Sunday, April 26, 2020

MD Guest Column: Protect Patients Now

This post is a guest column submitted by a local physician.    

Have the hospitals and clinics and physician's offices started setting up screening of their employees before they start work each day? With a loosening of restrictions soon, this should be the first requirement. Most healthcare facilities are staffed (largely) with 22-50 yr old doctors, nurses, clerks and the like. As is well known now, most of this demographic acquire the virus, develop no symptoms, shed the virus, and get over it without symptoms. They are among the great pool of the "healthy" shedding the virus. Most of the patients are in another demographic. They are the vulnerable. This is especially true in orthopedics.

The first premise of medicine is to do no harm. It should be a requirement that the vulnerable should be protected from those shedding the virus (who don't have fever or cough). That is, healthcare workers (especially for "elective” procedures) need to protect their patients from acquiring the virus from them. This will require daily (morning) screening for the virus for all physicians, nurses, clerks, greeting and billing personnel with an approved (EUA) RT-PCR test.

The cost of these screenings is the “cost of doing business” (to provide a safe environment for patients) and should be borne by the providers.

There are already medical supply distributors seeking the attention of physicians to “screen” patients with unapproved tests and allowing the physician to charge a large fee (to generate revenue) from the patients as a condition of being seen. This is deadly wrong and unethical.

The best screening test for fitness for our healthcare workers (including physicians) remains the RT-PCR test. Not all such tests are of equal quality. There are “rapid” tests (answer in less than an hour, to be performed before patients arrive). Some of these platforms (Abbott and Cepheid) have a small footprint and quick turn-around-time). There have been scientific issues with the Abbott ID Now instrument but they are being addressed.

One issue with all of the swab RT-PCR instruments is that they detect only 80-90% of positive cases. This means that some staff may slip through and test “negative” even though they are shedding the virus. This doesn’t reflect the quality of the instrument. It is sampling error.

What this means is that “look back” and contact tracing will need to be performed on all those patients seen by Nurse X or Dr. Y when, suddenly, they test “positive” one morning. Reasonably they could have been positive the day before and those patients seen must be contacted and informed that they may have contacted the virus from their healthcare provider.

When these screens are implemented, it will be great comfort to the patients (and to the staff) to have a reasonable assurance that this is a “safe” place to work and to treat patients.

When will the Governor, the Medical Board, and the state health officer require these tests as a condition of operation?


Anonymous said...

Hope so.

Anonymous said...

I hope this happens quickly. I had a Cologuard test come back abnormal the Friday after nonemergency procedures were stopped. Now I’ve finally got a colonoscopy scheduled on the 18th to see what’s up. I’ve got autoimmune disease and high blood pressure so I’m at a high risk of COVID complications. It’s a bad position to be in knowing I need to make sure I don’t have cancer, but also knowing COVID has a likely 10% chance of proving fatal. Regular testing would help prevent unnecessary infection of patients like me who are very vulnerable.

Anonymous said...

Yes yes yes! I have been saying this all along because I know several physicians who traveled to NOLA during spring break. They returned and were seeing patients. I wonder how many patients they infected and the patients never knew where they got it.

Anonymous said...

Most physicians/facilities I work with are already planning, developing protocols and taking appropriate steps to ensure all possible compliance with CDC guidance and best practices are followed to ensure safety in the workplace and for patients.

Anonymous said...

Well reasoned and convincing. The Governor and Dr. Dobbs have got to be made aware, if they have not already.

Physicians are often cavalier about their own health, but now is the time for tripled vigilance.

Anonymous said...

"Should be borne by the providers".. pass the cost on to health insurance companies... health insurance companies, pass that expense off on to the consumer.

We're losing our jobs, those of us who still have our jobs are going to foot this bill for this massive bailout, but hey let's just require upgrades to the health care system despite all the advances we've made over the years.

Anonymous said...

@2:26 pm Actually has less than a 1% chance of proving fatal, but yes, you are a higher risk.

Anonymous said...

@2:52 Especially the physicians who don't wash their hands all day and/or never change their gloves in between patients.

Anonymous said...

false sense of security. treat every patient/employee as if they were infected, period

this testing phenomena is political in nature, not science

Anonymous said...

... but what about the thousands of contagions that cause fever that AREN’T COVID-19 and AREN’T deadly? People can run fever from stress alone!! Plus, not everybody’s normal body temp is “normal.” How will they account for all of this?

Anonymous said...

@2:26p- I mean this with all sincerity... who should pay for these constant tests required by your conditions?

Before you think I’m being rude, I have MANY family members with multiple preexisting conditions. With that being said, 95% of their preexisting conditions were caused by lifestyle choices... things they could have prevented. I know none of us are perfect and hindsight is 20/20, but should the country remain locked down because huge sectors lived carelessly for decades? This is a sincere question. We as Americans really need to look at what we’ve done to ourselves...

Anonymous said...

