How HCPs Are Reacting to COVID19 – An Interview with Paul Bucca

Narrator: This is the DarshanTalks Podcast. Before this week's interview with Paul B. on healthcare practitioner reactions to COVID-19, Darshan will introduce this episode with the recap for the week of Thursday, April 30th, 2020.

Darshan: This has been a slower news week. It's interesting, and we'll sort of explore in greater detail, some of the conversations that are happening out there. One of the ones to keep in mind is a North Carolina testing lab just settled a whistleblower allegation for up to 43 million and those were primarily for claims that it billed for medically unnecessary lab tests. The settlement allegations suggest that the company improperly submitted claims to Medicare, TRICARE, and federal employee health programs for several different lab tests that were not medically necessary, they engaged in improper billing techniques, and they paid a compensation to three phlebotomy vendors that violated the physician self-referral prohibition, known as Stark Law. Under the settlement, the company agreed to pay $17 million.

It also was the week in which people are starting to look at their companies themselves and in that vein, the EEOC basically came up with some general rules, the EEOC being the Equal Employment Opportunity Commission, and they came up with some rules and suggestions and guidelines. So as you may already know, they issued a guidance permitting employers to conduct temperature checks of employees to help prevent the spread of COVID-19. They've gone ahead and actually expanded that and the guidance now says that you have to make sure that the COVID-19 tests are accurate and reliable, you have to stay abreast of the latest public health information from the FDA, you must consider false positives or false negatives and understand that the accurate testing only reveals if the virus is currently present. A negative test does not mean that the employee will not acquire a virus later.

However, there are some additional takeaways. Number one, if you are going to be doing these tests, you should have a policy and procedure to administer the test uniformly. If you are going to be performing the tests, they should be administered by a trained person or a trained third-party professional, you need to try to administer the test in the least invasive way possible and ensure that the appropriate disclosures are being made to the employees, including CCPA Disclosures, to the extent necessary. If you [inaudible 00:02:33], and CCPA for those of you who don't know, is the California Privacy Law. If using a third party to administer the medical tests, ensure that the appropriate consent and disclosures are obtained to share the data between the medical provider and the business. And the information that is received should be treated as confidential medical records.

This was also the week in which people started looking forward. They came up with 10 new inventions that might help crush future pandemics. One of them is a digital tattoo for monitoring blood so that you could get real time measurements and do analytical assessments of a person's blood. Ideally, graphene might be useful [inaudible 00:03:17]. There are conversations about odorometers for monitoring smells. Maybe getting skin coatings that might make us virus proof, for example. So there's a lot of sci-fi type stuff. If you want to read more about this, feel free to join our newsletter and you should get a link to the article itself.

The other bit of news that came out is that the FDA, as consistent, is now again warning CBD companies from advertising that their products treat medical conditions, such as opiod addiction. So stay tuned for that as well. Feel free to click in and we'd be happy to send you the link to what you might find interesting. Again, thanks for joining us.

Narrator: This is the DarshanTalks Podcast. Regulatory guy, irregular podcast, with host Darshan Kulkarni. You can find the show on Twitter @darshantalks or the show's website at darshantalks.com.

Darshan: Guys, welcome to another episode of DarshanTalks. We have a really, really special guest. We have Paul B., I'm not allowed to say what the B. stands for, but we have Paul B. And Paul is, so we say the clinician extraordinaire. I've seen him work in multiple facets, across multiple departments in the hospital, and right now is one of those times where you really start seeing what the inside of a hospital looks like and why it matters, especially with the Coronavirus going on. So Paul, talk to us a little bit about yourself.

Paul: Well thank you Darshan for that beautiful introduction. I will say that I work in a hospital setting, in the outpatient side. I deal with primarily infusion medicine, so patients come in and they'll stay for a couple of hours, receive treatment, and then they'll leave. So it's an ambulatory setting. Probably we see anywhere between 75 and a hundred patients a day. So it's almost like a revolving door type thing.

Darshan: Wait, you said you will see, as in like even now?

