Achives from Author

Covid19 Treatment- What You Need to Know

By editor
April 7, 2020

As more of our patients test positive for COVID19, it’s a good time to look at treatment options.

Caduceus is actively managing a case load of over 50 cases, all accumulated over the last three weeks. There will be more by the time you read this; we take on additional cases every day. Most are diagnosed through our own testing program, and we also accept referrals from patients unable to find doctors to treat them. Our cases stretch from LA to Riverside. 

We have developed a treatment protocol based on available research and old fashioned “trial and error.” By spreading the word, we hope current and future COVID-19 positive patients may find it useful. 

STEP 1---It seems obvious, yet we insist on COMPLETE AND TOTAL BED REST. Multiple studies over the years show the beneficial effect on our immune system to minimize stress on your body while fighting infections.  That means bed, couch, or recliner. Patients can get up to use the bathroom and shower and eat at the dinner table. Alone. 

The idea of exercising the virus away or keeping the body in shape will certainly prolong the symptoms. You feel fatigued with the virus for a reason- your body is asking for rest. Listen to it.

STEP 2--- Have a Covid cocktail.  NO, not that kind. (We named it, but feel free to steal it.) Sudafed, Promethazine DM, and an albuterol inhaler. A twist is optional.

The idea is simple; we need to keep the mucus and fluids out of your lungs. That is where the serious cases have problems.

The Sudafed shrinks the blood vessels in the nasal passages, reducing congestion. The Promethazine Dm (by prescription only) helps with the cough, thins the mucus, helps keep the lungs clear and helps you rest. 

The inhaler (also a prescription) opens up the airways. It’s like removing the cones from a two lane highway, making it a four lane highway. We want a path for the fluids to get out of your lungs. 

Not everyone needs all three. We grade all of our cases as asymptomatic, mild, moderate or severe. The exact ingredients of the cocktail and the frequency varies on severity of the case. 

Results? Unquestionable improvement.   

STEP 3---Finding a medication that fights the virus.  We have been putting all symptomatic cases on the "Double Z’s"- a Zpack and Zinc. For the Zpack, it is more than just preventing a secondary bacterial infection. Azithromycin appears to have activity over "atypical" bacteria, which have some elements of a virus. It was used in Asia with fair success. 

Zinc makes sense. We know there is activity using Zinc versus the common cold. It’s safe, cheap, and readily available.

Unfortunately, neither has been especially impressive. 

Hydroxychloroquine -aka Plaquenil - has been our go to for moderate to severe cases. The results so far ARE impressive.  Despite media reports that millions of doses are flooding the pharmacies, it is still a challenge to find it. The pharmacies want to see proof of a positive result. Most deny having it.

So far we have been able to find it for every patient we feel has needed it. But it takes a lot of calling around. We have had to send patients out of the OC to get it. Our advice- if you are positive and are sick, let us find it for you. Our goal is to keep you out of the hospital.

Both Proteus inhibitors (used for HIV) and Ivermectin (used for scabies) have promising reports- we will advise those in certain cases if Plaquenil is not available or fails.

That's about it. No other meds appear to be worth using at this time.  (Convalescent serum is being developed, but will be reserved for inpatient usage)

STEP 4--As a medical student in the ‘70's at the VA Hospital, I would need to get up at 3 AM to perform an order for "Pulmonary Toilet.” In the 21st Century, political correctness renamed the process “Pulmonary Hygiene.” Either way, it’s getting the yucky mucus out of the lungs.

The premise is simple- put a glass of water on your front porch. In a few days, it turns brown, and has little things swimming around in it. But a garden hose trickling for days stays clear. Stagnant fluid in the lungs turns badly infected, and needs to be removed. Here are the three processes we teach--they should be done 3-4 times a day.

TURN, COUGH, AND DEEP BREATHE- Lie in bed on your right side, cough hard, take a deep breath, and turn to your left side and repeat. Do this for 5 minutes. Imagine trying to get honey from the bottom of a jar to the sides. Same idea. 

INCENTIVE SPIROMETRY- If you have one of those gadgets with balls that rise as you take a deep breath; perfect.  Otherwise, improvise by exhaling totally, take as deep a breath as deeply as possible, hold it for 5-10 seconds, exhale, and repeat the process for 5 minutes. We need the airways open, and this accomplishes that.

PERCUSSION AND DRAINAGE- Again we improvise for home use. You'll need a partner wearing PPE (protective personal equipment). They cup each hand and begin playing the bongos on your back as you lie over a table with your shirt off. They should pound fairly hard. After about a minute, they should leave the room as you cough deeply to remove as much fluid as possible. Repeat the process for five minutes or more. (As a medical student I would sing “BABA LOU” as I played bongos on my patient’s back- it kept me awake and sometimes they'd even sing along.)

As part of the protocol, we schedule video visits every one to five days depending on the severity. Per CDC criteria, this protocol is complete once the patient is without fever or symptoms for three days, and at least one week after the original diagnosis (although we advise two weeks in most cases). 

At this point we can do a test.  A nasal PCR will tell us if the virus is still there. An ACCURATE antibody test will tell us if your immune and recovered. To date there is no test to see if you are an asymptomatic carrier other than repeated PCR swabs.  We currently advise a PCR nasal swab done at our curbside locations. By the time your home we will have an answer. Keep in mind both the antibody tests and nasal swabs are still in short supply. 

Results?

50 cases are hardly sufficient for a statistical analysis. What our records show is two patients that tested positive needed hospitalization -4% compared to a 12% national rate.

Of course we began testing earlier than most of the country and were able to start treating with milder cases. No deaths of our patients have occurred, compared to a 3% national mortality rate. As we head to 100 cases under our protocol, we must brace ourselves for that possibility. 

The three most effective treatments?

  • Total bedrest.
  • Plaquenil.
  • Aggressive Pulmonary Toilet- I mean Hygiene.

We share this with you hoping you will share this with others.  If you know someone with COVID19 and is not doing well, perhaps this data will assist. If you are a medical professional, please feel free to critique and/or use the info here. If you have successful treatments we didn't mention, please let us know. It will be awhile before the peer reviewed journals can give us strong data. By then it may be too late for some victims. 

Gregg DeNicola MD, Chief Medical Officer

See the doctor from your phone and schedule your next visit from the comfort of your own home.


