Ask Dr. Drew - From The Frontlines Of COVID-19 w/ Pulmonologist Dr. Joseph Khabbaza – Ask Dr. Drew – Episode 55

Episode Date: November 19, 2021

Dr. Joseph Khabbaza is a critical care specialist and pulmonologist at The Cleveland Clinic. He's been on the frontlines of the COVID-19 pandemic and is here to talk about vaccinations and what he's experienced while treating patients with the virus. Ask Dr. Drew is produced by Kaleb Nation ( https://kalebnation.com) and Susan Pinsky (https://twitter.com/FirstLadyOfLove). SPONSORS • BLUE MICS – After more than 30 years in broadcasting, Dr. Drew’s iconic voice has reached pristine clarity through Blue Microphones. But you don’t need a fancy studio to sound great with Blue’s lineup: ranging from high-quality USB mics like the Yeti, to studio-grade XLR mics like Dr. Drew’s Blueberry. Find your best sound at https://drdrew.com/blue  • HYDRALYTE – “In my opinion, the best oral rehydration product on the market.” Dr. Drew recommends Hydralyte’s easy-to-use packets of fast-absorbing electrolytes. Learn more about Hydralyte and use DRDREW25 at checkout for a special discount at https://drdrew.com/hydralyte  • ELGATO – Every week, Dr. Drew broadcasts live shows from his home studio under soft, clean lighting from Elgato’s Key Lights. From the control room, the producers manage Dr. Drew’s streams with a Stream Deck XL, and ingest HD video with a Camlink 4K. Add a professional touch to your streams or Zoom calls with Elgato. See how Elgato’s lights transformed Dr. Drew’s set: https://drdrew.com/sponsors/elgato/  THE SHOW: For over 30 years, Dr. Drew Pinsky has taken calls from all corners of the globe, answering thousands of questions from teens and young adults. To millions, he is a beacon of truth, integrity, fairness, and common sense. Now, after decades of hosting Loveline and multiple hit TV shows – including Celebrity Rehab, Teen Mom OG, Lifechangers, and more – Dr. Drew is opening his phone lines to the world by streaming LIVE from his home studio in California. On Ask Dr. Drew, no question is too extreme or embarrassing because the Dr. has heard it all. Don’t hold in your deepest, darkest questions any longer. Ask Dr. Drew and get real answers today. This show is not a substitute for medical advice, diagnosis, or treatment. All information exchanged during participation in this program, including interactions with DrDrew.com and any affiliated websites, are intended for educational and/or entertainment purposes only. Learn more about your ad choices. Visit megaphone.fm/adchoices

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contact Connex Ontario at 1-866-531-2600 to speak to an advisor free of charge. BetMGM operates pursuant to an operating agreement with iGaming Ontario. Here we go, everyone. Thank you for joining us. Just a few minutes, we'll be welcoming our guest. This is Dr. Joseph Tabasa. He's a pulmonologist and critical care specialist at Cleveland Clinic. Any housekeeping, Susan, we need to get into? We should get right to our guest is Dr. Joseph Tabasa. He's a pulmonologist and critical care specialist at Cleveland Clinic. Any housekeeping, Susan, we need to get into? We should get right to our guest?

Well, this will be a show about the I-word. That's right. That was the housekeeping. So if we start mentioning the I-word, we will have to switch off YouTube and over to Rumble because YouTube will put us in YouTube jail. Or we'll stay on Facebook and Twitter and also on Twitch. Right. YouTube would go over to Rumble. If we feel uncomfortable with the material we're talking about, two physicians talking about clinical science,

that God knows that's something that YouTube would not want to hear. Yeah. And I don't even know. I have no idea. I have no preconceived ideas about what we would be talking about. Pro, con, you know, just talking to the data. I don't know, but it gets uncomfortable to have any conversation about words that trigger

the, I guess the AI using the F word on the radio. We can't do it. Unfortunately, using the F word on the radio has a due process associated with it. There's the, the FCC will get involved and fine you and whatever,

and you can appeal it. Here, you're just out. You're just done. So let's bring our guest in. Our laws as it pertained to substances are draconian and bizarre. The psychopath started this. He was an alcoholic

because of social media and pornography, PTSD, love addiction, fentanyl and heroin. Ridiculous. I'm a doctor for. Where the hell you think I learned that? I'm just saying, you go to treatment before you kill people.

I am a clinician. I observe things about these chemicals. Let's just deal with what's real. And we used to get these calls on Loveline all the time. Educate adolescents and to prevent and to treat. You have trouble, you can't stop and you want help stopping, I can help. I got a lot to say.

I got a lot more to say. I want to give a shout out to our good friends at Blue Mics. If you've heard my voice on this show anytime over the past year, including right now, you've been listening to Blue Microphones. And let me tell you, after more than 30 years in broadcasting, including right now, you've been listening to blue microphones. And let me tell you, after more than 30 years in broadcasting, I don't think I've ever sounded better. But you don't need to be a pro or have a fancy studio to benefit from a quality mic. You may not realize it, but if you've been working from home or using Zoom to chat with friends, you probably spent a lot of time in front of a microphone. So why not sound your best? Whether you're doing video conferencing, podcasting,

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Or as always, you can find it by visiting hydrolite.com slash drdrew. Again, that is h-y-d-r-a-l-y-t-e dot com slash d-r-d-r-e-w. Be sure to use the code drdrew25 for a special discount. Dr. Cabaza works at Cleveland Clinic where he is a ICU specialist and pulmonologist. Dr. Kabaza, welcome to the program. Uh-oh, I got no sound. One second. I gather you can hear me, but I cannot hear you.

There you go. Here, try it again. There we go, we got you. Thanks for having me, Dr. Drew. I'll try to be careful with all the... there you go here try it again there we go we got yeah thank you for that let's um let's start with things that uh guys like you know guys and gals like you and i sometimes overlook which is understanding your scope of practice i think most people don't even know what a wise own the ic do, what a pulmonologist is, what an internist is. They have really no idea. So let's talk about what the training is and what it is you do. Yeah. So, you know, after college, I did the four years of medical school, like all physicians go through. And then

I did a three-year residency in internal medicine, which is really the study of general medicine in adults, really the major points of all organ systems, every part of an adult really. And then after those three years of training, I did a combined fellowship, which we further sub-specialized within internal medicine in pulmonary medicine and critical care. Pulmonary is generally the management of all sorts of lung diseases, so both as an inpatient and outpatient. And critical care is really just being an intensive care unit doctor, really taking care of some of the sickest patients who have multi-organ failure and really taking care of them on ventilators. And that's kind of how really the field of pulmonary critical care kind of came together, really going back to the polio days.

I mean, it was not really big specialty intensive care units, but when lots of people would kind of lose their ability to breathe with weakness in the breathing muscles of the iron lungs, a lot of pulmonologists were the ones managing these very sick patients. And gradually after that is kind of where that field of critical care evolved. So for a long time, it was pulmonary and critical care together. And I think with the recent big demand, especially the last decade or so on intensivist critical care doctors, there's now just, you can just specialize just in critical care now as well, and just jump straight to taking care of critically ill patients.

What is so fascinating, having been a part of the historical evolution of all this. So when I was in, well, when I was first even in practice as a, as a general internist, I did lots of critical care. I mean, that's probably half my day. I did tons of critical care. And when I was in training, did lots of critical care. And it was mostly the internist and the cardiologist that were hanging out in the ICUs at that time. If you remember, there was always the CCU, and then that kind of became the model for the ICU. The

coronary care unit became sort of morphed into the ICU. And it's funny, it's interesting to me. And I remember when a pulmonologist was put as the director of the intensive care unit, he was great. And his presence as the director still didn't replace the fact that there were lots of cardiologists and internists running around in the ICU until really it was when the whole hospitalist thing came about, when internists either became outpatient or inpatient specialized. And the hospitalists, I imagine, would swing by the ICU, but they were not managing the ICU patients. Yeah, things have evolved even depending on which type of hospital you're in, in a community setting or more of a rural setting.

