Categories
Outpatient Practice

Telemedicine Across State Lines?

Healthcare providers and patients have embraced telemedicine during the COVID-19 outbreak as a way to ensure on-going medical care while minimizing potential exposure to the virus. But many of my patients live outside of Ohio, so can I use telemedicine to care for them? Unfortunately, the answer is probably not.

“The practice of medicine is deemed to occur in the state in which the patient is located.”

 

Physician medical licenses are state-specific. Therefore, a physician must have a medical license issued by the state medical board in each state that physician practices in. But if the physician is in one state and the patient is in another state during a telemedicine encounter, which state is the medical practice location? The State Medical Board of Ohio, like most other states, defines the location of the practice of medicine to be where the patient is physically located, not where the doctor is physically located.

So, if a patient from West Virginia comes to see me for a face-to-face visit in my office in Columbus, Ohio, the practice of medicine occurred in Ohio. But if I did a telemedicine visit with that patient while the patient was in their home in West Virginia, the practice of medicine occurred in West Virginia. And since I only have an Ohio medical license, I would technically be practicing medicine without a license.

Each state has different laws about medical licensure

 

In Ohio, the laws pertaining to telemedicine are derived from section 4731-11-09 of the Ohio Administrative Code that applies to the prescription of medication. This law states that a physician cannot prescribe any controlled or non-controlled medication to a patient unless that physician has conducted a physical examination of that patient. However, an exception exists if the following criteria are met:

  • The physician establishes the patient’s identity and location
  • The patient provides informed consent for treatment
  • The physician completes a medical evaluation
  • The physician establishes a diagnosis and treatment plan
  • The physician provides appropriate follow-up recommendations
  • The physician documents the encounter in the medical record
  • The physician uses appropriate technology sufficient to conduct the encounter

The State Medical Board has stricter rules regarding the prescription of controlled substances, such as opioids. If a physician has never conducted a physical examination on a patient, the physician cannot prescribe controlled substances except in a few situations, such as the physician is cross-covering for another physician who has examined the patient or if the patient is in hospice.

Physicians outside of Ohio who want to provide telemedicine care for patients who live in Ohio must obtain an Ohio telemedicine certificate (at a cost of $350) and are held to the same standard of care as a physician having a regular Ohio medical license.

The COVID-19 emergency has changed state telemedicine regulations

 

Each state has responded differently to telemedicine regulation changes brought on by the COVID-19 outbreak and each state’s requirements are summarized on the Federation of State Medical Boards’ website. For the State Medical Board of Ohio, there were 2 concessions made for physicians outside of Ohio for the duration of the COVID emergency:

  1. They are able to provide telemedicine services to their established patients who were visiting Ohio and now unable to return to their home states due to COVID-19.
  2. If they are in a contiguous state to Ohio and have established patients who live in Ohio they can also provide telemedicine service to those patients.

In addition, the State Medical Board of Ohio has suspended the requirement that a physician must have performed a physical examination in order to prescribe medications and suspended the requirement for in-person visits to occur for the prescription of controlled drugs, such as opioids.


But the regulations are often very confusing. For example, during the COVID-19 emergency, West Virginia permits a physician licensed in any other state to provide telemedicine to patients located in West Virginia. However, Ohio has not made similar concessions permitting an Ohio-licensed physician to perform telemedicine visits with a patient located out of state. So, the question remains, can a physician licensed in Ohio perform telemedicine to a patient in West Virginia? The State Medical Board of Ohio says no whereas the State Medical Board of West Virginia says yes. This has important implications for malpractice insurance coverage in that if a physician’s medical license does not cover their telemedicine encounter in another state, their malpractice coverage may not cover that telemedicine encounter, either.

So what is a physician supposed to do?

 

The safest bet is to obtain a medical license in all of the states that your patients live in. This would also include states that your patients vacation in if you want to provide care for them by telemedicine if they get bronchitis while visiting relatives out of state. During the COVID-19 emergency, check with the State Medical Board of both the state that the physician is in as well as the state that the patient is in to be sure that both states permit out-of-state telemedicine.

For my own practice, I encourage my patients in Ohio to use one of our telemedicine options. For my patients in other states, I tell them they have to have travel to Columbus and have an in-person visit in my office.

July 25, 2020

Categories
Epidemiology

Mask Myths

One of the most effective ways of controlling the spread of respiratory viruses, such as the COVID-19 virus, is by wearing face masks. Last weekend at the Ohio Statehouse, a group of anti-maskers protested the wearing of face masks, complete with an escort of camo-wearing, body armor-clad, AR-15-wielding gun enthusiasts, presumably there to protect the protesters from throngs of violent mask-wearers. The protesters offered a multitude of reasons why people should not wear masks and so I thought this would be an opportune time to examine some common mask myths.

