new Covid wave

[Palex80]

For those of you at hospitals “limiting elective procedures”, does RadOnc face any type of pressure to slow down? None whatsover at my place.

Ultimately complex brachytherapy may become an issue due to limited number of anesthesia personell available to support us, we already have some slow down in the capacity available there. If things turn very ugly, I can imagine some of our technicians being called up to help out in the radiology department, performing scans.

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[Ray D. Ayshun]

For those of you at hospitals “limiting elective procedures”, does RadOnc face any type of pressure to slow down? None whatsover at my place.

Pressure to do more at my place. Somebody's gotta make up for the shortfalls elsewhere.

 

[ramsesthenice]

Ultimately complex brachytherapy may become an issue due to limited number of anesthesia personell available to support us, we already have some slow down in the capacity available there. If things turn very ugly, I can imagine some of our technicians being called up to help out in the radiology department, performing scans.

This is the only thing I see potentially being an issue for us. Otherwise, I feel like pressure is on to keep drawing as much revenue as we can.

 

[Ray D. Ayshun]

Has nobody had covid hit their clinic? I feel like it's coming. Its a rural clinic with no real backup capabilities. Not sure what happens if we shut down for a week.

 

[RadOncDoc21]

Has nobody had covid hit their clinic? I feel like it's coming. Its a rural clinic with no real backup capabilities. Not sure what happens if we shut down for a week.

Thus far no, but I’ve seen an uptick in patients either previously diagnosed with COVID, other employees, relatives etc so I feel like it’s coming soon.

 

[Ray D. Ayshun]

Thus far no, but I’ve seen an uptick in patients either previously diagnosed with COVID, other employees, relatives etc so I feel like it’s coming soon.

I called a Monday followup to see if she needed anything, and move her to march if not. She's a local nurse, and was at home with covid.

 

[Bequerel]

I live in a place that has an extremely high Covid positivity rate. I test everyone before they start treatment and have caught a couple asymptomatic patients. Obviously, if not pressing, I just have them quarantine appropriately and start treatment afterwards. I currently have 2 patients (symptomatic head and neck and lung) with Covid being treated. Luckily I have 2 machines and they are treated at the end of the day with hospital staff coming and doing appropriate cleaning and fogging. Thankfully, they can be at the end of the day, otherwise machine would be down for almost 3 hours with cleaning procedure. I’ve had my NP and multiple therapists test positive and need to quarantine. The cancer center has had a significant number of nursing and ancillary staff test positive and need to quarantine. Crazy and stressful times, but I feel we are adapting as best as we can. Hopefully the cases start to decline in our city soon!

 

[dieABRdie]

Policy was "10 days after symptoms or positive test" even though my entire team was comfortable treating him separately at the end of the day and deep clean afterward. I tried to just do it but administration stopped me. Very frustrating.

He did well and finished later, I got him back as soon as was "acceptable". My theory is he recovered quite quickly despite his performance status due to lack of functioning pneumocytes (this was third round of lung radiation and his lungs are awful).

I would document admin's refusal to let you treat in the chart. Let them share the blame if the patient fails.

 

[taserlaser]

Staff shortages

High risk exposure in clinic. 30+ patients and staff exposed

 

[FrostyHammer]

I would highly encourage everyone to be less aggressive about seeing follow-ups, and if possible coordinate with other specialties to have a single MD see ideally all follow-ups. From what I have seen, patients will love and appreciate you forever for this simple action, even if they follow with another specialty and never follow back up with radonc again.

 

[metallica81788]

I would highly encourage everyone to be less aggressive about seeing follow-ups, and if possible coordinate with other specialties to have a single MD see ideally all follow-ups. From what I have seen, patients will love and appreciate you forever for this simple action, even if they follow with another specialty and never follow back up with radonc again.

I would actually love to do this after inheriting quite a few follow ups from the prior doctor that won't let me unload them. Covid could be my chance!

