Author: sroyappa

I am so disappointed to read about unreliable Covid-19 antibody tests hitting the market. Since the FDA relaxed guidelines for confirming whether a test is actually valid, more than 70 companies have registered to sell their kits. It appears several of these tests are completely useless. This is more harmful than having no test at all.

This is a warning sign of what happens when we relax rules in an effort to speed things up due to panic and hysteria – we want that drug now, we want that test now, we want that vaccine now! Tests, drugs, vaccines – these are the keys to ultimately defeating this pandemic. We want them ONLY after they meet our established standards for quality, reliability, effectiveness and safety. Let us all demand this!

We’re talking about population level here. Obviously, in individual cases, experimental treatment protocols are all we have now.

Please don’t get mail-order, in-home tests. You must go through your doctor. It is not as simple as having a red “positive” line on a random rapid test. There are lots of nuances and interpretations surrounding immunity.

It is my fervent hope that we learn from our mistakes and work diligently to rectify them.

If you have not read Part 1, please read it first, otherwise this will appear one-sided. I’m aiming for a balanced look from the middle. https://www.facebook.com/sudhasue.royappa/posts/10158027271274631?

Continuing from Part 1, where we discussed the importance of long term Social Distancing..

Prolonged stay-at-home orders in the hope of virtually eliminating all risk would require everyone to stay at home for many months, maybe even years. But for most people, this is not a viable option. They won’t have money for medications or doctors’ visits to manage their chronic diseases like heart disease, diabetes and depression, and they are going to start dying from them sooner. They won’t have money to buy food, pay rent or utilities. There are already reports of increased child abuse and domestic violence from people being forced into prolonged close-quarter living in less than ideal situations.

That being said, we should not come out of stay-at-home orders in an irresponsible way, without social distancing, losing all that we gained in the past weeks. Neither should we stop living while being alive, allowing panic and hysteria to drive our feelings, thoughts, behaviors and decisions. We have always been willing to accept some level of risk as a society so that we can continue our activities of daily living. So we need to now accept that some people are going to get sick and die from the coronavirus just like people die from car accidents, flu, and other things. We will have to first allow the lowest risk groups, people younger than 20, to start developing immunity through exposure, then stagger exposure of higher risk groups as treatments become available. We must protect our elderly and most vulnerable for as long as possible until effective vaccines are available since they have an unacceptably high risk of death from this virus.

Social distancing allows us to minimize risks while still carrying on with many aspects of our lives. We may not be able to go to large parties, sporting events and concerts, but many of us will still be able to go to work with precautions and judiciously socialize in smaller groups. Some hard hit states like NY may need to continue stay-at-home orders until the danger of running out of health workers, beds and ventilators is past. However, for the rest of us, in the long run,  we need social distancing, not stay-at-home orders.

Based on questions that I’m getting from people, there appears to be a fair amount of confusion about stay-at-home orders and what to expect when these orders are lifted. I am breaking this post into two parts.

The main purpose of stay-at-home orders for a few weeks is to reduce the rate at which sick people come into the hospital. Let’s say 1000 really sick people were going to come to the local hospital in 1 week with Covid-19. This could lead to unnecessary deaths from lack of medical staff and equipment. By staying at home, we spread those out over one month instead. This way we have the required doctors, beds and ventilators to properly care for all of them, thus reducing the number of deaths.

Many people are under the false impression that when stay-at-home orders are lifted, we can just resume life as normal, and we will miraculously have fewer cases and deaths from Covid-19.  Conversely, an equal number of people feel that we should all stay home until “the virus is gone”. Although I understand both viewpoints, neither is realistic. A middle path is necessary in the long run  to balance the risk of Covid-19 with other physical, mental and emotional health issues. This middle path is Social Distancing. We cannot fully return to normal in the next few weeks, neither can we be in stay-at-home mode for months to years.

𝗦𝗼𝗰𝗶𝗮𝗹 𝗱𝗶𝘀𝘁𝗮𝗻𝗰𝗶𝗻𝗴 𝗶𝘀 𝗻𝗼𝘁 𝘁𝗵𝗲 𝘀𝗮𝗺𝗲 𝗮𝘀 𝗮 𝘀𝘁𝗮𝘆-𝗮𝘁-𝗵𝗼𝗺𝗲 𝗼𝗿𝗱𝗲𝗿. It is avoiding gatherings of people from different households where you cannot maintain a 6 foot separation. So you can get together with friends in your backyard, with chairs six feet apart. You can play golf as long as you can stay six feet away from the other person. But two high risk people with unknown Covid-19 status may not want to play tennis together as they are touching the same ball multiple times. So you would have to analyze each situation individually.

