Friday, February 28, 2020

COVID-19 update

Some of my readers have asked me to update my thoughts on the coronavirus. First of all, on February 11 2020 the novel coronavirus was officially named COVID19 

Viruses are named based on their genetic structure in order to facilitate the development of diagnostic tests, vaccines and medicines. Virologists and the wider scientific community do this work, so the International Committee on Taxonomy of viruses (ICTV) gets the honor of choosing the name. (I just learned this!)

It is hard not to be overwhelmed with all the stories circulating.
One one hand, the president has announced that there is no need to be alarmed. At the same time the mayor of our city in San Francisco has declared a state of emergency. It is confusing, to say the least.

Most of the information in my early post remains accurate. It is possible that the incubation period before someone shows signs of the illness is longer than previously thought, but otherwise the basics apply.

So far, children have handled any exposures and illnesses quite well. The folks getting hit the hardest are older adults. For those of you in the sandwich generation, you need to be more concerned about your parents than your kids.

Unfortunately, the numbers of people infected have continued to jump. This virus has also spread to multiple countries. I believe that it is naive to think that we can keep it from freely crossing our borders.

We have now had our first case of something called community spread. This simply means that someone managed to catch it without a traceable exposure. Because of this, I fully support the experts who are shouting “be prepared”.The state of emergency is simply to strengthen our response.

This does not mean you have to go out and hoard toilet paper! (Although make sure you have enough) What it does mean is be ready just in case.

If it ends up that you need to stay home for several weeks, do you have everything you need? It is time to check on your earthquake/ emergency supplies. Unlike in an earthquake, as we make sure we are ready for a quarantine, there is no reason to be concerned about water or electricity.

Check on:

  • Medications
  • Diapers
  • Pet food
  • Food in general
  • Special activities for the kids

What are your remedies for illnesses and immune support? Add those to the list. If your kids have to stay home from school, do you have a plan in place?

Here in California we live in ‘earthquake country’. Knowing that we have to be prepared doesn’t mean we have to stop living. It just means we are staying pragmatic and aware. If need be, we can keep ourselves and our families safe.

I have made some conscious changes. As I have been riding Muni downtown more often these days, I make a point of using hand sanitizer as soon as I get off the escalator and follow that up with a good soap and water scrub as soon as I am near a sink. I make sure not to touch my face until I have done so.

The other day, my friend Marti and I were going for lunch. We noted that at one cafe, someone was preparing the food and not wearing gloves. We opted to eat someplace else. That is not something I would have paid attention to prior to this. And now you couldn't pay me to take a cruise!

Awareness...Not panic.

Friday, February 21, 2020

Adverse Childhood Experiences/ We need to pay attention

Adverse Childhood Experiences
One of the things I have enjoyed the most about doing my blog posts is the research and personal education involved. I have years of experience under my belt, and while there is a great deal that I know about a lot of things, I have no shame accepting that there is even more out there that I don’t know. I am eager to keep learning.

Last week I went to the 2020 UCSF Chancellor’s Health Policy Lecture. The speaker was the brilliant and inspirational Doctor Nadine Burke Harris. Dr. Burke Harris was a pediatrician in San Francisco’s Bayview-Hunters Point neighborhood. She is currently the very first surgeon general for the state of California.

The topic of the lecture was Adverse Childhood Experiences, known as ACEs. This is a subject that she is clearly passionate about. The American Academy of Pediatrics is now asserting that ACEs are the single greatest unaddressed public health threat facing our nation today. That is quite the statement!

This isn’t new groundbreaking information. In fact, the data has been there for over 30 years, which makes it even more frustrating that it was not on my radar. Why isn’t there more general awareness?

The more I learned, the more intrigued I became. The findings are clear. Adverse Childhood Experiences (ACEs) experienced during childhood can have lifelong health implications. It makes so much sense! 

Often western medicine focuses on treating symptoms. It is not surprising that out of 3 trillion dollars spent on healthcare only 5% of that money is spent on preventive medicine.

I will borrow a metaphor from Dr. Burke Harris. If people are drinking from a well and many of them are getting sick, it is all too common for many doctors to treat the diarrhea rather than checking to see if the water is contaminated.