 

[RadOncMegatron]

I would highly encourage everyone to be less aggressive about seeing follow-ups, and if possible coordinate with other specialties to have a single MD see ideally all follow-ups. From what I have seen, patients will love and appreciate you forever for this simple action, even if they follow with another specialty and never follow back up with radonc again.

I’m also doing this as well. Not sure many patients will tolerate taking time off and driving to an appointment just to hear “everything looks good in your scan.”

 

[dieABRdie]

I would highly encourage everyone to be less aggressive about seeing follow-ups, and if possible coordinate with other specialties to have a single MD see ideally all follow-ups. From what I have seen, patients will love and appreciate you forever for this simple action, even if they follow with another specialty and never follow back up with radonc again.

During residency I always said I was going to stay involved with every definitive patient for life but I've changed my tune real quick in the real world. In my last practice environment I followed them very closely because I was often the only doctor they were seeing. Now I'm in a town of 250K or so and if I don't see I'm adding something I've really started to back off. Last week I saw my first early stage breast patient who finished treatment. Her surgeon follows them and does a breast exam... and the med onc sees her for AI. I ALMOST told her she didn't need to come back to me at all. But the easy follow ups are one of the best things about our job. I'm trying to figure it out.... but definitely backing off a bit. COVID really pointed out how much BS we do that just isn't necessary.

 

[RadOncMegatron]

During residency I always said I was going to stay involved with every definitive patient for life but I've changed my tune real quick in the real world. In my last practice environment I followed them very closely because I was often the only doctor they were seeing. Now I'm in a town of 250K or so and if I don't see I'm adding something I've really started to back off. Last week I saw my first early stage breast patient who finished treatment. Her surgeon follows them and does a breast exam... and the med onc sees her for AI. I ALMOST told her she didn't need to come back to me at all. But the easy follow ups are one of the best things about our job. I'm trying to figure it out.... but definitely backing off a bit. COVID really pointed out how much BS we do that just isn't necessary.

Well put. I completely understand.

 

[scarbrtj]

COVID really pointed out how much BS we do that just isn't necessary.

Me? Do unnecessary BS in early stage breast?

Doc, Shouldn’t We Be Getting Some Tests?
​

Randomized Trial of Long-Term Follow-Up for Early-Stage Breast Cancer: A Comparison of Family Physician Versus Specialist Care​

 

[Palex80]

My impression is that >80% of all radonc follow-ups can be perfectly managed by nurses, when they have a clearly defined set of things to do & check.

 

[medgator]

My impression is that >80% of all radonc follow-ups can be perfectly managed by nurses, when they have a clearly defined set of things to do & check.

Review scans? Sometimes radiologists aren't perfect

 

[RadOncDoc21]

Since E/M is going up, I might just add ya’lls follow ups to my schedule. I still got to eat!

 

[dieABRdie]

Review scans? Sometimes radiologists aren't perfect

This is one of the major reasons I would stay involved. Community radiologists miss findings on a very large proportion of patients. Not that its necessarily an indication of negligence.... many are general radiologists so they read a whole lot more than cancer. But our med oncs rarely look at them and its common for me to note things that change management.

 

[RadOncDoc21]

This is one of the major reasons I would stay involved. Community radiologists miss findings on a very large proportion of patients. Not that its necessarily an indication of negligence.... many are general radiologists so they read a whole lot more than cancer. But our med oncs rarely look at them and its common for me to note things that change management.

Also let’s face it, I don’t trust that my fellow med oncs would know when to bring back radiation into the equation. As I’ve said before, they are willing to “wait and see” what the chemo does for anything that may come in in the future (bone mets, lung nodules, brain Mets, uncontrollable bleeding, cord compression, early stage lung cancers, prostate, lymphoma, etc).

 

[medgator]

This is one of the major reasons I would stay involved. Community radiologists miss findings on a very large proportion of patients. Not that its necessarily an indication of negligence.... many are general radiologists so they read a whole lot more than cancer. But our med oncs rarely look at them and its common for me to note things that change management.