  1. You can get carbon dioxide poisoning. This theory espoused by anti-maskers proposes that carbon dioxide builds up inside of masks and then when one inhales, they inspire toxic quantities of carbon dioxide leading to disease and death. Carbon dioxide is a gas and cannot build up in a cloth or fiber mask. If it did, we would have to pay surgeons and OR nurses hazard pay since they have worn masks daily for decades. It appears that the protestors confused wearing a cloth mask with tying a plastic trash bag over one’s head.
  2. Masks cover up the image of God. This is the reason that state representative Nino Vitale from Urbana, Ohio used when he refused to wear a mask over his face inside the Ohio Statehouse. Mr. Vitale has quite a celestial opinion of himself and it is suspected that he refuses to wear pants in public for the same reason.
  3. Only N-95 masks protect you. N-95 masks are only necessary when performing aerosol-generating procedures and not when performing routing patient care or when out among the public. As long as you are not performing an upper endoscopy or colonoscopy inside of a McDonalds restaurant, you don’t need an N-95 mask.
  4. Masks only need to cover the mouth and not the nose. This one is partially true… as long as you are holding your nose, it won’t matter if your mask covers it. However, if there is air coming out of your nose, then it needs to be covered.
  5. If you’re not sick, you don’t need to wear a mask. Unfortunately, only about two-thirds of people infected with the COVID-19 virus have symptoms. In other words, one-third of those infected are asymptomatic. The guy sitting on the bar stool next to you who is yelling, laughing, sneezing, or coughing could quite easily be passing the virus on to you whether or not he has a fever.
  6. You only need to wear masks indoors. The idea is that sunlight kills the virus. Although it is true that most of the virus on surfaces is killed after about 20 minutes in direct midday sun, being in the sun will not kill viruses being passed through the air when someone coughs toward you, unless you can hold your breath for 20 minutes.
  7. Wearing a mask shuts down your immune system. Cloth masks are made of cloth, just like clothing is made of cloth. As long as your shirt is not causing you to get leukemia, your mask won’t either.
  8. Masks should be soaked in Clorox bleach before being worn. The idea behind this one is that since bleach kills viruses, any virus in the air that you breathe in will be dead-on-arrival when it gets into your lungs. Pulmonologists, such as myself, wish that this was true because if so, we would have lifetime job security from all of the asthma and lung damage caused by people inhaling bleach vapors.
  9. Wearing masks hurts the economy. Increasing numbers of viral infections hurts the economy. The economy will recover when it is safe to go to the store/theater/stadium/restaurant. Personally, I won’t walk into a public building if I seen other people not wearing masks. Wearing masks is the fastest way to rejuvenate the economy. Countries that enacted mask requirements early have recovering economies and are about to eat the United States’ lunch.
  10. Masks go against the American spirit of freedom. American freedom does not mean you have the right to infect other people with the virus. If a person is asymptomatically infected with the COVID-19 virus that person can infect others who are in contact with him/her. And if 4 of those others who get infected are over age 80, then statistically 1 of them will die. As a physician, I do not have the freedom to deny treatment to a mask-slacker who develops COVID-19 respiratory failure.

Anti-maskers join the legion of anti-vaxxers, anti-hand washers, anti-tooth brushers, and anti-bathroom users. Until we have an effective vaccine, the fastest way to get back to life as normal is to wear a mask.

July 22, 2020

 

Categories
Epidemiology

You Are Safer From COVID-19 In The ICU Than In The Grocery Store

This summer, COVID-19 numbers keep going up. Five months ago, we thought COVID-19 would behave like other respiratory viruses: have peak incidence in the winter and then drop off in the summer. But that has not happened. Across the United States, there is a second surge in new infections and southern states that seemed to be spared from the initial outbreak now have rapidly escalating numbers of new cases. As our hospitals admit record-breaking number of these patients, all of us in healthcare jobs wonder “Are we safe in our workplace?“. It looks like the answer is… we probably are.

In intensive care units full of COVID-19 patients, we are hyper vigilant about using personal protective equipment. Face masks, eye protection and hand sanitizer are mandatory. For patients undergoing aerosol-generating procedures, disposable gowns, gloves, and N-95 masks are added. It turns out that the coronavirus has a hard time penetrating all of that PPE to get to our mouths, noses, and eyes. Infection control procedures work surprisingly well.

The home is a dangerous place

On the other hand, in our homes, grocery store, bars, churches and restaurants, we let our guard down. The masks come off, we don’t use hand sanitizer every 5 minutes, and there are no plastic face shields to protect our eyes. Even worse are those around us who refuse to take any precautions, either because they believe that they are invincible, they are trying to make a political statement, or they are just plain ignorant. During the influenza pandemic of 1918, these people were called “mask-slackers”. Not only were there individuals who refused to adhere to infection control practices, there were entire cities that refused to adhere to these practices. St. Louis was an early adopter of closing schools and businesses whereas Philadelphia did not close businesses and instead held a public parade – the peak death rate in Philadelphia was 257/100,000 whereas the peak death rate in St. Louis was only 58/100,000.

A recent study from JAMA looked at 3,056 healthcare workers at a hospital in Belgium who underwent antibody testing to identify those who had become infected with the COVID-19 virus. All of them additionally completed a survey about exposures. 197 staff were identified as having been infected. But there was no correlation between taking care of COVID-19 patients and becoming infected oneself. Even working in the hospital was not associated with becoming infected. The only correlation was when a healthcare worker had a family member who was infected. The study indicated that healthcare workers who got infected did not get infected from hospital exposures but instead got infected from family members at home. U.S. hospitals are finding the same thing – when healthcare workers are identified as being infected, it is home exposures that are the cause and not patient exposures.

There are steps our hospitals can take

All of us in hospitals feel the risk. Many healthcare workers have decided to just retire or seek other jobs. Others have gone on disability purely due to perceived risk of becoming infected. But we know that strict use of personal protective equipment and hospital visitor limitation works. So what can we do to ensure our staff safety as elective procedures resume and visitors return? Fortunately, there are some specific things that we can do:

  1. Universal masking. Every person in the hospital should be wearing a mask unless they are alone in a room. This means not only doctors and nurses but also visitors and administrative staff. A mask for every person, all the time.
  2. Eye protection during patient care. In addition to face masks, goggles or face shields should be worn whenever a staff member is in a room with a patient.
  3. Hand hygiene every time. Alcohol hand sanitizer needs to be available throughout the hospital and must be used before and after every patient encounter.
  4. Beware of the break room. In hospitals, we often assume it is the patients who could be infected and are thus dangerous to us. However, we are more likely to get infected from a co-worker in the cafeteria, the conference room, or the office suite when we let our guard down by taking off our masks and not using hand sanitizer. It is probably more dangerous to eat in the doctor’s lounge than it is to intubate a COVID-19 patient while wearing PPE. When it comes to who hospital workers get their COVID-19 infection from, in the immortal words of Pogo: “We have met the enemy and they is us“.
  5. Limit visitors. Statistically, the more people that are in the hospital building, the more likely one of them is infected with COVID-19. Some studies indicate that as many as one-third of infected persons have no symptoms so simply screening visitors by symptoms or body temperature will not catch all of those people who can potentially spread the virus.
  6. PCR test all patients. Not only can visitors have asymptomatic infections but so can patients. So the patient coming in with appendicitis, a heart attack, or a bleeding ulcer can also have subclinical COVID-19. Every patient should be treated as if they have the infection until proven otherwise.
  7. Work from home. Healthcare workers can also have asymptomatic infection and so the fewer healthcare workers are in the building, the less likely one of them is going to inadvertently infect someone else. If you can do your job equally well from home, you should not be in the hospital.
  8. Encourage smart behavior outside of the hospital. We cannot control what our healthcare workers do when they leave the hospital but we can at least encourage them to do the right things. Avoid indoor gatherings. Always wear a mask in public. Avoid places where other people do not wear masks. Practice hand hygiene.

