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Christian Gogoll, MD, is a pulmonologist who suffers from post-COVID syndrome. Before being infected with SARS-CoV-2 in January 2021, he worked as a pulmonologist and was a department head in an acute care clinic. Gogall, chief physician of the Evangelical Lung Clinic in Berlin, was employed as a family doctor at a medical care center (MVZ) in Berlin. He has been on parental leave for a year.
He was admitted to the intensive care unit with COVID-19 and suffered from dyspnea and myocarditis. Gradually, his symptoms improved. As he says, there are good days and bad days. In what follows, he describes the treatments and therapeutic approaches he has taken, why the family physician should be the first point of contact for patients with long-term COVID, and he offers advice to his colleagues.
Medscape: Dr Gogoll, according to current estimates from the World Health Organization, at least 17 million Europeans could be affected by the long COVID or post-COVID syndrome. They suffer from symptoms that persist or first appear weeks or months after infection. What are the three most common symptoms?
Gogol: Stress intolerance, i.e. weakness after illness, is common after COVID. A special variant of this is chronic fatigue syndrome. Additionally, dyspnea symptoms, cardiological symptoms, and dizziness are also common. Symptoms such as hair loss, tinnitus, changes in taste and smell, skin changes and sleep disturbances are persistent, but rarer.
Medscape: You participate in the development of a guideline for the management of long COVID. What would you advise GPs if a patient in their practice has these symptoms?
Gogol: If the patient is on sick leave, still has symptoms and is in quarantine, they should already be known to the family doctor due to the sick notice. Once a period of 8 to 12 weeks has elapsed after the positive test, the patient should be re-examined by the family doctor for persistent symptoms. Ultimately, the family physician is an expert. They can make the call: should this patient be referred to a neurologist, a cardiologist or a pulmonologist?
But the family doctor himself can also recognize an acute illness and, if it is an emergency, carry out diagnostic measures. They have a stethoscope, ECG, lab tests and ultrasound equipment at their disposal. They can’t do everything, but there’s no sorcery involved here. There are no specific laboratory values or antibodies that one needs to measure.
Medscape: When is a referral to a specialist needed and what can the family doctor do in the office?
Gogol: Ideally, 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 directive group, we all agreed that the family doctor knows these patients very well and therefore knows exactly what to do. Patients also come to see them after Epstein-Barr virus infections, influenza, pneumonia, or after a hospital stay.
A supplement to the COVID/Post-COVID Long Syndrome guideline contains red flags for family physicians to watch out for. For example, if the patient has circular pains in the chest, this should be treated immediately. There is already a guideline for dizziness. It is complex and a challenge for the family physician. In terms of fatigue, current guidelines by Carmen Scheibenbogen, MD, PhD, can be used as a guide. For post-infectious coughs, for example, a pulmonologist is not necessarily necessary. The cough guideline recommends treatment with an asthma inhaler to soothe the airways first. However, it is important that persistent symptoms are absolutely monitored.
Medscape: How do you incorporate your own experience and medical history into your practice consultations?
Gogol: In my interactions with patients, and not just with post-COVID patients, I have noticed that my awareness of chronic illnesses, dyspnea, or non-specific discomfort that the patient cannot accurately describe is is significantly improved. I now know more precisely what it means when patients say, “Just recently I was able to reach the second floor with no problem, and now I need a break from the first floor. It is not clear if the patient is unfit, if his shopping bags are simply too heavy or if he suffers from a serious illness.
If you have been through such circumstances, if you suffer from dyspnea or if you simply need help with shopping, but the doctor cannot find anything, it can be very stressful. I have developed a better understanding of this and what can and should be specifically requested.
Medscape: What does the rest of the therapy look like?
Gogol: Chest physiotherapy is an important cornerstone of treatment. In my opinion, it can even be prescribed before rehabilitation, because it takes an extremely long time for the patient to get a slot. If possible, a specialist should be consulted beforehand. A physiotherapist must also be found here first, but this is doable. The same applies to occupational therapy, speech therapy, manual therapy or classical massage. These therapies don’t break the bank to begin with — according to the National Association of Statutory Health Physicians — post-COVID syndrome must have been diagnosed first.
Medscape: How does billing work here?
Gogol: All outpatient treatments take place before inpatient treatments. When prescribing remedies, there are special requirements for breathing exercises, manual therapy and speech therapy. The prescription is valid for 3 months.
As always, registration for the rehabilitation procedure takes place via the health insurance fund, the pension insurance fund or the professional association, depending on who is responsible for bearing the costs.
Medscape: How was it for you? What did you go through and what helped you?
Gogol: As a pulmonologist and internal medicine specialist, I thought I could decide everything on my own. After my stay in the hospital, I received follow-up treatment, but the dyspnea persisted. I went to see a pulmonologist, a colleague of mine. She said, “You’re just too fat and out of shape.” It wasn’t until 6 months later that I had an appointment with the cardiologist, who diagnosed myocarditis. It might have been better to go see the family doctor! They would have done certain things, checked lung function and done blood tests, and examined me much more closely. Overall, post-COVID outpatient clinics haven’t done anything different.
I made the classic doctor’s mistake and was overconfident in myself and thought I could arrange everything on my own. It would have been much faster if diagnostic measures had been carried out based on my symptoms and if the family doctor had coordinated everything. Associations of health insurance doctors have set up national networks for this purpose, because not all of the people concerned can be treated in specialist practices.
Medscape: What has changed since you were infected with SARS-CoV-2?
Gogol: Every day is different, but the good days have become much more frequent. I do rehabilitation sports through my employer. After my stay in the hospital and various complications, I still have severe shortness of breath and weakness after exertion. Working days here at the MVZ sometimes last 9-10 hours and are often very strenuous.
My ability to concentrate has improved a lot and I no longer suffer from trouble sleeping. The sleep disturbances were very persistent.
Medscape: What do we know about the link between SARS-CoV-2 infection and sleep disorders?
Gogol: The exact mechanisms are still unknown. In addition to the brain affected by COVID-19, psychogenic causes are also discussed. For example, in sleep studies in patients from Ischgl, Austria, it was found that the REM phase of sleep no longer restricts movement, causing you to wake up. A deep sleep phase is clearly limited by a neurological inflammatory reaction. Some patients in my practice report suffering from insomnia ― something I have also experienced.
Medscape: Three tips for your colleagues to manage post-COVID patients?
Gogol: Patience is very important for the patients and for the doctor. We physicians must protect these patients and keep each other informed. This is the most important thing. Family doctors have the opportunity to organize themselves in the network of associations of doctors of the statutory health insurance on the long COVID. The network is already in place in Berlin and Bavaria and is also being formed in other federal states. Colleagues can receive reliable information from other colleagues here about what is currently possible, where to get what information and where patients can receive further treatment. Cases that have reached an impasse can also be discussed.
The problem is what happens to patients who still have no 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 in long COVID support groups. We need to learn from this and think about how to reintegrate these patients. Increasing research on the disease and raising awareness about it is also an important part of this. The numbers are certainly not going down.
Medscape: Thank you very much for the discussion!
This article was translated from the German edition of Medscape.