In order to drastically reduce the number of cases and deaths, we would need to practice social distancing for several months to possibly two years, until these things happen:

𝗪𝗶𝗱𝗲𝘀𝗽𝗿𝗲𝗮𝗱 𝘃𝗶𝗿𝗮𝗹 𝘁𝗲𝘀𝘁𝗶𝗻𝗴 so people with Covid-19 infection can be isolated to prevent spreading it to others.

𝗪𝗶𝗱𝗲𝘀𝗽𝗿𝗲𝗮𝗱 𝗮𝗻𝘁𝗶𝗯𝗼𝗱𝘆 𝘁𝗲𝘀𝘁𝗶𝗻𝗴 so we can allow people who have recovered from previously undiagnosed Covid-19, and are now immune, to mingle with others safely. We don’t know for how long they will be immune, experts say anywhere from 6 months to 8 years, only time and repeated testing will tell. A good test is one that has few false positives, so people don’t mistakenly think they are immune when they’re not.

𝗣𝗼𝘀𝘀𝗶𝗯𝗹𝗲 𝗿𝗲𝗱𝘂𝗰𝘁𝗶𝗼𝗻 𝗶𝗻 𝘃𝗶𝗿𝘂𝘀 𝗮𝗰𝘁𝗶𝘃𝗶𝘁𝘆 due to heat, but the jury is still out on this one.

𝗗𝗲𝘃𝗲𝗹𝗼𝗽 𝗲𝗳𝗳𝗲𝗰𝘁𝗶𝘃𝗲 𝘁𝗿𝗲𝗮𝘁𝗺𝗲𝗻𝘁𝘀, first for really sick people that are hospitalized and then for people in the community before they become very sick. We cannot treat a large number of people based on one doctor or hospital’s experience with a particular drug or set of drugs. We can do that for severe cases when we have nothing left to lose. For treating large groups, we need randomized, controlled trials, which take time.

𝗗𝗲𝘃𝗲𝗹𝗼𝗽 𝗮 𝘀𝗮𝗳𝗲 𝗮𝗻𝗱 𝗲𝗳𝗳𝗲𝗰𝘁𝗶𝘃𝗲 𝘃𝗮𝗰𝗰𝗶𝗻𝗲. If you want a safe vaccine, you cannot rush it. The minimum time to get it fully tested is one year, likely closer to 18 months. It will take several months after the vaccine is tested and approved, for it to be mass produced and made widely available, and to finally have widespread public participation.

Part 2 coming soon.

I initially planned to send this for my monthly HAWL newspaper column, but I think it will be more useful right now, rather than a month later.

Originally published in the Hideaway Lake News on April 1, 2020

In an effort to minimize all risk from the “c”, I’m concerned that many of us may forget that we are more likely to have problems from our other medical conditions like heart disease and diabetes, if we don’t take care of them in the coming weeks to months.

My own lunch, one day last week, was a bag of Doritos, Andy’s concrete and a McD’s apple pie. Shameful, I know, but one day of such behavior is going to do no harm. However, I can see how it can be easy to slip into bad eating habits while hanging out at home in our PJ’s wallowing in self pity. So I would like to motivate you to get dressed in the morning and stick to your daily good habits of eating healthily and exercising. Make sure you stay in touch with loved ones virtually and with appropriate social distancing in person.

Many primary care doctors are open for restricted hours and urgent patients only, or are working via telemedicine during the pandemic. If your regular appointment was cancelled, please don’t just blow it off. Make sure you learn how to get set up on telemedicine. Your doctor won’t be able to provide the same level of care as they can in person, but it is far better than not going in at all. Even if your appointment is not for another month or so, get registered on their tele site so you can visit them remotely if you are a high risk person or if something urgent pops up.

