Good afternoon and good evening kung nasanman ko kayo. Welcome to our 57th installment of the Stop COVID Deaths webinar series brought to you by the University of the Philippines. So we are glad that you can join us today as we continue on with our fifth season of our COVID-19 learning journey at gaya po na nasayipon natin last week. Babalik po tayo this week sa ating virtual grand grounds to talk about clinical management updates. Ngayon po we are continuing to see an increase in cases po COVID-19 in the Calabarzone region, Western Decis region, Central Luzon and Davao region. Da kaya po na marapat po na madiskas po natin ang clinical management of COVID-19. But very, very important for today will be about long haul COVID. Ang good news po kasi is na basic po sa ating mga datos na meron po tayo and these are the publicly available data being shown to us by the Department of Health up to 94% or more than 94% of those who have contracted COVID-19 cases in the past year and a half have recovered. However, there have been reports po kasi na hindi po lahat ng mga nag-recover. So COVID-19 ay talagang shall we say fully recovered na po. If months after, again ang months after po ng kanilang pag-contract at pag-discharge so hospital. So kailangan po natin pag-usapan, ano po ba ang long term effects clinically na ang tinatahag po natin post-acute sequelae of COVID-19 or long-haul COVID at masaya po kami na dalhin po sa inyo ngayong aro na ito ang virtual grand grounds topic po ang ito. I'm Dr. Raymond Francis Sarmiento from the National Telehealth Center, National Institutes of Health. University of the Philippines, Manila, always a pleasure to spend our Friday lunch date with you and also my pleasure and my honor to introduce my co-host. I'm very, very happy whenever we get together po. She is our adjunct research faculty at the National Telehealth Center and also the special envoy of the President for Global Health Initiatives, Dr. Susie Pineda-Mercano. Dr. Susie? Hi, Raymond. Good afternoon at magandang hapon po sa inyo lahat. I hope wherever you are, you're all safe and great to have so many people from different parts of the country, Raymond, with us. Tapaka importantin ng pag-usapan natin ngayon ang complication ng COVID. Sabi ko, Raymond, tinitig ng Hoyun News ang Taiwan na datang parang zero cases, parang hindi sila nagkakakabig lang nagkarun sila ng maraming cases and then Vietnam. Today, I think the reports that Vietnam has a lot of cases and Japan is having a lot of difficulties. So Indonesia also, and many issues, pati ang mga nabakunahan na nagkakakarun pa rin ng COVID. So many pag-usapan. But for today po, we thought we would talk about the long-term effects of COVID. And no kumpisap, simula pa lang. Ang din ng College of Medicine was going to give our opening remarks later, already mentioned this before, na merong mga long-haulers. This was last year pa. Last year pa natin Raymond pinag-usapan niya na na. And I was thinking what's a good way to, what do we call it? Because the US CDC calls it post-COVID conditions. And then some call it long-haulers tapos yung the longer technical term that you used, Raymond, was it post SARS? Post acute sequelae of COVID-19. Of COVID-PASC. Pero naisim ko si Raymond, baka pwede ng long COVID? Kasi di ba sa atin, pagkanag-detect ka sa sabihin nila long press. Bakit lang yan na yung? Paano mo nga gawin yan yung long press mo lang? When I first heard that, I said, my goodness, that's so exciting. Long press. Long pressing. Pagkukuhan ng picture di ba? Pwede ng long press na. So ito pa, pag-usapan natin long COVID. I think that's possible to understand. Nangyari po, pag atapos po ng infection. Hindi po mga balik sa dati. Yung po ang ibig sabihin. Pwede ka, gumaling ka na dapat, pero hindi ka pa rin, hindi pa mabalik nung sa dati. So anyway, stay with us. I hope we're going to learn. We will all learn a lot. Balik po tayo sa virtual grand round. So meron po tayong pasyenteng pag-usapan at meron po tayong mga discussan. Okay, over to you Raymond na pagbentuan mo na ako. Go Raymond. Hello problem, Dr. Suzy. Thank you so much po. It's something that we had already tangentially discussed in one of our previous virtual grand rounds. But we had, I think neurologists and experts po who were our guests. And to talk about ang brain fog and other effects po. But today it will be a dedicated webinar for long COVID. So for those who are joining us