More than once, I've seen patients back in fu who develop new sx of pain and after examining them and reviewing the pet or ct, catch new lesions which were missed on the report and end up leading to new ebrt cases...

 

[BobbyHeenan]

More than once, I've seen patients back in fu who develop new sx of pain and after examining them and reviewing the pet or ct, catch new lesions which were missed on the report and end up leading to new ebrt cases...

Yes. It's no coincidence that the busiest partners in our group are the ones who follow their patients very closely.

Med oncs (even good ones) will often up pain meds often before referring for 8 Gy X 1 or some other palliative regimen. Especially post radiosurgery scans are often read as worse due to inflammation (lung/brain) and it takes some hand holding with patients to explain. During COVID I am able to do more telephone or telehealth follow ups, but sometimes I want to show the patient their scans and I'm not good enough on doxy.me to do that yet.

I think where I personally need to cut back is early stage breast. I'm not over-reading mammograms like I do scans in other disease sites and the patients are already seeing med onc regularly on their AI (which it seems we talk about the most at their appointment anyway because half of them are miserable on it).

 

[dieABRdie]

Yes. It's no coincidence that the busiest partners in our group are the ones who follow their patients very closely.

Med oncs (even good ones) will often up pain meds often before referring for 8 Gy X 1 or some other palliative regimen. Especially post radiosurgery scans are often read as worse due to inflammation (lung/brain) and it takes some hand holding with patients to explain. During COVID I am able to do more telephone or telehealth follow ups, but sometimes I want to show the patient their scans and I'm not good enough on doxy.me to do that yet.

I think where I personally need to cut back is early stage breast. I'm not over-reading mammograms like I do scans in other disease sites and the patients are already seeing med onc regularly on their AI (which it seems we talk about the most at their appointment anyway because half of them are miserable on it).

Hmm.... I had been sending the palliative ones back on their way after their first follow up. Maybe its a good idea to get them back after each time they have a scan? I think I will....

 

[medgator]

Hmm.... I had been sending the palliative ones back on their way after their first follow up. Maybe its a good idea to get them back after each time they have a scan? I think I will....

I usually let the Palliative pts go back, but it's something to think about if you have the clinic time

 

[RadOncDoc21]

I usually let the Palliative pts go back, but it's something to think about if you have the clinic time

These days all I’m seeing are palliative cases. This would be a good time to make my pun but I will be civilized for once.

 

[seper]

Treating 3 positive patients now. A nurse is out with symptomatic disease. Hospital is full. Regarding RadOnc encounters, no formal restrictions are encouraged by admins. So, doing what we can.

 

[BobbyHeenan]

Hmm.... I had been sending the palliative ones back on their way after their first follow up. Maybe its a good idea to get them back after each time they have a scan? I think I will....

For now I continue to see after each scan if reasonable prognosis. It's very taxing on clinic though. We've had a lot of med onc turnover though, so I don't have a great feel for how they practice yet, so that's part of it.

 

[Palex80]

Review scans? Sometimes radiologists aren't perfect

Scans? I'd say >50% of my follow-ups do not need scans (breast, prostate).

 

[FrostyHammer]

Hmm.... I had been sending the palliative ones back on their way after their first follow up. Maybe its a good idea to get them back after each time they have a scan? I think I will....

I can't recall the last time I ever saw a palliative patient even at 1 mo. Med oncs & patients aren't stupid and know what to do (or can be taught) if the time comes for more palliation.

 

[seper]

For those of you working for a large hospital / system, any insight on where RadOnc staff stands in the line for Pfizer vaccine allotment ? Our ER docs and unit nurses are getting calls to get ready for scheduling their shots.

 

[metallica81788]

For those of you working for a large hospital / system, any insight on where RadOnc staff stands in the line for Pfizer vaccine allotment ? Our ER docs and unit nurses are getting calls to get ready for scheduling their shots.