The COVID-19 virus is all around us. But it just may be that the safest place to be right now is working in the COVID-19 ICU.

July 19, 2020

Categories
Epidemiology

The Effect Of Age On COVID-19 Mortality Rates

Last week, I was asked if it would be OK if 20 family members visited one of my patients who is in his 80’s over the holiday weekend. My reflexive response was “Don’t come!” but it raised the question of what is the probability of dying should this patient get infected by COVID-19 and how does age effect mortality rates? Although we all know that age is a risk factor for death from COVID-19 infection, it turns out that specific probability statistics are hard to come by.

The U.S. Centers for Disease Control regularly posts information about the COVID-19 hospitalization rate by age and we know that older persons are more likely to be hospitalized than younger persons. For example, the hospitalization rate for people age 18-29 years old is 34.7 per 100,000 whereas the hospitalization rate for people over the age of 85 is 573.1 per 100,000. That means that an elderly person at 85 years old is sixteen times more likely to be hospitalized with COVID-19 than a young adult who is 25 years old. But this data does not tell us about the probability of death for different age groups.

The Ohio Department of Health regularly posts information about the number of Ohioans who have died from COVID-19 by age. This graph shows the COVID-19 deaths in Ohio as of July 1, 2020. It is striking that 1,516 deaths (53% of the total) occurred in people over the age of 80 whereas only 2 deaths have occurred Ohioans under the age of 20. However, the Ohio ODH does not post the total number of cases by age and so we still cannot determine the probability of death for different age groups. For that information, we have to turn to California.

The California Department of Public Health regularly posts both the number of infections AND the number of deaths for different age groups. This is the data from California as of July 1, 2020. By dividing the number of deaths by the number of cases for each age group, we can calculate the probability of death if a person in that age group becomes infected with COVID-19. The numbers are astounding: 25% or one out of every four people over age 80 who get infected with COVID-19 will die of the infection. On the other hand, a young adult between age 18-34 years old who gets infected with COVID-19 has a 0.084% chance of dying (or 1 death for every 1,196 infected persons). That means that an 85 year old person is 300 times more likely to die if infected with COVID-19 than a 25 year old infected with COVID-19. One a more personal front, if one of my children and I both get infected with COVID-19, I am statistically 38 times more likely to die than my child.

So, why is age such a striking risk for death by COVID-19? Although it is true that older people are more likely to have debilitating diseases such as heart failure and COPD that could make death more likely, I do not believe that this fully explains the association of age with COIVD-19 mortality. Furthermore, children almost never die of COVID-19; in Ohio, there have only been 2 deaths in those under age 20 and in California, there have been no deaths in those under age 18. One possible explanation that has been proposed is age-related changes in the level of the cell membrane receptor ACE2, a protein that the COVID-19 virus binds to in order to get inside of cells.

Virology research will eventually give us an answer to the question of why COVID-19 preferentially kills older people. But for now, I’ll stick to my original answer to my 83-year old patient’s family members question about having a family reunion at his house over the holiday weekend… don’t do it.

July 3, 2020

Categories
Epidemiology

Good News For The 2020-2021 Influenza Season?

I have a confession… I am a flu nerd. Every winter, I check the Center for Disease Control’s FluView website every Friday for epidemiology updates and I track the number of cases of influenza in our own hospital weekly. Most years, what happens in Australia in August and September predicts what will happen in the United States in February and March. And this year, there may be some good news from down under.

When it is summer in the United States, it is winter in Australia and so Australia’s flu season is the opposite months of the year as the United State’s. Last year, the Australian flu season was unusual: it started earlier in the year and there was a much higher percentage of influenza B than normal. Sure enough, last winter in the U.S., our influenza season also started earlier than normal and was characterized by mostly influenza B in the beginning of the winter and then mostly influenza A later in the winter. This graph shows the number of influenza cases by week of the year for 7 recent flu seasons (week 1 is in January). The red line is the 2019-2020 flu season (the gray line was the H1N2 pandemic of 2009).

Some studies of COVID-19 infections that occurred last winter indicated a high rate of co-infection with other viruses, particularly in children. The most common co-infecting virus was influenza. A fear of epidemiologists is that when the U.S. has its next influenza season in the winter of 2020-2021, co-infection of influenza and COVID-19 could result in an accelerated spread of COVID–19.

But it turns out that the same public health measures that help control the spread of COVID-19 also help control the spread of other respiratory viruses. Many physicians have wondered why there have been fewer emergency department visits for respiratory illnesses and fewer patients with asthma exacerbations in the past few months. The reason is likely because social distancing, wearing face masks, and frequent hand washing reduces the spread of all respiratory viruses, not just COVID-19.

The epidemiologic data coming from the Australian Department of Health Influenza Report indicates that this is going to be an influenza season like no other in modern history. What is so remarkable is that there is hardly any influenza this year. This graph shows the number of influenza cases over the past 6 seasons in Australia with the current influenza season in red and last year’s season in dotted green. Up until late March, the 2020 Australian influenza season appeared to be almost identical to last season. But then the number of influenza cases plummeted and there has been very few cases of influenza in April, May, and June.