Fortunately, there are doctors who make an effort to get to the root of problems. In 1985, Dr. Vincent Felitti was frustrated that patients in his San Diego obesity clinic, after initial success, were failing to keep the weight off. When he took a closer look, he was astonished to find that more than half of the clients who kept regaining their weight had some history of sexual abuse.
He realized that it couldn’t be a coincidence. Ultimately, he linked up with another doctor Robert Anda. Dr. Anda had been studying how depression and feelings of hopelessness affected coronary heart disease. They decided to collaborate on a much larger study and the findings were significant.

The ACEs study looked at the following risk factors:

  • Parents divorced or separated
  • Physical abuse
  • Physical neglect
  • Emotional abuse
  • Emotional neglect
  • Sexual abuse
  • Witnessed domestic violence
  • Substance abuse in household
  • Mental illness in household
  • Family member in prison

Since the original study, questions about other obvious stressors, such as loss of a parent, food scarcity, homelessness, disability, exposure to gun violence, and discrimination, have been added to the screening tools. However, the issues bullet-listed above were the ones that were tested and scored. They found that, as suspected, there was a link between childhood trauma and onset of chronic disease through the lifespan. What they weren’t expecting was how common of an issue this was.
While it may come as no surprise that poverty is associated with higher scores, it turns out that very few of us got a free pass. This initial large study was done through Kaiser and the participants were mostly college educated, middle to upper class:

  • 67% of people in the study had a score of at least 1 ACE
  • 17.6% had a score of 4 or more ACEs

This relates to so many of us. You may be one of the more fortunate with a low score, but unless you live a remarkably isolated life, someone you know is impacted.

There is a dose response relationship between ACE scores and health outcomes. This simply boils down to the higher the risk, the more an effect there is likely to be. A person with an ACE score of:

  • 3 or more is twice as likely to develop heart disease
  • 4 or more is three times as likely to suffer from depression
  • 4 or greater is 32 times more likely to have learning issue
  • 6 or greater has a 20 year lower life expectancy!

A high ACE score can be a predictor of high blood pressure, smoking, teen pregnancy, and suicide. The list goes on and on. This actually may be one of the biggest health discoveries we have ever seen! There seems to be a fairly strong relationship between cause and effect. 

The connection between these childhood stressful experiences and subsequent issues like depression, substance abuse, suicide and other social issues seemed fairly obvious. The reason for the connection to physical ailments such as cancer, heart disease, and immunity issues was a bit more baffling to me until I heard Dr. Burke Harris speak. Then the clouds lifted and it made total sense. DUH.

In her analogy, if you see a bear in the woods, you would have a full on “fight or flight” stress response. Your body is doing what it needs to escape. You also have an immune response to help you recover in case you are injured. This is just what your body needs to help you survive this emergency. But, if the bear comes home from the bar into your house every night, this frequent response is going to have serious implications. That frequent stress response is impacting the body and quite literally getting “under the skin”. 

I did a blog post several years ago about how your stress level can add up silently before it overflows:

Of course, not all stress is the same. Positive stress stems from adverse experiences that are short-lived. We learn how to cope and adapt. For a child, examples might be the first day at school, falling off of a bike, or even having to share a toy when they would rather not. For some infants, it can be something as simple as exposure to a stranger. This type of stress might cause an increase in heart rate and changes in hormone levels. With the support of a caring adult, children can learn how to manage and overcome positive stress. This type of stress is considered normal adaptive stress and coping with it is an important part of the developmental process. Kids learn to ‘go with the flow’. They learn to get back on the bike and learn how to ride. They learn to get along with others. Babies learn that some people other than mommy or daddy are safe.

Tolerable stress refers to more intense experiences that are hopefully short-lived. This could be an earthquake, death of a loved one, or family disruptions such as separation or divorce. The initial impact packs a wallop, and then eases somewhat.
Here is the important thing to note. If the child has support from a caring adult, this stress remains tolerable. Kids can learn how to adapt thereby building resilience.