Comments from another "expert". They're everywhere these days. There are the experts on COVID-19 and what should or should not be done. Then there are those experts on what the government is doing - too little, no too much; too soon, no too late. Then there is group of experts who tell us to reopen for business NOW versus those that tell us to keep hunkering down at home. It seems everyone is an expert.

Anonymous said...

Hey local physician, by all means save our Grandparents (and we will do our part too ) . . . but if you have any influence whatsoever . . . please help stop these damn redundant commercials every five minutes.

From pizza and car dealers down to cell phones, insurance and candy.

It's the same shit . . . slow piano notes . . . a deep solemn voice that says "in these uncertain times, we're with you. Stay safe and buy our product".

Gawd I love capitalism, but for the sake of humanity, convince the Ad Agencies to return to the old marketing plans.

Anonymous said...

3:25 - if you want to just bitch, why go to so many words?

To answer your question, good medical providers have dealt with those issues you 'ask' about in normal times as a matter of practice.

What the Doc is saying here is - in addition to the normal practices in your office, you should follow extra protocols due to the COVID.

Despite all the JJ experts that seem to know (but are generally always wrong) about COVID and think that these extra precautions are unnecessary, any doctor I have need to see in the coming months will be following this or similar protocols.

I believe, to answer the question raised by the Doc in his closing sentences - these protocols (or something similar) have been spelled out by the CDC, and thus they would apply to MS providers already.

Good column, though. Thanks to the Doc that provided it to you, KF

Anonymous said...

@4:17p- I wasn’t bitching, but rather asking a real question. You do realize that people run varying degrees of fever all day, every day... right? Are we going to be paralyzed by fevers for the rest of our lives?

It seems more logical that resources be put into treatments NOT screenings. If COVID-19 becomes recognized as treatable, all this non-sense vanishes. This virus, like flu and other contagions, will always spread and kill... we will never change that fact.

Handy said...

Hoops will be jumped through all for naught. All will be exposed and no need to make the medical staff do any of this, on the way to the Dr's Office and most other times, the patients are full time exposed. Skip the theatrics, life needs to go on, people will die on schedule from all kinds of stuff.

Anonymous said...

An anonymous MD guest opinion article. Just when you think you’ve seen it all.

JMoss said...

Who is this anonymous guest MD? Seems to have some sort of agenda against ortho, points out no other specialty like plastics, urology, dermatology, GI, etc. Maybe it’s written somewhere but I can’t find it.

Anonymous said...

6:44 Agreed.. but most of all dentists hovering over your face and mouth, hands in mouth, for prolonged periods. Sorry dentists.

Anonymous said...

"This will require daily (morning) screening for the virus for all physicians, nurses, clerks, greeting and billing personnel with an approved (EUA) RT-PCR test."

The hospital I work at screens the temperature of every single person who enters the hospital every day - no exceptions.

Anonymous said...

@8:38 You miss the point entirely. Most people (especially young healthcare workers) develop no symptoms. So testing for fever isn't testing. The only way to be successful (and screen healthcare workers) is to screen with the RT-PCR test. Every day. Because the test is good for precisely that day.

Anonymous said...

@4:17 There are no treatments. Zero. So you must make sure that healthcare personnel are not asymptomatic virus shedders and killing patients. We need to reverse engineer this as the post suggests. Instead of screening patients, we need to screen the medical community (frequently young and healthy) so that they don't give it to patients. they young and health(by and large) aren't the ones at risk of dying from the virus. It is grandpa going in for his colonoscopy.

Anonymous said...

My wife is taking monthly chemo treatments. Before you enter the building they take your temp and give you a mask. Waiting room is spaced out. I don’t know what the Drs and staff are doing. Hopefully checking themselves daily as chemo patients have very low immunity.

Anonymous said...

With half the infected individuals never having symptoms and those that do don’t start showing symptoms until two or three days after being contagious a temperature check by itself is just about useless.

JLowery said...

I’m a RN in an ortho surgery center. It’s obviously a scary time for everyone, but we are taking every precaution and providing the best care as safely as possible. Why call out ortho anonymously?

Anonymous said...

@9:43p- Wake up!! There ARE treatments being administered and they are WORKING for many. Do NOT trust the person or source that fed you that garbage... they are LYING to you!! Educate yourself!

Anonymous said...

My normal temp is 96.6, has been for as long as I can remember and I am 79, in good health, no underlying problems and I go to work every day. 3 person law office but we are careful with who we see and keeping the office cleaned twice a day. I hope that everyone gets through this pandemic. I see enough of my lifelong friends dying from natural causes much less covid.
Y'all have a great week!

Anonymous said...

Sigh....another "advocate" physician that doesn't understand limited budgets and resources, but feels the need to promote his position no matter how ridiculous it is. (They learned to do it anonymously so as not to get fired like the last princess.)

The days of doctors thinking they are gods "ordering" this or that is rapidly coming to an end. Healthcare (emergency or not) is a business.....and there will be no healthcare without money. What in the hell are the teaching students at UMMC? That Mississippi is made of money? Hahahahahahahahahaha!

Anonymous said...

