Twin Cities Riots

I watched the 1 hr press conference that was convened by Gov. Tim Walsh at 1:30 AM last night.  The mayor of Minneapolis Jacob Frye, the Commissioner of the Department of public safety John Harrington and the commanding office of the National Guard Maj. Gen. Jon Jensen were all present and spoke.  There was a strong unity message.  I was impressed that so far nobody has been killed despite people shooting at the National Guard.

There was a clear message that what started out as a protest against police brutality and killing has morphed into something else at this point.  I use the term morphed loosely because there is no real evidence that there is continuity between protesters and rioters.

There was evidence for example that drug cartels were operating to secure their distribution networks and that criminal enterprises were behind a lot of the looting and general chaos. I received an email that large retail pharmacy networks were closed and in many cases they were looted and prescriptions and other pharmaceuticals were stolen.  There was information that armed white supremacists were in the area and a photo of armed men standing in front of a Target store. There is video evidence that white men wearing all black clothing and face masks are vandalizing buildings and being confronted by protesters.  St. Paul has previous experience with anarchists from 2008 when they disrupted police operations at the time of a Republican National Convention.

There is probably a significant element of people who have the general solution to "burn everything down".  I encountered them during Vietnam War protests. They were the driving force behind the radicalism of the 1970s that led to 1900 domestic bombings in 1972 and the single most destructive act of sabotage in American history up to that point - the bombing of Sterling Hall on the University of Wisconsin campus.

I think it is a reminder to all of us how tenuous civil order can be.  We have all observed these behaviors in one way or another.  At the societal level, Americans are far too self-congratulatory as being "the best" when we clearly have done a very poor job of correcting racism and other forms of discrimination, mass shootings that are so routine they are part of the culture, and economic inequality. Addressing all of those dimensions lead to a preference over social order than not - and keep the opportunists in check.

The lesson from the call to violent revolution in the 1970s was that it eventually fell flat because nobody was interested apart from a few of the leaders of the radical organizations at the time. They made an active effort to expand and recruit more members to do more bombings and kill more people. The average man and woman on the street just wasn’t interested.  Life in general could be problematic but it was clearly preferable to anarchy.

Religious and civic leaders are making broad appeals today to their constituencies to remember the triggering event and actively work on reforming the associated factors of police brutality, racism, and justice for the victim and his family. But they are also reminding people to stay off the streets and remember that these changes need to occur in the context of community and cooperation.  

At the time I am writing this, the Governor has apparently mobilized the entire Minnesota National Guard or a total of 13,000 members.  That number was just 1,000 yesterday.  Given the effort and current uncertainty, I hope that it will be possible to look at the anatomy of this riot and draw clear markers around some of the elements involved.  I am sure that will not be an easy task.  But there is going to be political pressure to blame peaceful protesters for the riots and try to detract from their cause. That gives criminals and agitators a pass and it can also be used to emphasize some of their own pro-chaos messages.

The righteous protest that an innocent black man was detained using excessive force and killed by the police cannot be obscured by the subsequent riots.  Those responsible need to be prosecuted. Peaceful law-abiding protesters are not rioters.

And this cannot happen again in the state of Minnesota or anywhere else.

George Dawson, MD, DFAPA

Graphics Credit:

Minneapolis Riots map was apparently compiled by a number of anonymous users. I am posting it here because it is being used by some Twin Cities newspapers.  There is an extensive list of businesses that have been looted.  Many of them are pharmacies.  See the list at this link.

Current Evidence:

1.   St. Paul Mayo Melvin Carter: "Every single person arrested last night was from out of town".







2.  Not the first time that protesters have attacked the Twin Cities.  Here is a 2008 incident where "anarchists" attacked St. Paul and "took control" of the city for several hours:  https://youtu.be/gkZvtGCh5YA

Telepsychiatry - Week 7

It is week seven of telepsychiatry.  Things have been going reasonably well. I am as productive doing telepsychiatry as when I was sitting in an office. The constraints are becoming more evident as time goes by and I have the opportunity to confirm some of them with colleagues.   I have about 50-minute commute one way and doing telepsychiatry saves me that time every day. That is about 50 hours of time saved in the past 7 weeks. I also don’t have the additional expenses of purchasing food, coffee, and snacks at the workplace and that is a significant savings as well as the gasoline costs.

It is very convenient to sit in your office all day, click a tab, and immediately see your next patient. I do get notifications of people are running late but that is rare. The photo at the top of this post is what my desk looks like. The Mac Pro is the large monitor in the background. That is what I use for the telepsychiatry software. It is a high-resolution monitor with good sound quality but it is only as good as the monitor and sound quality on the other end. The small Dell laptop in front is what I use to access the VPN and secure networks and all of my previous notes. I only have access through this computer. The Surface Pro on the far right provides access to everything else I need including FDA package inserts, UpToDate, NLM searches, drug interaction software, an outside lab server that contains all the lab results on patients I am seeing, and the searches I need to locate a patient’s primary care clinic and psychiatrist. That is the information I commonly access during sessions with patients.  It turns out I am a lot faster with the additional computers than working on one computer in my office.

I have a number of documents that I present to patients in interviews that I have posted on this blog.  When I use web casting software for work related conferences, I have the option of posting material from Word, Excel, or PowerPoint right in the working field.  So far, I do not have that capability in my telepsychiatry software and I will be a lot more comfortable when I can do this. One of the critical documents is my standard list of psychiatric medications. It does prompt recall of many more medications than most people can recall spontaneously. 

I put up an earlier post on some of the limitations of telepsychiatry visits. I have had some further observations on that issue some of which have been confirmed by colleagues. Complex movement disorders for example are difficult if not impossible to assess in a telepsychiatry visit. The one I am thinking of was a combination of spasticity from a known neurological diagnosis, possible dyskinetic movements, and possible chorea. Asking a patient about their subjective experience of movements is useful to some degree but not absent an examination. I made the provocative suggestion to some colleagues that “telepsychiatry is not real psychiatry” to point out that there are both favorable and unfavorable consequences.

