Breathing 'Rheum' in COVID-19 Hotspots: New Orleans finds new 'camaraderie' amid economic bust
The very idea of social distancing runs contrary to congregation and celebration, two things that lie at the core of New Orleans culture. It is for this reason, perhaps, that New Orleanians were initially resistant to quarantine measures to contain COVID-19. But as the death toll climbed and Mayor LaToya Cantrell canceled St. Patrick’s Day festivities, the city slowly awakened to the idea that this was serious business.
As of April 21, 2020, Orleans parish alone had registered more than 6,000 infections and nearly 400 fatalities, according to statistics from Johns Hopkins University. But the numbers, of course, only tell part of the story.
Healio Rheumatology sat down with Madelaine A. Feldman, MD, president of the Coalition of State Rheumatology Organizations and clinical assistant professor of medicine at Tulane University School of Medicine, to discuss everything from challenges facing rheumatologists in New Orleans to the mood on the street in the city.
Q. As a rheumatologist, what are some of the biggest hurdles you are facing with COVID-19?
Feldman: Probably fear and anxiety in our patients. It is so common in New Orleans right now. Everyone is afraid of getting it, so I am constantly answering questions about the infection, about immunosuppression, about protection. What I am telling patients is simple: Take your medications. Don’t let your disease flare. But, of course, we, as physicians, are people too, so we are trying to keep up with our own families, as well. My daughter got infected, so we are worrying about our loved ones.
In terms of our practice, we need to make sure we have cash flow for payroll this month and next month. We are a small practice with three physicians, no office manager, doing our own billing and infusion inventory. We cannot afford to go on hiatus. As the “eldest” of the group, I have been navigating the Medicare changes, and handling the financial issues and red tape involving small business loan procedures. This kind of paperwork can be heavy duty if you are not a big group with a management and administrative team.
Q. How has the quarantine itself impacted your practice?
Feldman: Like everyone, this has impacted both our personal and our professional lives. My children are grown and gone, but my two partners both have spouses who are physicians, and they have small children at home. As we all know, with small kids at home anything can happen at a moment’s notice. That puts us all on alert to cover for each other. On top of it all, I had to self-quarantine for 2 weeks because of exposure to my daughter, and this was right around the time telehealth was starting — it is a lot of logistics.
Q. Beyond the logistics, what are some of the other challenges you have faced in your practice?
Feldman: One thing I have noticed, and maybe other practices have noticed as well, is that our staff feels much better when I am there. I noticed a palpable change when I had to handle tele-visits from home because of my quarantine. Even now, if something comes up and I cannot come in for some reason, there is a change in the energy of our staff.
The social distancing and lockdown have been a challenge to all of our inner and emotional strength. It seems to have resulted in a special bond among all of us in the office regardless of our station. The lack of personal social connectedness on the outside has made that bond stronger. It is a completely different kind of camaraderie than before COVID-19. We are a team that is not only there for our patients but for each other, as well.
Q. One thing we have been asking rheumatologists is whether there has been a hydroxychloroquine shortage for your patients. Is that happening in New Orleans?
Feldman: It is impossible for me to discuss this outbreak without mentioning hydroxychloroquine shortages. Very early on, one of my partners whose wife is a pulmonologist said HCQ was part of the cocktail given to admitted COVID-19 patients at her hospital. So, yes, it has been happening here for a while. That, of course, has created more fear among our patients. Although the shortage has diminished somewhat, there are a lot more requirements and limitations to acquiring it. It was surprising to hear a pharmacist tell us that you needed a diagnosis of COVID-19 or “some type of arthritis.”
Q. Do you have comments on the use of the drug for the infection?
Feldman: As all rheumatologists know, HCQ is actually a very safe and tolerable drug. One of the unfortunate consequences of this is all of the headlines proclaiming sudden death and other adverse outcomes with the use of HCQ. It is scaring patients. There is no validity to many of these reports. It is just another stress on my patients, in addition to the shortages. As far as its use in the treatment of COVID-19, there are a number of studies being conducted to examine what value it may or may not have. If I could make a final point, it is that hydroxychloroquine should not be given prophylactically for COVID-19 — the evidence is just not there.
Q. In terms of other shortages, has acquiring or maintaining personal protective equipment been a greater challenge since the spike in COVID-19 cases in the city?
Feldman: It is just a matter of understanding the situation. For example, early on, our governor asked for 12,000 ventilators. He said he knew we only needed 2,000 to 3,000, but had to ask for 12,000 to make sure we got the 2,000. As for PPE, from all reports we have yet to run out. While extended use was occurring for certain PPE equipment, I received word today from a consortium of hospitals that extended use is no longer necessary.
However, there are other needs that were not considered initially, like food for frontline health care workers. One of our walking Mardi Gras groups, The Krewe of Red Beans, started a fund early on that now is feeding hospital workers daily around the city. The food is bought from struggling neighborhood cafés and hires out-of-work artists of every kind to deliver the food to the hospitals. It is a win-win-win situation.
Q. Shifting away from the clinic, could you talk about how COVID-19 has impacted the New Orleans community?
Feldman: Well, one of the first questions that comes to mind is what part did Mardi Gras play in the spread of COVID-19. Hindsight is always 20/20, but apparently it played a big part. But then, even after Mayor Cantrell closed down the St. Patrick’s Day and St. Joseph’s Day parades, people went ahead and congregated anyway. New Orleanians do not easily give up their parades and parties. So, it seemed to take a bit of time for the city to really get the gravity of this. When we started seeing the curve tick up, people finally took it to heart.
Q. Given Hurricane Katrina and the recent history of New Orleans, it is a little surprising that it took so long.
Feldman: New Orleans is a tourist town. The biggest industries are hospitality, food and music. People who work in these industries know that when events are canceled, they no longer have jobs, and, for now, most are either furloughed or unemployed. If they are furloughed, they have no certainty that their jobs will be there at the end of this. If they even had health insurance in the first place, many do not have it now. So, the psychological burden on folks in these industries is significant. Many are less worried about getting the virus and more about how they are going to pay rent.
There is much collateral damage to lives in other ways in this fight against the spread of COVID-19. Just this week, the mayor canceled all festivals through the end of the year. Having grown up here, I know how much New Orleans loves its festivals, so we were all taken aback that the cancellations will extend through December. The mayor has let everyone know that she is serious about controlling the spread. Let’s just hope that there will still be workers left here when the hospitality sector starts to reopen.
Q. Can you add anything with regard to your personal experiences in the city?
Feldman: On the one hand, I have patients who won’t go to the emergency department for a potentially life-threatening issue, that is not COVID related, because they fear they will die just going out of the house. On the other hand, when I go to the grocery store, even now, very few people are wearing masks. – by Rob Volansky
Johns Hopkins coronavirus resource center: https://coronavirus.jhu.edu/us-map
For more information:
Madelaine A. Feldman, MD, can be reached at 2633 Napoleon Ave. #530, New Orleans, LA 70115; email: firstname.lastname@example.org.
Disclosures: Feldman reports having had advisory board roles with Bristol-Myers Squibb, Eli Lilly and Merck.