CII - Lisa Sanders, MD, FACP

August 28, 2023

Information

Lisa Sanders, MD, FACP, Associate Professor of Medicine, Medical Director

of the Yale Long COVID Multidisciplinary Care Center

“How about Afterwards: When the end of the infection isn’t the end of the illness”

ID10662

To CiteDCA Citation Guide

00:00So my name is Julio Silva,
00:02I'm a an MDPHD student in Akikawasaki's lab.
00:07And today I actually have the pleasure
00:10of introducing our next two speakers
00:14which in as a group I think our
00:18these two people in addition to being
00:22extraordinary clinicians really help
00:24bridge the gap between you know,
00:27medicine and science and helping
00:30the public understand it and
00:32communicating with the public.
00:34And I think that that you know often is
00:38something neglected but so crucial as
00:41it builds trust between the clinicians
00:44and people who who really you know,
00:47do this as as well as like the public who
00:50we you know ultimately our goal is to serve.
00:53So with that, I first want to
00:56introduce Doctor Lisa Sanders.
00:59She is perhaps she's a,
01:01she's an associate professor
01:02here at Yale School of Medicine.
01:05But she's perhaps best known,
01:07especially from a public perspective,
01:11for her biweekly column that she
01:14writes for in the New York Times
01:17Magazine called Diagnosis and this.
01:20This, of course,
01:21has served as an inspiration
01:23for TV shows like House,
01:26which she served as a consultant for,
01:28as well as the Netflix docu
01:32series called Diagnosis as well.
01:35So I I want to take this time
01:37just to invite her up and have her
01:40present. So thank
01:49you. Well, I don't know what I'm doing here,
01:51talking to a bunch of people,
01:52a bunch of scientists,
01:54but I'll do my best.
01:57So I'm interested, obviously,
01:59I'm very interested in long COVID,
02:01but I'm very interested in long
02:03COVID because it's part of a
02:05much bigger story about what
02:07happens to people when they
02:09get better but don't get well.
02:13So if you look at just long COVID, it was
02:22interestingly. Thank you.
02:27Okay, Okay, great. Thank you
02:33long COVID was first identified by
02:37patients Fiona Lowenstein at the top.
02:40She wrote an oped piece in the New York Times
02:44about her extremely slow recovery from COVID.
02:47The Oped was titled We Need to Talk about
02:50what coronavirus recoveries look like.
02:53There are a lot more complicated
02:54than most people realize,
02:55so that was the first sort of
02:58hint that something was going on.
03:00And that was published in April 13th of 2020,
03:03so very early in the pandemic.
03:05She felt lonely and so isolated
03:08because of her lengthy recovery.
03:11So she started an online chat group
03:13to talk to others who are trying
03:16to recover from this new virus.
03:19The woman on the bottom,
03:20Elise Perrego.
03:21She's a research scientist,
03:23and she introduced the term long COVID.
03:26She she created this hashtag
03:29long COVID in May of 2020.
03:32And of course that term was
03:35immediately embraced by the community.
03:39So it's made quite a splash since then.
03:44At there was a recent CDC study published
03:48I think 2 weeks ago that estimated that
03:51up to 23 million people in the United
03:55States have developed along COVID.
03:57That's a lot.
03:59That's a whole lot.
04:01So what exactly how do we define long COVID?
04:08Actually really badly,
04:09in my opinion and in everybody's opinion.
04:13I went to a conference a few weeks ago
04:16at the National Academy of Sciences
04:19or Medicine rather to consider whether
04:22the definition of long COVID should
04:25be changed to make it more narrow.
04:28Right now it's defined as the signs
04:34and symptoms and conditions that
04:36continue or develop after an initial
04:39COVID-19 or SARS COVID 2 infection.
04:41So basically what they're saying you had
04:45COVID and then something bad happened.
04:47So you can see that that's a that's
04:50a a ridiculously broad definition.
