May 28, 2025 • 39 mins
Are You Prepared for the Next COVID-19 Summer Surge?
Five years after the term “coronavirus” became a part of every household’s vocabulary, the virus continues to evolve – and so does our understanding of how to treat and test for COVID-19. Returning to share her expertise on NP Pulse: The Voice of the Nurse Practitioner®, infectious disease expert Dr. Ruth Carrico urges us to think about COVID-19 from both a personal and population vantagepoint – and shares her guidance about how to approach a likely surge in cases of the coronavirus this summer.
This podcast is made possible by Pfizer.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Sophia (00:12):
From the American Association
of Nurse Practitioners, I'm your host,
Dr. Sophia Thomas, and this is NP Pulse.
The voice of the nurse practitioner.
Welcome to NP Pulses, AANP'S
official podcast, bringing you
(00:34):
unique nurse practitioner voices
and expertise on issues that
matter to NPS and our patients.
Thank you for joining us today,
and thank you to Pfizer who
is sponsoring this podcast.
With the arrival of summer, many
of us are looking forward to a
vacation and imagining ways to
stay cool and out of the heat.
But just as we're reminding our patients
(00:56):
to take care of their skin in the sun, we
also need to remind them about something
they may not have on the forefront of
their mind, the likely summer surge of
COVID-19 and how to stay safe if the
disease spreads like we think it may.
Ruth Carrico is our returning
guest today on NP Pulses.
She's a professor, a family
(01:17):
nurse practitioner, and an
infectious disease expert.
We will be discussing how to consider
COVID-19 on both the population
level and how the disease affects
our patients as individuals.
We'll also be talking about the clinical
presentation of COVID and the unique
abilities nurses and nurse practitioners
(01:37):
especially have in preventing the
spread of this disease and in keeping
our patients healthy all year long.
Welcome to NP Pulse.
Thanks.
It's a delight to be here.
Ruth, we've had you as a guest before
and your expertise is always so
appreciated, and I know our listeners
really appreciate your knowledge
in the area of infectious disease.
(01:58):
But for those who maybe haven't
heard our interviews before,
please reintroduce yourself to us.
Ruth (02:04):
Be delighted.
My name is Ruth Ricco.
I am a family nurse practitioner
based in Louisville, Kentucky, so I
have the opportunity to work with a
variety of healthcare organizations,
industry, local, federal government,
international organizations as part of
my work with infectious diseases, and
(02:24):
I spent a good portion of my career.
At the University of Louisville
in the School of Medicine and the
Division of Infectious Diseases.
And so now I enjoy an adjunct
faculty position there and and
maintain a clinical practice in a
nurse practitioner driven clinic.
So that's exciting.
I learn from my colleagues every day.
I'm
Sophia (02:43):
sure you do.
And then in the area of infectious
disease, there's so much to learn.
And certainly we've had a prior
conversation about COVID-19
COVID has been around now for.
Five years, and I'm sure it's
gonna be around for a long
time in its various forms.
Speaking about COVID in general, how
has the infectious disease community
(03:04):
come to understand the disease now
versus at the beginning of the pandemic?
Ruth (03:10):
A, as you mentioned, five
years, it seems like a lifetime ago.
I was telling somebody the other day
that now in my life, I think of things
before COVID or B, that's my bc Yeah.
And then after COVID.
Now that's my ad. Because you're right
when COVID then exploded onto the scene.
It changed everything.
It changed all of our interactions
(03:32):
on the, as part of general public.
It changed our knowledge about medicine
and about the provision of healthcare
and availability of healthcare.
So much changed, but with respect to
actually understanding this virus.
When we first saw that initial, that
Wuhan, or what we often call that
ancestral strain, the original strain
(03:53):
of this particular coronavirus,
it presented in so many different
ways and it really flipped upside
down many of what we thought.
We knew many of those things we thought
we knew about infectious diseases.
Testing, recognition, treatment.
And when I look back and I think, oh
my gosh, I always thought before, if
(04:14):
you present with a respiratory illness,
you are going to present in these ways.
Or if you have pneumonia, you're
going to present in these ways.
But so much changed.
It broadened our horizons.
And I guess respect for how ferocious.
A new virus, a new illness can be,
and over time, as we have seen then
(04:36):
the mutations that have occurred
with this particular coronavirus,
we have continued to learn.
We've adapted not only our, our
approaches on recognition, treatment,
testing, planning, that's probably
the biggest thing, the biggest
change that I've seen in helping our
patients develop a plan and how we
(04:57):
as providers need to develop a plan.
For this coronavirus, and exactly
as you said, this now is part of
our ecology, that we are learning
how to deal with a new coronavirus.
We've had coronaviruses, we've
recognized them for years.
We've adapted, learn to address
(05:18):
them in a variety of ways.
Now we've added a new
coronavirus to the mix.
This one certainly is different.
We have not had a coronavirus that had
this level of ferocity with disease, but
it's done the same thing that the other
coronaviruses is done and that is mutate.
So it is continued to change.
(05:41):
So it's an important, I think,
reminder for us that as we
watch what is happening with.
This coronavirus, we are gonna need
to stay on our toes and continue to
monitor and see what changes it makes.
And it's a reminder that
microorganisms have two jobs.
Stay alive and multiply, and they do
(06:01):
that by adapting just like we adapt.
We're gonna have to keep an eye on what's
going on and be in very close partnerships
with public health, clinical practice,
laboratory sciences, industry as we look
at what types of VIR vaccines or antiviral
agents we have available and be ready.
Sophia (06:20):
Absolutely.
And right now I get my weekly virus
report for the area that I live in.
And right now what I'm seeing in my area
is of all the viral infections, COVID
has been about one to 2% of the viruses,
but I've heard that with summer coming
up, we're expecting a spike in COVID-19.
Have you heard this as well?
Ruth (06:40):
Yeah, and I think historically
what we've seen the last several
seasons, we've seen that instead of just
having one spike a year, like we, we
may see with other respiratory viruses
like flu or even RSV with, with COVID.
With this Coronaviruses,
we've seen two, two spikes.
We are gearing up with the anticipation
(07:00):
that in the summer we will see just what
we have seen in the last several years,
that kind of bimodal approach one, one
approach in in the colder months, and then
now one approach in the warmer months.
So we haven't seen this virus land
in a seasonal once a year pattern.
(07:21):
I can't say, and I don't think
any of us can say with any
certainty that will happen.
But our approach now is, okay, if
we're gonna see this twice a year,
and it is a respiratory illness,
meaning it's a, something that
occurs with breathing and fortunately
that's what all of us do, right?
And so we have to realize then
that something that that makes
(07:43):
its presence known regularly.
That means that we are all
going to be exposed regularly.
We are all going to continue to breathe
regularly, and that means we have
to be thinking about how do viruses
work, how does our immune system
work, who might be at greatest risk?
And then develop a, not only a
(08:04):
public health plan of action.
That is looking at what
happens across our population.
But one thing that I think all of us
have learned in that is that our patients
now are saying, yeah, I understand.
You know what, how we look at this on
a population level, but what about me?
As an individual.
Now, how does this impact me?
(08:25):
So we're having to now learn how
to juggle two things, what it looks
like on a population basis, but
then bring that down to the level
of the patient is our end of one.
Instead of an in of a hundred
thousand like we were looking at
previously, what's a challenge now
for us on the clinical side to make
it real and relevant to our patients.
Sophia (08:45):
Yeah.
And then clinical presentation
there, there's so many
different ways COVID presents.
It could just be a sore throat
or it could be a common cold type
symptoms or what are you seeing
as far as clinical presentation?
Ruth (08:59):
I think previously we thought,
oh my gosh, if somebody tells me they
lost their sense of taste or smell,
then I recognized that early on.
Now COVID looks like many other
respiratory illnesses and just like
people are different, hosts are different.
We all don't complain of the same things.
We're having to figure out what our
(09:20):
approach is gonna be when we have any
patient that presents with respiratory
symptoms and be particularly attentive
when we have patients that have
risk factors that place them at an
increased opportunity that they may
not be able to muster that rapid
immunologic response to protect them.
