Mechanical Ventilation Was Not The Proximate Cause of Death In Early Covid - Part 3

Mechanical Ventilation Practices During Early Covid In The U.S
 In Part 1 and Part 2 , I made arguments that most of the U.S hospital deaths early in the pandemic stemmed from the lack of corticosteroid treatment (or any treatment) being offerred to patients which resulted in unprecedented hospital mortality rates.
 A few key points to further support that argument:
 Prior to Covid ever happening, most if not all patients who died in the hospital did so on a ventilator, but for some reason, in Covid, many began to blame the use of mechanical ventilation as the proximate cause of death.
 Dying on a ventilator has always been the reality of hospital deaths. If a patient develops a life-threatening illness and the treatment approach doesn’t work or the patient presents in too advanced of a state or is refractory or poorly responsive to treatment, they deteriorate onto a vent and then deteriorate towards death on a vent. Pretty standard trajectory for any hospital death. Doesn’t mean the vent "killed" them just because they died on a vent. Nearly every patient who dies from critical illness does so on a vent. Conversely, anyone with severe critical illness who responds to treatment will be successfully removed from the ventilator. Ventilators are support systems, not treatments, and do not appreciably injure lungs when used correctly.

 Mortality rates began to plummet after corticosteroids (and other immunosuppressives) were systematically adopted despite the continued use of ventilators

 Now, I am not saying that mechanical ventilation was not inappropriately used, nor that it did not contribute somewhat to increased mortality rates, but the mortality rates were much, much more driven by the lack of effective treatment, again, as explored in Part 1 and Part 2 .
 Those posts largely argued that the systematic use of “supportive care only” practices and avoidance of corticosteroids was the principal cause of mortality in the “first wave.” However, there were multiple other contributing factors which I did not focus on. One reader wrote to me privately (an experienced nurse) and shared with me her traumatic memories of that time, reminding me about the lack of properly trained nurses and physicians in charge of the critically ill and the systematic avoidance of going into patient rooms by not only those staff but also consultants, radiology and EKG techs, ultrasonographers, physical therapists etc. Also the ever-shifting and burdensome PPE policies making nursing care more difficult than it needed to be.
 Compounding this situation was the lack of family visitation. That probably outweighed the harms of all the rest, as families are, and have always been, a patients best advocate when critical information about a patient is overlooked, or critical aspects of their care are underemphasized or flat-out forgotten, or the physician is not particularly skilled, all events which are unfortunately not rare.
 But mechanical ventilation use was also a contributing factor, albeit in my mind, a minor one, so lets analyze the issue of “inappropriate use of invasive mechanical ventilators.”
 The inappropriateness that I observed was due to “too early” initiation in the course of a Covid patient’s illness. However, again, even if “too early” mechanical ventilation caused harm (and it did), if effective treatments had been offerred after intubation and admission to an ICU, death rates would have been far far less.
 The reason for this is that if you do not treat critical illness correctly, patients almost uniformly die from critical illness (conversely, many outpatient infectious illnesses are easily handled by our immune system or simple anti-viral treatments, but once in critical illness (i.e single or multiple organ failure), it becomes almost impossible to recover without specific and often aggressive therapies. This is one of the reasons why I liked critical care so much, sometimes described as “general medicine on steroids.”
 So, what caused the proliferation of early mechanical ventilation?
 Some argue that it was due to perverse financial incentives that benefitted the hospitals bottom line or that providers around the world wanted “to kill patients.” The latter is still absurd to me (at least the idea that the average physician did so willingly and consciously) and financial incentives such as highly increased reimbursement rates for patients on ventilators have been a reality for long before Covid ever happened. I would instead argue that intubating early was not from explicit policies recommending early intubation but more from a lack of explicit policies or teaching which warned away from early intubation (same thing perhaps?)
 But here is another point - unless you have been in a situation where a patient under your care is exhibiting declining oxygenation or increasing respiratory distress despite often maximal oxygen support, you cannot know the stress of that situation/decision in terms of having to rapidly balance the competing risks, benefits, and alternatives in deciding for or against initiation. It is a difficult decision in many types of respiratory failure, but especially so in a novel disease whose trajectory or responsiveness to therapy was initially unknown.
 Being on the front lines, I saw early intubation being practiced out of ignorance and fear rather than policies or financial incentives. I should know because I was the Chief of the Critical Care Service at a major academic medical center at the time (the University of Wisconsin).
 I was also the Medical Director of their Trauma and Life Support Center (we called the center “the TLC” for short but basically it was just the name for the main ICU at UW). I was also one of the more experienced ICU clinicians and known as a “vent geek.” In fact, one of the reasons why I became a pulmonary and critical care doc stemmed from an early fascination with operating mechanical ventilators.
 Consequently, I long taught taught the management of acute respiratory failure and mechanical ventilation to medical students, residents, and fellows. One of my core teaching points focused on identifying the optimal timing for the decision to transition a patient to a mechanical ventilator.
 Since I suspect many of my readers are “geeks” like me, I decided to pull some slides from one of my old lectures on acute respiratory failure below. I think they cover all the factors that must be considered succinctly (sorry about all the acronyms, but if you want to decipher them as you go through the slides, they are; ARF : acute respiratory failure, NIV - non-invasive ventilation (BiPAP machines), CHF - congestive heart failure, PNA - pneumonia, HFNC - Heated high flow nasal cannula, WOB - work of breathing, AMS - altered mental status, OHS - obesity hypoventilation syndrome, ABG - arterial blood gas).

 From the above, guidance on how to make the decision is simple conceptually but stressfully complex in practice. Basically, the timing of transition to mechanical ventilation is that you always wants to shoot for “not doing it too early” while also “not delaying until too late.” See how simple that is?
 The reason for this approach is that mechanical ventilation and ICU care are “double edged swords” in that they can absolutely be life-saving when truly indicated (benefits outweigh risks), but their use typically requires heavy sedation and immobility, two factors that weaken the body’s ability to maintain strength and prolong recovery.
 Although it is true that mechanical ventilation, when used inexpertly, can subtly and progressively worsen lung injury, I do not think this was a major factor. Respiratory therapists (who, in my opinion, really “run” the ventilators in most hospitals) generally follow protocols which avoid such harms. And thats an entire other rabbit hole which I won’t go down right now - meaning that although RT’s follow safe protocols, they generally do not have the facility, expertise, or insight to know when a non-protocolized approach is optimal for a patient, something I have tried to teach them my entire career.
 Further, all ICU’s aim to remove patients from ventilators as soon as possible because every extra day in the ICU sedated and immobile worsens prognosis and consumes expensive and limited resources. Which is why you want to avoid doing it “too early.”
 The worsened prognosis stems less from the mechanically injurious forces of positive pressure ventilation and more from the deleterious effects of prolonged illness when sub-optimally treated. The longer you are critically ill in respiratory failure, the longer you will require sedation and immobility which then can cause confusion, delirium, muscle atrophy, and weakness. All of which prolongs patients recovery and opens them up to developing complications (the shorter time you spend in an ICU the better you will do).
 Again, I maintain that it was ineffective and/or absence of treatment which led to prolonged intubation and mechanical ventilation rather than mechanical ventilation itself which caused such high mortality rates. However, the timing of the decision to place a patient on a ventilator is still critically important to me – do it too early and you will be doing it unnecessarily in a proportion of cases while somewhat worsening prognosis, and doing it too late leads to an intubation procedure with higher risks (the act of intubating someone in severe distress with low oxygen is riskier than in a more stable patient). So knowing when to intervene while a patient’s respiratory status is deteriorating is a critical and challenging patient care issue.
 This challenge is best described by Professor Martin J. Tobin whom I call the “Godfather” of mechanical ventilation given that he is the author of the “Bible” of mechanical ventilation, a 3-inch wide textbook called “Principles of Mechanical Ventilation.” It is the only medical textbook that I have read completely… twice (see, I told you I was a vent geek). As an aside, Professor Tobin was the expert witness in the George Floyd criminal case while I was the expert witness in the civil case.
 Anyway, in that book, Dr. Tobin invoked the analogy of the mythical Greek sea monsters of Homer called Psylla and Charbybdis when describing the competing factors underlying decisions around mechanical ventilation:
 From Wikipedia:
 Scylla  and  Charybdis  were mythical  sea monsters  noted by  Homer ; Greek mythology sited them on opposite sides of the  Strait of Messina  between  Sicily  and  Calabria , on the Italian mainland. Scylla was rationalized as a rock  shoal  (described as a six-headed sea monster) on the Calabrian side of the strait and Charybdis was a  whirlpool  off the coast of Sicily. They were regarded as maritime hazards located close enough to each other that they posed an inescapable threat to passing sailors; avoiding Charybdis meant passing too close to Scylla and vice versa. According to Homer's account,  Odysseus  was advised to pass by Scylla and lose only a few sailors, rather than risk the loss of his entire ship in the whirlpool. [3]
 Because of such stories, the bad result of having to navigate between the two hazards eventually entered proverbial use.
 Tobin invokes Psylla and Charbybdis when he discusses how to “set” the mechanical ventilator properly, but his analogy applies just as well in regards to decisions around the timing of initiating mechanical ventilation.
 To wit, here are a couple of slides from one of my lectures on managing mechanical ventilators after intubation (this is slightly off topic from the above, but I thought some of you would find this of interest):