Some of those more rural settings, hospitalists still manage a lot of patients in the ICU and do some procedures while the intensivist has kind of gone as consults it's really evolving quite a bit where kind of the intensivist is almost turning into the icu hospitalist in a way where so many are just doing icu or just doing pulmonary but but isn't it it's it's it's weird now i was putting swans in a lines ventilating people what managed the ventilator. And I didn't realize that that had happened, that that evolution had happened until I was applying to volunteer in New York City. When they were in trouble, I raised my hand and said, I'll come in. And they started interviewing me for what my skillset was. And I went, yeah, yeah, I do that. Yeah, yeah. I'm telling lots

of that. Yeah, yeah. They're like, what? You do invasive lines and ventilator management. I was like, yeah, for years, for a decade. And that's all gone. That doesn't really exist anymore. And even a lot of internal medicine. I guess, you know. Yeah, and internal medicine residencies. I mean, a lot of them, a lot of the interns are doing lots of central lines and, you know, various different bedside procedures and in some cases intubations. And now it's kind of evolving more to, that's even being pushed back in residency to where it's kind of fellowship now is where those procedures are being done.

Everything's just... The fact that you say, it's so weird to me because I had my experience and my experience was my experience, but when you say, oh yeah, even sometimes they do intubations, I would do three intubations a night when I was on call routinely. It was just routinely. We just did them all night long. And weird. But I think, I guess it's great for the patients.

I worry that the trainees lose a little something. I don't know. I guess it just means more training, really, which is never bad for patients. But it kind of pushes back, though, the training, because even if it's a fellow who's learning the procedures, they're still new to the procedures. So everyone who's learning is still new. And I think getting that experience as an intern or just in your residency is so valuable. And you really learn ownership of the patients really early in your career. And I feel like we've lost a lot of that. It seems like in medicine.

Well, okay. Yeah. So you just leaped into something that I obsess about a little bit, which is the nature of our training sort of young physicians. And because we were, look at a MASH unit all the time, we were in the fire all the time. We were trained that we were doing something incredibly important and more important than our fatigue or our illness or our depression or anything. Nothing was more important than the care of the patient. And that came through loud and clear early, early on. And I'm not sure that's going on anymore, is it? Yeah. So at least when I trained, I did residency, you know, 13 years ago

is when I started residency. And we were still, it was a lot easier than when you did from an hour standpoint. We still have to do 30 hour shifts, you know, every fourth day for a lot of months. And so I thought it was kind of perfect. I mean, I think, yeah, you know, every fourth day for a lot of months. And, and so I thought it was kind of perfect. I mean, I think you still got to experience that, that grind where when you're in the real world, nothing is as bad as residency. Still, when I trained, when you admit a patient, you know, at 9am and you still have 27 hours to go, you know, you learn how to tuck in patients so well, you learn how to talk to their families and really develop that rapport and to make sure that every decision you made for those next few hours

helps so that the patient's tucked in for the rest of the night so you both benefit patients better cared for and you get less calls at night no that's right and you know that's right no and you also learn that spidey sense, like, hey, or the nurse asked me some strange questions, or I haven't heard anything a little while. You have a sort of a clock that goes off in your head, like, I better check in on that guy. And that's invaluable. Yeah, and I think the shift work now is most of the residency trainings now seem like it's more shift work. It's just day shift and night shift, and you kind of lose that, that ownership and someone in for the night. If there's a loose sandal, the night team will take care of it. I think that's

taken away a lot from training. I think we need to go more towards. I agree. But here we are. If only we had people who would listen to us. So, so, so let's talk about a little COVID-19. So what has been your sort of, shall we say, your narrative, your arc in this pandemic? How has it affect us in this country. You know, I think, you know, we've seen stuff before with SARS and Ebola things that looks like, you know, they seem scary, but they always just stay over there. You know, it never kind of makes it big here. And I did not think COVID was going to be a big deal here. I couldn't even see it sniffing the flu, really. I still have friends who kind of tease me for, you know, non-medical friends where I tried reassuring them, hey, guys, this isn't going to be that big a deal. Don't worry about it. But it wasn't until kind of, you know, in March, I was kind of on our ICU.

That first week, we turned into a COVID ICU in late March. And it was really eerie. I mean, seeing an empty hospital and kind of just fear in everyone's eyes. And I started feeling scared. It was just a really weird, eerie feeling in the hospital. Let's start with that. Cause I remember, I remember that if I, the only way I can sort of the feeling I had, the, the, the way I characterize the memory is it felt like nuclear winter, like everything was quiet and silent and cold, but let's say, let's just address that first sort of couple months. Was that appropriate? Should we have been that panic driven?

Should we have been so totally overtaken by the panic and anxiety around this thing? I mean, it was just such an unknown. We've just never been in a situation like this that I don't even know what the right move know move is you know i mean i think right right so we didn't know i like that yeah yeah so we were waiting to wait and see and maybe maybe it's worse than we think but then it became clear kind of what it was right so so now you're getting experience with it you're learning about the cytokine storm we're coming up with what were some of your favorite first treatment with the cytokine storm. We're coming up with, what were some of your favorite first treatment with the cytokine activation? Well, I mean, we didn't really have much treatment. It was March, April, May.

We didn't quite know really, I think, what we were doing. I mean, I think everybody got hydroxychloroquine initially those first couple of months. I mean, it almost felt uneasy. I mean, there wasn't really much that supported, but everybody was part of the infection disease treatment protocols. I mean, there wasn't really much that supported, but we, you know, everybody that was part of the infection disease treatment protocols, and there's really not much else that was done. It was mostly kind of supportive care. We didn't know from a ventilator standpoint, I mean, should we be using BiPAP and traditionally like we did, or did that aerosolize a lot

more droplets and risk staff a lot more? So we didn't always have that bridge, that BiPAP stretch where when people are in high flow oxygen before the ventilator, sometimes we try BiPAP, but we did not really do that. I think as quickly we maybe intubated versus use that BiPAP step. I think we started treating it a little bit differently than the usual severe respiratory failures we've really taken care of forever, whether it's influenza or pneumonia or whatever cause of ARDS that may occur. And it just seemed like this was a different looking pneumonia on CT scan, a different flavor of respiratory failure where you see very sick people at high amounts of oxygen who looked pretty good. If you didn't know how much oxygen they were on, they're sitting at rest, they look really comfortable. And I think that caused a lot of confusion

where is this a different kind of respiratory failure? And it was just, it was still kind of scary. I mean, those first couple of weeks, I mean, it felt very scary. I still remember the first COVID patient I intubated and the number of layers of protection I put on myself for fear that intubating would aerosolize you know quite a bit um so but then that kind of evolved you did you do it did you do a lot of people did when you came home stayed in

the garage for weeks that kind of thing yeah i i didn't i never went that far you know because i think i was pretty confident also i mean from a transmission standpoint i just did not really feel unless my clothes was soiled with live virus and somebody just coughed and drooled and spit all over me and then i right you know even then we didn't know what the we we weren't sure that it was fomite transmitted i mean who knew we didn't know that yeah and i think we thought it was more by you know contact especially i mean the big emphasis on hand washing and and you know not touching your eyes nose or mouth which are very important in general but but i didn't go that far now i still when i got home i changed you know right

yeah i went in i changed right away but you know i know some friends who you know undressed in the garage and then went right to the shower um and you know you'll never regret being extra cautious you know especially when we not quite sure what's going on but you know that thought kind of sinks in you know you know am i potentially hurting my family i mean that does uh come in but that first one things went from fear to a little bit of adrenaline once we kind of got a feel of things of like wow i'm really doing something important here you know i'm helping very sick people in a very historic part of time um and so you kind of got a little bit of adrenaline and felt good about what we were doing.

