COVID-19: Frontline GPs need consistent advice

COVID-19 update: As at 6.30am Wednesday 18 March Australia had 454 confirmed cases of COVID-19, including six fatalities, across seven jurisdictions – 210 in New South Wales, 94 in Victoria, 78 in Queensland, 32 in South Australia, 31 in Western Australia, 7 in Tasmania and 2 in the ACT. There have been 40 new cases since 3pm on Tuesday 17 March. Of the 454 cases, 43 are reported to have recovered. 228 cases were considered to be overseas acquired. Most of the overseas cases were acquired in the USA, Iran, Italy and the UK. 62 cases are contacts of previously confirmed cases. The likely place of exposure for 138 reported cases is under investigation. The source of infection for 26 cases is currently unknown. Across the world, there have been more than 190 600 confirmed cases of coronavirus (COVID-19) and more than 7700 reported deaths.

DESPITE statements from many people advising me about COVID-19, I remain confused. I am a GP, working in the city 11 months a year, and currently helping out bushfire-affected folk in southeast New South Wales, doing a month-long rural locum.

I am in communication with my city practice to sort out a COVID-19 protocol for our three sites, 17 GPs, five nurses and 12 administration staff, some of whom travel by public transport to work.

I am working in an underserviced small town, with a local hospital not manned by doctors for much of the time – three cheers for the nurses and distant medical support. I sat in on the recent Royal Australian College of GPs’ (RACGP) webinar, heard the RACGP president, the Australian Medical Association (AMA) president, the Chief Medical Officer and assorted ministers of health, and none of this helps me on the ground.

The only way you can understand my difficulty is to look at one of my patients. This man presented with a moderate dose of bronchitis, has a past medical history of pneumonia, and has not travelled overseas. He was sick enough not to work. He is over 65 years and has had his Pneumovax (Merck Sharp and Dohme).

Do I swab him? And if so, who does the testing? There is no local private collection centre, and I am unclear about the local hospital – we did send an email, we’re still waiting for the answer. The equipment our practice manager had was all in one place – a good thing – and, as we discovered, the visors did not work well – a bad thing – but the masks were good. All this equipment had been gathered by the practice itself: there was no delivery from the Primary Health Network (PHN) or money from any arm of government.

I assessed the man in a separate room the rural practice has — my city practice does not have a spare room almost all of the day. For various reasons, I decided to swab this patient and chose what I had been told was the correct swab. I did not have a long-sleeved gown, recommended by one advisor, but remembered the medical specialist at the webinar who said it probably did not matter. I had to walk back and forth down the corridor where folk were waiting, to get what I needed because the isolation room was intentionally kept very bare.

It turns out that I used swabs recommended by one arm of the pathology company, but not by the local collection agency. And I spent 40 minutes on this consultation because I had to work out how things needed to progress.

I think this means that I had more than brief contact – except, do I count when I was walking up and down the corridor? Who should I go to, to check on me, in my locum state?

In my city practice, where there is not a guaranteed spare room, we can ask people to wait outside, but two of our sites are on urban streets, with no car park, and parking is limited. So, how far down the street do I go in my gown to have the discussion?

The local PHN has a useful web page and information about access to masks. We have cancelled online bookings, so we can triage by phone. We will vary consultations so that the contact time is shorter to limit exposure. This is potentially a problem for patients with urgent distress, chronic disease, mental illness and disability.

Clear advice is difficult to get, when even the recommended level of personal protective equipment varies according to the advisor. The PHN points me to a reference that needs to be downloaded and then searched: it’s hard to find. The RACGP and the AMA have useful stuff, but not enough to answer my difficulties.

The federal government has announced a $2.4 billion health package, which includes “$100 million … to fund Medicare rebates for telehealth coronavirus consultations, while $206.7 million has been earmarked for 100 pop-up respiratory clinics designed to see up to 75 patients a day and take pressure off general practices and hospitals”.

“Another $1.1 billion will go towards ensuring patients and critical healthcare staff have face masks and other personal protective equipment, such as surgical gowns, goggles and hand sanitiser.”

The provisions for telehealth consultations are very welcome. I understand that the callers will be triaged – by whom? How long will I have to stay on the phone before I can talk with the patients? (Think of Authority Prescriptions, where it can take as long as 8 minutes to give numbers to a civilian, who only checks compliance.)

I am delighted about the provision of masks. Even the country locum where I am currently practising is promised 50 masks within days, and more after that. Presumably, we will receive the same number of gowns and visors.

The pop-up clinics information remains confusing. I understand that GPs will be providing those sites and running them. I am not aware of any spare fully fledged GPs who can come in when needed like that.

I look forward to more detailed information in the coming days. The bottom line is GPs want to help. We have been badgered for many years about overinvestigation and inappropriate use of pathology: now, do we swab, do we send people to private laboratories or to hospitals?

I realise the answer moves with the day, but it is confusing. We need to do all this while maintaining the health care for the majority of patients who are not symptomatic of COVID-19 and not at risk. At least, not according to the current criteria we are advised to apply. And that will change, again from day to day.

It feels to me that GPs are managing a moving target, with the skill and aplomb we bring to all the very different health issues we manage from day to day. I suspect that GPs and practices will use the references they have come to trust over time and experience.

I hope those references, experts and agencies all tell us the same thing.

Dr Linda Mann is a GP, and principal of Your Doctors in inner west Sydney.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.