One of the unfavorable consequences is that telepsychiatry is not universally accepted by patients. With the recent security problems in a popular teleconferencing platform people are more aware than ever of this issue and how it may affect personal discussions with a psychiatrist. There seems to be a general belief that everyone accepts security risks as the cost of doing business but that is not true. There are some people who refuse telepsychiatry visits. There are others who go along but are obviously anxious about it and may not disclose sensitive material. It is an issue that should be explicitly discussed especially if the patient is obviously stressed or the information flow in the interview seems restricted. I had one colleague state that his practice of psychodynamic psychotherapy was going well with telepsychiatry visits. Another variable may be whether the psychotherapy started before telepsychiatry or not.

Even though it is a different kind of psychiatric assessment it does tend to expand the horizon. I started to think about seeing people anywhere in the United States or the rest of the world. I started to think about people I would see from rural Minnesota who would have to drive 150 miles to see me, until they eventually decided it was too inconvenient. Now I can potentially see them immediately right at their home. My mind wandered to the current pandemic and a recent story about depression and suicide in physicians who are on the front lines. I could potentially volunteer my time and help these colleagues.  A critical question is what are the barriers to that kind of practice or volunteerism? A good place to start is looking at an ideal telepsychiatry practice in the state of Minnesota. In that practice a very highly-respected psychiatrist has been a consultant to several southern Minnesota counties for years and has provided their psychiatric care. He has a very well-defined model that includes seeing patients only in clinic settings after they had been roomed and their vital signs have been determined. He has nursing and clinical staff on the other end who know the patients well.  He also sees everyone in his practice on an individual basis every year. His computer system and software are state-of-the-art and high definition. I have seen him give two presentations on his practice, but until the pandemic it never thought I would be using that model.

For now, I will consider a pared down model that would allow volunteer psychiatrists help their colleagues in the current and subsequent pandemics. The first consideration is licensing. Currently physicians are licensed in their own states and that license is not typically allowed treatment in a neighboring state. The only exception I am aware of is licensing through the Veterans Administration for physicians working in that system of care.  A central licensing body or state waivers could potentially bypass state licensing in this situation. It would also allow a large number of retired or semi-retired psychiatrists to volunteer their services. Some of those psychiatrists have let their licenses expire or in some states there is a active but retired status.

The second issue is malpractice. One of the deterrents to opening a private practice or transitioning to a private practice prior to retirement is malpractice insurance and tail coverage. Tail coverage is malpractice premiums that carry it on in retirement, until the window for civil litigation has expired. That would typically involve a two or three year malpractice premium payment during retirement with no associated income. Some states make an exception to malpractice insurance for volunteer physicians. I would argue that consultation to front-line physicians is a priority not only in terms of medical care but also national security. I would suggest that volunteer psychiatrists in this model should be indemnified by the federal or state government.

The third problem is centralized documentation. All clinical encounters should be documented - even in the case of free volunteered care and those records need to be confidential. I would argue for a central authority that would record and house those records. Ideally there would be access to an electronic health record so that any necessary prescriptions could be routed to the appropriate pharmacy.

All three of those prerequisites are considerable obstacles to a volunteer psychiatric workforce. The United States has a government facilitated private system of care that is dominated by large healthcare companies. Their networks are largely expensive and exclusive. The Veterans Administration is a good example of a government run system with its own information technology and networks. It may be a potential system for the addition of the elements necessary for a volunteer telepsychiatry workforce in the event of national emergencies. One of the issues made apparent by the current pandemic is a lack of public health readiness in the country. A volunteer telepsychiatry workforce may seem like a good idea right now but what happens when the pandemic ends? I would suggest that the infrastructure and volunteers could still be effectively used in areas where there were shortages of psychiatrists or after natural disasters when care for people with ongoing mental illness is disrupted. In order for that to occur, there need to be substantial changes in government philosophy and creating systems that are more people centric than business centric. The system like the one I am suggesting would not survive as a football for the two-party system.

If I think of an ideal science-fiction approach to telepsychiatry the possibilities increase greatly. I can envision a time where psychiatric appointments can occur anywhere or when a psychiatrist posts their availability online and see people who sign in. My current system displays all of the necessary legal documentation at the first visit. I think that all the details of what is necessary for telepsychiatry informed consent are still not clear at this point. Standard wrist worn activity monitors at some point could post the relevant vital signs in the physician’s software. Billing and payment is always an issue. In the past 20 years I have not really seen any progress in that area. There is no reason why a physician visit should not be as easy to pay as buying a mocha at a coffee shop.

I have some concerns about abuse of the format. It would be fairly easy to set up a prescription mill to prescribe stimulants, benzodiazepines, and opioids. Those operations certainly exist today and there are many ways to get those drugs from nonmedical sources. Confidentiality is a potential problem. If there is a telepsychiatry visit at home are there going to be other people listening or recording what occurs on the patient end? That does not occur in an office setting but I see it as a potential problem if the patient end of the visit is at home rather than a clinic.

Those are some of my thoughts after week seven of telepsychiatry. Despite the limitations I do think it is effective. If it wasn’t, I would have stopped by now and in this era of a pandemic of uncertain length - retired.

George Dawson, MD, DFAPA

Admit What You Don't Know - An Unmentioned Organizing Principle

Everybody has ideas about medical ethics.  Often that is their own version.  There are medical ethicists who routinely comment on it in the media. There is endless speculation about what is ethical and what is not.  That speculation frequently focuses on financial compensation and reimbursement for physicians from outside services like pharmaceutical companies. Every physician in the United States is monitored by their state medical practice board who have varying ideas about what is ethical and what is not. Those ideas can even change over time. When I started out, it was common for physicians to prescribe various medications for friends and family members. At some point that was determined to not be a good practice for several reasons and it became a general rule adopted by most medical practice boards.

Ethics debates frequently are political debates and other common areas have to do with abortion, resuscitation, and unnecessary prolongation of life. Many of these debates played out in public arenas and resulted in legislation, court rulings, and practical applications like living wills and advanced directives in the event that the decision-maker is compromised and decision-making is limited.

