Short and Long-Term Lung Issues in COVID-19 with Louis Depalo, MD and Noah Greenspan, DPT


You off, we gotta roll. Okay. We’ll talk though. We’ll talk. Sure. Alright. You ready? You’re not nervous. Are you? Do I look like a nervous guy? I’m kidding. I’m joking. I know you’re not nervous. All right, let’s bring everybody in. Here we go. Here we go. Here we go. We’re just waiting for all of you to populate this, this screen here. All right. Good evening. My friends, my guest this evening is dr. Louis. DePalo. Dr. DePalo has been practicing medicine for more than 30 years. He is routinely listed among the top doctors in America, as well as the New York state Metro area. Most recently, he served as the system and psych clinical director of the respiratory Institute at Mount Sinai, which is also affiliated with the respiratory Institute in Philly and Philly in Denver, Colorado at national Jewish. He is a professor of pulmonary critical care and sleep medicine and adjunct professor of infectious disease at the Icahn school of medicine has been integral in the health systems work in researching and treating individuals with the novel Corona virus.


And he’s also a hell of a nice guy. And I’m happy to hear thanks for being a lo well thank you. And you were right, actually, because we have a relationship now in Philadelphia with the Jefferson Thomas Jefferson hospital as well. See that if all I have to do is say it, you know, I didn’t want to tell you about your new, your new center in Estonia, but get ready. So just to give you a heads up so these are many long haulers here. Okay. Many people who have suffered with coronavirus, some many are still trying to dig out of that hole. So the last time you and I spoke, which was, you know, fairly early on. So we spoke at the very beginning. We spoke in the middle, but the last time we spoke you, you said to me, ask me the same question every week and every week I’ll give you a different answer.


Is that still the case or are we starting to get a handle on things? Unfortunately it, in some respects is still the case. We have a mast, a lot of information about the coronavirus. Oh, I see a friend here. I’m going to give her a shout out to Judith. Paula our year, sorry, I just got to give her a shout out there. You’re gonna see a lot of people, you know. All right. So the answer is we’ve amassed a lot of information about coronavirus, certainly unfortunately, no specific treatments. We’ve learned to manage


Some of the complications and keep people alive long enough to begin to recover. So in that respect from the beginning there is hope that we’re seeing people survive. The ICU survived the acute illness. So in many ways, those questions are more stable when you save recover. That’s where I’m going to go back to ask me next week, because as we look at the recovery phase, we’re beginning to see that new symptoms are being layered upon old symptoms or you know, their, their new twist on and old complication. And we’re seeing that now, as people move through their journey in this recovery phase. So unfortunately in the recovery phase, I think the answer still is ask me next week. Every week we’re seeing an increasing list of symptoms that are being ascribed to the novel coronavirus, the term long haulers.


I wish I would say it was medical doctors who came up with that, but actually that came a grassroots. There were patients who would feel ignored, who doctors were saying, what are you talking about? You, you survived, you got out of the hospital, B be happy. And you know, the medical profession may have been a little bit behind in acknowledging the symptoms that were coming late, because we were dealing with people dying and on oxygen and on ventilators. And it was really the patients, I think who coined the term long haul was to post. They said, you, you doctors, you medical established, you listen to me. I am not well. And right now we are in the inventory phase. We’re I think we’re catching up. We’ve identified the need for COVID centers of excellence and these corporate centers of excellence. They don’t have any answers for you.


They’re going to do right now is taking inventory.


They’re going to listen to you. What’s your symptom. What’s going on, trying to figure out a, what are you complaining about? Is it real? If it is we all, how did you get there? How many people with chronic covert symptoms, how many people have GI issues? How many people have headaches? How many people have brain fog? How many people have this don’t want to know me or so we’re in that inventory phase right now, not a lot of answers. Hopefully, as we, as centers of excellence, identify the symptoms, begin to look at the characteristics of the patients. We can then begin to say, how can we address these complaints? So very long winded answer to ask me next week. Awesome. It makes my job super easy for even


So early on middle phase and, and chronic phase, what are some of the more common respiratory conditions that you have seen our seeing and expect to see?


All right. So, you know, early on COVID-19 it was described as a respiratory infection, which it is, it enters, the nose, goes into the respiratory tract. You get get a cough, you get the sniffles, you get fever, flu like symptom only if it was just that. Okay. That’s the early phase fascinating. Some people just get the sniffles and recover immediately that there’s a honeymoon period. And that first three to five days where it’s fevers, muscle aches, cough, not so bad. I can’t tell you how many people said to me, Oh, this isn’t so bad. We learned early on to not, not listen to people and say, no, no, you call me in a few more days. And in fact, you and I were talking about our colleague before David Petrino, who put in a home monitoring program where we realized we need to touch patients every single day, because Dave, for not so bad day seven became a disaster.


All of a sudden, you know, went from sniffles of muscle lakes, sounded like the flu to hypoxia. I can’t breathe. My pulse oximeter is 88. Cause some of those patients would progress into shock and failure and wind up in the hospital. So that was the early phase. So we learned that maybe not so bad, but keep you on a short leash for that first seven to 10 days while you’re acutely ill and see where you break out. If you’re one of the lucky ones you’ll recover, we’ll talk about x-rays and, and, and pulmonary physiology in a minute, then people who wound up in the hospital on a high flow oxygen on ventilators, those patients were very sick. Unfortunately we lost some as he developed shock and multisystem organ failure. And then some people recovered. So they graduated from the ventilator, the graduation, the use of oxygen, but they were spent, you know, they went home and they were spent and we didn’t have any rehab facilities.


I, if it wasn’t COVID-19, I would kiss Noah every day because because we were, you know, we, we had a huge vacuum. We were sending, you know, we were glad you were alive. We maybe sent you home with oxygen, but you were debilitated and weak. And we sent you home now with the crazy, and there was no good ability to help people get rehabilitated. Nowhere. I hooked up with a lot of people. He was doing his his home programs beginning to keep people moving and get back that muscle mass begin that long climb back in terms of functional recovery. And there are a few things. Number one, you just need to recover from the acute illness. And then the question was, what kind of hit did your Alliance take? What kind of damage did they get? Let’s talk about how the lungs were affected.


Pneumonia. Infiltrates couldn’t breathe. There was infiltrates could clear you get airway disease, almost like asthma CLPD, wheezing, barking bronchitic if anybody had an underlying lung disease to begin with, you know, what that feels like CLPD, those patients had exacerbations of their asthma exacerbations of COPD, coughing hacking getting decreased functional capacity. That’s another one. If you were one of the unfortunate patients who develop blood clots related to COVID-19 pulmonary embolize now you have problems with pushing blood through the blood, you know, blood through your lungs, getting the oxygen. That’s a anatomic deformity that takes a while to prove. So that’s what we saw as patients begin to recover as were bronchitis, wheezing, hypoxemia, resolving blood clots. And that is the analogy I use is it takes me two seconds to punch you and you get a black and blue in your eye, and that’s going to last you for two or three weeks, took me two seconds, right?


One pop you’re, black and blue. But look at the evolution of that injury. It takes weeks to recover. Well, my lungs just took a giant punch. And so even though the punches cleared, there’s an evolutionary healing process that has to go on. If you’re lucky, just like after a punch, if you didn’t break anything into form, anything, you’ll come back to normal and you’ll look normal. But what if you have a deforming injury where you broke a bone, you broke your nose. Now you’re left with a disability, with a deformity. And we are seeing some patients as they recover. They don’t recover back to normal. They recover back to some fibrosis or bronchiectasis, and those patients will be destined to have a disability. And depending on how much anatomic abnormality they’ll sustained, that’s how much disability they’re going to have and they need to fight their way back.


And again, that’s where I’m going to, I’m not contagious. Throw out kudos to know her, because again, he does more for long people than I do. You know, it’s it’s, it’s, it’s, it’s one of the great hidden secrets. He’s been my secret weapon for years. Medicine only takes you so far, but rehab and your courage as patients, your you, your fight to come back is so important. And and that’s the recovery phase from the injury, right? If you break an arm, you gotta recover. You gotta, you gotta gain function. That’s the fight that a lot of long haul those are dealing with is that recovery phase


To DePaul. Well, let me ask you this. So you mentioned asthma, you mentioned you mentioned bronchiectasis, you mentioned chronic bronchitis. So normally somebody will develop asthma, you know, over time somebody will develop chronic bronchitis, bronchitis over time. They will develop bronchiectasis over time. How and why are people developing this so quickly now? And is that something that you think will be lasting?


Ask me next week. Certainly I think the asthma story, we have a surrogate for it. We’ve seen this in mycoplasma pneumonia. We’ve seen this with influenza. Some people after a bad mycoplasma pneumonia, after a bad bout of influenza will develop an asthma like sym syndrome that can last for six months afterwards. And the patients say, Oh, do I have asthma? And you know, doctors get sloppy with the terminology. Asthma is a very specific term related to allergies and reactive airway disease. But some people post viral insult mycoplasma, influenza, and now COVID-19 will develop reactive airway disease. That to the lay person looks like asthma is not allergic, but you wheeze your cough. You hack, someone walks in with who’s smoking. You start to cough. It looks and smells like asthma. Hopefully if we can borrow from the mycoplasma story, we can borrow from the influenza story.


