Thread by @GIMaPreceptor

1/Many of my colleagues and I have not been redeployed to the hospital during the #COVID pandemic. We have been doing the ambulatory care of pre/non hospitalized patients, helped w admitted pts and starting to see post discharge pts.

Many thoughts/advice points:

A 🧵THREAD

2/ First our #primarycare triage function in this process is crucial.

Workflows/teamwork/infrastructure have to be worked out and optimized.

An updated list of daily follow up #telehealth covid pts must be kept. Day of illness, daily update notes and tracking has to happen

3/ Key points:

Age, comorbidities matter. And yet, there are those healthier patients that get sicker, hypoxemic/stormy as well

Don’t completely know (like so much in this illness) the grouped likelihood ratios for the following but these are things to ask to be complete ..

4/ fever, cough, myalgia, fatigue, smell or taste off, anorexia/nausea, diarrhea, headache.

The above are d1-5. Just an observation - be very careful w folks w strong GI symptoms early.

Now to dyspnea - how to ask/monitor? It is the key symptom for the pulmonary cytokine

5/ phone/video observations key. Your internist’s skills ... who’s sick?

Can they speak in sentences? Audible wheeze? Lips?nails?

Can you do ADLs? What can’t you do today that you could do yesterday? Take a deep breath and count as high as you can breathing out (Roth index)

6/ For the dyspnea/overall intensity of illness, watch ur pts carefully days 5 - 10. Not sure that I’ve seen this point studied, but (small N) in my group, this bears out.

W dyspnea, if homecare svcs available, introducing video visits &a pulse ox meter from them a welcome boon

7/ ER for mod-severe dyspnea, they are almost always more hypoxic than we realize. We’ve also been blessed to have local EMS check pt at home to check O2 sat and help decide.

Our communication skills are built for this.

Number needed to educate/calm/set up expectations = 1

8/ For our older home bound pts w comorbidities our communication skills are built for this.

Numbers needed to clarify goals of care w pt/family/caregiver =1 as well.

A word on diagnostic reasoning - pre triage/video probability of this damn virus is high, yes ..

But ...

9/ the bias the doc/team is subject to is AVAILABILITY

The occasional pt coming thru our triage/treatment pathway may have something else. There are sick non COVID pts staying at home, more deaths at home, we will have a secondary surge ..

Could this represent anything else?

10/ What’s in your supportive care toolkit. Yes I know a lot of this is barely evidence based for non COVID viral syndromes, but all too often common sense medicine has to apply where numbers needed to comfort =1.

In my doc’s bag have been

Acetaminophen, dextromorphan, ....

11/ benzonatate, inhalers, prednisone courses (think the concerns, esp once cytokines begin clinically, unfounded), inhalers, nebulizers w careful use re: others in home, anti emetics, immodium, BRAT diet, broth/hydration.

And yes, w early dyspnea, some home proning

12/ If homecare, O2 available pulse ox can guide early dyspnea management, within reason. I think ER if persistently < 90.

The next question 4us in pre hospitalization care concerns hypercoagulability of this disease.

Should hi risk ambulatory pts be on some prophylaxis?

13/ Would aspirin be enough?

While in hospital, pt/families can’t be together. I have found it very rewarding, essential to help w updates and communication for pt and family. Most pt rooms have iPADs in these circumstances, so pts do well to see their longtime doc and ...

14/ families are in super need of progress reports, expectation setting, end of life decision making, readiness. Good communication w our hospitalist/resident/student/nursing/intensivist colleagues pivotal to fulfill this role.

After discharge, telehealth/video has been a ..

15/ godsend. You can see O2 levels, residual work of breathing, caregivers, home environs, medication bottles. Physical/pulm therapy and nursing in home and video can be set up.

Single most challenging part for me post d/c has been - if pt complicated by pulm emboli, ....

16/ their NOACs are provided at discharge for 2 weeks, but then have to be continued.

I am begging eg, @Aetna, @Cigna @UHC @CMSGov and all payers/stakeholders eliminate tiers/formularies, deductible applications, hi copays for anticoagulants in this disease. The pt is in ....

17/ precarious enough position, our team/physician time is precious, we are working w very large numbers of pts with this disease and we can’t spend any time with the authorization game. Please ... a moratorium now would show good faith, not to mention we need help w all the ..

18/ uninsured/underinsured/#SDOH affected pts who need access2 COVID treatments like the NOACs when they’re indicated. While we’re at it, if these pts need inhalers, maintenance or rescue, the PA game is more of the same, insufferable 4us &most importantly 4seriously sick pts

19/ Last word: As #primarycare docs in these conversations we need an #EBM tutorial for the fed gov and press. QTs have to be simply explained for all - HCQ, azithromycin, zofran, some of the pt’s own lipid/depression meds a BAD mix. No COVID pt should die from bad science ..->

20/ or from an ill informed ratings driven impatient press.

Primum non nocere.

😳 Yikes - I’ve gone too long. Thx for indulging, hope helpful for #medtwitter, #twitternists, #primarycare, #getiatricians, all concerned

Fin.