I am constantly thinking about my training and how it relates to what I do every day. That means that from time to time I revisit what happened to me during that time frame and what it means today. I always seem to come up with something new even though I have thought about it many times before. Just yesterday I was contemplating the scenario where President Trump talked about disinfectants and ultraviolet light being used to kill coronavirus in humans. There are many places where you can view that videotape as well as the responses to it. In a politically charged partisan atmosphere many of those responses are predictable. The President and his allies are certainly in a spin control mode since this happened. They are contemplating having less frequent news conferences which I would agree with. Political opponents have seized the opportunity to characterize this as a lack of leadership and irresponsible statements. One of the physicians working with the president has suggested that he was simply “problem-solving” and “thinking out loud”with physicians in the Department of Human Services.

I think there is a more parsimonious explanation that will take me back to the third year in medical school. It should be fairly apparent to any trained physician that the President does not really know much about medicine. The clearest example would be his quote that we don’t really know much about nature of the coronavirus pathogen, when of course we do. There has never been a better time to study viruses and their molecular biology than right now. The President has made many other errors when talking about the pandemic and the associated medical problems. He approaches it like he does political rhetoric. He makes contradictory statements to gain some time and then sweeps in at the end with the correct position even though it is often in opposition to what he said in the first place. In medical school that would not get you past the third year.

Third-year medical school is an exciting time. Everyone is starting intense clinical rotations. You are scaling up in your ability to see more patients per day. You are getting more efficient in conducting the elements of the patient evaluation, differential diagnosis, and treatment planning. You are learning more about relevant laboratory and imaging testing. But there is also important ethical element that you need to discover right away or you rapidly get into very deep trouble. Simply stated that element is - know what you know and what you don’t know and clearly state whether you know something or not. The corollary is that time is of the essence and there is no time for equivocating. If you are asked directly by an attending physician or a senior member of the team and you draw blank - the correct answer is “I don’t know”. There is no room for guesswork or rhetoric.

During my training I saw some relatively brutal enforcement of that rule. One conversation went like this:

Attending: “Do you know this patient’s calcium level?”

Intern: “I think it was 10.8…”

Attending: “Do you know or not? Are you just guessing?”

Intern: “No I am pretty sure it was 10.8.”

In this brief scenario, the correct answer was “I don’t know”. It turns out the calcium level was not 10.8. That led to a fairly intense private conversation between the attending and the intern about his expectations of patient care and how they were not being met. The intern was subsequently asked to leave the program.

I witnessed several scenarios like this and they are tense situations. The expectation of course is that individual team members will know everything about the patient particularly all the relevant evaluation and testing that occurs in the hospital and that they will be able to synthesize that for the attending during rounds. It is a high-pressure situation because all eyes are on the person being questioned. I can still recall being in ICU with a fairly intense pulmonary medicine staff person who decided he wanted to question my favorite Internal Medicine intern on pulmonary function testing in various lung disorders. For anyone not familiar with this testing there are a set of esoteric terms and concepts that vary across lung diseases and the attending in this case wanted an extemporaneous summation. He provided no structure whatsoever for the intern. The other four members the team took a deep breath and focused on the intern. In his southern drawl he provided a perfect description of pulmonary function testing and how it varied in the pulmonary conditions of interest. It was pretty amazing.

Similar high-pressure situations don’t go that well. I had just started out on a cardiology team in the same hospital and rounded on a patient and went to present to one of the cardiologists. It seemed to be going pretty well until he asked me to show him the chest x-ray. In those days, we had to go to Radiology and collect all of the films we needed, check them out, carry them around all day and then return them. I did not have a chest x-ray and for the next several minutes fielded a few sarcastic comments like “You didn’t think a chest x-ray was important in a cardiology patient?” In similar situations it was always better to say “I don’t know” rather than trying to bluff your way through a barrage of questions from an attending physician. Not having a chest x-ray is relatively easy one.  It is harder if it is a question about specific history or data or information that you are expected to know.

An important part of the lesson is that even though it may be emotionally painful to say “I don’t know.” it must be said if you really don’t know. There is no spin after the fact in medicine. The patient and everyone else on your team depends on you being able to make that statement. When you complete your training - it is equally important to make that statement to your coworkers and the patients you treat.  I have never really heard much comment about it in the media or by the ethicists but for me it is a central organizing value. There is a ripple effect. If you don't want to end up with that statement - you do everything possible to prevent it.  But most importantly you recognize the vast information base of medicine and you recognize the uncertainty of the day to day decisions.

This post is not supposed to be a lesson for politicians. It is not a suggestion that politicians should adopt ethics that are useful to physicians. It is a simple observation that being able to admit that you don’t know something even when it seems like you should is transformative. It is better to be brutally honest with yourself upfront than having to do it later to deal with the complications. All medical decision-making and professionalism hinges on this ethic. 

When it comes to medicine - you can't just make something up or think you know something - when you don't.

George Dawson, MD, DFAPA





Full Disclosure:

I am a small "i" independent.  Yes - I am one of those guys who does not hesitate to "waste" his vote on a non-major party candidate, but at times have voted for those candidates.

COVID-19 No "Worse" than The Flu?

It is very common these days for people with varying motivations to make the argument that that COVID-19 the current pandemic caused by the SARS-CoV-2 virus is no worse than seasonal influenza.  After presenting that premise, the conclusions are typically that there is really no reason to implement social distancing, stay at home orders, and all of the additional precautions currently in place to prevent the spread of the virus.

The important qualifier here is the need to include how deaths from both illnesses are estimated.  The CDC is very clear that it does not know the exact number of influenza deaths each year but it estimates them from statistical models. This is nothing new and they have been using this procedure for decades.  The reasons include the fact that influenza deaths are not reportable at a national level, although pediatric influenza deaths are.  It is also not possible to know if influenza is the proximate cause of death because the death may occur weeks later as a result of a secondary infection or an exacerbation of a chronic medical condition by the influenza infection.  In these cases, influenza may not be listed as a secondary infection.  Finally - not everyone who dies from an influenza-like illness (ILI) has influenza and not everyone who dies from ILI is tested for influenza. The influenza death estimates are not based on death certificates for that reason.  