 Similarly, knowing when to intubate someone (i.e. the act of sedating and paralyzing someone in order to insert a breathing tube through the vocal cords and into the trachea) is a procedure that presents increased risks the more unstable and distressed the patient becomes. So, you don’t want to do it too early and you don’t want to do it too late.
 Meaning that if you don’t establish a supportive airway quickly in severely hypoxemic patients, a cardiac arrest can ensue. Fortunately, due to modern intubating techniques, equipment (video laryngoscopes), simulation training practices, sedation and paralysis protocols, death is rare but still non-zero. Now, although death is quite rare, I have been involved in more stressful/scary intubation scenarios than I (or my patient) would have liked.
 “Managing a difficult airway” is the medical emergency of all emergencies because you have a patient still alive where you are responsible to prevent a cardiac arrest from deprivation of oxygen and/or excessive respiratory fatigue. If you are in overall charge in that situation and you fail at the task of successfully inserting the tube, it can result in heavy emotional trauma. Nearly every pulmonary and critical care doc has endured that reality at least once in their career.
 Certainly cardiac arrest resuscitations are also emergencies, but the heart is already stopped and CPR is relatively straightforward in my opinion.. so the complexity of decision making is far less in that situation. In one setting you are trying to bring someone back from an arrest while in the other you are trying to prevent its occurrence.
 In every instance that I made a decision to put a patient on a ventilator, I would always reflect afterwards as to whether I felt I had done it too early or too late. Psylla or Charybdis. With rare exceptions, I generally felt like I did it too late (not late late, but generally beyond the time that it should have been clear that they were not going to be able to avoid the ventilator.)
 The reason for my delaying is that I tried to give every patient as much time and treatment as I could until it was clear they were not improving enough or quickly enough to avoid it. But I tried to give them every possible chance without endangering them. So I would consider myself a “late intubator” by practice. The comfort level with deciding on the appropriate time to intubate obviously varies across physicians as their risk tolerance (and their perceptions of the competing risks) varies according to their training, experience, and personality.
 Further, most providers do not perceive mechanical ventilation as harmful. Which is largely true if you just look at the subtle negative impacts of mechanical ventilation in and of itself. But when you figure in the need for ICU care, isolation, sedation, and immobility, the benefit/risk ratio narrows greatly. Again, I remind all that patients with neurological diseases can be supported for decades on mechanical ventilators without progressive harm to the lungs.
 I never forget one fellow I had when I was the Director of a Fellowship training Program back in New York who, during his three years of training had more than double the amount of intubations as any other fellow (although not the only reason, I did feel he was an “early intubator” and I tried to guide him to a more conservative approach before he graduated my program).
 However, as Covid patients began to be admitted to UW, suddenly a number of my highly trained and experienced colleagues came up to me to argue that we needed a “rule” for when to put a Covid patient on a ventilator.
 They were suggesting that we use the amount of oxygen the patient was requiring. I immediately thought this would have innumerable negative consequences but I also understood where they were coming from – the doctors were scared as they had not developed familiarity with the disease and this was compounded by rumors or reports of Covid patients who were supposedly coming in with low oxygen levels and who, despite oxygen supplementation and looking fairly stable, would suddenly “crash.”
 This ignorance as to the trajectory of the disease is what triggered the early intubation practices rather than corruption or financial incentives (at least initially in my opinion). Most would eventually (and rapidly) learn that patients with Covid did not “suddenly deteriorate” and instead would do so slowly over time such that decision on the timing to intubate someone was actually much easier that initially feared.
 The suggestion to intubate based on oxygen requirements only, although ignorant, was well-intentioned (like many disastrous decisions). I knew these colleagues and knew why they were recommending this. They were concerned about these early patients with Covid and didn’t want to “lose” a patient from inaction. They wanted to protect the “safety” of the patient by avoiding what they thought would be a sudden and perilous intubation procedure (for both the patient and the staff - their was a lot of fear of being exposed to Covid during a chaotic emergent intubation). However, I knew this would paradoxically spell disaster if the practice became standard. Plus, I had serious doubts a viral induced pneumonitis would cause “sudden crashes.”
 Another troubling factor which led to “too early” mechanical ventilation was the initial fear of using “heated, humidified high-flow nasal cannulas,” a device which can avoid intubation in certain circumstances (like Covid pulmonary disease). I participated in a number of Covid policy discussions at UW, well before we had admitted our first Covid patient. HFNC’s in my opinion are nothing short of revolutionary in pulmonary and critical care medicine because they can support someone in certain forms of respiratory failure with high oxygen requirements in an incredibly comfortable manner where they can talk, drink, eat, and do not require sedation nor bed immobility (they can sit in chairs/recliners).
 Here is where it gets uncomfortable - the reason why leadership at UW avoided using them early on was an exaggerated fear of “contagiousness” to others with their use, i.e. they feared that the high flow rates of oxygen jetting into their noses would “circulate” the virus much more than other devices. I disagreed with this cautiousness, feeling that, even if true, it was not a clinically significant increased risk (more theoretical) compared to the routine risk of exposure when a patient is on a regular nasal cannula or a non-invasive ventilator.
 But, it is also true that when patients are intubated and attached to a mechanical ventilator, their risk of infecting others approaches zero. Why? Because they are now breathing through a “closed system.” i.e. the tube in the trachea has a fully inflated ballon or “cuff” such that little to no exhaled air escapes around it into the room, and further, the air that is exhaled back into the tube returns to the ventilator and then passes through a highly sophisticated filter before puffing out the exhalation port on the side of the ventilator and back into the room.
 So yes, placing the safety of caregivers atop the needs of patients is a troubling ethical situation, and one that, if it had been true that it truly increased risks to staff, would provide no clear definitive ethical answer because if all the staff got sick, this would prevent the wider population of patients from getting needed care due to lack of staff.
 But it was concerns regarding safety of staff which drove the initial cautiousness towards use of HFNC’s, at least at UW.
 Anyway, back to my situation that day in March of 2020 when a cohort of colleagues came up to me and proposed that we institute an “oxygen rule” for deciding on when to intubate.
 I simply refused to believe that an inflamed lung would lead to precipitous crashes and I knew this both intuitively but I also knew it from talking to my colleagues on the front lines in New York City. So I argued with the “early intubation” crowd that, even though this was a novel disease, it doesn’t change the foundational principal of when to institute mechanical ventilation.
 So, at the daily Covid briefing that I led at UW (attended in person or remotely by all residents, hospitalists, and intensivists in charge of taking care of COVID patients), I argued very strongly that we should avoid setting an arbitrary oxygen requirement limit for intubation.
 Some had suggested to intubate once a patient required more than 6 liters per minute of oxygen via nasal cannula while others were suggesting something higher. I explained that the indication for the institution of mechanical ventilation should never be based on an oxygen level and instead must be almost solely based on an assessment of the patients “work of breathing” and their ability to sustain that work of breathing.
 This is where it gets a bit more complicated as a patient’s ability to sustain an elevated work of breathing is itself dependent on multiple factors such as their frailty (or conversely their strength), their mental status, and the cause of their respiratory failure (some conditions are more easily and quickly reversed than others). Here is a schematic that I would use to try to teach this concept to my students (made by my old colleague Nate Sandbo at UW.)