(09:41):
So now we're thinking,
oh my gosh, here we are.
We've got a respiratory season.
Or not, we have respiratory symptoms.
How do we approach it?
So it really means that we as
clinicians need to up our game a
little bit and think, okay, what
is gonna be our approach, our
plan of action with our patients?
(10:02):
And then how do we have a plan in mind?
And then how do we convey that plan to our
patients so that they have information?
So that they're in charge of their
healthcare, certainly, but we're
giving them the information they need
to make the best decision in their
minds for their care, and in many
instances, the care of their families.
(10:24):
We're seeing so many mul,
multi-generational households now
where people are living together.
People are interacting in a different way.
So what goes on with one
individual doesn't just impact
them, but it may impact children.
It may impact.
Their, maybe their mom
or dad, or sometimes even
grandparents that live with them.
So we're having to think really
(10:44):
differently now, and we're having to
help then our patients think really
differently about how not only COVID,
but other respiratory illnesses may
represent new risks to them and their
ability to live, work, and play safely.
Sophia (11:00):
And so for example, if a
20-year-old otherwise healthy appears
to the clinic and they have clearly
a viral upper respiratory infection,
normally we'd say it's viral.
It's nothing we can do, treat it
symptomatically, but maybe we need
to consider that person's living con
conditions and do they live with a
grandparent who may be at a higher risk of
(11:23):
complications if it truly is COVID right.
Ruth (11:26):
Yeah, and I think when you mention
that you really bring out what I think
are some unique skills that we as nurses
have that we tend to wanna understand,
not only the medical side, but we
understand the social side of care.
Now, the third stool in that part
of that triangle is we also need
to understand local epidemiology.
(11:47):
So we are looking at the patient
and their physical presentation.
We are looking at their social
issues, and now we're looking at
what is going on in the community.
And we're trying to pull all of
those things together and then try to
figure out can we decipher this Now,
are we gonna be right all the time?
All the time?
Absolutely not.
(12:07):
But this really is the underpinning
behind why when we talk about vaccines.
That we are hearing so much about
co-administration because if we are at
a period of time where it may be flu,
it may be RSV, it may be COVID, we don't
really know which one of those are,
but I used to think I could predict.
But now if I don't have a magic eight
(12:29):
ball or something else, you know that my
crystal ball that can help me forecast
the future and I'm not really good at
forecasting even if I do have those tools.
Now I'm trying to think, okay, what
might that patient be at risk for?
And then do I wanna take a guess, even if
it's an educated guess, or do I wanna tell
my patient, okay, here's my situation.
(12:51):
I want to make sure that we have,
we have the information so that you
can make best decisions for you.
We have these three viruses that,
that we know are circulating at some
point in our community or maybe in
another community where you may be
visiting or vacationing or whatever.
I can't tell which one you may be
(13:12):
exposed to first or at all, but I know
that I can provide you with vaccines
that may help protect you against the
worst outcomes for all three of those.
Now, that may mean.
Three injections, three
vaccines at the same time?
No.
We've got data and recommendations
from CD, C that will say, go ahead
while you have the patient there.
If they're at risk, go
(13:32):
ahead and give 'em all.
But I've gotta, I've gotta make
sure that my patient understands the
why behind my recommendation, and
they may elect to do that or not.
But what I wanna do is make sure
that they've got the information and
they understand the why behind this.
So they then are able to
make the best decision.
And if they decide that they don't want.
(13:53):
All three at the same time that I can
say, okay, here's some data that we may
use, and I don't know whether it's gonna
be on target, but it may be something
to help us with those decisions and
then come up with a plan of action.
For example, I'm, they may
say, I don't want this vaccine.
Maybe I don't want flu vaccine now.
Then I can think about, all
right, what about a flu antiviral?
Let's think about our plan.
(14:14):
Are you gonna be able to test quickly?
Are you gonna be able to reach out to me
quickly so we can figure out what to do?
So maybe it's COVID that
they want to delay vaccine.
Then let's think about are you, are
you a candidate for this antiviral?
Do you meet then that eligibility
criteria with respect to underlying
health condition and so forth.
(14:36):
Then we make a plan for that
to happen because none of
these things happen magically.
Like all things in our job, we have
to make a plan and then see how the
patient then can implement that plan.
Sophia (14:48):
Exactly.
And I wanna get into treatment,
but I wanna go back to testing.
You mentioned testing.
We've come a long way as far
as our COVID to 19 testing.
What is the latest on testing?
Ruth (15:00):
I think we still have a
variety of test methodologies.
Our PCR testing is still the gold
standard, but we now also have
molecular tests that you can purchase.
In fact, it's funny, I, for
Christmas for my kids, everybody
got a molecular COVID flu test.
Most people, that may not be the first
thing you think about as a Christmas
present, but I'm like, okay, I want you
(15:22):
to get something that is easy to use.
And in these, I bought
it off, off the internet.
So you can get tests everywhere.
You can go to the drug
store and get tests.
You may be able to get an antigen
test, which is not gonna be quite,
you know, as, as sensitive and
specific as a molecular test.
But if you, your patient knows how
(15:43):
to use them appropriately, they
know how to use them and know when
to use them, then it may give you
enough information to, to make some
reasonably, uh, correct decisions.
But I think you know, it, it.
Goes back to what is your,
what is available for you?
How likely or inclined are you to use it?
(16:06):
I've talked to patients, they'll
say, yeah, I've got a test,
but you know, I don't wanna
use it unless I really need to.
When do you really need to, you need
to use it when you are symptomatic.
Might it be wasteful in terms of, oh
shoot, I used and it was negative.
Yeah, but then we know probably what
you don't have, and then that helps
us then with treatment decisions.
(16:26):
So.
Having these kinds of discussions with
patients, knowing you have a test, looking
at the date, the expiration date isn't
going to be a test that will work for you.
And then having those down
to earth, and I think really
practical, pragmatic discussions.
With patients.
I think really, again, bring home
(16:46):
the importance of what we do.
As a nurse practitioner, we have those,
all right, how is this gonna work?
And we get very operational on
the side of our recommendations.
Are they able to do this?
If somebody says, I would love to
have a test, but I can't afford it,
what might our recommendation be?
What is our relationship
with our local public health?
(17:06):
Is there a way that we can identify.
Testing for them?
Do they have health insurance coverage?
Is this something that they can provide?
We're doing a lot of that investigation.
All of these activities that we
don't bill for that take our time.
But I think what makes us better at
what we do and at, at the end of the
day, we want our patients to view us.
(17:28):
As a resource that is credible, something
that they can, somebody that they can
trust, somebody that if they don't, if
we don't know the answers, that we feel
very comfortable saying, I don't know.
I've got some people, I've got
some friends that I can call.
Or I've got some somebody that
I know that I can reach out to.
Let me get back with you.
And then through many of our
electronic medical records, we have
(17:48):
the communication through the portals
and that we can reach back and then,
and continue that communication.
There are a number, and back to your
original question about testing.
There are a number of opportunities.
We have tests that are extremely
accurate and some that are not quite
as accurate, but they can give us some
(18:08):
good basic information as we need,
and then making sure that our patients
have access to testing, that they
know how to perform the test, if it's
gonna be something they do at home.
If they're not gonna do it at
home, do they know where to go?
Can they afford testing?
And then encouraging them to use
what they can within their resources.
And if they don't elect to test, then
(18:31):
how can they still stay in contact
with their healthcare providers?
We can then help them
with future decisions.
Sophia (18:37):
Yeah.
And so once testing has been completed,
if a patient tests positive, now
what are our treatment options?
What are, what do we talk about
when we talk about a plan of care
for that individual with COVID?
Ruth (18:50):
I think, and this is a great
discussion, that's something we
must have with our patients upfront.
And we look at their
underlying medical conditions.
If I have a patient that has a number
of comorbid conditions, that they
are immunocompromised and maybe a, a
patient that is undergoing active chemo
chemotherapy and they are seeing an
oncologist and maybe they're seeing
(19:11):
an NP for their primary care, this is
a good discussion for us to have then
with their oncologist to say, in the
event they test positively for COVID.