There is considerable variability in mortality estimates based on the model being used.  A description of their current methodology and its limitations is available at this link.   There is a similar limitation of COVID-19 related deaths and the CDC has a specific reporting procedure suggested for that process.  CDC clinical criteria and lab testing is further specified to determine if COVID-19 is an underlying cause of death. COVID-19 can be reported as "probable" or "presumed" based on clinical judgment.  Three examples are given in the linked document in how to fill out the death certificate. The main difference is that COVID-19 mortality depends on deaths certificates and influenza mortality does not.  At least for now.

Looking at the CDC death rate estimates for influenza over time looks like this (click to enlarge any graphic):

But looking at the raw data based on death certificates looks like this:

Looking at the typical influenza season going from 2019 (week 43) to 2020 (week 15) shows that the raw death certificate data for pneumonia is 90,369 and for influenza it is 7,591.   


The argument typically is made looking at disease mortality and the raw number of deaths are not used. The CDC and other agencies report rates per 100,000 to correct for differences in population.  The current mortality rate for COVID-19 as of today is shown below - even though the lead graphic illustrates that deaths are continuing to increase at this point.:


COVID -19 Deaths  CDC Page

Total Deaths: 37,158

Death Rate/100,000: 11.3

First Case January 21,2020


Influenza Deaths

Total Deaths:  24,000 - 62,000  2020 estimate based on above data and methodology

Death Rate/100,000:  7.3 - 18.9

First Case October 2019


The second consideration is that the COVID-19 pandemic is clearly not over. Different geographic areas in the US are at different points in the curve that depicts new cases.  The key point on that curve is the inflection point where the new cases per day go from a linear increase to an exponential one.  A panel of 20 experts in infectious disease modeling was referenced as the source for a recent White House estimate of 240,000 deaths by the end of 2020 (8).  If you look at that reference there is a wide confidence interval.  That is four times the CDC estimate of 2020 influenza deaths.  For comparison there were 675,000 deaths in the USA in the 1918 pandemic.

How does this information assist with the analysis of rhetoric?

1.  COVID-19 is no worse than seasonal flu: 

First off, influenza is a severe infection and can't be trivialized. Everyone who is able to should get an influenza vaccination. Based on the available data - is certainly seems that COVID-19 is as bad and much worse in the worst case scenario.  It is at least on par with modern CDC influenza death rates estimates over the past 20 years and based on the current number of deaths is likely to exceed the 2020 estimate for influenza deaths.  The outliers for the White House estimate in the survey are much higher - in some cases exceeding the mortality from the 1918 pandemic.  These estimates are also based on current rates and if the country is "opened" and stay-at-home orders, wearing masks and social distancing guidelines are abandoned it is very likely that there will be secondary spikes and prolonged exposure to the virus. Does anyone really want to take the chance of this virus killing more people than the 1918 pandemic?  

2.  COVID-19 rates are inflated based on inaccurate reporting:

This meme was reinforced by a physician appearing on a conservative talk show who stated that he only reports what he considers to be the underlying cause of death on death certificates.  The example given was that if the patient died of pneumonia - the cause of death was pneumonia and would not speculate on what caused the pneumonia.  The implication being that death certificates are highly accurate and the suggested reporting guidelines for COVID-19 will result in over-reporting the condition.  The information clearly shows that this is not the case. The actual numbers of deaths due to influenza as reported on death certificates are a fraction of the number estimated by the CDC.  The CDC plainly states that they have no idea how many people actually die from influenza and for decades they have estimated the number based on hospitalizations, hospital mortality, and other surveillance numbers.  COVID-19 death counts are made on the basis of death certificates.  Even though death certificates are not perfect, it is likely that many more people who die from COVID-19 are tested than people who die from influenza. It will be interesting to see if the CDC develops statistical models for COVID-19 to see if the current deaths are an underestimate like influenza. 

That is my brief look at these two arguments that are being used to suggest that the current environmental approach to virus containment are unnecessary.  I am also reminded of an old statistical concept called face validity.  Briefly stated that would mean the null hypothesis of no difference in death rates makes sense.  Given that COVID-19 has risen to the highest daily cause of death in the US, that hospital and ICU beds in many locations are overwhelmed, that there is a catastrophe in New York City at this point, and it has led to the only mass shortage of personal protective equipment, ventilators, and medical gear that I can recall in my 3 decade career - I don't think that it does make sense.

And this is exactly not the time to trivialize this pandemic.


George Dawson, MD, DFAPA


References:

1: CDC:  Frequently Asked Questions about Estimated Flu Burden.  Link

2: CDC:  Estimating Influenza-Related Deaths.  Link

3: National Center for Health Statistics. Guidance for certifying deaths due to COVID–19. Hyattsville, MD. 2020. Link

4: Reed C, Chaves SS, Daily Kirley P, Emerson R, Aragon D, Hancock EB, et al. Estimating influenza disease burden from population-based surveillance data in the United States. PLoS One. 2015;10(3):e0118369

5: Rolfes, MA, Foppa, IM, Garg, S, et al. Annual estimates of the burden of seasonal influenza in the United States: A tool for strengthening influenza surveillance and preparedness. Influenza Other Respi Viruses. 2018; 12: 132– 137. https://doi.org/10.1111/irv.12486

6: Centers for Disease Control and Prevention. Estimated influenza illnesses and hospitalizations averted by influenza vaccination – United States, 2012-13 influenza season. MMWR Morb Mortal Wkly Rep. 2013 Dec 13;62(49):997-1000.

7: Reed C, Kim IK, Singleton JA, Chaves SS, Flannery B, Finelli L, et al. Estimated influenza illnesses and hospitalizations averted by vaccination–United States, 2013-14 influenza season. MMWR Morb Mortal Wkly Rep. 2014 Dec 12;63(49):1151-4.

8:  Thomas McAndrew Spring March 25, 2020 COVID19-Expert ForecastSurvey6-20200325.pdf 


Graphics credit:

Lead graphic is from Our World in Data licensed under Creative Commons BY-SA and may be freely used for any purpose. 