And then I think the deaths just started really raining in, kind of that May and June. And it just felt like it almost felt like it was hard to keep anyone alive. And, you know, we're used to death a lot in the ICU. I'm very comfortable around the end of life. Let me stop you. I'm going to stop you again, which is that's actually kind of the confusing, one of the confusing parts of what people are reporting who are ICU nurses or pulmonologists, which is when someone rolls into the ICU, their probability of coming out alive is low. Anybody, any illness. And you as a pulmonologist, I certainly as an internist,

I knew who was going to come in and come out and I knew who wasn't likely to. I mean, it's pretty obvious when you roll them in. All day long, that's all we do in an ICU. Why did this have such a disproportionate, cause so much disproportionate distress? I think what was hard about this is that it behaved so differently and very unpredictably. You know, I used to feel confident that I could tell when somebody was turning the corner in a critical care setting up there in the ICU right or whatever reason I felt pretty good about pointing all right the corners been turned to tell them and their family you know I think what we're moving forward here I

know exactly you're talking about yeah yeah I've never been more wrong with these patients where i feel like they're doing uh turning the corner you know a couple a day or two doing better and then quickly shoot backwards and it's been unpredictable and there are people you think that there's no way they're going to survive this and some will and others you know even even as recently as a couple weeks ago i mean a patient i thought would you, just be a couple days on the ventilator and come off. And he spent five or six weeks on the ventilator and then died in the ICU. And it's just, it's, and I don't know why, I don't think any of us really understand why some people, why it behaves like it does in certain people.

And it's just been so hard to predict. And what's also unique, like in the flu or other kinds of respiratory failure, you get sick very quickly. You know know you feel poorly a day or two you're on the ventilator um and with covid it can take a week or two before they gradually get sick enough to end up needing ventilatory support or end up in the icu at least and that's been such a weird process as well and it's made it kind of eerie also these patients are wide awake as they're slowly worsening over days before ending up on the mentally and and that presumably is the cytokine syndrome cytokine activation whatever we'll call it cytokine storm were you guys fooling around with any of the the uh immune modulatory medication early on or even now yeah so I think yeah early on we did I mean everyone kind of got hydroxychloroquine.

That was kind of out of studies. And then big studies came out, strong studies that suggested it didn't really work. And then we stopped using that after a couple months. But everybody got that in the beginning. Some of the immune modulators, especially tocilizumab and some of the ones that kind of stopped various cytokines in that chain were studied, and some antivirals were studied. And really what's come to the surface over these last, really these past few months, really for much of this year, I mean, what we've found, the dexamethasone seems to be quite helpful at really kind of blunting some of that immune response and kind of the cytokines. And then by adding one of those secondary agents that stops a cytokine down more specifically.

So tocilizumab is one of them, which just blocks that IL-6 receptor. It seems to help a little bit when added to dexamethasone in people who have high inflammatory markers. But most recently, about maybe a month and a half ago or so, baricitinib, which is a JAK inhibitor, it blocks multiple cytokines down in that pathway. When that's been added to dexamethasone, that has really seemed to do nicely at really preventing or minimizing progression to severe disease, shortening time on the ventilator, and the mortality benefit as well. So those are really the main ones that we're using, you know,

when you look at kind of over time how things have evolved. It's interesting. And personally, Decadron helped me a lot. I stayed out of the hospital because I got on Decadron early, got monoclonal antibodies after a few days, and that was, you know, sick as hell, but no hospital. And really no desaturation, no significant desaturation. Yeah.

Yeah, the monoclonal antibodies certainly seem to kind of, especially in high-risk people, really, you know, seem to blunt things a little bit and minimize at least some people from progressing to severe illness. But really the dexamethasone, it seems when we started, when that was found to be helpful and we started using it more, that seemed to kind of really cap off some people's severity of respiratory. I feel like it's not perfect. None of it, unfortunately, has been a silver bullet. No, no. Although I'm, I'm very hopeful

for this new antiviral, the, the, I'm blocking the name of her, Molnupiravir. Yeah. But it's funny. I, I, now I guess we can say out loud, we were using hydroxychloroquine at the beginning. Doctors were using it because it had no adverse effect and there was some bench work that suggested it might be helpful. So we reached for it because there was no reason not to in case it did help while we figured out the science. And let's be clear, I was doing my MKSAP. Do you get pulmonologists do MKSAPs too? The board reviews? Yeah.

Yeah. So I was doing my MKSAP right in the middle of the pandemic thing. And the rheumatology questions in there had, should you keep this pregnant woman on hydroxychloroquine? She had mild lupus or something. And the answer was, yes, it's the only medication I'm aware of that categorically women should, it's so safe and so inert, they should stay on it during pregnancy. Yeah, I have a lot of patients. I do a lot of sarcoidosis and interstitial lung disease that are affiliated with some autoimmune conditions

like rheumatoid arthritis or lupus. And we have many people on hydroxychloroquine, you know, for years, long-term. It requires some monitoring for the eyes, but overall it's safe and tolerated certainly long-term. I think, though, in critical care medicine. Go ahead. I'm sorry. In critical care medicine, though, we've kind of, you know,

with time and just as we study so much in critical care over the last, you know, decade plus or so, you know, a less is more approach seems to consistently benefit patients, at least in the ICU. If you're so sick, it may not take much to kind of tip you over into a poor direction, which is kind of shown in other parts of critical care. But I think overall hydroxychloroquine, I think on the surface to an outpatient immune conditions, I mean, very safe, we have many patients on it long-term. But yeah, but that was kind of the only thing we really used without having- It was a slop shot. Studies. Yeah. Yeah. It was a slop shot. And I accidentally used steroids, not accidentally,

I thought I was treating something else. I had a patient with frequent exacerbations of emphysema and pneumonias and things, and she responds to antibiotic and steroids. She got sick, seemed like her usual syndrome. I put her on steroids and her usual antibiotics, and she was positive. And she did very, very well. And she shouldn't have. She was 75 years old. She was with emphysema. And just having the steroids started right away, it caught my attention. This was back in the, during the nuclear winter we were talking about. And I thought, I think steroids make a difference. I think they do. Yeah. And timing of steroids has always been, you know, important also because too late, it might harm you. I mean, too early before you're really sick might reduce your initial kind of immune response. So, yeah, so timing

of it seems to be everything and the studies have kind of showed that as well. It's just kind of blunting some of that immune response. Now, again, a lot of still, even a lot of the highest risk patients early on have mild know and go on to live even without you know any intervention so there is a big luck component why do people who look exactly the same on paper take different courses it's unbelievable yeah it's very weird um back to uh let's have a bunch of little questions i want to get to uh oh, somebody, a couple of quick questions off the restream here. Any, have you seen anything you're using that predicts any medications that are more likely to be associated with long COVID? That I, we unfortunately don't know too much about long COVID, but I don't know about any

associations, you know, of being on prior medicine that might make you susceptible to it. I know there's just a ton more exponentially more questions than answers in long COVID. I do see some of them in my pulmonary office, you know, people who are short of breath long after mild COVID that didn't even require a hospital, but with completely normal pulmonary testing and imaging. So it is a big challenge. We're slowly learning more, you know, there's probably, you know, an immune component. We think autonomic dysfunction and perhaps some small fiber neuropathy might be a component. We just know so little about long COVID, but I certainly in my outpatient practice

see a lot of patients post-COVID just short of breath with completely normal pulmonary testing and no response to inhaled medications. It's a head scratcher for all specialists. And somebody else asked me, they had mild COVID and ended up with a pulmonary fibrosis. Are you seeing that? I understand it in severe COVID, but are you seeing that in mild COVID? Yeah, mild COVID, not often. it is rare. Now, you can have a pneumonia, a pneumonitis, a lung inflammation, and maybe not need much oxygen. And then you may heal. So I hate admitting this as a lung doctor, but we don't need most of our lungs. You know, in fact, people with severe, you know, fibrosis or emphysema will sometimes transplant one lung.

And they do very well. So you can damage and scar a part of your lung after any kind of pneumonia and not have any residual symptoms. And it's just incidentally found on follow-up imaging. But yeah, I think for mild outpatient disease to then have a clinically significant scarring where you're still symptomatic afterwards is very atypical. I don't see that in my office much. It's usually the severe people who are quite ill in the hospital who then have a post-infectious fibrosis noted on span and that and that happens in any ARDS patient so maybe we had a back up and talk about yeah maybe I talk about tell people what ARDS is and what was what's different about the COVID ARDS. Yeah. So ARDS is acute respiratory distress

syndrome. And so it's essentially a non-specific term that encompasses severe respiratory failure when you've got both lungs inflamed for whatever reason, and you're requiring lots of oxygen. Most of the time it's for people on ventilators, but there are people who can be on very high flows of oxygen who kind of meet the criteria and cut off. So historically, pneumonia, I mean, and that it can be due to heart failure. Heart failure itself can cause both lungs to look infected and fluid in the lungs. I always thought about it as something that caused alveolar filling with inflammatory fluid, typically inflammatory. So with heart failure, it could be any fluid exactly so you have little air sacs yeah your little air

sacs your lungs are like clusters of grapes those are your air sacs and in when the lining of the alveoli get inflamed they just like if you were to scrape your arm and fluid comes out same thing happens in the lung and it fills the alveoli. They can't be used then to exchange oxygen. And because they're inflamed, they get sick, they get stiff, and then they get scarring. Is that about right? Is that okay? Exactly.

