Welcome to a special edition of The Q-Wave, our newsletter for PAs and NPs, and John Bielinski Talk EM, our podcast for emergency medicine practitioners. Our focus here is always on enhancing the clinical skills of advanced practice providers.
We want to make you better at what you do. Today’s special edition of the Q-Wave and Talk EM is brought to you by CME4Life’s newest program, Effectiveness in Medicine. This CME conference series is specifically designed for PAs and NPs, to enhance their performance and make them better at what they do. Effectiveness in Medicine is a three-day immersion course in Sarasota, Florida. In this course, we are adapting the Dale Carnegie principles of effectiveness for medicine. It’s giving you tools to increase your self-confidence and decrease fear. It is an absolutely life-changing course.
John Bielinski: My name is John Bielinski and I am the owner and founder of CME4Life. I experienced a Dale Carnegie course in 2009 and it gave me the tools to be a much better clinician, teacher, educator and leader. Our Effectiveness in Medicine program is approved for 24.00 Category 1 AAPA CME Credits for nurse practitioners and physician assistants.
It is an honor to be with Dr. Gluckman today. Dr. Gluckman is an infectious disease specialist. He’s been an infectious disease doctor for 48 years.
Dr. Gluckman: I know, it’s hard to believe. I don’t know what happened or where the time went, but it’s been 48 years.
John Bielinski: Are you going to retire?
Dr. Gluckman: Well, yes, someday. There’s a reality to the number. I’m getting older. But I don’t have a specific plan. I really enjoy what I’m doing and it’s a great field to be in. There are new challenges.
John Bielinski: Yes, like the coronavirus.
Dr. Gluckman: Like the coronavirus.
How to Protect Yourself from Coronavirus as an Individual
John Bielinski: You have a lot of experience and exposure to what’s going on now with this coronavirus and what we can expect. Let’s talk about what we know. People are afraid. What advice would you have for the general population about this coronavirus, COVID-19, that’s all over the news?
Dr. Gluckman: Well, firstly, it’s complicated. It’s complicated because it’s gone way beyond just a medical disease at this point. That’s understandable. That’s not a criticism, it’s just reality. People need to know that coronavirus is contagious, and you can be sick. But for the vast majority of people, COVID-19 is flu-like.
It’s not a fatal disease. It can be, but so can flu. There’s not the same anxiety associated with flu as there is with coronavirus, but I think they’re fairly analogous. Coronavirus causes a very similar illness, with what’s going to turn out to be probably the same degree of mortality.
Like many new illnesses, initially the mortality rates seem very high because we find the sickest people. But as we learn more about it as a new illness, we start to identify less sick people and less sick people. People who have no symptoms were infected. That’s certainly been the case with coronavirus; every couple of days the mortality rates have fallen, and now they’re in the range of flu.
I’m giving people a mixed message in a sense. Coronavirus is real and you should have some concern about it, but panicking is inappropriate. Locking yourself up and avoiding going out because of the coronavirus is no more sensible than doing so for flu.
John Bielinski: So, if I’m part of the general population – I’ve not been to a high-risk country, I haven’t been exposed to anybody with high risk – how should I protect myself?
Dr. Gluckman: Well, at the moment there is no vaccine, so the only option is avoiding the virus, which basically comes down to good hand washing. We need good hand washing, either with soap and water or an alcohol gel. You should also cover your mouth when you cough, so you don’t potentially spread the virus. The standard surgical face mask has no utility.
You might feel better wearing one, but it’s not protecting you from the virus and there’s no particular benefit. If you are going to wear something, it needs to be a respirator mask and it has to be fit properly. They issue us, as healthcare providers, respirator masks. They’re tested to make sure they fit us.
So, if you’re going to wear something, and I’m not suggesting people should, it should be an N95 and it should be fit-tested to make sure it’s properly fit to your face. By the way, mine doesn’t work well because I have a beard.
John Bielinski: In a couple days I’m supposed to get on an airplane. Should I be concerned about the air on an airplane? If someone has coronavirus, will everybody on the plane be exposed and get sick?
Dr. Gluckman: This is a common misunderstanding. I don’t work for the airplane industry, let me start with that. In reality the safest, cleanest air we’ve ever likely to breathe is on an airplane. It comes in through high-efficiency filters over our heads. It’s a laminar flow, which means it goes in one direction. It goes out at our feet. There are approximately 20 air exchanges an hour. At every air exchange, the air is cleaned through those filters. Of course, the air that’s sucked in from the outside is sterile at that altitude anyhow.