for the very first time, agalito po ang ating structure for our virtual grand rounds. We often times bring stories of the patients from the frontline to provide us some sort of idea of what is happening po on the ground and the realities po. We provide dramatic personal narratives of those patients and hopefully that will help us frame ano po ba ang nga na experience po ng isang typical na patient with that particular condition. For virtual grand rounds, we will have a set of presentations. The presenter po will provide a very, very brief, essentially clinical summary of what happened to the patient followed by a theoretical discussion on the topic at hand which is post acute sequelae of COVID-19, followed by reactions po from our esteemed set of reactors. And after that, we will be entertaining questions from the audience. We may be able to call in maybe one or two from the live audience po to ask their questions and open their videos po in asking those questions. But before we proceed, I think Dr. Suzy as a couple of announcements po, Dr. Suzy na hindi po may kinalaman cementimeter muna. Okay, so remedy ko naman nga nung cementimeter. So we would like to of course greet the University of the Philippines on its 100th. UP was founded through Act No. 1870 of the Philippine Assembly, surviving world wars, colonial occupation, civil rights struggles, cultural upheavals, economic downturns, natural disasters and this pandemic. Tomatayon pa rin ang University of the Philippines, serving the people by putting its best minds to provide solutions to the country's problems. And this top COVID-19 webinar series is one of the COVID-19 initiatives of the University of the Philippines. So you people ay kailan paman, hindi titigil sa pagliling ko sa ating bayan. So congratulations to everybody to the University of the Philippines and it's great to celebrate 113 years. Oh my goodness. That's a long time. Congratulations everyone. Very very auspicious day. Maraming salamat birthday ngayong araw po ito. I think the second announcement will have to do with the cementimeter. Nakita po natin sa ating chat, marami na po nakatanong. So for those who are, especially for those who are watching us outside of Zoom, please open your browsers. Go to www.menti.com and enter nyo po ang code na 52591273. That is 52591273. Hindi po kayo makakapag participate po kasi sa ating polls without entering the code. So it's very very important po that you enter that code kasi po hindi po automatic napagpunta nyo po sa menti.com ay madedirect po kayo doon. So alalu na po for those who are watching us in Facebook po at sya ka sa YouTube, maraming maraming salamat po. We will want you to especially participate in this opinion poll that we have. But I'll take this opportunity po before we proceed further. To acknowledge the very hard working team behind the stop COVID-19 webinar series, maraming maraming salamat po for each and everyone without each of you. Hindi po magadampanan ang ating rather successful webinar series. And for those who are asking about the certificate, we'd also like to flash on the screen what you are expected to receive as a certificate po. PBUP. Thank you. Okay po. So for today you'll be receiving something very very similar to this one. Whatever you input po kasi sa inyo registration page link will be what will be input as your name. And for those who are asking, we have already distributed all certificates for the previous 56 webinars. So I think there are still medyo manakan na kapapong kulang for webinar number 56 pero medyo kontin na lang po yun. So for those who are asking paano po sila mga katanggap, we check our servers po kasi in terms of your attendance and webinar duration at least 50% po sa para makatanggap po kayo ng certificate. Over to you Dr. Susie. Okay. Thank you very much Raymond for that. So all of you are watching on YouTube or Facebook. You can participate but so are with us now in Zoom. When we do our opinion po, you'll be able to go straight from your laptop. Okay. It's time to introduce our introductory speaker and it's my pleasure, my honor to welcome the Dean of the UP College of Medicine, Dr. Charlotte Chong. Charlotte, welcome. Hello. Can I start my video? Yes. Charlotte, how are you? It's okay naman, laging naman busy, ay padagdag ng padagdag ng trabaho. Okay Charlotte, pag gumabigay ang opening statement mo. We were talking earlier and I think I don't want to miss