04:55So it has the symptoms have to be
04:58present for four weeks or more after the
05:01initial phase of the of the infection.
05:03And actually The Who uses 3 months
05:06because it's not uncommon for
05:08people to be to still feel terrible
05:11a month after their infection.
05:14But the National Academy said four weeks.
05:19It's multisystemic, often.
05:23It often presents with relapsing
05:26and remitting, A relapsing,
05:28remitting kind of pattern and it
05:31might progress or worsen over time.
05:34It can even get to be very severe
05:36and life threatening, months,
05:38even years after the infection.
05:42And finally what they say is that
05:45long COVID is not one disease.
05:47It's lots of different things.
05:49It's like, I don't know, cancer, you know?
05:52I mean, it contains multitudes.
05:54It's not like cancer, but in that way it is.
06:00How does it manifest itself?
06:02Everywhere, I mean everywhere.
06:04You know, it's it's in the brain,
06:08it's in the heart,
06:09it's in the stomach, insomnia,
06:12anxiety, cough, pulmonary fibrosis.
06:17I mean it's just insane the range of
06:20the symptoms that it includes in.
06:24In May, there was a study published
06:29in JAMA that looked at at a lot
06:32of did a meta analysis of a lot
06:34of studies that were reporting
06:35on long COVID and came up with
06:3812 symptoms linked to long COVID.
06:40This has been a source of great
06:43irritation to a lot of the people I see
06:46who don't find their symptom up on that list,
06:49but they were trying to figure
06:51out a way to narrow it down so
06:53that it's not just anything bad
06:55that happens to you after COVID.
06:57So that was their effort.
07:02I'm a clinician, so the answer to
07:07why is not something that I embrace.
07:11My question is what can I do to help?
07:14Why is not so good?
07:15So I depend on other people
07:18to help me understand why.
07:20And so you can see that there are many
07:23different possible causes and probably
07:26even more than this that lead to
07:30different pathophysiologies that can end,
07:32that can bring a patient to having
07:36task or long COVID endothelial
07:39dysfunction and these microclots
07:41that get talked about a lot or
07:45persistent viral reservoir which
07:47Harlan Krumholtz is trying to possibly
07:51identify through his Paxlovid study.
07:55So there are a lot of different
07:56ways auto antibodies.
07:57So there are a lot of different ways
07:59that this disease impacts our patients
08:02and because it's got because it's
08:05such a a huge disease where which can
08:08manifest in so many different ways,
08:10there's a there's a fair
08:12amount of skepticism.
08:13So you know I have a a very well
08:15used box of Kleenex that is replaced
08:18daily because people are quite
08:21frustrated and sad and wonder if
08:24they're insane when they come in with
08:26some of the symptoms that they have.
08:30So there is some good news. Last week's
08:37Morbidity and Mortality Weekly
08:39Report from August 11th reported
08:41that the prevalence of long COVID
08:43had declined over the past year
08:52from like. So if you look at all Americans,
08:57the number of patients with long
09:00COVID decreased from 7.5% to 6%.
09:02So that's good.
09:04And if you just look at adults who
09:08who actually had known COVID-19,
09:12if you just limit it to that,
09:13it decreased from basically 19% to 11%.
09:17But still, if you knew that you had a
09:21one in ten chance of having this bad
09:25cold last for weeks or months or years,
09:31I mean it's I think that's pretty it's
09:33still a pretty frightening possibility.
09:39Approximately 1/4 of adults with long COVID,
09:43it's a lot of people report significant
09:46limitations on their activities.
09:50That same report from the MM from
09:53the CDC said that long COVID is
09:56associated with a lower likelihood
09:59of working full time and a higher
10:02likelihood of being unemployed.
10:04The report cites data from the New
10:06York State Insurance funds that 18%
10:09of claimants with long COVID could not
10:13return to work for more than a year.
10:16So that's devastating for most people.
10:21Just to let you look at the,
10:24the change in prevalence,
10:29sorry for it being so busy,
10:32but that big fat black line is the
10:35average and you can see that it drops
10:37at the at the end of last year and
10:40then around January sort of stabilizes.