COVID-19 TESTING 101

By editor
March 31, 2020

AN IMPORTANT MESSAGE FROM OUR CHIEF MEDICAL OFFICER GREGG DENICOLA MD

One of the most heated topics when reviewing patient feedback on our blog involves COVID-19 testing and the length of time to receive results as well as the availability of tests. We sympathize on the turn-around time complaints as we are as anxious to get these results back as our patients are. When the lab machine can handle 250 tests a day and they are getting 750, things back up as one may expect. Hopefully between lower demand and more machines we will see this be less of a problem soon.

So let’s do a “Testing 101” and emphasize three major issues:

1. Who should get tested?
2. What are the different type of tests now coming out?
3. When should a negative test be rechecked and a positive test as well?

Who Should Get Tested-

In the first blog post we went over the five major criteria- personal exposure, recent high risk travel, fever, upper and lower respiratory symptoms.  What makes it confusing is that the CDC is leaving it up to each provider to determine the need for a test. One group may be very "tight" in their approvals, while others very "loose.”  The wild card is the chronic lack of availability of the tests. Some days Caduceus starts the day with only 25 tests that would typically last a half day. Other days we wake up to 250 tests at our three swabbing centers. 

Calling the local OC health department was of little help; they suggested a common sense solution. Save the tests for the highest risk patients- seniors, smokers, and those with impaired immune systems. So the days we are low, as CMO, I have had to tighten the approvals to those groups only.  Other days, we are much more liberal in who we can screen.

Is this a form of rationing? Absolutely. It goes against everything we stand for as a medical group.  Fortunately, we have never run out of tests since we started after they first became available.  At this time we appear to have sufficient tests to keep our current testing capacity. We have done well over 500 tests, with a 6% positive rate. We commit to our patients- as long as we have it within our power –that we will have enough tests to continue testing daily as long as necessary.

We continue to insist that everyone who even THINKS they meet criteria, attempt to get tested. Otherwise, one may compare it to off-roading in a Jeep at night without headlights. Yes, one MAY be fine- until coming to a cliff.

Caduceus must give HUGE accolades to our Senior VP’s of Operations, Monique Wusstig and Katie Franklin.  Their focus and determination to keep us fully stocked with swabs has been inspirational and life-saving. 

The take home message?

If you have a fever or are sick, DO NOT IGNORE IT. Don't "watch" it. Ask your physician or provider a medical question at mousecalls@caduceusmedicalgroup.com.  Schedule a video visit on our app or email our team at videovisits@caduceusmedicalgroup.com. Get swabbed. We will figure out a way to get you tested. 

Let’s discuss the different type of tests now coming to the market-

The gold standard--the only test Caduceus has used--is the "PCR" test on a nasal swab. This can detect as little as one virus particle in swabs taken from inside the nose.  For Covid-19, the exact accuracy of PCR is unclear but PCR’s in general for other conditions are usually over 95% accurate.

The MOST important statistic is the "false negative.”
To be told you don’t have Covid-19 could be a disaster if you go back home and continue normal daily activities and sleeping habits with your spouse or partner and you really do have it.

A false positive is no  picnic either; to stay quarantined alone and pray you do not contract life- threatening pneumonia when you don’t have Covid-19 at all is also not ideal.

The PCR nasal swab has very rare false positives or negatives.

The two problems with the PCR test are the lack of availability and the turnaround time on results, which should be three days, but has been over a week in some cases. 

Enter the new antibody test. It’s a blood test and may be easier to find. Most only take 15 minutes, so you can get the result while you wait. Problem solved? 

You guessed it; nope. The false negative rate is at least 10%. If we do 200 tests this week on that machine, 20 people will be told they are negative when they are actually positive. Also, there are different types of antibody tests with varying time for results and accuracy. 

Some are even "fake" with reports that clinics charging are $250 for the test. My advice is NEVER to pay for a Covid-19 test. It’s against the law to charge the patient for the test. A doctor “on the level” will bill your insurance.  As tempting as this test is, I’m afraid I MUST advise you to pass on the blood antibody test. One disclaimer- If we run out of PCR swabs for the long term, we WILL revisit using the antibody test. 

A third player will enter the game in the next few weeks. Abbott Labs has a small machine intended for private medical and urgent cares. Called Abbott ID Now, it is a swab, not blood, and gives results in 5-10 minutes. They envision tens of thousands of these machines being utilized around the country through the month of April. Now we are “cooking with gas” right? Not so fast. Although Abbott hasn’t released exact data yet, one study shows a whopping 40% false negative rate! 

Extreme caution must be used NOT to follow the temptation of a rapid test readily available. Time will tell if they are adequate for accuracy. If you’re skeptical of my cynicism, just Google “Theranos.” 

 The take home message? 

I do NOT advise rapid "point of care" antibody blood tests or swabs on small machines at this time. The current PCR test is the gold standard for a reason. It’s accurate. The Covid-19 virus is not the time to be experimenting and risking a false negative or positive .Your life and the lives of your loved ones may depend on it.

Testing re-checks for both negative and positive-

Even though the PCR is accurate, are there times to re-swab? Yes.  If you test negative, but you just landed from New York and then develop a fever, you need to be swabbed again. If you have a productive cough, test negative, but the cough worsens with trouble catching your breath, do a re-swab. If your partner tests positive, and you test negative, but you later spike a fever---you guessed it... re-swab. You could have another video visit to discuss things and confirm with the doctor but they WILL advise a re-swab. 

What about those that have tested positive? When do they get swabbed again? Ahhh, this question is a bit trickier. 

We call that a "test of cure" and it is very controversial. Mainly because it’s possible to stay positive for an extended period of time but we aren’t sure you're really contagious if symptoms have resolved. The CDC has gone on record as leaving it up to the treating physician or care provider whether to test a positive case until we receive a negative result. At first it was standard to re-swab once feeling better, but the trend now is swinging away from re- testing.

It is possible once the quarantine is over employers will require a “test of cure.” Bed partners may request one. Those seeking peace of mind will ask for one. At Caduceus we are taking this on a case by case basis. Surprisingly, most of our victims of Covid-19 have declined the “test of cure.” Most say they feel great and to save the swab for those that really need them. In times of crisis, we see that people really DO care.

The take home message?