Remember, since your doctor may be working from home, they may not have access to your full chart which may be in their office. Not all doctors have electronic medical records that are in the cloud. Here’s how to prepare for your next chronic care telemedicine visit:

On the day before your appointment, check that your webcam or phone camera, as well as your audio, are working properly. Also make sure you can get on the telemedicine site and connect correctly with your doctor’s office.

Type out a list of all your medicines with doses ahead of time.

Keep your blood pressure, sugar and any other data record readily available, if you were asked to keep track of them.

Have your most recent blood test results handy if you have them.

Make a list of things that you need to speak with your doctor about. Keep it to three items or less, otherwise there won’t be enough time to thoroughly address all of them.

Make sure you FIRST address any important symptoms such as chest discomfort, difficulty breathing, nausea or dizziness. This allows your doctor to spend the most time evaluating them.

Our lives are going to be quite different in the coming months. These are uncharted waters for us all. The doctors and nurses need time to figure out this telemedicine thing. Let’s be patient, kind and understanding with those who are caring for our health. Practice deep breathing, prayer and meditation to help keep tempers down and anxiety in check. Sometimes anxiety can manifest as irritability, anger or frustration. We all need an inordinate amount of patience right now as we show love and kindness to everyone struggling to get it right, including ourselves.

Good health and good spirits to all!

Dear friends and neighbors, what a difference a month can make. As I write this, we’re all under a “Shelter at Home” order. For us in Hideaway, a very close- knit, highly social community, it can be particularly difficult to adapt to this sudden and prolonged withdrawal from the many social connections that we rely on so heavily, not only during normal days but during other times of stress and uncertainty.

We love getting together with our friends and family. We love our social gatherings – church services, weddings, birthdays, anniversaries, sports, games, clubs and parties. All of those have come to a complete standstill and will likely stay that way for possibly many more weeks. Most of us, to varying degrees, will have a tough time dealing with both the physical and mental ramifications of isolation and information overload.

The first thing that we can all do right now to reduce stress and anxiety is to take a break from TV news and social media. It is important to stay informed, but there is no need to be watching or reading news 24/7. Set specific times when you will watch the news on TV or interact on social media. Otherwise, all we hear and read about all day long is the coronavirus. This is not healthy because we can start to see things more negatively than they really are. It will be easy for us to forget that there is still plenty of good happening all around us as well.

We can get paranoid about one cough, one sneeze, the slight warmth of our skin – do I have coronavirus, does my grandma, does my child? We can become suspicious and fearful of others. We might verbally attack or Facebook shame the person on the street that coughed once without covering his mouth because he had some food stuck in his throat or swallowed the wrong way. For those with pre-existing anxiety, these fears can quickly escalate to panic, which in turn can raise blood pressure and sugar, which can then affect the heart, brain and kidneys. See the cascade effect? And to make matters worse, our dear friends can’t hold our hands or give us a hug to let us know that we will make it through.

Now that we’ve turned off our favorite news channels and snoozed our fear-mongering Facebook friends for a few days, let’s try to find ways to calm and uplift ourselves. Our community has already come up with creative ways to let neighbors know that we care – the teddy bears and hearts on people’s porches and windows, the positive photos on social media, and the neighborhood walks with friendly waves and micro visits while practicing social distancing. But let’s not forget those that live alone, are too debilitated to go out on walks, or are not on social media to connect with the rest of us. Make a special effort to reach out to them with a friendly call, maybe a longer one than usual. Let them share their fears and worries with you. Ask them if they need any help. Don’t hesitate to tell a friend, neighbor or the administration if you are lonely or afraid. We know you are there and we want to help you. Call the volunteer group in Hideaway.  They will be able to connect you with the right person or organization.

And finally, don’t forget to maintain your usual healthy lifestyle – lots of vegetables and whole grains for vitamins and minerals (stores were fully stocked with these items every time I’ve been), lots of water to stay well hydrated (you don’t need bottled water, our tap is just fine), and plenty of exercise, fresh air and sunshine for a mood boost. You can incorporate meditation, mindfulness and thankfulness to your daily routine. Meditation has been shown to be very effective in decreasing anxiety as well as blood pressure. So maybe try one of the free popular meditation apps on your smartphone. Use technology for all its benefits. Maybe you’ve never used video chat before but are longing to see, not just hear people. Don’t hesitate, get on that video chat now. If you don’t know how, just call one of the many savvy kids in town, they’ll get you going right away.

