Sunday, November 23, 2014

Immigration Reform.

The million immigrants a year are not entering booming industries, but serving as cheap labor in declining ones. And they’re doing it in a country where declining industries and poor workers are already being subsidized by taxpayers in a dozen different ways. Why then should taxpayers also be subsidizing the replacement of American workers with Somali and Honduran workers?
-Sultan Knish

Saturday, November 22, 2014

Why have the patients treated for Ebola in the U.S. done so well?

The truth is, we don't know.  There is a scarcity of quality information on this outbreak because the governments in the 3 hardest hit countries don't want negative publicity. The reporters from developed Western countries have returned to their countries after some of them contracted the disease, and I have not heard of any news crews returning to West Africa.

Recently, there was a study published in NEJM by Schieffelin et al, which reported observations made at the Kenema hospital in Sierra Leone. There, they found 57 percent mortality among those younger than 21, and 94 percent mortality among those aged 45 and older. Overall fatality from Ebola was 74 percent. These are some pretty scary numbers and they simply do not compare with what has been reported in the case updates provided by WHO and the CDC. In the latest situation update from WHO, Sierra Leone reports a total of 6190 cases, with 5150 of them being confirmed and only 1267 fatalities. If you calculate the mortality from this report, you get only 20% using total cases or 24% if you only use confirmed cases number. The most likely explanation is that the numbers reported in WHO and CDC surveys are bogus.

Here in USA, everyone who received treatment early during the course of their illness, including the 2 nurses from Texas and the irresponsible doctor treated in NYC, survived. So how do you square the remarkable survival rates we've seen in the few people treated here at the US, with the survival rates reported in that study cited above? One possibility is that the people who were treated at the Kenema hospital were much sicker than the typical person who contracts this strain of Ebola. Perhaps those with only mild symptoms never show up at treatment centers in Sierra Leone and are able to weather this disease at home. Another possibility is that the folks treated in the U.S. were given medications unavailable in West Africa, such as Zmapp, early during the course of their disease, and such medications proved very effective. To repeat what I said in my opening sentence, we just don't know.

Saturday, November 15, 2014

Some Hopeful News on Ebola

First I would like to state that this epidemic, in all likelihood, is still raging out of control in West Africa. The numbers being reported by WHO and CDC are likely nonsensical and the motivation for under-reporting is that the 3 hardest hit countries are under tremendous financial pressures. In many villages there are no signs of life and many people are struggling to find food. The fact that the number of dead in Liberia keeps going down, offers ample proof that this number is bogus.  Our best solution to keep our own country stable is to institute strict quarantine on travel from West Africa and do everything we can to prevent this disease from reaching our shores.

Furthermore, as this disease spreads beyond Liberia, Sierra Leone, and Guinea, the number of infected travelers to the U.S. will briskly increase once there is a significant outbreak in Nigeria and the Ivory Coast. The reason for my statement is partly anecdotal as, in my 8 years of working for a city hospital, I don't recall treating anyone from these 3 countries but I have had several patients from the Ivory Coast and numerous patients from Nigeria. The population of Ivory Coast is about 23 million and Nigerian Population is 174 million, while the combined population of Sierra Leone, Guinea, and Liberia was around 15 million.  Obviously we have many more commuters to the U.S. from these 2 larger populations.

I predicted that people would run from there, once the threat of Ebola became bad enough, and obviously some people like Duncan did run. Perhaps these countries are so destitute that most people simply don't have the means to travel outside their area and so far, the rapid transit of Ebola stricken people to the rest of the world hasn't been as severe as I feared. For the reasons stated above, I believe all this can change once these other countries, that border the 3 currently affected, become heavily infected.

By this point, you are probably wondering where is the hopeful aspect of my post. The hopeful aspect has to do with the ability to survive this infection inside the U.S. or other first world countries. While we haven't had tons of experience dealing with this virus here, thank God, we have had some. The early case named Duncan didn't make it, no matter what we threw at this illness, but several others have. What we can offer here that is unavailable in West Africa is appropriate management of kidney failure and appropriate fluid management. It appears that the early period of a severe Ebola illness is marked by profound diarrhea, to the tune of 6 litters per day and inability to drink enough fluid - probably due to vomiting. They can set up an IV in West Africa, but they are unlikely to get quick lab results back and manage the associated electrolyte disturbances as well as we can here. This has to do with having a good lab in your facility that can give you results within an hour or 2.  Another item they don't have as good an access to is dialysis, which seems to have played a role in stabilizing several Ebola patients who were treated successfully with 1st world medicine.  Duncan did receive dialysis, which was a very risky procedure for the staff, but he still died. However others lived, and consequently Ebola mortality here hasn't reached the 70-90% range seen elsewhere. As the illness progressed further and complications of bacterial sepsis occurred in the severely ill man treated in Germany, he had access to effective and powerful antibiotics and mechanical ventilation. These things are also not widely available in West Africa. Bottom line, he lived because of his access to such medical treatments whereas, if he had stayed in Africa, he would have died.

So in this hopeful part of my post, I have reason to believe that mortality from Ebola in the U.S. will not be as severe as it is in Africa. If I had to guess based on known survival patterns for sepsis and organ failure, I would guess it will be somewhere in the 25% range. Still, you should take such assessment with a grain of salt because it is impossible to do good statistics on so few cases as we have treated here, and often times theory based predictions turn out to be poor predictors of reality.