How do you wanna handle
this with their treatment?
Is this somebody that you want
to be seen in the hospital?
Is this gonna be a candidate
for, for an infusion?
Is this somebody that you may be
(19:32):
thinking about convalescent, plasma?
I. Where are they in this spectrum?
Or it may be somebody that you're
gonna say, all right, let's look
at your comorbid conditions, and we
have a couple of antiviral choices.
Do you meet criteria based upon
your underlying medical condition,
based upon your medication history?
What are you taking Now?
(19:54):
Is one medication go going
to need to be discontinued?
Or will a medication that you're on
prevent you from having one or the other?
Of the antivirals.
Maybe you've got kidney disease, liver
disease, and may not be able to take one
or the other or any antiviral medication.
These are the types of
conversations we have.
(20:14):
Number one.
Where does the patient sit in terms of
their willingness to have medication?
Number two, which medication or medication
pathway makes sense for them with their
underlying medical conditions and how
does the patient feel about that pathway?
Number three, where can
they access medication?
(20:35):
Now I'll, let me share
just a personal experience.
This past flu season, I had my influenza
vaccine, but I developed influenza A and
let me tell you, I was sick, but I'm one.
I told you everybody in my family
had a test and I also had access
to medication very quickly.
(20:55):
If I had not had access to medication
very quickly, if I had to go out
and think about where am I gonna
get it, who am I gonna call?
I was, I felt so badly that I
don't know how well I would've done
had I not had a plan of action.
I. And the thought in my mind, I thought,
oh my gosh, older adults or people that
have underlying medical conditions that
(21:17):
haven't outlined this plan of action.
I can understand why people can do
poorly very quickly, but really, I
guess all of us need that, that that.
Experience that really underscores
the importance of having
a plan and being prepared.
I certainly experienced that this fall,
so it, it just reinforced then with
(21:40):
me, what do I need to tell my patients?
And then this is a story
that I share with them.
This is why I want you to be prepared,
because I don't want you to feel as badly.
As I did without having something
then that, that you could go to.
So, you know, thinking about how they will
access medication, what type of education
do they need before they take it.
(22:01):
For example, they may take an
antiviral that causes them to
have an altered sense of taste.
They may think, oh my
gosh, something's wrong.
And then they may stop it.
I've gotta prepare them.
And if your patients are like
mine, they don't remember
every single thing I tell 'em.
That oftentimes I'm on the too much
information side, but I've gotta make
sure then that this is something in
(22:22):
writing and I've gotten so that I'll
tell my patient, okay, here's our plan.
It's on this paper.
Maybe the after action summary.
If you're like me, this is gonna be on the
floor of my car or the bottom of my purse,
and I'm not gonna know where to find it.
So I want you to take a picture of it
because you'll probably never lose your
photographs in your cell phone, right?
None of us are ever gonna lose
our pictures, so get 'em to take
(22:44):
a picture of that and then they
can go back and find it, or we
can go back together and find it.
In the event we have to regroup and
think about what our plan of action was.
And the fact that it's a picture, I think
also gives it a level of importance.
To that patient because as they're
scrolling through their pictures, they're
gonna scroll through that and they're
(23:05):
probably gonna stop and say, what is this?
They'll read it again, and then
that may be fresh in their mind.
The picture thing.
Sometimes there's a method behind the
madness, I think, in our approach.
Sophia (23:14):
Exactly.
And I've recommended taking a photo of
lots of things to my patients before.
When you talk about the oral antivirals
for COVID, what are some special
considerations that we need to
take into account when prescribing?
Ruth (23:28):
The first one, I think that that
comes to mind with the antiviral with
COVID is gonna be Norvir Ritonavir,
the combination drug that where we
have FDA authorization and we have
some pretty consistent guidelines.
We also have Moira Vir that
is still available under ua.
That is an option, and that if our
patients are not able to tolerate VIR or
(23:49):
ritonavir, then we do have an alternative.
So we have something then to provide.
To our patients, the vir ritonavir,
that is a, a drug where we need to
be thinking and actually both of them
getting, giving them quickly enough,
you know, ideally within the first few
days, within five days after the onset
(24:10):
of symptoms, the sooner the better.
So if we can even be sooner than five
days, then that's what we wanna do.
But we've gotta know then what
is the medication history.
There may be some drugs that will
react poorly and, and when you take
then this CYP three a issue, then.
We will have then potential to potentiate
(24:31):
some current medications and we may
not be able to give them that drug.
So, you know, having an
alternative is important.
If we have patients that have
altered renal function, we may
have to adjust their dosing.
So we need to know then which one
of those dose packs to prescribe.
So there's some education we need.
So it's a good reminder for all of us.
(24:52):
Make sure that we've.
We've got then something of if other nps
are like me on my cell phone, I've got the
ability to look at one of the apps that
can help me look at drug interactions so
that I can very quickly then follow up.
But if my patient can't always
remember what drugs they're on, if I
don't have access to their electronic
(25:13):
medical record, maybe I'm out away
from my computer, it may be a little
bit more difficult for me to connect.
And look at their electronic
medical record and look at
their medication history.
That's why I always think it's
better to make that plan of action
beforehand so I can tell my patient.
Now we talked about this and where did you
stand with respect to antiviral treatment?
(25:35):
All right, that we know that we've
got right now two, two options
for this outpatient treatment.
I need to make sure then that
we're looking at the one that
is going to be safe for you, so.
Let's look up your medications.
Do you have your list of medications?
What did we talk about?
Did you take a picture of that plan, pull
it up and then read to me what it says?
(25:56):
The patient then feels, continues to
feel like they are the driver of their
care, and that's what we want, right?
We want our patients to to be in charge.
We are supporting them and
supporting their decisions.
And again, because there's gonna be
this back and forth conversation if
that happens when somebody feels badly.
As I mentioned, like I felt with
(26:16):
flu, I'm not thinking as well.
My, my thinking may be a little bit foggy.
Maybe I can't find my pictures or I just
don't feel enough well enough to do that.
So the more that we can do upfront, the
more that we can help that patient take
care of before they need that information,
I think the better off we're all gonna be.
Certainly the happier the patient
and the provider are gonna be.
(26:37):
In the midst of those conversations.
Sophia (26:39):
So you would say, as a primary
care provider, as I am seeing my
patients for their routine care, I
could mention we are perhaps going to
be seeing a spike in COVID this summer.
If you happen to get COVID-19,
let's talk about how we may treat
you and let's look at our treatment
considerations ahead of time to get
(27:00):
a plan in place should that patient
actually test positive for COVID-19.
Ruth (27:05):
Absolutely, and I think
this gives me a chance also to
talk not only about the vaccine,
but about the antiviral as well.
I'll usually tell my patients that
respiratory viruses like this have
a fairly short incubation period.
So that means once you're infected, you
immediately then have the this virus
that is replicating inside your body.
(27:27):
If you have antibodies that are
circulating around your body,
then you immediately, it's here.
You've got the home invader.
You've got somebody to
start the fight, right?
Then.
If you don't have those circulating
antibodies, then your body has to
recognize, and then your immune system has
to begin firing from the very beginning,
(27:48):
so you're already behind the wave.
So this is why we want to give you vaccine
to keep those circulating antibodies and
why we have, for example, our patients now
with those that are 65 and older, those
that have underlying health conditions,
they may be recommended a second dose.
(28:08):
Of a vaccine that then maintains
those circulating antibodies.
So they always have those soldiers
that are roaming around ready and on
the watch for these invading viruses.
So it gives me the chance to give
them the why behind vaccines.
Now if you do not have those circulating
antibodies, or even if you do, I
(28:30):
wanna be able to provide you then with
this antiviral agent, because you may
need those extra soldiers because.
That has that short incubation period.
We don't have a whole lot of
time to get this medication, get
these drugs into your system.
So that means you've gotta test
as soon as you feel poorly.
(28:51):
So we know what are we working with.
If it's COVID, then call me.
So I've gotta talk with them about what
happens if it happens on a Saturday night.