 So when you look at a patient who is struggling to breathe you have to ask yourself, can they sustain that amount of effort, for how long, and what is the underlying cause and is it rapidly reversible?
 There are certain conditions like acute pulmonary edema which can sometimes be turned around quite quickly with diuretics and blood pressure management and something called a non-invasive ventilator (called BPAP or CPAP machines) such that even when patients are in significant distress, you sometimes have enough time to “turn them around” and can avoid “crashes” (medical emergencies). Other conditions like a worsening pneumonia with low blood pressure from sepsis generally need to be intubated once significant signs of respiratory distress are observed given that in such patients the “turnaround” is not so quick and there is a higher mortality associated.
 Anyway, my colleagues and trainees carefully listened and for maybe the first and last time in the pandemic, simply trusted my judgement and advice without too much “argument.” Whew. The idea of setting arbitrary oxygen limits as the trigger for intubation simply disappeared . I’m pretty darn proud of that because I don’t think that was the case around the country and I believe it was one factor which led to the widespread need for additional ICU rooms as well as ventilator shortages.
 I must say however, that I do not believe this “early intubation” practice lasted very long as doctors quickly gained more experience in managing Covid patients. They began to recognize that the pulmonary phase of Covid presented as a relatively unique form of respiratory failure in that patients would come in with often quite low blood oxygen levels yet would appear fairly comfortable in terms of their work of breathing, a condition doctors started calling “happy hypoxia.”
 Doctors and hospitals also quickly overcame their “fear” of using high flow oxygen devices instead of mechanical ventilation. These devices, called “heated high flow nasal cannulas” (HHFNC) are a marvel of technology as you can deliver incredibly high flows of oxygen (up to 60 liters per minute) into their nose given that the oxygen is 100% humidified and heated (they also helpfully produce mildly positive end expiratory pressure and reduce dead space ventilation).
 With normal low flow nasal cannulas that are not fully humidified or heated, if you try to increase the flow past 5 liters per minute, the patients cannot tolerate it due to discomfort and dryness. HHFNC’s thus became the workhorse of Covid and I believe many lives were saved by those devices. Fun fact: the devices were originally developed for use in racehorses (WTF? Horses again?). They were first applied in humans in 1999 then fell into into widespread use after 2010.
 However, and I will finish here, there does seem to be a persistent belief among the public that over use of ventilators not only were the proximate cause of death but were done so out of Covid financial incentives. One fact overlooked in the latter argument is that hospital reimbursement rates for mechanical ventilation in any form of acute respiratory failure have always been the highest of any type of patient. That is because the costs of caring for intubated ICU patients have always been astronomical - and early on in Covid, ICU care often entailed weeks of ventilator and ICU support.
 Further, the reimbursement rates paid to the hospital has never been a factor in my or my trainees or my colleagues decision to intubate a patient. Ever.
 A Hypothetical Case Of Acute Respiratory Failure From Covid
 I will finish by sharing a hypothetical case, cobbled from a few Covid cases where I have served as the expert witness. In a few of them, social media mavens “screamed” that the “hospital and the doctors killed him with a ventilator.” Let’s go through a hypothetical case which I believe will best illustrate the factors and decisions in play.
 Imagine a 52 year old man presenting to the ER on Day 9 of Covid symptoms, complaining of shortness of breath, with mild to moderately decreased oxygen level. He is placed on a nasal cannula (regular, low-flow one) and kept overnight at a somewhat rural hospital with limited specialist staff. The staff is worried about the lack of specialty care available so they decide to transfer him to a more resourced center (an extremely common occurrence in non-urban ares throughout Covid).
 He was tolerating 15 lites of flow via a non-rebreather mask when he departed from the small community hospital on a fixed-wing aircraft to a large University Hospital

 En route, he started developing low oxygen levels requiring increased oxygen support.

 On arrival to the University Hospital’s emergency department, he was placed on heated high flow nasal cannula at 60 liters per minute, 100% oxygen. However, he then began to “desaturate” to 86% despite the addition of a regular nasal cannula at 6 liters per minute (i.e. he was now on two nasal cannulas).

 Although from documentation, his “work of breathing” was not overtly excessive and he was clear mentally, the decision was made to intubate, which was then done in an uncomplicated, controlled, successful manner. They also informed the patient what they were about to do and this was also discussed with the patients surrogate, neither of whom were documented to have objected (I will say that the exact content of the informed consent discussion is rarely documented in regards to the specific risks, benefits, and alternatives communicated).

 So, was the decision to intubate the patient at that time wrong?
 I would say that there are arguments for both intubating and avoiding intubation at that time but that neither decision would represent a clear violation of accepted medical practice.
 Based on my extensive experience managing different forms of respiratory failure and my deep knowledge of the trajectory of pulmonary Covid-19, I personally would have waited. Instead, I would have started treatment in the hope we could “turn him around” before overt distress developed. I would have first trialed him on a non-invasive ventilator (i.e. BiPAP) to see if that would improve his oxygenation and would have kept him under close monitoring in an ICU setting. Further, I would have tolerated what was, to me (not to others) a “mild” degree of hypoxemia - i.e. 86% is not in itself harmful in a generally healthy patient but the trajectory was concerning as well as the amount of support he was on, thus the need for monitoring.
 My approach, if not successful, would have led me to having to intubate in a more “high-risk” situation though. The emergency room physician’s decision to intubate at that time led to a smooth, successful uncomplicated intubation.
 Thus they avoided having to intubate someone in a state of even lower oxygen reserve (when you intubate, patients are given medications such that they are temporarily paralyzed and stop breathing). This is done to facilitate the insertion of the endotracheal tube through their vocal cords, something that is very difficult or impossible in an awake patient struggling to breathe.
 Stopping their breathing when their oxygen levels are even lower than they were at that time likely would have led to an acute, severe oxygen desaturation which can be prolonged unless bag-valve-masking is done quickly and in a skilled manner (which is not always the case). What so few realize is that transient low oxygen levels, even if severe, do not cause brain damage as long as cardiac output/circulation is preserved.
 Anyway, the doctors elected to intubate rather than wait for further instability/more severe hypoxemia. They placed more emphasis on stably supporting him with a mechanical ventilator while allowing the treatments to work. I personally would have tried to stably support him without intubating him while also “waiting for treatments to work.” Although my sense is that their decision was “sub-optimal,” it was not unreasonable, not criminal, not influenced by financial incentives, and largely was consistent with the “standard of care” in such situations, both during Covid and prior to Covid.
 Further, he was successfully extubated days later.
 Thus, my expert opinion, contrary to social media opinions generated from what they knew of the case, instead found that the doctors did not grossly “violate the standard of care” as most doctors (but not FLCCC doctors) would have done the same thing in that situation.

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Summary: Here I explore the nuances around the use of mechanical ventilation in 2020. It is not a simple story, contrary to many like Elon Musk that believe "the ventilators killed patients."


