Will we ever get back to managing MS proactively or is this the new normal?
I saw a new patient with probable MS via video consultation this week. He was from a BAME background and I could sense that he has very active MS despite only having had two relatively mild attacks in the last 14 months; an episode of transient diplopia lasting a few days and a mild sensory relapse lasting just shy of two weeks. An MRI done two and a half years ago when he presented with optic neuritis was abnormal. At the moment he is fully functional without any physical disability apart from some persistent fatigue.
Without being able to do a physical examination of this patient (I need to know if there are subtle motor and cerebellar signs), arrange an MRI and do a semi-urgent lumbar puncture to confirm the diagnosis and check neurofilament levels, I can’t do an accurate prognostic profile. If he has definite MS (diagnosis to be confirmed) he would only be eligible for platform therapies and ocrelizumab. But as ocrelizumab is an irreversible treatment I want to be confident of the diagnosis. In addition, I want to be able to offer this patient other options and not only one highly-effective therapy.
What should I do? Well, I have had to tell a sort-of-a-porky and book a Gd-enhanced MRI claiming it is urgent when in reality a diagnostic/prognostic MRI for multiple sclerosis is not a neurological emergency. If this patient has to wait prerequisite 3-4 months, or possibly longer, for us to complete the diagnostic workup because of the COVID-19-induced changes to our MS service there is high likelihood of him having a catastrophic relapse and ending up disabled. ‘Time is Brain’ is how I justified asking for an urgent MRI to myself.
Managing MS during the COVID-19 pandemic is clearly suboptimal and people with MS or possible MS are getting a raw deal. I suspect the same is happening across other specialities. I know it is happening in oncology, I saw it with my own eyes on the medical wards.
Have you seen what is install for the NHS post-COVID-19? The following graph is from a recently launched online ‘NHS Waiting List Estimation Tool’, which shows you the backlog in terms of outpatient appointments that are waiting for the NHS post-COVID-19. People are talking about COVID-19 burnout amongst NHS staff, it is going to be much worse post-COVID-19 when we have to try and clear the backlog created by the reconfiguration of the NHS to deal with COVID-19.
If any of you have had bad experiences, delays in diagnosis, monitoring or treatment please let us know. I shudder to think about how much brain will be lost due to the change in the way we manage MS induced by COVID-19. I sincerely hope this does not become the new normal.