How do you reach me?
What about if it's on a
holiday, how do you reach me?
And then we have these
types of discussions.
So that patient has a plan
and now let's write it down.
Let's take a picture, put it in
(29:12):
your cell phone so you can call me.
And it's the same approach whether
we are talking about COVID or flu.
So I'm influencing then how that
patient thinks about respiratory
illness and how they think about.
How am I a participant
in my own healthcare?
So I'm reinforcing, I'm, I'm using
(29:34):
these as examples to, for a number
of reasons, not only for COVID.
Certainly COVID is a, is a great example.
But I think what we wanna do
with all of our patients is
develop a sustainable approach to
healthcare, to preventive care.
And so when they say, oh, now
I get it, I understand why.
(29:54):
I am concerned about.
Diseases that are
transmitted by breathing.
I understand the role of vaccines and
if I have a patient that chooses not
to be vaccinated, I remember that's
their right to make that choice.
I want them to make a choice based on
accurate information, but I'm gonna
support that patient regardless.
(30:14):
So I'm gonna say.
You.
You don't wanna be
vaccinated at this point.
Now let 'em know now because I like
you, because you're important to me.
I'm gonna ask you again.
I'm gonna ask you next time.
But because you've elected not
to be vaccinated, I don't want
you to think that's your only
option in the fight against COVID.
So now let's think.
What about taking an antiviral
in the event you become ill?
(30:36):
Then again, does that patient meet
all of the eligibility criteria?
What?
What is our plan of action?
And then I'm letting them know that
I have respect for them, even if
their choices don't agree with mine.
I still respect what they are doing, and
I'm trying then to understand and provide
the patient with the best outcomes and
(30:57):
the best information as we move forward.
Sophia (30:59):
Absolutely.
And I think a special consideration would
be now that we have these home tests
available like we never have before,
our patients will be testing at home.
And I think one thing we should
consider is that when a patient
calls my office and says, I tested
positive for COVID-19, I would like
to be treated, that we don't give them
(31:21):
an appointment in two, three days.
We, we really need to try to.
Provide them access to treatment
immediately, whether that would be
our predetermined plan, and we just go
ahead and e-prescribe or call in that
medication for the patient or get them
right into the office for evaluation so
they don't have to wait to be treated.
(31:41):
Because as you said, the sooner we start
antivirals, the better off they are.
Ruth (31:47):
You made several critical points
that I think I are vital for us to
think about, and that is what is
our role as the clinician in making
sure that our office is part of our
team now spend, get to spend, have.
We don't have the luxury of spending a
lot of time with each individual patient.
(32:09):
So this is a team effort.
So from the time they put their foot
across the threshold, entering whatever
clinic, whatever, wherever our office
is or our healthcare facility, the
minute they walk into our environment,
that's when we need to engage.
Whether they are talking with a person
that is checking them in, whether they're
talking with a medical assistant, or
(32:30):
if we're lucky to have pharmacists and
other others in our practice, everybody
needs to, they need to know the drill.
Here's the assignment and everybody
needs to be operating in lockstep,
and this really is our chance to talk
with our office and make sure that.
How does everybody feel about vaccines?
How does everybody feel about antivirals?
(32:53):
We realize that the beauty of our
country is that we have many, we have
diversity and thought in action, and
that is a richness that we have in
our country and in our communities.
So we need to understand where does
everybody, what are the thoughts?
That, that we need to decide then what
is our plan of action together, and
(33:14):
that when we see patients our, our true
north is the right for our patient to
make decisions, but it's to make the
decisions based upon best information.
I.
Accurate information.
So we need to make sure that everybody
in our office knows what is accurate
information, and then how do we address
misinformation or disinformation, and
(33:35):
that everybody is willing to do that.
And if they don't feel comfortable,
then they know how to pass the
baton or who to pass the baton to.
So that every patient that
comes in is getting good
information, accurate information.
We are deeply involved in health promotion
and preventive care regardless of our
specialty, regardless of the age of our
(33:57):
patients or their social situations or
their backgrounds, that we are always
thinking about what's our true north?
How do we help our patient?
Then.
Have best health outcomes so they can
come back tomorrow and tell us about who
won the soccer game or who got married
or who has a baby, so that we are able to
celebrate then those activities of life.
(34:17):
And we do that as a team.
So you know, we've gotta be
involved as nurse practitioners.
How do we train others?
How do we pull information?
How do we use that same kind
of motivational interviewing
with people in our office.
That we're gonna use with our patients.
We still use those same techniques that
we have become to be so proficient in,
(34:38):
in doing, and we realize that together,
that whole thing of rising tide, what
rising tide moves all ships, right?
So as our office, as everybody in our
office is more proficient, who benefits.
Everybody benefits, we benefit our
patients benefit, our communities benefit.
And so to me that's the,
that's the hat trick, right?
(34:59):
We have a lot of wins.
We, exactly.
Sophia (35:01):
And so finally, as we prepare
for the summer and the anticipated spike
in COVID-19 infections, who knows by
what percentage it's going to increase?
What are some ways that we can
prepare our patients and communities?
I know you've mentioned a few things
before, but what are a few key
things that you would recommend?
Ruth (35:21):
I think that always
we're gonna plan ahead.
We spend a lot of our time living in
the here and now, and certainly we
wanna address then what are the health
issues that our patient has right now.
But I think also it's
helping them recognize risk.
And I think many times we
don't even recognize that we.
Our own risk.
We don't recognize our own
(35:42):
risk factors age for many of
these respiratory illnesses.
Age is the strongest risk factor.
But because we get up and we come to work
every day and we, we manage to run through
and keep our body and soul together.
We tend to say, great, I don't
have any risk factors, but we do.
And so we need to recognize what
places our patients at risk, not
(36:03):
only what places us at risk, and
then be planning for the future.
What does that mean so many times for
us, that may mean that, oh my gosh,
I if I'm sick, number one, do I need
to come to work or do I need to have
a plan of action if I do become.
Ill, so I'm not a
transmitter in my office.
Secondly, how do I protect my health?
(36:24):
What is it that I need to do in the event
that I'm feeling Ill, do I have access?
Do I have access to a home test myself?
Or do I think, oh my gosh, I could
always go into the office and be tested.
Maybe we don't want you to bring
whatever it is that you have to the,
so you've gotta be thinking about you.
And I think many times when
we go through that kind of
operational exercise ourselves.
(36:46):
It helps us realize the complexity that
is involved with our everyday patients.
So it helps us then begin, I think, to
maybe heighten not only our awareness,
but prioritize not only what our
patients need for today, but we may not
see them now for other, another three
months or six months, or maybe a year.
(37:07):
So how do we need to best prepare them?
We may not be able to do everything for
them, but we may be thinking about almost
giving our patient their homework list.
Here's some things that I want
you to think about and be prepared
and call me if you need that.
We may be too far out to be thinking
about some of this to maybe make it
be real for them, but let's give 'em
(37:28):
a hint and let's keep in mind then,
and by doing so, we're saying that
health maintenance requires work.
It requires a plan of action.
It requires that we anticipate to whatever
extent possible, and that we engage our
patients so they realize that we are
their partner, they're the driver of
this vehicle, but we're their partner.
And so we stand ready to help
(37:50):
them when they have questions.
Call us.
Here's how you reach out.
Here's what we have available for
you, and that we let them know very
clearly how important they are to us.
That we wanna be involved in their
health decisions and that we, again,
are here to work with them and beside
them in many of these decisions.
Sophia (38:08):
Absolutely.
And I think one of a and P'S slogans in
the past was nps, your partner in health.
And certainly it goes for many
of these diseases and disorders.
We do wanna be their partner in
health no matter what comes their way.
Absolutely said.
Ru thank you once again for
joining us on NP Pulses.
(38:28):
As always, you've provided us an
immense amount of information, I
think very important and timely.
Your expertise in infectious disease
is always appreciated, so again, thank
you for joining us today on NP Pulses.
It's always a
Ruth (38:42):
delight.
Thanks
Sophia (38:42):
a lot,
Ruth.