And yeah, that's perfect. Uh, you know, the, the, just a lot of inflammatory gunk kind of fills up the spaces where air should be. It's usually due to infection or sepsis, but also like pancreatitis, trauma, you know, other things, you know, other things, you know, anything that rips inflammation through the body, everything gets filtered through the lungs. And then, but it ultimately makes the lungs very stiff. And this can be a big problem. When you have someone on a ventilator and you have stiff lungs,

you're blowing air in and they're just going to the few healthy alveoli, the few healthy air sacs. And then by concentrating that air on those few healthy air sacs. And then by concentrating that air on those few healthy air sacs, they're at risk of getting inflamed and damaged further. And that's where it was kind of in COVID at least, which we've been using a lot, which we've used a little bit in ARD as before, is kind of prone position ventilation, which really means flip people on their stomach for 16 hours a day or so. Most of our surface area of our lungs is on our back, and we're laying on our back, and fluid and inflammatory gunk fills up. Those are a lot of big areas that oxygen cannot be absorbed through. So by flipping patients on their stomach,

gravity opens up that part of the lungs and really helps more alveoli, spare them a little bit from just drowning in those inflammatory cells, and it allows the oxygenation to improve. And that's really something we've been using a lot, just because of the severity of respiratory failure that people have developed in COVID. And I want to swing back around to the cytokine thing again, but just so people understand that the art of ICU medicine is you're trying to, I want to make it specific what Dr. Cabaza was saying,

which is if you send too much oxygen in, you damage the lungs. So you have very few alveolar left. You need the oxygen going in there, but if you're too high a flow, damage the lungs. You have a stiff lung, too high a pressure,

damage the lungs. And it's this balancing act of creating, you know, enough positive pressure going in, the right amount of end expiratory pressure, the right amount of oxygen flow. It's sort of this weird balancing act you're doing. I used to think of it as sort of hour by hour. I would try to, maybe that's a mistake to adjust things so much, but I used to always try to adjust things all the time. I didn't like leaving things be. No, you're a hundred percent right. It shouldn't be a change in the ventilator on rounds at 8am and then don't touch it until tomorrow. You know, the compliance and stiffness of people's lungs changes, you know, pretty

regularly and too much tidal volume can hurt lungs, too little can hurt lungs, too much oxygen hurts lungs, too little oxygen hurts lungs, the rate we breathe that we set the ventilator at can, you know, affects quite a bit. And then that peak, that positive pressure, the amount of constant air that's blowing in and inflating the lungs, too much of that can be harmful and too little of that.

So there's a lot of tweaking and fine tuning that should occur multiple times a day to try to find that sweet spot. Because the lung stiffness is going to change as people heal or as they worsen. So things always need to be adjusted. I think hour to hour is, I mean, that's ideal. But definitely multiple times a day. I used to hang out in the ICU an awful lot. So back to the cytokine inhibitors. Do you first do inflammatory marking tests? Do you do CRPs?

Or what are you doing for inflammatory markers? Yeah, so pretty much CRPs and D-dimer are checked on the front end and kind of every, for the first couple of days, almost daily until there's kind of a trajectory. Then it kind of backs down a little bit. You know, interestingly, in other kinds of infections, we don't really check inflammatory markers. So I'm not sure how that... Historically, I predict you will be in the future.

I think this will change a little bit of ICU medicine. You'll say, I bet cytokine storm or cytokine activation is more around than we knew. Yeah, I agree. Because if we checked a lot of our severe sepsis patients or ARDS for other reasons and followed them, we might learn quite a bit more. Even just prior to COVID, we were getting a lot of our ARDS steroid data, some of which we're extrapolating now. We're kind of more immune suppression early on in ARDS is probably gonna be helping the lungs long-term. So yeah, CRP and D-dimer are checked early on.

For some reason, a lot of people's blood, it gets pretty thick in COVID, and we do see quite a bit of clots, which is really like nothing I've ever seen before from a thrombogenic process. And so that D-dimer can help us have a clue of what dose of anticoagulation should we use to try to prevent clots, or is our suspicion going to be high of active clots? So that helps with trying to keep the blood thin.

But the CRP helps play a role in when would we add some of the tocilizumab or some of the immunomodulators where that gets factored in by the infection disease doctors and kind of the protocols they use yeah the clotting story is yet to be told as far as I'm concerned it is something with the spike protein and the endothelium we're looking at the platelet part I know but there is something more going on here than that is a little it's weird and I think they have some sort of speech yeah we'll have some sort of specific something for that because the the anticoagulants don't work the way they should and that's telling you something that that says something uh and by the way i i i look at the the vaccines and the the platelet consumptions and the clotting and all

there's something about that spike protein. That's doing something that we're going to figure out eventually. So when you were, when we were in the throes of all this, you know, I, I was always very hopeful that the medical system, nobody in the world adjusts and flexes up and figures out ways of dealing

with really sick patients and coming up with novel therapeutics and vaccines than this country. Were you hope? I just knew we'd come up with stuff. I didn't know how long it would take. I figured it'd be pretty quick. It was about on the time course, I figured. Were you hopeful at the beginning? I think from a, I was hopeful really from a vaccine, I was always kind of optimistic and hopeful that we would eventually get to a point where we'll have a good vaccine that I can be a little less worried when I'm at work and kind of around my family and all that. I was very skeptical about would anything else help? You know, I think our strongest weapon, and it still is, is to not get infected or avoid the virus. Not practical unless you live in a bubble. And

that's not, I mean, that's not really realistic either. So the vaccines certainly have been very helpful at preventing getting infection. But I was not really optimistic that we would find really much helpful stuff in the way of immune modulators. I feel like once the train has left the tracks, it seems so hard to stop. That was kind of my early on thoughts. And especially that, you know, May and June, I'll tell you tell you the number of people they were dropping like flies and it was really hard emotionally where i just felt like i mean it's just how are we going to get through this and then you know that summer was therapeutic you know i'm not i'm a pretty uh relaxed easygoing guy that kind of brought me to critical care uh pretty resilient and but i was hit with emotions that I've never really experienced before.

June, I really hit a wall emotionally. I'm not a burnout guy. I, you know, I really very even keel and take care of myself. But that was a really weird feeling for me as somebody who doesn't really, you know, lose, lose sleep from ICU care. You know, I, it's just, I've never seen that volume of death. And I really hit a wall emotionally. And I just think, you know, I was always hopeful for a vaccine, but I wasn't very optimistic that any therapeutic would be helpful. But thankfully we have amazing scientists, you know, doing a job where, you know, we are finding more and more stuff and really the antiviral that you referenced earlier. I mean, that, I mean, on paper seems so promising and exciting. And I hope, I hope that pans out to be something as well. Me too. Me too. You never know until we can start

using it. Somebody asked, Regeneron says, is it possible it could interfere, no, apparently Generon in their package insert or something says, possibly could interfere with your body's own body's ability to fight off future interferon of SARS-CoV-2, infection of SARS-CoV-2. That was Shawnee J. That was early concerns. I don't think people have concerns about that anymore. I mean, there may be some. Go ahead. Yeah. Yeah, I actually spoke to an infection disease doctor just about this a couple days ago, where, you know, these are targeted monoclonal antibodies, so they're not like the diffuse antibodies that are produced in the face of an infection.