Elon Musk's Comments On The Initial Use Of Mechanical Ventilation In the Covid Pandemic - Pt. 2

In Part 1 of this three part series triggered by Elon Musk’s comments on mechanical ventilation :), I argued that the unprecedented mortality rates observed with mechanical ventilation was almost completely due to the lack of effective treatments being offerred rather than the use of the ventilators alone.
 In this post I will review all of the evidence that we had in the Spring of 2020 to supported the FLCCC’s recommendation to treat patients in the hospital phase of Covid with corticosteroids.
 The problem we in the FLCCC had in 2020 with getting the world to use corticosteroids in the hospital phase were many (first is that we were not as well known then as we would later become when Paul Marik unwittingly launched us into the global war on ivermectin :). Anyway, at the time:
 Most physicians believed that anything immunosuppressive would worsen the body’s “ability to fight off the virus” because, you know, it was a viral pneumonia (not) . The fact that there was no live virus in the hospital phase of the disease showed this to be a tragic error borne of ignorance when estimating the risk of corticosteroids (I know, I know, there were no “errors” but this was the “consensus” thinking at the time by the average physician on the ground, even before medical propaganda was being issued in a torrent from the high-impact medical journals).

 The above was compounded by the fact every national and international health care organization was recommending against corticosteroids at the time (purportedly for the same reason).

 I was unable to rapidly publish my paper which argued that Covid-19 pulmonary disease was not a viral pneumonia and was instead a form of lung injury called “organizing pneumonia” (i.e. not infectious), whose first line treatment is corticosteroids. 5 journals and 6 months later, it was published in BMJ Open Respiratory Research.

 So, the below was what I was up against in my first testimony in the U.S Senate on May 7, 2020:

 It gets worse. Umberto Meduri, one of the founding members of the FLCCC and one of the world experts on the use of corticosteroid use in critical illness and lung injury syndromes, published this paper below in the journal of the Society of Critical Care Medicine in April of 2020, weeks before my testimony . The SCCM blasted it out as a bulletin to all 17,000 of it’s members. Response? Crickets.

 In the above, Umberto and his colleagues meticulously re-analyzed the large observational corticosteroid trials from the SARS and MERS epidemics and found, after controlling for timing, type, and dose, that corticosteroid use led to large reductions in mortality . This was an analysis that the WHO and/or the NIH should have done… but didn’t.
 Further, and more importantly, Umberto and colleagues included the early Covid data and recommendations from medical associations in China and Italy, both countries finding large mortality reductions when corticosteroids were used.
 Re-reading the paper now, these sentences jumped out at me:
 In conclusion, this is a critical moment for the world, in which even industrially advanced countries have rapidly reached ICU saturation and intensivists are forced to make difficult ethical decisions that are uncommon outside war zones. Although there is a wide divergence of opinion in the literature on whether corticosteroids should be used in patients with COVID-19, the two largest studies on H1N1 and SARS (n = 7,568) ( 25 , 27 ) lend support to its use. However, the lack of sufficient evidence is not tantamount with negating the plausible efficacy of corticosteroids in COVID-19-associated ARDS. The stronger evidence for nonviral ARDS, the early reports from China, and the recommendations from the frontlines of China and Italy should be considered. Inconclusive clinical evidence should not be a reason for abandoning CST in COVID-19-associated ARDS. RCTs are in progress ( NCT04273321 , NCT04244591 , NCT04325061 , and NCT04323592 ) and results will not be available for months. Until then, there is no justification based on available evidence and professional ethics to categorically deny the use of CST in severe life-threatening “cytokine storm” associated with COVID-19 in hospitals not involved in a RCT.
 This is part of the reasons why the FLCCC, during the first 7 months of the pandemic, near completely focused on the hospital phase of the disease with our first protocol called MATH+ that came out in early April 2020. Note how it primarily addresses inflammation and clotting (although ivermectin is included in the version below, it was actually not on the MATH+ protocol until 7 months later in November of 2020 when the clinical trials data amassed finding overwhelmingly positive impacts):

 The actual “science” supporting corticosteroid use at the time of my testimony in May of 2020 was even stronger:
 This remarkable study was available on a pre-print in early 2020 (albeit not published in a medical journal until Sept. 2021). In that study, the researchers matched the inflammatory gene expression patterns induced by SARS-CoV2 in human lung tissue against a database of the expression of inflammatory suppression genes activated by over 5,000 FDA-approved drugs.
 They found methylprednisolone to be the drug with the greatest potential to revert the changes induced by COVID-19, while other closely related corticosteroids, such as dexamethasone or prednisone, were not. Methylprednisone was #1 out of over 5,000 medications. The FLCCC had already chosen methylprednisone based on the decades of research into corticosteroids that Umberto had done throughout his career.
 Also note this sophisticated analytical search for existing therapeutics and their known mechanisms of action allows for the rapid identification of optimal treatments - a powerhouse approach in a pandemic situation (plus it avoids the years of delay and billions of dollars needed to develop novel, high-cost, patentable drugs such as the mutagenic molnupiravir or variant-driver paxlovid). Was this method used by any government health agency across the world? No. Just Big Pharma RCT’s please.
 Then observational studies reporting large impacts on survival with corticosteroid use came out of Detroit and Italy on pre-print servers.. and were promptly ignored because again, they were not the cherished “gold-standard” double-blind, randomized controlled trials.
 Here is where I get to again remind my readers that in clinical research (not in vitro or in vivo ), on average, randomized vs. observation controlled trials throughout the history of modern evidence based medicine.. reach the same conclusions . See this landmark systematic review paper from the Cochrane Library by Anglemeyer in 2014 :

 The above is a known fact, proven over decades, yet suppressed and fought against by Pharma who instead prefer medical journals to rely solely on big Pharma funded and conducted RCT’s to “prove” something works or doesn’t. One key difference between RCT’s and OCT’s is that the latter can be done by any motivated clinician or team of residents, students, fellows etc., simply by using electronic medical record systems and comparing the outcomes between patients already treated with the medicine vs. those who were not.
 The most impactful statement in the conclusion above is “Factors other than study design per se need to be considered (I would say investigated) when exploring reasons between (discordant) results of RCT’s and observational studies.” I would start and end my investigation with looking for impacts of the bias of the RCT funding source. Things like the authors conflicts of interest (among other obvious influences like study design).
 The best illustration of the bias of the funders of big RCT’s can be seen in the below table compiled by the best Covid research scientists in the world, the anonymous group at c19early.com :

 In the above table, they list the trial design features employed by the same Principle Investigator at Oxford University who was tasked with studying two different early treatment drugs. One was a pricey, patented, pipeline pharmaceutical drug (Merck’s molnupiravir) and the other was an off-patent, repurposed, widely available, ridiculously safe and ridiculously inexpensive drug called ivermectin (ever hear of it?)
 To summarize the table, it shows that for monupiravir, Oxford enrolled patients as early as possible, enrolled the sickest patients as possible, and treated at the highest doses for as long as possible.
 For ivermectin, Oxford enrolled patients as late as possible, selecting the healthiest and most mildly ill as possible, treated with as low a dose as possible for as short a duration as possible (plus they instructed patients to take ivermectin on an empty stomach which lowers absorption). Not subtle eh? Why such major design differences between the two study drugs Professor Butler?
 The most brazen difference was in the speed and size of the trial conducted. The molnupiravir study enrolled 25,000 patients a median of 2 days from first symptoms (a truly impressive result), finished the trial in 5 months, and published the trial 4 months later.
 The ivermectin trial started enrolling 7 months before the molnupiravir trial, was less than a quarter of its size yet it took 14 months to conduct and we still don’t know the results even after 16 months since they completed the enrollment. Weird right?
 Please don’t bother me with their bullshit excuses on their website about “requiring a one year follow-up of patients after the study ended before publishing the results.” Puleeze. They weren’t studying cancer, they were studying an acute viral syndrome. Also, this one year follow-up period was never in their original trial protocol yet it magically appeared during or at the end of the trial. Whatever.
 Forgive me for I digress. Again, the above data and insights on corticosteroids led me to testify for the first time in the Senate in May of 2020, where I (we) recommended that the world use corticosteroids in the hospital phase of Covid (again, I did this at a time that every national and international health care organization recommending against doing so). It was also the first (but not last) time I lost my temper a bit during U.S Senate testimony - exasperation starts at 12:30. I also talked about avoiding use of early intubation! (More on that in my 3rd post which is already available).

