- Obviously the flu can be deadly in some circumstances, but for most people that are healthy, generally healthy, first of all, how concerning is flu? Like, should I really be concerned about flu this winter season, even though I feel robust? And then the second question is, do you personally get the quote unquote flu shot?

I said on a previous podcast that I don't get it, and I took a lot of heat for that. I understand that the flu shot does protect against certain forms of flu, not all of them. That statement was kind of pushed out there by folks saying that I was going against CDC guidelines.

I'm not going against CDC guidelines. People should do as they choose. They should just know what they're doing. I've never gotten a flu shot. I don't know if I've ever gotten the flu, but that's my personal choice, and it's not based on any specific fear of the flu shot.

It's because it's never been an issue for me, and I'm okay with getting a cold or a flu every couple of years, feeling miserable for a week or two, and bouncing back. I feel like that's good to develop my own antibodies, but maybe I'm thinking about this completely irrationally.

So do you get the flu shot? Do you recommend the flu shot for healthy people? Do you recommend the flu shot for people that are metabolically challenged? - Yeah, it's a good question. I think it's, and the approach that I take is the approach that I take with any intervention in medicine.

Every intervention in medicine has a benefit, and every intervention has a risk, no matter what it is. So for me, because I work in an intensive care unit around sick patients all the time, I'm exposed to a lot of flu. I mean, you literally walk in, and the next day they say, "Oh, by the way, that guy, yeah, he had the flu." So you find out after the fact.

So for me, I've always, since I've been a physician, I've always gotten the flu shot every single year. - Do you get it multiple times per season? - No, just once. - Okay, so at the beginning of the flu season, when they say, "Flu shot available now." So it's a mix of antibodies against known strains of the flu.

- Yeah, interesting. The way that they try to figure out or guess the way it is, because that's what it is, it's a guess, is they look six months earlier to see what happened in the Southern hemisphere, and they see what was circulating there, and then they believe that's what's gonna be circulating in the Northern hemisphere.

And they do the same in the South. They look and see what's circulating up here, and they try to figure out what is gonna be there. So there's usually about three or four different ones that they try to put in there. Ever since 2009, they've tried to put one in there about 2009, because that was a really bad year.

We mentioned that in terms of that study on sunlight, but in terms of the side effects as a result of that, it's been pretty bad. I mean, to give you an example, I had a patient recently in the intensive care unit. This patient came in, very poorly controlled diabetes, hemoglobin A1C of like 16, 17, it was very bad.

And she developed, she got the flu, and her immune system was not well. She actually also got a very bad fungal infection that was near fatal. And so that's the typical patient that we're gonna see who's gonna have that type of a bad reaction to the flu. People who are immunocompromised, people who are not metabolically healthy, these are the ones that are wide open.

And so a flu virus is going to do a lot of damage there. So what does the flu vaccine do? It gives the immune system an advanced notice of what this antigen is. And that has two effects. What a lot of people believe is that it's gonna protect you from ever getting infected.

That's not the case. You can still get infected, but what happens is that the symptomatology or the side effects of that infection will be greatly diminished. So instead of you being hospitalized, perhaps, maybe you're only coming down with the flu and you stay at home. A lot of people would say, "I got the flu shot and it didn't help, I got the flu anyway." What we don't know is how severe that infection would have been in the first place.

So that's why, for people who are immunocompromised, I generally recommend it to get the flu shot. - Or people that are exposed to a lot of flu, because like you, you work in the ICU. But, and if I may, do your kids get the flu shot? - Yeah, we give them the flu shot as well.

It's more because they're the kids of doctors who might bring home the flu more than anything else. But there was a point where we were not doing it. When they're in their teenage years, that's when we start actually giving them the flu shot. That was just a personal opinion, even though I know it's approved down to six months of age, I believe.

- So you started your kids once they were in their teen years? - Yeah, yeah. I remember one year, our son, Ryan, he got some virus, I don't know what it was, but he had very bad diarrhea. And we had to take him to the emergency room to actually get an IV and get fluids into him.

He was very dehydrated. I don't know what that was. I don't know if it was rotavirus, but something was going around that year. So, and he's perfectly healthy. So this is something that can happen. And you just have to look at the risks and benefits. - So if, well, I am telling you that I've never gotten a flu shot.

Am I being irresponsible as a citizen? I don't tend, I mean, I go places, I go to restaurants, I go to the gym, I've remained healthy for the most part. I'm in an occasional sniffle here and there. Every couple of years, I'll get, it's been a long time actually, now that I think about it.

- I think irresponsible is probably too strong of a word. The way I look at things is through what I call the Swiss cheese model. I don't know if you've ever heard of the Swiss cheese model. - I love Swiss cheese. - Okay, so the Swiss cheese model says this.

Every, if I cut up a bunch of pieces of Swiss cheese, you'll know that every piece has a hole in it, right? Or maybe a couple of holes. And if you line up those pieces of Swiss cheese, those holes might be in different places. So if you are, let's say you're on one end of those multiple slices of Swiss cheese and little particles are coming through.

If you have enough pieces of those Swiss cheese, no particles are gonna get through. And that's really what we look at in medicine. We don't just depend on one slice of Swiss cheese. Like in the operating room, for instance, we don't wanna have infections. So what do we do?

We sterilize the instruments. But we don't just leave it there, right? We sterilize the skin that we're going to incise. We make sure that the room is the right temperature, the right humidity, because that has an effect. We make sure it's under positive pressure. The surgeon is wearing a mask.

He's also wearing sterile gloves. So we go through, we try to do everything that we can possibly do so that if there is a breakdown in one place, we still have a bunch of other Swiss cheese slices in place. It's the same thing with the flu and new start.