From the emails and breakdown of our large hospital system rollout, it seems to me that RadOnc would fall under the "outpatient provider" category. Which I interpret as being 3rd in line.

1st - ICUs/Covid units, ED, Urgent Care
2nd - Inpatient, Acute Care, OR, Primary care clinics, ENT/Pulm Clinics
3rd - Outpatient clinics, infusion clinics, radiology

 

[elementaryschooleconomics]

For those of you working for a large hospital / system, any insight on where RadOnc staff stands in the line for Pfizer vaccine allotment ? Our ER docs and unit nurses are getting calls to get ready for scheduling their shots.

My system has opted to break us into two categories, "ER/ICU" and "everyone else", with ER/ICU going first.

Personally, I find this exceedingly fair.

 

[RadOncDoc21]

My system has opted to break us into two categories, "ER/ICU" and "everyone else", with ER/ICU going first.

Personally, I find this exceedingly fair.

Also good to get some lead time in just in case the first wave starts dropping like flies. I find this fair as well. Now the question is will the entire team get vaccinated (front desk, admin, etc).

Why do I feel like my nurse will have more political power to get one more than I do? If anybody was to get one first in my dept, it should be the therapists.

 

[seper]

RadOncs doing implants (especially in main OR) and those seeing inpatient routinely are at pretty high risk... however I agree, not reasonable to expect to be in the "1st tier"

Also good to get some lead time in just in case the first wave starts dropping like flies. I find this fair as well. Now the question is will the entire team get vaccinated (front desk, admin, etc).

Why do I feel like my nurse will have more political power to get one more than I do? If anybody was to get one first in my dept, it should be the therapists.

 

[RadRadRad]

Biggest argument for radonc department early on list (but after er/icu/Covid units) is for our patients, many of whom are immunocompromised. I would think oncology should be ahead of most other specialties for this reason.

and agree that therapists should be first within the department

 

[RickyScott]

Biggest argument for radonc department early on list (but after er/icu/Covid units) is for our patients, many of whom are immunocompromised. I would think oncology should be ahead of most other specialties for this reason.

and agree that therapists should be first within the department

Will be getting vaccine on Tuesday. Only 2 therapists were willing.

 

[Ray D. Ayshun]

Biggest argument for radonc department early on list (but after er/icu/Covid units) is for our patients, many of whom are immunocompromised. I would think oncology should be ahead of most other specialties for this reason.

and agree that therapists should be first within the department

The other big argument is staying open consistently. Not much redundancy built into rural departments.

 

[medgator]

Will be getting vaccine on Tuesday. Only 2 therapists were willing.

Shouldn't be surprising considering public polling on it

 

[deleted969641]

Will be getting vaccine on Tuesday. Only 2 therapists were willing.

An FDA cleared but not FDA approved vaccine that Trump assures the public is safe and a miracle that only he and his "perfect" leadership could have pushed through?
To prevent infection with a virus that has a 99.8% survival rate for all comers? That probably half of the staff have already had and recovered from?
People aren't beating down the doors to get that? I'm shocked. Shocked I tell you.

Perhaps if you told them they didn't have the wear the masks anymore if they got it. Doesn't exactly instill confidence that the thing is effective if you are telling people they still have to wear masks anyway.

Our hospital sent an email with a link to a video by Bill Nye the science guy (literally not making this up) to all of the staff, including physicians, explaining how masks work and using that as justification for why masks are still necessary after getting vaccinated (definitely not about image or theater or anything like that -- it's science. Bill Nye says so.). Bill Nye has a bachelors degree in mechanical engineering and wears a bow tie. Who am I to question him with my decade of medical training and 4 board exams and what not...

 

[elementaryschooleconomics]

An FDA cleared but not FDA approved vaccine that Trump assures the public is safe and a miracle that only he and his "perfect" leadership could have pushed through?
To prevent infection with a virus that has a 99.8% survival rate for all comers? That probably half of the staff have already had and recovered from?
People aren't beating down the doors to get that? I'm shocked. Shocked I tell you.