All others are from the CDC under public domain.

SARS-CoV-2 is an Airborne Virus?

I thought I would say something more about airborne viruses. They have been a hobby of mine for some time.  The first time I heard about how easily the current coronavirus was spreading I thought “this is an airborne virus”. But then there were the usual protests. Some scientists came out and said that coronavirus requires “droplet” precautions rather than “airborne” precautions. The common definition is that droplets are large enough settle out quickly. They may touch you directly if you are close enough but a lot of what droplets do is settle on surfaces. That leads to surface contamination and spread of the virus.  Airborne viruses can travel longer distances within smaller droplets. An even more unique characteristic is that airborne viruses are released with normal expiration. No coughing, sneezing, or shouting is necessary. Just normal breathing can release airborne respiratory viruses into the air in the smallest droplet fraction.

An easy way to conceptualize airborne viral spread is to look at the distribution of particles occurring with every breath. They can range in size from 200 µm on the large end to less than 5 µm on the lower end. Experiments can be done to show how aerosols of these particle sizes spread through a room. Naturalistic experiments can also look at how these are all spread through hospitals, airplanes, and other natural settings. By looking at those patterns and the distance involved as well as any other paths that could lead to transmission – a determination can be made about whether or not a viruses “airborne” or not.

The second issue is whether or not live infectious virus is spread by these droplets. In many cases that has been limitation in the experiments. Direct evidence of viral spread at a distance requires culture of the virus or a bioassay that shows the samples have a cytopathic (killing) effect on live cells. Indirect evidence is typically by PCR where the available nucleic acid is amplified and assayed.  In researching this topic, I found early literature that documented numerous respiratory viruses in ventilation systems of buildings. That research was possible because nobody knew how to capture and culture the virus samples until that time. The other technical issue is air sampling. Certain air sampling devices do not allow for adequate virus detection. There is a technical report recently that showed of a total of four commonly used air sampling devices only one allowed virus to be identified or cultured. These technical constraints have led to a lot of confusion about whether a particular virus is airborne or not.

A practical definition of an airborne virus is one that is exhaled during normal breathing can travel a distance in small droplets (less than 5 µm) and create infection by landing on mucosal surfaces, facial services, or the lining of the nasopharynx, oropharynx, or lungs.  In that case you don’t have to be in the presence of anyone coughing or sneezing. You don’t have to touch any contaminated surfaces. You don’t have to touch your face. You just have to breathe contaminated air. It is entirely possible that you can walk through a cloud of airborne virus and not be aware of how it got there. A common example is walking down the hallway after a crowd of people have walked through some of them carrying the virus. Once you know about airborne viruses it gives you an entirely different perspective on social distancing.  Airborne particles can easily transverse the longest dimension of typical rooms. The distance of 6 feet suggested in typical social distancing guidelines is not nearly far enough.

In a previous post I highlighted an experiment by Donald K. Milton where he designed a machine to sample flu viruses in a natural setting. Research subjects breathed normally and their expired air was sampled for influenza virus. Influenza virus was recovered from 89% of the nasopharyngeal swabs and 39% of the fine aerosol sample defined as droplets less than or equal to 5 µm and greater than 0.05 µm. There was no coughing or sneezing during the collection.. That is proof that influenza virus is airborne.

A recent experiment carried out at the University of Nebraska Medical Center (3) in their bio containment and quarantine units showed that in addition to abundant surface contamination by SARS-CoV-2 the virus was also present in hallway air samples, in areas where only aerosol deposits could reach, and personal air samplers carried by staff.  The virus was detected by PCR analysis as well as culture in some cases. The authors concluded that this was definite evidence of an airborne virus and that facilities treating patients with SARS-CoV-2 should use airborne precautions. This paper is currently undergoing peer review and is on a preprint server.

The technical aspects of aerosol fractionation and dispersion is a subject best addressed in the engineering literature. The best paper I could find on the subject (4) had a goal of studying the dispersion characteristics of exhaled droplets in a ventilated room. The engineering goals are to find out what physical parameters affect the dispersion rate and hopefully lead to better indoor environments. The experimental paradigm looked at a room that was 5 x 4 x 3 m (L x W x H) and ventilated by a downward airflow from the ceiling. Aerosols were injected into this room and the following distance and trajectory along with trajectory time was calculated for the fractional droplets. As expected droplets with larger diameters (110-115 µm) fell at a faster rate and traveled a much shorter distance than the smaller diameter fraction. Droplet dispersion was studied under a number of physical conditions including different airflow, different temperatures, different relative humidity, and the original exhaled initial velocity.

The 0.1, 1.0, and 10 µm droplets covered horizontal distance of 5 m or the entire length of the room. Droplets in the range of 50 to 200 µm cover distances ranging from 0.5 to 4 m.  This study has numerous excellent graphs about varying conditions and how droplets in different fractions are dispersed. The reader is referred to the original reference to review all those conditions. The bottom line for me was it is clear that airborne droplets in the 0.1 to 10 µm range are commonly seen in exhaled air and easily covered distance in this experiment of 5 m or (for Americans) 16.4 feet. That is well beyond social distancing recommendations it explains why this virus continues to spread. Within the past week I have seen clips of New Yorkers in congested subway cars.  Any asymptomatic SARS-CoV-2 carriers in those cars are expelling virus into the air just by tidal volume breathing.  Coughing and sneezing is not required. It would be very good if you covered your cough or sneeze but when your mouth is not covered and you are a symptomatic or asymptomatic carrier you are exhaling viral particles.

The relevance of this virus being airborne cannot be underestimated. It is a substantial part of the reason behind social distancing and stay-at-home orders. It is the reason for the new recommendation to wear masks in public and the various explanations being given for those masks. The absolute best approach is to not have any close social contact until this pandemic is over. I am very concerned about my colleagues and fellow healthcare workers who have inadequate personal protective equipment (PPE). The expectation is that they will continue to take care of the very ill patients with COVID-19. Every effort must be made to make sure they have adequate protection. 

