Hi, #MedTwitter! You have inspired me with your stories from the front lines of COVID-19. I’m seeking a sense of community with my colleagues in healthcare, so I decided to join and share my recollection of how things unfolded in an internal medicine clinic in the Bay Area.
When news of the virus in China hit, we started receiving phone calls and messages from patients who had recently traveled there, asking if they could get tested. Most of them didn't have any symptoms at the time.
We followed the CDC guidelines, so if they’d traveled to the Hubei Province, then we reached out to the public health department to seek authorization to test. Very few ended up being approved for testing.
As the virus spread outside China, patients started asking us if it was safe to fly. Many were requesting notes to be excused from their upcoming travel, so we started writing them if their itinerary included countries the CDC listed as Alert 2 or 3.
Our situation took a turn when the first cases were reported in Santa Clara County. Patients with mild cold symptoms, some who had traveled and some who hadn’t, were (understandably) coming in feeling extraordinarily anxious and requesting to be tested.
Patients with potential exposure were met outside by a medical assistant in PPE, brought through the back door into the only isolation room in our clinic, and then seen by one of the physicians, physician assistants, or nurse practitioners in full PPE.
Initially, we had very limited information, so our process was to contact the public health department by phone for consultation for every potential case. Swabbing patients for the virus required their authorization.
Consulting the public health department meant leaving the exam room, taking PPE off, calling, holding, briefing them on the patient, and then they would determine if they should be swabbed. Then we put (brand new) PPE on, swabbed the patient, and results would take 5-7 days.
As cases in the US ramped up, we started getting inundated with calls and messages from patients about everything from testing, travel, Ju-Jitsu classes, visiting grandparents in Nebraska, and interacting with pets. All we could do was to refer them to CDC and WHO guidance.
People started to worry that they could be carrying the virus, putting their elderly or immunocompromised loved ones at risk. Our triage system evolved to determine if they should self-quarantine, come to our clinic, or go to the hospital, depending on risk and symptoms.
Some patients with mild symptoms who didn't meet criteria to be tested, despite us telling them to self-quarantine and not come to the clinic, started showing up without an appointment, demanding to be tested.
They were putting our team and other patients at risk by walking through the clinic and not keeping ample distance or wearing any protective gear. Things were getting scary, and people wanted answers. Community spread created asymmetric demand for testing compared to capacity.
We implemented an outdoor respiratory clinic and a drive-up clinic where patients could get tested if they were “high risk.” We still had to limit tests given because viral swabs were in short supply, and we were also running low on PPE. Turning people away felt terrible.
Should we face another event like this in the future, there are several things I hope to see play out differently. I humbly would like to call on all senior healthcare leaders, the US government and members of every community to hear me out:
Successful processes we learned during this episode need to be documented, trained, and ready for rapid execution. I’m sure you have a pandemic response plan, but is your whole team required to know it? The faster we can activate cohesively, the more lives we can protect.
Access to testing at scale as fast as possible is a critical success metric for our Federal government. In this instance, testing in other countries was widely available before it was in the United States. Testing more people earlier makes quarantine more effective.
My heart goes out to everybody who has been affected by this pandemic. For now, the best weapon we have is social distancing. Please stay home unless you absolutely can’t. Zoom is a lovely way to enjoy a glass of wine with friends. 🍷
You can follow @npsteph_.
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