It is still early to be sure since the peak of influenza in Australia normally occurs in August and September. But the early indication is that this is going to be one of the lightest influenza seasons on record in Australia and if so, then history tells us that the U.S. could have a light influenza season, also.

However, for this to happen, the U.S. will need to keep up social distancing and hand hygiene. As schools re-open in the fall and as workers return to their jobs, it may be very difficult for us to maintain our public health momentum next winter. So, this year Australian influenza epidemiology may not predict U.S. influenza epidemiology. Nevertheless, the information indicates that influenza can be controlled the same way that COVID-19 is controlled: staying home when you’re sick, washing your hands regularly, and avoiding those people who are sick.

But all Americans still need to get a flu shot this fall.

June 24, 2020

Categories
Outpatient Practice

Optimizing Telemedicine Into Outpatient Clinical Practice

The medical field has been dabbling in telemedicine for decades but until now was held back largely by reimbursement. Quite simply, Medicare and insurance would not pay for it except in a few very specific situations. But COVID-19 has opened the door for broad adoption of telemedicine into regular outpatient practice. When COVID-19 first emerged in the United States, Medicare allowed physicians to see patients via telemedicine and get paid the same as they would have if they had seen patients in a regular physician office. Although the future of telemedicine is subject to the vagaries of Medicare decision-making, my suspicion is that it is now here to stay – Americans have tried it and they like it.

Being old-school, I believe in the value of a well-performed physical examination and so telemedicine is not going to replace all office visits. For some specialties, for example wound care, telemedicine may only be able to be used in a minority of visits. However, not every office visit requires a physical examination – in my practice, I believe that I can do about one-half to two-thirds of my office visits by telemedicine and deliver the same quality of medical care. But with a mixture of in-person and telemedicine visits, how does a physician most efficiently design their schedule templates? As I am setting up my own templates, I’ve found that there are several factors to consider.

Patients like telemedicine

With telemedicine, patients no longer have to take several hours off of work to travel to and from the doctor’s office. For patients like many of mine who are on home oxygen, they don’t have to worry about their oxygen tank running out during the trip to  the doctor’s office. Patients who live a hour or two away from the doctor can now see their doctor without having to travel to the city that their doctor practices in. And patients don’t have to endure the aggravation of waiting in a crowded waiting area for the doctor who is running behind schedule. With COVID-19, patients don’t have to fear going out of their homes to a place where they could become infected by someone with the virus.

Telemedicine-only schedules

Most physicians think in terms of half-day templates. In my own practice, I take care of administrative and teaching responsibilities in the mornings and then see outpatients in the afternoons. By making an afternoon telemedicine-only, a physician can greatly reduce overhead cost. You don’t have to pay for rent for examination space and the office staff can do patient registration, medication list confirmation, etc. anytime that day or even the day before so that their time can be utilized more efficiently. The physician does not even have to be physically in the office – he or she can be in the hospital or even at home. This frees up the office space for another physician to use it for in-person visits.

Another advantage of telemedicine-only schedules is that by giving the patient a time range that the physician will contact them for the telemedicine visit (for example, between 1:00 – 2:00 PM), the patient does not need to sit in the exam room waiting for the doctor, they can be in the comfort of their own home or workplace. This way, if the physician is running a few minutes late because the previous patient took longer than anticipated, patients are less likely to become angry from long waiting times.

The disadvantage of telemedicine-only schedules is that the physician has to have enough days that they see outpatients so that some days can be devoted to in-person visits since there are inevitably some patients who must be seen face-to-face. So, if a physician has a very small outpatient practice, this approach is not practical.

Combining telemedicine and in-person schedules

In this strategy, the physician intersperses in-person visits with telemedicine visits. An advantage of this strategy is that the physician needs fewer examination rooms – a doctor who normally uses 4 exam rooms to optimize outpatient practice efficiency may only need 2 or 3 exam rooms. This can cut down on overhead costs. If the doctor gets behind on the schedule, then the doctor can postpone a telemedicine visit by 20 minutes and see the patient already in an examination room – by and large, patients waiting in their own home will be less irritated if the doctor is 20 minutes late for the telemedicine visit than the patients waiting in an exam room or waiting room. Additionally, telemedicine visits generally take a few minutes less than an in-person visit (no physical exam) so alternating telemedicine visits with in-person visits helps keep the doctor on-time for all of the patients.

In the COVID-19 era of social distancing, physician office waiting areas are not able to safely hold as many people as in the past. By mixing telemedicine and in-person visits, the number of people coming into the office is lower and this results in fewer people in the waiting area. Mixed visits on the schedule also give office staff extra time needed to sanitize exam rooms between patients.

The fate of in-person-only schedules

Until 3 months ago, this was the model used by most U.S. physicians. The result was crowded waiting rooms, irritated patients when the doctor was running behind, and the expense of no-show patients. This model is inefficient and costly. It places high demands on office staff and the physician to keep the schedule on time. In the future, this will probably not be a financially viable method of seeing patients.

So how should you structure your schedule templates?

There is no single best answer and template optimization depends on the medical/surgical specialty, the number of half-day blocks of office hours an individual physician has, and how COVID-19 is affecting the community at any given time. My recommendation would be to:

  1. First, create half-day blocks of mixed telemedicine + in-person office visits. Depending on the size of the waiting room, the number of exam rooms per physician, and the practice specialty, this could be 2:1 telemedicine:in-person or perhaps 1:1 telemedicine:in-person visits.
  2. Second, create half-day blocks of telemedicine-only visits. For many physician practices, this will be approximately 1/3 or 1/4 of the total half-day blocks.
  3. Have more than 1 telemedicine software application that your office uses and educate your patients on how to use the app. Many of the video chat programs currently being used for telemedicine require a specific web browser or a specific cell phone operating system. Also, many of these programs require the patient to update to the latest version of web browser software. In order to accommodate the largest number of patients, have 2 or 3 available options for telemedicine video conferencing in order to tailor each patient’s web browser or operating system.
  4. Know your patients’ technologic limitations. A surprisingly large number of patients do not have a computer or phone with a camera or live in an area where there is insufficient internet bandwidth or cell service to do video telemedicine visits. These patients will need to be scheduled for in-person visits.
  5. Be aware of state-specific rules regarding out-of-state telemedicine visits. Many states have eased regulations in the COVID-19 era but most normally have restrictions about medical licenses being valid only for telemedicine visits performed within that state and not for visits when the patient is in another state. These patients will need to be scheduled for in-person visits.
  6. Train the office staff on how to instruct patients to use the video chat telemedicine app. When we first started using telemedicine at the beginning of the COVID-19 outbreak, I would frequently wait for 5-10 minutes for a patient to join the video visit and then I would have to call them on the phone to talk them through using the applications. Ideally, the office staff should do this before the physician video visit with a practice video visit so that the patient becomes familiar with how to use the program.