 I presented the findings from our papers above, the recommendations by the Chinese and the Italian societies, and concluded with testimony from physicians on social media who were posting, largely anonymously, compelling observations and experiences, essentially crying out for doctors to start using corticosteroids at the first sign of low oxygen in COVID patients.
 Some memorable posts read as follows (they were in my official written testimony to the Senate):
 “We floundered for two weeks. Lots of codes, intubations and death. Maybe 15 discharges. We started steroids and discharged 250 patients. Less intubations, less codes. And the ones that ended up on vent, not as serious. CXR/CT Changes = steroids. Hypoxia on admission = steroids. Ambulatory hypoxia = steroids. Completely changed our trajectory. Steroids are a game changer.” Hospitalist, SE Michigan - our group is taking care of 700 plus COVID+ patients

 “I'm here in New Orleans, since we started using steroids, we were able to free ventilators and get elderly patients out of the hospital without needing a ventilator. Patients that were obviously crashing quickly, who we had to have end of life talk with were able to walk out of the hospital. At no point did any of our patient’s worsen because of steroids. These patients shed viruses 4 weeks later, with or without steroids. The virus doesn't kill anybody, it’s the inflammation that does. Let the virus replicate however slow down the inflammation”

 But remember, modern evidence-based maniacism does not believe in anything but a “Big RCT”, designed and conducted by a heavily funded public health agency or corporation (same thing). And, as I have written before, the control of funding and design of Big RCT’s is literally the main tactic that corporate (and other) interests use to get doctors to believe and do everything “they” want them to - things like;
 remdesivir is an effective or safe drug in hospitalized patients

 statins prevent and/or treat heart attacks and strokes

 SSRI’s are safe and effective anti-depressants

 mRNA vaccines are safe and effective

 ivermectin and hydroxychloroquine are both highly dangerous and woefully ineffective in treating Covid.

 The last campaign against IVM and HCQ was so effective that doctors who dissented with their analyses or worse, actually treated patients with such dangerous and ineffective drugs had their medical licenses and livelihoods stripped, board certifications revoked, social media accounts deplatformed, and endured endless regime media attacks (my new favorite word).
 Until the system docs wake up to the research trial and publication fraud endemic in modern biomedical sciences, that entire system rot will continue to kill patients. One hopeful sign is that the rot has never been so exposed before as it was during Covid, so much so that many physicians and patients have started to flee that system (this is probably a good time to plug our upcoming FLCCC conference where we plan to offer and launch a sort of “home” for the increasing amount of medical system refugees.
 This exodus will continue as long as “system” doctors continue to pray at the altar of an evidence based medicine system that has been completely captured by industry and regularly spews out sophisticated sounding statistical lies from the top medical journals in the world.
 Anyway, as you can imagine, my testimony fell on deaf ears at the time. Inexplicably high mortality rates with frequent prolonged durations of mechanical ventilation (MV) continued to be observed and reported. These reports were emanating from centers expert in supportive care strategies. Unsurprisingly, these same centers were literally running out of ventilators such that state and federal governmental agencies started scrambling and competing to purchase huge lots of them (as the Chief of the Critical Care Service at UW and an expert in mechanical ventilation, I was regularly consulted by the Wisconsin ventilator procurement officer to rapidly evaluate various machines coming onto the newly chaotic ventilator market).
 There was one country that “listened” to the FLCCC however… Ukraine! Two papers were published on our protocol by prominent Ukrainian physicians and we heard from good authority that MATH+ was being widely deployed in hospitals there (one paper was in English, the other in Ukrainian as seen below):

 However, despite this, the first “attacks” from the medical system and media towards me, Paul, Umberto and the FLCCC came in the wake of that first Senate testimony in May. The censorship began to ramp up as well.
 Sadly, it was not until months later that our recommendation to use corticosteroids became the standard of care for the hospital phase of Covid worldwide, after the publication of the RECOVERY trial from Oxford in July of 2020. Mortality rates in hospitalized patients thereafter began to plummet.
 So Elon, the above is why I believe it was the lack of effective treatments in the hospital phase (and pre-hospital phase) that led so many to the often “death sentence” of a mechanical ventilator rather than the mechanical ventilator itself. That and the fact that ventilators alone do not kill people, period. Inappropriate use does cause harm and can worsen prognosis but would still not be the proximate cause of death in the overwhelming majority of cases. Ventilators don’t kill people but crappy medical care does.
 However, mechanical ventilation was definitely misused in early Covid and did cause harms. I more deeply explore this issue in Part 3 (already available).

 *I just want to say that writing this Substack is only one of my jobs, and I put a lot of work into it (at the cost of sleep and personal time). I also believe in an ethos of paying people for their work. If you love this Substack, get value out of it, and believe in paying people for their work, consider a paid subscription. Thanks, Pierre
 Subscribe now
 P.P.S - Proud to report that my book is gaining Best Seller status on Amazon in several countries and is climbing up the U.S Amazon rankings… Link:

Summary: The near-global ignoring of the evidence supporting corticosteroid treatment in the hospital phase of Covid is what led to the initial historically unprecedented mortality rates. It wasn't the vents.


"Shedding" Part 9 - More and More Clinical Case Descriptions of Shedding Pour In

This article is a continuation of Part 8 of my series of shedding, where I again provide detailed reports from subscribers and readers who have observed similar phenomena in their own lives. I would say that the majority (but not all) are highly convincing for shedding induced illness.

 *Since acute vertigo after exposure to the vaccinated is described in a number of the posts below, I chose this picture above.
 OK, now, in no particular order, here we go:

 Dr Kory, thank you so much for tackling this issue! I was waiting for someone to finally address this. When vaccine mandates came in May of 2021 to colleges in US - I was working in one as a molecular lab manager. Im molecular biologist and worked in that field for over 30 years. At that time - summer of 2021, I worked with numerous students daily in the lab setting, in close proximity to 5-10 freshly vaccinated students at any time. M-F 9-5. I refused to be vaccinated.
 In a matter of days since the vaccine mandates rolled out I started to feel sick. Migraine, low grade fever, dizziness. After two weeks my body began to hurt. After a month I was literally incapacitated, couldn’t raise my arms to comb my hair or brush my teeth. Joints im my upper body were on fire. Intense, burning, throbbing pain, constant. Went to ER and was promptly diagnosed with polymyalgia rheumatica (PR).
 **ED: In our Leading Edge practice , we frequently see syndrome descriptions like the above amongst our Long Vax patients.
 I knew at that point that it was vaccine shedding. I observed that after a day of close contact with several young healthy adults who just got vaccinated a few days prior- my symptoms were most severe. Pain was subsiding on weekends. I asked students about dates of their vaccination. They got it anywhere from 3days to a few weeks before and vast majority was Pfizer. I was myself faced with decision to get vaccinated or lose my job. I chose the latter, I retired early. My health was my priority. I went to rheumatologist who promptly put me on massive doses of prednisone. I ask him how many new cases of PR he usually gets per year. Answer - maybe 2. How many since vaccines rollout, half a year ago? 24!!! I said- you realize that I’m vaccine injured? He asked me to find another doctor.
 I took a test offered by dr Bruce Patterson for long covid. My score was 10.5 which is very high. Except I had covid a year and half prior and recovered within two weeks.
 I went to my FP and asked for some blood tests. My inflammation markers CRP and ESR were very high. I took a d-dimer test and it was “borderline “.
 My FP told me to accept the fact that I’m getting older and need to stay on prednisone for the rest of my life. I am a very healthy, active, now 66 years old, no medical conditions, no medications.
 There is so much more to this story, I’m trying to be brief. As a scientist I found myself observing my symptoms carefully and decided to stay away from mainstream medicine. Now I’m almost completely recovered- combination of supplements, PEMF therapy, acupuncture, therapeutic massages. I took ivermectin, NAC, nattokinase, etc. I will be happy to share more information with anyone interested.
 God bless you Dr Kory for addressing this! I knew I wasn’t crazy but your articles are so reassuring for me.