But the ones that are infused are really targeted, so they do not seem to affect your big picture immunity. Because my question was, well, if you get monoclonal antibodies, is your natural immunity weaker than if you did not get them? That's right. And I've been reassured in my colleagues, yeah, infectious diseases, that that would not be the case

just because it's a very targeted monoclonal antibody. It doesn't really affect- I can also tell you, as an N of one here, I'm an N of one. I had monoclonal antibodies day five, literally improved during the infusion. I now get regular comprehensive antibody profiles, including neutralizing

antibody measurements. And I'm way up, way, way, way up. I'm one of those people that have stayed up and just crazy up. So it clearly had no effect on anything. Yeah. And it's not felt to, yeah, based on kind of what the experts say, my colleagues, infectious disease area should not affect at all your natural immunity beyond that. And so I'm going to swing back one more time on the JAK inhibitors, the JAK inhibitor,

the baricitinib and the toxaluzumab. Is that only for ICU medicines now or do you think we're ever going to back that to try to keep people out of the ICU? Well, right now, I mean, a lot of non-ICU patients are getting it now. Also, if you qualify, you know, if you've got, because you can be, you can have respiratory failure and still be on the floor. You can be on six liters. I mean, you know, there are a whole, until you're on really high flow oxygen, really up to 15 liters, you can still be maintained on the floor. So you really just need to be in some kind of respiratory failure. And you qualify. If your institution has baricitinib, you know, that should be our kind of first thing to add on to dexamethasone. Luckily, what we're finding out is that because places that don't have

baricitinib or tocilizumab are, you know, higher dose dexamethasone is probably going to be very helpful in those patients who cannot get that extra immune modulator based on some of the other things. Higher dose meaning what? Higher dose, how much are you talking about? Yeah. So dexamethasone right now, everyone who's on oxygen gets six milligrams a day for 10 days. So it seems like for people with mild to moderate disease, if they don't have access to tocilizumab or baracinib, 12 milligrams a day is probably going to be much better. But if you also have severe ARDS and don't have access, 20 milligrams for five days and then 10 milligrams for five days after that in the severe ARDS people. That's from data in a

study that came out just before COVID in severe ARDS and non-COVID patients that seem to kind of really help the lungs short term and longer term by suppressing inflammation and then kind of a lot of that inflammatory drive early on. I'm really concerned about the lack of attention to the, to keeping people out of the hospital. I mean, that should have been public health priority one, and they just dropped the ball completely on educating people how to use telemedicine, what monoclonal antibodies

are. You just heard CNN reported yesterday, this is Keith Shaward is reminding me, that doctors, many doctors are unaware about what monoclonal antibodies are, how they're used, which is stunning to me. That is absolutely stunning. But why not? So the way you're describing the Decadron therapeutics, why not give everyone with progressive moderate disease 12 milligrams a day for three days, then drop them down to six? You mean outside the hospital or inpatient? Correct. Correct. Keep somebody out. Keep somebody out. Because you're saying 12 works pretty well. I'm thinking, boy, if somebody's progressing and they're outpatient, I really want to hit them.

Let's do it for three days and then drop them down to six for the rest. Yeah. So certainly at least my population is mostly, you know, I'm seeing the sick people in the hospital and respiratory failure. I don't think it's really been studied as, or I don't know of at least the studies from the outpatient side there. Because I know in a lot of steroid studies in general, and even some of the ones with COVID, there were some small groups that maybe had harm by having steroids. So there is, as you know, they're not benign, they're great medicines, and they can help a lot of stuff, but they've got to use at the right time, right doses. But I don't know specific studies from the outpatient side, but I do know that budesonide or inhaled

corticosteroids have been studied as outpatients, and they seem to blunt severity of illness probably by a similar mechanism of steroid targeted right into the lungs. And my population is a little bit skewed because most of my outpatients are on inhaled corticosteroids, as well as just being of asthma or in a subset of the COPD patients. So there certainly seems to be a role to some steroids early on. So my patients who have lung disease, who develop COVID as a patient, I put them on steroids, just more kind of more try to protect for their lung disease from inflaming or exacerbating. Which is what we do every time our lung patients get an infection.

That's what we do with other stuff too. I mean, it's just what we do. And there's a lot of chatter here about decadron versus methylprednisolone. I'm not sure there's anything magic about decadron. I mean, you can use methylprednisolone or prednisone, it seems to me. Yeah, definitely.

Yeah, you just kind of convert it to the equivalent dosing. I think just, you seems to me. Yeah, definitely. Yeah, you just kind of convert it to the equivalent dosing. I think just, you know, when the studies, you know, they use Decadron. So if we have it, we use it. But in settings, you know, if you don't have it, there's certainly, there's no reason they should really behave differently. So that is acceptable if you don't have access to Decadron. So when we get back, I'm going to take a little break.

When we get back, we'll talk about where we're at now with COVID, where we see things are going. I may take a few calls off Clubhouse. Susan, our restream has been adulterated, speaking of adulterations. Yeah, I just blocked the guy on Facebook. Good, well done. And there's just somebody putting these long diatribes on there that are being cut and pasted in.

You can do it once, but 12 times, no thanks. So again, Dr. Kabaza, is there a website or anything you want to refer people to during the break here? A website in terms of, for me, I have no website, but certainly Cleveland Clinic, we have a lot of resources up of just the most up-to-date practices in COVID and what we do and what you can expect at our hospital. Perfect. All right. We'll get back to more. Again, we're going to sort of bring us.

We've been talking about the background, our experience, what we're thinking about medically with all this. And interestingly, zero disagreement between us on how to deal with this or what we experienced, frankly, in the early stages of this thing. I feel exactly the way you did. And let's talk more about where we are now after the break. Here with my daughter, Paulina, to share an exciting new project. Over the years, we've talked to a ton of young people about what they really want to know about relationships. It's difficult to know who you are and what you want, especially as a teenager. And not everyone has access to an expert in their house like I did.

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It doesn't have to be awkward. On sale September 21st. So there's a lot of questions on the restream about what to do with long COVID. Go to covidlonghaulers.com. The reason I got on to the cytokine activation syndrome early on in the pandemic was I was communicating with lots of doctors across the country. I heard about it week one. I knew what people were describing. I'd never heard of such a thing. And so I immediately started looking into it. And it was when we came across Dr. Yeo and Dr. Bruce Patterson,

who were doing research on loranthamab, which is a CCL5 inhibitor, that I started sort of coming to an understanding of where the different, um, I just call them immune modulators might be of use. And I started hearing from other ICU specialists. Toxeluzumab was an early one that people started getting into. Steroids of course were early ones. So I felt very grateful to have sort of seen this thing, uh, evolve from, from the early days. And, uh, it's interesting to me that we're still sort of, we've sort of come back again, just kind of a similar place with it. And it's interesting to me that we're still sort of, we've sort of come back again to kind of a similar place with it. But let's not talk about that. Let's talk

about where we are now. How do you feel about where we are now in terms of, I guess I should frame this as moving from pandemic to endemic. Are we there? Are we still, you know, in Ohio, maybe you're, I don't know what Ohio is like. In California, it's still like we're imprisoned and people are very big on virtue signaling and wearing masks. riding bicycles, what percentage were wearing a helmet versus what percentage were wearing a mask outdoors, riding a bike, 60% mask, 20% helmet. So the insanity of what we're getting into in terms of our sort of primitive relationship with this virus and our panic porn that we're still steeped in concerns me a big deal, at least in this state. Where do you think we're at with this move from pandemic to endemic? Yeah, I'll tell you, all my guesses have pretty much been wrong to date. And I've just not really been smart enough to have really any accurate guess. I mean, I thought we were out of the woods in July. You know, I mean, our numbers, we had less than 200 cases a day. I

actually went to a comedy club. I mean, Louis C.K. was doing a small show at a club here. And I was, it was our first time I went out really to a setting like that since the pandemic started. And it was kind of weird, but I felt very comfortable. I'm vaccinated. There's so few cases in the state. Fast forward four or five weeks, I wouldn't go back to that same show. And that's how quickly things have changed. Delta kind of changed everything for me. I mean, I felt, you know, yeah, we're not at herd immunity, but we did good enough that, you know, our numbers are so low. And I think we're going to get into that endemic phase that we're all kind of longing for. But Delta really changed so much of what I saw and

