All posts by Politics, Economics, Society, Healthcare

From USA

Give Me the Fences

A virus is not a living organism in the traditional sense of the word. To use the term ‘live” regarding viruses is inexact but probably the best word to use. A virus is an entity because of what it does rather than a description of its molecular integrity. Apart from their detrimental effect on humans and other living organisms, they don’t do anything. Viruses cannot “live” (maintain their molecular integrity) independently for very long, cannot reproduce, and have no energy requirements. In the traditional sense, “living organisms” require energy to maintain their molecular integrity and reproduce. Because viruses have no machinery to preserve their molecular integrity or survive the elements, they do not last long out there on their own.

Viruses are bits of genetic material. They are surrounded by protein. That’s it. When they “infect” us, they enter our bodies, get into our cells, and “use” our cellular machinery to create duplicates of themselves. They duplicate themselves in large numbers; some exit our bodies and disintegrate once exposed to UV light and air. Except for the few that enter the next body, and so on.

Our body responds to the virus by developing a fever. The elevation in body temperature is an outmoded and relatively ineffective attempt at making an inhospitable environment for the little buggars. We also mount in “immune response. In this response, we create antibodies to the proteins that coat the virus. Not the genetic material. That would be impossible. Your body would end up attacking your genetic material. Thank goodness that doesn’t happen. Once your body has an idea of the existence of this protein, it can now much more quickly mount a response to the virus. You will no longer get sick when exposed to this virus. We call this “immunity.”

Vaccination is when you introduce a protein to your body that is not associated with an infectious agent. Your body doesn’t know anything except to do what it does any time a foreign protein presents within your body. It creates an immune response. If exposed to an infectious agent with that same protein, your body can mount a much faster and more robust immune response, so you do not feel sick. This quick response does not preclude you from having the virus in your body and does not preclude you from passing the virus on to the next person. Although, it does reduce the duration of time for which you are ‘infectious.”

This reduced infectious time cuts down on the spread of the disease.

Masks are effective barriers to the spread of airborne viruses. Someone who was “anti-mask” compared surgical masks to shooting a .45 caliber bullet through chicken wire. Here’s what the chicken wire would look like; A standard .45 bullet is 11.5 mm in diameter, roughly. A pore in a surgical mask is 200 to 800 times larger than a virus (they vary). The fiber in a surgical mask is 260 times larger than the virus. So if we extrapolate that to a .45 bullet, the holes in the chicken wire are 4.6 meters in diameter, and the “wires” are 3 meters in diameter.

If you had your choice, would you instead face a random shooter behind two fences or no fences? I will take the fences.

But let’s extrapolate this to reality. The virus will not “live “long outside of a body and does not travel in a straight line. Also, it is surrounded by a droplet as it flies through the air. This makes it much larger than the size of the virus alone. Likewise, it has no “intentions” like a shooter might. Yes, you can still get a virus when you are both wearing a mask, but you reduce the risk just as you reduce the risk of being hit by a stray .45 bullet when behind two 3-meter diameter chicken wire fences.

To say, “You can still get COVID while wearing a mask,” is a true statement. There is no opposing argument to that in existence. The opposing view (you can never get COVID when wearing a mask) is implied by the propagandist. A scientist telling you the truth will tell you that you reduce your risk of catching and spreading COVID when you wear a mask. The propagandist wants you not to wear masks and believe them ineffective. You only need to question, “What’s in it for them?” Who is behind it?

Three sources come to mind. One is when you follow the money trail; who profits when we don’t protect ourselves from COVID? For one, the vaccine manufacturers. Let’s face it, as long as we keep spreading COVID; they are not going out of business. Compare this to smallpox vaccine makers. They are out of business.

Another “trail” would be political. Our enemies would not mind if we all died, were too sick, or were mired in too much propaganda to fight.

How about just good old, “I want to be right at all costs?” The anti-vaxxers that have been around since before COVID don’t want to be proven wrong.