Telemedicine is (hopefully) here to stay and promises to improve the efficiency of outpatient practice, reduce no-show rates, and provide care to patients who otherwise would not be able to travel to see the doctor. Creating the right schedule template will allow the physician to function with maximal efficiency and generate maximal patient satisfaction.

June 23, 2020

Categories
Outpatient Practice

Is It Safe To Go To Your Doctor’s Office During The COVID Outbreak?

In March 2020, outpatient medicine as we previously knew it changed, perhaps forever. The COVID-19 outbreak was accelerating in the United States and by the beginning of June, it would kill more than 100,000 Americans. People self-isolated in their homes, businesses shut down, and hospitals prohibited visitors. Patients were scared to go to their doctor’s offices and doctors were scared to be in their offices with patients.

In Ohio, the Governor and the Director of the Department of Health issues orders to stop elective medical testing and procedures. Medicare eased restrictions on telemedicine so that patients could still see their physicians without risking exposure to the virus in the doctors’ offices. All of a sudden, it wasn’t safe to go just about anywhere.

Today, our state’s medical practices and hospitals are opening back up for regular medical care and procedures. But the virus is still in our communities and is still causing hundreds of deaths per day. So, is it safe to go to your doctor’s office or to your hospital for an elective surgery? As usual, the answer is… it depends.

In the era of COVID-19, the moment we step outside of our homes, everything we do is a calculated risk. Going to the grocery store for on-line ordering with curbside pick-up is relatively low risk. Going to a sold-out concert and spending 4 hours in a mosh pit is relatively high risk. In our community, many people have died because they got infected with COVID-19 but many others have died because they stayed home in fear of the virus rather than going out to get needed medical care. So, how do you know if it is safe to go to your doctor’s office? Fortunately, there are several things that you and your doctor’s office can do that will improve the safety of patients coming in for medical care.

  1. Limit visitors. The risk of getting infected with COVID-19 increases with the more people you have close contact with. By limiting visitors, there will be fewer people in the building and statistics will be in your favor. Ideally, there should be no visitors except for those necessary to accompany patients with impairments.
  2. Screen everyone entering the building. This means asking if people have had contact with persons known to be infected with COVID-19, if they have fever, or if they have cough. Ideally, everyone entering the building should have their temperature checked at the entrance.
  3. Provide masks. The main reason for non-medical people to wear a mask is to prevent them from infecting others – wearing a mask does less to help keep you from getting infected yourself. When I go to a store, I wear a mask to protect everyone else from me, not to protect myself from everyone else. Buildings where everyone else is wearing a mask are buildings that are safer for you to enter.
  4. Improve throughput efficiency. The less time that a person is in the building, the lower their potential exposure risk. Strategies can include pre-visit registration on-line, reducing time spent in waiting areas, and minimizing time between tests and the doctor’s appointments (for example, the time between a doctor’s appointment and getting an x-ray in the same building).
  5. Safe waiting rooms. Most doctors’ offices and hospitals have waiting rooms that are designed to fit the largest number of people comfortably in the smallest space possible. In the era of COVID-19, there should ideally be 6 feet between people in the waiting areas. This means that most waiting areas should only hold about a quarter of the number of people that the same waiting areas held in the pre-COVID-19 era. Waiting areas can be restructured by removing chairs and by putting up plexiglass or other barriers between chairs.
  6. Don’t shake hands. Almost overnight, the handshake has gone from a welcoming greeting to a threatening gesture.
  7. Go before you go. The fewer doorknobs, handles, and buttons that you have to open, press, or push, the lower your risk of acquiring the COVID-19 virus if the person before you opened that door, pressed that toilet handle, or pushed that elevator button. Use the restroom before you leave home.
  8. The smell of disinfectant is perfume to your nose. If the exam rooms smells like fresh bleach or alcohol-based disinfectants, then the office staff are likely sanitizing that room between patients. That will make chair hand rests, examination tables, and counter tops safer for you to touch.
  9. Use telemedicine. Sometimes, an in-person visit with the doctor is necessary. A physical examination may be required. Maybe you need a vaccination, a blood draw, or an EKG. However, many (and maybe most) doctor’s visits can be done by video visits or even telephone visits. Currently, Medicare and many insurance companies are relaxing restrictions on telemedicine so that doctors can get paid to do telemedicine visits whereas in the past, those insurance companies would only pay for face-to-face office visits. If you can get everything accomplished by a telemedicine visit from the safety of your own home, then do so. A side benefit of telemedicine is that if the doctor is doing two thirds of the visits by telemedicine, then there will be fewer patents in the waiting area and fewer patients in the building thus making it safer for those patients who do require an in-person visit. Because I care for patients with COVID-19 in our hospital’s ICU, I am sensitive to the fact that many of my outpatients would rather not be in the same room as I am on the outside chance that I could have picked up the virus and either be asymptomatically shedding it or be in the incubation period before full-blown infection. Therefore, even if my patients have to come in for pulmonary function tests or x-rays, I will still offer them a telemedicine visit so that they can come in, get their tests, go home, and then have a telemedicine visit with me later.
  10. Schedule acutely sick patients for the end of the day. In the past, I often used the last appointment of the afternoon for those patients who I anticipated would need extra time for counseling – that way, if I spent 30 minutes for a 15 minute appointment, I wouldn’t be behind on my schedule for all of the subsequent patients. Now, I’d rather have that last patient of the day be the one who has more acute respiratory symptoms so that most of the other patients are out of the building and the waiting area when a patient who could potentially have COVID-19 shows up.
  11. Show up on time but not too early. If your appointment with your doctor is at 11:00, don’t come to the office at 10:00 or you will have to wait in the waiting area for an hour. But don’t be late either since you might then have to wait an hour or two until the doctor has another opening on his/her schedule to fit you in.
  12. Hand sanitizer everywhere. Ideally, there should be alcohol-based hand sanitizer in waiting areas, hallways, offices, and exam rooms so that office staff and patients can sanitize their hands as often as possible.
  13. Keep COVID-19 patients away from other patients. Most patients with COVID-19 are treated as outpatients but they still need regular medical care. Our medical center has drive-up swabbing stations to safely test patients for COVID-19 infection in their own cars and we also can do blood draws at these sites so that patients with known COVID-19 infection can get regular blood tests, such as INR levels if they are on anticoagulants. This keeps patients with COVID-19 pneumonia from having to go to the clinic lab to get those blood draws and thus keeps them away from healthy people.
  14. Don’t touch your face. One of the side benefits of wearing a face mask is that it will keep you from subconsciously touching your mouth or nose after you have touched a surface that harbors the virus. If you need to blow your nose  or sneeze, use hand sanitizer both before and after you use a tissue.