Perhaps if you told them they didn't have the wear the masks anymore if they got it. Doesn't exactly instill confidence that the thing is effective if you are telling people they still have to wear masks anyway.

Our hospital sent an email with a link to a video by Bill Nye the science guy (literally not making this up) to all of the staff, including physicians, explaining how masks work and using that as justification for why masks are still necessary after getting vaccinated (definitely not about image or theater or anything like that -- it's science. Bill Nye says so.). Bill Nye has a bachelors degree in mechanical engineering and wears a bow tie. Who am I to question him with my decade of medical training and 4 board exams and what not...

I have also received infantilizing emails from some of the places I work. What a weird time to be alive.

 

[medgator]

An FDA cleared but not FDA approved vaccine that Trump assures the public is safe and a miracle that only he and his "perfect" leadership could have pushed through?
To prevent infection with a virus that has a 99.8% survival rate for all comers?

I thought mortality was still a little higher than that, besides, surviving isn't always a walk in the park

 

[Burt Radnolds]

https://www.who.int/bulletin/online_first/BLT.20.265892.pdf

CFR/IFR for patients under 70 is calculated at 0.05% (99.95%) survival. This is posted on WHO website, peer reviewed, based on aggregate serology and fatality data over many cities/countries and corroborated by other data sets.

I will get vaccinated if offered (no mention yet). I will not really be doing it for myself, but more so for my patients and to maybe help end the pandemic.

The acute toxicity profile of these vaccines is a tad impressive, moderna was 10% "severe", meaning you are basically out of commission for a day or two (if you are in the lucky 10%), and worse in younger people. Also a brand new vaccine using new tech with limited follow up does make me a tad uneasy. The mechanism of an mRNA vaccine does seem quite elegant though and overall I'm good with it.

 

[Lamount]

I will take the vaccine when offered

1) Benefits appear to outweigh the risks. Even assuming COVID only has mortality of 0.2%, that’s probably several orders of magnitude higher than the vaccine. Same can be said for morbidity



2) Though not proven, it’s likely the vaccine makes us less infectious even if we are infested

3) I want my patients to take it, and I want to be able to look them in the face and tell them that I already did

4)There are already international airlines discussing requiring proof of vaccination for travelers. Something tells me this will be the new currency

 

[DoctwoB]

https://www.who.int/bulletin/online_first/BLT.20.265892.pdf

CFR/IFR for patients under 70 is calculated at 0.05% (99.95%) survival. This is posted on WHO website, peer reviewed, based on aggregate serology and fatality data over many cities/countries and corroborated by other data sets.

I will get vaccinated if offered (no mention yet). I will not really be doing it for myself, but more so for my patients and to maybe help end the pandemic.

The acute toxicity profile of these vaccines is a tad impressive, moderna was 10% "severe", meaning you are basically out of commission for a day or two (if you are in the lucky 10%), and worse in younger people. Also a brand new vaccine using new tech with limited follow up does make me a tad uneasy. The mechanism of an mRNA vaccine does seem quite elegant though and overall I'm good with it.

From the linked study


“In people < 70 years, infection fatality rates ranged from 0.00% to 0.31% with crude and corrected medians of 0.05%.”

Not terribly reassuring as to the .05% estimate. Likewise they found CFR estimates were over twice as high in high fatality countries (like the US).
And even if 0.05% is accurate, that’s 1 in 2000. As opposed to 0/40000 who got the vaccine.
Plus the benefit of not infecting your patients. All so you don’t get a fever and some muscle aches.

 

[medgator]

From the linked study


“In people < 70 years, infection fatality rates ranged from 0.00% to 0.31% with crude and corrected medians of 0.05%.”

Not terribly reassuring as to the .05% estimate. Likewise they found CFR estimates were over twice as high in high fatality countries (like the US).
And even if 0.05% is accurate, that’s 1 in 2000. As opposed to 0/40000 who got the vaccine.
Plus the benefit of not infecting your patients. All so you don’t get a fever and some muscle aches.

