Long COVID Seminar

The American College of Occupational and Environmental Medicine (ACOEM) hosted a free webinar (with excellent written materials) on April 13, 2022 regarding the topic of "Long-COVID." Readers may remember that I first explored that topic first in COVID-19 Regressive Impact (May 2020), in COVID-19 in Comp - October Update (October 2020), Always on my Mind (February 2021), and Mental Health (January 2022). "Long-COVID" was a potential I identified early and have studied and followed now for almost two years. That is noteworthy: we feel like it has been forever, but SARS-CoV-2 has been with us only about two years. See Happy Anniversary (March 2022).

 

Through it all, COVID has graced these pages. In 2020, that word appeared in over 35 posts (catalogued and linked in Florida COVID-19 Litigation September Update (September 2020). The COVID posts since September 2020 are catalogued and linked at the end of this post. It is fair that the virus, its disease process, and impacts to our world of work and workers' compensation have been on my mind periodically in the last 24 months. Perhaps there is some name for such attention (obsession?).

 

The ACOEM presentation was absolutely fascinating, and involved multiple experts: Kerri Wizner, MPH, CPH; Greg Vanichkachorn, MD, MPH, FACOEM; Kurt Hegmann, MD, MPH, FACOEM; Les Kertay, PhD; and William Niehaus, MD. This was certainly a who-is-who. The discussion was detailed, focused, and supported by multiple statistics and reports. Ultimately, I concluded one critical point: Long COVID it is complex and disheartening. Ancillary to that is the conclusion that it may be significantly subjective, and there is potential for emotional factors to play a role in patient perspectives.

 

The entire COVID-19 community experience, without even personally suffering any infection per se, has been notably emotional for some, likely many, potentially even most. I touched on our expectations and anxieties in Mental Health (January 2022) and Uncle Buck to Ray Kinsela (July 2021); Some poignant reactions to anxiety are also discussed in Is there Repair (April 2021). Long before the pandemic, I penned Can We Help Each Other (January 2014). There I suggested that we have no way of knowing what people are subjectively experiencing; emotions and pressures surround us, and recognition of that can go a long way in working through conflict and litigation. That was true before COVID, during COVID, and will persistently remain now that COVID is largely fading in our rear-view mirror. 

 

Thus, the ACOEM inclusion of emotional challenges is appropriate. The speakers noted that clinicians are documenting a litany of symptoms and complaints being reported by various patients. Common "Long-COVID" symptoms include fatigue (80%), respiratory (59%), neurological (59%) subjective cognitive impairments (45%) sleep disturbance 30%), and mental health (26%). It is fair to say that I am not a medical doctor, and have no formal medical training. In fact, I have never played a medical doctor on television, and have not even stayed at a Holiday Inn express recently. Despite that deficit in expertise, I was able to reach some solid conclusions.

 

First, the research and investigation of this virus' physiology has just begun. There are a multitude of scientists and practitioners that are gathering data. There are teams working on isolating various aspects of both virus and disease process for further study. There are research projects underway intended to lead to better understanding of various intricate portions of the viral process, impact, and recovery. In short, the time seems long, but we have only just begun to fight the battles regarding COVID.

 

Intriguingly, one set of data demonstrated that the average time between evaluation for “Long COVID“ and initial infection was about three months. In that data set, it was demonstrated that 63% of patients had returned to work in some form by the time they were evaluated. Only 46% had return to work “at baseline.“ In this population, 34% were experiencing impairments in the activities of daily living and 82% were experiencing impairment in the IADLS (Instrumental Activities of Daily Living (more complex). For a simple explanation of the distinctions between those two task lists, see ADLs v. IADLs: Understanding Daily Care in Assisted Living (September 2019).

 

Thus, as subjectively reported, there are significant volumes of patients experiencing notable deficits long after initial infection recovery. Dr. Vanichkachorn described a decision tree being used for evaluation of such complaints. This begins with a general evaluation and testing, with focus on things like vitamin levels, blood count, metabolic panel, and more. The second stage is "psychosocial support," followed by more "targeted evaluation." It is noteworthy that the emotional component is addressed immediately in this process (at least in the Mayo Clinic process described by Dr. Vanichkachorn).

 

Note here that we are discussing, largely, "subjectively reported" symptoms. There is not, as yet, a great deal of objective testing with which to verify symptom causation, that is to directly tie fatigue to infection (an example only). I am often fatigued and have never been infected with SARS-CoV-2. There is certainly coincidence (had COVID-19 and now has shortness of breath, fatigue, brain fog, or other complaints). There is certainly some consensus (lots of people who had the infection are voicing similar or identical ongoing current complaints). But, as to science, experiment, and study, there is still much to learn and we are only in the beginning of what will undoubtedly be thousands of studies, experiments, papers, journal articles, and presentations. 