how I was thinking. And now that Delta, at least in Ohio, our last kind of six weeks, eight weeks or so, been really scary, almost December, January-like scary in terms of volumes and not able to accept new patients to our ICU. I mean, we're the Cleveland Clinic. We take care of so many patients around the region who get flown in to us to give more advanced intensive care. Sometimes people are flown in from other states even, but we couldn't even take in patients from a hospital 20 minutes away because of how full our ICU was. I never imagined, looking back December, January, that we would be at that point again. So Delta humbled me even further, where it's just really a day at a time

approach, but I did not expect to ever be at capacity like we were the last couple months. And the stories, unfortunately, have just been sadder and sadder that we see in the ICU. So as we're now coming down on our Delta surge, I'm very hopeful, optimistic. Hopefully this was the worst of it and we'll never have any kind of surge like that again. But I don't know what variant might be around the corner. I don't know, but I'm happy when things are going down. And I think the worst of these last two months is behind us. Although our numbers are still quite high, but definitely coming down and less influx than we had. But I have been wrong about most of my thoughts and

convictions. Yeah. The only thing that keeps me up at night is the idea that we'll come up with some variant that gets around the vaccine or gets around immunity. Even a little bit, we'll have a massive, we would have a big problem then. And unless Molnupiravir really works or any of the other antivirals that are coming, in which case, that could change everything. It really could change everything, right? I mean, I also worry about the therapeutics. You know, vaccines don't cause, don't put the same kind of evolutionary pressures on a virus that the therapeutics do. Therapeutics, you and I know that pathogens of all types, because of the evolution pressure

of a single agent therapeutic, the pathogens find a way around it. Whether it's plasmid acquisition or viral genetic mutation, whatever it is, pathogens have an uncanny ability to figure out a way to get around our therapeutics, which is why I'm hoping they very quickly come up with a second one.

But I can't imagine a therapeutic causing a more virulent strain of the pathogen. Can you? I mean, with Delta kind of really shook me a bit. I mean, in terms of how contagious. Yeah. Yeah. And I've never, I think early on when I started ICU week in the COVID ICU, and I saw there's a 30-year-old in the ICU. Without looking, I can almost tell you their BMI is probably above 35, 40 in their diabetic. So young people in the ICU early on were almost always had either obesity, diabetes, some kind of risk factor that I could predict before opening their chart. That has all changed with Delta the last couple months. And I see young people my age and younger who look like me, who are putting on ventilators in the ICU.

And I innovated a young man who's exactly my age, three months ago or so, he had three daughters like myself. And I put him on the ventilator. And before vaccines vaccines I used to lay at night at home wondering are my daughter's one day gonna hear of me on a ventilator but but you know I wasn't seeing a lot of people who looked like me on ventilators prior but post you know these last couple months you know so I see that but because of vaccines I'm so confident that that will not be

me that I don't I don't lose sleep like I used to wondering if I'm next because of vaccines. But seeing young, relatively healthy parents get very sick and knowing young kids are losing parents has been a really hard part of the last couple of months that I did not really see coming just from our experiences in the first chunk of the pandemic. You know, the other thing we haven't talked about, and this isn't your organ system, but I imagine you've seen a fair bit of this, is the neurological effects of this illness. I kept saying, you know, I had a pretty bad case, and I just kept saying,

this is what a bad head injury feels like. This is, if I'd been in a car accident or got hit with a baseball bat, this is exactly what bad head injury feels like. This is if I'd been in a car accident or got hit with a baseball bat, this is exactly what I would be like. What are your thoughts on the neurological effects? Yeah, and certainly even for mild outpatients, the way they describe that headache, almost like a pitchfork through the skull, is really the description we get so often from the outpatient side.

And even the mild patients, they get this brain fog. It does something to the wiring of the brain where people are off, let alone, you know, the severe headaches. And even like for me, after my second vaccine, I had a really bad headache, you know, for that few days or so. I mean, there's, there's something about the immune response that's affecting our wiring, our central nervous system a bit, let alone, you know, the strokes and the vascular. Yeah. Yeah. I think, I tell you what I think, because a lot of the pathology that has been examined shows a lot of microvascular damage. And my bet is, so it's also why people get a little weird from the vaccine, once again it's something to do with the spike protein and the endothelium of the cerebral vasculature causing something some microvascular something and that's what it feels like a diffuse microvascular something you know and you and of

course your brain gets injured by that and it generally comes back but after a certain age probably not you know know, maybe not. Yeah. It seems to be a component of that, certainly for some patients and similarly to the lungs and some people you see kind of those micro thromboses. It's not everyone, but what's also unique, you know, you know, from your time in the ICU, ICU delirium is so common and so serious. And, you know, there's so many layers and things we could talk about on that standpoint, but for some reason, patients who get COVID and critical illness have a denser delirium compared to

patients with other infections that lead them to the ICU. And the delirium is just, it's been so odd, that part of it. Yeah. Well, do you, are you putting them on propofol? Are you paralyzing them? Is that, it seemed like you were doing it at the beginning. Are you backed off that? What's going on there? Well, I think our paralyzing is really mainly occurring in people with severe refractory hypoxemia before we end up proning them.

It's generally when we're paralyzing. So if they're hypoxic despite being on 100% oxygen and they're optimized on the vent, we paralyze them and wipe out the oxygen utilization from their muscles to help. And then we'll kind of flip them on their stomach for 16 hours and, you know, for the lung recruitment that we had talked about earlier. Still now, we've kind of gone back to our basic sedation approach. It's really no different than non-COVID patients now. And we just try to keep sedation at a minimum, you know, keep them on either, you know, propofol or Presidex or ketamine drips, and then just some as-needed fentanyl here and there. Less sedation across the board is better in critical care, but especially as little as you can get away with in these COVID patients who already are so prone

to a really bad delirium will help try to minimize time on a ventilator and hopefully minimize the number of people who need tracheostomies. Yeah, personally, you can give me the ropofol. I'll tell you, that'd be just fine. If I'm going to be on a vent, go ahead, put me to sleep. All right, let's take a couple calls. We, again, I'm watching you all on the restream. We're trying to get at those questions you guys very kindly put up there. We're also in Clubhouse. Hands are up. I'm going to get some callers there in a second and just a reminder that you will be out on Twitch, Twitter Facebook Facebook

Rumble and YouTube if you come up to the podium here so let's see if I can get Arizona wife it looks like if I'm getting that name correct AZ wife 480 let's see if he or she can come up. There we are. Janice, how are you?

Hi, I'm good. Thank you. I was just wondering if you guys could give any information on if these mRNA vaccines were in development for so long, because I've heard that they've been in development for decades, why would they announce as a possibility when talking about vaccine was first being discussed? My understanding, I'll let Dr. Cabaza answer this in a second, but my recollection is as soon as everyone turned towards the manufacturer, the buzz I heard was the mRNA vaccines are the only ones that can be scaled up fast enough. Let's get on that immediately because they could be scaled so much more quickly than everything else.

They just got on it and they were right. They were quick to bring to market. Dr. Kabavaza, what do you say? Yeah, I'm certainly not an expert in kind of the origins from vaccines, but my general, I mean, mRNA technology is something that has been studied really since the early 90s. And I think SARS, and I don't know if SARS was in 2003 or before, you know, whenever SARS was, I think that put kind of a scare in a lot of the public health scientists and in the lab, because if this thing spread, a lot of

people were going to die. So my understanding, and SARS, which is a cousin of COVID-19, is where they kind of started, well, we may need to try to figure out a vaccine here if this thing gets out of hand. And that's kind of where I think the original foundations and framework and basis came from. But SARS kind of outsmarted itself. It killed people so quickly that you couldn't really transmit it to a lot of people.

