When patient data or medical conditions don’t quite add up, I default to further investigation. For instance, when a healthy person who has never been to the ER arrives in an ambulance complaining of chest pains and initial lab results including an EKG shows nothing is wrong, I’m still suspicious. It raises red flags. What is missing? Sometimes it just takes ordering the right test or sometimes just admitting a person to the hospital for further investigation. No one wants unnecessary tests or hospital stays. Nor do they want the proverbial needle the haystack overlooked.
Medicine isn’t always about routine tests and standard lab work. Sometimes, it’s following a hunch or inspiration or seeing when 1 + 1 doesn't equal 2 that I need to ask a different question even though it may not be clear what questions still need to be asked. Another example: if all a patient’s blood tests come back fairly normal but a single vital sign such as temperature or heart rate are noticeably off, there is more to the story. In such cases it could be an early infection, ranging from pneumonia to appendicitis. It could be an underlying autoimmune or neurological disease that begins undetected, slowly, insidiously.
Practicing medicine is more than just detective work. Diagnosing a patient’s illness can be serendipitous or even just following a gut feeling. It can require matching seemingly unrelated stands of data or symptoms. It requires more than knowing the answers to the equation, it requires figuring out what the equation is in the first place. Practicing is more than being a good problem-solver: it can be lifesaving.
I saw a 10 year old boy not long ago in our community hospital ER. The boy had crashed his bike at a skatepark the day before. When he arrived at the ER a day later, he was complaining of both abdominal pain and pain in his left shoulder. Minor pediatric trauma is a common reason for ER visits. At first blush, he seemed to have only minor bumps and bruises. Initially, the x-rays ordered in triage of his shoulder and abdomen were totally normal.
After getting these results, I walked to the examination room and he and his mother were planning to say ‘Everything looks great on your x rays.’ Then, discharge him. Immediately, I knew something more was wrong. He didn’t have any pain when I moved his shoulder. And, while his abdomen was tender, there were no outward bruises or scrapes. Following a hunch, I did a bedside ultrasound of his abdomen. There It was, the missing link! The ultrasound showed unmistakable signs of internal bleeding. Immediately, I ordered blood work, a CT scan, and called the trauma surgeon. He had a ruptured spleen. It was causing what is known as “referred pain” to his shoulder. Referred pain can occur anywhere. It is when one part of the body refers or sends “pain messages” to another part of the body. It is hard to diagnose the underlying condition because there is no obvious connection between the body parts, no distinguishable patterns, no clear linkage. Checking further, I found this boy’s blood count had dropped by 50%. He urgently needed a blood transfusion and surgery to remove his spleen. Without these immediate interventions, he could die within hours.
I didn’t do anything extraordinary. He was in real pain despite the initial evidence that suggested everything was fine. Except somehow things didn’t quite add up. So, I followed a hunch. When something doesn’t quite seem right, there is always a reason. Uncovering the explanation isn’t always easy, but there is always an explanation. Always.
Today, there are things that don't add up with what we know about the novel coronavirus and the respiratory illness it causes. There are a lot of unknowns. Viruses can be tricky for sure. Viral liver infections and HIV can cause seemingly mild initial symptoms and even lay dormant for years with no outward symptoms for a time. They will wreak havoc later on even when they don’t initially cause problems. Other viruses cause severe disease that have a high risk of mortality. Hantavirus and ebola are two well known viral infections that cause a high risk of severe sickness and even death when contacted. Fortunately, they don’t occur very often in the United States.
Early reports show three seemingly unrelated characteristics of COVID-19 that don’t fully add up. COVID-19 can be asymptomatic in as many as half of all people who are infected, but cause significant symptoms for more than 10 percent of its victims and be fatal in 1-3 % of the population. Further time, testing, and investigation will reveal information that will seem obvious only in retrospect.
It now appears the root cause of patients with high mortality rates from COVID-19 aren’t just age related or even stemming from chronic respiratory diseases as originally supposed. Rather, these two other very real, but seldom acknowledged “epidemics” that have been raging for decades are now exerting their ugly influence on us and our medical management system. These silent killers--well known but often ignored-- have teamed up with COVID-19 to create “a perfect storm” of health care havoc, pain and misery in the United States. These long standing twin epidemics are separate but related and unlike COVID-19 didn't come from China and have very common names: Inflammation and Obesity.