3:12 pm
2:26 pm's risk percentage falls within the grouping of " all CV 19 patients with auto-immune disease", not all patients.
Please don't weigh in on subjects you don't understand, two of which are auto-immune diseases and statistics.

Anonymous said...

Congratulations to Sweden on achieving herd immunity to Covid 19! They may go back to their daily lives now. Wait, they never left it. I wonder if they threw the millions of bodies into the sea. Where did they hide the bodies?

Anonymous said...

The need to target a specific type of practice undermines this column and brings the author's (conveniently anonymous) motives equally into question.

Kingfish said...

Or he could be speaking about a specialty where the vast majority of patients are in the high-risk group.

Anonymous said...

The author comments: I appreciate all the thoughtful comments and opinions rendered. I have one objective and no others. Physicians' first duty is primum non nocere. "First do no harm." I fear that the rush to return to elective procedures will put patients in danger (for business purposes) and could lead to death by doctor's visit.

I agree that the choice of orthopedic surgeon looks like I am singling them out. That is a reflection of my poor writing and not orthopedists. Orthopedic surgery is a great profession and they do wonderful healing work. I could just as easily have said rheumatologists or Moh's surgeons or a host of other specialties. These are groups that have a disproportionate clientele of "at risk" (over 65) patients and the patient interactions are often prolonged. As such, these patients in particular need protection from their physicians who could inadvertently give them the virus and have the patient dies as a result.

What I am urging is careful protection for patients and from their physicians. Temperature checks before work are totally insufficient. The vast majority of people carrying (and exhaling) the virus have no symptoms including fever. So if you just check a healthcare worker's temperature you are allowing 70% of the rest of the infected into work.

There is a great rush to open physician offices for elective procedures. Testing patients is not the way to protect them. They need to be protected from physicians and their staffs. Neither the governor nor the state health officer nor the medical board nor the medical association have established evidence based methods to protect patients from physicians and their staffs. The proposal I laid out would do just that: Screen physicians and staff each day with an EUA (that means FDA) test for the virus. Wear N95 masks. The objection is cost. The rapid testing machines (e.g., Abbott and Cepheid) have a cost of testing at about $10. Is that too much to ask to protect patients? Would you not rather take your Uncle Charles to a gastroenterology clinic and have that clinic announce, "We know our patients are at risk. We are doing all we can to prevent the spread of the virus to our patients. We screen out staff daily for the virus."

As it stands, there are no standards. None. And I urge you to join me in seeking to have physicians live by the notion of "first do no harm."

Anonymous said...

"The only way to be successful (and screen healthcare workers) is to screen with the RT-PCR test. Every day. Because the test is good for precisely that day."

Please give us 1) a cost estimate and 2) a payment plan.

We'll wait.

Anonymous said...

@10:47 Yes, I did give the cost figure above. So if you have a clinic with 30 employees including physicians, that cost would be about $300/day. You can pay for it any method you wish. The benefit is that you won't kill patients.

Anonymous said...

7:49AM wrote: "Congratulations to Sweden on achieving herd immunity to Covid 19! They may go back to their daily lives now. Wait, they never left it. I wonder if they threw the millions of bodies into the sea. Where did they hide the bodies?"

You might want to research the latest data on Sweden before you start congratulating it. First, it is not remotely close to "herd immunity." But more telling and worrisome is that its rate of infection and deaths are rising fairly rapidly and are now something like 12% deaths per case/22 deaths per 100K, up from around 18 per 100K a few days ago (the US is currently around 5.7%/16 per 100K, Italy is around 14%/40 per 100K).

Handy said...

Am I the only one to say that Doctors mistakes and prescribed drugs will kill more than this virus?

Anonymous said...

@Handy, you are exactly right!!

My ONLY fear regarding this virus hype is my mother being hospitalized. She will not come out alive if she gets sick enough (for any reason) to be hospitalized. This is based on my previous experiences with her in hospitals.

After numerous stays and a multitude of errors by nurses and doctors, I truly fear them. It’s insane that families are being kept out of hospitals. On numerous occasions, my mother would have been given the wrong drugs or too many of her meds if I hadn’t HOVERED the entire time she was hospitalized. My beef is not their errors (they are human, not super natural) so much as their attempts to hide their errors and behave arrogantly about being wrong. Many medical professionals are desensitized.... it’s a true hazard of the job.

Anonymous said...

After reading this blog I wondered how my doctor could afford to do testing of her staff and her each day. As in who would pay for it? Then I found out that doctors are being paid billions now (through United Health Care) for doing nothing or for their COVID-19 expenses. The AMA describes it here:

Now there is no excuse for them to not protect patients from COVID by testing themselves and their staff. Hooray!

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If you get tired come relax at the Fox News Tent. To gain admittance to the VIP section, bring either your Republican Party ID card or a Rebel Flag. Bringing both will entitle you to free drinks.Get your tickets now. Since this is an event for trolls, no ID is required, just bring the hate. Bring the family, Trollfest '07 is for EVERYONE!!!

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