Maybe that will get better in six to 12 months. So even though I used the word asthma, I’m guilty of being sloppy with my language as well. It’s really not asthma it’s asthma. Like in that you, we use you react to environmental irritants. And my hope is for those patients, they will recover. You know, at some point in time I’ve seen people. And that to me is the earliest. I’ve seen people who were coughing and I put them on asthma medications and, and three or four months like, Oh, I’m back. That chest tightness is gone. I can go around. I don’t use my nebulizer anymore. I don’t use my out. Beautiful. So I’m seeing those patients come back.


My next question. So, so a lot of people you know, first of all, let’s start with the premise that a lot of people have difficulty even getting to see a specialist. But a lot of times people are not getting on meds. So my feeling is that for a lot of the patients we’re seeing, they’re having difficulty taking a deep breath, they’re taking a deep breath. They’re, spasmodically coughing. Is there a role for Bronco dilators? Is there a role for inhaled corticosteroids and how do people broach that subject with their doctors so that we could get them?


Right? So the answer is yes. But you have to get the right diagnosis, right? It’s the right drug for the right diagnosis. So we’re talking about asthma and bronchitis and therefore those drugs Bronco, dilators, inhaled corticosteroids. They have a role if you have pulmonary fibrosis, which is the other way lungs can heal. That’s the bad way. That’s a scarring, fibrotic, restricted process. Those drugs probably will have very little, very involved. So part of the question becomes and we did it by telemedicine. I mean, I could talk, be talking to you and if you were balking like a dog and hacking and you know, okay, you’ve got airway disease and I can treat you if you say, gee, my chest is just tight and I can’t take a deep breath at that might not be asthma. And then we have, so we can often get pretty close by just talking to you.


And you know that you heard about the breath, hold that ten second breath hold. Someone tries to take a deep, that’s what we used to do when we’re trying to figure out how bad a COVID patient was. Can you hold your breath for 10 seconds? If they crashed and burned on five, it’s not a hacking, like there’s an airway component to that. And then a Bronco dilator in headquarters, too. It might help with the idea. We’ll help them participate in their rehab. So anything medically I can do to get them into your room. That’s my job. I’m not fixing anybody. You’re fixing them. I’m getting them in your room. If I can get them to do 10 extra steps, spent 15 extra minutes in your room. That’s my job until the patient heals.


Well, you’re being very modest, but you know, patients, just one thing I would like to throw out there is that, you know, I’ve never seen the Bronco dilators or the corticosteroids as the treatment, as the, be all and end all of the treatment, but it is a tool it’s a bridge to help you do the things and make the lifestyle changes that will actually get you better. Things like exercise. You know, if you saw the meeting the other night, one of the things that we’re seeing differently with COVID is that we have to really tip toe along with exercise, because as you guys know better than anybody else, if we overstep that line by one foot, well, that step could be a doozy and you could wind up in bed for a week, but I would encourage people to at least. So what are we talking about in terms of testing? Dr. Depalo PFT.


Yeah, it’d be nice. I mean, our part of the problem we were struggling with, how do we test people? Okay. Breathing, you know, if you’ve ever done a PFT, you know, we try to get you to take a deepest Victoria expository phase. You wind up coughing, maybe in a procedure. If you’ve got active you’re you’re, aerosolizing that all over the place. How do we do PFT testing in the, in the covert here? I cannot tell you how many countless hours of conversation I’ve had. Should we test who do we test? When do we test? Well, you know, it’s it’s yes, we need testing. We’re now talking about, and we’re going to see things dramatically change. The price point is coming down on home spirometers so that eventually we can give you a spirometer at home, teach you how to do it, Bluetooth it, and it’s probably a better world because actually then instead of checking a blood sugar once a month, if you’re a diabetic, the checking of spiral Hammetry every day, which is so I think some good will come out of COVID.


So we’re looking at ways to test people at home. So because we have a problem in our environments of testing people safely. So the answer is you get tested my world. You need to have a negative Colbert test that we bring you in, and we will test you. We have limited capacity to do that, but full PE, we are bringing back people now to figure out at three months, how damaged are your lungs? And we can talk about that later. The kinds of dimunition that we’re seeing it’s a research question. First of all, also it helps us prognosticate. What’s your life going to look like would help us decide is a Bronco diet is going to help you. If you’re purely restricted, meaning your lungs are like plastic. You know, I use the analogy of a balloon and a hot water bottle. Yup. Everybody know what a hot water bottle looks like, right? It’s that red, rubber, right? Try to blow that up. Not going to happen.


Well, lane only Jacqueline Lane was able to do that.


You can blow a balloon up all day long. You can’t blow up a hot rubber bottle. So a fibrotic that stiff long is that hot. Is that hot, that red, rubber water bottle, that’s not going to get better with a Bronco dilator. Don’t you know, the, the airway disease. Well, the asthmatic the sooner, whereas magic, the bronc headache, bronchitis patient, they will get better with Bronco dyers. And so that’s where testing would be nice because I can say yes, take this Bronco dilator and go see nowhere. Alright. If you’ve got very badly stiffed lungs, I’m going to go say, go see knower, but maybe we need to talk about lung transplant. So it becomes a very different conversation,


I think certainly by September one, but hopefully before that we should have access to home spirometry. So that that’ll be Bluetooth. So we’ll, we’ll talk about that. Let’s talk about fibrosis for a few moments because that’s scary. Okay. do you have a sense, you know, and I’m sure when you just said lung transplant, probably everybody went, what did you just say? But do you have a sense and I know there’s, there’s no definite answer, but do you think that this is going to be similar to a, an IPF where we see a progressive scarring after the damage? Or do you think people are going to sort of have a fixed defect and then that’s what we have to work with?


So, so on that question asked me in a year. So, so the answer is, there’s no question. We’re seeing some people at three months who still have the ground glass opacities that you’re heard about early on. We feel good about those patients in that they’re not scar, they’re not fibrotic. And what we’re looking at right now, is there an opportunity to salvage some of those patients? I may be in another course of steroids, maybe giving the anti-fibrotic drugs because at ground glass opacities suggest normal architecture. That’s the black guy that’s still swollen, but not deformed. The, I was knocked out, you know? So that, that ground glass leads me to believe that that person may still heal to normal. And as it’s something I can do to help them,


There’s some pliability there, there’s some pliability there. Now let me ask you this. A lot of people have come up with that diagnosis on their, on their, on their x-rays or cat scans. So should they be treated like, because what I’m hearing over and over again is, is people who are, are being given sort of findings without a diagnosis, but then being denied treatment. How, again,


No denied treatment. So it’s not denied treatment. It’s it’s we don’t know what the hell we’re doing. So let me remind everybody about the, about the vaping epidemic we had, was it last summer or the summer before? Probably last summer, vapors got a lot of ground glass capacity that if I buried them into a bunch of covert cat scans, my radiologists, we said, COVID-19 the baby lung injury that we’ve read about with people who were vaping. THC products look very much like this and almost to the person, those patients got better resolved. Those ground gloves have passed, has got better. And we treated them with steroids. We’ve made it up, but I will tell you, I’m not. One of my patients did not respond in that setting. And I’m not saying the vaping injury is the same as COVID-19, but radiographically those ground glass opacities kind of begging for us to want to do something.


But the question is, what do you do? Steroids are not chicken soup. Okay. Anybody in the room who’s been on? Steroids knows they have lots of side effects. So steroids are not chicken soup. And you know, in the absence of a randomized control trial, should we be giving her? So at Mount Sinai where we’ve got a registry of about 400 patients who were sick in the hospital, we collected genetic material, inflammatory mediators, we’re drain those patients back. We’re getting cat scans and people who are symptomatic and have ground glass opacities. We’re talking about doing bronchoscopies. If they have inflammatory cells on their bronchoscopy, say that inflammatory cell is a marker of ongoing injury. And I want to turn that off and we’re going to come up with a protocol to give those patients steroids. This is in a research setting. So the answer is, yeah, I want to do something.


Those cat scans. When I look at them, they’re begging for me to do something. But the question is, what is that something? And this is where research is required. And if the drug was chicken soup, we’d give it to you. But prednisone is not chicken soup. And you know, a lot of patients have comorbidities like diabetes, obesity, depression, bone problems. We get awards. So giving people’s six to eight weeks of stewards, not knowing it’s going to work outside of a research setting is a little bit dicey read. There are other antifibrotics. We talked about them. If anybody knows anybody with pulmonary fibrosis idiopathic pulmonary fibrosis, there are two drugs out there that will be used. You know presented on an OFAC. We are now have a drug trials for patients who have ground glass opacities, maybe some early fibrotic changes with the idea of giving these patients, Anthony fiber-optics again, within a research within a research setting.