 Last year and this year my daughter Has Had Alopecia issues / hair loss. Everything was fine her hair grew back. Her best friend was vaxxed oct 6 and her hair has begun to fall out again. her friend got really sick 103 fever. My daughter sat next to her at lunch and began to have a stomach ache then headache. The timing is very strange and not a coincidence as the updated COVID vaxes were rolled out at the same times late sept / early oct. She is 13 and this has been devastating. I know others that took the vaccine that have hair loss. That seems to be known and admitted to by drs. Her pediatric derm thinks it is idiopathic. My mom gut says not so. Dr. Pierre can you help? Has anyone else heard of this happening ?

 This explains what happened to me. I am unvaxxed and in July 2021 I agreed to housesit for my brother while they were away, which included sleeping in their bed. His wife has just been vaxxed with Moderna prior to them leaving. I spent the first night and woke up the next day feeling like I could not breathe. It was deep in my lungs. This then progressed into COVID. I found out later that they had not changed the sheets on the bed I slept in. My brother flipped out when I told him I got COVID, told me I was crazy, and now I learn this. So I understand that the spike can be transmitted, but could it cause Covid in that way?
 I went through 2 rounds of Ivermectin (God bless Dr. Robert Apter) and one round of HCQ. I have also been on Nattokinase since early 2020. I have not had any issues with Covid since and thank God no issues with Long Covid.
 However, in 2022, I had a wicked case of Shingles come up about 2 days after I took an exercise class next to a woman who told me she had just been vaxxed for Shingles. Is this all in my head or what is going on here?

 I met a midwife from London, Alison Shaloe, in September while we were both visiting Glastonbury. She said she has seen an enormous increase in stillbirths, miscarriages and infertility in her clientel since the "vaccine" roll out and that all the women affected had been vaccinated. She said she’s also seen women unable to produce milk after giving birth.

 Dear Doctor Kory
 Let me start by thanking you for all you do. I am writing to share some information regarding shedding. I recognized my symptoms when I read your most recent installment and I am including an image in hopes of alerting others to what it might look and feel like.
 I received two Pfizer shots early on. We had been through two incredibly traumatic events during the previous five years, and as a result, I was experiencing PTSD and unable to think clearly. Clarity did come eventually, and both my husband and I spent the next two years detoxing as much as we could. I managed to get hold of some Ivermectin, but my last order was flagged at customs (I am in Canada) and although I now have a US post box, I am nervous about ordering more.
 I work in a school where many of the staff are boosted and jabbed to an extreme. I have tried to direct these very “smart” individuals to research, but it seems to fall on deaf ears.
 I began to feel extremely tired despite more than adequate sleep about two weeks ago. About five days ago I began to be quite itchy on my upper left back. I put it down to the extremely dry weather we were having, but it persisted through a change in humidity. Three days ago I had my husband give a look after my attempts to look showed what appeared to be rash-like.  What he saw was strange bruising on my upper left back that seemed to have started as a strangely configured rash.

 After reading your article, I am convinced this is die to shedding exposure. I would be more sensitive due to some autoimmune disorders, and the “rash/bruising” is only located on the upper left back “heart” area.
 We are now both on Nattokinase as well as NAC, and I am now contemplating an order of the Ivermectin using my US post box.
 I am sharing this so you have a visual that might help others and to thank you for the work you do.
 I am only providing my first name as I am super paranoid living in a country that has become monstrous to its citizens.

 I am one of those physiologically sensitive and was sick 2 days each week(Friday and Saturday) last year after I worked M/W/Th each week as an osteopathic doctor working with my hands.  I used ivermectin weekly for 2 years as prophylaxis and only had a mild case of the original COVID.
 My spike protein antibodies continue to grow though.  I seem to be better this year, but (now I) rarely see a newly vaccinated person and only work 2 days per week.
 So, thank you for all you do!

 I'm convinced (as an emotional mom) that shedding does occur. My 16 year old had perfectly normal periods for over three years until her father got that shot, and we got her low hormone birth control pills just last week in an effort to stop the HUGE clots and bleeding through her tampons that have affected her life these past two years (suddenly). It's not normal. But are you saying, Dr. Kory, that we should try Ivermectin first to get her back to normal? I actually have some, but would seriously need to talk to an open minded doctor about it and don't know where that would happen...
 I'm convinced I got A-Fib a year ago just after four family members visited us from California. I suspect from the things they were saying that they got boosters to come to "unvaxxed Georgia" and they would not leave my kitchen table the entire time since we're "cavemen" and none of us (except their son) "got the shots." I've long suspected my A-fib originated with their visit, as it happened just a couple weeks later. I swim four days a week (for an hour) and am in great shape and never, ever had a heart issue previously at age 61. Since shocking my heart back, I've NOT gone back into A-Fib, and have been told that's unusual, that once you get it people often slip back in. I cannot get info from ANYONE who hasn't swallowed the covid shot Kool Aid though, so no way of knowing if the shedding thing is possible (nothing for me to really compare to).