In my particular specialty, all psychiatrists should have access to electronic interviewing at this point. As I pointed out in my earlier posts, I am used to talking people for 30 to 60 minutes at time. Some of those evaluations are 90 minutes in duration. During that time the patient may be coughing or sneezing but for the most part they are breathing and engaged in normal interview conversation. My office is smaller than the room described in the droplet dispersion experiment. By the end of one interview, the smallest fraction of exhaled droplets is dispersed throughout the room. Any viral particles in that fraction can lead to infection.

All health care workers in these environments need immediate protection by the implementation of airborne precautions. I am hopeful that as more people become aware of the airborne route of transmission that it will lead to more caution on the part of the public and the social distancing and staying at home and away from this kind of transmission will make more sense. In the future we need to design indoor environments that can minimize this type of transmission. There is too little innovation in the role of the physical environment in airborne transmission of infectious illness.

I hope the added cost will be looked at in terms of the total cost of illnesses caused by respiratory viruses every year with the recognition that they can still cause devastating pandemics.

George Dawson, MD, DFAPA


References:


1: Lei H, Li Y, Xiao S, Lin CH, Norris SL, Wei D, Hu Z, Ji S. Routes of transmission of influenza A H1N1, SARS CoV, and norovirus in air cabin: Comparative analyses. Indoor Air. 2018 May;28(3):394-403. doi: 10.1111/ina.12445. Epub 2018 Jan 6. PubMed PMID: 29244221. 

2: Yu IT, Li Y, Wong TW, Tam W, Chan AT, Lee JH, Leung DY, Ho T. Evidence of airborne transmission of the severe acute respiratory syndrome virus. N Engl J Med. 2004 Apr 22;350(17):1731-9. PubMed PMID: 15102999.

3: Santarpia et al. (2020) Transmission potential of SARS-CoV-2 in viral shedding observed at the University of Nebraska Medical Center. Retrieved from https://www.medrxiv.org/content/10.1101/2020.03.23.20039446v2.

4: Chen C, Zhao B. Some questions on dispersion of human exhaled droplets in ventilation room: answers from numerical investigation. Indoor Air. 2010 Apr;20(2):95-111. doi: 10.1111/j.1600-0668.2009.00626.x. Epub 2009 Sep 24. PubMed PMID: 20002792.

5: Li, Y., Huang, X., Yu, I.T.S., Wong, T.W. and Qian, H. (2005), Role of air distribution in SARS transmission during the largest nosocomial outbreak in Hong Kong. Indoor Air, 15: 83-95. doi:10.1111/j.1600-0668.2004.00317.x

6: Carl Heneghan, Jon Brassey, Tom Jefferson. SARS-CoV-2 viral load and the severity of COVID-19.  March 26, 2020.  Link

7:  National Research Council 2020. Rapid Expert Consultation on the Possibility of Bioaerosol Spread of SARS-CoV-2 for the COVID-19 Pandemic (April 1, 2020). Washington, DC: The National Academies Press. https://doi.org/10.17226/25769.

"While the current SARS-CoV-2 specific research is limited, the results of available studies are consistent with aerosolization of virus from normal breathing."

8: Pan M, Bonny TS, Loeb J, Jiang X, Lednicky JA, Eiguren-Fernandez A, Hering S, Fan ZH, Wu CY. Collection of Viable Aerosolized Influenza Virus and Other Respiratory Viruses in a Student Health Care Center through Water-Based Condensation Growth. mSphere. 2017 Oct 11;2(5). pii: e00251-17. doi: 10.1128/mSphere.00251-17. eCollection 2017 Sep-Oct. PubMed PMID: 29034325.

9: Lu J, Gu J, Li K, Xu C, Su W, Lai Z, et al. COVID-19 outbreak associated with air conditioning in restaurant, Guangzhou, China, 2020. Emerg Infect Dis. 2020 Jul [date cited]. https://doi.org/10.3201/eid2607.200764

Graphics Credit:

Graphic is from Shutterstock per their standard agreement.

Acute-Care Psychiatry During the Pandemic

in the early days of this century, I spent a lot of time in Avian Influenza Task Force meetings. I was on two separate task forces and at the same time working on an acute care inpatient psychiatric unit. One of the meetings took up four hours in the afternoon and I would have to go back to my unit and make up those four hours. I made the mistake of that not saving all the documentation from those meetings. There were hundreds of pages. The main focus of one task force was on “surge suppression” or helping with crowd control to prevent emergency departments from being overwhelmed by people who did not really have the viral infection. The other meeting was more about the actual response to the viral infection. I was always skeptical of what I heard. We kept hearing that if there was an epicenter of infection, large pallets of Tamiflu would be on the way. We saw presentations with pictures of those pallets under plastic wrap. At the same time there was discussion about morgues and refrigerated trucks that have become part of the current crisis.

I was more concerned about what would happen to inpatient psychiatry units. I kept hearing that the medical and surgical beds would be overwhelmed. When I suggested that we increase the capacity of negative airflow rooms and rooms vented directly to outside air, I was told that was impossible. One expert gave the opinion that if there is an airborne virus in the hospital: “The minute you walk into the hospital you should be wearing an N95 mask”.

That was about 2005 and I had never heard of an N95 mask before that. I had certainly worn masks for painting, dust protection, and various chemical and biological experiments that I did in the course of education and research. I went out and bought a small package of N95 masks. I fitted them per the instructions and noticed a couple of things. The fit was extremely snug due to upper and lower elastic bands (that have a much smaller circumference than a human head or neck), the circular contour of the mask providing a suction fit to some extent, and a flexible metal band that bends over the bridge of the nose to effectively seal that area. When you are wearing an N95 mask your voice is muted and you are breathing against resistance. If you wear it long enough, it becomes soaked with exhaled droplets. I rapidly concluded that it would be nearly impossible to conduct a psychiatric interview wearing this mask.

I never really learned at the time whether there was a plan to shut down inpatient psychiatry and use all the beds for avian influenza patients. Thankfully it never got to that point. Flashing forward 15 years a real pandemic is upon us and the problems remain unsolved. Inpatient psychiatric units and residential drug and alcohol treatment units are considered necessary services in most states and they remain open. Very recent information from the authorities now suggest that SARS-CoV-2, the virus causing COVID-19 is airborne and that there are a significant number of asymptomatic carriers.

