ReachMD

Dr. Russell:
Once a patient is discharged from the hospital after battling COVID-19, the war they face with this disease may not be over.  In fact, many patients continue to experience long-term effects, which is why some institutions have formed clinics that are solely dedicated to caring for these patients, and how one such clinic is helping patients manage these devastating effects is what we'll be diving into today. 

Coming to you from the ReachMD studios, this is COVID-19: On the Frontlines.  I'm Dr. John Russell, and joining me is physiatrist Dr. Benjamin Abramoff, who's part of the team of the Post-COVID Assessment and Recovery Clinic at Penn Medicine in Philadelphia. 

Dr. Russell:
So to start us off, could you give us an overview of some of the prolonged symptoms that patients who have had COVID might exhibit? 

Dr. Abramoff:
Yeah, so in looking at kind of systematic reviews and other analyses of post-COVID symptoms, they really span almost every organ system:  neurologic, cardiovascular, GI in some cases.  And whether it's loss of taste and smell, whether it's numbness and tingling of hands and feet, tinnitus, some patients have more of one; some have more of the other.  The most common things we're seeing are fatigue, generalized fatigue,  cognitive impairment, often called brain fog in those who have persistent symptoms following COVID, and dyspnea or shortness of breath as the other common symptom.  

Dr. Russell:
So with that background in mind, I'd like to zero in on the Post-COVID Assessment and Recovery Clinic that you work in.  What was reason behind forming it, and what are your objectives day in and day out at the clinic? 

Dr. Abramoff:
Yeah, so we opened this clinic actually back in June 2020.  At that point, you know, initially, kind of in the early stages of the infection and the pandemic, April, May, we were seeing this as kind of the typical, critical illness, being in the ICU, possibly more of a post-ICU syndrome-type clinic, but what we were hearing more and more over the course of that summer was that even patients who weren't hospitalized and weren't critically ill initially were having these prolonged symptoms.  And at Penn, what was happening was patients were seeing pulmonology and different pulmonologists, and then they were seeing cardiology and different cardiologists, different neurologists, and they were seeing us and kind of getting often shuffled from one provider to the next to the next to the next because we didn't really know the cause of the symptoms; we didn't know what treatments may work; and when you've only seen one or two patients with long COVID, it can be can hard to really know what next steps there were.  And at that point there wasn't kind of this widespread discussion of persistent symptoms following COVID, so in that kind of context, we decided the patients at Penn needed a central home and some providers who would consistently see these patients moving forward to gain that experience, kind of start some of the research and studies and get the patients, if needed, to appropriate additional diagnostics, treatments, referrals to the specialists who ideally had expressed some interest in seeing patients with persistent symptoms following COVID, or long COVID, and so that we could start to develop some of that continuity.

Dr. Russell:
So as a primary care doctor, if I have someone in the area and I want to refer them to your long COVID clinic, what happens?  How are you evaluating them?  What are some of the key things that you're looking for to decide "I need to do some more testing," "I need to do referral someplace else," "I need to do some treatments"? 

Dr. Abramoff:
COVID is a really significant illness, obviously, for a lot of people.  Even if they're not hospitalized, it really can wipe you out so having some persistence of symptoms following COVID is not necessarily unexpected—to have some fatigue, to feel a little bit debilitated in terms of going back to your regular activities.  But if it persists longer than a month, and certainly longer than three months it is often useful to consider getting kind of that next-step evaluation. 

So the way our clinic is set up is we start with a one-hour, comprehensive visit.  At our one-hour screening visit, we go through a full course of their infection: When were they sick? When did they test positive? What initial treatments did they have? What symptoms did they have initially?  And then, obviously, the course and the progress of their symptoms:  How do those change over time? Who have they seen? What medications and treatments have they tried? Have they been vaccinated? What vaccine have they had? Did they get a booster?  And then in addition to kind of the typical questions:  what medications they're on, what medical comorbidities do they have, what's their family history.  We do some standardized screening measures, ask about their function, their pain level, spasms, GI symptoms, any cardiovascular symptoms. We do very comprehensive cardiovascular and pulmonary screening that would give us indications of whether they need more testing.  We do a standardized cognitive evaluation. We do a standardized psychiatric evaluation for anxiety, depression, and PTSD. We ask about sleep, headaches, tinnitus.  We ask them about interest in research studies.  So we do a very comprehensive evaluation, and then from there, based on how they answer those questions and what we find, we decide on next steps. 

Dr. Russell:
So you guys are about 17, 18 months into doing this, right?  So what you're doing, what you're learning, how has that evolved in real time, and what's different now versus the summer 2020 in the patients you're seeing? 

Dr. Abramoff:
Yeah. Early on there was a lot of patients with more diagnostic uncertainty.  They were not getting tested.  They were told to stay home.  Now almost every patient we see has had a positive COVID test or positive antibody testing.  Early on in the pandemic patients felt very dismissed that, "Oh, this is fine.  You'll be fine.  It's all in your head.  You're just anxious, because of all this," and telling patients it's all for psychiatric reasons.  And now I think there's much more widespread understanding and knowledge of these persistent symptoms, that they are very common following COVID, and so I think patients appreciate that they're not being dismissed. 