You got SARS and you were kind of dead quickly afterwards. So you couldn't really have this pandemic level outbreak. So my understanding was that that's when a lot of kind of COVID related, or at least that SARS kind of COVID-related, or at least that SARS, you know, cousin of COVID-19, that kind of foundation was starting to set. And then, you know, signs that they're always trying to work on things over the years and refine them and make them better. So I think if this pandemic happened before SARS, I imagine we'd be waiting a little bit longer for a vaccine, but I certainly am not a vaccine expert of kind of the origins, but that's kind of my general, well, yeah, I mean,

I'm with you. Yeah, I'm with you. I just sort of saw it happen and heard, I, you know, from communicating with peers and things that people in virology, my understanding, but we could get, Susan, maybe we get Dr. Nock back at some point to get more detail about that. But I had been hearing about mRNA technologies for cancer for quite some time. And what was holding it back is the same thing holds everything back, which is market forces and the expense of phase three trials. I mean, to get enough people with a particular diagnosis and to do the studies and do them properly and long enough cost hundreds of millions of dollars. And they just, it takes forever it just takes them forever and this this the good thing about the pandemic it's sped a lot of stuff up

that uh normally takes years to decades okay because i was just wondering why we hadn't heard about the technology until well much we we had no no we had for sure we had for sure um those physicians but janice are you in arizona right now yes i am we had we came back from phoenix yesterday and had the worst experience of our lives who's you want to bring in on this everybody on race rooms how are you today we we literally janice having ptsd we visited our, we visited friends in Sedona, lovely part of your gracious state. And the Arizonans were wonderful. But we had to do that drive down to Phoenix and then got in a plane. And we're literally.

Oh, Phoenix to Sedona. Yeah. And then Phoenix to Burbank. We were on approach to Burbank. And the captain comes on the speaker and goes, we're going back to Phoenix. And I was like, what? We were like, we were literally landing and they just took us back. And so we spent the day at what Sky Ranch. What's the name of the Sky Harbor? Sky Harbor. And so we got a big, a big Phoenix yesterday. So thank you for the, for the Arizonans and their,

their lovely demeanor. We appreciate it. Anytime. You're always welcome. Well, thank you. I got that sense. I got that sense about Arizonans. So thank you. Let's get another call going here. Josh, if he wants to come up. Dr. Drew. Yeah, there you are. I enjoyed this conversation and especially the neurological part at the end, even though it's not the specialty of the guest. And I was wondering, it's sort of like a brain fog I've heard. And I wanted to tie that into what your

specialty is, which is addiction. And especially the clarity that comes when you have a moment of change in your addiction and how that relates to the rest of the time. Well, I can't, moments of change. I don't really, I don't equate these two things in my heads, but they are worthy of sort of describing. So COVID is a global, a diffuse injury, like a head injury, right? It's a neurological injury. It may have exactly what's being injured and how we're all sort of trying to figure that out. But it is a widespread global injury to the central nervous system, which is more along the lines of post-concussive syndromes, dementias, things like that.

The moment of change in my experience is essentially people who are in a disease, psychiatric illness, that have prominent what's called anosognosia anosognosia joe is essentially you remember it from uh left-sided neglect syndromes from your you know back in the days when you're seeing middle right middle cerebral artery strokes you get a left-sided neglect, right? Anesthesiognosia. Yeah. Yeah.

Yeah. So anesthesiognosia, we have now sort of co-opted that to describe really profound denial that has really kind of a neurological basis to it, where people's frontal lobes aren't functioning right and they have anesthesiognosia about their schizophrenia, about their manias, about their addictions. And with addiction, people are able to break through that anoscognosia sometimes when they see themselves the way I describe it, literally through a new pair of glasses. Like they start to have some sort of relationship with another person and they're able to see that person's experience of themselves reflected back to them sufficiently that they gain an ability to push

through their denial and they kind of see themselves as they are and they'll have these moments of clarity and go, holy shit, I got to do something about this. Now, that's sort of how I commonly see those things. They're very, very different things, but very interesting things. If anybody else on Clubhouse wants to come to the podium again, you can raise your hand. I will bring you up. And if you do raise your hand, you will be out here on Rumble and YouTube and Twitter. Does Dr. Kibaza have time to stay? My schedule says about seven more minutes. Is that okay with you, Joseph? Yeah, of course. Yep. Yeah. So if there may not be any more questions, frankly, I'm just allowing people the chance to

raise their hand if they wish. And I'm also looking, let's talk a little bit. This is somewhat out of our field, which is vaccines and boosters. I talked to Monica Gandhi about natural immunity and vaccines. I think the reasons we're telling everybody to get vaccines if you have natural immunity is about 30% of people lose that natural immunity. And we don't have a standardized way to measure what that is, you know, when somebody's immunity is no longer effective. So we just say, get the vaccine. It's safe enough. Get it.

The question is, should people get boosters if they have natural immunity? That's kind of a more interesting question. I had a terrible reaction to my Johnson & Johnson vaccine. And fortunately, I'm doing the testing where I'm looking at my antibody profiles, but there is no standardized way to, you know, it's not like, you know, serum sodium should be 135 to 140, right? We don't have a standardized range like that for our immunity. What do you think about that? And I think that's really been the big challenge really throughout us, you know, and a lot of other diseases, you you know we follow antibodies and titers and they help us have an idea how good our immunity is we still don't know yet you know exactly like i said those standardized numbers

what level is good enough what level protects us does it vary between strains um now who knows but we don't know natural infection is very good uh you know especially in the short run I mean it's you know I think early on pre-delta you know I very rarely I maybe get three patients I may have seen who've been reinfected between my outpatients and the many patients I take care of in the hospital so still not very common yeah seem to probably be pretty good probably for at least six months but we just don't know in who and for how long. And so throughout this pandemic, my views are that more immunity is better than less, especially since we don't know what's around the corner from a variance or what have you.

And getting immunity the easy way is, I think, far preferred compared to rolling the dice. And I will tell you, even just a couple of months ago, I had a patient, a young person, a couple of years older than me, lives around the corner from me. I didn't know that, but took care of them in the hospital, had infection last winter, died of COVID nine months later. I have not seen any young person in their forts died of a breakthrough infection who had been vaccinated. And that's just an anecdotal story. That's just kind of one thing that catches my attention. But natural immunity is probably very good for a reasonable time in a bunch of people. We just don't know who. And I think putting all your money in natural immunity when you have the access to get extra free immunity to give longer duration. I mean, my bias is to take advantage of that free immunity,

immunity the easy way, because I'm really skewed. I'm seeing the worst of the worst. I'm seeing the people whose immune systems were not enough to keep them from getting very sick. So that's kind of my bias. If you fall into a category where boosters recommended, I definitely recommend getting it. I couldn't wait to get mine. I agree. Yeah. See,

I think that's the point is, is that community, the easy way, that's a good way of putting it. Assess your risk. And if you fall, I I'm still trying to decide for myself. I,

I, cause I had such a nasty reaction to the vaccine and I'm trying to decide which one. And, and I kind of feel like J and J is probably my best bet i'm a little afraid of it but but i'm going to check my antibodies if they're going down i'm going to do it i'm going to get another booster and see what what's what uh let's get another caller up here very quickly uh chad hey dr drew how are you? Good, Chad. Good.

I just wanted to let you know I got my Moderna booster yesterday. I originally got Johnson & Johnson and had absolutely no problem with it at all. Oh, that's good to hear. Did you have any reaction to the J&J at first? I did. The only thing I got from J&J was like a headache, pretty moderate headache for the first maybe 12 hours and then took some ibuprofen and it kind of went away. Well done. Is that it?

You're just announcing your Moderna success? No, I have another question. I'm sorry. My son who just got over having COVID, he's nine with asthma. He made it through pretty good. My question is when they come out with these new shots for, you know, five to 11, I think, how long should I wait for with his natural immunity that he has right now?

Because he had really moderate symptoms. Dr. Cabaza, what do you say? Yeah, so I think what we know, I don't know the pediatric population, but extrapolating to adults, we say, you can get it anytime, but it's almost unheard of to be reinfected within three months. Six months. So definitely, we say- Yeah.

Okay. Well, yeah, I mean, we see it a little bit, a couple kind of within six, but three months is definitely unheard of. Six months is probably very low likelihood in general. So you can get it any time but i recommend it usually waiting at least you know three months just then you get a little bit more shelf life from whatever the next immunity you build will kind of be longer before it cleans um so i don't know what you know definitely talk to pediatricians please talk to peter we are not

pediatricians and they may see things a little differently than we do. You know, here's what happened to me with, you'll love this, with Johnson & Johnson. I got sick. I got the full, you know, my immune system does not like viruses. I get everything like that. Or vaccines. I had H1N1, catastrophe. I mean, that was actually worse. I was sicker from that. And I woke up on day two with a spontaneous, full-on raccoon's eye.