If you test negative, don’t be bashful if your symptoms are new or persisting. We will re-swab you if there is any doubt. If you are recovering, you should discuss re-swab with your physician. We feel everyone who has any reason to be tested, should be. 

After all, shouldn't we follow the lead of that great troubadour, Bob Dylan, who, in the song Rainy Day Women, sang "Everybody must get swabbed"? 

Gregg DeNicola MD
Caduceus Medical Group
Chief Medical Officer


COVID-19 IMPORTANT UPDATES FROM OUR CMO

By editor
March 24, 2020

AN IMPORTANT MESSAGE FROM OUR CMO (CHIEF MEDICAL OFFICER) GREGG DENICOLA MD

There is a new phrase I've noticed being used regularly. It used to be when discussing travel plans and logistics, we would refer to a time frame. 

“Want to plan a vacation?” Maybe in the fall!
“Try the new sushi place?” Let’s go next month!
“Go wine tasting?” Next weekend!

Now the answer to all of those ideas is the same - "After all of this is over.” Six short words that express simultaneously both despair AND hope.

 I want to discuss 3 important--and possibly life-saving topics:

1. A plea to not ignore your normal health care needs.
2. Our take on the new therapies being touted.
3. The need to test---real or overblown?

I noticed about 10 days ago a patient I am treating for an irregular heartbeat had cancelled his appointment.  He normally sees me to check-in every six months. He has been stable for years. Concerned, I called him. He said-you guessed it-he wanted to "hunker down,” and he would reschedule after “ALL OF THIS IS OVER."

I convinced him to convert the office visit to a video visit. He needed blood drawn, since he was also on thyroid medication, which could affect his heart rate and his blood sugar was always in the pre-diabetic range. We arranged a curbside blood draw a few days before the video visit.

Sure enough his thyroid level was elevated and required a reduction of his thyroid medication. Unchecked, it easily could have led to a serious arrhythmia. His blood sugar was also higher than usual, which he admitted was due to increased snacking and poor dietary choices during his "hunkering.” 

It is obvious that high cholesterol stays high during a pandemic. Fatty livers are still fatty and those patients need their blood tests to check them.  Moles do not stop their progression to melanoma just because Mr. Newsom tells us to stay home.  

With video visits and curbside lab draws, all of these can be evaluated and managed via telemedicine. We have been doing telemedicine at Caduceus for over six years with excellent results. Of course there are situations where the patient must be seen in person. Since our lobbies and rooms have been infection-free for some time; it is still safer to be seen by your doctor than letting your non-COVID health suffer.

The moral of the story? 

  • Keep your appointments.
  • Convert them to Video Visits.
  • Have your blood drawn curbside.
  • Do NOT wait until "all of this is over" and this message is even more important than preventing the spread of the virus. And it is even more essential than a trip to Costco.

I have examined the evidence to use Hydroxychloroquine for COVID-19 cases and it is promising.  We have been using it at Caduceus to treat swab positive cases, but it is very hard to find. Some pharmacies are concerned about supply depletion which will lead to lupus patients unable able to refill their prescriptions.  Others say they don't agree with the indication. Yet others simply deny having any. There is little question the risk/benefit curve points in favor of the liberal use of it in positive cases. If there are no symptoms (e.g. the patient was returning from Europe and tested positive but had no symptoms) it is NOT indicated. 

For any physicians and other care providers reading this, the dose is 400 mg. BID x 1 day, then 200 mg bid x 4 days. Warning-you will need to call around and be prepared to beg. 

Also, Proteus Inhibitors have shown activity against COVID. You may have heard of them as HIV medications.  Current COVID-19 guidelines reserve their use for cases admitted to the hospital.  Both WHO and CDC are advising us AGAINST the use of Tamiflu for COVID, as well as NSAID’s like Ibuprofen.  More importantly, they also now advise against the use of steroids, such as Prednisone or a Medrol dosepak. 

The moral of the story?

  • Although there is no consensus from the specialists on this, as CMO I advise the routine use of Hydroxychloroquine for all swab positive Covid cases with symptoms.
  • It is NOT to be used preventively.  
  • No other drug therapy is currently advised unless admitted to the hospital.

I am sure most of you know Caduceus and PDQ and More Urgent Care has been testing for over a week now. The first day we allowed in-office testing but soon saw the need to screen/test
patients in the comfort of their homes and cars. A video visit is required to receive the order from the provider then the patients are directed to one of our three curbside locations in Orange County to be swabbed. Results currently take a minimum of 2-4 days.  Unfortunately supply of tests being distributed to physicians is  not matching the demand for testing.  The number of test kits being made available is not enough.  We need to test everyone with symptoms or at risk due to exposure. Caduceus has done over 350 swabs so far but could have done thousands more if we had them.

I must respectfully disagree with Washington officials who say if you don't have symptoms, you do not need to be tested. It is very easy to spread this virus without symptoms. Not every COVID patient knows how they were exposed. The problem with comparing this to the flu or to almost any other virus is that it has such a long incubation period.  For non-nerds that means you can spread it without knowing you have it. And its penetrance is quite high; for non-nerds that means it is VERY easy to catch it, no matter how good your immunity is. To our immune systems COVID is a new enemy, never seen before, which makes fighting it very difficult.  
These are the reasons we are seeing it spread like a wildfire and why officials demand quarantining of everyone to control it.

Worse, it is NOT true that only the old and infirmed are at risk for dying.  The last two deaths I am aware of were a 35 year old and a 24 year old. It appears COVID is a "lung eater.”

If it stops at a sore throat or bronchitis there is a full recovery. But 10-20 % of the time it goes into a full pneumonia, causing a SARS situation. This is more common in vapers. It makes more and more mucus and fluids, which doctors cannot always successfully manage. These victims literally drown while in ICU. 

Despite this plea for more tests, I want to caution AGAINST the new "at-home" test kits. User error is one issue and the accuracy is suspect. There are already knock-offs that are not FDA sanctioned. They may be perfected soon, but as of now, I'd avoid them.

The medical board of California is investigating concierge physicians selling at-home test kits for up to $400.  Besides probably being inaccurate, it is also both illegal and unethical. Current law waives any patient responsibility for COVID-19 screening and swabbing. Do NOT agree to pay cash for any type of screening or swab test.

The moral of the story?