Thank you so much for being here,
and thank you all for listening.
I also wanna thank Pfizer for
sponsoring today's podcast.
Please subscribe to this podcast,
share it with your colleagues, and
check back regularly for new episodes.
(39:04):
And as.
Always be kind, be safe, be effective, and
be the voice of the nurse practitioner.
From the American Association
of Nurse Practitioners, I'm your host,
Dr. Sophia Thomas, and this is NP Pulse.
The voice of the nurse practitioner.
Welcome to NP Pulses, AANP'S
official podcast, bringing you
(00:34):
unique nurse practitioner voices
and expertise on issues that
matter to NPS and our patients.
Thank you for joining us today,
and thank you to Pfizer who
is sponsoring this podcast.
With the arrival of summer, many
of us are looking forward to a
vacation and imagining ways to
stay cool and out of the heat.
But just as we're reminding our patients
(00:56):
to take care of their skin in the sun, we
also need to remind them about something
they may not have on the forefront of
their mind, the likely summer surge of
COVID-19 and how to stay safe if the
disease spreads like we think it may.
Ruth Carrico is our returning
guest today on NP Pulses.
She's a professor, a family
(01:17):
nurse practitioner, and an
infectious disease expert.
We will be discussing how to consider
COVID-19 on both the population
level and how the disease affects
our patients as individuals.
We'll also be talking about the clinical
presentation of COVID and the unique
abilities nurses and nurse practitioners
(01:37):
especially have in preventing the
spread of this disease and in keeping
our patients healthy all year long.
Welcome to NP Pulse.
Thanks.
It's a delight to be here.
Ruth, we've had you as a guest before
and your expertise is always so
appreciated, and I know our listeners
really appreciate your knowledge
in the area of infectious disease.
(01:58):
But for those who maybe haven't
heard our interviews before,
please reintroduce yourself to us.
Ruth (02:04):
Be delighted.
My name is Ruth Ricco.
I am a family nurse practitioner
based in Louisville, Kentucky, so I
have the opportunity to work with a
variety of healthcare organizations,
industry, local, federal government,
international organizations as part of
my work with infectious diseases, and
(02:24):
I spent a good portion of my career.
At the University of Louisville
in the School of Medicine and the
Division of Infectious Diseases.
And so now I enjoy an adjunct
faculty position there and and
maintain a clinical practice in a
nurse practitioner driven clinic.
So that's exciting.
I learn from my colleagues every day.
I'm
Sophia (02:43):
sure you do.
And then in the area of infectious
disease, there's so much to learn.
And certainly we've had a prior
conversation about COVID-19
COVID has been around now for.
Five years, and I'm sure it's
gonna be around for a long
time in its various forms.
Speaking about COVID in general, how
has the infectious disease community
(03:04):
come to understand the disease now
versus at the beginning of the pandemic?
Ruth (03:10):
A, as you mentioned, five
years, it seems like a lifetime ago.
I was telling somebody the other day
that now in my life, I think of things
before COVID or B, that's my bc Yeah.
And then after COVID.
Now that's my ad. Because you're right
when COVID then exploded onto the scene.
It changed everything.
It changed all of our interactions
(03:32):
on the, as part of general public.
It changed our knowledge about medicine
and about the provision of healthcare
and availability of healthcare.
So much changed, but with respect to
actually understanding this virus.
When we first saw that initial, that
Wuhan, or what we often call that
ancestral strain, the original strain
(03:53):
of this particular coronavirus,
it presented in so many different
ways and it really flipped upside
down many of what we thought.
We knew many of those things we thought
we knew about infectious diseases.
Testing, recognition, treatment.
And when I look back and I think, oh
my gosh, I always thought before, if
(04:14):
you present with a respiratory illness,
you are going to present in these ways.
Or if you have pneumonia, you're
going to present in these ways.
But so much changed.
It broadened our horizons.
And I guess respect for how ferocious.
A new virus, a new illness can be,
and over time, as we have seen then
(04:36):
the mutations that have occurred
with this particular coronavirus,
we have continued to learn.
We've adapted not only our, our
approaches on recognition, treatment,
testing, planning, that's probably
the biggest thing, the biggest
change that I've seen in helping our
patients develop a plan and how we
(04:57):
as providers need to develop a plan.
For this coronavirus, and exactly
as you said, this now is part of
our ecology, that we are learning
how to deal with a new coronavirus.
We've had coronaviruses, we've
recognized them for years.
We've adapted, learn to address
(05:18):
them in a variety of ways.
Now we've added a new
coronavirus to the mix.
This one certainly is different.
We have not had a coronavirus that had
this level of ferocity with disease, but
it's done the same thing that the other
coronaviruses is done and that is mutate.
So it is continued to change.
(05:41):
So it's an important, I think,
reminder for us that as we
watch what is happening with.
This coronavirus, we are gonna need
to stay on our toes and continue to
monitor and see what changes it makes.
And it's a reminder that
microorganisms have two jobs.
Stay alive and multiply, and they do
(06:01):
that by adapting just like we adapt.
We're gonna have to keep an eye on what's
going on and be in very close partnerships
with public health, clinical practice,
laboratory sciences, industry as we look
at what types of VIR vaccines or antiviral
agents we have available and be ready.
Sophia (06:20):
Absolutely.
And right now I get my weekly virus
report for the area that I live in.
And right now what I'm seeing in my area
is of all the viral infections, COVID
has been about one to 2% of the viruses,
but I've heard that with summer coming
up, we're expecting a spike in COVID-19.
Have you heard this as well?
Ruth (06:40):
Yeah, and I think historically
what we've seen the last several
seasons, we've seen that instead of just
having one spike a year, like we, we
may see with other respiratory viruses
like flu or even RSV with, with COVID.
With this Coronaviruses,
we've seen two, two spikes.
We are gearing up with the anticipation
(07:00):
that in the summer we will see just what
we have seen in the last several years,
that kind of bimodal approach one, one
approach in in the colder months, and then
now one approach in the warmer months.
So we haven't seen this virus land
in a seasonal once a year pattern.
(07:21):
I can't say, and I don't think
any of us can say with any
certainty that will happen.
But our approach now is, okay, if
we're gonna see this twice a year,
and it is a respiratory illness,
meaning it's a, something that
occurs with breathing and fortunately
that's what all of us do, right?
And so we have to realize then
that something that that makes
(07:43):
its presence known regularly.
That means that we are all
going to be exposed regularly.
We are all going to continue to breathe
regularly, and that means we have
to be thinking about how do viruses
work, how does our immune system
work, who might be at greatest risk?
And then develop a, not only a
(08:04):
public health plan of action.
That is looking at what
happens across our population.
But one thing that I think all of us
have learned in that is that our patients
now are saying, yeah, I understand.
You know what, how we look at this on
a population level, but what about me?
As an individual.
Now, how does this impact me?
(08:25):
So we're having to now learn how
to juggle two things, what it looks
like on a population basis, but
then bring that down to the level
of the patient is our end of one.
Instead of an in of a hundred
thousand like we were looking at
previously, what's a challenge now
for us on the clinical side to make
it real and relevant to our patients.
Sophia (08:45):
Yeah.
And then clinical presentation
there, there's so many
different ways COVID presents.
It could just be a sore throat
or it could be a common cold type
symptoms or what are you seeing
as far as clinical presentation?
Ruth (08:59):
I think previously we thought,
oh my gosh, if somebody tells me they
lost their sense of taste or smell,
then I recognized that early on.
Now COVID looks like many other
respiratory illnesses and just like
people are different, hosts are different.
We all don't complain of the same things.
We're having to figure out what our
(09:20):
approach is gonna be when we have any
patient that presents with respiratory
symptoms and be particularly attentive
when we have patients that have
risk factors that place them at an
increased opportunity that they may
not be able to muster that rapid
immunologic response to protect them.
(09:41):
So now we're thinking,
oh my gosh, here we are.
We've got a respiratory season.
Or not, we have respiratory symptoms.
How do we approach it?
So it really means that we as
clinicians need to up our game a
little bit and think, okay, what
is gonna be our approach, our
plan of action with our patients?