US has been abysmal with mortality rates compared to other countries, despite our more advanced capabilities

 

[Burt Radnolds]

From the linked study


“In people < 70 years, infection fatality rates ranged from 0.00% to 0.31% with crude and corrected medians of 0.05%.”

Not terribly reassuring as to the .05% estimate. Likewise they found CFR estimates were over twice as high in high fatality countries (like the US).
And even if 0.05% is accurate, that’s 1 in 2000. As opposed to 0/40000 who got the vaccine.
Plus the benefit of not infecting your patients. All so you don’t get a fever and some muscle aches.

1/2000 is a devastating number given the scope of infection rates and the number is much much higher in more vulnerable populations, never said anything to suggest otherwise.

Here is another broad IFR study with a bit more granular data by age (Assessing the age specificity of infection fatality rates for COVID-19: systematic review, meta-analysis, and public policy implications). For my demographic, the rate holds at close to 0.05 and is probably lower given my current health status. Less than my yearly chance of an accidental death.

It's okay to acknowledge that the vaccine might have significant acute side effects. These issues will become apparent when mass vaccinations start and better to have total transparency. People need to be careful about vaccinating their entire workforce at once as you may have some people at home for a few days and not be able to keep services going.

COVID is an absolute public health nightmare and it's consequences will reverberate for decades. I will gladly take a vaccine to do my part in mitigating. Yes, I have slight unease about it given the unprecedented (how many times have you heard that word lately?) nature of it's production, but I can easily shelve that given the perceived net benefit. When a patient or layman asks my official vaccine stance I express full support and inform them I will be taking it.

 

[seper]

People who’ve been working since March but consider refusing vaccine, I envy your setup

 

[Palex80]

I am a strong believer that results of the Phase-III-trials should not have been awaited and the vaccines should have been made available as soon as they were manufactured after Phase-I/II-trials had shown efficacy and some data on safety.

That's what the Russians are doing with Sputnik-V, more or less.

In my view, more people will die in the weeks/months we are delaying introduction of the vaccines because of Covid-19 than those people who may have died because of possible vaccine-side-effects, even in the worst case scenarios. "Selling" this argument however to the general public is unfeasible.
FDA-approval in the US was fast, but the EMA seems to want more data before approving the vaccines.

Apart from the Phase-III-blacebo controlled trials, companies could/should have started a "who wants to get the vaccine based on Phase-I/II-data"-project and looking only at side effects. If I was able to get a vaccine based on only on Phase-I/II-data, I would do it.

But that's just my opinion. History will tell.

 

[yesmaster]

https://www.who.int/bulletin/online_first/BLT.20.265892.pdf

CFR/IFR for patients under 70 is calculated at 0.05% (99.95%) survival. This is posted on WHO website, peer reviewed, based on aggregate serology and fatality data over many cities/countries and corroborated by other data sets.

Let’s assume COVID-19 or just mere exposure to SARS-CoV-2 with seroconversion has a case-fatality of 0.05%. In the USA, with 300k deaths from COVID-19 so far, that would imply 600 million Americans have been exposed to SARS-CoV-2.

This is what we call a “sanity test” and this case-fatality claim obviously doesn’t pass muster.

 

[Burt Radnolds]

Let’s assume COVID-19 or just mere exposure to SARS-CoV-2 with seroconversion has a case-fatality of 0.05%. In the USA, with 300k deaths from COVID-19 so far, that would imply 600 million Americans have been exposed to SARS-CoV-2.

This is what we call a “sanity test” and this case-fatality claim obviously doesn’t pass muster.

False. The stats can still easily work considering the VAST majority of deaths are in those above the age of 70, with a median age of COVID related death in the US around age 80. The 0.05% screens out the high risk population >70, which was pointed out clearly in the posts. Read the actual studies and posts before you commence with the strawmanning. The 2 studies I cited are the highest quality data available on the subject.