  • If you are sick or have been exposed get tested. We will help.
  • Don’t count on your immunity to save you.
  • Don’t use the new at-home tests quite yet. 

Only by testing as many people as possible can we get our lives back....
"After all of this is over."

Gregg DeNicola MD
Caduceus Medical Group
Chief Medical Officer

Reserve your next visit from the comfort of your home at videovisits@caduceusmedicalgroup.com.  


COVID-19 CORONAVIRUS LATEST UPDATES AND FAQ'S

By editor
March 16, 2020

AN IMPORTANT MESSAGE FROM OUR CHIEF MEDICAL OFFICER GREGG DENICOLA MD

Published 3-16-2020

It is impossible to turn on TV or engage on any social media platforms without being informed about the Covid-19 crisis, thus we felt it best to use the newest update in an “FAQ format.”
 
Q: Are things getting better at all? How do we know if all the measures are working?
 
A: We advise you to follow us on Facebook and Instagram where we post the number of new cases globally every morning. It has been suggested we post U.S. numbers but this is a global pandemic. As long as the number of global cases are increasing, we are at risk. 
About a month ago, it was 1000 new cases a day. Then at the end of March, 3000. A week ago, 5,000. Today 10,000.That is because each new case has infected numerous others. The biggest difference between Covid-19 and the flu is that we know the flu season ends each March historically. We have no end in sight to this virus.
 
Q: I understand the need for self-quarantine to limit the spread. But what CAN I leave the house for? 
 
There are always special situations, e.g. a loved one who lives apart from you and needs assistance, your pharmacy doesn't deliver and you need your meds, etc. In reality there are only two essential reasons to leave quarantine.
1. Food. You need to eat and drink. As the shelves get restocked you need to buy your provisions. 
BUT--consider learning to use delivery services (Instacart, etc.) to get your groceries without leaving your home. Especially if you are a senior or not in perfect health.
 
2. Health. You should still take care of your health which means keeping your medical appointments. It makes no sense to isolate to prevent this virus yet have your diabetes run out of control, your blood pressure become elevated, or your tension headaches go without treatment, which could indicate something more serious. 
 
BUT --consider using video/virtual visits aka “telehealth” or “telemedicine.” Over 80% of visits can be done via face to face video from the comfort of your home. It’s easy to set up and is used with your mobile device or tablet (ex. iPad)
 
Q: Are Caduceus' offices open?
A: We are taking it day by day and yes we are open for normal business. We STRONGLY encourage all of our patients to use the Caduceus or the PDQ Urgent Care and More app and seek out care via a video visit from your mobile device during this crisis.
IF YOU ALREADY HAVE AN APPT, please change it to a video visit. Please DO NOT CALL THE OFFICE during this time. You can email patient support at mobile@caduceusmedicalgroup.com or use the “Live Chat” feature on our website at caduceusmedicalgroup.com. Our staff will be calling all patients with appointments to ask them to change it to a video visit.
 
IF YOU DO NOT HAVE AN APPT BUT WANT TO MAKE ONE, start off by scheduling a video visit. It is easy to request by email at either mobile@caduceusmedicalgroup.com or by “Live Chat” on the website. If your doctor doesn't currently offer video visits we can have you see a provider that does temporarily until you can come in the office to be seen.
 
IF YOU ONLY WANT TO BE SEEN IN PERSON, we are open for you. We have not allowed suspected infections into our lobbies for almost a week. There will be no one infected near you during the visit. Of course that doesn't guarantee the people you will come in contact with are not infected. Any staff member who has any signs of infection is not allowed to work. 
 
Q: Is Caduceus still doing Covid-19 swabs?
Yes. We have a limited number of swabs still available and are awaiting word on having the labs sending more. If we do not have a new shipment soon, we will run out mid-week.
We are now announcing a new protocol for Covid-19 testing.
-All patients wanting COVID-19 testing must first be screened by a provider through a video visit. You can book that through the PDQ Urgent Care and More app. If you have trouble, please use “Live Chat” on pdqurgentcareandmore.com . We have been doing video visits since 2012 and have the technology and systems set up to handle the volume assuming the PDQ app is used on an iOS or Android mobile device or tablet.
-Once the screening is done, you can be directed to one of our THREE curbside testing centers.

  • We cover all of Orange County
    • North County- Caduceus Yorba Linda Family Practice and Urgent Care Ste 201 and 203
    • Central– PDQ Urgent Care and More in Orange
    • South County- Caduceus on Thalia in Laguna Beach

 
For Covid-19 screening, we are using video visits and curbside swabbing only. This allows for evaluation from the comfort of your home and car.

For ANY infection that presents to one of our urgent cares including ANY FEVER, you will be directed back to your car for a video visit. Our staff will assist in setting up the video visit for you.
If a fever is discovered after performing vital signs prior to your actual visit with the provider in ANY Caduceus office, you will also be directed to your car for a video visit. Patients with fevers will not be roomed in any Caduceus office. 
 
-Once screened, you MUST return home for self-quarantine until the result is in, usually 3-5 days. 
 
This is a daily evolving situation. Please monitor our social media, e-newsletter, and website for updates. Since we are sending any staff home that are even possibly sick, including our doctors, we ask your understanding as we mobilize our resources to best handle the Covid-19 pandemic. 
It is best to NOT cancel any visit, including annual check-ups, with the idea of rescheduling in the summer. We anticipate our provider schedules to be full so it is advised to keep your appointments. We can do a lot to treat you via a video visit, so please give some thought to changing your appointment to see the doctor from your phone.  We can always reschedule your in-person appointments once the crisis allows. 
 
Q: Anything new with prevention or treatment?
 
A vaccine is being tested but not available for community use. There are anecdotal reports of various anti-viral antibiotics being successful, but the data has not yet been published.
I have read reports on social media and even mainstream media supporting ginger tea, vitamin c, turmeric, garlic, and CBD drops being successful treatments. There is NO evidence for ANY of these, although they may be harmless to try. 
 