10:43But if you look at the different age groups,
10:47the bottom age group,
10:48those are people over 80.
10:50Obviously they have the lowest
10:53prevalence of long COVID,
10:55but it is creeping upwards and the
10:58other group where there's an inflection
11:00point and it started to creep up
11:02by the people 50 to 55 years old.
11:05So people still in,
11:09I like to thank the prime of their
11:11life or at least part of it.
11:13So it's distributed differently.
11:14I mean it is good news overall,
11:18but people are still quite debilitated.
11:26So this comes from the INSPIRE study
11:30that's the innovative support for patients
11:34with SARS COVID 2 infection registry.
11:37This looked at, I thought this
11:38was such a an interesting idea.
11:41So this looked at 3800 patients who
11:44are getting tested for COVID and
11:47were recruited before the results
11:49of their tests were known and
11:51surveyed then about their symptoms.
11:53And then at three months, six months,
11:56nine months and a year after that test,
12:00the dark blue lines at the top.
12:02The dark blue bars represent the 12188
12:07patients who tested positive for COVID,
12:09who filled out all of the surveys.
12:11The lighter blue below are the survey
12:15results of the 453 patients who were
12:19presumably sick when they take took the
12:22test but tested ultimately tested negative.
12:24For COVID, the dark bars represent
12:27persistent symptoms in both groups.
12:30The lighter tinges at the
12:32end are new symptoms,
12:34symptoms that they didn't have
12:35when they took.
12:36For this one, this is 3 months out.
12:40So the light blue is symptoms that
12:42didn't exist when they took the first
12:45survey when they were first sick,
12:47but exists now.
12:48And so you see that the people who
12:52didn't have COVID had something and with
12:57persistent symptoms at three months,
13:02then again at six months
13:08and again at a year. So these are,
13:12this is the same group of people
13:14just tracked over the year.
13:19So I was surprised by this when I when
13:24Erica Spatz first told me about it.
13:26But I shouldn't have been because
13:29this idea of a post viral or a post
13:33infectious syndrome is far from new.
13:37You know, if you look back in history,
13:42the Russian flu in 1892,
13:46it's called the Russian Flu because
13:48the first reported cases were in
13:51Saint Petersburg was a devastating
13:55pandemic. This is the cover of
14:00London's Illustrated Police News.
14:02It reported on the 1st and most deadly
14:06pandemic of the industrial era.
14:08It killed one out of every 1400
14:11people alive on the planet.
14:13So a really terrible flu.
14:18But even then, there were many
14:20cases where the symptoms persisted
14:22well after the flu resolved.
14:24The neurologic conditions observed
14:26after the Russian influenza were
14:28given many different names. Neuralgia.
14:30Do you know them from old novels,
14:33if you read old novels or
14:35from your history books?
14:36Neuralgia, Neurasthenia,
14:38neuritis, nerve exhaustion grip,
14:42cataplexy, postgripple, numbness.
14:44I mean, you can recognize
14:47aspects of long COVID in this.
14:50You know, the peripheral neuropathy,
14:52the post exertional malaise,
14:56prostration, psychosis,
14:58inertia, anxiety, paranoia.
15:00These are what how these
15:03people's symptoms were described.
15:05There was a a Victorian Dr.
15:08throat specialist who described
15:09how influenza appeared to quote run
15:12up and down the nervous keyboard,
15:15stirring up disorder and pain in
15:17different parts of the body with what
15:21almost seemed malicious Caprice.
15:23That's how that was described.
15:25And that was 1892.
15:28And then of course there was
15:30the Spanish flu in 1918.
15:32And let me just put in a
15:33good word for the Spanish.
15:34The reason it's called the Spanish
15:36flu is because during World War
15:38One they weren't involved in the
15:40war and so they had a Free Press.
15:42And so they were the first people
15:45to report this epidemic,
15:46which was absolutely devastating.
