Opinion | It’s ‘Deja Vu All Over Again’ at Our ‘Cough, Cold, and Fever’ Clinic

Here we go again.

This week, as the current surge continues, fueled by the recent holidays and associated travel, we are reopening our Cough, Cold, and Fever Clinic, which had been shuttered for a few months in the lull between peaks of this terrible pandemic. This clinic, housed in one portion of our practice, exclusively sees people with symptoms compatible with COVID-19 infection, or those who need to be examined in person once we know they have COVID-19, as well as many of those who were just worried and needed to be tested for reassurance or confirmation.

Born in the depths of the worst of the pandemic, when our hospitals were full and every square inch of the inpatient service had been repurposed to find places to care for the critically ill and dying, we were seeing patients that had been screened by our own practitioners — as well as others in the community — and by our subspecialist colleagues, as well as overflow from the emergency department, people sick enough that they really needed to be seen but not likely sick enough to need to be admitted.

We created standardized workflows and algorithms, incorporating the latest data as it came in. And we built in adaptation, flexibility, and rapid updates as we learned more and more about this disease. We called it the Cough, Cold, and Fever clinic — really a euphemism for COVID-19 clinic, since we didn’t think that people would really want to come into something labeled so blatantly.

In those darkest days, we were in a time where we didn’t have much to offer patients — no outpatient medical treatments, no monoclonal antibodies, not even a vaccine, and we were just learning how to care for the sickest of the sick on the inpatient services.We all recall sending patients home from this clinic with multi-lobar pneumonia from this virus, high fevers, and desperately low oxygen saturations, all of which would’ve, in pre-pandemic days, absolutely led to admission to the hospital. “Here’s a portable oxygen concentrator, here’s a pulse oximeter; keep hydrated, keep moving, back to the emergency room if things get worse; we’ll check on you tomorrow.”

But as the pandemic stretched on, and we got better at caring for patients with this disease, we began to see that not everyone was critically ill, and certainly with this latest variant in the vaccinated and boosted population we are seeing what people are characterizing as “milder disease,” with classic upper respiratory infection symptoms and mild flu-like symptoms. And yet our systems are once again maximally taxed, the ER is bursting, and the inpatient services are starting to be stretched to their limits. All this on top of a bruised, battered, and depleted healthcare workforce.

I know that in many hospitals elsewhere in the country, things are even worse, and more and more people are being admitted critically ill and requiring desperate measures to try and keep them alive. For now, we are hopeful that this current iteration of our Cough, Cold, and Fever Clinic will take some of the workload away from the overburdened emergency department, moving what we would all consider “primary care responsive” cases away from them, so that they can focus on the sickest of the sick.

Ideally, we would be able to triage these people before they even get to the emergency department, and we are working to improve our screening scripts with the folks answering our telephones, so that we can do video visits and decide who needs to be brought in to the Cough, Cold, and Fever Clinic, who needs to be kept safely at home, and who should be sent immediately to the emergency room. We are expecting that many of the people sent over will be presenting with these milder symptoms, and once we’ve established that they’re safe to go, we are hoping that we will be able to offer them some things that may help them get better.

Currently, due to situations that we all know so well, the outpatient options for treatments, such as the new oral antivirals and monoclonal antibodies that cover the Omicron variant, are in extraordinarily limited supply, if available at all. So for now, we’re probably just going to be going over symptomatic treatment, signs and symptoms for patients to watch for, giving out more pulse oximeters and digital thermometers, reviewing current guidelines about isolation and quarantine, and hopefully connecting patients who don’t have one to a primary care doctor so they can get hooked into the system.

Primary care has always been on the front lines, and we expect that to continue, no matter how things change — for the better or for the worse. In the early days of the pandemic, we started to learn what risk factors were for progression to severe disease, as well as when lab testing and imaging could be useful additions to the care of COVID-19 outpatients. Right now, we will continue to watch the current evolution of this surge, this variant, and hopefully be part of the process of detecting when it starts to go away, or when things take a turn for the worse.

So wish us luck. Everyone keep doing what they can, reaching down for the reserves we all have in us, while recognizing the toll this battle has taken on all of us. Keep those masks on tight, those face shields down, and wash your hands.

Oh, and vaccinate. Vaccinate. Vaccinate. Vaccinate. And boost.