Let me put this in a context that many can relate to. Think of your child as a bank account. Stress is a debit, nurturing is a deposit. The positive stress that I mentioned previously could be like using your credit card and paying it off in full every month. This actually gives you a good credit score. If you use the card for a much larger purchase, you may begin to have a negative balance if you don’t have enough to pay it off right away. This is tolerable if you are able to make regular payments. It becomes a real problem when you can’t keep up and are now accruing more and more interest. It is easy to slide deeper and deeper into debt.

If you are filling up the “account” with positive nurturing behaviors, hopefully your child can “afford” the occasional larger expenses because you have helped them have a robust savings account filled with positive past experiences that can be used to inform current and future expenses.

Without “funds in the account” constant stress is no longer tolerable and can become maladaptive and is referred to as toxic stress. This toxic stress can result in direct and measurable physical impact by altering healthy brain development and causing multi-system effects. It can lead to disruptions in the ways that the neurological, endocrine, and immune systems operate. This then can affect other systems throughout the body as well. MRIs show that actual changes are taking place in the brains of kids who experience early adversity.

Science is telling us that ACEs are risk factors that have real implications for our children’s health...the mind may forget but the body remembers. You might not even recognize that there is an issue. Some research revealed that many children who develop emotional and behavioral problems don’t begin showing symptoms until the 4th grade.

Bear with me as I bring in another analogy. Think about lead poisoning. Generations ago we didn’t realize that exposure to lead in our environment was a problem. In fact, most of our homes were covered in lead paint. Eventually, we learned that exposure to lead levels had dramatic implications. The higher the exposure the more of a problem. Some folks live in homes with flagrant peeling old paint and we knew we needed to take action. Others might be getting exposure from a sneakier source such as soil, a brightly colored painted toy, lead pipes, even the varnish on a bathtub. We wouldn’t know until we tested. Now, it is standard for every child to be screened for lead.

This post is simply an attempt to build awareness about an important issue. Every child should be screened for ACEs.

There are easy ways to do this (think audit) and more and more ways to make changes and make real differences for people (think deposit). Those will be addressed in a future post.

What is your score?????

I want to thank Dr. Michelle Stephens, PhD, PNP for her valuable input on this post!

If you are interested in what I have been up to lately aside from blogging and classes
check out

Friday, February 14, 2020

Personal Musings/The End of an Era

Personal musings

I am taking a break from writing about illness for a week.
In the years that I have been doing my weekly emails, some of the posts have been personal stories. Those are often the ones that have gotten the warmest responses. For you loyal readers this one's for you.

I am one of the lucky people who until this week still had my childhood home. With such a transient society I know how rare that is. Especially at my age. 

My family moved into our house when I was four years old. Since I met my husband when we were both teens, the house was also part of his life for almost 43 years. It was the hub, for my sisters, daughters,nieces, nephews, friends and neighbors.

Pittsburgh, Pennsylvania is a hilly city. One of my mother's important criteria for choosing a home was picking one on the flat side of the street. With the new house, there was only one step up onto the porch in order to get to the front door. Once residence was established, there was often a pause to sit on the front porch swing before going in.

Mom was in her thirties when my parents bought the house. Her insistence that they pick a house with an easy entry wasn’t for her. Although it would be a relief not to have to schlep her cello up a flight of stairs, she was thinking about her older relatives and friends who would visit. I don’t think she was planning for her own future, but having an easily accessible house ended up enabling both of my parents to live out their years there.

It was a magic house. It was infused with a welcoming, loving atmosphere. It was also filled with stuff. We called it the house of requirements. If there was something you needed for an art project or a costume, it was somewhere in the house. One of the many medicine cabinets likely had just the medication you needed.

In the house were any number of games and books on every subject. A  romance with the classic muscled Fabio on the cover (mom called these her key to relaxation) would share the shelf with physics textbooks and poetry books from the 1800s. There were enough children’s books and toys to keep the generations of grandchildren and great grandchildren captivated.
There were pets, of course! This included many cats, fish, gerbils and birds.

There were musical instruments of all kinds. Better yet, people actually played them! There was a trove of old photos and hand written letters. Thousands. 

My mom passed away 3 years ago and it has taken that long to carefully clear out the house. My older sister was the local one and she insisted on honoring every item by finding a home for it. It was a herculean effort. Nothing was carelessly discarded. Now, finally it is empty.