15:49It's estimated that about 500 million people,
15:53or 1/3 of the world's population,
15:55became infected with this virus.
15:58The number of deaths was estimated to
16:00be at least 50 million worldwide and
16:02about 675,000 occurring in the United States.
16:06Mortality was mortality was high
16:09in people younger than five,
16:11those between 20 and 40,
16:14and those who were 65 and oldest,
16:17the highest.
16:18Mortality in healthy people was a
16:21unique feature of this particular pandemic,
16:25but for those who are who survived,
16:27at least some of them,
16:29the suffering was not over the the
16:33long term neurologic effects of
16:35this flu included Parkinsonianism,
16:38catatonia,
16:39and something called Encephalitis lethargica.
16:46That term was first used by an
16:50Austrian neurologist after he
16:52identified an increased number of
16:54patients in Vienna with meningitis and
16:57delirium during the winters of 1916 and 1917,
17:01and in 1980.
17:02Eighteen disorders that were similar to
17:04encephalitis lethargica were reported
17:06elsewhere in Europe and the United States,
17:09with a peak of cases in 1923,
17:12and declined over the course of the decade.
17:15So as with the the post Russian flu epidemic,
17:21it spiked and then disappeared
17:24and nobody talked about it.
17:28So it's not just COVID.
17:32This is from Akiko's fantastic
17:36article in Nature magazine last year.
17:39Fatigue has been the most widely
17:42measured and followed symptom,
17:44but of course not the only symptom.
17:46And you can look.
17:47I mean, what a, what,
17:49a what a range of illnesses,
17:52many of which are studied by this group.
17:58So it ain't just COVID.
18:02So I run the newly started the
18:07New long COVID Clinic.
18:10But I would be,
18:11it would be wrong of me not
18:13to talk about the real,
18:15the source of that clinic.
18:17These are the people who cared,
18:21who provided long COVID care
18:23for the first years of
18:26this pandemic. And actually several
18:28of the people in this slide,
18:30specifically Jennifer Possek,
18:33Erica Spatz, Lindsay McAlpine put
18:39together the clinic that I now run.
18:43And they were very thoughtful in how
18:45they put it together and and recognized
18:48that this required a multidisciplinary
18:50approach and that it required an internist.
18:53So I was thrilled when I heard about it.
18:57So this is our crowd.
19:00This is along COVID and you see that
19:03there there are respiratory therapists,
19:05there are nurses,
19:07there are physical therapists,
19:10there's a PA and ME and we see
19:14patients five days a week, 3 days.
19:18We see new patients two days.
19:20We do follow-ups.
19:24It's a multi specialty clinic.
19:32So we get to open.
19:34We got to open with the hard one
19:36knowledge of those who people who
19:37had seen patients here at Yale.
19:42Patients are screened by nursing before they
19:45come in so that we can get their records.
19:47We know that for most of them this
19:51is not their first visit by far.
19:54At the time of their visit,
19:55they're always seen by a physical therapist,
19:58also by social worker and and by a physician.
20:03And when appropriate,
20:04they're also seen by a respiratory therapist.
20:10We. Require referrals.
20:13We require referrals because after we sort
20:16of address these immediate concerns there,
20:20it's not like they're going to go away.
20:21It's not like we can give them two weeks
20:24of doxycycline and they'll get better.
20:26They're going to have these symptoms
20:28for a while, so we need to have them
20:30go back to their regular doctors.
20:32And we're located at the medical
20:36office building at Saint Ray's.
20:39So we opened on,
20:41we saw our first patient on March 20th
20:44and since then we've gotten about 240.
20:48This is up to July 1st at 245.
20:51Referrals we've seen had seen
20:54at that .206 patients,
21:00most of the most common
21:03referring diagnoses were
21:04exactly what you would think.
21:06Shortness of breath, fatigue,
21:10brain fog, pots, cough, anxiety.
21:15So that's what that's what
21:16they're starting with.