I have been using telepsychiatry at this point for two weeks and it seems to be going well. There are definite constraints compared with face-to-face interviews. I have noticed more constraints since my original post on this topic. I put a couple of questions out there on social media today to see how my colleagues who are still actively engaged in acute care are adapting to the changing parameters of this pandemic. Before putting those questions out, I had the thought that telepsychiatry could be used over the short distances in inpatient settings. As a resident I had the experience of observing psychotherapy firsthand and being observed from adjacent rooms that also had microphones for communication between those rooms. I was interested in seeing whether or not anyone had implemented those solutions.  I was pleased with the feedback that I have so far.

One of the first responses was that psychiatric staff were using surgical facemasks and face shields in some settings. In other settings, adjacent rooms and telepsychiatry both on-site and off-site were being used for acute-care units. The most unique solution I heard of was a consultation liaison team using iPads to interview medical and surgical patients remotely where possible. That reminded me that some people have joined my telepsychiatry sessions using smart phone apps. It was generally very suboptimal if the phone was not completely stabilized.  I also had the experience this week of getting a link sent to me from a colleague who worked for a large healthcare system. It was an invitation to open up a video session with him even though I am not registered in his clinic.  It was very similar to a Zoom session that I did for a podcast. All this information shows that there are technologies available right now that are effective and actively being used. They have also been very rapidly deployed or are in the process of being deployed. There is some potential that this sudden change in the delivery of psychiatric services may be a more permanent one.

I asked the question about whether or not the services were saving personal protective equipment (PPE). The response to that question was somewhat mixed. I am not clear on what it means but speculate that some of the staff still need to have direct patient contact at some point during the day. Most acute-care staff at this point have been assigned PPE. The PPE specifics seem to vary from place to place but it is clearly rationed. If I was designing a survey of acute-care psychiatric facilities I would like to see the specifics of how many people had N95 masks and other kinds of protective gear.

Preadmission screening remains a question mark.  There is general agreement that there is an asymptomatic carrier state for SARS-CoV-2 (1,2).  Carriers may have a lower viral load and be partially symptomatic. Most people admitted to inpatient psychiatric units these days require intensive nursing care for their own safety. If there were environments where patients with COVID-19 could be safely segregated and treated that would be ideal, but I doubt those kinds of environments exist on inpatient psychiatric units. Even then the asymptomatic carriers would require the same psychosocial interventions as non-carriers.  The general screening done is to ask about contact with known cases and daily temperatures. I am not aware of any screening procedures that involve trying to identify the virus and carrier state.

My overriding concern is that medical and psychiatric staff everywhere have adequate protection. We have known since my days on the avian influenza task forces that airborne viruses are difficult to contain. They can infect through surface contamination, droplet contamination, and traveling on air currents. Working to cancel all those routes of infection is a tall order especially on an inpatient psychiatric unit.

The only practical way to maintain the level of communication necessary and minimize risk of infection is through some type of electronic communication. Some of the early methods have been listed in this post. Having worked in these settings for a large part of my adult life I am very concerned about the staff with daily direct patient contact including nursing, nursing assistants, and occupational therapy.  Housekeeping staff also have a vital role and are directly exposed to most contaminated surfaces. I have seen large numbers of inpatient staff come down with seasonal respiratory viruses and I know that vulnerability is there. They all need PPE. We need additional innovation in these settings to protect all staff and patients.  

And we have needed that innovation for a long time.

George Dawson, MD, DFAPA




References:


1: Lai CC, Liu YH, Wang CY, Wang YH, Hsueh SC, Yen MY, Ko WC, Hsueh PR. Asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): Facts and myths. J Microbiol Immunol Infect. 2020 Mar 4. pii: S1684-1182(20)30040-2. doi: 10.1016/j.jmii.2020.02.012. [Epub ahead of print] Review. PubMed PMID: 32173241.

2: 1: Hu Z, Song C, Xu C, Jin G, Chen Y, Xu X, Ma H, Chen W, Lin Y, Zheng Y, Wang J,Hu Z, Yi Y, Shen H. Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China. Sci China Life Sci. 2020 Mar 4. doi: 10.1007/s11427-020-1661-4. [Epub ahead of print] PubMed PMID: 32146694.

Supplementary 1:

I am very interested in what you are doing at your facility to contain this virus while continuing to go to work every day and treat patients.  I am also very interested in whether you have enough PPE.  I am interested in hearing from everybody staff psychiatrists, residents, social workers, occupational therapists, nurses, nursing assistants, and housekeeping staff.  Please post in the comments section below and feel free to remain anonymous. 


Graphic Credit:

Shutterstock per their standard agreement.

Telepsychiatry - Day One

These are strange times.

For the past several years I have attended seminars on telepsychiatry. In Minnesota, we have an expert who has been doing it for a long time. He talks about the advantages of being an independent practitioner and using your own equipment rather than being a subcontractor. He has a definite method that includes seeing all of his patients in person at least once a year. His practice covers a large area that would otherwise probably not have a lot of psychiatric services. Over the years that I have been going to the seminars, I have thought about private practice and Telepsychiatry. I even looked at a storefront building at a shopping mall and fantasized about starting it up. But I am too close to retirement and there is a thing called tail coverage. That means if you carry malpractice insurance and retire you need to still pay the premium for two or three years into retirement in the event that you are sued.  That was a major deterrent and it seemed like I would just carry on in my current position until I decided to quit. And then the coronavirus and social isolation hit.

The transition to Telepsychiatry rapidly happened last Thursday. I was going about my day when my younger colleague told me that she was switching to Telepsychiatry this week. She encouraged me to get on board. Several people were critical to the effort and I was up to speed on the system by this weekend. I had to confirm that I had the computer power, bandwidth, and dropped frame rate consistent with software. I pulled up my schedule this morning and the main difference I was sitting at home looking at it on my big Mac Pro. I tested the camera and microphone. It produced a good image of me sitting in my home office and I was ready to go. What followed was a big glitch and some realizations about the visual aspects of psychiatry.