We know from the rest of the world that this virus can be controlled. Normal (almost) life has begun again in Taiwan, South Korea and Singapore. Normal life will begin again for us too.

I’m responding to a dear neighbor’s question. It is an excellent question and I thought others might be wondering the same.

“They tell us that wearing the mask won’t keep us safe so why are healthcare workers using them everywhere? I understand in certain situations.”

Healthcare workers are coming in very close contact with lots and lots of people that are potentially very, very sick. We are often within inches of a patient who we’re examining. The regular masks protect against droplets – that means when you cough or sneeze very close to someone, those droplets are prevented from landing on your face and causing an infection.

The risk to healthcare workers is MUCH higher: first, the person in front of them is sick (if not with coronavirus, then with flu or pneumonia, likely not just a cold or allergies). Second, they are right in their face. Third, they are seeing a lot of sick people. This cumulative risk is much higher than for a regular person walking down an aisle in Walmart and someone a few feet away sneezes or coughs, maybe because of an allergy or a cold. So it’s not the same situation at all.

Even now, all healthcare workers are NOT using masks everywhere and with every patient in the clinic, only with those who are having respiratory symptoms. Right now they should be, actually, but they can’t due to the shortage of masks. In the ER, however, which is very crowded and where doctors are seeing multiple patients, they do need a mask the entire time, because they may be going between a cough patient, a heart attack patient and a cancer patient.

If we had enough masks for everyone to wear for weeks on end, we could certainly all wear them, all the time, or during flu season. They would definitely protect us from other diseases like flu and cold too, when we unknowingly come in close contact with sick people. But nobody does that. So in these difficult times, let’s first give them to the people who need them more than us. My doctor friend Jessamy, working with cancer patients, should not have to beg people to sew handmade masks for her patients and staff – that is just wrong. Since the benefit to the general public is so much lower than to the people inside the hospital, the public is being asked to make prudent use of limited resources, for the time being.

Hello everyone, I’m getting questions from our community members about alternative medicines for preventing coronavirus and boosting immunity during this pandemic. I have one simple response: before taking anything new, just check with your doctor! For more details, read on.

If you are already on medications, there may be serious side effects or interactions. If a substance is powerful enough to do good, such as raise immunity, it is powerful enough to cause side effects and interactions.

Several natural substances interfere with common drugs. I just had to remind Andrew not to eat grapefruit because it interferes with his cholesterol medication. It also interacts with some blood pressure medications. Garlic can cause prolonged bleeding during surgery and increase your risk of bleeding if you’re on a blood thinner. My Mom uses an inordinate amount of garlic in her cooking and I had to warn her about this – she is on multiple blood thinners for her heart stent and AFib.

We think of grapefruit and garlic as natural, harmless and even healthy – which they are! – but they are also very powerful. Your doctor will advise you of any such interactions specific to YOUR medical history.

Many of our current medicines were initially synthesized from natural sources. Aspirin, the blood thinner, was originally extracted from willow tree bark. Digoxin, the heart failure medicine, was made from foxglove. These are all potent chemicals found naturally in plants. They can do a lot of good, but they can also do a lot of harm when taken incorrectly, especially with regard to dosage, timing and combination with other drugs.

Let us respect the power of things that nature has given us.

Let us evaluate them rigorously and use them carefully.

Please check with your doctor before taking a natural substance to fight the coronavirus.

Dear Hideaway friends, as expected, COVID-19 is in our backyard. Let’s not be cavalier with it like many are with the flu. There is a difference between panicking and being prudent. What is of utmost importance now is to slow the spread of the virus so we don’t overwhelm our healthcare system. Please pay attention to infection control guidelines from reliable sources such as the local health department. The recommendations will change as we get more information about the virus.

The facts as of now:

80% of people with known coronavirus infection have relatively mild disease without requiring hospitalization. But that means 20% of them are getting hospitalized – a big strain on our system. That also means many people with mild symptoms are infecting others who might be more vulnerable.

2-3% of known cases in China are dying. In South Korea, where testing is more extensive, the numbers are just shy of 1%. These figures may decrease with greater testing, but for now that is all we have and that is all we can go by. The average seasonal flu mortality rate is 0.1%.

There is no vaccine and there won’t be one for likely another year.

We have limited number of test kits and limited number of labs who can run these test kits.