21:19Our job in this initial clinic
21:23evaluation is to see if their lungs work,
21:26if they have short shortness of breath,
21:28see how debilitated they are.
21:32They are the vast majority of
21:35patients who we see have not
21:37been active since they got sick.
21:41You know, I mean,
21:42many of them have spent a lot of far
21:45too much time on the sofa because
21:47they felt too terrible and because
21:49they were afraid that if they
21:51exercise they would get worse Because
21:52there were stories about people
21:54who had post exertional malaise,
21:55who exercised and got worse,
21:58or they did it themselves.
21:59They exercised.
22:00They decided to push through and go
22:03for that run and then you know they
22:06were in bed for days afterwards.
22:08So there with the physical therapist,
22:10we do 6 minute walk test for people who
22:15have symptoms of autonomic dysfunction.
22:17We do something called an active stand test.
22:20That's the poor man's tilt table test,
22:24which is supposed to be as good,
22:25but I don't know.
22:28That's what I read.
22:30Social work tries to assess their
22:32needs and their support and
22:34provide counseling when needed.
22:36And we have a psychiatrist we work
22:39with when medications are indicated
22:41and we have a support group,
22:44A zoom support group that will
22:46be starting in September.
22:49So and then I see them or sometimes
22:51my PA sees them,
22:52although he usually sees people in
22:53follow up and we get a thorough
22:55history and we do a physical exam.
22:57We get whatever work up we think is
23:01needed and we either treat them or
23:04refer them to subspecialists for treatment.
23:07My goal when I see them is to to make
23:11sure that they have long COVID and
23:13they don't have anything else about,
23:16I would say 1/6 or so.
23:19You know a good,
23:20a decent sized handful of the
23:22people who come to see me actually
23:24have something else.
23:25And so we try to get them taken
23:29care of for those things as I think
23:31it's actually kind of a victory
23:33when they have something else
23:35because most things we can do more
23:38for than we can for long COVID.
23:42So what do we have that works in long COVID?
23:48It's it's not a pretty picture,
23:50but I'll show them to you.
23:54So some things we can be
23:57sure are pretty helpful.
24:01Physical therapy is often helpful,
24:04with some caveats.
24:06Some patients crash when they
24:09push themselves too hard,
24:11something known as post exertional malaise.
24:13These patients have to increase their
24:15workload super slowly and recognize
24:18their limits so that they don't crash.
24:20I don't think that there's any
24:22evidence that these crashes cause harm,
24:24but they do steal time,
24:28and that's a bad thing.
24:32But they're kinds of exercises
24:33that have been developed.
24:34You see this woman who's
24:37exercising loaded to the floor.
24:39People who have or autonomic
24:42dysfunction often need to do
24:45exercise in a recumbent position.
24:47So there are a couple of
24:49protocols that we do for them.
24:56So something that we see a lot is pots.
25:02It's a kind of orthostatic intolerance.
25:05Pot stands for Postural
25:08Orthostatic Tachycardia syndrome,
25:09where they'll tell you their heart races
25:13and they get dizzy when they stand up.
25:16And these are the people you see in stories
25:19about long COVID who are in wheelchairs
25:23because they really cannot stand up.
25:26And it's been shown that certain kinds
25:30of exercises can be helpful for them,
25:33you know, recumbent exercise.
25:34But also one of the things that helps
25:37and there are, I'll get to this,
25:38there are a couple of medicines,
25:39but compression stockings,
25:41serious compression stockings,
25:44not the, you know,
25:45not the ones that you that you normally
25:47buy that have a pressure of about 15 to 20
25:51millimeters of mercury per
25:53square inch, but 30 to 40.
25:56And the compression increases as you
25:58move upwards and they have to go
26:00all the way to the waist because so
26:02much of that extra blood that we're
26:03trying to get back to the heart is in
26:06those in those lower blood vessels.
26:09So that's been shown to work
26:11in combination with sodium
26:16for brain fog, which is a super common
26:21complaint of those with long COVID.