Interestingly, it turns out that even though it is has been cleared out, the echoes of joy and love remain. The imprint of the positive energy is just as strong. It is hard to let go of the house but it's time. It is the end of an era. Change is hard. We can’t stand in it’s way. We  can just do our best to handle it gracefully.

Here is a piece that I wrote about the house and one special piece of furniture.

The Diaper Dan Drawers
My grandmother Flora Isaacs lived on Darlington Road, just a few blocks away from the house where my own family lived. Our Pittsburgh roots go way back. Her father, Morris Meyers, moved there in 1860 and also lived for a time in the same triplex as my grandmother. For the record, their house was on the hilly side of the street. It was a long and steep set of steps getting up to the house.

When we would visit grandma, my mother’s childhood bedroom held a certain allure. The furniture was dark antique wood and included a large vanity with an enormous mirror. It is a lovely, but odd piece of furniture. It is too low to sit in front of it on a regular chair. One must sit on a very low stool in order to make use of the surface and mirror. There are two large drawers on either side. My sister Marjie named them the ‘Diaper Dan’ drawers. I have absolutely no idea where that moniker came from, but the Diaper Dan Drawers they were.
Grandma would store all sorts of odd and ends in those drawers. We were allowed to take whatever we wanted. Good move wise grandmother; what a simple way to rid yourself of junk!

These drawers became our treasure chest. When we would get to grandma's, we would say our hellos and then scamper upstairs to see if there was anything of interest that had appeared in the drawers. One item that comes to mind was a porcelain bowl in the shape of a set of hands. I thought they were beautiful. 

We carefully wrapped them and bestowed them as a gift to our mother for her birthday. She couldn’t contain her laughter. Of course it had been a gift to her from a long ago boyfriend. Who knows where it had been all those years, until grandma was cleaning up and tucked in in the drawer. This time my mom kept it. It stayed on the dresser in her bedroom and was used as a container for the odd safety pin or general  knickknacks.
(When we were dividing the family treasures after mom died, I kept the hands.)

When my grandmother was in her 90’s she moved in with my parents for her final years. Some of her furniture, including the Diaper Dan drawers came with her. 

Alas, time passed, Grandma was gone, my parents were gone, the difficult decision was made to sell the house. We embarked on the epic task of emptying it of all the stuff and furniture. The sisters and grandchildren routinely gathered to clear and sort.
“ Do you want this? No! Do you?” “What on earth is that?”
My daughter Alana was clearly the easy mark. She had a hard time refusing things that were connected to the house. Because of that there are boxes with her name on it, stored in our garage. These are filled with mystery items for when the time comes that she has room for them. Lauren was quicker to say "no thanks", but my dad's barometer is now on the wall of her house and she has her own collection of mystery cartons in her garage. The letters and photos were taken in boxes to my sisters house. The local historical society took its share of things as well.

One by one things were claimed. We had a “give it away day” and family, friends and neighbors came and chose mementos.
The process continued until there was almost nothing left. Just  like kids being picked to be on the sports teams at the playground, there was something sad about being the last one selected. No one chose  the Diaper Dan drawers.

Then, the magic continued. It was as if the house got to choose it’s new family.. There was no need to have it listed with an agent. Friends knew friends. A lovely family had been searching for the right home for two years. The new mom nodded in approval that there are no steps; her older relatives will have no trouble visiting. The new children scampered around the house claiming which rooms would be theirs.
When asked, the family said, "Sure! The Diaper Dan drawers, as well as some of the books, are welcome to stay." They gathered and listened as I told them the story of the drawers.

There are treasures waiting in the drawers for them when they move in later this month! I wish the new owners as much love and happiness in the house as we had. 

Friday, February 7, 2020

The Novel Coronavirus/ Do you need to be wearing a mask?

The Novel Coronavirus

I worked a shift at Noe Valley Peds this week and it was lovely being there. While I was there an email alert and update from the Health Department was sent about the Novel Coronavirus. Of course it is all over the news. Not surprisingly people want to know how worried they need to be and also if they need to be wearing masks.

Over the many years that I have worked as an advice nurse I have seen dozens of scary viruses make headlines. Thankfully most of them have quieted down soon after stirring us all into a tizzy.

