Covid Resources

[radoncgrad2019]

Let’s compile important stuff here

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[Palex80]

Let’s compile important stuff here

This "paper" can be also titled: "How we should have been conducting breast RT if we were not thinking about earning money all the time"...

 

[RickyScott]

Redirect Notice

www.google.com

 

[radoncgrad2019]

This "paper" can be also titled: "How we should have been conducting breast RT if we were not thinking about earning money all the time"...

Well yeah you’re in Europe. Tell that to most of the posters here, they won’t like it.

 

[KHE88]

Ahh... never miss an opportunity for an easy low-hanging fruit "greatest hits" publication.
Regardless, probably helpful for people not up-to-date on data, so I'll give them credit for that as it will probably make a difference (although we know there will still be practices giving 7 weeks of RT for stage I breast to 80 year olds COVID be damned). Recently graduated residents have no excuse for not already knowing this stuff.

But....

I have been wondering about this. Rad oncs are all buzzing about how to delay patients 2-3 months.
Let's think critically about this. We are still in the very early days and weeks on the exponential curve. All indications point to this problem not being solved for at least 12 months. Containment has failed.

Are we just delaying patients 2-3 months only to have a glut of people that need to start when the crisis/infection rates may (likely will) be much worse? Isn't that a big problem? I'm really focusing on trying to get people in and out as fast as possible or pushing obs when supported by data rather than delaying people 2-3 months out. This seems somewhat futile and potentially harmful/self-defeating IMO.

 

[KHE88]

Well yeah you’re in Europe. Tell that to most of the posters here, they won’t like it.

Palex actually does real IMRT (VMAT) for breast cancer!
In the US, we actually still have people trying to make the argument that 3D tangents with field-in-field is IMRT based on a nonsensical semantics argument. It's pretty shameful.

 

[radoncgrad2019]

I think both things help. Trying to delay spread by not having a bunch of people together right now helps and so does shortening course. I see what you are saying though there are no easy answers here.

I agree that many new grads know this stuff but so many people out there as you know that are in practice that are straight CLUELESS.

 

[Gfunk6]

On a practical front, what are you guys using to protect yourselves in clinic? Surgical masks? N95 masks?

I'm also washing my hands regularly and meticulously and wiping down common areas.

 

[medgator]

On a practical front, what are you guys using to protect yourselves in clinic? Surgical masks? N95 masks?

I'm also washing my hands regularly and meticulously and wiping down common areas.

Keeping 6 ft distance from everyone, using surgical masks, conserving precious n95s for encounters with symptomatic pts. Apparently many are doing telephone OTVs, not sure that is kosher or great for pt care. Can't do things like skin checks etc.

 

[Gfunk6]

Keeping 6 ft distance from everyone, using surgical masks. Apparently many are doing telephone OTVs, not sure that is kosher or great for pt care. Can't do things like skin checks etc.

It's such a weird situation. I agree that follow-ups can be deferred or done remotely. It makes me feel weird to do OTVs remotely especially when the patient is already in the department sitting 20 feet away from me. I'm still doing consults though that number too is dwindling. I don't feel comfortable to treat someone without even seeing their face.

 

[BobbyHeenan]

We are debating screening at the front door with temps, however our only thermometers are under tongue/axilla.

I’m telling admins to get infrared or forehead. Would you guys want your nursing doing oral temp screens? I really don’t.

 

[RadOncDoc21]

We are debating screening at the front door with temps, however our only thermometers are under tongue/axilla.

I’m telling admins to get infrared or forehead. Would you guys want your nursing doing oral temp screens? I really don’t.

We’re doing that already but honestly if asymptomatic, no way of really knowing unless you get to test everyone everyday which we all know isn’t happening. Just be careful and treat everyone as if they and you have it already because eventually you will.

 

[scarbrtj]

Let’s compile important stuff here

Are you on that side or the Side of scarb who posts here on a daily basis that what we do doesn’t matter at all?

