Palex80

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So, I am not here to spread panic, but: You have seen that contingency plans have been implemented in several countries aimed at containment of COVID-19.

a) Towns / Regions have been locked down, not allowing anyone in and out
b) People presenting with symptoms pointing at possible infection but with mild symptoms or those who have had contact with people who are infected are being sent home and told to stay there for 14+ days.
c) Extensive decontamination of surfaces / rooms is necessary in hospitals after a patients with COVID have been there.

Have you guys formulated any plans for your clinic / department in case virus spread continues?
Scenarios on how it's gonna spread are variable. I have seen a wide range of figures ranging up to "40% of earth's population get's it"

We are not seeing any additional burden right now despite the fact that we had confirmed infections in the area, since authorities have not implemented measures that seriously affect us, however we thought about a-c and how this would affect our clinic.

a) What happens with patients that have to travel to come to us and are outside any kind of quarantine zone imposed? The same question is valid for colleagues who live outside a quarantine zone which includes the hospital /practice.

b) Is a major issue for co-workers. If a sizable number of them are sent home and told to stay there for 14+ days, how are supposed to operate our clinic and treat patients? The same goes of course for patients, but one could try to put those who may be infected but need radiation treatment in hospital wards, so that they can still come to treatment. The next issue of course is going to be than in an event of wide spread of COVID, there won't be enough beds for everyone...
A big issue are kids. Some countries have been shutting down daycare & schools (--> Japan). Who is supposed to take care of them at home? Health officials have advised against calling grandpa and grandman, since they seem to be the group that is affected the most by COVID, thus letting them take care of the kids (who may be bearing the virus) may put them at higher risk.

c) I witnessed a CT room being sterilized after a patient, who was tested positive for the COVID, got a CT scan there. It took ... hours, although I do presume there's a "learning curve" or perhaps extreme precaution still in this early phase. Now imagine having a few patients with COVID and clear indications for RT, for example a SCCHN patient on his 4th week of irradiation who develops fever and tests positive for COVID. You can't stop treatment for 14+ days, until he's clear... When/How are you going to treat him? Should those who have the "luxury" of multi-rooms simple designate a linear accelerator only for COVID-confirmed cases and one for the rest?

Questions, questions... Any ideas?

Cheers and stay safe!
 
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I honestly feel like this is a futile battle at this point. I don't think containment is possible and think this is going to be everywhere.

But to answer your question, no, we do not have any contingency plans at this time. We don't have the resources.
 
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Right now I think the most productive thing we can do is to get really pissed at China. After SARS from civet cats, you would think they would have shut down these horrible markets trafficking in wierd and EXPENSIVE Animals. Why should we loose 2 trillion in stock market value and potentially hundreds of lives because they want to eat bats (chicken of the caves? And pangolins/anteaters? Again these animals are expensive and housed in very unsanitary conditions. No lessons learned from SARS.
 
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KHE88

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Right now I think the most productive thing we can do is to get really pissed at China. After SARS from civet cats, you would think they would have shut down these horrible markets trafficking in wierd and EXPENSIVE Animals. Why should we loose 2 trillion in stock market value and potentially hundreds of lives because they want to eat bats (chicken of the caves? And pangolins/anteaters? Again these animals are expensive and housed in very unsanitary conditions. No lessons learned from SARS.

Oh, I've been pissed at them for quite a while. Their b.s. traditional medicine/voodoo involving the trafficking, tortue, and killing of endangered species. All to create magical potions. Pangolins, rhinos, bile bears, etc. It's disgusting.
 
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RickyScott

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Oh, I've been pissed at them for quite a while. Their b.s. traditional medicine/voodoo involving the trafficking, tortue, and killing of endangered species. All to create magical potions. Pangolins, rhinos, bile bears, etc. It's disgusting.
Look, in name of multiculturalism, tolerant of monkey eye ball soup, but not when it effects my wallet and health.
 
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taserlaser

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Currently I’m at a larger academic centre. There’s been talks of cancelling routine follow ups. Ok, thats low hanging fruit. If we don’t have enough techs to treat, then we might be looking at extended hours (which can only be sustainable for so long).