 

The "targeted evaluation" discussed in the ACOEM presentation next brings focus to specific complaints or deficits. This is largely in cardiac, pulmonary, neurological, or psychological specialties. A variety of symptoms are considered, as is the potential causative factor(s) for each. One obvious conclusion from this spectrum of specialties is that the "Long COVID" is notably complex and the investigation potentially extensive (and expensive). The discussion included references to the breadth and depth of medical investigation that is invested in the treatment of "Long COVID," and it is extensive. The panel did not address how this impacts those of us with less than "Cadillac coverage," except the oblique acknowledgement that testing and investigation can be expensive and a patient's ability to pay may be a factor in any plan for remediation of "Long COVID." For the younger folks, there was a time in America when "Cadillac" was synonymous with the epitome of luxury and perhaps excess; the younger generations might instead use "Mercedes," "Lexus," or other adjectives instead. 

 

Dr. Les Kertay provided an interesting and informative perspective regarding mental health in the wake of COVID. He noted that anxiety is a normal reaction to uncertainty and stress. The rapid and unexpected arrival of COVID, the rapidly shifting societal and governmental reactions to COVID, the 24-hour new service with politicized perspectives, and the various uncertainties of disease, economic impact, social isolation, etc. are all probable contributors to some level of stress and anxiety. In short, he emphasized that the pandemic was and is a stressor even absent personal infection or symptoms. Upon that foundational, societal, stress is layered the additional personal experience of infection, recovery, family impact, and then the "Long COVID." Dr. Kertay cites various studies in support of the prevalence of anxiety and other emotional challenges. His perspective is refreshing, informative, and worthy of consideration.

 

Notably, studies were cited in support of various characteristics identified with increased risk of mental health symptoms: gender, age under 40, pre-existing mental or physical diagnoses, unemployment, being a student, frequent social media exposure," substance abuse, pre-existing obsessive compulsive disorder, and occupation (specifically noting "healthcare workers." This portion of the discussion reminds us we are individuals with challenges, needs, and emotions that are personal and subjective, if not completely unique. And, our individual reaction to stressors may be influenced by any number of pre-existing stressors, emotions, feelings, and predispositions (and the same could be said of ongoing, but similar, comorbidities). 

 

There were various mentions of the process of forming opinions about "Long COVID." Speakers lamented the present lack of numerous peer-reviewed quantitative, scientific studies. There seems a great reliance on scientific consensus at this stage of the investigation, care, and treatment. I have repeatedly noted the potential pitfalls of consensus, but have noted that in certain situations we are left with consensus as our only guide post. See Consensus in the Absence of Proof (January 2021). From the discussion in the ACOEM seminar, it appears that consensus will have to tide us over until we gain better chronological distance from the pandemic, as well as the corresponding greater chronological opportunity for the completion, review, and publication of more empirical and qualitative data. Undoubtedly, greater scientific proof or disproof is coming in time, but in the interim consensus reigns. 

 

This webinar and the accompanying slides are worthy of consideration and study. It includes questions, doubts, and conclusions. The personalities are amiable and the dialogue valuable. There is much presented regarding the accumulation of data, and some edification regarding better understanding a portion of the complaints and symptoms being presented, and being blamed on "Long COVID." 

 

As this pandemic evolves to endemic, and the world increasingly returns to normal (the plexiglass is disappearing at retailers this last few weeks), there will be challenges with the physical and emotional sequelae in its wake. We will all either face ongoing challenges from the SARS-CoV-2 virus or know someone that is. Those who must then makes decisions as to compensability, care, and impairment/disability will be faced with questions, challenges, and disputes. It is, indeed, an interesting time through which to live. Surreal at moments, frustrating, stressful, but interesting. 

 

 

Fifty plus (approx. 57) Prior COVID Posts:

 

Florida COVID-19 Litigation September Update (September 2020) - includes links to 25 other posts.

 

COVID -19 in October Update (October 2020)

We're Back (October 2020)

Evidence and Evolving Medicine of COVID (November 2020)

Incidence or Prevalence (November 2020)

COVID-19 Update November 2020 (November 2020)

Litigation of COVID-19 Update November (December 2020)

COVID and Florida Adjudication (January 2021)

COVID-19 in Florida December Update (January 2021)

The Future is so Bright (February 2021)

Vaccinations and Implications (February 2021)

Vaccination Tribulations (February 2021)

Catch a Cold (March 2021)

A Great Hamburger with a Smile (April 2021)

Hope for No Breakthrough (April 2021)

We're Really Back (April 2021)

Is there Repair (April 2021)

The Science of Consensus and Masks Again (June 2021)

Presenteeism and the Coming Divide (June 2011)

Uncle Buck to Ray Kinsela ((July 2021)

How does the Story End? (July 2021)

Breakthrough Vacillation and Consensus (August 2021)

Tootsie Pops Make you Think (August 2021)

Inoculation Tribulation (August 2021)

Vaccines and Movies (August 2021)

Show me the Science (September 2021)

Common Sense or Evidence (October 2021)

Departures from the FDA (October 2021)

Comorbidity of Obesity (October 2021)

Mental Health (January 2022)

Never COVID Cohort (February 2022)

Shocking Diabetes Findings (February 2022) 

Happy Anniversary (March 2022)

 

By Judge David Langham

Courtesy of Florida Workers' Comp