In Summary:

  • Stay home except for essential reasons
  • Use delivery services for food
  • Use video visits for your health care in lieu of rescheduling in person appointments
  • Do NOT ignore a fever or signs of infection.  Ask a medical question to your physician at mousecalls@caduceusmedicalgroup.com or schedule a video visit ASAP
  • Follow us on social media to keep current on the numbers and our latest recommendations

 
Gregg DeNicola MD
Caduceus Medical Group
Chief Medical Officer


COVID-19 (CORONAVIRUS) TESTING NOW AVAILABLE

By editor
March 12, 2020

BREAKING NEWS FOR LA/OC/RIVERSIDE county residents – Caduceus Medical Group will now be offering Coronavirus COVID-19 curbside testing and medical travel clearances.

A few COVID-19 facts:

• The virus is NOT slowing down. A month ago the WHO (World Health Organization) was publishing 1000 new cases a day. Two weeks ago, 2000. As of this morning, WHO announced 4627 NEW cases in the last 24 hours..

• Please ignore posts on social and news media comparing Covid-19 to the "flu" which had more cases and deaths this year. There are 3-4 strains of the flu, all lumped into one statistic. Covid-19 is ONE strain of coronavirus and appears to be a very different strain.

• Also the seasonal flu season is over and generally ends of February. Covid-19 appears to be just getting started, unless, as we are all hoping, the warmer spring weather kills it off.

• The biggest difference is that it is easy to test for the flu. Standard swabs are available at most urgent cares and emergency rooms across the country and the world. Since patients typically feel sicker with the flu, they are more likely to be seen and get a diagnosis. Covid-19 can start with milder symptoms and until very recently there was NO easy way to test for it; we are seeing a definitive UNDER-reporting as to the number of new cases and fatalities. Some authorities are estimating the number may be being miscalculated by at least TEN fold; in other words, the total may have actually been 39,000 in NEW cases today alone.

What makes this virus so different?

• During the 14 day incubation period an infected person can spread it even exhibiting NO symptoms. That is very unusual for most viruses.

• It appears to be VERY easy to "catch.” Very casual contact can spread Covid-19 where as most other viruses need a form of closer contact.

As CMO, I am taking this opportunity to announce two new initiatives.

1. Clearance letter for airline travel-

Many airlines and resorts are requiring a "clearance letter". A swab is unnecessary. The clearance letter requested asks the medical provider attest the patient is healthy, asymptomatic, and has experienced no recent fevers. The patient should have no known exposure to viral diseases and a normal physical exam.  Caduceus will do these clearances on a walk-in basis at two locations- PDQ Orange and Caduceus on Thalia in Laguna Beach. Since clearances are not covered by third parties, Caduceus will charge an affordable cash price of $69 for this visit. If a blood test, such as a CBC (complete blood count) is needed, a $20 charge may be assessed.

2. COVID-19 (coronavirus) curbside testing-

Local labs such as LabCorp and Quest are now offering the kits for testing for Covid-19. As you can imagine, they have been swamped with calls, but here is what we can report as of Thursday, March 12th.

• Caduceus has ordered and received swab kits from both Labcorp and Quest.  These kits are in short supply and being rationed; we will reorder when the stock has been depleted and cannot guarantee delivery dates.  Priority will be given to those patients determined by the provider that are good candidates for the COVID-19 swab that arrange for a video visit in lieu of coming in to an office location.

• The labs do NOT want patients to come to their draw stations. They will run tests only ordered by a physician, physician assistant, or nurse practitioner.

• Governor Gavin Newsom has announced these tests will be free of any cost sharing. In other words, FREE.  There will be no co-pay, co-insurance, or applied to a deductible for running the test.

• This new rule applies to all commercial insurance plans, both HMO and PPO, as well as MediCal. It does not apply to Medicare patients.

• The labs do not know the cost but will bill your insurance. Any payment billed to the patient will be from the lab, not Caduceus. The patient should NOT receive a bill. Any dispute on the "free" testing should be directed to the Department of Insurance or Managed Health Care. Caduceus only performs the swab.

• The labs and health department will NOT run tests for patients without symptoms; there are simply insufficient kits. Caduceus providers will also abide by this protocol and will only do the swab on patients with symptoms or findings consistent with a viral illness.

• We are directing ALL patients WITH SYMPTOMS (fever, coughing, sneezing, and shortness of breath) to our PDQ Orange urgent care for North County patients and Caduceus on Thalia in Laguna Beach for South County patients. NO appointment necessary.

• A curbside video visit from your mobile device in your vehicle will be required to be swabbed for Covid-19. This will be billed as a standard office visit, subject to co-pays and/or deductibles, and we also offer a cash price option.

• If you are doing a walk-in, please text or call PDQ Orange (714-287-0459) or the Laguna Beach office (949-482-9699) and let the staff know you are in the parking lot and are wanting the Covid-19 swab. A staff member will be out to assist you.  If you prefer to do the visit in-office, let the staff know and they will escort you to a room.

• The estimated time for results is 3-4 days. They will be emailed to you directly through the secure patient portal.

Since we can only provide the Covid-19 to swab patients with symptoms and we feel ALL patients with symptoms should stay home, the swab is not useful for the clearance letter. These are two separate and distinctive initiatives we are offering for our patients and the community.

If you aren't sure you qualify for the Covid- 19 swab, consider doing a same day video visit from the comfort of your home, office, or other location. You can message your physician through the patient portal or email your physician a medical question via mousecalls@caduceusmedicalgroup.com.

Follow us on Facebook@caduceusmedical and also make sure you are on our email list for regular coronavirus updates.  If you are not receiving our emails, request patient support to be added at mobile@caduceusmedicalgroup.com.


COVID-19 (CORONAVIRUS) TESTING NOW AVAILABLE

By editor
March 12, 2020

BREAKING NEWS FOR LA/OC/RIVERSIDE county residents – Caduceus Medical Group will now be offering Coronavirus COVID-19 curbside testing and medical travel clearances.

A few COVID-19 facts:

• The virus is NOT slowing down. A month ago the WHO (World Health Organization) was publishing 1000 new cases a day. Two weeks ago, 2000. As of this morning, WHO announced 4627 NEW cases in the last 24 hours..

• Please ignore posts on social and news media comparing Covid-19 to the "flu" which had more cases and deaths this year. There are 3-4 strains of the flu, all lumped into one statistic. Covid-19 is ONE strain of coronavirus and appears to be a very different strain.

• Also the seasonal flu season is over and generally ends of February. Covid-19 appears to be just getting started, unless, as we are all hoping, the warmer spring weather kills it off.