In rad onc, we rely a lot on having full work ups before we start treatment, that if there’s a delay in the pipeline (DI, path, surgeries, etc), we might see a drop in consults/utilization as well. The questions we have for our linac in terms of what happens if they become contaminated/what happens if we have to treat contaminated people, those will he asked the same of the diagnostic scanners too. Will rads have some excess capacity that we won’t have? Perhaps. But there will probably be some delays. If a patient hasn’t started treatment, it might be that their start might honestly simply get delayed until they’re better in order to limit exposure to healthcare workers and healthy patients.

If the ICUs are full, then people might be scrounging for extra ventilators from ORs. Will ‘less urgent’ cancer surgeries get bumped for vents? Or will they be done via spinal/epidurals/bag-valve masks? What happens if the subspecialty surgeon has to be quarantined?

In a resource constrained environment but still time sensitive diagnosis such as cancer, I see an even bigger push to hypofractionate as many treatments as possible for an efficient use of resources, or to only treat curative patients in the extreme example. So practice patterns may change/respond appropriately. If physics gets hit, will plan QAs be sacrificed? Will more patients end up with 3D or even AP-PA plans by physicians, if planning support goes down? If your practice partner is quarantined, or if you are yourself, are you willing/able to cover increased patient load? Do locums rates increase for those willing to parachute in?

There are so many different levers/possible responses to such an outbreak, and what is ‘reasonable’ or even ‘feasible‘ depends on acuity if the cancer, severity impact of the resource shortage (treatment planning/delivery/adjuncts/diagnostics/etc). I find that it’s really hard to solidly predict how things will turn out without knowing exactly how bad things will be. But thinking about some of these questions ahead of time might prove to be a worthwhile exercise. Or not.

I am definitely eager to hear others‘ thoughts with regards to pandemic planning, and if they end up having to enact some measures in the coming months, how well they’ve been working.
 
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I’m starting to think about these things too. Better to over prepare than the opposite.

Biggest worry would be a chunk of therapists get exposed. Really not like a nursing pool to draft from for back up help.

Would really appreciate people continuing to post their thoughts. This is not something I feel prepared to tackle yet but want to start looking at strategies.
 
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One thing that we have going for us, at least so far as physics QA, treatment planning, etc... can be done remotely. So no rest for the quarantined docs and physicists!
 
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seper

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Still need a physicist in person to radiate IMRT QA.

One thing that we have going for us, at least so far as physics QA, treatment planning, etc... can be done remotely. So no rest for the quarantined docs and physicists!
 

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Still need a physicist in person to radiate IMRT QA.
Can be done remotely with some systems like sun nuclear and mobius. Techs load it into machine. Btw last time I checked mskcc doesn’t even do imrt qa?
 

Palex80

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The hospital administration just called out for every department/clinic to make 1 physician & 1 nurse available for an emergency anti-COVID taskforce 24/7. Which means that if we are overrun by patients coming into the ER with COVID-like symptoms, they are going to call up those physicians and nurses so they can take care of the COVID-suspected/confirmed cases. They will be then put on shifts and work at the ER (which will be expanded in size).
We only have something like 4 confirmed COVID-cases in my city, not Italy-like outbreak.

Posting this as an example of what measures may be undertaken when the situation escalates.

I guess we have to see how we are going to handle our regular workload with one physician & one nurse less now.

We have started talking with new prostate cancer patients with planned ADT and luminal A breast cancer patients to postpone their treatment for a few months in order not to have too many patients on treatment should disaster strike...
Disaster meaning either a) a large amount of our workforce becoming unable to work due to being quarantined for COVID or b) patients on treatment who need to continue treatment being exposed blocking the machine for hours because of all the decontamination measures you need to undertake.

This is a highly dynamic situation, noone knows what the situation will be like in 1 or 2 weeks from now...
 
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I think Dustin Hoffman's character in the movie Outbreak was actually a rad onc who drew the short straw of pandemic coverage.