26:23Cognitive therapy is sometimes
26:25useful for brain fog.
26:27Studies evaluating cognitive
26:29deficit after COVID generally show
26:32impairments in the cognitive domains
26:35of attention and executive function.
26:37And let me just say for daily life,
26:40those are the two skills
26:42that you use the most.
26:43And so these people are can be terribly
26:46debilitated and cognitive therapy
26:48has been shown to be helpful in some
26:51types of cognitive deficits or brain
26:53fog for example post traumatic you
26:57know post concussive brain fog has
27:00been shown to be helped by cognitive
27:02therapy or chemotherapy chemo brain.
27:07So for cognitive therapy, they're
27:09usually two kinds of approach it or two.
27:12Two aspects to this.
27:13First, they give them the skills to
27:16manage not having executive function
27:18and not having very good attention.
27:21So they give them some skills to
27:23learn how to manage that life.
27:25And then there are exercises
27:26to try to get things working.
27:28Again, the evidence isn't great,
27:32none of the evidence is great,
27:35but it's often helpful.
27:39And then there are medications.
27:44I haven't done a deep dive into their use,
27:46but other long supplements,
27:48for example, they are used.
27:50I haven't done a deep dive into their use,
27:52but other clinics like the one at
27:54Mount Sinai in New York use them a lot.
27:561 combination that's supposed to be
27:58useful is L, arginine and vitamin C
28:01I'm not really sure what those do.
28:04I think it's for Vasospasm.
28:06I'm not exactly sure how it works,
28:09but there are some studies that look at that.
28:12I use the combination of supplement and
28:15medication that was evaluated by Armin
28:18Feshirakis a day a couple of years ago,
28:21an acetylcysteine and guanfacine,
28:24an acetylcysteine.
28:26I mean, I know about it because people
28:28use it after an overdose with Tylenol,
28:30but it's been used for a lot of things.
28:32And guanfacine was a medicine
28:34that was used for a DD and those
28:37have been shown to help many.
28:39And of course lots of people come in
28:41after hearing about low dose naltrexone.
28:44It's been used to treat chronic
28:46pain for many years.
28:47And one study done specifically in
28:50people with long COVID shows that
28:53it improved fatigue and brain fog.
28:56So one of the things that's been
28:59most well studied is loss of sense
29:01of smell and sense of taste.
29:04I think it's been studied so much
29:07because it's easy to measure and cheap.
29:10There are these things called sniffing
29:12sticks and you can, they've been,
29:15they're, they're measurable.
29:17So one of the easiest things are using
29:21a combination of four aromatic oils
29:25to help you improve your smelling.
29:28You're supposed to smell them every day,
29:32seven days a week for six months.
29:35And at the end of that time period,
29:37most people like over 60% of
29:40people will have their smell back.
29:43Was that just over time?
29:44I don't know, but that's what we know.
29:50There's also,
29:53I just read a fascinating piece,
29:55a systematic review looking at
29:58what works in in long COVID.
30:02And so they looked at, they did a
30:05deep dive into what's been tried for,
30:07the sense of smell and taste.
30:10So as an internist,
30:12everybody goes to steroids.
30:14And so nasal steroids have been extensively
30:18evaluated and found to not work at all.
30:22So there are a couple of other
30:24nasal solutions that have been
30:25shown to have some effectiveness.
30:27They're not on the market that you can't.
30:29You can get them made at
30:30a compounding pharmacy.
30:32One is a sodium gluconate solution.
30:36Another is something called Tetra
30:40sodium pyrophosphate nasal spray.
30:42I just learned about these and
30:44so I haven't examined them at
30:46all or tried to get them made,
30:48but they did seem to be effective.
30:51But they have to be made.
30:56So one of my patients came in
31:00and demanded this for her lack
31:03of sense of smell and taste.
31:06This is a stellate ganglion blockade
31:11they injected with lidocaine,
31:13which of course only lasts
31:14a few hours and wears off.