(10:02):
And then how do we have a plan in mind?
And then how do we convey that plan to our
patients so that they have information?
So that they're in charge of their
healthcare, certainly, but we're
giving them the information they need
to make the best decision in their
minds for their care, and in many
instances, the care of their families.
(10:24):
We're seeing so many mul,
multi-generational households now
where people are living together.
People are interacting in a different way.
So what goes on with one
individual doesn't just impact
them, but it may impact children.
It may impact.
Their, maybe their mom
or dad, or sometimes even
grandparents that live with them.
So we're having to think really
(10:44):
differently now, and we're having to
help then our patients think really
differently about how not only COVID,
but other respiratory illnesses may
represent new risks to them and their
ability to live, work, and play safely.
Sophia (11:00):
And so for example, if a
20-year-old otherwise healthy appears
to the clinic and they have clearly
a viral upper respiratory infection,
normally we'd say it's viral.
It's nothing we can do, treat it
symptomatically, but maybe we need
to consider that person's living con
conditions and do they live with a
grandparent who may be at a higher risk of
(11:23):
complications if it truly is COVID right.
Ruth (11:26):
Yeah, and I think when you mention
that you really bring out what I think
are some unique skills that we as nurses
have that we tend to wanna understand,
not only the medical side, but we
understand the social side of care.
Now, the third stool in that part
of that triangle is we also need
to understand local epidemiology.
(11:47):
So we are looking at the patient
and their physical presentation.
We are looking at their social
issues, and now we're looking at
what is going on in the community.
And we're trying to pull all of
those things together and then try to
figure out can we decipher this Now,
are we gonna be right all the time?
All the time?
Absolutely not.
(12:07):
But this really is the underpinning
behind why when we talk about vaccines.
That we are hearing so much about
co-administration because if we are at
a period of time where it may be flu,
it may be RSV, it may be COVID, we don't
really know which one of those are,
but I used to think I could predict.
But now if I don't have a magic eight
(12:29):
ball or something else, you know that my
crystal ball that can help me forecast
the future and I'm not really good at
forecasting even if I do have those tools.
Now I'm trying to think, okay, what
might that patient be at risk for?
And then do I wanna take a guess, even if
it's an educated guess, or do I wanna tell
my patient, okay, here's my situation.
(12:51):
I want to make sure that we have,
we have the information so that you
can make best decisions for you.
We have these three viruses that,
that we know are circulating at some
point in our community or maybe in
another community where you may be
visiting or vacationing or whatever.
I can't tell which one you may be
(13:12):
exposed to first or at all, but I know
that I can provide you with vaccines
that may help protect you against the
worst outcomes for all three of those.
Now, that may mean.
Three injections, three
vaccines at the same time?
No.
We've got data and recommendations
from CD, C that will say, go ahead
while you have the patient there.
If they're at risk, go
(13:32):
ahead and give 'em all.
But I've gotta, I've gotta make
sure that my patient understands the
why behind my recommendation, and
they may elect to do that or not.
But what I wanna do is make sure
that they've got the information and
they understand the why behind this.
So they then are able to
make the best decision.
And if they decide that they don't want.
(13:53):
All three at the same time that I can
say, okay, here's some data that we may
use, and I don't know whether it's gonna
be on target, but it may be something
to help us with those decisions and
then come up with a plan of action.
For example, I'm, they may
say, I don't want this vaccine.
Maybe I don't want flu vaccine now.
Then I can think about, all
right, what about a flu antiviral?
Let's think about our plan.
(14:14):
Are you gonna be able to test quickly?
Are you gonna be able to reach out to me
quickly so we can figure out what to do?
So maybe it's COVID that
they want to delay vaccine.
Then let's think about are you, are
you a candidate for this antiviral?
Do you meet then that eligibility
criteria with respect to underlying
health condition and so forth.
(14:36):
Then we make a plan for that
to happen because none of
these things happen magically.
Like all things in our job, we have
to make a plan and then see how the
patient then can implement that plan.
Sophia (14:48):
Exactly.
And I wanna get into treatment,
but I wanna go back to testing.
You mentioned testing.
We've come a long way as far
as our COVID to 19 testing.
What is the latest on testing?
Ruth (15:00):
I think we still have a
variety of test methodologies.
Our PCR testing is still the gold
standard, but we now also have
molecular tests that you can purchase.
In fact, it's funny, I, for
Christmas for my kids, everybody
got a molecular COVID flu test.
Most people, that may not be the first
thing you think about as a Christmas
present, but I'm like, okay, I want you
(15:22):
to get something that is easy to use.
And in these, I bought
it off, off the internet.
So you can get tests everywhere.
You can go to the drug
store and get tests.
You may be able to get an antigen
test, which is not gonna be quite,
you know, as, as sensitive and
specific as a molecular test.
But if you, your patient knows how
(15:43):
to use them appropriately, they
know how to use them and know when
to use them, then it may give you
enough information to, to make some
reasonably, uh, correct decisions.
But I think you know, it, it.
Goes back to what is your,
what is available for you?
How likely or inclined are you to use it?
(16:06):
I've talked to patients, they'll
say, yeah, I've got a test,
but you know, I don't wanna
use it unless I really need to.
When do you really need to, you need
to use it when you are symptomatic.
Might it be wasteful in terms of, oh
shoot, I used and it was negative.
Yeah, but then we know probably what
you don't have, and then that helps
us then with treatment decisions.
(16:26):
So.
Having these kinds of discussions with
patients, knowing you have a test, looking
at the date, the expiration date isn't
going to be a test that will work for you.
And then having those down
to earth, and I think really
practical, pragmatic discussions.
With patients.
I think really, again, bring home
(16:46):
the importance of what we do.
As a nurse practitioner, we have those,
all right, how is this gonna work?
And we get very operational on
the side of our recommendations.
Are they able to do this?
If somebody says, I would love to
have a test, but I can't afford it,
what might our recommendation be?
What is our relationship
with our local public health?
(17:06):
Is there a way that we can identify.
Testing for them?
Do they have health insurance coverage?
Is this something that they can provide?
We're doing a lot of that investigation.
All of these activities that we
don't bill for that take our time.
But I think what makes us better at
what we do and at, at the end of the
day, we want our patients to view us.
(17:28):
As a resource that is credible, something
that they can, somebody that they can
trust, somebody that if they don't, if
we don't know the answers, that we feel
very comfortable saying, I don't know.
I've got some people, I've got
some friends that I can call.
Or I've got some somebody that
I know that I can reach out to.
Let me get back with you.
And then through many of our
electronic medical records, we have
(17:48):
the communication through the portals
and that we can reach back and then,
and continue that communication.
There are a number, and back to your
original question about testing.
There are a number of opportunities.
We have tests that are extremely
accurate and some that are not quite
as accurate, but they can give us some
(18:08):
good basic information as we need,
and then making sure that our patients
have access to testing, that they
know how to perform the test, if it's
gonna be something they do at home.
If they're not gonna do it at
home, do they know where to go?
Can they afford testing?
And then encouraging them to use
what they can within their resources.
And if they don't elect to test, then
(18:31):
how can they still stay in contact
with their healthcare providers?
We can then help them
with future decisions.
Sophia (18:37):
Yeah.
And so once testing has been completed,
if a patient tests positive, now
what are our treatment options?
What are, what do we talk about
when we talk about a plan of care
for that individual with COVID?
Ruth (18:50):
I think, and this is a great
discussion, that's something we
must have with our patients upfront.
And we look at their
underlying medical conditions.
If I have a patient that has a number
of comorbid conditions, that they
are immunocompromised and maybe a, a
patient that is undergoing active chemo
chemotherapy and they are seeing an
oncologist and maybe they're seeing
(19:11):
an NP for their primary care, this is
a good discussion for us to have then
with their oncologist to say, in the
event they test positively for COVID.
How do you wanna handle
this with their treatment?
Is this somebody that you want
to be seen in the hospital?
Is this gonna be a candidate
for, for an infusion?
Is this somebody that you may be
(19:32):
thinking about convalescent, plasma?
