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Christian Gogoll, MD, long term effects of diclofenac is a pulmonary specialist who suffers from post-COVID syndrome. Before he was infected with SARS-CoV-2 in January 2021, he worked as a pulmonary specialist and was head of department at an acute care clinic. Gogall, the senior physician of the Evangelical Pulmonary Clinic Berlin, has been employed as a family physician in a Medical Care Center (MVZ) in Berlin. For the past year he has been on parental leave.
He was admitted to the intensive care unit with COVID-19 and suffered from dyspnea and myocarditis. Little by little, his symptoms have been improving. As he says, there are good days and bad days. In the following, he describes which treatment and therapy approaches he underwent, why the family physician should be the first port of call for patients with long COVID, and he gives advice to his colleagues.
Medscape: Dr Gogoll, according to current estimates by the World Health Organization, at least 17 million Europeans may be affected by long COVID or post-COVID syndrome. They are suffering from symptoms that either persist or that first occur weeks or months after the infection. What are the three most common symptoms?
Gogoll: A stress intolerance, that is, weakness after the disease, is common after COVID. A special variant of this is chronic fatigue syndrome. In addition, symptoms of dyspnea, cardiological symptoms, and dizziness are also widespread. Symptoms such as hair loss, tinnitus, changes to the sense of taste and smell, skin changes, and sleep disorders are persistent, but rarer.
Medscape: You are involved in the development of a guideline for the management of long COVID. What would you advise general practitioners if a patient in their practice displays these symptoms?
Gogoll: If the patient is on sick leave, still has symptoms, and is in quarantine, they should already be known to the family physician due to the sick note. Once a period of 8 to 12 weeks has passed after the positive test, the patient should be examined by the family doctor once again for lasting symptoms. At the end of the day, the family physician is an expert. They can make the call: should this patient be referred to a neurologist, cardiologist, or pulmonologist?
But the family physician themselves can also recognize an acute disease and, if it is an emergency, perform diagnostic measures. They have a stethoscope, ECG, laboratory tests, and ultrasound equipment at their disposal for this. They cannot do everything, but there is no sorcery at play here. There are no specific laboratory values or antibodies that one must measure.
Medscape: When is a referral to a specialist necessary, and what can the family physician arrange at the practice?
Gogoll: In the best-case scenario, the family physician is on good terms with a pulmonologist or cardiologist and can refer the patient for clarification. The same symptoms also occur after pneumonia or the flu. It is rare for weakness to develop suddenly. In the guideline group, we all agreed that the family physician knows these patients very well and therefore knows exactly what to do. Patients also come to them after Epstein-Barr virus infections, the flu, pneumonia, or after a stay in hospital.
A supplement to the guideline on long COVID/post-COVID syndrome contains red flags for family physicians to look out for. For example, if the patient has circular pains in their chest, this must be treated immediately. There is already a guideline for dizziness, too. It is complex and a challenge for the family physician. In terms of fatigue, the current guideline by Carmen Scheibenbogen, MD, PhD, can be used as guidance. For postinfectious coughs, for example, a pulmonologist is not necessarily needed. The guideline for coughs recommends treatment with an asthma inhaler to first soothe the airways. However, it is important that persistent symptoms be absolutely followed up.
Medscape: How do you incorporate your own experience and medical history into your consultations at the practice?
Gogoll: When interacting with patients, not just post-COVID patients, I have noticed that my awareness of chronic diseases, dyspnea, or nonspecific discomfort that the patient cannot precisely describe has significantly improved. I now know more specifically what it means when patients say, “Just recently, I could reach the second floor without a problem, and now I need a break after the first floor.” It is not clear whether the patient is unfit, their shopping bags are simply too heavy, or they are suffering from a severe disease.
If you have experienced such circumstances, have dyspnea, or simply need help with the shopping, but the physician cannot find anything, that can be very stressful. I have developed a better understanding of this and of what can and must be asked specifically.
Medscape: What does the rest of the therapy look like?
Gogoll: Respiratory physical therapy is an important cornerstone of treatment. In my opinion, this can even be prescribed before rehabilitation, since it takes an extremely long time for the patient to get a slot. If possible, a specialist should be consulted beforehand. A physical therapist must also be found here first, but this is achievable. The same applies for occupational therapy, speech therapy, manual therapy, or classic massage. These therapies do not break the bank to begin with — according to the National Association of Statutory Health Physicians — post-COVID syndrome has to have been diagnosed first.
Medscape: How does billing work here?
Gogoll: All outpatient treatment takes place before inpatient treatment. When prescribing remedies, there are special requirements for breathing exercises, manual therapy, and speech therapy. The prescription is valid for 3 months.
As always, registering for the rehabilitation procedure takes place via the health insurance provider, the pension insurance provider, or the trade association — whichever is responsible for the assumption of costs.
Medscape: How was it for you? What did you go through, and what helped you?
Gogoll: As a pulmonologist and internal medicine specialist, I thought I would be able to decide everything myself. After my stay in hospital, I received follow-up treatment, but the dyspnea persisted. I went to a pulmonologist, a colleague of mine. She said to me, “You are just too fat and unfit.” It was not until 6 months later that I had an appointment with the cardiologist, who diagnosed myocarditis. Maybe it would have been better to just go to the family physician! They would have done certain things, checked lung function and done blood tests, and examined me a lot more closely. All in all, the post-COVID outpatient clinics did nothing different.
I made the classic physician’s mistake and was overconfident in myself and thought that I could organize everything myself. It would have been much faster if diagnostic measures had been performed based on my symptoms and if the family physician had coordinated everything. The associations of statutory health insurance physicians have formed nationwide networks for this, since those affected cannot all be treated in the special practices.
Medscape: What has changed since your SARS-CoV-2 infection?
Gogoll: Each day is different, but the good days have become much more frequent. I am doing rehabilitation sports through my employer. After my stay in the hospital and various complications, I still have significant shortness of breath and weakness after exertion. Workdays here at the MVZ are sometimes 9 to 10 hours long and often very strenuous.
My ability to concentrate has gotten much better, and I no longer suffer from sleep disorders. The sleep disorders were very persistent.
Medscape: What is known about the connection between SARS-CoV-2 infection and sleep disorders?
Gogoll: The exact mechanisms are still unknown. In addition to the brain being affected by COVID-19, psychogenic causes are also being discussed. For example, it was found during sleep studies on patients from Ischgl, Austria, that the REM phase of sleep no longer restricted movement, which wakes you up. A deep-sleep phase is clearly being restricted by a neurological inflammatory reaction. Some patients in my practice report suffering from insomnia ― something I also experienced.
Medscape: Three tips for your colleagues on handling post-COVID patients?
Gogoll: Patience is highly important for the patients and for the physician. We physicians must protect these patients and keep each other in the loop. That is the most important thing. Family physicians have the opportunity to organize themselves in the network of associations of statutory health insurance physicians on long COVID. The network is already in place in Berlin and Bavaria and is now being formed in other federal states, too. Colleagues can receive reliable information from other colleagues here about what is currently possible, where to get what information from, and where patients can receive further treatment. Cases that have hit a dead end can also be discussed.
The problem stands of what happens to patients who have still not had any improvement 18 months later. They can no longer go to work and fall into unemployment or disability benefits. We are already aware of such cases from the long COVID self-help groups. We must learn from these and consider how to integrate these patients again. Increased research into the disease and awareness of it too is a major part of this. The numbers are definitely not falling.
Medscape: Thank you very much for the discussion!
This article was translated from the Medscape German edition.
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