• The biggest difference is that it is easy to test for the flu. Standard swabs are available at most urgent cares and emergency rooms across the country and the world. Since patients typically feel sicker with the flu, they are more likely to be seen and get a diagnosis. Covid-19 can start with milder symptoms and until very recently there was NO easy way to test for it; we are seeing a definitive UNDER-reporting as to the number of new cases and fatalities. Some authorities are estimating the number may be being miscalculated by at least TEN fold; in other words, the total may have actually been 39,000 in NEW cases today alone.

What makes this virus so different?

• During the 14 day incubation period an infected person can spread it even exhibiting NO symptoms. That is very unusual for most viruses.

• It appears to be VERY easy to "catch.” Very casual contact can spread Covid-19 where as most other viruses need a form of closer contact.

As CMO, I am taking this opportunity to announce two new initiatives.

1. Clearance letter for airline travel-

Many airlines and resorts are requiring a "clearance letter". A swab is unnecessary. The clearance letter requested asks the medical provider attest the patient is healthy, asymptomatic, and has experienced no recent fevers. The patient should have no known exposure to viral diseases and a normal physical exam.  Caduceus will do these clearances on a walk-in basis at two locations- PDQ Orange and Caduceus on Thalia in Laguna Beach. Since clearances are not covered by third parties, Caduceus will charge an affordable cash price of $69 for this visit. If a blood test, such as a CBC (complete blood count) is needed, a $20 charge may be assessed.

2. COVID-19 (coronavirus) curbside testing-

Local labs such as LabCorp and Quest are now offering the kits for testing for Covid-19. As you can imagine, they have been swamped with calls, but here is what we can report as of Thursday, March 12th.

• Caduceus has ordered and received swab kits from both Labcorp and Quest.  These kits are in short supply and being rationed; we will reorder when the stock has been depleted and cannot guarantee delivery dates.  Priority will be given to those patients determined by the provider that are good candidates for the COVID-19 swab that arrange for a video visit in lieu of coming in to an office location.

• The labs do NOT want patients to come to their draw stations. They will run tests only ordered by a physician, physician assistant, or nurse practitioner.

• Governor Gavin Newsom has announced these tests will be free of any cost sharing. In other words, FREE.  There will be no co-pay, co-insurance, or applied to a deductible for running the test.

• This new rule applies to all commercial insurance plans, both HMO and PPO, as well as MediCal. It does not apply to Medicare patients.

• The labs do not know the cost but will bill your insurance. Any payment billed to the patient will be from the lab, not Caduceus. The patient should NOT receive a bill. Any dispute on the "free" testing should be directed to the Department of Insurance or Managed Health Care. Caduceus only performs the swab.

• The labs and health department will NOT run tests for patients without symptoms; there are simply insufficient kits. Caduceus providers will also abide by this protocol and will only do the swab on patients with symptoms or findings consistent with a viral illness.

• We are directing ALL patients WITH SYMPTOMS (fever, coughing, sneezing, and shortness of breath) to our PDQ Orange urgent care for North County patients and Caduceus on Thalia in Laguna Beach for South County patients. NO appointment necessary.

• A curbside video visit from your mobile device in your vehicle will be required to be swabbed for Covid-19. This will be billed as a standard office visit, subject to co-pays and/or deductibles, and we also offer a cash price option.

• If you are doing a walk-in, please text or call PDQ Orange (714-287-0459) or the Laguna Beach office (949-482-9699) and let the staff know you are in the parking lot and are wanting the Covid-19 swab. A staff member will be out to assist you.  If you prefer to do the visit in-office, let the staff know and they will escort you to a room.

• The estimated time for results is 3-4 days. They will be emailed to you directly through the secure patient portal.

Since we can only provide the Covid-19 to swab patients with symptoms and we feel ALL patients with symptoms should stay home, the swab is not useful for the clearance letter. These are two separate and distinctive initiatives we are offering for our patients and the community.

If you aren't sure you qualify for the Covid- 19 swab, consider doing a same day video visit from the comfort of your home, office, or other location. You can message your physician through the patient portal or email your physician a medical question via mousecalls@caduceusmedicalgroup.com.

Follow us on Facebook@caduceusmedical and also make sure you are on our email list for regular coronavirus updates.  If you are not receiving our emails, request patient support to be added at mobile@caduceusmedicalgroup.com.


Coronavirus-What You Need to Know

By editor
March 4, 2020
As Chief Medical Officer I am asked daily about advice to Caduceus patients about the Coronavirus; now called Covid-19.  Wanting to keep the advice timely and factual, it is very difficult to separate the facts from hysteria. But someone has to do it, so here are the recommendations for Caduceus patients from the CMO.

First realize there are FOUR different bugs going around now plus the threat of Covid. Let's look at each...

1. A bacterial infection is currently on the rise-sore throat, productive cough, fever, maybe sinus symptoms. If you are fit and healthy, it may wear itself out in 3-5 days. If you are very young or very old, frail, or sickly, it may lead to pneumonia or sepsis. An antibiotic is effective, and we may be able to swab for it, or do a blood test or xray to make an accurate diagnosis. 

2. A viral syndrome with low grade fever, sneezing, cough, can be difficult to differentiate from a bacterial one at first. Even an experienced provider may need testing to tell the difference. It is usually less serious and runs its course over 2-3 days. Antibiotics do not work for a typical virus. We are seeing a fair number of these cases now, on par with this time of year.

3. NEITHER of these are the "flu". Influenza is a totally separate animal. High fevers, aches, abdominal distress, dry cough, and feeling like you've been run over by a truck are common symptoms. It can be diagnosed via a swab in the office. There are special influenza medications (eg Tamiflu) that help reduce the symptoms and duration. The "Flu" seems to have peaked and even gone in Orange County for 2020. In my personal practice we haven't had a positive case since Feb 15th. The Health Department confirms we should see very few new flu cases in March. 

4. Covid-19 begins as a typical viral illness- sneezing, coughing, low grade fever. But there are serious differences.

Fortunately, we have not had a lot of cases in Southern California--at least not officially diagnosed. But the virus can be spread for two weeks before symptoms appear. In that time, hundreds of people have been put at risk. It is spread by droplets, so simply being near an infected person can spread it if they cough or sneeze. And the 88,000 cases (as of this writing) is misleading since those are CONFIRMED cases. At least 10 times that number have occurred but just not tested for.

