NEWS/EVENTS

More Adventures with COVID in Primary Care

By Russ Herring, DNP, FNP-C, FNP-BC

I’m sitting at my desk, head in my left hand, holding the phone with my right. I do this thing when I’m tired, where I rub my face. It’s close of business on Friday, and I just found out another of my patients has COVID. I’m bent forward, rubbing my face with my left hand, talking to my patient on my office line. I just have them handing the phone from person-to-person on the other end since numerous patients all share the same number. The problem is that the entire family are my patients, the entire household (minus the grandchildren). Two of three generations under one roof call me doctor, and none of them were vaccinated.

I tried.

The phrase “please get your COVID shots” has left my mouth thousands of times in the past 20 months, easily. THOUSANDS OF TIMES.

The phrase “please get your COVID shots” has left my mouth thousands of times in the past 20 months, easily. THOUSANDS OF TIMES. I began telling patients that I would be vaccinated the second it was possible, in Spring of 2020. I’ve always advised my patients do the same. I would tell patients that I was already sick of the masks, and that the only way out of the eternal mask era, would be for all of us to be vaccinated the second they were available.

But now I’m rubbing my face, exhausted, because another of my patients has COVID 19 who hasn’t had their shots and I have to try to fix it.

The patient’s wife, who is also my patient, answered the phone. How do you tell three generations to isolate from one another under the same roof? She’s going to remain in the bedroom with her husband. What do I say? If she’s going to develop an infection, those seeds are probably already planted. The son will go to the other end of the house and the granddaughters will hide upstairs, apparently. It isn’t the best plan, but it’s what we’ve got to work with.

I can’t help myself, “I sure wish you’d gotten the shot, and we weren’t having this conversation.” I continue, “but since we are, here’s what we’re going to do…”

I pause and rub my face while I take a deep breath in.

I suspect many healthcare providers have cooked up something to throw at COVID infections. Something, anything. We’re so used to having more and better tools to wage wars on behalf of our patients’ health, that this feeling of helplessness is extremely foreign. Vitamin D might help. Zinc might help. I’ve seen enough blood clots associated with COVID infections that I recommend my COVID-positive patients take a daily baby aspirin for a couple months. The humidifier is an easy call, since our Montana air is dry as the Sahara, and once you develop a cough, the dry air turns it into a sort of perpetual motion machine. From there, it isn’t as easy to support with science. Obviously, COVID is primarily a respiratory infection – primarily. But it does so many other horrible things, and we just keep finding them, don’t we?

I’d been hard on the ivermectin crowd (and remain so), but as I was driving home from Billings last night, pushing these thoughts around in my mind, it occurred to me that we’re all doing whatever we can, some of it helpful, some probably less so. As a provider in the American healthcare land of plenty, IT HURTS TO FEEL USELESS. IT HURTS TO DO NOTHING. It’s DEMORALIZING. So, if the provider thinks ivermectin might help, or they have no other options, then they’re likely to write it. If vitamins and minerals are all I have, I’ll write them till the cows come home.

The patient on the line had initially visited a walk-in provider, and there was a… Let’s say a “mild disagreement regarding the course of diagnosis”. The patient didn’t want to be tested for COVID and wanted antibiotics for their chest cold. This is an animal that healthcare has done very poorly to fight back. Not all infections require antibiotics, and most actually do not. The provider and the patient had to work their way to a therapeutic relationship…. Which may have included the provider warning the patient that they risked going home and dying if they didn’t allow the provider to pursue appropriate diagnostic testing. We can’t treat in the blind. I could write every antibiotic known to man for COVID and you’re still going to die, because antibiotics don’t work on viruses. Likewise, I can drown a bacterial pneumonia in all the latest and greatest monoclonal COVID antibody therapies available, and the bacteria won’t flinch. The provider was able to get a chest Xray, which clearly showed COVID pneumonia and advised the patient of this, before the patient finally agreed to COVID testing.

Catharsis.

For those of you who have never seen COVID pneumonia, or any pneumonia, on a chest Xray, it looks differently than most pneumonias. Radiology can guess the type of infection based on where it sets up shop in a lung. Most pneumonias are only one-sided. You can often hear it with a stethoscope, too. Right lower lobe pneumonia is probably the most common, just based on the anatomy of the human body and the fact that gravity works. The straightest shot from your mouth to your lungs is into the right lower lobe. Upper lobe pneumonia is less common and tends to fall under the auspices of “atypical”, if for no other reason than, “why is it in the upper and not lower lobe?”

