Practice Updates and COVID-19 FAQ, 3-19-2020

Paul Abramson MD COVID-19, Updates Leave a Comment

This is a letter I sent out to patients of our concierge medical practice My Doctor Medical Group here in San Francisco.

I wrote a “frequently asked questions” letter 3 days ago, and by today, it was already out of date. So here is an update on My Doctor Medical Group, and a revised COVID-19 FAQ.

PRACTICE UPDATES: We are up and running 24/7 but the structure of the practice has changed in some ways with some employees working from home, some in the office, and a shift to 90% telemedicine/video and 10% in person care (office / home / hospital).

TO SCHEDULE A VIDEO VISIT: We are accepting new patients.
— Go to https://app.elationemr.com/book/mydoctorsf for self scheduling of 30 minute visits. Or call our office 415-963-4431 during business hours if you have questions or need a longer visit.

— Video visits have worked very well, especially for some urgent care type issues and the cognitive/discussion part of annual checkups (deferring the in-person physical exam to later). Between labs, vital signs taken by thepatient, and a video visit, I’ve already picked up important things that would have been bad to have deferred detection of for a month or three. If you do need physical examination we will help figure out where & how.

— Many of our patients have gotten BP cuffs, pulse oximeters and thermometers which augment a video visit nicely. Our Eko remote stethoscope trial is in progress to see if that will end up being a useful tool, goal is to sort that out by the weekend.

— We have had good success direct admitting our patients to Sutter CPMC (Van Ness and Davies campuses), often successfully skipping the ER. For now, there are hospital beds available at CPMC.

— Our home phlebotomy partner has been extremely effective at testing people in the home – lab tests, blood cultures, COVID-2 swabs. We can also often arrange home x-ray, home ultrasound and other modalities if needed.

Q: “What should I do if I need medical help?” (for existing patients)
A: Contingency planning
— If you have a NON URGENT question or update, you can send it via our online portao, email us, call us, or after hours leave a non-urgent voice mail via the office.
— If you have an URGENT question or are ill (but not too ill), call us and use the option to page if after hours. We can then talk by phone or video in the right time-frame.
— If you are very ill and/or need a hospital. Go to the ER at CPMC Van Ness campus and/or call 911. Second choice CPMC Davies campus. Third choice CPMC Mission Bernal campus. If a pants-on-fire emergency, just the nearest hospital or call 911.
— IF GOING TO THE ER ALSO CALL/PAGE US so we can help coordinate this process, hopefully get you seen more smoothly, and admit you if needed.

AND OUR COVID-2 FAQ:

Q: “Can I get tested for COVID-2?”
A: We can now do in-home COVID-2 testing. Cost is high due to a tech in biocontainment gear having to come to the home, collect specimens, and then transport them frozen to a lab – it involves time, risk and logistics. We are working on a drive-through option in downtown SF but supply of swabs and viral transport media has been limiting.
— For now we are only testing high-risk patients until the labs/government relax rules about testing – this will conserve swabs/UTM tubes for high risk patients until there’s a better supply. There’s reason to believe supply will increase in the next 1-2 days.
— Please contact us if you would like to be tested at home. We can schedule a video visit and figure it out from there.

Q: “Is meal delivery safe or should I be sterilizing and cooking everything myself?”
A: Hard to say. SARS-CoV2 is probably transmitted by droplets more than airborne aerosol. So it all depends on who’s preparing the food and how careful they are, if they happen to be carrying the virus. Your risk tolerance may vary, perhaps inversely proportional to your cooking skills.

Q: “We are moving to Texas because the virus doesn’t like warm climates. Will this protect us?”
A: “It’s not known yet whether SARS-CoV2 thrives in warm climates/seasons or not. i’ve seen conflicting reports. My guess is that it will be far less seasonal than influenza virus. But time will tell.”

Q: “I’ve got a low grade fever and cough. I might be a little short of breath, but I’m not sure if it’s just anxiety. Should I go to the ER?”
A: “This is where having a pulse oximeter and a thermometer would be helpful. We can get you on a video call and with these data points and seeing your on video, often be able to advise whether staying home or going to the hospital is the right move. If you are pretty sure you don’t need hospital-level supportive care, the ER is unlikely to be fruitful. Call your doctor if you’re unsure what to do.”

Q: “Are there treatments for COVID-19?”
A: A number of drugs have been used, mostly in China, South Korea and other places outside the US, in a frantic effort to treat severely ill COVID-19 patients. There is a recent very small study suggesting an HIV/Ebola drug being developed in Japan may reduce the need for intubation in ICUs, but this drug is not available. An Ebola drug in development by Gilead has also been looked at but there’s no data, and it’s not available. Chloroquine and hydroxychloroquine have been discussed, but no data has been published with human subjects, and they have various potential side effects.
— If you’re not very sick, and don’t need a hospital, then self treatment with an unproven remedy with potential toxicity doesn’t make much sense.
— If you’re critically ill in a hospital, the treating medical team will work with the most current protocols to get you the best care.
— Thus I’m not advising people to try to acquire unproven meds at this time. But if you’d like to discuss just schedule a video visit.

Q: “Can I have a 3 month supply of my medications?”
A: “Sure, with the following caveats:”
— If the medication is a controlled substance being monitored as part of a treatment program, we do not provide refills beyond your next scheduled appointment. We will work with you to make sure you can get a supply when you need it.
— For non-controlled meds, we generally are happy to prescribe a 3 month supply.
— However, if your insurance company only covers a month at a time, or if the prescription is early, not meeting their refill timing criteria, you may have to pay cash for the extra medication.
— https://goodrx.com offers coupons that lower the cost of meds when paying out of pocket. Or we can often order medications wholesale for you. Goodrx coupons at a commercial pharmacy are often cheaper, however.

Q: “Should I get the pneumonia vaccine?”
A: “A vaccine for Strep pneumoniae bacteria is alreacy recommended for the following classes of people who should get it (or have already gotten it). If you are not in one of these groups, it likely wouldn’t help you, because you are also not in a high risk group to get very ill from COVID-19 and superimposed bacterial pneumonia is mostly a risk to those in hospital/ICU settings with severe COVID-19. Nonetheless the vaccine is pretty safe so it’s an individual decision. (For childhood vaccine recommendations see the CDC web site, these are for adults)
— Healthy non-smoking adults under 65 do not typically get vaccines against Strep pneumoniae.
— Adults 65 and over get PCV-13 (Prevnar) then PCV-23 (Pneumovax) a year later
— PCV-23 (Pneumovax) first for adults under 65with the following medical conditions; Smoking cigarettes, Asthma, COPD or other chronic lung disease, Chronic heart disease (except high blood pressure), Chronic liver disease or cirrhosis, Alcohol use disorder (formerly called “alcoholism”), Diabetes mellitus type I or II
— PCV-13 (Prevnar) first for adults under 65 with the following medical conditions (sometimes followed by Pneumovax later): Immunocompromising conditions, congenital or acquired including HIV; Anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies); Cerebrospinal fluid leak or cochlear implant.

Sincerely,
Paul Abramson MD
Medical Director, My Doctor Medical Group
Staff Physician, Sutter/CPMC
Clinical Assistant Professor, UCSF

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