 Thank you for taking the time to gather the Info regarding shedding. I do know for a fact that it’s been an ongoing exposure related problem since the very first brief exposure to my elderly neighbor after her first injection of the blasted gene therapy. It was brutal. I suspected my severe reaction was caused by her exposure. Deductive reasoning and breaking it all down, I knew it but how?? But no one wanted to admit or believe that reality at that time. My brief exposure was outside. Maybe 5 min. No direct contact but I did hand her an item. So outside, less than 5 min and I got vertigo. It lasted for 3 solid months.
 I did whatever I could to improve my health. I was already taking vitamins, eating healthy, following the flccc, as well as my own knowledge of natural supplements and nutrition.
 After 3 months - it happened again! And again from outside exposure to the sane neighbor, increased distance and I was hit again with another bout of months of vertigo. I never had Covid. I’m careful and stick to my own regimen and a kit I carry with me wherever I go. Which is limited due to the vertigo.
 I have noticed in certain surroundings I can feel a heavy pressure in the air that feels like a spatial fog weighing on my brain... perhaps an early warning of my limit. If I push it any longer , exposure will turn into vertigo. This is my own paying attention to how I feel. And it was a transitional experience.
 If I’m driving through a heavy traffic area, stopped at a light , 3-4 rows of cars, trucks parked all open windows or many open windows I can feel that pressure. It doesn’t quite turn into Vertigo. And as I’m able to wait out the minute or two at the lights it seems to be just enough time to drive away and in 15 - 20 min that pressure is gone.
 Each time I’ve been around people who are injected with these blasted gene therapy injections my time frame is limited and it varies.
 It is not about how recent their injection or the 2 week time frame to avoid them ( that 2 week time frame is an old flu vaccine method- it is not at all the same connection to the MRNA time frame. That’s comparing apples and oranges ) with all due respect please reevaluate that recommended 2 week avoidance.
 **ED: My partner Scott and I both admit we don’t really know the duration of symptomatic shedding from a vaccinated individual, although we initially thought it “might” be about two weeks. Subsequent reports and studies vary widely and more research is critically required. I am highly anticipating the impending publication of a study of 100? unvaccinated women exposed to other vaccinated women looking at the outcome of development of abnormal menses. I trust they will provide vaccination dates of the vaccinated subjects so we can learn more about this aspect.
 It’s so much longer with so many factors. The studies have already confirmed that the spike protein alone is found at a minimum of two months out. As well as up to 18 months. The dose of spike might vary but the time frame seems to be ongoing. Persistent and no indication of stopping individuals from producing their own.
 If the gene therapy injected are in a group environment- be it an office for 8 hours , an airplane, a grocery store, in a car, a bus, a public bathroom, a doctors office, sweating in a sauna, a gym, that is the exposure that needs to be addressed. Not out of fear. Out of reality. Awareness helps us all.
 If anyone is in any of those environments they are at risk. Period.
 Not everyone is impacted the same way. Each individual has a separate immune threshold. But prolonged repeated exposure to these gene therapy injected individuals can cause a shedding reaction at any time.
 Those more susceptible will react sooner, or more frequently. Others will also react at their own exposure limits. It can kick in any time. It depends on the exposure - and if you’re in any of the previously mentioned environments listed above the amount of spike protein, lipid Nanoparticles,dna plasmids, sv40 - and any toxin that can be carried and distributed by the LNP it all intensifies astronomically when it’s simultaneously being released by any number of gene therapy injected individuals into that one environment.
 Walk into a grocery store and you’re shed on whether you feel it or not. I think, I’ll pass out if I stay in that environment for any length of time. Minutes can be serious and debilitating. It lingers for several days after exposure.
 Others may feel nausea, fatigue , headaches and it goes away within 15 min after they remove themselves from the exposure but does the impact of exposure remain within our bodies even after the symptoms subside?
 What about the length of time shedding can survive without a host? Is it possible if you have skin to skin contact it does linger on some surfaces? That could be true. It does happen with certain virus particles and contaminants. The ok’d grocery cart flu virus germs exposure happens. And our immune systems can build up a protection but when it comes to the synthetic spike, and the gene therapy it’s a completely different scenario. We are dealing with more toxicity within the spike protein and exposure than anything else prior in this mechanism.
 All bets are off when addressing this issue.
 Another factor is people who have prior allergic reactions to the ingredients in these gene therapies or other prior vaccines are at an increased risk of serious health issues
 And if those individuals also have prior history of cancer, in remission- it is not far fetched for them to be exposed to others, shedding, repeated exposure can trigger their cancers to return and also be part of the turbo cancers that are occurring with such aggression that they are not able to be treated successfully. Add in the fact that they can’t receive safe blood in those emergencies because the very transfusions they need to survive and the number of them - they would end up with injected donated contaminated blood making it worse.
 It’s one life threatening exposure on top of another.
 This is why some people who are able to work remotely continue to work remotely.
 Unless every single person grasps this reality and stops using these altered, mutated adulterated gene therapy shots and also takes the necessary detox supplements and protocol for at least a year or more - it’s going to keep causing all of these health issues to occur.
 They knew! They knew about all of the adverse events , the heart issues, anaphylactic shock, kidney issues, adrenal, menstrual, pregnancies, hair loss, rashes, headaches, vertigo, arthritic pain and the various auto immune illness as well
 As death BEFORE any of these shots were administered. We were all lied to, every step of the way.
 Thank God for you, for the thousands like you who fight for the truth and open the eyes of the others who continue to sleepwalk.
 This shedding info with all of its components needs to be known. The truth is the very people who believed in the shots from day one are the individuals who have a progressive degrading damage of their own internal immune system and they are damaging the rest of us.

 Dear Dr Kory,
 We certainly believe in shedding. We’ve seen it with a dear friend who’s not vaxed. We are not vaxed.  We have followed you & FLCCC since the beginning of this mess, since maybe late 2020. We started on Iv in June of 2021. We’ve followed the protocol since it first was created. Just when you think you’re finally out of the woods, now there’s covid everywhere among our friends, and the shedding to worry about. (we as carefully as we could, would avoid newly vaxed for two weeks) We have many close friends. Everyone is doing the fully vaccinated stuff. We’ve watched many a dear friend die, get serious heart problems, turbo cancers, just deteriorate in otherwise healthy people. So sad. We try to do nice things for our friends, but can’t discuss Iv. Only one. Needless to say we are a group of hugging, hand shaking, riding in the car with people.
 Now my question….. how do we best protect ourselves? Continue with the protocol?
 Any other suggestions?
 Thank you for all you do

 Here is what I know based on my experience: if you are unvaccinated and you don't do anything to prevent or treat the shedding, you can get sick if you are sensitive to shedding. This was my case.
 But thanks to Dr. Kory, I don't have health issues anymore. The interesting part is that there are people who don't have any shedding problems, and they haven't had covid either. This is the case of my neighbors who are both severely overweight and are unvaccinated. And when I was telling them that that our vaccinated friends were making me sick, they were telling me that it's my imagination. Well, now we know it wasn't. I also saw what happened to my child after visiting our friends( four of them and all vaccinated). The next day she started having strong stomach pain that was very scary. It came out of the blue! This must have been shedding because there was no other reason since it was during the weekend. We didn't meet with anyone else. After this episode I was extremely worried to let my daughter meet with them. I also had shedding from them that day, but nothing even close like my poor young child. These shots are criminal and it's even more criminal that they are still on the market. I pray every day that those behind this atrocities will be hold responsible one day and pay for all the pain and nightmares they have caused to all of us. Their time will come, they won't escape forever.

 In my situation, I have experience using natural products prior to any of these shots. For colds, flus, sore throats - and other things that can pop up. Used the products as needed and they always work.
 When the shedding occurred, I got vertigo . the first time it lasted for 3 months.
 The second time, i was exposed the vertigo returned and it lasted about 3 months but not quite the same.
 The third and fourth time was the most recent exposure and to reiterate all of these exposures were outside. The last two times - it was also vertigo , it started about 20 min after I removed myself from the exposure and I could feel the beginning of it starting to develop. This time it lingered for 2 days after exposure. Significantly Much better than the 3 months of it each time prior.
 I did have ivermectin prior to my exposure. and my daily regimen of vitamins.
 I did use a combo of bromelain, Natto and turmeric after this last exposure and I noticed it lifted the heaviness of the fog that kicks off the vertigo( like a forewarning)
 The following week, the 4th exposure I had the same type of reaction. And again it lingered for two days. It’s still problematic but seems to be more manageable.
 However, because of this problem I am reluctant to go into groups - grocery stores, homes, and spend time around people who are shedding. What is the shedding doing? Even after symptoms subside is it still doing damage internally. Do the individuals who have reactions have the spike the same synthetic spike manufacturing as if they took the shot as well?
 One additional bit of knowledge- the neighbor who I was exposed to twice has developed diabetes and also recently was told that the drs found too much protein in the blood. This Information about too much protein - was not a requested test. However it makes me wonder if it’s a better way to keep track of more severe shedding. If we become aware of these illnesses that are occurring after people receive these shots... pay close attention. Maybe their dose of spike production and shedding is significantly more toxic or increased. This individual still believes in the shots and I cannot be near this person.
 One person I was exposed to directly for 15 minutes outside only received 1 shot over a year ago and it’s a J&J shot. There is no shedding no reaction and it it THE ONLY individual that did NOT cause a shedding reaction ( still outside exposure but lengthy intervals and several exposures.
 How am I ever going to be able to go indoors again and be able to breathe and not become ill from shedding?
 Does anyone else feel that way? What do you do to stop it in its tracks? Is anyone still getting hit with it inside to the point where they don’t want to risk their health anymore?

 Your comment about additional mortality among children when their parents were jabbed is absolutely what I found in the Philippines from the 2021 data. Pediatric deaths started rising concurrent with adult injections starting and accelerating. The relevant figure showing monthly pediatric deaths is at the end of the following article.
 Super Sally’s Newsletter
 Review of DOH Covid-19 Death Tracker to End of 2022: Age Breakdown Shows that Deaths Increased in Younger Age Groups Concurrent With Vaccines Rollout and Despite Lower Variant Pathogenicity.