Most hospitals and physician offices are actually fairly safe, as far as COVID-19 is concerned. There is heightened attention to infection control, hand sanitizing, and masking that is not as universally practiced at other venues such as stores, gas stations, and public spaces. That being said, there are steps that both the doctors and the patients can take that can make outpatient visits even safer.

June 6, 2020

Categories
Epidemiology

When It Comes To COVID-19, Are We Testing The Right Thing?

During this COVID-19 outbreak, I have the dual roles of overseeing our hospital’s response to the pandemic and also of rounding in our ICU and taking care of COVID patients first-hand. One of issues that I struggle with in both of these roles is how accurate is our testing? Currently, we have 3 ways that we test for active COVID-19 infection: a nasopharyngeal swab for a rapid molecular test (made by Abbott Corporation), a nasopharyngeal swab for a PCR (polymerase chain reaction) test, and bronchoalveolar lavage fluid for a PCR test. We use the first two a lot and use the last one rarely. But do we have this backward?

The rapid molecular test by Abbott is very quick and our lab can have the results in < 1 hour. The criticism of this test is that it is less sensitive than the PCR tests so you can miss patients who are infected with COVID-19, particularly if they have mild symptoms or are asymptomatic.

The nasopharyngeal PCR test is currently considered the “gold standard” test for COVID-19. It appears to be more sensitive than the Abbott rapid test so it pick up more patients infected with the virus. However, it takes longer – 8-12 hours if your hospital does testing for it in-house and 2-3 days if it has to be sent to an outside lab. We primarily use this test if the Abbott rapid test is negative and we still clinically suspect COVID infection or if a patient without symptoms needs to be cleared of having the infection prior to undergoing an elective surgery.

The bronchoalveolar lavage (BAL) PCR test requires the patient to undergo bronchoscopy, an invasive procedure that requires sedating the patient and can put hospital staff at risk due to aerosolizing infected lung fluids into the air. Doing bronchoscopy on patients with suspected COVID-19 infection is generally discouraged because of the risk to the staff and the risk to the patient of an invasive procedure. Therefore, we don’t do a lot of BAL COVID tests.

Most respiratory viruses affect either the upper respiratory tract alone or both the upper and lower respiratory tract. The upper respiratory tract consists of the nose and throat; the lower respiratory tract consists of the lungs. COVID-19 is unusual among respiratory viruses in that it primarily causes symptoms in the lower respiratory tract resulting in cough, low oxygen, and shortness of breath. COVID generally does not cause much upper respiratory tract symptoms, such as sneezing or a runny nose.

So one has to wonder, if COVID does not affect the upper respiratory tract, how good is testing nasopharyngeal secretions?  Most of us who care for patients with COVID infection have encountered patients who had 1 or more nasopharyngeal Abbott rapid tests or PCR tests that were negative only to have the 2nd or 3rd PCR test end up being positive. We are also now seeing patients who have multiple negative nasopharyngeal PCR tests who then get a bronchoscopy and their BAL COVID PCR test comes back positive.

We spend a lot of energy debating whether the nasopharyngeal Abbott rapid or the PCR test is the best test. But maybe we ought to be asking whether the BAL is really the best test. When asked why he robbed banks, Willie Sutton famously said “Because that’s where the money is”. For those patients who present to the hospital with COVID-like signs & symptoms but have a negative nasopharyngeal PCR test, we may need to start doing more bronchoscopies with BAL COVID testing before pronouncing those patients virus-free.

May 17, 2020

Categories
Intensive Care Unit

The Pandemic Of Dogma Within The Pandemic Of COVID-19

Our generation of physicians prides itself on the practice of evidence-based medicine. Ideally, this means making medical decisions based on peer-reviewed clinical studies and randomized, controlled clinical trials. It means getting away from the “this-is-the-way-you-do-it-because-this-is-the-way-we’ve-always-done-it” approach to medicine to ensure that patients get the best known treatment for any given medical condition.

But what happens when you face a disease and there are no peer-reviewed publications and randomized controlled clinical trials? In that situation, physicians’ definition of what constitutes evidence can vary considerably. Thus enters dogma and nowhere in recent memory has there been a greater pandemic of dogma than in our intensive care units managing patients with COVID-19. As critical care physicians, we hold our convictions about how to best treat patients with COVID-19 respiratory failure more tightly than we hold religious convictions or political convictions. And given that many of these convictions are diametrically opposed, we can’t all be right. Forty years ago, in my first week of medical school, one of the professors told me that 50% of everything I was about to learn was going to ultimately be proven to be wrong. I think those words could be just as easily applied to our approach to managing patients with COVID-19 in the ICU today.