The stethoscope will relay crackles, rubs, wheezes – and sometimes no sound at all where there should be air moving.

COVID pneumonia shows up EVERYWHERE AT ONCE. Bilateral pneumonia – pneumonia in both lungs, and all lobes, simultaneously. The impact on oxygen transfer when the pneumonia is EVERYWHERE is enormous. Patients will come in with horrible oxygen saturation because all of their lung surfaces are infected. I’ve met people who live healthy lives with only one lung, but COVID pneumonia in both lungs, and all lobes…. Is a medical emergency. You can throw a stick in a room full of blind men and hit five who can read a chest film better than yours truly, but even this poor, Wyoming kid can diagnose COVID pneumonia from a chest film.

It’s that obvious.

The patient will be called by the emergency department to schedule their monoclonal antibody infusion. I had a patient receive an infusion earlier in the week at 0200. The Benefis and Great Falls Clinic EDs are running infusions 24 hours/day, 7 days/week – except for the period when WE RAN OUT THIS WEEK.

WE RAN OUT OF ANTIBODY INFUSIONS FOR A WHILE THIS WEEK.

I have to digress for half a second and tip my hat to the ED, ICU and hospital inpatient staffs who are bearing the true weight of the pandemic. From this provider in outpatient land, thank you from the bottom of my heart. We’re trying to help, we really, truly are…

We haven’t run out of vaccines. I don’t know that we’ve ever come close. Please, please, please – don’t rely on the emergency medicine when the preventative medicines were offered months ago at a time of your choosing. PLEASE. What happens if you’re the person who gets sick the day we’re out of antibody meds? I’m terrified even thinking about it.

We haven’t run out of vaccines. I don’t know that we’ve ever come close. Please, please, please – don’t rely on the emergency medicine when the preventative medicines were offered months ago at a time of your choosing. PLEASE. What happens if you’re the person who gets sick the day we’re out of antibody meds? I’m terrified even thinking about it. This is America, WHY ARE WE RUNNING OUT OF MEDICINE?!?!? I’ve had three of my patients (that I’m aware of and personally brokered) get antibody infusions this week. One was vaccinated, but caught COVID and due to their poor baseline lung function, required antibody infusion. The other two were not vaccinated. All three had been advised to be vaccinated by their primary care provider – me. One had been advised against vaccination by another member of their medical care team. That provider was nowhere to be found when it came time to treat the patient’s COVID infection.

We took care of it, and I think the patient will be ok.

Two of the three positives were people who have my private cell number, and I spent portions of my week, through Saturday night, arranging antibody infusions and follow-up visits between patients and other providers in immediate and emergency care. The next time a healthcare provider tells you not to be vaccinated, please come talk to myself, or somebody else in primary care. Vaccines are OURS. Your family doc, your PRIMARY CARE PROVIDER are your resource for vaccines. If we don’t have the answer on the tip of our tongue, we’re the people who will beat the bushes to get you the RIGHT ANSWER.

I’ve been fired by patients for advocating for vaccines. I’ve had profanity-laden tirades launched at me. I’ve been accused of playing politics in my quest to protect my patients. My response? “I’m your doctor, not a politician.” I try to help those patients, too. I call them back, after I’ve been verbally assaulted, and tell them my post-COVID cocktail. I tell them to seek care immediately if they grow short of breath. I tell them that I’ve seen a couple blood clots show up in lungs a month or two after primary COVID infection.

I’m rubbing my face again.

You can’t win them all.

Russell HerringAbout Russell Herring, DNP, FNP-C, FNP-BC

Russell R. Herring, DNP, joined the Great Falls Clinic in 2018 and is among the newer healthcare providers in the State of Montana. He works alongside Drs. David Engbrecht and Dr. Carey Welsh in Family Medicine at the Great Falls Clinic Northwest location. Russell specializes in diagnostic, preventive, and therapeutic healthcare and treatment plans for acute and chronic illness, and in education and guidance of patients regarding disease prevention and health promotion. He is currently accepting new patients at the Northwest Clinic, 1600 Division Road, Great Falls. For more information or to schedule an appointment, please call 406-268-1600.