it- you can’t prove a thing," she argued. She went on, “the quickie tests are inaccurate. The PCR test is the only thing that can diagnose him, and those take 3-13 days for a result. And the specialist only gave Frank 48 hours to live without a diagnosis. It appears my dear husband’s number will be up very soon."
 
"Oh but Fanny I can prove it,” I said with an evil grin. “I used the new PCR test now available at Caduceus. We swabbed him curbside yesterday and I knew we would have the results within 48 hours. And as this report clearly shows, Frank is indeed suffering from Covid 19--no doubt a consequence of being an anti-masker, anti-hand washer, and anti- social distancer. A mere $189 and I hold the proof here, in plenty of time to get him on inhalers, some pulmonary hygiene, and maybe a little Decadron. Frank should be fine!"
 
"But I had it all planned,” Fanny said and stopped abruptly.

"Yes, Fanny. You are named the beneficiary in his multi-million dollar life insurance policy. Knowing he felt Covid was a hoax, you paraded him all over town to get him infected. Thinking we could not diagnose him in 48 hours, you came to me to avoid you being a suspect. But I have the smoking gun right here."

"Nonsense!” yelled Fanny.
 
"This is an IgG moderate complexity antibody test you took at Caduceus two weeks ago, showing you are likely immune. So you knew you couldn't get Covid yourself as you tried to infect your husband. And that dear Fanny is the reveal our dear readers have been patiently waiting for---you were brought down by a 48 hour PCR swab and a moderate complexity antibody test."
 
"But Samme, aren't we going to be true to the genre? The wife always becomes a femme fatale who then falls in love with the detective and they run away together?” she asked out of desperation.
 
"Sorry Fanny. I'm going to take a load off you, and put the load right on me..."
 
I left the office and walked a block to Thalia Beach. I had a date with sunset, a beach chair, and a Laguna Feast taco.
.
 And Covid? It’s like a cheap bourbon. And I put it on ice.
 
 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group
 

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Email any medical questions about Covid to mousecalls@caduceusmedicalgroup.com