I. Where are they in this spectrum?
Or it may be somebody that you're
gonna say, all right, let's look
at your comorbid conditions, and we
have a couple of antiviral choices.
Do you meet criteria based upon
your underlying medical condition,
based upon your medication history?
What are you taking Now?
(19:54):
Is one medication go going
to need to be discontinued?
Or will a medication that you're on
prevent you from having one or the other?
Of the antivirals.
Maybe you've got kidney disease, liver
disease, and may not be able to take one
or the other or any antiviral medication.
These are the types of
conversations we have.
(20:14):
Number one.
Where does the patient sit in terms of
their willingness to have medication?
Number two, which medication or medication
pathway makes sense for them with their
underlying medical conditions and how
does the patient feel about that pathway?
Number three, where can
they access medication?
(20:35):
Now I'll, let me share
just a personal experience.
This past flu season, I had my influenza
vaccine, but I developed influenza A and
let me tell you, I was sick, but I'm one.
I told you everybody in my family
had a test and I also had access
to medication very quickly.
(20:55):
If I had not had access to medication
very quickly, if I had to go out
and think about where am I gonna
get it, who am I gonna call?
I was, I felt so badly that I
don't know how well I would've done
had I not had a plan of action.
I. And the thought in my mind, I thought,
oh my gosh, older adults or people that
have underlying medical conditions that
(21:17):
haven't outlined this plan of action.
I can understand why people can do
poorly very quickly, but really, I
guess all of us need that, that that.
Experience that really underscores
the importance of having
a plan and being prepared.
I certainly experienced that this fall,
so it, it just reinforced then with
(21:40):
me, what do I need to tell my patients?
And then this is a story
that I share with them.
This is why I want you to be prepared,
because I don't want you to feel as badly.
As I did without having something
then that, that you could go to.
So, you know, thinking about how they will
access medication, what type of education
do they need before they take it.
(22:01):
For example, they may take an
antiviral that causes them to
have an altered sense of taste.
They may think, oh my
gosh, something's wrong.
And then they may stop it.
I've gotta prepare them.
And if your patients are like
mine, they don't remember
every single thing I tell 'em.
That oftentimes I'm on the too much
information side, but I've gotta make
sure then that this is something in
(22:22):
writing and I've gotten so that I'll
tell my patient, okay, here's our plan.
It's on this paper.
Maybe the after action summary.
If you're like me, this is gonna be on the
floor of my car or the bottom of my purse,
and I'm not gonna know where to find it.
So I want you to take a picture of it
because you'll probably never lose your
photographs in your cell phone, right?
None of us are ever gonna lose
our pictures, so get 'em to take
(22:44):
a picture of that and then they
can go back and find it, or we
can go back together and find it.
In the event we have to regroup and
think about what our plan of action was.
And the fact that it's a picture, I think
also gives it a level of importance.
To that patient because as they're
scrolling through their pictures, they're
gonna scroll through that and they're
(23:05):
probably gonna stop and say, what is this?
They'll read it again, and then
that may be fresh in their mind.
The picture thing.
Sometimes there's a method behind the
madness, I think, in our approach.
Sophia (23:14):
Exactly.
And I've recommended taking a photo of
lots of things to my patients before.
When you talk about the oral antivirals
for COVID, what are some special
considerations that we need to
take into account when prescribing?
Ruth (23:28):
The first one, I think that that
comes to mind with the antiviral with
COVID is gonna be Norvir Ritonavir,
the combination drug that where we
have FDA authorization and we have
some pretty consistent guidelines.
We also have Moira Vir that
is still available under ua.
That is an option, and that if our
patients are not able to tolerate VIR or
(23:49):
ritonavir, then we do have an alternative.
So we have something then to provide.
To our patients, the vir ritonavir,
that is a, a drug where we need to
be thinking and actually both of them
getting, giving them quickly enough,
you know, ideally within the first few
days, within five days after the onset
(24:10):
of symptoms, the sooner the better.
So if we can even be sooner than five
days, then that's what we wanna do.
But we've gotta know then what
is the medication history.
There may be some drugs that will
react poorly and, and when you take
then this CYP three a issue, then.
We will have then potential to potentiate
(24:31):
some current medications and we may
not be able to give them that drug.
So, you know, having an
alternative is important.
If we have patients that have
altered renal function, we may
have to adjust their dosing.
So we need to know then which one
of those dose packs to prescribe.
So there's some education we need.
So it's a good reminder for all of us.
(24:52):
Make sure that we've.
We've got then something of if other nps
are like me on my cell phone, I've got the
ability to look at one of the apps that
can help me look at drug interactions so
that I can very quickly then follow up.
But if my patient can't always
remember what drugs they're on, if I
don't have access to their electronic
(25:13):
medical record, maybe I'm out away
from my computer, it may be a little
bit more difficult for me to connect.
And look at their electronic
medical record and look at
their medication history.
That's why I always think it's
better to make that plan of action
beforehand so I can tell my patient.
Now we talked about this and where did you
stand with respect to antiviral treatment?
(25:35):
All right, that we know that we've
got right now two, two options
for this outpatient treatment.
I need to make sure then that
we're looking at the one that
is going to be safe for you, so.
Let's look up your medications.
Do you have your list of medications?
What did we talk about?
Did you take a picture of that plan, pull
it up and then read to me what it says?
(25:56):
The patient then feels, continues to
feel like they are the driver of their
care, and that's what we want, right?
We want our patients to to be in charge.
We are supporting them and
supporting their decisions.
And again, because there's gonna be
this back and forth conversation if
that happens when somebody feels badly.
As I mentioned, like I felt with
(26:16):
flu, I'm not thinking as well.
My, my thinking may be a little bit foggy.
Maybe I can't find my pictures or I just
don't feel enough well enough to do that.
So the more that we can do upfront, the
more that we can help that patient take
care of before they need that information,
I think the better off we're all gonna be.
Certainly the happier the patient
and the provider are gonna be.
(26:37):
In the midst of those conversations.
Sophia (26:39):
So you would say, as a primary
care provider, as I am seeing my
patients for their routine care, I
could mention we are perhaps going to
be seeing a spike in COVID this summer.
If you happen to get COVID-19,
let's talk about how we may treat
you and let's look at our treatment
considerations ahead of time to get
(27:00):
a plan in place should that patient
actually test positive for COVID-19.
Ruth (27:05):
Absolutely, and I think
this gives me a chance also to
talk not only about the vaccine,
but about the antiviral as well.
I'll usually tell my patients that
respiratory viruses like this have
a fairly short incubation period.
So that means once you're infected, you
immediately then have the this virus
that is replicating inside your body.
(27:27):
If you have antibodies that are
circulating around your body,
then you immediately, it's here.
You've got the home invader.
You've got somebody to
start the fight, right?
Then.
If you don't have those circulating
antibodies, then your body has to
recognize, and then your immune system has
to begin firing from the very beginning,
(27:48):
so you're already behind the wave.
So this is why we want to give you vaccine
to keep those circulating antibodies and
why we have, for example, our patients now
with those that are 65 and older, those
that have underlying health conditions,
they may be recommended a second dose.
(28:08):
Of a vaccine that then maintains
those circulating antibodies.
So they always have those soldiers
that are roaming around ready and on
the watch for these invading viruses.
So it gives me the chance to give
them the why behind vaccines.
Now if you do not have those circulating
antibodies, or even if you do, I
(28:30):
wanna be able to provide you then with
this antiviral agent, because you may
need those extra soldiers because.
That has that short incubation period.
We don't have a whole lot of
time to get this medication, get
these drugs into your system.
So that means you've gotta test
as soon as you feel poorly.
(28:51):
So we know what are we working with.
If it's COVID, then call me.
So I've gotta talk with them about what
happens if it happens on a Saturday night.
How do you reach me?
What about if it's on a
holiday, how do you reach me?
And then we have these
types of discussions.
So that patient has a plan
and now let's write it down.
Let's take a picture, put it in
(29:12):
your cell phone so you can call me.
And it's the same approach whether
we are talking about COVID or flu.