You definitely want the rad onc triaging you in the "ED is overrun with severe illness" scenario.
 
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Lamount

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Point of debate.

If this thing goes pandemic (which seems almost unavoidable), is there really any sense in altering practice? It seems like it is worse than the flu... but not by all that much. Sure 1.4% mortality in confirmed cases sounds bad, until you consider the inescapable truth that there are likely many more people infected with mild symptoms who were never tested (as noted by Dr. Fauci). If this diffusely spreads throughout the community, as healthcare workers, we will likely all be exposed at some point... so why do anything different?
 

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Point of debate.

If this thing goes pandemic (which seems almost unavoidable), is there really any sense in altering practice? It seems like it is worse than the flu... but not by all that much. Sure 1.4% mortality in confirmed cases sounds bad, until you consider the inescapable truth that there are likely many more people infected with mild symptoms who were never tested (as noted by Dr. Fauci). If this diffusely spreads throughout the community, as healthcare workers, we will likely all be exposed at some point... so why do anything different?

3.4%?


It's a moving target obviously
 

taserlaser

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Yeah, the UK just said they estimate 20% if people to be off at work at once for a while. a lot of what I said was with more in mind. 20% while still not great might be manageable, but also depends on for how long.
 

Palex80

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Point of debate.
If this thing goes pandemic (which seems almost unavoidable), is there really any sense in altering practice? It seems like it is worse than the flu... but not by all that much. Sure 1.4% mortality in confirmed cases sounds bad, until you consider the inescapable truth that there are likely many more people infected with mild symptoms who were never tested (as noted by Dr. Fauci). If this diffusely spreads throughout the community, as healthcare workers, we will likely all be exposed at some point... so why do anything different?

I fully agree with you that healthy, rather young individuals have a quite low mortality rate. However mortality rates due to COVID rise up pretty sharply in the elderly. 70-79 year old have a mortality rate of around 8% and in over 80 year olds mortality hits 18%. That's a lot.
The figures must be however put into context too. Most deaths happened in China so far, so you cannot extrapolate them to other populations / different health systems.

My main issue is what the measures the state will undertake to put a brake on the virus' spread. People will die and at the end of this whole process a large percentage of the world's population would have come in contact with the virus. The measures undertaken are aimed at one thing only, in my opinion: To make sure the pandemic process goes step-by-step and not like a tsunami. Slowly growing numbers of infected, slowly growing numbers of dead and recovered patients are needed. It's not about eliminating the virus, that won't work. Why? In order to make sure our health systems don't break. Let's presume that 30% of the people may get it. Let's presume that you have a city of 1.000.000 people. This means 300.000 sick people. Let's presume 2% develop a severe form and need hospitalization for 2 weeks and let's say 1 out of 5 cases hospitalized need an ICU bed. Which city of 1 million people has: 6.000 beds in wards and 1.200 beds in ICUs available (next to all the other sick people who need a bed - I am not talking about elective hip prothesis cases)? Let's even assume that the 30% get it over the course of one month. That still means 3000 beds in wards and 600 beds in ICUs...

The problem that arises in our discipline is how we can cope with less resources (mainly staff) and sick patients.
If you present with symptoms, you are told to stay home until they fade away. If you come in contact with anyone who has had COVID or is being tested for it, you are quarantined home. All these "precautions" mean less staff at work.
The politicians where I live are considering shutting down schools and daycare next week. Who is going to take care of the kids?
 
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seper

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My mother-in-law better gets ready for some serious babysitting.
 
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3.4% with 40-70% of the world getting infected within a year. That’s well over 150 million deaths. In 1 year. The influenza comparison has been made to reassure people, this is nothing like that. It’s also all in a compressed time schedule so the hospitals will be overwhelmed. In Washington a 30 something and a 40 something died - that’s not nursing home ages. There is massive risk right now, maybe it’s over-exaggerating it a bit or maybe it’s not.
 