31:16But she said that the Facebook
31:19group on people who have lost their
31:23sense of taste and smell through
31:25COVID was all a flame over this.
31:29She'd already tried the aromatics.
31:32I didn't know about these other nasal sprays,
31:34but I didn't know that nasal
31:36steroids didn't work,
31:37and she'd also tried them several times.
31:38So I'm like, okay,
31:40Let's see if there's anybody at
31:41Yale who does this kind of thing,
31:43because it's used for a lot of things,
31:45mostly pain control.
31:46So I found a guy who does it,
31:49who was willing to do it.
31:50And so you see, there's ultrasound,
31:52there's an injection of lidocaine
31:55into the Stella Ganglion.
31:57And I thought, well, here's hoping.
32:00So took her three months to get in
32:02to see the surgeon because that's
32:04how medicine rolls these days.
32:08And she called me.
32:10She said she went, she got the injection.
32:12Her husband took her to a diner for lunch.
32:15She said for the first time in
32:16three years she smelled coffee
32:18since she burst into tears.
32:21That's an end of 1, so I don't know.
32:23There are a couple of studies being
32:25done now, so we'll see if this works.
32:28I called the surgeon Robert Chow
32:31and I said why would that work?
32:36And he said got me.
32:39So I don't think we have a Gray.
32:41He said maybe the lidocaine
32:43shuts down the nerve and then
32:45it when it's like turning off
32:47your computer and it reboots.
32:49I don't know,
32:52maybe.
32:54But the long and short of it is
32:58that treatment for these symptoms is
33:02still a work in progress, like St.
33:04Raphael's and New Haven itself.
33:06A work in progress.
33:08And I hope to be able to do
33:11something for these people.
33:13And I'll tell you what,
33:14what we do most consistently
33:16is make them here feel heard,
33:19which turns out to be really important,
33:22and tell them that they're not crazy,
33:24which turns out to be really important
33:27as well. So that's all I got.
33:29Thank you.
33:45See, y'all don't take care of patients,
33:46right? The view up there, talk to people
33:55with ideas, without evidence and
33:57how do you make the decision about,
34:05Well, of course that is the hard part.
34:07I try to you know, if they come in
34:10asking for something that doesn't seem
34:12harmful and maybe has gotten a couple
34:15of small studies, I'm open to it.
34:18Supplements seem okay.
34:22This, still a ganglion block,
34:26pushed me to my limit.
34:27She had to push hard,
34:30but it's what she came in for and
34:35so I thought, okay, let's try it.
34:39I don't know. I assume her insurance
34:41paid for it because when people's
34:44insurance don't pay for things,
34:46I do tend to hear about it
34:47and I didn't hear about it.
34:48So that was my question is how
34:51are these treatments paid for
34:54if there's not evidence of?
34:56I don't know how the insurance companies
34:58are dealing with that, Not well.
35:00But I'll tell you before you
35:01can get in to see anybody,
35:03they have somebody whose job
35:05it is to call the insurance
35:06company and say is that paid for?
35:08So nobody gets in the door without that.
35:12Yes, Sir. I loved your talk earlier today.
35:16So this is, it's a common kind of striking.
35:20So whenever you describe, you know,
35:22the literature that serves
35:24that you've done for, you know,
35:27this viral epidemic based 92,
35:30I've actually talked to other people
35:32about this both in science and,
35:34you know, kind of media and stuff.
35:36And some people actually hypothesize
35:38that without evidence you don't
35:40really have didn't have the ability
35:42to do accurate back prostate and
35:43what could have test back then
35:45but that could have actually been
35:47the introduction of a ancestor of
35:50OC 43 which is a common coronavirus
35:53from a build line coronavirus. So
35:56and and the reason why they got me
35:58in to myself is because you mentioned
35:59many of the you know posts that you
36:02infection symptoms of that 1892 viral
36:06out rate that if it in fact was a you
36:10know essentially a no supporting pre
36:12ancestor then that would have been
36:15you know I I guess accurate in in that
36:17regard but there's really no way to
36:19know whether that was an influenza
36:21virus or a coronavirus you know that
36:23the socalled Russian Russian flu.