An initial series of emails let me know that the visual feed was not working. That essentially took out the software and as a replacement I was supposed to do telephone interviews. Hoping that they could get it up and running I moved the first patient new evaluation to the last slot in the daytime. There was some suggestion that only follow-ups should be seen as telephone interviews. I was concerned that patients would have to hold the telephone receiver for 45 to 60 minutes but was reassured that it would all happen over speakerphone. The locations were all secure and managed by our clinical administrator. When it became apparent that the visual feed would not occur I started doing new assessments and follow-ups strictly on the telephone.

In retrospect I found myself myself in an ironic position. For years I studied telephone switching both as a high-tech investor and as electronics hobbyist. I eventually got involved in communications theory. The engineering version of communications theory is highly technical and interesting but I have never been able to apply it to the clinical interview. The clinical interview is an exchange of information. There is always a certain noise level that varies significantly from person to person. That noise can occur strictly on the information being exchanged or various emotional levels that can add or subtract from the overall noise level. A good example would be a person who brings a lot of biases into the interview. As an example, I have had people slow the interview down or bring it to a halt just based on my physical appearance and how it was interpreted. Some of those people would be very explicit in telling me they could only work with a psychiatrist who had a certain religion, philosophical bent, or political affiliation. There was often speculation, that I did not meet the preferred categories. Interviews done without the visual channel, removed those factors.

I dictate all my valuations and follow-ups and have done that most of my career. Critical parts of what has become known as the Mental Status Exam are dependent visual assessment. A few examples of common bullet points include:

Appearance: I comment on whether the person appears to be alert, interactive, their overall grooming and hygiene, their eye contact and social demeanor. Where it applies I also comment on whether they appear to be intoxicated, distracted, potentially delirious, and in some situations whether they realize I am in the room with them.

Psychomotor: Hyperkinetic and hypokinetic movements and possible movement disorders need to be described. Psychomotor agitation and retardation as well as motor restlessness also need to be commented on. It is about a 40 foot walk to my office and the person’s gait also needs to be described.  Gait analysis is useful because of the association with dementias, neurological disorders, and medication side effects. It is also useful in assessing chronic pain patients. The commonest acute pain disorder I notice is gout due to its high prevalence in men of all ages. Specific movements require additional examination in some cases rating scales. For example if tardive dyskinesia is noted and AIMS (Abnormal Involuntary Movement Scale) can be done to determine a baseline score. There are additional rating scales for Parkinson’s, akathisia, tics, and dystonia.

Affect: Psychopathologists like Sims have pointed out the subtle differences between affect and mood. In his text for example he describes affect as “differentiated specific feelings directed toward objects”. Mood is described as “a more prolonged prevailing state or disposition”. He comments that both terms are used “more or less interchangeably”. Modern use is much more basic and it has to do with direct observation of the patient’s emotional expression, the specific context, and whether or not it may be consistent with an underlying phasic mood disturbance.  A common error I notice in many descriptions is that the time domain is omitted - people never seem to comment on the affective state over the course of the interview or the fact that the patient's affect appears to be completely normal - despite the assessment being done for a mood or anxiety disorder.

If you are interviewing people by telephone rather than Telepsychiatry, you don’t have access to any of those three critical domains as well as other parameters that might be important. For example, vital signs, focal physical examination, and the overall determination about whether or not a patient may be physically ill or critically ill just based on their appearance.  There is also a pattern matching aspect to psychiatric diagnosis. After psychiatrist has evaluated hundreds or thousands of patients, certain patterns are evident that can facilitate diagnosis. The most obvious one is delirium. It has always been a mystery to me why that diagnosis is so difficult for a lot of people to make. Once you have seen a few delirious people, the pattern seems obvious. Other findings are much more subtle. An example might be a patient appears to be in pain but also does not want to disclose the source of that pain. It could be a self-inflicted injury or injury from intimate partner violence. Those findings would be very difficult to pick up over a telephone interview.

A couple of examples come to mind when I think of critically ill patients who did not come to see me because they were critically ill. The first was a patient who looked the whitest I had ever seen a person. I asked him if he was physically ill and he denied it. I asked him about possible causes of blood loss and that was also denied. He did eventually allow me to order a complete blood count. I got the results back his hemoglobin was extremely low and when I called him - he did acknowledged some symptoms of G.I. blood loss and agreed to go to the emergency department. He was subsequently found to have a gastric ulcer. In another case I was talking with the patient appeared to be physically ill. He seemed to have some abdominal distress. He allowed for a limited exam of his abdomen and appeared to have right upper quadrant pain and tenderness. He was also referred to the emergency department and had acute cholecystitis and required surgery. Both of these scenarios depend on how the patient actually looks to the psychiatrist and that is why the visual presentation is so important.

Many people think that psychiatry is an exchange of words. A common myth these days is that these words allow people to be grouped into diagnoses based on other sentences and phrases. A discussion between two people is always much more than that. When a psychiatrist is in the room the discussion is between two people one of whom has memories of tens of thousands of important patterns and findings that mean something. A significant number of those patterns are visual rather than strictly verbal.

I have lost count about how many times a rapid visual diagnosis played a critical part in the diagnostic process. When I see a patient with serotonin syndrome or neuroleptic malignant syndrome or malignant catatonia - I am not running down the diagnostic criteria in my head. I am thinking that they are critically ill probably have a specific diagnosis - but I have to get them somewhere fast where they can receive the necessary supportive care while that diagnosis is clarified and treated. Most of that is a visual process based on what I have seen in the past. In most cases, the diagnosis occurs in seconds to minutes.

I thought the telephone interviews went well. My notetaking was as intense as ever. I am looking at an average of about six pages of handwritten notes that I base my dictations on. But I know the process can be much better. Telepsychiatry is superior to telephone psychiatry, and I hope to find out how close it is to a face-to-face interview.

Hopefully that visual feed will be there tomorrow.

George Dawson, MD, DFAPA