the opportunity na there are still people who are self-medicating and pharmacists that are actually allowing people to buy medicines that could actually be harmful for them. So sabi mo ang kanina, meron kang mga pacientin na nagkakaroon ng ubong sa tega kasi umi-inom silan ng hydrochloroquine. So can you tell us a little about that? I think it's a very current issue and let's just have a reminder na wag tayong mag-self-medicate. Go ahead Charlotte. Actually, that's a problem because sometimes some pharmacists are not very strict. So sa sabihin ang paciente, ah na iwan ko po ang aking prescription pero kailangan ko po ang hydrochloroquine or isytromycin. Things that they read in the internet regarding COVID and they're not of course updated about what's recent, what are the new guidelines. So ang alam nila mga gamut na effective, binibili nila sa mga pharmacy and then they self-medicate. And I've seen recently some cases na uugong talaga ang tega. And these are really severe, tinay ko, di makatulog, di makakoncentrate. So Charlotte, pa niyan parang masakit ang tega nila? Parang ganun? Sobrang lakas ng uugong. So here sounds very loud so they cannot sleep, they cannot concentrate. What side effect ng gamut yun? What medicine is giving that side effect? Well, hydroxychloroquine is one and if you add it with acetromycin sometimes there's also an additive effect because both are autotoxic actually. Ayun. And so Charlotte pag may ginyan sila, gumagaling ba yun? Yung nga ang gusto ko sabihin sa lahat ang sakit sa tega, madali namin sa gutin, gagaling pa ba ako doc? Madali namin sa gutin ang tanong na yan. Pero pag uugong ang pasyemp, uugong ang tega ang problema, mahirapin sa gutin kung gagaling pa sila. Oh my goodness. Okay. So reminder po na, alam nyo marami kasing, by the way batihin natin mga tagamin na rau, maraming tagamin na rau na nunud ngayon, sambuanga, bukid noon, marawi, I saw so many. So reminder lang, please remind mga communities natin, mga leaders natin, magpong mag-self-medicate kasi katulad nito, nahakasirap ala nandeng ay itong hydrochloroquine na kong imbista makatulong, napas nagkakaproblema pa tayo. Yes. So a reminder. Okay Charlotte, go ahead with your opening remarks. It's indeed another great afternoon for all of us to be gathered for our virtual grand rounds. And this is of course thanks to our organizers, BP Nemi Pernia of the UP system, TV UP team led by Executive Director G.G. Alfonso. And of course our two hosts, our gracious hosts, Dr. Suzy Mercado and Dr. Raymond Cerviento. It's been a pleasure meeting every Friday to discuss cases like in the virtual grand rounds. And as you know, our country already registered about 1.3 million cases of COVID-19 and about 23,000 have died from this problem. Nito po sa UP College of Medicine and the PGA community of dedicated faculty, health workers, students, we stand committed to contribute to the science with hundreds of ongoing researches that are now ongoing just to be able to address the issue of COVID-19. Anakakatua is that 7% of our researches are in fact also even led by our students and about 42% led by our faculty and about 47% by residents and fellows guided by their consultant advisors. So malinigyong po ngayon, mga ang viskas na ang protocol will be based on science and our experiences at UPPGH. So while our mortality rates comprise only around 1.7%, we know that about 45% of them might have moderate to severe COVID. And given the increasing, continuous increasing cases, acute cases, more questions like this will be common. Sabi ko nga as an ear specialist, you find questions like this easier to answer except for tinnitus. But the situation may really be very different for COVID-19. COVID-19 experts are stumped. There are stories of chronic pain, numerous emergency lung visits for severe pain, acute exacerbations, and the number of long-haulers or long COVID are increasing. And therefore, it's like having a second pandemic after the first pandemic. Given the number of patients with persistent symptoms of homelessness, cough, and other symptoms that we will hear about this afternoon. So we're really indeed very fortunate to have Dr. Gabrielle Hippol to present this case and discussed by Dr. Marichelle Samonte of the UP Health Service, as well as our experts for pulmonary medicine, Dr. Lenny Fernandez, and the chair of our rehab medicine department, my classmate, UP7 Class 85, Dr. Sharon Ignacio, as