So I'm influencing then how that
patient thinks about respiratory
illness and how they think about.
How am I a participant
in my own healthcare?
So I'm reinforcing, I'm, I'm using
(29:34):
these as examples to, for a number
of reasons, not only for COVID.
Certainly COVID is a, is a great example.
But I think what we wanna do
with all of our patients is
develop a sustainable approach to
healthcare, to preventive care.
And so when they say, oh, now
I get it, I understand why.
(29:54):
I am concerned about.
Diseases that are
transmitted by breathing.
I understand the role of vaccines and
if I have a patient that chooses not
to be vaccinated, I remember that's
their right to make that choice.
I want them to make a choice based on
accurate information, but I'm gonna
support that patient regardless.
(30:14):
So I'm gonna say.
You.
You don't wanna be
vaccinated at this point.
Now let 'em know now because I like
you, because you're important to me.
I'm gonna ask you again.
I'm gonna ask you next time.
But because you've elected not
to be vaccinated, I don't want
you to think that's your only
option in the fight against COVID.
So now let's think.
What about taking an antiviral
in the event you become ill?
(30:36):
Then again, does that patient meet
all of the eligibility criteria?
What?
What is our plan of action?
And then I'm letting them know that
I have respect for them, even if
their choices don't agree with mine.
I still respect what they are doing, and
I'm trying then to understand and provide
the patient with the best outcomes and
(30:57):
the best information as we move forward.
Sophia (30:59):
Absolutely.
And I think a special consideration would
be now that we have these home tests
available like we never have before,
our patients will be testing at home.
And I think one thing we should
consider is that when a patient
calls my office and says, I tested
positive for COVID-19, I would like
to be treated, that we don't give them
(31:21):
an appointment in two, three days.
We, we really need to try to.
Provide them access to treatment
immediately, whether that would be
our predetermined plan, and we just go
ahead and e-prescribe or call in that
medication for the patient or get them
right into the office for evaluation so
they don't have to wait to be treated.
(31:41):
Because as you said, the sooner we start
antivirals, the better off they are.
Ruth (31:47):
You made several critical points
that I think I are vital for us to
think about, and that is what is
our role as the clinician in making
sure that our office is part of our
team now spend, get to spend, have.
We don't have the luxury of spending a
lot of time with each individual patient.
(32:09):
So this is a team effort.
So from the time they put their foot
across the threshold, entering whatever
clinic, whatever, wherever our office
is or our healthcare facility, the
minute they walk into our environment,
that's when we need to engage.
Whether they are talking with a person
that is checking them in, whether they're
talking with a medical assistant, or
(32:30):
if we're lucky to have pharmacists and
other others in our practice, everybody
needs to, they need to know the drill.
Here's the assignment and everybody
needs to be operating in lockstep,
and this really is our chance to talk
with our office and make sure that.
How does everybody feel about vaccines?
How does everybody feel about antivirals?
(32:53):
We realize that the beauty of our
country is that we have many, we have
diversity and thought in action, and
that is a richness that we have in
our country and in our communities.
So we need to understand where does
everybody, what are the thoughts?
That, that we need to decide then what
is our plan of action together, and
(33:14):
that when we see patients our, our true
north is the right for our patient to
make decisions, but it's to make the
decisions based upon best information.
I.
Accurate information.
So we need to make sure that everybody
in our office knows what is accurate
information, and then how do we address
misinformation or disinformation, and
(33:35):
that everybody is willing to do that.
And if they don't feel comfortable,
then they know how to pass the
baton or who to pass the baton to.
So that every patient that
comes in is getting good
information, accurate information.
We are deeply involved in health promotion
and preventive care regardless of our
specialty, regardless of the age of our
(33:57):
patients or their social situations or
their backgrounds, that we are always
thinking about what's our true north?
How do we help our patient?
Then.
Have best health outcomes so they can
come back tomorrow and tell us about who
won the soccer game or who got married
or who has a baby, so that we are able to
celebrate then those activities of life.
(34:17):
And we do that as a team.
So you know, we've gotta be
involved as nurse practitioners.
How do we train others?
How do we pull information?
How do we use that same kind
of motivational interviewing
with people in our office.
That we're gonna use with our patients.
We still use those same techniques that
we have become to be so proficient in,
(34:38):
in doing, and we realize that together,
that whole thing of rising tide, what
rising tide moves all ships, right?
So as our office, as everybody in our
office is more proficient, who benefits.
Everybody benefits, we benefit our
patients benefit, our communities benefit.
And so to me that's the,
that's the hat trick, right?
(34:59):
We have a lot of wins.
We, exactly.
Sophia (35:01):
And so finally, as we prepare
for the summer and the anticipated spike
in COVID-19 infections, who knows by
what percentage it's going to increase?
What are some ways that we can
prepare our patients and communities?
I know you've mentioned a few things
before, but what are a few key
things that you would recommend?
Ruth (35:21):
I think that always
we're gonna plan ahead.
We spend a lot of our time living in
the here and now, and certainly we
wanna address then what are the health
issues that our patient has right now.
But I think also it's
helping them recognize risk.
And I think many times we
don't even recognize that we.
Our own risk.
We don't recognize our own
(35:42):
risk factors age for many of
these respiratory illnesses.
Age is the strongest risk factor.
But because we get up and we come to work
every day and we, we manage to run through
and keep our body and soul together.
We tend to say, great, I don't
have any risk factors, but we do.
And so we need to recognize what
places our patients at risk, not
(36:03):
only what places us at risk, and
then be planning for the future.
What does that mean so many times for
us, that may mean that, oh my gosh,
I if I'm sick, number one, do I need
to come to work or do I need to have
a plan of action if I do become.
Ill, so I'm not a
transmitter in my office.
Secondly, how do I protect my health?
(36:24):
What is it that I need to do in the event
that I'm feeling Ill, do I have access?
Do I have access to a home test myself?
Or do I think, oh my gosh, I could
always go into the office and be tested.
Maybe we don't want you to bring
whatever it is that you have to the,
so you've gotta be thinking about you.
And I think many times when
we go through that kind of
operational exercise ourselves.
(36:46):
It helps us realize the complexity that
is involved with our everyday patients.
So it helps us then begin, I think, to
maybe heighten not only our awareness,
but prioritize not only what our
patients need for today, but we may not
see them now for other, another three
months or six months, or maybe a year.
(37:07):
So how do we need to best prepare them?
We may not be able to do everything for
them, but we may be thinking about almost
giving our patient their homework list.
Here's some things that I want
you to think about and be prepared
and call me if you need that.
We may be too far out to be thinking
about some of this to maybe make it
be real for them, but let's give 'em
(37:28):
a hint and let's keep in mind then,
and by doing so, we're saying that
health maintenance requires work.
It requires a plan of action.
It requires that we anticipate to whatever
extent possible, and that we engage our
patients so they realize that we are
their partner, they're the driver of
this vehicle, but we're their partner.
And so we stand ready to help
(37:50):
them when they have questions.
Call us.
Here's how you reach out.
Here's what we have available for
you, and that we let them know very
clearly how important they are to us.
That we wanna be involved in their
health decisions and that we, again,
are here to work with them and beside
them in many of these decisions.
Sophia (38:08):
Absolutely.
And I think one of a and P'S slogans in
the past was nps, your partner in health.
And certainly it goes for many
of these diseases and disorders.
We do wanna be their partner in
health no matter what comes their way.
Absolutely said.
Ru thank you once again for
joining us on NP Pulses.
(38:28):
As always, you've provided us an
immense amount of information, I
think very important and timely.
Your expertise in infectious disease
is always appreciated, so again, thank
you for joining us today on NP Pulses.
It's always a
Ruth (38:42):
delight.
Thanks
Sophia (38:42):
a lot,
Ruth.
Thank you so much for being here,
and thank you all for listening.
I also wanna thank Pfizer for
sponsoring today's podcast.
Please subscribe to this podcast,
share it with your colleagues, and
check back regularly for new episodes.
(39:04):
And as.
Always be kind, be safe, be effective, and
be the voice of the nurse practitioner.
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