What do you do with the asymptomatic patient? We ground glass right now. We’re kind of just watching them. And I will tell you, the Chinese are nine months ahead of us in terms of the epidemic. So they have a much bigger cohort of people coming through right now. And when you look at six months for the cohort, there’s something called a diffusion capacity, which is how effective oxygen gets across the bloodstream. In those patients who have persistent CT findings of six months, those diffusion capacities are about 50% of normal. And that’s the level where people begin to get into trouble with exercise, Neve, oxygen dependent out tattooed. So real question is what do you do with that ground glass abnormal diffusion six months in is there an opportunity to move them back a little bit off the ledge? Because with the fusion capacity of 50%, you’re sitting on the edge of lifelong disability. So we’re trying to struggle with what are we going to do with those patients? We have to test them, Hey, we have to find them. And then B, we have to test their diffusion capacities. And then if you’re on the edge, we have to decide, do we want to treat you, what drug will we treat you with? And are we going to do it as department research protocol? That’s why I said to you ask me in a year,


I’m not being a wise guy when I asked this question, but you mentioned well, I might be, but you, you mentioned asymptomatic patients with ground glass opacities. So why would you know they had ground glass opacities if they were asymptomatic


Because I saw their first x-ray and there, and their first x-ray was really, really ugly. And so I want to know what their followup x-ray looks like, because I want to know since we don’t know how this is going to go, we wanted to know because he has a problem. Anybody who knows me has heard me use the analogy five fingers. I can cut off my one finger. I can do anything I want for a baseball type. Play the piano. Maybe not so well, you know, losing a finger. I can live a pretty normal life. I can even lose two fingers. I could still throw a baseball type, feed myself. I can live a pretty normal life. Two fingers down, three fingers down. Now I’m not really playing the piano so well not having, not throwing a baseball so, well, maybe you can turn a door with some difficulty.


The minute I lose my fourth finger, I’m now disabled. So what happens with lung patients? They lose don’t notice it lose. They don’t notice it moves. They notice it a little bit. They start making some adjustments and then bam, they’re disabled. So the reason why I took those x-rays was, you know, yeah, you may be pretty good, but are you climbing mountains? Are you skiing? Are you testing yourself? No, you don’t know how good or how bad you are because you’re not pushing it. And I don’t want to wait till you’re like this, because when you’re like this, I got nothing for you. So that’s why we started getting those. X-Rays early to see if we could find people who might be in trouble that they didn’t know they were in trouble.


And time is really of the essence when it comes to testing and treatment. You know, we see this with a, with a lot of patients where, you know, if you, if you get people early on, that’s why I encourage people to really, you know, push their physicians to, you know, to test and to try to treat if there’s any evidence of it. What about so for patients that have a normal chest X Ray, because a lot of, a lot of patients haven’t gone further than a normal chest X Ray, and they say, you know what? Normal chest X Ray, you’re either anxious or you’re deconditioned or it’s in your head. So how does that patient go further and how much further should they be asking to go? Right?


So a normal chest X Ray tells you, you don’t have parenchymal lung disease, airspace disease. What that means is you don’t have pneumonia, don’t have infiltrates. You’re going to have a giant pulmonary embolism and your x-ray will be normal. So patients COVID-19 who develop blood clots, they have a normal x-ray because their arteries are clogged with blood clots and their x-rays totally normal. If you have the airway disease component of COVID meaning that bronc or that airway, reactivity that wheezing or coughing the hacking, you will have a normal chest extra. So it’s not just the x-ray. Yeah. Everybody talked about the lung part, you know, the parenchymal disease, the ground glass opacities, because those were the people who were dying in the hospital with respiratory failure. But late the blood clot story came in late three, four weeks in. And why? Because we have people who are possibly, the XR has been normal. Like, what the hell is that? And what that was, was blood clots. And until we started scanning those patients, we didn’t realize that their hypoxemia was because of the blood clots. So x-rays would start not, not the, not the ending point of hypertension. So you need kind of need needed all, you need a patient need to be examined, or you’re wheezing. You need to have some spirometry to diffusion capacity, and then you need an X Ray and maybe a CT scan, depending on where you are in your journey.


Just a show of hands. How many people here have had chest X rays? How many people keep your hands up if you’ve, you know, keep them up, keep them up if you’ve had a cat scan. Okay. That’s a good number. Okay. So what about as far as you mentioned people who are so hypoxic, I know that, you know, people were hypoxic, but there’s a term called the happy hypoxic people who had very, very low numbers, but were generally unaware of their of their degree of actual disability. And then there’s people whose oxygen saturation is normal, but they’re short of breath. So if you could explain that and then I want to move to a question which may be related, is there a dysautonomia component to respiratory disease?


So give me way too much credit because if I could explain that, I’d be honest.


So humble. He’s smart. He’s humble. He’s accomplished. He’s good looking.


So, and also why is the sky blue low, right. Exactly. It’s, it’s, it’s, it’s difficult. I mean, let me tell you, I’ve been doing this for 30 years. I’m trained in critical care. We did a R D S this was being labeled as ARDSM, which was the adult respiratory distress syndrome. That was defined actually in the Vietnam era when young soldiers, who we got trauma with developed these bilateral white outs with hypoxemia and stiff lungs. This was not a RDS. This is not your grandmother’s. They are the S this a whole new disease. You know, the amount that just, when we start seeing our first cases, we were intubating people right away because, Oh my God, they’re going to crash and die. Their oxygen levels are dropping they’re on 60, 70% oxygen. You know, when people were more, went from five liters to 10 liters, we would intubate somebody, all of a sudden, number one, we couldn’t intubate them.


We were full. We were frankly scared to intubate them because of aerosolized virus all over the place. Plus, we were worried we didn’t have enough ventilators to go around. So we wound up realizing early intubation was not the way to go because patients actually would die from the trauma of intubation. So we played a game of chicken and I had jet black hair when this started the, this, this, yeah, Judith knows. I just lied, but that’s okay. I know, I know. Yeah. Okay. I just told a little white lie, but we played this game of chicken where we basically sat there. The patients looked okay, the other vitals were fine and we put five liters and 10 liters. And I know there’s been, not mean anything to anybody. And then we say, okay, let’s put a face mask on top of the nasal cannula and give them another 10 liters.


That’s 20 liters of oxygen, not intubated, unheard of unprecedented. I would have gone to jail two years ago. If I did that on a patient two years ago, I’d be wearing a different Stripe outfit right now. It’s crazy. You know, and what we realized was there’s something strange about this disease because this patient has 80%, the respiratory rates, 16 they’re awake. They’re talking to me and there are 35 liters or bypass. And so that’s where the whole coagulation piece came out because we began to realize this is probably something related to shunt, which means blood and oxygen. Weren’t going to the same place. Oxygen was going over here and blood was going over there and that’s not the way the lung works. Right? The lung works is blood oxygen. Bring that, you know, get the oxygen to the bloodstream. It doesn’t work if the oxygen is over there and the blood’s over there.


So the notion was that there were, the blood clots were isolating parts of the lung, such that they wouldn’t get oxygen. That’s why these people were hyperly hypoxic. We can talk about the neuro about the neurocognitive stuff later, if you want. I dunno how happily hypoxic they really were because the brain kind of that’s food for the brain. Oxygen is food for the brain. So yeah, they were awake and yeah, they were asking my answering my questions. But the brain cells were bathing in a hypoxic environment. So some of those neurocognitive effects we’re seeing on those patients may have been because we let this saturation sit at 85%, the magic number, 88 or above. So when you have people sitting at 85%, yeah, they were, maybe they were happy because they were hypoxic. So anyway, that’s,


You’re saying absent, absent a stroke. So absent a bleed, absent a clot to the brain, but they’re just, they’re just by nature of the fact that they’re low saturation was what was feeding the brain. That is what was causing these cognitive.


I think, you know, I don’t have proof for that, but again, I think you’re right about that too. What I do know is when I have patients complaining to me about the brain fog, I can’t find words. I walked into a room, I dunno why I walked into a room. I’m talking to somebody, I forgot what the conversation was about. You know, and these are very small people when I scan them MRIs, reigns they’re normal. So this was a cellular event. So I think what we’re seeing, wasn’t a stroke. It wasn’t a, an anatomic event. This was a cellular event. So I think there’s a re we took out some brain cells, you know, it’s like people drink too much and already kill a few brain cells. I think I think this chronic hypoxia probably killed a few brain cells globally. And so therefore you have these memory issues, these cognitive issues. So


Do you feel that’s something that can come back or do you feel like that’s,


Yeah, the nervous, system’s a wonderful thing. You know, we talk about neuroplasticity. We know, you know, better than I do. You’re in the rehab world. We know it takes longer. We know the brain right now. The brain can rewire itself a little bit age dependent, you know the younger you are, the newer, the more neuroplasticity you have, the older you are, the less neuroplasticity term neuroplasticity means the ability of the nervous system to learn a new task. You know, we were born with all the brain cells. We have, we were the smallest, whatever, gotta be. The minute we fly out of our mom’s room, that’s where we have most of our brain cells and it’s downhill from there. So we lose brain cells over time. So the real question is the nervous system learns tasks and wires itself to do stuff. And the term neuroplasticity is okay, you used to do that. Now do this. Okay. You used to be a pathway that was involved in calculation. Okay. Now I want it to be a pathway that’s involved in in talking, speaking language. So I think the answer was, we will see some recovery would help people like Noah. And then again, I think it is a little bit age dependent.