We “dumb” doctors wear masks to protect ourselves and our patients, and we have done so before COVID and will do so after COVID. We don’t fall prey to propagandists because we know what questions to ask. Nobody had to explain the pore size to me to understand how masks work. The “pore size” experts came out of the woodwork during COVID faster than the “how hot jet fuel burns and the melting properties of industrial steel” experts after 9/11.

Want to Get Paid like a Doctor?

If everyone got paid the way doctors get paid, we would see a revolution in how healthcare is delivered in this country.

I don’t mean getting paid “as much” as a doctor. I’m talking about getting reimbursed for the work you do the way many doctors do.

But, for fun, here’s what it would be like if you got paid “as much” as a doctor. In a nutshell: I’m making half of what I was making 20 years ago. So, imagine getting paid less and less year after year. Instead of getting a “cost of living” raise, you get a “cost of living” reduction. Awesome, right?

But imagine getting your paycheck the way doctors get paid by insurance companies. I will lay out a hypothetical situation to illustrate what I mean.

Let’s say you agreed to do a certain amount of work for $100.00. You do the work, but you don’t just get a paycheck for the work you did. No, you have to now appeal to your boss and request that they pay you for the work you did. And your boss has the option to pay you or not. Your boss has the luxury of changing the definition of work and can, therefore, decide that you did no reimbursable work after all. Nice, right? You have done the work, but you STILL have to ask your boss to pay you. And if you don’t ask your boss to pay you, he gladly will not pay you.

Now, imagine both. After a lengthy and costly process, you have to appeal to your boss, but your boss decides that you only did $98.00 worth of work after the fact. Your option is to take the payment or take nothing and fight it. Obviously, it will cost you more to fight it than to accept it, so you accept it. And you see where this is going. You now do $98.00 worth of work, and the next time you ask your boss to pay you, they decide you only did $96.00 worth of work. And so on.

What is your boss doing with the extra money they are taking from you? They are simply adding it to their profit margin. And what recourse do you have? Quit your job and get nothing? Imagine if you had (like a doctor) gone a million dollars into debt before you even set foot on the job. Imagine if you had invested 12 years of your life into doing that job. How easy is it to quit? You complaining about the pay only allows them to reinforce their message; all you care about is money.

And imagine if your boss had been part of a decades-long scheme to condition the public to not listen to your concerns. Who are you going to complain to? They point out that you are “worried about money,” but they need to add in the fact that you are a million dollars in debt. But they don’t.

So, does your boss pass these savings on to the customers? Nope. Instead, they use it to pay shareholders, lobby politicians, and regulatory agencies. Make note; they are not asking these people to allow you to offer a better product. No. They are asking politicians and regulatory agencies to help make their shareholders wealthier and wealthier. They ask the regulatory agencies to require you to do more work that adds no value to the customers. You are required to make it harder for your customers to get value for their dollar, and you have to pay the price for that. All that extra money goes into the pockets of those who add no value to your product. Your boss requires you to do less and less valuable work with your time while they make more and more profits.

Imagine if your job was like this. Imagine you had to sit back and watch your boss continue to take advantage of people, where nobody outside your profession cared about what you were going through. Or would listen to what you had to say. And you had to sit back and watch people, including yourself, get ripped off. Imagine watching the ship go down, but everybody on board has been conditioned to ignore your warnings.

They say never to fight with someone who purchases ink by the barrel. Well, these people have all the ink.

You all know the parable about boiling a frog. You put the frog in a pot of cold water and turn the heat up by one degree at a time until the frog is boiling. Well, consider the frog sitting in 211-degree water. The frog thinks everything is fine, but you’re trying to tell the frog of the danger, but the frog doesn’t listen. Sure, I could sit back and watch the frog boil. I might not have the option if the frog won’t listen. You are yelling at a frog who ‘knows better” than to listen to you.