36:25But anyways, I heard that and I
36:27was like that's super interesting.
36:29You know that if it was a coronavirus
36:31like that, the the overlap and you know,
36:35prosecute symptoms are strikingly
36:36similar to COVID,
36:38right. And but actually even with the flu,
36:41you know, it depends on which
36:42flu strain it is. But you know,
36:44just in the reading that I've done,
36:46it looks like up to 25% of people
36:49after they get just the flu have
36:52symptoms that can last up to a year.
36:54So I mean the difference and like the
36:57people who were in the INSPIRE study,
37:00who who went to get a COVID test,
37:02I mean probably a good portion
37:04of them had the flu.
37:06And so you know,
37:08I think that's why they had such
37:10a dramatic and lengthy recovery.
37:14Yes, Sir. Hi,
37:16Justin Belski, Emergency Medicine.
37:17So we we see quite a few of these
37:19patients who are kind of desperate to
37:21come to the emergency room and really
37:23it's nothing we can really offer them.
37:25two-part question,
37:26one is you said there's sometimes
37:28an alternative diagnosis.
37:29What is your #1 alternative
37:31diagnosis you find?
37:32And #2, are there any objective
37:35tests such as abnormal PFT's and
37:38young healthy patients or anything
37:41objective that you can say okay,
37:43this is long COVID versus just
37:44kind of going off their symptoms.
37:46There's
37:48nothing. I mean that's not true.
37:50There are some super specialized testing that
37:54shows that are abnormal in some patients.
37:57Like I was talking to a group of doctors
38:02earlier today and was hearing about CPET
38:06that often that can show something.
38:08I mean, some people have studies that
38:10show they have endothelial dysfunction,
38:13but most people in most testing that is
38:17done routinely outside of research centers,
38:21they're completely normal,
38:22but they don't feel normal.
38:24But you know, tests are like questions,
38:27you know, and we've all played 20 questions
38:30where the 1st 20 answers we get are all no.
38:33And that's what's happening.
38:35I think in these postinfectious syndromes,
38:37we're asking the wrong questions.
38:39We don't know the right questions to ask.
38:41We don't have, maybe we don't even
38:44have the test yet to get there.
38:46But that's why they're their
38:48tests are negative.
38:49But that's of course why they they're
38:52looked at with such skepticism.
38:53Hey, I've done every test that
38:55I do want patients who are sick
38:57and I I can't find anything.
38:58But you know,
38:59I've written my column for 20 years,
39:0121 years now.
39:02And virtually everybody I've
39:04written about got that comment
39:07from a doctor at one point,
39:09you know that we've done everything we can
39:11to figure out what's going on with you.
39:12It's because they hadn't thought
39:14or didn't know the right test,
39:17the right question to ask.
39:18And that's where these patients are
39:23six. Well, I mean, they've been different.
39:25You know, I had one person who who's
39:29described monthly episodes of fever
39:32and pain and terribly heavy periods,
39:35and so I thought she probably
39:37had some sort of endometriosis.
39:39And I had a patient who I wrote about in
39:41my column, because I totally missed it,
39:43who had hyperthyroidism.
39:44I wanted to shoot myself.
39:46It was such an obvious diagnosis.
39:48But, you know,
39:48so they have a variety of different things.
39:50Some have neurologic problems
39:51that I don't know what they have,
39:54but it's definitely not long COVID and
39:57you definitely need to see somebody else.
39:59So you know I've I've referred
40:01people on to specialists,
40:03subspecialists who are still seeing
40:04them and we'll see what they have.
40:06Maybe they'll get sent back to me.
40:08We can't find anything.
40:09Probably is long COVID that's also
40:11that's also a possibility but at least
40:14they seemed atypical at the time.
40:16Thanks.