If you’re sitting next to somebody who’s coughing and sneezing, you’re at risk. But infectious diseases don’t travel up and down the aisles of a plane. Now the rest of the trip, it’s a different issue. You don’t have that clean air in an airport, or in a hotel, or even in a restaurant. But you shouldn’t be worried about the plane. There’s no particular benefit of wearing a mask on a plane.
How to Protect Yourself from Coronavirus as a Clinician
John Bielinski: Now, say I’m a clinician. I’m a physician, I’m a nurse practitioner, I’m a physician assistant. What are the recommendations from the CDC about the coronavirus right now?
Dr. Gluckman: The CDC breaks it down a little bit in terms of whether a person is symptomatic or not, and likelihood of exposure or not.
John Bielinski: Let’s make sure we’re talking the same language. If I’m symptomatic with coronavirus, what are my primary symptoms?
Dr. Gluckman: You’ll have a fever and respiratory symptoms: cough, runny nose, sometimes shortness of breath.
John Bielinski: As a clinician, that sounds like someone has a cold or bronchitis.
Dr. Gluckman: You bet. And they could.
John Bielinski: Okay, so that’s the big dilemma for clinicians right now.
Dr. Gluckman: That is exactly right, because we don’t have a rapid test. We need to concern ourselves when we see symptoms plus exposure. The exposure would be travel to an area of the world where there’s a high rate of coronavirus or exposure to somebody who has recently been in that area of the world who is sick. Otherwise, they probably have another virus.
If somebody is symptomatic and has a risk of exposure, the health department should be notified. They will be isolated for 14 days, whether they have it or not. Because, again, the department is trying to control the spread of this disease. I don’t think that is going to happen.
John Bielinski: How much of the concern on the news right now is medical fact versus fear, and how can you relate this to what you’ve seen in the past?
Dr. Gluckman: Well, a sizable component of this is fear. It is a real disease. People are sick and occasionally people will die, but certainly flu is pretty analogous. Nobody is canceling meetings and travel because of concern they might be exposed to flu. The coronavirus has really generated a ton of over-the-top fear, in my opinion.
The only disease I can relate this to would be early on in the HIV epidemic. But that fear was really mostly in healthcare workers. Early on in the HIV epidemic, the disease was somewhat inappropriately attributed to a couple of specific risk groups.
And so, if you didn’t think you were in one of those risk groups, then you didn’t really have to worry about it. On the other hand, if you are caring for patients with HIV, there was a considerable amount of concern that you might acquire it. So that was similar to our current situation, but HIV never caused a national panic.
John Bielinski: What countries are we concerned about? Are there any countries the CDC is actually banning travel from?
Dr. Gluckman: The two main countries are China, of course, and South Korea. The additional countries are Iran and Japan. Israel has included Germany on that list as well. So, if you’ve been in Germany in the last two weeks, you’re supposed to self-isolate. The list is going to continue to expand. I don’t think it’s possible to stop this expansion merely by prohibiting travel.
How to Protect Yourself from Coronavirus as a Patient
John Bielinski: If a patient with viral symptoms is reading this and they’re concerned, what advice do you have for them?
Dr. Gluckman: If they’ve had a potential exposure, then they clearly have to contact their healthcare provider.
John Bielinski: Just to make sure we’re clear, that would mean exposure to an individual who was in one of those countries or someone who has coronavirus. If you have not been exposed to someone who traveled to one of those countries and you have not been exposed to someone who was diagnosed with coronavirus, you’re not at risk?
Dr. Gluckman: I wouldn’t say not at risk, but the risk is so low.
That could change as coronavirus spreads more and more into the community. It may no longer require having an exposure to a known risk. But for the moment, that is true. If you have a viral illness, you probably have a viral illness that is, in this country, not coronavirus.
John Bielinski: Yes. As a clinician, you need to explore the risk in order to document it and legally protect yourself. Is this a low-, medium- or high-risk patient? That’s what we do in the clinic anyway. We risk stratify them.
So once again, to a patient who has a viral syndrome:
Dr. Gluckman: The first question, again, is there any reason to think this patient is at increased risk for coronavirus?
The other criteria we use is whether they’re very sick, if they wind up in an ICU-type setting. We also need to consider whether they had an exposure that wasn’t identified, such as community exposure. That’s also on the list officially at the moment.
But if you have the usual cold without a known exposure, then at the moment there’s no particular recommendation.
John Bielinski: To clarify, what recommendations do you have for a clinician who, in the midst of cold and flu season, is seeing 10 of these types of patients a day?
Dr. Gluckman: Looking for exposure and looking for severity.
John Bielinski: It’s been an honor to have this time with you. I appreciate your time. Good luck to you, my friend.
Dr. Gluckman: Thank you.