To Ventilate or Not To Ventilate?

That  is the question… or is it? For decades, we have defined patients as having ARDS (acute respiratory distress syndrome) if they have acute onset of diffuse pulmonary infiltrates with severe hypoxemia in the absence of heart failure and in the presence of something known to cause non-cardiogenic pulmonary edema, such as infection. And ever since 1967 when surgeon David Ashbaugh and pulmonologist Tom Petty first described the ARDS in the medical literature, it has been well-accepted that mechanical ventilation with PEEP (positive end-expiratory pressure) is the first line treatment.

But in the era of COVID-19, we read on-line news articles about a hospital in New York that reported 88% of their patients placed on mechanical ventilators died. And then all of a sudden, some critical care physicians are having second thoughts about intubating COVID-19 patients in respiratory failure and instead letting them be hypoxic. On the other hand, we read a blog post from a physician in Europe that he observed hospitalized COVID-19 patients develop sudden severe hypoxemia and go from needing 4 L oxygen by nasal cannula to having respiratory arrest despite 100% oxygen by face mask in just 30 minutes. And all of a sudden, some critical care physicians are intubating every COVID-19 patients who needs 4 L oxygen by nasal cannula.

Maybe COVID-19 really is different from ARDS from any other infection. But until someone proves that, I know that mechanical ventilation can bridge patients through life-threatening ARDS until time heals the lungs, that PEEP helps, and that low tidal volume ventilation is better than high tidal volume ventilation. We should not throw out everything that we’ve learned about the management of ARDS over the past 53 years because of a blog post.

Steroids Yes or Steroids No?

Over the past 35 years, the steroid pendulum has swung back and forth several times with respect to treating ARDS. First, studies showed steroids were beneficial, then studies showed they were not beneficial, and now studies again suggest they might be beneficial again. Similarly, you can find studies that show steroids improve the mortality rate of other coronaviruses and influenza; you can also find that steroids have no effect on the mortality rate of viral pneumonia. Some critical care physicians believe that steroids are the cure to the “cytokine storm” attendant to COVID-19 respiratory failure. Other critical care physicians believe that steroids paralyze the body’s immune defenses against COVID-19 resulting in increased viral replication. Our resident and fellow trainees are often caught in the middle, hearing that “You’re going to kill your patients if you don’t give then steroids” from one critical care attending physician on Monday and then hearing “You’re going to kill your patients if you give them steroids” from another critical care attending physician on Tuesday.

Hydroxychloroquine?

A non-randomized, non-placebo-controlled study from France suggested that 20 COVID-19 patients who got anti-malaria drug hydroxycholorquine had lower levels of detectable virus than patients previously published in the literature. This made immediate news in the lay press and the U.S. President called the drug a “game changer”. Within 3 days, pharmacies all across the country were sold out of hydroxychlorquine and I had patients calling in and asking me to prescribe it for them to prevent getting COVID-19 infection. Physicians throughout the world began prescribing it for any of their patients sick enough to be admitted to the intensive care unit. But then other studies showed that patients who received hydroxychloroquine actually did worse than those did not receive it because of potential fatal heart rhythm disturbances brought on by hydroxychloroquine. Once again, you’ll find critical care physicians who think it is the standard of care and others who think that it is nonsense.

Tocilizumab?

Patients with COIVD-19 have high levels of the cytokine, IL-6. This occurs during the “cytokine storm” that these patients can get when their macrophages and monocytes produce enormous quantities of pro-inflammatory cytokines. This is also called the “macrophage activation syndrome”. Tocilizumab is an inhibitor of IL-6 and so some physicians believe that by inhibiting IL-6, the cytokine storm can be attenuated. It is one of those “makes sense, no data” treatments that might make patients better, might not do anything at all, or might actually make them worse. But in the absence of randomized, placebo-controlled clinical trials, you can find critical care physicians who are staunch proponents and others who are staunch opponents.

And Everything Else?

Across the United States, there are some critical care physicians who believe that because D-dimer levels are high, that anticoagulation helps by preventing clotting; other critical care physicians thing that empiric anticoagulation just makes patients bleed more. Some physicians believe that inhaled vasodilators such as nitric oxide or epoprostenol improve oxygenation in COVID-19 patients by redirecting blood flow to less affected parts of the lungs; other physicians believe that these drugs can cause patients to become hypotensive and develop cardiac arrest. Other treatments that might or might not work include transfusion of plasma from patients who recover from COVID-19 infection, the anti-viral drug lopinavir/ritonavir, another anti-viral drug remdesivir, and the complement inhibitor eculizumab.

As humans, for thousands of years we have sought ways to control nature. And we base a lot of our attempts at control on anecdotal experience that leads to superstition. For example, a child falls into a volcano and the next day it rains so the village starts throwing lots of children into the volcano the next year when there is a drought. As physicians, we are no different. We see or hear about a patient who got one treatment or another and got better and then that one patient or small group of patients becomes the evidence that we base our practice on when there is a vacuum of randomized, placebo-controlled clinical trials. COVID-19 has overtaken the world suddenly, too fast for science to give us direction about how to best treat patients and so we fall back on medical superstition. Some of those superstitions will ultimately be proven to be right and others will ultimately be proven to be wrong.

So, all of a sudden, what constitutes evidence in evidence-based medicine today is a lot different than what constituted evidence last year.

April 25, 2020

Categories
Epidemiology

Imagining Life After COVID-19

It is mid-April and physicians and hospitals are already planning on how and when to re-institute normal operations, like flowers poking through snow after a cold winter. But it is pretty clear that the normal operations of the future will not be like the normal operations of the past. I’m using this post to speculate on how things may be different.

