GENERAL PRACTITIONERS’ ROLE IN THE CURRENT COVID 19 PANDEMIC
Introduction
General practitioners (GPs) were the first line of contact for most medical conditions ranging from Simple Upper Respiratory tract Infections to complex diseases like Diabetes. Before the Covid 19 pandemic GPs were also the first contact point for most infectious diseases which they treated willingly, and without any spread of the disease to themselves, to the nursing staff or to other patients not diagnosed of such infection. But conditions have changed with the emerging Covid 19 infection, due to the high possibility of the virus being infected to the Doctor, the nursing staff and the other patients in their clinics. The only strategy is to clearly isolate the infection of diseased patients and to treat the other patients.
The role of General Practitioners is discussed under the following criterion:
- Identification of the legal position in connection with the Health Ministry directives regarding the general practice.
- Identification of potential Covid 19 patients, and directing them to designated government hospitals.
- A new appointment system via telephone consultation to treat all patients other than Covid 19 suspected patients.
- Upgrade the infrastructure facilities of the practice centres to minimize personal contamination and the spread of the virus from patient to patient.
- Availability of personal protective equipment, sterilizing chemicals and a proper sterilizing procedure.
- Purchase of newly required medical equipment.
- Identification of the legal position in connection with the Health Ministry directives regarding the general practice.
It is of satisfactory understanding that there has been no circular issued to close down the private practice of Medical Practitioners during this pandemic or such circular has been later removed as it is not to be found among the circulars issued so far.
Yet again, any dispensary that has been sealed by the police has been done taking into consideration the Quarantine act section 3(1)(p) {Quoted below} together with section 262 of the penal code {Quoted below}, for the offence of helping to spread disease.
“3. (1) The regulations made under section 2 may provide amongst other things-
(p) for prescribing the reporting to such officer or officers as may be named in the regulations, by medical practitioners and persons professing to treat diseases, of cases of disease treated by them.”
-Quarantine Act Section 3(1)(p)-
“262. Whoever unlawfully or negligently does any act which is, and which he knows or has reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of either description for a term which may extend to six months, or with fine, or with both.”
-Penal Code Section 262-
As such it can be safely concluded, that so far as the safety measures and precautions to spread the virus have been adhered to, there will not be legal repercussions on General Practitioners.
- Identification of potential Covid 19 patients, and directing them to designated government hospitals.
Patients should not enter the clinic without a prior telephone consultation. If the patient’s contact details are already available as a regularly visiting patient, then such patients should be informed to consult the doctor over the telephone before coming to the clinic.
Display a notice outside the clinic giving the General Practitioner’s personal telephone number advising them to contact such General Practitioner before coming for a consultation.
As there are community transmission and asymptomatic patients, we have to consider all patients as potential Covid 19 patients. Therefore, a patient may be asymptomatic, have mild upper respiratory tract symptoms with fever or may have the full-blown picture with high fever, sore throat, cough, vomiting, difficulty in breathing which is very severe and is not experienced by the patient before with a contact history as described below.
- A new appointment system via telephone consultation to treat all patients other than Covid 19 suspected patients.
During telephone consultations, if the patient falls into any of the categories listed below, these patients should not be consulted in person at the General Practitioner’s clinic, but should be given necessary medical advice and should be directed to a designated government hospital for treatment. They can call hotline number 1390 where the government will arrange transport to the hospital.
- If having symptoms of fever, upper respiratory tract infections, body pain, headache, vomiting, rhinorrhoea, or any other symptoms suggestive of Covid 19
- Patients with any contact history with a Covid 19
- Patient with any history of foreign travel in the recent past.
- A patient who has been quarantined by the government. (Home quarantined patients)
- Patient presenting within 14 days of return from a quarantine centre.
- Patients with medical emergencies. It's best to avoid medical emergencies as our aim should be to treat only chronically ill regular patients. General Practitioner must give timely appointments and may not be able to handle patients all the time.
After excluding all the above patients, others can be given time appointments with 15-minute gaps between appointments. Two patients could be allowed at a particular time to the clinic, one patient in the consultation room while the other patient is obtaining the medicine and advice from the practising nurse/pharmacist.