Paul: Even now. We have seen a slight decrease in our numbers. We have transitioned some treatments that are deemed not necessary to come in. So there's home infusion, that's the other aspect that we work with. And there are certain treatments that we moved to home infusion so we have less patients coming in, but we do a lot of hematology, we do a lot of blood transfusions, we do hydration fluids, and we do a lot of chemotherapy and immunotherapy. So certain treatments, we really don't want our immunocompromised patients to be in that setting as often as they used to be, with the whole pandemic going on, so we're trying to transition some of those treatments to home infusion.

Darshan: So what do you do at home infusion, Paul?

Paul: So I personally don't work with home infusion. We have a home infusion nurse who will set up our patients-

Darshan: Sorry, let me rephrase. What do you do in the ambulatory care setting in your ... Please continue.

Paul: So let's say that you are the patient, you're sitting in the waiting room, I will come out and I would take you back to your infusion bay, we'll do your vital signs, we'll do height, weight. Usually I won't have to draw any blood, we do have a phlebotomist, but we'll draw blood, we'll do an EKG if need be. And then at that point we'll do your vital signs and I'll make you comfortable. So if it means getting you a pillow, it means warm blanket, if it means you go unresponsive and I'm doing CPR, you know? So it's still the full range of patient care.

Darshan: Do you start infusing people or is that someone else?

Paul: The nurse usually will access ports and pick lines, we're not, as technicians, not allowed to do such.

Darshan: Got it. So your experience is working in this setting, but right before that, what was your last job?

Paul: I was in inpatient setting, working in heart failure. Again, this was inpatient at the same facility, same hospital, and there it was for the admitted patients, the patients that would have a bed and would be usually in for multiple days. And there I was a little more involved physically because you're literally caring for the patients. And a lot of the patients [inaudible 00:07:46] ambulatory, some patients couldn't toilet themselves, so you were really in the trenches there. Whereas with ambulatory patients, the level of involvement isn't as deep because it's not as necessary, patients can emulate and they can do the daily activities, for the most part, themselves without assistance or with minimal assistance.

Darshan: Right. And what was it ... Sorry, I sort of interrupted your flow. What was the job before that?

Paul: Pharmacy. God bless you.

Darshan: Excuse me, sorry. I've got the allergies going as well.

Paul: No Corona, right?

Darshan: No Corona, no Corona, #noCorona. So you worked in the pharmacy, so you've sort of seen medications being given in multiple settings, you've seen patients come in, get these medications and you've taken care of these patients throughout the process. You've actually seen them before they harden up, before the doctors and the nurses come in, you've got them comfortable, you're the one sort of getting them ready. How are the patients?

Paul: So I would say the majority of the patients are very cautious. Some of them have a handle on what's going on and others are freaked out, both resulting in them being cautious or in their minds cautious. One of the biggest things ... What I mean by cautious is you'll see patients come in with masks of all sorts. You'll see patients coming in with their homemade mask, you'll see patients coming in with bandanas tied around their face, and then you'll see patients with N95s. You'll see patients with gloves, sometimes multiple layers of gloves. I had a patient with a face shield. And there seems to be a little bit of a misunderstanding or lack of patient education when it comes to how to truly protect yourself and how to properly use the PPE that's available.

Darshan: So available from who? Oh, you mean from the market. I didn't know if your hospital provides that.

Paul: So where we are, we screen our patients and we ... So the building I work in has multiple different offices. I work on the second floor where there's infusion, we have orthopedics, we have multiple different departments in my building. So we do have somebody in the lobby who is asking screening questions and the questions are basically to find out if they have any symptoms and if they've traveled in the past 14 days to any of the CDC identified hotspots. And this is purely self-reported and we're taking patients and visitors at their word. We actually are not allowing visitors to go up with the patients into the treatment areas. Our patients can-

Darshan: Is that making patients nervous though?

Paul: That is. A lot of patients that come in usually have a family member that either assists them or always accompanies them and they were very resistant to the change, originally. We do make certain exceptions for a patient who there might be a language barrier. Or where I work, a lot of times if a patient's getting a treatment for the first time, we don't know how their body's going to respond to that medication. And there's a language barrier on top of that, a lot of times we as clinicians feel more comfortable if there is someone with the patient to help calm their anxiety, but also to help communicate. Because for that patient, who might be going into anaphylaxis, who already is a nervous wreck because of that, and not being able to communicate effectively, having someone there who does understand the language can help communicate for us and tell us how we can treat and help the patient.

Darshan: So do you end up taking care of kids?