Hand sanitizer will become the new tabletop condiment

If  you go to a breakfast restaurant, you’ll find pitchers of syrup and honey on the tables. At lunch and dinner, there will be bottles of ketchup, mustard, and hot sauce on the tables. In the future, look for bottles of hand sanitizer on your restaurant tables.

Obstetricians will be busy in January 2021

“Blizzard baby booms” are a debated phenomenon that lie somewhere between urban myth and obstetric reality. I am a member of the baby boom generation, a surge in babies born after soldiers returned to the U.S. after World War II and the Korean War. That baby boom was a reality but whether there is a mini-boom of babies born 9 months after hurricanes and blizzards keep people indoors for a period of time is more uncertain. A blizzard or hurricane keeps people cooped up together for just a few days but COVID-19 keeps couples isolating at home with little to do for weeks. Will the social isolation of March and April result in a lot of babies in December and January?

Infectious disease physicians will be hospital medical directors

In a war, Majors are promoted to Colonels and Colonels are promoted to Generals by demonstrated success in battle. Similarly, hospitals select their medical directors based on administrative success in leading individual hospital programs. Throughout the world, hospitals are having their COVID-19 response led by epidemiologists and infectious disease specialists. Those who successfully steer their hospital through the infection control and financial perils of the pandemic will find themselves in line for promotion to hospital leadership positions.

Surgical masks won’t just be for surgeons any longer

Wearing a surgical mask does help prevent one from becoming infected with respiratory viruses when an infected person coughs or sneezes in your face. But when everyone wears a mask, there are two other important infection control effects. First, if the person wearing the mask is unknowingly infected with a respiratory virus, it helps prevent that masked person from coughing or sneezing on others. Second, when a person is wearing a mask, it reduces the chance that the person will touch their nose, mouth, or eyes with hands that could have picked up respiratory viruses from fomites such as a door handle, shopping cart, or elevator button that harbored viruses. In the future, people may likely feel more safe when those around them are wearing masks and that may be doubly so for their doctors and nurses wearing masks. Look for future masks emblazed with people’s favorite NFL team, alma mater, or beer maker.

A COVID-19 PCR test will become a routine admission order

When most patients get admitted to the hospital through the emergency department, they get “routine admission labs” – generally a CBC and chemistry panel. Look for a COVID-19 test to be added to that list of routine tests. Right now, there is near-paranoia by many physicians that their patients will have asymptomatic and potentially contagious COVID-19 to the point that they will not do procedures unless their asymptomatic patients have a negative COVID-19 PCR test. Even then, many demand that they be allowed to wear an N-95 mask for patients with a negative test because of the theoretic possibility that the test is a false negative.

Public health nurses will have job security

Countries that have been successful in controlling the COVID-19 outbreak have had very strong case isolation and contact identification. This takes manpower – primarily public health nurses that can go out in the community to interview patients and do testing of contacts. Public health departments are often underfunded  and understaffed. There will be increased demand for public health nurses for the foreseeable future.

Don’t expect your hospital to replace the old MRI machine

Although many U.S. hospitals have their ICUs full of COVID-19 patients, their overall medical/surgical census is generally low. That is because elective surgical procedures have all been postponed. Not only are surgeries not being done but neither are non-emergent diagnostic tests such as MRIs, CT scans, cardiac non-invasive tests, and pulmonary function tests. Hospitals don’t make much money off of medical admissions and depend on those surgeries and diagnostic tests to show a positive financial margin at the end of the year. Currently, hospitals are burning through their reserves (“days cash on hand”) with all of these surgeries and procedures not being done. With days cash on hand depleted, hospitals will be postponing large expenditures over the next couple of years.

The handshake will be a custom of the past

When a patient is infected with COVID-19, their hand becomes a fomite that can transmit the virus to everyone that they touch. Overnight, the handshake has changed from a greeting of politeness to a gesture of threat. Look for the handshake to disappear as an American social convention.

Telemedicine will come of age

Until March 2020, telemedicine was relegated to a few specific circumstances and primarily used in rural, sparsely populated areas of the nation. With the federal government relaxing rules for telemedicine, physicians all over the country are realizing that a lot of routine outpatient care can be done by telemedicine. Medical practices are adopting video telemedicine platforms through their electronic medical record or through separate commercial video applications. I have found that video telemedicine works very well for many of my patients, for both new and return visits. For patients who lack transportation or who live long distances from the office, the convenience of a video visit is a game-changer.

Anti-vaccine proponents will finally be quiet

One of the reasons that anti-vaxxers have flourished is that enough other people get vaccines so that devastating diseases such as polio, measles, and hepatitis B are uncommon enough that herd immunity protects the anti-vaxxers. If there were no influenza vaccines, then even influenza could periodically be as threatening as COVID-19. The current pandemic is a reminder of just how deadly infectious diseases can be and how much they can disrupt the economic structure of a community. An effective vaccine against COVID-19 will hopefully silence the anti-vaxxers since COVID-19 is unlikely to otherwise go away – it will just periodically die back and flare up as long as there are immunologically susceptible people for it to affect. The older the anti-vaxxers get, the more likely they are to become critically ill and die should they become infected and this will hopefully motivate them to forget their conspiracy theories and get a COVID shot.

It will be safe to go outside when your doctor has a beard

All of a sudden, most doctors and nurses in the United States became clean-shaven. That was because they needed to get fit-tested for N-95 face masks and a couple of years ago, OSHA made a rule that men with beards could not undergo fit-testing. Because I normally see patients in the hospital in airborne isolation (for example, those who are suspected of having tuberculosis), I have had an annual N-95 fit test for many years. And each year, I always passed my fit test, even though I had a beard. When OSHA came out with their rule, I was no longer permitted to wear an N-95 mask and had to switch to a PAPR hood but with PAPRs in short supply nationwide, men who provide inpatient healthcare had to shave and be fit tested. Just like robins are the first sign of spring, doctors with beards will be the first sign that the hospitals are no longer full of COVID-19 patients.

April 16, 2020