There is no drug treatment that is effective right now. All treatment is supportive. That means if you have mild symptoms of fever and cough, you can take acetaminophen (Tylenol), cough drops and plenty of water. If you have moderate to severe symptoms and in the hospital, you will be treated with oxygen and/or breathing machines for breathing difficulties, IV fluids if you are dehydrated, and IV medicines to keep your BP up if your organs are failing. Experimental combinations of existing drugs may be tried for the most severe cases.

What we should or should not do:

These are my recommendations as a doctor of Internal Medicine. In addition to my MD, I also have a Master’s  in Public Health. These are based purely on what we know now and may change as more information about the virus becomes available.

We are in this for the long haul – it could take several weeks to months for things to return to normal.

1. Buy enough acetaminophen (Tylenol) and cough drops to treat your family for 2 weeks. Please do not empty out the shelves.

2. At the next grocery trip, get enough food for two weeks. Please do not empty out the shelves.

3. If you are on chronic, life-saving medications, see if you can switch to a 90 day prescription plan if you are getting just monthly refills now.

4. Avoid unnecessary travel by air, ship, train and bus until we know more.

5. Avoid large scale events like concerts and conferences until we know more.

6. Avoid forwarding messages on social media if you are not certain of its origin. There is rampant fake information about fake preventive and curative treatments, which is especially dangerous now when people are vulnerable and afraid. If you are unsure about some information circulating in social media please check on Snopes.com, which is a reliable source for fact checking.

7. Stay home if you have mild symptoms of just fever or cough, but do call your doctor for further instructions. Please don’t show up at the ER demanding to be tested for coronavirus if you normally would not have gone. If you have shortness of breath or difficulty breathing, dizziness or lightheadedness, confusion or altered consciousness, then please do go immediately to the ER. According to our own excellent infectious disease specialist, Dr. Debbie Bridges, please call the hospital ER and let them know you are coming. There are separate areas set up for Covid screenings. Following your screening, if you are eligible for testing you will be assigned a PUI number through the health department. You are eligible for testing only if you have appropriate symptoms.

8. If you have tested positive for Covid-19 (but not sick enough to require hospitalization), you should stay under house quarantine for 7 days OR 72 hours after your last fever, whichever is later.  If you have not been tested but think you have been exposed, please do the same.

9. If you need to isolate yourself, do so only physically. Do not isolate yourself socially, emotionally and mentally. Stay in touch with your friends and family via phone and internet.

10. Let us check in on our elderly neighbors and loved ones – remotely if they need to be isolated for symptoms. Gather in small groups where you know the people and where all are committed to taking infection control precautions.

9. And continue to do what all medical professionals have been telling you to do since the day we heard about the virus. Wash your hands, wipe down frequently used surfaces, cough into your elbow or tissue and promptly discard (tissue, not elbow!).

10. Finally, as a person of Indian origin, I give carte blanche permission to culturally appropriate the heck out of “Namaste” instead of doing the handshake. For those of you not familiar with it, Namaste is the word associated with pressing your hands together with fingers pointing up.CoroNamaste to all!! 

Originally published in the Hideaway Lake News, March 2020

One unfortunate consequence of aging is our decreasing ability to fight off infections. People over the age of 60 often have more severe symptoms, more serious complications, and a greater chance of dying from both bacterial and viral infections. With the coronavirus wreaking havoc and panic the world over, now is the time to take a closer look at keeping all nasty bugs at bay. If we didn’t know it before, we all know now to wash our hands frequently with soap and water, stay home when we are sick with respiratory symptoms, and sneeze or cough into a tissue and discard it promptly. But what else can we do to protect ourselves? We can get vaccinated. The coronavirus vaccine is likely still at least a year away, but we have effective defenses available right now for other infectious agents.

Pneumonia from bacteria and viruses is the leading cause of infectious death among the elderly. We have two vaccines that together prevent 36 strains of pneumonia causing bacteria. And we have the flu vaccine that reduces the risk of viral pneumonia. Unlike the flu vaccine which needs to be given yearly, the bacterial pneumonia vaccines are needed just once for the average person 65 years and older. Make sure to discuss with your doctor if you need one or both the pneumonia vaccines. Your doctor may also advise you to take the vaccine before 65 if you have certain chronic diseases like diabetes, cancer or chronic obstructive pulmonary disease (COPD). And remember, even if the flu vaccine is just a 40-50% match for the season, it still reduces the severity of symptoms, and the risks of hospitalizations and complications like viral pneumonia, so get the flu shot every year.