My sales pitch, which I truly believe is that so much of this was inflammation based. And I tell people every day that you’re only going to get well as fast as your slowest system. And you know, the neurosystem is slow. So especially for patients who, you know, so much of what they’re dealing with is related to this kind of dysautonomia or this, this nervous system stuff, it’s going to be awhile, but that doesn’t mean wait for it to be better. It means let’s get on the path and do what we can so that when that inflammation goes away and when that neurosystem is ready we’re ready for it. You know, and your heart, hasn’t totally gotten gone to pot and your, your muscles, haven’t gone to pot. That’s what bootcamp is about, you know, and that’s why we, you know, we, we, we had an original bootcamp and it w we thought it was very gentle. But it, it actually turned out to be a little bit not gentle enough or some of the COVID patients. So we’ve scaled it back quite a bit. And I think we’re finally on the track where we can sort of say, we have a good idea of how to do it. But I’m happy to hear you say that.


Yeah, but this is fascinating. And this is how smart he is because he, not many people even know about this this whole idea of dysautonomia everybody’s heard of chronic fatigue. Some doctors don’t even believe that exist right related to Epstein BARR virus. How many people got off chronic fatigue, another crazy person, right? Lyme disease, chronic Lyme disease, some doctors that didn’t believe in chronic Lyme disease, chronic Lyme, another crazy person, right. And all these symptoms, you know, doctors are system based. So we, we try to come, we take a list of symptoms and try to make sense out of it and say, okay, chest pain, jaw pain, radiate down my arm. That’s a heart attack. Okay. you know, we, that’s how we learned in medicine to put these, connect the dots and then make a diagnosis. People with these syndromes, chronic fatigue, Lyme chronic Lyme.


Now we’re going to hear about long haulers. I’d be interested in a raise of hands of how many people have been blown off by your doctors and said, you’re crazy. Or you’re nuts. You’re crazy, fine. You know, find a shrink. And part of it is because your inventory of symptoms all over the place so that when we try to sit there and say, okay, you know, I’m a long guy. So I understand coughing, wheezing, shortness of breath. And I’m a neurologist. So I understand headache and weakness and cognitive issues. And I’m a GI guy and I understand diarrhea. And this I’m a cardiologist. So I understand, you know, high blood pressure, but I don’t understand fainting and stuff. I’m a neurologist, so I understand dizziness, but putting it all together and you’re nuts. Yeah. That’s what happens. And what’s happening is you’re not nuts what you may be, but, but


That’s not related to this. Not related to this.


Wait, as Freud said, just because you parent or it doesn’t mean they’re not out to get you that the autonomic nervous system is a one organ that hits all the organs. We just talked about. It controls blood pressure, heart rate, sweating GI function, respiratory function. So once you have a disorder, Nomia, you can begin to tie these symptoms that don’t belong in the same sentence, under normal circumstances. This, this litany of symptoms don’t belong in the same paragraph. They don’t belong in the same sentence. And that’s why doctors are like, you know, this person, captain, right. Once you roll in that, the nervous system, the autonomic nervous system, which controls all of these organs, if it ain’t right, then all of these organ functions may be off. And that’s probably some of the patients, chronic fatigue. That’s some of the patients with Lyme and it’s going to be some of the patients with COVID-19.


There’s no test for it. So that’s the other problem. We doctors love test, right? I, you know, you’ve heard me say about, get me spirometry, get me a cat scan, get me something objective. I can point to a scan and say, there’s an infiltrate to point to a pulmonary function test and say, look, you’re obstructed. There’s no test for them did for dysautonomia. So we’re stuck listening to you. And, you know, it was an interesting dynamic between the patient and the doctor and because doctors don’t like being not being helpful. So they sometimes get mad at the patient, right. Sometimes like, I want to help you and I can’t help you. So it must be your fault.


That’s a great comment. That’s a really great observation.


Yeah. Which is crazy. You know, I understand it because we’re, you know, I get mad when I can’t help you, but I don’t get mad at you. I get mad at the world. Right. But it’s very frustrating. So I think this dysautonomia it’s going to be, you know, and the key, the hint, all of this was he knows Mia and the loss of taste that’s nervous system. So that’s autonomic nervous system. So the virus entered, that was probably the hint that this was a, it’s also a neuro centric virus winds up in the autonomic nervous system. And therefore, and I think that’s why we got, we got to this concept quickly more quickly than some of the other disorders, because there was a significant early signal with the, and no loss of sense of taste, which is part of the autonomic nervous system. So


You see people with their masks down around the upper lip. That’s, that’s not the right way to wear it. Right. like down here, that’s not the right way to wear it.


No, unfortunately not. But if you want to talk about math wearing you know, the politics of that is infuriating. You know, it’s, we have demonstrated that the efficacy of a mask goes down 50% once it’s below your nose. So we have a saying, I w I I’m here for you. You wear a mask for me, the mask you wear does nothing for you, unless you were going to in 95, the mask you wear is to protect the person you’re in the room. So I respect you and I will wear a, I will wear a mask and I will wear it properly above my nerves. Cause I don’t want you to get sick. Will you please do me the courtesy of the favor back? So people who don’t wear a mask, I have very little patience for it. It’s not about, you know, it’s, it’s really not about you. You need an a 95. If you’re trying to protect yourself, it’s really the mask it’s protecting those. You love around you. And it has to be above the nose because the FDF deficiency, well-documented 50% decrease in efficiency by the simple act of wearing around your nose. If you wear it as eye shades, it doesn’t work at all.


Doesn’t work. Ladies and gentlemen, I’m going to ask a few more questions, but feel free to start asking some questions in the chat, if you have questions. So let me ask you this for patients that pneumonia. So is, is there, are you seeing similar pneumonias, like garden variety, pneumonia, or was this a different,


No, sir. It was fascinating. You know, everybody got antibiotics, right? So if you can’t, you know, and that was really more an admission of, we didn’t know what the hell we were doing. A patient came in, you see an infiltrate on x-ray, they got a fever. You know, what a doctor’s do we give an antibiotic, right. Even though we knew it was viral we have no treatment for viruses. God forbid we don’t do something. So we gave people antibiotics shocking how few bacterial pneumonia is it really work. The other interesting fact is flu. You know, we were terrified that flu and covert together was it’s going to be a death sentence. The incidents of flu this year with down right now in South America and Australia which is where they’re having their flu season right now, they’re reporting record low one more time, record, low numbers of flu.


So what is that all about? This COVID protect people from flu or is it that everybody’s hiding so that the flu epidemic is, is, is down. Everybody’s hiding from each other. But right now there are record low numbers of flu. We saw very few co-infections with flu, interestingly, very few at the height of the season, they collided together our flu season and our corporate season came together. And I can count on one hand out of the hundreds of patients I took care of that were co-infected with flu and COVID-19 so so that certainly, you know, didn’t go along, didn’t see garden variety, pneumonias. I prayed to see a garden brought in pneumonia, you know, that made my day out. And I, every day I would see 25 people with COVID-19. I was like holding my head just in despair. And when I got back to pneumonia, I was like, happy.


I was like, Oh my God, I can do something about this. That was unfortunately rare. In hospital, people who wound up on ventilators and was sick for a long time, they got what everybody gets in the hospital. They started getting the nosocomial hospital, acquired pneumonias at the same rate that they normally do. So once you’re sick and you’re in a hospital and you’re on a ventilator now you’re susceptible to all the bad bugs that are in the hospital. And those patients did get bacterial infections and sepsis, but that was a result of just being so damn sick.


So nosocomial means that you got it in the hospital? Correct. Okay. Gotcha. so what about things like respiratory muscle training, incentive, spirometry? You think there’s anything to that? Oh, before you say, I’m sorry. I’m sorry. Before you go to that, should this, should this group right here be getting flu shots.


Yes. Why? Because of a one, keep you out of the medical system, because if you get the flu, if you get the flu, you’re coming into the medical system and you really, if we have a second bump, do you really want to be coming to see me? I don’t think so. So if we can keep you out of the system that’s number one. So the flu shots are effective. They may not always work. That’s a different story. You cannot get the flu from the flu shot to dead vaccine. You can get a reaction, you get a flu like symptom. In fact, when people get a flu, like reaction, I’m like, yay, it’s going to work because now you have an immune system that’s kind of primed and ready to go. You can feel achy fevers for a day or two after flu shot.


It’s not the flu. It may not totally protect you. You may still get the flu, but you’ll get a mild form of the flu. If you can stay out of the system, you really want to stay out of the system. Particularly if we’re going to be in another resurgence of covert, I don’t have no idea what we’re going to be lacking for. So the answer to your question is stay out of the system, right? Take your flu shot. If you can. I did tell you about what’s happening down South. You know, there is a lower incidence of Carling there. It’d be interesting. You know, it’s a small country, smaller population. We certainly saw it up here. We just saw a far fewer flus. And so, but I don’t think that’s an excuse to,


Just to be clear. You mean South America? Not Miami, right? Miami. That’s a whole other ball game. Okay.


No, that’s a different planet.