“In medicine, believing something is true is not the same as being able to prove it. Because the idea that inflammation—constant, low-level, immune-system activation —could be at the root of many noncommunicable diseases is a startling claim, it requires extraordinary proof.” (Red and Raw-HOT, Harvard Magazine Shaw, Jonathon https://harvardmagazine.com/2019/05/inflammation-disease-diet)
Chronic inflammation, due primarily to lack of exercise, leads to higher levels of oxidative stress on the body. This oxidative stress, in turn, leads to heart disease, dementia, diabetes, depression, and even some forms of cancer. Coincidentally, in December 2019, as the current COVID epidemic was just beginning, a collaborative group of scientists published further scientific proof that chronic inflammation was a preventable epidemic that needed immediate attention. Without massive attention and sustained action, it would further erode the effectiveness of other preventative health initiatives, strain our already overburdened healthcare system, have a debilitating impact on millions of individual Americans, and unnecessarily weaken our economy. (Furman, D., Campisi, J., Verdin, E. et al. Chronic inflammation in the etiology of disease across the life span. Nat Med 25, 1822–1832 (2019). https://doi.org/10.1038/s41591-019-0675-0)
The other major epidemic is not as well concealed as inflammation, but is equally ignored. Obesity has spread rapidly and quietly in this country over the past 30 years. It is estimated that it affects more than 30% of the population. Obesity is not just being a few pounds overweight, but instead its official definition from the National Institute of Health is being 30 pounds overweight. I have seen patients as young as 6 years old with morbid obesity, a BMI (or Body Mass Index) greater than 40, and already showing signs of type 2 diabetes. Obesity affects young and old, rich and poor, men and women. Obesity leads to long term, expensive health conditions and is a main contributor to the leading causes of death worldwide. It is a major contributor to cardiovascular disease-- including strokes and heart attacks-- as well as kidney and liver failure. In almost every case, obesity can be traced back to lack of exercise and poor dietary intake. It is preventable.
Combining these two long standing and yet patently ignored epidemics--inflammation and obesity-- with the novel respiratory virus simply spells trouble. Big trouble, as we are seeing daily in death rates and hospitalizations across the country, along with an economy that is wobbly and teetering on the brink of a major economic depression. Any minor illness, left unaddressed, results in further deterioration in both individuals and groups. A cold can turn into pneumonia, infection from a cut can result in gangrene, lingering oral bacteria can cause periodontal disease. Widespread obesity and unaddressed inflation intensify nationwide viral infections like COVID-19 with devastating global economic, social, and environmental consequences. consequences. Initially it seemed that covid had a higher risk among the elderly. Then reports came out that increasingly higher numbers of younger patients could unexpectedly have severe disease.
The CDC website warns “people of any age who have serious underlying medical conditions might be at higher risk for severe illness from COVID-19.” Among the underlying medical conditions listed: severe obesity, diabetes, liver and kidney disease. No longer does it seem that COVID-19 targets the older population nor those with respiratory conditions. In fact, asthma patients, once thought to be at very high risk, surprisingly are almost unaffected by COVID-19 unless there is also some additional, underlying medical condition.
COVID-19 is a very real pandemic. No doubt, it will continue to receive all the press and most of the blame for the current crisis. Likely, it would be far less devastating and have much lower impact on the country if we had heeded earlier warnings messages about healthy eating and exercise instead of remaining on the couch, bingeing on Netflix, and eating a double meat cheeseburger with biggie fries delivered by Ubereats.
We are not just fighting COVID-19. It would be a mistake to see the current crisis as dealing with only one epidemic. It would also be a mistake to long for normal, everyday activities if that means returning to sedentary living. There will be other viruses in the future just as there was SARS and MERS in the past. No doubt future viral pandemics will have a similar, devastating impact on those with preventable obesity and inflammation. Somehow, we must see these underlying conditions for what they are: very real, very destructive epidemics. We must summon both our individual and national willpower to address them in the same way that we are now fighting COVID-19.
COVID-19 can be a nationwide wake up call. We can prevent future viruses from having such a destructive impact on our lives, our healthcare system, our economy. We can pay attention to these three intersecting and overlapping epidemics. We can “flatten the curve” not only for the coronavirus pandemic but also for obesity and preventable inflammation epidemics. The venn diagram shown above paints a more complete picture of our national crisis: not one epidemic, but three of them.
We must summon the courage individually and collectively to resist all three epidemics. The huge national support for lockdowns, stay at home directives, and self-quarantines measures shows that we can work together to make a difference. As simple yet effective as these measures have been, the path forward to address obesity and preventable inflammation are just as simple and just as easy. We can start by putting on a pair of tennis shoes and walking 5,000 steps today. Then, tomorrow eat an apple or carrot instead of a twinkie. Start somewhere. Take these small steps. Encourage your neighbor. We can do this together. As Neil Armstrong said when he first stepped out of his space capsule and onto the surface of the moon: a tiny step for man, a giant leap for mankind.
Flatten the other epidemic curves. Eat better, exercise more, and, oh, by the way, wash your hands.