The American public is sitting in 211-degree water. Like your insurance premiums, that temperature never goes down, only up. Your access and value never get better, only worse.

The people ripping you off will ride that ship to the bottom of the ocean. Don’t worry; they will provide you with a bucket.

Coronavirus: Don’t Worry About the Test

A word about medical tests. In light of the coronavirus pandemic, you have probably seen me on Facebook telling people not to worry about getting the test. Clearly, I must be mad. Clearly this must be some kind of evil plan to capitalize off of sick people. Let me explain myself.

It is not uncommon for the lay public to think a medical test will have one of two outcomes; the patient has the disease and the test indicates they have the disease or the patient does not have the disease and the test indicates that the patient does not have the disease. In an ideal world, all medical tests would be that good. But guess what? There’s not a single medical test on the planet that does this. Not a single one.

In fact, a medical test is going to have one of four outcomes not two. Here are the four possible outcomes: Either

1)  The person has the disease and the test indicates that the person has the disease.

2) The patient has the disease, but the test indicates that they do not. This is a false negative.

3) The patient does not have the disease and the test indicates that the patient does not have the disease. Or,

4)  The patient does not have the disease, but the test indicates that the patient does. This is a false positive.

Every single test that we have at our disposal in medicine has false negatives and false positives. As a practitioner of medicine I have to know the characteristics of the test that I am using. But let’s back up a second. How would I know the test for disease is giving false results? I  need a second “More accurate” test to determine that the disease is actually present in those for whom my test is falsely negative. This second test acts as a gold standard to which the first is compared.

Here’s an example. Let’s talk about pneumonia. If you come in to see me and you tell me that you’re coughing, you have a fever, and you’re getting green mucus. Then, I listen to your lungs and I hear abnormal sounds in one area of your lungs. I could diagnose you with pneumonia. But, “wait a second” you’re saying. “Don’t I need a chest x-ray?” Well the answer to that is “no”…unless I think that there is an alternative diagnosis that has to be ruled in or out. Or maybe I just want to be extra sure because of the implications of the treatment that I will be prescribing. So let’s say you do get that x-ray and it shows pneumonia in the place where I already knew you had pneumonia. That would be the gold standard for pneumonia. I don’t need to apply the gold standard to everybody with pneumonia because literally millions of such X-Rays have confirmed this clinical presentation time and time again.

With that in mind let’s move forward. So we use a gold standard to determine what we called the sensitivity and the specificity of a test. Sometimes that gold standard is something as simple as a chest x-ray… Historically the gold standard was the autopsy. Now the autopsy won’t always tell you what somebody had but it will definitely always give you the prognosis 100% of the time. In fact, the autopsy is the only test in medicine that has 100% of anything and that is its prognostic value. After an autopsy no matter what I find… Your prognosis is that you’re dead. That you were dead was generally an assumption, within acceptable accuracy standards, made before the autopsy…but is without a doubt 100% certain afterwards.

But I digress. So any test is going to have true positives true negatives false positives and false negatives. And we will determine this by measuring against a gold standard.  Sensitivity is the measure of how well the test detects the disease in the presence of the disease. Specificity is how well it detects the absence of disease in the true absence of disease.   Us medical people go to school a long time to understand this concept and its application to all the tests we do in medicine. See…we’re not just people who wear white coats and don’t do what you want.

The coronavirus test has about a 30% false negative rate. What that means is if you get a coronavirus test that comes back negative there’s still a 30% chance that you have coronavirus. Needless to say, that’s pretty useless information isn’t it? If you have a positive coronavirus test, then you most definitely have the disease. So if you get a coronavirus test that has a 30% false negative, what can you do with the results? If it comes back positive you can quarantine yourself. If it comes back negative… You’re going to quarantine yourself. If you don’t get a test at all… You’re going to quarantine yourself. So clearly for patients who do not need mechanical ventilation, there’s truly no benefit to the test.