That’s a, that’s a, that’s a, that’s a whole other ball game right there. Right?


That’s a different planet. Okay.


All right. I’m going to go to some question. Oh, let’s talk about let’s talk about rehabbing and inspiratory muscle training. You think people should be opening their doors and going to rehab at this time.


Let me bring it back to one thing about the respiratory muscle. You, you asked about chest wall stuff. That was another thing. We saw a lot of chest wall pain and discomfort, which if you took the lungs out of those patients, they were totally normal, but they were stiff. They couldn’t take deep breaths. There must be. They just said, you know, I can’t take a deep breath. And you know, I used yoga for people who couldn’t get the knower. Cause people, interestingly, people don’t know how to breathe. And I would send people to yoga classes if they couldn’t get to know her, to teach people how to hold their breath, how to take deep breaths. There was a lot of chest wall stuff. Again, normal x-ray short of breath. The analogy I use arrows. If you were football fans, you ever watch a guy take a hit.


When they get up, what are they saying? I can’t breathe. I can’t breathe. There’s nothing wrong with their lungs. They can’t breathe. Their chest hurts. And so they just can’t take that deep breath. And the brain interprets that as I can’t breathe, your brain is not very smart about the signals. It gets. It just says to you, you can’t breathe. It’s you know, if I gave you a big hug and how to do it, a bear hug, nothing wrong with your lungs, but you’re going to tell me, Lou, or stop holding me so tight. I can’t breathe. That’s muscle stuff. That’s the respiratory muscle stuff. So be able to learn how to breathe correctly, learn how to build those muscles will retrain your brain or you’ll feel better. I learned this trick from a patient of mine who had emphysema. He said, I don’t know why I can bother to see you.


You know, you don’t do anything for me. My, my yoga therapist does more for me than you do. I heard this for five years and fives and Phyllis, I’m tired of this already. I want to meet your yoga person and I’ve met her and she got to it because her mother had emphysema and she tailored her yogurt regimen to not, you know, they’re trying to get a class with 21 year old and do yoga. Oh my God, how awful is that? She tailored it to people who were our age, you know, who couldn’t bend over and touch their towers. And it worked. I tell you, so, you know, learning that is very important. Should it be going through rehab? You know, again, it’s like any industry that question can be applied across any industry. She did go to a restaurant. Did you go to your movie theater? Same question. Should you go to your doctor rather than that? You know, we’re under diagnosing cancer because people don’t want to go for this screening. They don’t want to go for the mammograms. They don’t want to go for the colonoscopy. So the answer is


On like usually when they want to go for that colonoscopy, right. That, that rush on the colonoscopy no longer there. So if you want one, now’s a good time.


Absolutely. Oh my God. Now’s the time to do it all. I’ve taught people, this is your window to go get your stuff done. So I think the answer is you have to we’re at a good place right now. So the answer is the numbers are as low as they’re going to be where, you know, chromo has done a great job or


Yeah, not everybody here is in a good place. A lot of these,


I’m trying to know the numbers right in the state, we’re in a good place so that if you need to go out, now’s the time to go out. So I tell, I’m telling all my patients prioritize the things you’ve put off. And so again, answers Noah’s question prioritize. Do you need to go, should you go? Then you call those people. And if they don’t make you feel safe, don’t go to my practices. We’re working really hard to make you feel safe. So, you know, ask the hard questions. Are you socially distancing? Are you screening? You know, did you ask me for a Colbert test? You know, if I’m to be tested, you ask me, did I have a covert test? What’s your foot traffic? You know, we’ve reduced all foot traffic by 25 to 30%. We’re extending our hours. Do you have a waiting room?


What are you doing? So make them feel safe for you. So going back to nowhere gyms, you know, nowhere is akin to a gym and you know, this whole argument about gyms. Can you open them up safely? Well, the problem is what financial model is going to make sense. If you reduce your foot traffic to 25%, you may be safe, but he can’t pay the rent. So that’s the problem. So the answer is you could safely go to a place. If Noah said, I’ll see two people an hour and you’re at opposite ends of the gym, but how is no are going to pay the rent with two patients?


It’s going to be $12,500 a session, ladies and gentlemen. So for those of you that are well to do, we’re on 38th, between fifth and sixth. I just want to say one thing before you go on you know, one of the things and we asked this question, one of, one of the things I love about the series is this is like allows us to tinker with our programs. So it’s like, we went, we had Rob caner here. Then we had cardiology. Then we had neurology. Then we had ream Shariah to talk about GI. Now we’re on the second round of


It may come after Rob caner, my God, what a hard act to follow.


Actually, I only, I only told Rob, Rob actually, Rob was thrilled when he found out you were on the board now. So yeah, I did make you come after Rob, sorry, but you guys were, were co co on the, on the other series. We did you know, I want to just say one thing, which is that, you know, each time we get, we, we ask the questions of different doctors and at different time periods. And it has allowed us with what we’re doing in our own lab to really evolve a treatment program. And if you guys were at bootcamp one Oh one the other night, which is now also on our website, you can watch it. Even if you weren’t there. It’s not just that we’re going to say, okay, well, this, this chest discomfort that you’re feeling is musculoskeletal without working it up.


So my feeling is always, is always risk stratification. Like I, to me, safety is my number one priority. I could say, thank the Lord. In 20 to two years at pulmonary wellness, we’ve never lost a patient, you know? And it’s because I put safety first. So if you’re having chest pain if you’re having something that could be related to your heart, then we have to check it out and we have to prove that it’s not your heart before we go forward. So I think of things in terms of heart, and this is what I’ve seen with COVID patients. And now we’re probably up to about 55 60 patients, but I view it in terms of heart. So let’s make sure your heart’s okay. And to me that doesn’t just mean an EKG. That means a halter monitor, especially if you’re having this up and down racing heart rate, it means an echocardiogram because with those two tests, we see the electrical, we see the, we see the mechanical and we see the circulatory aspects of it.


And then we go to brain. So are you having a clot? Are you having a bleed? And then we go to the other stuff, respiratory, but we don’t want to assume that you’re good, especially when a lot of these symptoms mimic things that could potentially be dangerous to you. So my question is always, did you have an injury? So in other words, did you have a lung injury? Did you have a heart injury? And now you’re dealing with the after effects of that. Do you have something that’s ongoing and current that has to be addressed? And are you at risk for something future? So with bootcamp, don’t just assume, Hey, I’m probably okay. And, you know, just cause you’re, there’s a clear testing method and there’s a clear risk stratification method to it. And that’s one of the biggest things we’re doing in our consults is we’re trying to help people navigate the system and say, Hey, you know what? I think you might ask your doctor if they would order this, this and this, because we don’t want surprises. We don’t want to find out, Hey, you know, we thought it was that burrito. You ate at lunch, but it’s really not. So


That’s the next generation of rehab is because it’s going to be remote. We’re not going back. The, you know, there’s, there’s, there’s going to be a huge footprint in rehab. And what we need now is for the tech companies to develop wearables that are cheap and can feed into dashboards. And so that knower can feel safe. Cause when, you know, when he’s in front of you, if you’re sweating profusely looking like you’re gonna faint, you know, you get a gestalt, right. You know, you got to look, you got to let you know, you got to look in their eyes. He’s absent that. And he’s absolutely right. We’re looking at doing MRIs on patients post COVID, the heart damage is more, more frequent than we thought. So, you know, is there some cardiac damage? How does, how, how does no, you know, you’re, you’re a little, you a little spot on a window, on a computer screen. He needs tools to feel comfortable that yep. I can push you around. You know what I would have done. If you were in front of me, I need to have you, I need remote monitoring. And that’s the next that’s teller. We have one Oh one, one Oh 1.1 or two.


No, you are going to Philadelphia though. But you know, people don’t realize this. Like, you know when, when we exercise patients at our rehab center, so we have an EKG on every patient all the time. So we’re looking at not just your heart rate, that you could get off a pulse ox, but we’re looking at the rhythm and we’re checking your oxygen every five minutes. And you know, there’s certain things like I liken it to like when I’m under water sometimes, and I get a sense, like, you don’t know what it is. You don’t see anything. You don’t hear anything. You just get a sense that there’s a shark in the area. Sometimes with a patient, you get a, I don’t know what you’re showing us. What does that watch? Apple watch. Okay. Next generation. I want to show you my view blow.


So anyway but the I, but the idea is we need these things and they’re there. Okay. They are they’re out there. But one way that we’ve we’ve, you know, cause we held off on, we held off on telerehab for many years. Why a safety? I didn’t know if we could keep patients as safe as we did at the center and be a, we didn’t know if we could have the same effect. Bootcamp has taught us that we can. And the way we get around pushing people as vigorously as we would, as if they’re in front of us is we lower the intensity, but we increase the frequency. So the key to bootcamp is that it’s a 42 day straight program. And guys, if you think I’m just shamelessly plugging, just, you know, it’s a free program. So it’s yours. If you want it. I’m not trying to get something from you. Dr. The Pala, can we go to some questions from the audience unless you have anything. Okay.


And any friends out there please shout out. I miss a lot of you. Shout it out. All right.