There is hope that as a cold weather bug, it will fade away with warmer weather. Yet it is still growing at over 1,000 cases a day being reported world wide; the same number as late January when it first appeared.  If more kits were available, you can estimate how many new cases are actually occurring.

To hear an official say "we have this under control" is irresponsible. To hear people on social media say "There were more flu deaths, life goes on" is just idiotic. For one thing, the flu deaths were over an entire season. This pandemic has just begun.For another, would these same people take a vacation to beautiful downtown Baghdad? Stroll thru the streets of Sinaloa Mexico? Of course not because we know that is dangerous. Covid 19 should also be considered dangerous.

What is the difference between an epidemic and a pandemic? An epidemic refers to a condition spreading rapidly. A pandemic is an epidemic spreading throughout the world. We are now in a pandemic. The flu was not a pandemic.

As CMO, I am advising the following measures for our patients at least thru March:

1.If you are sick, don't travel. In fact don't leave the house if possible. Of course this is always common sense. But now you run the risk of being quarantined if it is considered possible you harbor Covid 19. Many countries are screening passengers for even low grade fever. Flight attendants are instructed to report anyone they feel is showing signs of infection. If you have a fever you will be detained. and not just sent home, but put in isolation.

2. If you are not sick, but very young, very old, frail, or sickly avoid ALL non-essential travel, or areas where crowds circulate. That means malls, theme parks, churches, even ball games. Going to a school or office may only expose you to dozens of close contacts. But a crowded day at Disney will expose you to THOUSANDS of people who may be incubating Covid. 

If you are fit and relatively healthy, use common sense. Avoiding crowds and non essential travel may seem like overkill but it isn't just about protecting you- its keeping an unknowing carrier from spreading the virus to thousands of uninfected people. We do not advise staying home from work or school, but if you can cancel that trip to Europe or postpone the day to Universal Studios, it will go a long way to stopping the spread and protecting yourself and your family.

3. If you do travel in March, realize there is a high chance of disrupted travel. You may be not allowed to leave your area or be house confined. Bring your own thermometer, your own cold meds, and an extra supply of your prescription meds in case you are stuck somewhere for weeks. Have documentation of your health insurance with you. Realize you may find tourist venues closed, events canceled, and long lines at areas where screening is going on.

4. Common sense dictates frequent hand washing. Remember the rule is to wash singing "Happy Birthday" to allow enough time to wash. If you are using hand sanitizers like Purell, five seconds is sufficient. Avoid touching other people if possible, maybe a thumbs up instead of shaking hands. Prepare your own meals as much as possible. If you must cough or sneeze in public, cover the face or turn away. Normal face masks are insufficient to block Covid--you'll need to look for N 95 masks. But if your coughing enough to need the mask --STAY HOME! If you are wearing the mask to protect yourself its probably not necessary if you are fit and healthy.

5. If you feel you may have one of those three conditions at the beginning of this blog, DO NOT ignore it. Use Mouse Calls or video visits to talk to your provider. If you feel you must come to the office, alert us so we can swab you or draw your blood in the comfort of your car. If you need to be seen in an exam room, you will be escorted thru the lobby if you alert us in advance. ALL respiratory type infections should be seen and worked up during this crucial time. Covid testing is done at the health dept. 

IF world wide screening is effective

IF everyone follows these FIVE simple rules

IF Covid is a cold weather bug only

The pandemic will be history. Otherwise we may witness a pandemic unseen in our lifetimes.

Gregg DeNicola MD Chief Medical Officer


Coronavirus-What You Need to Know

By editor
March 4, 2020
As Chief Medical Officer I am asked daily about advice to Caduceus patients about the Coronavirus; now called Covid-19.  Wanting to keep the advice timely and factual, it is very difficult to separate the facts from hysteria. But someone has to do it, so here are the recommendations for Caduceus patients from the CMO.

First realize there are FOUR different bugs going around now plus the threat of Covid. Let's look at each...

1. A bacterial infection is currently on the rise-sore throat, productive cough, fever, maybe sinus symptoms. If you are fit and healthy, it may wear itself out in 3-5 days. If you are very young or very old, frail, or sickly, it may lead to pneumonia or sepsis. An antibiotic is effective, and we may be able to swab for it, or do a blood test or xray to make an accurate diagnosis. 

2. A viral syndrome with low grade fever, sneezing, cough, can be difficult to differentiate from a bacterial one at first. Even an experienced provider may need testing to tell the difference. It is usually less serious and runs its course over 2-3 days. Antibiotics do not work for a typical virus. We are seeing a fair number of these cases now, on par with this time of year.

3. NEITHER of these are the "flu". Influenza is a totally separate animal. High fevers, aches, abdominal distress, dry cough, and feeling like you've been run over by a truck are common symptoms. It can be diagnosed via a swab in the office. There are special influenza medications (eg Tamiflu) that help reduce the symptoms and duration. The "Flu" seems to have peaked and even gone in Orange County for 2020. In my personal practice we haven't had a positive case since Feb 15th. The Health Department confirms we should see very few new flu cases in March. 

4. Covid-19 begins as a typical viral illness- sneezing, coughing, low grade fever. But there are serious differences.

Fortunately, we have not had a lot of cases in Southern California--at least not officially diagnosed. But the virus can be spread for two weeks before symptoms appear. In that time, hundreds of people have been put at risk. It is spread by droplets, so simply being near an infected person can spread it if they cough or sneeze. And the 88,000 cases (as of this writing) is misleading since those are CONFIRMED cases. At least 10 times that number have occurred but just not tested for.

There is hope that as a cold weather bug, it will fade away with warmer weather. Yet it is still growing at over 1,000 cases a day being reported world wide; the same number as late January when it first appeared.  If more kits were available, you can estimate how many new cases are actually occurring.

To hear an official say "we have this under control" is irresponsible. To hear people on social media say "There were more flu deaths, life goes on" is just idiotic. For one thing, the flu deaths were over an entire season. This pandemic has just begun.For another, would these same people take a vacation to beautiful downtown Baghdad? Stroll thru the streets of Sinaloa Mexico? Of course not because we know that is dangerous. Covid 19 should also be considered dangerous.