A paper saying that RT "doesn't matter at all" for many breast patients, so skip it? Heaven forfend. But thanks for the shout out @radoncgrad2019

Scarb, is there literally anything that you do that falls in line with what is generally accepted as normal practice? I have the sense that you just like to debate, but you seem to almost always take a contrarian view. You don't treat nodes, you don't boost...

View attachment 272111

FWIW Whelan has said himself that he typically boosts, despite the lack of a mandated boost on his trial.

Boost!

"Boost radiotherapy has more limited applications..."
Even seems people are coming 'round to my way of thinking on boost.
I should write coronavirus a thank you note.

Palex actually does real IMRT (VMAT) for breast cancer!
In the US, we actually still have people trying to make the argument that 3D tangents with field-in-field is IMRT based on a nonsensical semantics argument. It's pretty shameful.

Routine boosting will make you more money vs silly arguments about technological technicalities. But I wouldn't say people made the argument so much as CMS did FWIW.

 

[KHE88]

We are debating screening at the front door with temps, however our only thermometers are under tongue/axilla.

I’m telling admins to get infrared or forehead. Would you guys want your nursing doing oral temp screens? I really don’t.

Good luck getting infrared thermometers. I am being told it's impossible to order them.

Regarding OTVs over the phone, I don't understand how you would bill for this and hence this is verboten to admin. The vast majority of my OTV time is spent with chit-chat with asymptomatic patients who just want someone to talk to. In this case, I have been making it clear that we are sticking to business and asymptomatic OTVs are taking < 1 minute.

 

[Palex80]

On a practical front, what are you guys using to protect yourselves in clinic? Surgical masks? N95 masks?

Surgical masks mainly. FFP3 masks are reserved only when encountering patients tested positive as well as for those undertaking procedures which produce aerosols, such as bronchoscopy for instance.

 

[radoncgrad2019]

Don’t sleep

 

[taserlaser]

Good luck getting infrared thermometers. I am being told it's impossible to order them.

Regarding OTVs over the phone, I don't understand how you would bill for this and hence this is verboten to admin. The vast majority of my OTV time is spent with chit-chat with asymptomatic patients who just want someone to talk to. In this case, I have been making it clear that we are sticking to business and asymptomatic OTVs are taking < 1 minute.

Our clinic had a hard time ordering one, but found one in the end. I had offered to put together a DIY arduino one though - those pieces were readily available still at least a few days ago.

 

[Mandelin Rain]

We are debating screening at the front door with temps, however our only thermometers are under tongue/axilla.

I’m telling admins to get infrared or forehead. Would you guys want your nursing doing oral temp screens? I really don’t.

We did this all week

 

[scarbrtj]

Good luck getting infrared thermometers. I am being told it's impossible to order them.

Regarding OTVs over the phone, I don't understand how you would bill for this and hence this is verboten to admin. The vast majority of my OTV time is spent with chit-chat with asymptomatic patients who just want someone to talk to. In this case, I have been making it clear that we are sticking to business and asymptomatic OTVs are taking < 1 minute.

At least in theory as the code was written and first envisioned the majority of the "OTV time" actually happens from "overseeing the chart." It's a code that happens over a 5 day (or fx) tx time period. It's not officially called a "visit" by Medicare; it's "weekly treatment management." It includes many other things besides just a visit, things that happen when the patient is home and/or without the doctor actually seeing or touching the patient: "review of port images, dosimetry, dose delivery, treatment parameters and patient set-up, among other professional services as clinically indicated." Also, when the code was developed ~20 years ago, it being an E+M type code (suggesting face-to-face necessary) was expressly rejected by CMS in a description of the code. Many have tied verbal knots to explain the necessity of face-to-faceness, and of course that's what we all do. But was a face-to-face totally legally mandated? It's never quite been tested. But now's a time where I think face-to-face doesn't have to happen and a phone call, along with the "weekly tx management" activities as ASTRO describes them happening over a 5-7 day stretch, could suffice. YMMV of course!

 

[radoncgrad2019]

My opinion is that under usual circumstances it is not kosher to not ‘see’ your OTV, even if just on the machine.