Another infectious agent that can cause significant pain and suffering is reactivation of the chickenpox virus which results in shingles. Shingles appears as a band of painful blisters that develops along nerve pathways. Common sites are the chest, back and face. If it occurs along the nerve close to your eye or ear, it can cause blindness or hearing loss. It can also cause inflammation of the brain and paralysis. After the rash heals up, you may also be left with weeks to months of debilitating pain. If you are 50 years or older, talk to your doctor about the shingles vaccine, which is given once in a lifetime as a two shot series.

Other ways to boost your immune system are to stop smoking, eat a healthy diet full of vegetables and whole foods, and get plenty of exercise. Minimizing stress and getting ample good quality sleep have also shown to improve your ability to ward off infections. You will see a pattern here – the same things that help you maintain a healthy heart, and a healthy brain, also help you maintain a healthy immune system. This is because healthy lifestyles reduce chronic

diseases like diabetes, cancer, heart and kidney disease, all of which suppress your immunity.

And finally, please stay home when you are sick. If you have a fever, body aches or fatigue with runny nose, itchy eyes, sore throat or cough, you do not have allergies, you have an infection. Don’t say you have allergies when you are infected and go to the gym or to a big party. Just because you feel well enough to go, doesn’t mean you should go. Please stay home so you can prevent it from spreading, be it the flu or the coronavirus.

Originally published in Hideaway Lake News, February 2020

When we think of health and aging, we often think of heart disease and cancer, but often forget that falls are also a significant source of mortality as we age. People over the age of 65 have the highest risk of death or serious injury from a fall.

Make your environment safer: Start with getting rid of small area rugs and loose floor mats that you can easily trip and fall on. Even with rug pads, the edges and corners are often not fully taped down, so they present a real fall risk. Children’s toys and excess clutter should be promptly addressed. So when you take little Johnny to grandma’s make sure his toys are not scattered on the floor. Small pets that come between your legs or wrap themselves around your ankles are another hazard. I’m not asking you to give up your pets, because pets do wonders for both our physical and mental health in so many ways. But before getting a new pet, think about it’s temperament and size, whether the giant retriever is going to welcome you with his paws on your shoulders and push you back with vigorous licking, or is the boisterous terrier going to get all tangled up between your legs? Also make certain that your dog is well trained and doesn’t pull on you when you take it for a walk. Finally, make sure there’s good lighting in your home, the floors are not slick, and the showers have non-slip bath mats and handrails.

Keep your bones strong: Thinning of the bones, or osteoporosis, can cause problems in two ways. It can cause a spontaneous fracture leading you to fall and potentially break other bones. Or you could fall for some other reason and easily break a bone. Make sure you get adequate calcium and vitamin D from your diet and/or supplements. You should engage in some form of resistance training like light weights, calisthenics, yoga or pilates, starting as a young adult, but it is never too late to start. Studies show that weight bearing exercises are very effective in maintaining and improving bone density and preventing fractures. Always check with your doctor before you begin any new exercise program. Always start slow and build up.

Maintain your balance and flexibility: Balance is complex, requiring strong joints and muscles, good sensation on the soles of your feet, proper vision, and a healthy inner ear. If any of these things are off, you could lose your balance and have a fall. A good strength training program will of course take care of the joints and muscles, while yoga and tai-chi can help with overall balance and flexibility. Get your vision checked annually and your ears checked for wax impaction if you are dizzy. If your ear canals are fine and you’re still dizzy or losing your balance, your doctor will check you for other conditions. Maintaining healthy sugar levels will preserve your vision as well as your sensation. If you’re already a diabetic, then keeping your sugars well controlled will avoid damage to your nerves and eyes, thus reducing your risk of falls. And remember to wear shoes with a good grip for both regular activity and exercise.

Try to have a buddy when using a ladder, avoid tiptoeing and overreaching when trying to get at things in tall cupboards, and walk carefully on stairs. Finally, do perform a home safety check annually for yourself and elderly loved ones to ensure that there are no fall risks in the home.