I see a lot of your friends. I see at least seven on here. I have bronchiectasis with an underlying NTM infection. Any idea of what the prognosis? Okay. Let’s not, let’s not go to a specific event. People ask this question all the time. I have COPD. I have pulmonary fibrosis. I have NTM. I have so on. And so I know if I get COVID, I’m not going to make it true or false.


All right. So I can tell you, I’ve seen both ends of the spectrum. I lost a 21 year old healthy boy. Tragic, you know, died up in Westchester. I was second consultant didn’t fit. And did he didn’t read the book? He was supposed to be fine. And then I got a phone call from a chronic asthmatic of mine who was on steroids for 50 years. I fought with him to get off steroids. He was 85 and out in the Hamptons, I got a phone call. He told me he’s got COVID. I said, okay, I hung up with him. And I said, he’s going to die. And I got in touch with his I hope manage with him out in the Hamptons at South Hampton, the hospital he’s home did great. So the answer is, you know, unless you’d read the book, we don’t know.


I’m sure there are statistical recurves and younger people do better than all the people. People we know the climate, the comorbidities, you’ve heard all the comorbidities. So there’s no question that if you, if you have bronchiectasis, you have a chronic lung infection. If you get COVID-19, you will probably have a rougher time with it. It’s not a guarantee you’re going to die. I have lots of patients. I had enough, I had a woman who I’d had a deal with her that once she hits a hundred, I’m going to cook for her. I love to cook. That’s one of my secrets at age 99, she got her Cobra infection. And I said, well, it looks like I got out of that one. I’m happy to say I will probably be cooking for her. Okay. Age 99 home. Bad COPD. So the answer is be afraid. Be healthy. No, no. Don’t be afraid. Be respectful. Yes. If you have a comorbidity, one of those lung diseases, yes. Take care of yourself. Ask the people around you to take care of yourself. So I don’t want to say be afraid, but be mindful. Certainly be careful. But you can survive it. And we’re seeing, particularly in this country, the younger people not getting away as free as some of the other countries did. So it’s not, it’s not a guarantee that being 20 is going to be okay to get away with it.


Yup. And one thing we say to our patients is don’t, don’t set the limit in your mind before your body sets it for you. Okay. Because a lot of times we have this idea. I used to have a coach to say, if you think you’re going to win, or you think you’re going to lose either way, you’re going to, you’re going to be right. Don’t, don’t quit. There’s plenty of time to be dead later. So we fight until, until the fight is over. So what about diocese and our gas exchange issues from lung damage? Are people looking at blood gases and what can we learn from that?


Right. So adolescence is, you know, the lungs of balloon. So it likes to be inflated. If you take shower, breast along will collapse and you can have portions of the lung that are what we say, look static, meaning don’t have air in them. And that was a big problem with the, with the patients sickly too, they couldn’t take a deep breath either with the chest pain or the lungs were restricted. So they developed radiographic evidence of that electricity, that impairs hypoxia, you know I mean that, that impairs gas exchange, that’s why pony, everybody knows about pony training was lay on your stomach. Okay. Easier said than done. It’s interesting, fascinating. Most people sleep on their backs. Some Americans, we tend to be a little bit overweight. So the big belly has gotten away, but simple act of lying on your stomach, improved at gas and change because you actually prevented some of that out electricity.


So adolescence is, was an important component of it. That’s where the yoga. And again you know, where Noah comes in, teaching people to stretch those lungs out, hold those breaths you know, blood gases, either painful. Have you ever had a blood gas? We in the hospital, we monitor them. It told us what we already knew. These patients were hypoxic and profoundly hypoxic. So we stopped doing blood gases. The sat monitors are good enough that we basically used as the sat monitoring. We didn’t use a lot of blood gas, you know, in the ICU we did because we could I think it tells you less than you think it’s really the, the SATs were all about it. And proning simple act opponent lying on your stomach was all directed at the concept of adult Lexuses.


What do you do if your cat scan showed ground? Let me back up on that a little bit. The other thing is, you know, a lot of people were given these kinds of incentive, spirometers. We, we use also the aerobic gun, some of the positive expository pressure devices, but positioning is so important. And like, for example, lying on your left side, lying on your right side. And Marianne later this week, or next week is going to teach about all these different positions and things we can do to open up the airways. What do you do if your cat scan showed ground glass opacity and the pulmonologist did not recommend any type of treatment?


Yeah, well admit the enemy and the enemy is me. I have a bunch of patients like that. I was, I told you I started again, I’m an academician as well. So I had somebody who was sick that ugly x-rays they got better. I wean them off their oxygen. I was like, gee, I want to know what your cat scan looks like. Now, three months later, I feel great. You know, again, are you climbing Mount Everest? No. Are you exercising? No. So I don’t know how great you really are because you’re just happy to be alive. So I get the cat you’re untested. So I get the cat scan and I get those ground glass opacities better than they were. So they’re clearly on the men. Going back to my black eye analogy. You, if I wait another couple of weeks, the group, you know, black and blue becomes green, becomes yellow, becomes normal.


That I just happened to get you when you’re moving from green to yellow. And if I wait another couple of weeks, you’ll get better. We just don’t know. So the answer is if I have a conversation with the patient, I do breathing tests if the beta tester stink. And if I walk on it, I often just take a people are grabbing by the hand, go a flight of steps. If they do saturate, I’ll say, you know what? You’re not as good as you think you are. And then we’ll have the steroid conversation and understanding stewards are not chicken soup. And so, and it’s completely made up where I just told you has no basis in, you know, double blind controlled trials. It’s someone who’s been doing this for a long time saying I don’t like when I’m looking at. And I think it’s inflammation. And I think if I give you a steward of my, it might help notice. I gave you a lot, a lot of disclaimers. It might think it might, you know, a lot of disclaimers in there. Right.


Did you say that you grabbed the patient by their hair and drag them up? The steps that’s that’s that’s good. I thought that was barbaric. Oh my God. Okay. How often, how frequently should someone get a cat scan or, or chest X Ray?


You know, it’s, I think it should be simple. I think it should be symptom-based depends on where you’re coming from. You know, if you had the sniffles and you got better and you’re back to your normal life, you don’t need an X way at all. If you’ve got persistent pulmonary symptoms, if your exercise tolerance is down if you had a really, you know, how did I look? I saw our extreme spectrum. By the time he got to me, I wasn’t seeing healthy people, right? So I saw a lot of very sick people. I looked at a lot of bad x-rays so I got early x-rays because I needed to know they were heading on the mend. So I would argue those patients where they were on oxygen. They weren’t doing well. They had an X Ray that gave me nightmares. I would get x-ray in a month.


And if it was getting better, I’d get another x-ray in a month. And then if it’s stalled, I get a cat scan and say, we’re all we some people, if the x-ray looked really normal about a month, but they still, if I dragged him by the hair up the stairs and their oxygen levels dropped, then I might get a cat scan to see what was going on. Because even though the x-ray looked okay, the fact that they’re also level dropped when I walked them up, a flight of steps suggested that maybe something was going on. The problem with all of this logic is yeah, I can describe stuff. And this is why I said to you in the beginning, we’re still in the inventory. We’re still collecting information and collecting data. So you’re gonna, now that I’ve found something, what do I tell you?


And I have very little guidance to say, I don’t know what to do with that ground glass and tacitly, if you’re symptomatic and you and I can have an informed discussion and we discussed the pros and cons of stewards, then maybe we’ll go for it. But it’s a partnership. And I’ll be the first one to tell you, you know, this is not my decision. You and I have to decide what are you more afraid of? Or you’re more afraid of the steroids, or you’re more afraid of being stuck with something that’s not reversible. Cause I don’t know what the hell I’m doing. I’m just bringing years of experience to you. And I’m trying to co manage with you until we get better data. We get better information.


I dunno if you feel the same way I do. But I feel like for so many of these patients that were sent home, it’s like at any other time in history, they would have been in the hospital. They would have been in the, in the ICU and they were kind of sent home for months to fend for themselves. I wonder how much that’s contributed to this sort of long haul or sequella.


Yeah, I think it’s absolutely true. I mean, you know, if you think about, I mean, I, or you know, those, I used to tell people every day in a hospital was two days a week, right? It’s just, you know, you lose immediately, you know, gravity is your best friend, just being upright. You build muscle tone and fighting. You’re building bone gravity is your best friend. People old enough to remember when the astronauts used to circle in space when they were land and they’d got all, you know, they land in the ocean, the boat would come and pick them up. They had to take them off in stretchers. They could not stand because of the zero gravity atmosphere. They lost all their muscle tone. So the patient has been sick in the hospital for a week, not eating chewing on their own muscles. They have no condition.


And then you throw them home and say, good luck, you know, not going to work. And so I mean, you know, I’m at an age right now when I get out of bed, you know, I’m aching and creaking and cracking until I start moving. So do that for five days, you know, and try to get up and walk. It was, it was a national crime. It demonstrated one of the major gaps. Those of us who were in hospital care, I knew for a long time, there was a gap in our healthcare system, acutely ill. You’re great. If you have a either a surgical lesion or something that’s amenable to acute rehab, you know, hip fracture stroke, you go to acute rehab, you’ll get better. The gap was, you’re not sick enough to get acute rehab, but you’re, you know, you’re not well enough to do it on your own.