 Thanks to my friend Barry who has downloaded and analyzed the just released DOH Covid-19 Death and Case Tracker data up to 31 December 2022. I have included some of his evaluations as well as my own on breakdown of deaths by age. Here are the overall Covid-19 Cases and Deaths plotted from the start of the declaration of pandemic. Cases are not an accurate metric due to mass asymptomatic testing with a poor accuracy test, and they depend on the number of tests conducted. Regardless, it can be noted that cases massively outnumber deaths…
 Read more
 4 years ago · 14 likes · 5 comments · SuperSally888

 Here is a very controlled environment in this anecdote
 My friend while working on ships 🚢 as a
 Captain got nosebleeds while working on the ship offshore with the v’d crew
 He quit because of this and his nosebleeds subsided when he wasn’t on a ship 🚢 full of vaxholes

 Shedding is ongoing. Sporadic and can impact anyone at anytime. It is not always an obvious connection to the fact that symptoms happen around others who have taken these shots. It can happen during home holiday get togethers, in grocery stores, at work in an office, shopping, using public shared restrooms and outside. Any skin to skin contact, any form of intimacy, sweating, urine, feces, breathing in the air that is exhaled by others ( exosomes) it is all causing shedding to transfer to unvaccinated individuals and each person impacted by shedding has a different type of reaction but it seems that anything the actual injection side effect, and injury can also be caused by shedding.
 Pay attention to time around others, how you feel, do you notice fatigue, headaches, menstrual cramping, menstrual irregularities, nausea, dizziness, vertigo, heart arrhythmia, arthritic pain, and actually hair loss is also part of the shots as well so it could be from shedding, Covid or the shots. Although the other symptoms above are more common, they vary in severity and length of time. There are also some shedding that have caused serious syndromes and death from prolonged repeated extend exposure. I do know a teen who was exposed to so many teachers, and then living with a house of family members who also received these shots - prior to child given these shots and he developed a sudden toxic overload of liver damage - this liver impact was an early cause and some are more susceptible than others. The shots and the spike shedding are toxic - more toxic than anything else we have ever had to deal with in our life, with the cocktail of mr NA and the formula of toxins.
 Not everyone will or has developed a reaction to shedding. But our individual immune systems threshold is different and given enough exposure to these toxins it is very possible to have a reaction at different times over time.

 Before we end, know that as a physician committed to education, I (finally) decided to respond to the void of information around shedding with this series of deeply researched posts. If you appreciate the effort, please consider supporting my commitment to continuing this Substack with a paid subscription. Thanks, Pierre
 Subscribe now
 Links to all the other already active posts in this series are below.
 P.S. My book called The War on Ivermectin is available on Amazon and anywhere else books are sold.

 “Shedding” Part 1 - Shedding of Covid mRNA Vaccine Components and Products From The Vaccinated to the Unvaccinated - Part 1
 “ Shedding” Part 2 - The Bio-Distribution and Excretion Potential of Covid mRNA Vaccine Products
 “ Shedding” Part 3 - Can You Absorb Lipid Nanoparticles From Being Exposed To a Vaccinated Person?
 “ Shedding” Part 4 - Evidence of Placental and Breast Milk Transmission of Covid mRNA Vaccine Components
 "Shedding" Part 5 - Evidence of Shedding Causing Illness In Others
 “Shedding Part 6 - Clinical Case Notes Describing Shedding Phenomena Among Leading Edge Clinic Patients
 “Shedding” Part 7 - Shedding Via Sexual Intercourse - Clinical Reports
 “Shedding” Part 8 - A Deluge of Clinical Reports Pour In

Summary: The continually submitted clinical case reports are both disturbing and compelling examples of shedding induced illnesses being observed from readers all over the world.


Don't Look a Grift Horse in the Mouth

Of all the many insults hurled at the pro-ivermectin camp during the pandemic—and believe me, there have been boatloads—my favorite has to be “grifter.” Because clearly people like Dr. Pierre Kory, the tireless researcher, brilliant physician, and fearless author of The War on Ivermectin —risk their lives and their livelihoods to promote a cheap, off-patent, life-saving medication out of overpowering, barely-veiled greed.
 [Insert string of eyeroll emojis here.]
 The internet defines a grifter as, “a person who operates dishonest schemes or cons to deceive and swindle others, often for financial gain.”
 For those not in the know, Dr. Kory lost three jobs during the pandemic for daring to decry the carefully constructed narrative. The American Board of Internal Medicine voted to revoke his certification, a painful strike that is not merely offensive but deeply injurious. (ABIM certification implies expertise and credibility and also is critical to a doctor’s ability to enjoy hospital privileges and be reimbursed by insurance companies for services rendered.) He’s been called everything from a fringe doctor to a fraud—two titles that rarely result in generous pay hikes come review time last time I checked.
 “We’ve obviously got a long way to go before the most indoctrinated of the flock stop slinging misguided digs at the Korys of the world and get rightfully and righteously furious at the folks doing the real grifting.”

 In a recent Facebook post promoting The War on Ivermectin (which I had the honor of co-authoring), a “friend” felt the need to drop this comment: “I see grifters are still trying to scrounge a few dollars from the ivermectin nuttiness [sideways laugh-cry emoji].” He also included this ironic little meme, which naturally I had to respond to:

 Interestingly, the sanctimonious name-callers don’t seem to be even a tiny bit bothered by the $100 billion in revenue Pfizer recorded in 2022, the $2.82 million Dr. Fauci earned the year prior alone, or Bill Gates’ tone-deaf boast that his $10 billion investment in vaccines has seen a twenty to one return . They don’t care that hospitals get hefty bonus payments for every patient listed as having COVID-19 or put on a ventilator (a reality even USA Today’s patently weaponized “fact-checkers” had to admit is true ), or get ruffled by the hundreds of millions of federal dollars individual school districts across the country accepted to enforce mask and vaccine requirements on students. Nope, it’s doctors like Kory—for whom incidentally it is a felony to accept monetary compensation for prescribing medications—who are the real pandemic profiteers. (And if you come at me with any sort of “books make people millionaires” ignorance, I’ll gladly torture you with a painful lesson in publishing accounting.)
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 When I was searching for a title for this post, I came across the expression “don’t look a gift horse in the mouth.” What struck me as oddest about that phrase is the fact that—as a lifelong word nerd—I’d never pondered its oddness before. It turns out, the proverb dates to the 4 th century and warns of the impoliteness of inspecting the teeth (an indication of age and vitality) of a horse you’ve been given. In other words, someone just gave you a freaking horse! Don’t go poking around looking for signs he’s ready to be put to pasture; that’s tactless. Accept the damned horse gratefully and graciously, even if that toothless nag is teetering on death’s doorstep.
 A frightening portion of the planet seems gripped by gift-horse mania. “Look at these shiny new vaccines we’ve been given! They’re safe and effective —the manufacturers say so themselves! Why look for a way to prevent or treat COVID with an inexpensive and undeniably safe medication when Pharma’s generously rolled out a plethora of experimental, disastrously ineffective, insanely profitable, and manifestly dangerous options? How rude .”
 To be fair, as my co-author and I painstakingly detail in our book , the pandemic propaganda has been relentless. And while the masses seem to be slowly wakening from their collective stupor (it’s pretty hard to deny the skyrocketing death and disability rates around the globe in the wake of the vaccine rollout, for one thing), we’ve obviously got a long way to go before the most indoctrinated of the flock stop slinging misguided digs at the Korys of the world and get rightfully and righteously furious at the folks doing the real grifting.
 As someone I’m not in the habit of quoting once said, we’ve been patient… but our patience is wearing thin. If we could get a world-wide wakeup sometime around yesterday, that’d be great.

 The War on Ivermectin is available on Amazon and anywhere else kickass books are sold.

Summary: Apparently some people don't really understand what a grifter is. I'm here to help.