And raccoon's eye is the presenting feature of transverse sinus thrombosis. So I'm staring in the mirror going, holy shit. Am I going to have to deal with a transverse sinus thrombosis from this damn vaccine the only male to get a transverse sinus from the vaccine so that's why i'm worried about taking what's that it cleared out my eye cleared up but i don't know maybe i had some my walked around with a maybe i had some some platelet consumption in my you know in the veins in the skull who knows uh but but it makes me nervous about the second j and j yeah what do you say i think that's natural i mean anyone who's had any kind of side effect to

to any of that i mean you're gonna be nervous about experiencing the same thing now should i get the second if i need the second one should i get j and j sure should i get moderna that's the question i mean i think with've had, anything you get is going to be good. I mean, it's going to boost you and give you those, that extra immunity. That's going to, I've seen some, I've seen some studies that say the J and J is, has some, some, for some reason, a little better for the, uh, those with natural immunity. It just seems a little bit better. So I'm still thinking I'm going to take a second J&J, even spite of the raccoon's eyes. You win either way.

It's a win-win situation. Well, I don't want an actual transverse sinus thrombosis. Thank you very much. If I could avoid that, I'd like to. I'm so sad. I know the deal is the sensitivity of the spike protein. That's my deal. I'm very sensitive to that, and particularly neurologically,

because I had lots of neurosymptoms. Well, maybe you just had it too soon after you were sick. No, I think I waited six months. Or maybe I accidentally elbowed you. Well, that could be because Susan, maybe there could be some domestic violence involved, but we're not going to talk about that publicly. So, so all right, Dr. Carvazza, we really appreciate you coming in and sharing your thoughts with us. Uh, anything we missed, anything you thought we would get to that we didn't, or that you'd like to shine a little light on before you go? Oh, no. I mean, I think we've kind of hit really a lot of the big points. And I could spend hours sharing just stories really at the bedside. But still, our strongest weapon is to prevent

getting infected. And we're very lucky that of how well these vaccines have worked and just walking in the hospital. And I mean, it's really just a lot of suffering and people who kind of wish they had more immunity prior to that illness. And it's hard seeing human suffering, you know, even if people may have chosen, made decisions that may have increased the odds of that. It's when you're looking at them and they're talking, these are some of the sweetest, nicest people and who just were kind of steered in a path that had to make a poor decision. And, you know, it's heartbreaking.

And I think the less people we see suffer and in those position, really fearing for their lives, the better off we'll be. And I just hope as this surge goes down, we're endemic. pandemic and the idea that we would disdain or restrict access to care for people who made bad decisions we would have to keep most of the people out of the emergency room every day because the emergency room is just filled with drug addicts and car accidents and stupid things that people do so uh yeah i completely agree and i don't want to give the impression that if you've had the vaccine, there's no way you can get COVID. It happens. People get breakthrough infections.

So just keep being careful. Do you agree? Yeah, definitely. You're just less likely to get very sick from it. Yeah, but breakthrough infections with Delta have not been uncommon. Really, Cleveland Clinic, the last two months, I mean, 15% of our cases have been breakthrough infections. And so it's certainly not rare at all. It's

uncommon they end up in the ICU unless they're very old or immunocompromised. But more immunity, the better is really the thing. And I just hope I hope the worst is behind us. Oh, God, I hope your mouth to God's ears. Well, thank you. Great to meet you. And thank you for just chatting it up with me. I don't get to, you know, get nerd out with my peers so much and I love doing it. So I appreciate it. Thanks for having me.

I appreciate it. You bet. And Kayla, thank you for all this. Susan, thank you for doing it. We still have a couple of questions up in the clubhouse. I think I'm going to have to wrap it up because uh what's that susan well i think we're gonna do just an ask dr j tomorrow so you want to come

back so tomorrow you come on back tomorrow if i'm not gonna be here i'm gonna set it up and we'll see how yeah we will do around what time we're supposed to do it yesterday but yeah we got stuck in an airport for 12 hours uh so tomorrow uh kayla do we have a time i'm not sure yet uh it's it's something like midday tomorrow it's an earlier time than usual 12 30 i i could do i have to leave here by 12 so it's a little bit can you do that for me yeah because you have to be at um i might need to do earlier, like around 11. No, I can't do that either. No, 12, 1230.

Well, the problem is getting all the way across the valley at 1.30 in the afternoon. I got to be there by two. Oh, across the valley? It's only like a half hour. Yeah, it's about that. You can do 45 minutes. All right, I can definitely do 45 minutes. I can definitely do that.

So let's say 1230 tomorrow will be... Unless Caleb can start earlier, but... No, no, no, because I've definitely do 45 minutes. I can definitely do that. So let's say 1230 tomorrow will be. Unless Caleb can start earlier, but. No, no, no, because I've got something before this. So let's say 1230 tomorrow, we will take calls again from Clubhouse. So if you guys are on hold and have, even if it's a COVID question, I'll answer it tomorrow, but I'm interested in more general topics.

We'll sort of pick up on what's going on in the news and we appreciate y'all being here. And then we'll be back Monday, we're gonna be out of town. No, no, we're doing a Friday show. Oh, Friday, did we book that? We have not, we have a very special, special, maybe special. We haven't confirmed that yet.

We might have a special Halloween special. Yeah, we have a special Halloween guest. From New Orleans. And we're gonna have to do it from New Orleans. It's gonna be quite a deal if we get people to pull this off. Yeah, we can't do it from a haunted mansion. But this guest is somebody uh iconic uh for halloween if she's willing to come and we're going to squeeze a psychic in too maybe

we'll get we'll get one lucky caller who can and because susan would like me to squeeze a psychic in i'm going to squeeze one in and we're going to have our very special guest um on friday right right in the afternoon time, I'd say later. Well, it'll be like five or six o'clock central. Tomorrow TS is just questions, just calls off Clubhouse. Maybe we should get Tyrus to get another psych agreement. Remember when we made him cry? Yeah.

Anyways, Monday we have your boyfriend. Oh no, you have Art Kaplan. Art Kaplan is a medical, he has a very fine medical. He says, I want to talk to him everything COVID and you know, what, what we've been doing right and wrong as it pertains to how we trying to lose that YouTube channel and then unvaccinated. And then also Vinay Prasad is on Tuesday.

Vinay Prasad is a, is amazing. Check out his podcast, Plenary Sessions. I can't wait to talk to him. He's penned a bunch of interesting stuff recently. Then we have some podcaster, Dax Holt. He used to be on TMZ and his buddy possibly that evening. I think they're going to zoom in. We're trying to figure out if they can do that. Yes.

Ça a l'air amusant, Florent. Indeed. Vraiment. Carrément. Okay. We appreciate you guys being here. We'll see you tomorrow around 12.30 for a short one where we just take calls. And if anybody on Holder Clubhouse wants to come back. Caleb, I need a longer picture. Not just my little mug.

I like that picture. Like a long one. Like we always have on the banners. I don't know. Look at it. I'll fix it. No. Or maybe just put it.

Maybe can you move it up the page a little bit so our heads are sort of equal level? I have such great boobs. Come on. Oh, I see. Okay. Well, just so it's like work.

I don't know. I don't want to be on camera. I just have to complain about my pictures on camera. Okay. I'm looking at the restream. See if there's anything else you guys want to chat. We got our luggage though, Drew. Oh,

right at the top of the hour. When we started the show, I've been trying to get our luggage from Phoenix since yesterday. So here we go. All right, everybody. Thank you for being here. We'll see you tomorrow after around 1230 Pacific. Ask Dr. Drew is produced by Caleb Nation and Susan Pinsky.

As a reminder, the discussions here are not a substitute for medical care, diagnosis, or treatment. This show is intended for educational and informational purposes only. I am a licensed physician, but I am not a replacement for your personal doctor and I am not practicing medicine here. Always remember that our understanding of medicine and science is constantly evolving. Though my opinion is based on the information

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