What is the difference between an epidemic and a pandemic? An epidemic refers to a condition spreading rapidly. A pandemic is an epidemic spreading throughout the world. We are now in a pandemic. The flu was not a pandemic.

As CMO, I am advising the following measures for our patients at least thru March:

1.If you are sick, don't travel. In fact don't leave the house if possible. Of course this is always common sense. But now you run the risk of being quarantined if it is considered possible you harbor Covid 19. Many countries are screening passengers for even low grade fever. Flight attendants are instructed to report anyone they feel is showing signs of infection. If you have a fever you will be detained. and not just sent home, but put in isolation.

2. If you are not sick, but very young, very old, frail, or sickly avoid ALL non-essential travel, or areas where crowds circulate. That means malls, theme parks, churches, even ball games. Going to a school or office may only expose you to dozens of close contacts. But a crowded day at Disney will expose you to THOUSANDS of people who may be incubating Covid. 

If you are fit and relatively healthy, use common sense. Avoiding crowds and non essential travel may seem like overkill but it isn't just about protecting you- its keeping an unknowing carrier from spreading the virus to thousands of uninfected people. We do not advise staying home from work or school, but if you can cancel that trip to Europe or postpone the day to Universal Studios, it will go a long way to stopping the spread and protecting yourself and your family.

3. If you do travel in March, realize there is a high chance of disrupted travel. You may be not allowed to leave your area or be house confined. Bring your own thermometer, your own cold meds, and an extra supply of your prescription meds in case you are stuck somewhere for weeks. Have documentation of your health insurance with you. Realize you may find tourist venues closed, events canceled, and long lines at areas where screening is going on.

4. Common sense dictates frequent hand washing. Remember the rule is to wash singing "Happy Birthday" to allow enough time to wash. If you are using hand sanitizers like Purell, five seconds is sufficient. Avoid touching other people if possible, maybe a thumbs up instead of shaking hands. Prepare your own meals as much as possible. If you must cough or sneeze in public, cover the face or turn away. Normal face masks are insufficient to block Covid--you'll need to look for N 95 masks. But if your coughing enough to need the mask --STAY HOME! If you are wearing the mask to protect yourself its probably not necessary if you are fit and healthy.

5. If you feel you may have one of those three conditions at the beginning of this blog, DO NOT ignore it. Use Mouse Calls or video visits to talk to your provider. If you feel you must come to the office, alert us so we can swab you or draw your blood in the comfort of your car. If you need to be seen in an exam room, you will be escorted thru the lobby if you alert us in advance. ALL respiratory type infections should be seen and worked up during this crucial time. Covid testing is done at the health dept. 

IF world wide screening is effective

IF everyone follows these FIVE simple rules

IF Covid is a cold weather bug only

The pandemic will be history. Otherwise we may witness a pandemic unseen in our lifetimes.

Gregg DeNicola MD Chief Medical Officer


How effective was the flu vaccine this season?

By editor
February 25, 2020

Does the flu vaccine cover A or B or both?

Many patients have inquired about the efficacy of this season's flu vaccine. The flu shot designed by the CDC in cooperation with other countries covered both A and B. But because there are new strains every year, they are basically making a best hypothesis on the exact protein structure of the influenza virus.  This year they did a good job preparing antigens that looked like A but not such a good job at guessing B, thus the large number of B cases this year.

How much will the vaccine reduce my risk?

Recent CDC reporting show that flu vaccination reduces the risk of flu illness by between 40% and 60% among the overall population during seasons when most circulating flu viruses are well matched to the flu vaccine .  To help put in perspective, 80-90% may become infected with seasonal flu if a flu shot didn't exist. Thus it is still strongly advised that everyone get a flu shot every year.

If I still contract the flu will it reduce the severity if I do get the vaccine?

Another important reason to be vaccinated is even for those that did get the flu shot but still have the flu strain for both A and/or B, the severity appears less with people who received the vaccine.  Even if you or your children do catch the flu, you’re more likely to get a milder case that you can bounce back faster from with the flu shot in your system.

Can I get relief even if I did not get the flu shot?

If you did not or choose not to receive a flu shot, there are medications to shorten the flu, such as Tamiflu. It can also be used to prevent the flu but not as effective as a vaccine.  This year all four of the vaccine viruses used to produce the vaccine were grow in cells, NOT EGGS. Egg allergy should NOT be an issue this year.

How much longer is this flu season?

Since the flu season is typically worse mid-December thru mid-February, the cases have hopefully peaked and we should start to see a reduction in positive diagnoses by the end of the month.

Gregg DeNicola, Chief Medical Officer


How effective was the flu vaccine this season?

By editor
February 25, 2020

Does the flu vaccine cover A or B or both?

Many patients have inquired about the efficacy of this season's flu vaccine. The flu shot designed by the CDC in cooperation with other countries covered both A and B. But because there are new strains every year, they are basically making a best hypothesis on the exact protein structure of the influenza virus.  This year they did a good job preparing antigens that looked like A but not such a good job at guessing B, thus the large number of B cases this year.

How much will the vaccine reduce my risk?

Recent CDC reporting show that flu vaccination reduces the risk of flu illness by between 40% and 60% among the overall population during seasons when most circulating flu viruses are well matched to the flu vaccine .  To help put in perspective, 80-90% may become infected with seasonal flu if a flu shot didn't exist. Thus it is still strongly advised that everyone get a flu shot every year.

If I still contract the flu will it reduce the severity if I do get the vaccine?

Another important reason to be vaccinated is even for those that did get the flu shot but still have the flu strain for both A and/or B, the severity appears less with people who received the vaccine.  Even if you or your children do catch the flu, you’re more likely to get a milder case that you can bounce back faster from with the flu shot in your system.

Can I get relief even if I did not get the flu shot?

If you did not or choose not to receive a flu shot, there are medications to shorten the flu, such as Tamiflu. It can also be used to prevent the flu but not as effective as a vaccine.  This year all four of the vaccine viruses used to produce the vaccine were grow in cells, NOT EGGS. Egg allergy should NOT be an issue this year.

How much longer is this flu season?

Since the flu season is typically worse mid-December thru mid-February, the cases have hopefully peaked and we should start to see a reduction in positive diagnoses by the end of the month.

Gregg DeNicola, Chief Medical Officer