I think, unfortunately, we still don't have a one-size-fits-all type treatment. There's no medication that will make all the symptoms of post-COVID get better all at once, even though that's what many patients seek and desire. We really need to take it by a symptom-by-symptom format. And we've found through our experience and talking to other clinics and helping to come up with some guidance statements that there are things that tend to work for different symptoms. 

Dr. Russell:
For those just tuning in, you're listening to COVID-19: On the Frontlines on ReachMD.  I'm Dr. John Russell, and I'm speaking with Dr. Benjamin Abramoff about his experiences caring for patients at Penn Medicine's Post-COVID-19 Assessment and Recovery Clinic. 

So you talked about the evaluation process being roughly an hour telehealth initial visit.  After that initial visit, what happens next?  And as a physiatrist, how do you begin the rehabilitation process for your patients? 

Dr. Abramoff:
Yeah, so that's a great question.  So we try not to send patients from test to test to test, you know, "Oh, you're having some brain fog; let's get EEGs and MRIs of the brain."  "You're having some shortness of breath when working out and exercising; let's get a cardiopulmonary ex stress test, echocardiogram," you know, EKGs.  We try to kind of look at the patient holistically and give some treatments that can help in multiple domains.  Certainly, if there's red flag symptoms or things that are particularly concerning, we have referred patients for all of those tests, but really it depends on what symptoms they're having. 

So some of the more common symptoms, for example, like post-COVID fatigue, we look at all those different comorbidities.  Oftentimes patients aren't sleeping well or they have disrupted sleep or insomnia, so we'll treat that.  If anxiety is a big contributor to their fatigue or depression, we make sure we're addressing those issues.  For many of our patients, we've found a lot of success with a post-COVID rehabilitation program.  And this program is not going to be your typical exercise routine, progressive exercise program.  It's really designed to get patients back into activity but in a very slow and methodical way, and one of the key pieces of this is measuring patients' perceived exertion, making sure that they don't feel that they're getting to the point that they're putting a hundred percent of their effort in because oftentimes that can lead to steps back and can lead to small relapses, and finding that level of exertion, that level of exercise where they feel better afterwards and better in the next few days and not worse. And for some patients that starts off with simple stretching and strengthening routines, and other patients they progress more quickly.  Some patients who weren't hospitalized and have minimal persistent symptoms we can even do as part of a home program with some guidance that we provide. 

Dr. Russell:
So are you seeing any bounceback patients? Are you seeing patients who complete your program, feel a lot better, but then they start feeling worse again? 

Dr. Abramoff:
That happens.  Some of our patients kind of feel really bad initially after their COVID infection, and they just have a slow, steady, progressive improvement.  There's other patients who really their course is manifested with feeling well one day and then two days later have an exacerbation, and then "I feel better," for two weeks, and then “I feel worse again."  Usually, over time, the periods of feeling better last longer and exacerbations are less severe.  We will follow these patients, and we usually do follow these patients up periodically to make sure they are progressing and getting a sense of the course of their relapses. 

One thing we always stress to patients is try to identify triggers.  There's research that's shown that the most common triggers include overexertion and stress and anxiety, so managing those triggers often prevents some of those relapses down the road. 

Dr. Russell:
So you're 18 months into doing this.  Are there any patient stories that really stand out for you? 

Dr. Abramoff:
Yeah, that's a good question. So I think one thing to keep in mind is  minimal long-lasting symptoms can still be life-changing and really disruptive.  We've had a couple patients, and one that I can think of particularly, who all they had was persistent loss of taste and smell.  They felt fine, they had their normal energy, they could exercise, they could go to work, but they couldn't eat because nothing appealed to them.  They had lost a lot of weight.  It was leading to anxiety and depression because of their not eating and this loss of taste and smell, so even things like that that are very mild can be really disruptive. And it can be a very challenging thing to treat the loss of taste and smell, and we went through a number of treatment options until we got to a combination of therapies that did slowly seem to help.  Now, her smell is not back to a hundred percent, but it has improved to the point where she's eating more, and through some of our more psychological resources, it's not quite as distressing and depressing as it was before, and that element I think is important for us to address as well.  

Dr. Russell:
So certainly through all your work and all your training, you probably never envisioned that you'd be working at a clinic taking care of the aftermath of a virus.  So how has this experience changed you, and what are some of the lessons you've learned along the way? 

Dr. Abramoff:
So yes, you're right.  This is not  part of my career plans.  I was very focused on some spinal cord injury efforts.  I think the overlap kind of between what we do in neuro-rehab and what we do in post-COVID is that the patients have lots of multisystem, multiorgan dysfunction, and we have to look and address all those in a team fashion.  I think some of the lessons that have come out of this is when faced with something new, it's always important and it's very helpful to start counting, start documenting, start doing kind of consistent screening measures early on because we've learned a lot from our patients and how they have responded to treatments, and so the more you kind of objectively measure those changes and objectively keep track of the interventions, I think it's very helpful moving forward in kind of deciding the next steps.  

Dr. Russell:
Well with those closing thoughts in mind, I want to thank you, Dr. Abramoff, not just for joining me today but for doing this important work in helping patients recover from the long-term effects of COVID-19.  It was great speaking with you today. 

Dr. Abramoff:
Great speaking with you.  Thanks for having me. 

Dr. Russell:
I'm Dr. John Russell.  To access this and other episodes in our series, please visit ReachMD.com/COVID-19, where you can Be Part of the Knowledge.  Thanks for listening.