Alternatively, the General Practitioner also could do an extensive telephone or video conversation with their regular patients as a comprehensive consultation, as the General Practitioners are quite aware of the medical history of their regular patients and is at a position to identify any irregularity if so connected to any symptom that does not come across in their regular illnesses. For any illness recognized other than Covid 19 or even a mere suspicion of Covid 19, the General Practitioner can prescribe the course of medicine also via the same telephone or video consultation, if possible, and could arrange for the prescribed medicines to be collected from his/her Clinic. The General Practitioners can also charge a reasonable consultation fee for such telephone or video consultations, and that could also be collected by the practising nurse/pharmacist along with the charge of the medicines. By following this methodology, patients would not be gathered in the Clinic and also there will be the least confrontation with the practising doctor and other staff.
General Practitioners in such case, will have to stock up the required medicines for his/her patients and dispensers appropriately.
This could also further be expanded, if in any case, the General Practitioner needs to investigate further via any laboratory tests, the patient can be advised to take the test and to send a photograph of the report through some personal social media such as ‘Whatsapp’ or ‘Viber’ so that the General Practitioner can observe the report and follow to prescribe medicines as stated above for collection.
- Upgrade the infrastructure facilities of the practice centres to minimize personal contamination and the spread of the virus from patient to patient.
The medical centre should be upgraded before commencing to see non-Covid 19 patients. Ideally, the practice centre should consist of a consultation room, a patient waiting area, pharmacy, emergency treatment area and an area for wound dressing. If you are doing blood withdrawal for tests, that area should be completely separated from the other areas. All the clinic areas should have negative pressure ventilation, which could be achieved by fixing high capacity extractor fans in the appropriate areas. The extracted air should be heated and released to the atmosphere above the roof level. Negative air pressure will minimise the chance of contamination of the virus from person to person inside the clinic. Air-conditioning should be discouraged as this will trap air at a low temperature increasing viral viability and spread.
Please find below a link to an architecturally designed model medical unit plan for your perusal.
[This link will be updated later]
- Availability of personal protective equipment (PPE), sterilizing chemicals and a proper sterilizing procedure.
The practising doctor and all support staff should be wearing full PPE, as even though we have excluded potential Covid 19 patients there can be asymptomatic carriers. PPE should include the overall with headcover, apron goggles, surgical mask/N95 mask, gloves, surgical cap, shoe covers and boots. Locally turned out and imported PPE is becoming freely available in the market now.
You could also visit the following link to learn the proper technique of donning and doffing.
[Link] https://www.youtube.com/watch?v=Ca66dpjPWZc ,
https://www.youtube.com/watch?v=bZA424c5sWQ
The separate area should be available and all precautions should be taken when removing the PPE to avoid the possibility of contamination during doffing.
The best option would be to sterilize gowns in a washing machine capable of heating up to 90 degrees centigrade. We should urge the government and other relevant authorities to arrange for General Practitioners a tax-free concession for heat drying washing machines, as then it would be affordable sans any difficulty.
If a heated washing machine is not available, the best option would be to soak the gowns in a covered bin containing sodium hyper chloride and boiling water. Though normal autoclaving procedure needs 15 minutes of sterilization at 120 centigrade under pressurized water vapour, Corona viruses cannot withstand temperatures above 50 centigrade according to research1. As such soaking in boiling water and later washing with detergent would be the best option but no research is available to confirm the same to Covid 19.
- Purchase of newly required medical equipment.
In future, reliable rapid diagnostic kits will be available to detect both IGM and IGG antibodies. If patients could be screened at GP level, IGG positive patients could be identified and listed as safe patients to see in future. If GPs are to perform this test, they should perform this only on non-Covid suspected patients for screening purposes only. A separate isolated room as mentioned earlier should be used for blood withdrawal.
It is advisable to GPs to purchase heating and drying enabling washing machines for sterilizing purposes. Adequate stocks of hand sanitizers containing Isopropyl alcohol should be available at all times. Hand sanitizer should be available, both at the points of entry and exit to the Clinic and patients should be thoroughly advised to use them when entering and leaving the premises. It should be made a must for all patients to wear a face mask within the premises.
Adequate stocks of PPE should be available at the clinics.
In summary, GPs’ main role would be to exclude Covid and potentially avoid Covid patients and thus treat all other patients in safe protective environments.
Acknowledgements
Miss Dilani Jayatilake Attorney at Law for her expert legal advice and Chayanka Hettige for assistance in the initial draft.
Reference:
- Chan, K., Peiris, J., Lam, S., Poon, L., Yuen, K. and Seto, W., 2011. The Effects of Temperature and Relative Humidity on the Viability of the SARS Coronavirus. Advances in Virology., 2011, pg.1-7.[online] Available at: <https://www.hindawi.com/journals/av/2011/734690/> Accessed on 9 April 2020
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