So nutrition, exercise, water, all of those things. And then at the end, when you've done that for yourself, if you wanna have extra protection, you wanna add on another piece of Swiss cheese, then you, well, you can talk to your doctor, see what the risks and the benefits are, and then make that decision if that's something that's right for you.

- Are there any known risks of the so-called flu shot? And if so, what's the percentage risk? - Yeah, well, definitely there are risks in terms of allergies. So they should be asking you when you get it, have you ever been allergic to the flu shot before? I mean, you can have anaphylactic shock.

That's one possibility. Of course, you can have that with anything, right? But specifically to the flu, there was actually, interestingly, one year, and I can't remember which year it was, but there was a, I think it was in Europe, and we actually never got it in the United States, but there was a rash of narcolepsy that was occurring.

So something about the flu vaccine was causing a reaction that was causing an autoimmune response, and the antibodies, they believe, were acting against where hypocretin is made in the brain, hypothalamus. And so they noticed that there was an association. I don't know if they actually determined that it was causal, but they stopped that brand.

- I would not want narcolepsy. I used to work in a laboratory for a summer that studied narcolepsy. It was the Laboratory Emmanuel Mignon's lab at Stanford School of Medicine. He and his colleague, Seiji Nishino, identified the hypocretin-orexin mutation as the source of narcolepsy. And people with narcolepsy, people think it's just excessive daytime sleepiness, but anytime they have it, in the extreme examples, when people with narcolepsy have any kind of emotional activation, they fall asleep.

And they have cataplexy too, so they can't drive. They become essentially paralyzed, like a sleep atonia. Pretty devastating disease. So it sounds like that particular strain of the flu shot in Europe was neurotoxic in some way. - Yeah, there was one particular strain. We'd never seen it before, never seen it since.

And so yeah, there are these one-offs, right? But everything has risks. And so the example that I give is, look, I'm in the ICU all day, and I'm seeing people occasionally with head bleeds, and they're on a blood thinner. But I don't go back to my clinic in the pulmonary office and then take everybody off of blood thinners, because we know that blood thinners, epidemiologically, in the long run, actually save lives because they prevent strokes, heart attacks, things of that nature.

So what we try to do is figure out what's the right individual for this medication, or what's the right medicine for this type of situation. And that requires training. And that requires, sometimes you have calculators that can figure out these risks. - In the winter months when flu levels are high, are you wearing a mask from the moment you walk into the clinic in the morning until when you leave?

When you walk up to a new patient, if you know they have a flu, or if you know they don't have the flu, are you masked up? I mean, this became a big issue around the COVID discussion, but to what extent does wearing a conventional mask, or even an N95, actually protect you from flu?

- Yeah, so the regular surgical masks are very good at preventing things from coming out of your mouth and going to other people, or coming onto your mouth if you happen to have one on. So in our clinic where we work, we actually look at the flu incidents. And then we see if it's rising, everybody that comes into that place, physicians, patients, everybody puts a mask on to reduce that.

N95s are a little different in that they don't prevent viruses from coming out of somebody. You may notice when you put an N95 mask on, they may even have a valve that pops open, and gas can come out, respiratory air can come out, or comes out the sides. It's when you take a breath in and it seals, now it's filtering that air.

So N95s are very good for people who don't wanna get infection and don't have respiratory issues, because you're now having to breathe air in through a filter that takes a little bit more work. If someone has COPD, which is an obstructive lung disease, or other lung diseases, that might not be the best thing to have in those situations.

So, yeah, I do wear a mask. I was very careful. I know I was coming on your show this winter time, and I was like, "There's no way I wanna get the flu "and miss getting on to see you." So, yeah, I wore a mask. Well, thank you for not, for avoiding bringing flu here.

It's wild because ever since I started this podcast, we put out now two episodes a week, full-length episodes on Mondays and the shorter essential episodes on Thursdays. So, I can't afford to get sick. Yeah, and I haven't been sick in years. I take care to not get sick, but I'm gonna think real carefully about this flu shot thing.

What about hand-washing? Is that? So, a friend, let me give a little bit of backstory. The guy I worked for as a postdoc was an MD, PhD, and he used to joke about the fact that hand-washing did nothing, because he was, in his prior life, he was a surgeon.

He did a, I think he did a rotation, a surgery rotation. He eventually became a neurologist, then a researcher. And I used to say, what do you mean? The hand-washing does nothing. And he's like, well, have you ever seen what a physician does before surgery? You know, they wash up to their, up to their, basically their shoulders.

They've got betadine, they glove in properly. And, you know, that's how you prevent infection. Washing your hands does nothing. It's a formality. And I thought, there's no way that could be true. Then I started digging around in the literature about this, and it's kind of mixed. Like, so, to what extent does washing our hands actually help us avoid getting infection?

I, you know, it's a good question. And I think it probably comes down to some of the studies are probably not good data or heterogeneous enough to do a meta-analysis. But what's really interesting is how many times a day, if you were to watch yourself, that you touch your nose, you touch your face.

And these are the portals for viruses to come into your body. - Eyes. - Yeah, eyes, nose, mouth. That's where they come. And we touch them all the time. You touch handles. I mean, if you think about it, it's almost, I don't know, creepy. - And flu, it is creepy.

And flu and cold can survive out on surfaces for how long? - I'd have to look up the numbers, but it's longer than you might think. I know that when we looked at COVID, it's that really, I know we went crazy at the beginning of the COVID pandemic about wiping things down.

And really, that's not the way it seems to spread for COVID and more airborne things, but for influenza droplets, that is, you know, rotavirus, C. diff, that's clostridium difficile infection of the bowel. That's the primary way that it actually spreads. (upbeat music) (upbeat music)