So you get one hour of rehab, three times a week at home, are you kidding me? And that wasn’t a old days. Okay. That’s when we actually, you know, we were able to do rehab at home. So this COVID-19 demonstrated a huge gap in the rehab space. Cause there’s no financial reimbursement for it. People like, you know, Noah labored out of love to get this done. Pulmonary rehab particularly has always been the orphan child to rehab. And now we have to figure out how to deliver to the home. And that’s the challenge is they’re get more rehab at home.


You know, if you you know, if you had an idea, anything that, that reminded, you know, like rhymed with like a moot stamp or something like that, like just feel free to say


So [inaudible]


Yeah, no, no, I’m joking. I’m joking. We’re going to go to the speed round. Okay. I had clotting three months post COVID. Are you seeing a lot of clots in people months in and not necessarily at the onset? So in other words, they didn’t have clots early on. Should they be worried later on?


We all are it’s resort in the, in the, in the immediate postop. I mean, in, in, in media post hospitalization, someone came in, they were sick. Again, we figured it out a little bit late. We weren’t necessarily checking D dimers or we would check it the dimer, which is a blood clotting factor. We’d give them anticoagulants, say our two weeks is enough. Send them home on a no act like Eloqua. This is an elbow for two weeks. So that’s all you need. You’re better. The patients got better and boom, six to eight weeks later, they came in with their blood clots. So the answer to that, the short answer to that question is yes. I don’t think I’ve seen it three or four or five months later, unless what’s a risk factor for blood clots sedentary. So if you were so weakened by your illness, that you have become sedentary, then you might not be getting it from the COVID, but you’re getting it from just being sedentary ankle.


And, and you know, another thing is that for a lot of people with the dysautonomia that stand up and all of a sudden they get dizzy and their blood pools in their legs. They’re not going to be spending a lot of time, you know, standing up. So what happens is, you know, one of the best ways to prevent blood clots is the muscle pump of the calves. So if I stand up and I’m like, Whoa, I better sit back down. That’s dysautonomia training. So that’s what, that’s what this is all about.


Trash hole to keep we’re extending anticoagulants. I tend to go swimming. No, contra-indication again, anticoagulants on chicken soup dealer. You know, if I could extend it, if the person wasn’t at risk, I would go longer rather than shorter. But again, they’re not, they’re not chicken soup. So you have to respect these drugs. How long do you think


The virus stays in your body after you contract it? Or let’s say after you test negative


Well controversial. They’re all these long persistently positive patients meaning I’ve had patients test positive 60, 70 days after the infection. That’s probably dead virus. The test we have, the PCR based testing is very sensitive. So you can test positive for a long time. The, the real test is a little bit too quiet to be, to answer this question. If we took this, the swab from those patients were persistently positive and try to infect the cell. It’s not infectious. So that, that particle. So what the CDC says that 10 days after the onset of your illness, and three days after resolution of your symptoms, you are no longer infectious meaning you’re no longer shedding virus. So one more time, 10 days from the onset of symptoms, three days after your last pulmonary respiratory symptoms like fever and cough you are no longer shedding infectious virus and you can go back to the workplace.


So you may test positive and you may test positive for the next 60 days. You are not infectious. That’s a different question. Then we know there are certain viruses that live in the nervous systems. The classic one is shingles, right? Chickenpox those with you. And it can be reemerge, you know, 20, 30 years later, we don’t think this far as does that. We think that there, the immune response that the virus triggers may stick with you forever. A lot of water immune diseases work that way. A lot of water, immune disease diseases, stars, the virus tricks your immune system to go after it, but it was hiding under your under normal tissue. So now your body actually thinks that your normal tissue is, is bad, but it’s because the virus hijacked some of the antigens and it’s called it’s called mimicry. And so therefore it’s trying to hide in your normal tissue. And when your antibody responses came, it went after normal tissue that can last for a lifetime. So again, very convoluted answer to you can be positive for a long time. You’re probably really only infectious for 10 days after onset of symptoms. And three days after you no longer isn’t, you’re no longer symptomatic.


That sounds like a trust fall to me. That scares me. I gotta be honest. It’s it’s scary. What, what do you, what do you say to people who say that they are too sick to wear a mask when they go out? Yeah.


I’m probably gonna get some screams about this one. But number one, there’s lots of data out there that demonstrates that carbon dioxide does not go up. Oxygen levels do not go down. So physiologically nothing bad’s happened to you. If you wear a mask, not in a, I’m not talking about at 90 fives, they’re a little bit tighter. There’s no question. There’s a claustrophobia associated, wearing a mask. Okay? Your nose breathers. 80% through the nose, 20% through the mouth. Why do people feel short of breath? When I got a stuffed nose, because most of our breathing actually goes through our nose. So if you have a cold, there’s nothing wrong with your lungs. You have a cold, you have a runny nose, right? But you feel crappy and you feel like you can’t breathe, but there’s nothing wrong with you. So, but you feel badly.


And I’m not saying that’s not, that’s not unpleasant, but there’s nothing bad happening to you. You just don’t feel good. So if you have a social responsibility, there’s almost no one who’s too sick to wear a mask. They may not feel comfortable because of the claustrophobia. You may have to work a little bit harder because you trying to breathe through your nose. It may not be comfortable. Your blood gases are not changing. You may be a little bit slower. I would argue that’s okay, because you’re protecting, remember you have social responsibility, you protecting your neighbor. All of these are for the cloth mask. All right, I’m not talking about in 95 and 90 fives, a tight mask. They they’re the ones you use to protect yourself. If you’re going in. Number one, no one hears me wearing it in 95 and 95 is for healthcare.


Workers will be exposed, you know, with a shorter event, 95 to the end, 95, being safe for people who are going and actively taking care of Colby patients, where they need to protect themselves. So in 90 fives, a tight CO2 can go up in certain circumstances. Oxygen level is actually still pretty well preserved healthy people. So the end 95 could be a challenge for people who have hypoxemia. So that’s a different level. So I would say, but as I said, you shouldn’t be wearing a 95 anyway, unless you’re a healthcare worker or you can avoid an environment where there are other Cobra, positive patients. So God forbid you’re home with someone who has covered and you might want to wear an a 95. But in general, or if you’re allergic to the mask, that’s the one when I come up with, right, is if you have asthma and you’re allergic to the mask, then you’re probably too sick to wear a mask. So there probably are certain cohorts where you’re, if you’re allergic to material, then you might have a problem. But in general, few and far between I’m ready to be yelled at if anybody wants to yell at me about that. But


I also feel if your argument is, is that you’re too sick for a mass, then you should really be concerned about, you know, being sick, maybe too sick to be exposed, you know? And it’s it, you know, very often on YouTube, the ones that we see saying that they can’t wear a mask is are the ones screaming at the top of their lungs. And I know there’s nothing wrong with their lungs. What about face shields?


Yeah. So, you know, our face Sheryl’s eyes are definitely a portal of entry. So for, you know, it’s droplet nuclei with coffin. The eyes are a portal, meaning it’s a mucus membrane. So governor chromo actually came out with a mandate that all healthcare, where if you’ve been to a doctor recently, you’ll notice they’re either wearing face shield or goggles because governor Cuomo has come out with a mandate that all health care workers wear some sort of eye protection. So not a bad idea. Again, it’s in an environment where you can’t control, who’s coughing at you and who’s hacking at you. So it’s not a bad idea


In, in, not in instead of a mass though, right?


No, no, absolutely not. It’s again it’s mostly in the hell, that’s the major portal of entry of this virus. So if you have a choice between a mask and a face shield, bask wins 100% of the time, the face meal the face mask or the Goggle is really meant to protect your eyes. And glasses unfortunately are not good enough. They helped a little bit. There’s a lot of room around the glass. I see a lot of you wearing glasses, get it safe. If you’ve got to go out of the environment you, you need either goggles or face shield, you know, again where are you going? Right. If you’re going, I would not go on in some way without wearing official.


I have issues when I talk my lungs get inflamed almost and keep in mind, this is a speed round. I have issues. I have issues when my lungs get inflamed, almost immediate. When I talk, my lungs get inflamed almost immediately for weeks. Now, I have been severely limiting talking. Are there strategies to help increase my endurance with this? The answer is yes. Marian Machlis knows them all bootcamp prints. Do you think the Zephyr valve is useful for someone with severe emphysema and COPD? Maybe? I got a PE in month, three of recovery. There were four of us in one of the groups who got PAs the exact same week. All of us were about three months into recovery. Any comment on,


Yeah, I’ve definitely seen it as I said, most of the recurrences I saw were post-hoc post hospitalization where I think we stopped the anticoagulants a little bit too early on. Definitely have heard that story. So it’s not unique. It’s, it’s not the most common. And then what I would do is go back and ask what, what were your, what, what risk factors at that three, four month period where you not mobile, where you w what kind of status, where if you were bed bound, that’s a, this factor all by itself. So I would go back and ask you that group when you ambulatory, if you were fully ambulatory and back engaged in life, it’s unusual happens for sure. But it, usually


The two times I went to the ER, my Oh two, was it a hundred percent? I was having Disney problems. I’ve had PFT echo and stress test. I’m slowly getting better. No explanation of why I feel short of breath. What are possible explanations?


