Tuesday, March 17, 2020

Emergency Room Doctor: How We Treat Cancer Patients With Coronavirus Symptoms

This article appeared on the SurvivorNet.com website today. I'm reprinting it here. I hope that this information is helpful.

So what happens when a person undergoing cancer treatment goes to the emergency room worried they might have coronavirus? As many people in the SurvivorNet community are concerned, the editors thought it could be helpful for me to explain how we take care of these patients. Hopefully, knowing the specific medical protocol can help demystify the process, and maybe lessen the anxiety.

Most Emergency Departments, which is where I work as a doctor, have protocols on what to do with a feverish person undergoing chemo.

First Step On Arriving At The ER

When you arrive in the ER, you’ll likely be screened with questions first. If the staff is concerned you might have Coronavirus, you’ll likely be given a  mask and hand sanitizer.
Your vital signs will checked: the temperature, heart rate, blood pressure and how much the oxygen saturation is. Vital signs offer a clue if something is off in the body. After a physical exam, a series of tests are ordered: a chest x-ray to see if there is a pneumonia, a urine test to see if there is a urinary tract infection. Blood work, like the following, is also ordered:
  • CBC ( complete blood count) with differential: this tells the white blood cell count ( is there leukopenia or neutropenia?), if the person is anemic (does the person need a blood transfusion?) and if the ability to clot blood is ok ( is the person bleeding easily?).
  • Complete Metabolic Panel (CMP): this checks all the electrolytes (like sodium, potassium, kidney function and blood sugar) as well as liver function.
  • Blood and urine cultures: Bottles and vials of blood and urine are sent to the lab to see if any bacteria are growing in them that might be responsible for an infection. If bacteria is found, tests are run on it to see what specific antibiotics works against it. Cultures can take a few days to grow; it is not a same day test.
  • Other tests can be added on like a flu swab, stool tests, etc. COVID-19 cultures are sent based on whether a person meets testing criteria by the CDC. The purpose of this work up is to find the fever source. Sometimes, the answer is not immediate. So, many protocols include giving a dose of broad-spectrum, intravenous (IV) antibiotics. Broad-spectrum antibiotics cover a broad range of bacteria to treat everything that it could be. The antibiotics can be narrowed down or stopped once the culture results are known.
We understand a hospital is the last place a person dealing with cancer wants to be. Between frequent hospital visits, the desire to spend time with loved ones and simply missing home, people do not want to stay in the hospital.

Admission vs Discharge?

The decision of admission versus discharge depends on certain factors:
  • If the person is sick ( very weak, dehydrated, can’t keep down medications because he or she will vomit so IV treatment is needed) or unstable     (vital signs are abnormal, or a person’s mental status is off, or not breathing properly) the concern is, if sent home, the person can deteriorate. People meeting these criteria should be admitted. People who have normal vital signs and are otherwise well, may be admitted until the cultures come back negative, or sent home after a discussion with the oncologist. In cases of discharging home, it is essential that the oncologist is following the culture results. If a person is going home, it is helpful to obtain a copy of the test results for home records and to share with other health providers. It is important to also know what to return to the hospital for.
  • The whole goal, from the ED, is to make sure that the person is safe, monitored and treated appropriately so that he or she can either go home or continue the treatment process upon admission. There should always be discussion between you and your healthcare providers and, please, ask questions freely. That said, we might not have all the answers right then and there. This is especially true in the ED where tests are still running, there is a limited amount of time to talk, or the environment is hectic.  However, remember, this is an ongoing and dynamic process involving a lot of discussions, fighting and hope- and we as your health care providers want to support you through all of that.

What We Worry About With Cancer Patients & Coronavirus

Chemotherapy continues to be a typical treatment for many cancers.  However, “living life” while on chemo can be anything but typical. Mundane tasks such as running errands, preparing meals and self-care can be challenged by chemo’s side effects, such as fatigue, nausea, vomiting and a weakened immune system.
  • Weakened immune systems due to chemo can present itself in blood work through leukopenia. Leukopenia is a low white blood cell count- the cells that help the body fight infection. Sometimes, white blood cell numbers can go so low that it can shift to neutropenia- which is when then main white blood cell that fights infection, the neutrophil, is super low.
  • The weakened immune system complicates what were formerly simple issues. A fever that could have just been treated with medicine and some rest becomes an event. What does fever while on chemo and/or a low white blood cell count mean? To medical professionals, it can mean different things.
  • It can mean it’s a reaction to the treatment. It can also mean there is an underlying infection that is taking advantage of the body’s compromised defenses and is causing the fever. The infection can be viral like a cold, or bacterial like a urinary tract infection. It could be simple and go away with medications or it can get complicated and require further in-hospital treatment. Either way, healthcare providers are conservative with treating fevers in people undergoing chemo because a person can get sicker quicker and, sometimes, in a bigger way.

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