Paul: Not by the legal age. Our treatments start with patients 18 and older.

Darshan: 18 and older. Okay. I just wondered whether kids are more susceptible or they're mostly oblivious to what's going on.

Paul: Yeah, I would have no-

Darshan: No gauge.

Paul: ... no idea.

Darshan: Fair enough. So-

Paul: I can tell you about my parents though. They're seniors and they are of the at-risk population, they have been behaving more irrationally and just seem to not have a handle on it. So I think on both ends of the spectrum, children and people who have been separated from the daily routine of everyone who is working, everyone who has a commitment, so to speak, not saying that retired people don't have commitment, but they have less commitments than those who are raising families, working, going to school. I feel like they are a little more out of touch about what's going on with COVID-19.

Darshan: Look at Paul, [inaudible 00:13:22] his own parents.

Paul: I tried to find the politest way to say it.

Darshan: Fair enough. So when you see these patients come in and you see the steps being taken, do you see more hysteria or do you see the appropriate level of care? You described panic, but I didn't know which way that goes. Like appropriately or inappropriately?

Paul: I would say it's ... Oh you're saying on the clinician side or [crosstalk 00:13:58].

Darshan: On your side. From what you see.

Paul: From what I see, I would say it would be the appropriate level. Just say that again. I'm sorry.

Darshan: No, no, you're fine. Keep going. Why is it appropriate, I guess is what I meant.

Paul: We have to work with what information we have and what's available to us. Right now, we don't have the capability to test everybody. So the procedure right now, I think it's across the country, is unless you are showing signs and symptoms, then we're going to go on the assumption that you don't have it. So I can't assume that every patient who walks in who has a cough and doesn't have a fever, I can't necessarily associate that cough, that dry unproductive, with COVID-19. Patient comes in, I take their temperature and they have a fever and a cough, I still can't assume that they have COVID-19. So to a certain degree there is a level of uncertainty and it does freak some of us out.

Darshan: How are you seeing people-

Paul: And the same with patients-

Darshan: I'm sorry, please continue.

Paul: Same for the patients. So like our infusion bays are like cubicles where you have cubicles that face each other. So you might be like 12 feet across the hall, but you can see the next patient as you are sitting in your respective infusion bay. And you can hear the next patient cough and everything. When I'm taking a patient's vital signs, I usually like to say their vital signs out loud to them, so the patient next door, possibly if they're paying attention, can hear it.

So if I'm sitting in an infusion bay as a patient and I hear the guy next to me, his temperature was 100.2. And then 10 minutes later I hear him coughing, I can understand why that patient feels nervous. So there is some of that going on where patients have called their doctors and their treatment teams in the infusion bay saying, "Hey, I know the patient across the way from me who's coughing and hacking," and it has caused some panic. And I mean, on the clinician side of things, the best we can do is assure that ... We're not going to give information that we don't have, but we're going to tell patients that patients are being tested if they show signs and symptoms and that as long as everybody adheres to wearing their mask while they're in the building ... That's the part I forgot to mention. Besides screening our patients, we are giving them a surgical mask as they enter the building and ask them to wash their hands, you use hand sanitizer, and don't wear gloves in the building.

Darshan: Don't wear gloves? Oh.

Paul: Right.

Darshan: Why don't wear gloves?

Paul: So that is actually a very ... So a lot of patients have this sense of security with the gloves. They feel that they are doing the right thing and we try to explain to them the best thing you can do is wash your hands frequently, wash your hands with soap and water or use an alcohol based hand sanitizer. But for some reason the gloves, I don't know if it's because it's a physical thing for the patients to see, that they feel protected. However, we know that when they touch that door handle with the gloves, then they go touch that elevator button, then they go touch that cup of juice that they're about to drink and they grab that straw, everything that was on that door handle, that elevator button, and all that is now on that cup and now on that straw and they're actually cross-contaminating.

There was a nurse, I forget where she was, who made the news, she made a YouTube video where she used paint to show how cross-contamination works. And she wore the pair of gloves and did what most people in the public are doing right now, wearing the gloves to go shopping, this and that, to illustrate the point that gloves give you a false sense of security. There is a purpose for gloves. I actually printed out the CDC guidelines on how to properly use gloves. And I've actually had to tell multiple patients, when they come in, to please remove your gloves while you're here. I'm just going to ask you that you use the hand sanitizer or more preferably, wash your hands with soap and water. And I said, "I can't tell you what to do when you're not here, but while you're here," I said, "Please refrain from using your gloves and the gloves that you just took off, please throw them out."

It's funny how many patients, when you ask them to take their gloves off, they immediately put them in their pockets, that way they can reuse them. And that's actually another one of the guidelines that says never reuse or try to wash the gloves, which patients also do. I had a patient who was very resistant to me when I asked her to remove her gloves and she said, "Well I've used hand sanitizer on them." And I said, "Well hand sanitizer's proven to remove germs off your hands between the friction and the alcohol." I said, "I don't know what the science is on it removing those germs off gloves."

Darshan: Go ahead.

Paul: No, no, no.

Darshan: So what do you see now, based on what you're seeing, as things that were learned during COVID-19 that'll probably get used once this whole pandemics over?

Paul: Well there are a few things I would like to see that we would learn. That I think as we have gone through this season, as we continue to go through this season of life, I think people will start to take a step back from now on and really be a little more cautious in terms of the shared public spaces and the things that we touch. And I think it will cause people to hopefully wash their hands more and to be more cognizant that ... You know, these shared spaces, we don't know the last time ... Like for instance, we at the hospital, we know that we disinfect every patient area in between patients, but when you go to the supermarket and you get that shopping cart ... Recently, I would say within the past couple of years, a lot of the supermarkets have some type of disinfecting wipe so you can wipe the shopping cart, but I think now you'll see all the supermarkets doing that. I think you'll see all the patrons of the supermarkets, all the shoppers, doing that. Whereas before, a lot of people would still just grab the cart and go.

I think public transportation is somewhere where I would like to see a change as well. I know for me, once this all started, I actually refused to take public transportation. I've been driving or walking everywhere. And same thing with like ride sharing, I'd like to see something go across those lines too. I don't know how, as a rideshare driver myself, I have not driven rideshare during this and I do have a habit of cleaning my car at the end of each night, but not in between passengers. And that's one of my biggest fears about taking rideshare, for anybody right now, is you don't know who was in the car, in that seat, prior to you and has it been disinfected.

Darshan: So what do you think is going to ... How's it going to affect what you're doing in the hospital?

Paul: I mean we can't police how patient, that's the wrong word, we can't monitor how patients get to and from our facility and whatnot. We have to find the happy medium, where not to go overboard, but it is very possible for a patient who took the bus, that now they might be carrying it with them and bringing it in and be asymptomatic. And that's a whole different story. There's no way we can go crazy micro-managing and detail all of that. But I think for what we do at the hospital, I think what we will see is a little more screening in the name of infection control, like how we're doing now where we're asking patients if they're having any symptoms. I think you'll see that during flu season. I don't think you'll see that necessarily-

Darshan: So you think there'll be a rise in infection control's importance?

Paul: Right. I think you'll see a lot more of that. And I think, as clinicians, we will be a little more mindful with the way we use and supply our PPE. Now with the shortages, it's been ever so apparent that ... Like for instance, when our nurses access patients' ports, in the port kit there are two masks, a mask for the nurse and a mask for the patient. Right now, since we're all wearing masks, those two masks are not being used. We're saving them, as opposed to tossing them, when prior we would just toss them. So now we're starting to see where all of the waste and we know all hospitals have a lot of waste.

Darshan: So interesting.

Paul: That would be nice to see how this pandemic and the supply shortages affects the way hospitals manage waste.

Darshan: So any last words, Paul?

Paul: I just want to thank everybody. Thank you for having me on.

Darshan: Thank you.

Paul: I just want to thank everybody who is staying home and thank everybody who's out there on the front lines and continuing to fight the good fight. I want everybody to stay safe and the system only works if everybody follows the rules, so please, please, please follow the rules and hopefully we'll be out of this sooner rather than later.

Darshan: Well said. Thanks again, Paul. This was excellent. I appreciate having you on.

Paul: Thank you. Thank you very much, Darshan.

Narrator: This is the DarshanTalks Podcast. Regulatory guy, irregular podcast, with host Darshan Kulkarni. You can find the show on Twitter @darshantalks or the show's website at darshantalks.com.