Now, what about the people who do need to be hospitalized with coronavirus. Same situation; if I do the test and  its positive, then you definitely have coronavirus. If I do the test and it’s negative, there is still a 30% chance that you have coronavirus. The treatment will not change one bit. You’re still going to get mechanical ventilation. You still might get hydroxychloroquine and azithromycin. But the test is completely unnecessary in this scenario…and, quite frankly, takes too much time to be relied upon to decide to initiate any therapy.

Now the forthcoming antibody test? That I think has tremendous value for you as an individual. If you test positive for antibodies to coronavirus you are definitely safer out there in the world than you were if you don’t have antibodies to coronavirus. That’s an actual useful test that will have impact on you.

The coronavirus test itself is not that useful for you as an individual. It’s incredibly useful as a surveillance tool and epidemiological tool. I’ve heard friends tell me that they’ve been exposed to somebody and their work won’t allow them to come back until that person’s test comes back negative. This employer doesn’t understand the test. My assumption would be that they’re trying to prevent the spread of coronavirus but their methodology is horribly flawed and is going to ultimately yield the opposite result. So if they have restrictions on who can come to work they need to base it on something else. Most places base it on whether or not you’re symptomatic. Now of course we all know that that’s not perfect, that plenty of asymptomatic people have the disease and can spread it. But there’s literally no way other than shutting down completely to prevent that. And guess what most businesses are doing… They’re shutting down.

In summation… Don’t worry about the coronavirus test. it’s not going to change much for you if anything.  When the antibody test is available, get it.  Stay home, stay safe. Protect your healthcare workers by staying home.  Come to the ER if you have an emergency situation, but simple cold symptoms (cough, fever, aches) can all be taken care of at home the exact same way we will take care of it in the ER: Tylenol, fluids, rest.  Try a tele-medicine service. This is as good a time as any to try this out.

Disclaimer: The opinions stated herein are my own and not representative of any organizations to which I belong.

The Franklin Effect

I have discovered an interesting phenomenon.  when asked, most health care professionals state they have a desire to have something important named after them.  I have named this, “The Franklin Effect.”  It is quite prevalent.  I had been in the process of claiming the secondary name for a Mobitz II arrhythmia, with Wenkebach having claimed the Mobitz I.  What I found was that many others had also lobbied for the naming rights.  It turns out, many had even offered up money.  Let’s just say that it was too rich for my pocketbook, but it gave me the idea that apparently I wasn’t the first to try to get so cheaply recognized for something I had nothing to do with.  It was this idea that led me to the work that ultimately revealed that the Franklin Effect is quite real and quite prevalent amongst many whom have never discovered anything important.

I have now also decided to name my short educational videos after this.  I will be launching periodical (period defined by how much free time I have) videos on core content and special topics and posting them under the Franklin Effect title.  I felt it important to remind you all of what the Franklin Effect actually is.

Ischemic Foot in Progress


This was the first time i saw this patient.  He had a Left BKA already, presents with a cold foot.  Ultimately gets vascular studies and no treatment.  Plan was to await full extent of ischemia to become apparent. Patient presents a few months later with the findings in the image below.


In an effort to preserve his ability to ambulate, a forefoot amputation was undertaken. Images below were form a follow up several weeks later.  It was certainly a rare opportunity to wee this each time in the ER and to participate in the excellent care of this very nice gentleman.

IMG_0980.2014-09-16_205850IMG_0569.2014-05-23_025010 IMG_0570.2014-05-23_025207

Large Hiatal Hernia

IMG_1135.2014-11-06_060500 IMG_1136.2014-11-06_060508

This Chest XRAY depicts a large hiatal hernia.  on the AP, it looks almost as if the heart is a water bottle half full (or half empty for you Debbie Downer’s out there). Also COPD id demonstrated with the hyper-inflated lungs and paucity of soft tissues, and a right sided pacemaker. Notice on the lateral how his calcified aorta has to circumnavigate the hernia.
Photos Copyright 2015 William E. Franklin, DO