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Gfunk6

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From reading I’ve done there appear to be a few things that are uniquely American that may make outbreak worse here:

Lack of sick days - people can not tolerate taking unpaid time off

Not wanting to see a physician unless things are really bad due to high copays/deductibles

Lack of government autocracy to compel self quarantine (eg. see China and Vietnam)
 
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taserlaser

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I think I will email the ABR today and ask what if any their contingency plans are for the orals. That would not be good if some of those who are writing or if some of the examiners are quarantined.

Also, one unsubstantiated comment I read online states that NYU was restricting their physician travel. If that becomes common too then fml
 
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seper

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Just today, my hospital system suspended travel for any international conferences.
 
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Also, one unsubstantiated comment I read online states that NYU was restricting their physician travel. If that becomes common too then fml

One of my buddies at Columbia forwarded me the e-mail that they're not allowed to travel internationally or travel to any conferences foreign or domestic.
 

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From reading I’ve done there appear to be a few things that are uniquely American that may make outbreak worse here:

Lack of sick days - people can not tolerate taking unpaid time off

Not wanting to see a physician unless things are really bad due to high copays/deductibles

Lack of government autocracy to compel self quarantine (eg. see China and Vietnam)

Medicare for all.
 
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Of course too short notice to set this up for first week of May, but could be the straw that broke the camel’s back for the years ahead
 
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bluebubbles

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Medicare for all.

The austerity-driven NHS in the UK will get hit hard by coronavirus. No ventilators, no ICU beds, no luck.

Cancer still worst.

Show me a bread & butter cancer with a mortality rate of 5-15% for older adults and vulnerable populations [JAMA: 2762130] within 1 month of diagnosis.

If this thing goes pandemic (which seems almost unavoidable), is there really any sense in altering practice? It seems like it is worse than the flu... but not by all that much.

Mortality rates are 10-20x that of flu, across age groups. This is the sort of thinking that prevents large-scale action (no offense). Coronavirus will likely be worse in USA than China, unless spring & summer save us.
 
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RadOncDoc21

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The austerity-driven NHS in the UK will get hit hard by coronavirus. No ventilators, no ICU beds, no luck.



Show me a bread & butter cancer with a mortality rate of 5-15% for older adults and vulnerable populations [JAMA: 2762130] within 1 month of diagnosis.



Mortality rates are 10-20x that of flu, across age groups. This is the sort of thinking that prevents large-scale action (no offense). Coronavirus will likely be worse in USA than China, unless spring & summer save us.

not fair, why does mine have to be a bread and butter cancer if this isn’t a bread and butter virus. Also, one subgroup in the elderly... you really tied my hands!

Also my timeline is one month, hell in that case we should all be more worried about gunshot wounds to the head!
 
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Lamount

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Mortality rates are 10-20x that of flu, across age groups. This is the sort of thinking that prevents large-scale action (no offense). Coronavirus will likely be worse in USA than China, unless spring & summer save us.

I think you are misinterpreting the statistics and following the alarmist media narrative. When testing only floridly symptomatic people, the mortality rate approximates 2-3%. However, in S Korea, where they have drive through testing centers and have tested of 140,000 thousand people, mortality is considerably lower. "Out of reported 6,088 cases and 40 deaths, the mortality rate appears to be hovering around 0.65 per cent"

Given that approximately 80% have mild symptoms, countries with limited testing capabilities are only testing floridly symptomatic patients. Unless you test everyone with a chest cold (or better yet, EVERYONE as some likely have no symptoms at all) you have no idea what the true denominator is... and you are almost certainly enriching for the sickest patients. This would be like trying to approximate the likelihood of the average person dying from lung cancer by looking at lung cancer mortality in smokers.

If we assume that S. Korea's numbers are reflective of true mortality rates (and, these still may be an overestimation), Covid-19 is about 6 times deadly than the flu... While that's not great, it certainly isn't 20-30x worse.