Right now, all rules out the window IMO

 

[medgator]

At least in theory as the code was written and first envisioned the majority of the "OTV time" actually happens from "overseeing the chart." It's a code that happens over a 5 day (or fx) tx time period. It's not officially called a "visit" by Medicare; it's "weekly treatment management." It includes many other things besides just a visit, things that happen when the patient is home and/or without the doctor actually seeing or touching the patient: "review of port images, dosimetry, dose delivery, treatment parameters and patient set-up, among other professional services as clinically indicated." Also, when the code was developed ~20 years ago, it being an E+M type code (suggesting face-to-face necessary) was expressly rejected by CMS in a description of the code. Many have tied verbal knots to explain the necessity of face-to-faceness, and of course that's what we all do. But was a face-to-face totally legally mandated? It's never quite been tested. But now's a time where I think face-to-face doesn't have to happen and a phone call, along with the "weekly tx management" activities as ASTRO describes them happening over a 5-7 day stretch, could suffice. YMMV of course!

How do you skin check a pt over the phone? I think social distancing would be a reasonable compromise, so you can still do skin checks

 

[radoncgrad2019]

Scarb, I got this one for you brotha:

(Extremely Scarb voice): how often do skin checks even matter (insert hyperlink here)

 

[deleted1002574]

Scarbs voice is like Jon Hamm? Or Ralph Wiggum?

 

[radoncgrad2019]

Scarbs voice is like Jon Hamm? Or Ralph Wiggum?

No, Jon Snow.

 

[deleted1002574]

No, Jon Snow.

You know nothing

 

[RickyScott]

I am flying my drone to patients houses and then doing skin checks through the window because I am so tech savvy.

 

[BobbyHeenan]

We did this all week

Oral temp or forehead?

 

[Mandelin Rain]

Oral temp or forehead?

Forehead

 

[scarbrtj]

Scarbs voice is like Jon Hamm? Or Ralph Wiggum?

May not resemble him vocally but probably in other ways? But speaking of Hamm, watch 'Richard Jewell.' An underappreciated movie gem from last year. Usually Clint does his own music but he picked the great Arturo Sandoval for the score for this one. My favorite line of the movie, spoken by Sam what's his name's Russian secretary: "In my country, if the government says you're guilty that's how we know someone is innocent." Zing!

 

[Palex80]

How do you skin check a pt over the phone? I think social distancing would be a reasonable compromise, so you can still do skin checks

Facetime!

 

[w00tz]

Our governor waived certain telemedicine regulations.

Did OTVs over the phone last and temperature screening at the door. Patients were very receptive to it. Felt "protected".

During phone OTVs, told the patient, if they ever need something looked at, like their skin, just tell a nurse after their treatment and we can take a look. 90% of the time, you can get a good a idea of what's going on based on what the patient tells you and how far a long they are on their treatment. I have been a little bit for liberal with silvadene rx. Our IT did get Zoom for us to use, but patients don't have it installed on their PCs/phone, so...meh.

Follow-ups mostly over the phone.

Consults still in person. Thorough handwashing. Only use a stethoscope if pertinent and putting a glove over it.

Therapist,s unfortunately, limited to one mask a day for now.

 

[RickyScott]

Goes without saying but no ties and white coats.

 

[medgator]

Goes without saying but no ties and white coats.

Yup, mine are on hiatus for awhile

 

[evilbooyaa]

On a practical front, what are you guys using to protect yourselves in clinic? Surgical masks? N95 masks?

I'm also washing my hands regularly and meticulously and wiping down common areas.

Surgical mask when going to see patients in a clinic room. As long as patient is not coughing/aerosolizing, re-using it in-between patients.

Still doing OTVs in person. I can maintain reasonable distance from an asymptomatic patient for skin checks. People are worried about asymptomatic spread but not sure how they would 'shed it' onto me in the absence of coughing, if I sanitize in, sanitize out, and don't touch my face in-between it while wearing a surgical mask.

I have a N95 available (hidden in my office) if there is a symptomatic patient, but haven't needed it yet.

Hospital is doing temperature screening at the door for everyone including staff. Patients are limited to one visitor to accompany them on entry to minimize foot traffic.