primary care provider on Humira

[TWR]

Thoughts on whether this person should even be at work.  No PPE.

[Reality Check 2]

Nope. Not at work. All the British guidance suggests this person work from home or stay home and to stay home in general. Immunosuppressed with underlying autoimmune disease process.......

[Cideous]

No way.

[ANESMCR]

Tough question. I would say depends on their age and setting. I’m around providers on biologics that are still working, however they’re taking extra precautions when doing procedures or in the hospital. I’ve had pts come in on azathioprine and long term pred, which is more concerning to me. 

Edited March 21, 2020 by ANESMCR

[ventana]

jus a thought..... stop the humira, extra ppe, and work

just skip 1-2 injections.... every option sucks, but getting dead is the worst option....

[Kaepora]

I work critical care and I'm on remicade infusions.  No option to stay home.  I wear a PAPR if SARS-CoV-19 is suspected and when intubating go straight to glidescope.  I would say if this person is primary care and there is no PPE available, should any of you be there?  How critical is this practice?

I would contact your prescriber before stopping.  Keep in mind if you take a break from a biologic, it might not work as well, or at all, when you start again.  And the risk of a relapse or flare may be just as serious depending on what autoimmune disease you have.  

[EMEDPA]

apparently some biologics are higher risk than others. I have a friend on xolair so did a bit of research. Apparently that particular agent does not confer additional risk, according to pulmonologists, allergists, and immunologists. 

[AbeTheBabe]

I was on Humira for 3 years then about a year ago I came down with something that knocked me out for weeks. I had high fevers for two weeks, fatigue, aches. After a couple of UC/ER visits I was admitted for FUO. They did every test under the book. Chest/ABD/pelvis CT, HIDA, LP, MRI, etc. I was on IV ABX for a week. To this day don't know what it was. Took weeks for my energy to fully recover.

After a year hiatus, I'm now on Entyvio which is supposed to be gut specific. I hope. But I'm not taking any chances, I'm in outpt ortho so I took the next couple of weeks off. I definitely wouldn't be anywhere near a COVID patient without PPE on Humira. Sounds like a bad time.

[Reality Check 2]

My thoughts are turning toward WHICH PROVIDERS should be seeing patients with potential COVID and is that actually everyone until proven otherwise??

Very conflicted right now. 

All non urgent stuff needs to go back burner and video (gawd, help me, I said that) or phone visits need to be for everything - diabetes, blood pressure, etc.

Folks will still cut themselves in the garage, break bones and do bizarre stuff - but we should reserve PPE for first response folks 100% and inpatient folks. 

Those of us in Primary Care and Internal Medicine should not be having much if any patient face to face contact. Chest pain notwithstanding. Holy Hell, the ART of medicine is taking a hit right now. 

We still don't know enough about the disease - reinfection, relapse, carrier status, continued exposure, mutations, etc. Do we ever get immunity? 

When will we be able to test folks en mass and find some sort of function?

Also, how long does it take a biologic agent to get out of your system and does the underlying disease not make one just as susceptible to infection and intolerant of excess stressors?

So, I guess I go back to minimize, minimize and a heaping dose of common sense.

Bless our colleagues who are on the front line of this mess. 

[Febrifuge]

I'm on Humira - when I had my cancer scare, I was taken off it, and within a few months I had one of my severe flares, the kind I've had just a few times in the 30-ish years since I was diagnosed, and in the 18 or so years I've been on biologics. So stopping is arguably my least favorite option.

But my health system has done some re-organizing and planning, and I feel pretty well protected. Patients are assessed on the phone first, and in the past week or so we have done everything possible to move scheduled office visits over to phone visits. Visitors and patients entering the building are asked all the screening questions first. People with respiratory symptoms are directed to a specific subset of our Urgent Cares, for either scheduled or walk-in visits. People with no respiratory symptoms can use the rest of the UC locations. 

Last week on Monday, I saw 8 patients in the office plus 12 on the phone. Yesterday it was just one pre-op, for a surgery that can't be postponed, and the rest were phone. We still have the option of asking a patient to come in if there's something we need to assess in person, and if they have no respiratory symptoms, but even those are being treated as high-risk.

I know there's debate and sometimes strong opinions about telemedicine, but right now is a good time to lean on your history-taking skills and clinical judgment. As a good Oslerian, I consider the physical exam a way to confirm what I think I know, or find out what I know I definitely don't know yet, based on the history. If something needs to be done in person, I have a process for getting it done. 

But yeah, in a situation where I was seeing undifferentiated patients, some of whom had obvious COVID-19 symptoms, hell no I wouldn't accept that without a lot of discussion and planning. 

[ventana]

great thread......  thanks for sharing

 

[ddiaz4]

For all of us in this situation, it is a hard decision and I can personally say the confusion is demoralizing.

My rheumatologist was the one that put this to bed for me and I am on fmla as I am neutropenic and on ivig. I hate not being there, I hate having bailed at a time when I am needed most... but you cant bail on yourself. 

 Having a discussion with your doctor for a candid talk on your risk factors and possible ways to mitigate them is a kindness done to yourself. And they may find creative ways to protect you, keep you in the game or can give you some resources, such as short term disability or other options to keep you financially solvent.

Keep the faith friend. Self care and lean on your care team.