As a quick summary, coronaviruses are not new. They are a large and diverse group of viruses, many of which are animal viruses. 

Coronaviruses are zoonotic. That’s a great cocktail party word. It means that some strains can be passed between animals and humans. Prior to this new one that was first recognized in 2019, only six coronaviruses were known to affect humans. Four of these predominantly caused only mild to moderate upper respiratory symptoms. In fact they are thought to be responsible for 10-30% of all colds. Two of the six have been strains that have been responsible for more severe illnesses. The one that leaps to my mind is SARS (Severe Acute Respiratory Syndrome.)

I remember when that was starting to circulate. My girls were teens at the time. They were taking a flight and I tried to convince them that they should wear a mask on the plane. They refused. I remember the conversation.

“Masks are so dorky”

My response of “better dorky than dead” did not change any minds. They kept the masks in the carry on. Happily for all involved they survived.

The other more severe strain is called MERS (Middle East Respiratory Syndrome). That one made its first appearance in 2012. It is known for its ability to pass from camels to people. If you are not riding camels in the Arabian peninsula, you likely don’t need to worry too much about catching it.

The strain that is going around now is called a Novel Coronavirus because it is new and until now was not seen in humans. It was first identified amid an outbreak of respiratory illness cases in Wuhan city, Hubei province, China. It was declared a global emergency by the World Health Organization (WHO) on January 30, 2020.
The incubation period seems to be between 2 days and 2 weeks.

Common signs of infection include fever, respiratory symptoms, cough, shortness of breath and breathing difficulties. Fevers occur in 98% of the cases. Many of these same symptoms are what you can expect from the flu. Most cases are not serious and people recover without intervention. In the worst cases, infection can cause pneumonia, severe acute respiratory syndrome, kidney failure and even death. Older adults with prior health concerns are the ones being hit the hardest. Early estimates are that the mortality rate for this is between 2-3%. This might decrease as more studies are done. Because some people might actually not show any symptoms at all getting an accurate count is a challenge. One of the big dangers of course is that because it is new, this is not something most people have immunity to, making it terribly contagious.

My heart goes out to all the folks in China who are dealing with this, but for my local patients at this time, I would say that there is no need for panic. The health department is doing an amazing job trying to stop the spread here.

This is an emerging, rapidly evolving situation and CDC will continue to provide updated information as it becomes available.

Hopefully in several weeks we will be able to see that we were able to contain it. As things stand right now, we need to be more concerned with the flu which is actively circulating.

Standard recommendations to prevent any infection from spreading include regular hand washing, covering mouth and nose when coughing and sneezing. Sneezing into your elbow is a good tip and one worth modeling and teaching to your kids. Avoid touching hands to faces, especially the mouth, nose and eyes.

If you can, avoid close contact with anyone showing symptoms of respiratory illness such as coughing and sneezing. This is especially important if you have a young infant or someone in the family with a compromised immune system.

If you are getting sick and you have recently traveled to China or have been exposed to anyone who has been in the impacted areas, it is essential that you let your doctors office know that before simply showing up there.

Make sure you thoroughly cook all animal products and wash your hands especially well after contact with any animals (especially camels.)

You will note that wearing a mask is not on the list.

If you have been one of my readers for a while then you already have a box of N95 masks in your house, right?? I like all of us to be prepared.

But, while it is nice to have them, masks are more useful if you are sick and wearing one to keep from spreading than they are at protecting you from catching something.The N95 masks, if they are fit properly with a nice tight seal, can offer some protection, but they aren’t hazmat suits. 
Also, good luck getting one that fits your young child. You then need even better luck having them keep them on! In general many studies feel that masks offer a false sense of security.

What you should focus on is avoiding crowds and encouraging good hand washing. Here is a do it yourself science project to help your kids see the importance of hand-washing.

I read about a brilliant “hands on” experiment that you can do at home with your kids. Take several pieces of bread. Store them in some baggies, and monitor the pieces to see what gross stuff grows on them.

One piece should be untouched by hands...use clean tongs when you place it in the baggy

One piece should be touched by hands that were cleaned with soap and water

One piece can see how well the just hand sanitizer worked.

One piece should be rubbed all over your phone or computer keyboard.