Yeah. So those patients, you know, I mean, you have to dig a little bit deeper. You know, chest wall is a big one. I sort of gave you the analogy of, if you can’t take a deep breath, if you’re constricted that’s a big one. It has no good objective test. You may test out perfectly normal on those in those settings the D the dysautonomia, maybe another explanation of what’s going on there. Did I hear stress testing those stress tests?


Yeah. echo PFPs stress test normal.


Yeah. So, you know, that’s just to heart and lungs, functionally on normal, shortness of breath is a funny symptom. You know, you get in the elevator and you get claustrophobic and short of breath. Is there anything wrong with, you know, my whole year in a bear hug, there’s nothing wrong. Your lungs, the heart. Are you short of breath? Yes. If I punch you in the chest or you’re short of breath. Yes. If you have a panic of reaction, anxiety, are you sure of breath? Yes. The brain is kind of dumb about interpreting shortness of breath. So it’s difficult. What those tasks can tell you that looks like your heart and lungs seem to all be working properly. The mechanics have not been assessed. That’s the chest wall thing. And there was about two. So I would say get into your, get into, on Noah’s hand you over there to learn how to breathe properly and see if that helps you improve.


Well, I got to tell you, I never, never knew you were this violent before, but you’re punching people. You bear hugging them. You’re dragging them up the steps by that hair. I’m staying away from you from now on


I’m Italian. I’m a tie in man. I I’m real. I do. You know,


Not smiling at all. Don’t worry. It’s not going to break your face. All right. You got to have a little fun here and there. Okay. So Ken pneumonia resolve on its own without antibiotics. Yes. To get a flu shot, we need to be exposed to the medical system after cocooning since early March, you still think flu shot.


Yeah. I, you know, I’m going to be an advocate of flu shots. Probably gonna give it earlier than I normally would have, because I don’t know what’s going to happen in the fall. So normally I tell people in November, because the flu shot won’t last for so long and we’ve had long flu seizes the last five years. So I’m going to probably make the recommendation to go a little bit earlier this year, probably mid to end of September while the numbers are still good. And in the Tristate area, because I don’t know what’s going to happen. School opening is going to be an interesting exercise.


Yeah. Incidentally, you can get a flu shot at the, at the, at the, at the drug store. I mean, I’ve got a flu shot and I in a little apothecary in Woodstock, New York, no one else was in the store. So choose your flu shot, you know, carefully. So,


So now you give me a second because I just realized I’m sitting in the dock and I turn on my lights. Okay.


Now give me some time to tell some more jokes. I could tell this crowd is an easy crowd. Let me just say a few things. So shortness of breath chest discomfort, coughing, mucus inability to change positions, any symptom that you’re having. We’re seeing a huge variety of things in a wide variety of patients. And it’s like, you guys are consistently inconsistent. So the only consistency is that it’s like every person kind of reaches into a bag and comes out and it’s like reading tea leaves. It’s like, you know, everybody’s a little bit different. And so when we talk about certain things, understand that there’s no one answer that’s going to fit everybody. And when we are evaluating patients and when we’re you know, doing with, but some of these take two hours, somebody take two and a half hours, because what, you know, look around the screen, you may be every person on this screen may be short of breath and it may Patricia.


But, but, but Tricia, I know you’re not yawning while I’m giving an inspiring speech. Are you alright? Come on shit. But the idea is that, you know, you could all be short of breath for a different reason. And so there’s no one size fits all. And one of the things that you know is really important is that in addition to, you know, bootcamp is not just like here, follow these instructions. One, two, three, four, five. We try to teach you about how do you interpret things on your own? How do you know what’s okay. It’s like, you know, they say that you could teach, you could give a man a fish and you feed him for a day. We want to teach you how to fish, but also teach you when is something okay? When is it not? Okay. And and that’s it.


I think it’s time to say goodbye to all our company. I want to just say one thing about dr. Depaula before he goes you know, first of all, I love this, man. I love you, Luke, because, you know, in addition to being a brilliant doctor, I’m not going to propose you. Don’t don’t get embarrassed, but you know, the things I’ve heard about, you know, during this pandemic, I’ve heard you say to people, don’t worry. Now your daughter is my daughter. I’ve heard people say that about you. I’ve heard people say that at the height of the pandemic, you said, don’t worry if they need it on me, a guy call me at any time. You know, and that’s, that’s my, that’s been my experience of you too. So it’s, it’s your brilliant doctor. You’re, you know, obviously a very debonair dashing guy. But you know, it’s your heart that I love. And it’s, it’s, it’s, it’s really I’m so proud to be friends with you and the fact that you’re on our board, I mean, I’m so appreciative of you as a human being, and I’ve learned so much from you over the years. So I really, I thank you for being here tonight and


Thank you for that. And I’m looking at your group of patients and I, you know, I’m sad to say I see some pain there. You know, and I, I feel that, and I hope that your pain will get better over time. I’m just the process of reading a book about Winston Churchill and the bombing of London. Some of you may be of the generation that lived that I wasn’t I found hope in that because other generations have gone through terrible deals. And while reading this book about the bombing of London, about the scarcity of resources, about the fear of the post traumatic stress there’s another side to this and we’re we together. And that’s why he said, you know, I adopted people as they went along there. We will come out of this. There is another side of this, you and I see the pain.


I see the suffering. There are please be helpful. This is a little bit like the Manhattan project. A lot of people are working on cures or working on treatment strategies. So you know, it’s going to be people like you who are going to teach us, you’re going to take us to school with your symptoms, your reporting of your symptoms. And hopefully you’ll take us to school and we’ll come back with the answers. So I’m honored to be here, a knower. You can tell it to mutual fan club because I’ve known him for years and you know, he’s been my secret weapon when I have patients. I can’t take care of you know, they, they think I’m brilliant only because I sent them to nowhere.


So I think what he’s trying to say is that once they meet me, they think he’s really smart in comparison. So now I know why I’ve been sending these patients to me to make you look smarter. So can I ask you just one more question? What about people who have fevers like weeks and months later?


Oh my God. I’ll tell you about one patient. I had that with a nurse who was fed every day, there were 103, and we had a deal that you would text me twice a day, morning and night, because I just said, I’ll wait this thing out. Right. I did three good out of 101 on like, yeah, next day, 103, you know, this went on for weeks and weeks. And I said, okay, Lou, you just speak stupid here. You’re missing something. I’d send her for blood work. And there was okay. I send it for an X. Ray was okay. And she would send me this. We did this twice a day. You know, she had marching orders twice a day. I got these fever curves. And I call her up and say, okay, what am I missing? And it turns out she was a nurse and she had come to the Philippines and she had malaria a million years ago.


And I said, Oh, well, it tested for malaria. And so finally I just gave up and I gave a doxycycline and fetal went away. And I have no idea if that had anything to do anything but months, literally months of 101 to 103. Right. I got somebody telling me here five months when they so we don’t know what that is. I mean, is this part of that auto-immune phenomenon that and I guess the answer is yes. We don’t think it’s persistent virus probably deserve look and say, am I missing something? Self doubt is a good, is useful in your doctors. So I have, you know, I think at some point that somebody is outside of the box, I have to start doubting myself about the diagnosis or what’s going on. That’s what I did with the doxycycline. You know, she also was in long Island as a baby.


She had line, you know, it’s so self doubt. We get trapped in our own head sometimes, right? We make a diagnosis and then we live with it and we, we hold onto it till we die. And what I’ve learned is sometimes when I can’t figure out, I’ll say, you know, when you go see my friend and they’re like, what are you trying to get rid of me? And I’m like, no, but I need a fresh set of eyes on you because I get you get stuck in your own head where human nature. And so I would argue maybe it’s time to get someone out, to look at you, not because they’re doing a bad job, but you know, we get stuck in our own heads. So persistent fever is a problem. I see it, thankfully, not very common. Eventually they seem to go away. But it’s one of the more frustrating ones.


If I’m hearing you correctly. What I think you were saying was she’s from long Island, you gave her a mimosa and miraculously, the fever went away.


I took them all. So she took the boxes.


You both got better. All right, Luke, thank you so much, ladies and gentlemen, all of our previous webinars are on our website right now. This one will be up in the next two days. We will see you Sunday night. And I’m going to unmute everybody that you can automatically tell dr. Depaul,


Thank you.


And I’m just going to say, Lou, you know, I assumed, I assumed you were sending people to me to make you look good, looking in comparison. I didn’t realize that intelligence thing. You know, now I’m glad you all feel, but I feel much worse about myself after this meeting. So little, thank you so much. This was awesome. And ladies and gentlemen have a great night feel good. We’re going to get through this. Hang in that state. Tough.


Thanks to both of you guys. Thank you so much. Thank you so much. No, you’re wonderful. Look up, mention the [inaudible]


Ladies and gentlemen. We’ll be here all week. Tip your waitresses,


Got a fish.