Sunday, March 29, 2020

Telemedicine , The Right Way

An emergency declaration from the State of Texas has made it easier for physicians to take care of patients during a time where routine clinic visits pose substantial risk of infection spread.  A host of well marketed telemedicine organizations, some promoted by your insurance company have swooped in, attempting to fill the gap.  They are missing one crucial element - YOUR doctor.  

Adapted from the Texas Medical Association, here are answers to common questions on the patient side:

1. What technology do I need for telemedicine?
Texas law says that  telemedicine services can occur through:

  • Real-time audiovisual interaction between you and the doctor (for example, a simple digital camera on a laptop or a desktop with secure broadband internet);
  • For many, a "Facetime like" interaction can take place with your doctor using a simple downloadable app on your smart phone
  • A telephone only consultation for new or follow-up patients may be appropriate in some circumstances
2. Are initial in-person visits mandatory?
No.  For some medical conditions, the standard of care has always been in office visits.  In office, we have the opportunity for a more comprehensive exam and additional testing to evaluate lung disease.  However, given the risk of infection spread in offices, emergency rooms, and urgent cares, even initial visits can take place through telemedicine.

3. Can the patient be at home for a telemedicine visit?
In short, yes. The new state law removed the requirement for a clinical place of service, as long as the standard of care is uncompromised.  Keeping you at home improves the chance of flattening the curve while still providing you access to a board certified medical specialist.

Friday, March 27, 2020

One Ventilator and Multiple Patients?

Economy does not equal quality.

An anticipated shortage of hospital ventilators has led some organizations to look at potential innovative ways to maximum the use of available hospital equipment.  Undoubtedly, these are trying times for critical care docs.

However, numerous organizations have highlighted major potential risks associated with these measures, including this list provided by the Society for Critical Care Medicine:

  • Volumes would go to the most compliant lung segments.
  • Positive end-expiratory pressure, which is of critical importance in these patients, would be impossible to manage.
  • Monitoring patients and measuring pulmonary mechanics would be challenging, if not impossible.
  • Alarm monitoring and management would not be feasible.
  • Individualized management for clinical improvement or deterioration would be impossible.
  • In the case of a cardiac arrest, ventilation to all patients would need to be stopped to allow the change to bag ventilation without aerosolizing the virus and exposing healthcare workers. This circumstance also would alter breath delivery dynamics to the other patients.
  • The added circuit volume defeats the operational self-test (the test fails). The clinician would be required to operate the ventilator without a successful test, adding to errors in the measurement.
  • Additional external monitoring would be required. The ventilator monitors the average pressures and volumes.
  • Even if all patients connected to a single ventilator have the same clinical features at initiation, they could deteriorate and recover at different rates, and distribution of gas to each patient would be unequal and unmonitored. The sickest patient would get the smallest tidal volume and the improving patient would get the largest tidal volume.
  • The greatest risks occur with sudden deterioration of a single patient (e.g., pneumothorax, kinked endotracheal tube), with the balance of ventilation distributed to the other patients.
  • Finally, there are ethical issues. If the ventilator can be lifesaving for a single individual, using it on more than one patient at a time risks life-threatening treatment failure for all of them.

Monday, March 23, 2020

Clinic Update During COVID 19 Pandemic

We have stepped up to protect our patients, our staff and the community during the coronavirus (COVID-19) pandemic Houston Specialty Clinic has CHANGED almost all clinic office visits to telemedicine, effective immediately due to the urgent need for all of us to reduce the risk of infection. 

   We will still be OPEN for the following patient visit types: 

  • Patients requiring regular injections for asthma management  
  • Urgent visits

Fortunately, the State of Texas has issued an emergency declaration waiving many restrictions on telemedicine.  Therefore, our providers are available during office hours for telemedicine consultation for both new AND existing patients. 

Please see the following links for useful resources infection prevention: