Rethinking ID (infectious disease)

Being a small fish in a hamster wheel I’m not expecting to accomplish much from another Covid post. CPAP hoods, crowd sourced masks, antibody tests, Lysol, UV lights, H type – L type(???), and the surrounding politics are fascinating. But with so much talk about reopening, I’m fixated now on flu/COVID20/21.

Folks clearly need to return to work and salvage their lives and livelihoods. That said, however, if we return to the “old normal” then we’ll likely get what we deserve next season. I also don’t think lockdown round two will go well at all. So I’ve been trying to come up with things I/we can do to nudge this nuclear Titanic, looking 6-8 months down the road. It’s probably delusional, but I do think there are some systemic tweaks that could help.

This will sound extreme, but in the wake of Covid19, using my Etch-A-Sketch, I would like now to see all ID managed physically and fiscally away from hospitals, urgent cares and clinics even. I’m not a “Medicare for all” guy either. But I am a “Medicare for select conditions independent of age, and especially for problems that have enormous surrounding blast zones like Covid” guy. We manage psyche off site for reasons I’ve never fully understood; maybe reimbursement related. It certainly doesn’t seem better for patients. ID has far greater potential to destroy systems as we’ve already seen. So I’d like it to be managed in its own separate channel.

Of course like psychiatry there will be combo packs like the suicidal diabetic or the hyperthermic schizophrenic. Cholecystitis, diverticulitis and UTIs shouldn’t need transfer elsewhere because “those are ID and we no longer have antibiotics.” But at the core, I just want illnesses that are easily transmitted human to human managed very different.

So splitting ID between the worried well, the maybe sick and the sick sick, here’s how I wish we’d manage all three:

  • Worried well:
    These are folks who had, or maybe still have, a mild fever and want to know what to do to keep friends and family safe. Or maybe they have a cough that’s persisted longer than expected. Or they want to return to work or school, but just need a release.

    Like a suicide hotline, I want a free ID hotline that offers more than “if you’re concerned then you’ll have to come in to be seen.” Maybe it’ll get overused and abused, but the cost couldn’t be over a $trillion, right?

    Telemedicine is already taking off for this group and I think hospitals, urgent cares and clinics that don’t get on the bandwagon will lose out. I want virtual care for this group to be low hanging, multilingual, and accessible regardless of socioeconomic status.
  • Maybe sick:
    These are folks who feel pretty miserable. They want testing. They want vital signs and they want to feel better.

    For them I’d like to see a system modeled after In-n-Out Burger. Literally parking lot medicine perhaps with some easily cleaned pods for point of care quick turnaround tests. Drive up and stay in your car for pulse ox, heart rate and temp readings as well as nasal swabs and blood draws.

    Maybe even receive IV saline while in your car. I’ve done this with Pre-R and patients are super grateful to be able to stay in place. Speak with a doc from a safe distance or by video call to give more history and interpret test results. If needed, step into an easily cleaned pod for an X-ray or ultrasound.

    This would be incredibly easy to implement quickly. Versions of this exist at some hospitals. But to me that’s still too close to the broken hips, strokes and heart attacks. I want a repurposed drive-in. I think it would also make people with heart attacks and hip fractures far less fearful to come back into hospitals again. Hospital fear is a problem getting more and more attention and causing administrators more and more anxiety as well.
  • Sick sick:
    For folks who are severely short of breath, or with altered mentation, 911 will still be the goto. That’s a hard system to change in 6-8 months. But I do hope that one day patients needing transport by ambulance will be taken to dedicated ID centers the way they frequently are today for trauma, neuro, cardio, peds and even psyche.

    I wish there were ID specialized ambulances as well that protected paramedics far better than they do now as well. On my last few shifts I’ve been struck by how underprotected the medics have appeared. Seeing them with simple gloves and masks handing off to teams of nurses and docs in hazmat gear has caught my eye a number of times already.

Hospital, urgent care and clinic administrators may not like any or all of my suggestions since monetized sniffles cover a lot of the bills. But maybe the drops in patient volumes could make these thoughts more palatable. Wouldn’t it be nice to be able to advertise: “Covid free facility for 8 months and counting!”

I know… more Slishmania. But people can’t just run to urgent cares or ERs with sniffles any more, and they shouldn’t be marketed to in the same ways either. Emergency medicine is shaped by EMTALA and loosely defined in the US by “if you think you have an emergency then come on in.” But I’m convinced that model needs refinement.

I’ve no say in anything beyond Pre-R really. So putting money where my keyboard is, Vanessa and I have decided to change our pricing model yet again. If you call with an ID related question, no charge for conversation unless we call in an Rx. Instead we’ll send a request for donation prompt like we used to 5 years ago. If you can, great. And if not, no worries. We’re raising our flag like “Dan the Bread Man”. And if you own an empty parking lot give us a shout. #RaisetheBar

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