[ohiovolffemtp]

One of my ED nurses is s/p liver transplant by about 15+ years.  After working for several weeks, she called her transplant doc who said, "you're still working??????"  So, now, for the duration, she's doing follow-up calls from home.  Definitely the right choice.  I need her back, and it would devastate her family and the hospital family if we lost her.

[ddiaz4]

On 3/24/2020 at 3:24 PM, Febrifuge said:

 

But yeah, in a situation where I was seeing undifferentiated patients, some of whom had obvious COVID-19 symptoms, hell no I wouldn't accept that without a lot of discussion and planning. 

The next question then becomes if you work in a non-supportive environment where people don't know/shouldn’t know your health history, how do you protect yourself without self-disclosing/setting yourself up for discrimination? In the rural clinic where I work my diagnosis would become gossip fodder quickly ( I once mentioned an allergy to a coworker and the next day had random front office staff asking me about it) and the ones that know my dx are because a physical was required at the time of employment, or else they wouldn't know either. 

I get sick OFTEN and it has become increasingly difficult to hide that and the stiffness, so Im genuinely curious how people handle these conversations, especially during situations like Corona or hell even flu season, with teams and if it all just depends on your level of support/length of time at place of employment.

Also, out of sheer curiosity how many of you have issues during flu season if you are on immunosuppressives and cant take flu vax.... can of worms officially opened.

[kidpresentable]

How about working primary care and having a family member at home on any of the mentioned agents + azathioprine? Keep working?

[Reality Check 2]

I have been open with my supervisors and coworkers about my high risk issues. Nothing to hide - it doesn't affect my ability to be a provider - except when faced with a potentially deadly virus with 35 different sx and no one presentation, high chance of late demise after improvement,  no truly 100% test and no vaccine..................

I did get a letter from my PCP stating my high risk situation and would use FMLA if I had to. Self protection and job protection - plain and simple.

My last few face to face appts - one patient scoffed at the whole thing and was kind of a butt. I mentioned to him that the virus could kill me or people who work with me and even if he didn't think he had it - he could pass it along. He got quiet and quit spewing crap. No self realization or world view.................

Working from home now and doing phone and tele. Feeling guilt for not being on the front line but using some Vulcan Logic to remind myself that dead or on a vent isn't a really good option and not wanting to become a patient when avoidable. Trying to help anyone I can in whatever way I can. 

One of my colleagues is living in an RV outside of home to protect family from exposure at work. There is a national movement to get RVs to front line workers to give them someplace to stay away from their families.

I know a lot of couples self distancing inside the house due to work exposures - separate bathrooms and bedrooms when possible - at least for a while.

I do not think medicine will ever be quite the same. Entire office set ups and how we handle interactions will change forever. Handshakes might go away - I have personally been using Namaste and hands for a while now.  Ordered long term use N99 masks from England for my family. Masks will become the norm for the future. 

A whole new branch of insurance will crop up - pandemic coverage - for lost wages and protection.  PTSD will now have a sister - PCSD - post corona stress disorder and COVIDIOT will be a new dictionary entry. 

We will all contribute in whatever way we can and hopefully come out of this whole.

Stay Safe Everyone!

[Cideous]

5 hours ago, Reality Check 2 said:

I have been open with my supervisors and coworkers about my high risk issues. Nothing to hide - it doesn't affect my ability to be a provider - except when faced with a potentially deadly virus with 35 different sx and no one presentation, high chance of late demise after improvement,  no truly 100% test and no vaccine..................

I did get a letter from my PCP stating my high risk situation and would use FMLA if I had to. Self protection and job protection - plain and simple.

My last few face to face appts - one patient scoffed at the whole thing and was kind of a butt. I mentioned to him that the virus could kill me or people who work with me and even if he didn't think he had it - he could pass it along. He got quiet and quit spewing crap. No self realization or world view.................

Working from home now and doing phone and tele. Feeling guilt for not being on the front line but using some Vulcan Logic to remind myself that dead or on a vent isn't a really good option and not wanting to become a patient when avoidable. Trying to help anyone I can in whatever way I can. 

One of my colleagues is living in an RV outside of home to protect family from exposure at work. There is a national movement to get RVs to front line workers to give them someplace to stay away from their families.

I know a lot of couples self distancing inside the house due to work exposures - separate bathrooms and bedrooms when possible - at least for a while.

I do not think medicine will ever be quite the same. Entire office set ups and how we handle interactions will change forever. Handshakes might go away - I have personally been using Namaste and hands for a while now.  Ordered long term use N99 masks from England for my family. Masks will become the norm for the future. 

A whole new branch of insurance will crop up - pandemic coverage - for lost wages and protection.  PTSD will now have a sister - PCSD - post corona stress disorder and COVIDIOT will be a new dictionary entry. 

We will all contribute in whatever way we can and hopefully come out of this whole.

Stay Safe Everyone!

Glad to see you still have a job and health insurance.  Many of us are not so lucky.  Cobra is a cruel joke and living in a no Medicaid expansion state for adults created just for just times like these is horrible.  Yet, no other options than the $1100/month $8000 deductible crappy Ambetter plan through the ACA.  Another cruel joke.

Edited April 29, 2020 by Cideous

[Reality Check 2]

It baffles me that any medical provider would get furloughed. So many with so much to offer!

I am very fortunate in that the VA has a fixed population and there will always be work. I also like what I do.

Cideous - I hope things come back for you and others! 

Perhaps some unique opportunities will come from this.