Moral of the story: take a deep breath (and wash your hands frequently)
 
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taserlaser

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I think you are misinterpreting the statistics and following the alarmist media narrative. When testing only floridly symptomatic people, the mortality rate approximates 2-3%. However, in S Korea, where they have drive through testing centers and have tested of 140,000 thousand people, mortality is considerably lower. "Out of reported 6,088 cases and 40 deaths, the mortality rate appears to be hovering around 0.65 per cent"

Given that approximately 80% have mild symptoms, countries with limited testing capabilities are only testing floridly symptomatic patients. Unless you test everyone with a chest cold (or better yet, EVERYONE as some likely have no symptoms at all) you have no idea what the true denominator is... and you are almost certainly enriching for the sickest patients. This would be like trying to approximate the likelihood of the average person dying from lung cancer by looking at lung cancer mortality in smokers.

If we assume that S. Korea's numbers are reflective of true mortality rates (and, these still may be an overestimation), Covid-19 is about 6 times deadly than the flu... While that's not great, it certainly isn't 20-30x worse.

Moral of the story: take a deep breath (and wash your hands frequently)

I agree with most of the above. Biggest issue is having local hospitals and ICUs overwhelmed, in which case the mortality rate can dramatically rise for both COVID-19 patients and the regular inpatients due to inadequate resources. If we run out of PPE, then healthcare workers are at high risk of contracting illness and if they can't attend to patients, then all patients will suffer.

Personally I am on the fence of preparedness is not overreacting. I suspect the world still has a difficult few months at least ahead of it.
 
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Lamount

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This is about the same mortality rate as early papillary thyroid cancer.
Imagine this headline, and the public's reaction:

Thyroid cancer mutates into contagious illness

I'd take a deep breath, sure. But I might not do it in public again.

I am sure the mortality of thyroid cancer would be even larger if your denominator only included those with fist-sized primary tumors
 

Lamount

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You mean the alarmist WHO narrative? Not sure that's any worse than thinking the vaccine be here by the end of the year and everything will be back to normal in 2021...

It merely depends on how many people you test.

Test only those who present to the hospital with significant symptoms and you have a low incidence and high mortality... test everyone and your incidence increases and mortality decreases. Glass half full or half empty?
 
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Palex80

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I think you are misinterpreting the statistics and following the alarmist media narrative. When testing only floridly symptomatic people, the mortality rate approximates 2-3%. However, in S Korea, where they have drive through testing centers and have tested of 140,000 thousand people, mortality is considerably lower. "Out of reported 6,088 cases and 40 deaths, the mortality rate appears to be hovering around 0.65 per cent"

Given that approximately 80% have mild symptoms, countries with limited testing capabilities are only testing floridly symptomatic patients. Unless you test everyone with a chest cold (or better yet, EVERYONE as some likely have no symptoms at all) you have no idea what the true denominator is... and you are almost certainly enriching for the sickest patients. This would be like trying to approximate the likelihood of the average person dying from lung cancer by looking at lung cancer mortality in smokers.

If we assume that S. Korea's numbers are reflective of true mortality rates (and, these still may be an overestimation), Covid-19 is about 6 times deadly than the flu... While that's not great, it certainly isn't 20-30x worse.

Moral of the story: take a deep breath (and wash your hands frequently)


The same argument can be made for the flu. Many people go through it but do not get tested positive for it.
 
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I know of at least one large centre that’s cancelling all of their elective students across all depts in the wake of COVID-19, at least until end of June. We’ll see if other universities follow suit.
Insanity epidemic
 

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Maybe insane. But China has had their case numbers plateau as shown for the first time this week in part due to hyper aggressive measures such as this as well as aggressive testing.

The USA is behind
 
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RickyScott

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Maybe insane. But China has had their case numbers plateau as shown for the first time this week in part due to hyper aggressive measures such as this as well as aggressive testing.

The USA is behind
I am sure China is hyper aggressive, but absolutely don’t trust their stats.
 
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medgator

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Maybe insane. But China has had their case numbers plateau as shown for the first time this week in part due to hyper aggressive measures such as this as well as aggressive testing.

The USA is behind
You mean the same group of folks that lied about it to begin with are somehow being honest about their figures now?
 
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