Another important point to make is that our ability to deliver such high level of care to someone infected with such a deadly pathogen is very limited. Outside the 20 or so BL4 beds available in this country, the other hospitals attempting to treat such patients will place themselves and their other patients in great risk. In terms of financial risk, the hospital that treated Duncan in Texas lost millions, even before they settled with Duncan's family. This was a 900 bed hospital and patients continue to avoid it like the plague, and therefore much of it remains empty. I would not be surprised if it goes belly up soon. Just imagine such financial impact hitting multiple hospitals throughout the U.S. The key to avoiding this devastating burden on our already severely stressed medical system here, is to send all such infected patients to the few operational BL4 beds we have. The best way to keep a manageable low census of such patients remains through effective quarantine.  I sure hope our politicians will take this threat seriously and not become fooled by the obviously false estimates coming out of West Africa.

Wednesday, November 12, 2014

Back to Ebola News

I found this information from a comment on Raconteur Report.  Some imam arrived in Mali from Guinea and died at a clinic in Mali. There, he infected at least one person, whose infection is now lab confirmed, while other medical staff also appear to be ill and the number of infected will rise, if any honest reporting will occur. As a reminder of what we should expect, the man in a Nigerian hospital infected 20 staff and 8 of them eventually died. For unclear reasons, this second Mali case was never considered to have Ebola and so it is unknown what precautions the clinic staff took while treating him.  Obviously, he was contagious in that clinic and his body remained contagious while it was transported back to Guinea.  It is unlikely that appropriate precautions were taken during this transport. Also, it won't be surprising if others infected by this man will delude themselves and those around them about what they are infected with.

I am glad that Hajj is over for this year, and I am glad about the reported ban for West Africa that seemed to have been in effect for hopeful travelers to Saudi Arabia.  I just hope no one infected with Ebola reached that market of potential new infections, because it would accelerate the global spread and we need time.We need time to develop drugs and we need time to develop vaccines. We need at least a year and I am not so sure that we have it.

Despite a lack of reliable reporting about the spread of Ebola in West Africa, this disease remains a very serious global threat. Serious people should be working on how to contain it, but our leadership in DC is anything but serious.  In what should not surprise anyone whose brain function remains above moronic, our president has spent time at the Asian conference working on climate change agreements, further undermining our economy while chasing some opium pipe dream. In the picture this link leads to, the Chinese leader appears annoyed while Obola is flashing an idiot's smile.

Tuesday, November 11, 2014

Driving and Parking in NYC

I went shopping today near avenue J and Coney Island. It is a very busy area and I was fortunate to find a parking spot only one block away from my intended stores. After returning from one store and leaving several bags in the car, I started walking towards my other destination. As I walked 2 steps away from my car, a driver pulled up and with hopeful eyes asked me if I was leaving. I said no, and he replied "Why not?" I smiled and kept walking. A few more steps and another car slowed down near me and the driver screamed out - "Are you leaving?"...I again said no. He asked again either from deafness or, more likely, still hoping to hear the answer he wanted to hear. I again said no. This driver also followed up his queries with a "why?" and I really felt like answering - "out of spite", but just smiled and kept walking.

 New Yorkers are crazy and sometimes in a very funny way.

The new city-wide, 25 miles/h speed limit is now in effect but all the lights are still set up to accommodate a faster speed; previously it was 30 but everyone drives near 35 if they actually want to reach their destination within reason.  I saw a cop car flashing his lights while double parked and everyone slowed down to 25 or under. This meant that every street light turned red by the time I reached it and what used to take me 5 minutes to drive now took over 10.

I would like to see city officials and the police follow the laws they impose on the rest of us. If they don't, then someone should sue the city for discrimination and failure to uphold the equal protection under the law clause in our constitution.

Staying Alive in a World Dominated by Muslims.

"There are only so many second chances when someone wants to kill you. And if you are a non-Muslim in the Muslim world, then someone always wants to kill you." -Daniel Greenfield

Another reason to move out of NYC. 

Wednesday, November 5, 2014

Interesting Accounting of Ebola Cases on WHO Website

Last week, we saw a report of 13,700 cumulative cases of Ebola. This report included an adjustment from Liberia, which over the prior several updates failed to report their new cases and deaths. Surprisingly, the next follow up report saw a decrease in total number of cases from Liberia, but now included over 1,000 new cases from Sierra Leone. Friday went by with no further news, as did Monday, and then I noticed several hopeful accounts, claiming of this epidemic slowing down in Liberia.  The rationale for decrease in Liberian transmission seemed dubious as it referenced new facilities being built with international help, while such beds are yet to be filled and the number of health care staff in the worst off countries has actually decreased., Other amazing interventions mentioned include texting...
Seriously, the typical Liberian is sitting somewhere in the middle of a forest, reading health alerts through their smart phone. So I would be a fool to take such reporting seriously.

Today, a new account of cases was published on the WHO website, which again notes a decrease in total number of recorded cases; here both Liberia and Sierra Leone decreased their cumulative case numbers, and miraculously their number of dead also decreased.  I hope this doesn't mean that hundreds of undead are roaming West Africa.

So what does one make of these reports. It is possible that prior reports overestimated the number sick and dead, however this would also contradict prior WHO assertions that official numbers are under-reporting those affected by a factor of 2-3. There is a strong incentive to not report Ebola in the community, as this will adversely affect their ability to do commerce.  Bottom line.., we don't really know what is going on in West Africa and at what stage this Ebola epidemic is currently.  We do know that the situation is pretty chaotic, and that is good reason to remain very concerned.

Tuesday, November 4, 2014

Swinging at Windmills

I realize that my voting NYC is a quixotic endeavor. I still did it.

The voting place was largely empty, as compared to prior years.  You never know...

Could be this:

Or this:

I still feel better simply for doing it.