From the Governor Allison's Desk - “I see the Eclipse, but what about the Plane and the Star?”
Just thought I would take a few minutes to reach out to my chapter during this time of stress and share some of my recent personal outpatient experiences. We need to develop mechanisms to deal with practice management stress, particularly in this time of practice isolation. I know that my practice has changed, as you can see from two examples below.
Patients are delaying seeking medical care for major problems, and hospitals are reducing elective and noncritical admissions to prepare for the surge. In our small 22 bed hospital (now prepared for 80 possible patients), we have dramatically limited admissions to a point that there now may only be a few planned or necessary patients in the hospital. That said, the people of South Dakota are also staying away as directed, or out of fear of getting exposed to the Coronavirus
Recently in my outpatient clinic I talked a 70-year-old patient BY TELEPHONE 8 days after her TIA, followed by an episode of loss of consciousness 3 days later that lasted many hours. I'm used to noncompliant and even patients in denial, but the coronavirus was surely involved in her decision to not seek care. She refused to come into the clinic to be seen in person and did not have video technology for me even to look at her on a video screen. She had multiple risk factors and the best I could do was start aspirin, order an outpatient CT, tell her to take her BP meds (I couldn't get vitals) and pray she did not have the final event.
The second patient was an 84-year-old female that came into clinic for a face-to-face visit with maroon-colored stools. She has a history of mild cognitive impairment and lives 40 miles away, taking care of a demented husband by herself. She was admitted 2 months prior for a hemoglobin of 5.9 with a similar complaint of stool changes and shortness of breath. She received 3 units of blood and was sent home with the plan for an outpatient EGD and colonoscopy to be set up.
As you can guess, things fell apart because of the coronavirus. Her procedures never got set up. To be fair it may have been the patient's fault as much as coordination difficulties, but neither matters in a patient who is short of breath at rest, and in clinic with a hemoglobin now of 7.2. Her vitals were stable, and she refused admission because of her husband and the risk of the Coronavirus. I classified her with symptomatic anemia, because she was short of breath at rest, and because of her other comorbid illnesses, but I still had difficulty trying to get her admitted because she just wasn't quite “unstable enough” for admission criteria.
For the first time in 25 years I felt “forced” to manage this high risk patient as an outpatient. I felt abandoned. My tools to do this outpatient care were all broken. My outpatient infusion center for blood had its hours changed, coordinating an outpatient EGD/Colon was a phone nightmare with consultants and scheduling. It wasn't the hospitalist or the hospital that made me feel that way, but I was trying to do the “right thing” for the patient with limited resources and felt the risk for my patient and my medical practice.
I miss the old days when common sense and doctors could practice around the new world of fiscal responsibility. I have since come to peace with that. It is the new complexity and stress that comes with dealing with a sick elderly population, that is even more now delaying care and dealing with a system that it is preparing for the worst and learning how to deal with resources available to me as an outpatient internist.
It is tough to see the beauty around you when chaos exists. I would encourage everyone to take as much personal reflection time as you can during this coronavirus outbreak. I took a break after my recent experience and looked at my own pictures of the Great American Eclipse of 2017. I had traveled to Nebraska to be in the eclipse zone and set up my cameras near Miller, NE. As I sat on a hill overlooking the Nebraska cornfields that I grew up around, the temperature dropped, sunlight faded, animals stopped making noises and the world paused. For 2 minutes there was a mystical sense of awe that God was present with you. I hope everyone gets to experience that sense of peace one time in their life.
This photo is my own image cut from the video of the moment. See if you can see the beauty besides the eclipse, note the star peeking out from the day sky when the eclipse gave it permission, and the small plane crossing the heavens to be closer to God.
Rob Allison, MD MACP