As the COVID-19 pandemic rages on, reports are starting to emerge which paint a fuller picture of short- and intermediate-term damage to COVID survivors. Long-term studies obviously are years away, but we may increasingly see a pattern of symptoms and signs that indicate that while the patient may be considered recovered, significant ongoing issues remain.

A recent Science article by Jennifer Couzin-Frankel, “From ‘brain fog’ to heart damage, COVID-19’s lingering problems alarm scientists,” reviews some of these effects. Persistent problems include dyspnea, fatigue, tachycardia, joint aches, cognitive difficulties, persistent anosmia and multiorgan dysfunction. There are no large multicenter peer-reviewed studies on survivors published yet, only small studies measuring various outcomes with relatively small numbers of subjects.

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Within a few generations of the Emancipation Proclamation, the social and political environment of the South became inhospitable for African Americans. In the three years known as the Great Migration, 1916 to 1919, over half a million African Americans fled the South seeking higher wages and a less hostile environment. During the great Depression in the 1920s, when sharecroppers were turned away from their farms and the Ku Klux Klan was on the rise as a home grown terrorist organization, more than a million African Americans left the South in an attempt to escape the rigid race-based social hierarchy, poverty, lack of educational opportunities and racial violence.

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Besides the astoundingly rapid progress made in describing the nature of SARS-CoV-2 (COVID-19) and the advances in describing the virus and approaches to treatment, another result of the recent pandemic has been resurgent interest in previous epidemics and pandemics, and most notably the Spanish Influenza of 1918-19. The estimated world-wide death toll of that H1N1 illness was probably 50 million, and possibly as high as 100 million. The world population in 1918 was only 28 percent of today’s population, thus a comparable toll today would be 175 to 350 million. It has been estimated that one-third of the world’s population may have been clinically infected during the pandemic, with mortality rates among the infected of more than 2.5%.

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Although physician offices were always classified as essential businesses under the Pennsylvania Emergency Closure Rules, and could always have remained open, many physician practices nevertheless opted to close the practices, reduce hours, or remain only open for emergency patients. Now that Pennsylvania is reopening to all businesses in stages, we thought it would be valuable to have a source of curated information specifically applicable to the reopening of physicians’ offices, similar to the COVID-19 Private Practice Checklist published by ACMS on March 19, 2020.

We believe the risk issues can be separated into four basic categories:

  1. Patient management
  2. Facility management
  3. Staff protection
  4. Patient consent forms and waivers

Patient management

The scheduling, management and testing of patients returning to the practice, and prioritizing their treatment based upon the severity of their medical conditions, will be one of the most challenging aspects of reopening the practice, if only because of your lack of actual control over patients’ conduct.

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I started this narrative 17 days into my “house arrest” resultant from the COVID-19 pandemic. Unfortunately, despite having more free time than I cared to admit, I was too worried and preoccupied to continue my chronicle. I had been confined to “house arrest” several times previously. Twice while recovering from extensive orthopedic surgery and again as a precaution secondary to life-threatening neutropenia. But this time is very different. “House arrest” is the norm, especially for those in my demographic group. I don’t have a friend or family member to help navigate the outside world for me. I can’t invite the outside world in.

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Within a few weeks, COVID-19 has transformed our lives, medical practices and global networks in frightening and devastating ways. Yet at the same time, it has been remarkable to observe how the scientific community is working together at almost lightning speed to acquire and disseminate knowledge on the virus. Our understanding of the virus is expanding daily thanks to this collective effort.

Dermatologists across the world have been actively documenting cutaneous manifestations in patients with COVID-19. One of the first studies emerged from Italy in March. They followed 88 hospitalized patients with COVID-19 and found that 20% developed skin findings.

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Like most attorneys in the spring of 2020, I am working from home and composing this article on my laptop. Most of what I do can be done from anywhere that has an internet connection. Many forms of medical evaluation and treatment also can be performed remotely via commonly available technology. In some cases, telemedicine was already permitted, if not commonly used, before the advent of the novel coronavirus, COVID-19, and in other situations a number of regulatory and reimbursement barriers have been modified to respond to the crisis.

First, we should define what we mean by “telemedicine.”

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March 30, 2020

The Honorable Donald Trump
President
The White House
1600 Pennsylvania Avenue, NW
Washington, DC 20500

Dear Mr. President:

On behalf of the American Medical Association’s (AMA) Board of Trustees and our physician and medical student members, I am writing to commend your recent decision to extended physical distancing guidelines, but also to underscore our serious concerns about shortages of personal protective equipment (PPE). Physicians are on the front lines combatting this destructive and invisible enemy. They are working tirelessly to care for overwhelming numbers of critically ill patients, but they cannot do this alone. We need the help of everyone in the nation, including the federal government, to ensure we succeed.

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