well as the chief resident of psychiatry and behavioral medicine, Dr. Cedric Factor. So this is really a great panel of presenters, discussants, and the actors that you will hear today who represent the community of scholars and scientists at UPPGH. So we're really already excited to hear about this case presentation. It's very typical of what you call PASC or post-acute sequelae of COVID-19. And once again, we are very happy to welcome you to another session of making sense of what is really happening in these patients and also perhaps have a glimpse of how we can better help patients who cannot seem to recover from COVID-19. Back to you, Susie, and Raymond. Thank you very much. That's Dean Charlotte Trong of the UP College of Medicine. Okay, so thank you so much, Dean Charlotte. I know you have to leave early later, but if you can stay for some of our panel discussion, I think it will be great. Okay, so Raymond, over to you please. Thank you for really setting the tone for our virtual grand rounds today, Dean Charlotte. And right now, it's time for our fun opinion poll. So for those who are in the Zoom poll, please, TVUP may we ask you to launch po ang ating Zoom poll. TVUP is also displaying on the screen kung ano po anay kita puning nyo sa ating Mentimeter. We only have two questions and they are the same. Ganon din po, ang nakatanong po kung ano po ang pinapalabas sa Zoom yun din po ang pinapalabas po sa Mentimeter. Ang dalawang katanongan po ay, first question, what are the risk factors that will make a person a COVID-19 long hauler? Is it age? Is it ICU admission? Is it the comorbidities of the person such as diabetes, congestive heart failure, COPD? Or is it all of the above? So maylip po ang team na all of the above, no? But hopefully that's something that really sticks with you kung ano po ang mga risk factors na meron po tayo, okay? And then for our second question, we are seeing po kasi that more and more are answering but for our second question, we have this one. Okay, what will make you a long hauler? So please key in your answers po ang options po ay persistent shortness of breath, depression, brain fog and all of the above. We are seeing that we have a little over 1,000 attendees po sa ating Zoom webinar and a little more sa ating YouTube at sa Facebook pages ng University of the Philippines, ng TV UP at na stop COVID deaths. So while you are trying to key in your answers, let me take this opportunity to greet our registrants and attendees from the Lima Emergency Health Center Balanga Bataan Central Luzon, from the Universidad de Santa Isabel Health Services Department, Mother Seaton Hospital Naga City in Camarinesur in Bicol, Negros Oriental State University in Dumagete Central Visayas, from Metro Davao Medical and Research Center, Incorporated, Bamba Hadda, Davao City, and Kotabato Regional and Medical Center in Kotabato City in Mindanao, from Magindanao, from BARM, and then internationally, we have those attending. All the way from the University of Delhi, the Department of Anthropology, New Delhi, India, from Adam University in Kyrgyzstan, from Chonin Hospital in Taipei, Taiwan, Ho Chi Minh, Vietnam, Bangkok, Thailand, Prince Mohammed bin Abdulaziz Hospital in Riyadh, Saudi Arabia, are regular from Niagara Falls, Ontario, Canada, from FPO Diego Garcia, British Indian Ocean Territory, at meron po tayong very, very first attendee po from, I hope I pronounced this correctly, St. Augustine's Catholic Primary School Royal Tunbridge, Tunbridge Wells from England in the UK. So yung po ang aking mga attendees, maraming-maraming salamat po, and then without further ado, I'll call on Dr. Susie for our 2-sec double road. Thank you. It's been a year since the pandemic and when we started we didn't know very much about it, but I think more than a year now after we are understanding that there are a number of patients and Time Magazine recently said that it could be up to 25% of all patients who develop COVID who have what the US CDC calls post-COVID conditions. These are longer term effects that can happen even if you were asymptomatic or only had mild COVID. And they're called many things, so it's called post-acute COVID-19, long-term effects of COVID, long COVID, post-acute COVID syndrome, chronic COVID, long-haul COVID, late sequelae, the research term is post-acute sequelae of SARS-CoV-2 or PASC. So many, and I think we're calling it long COVID, many are being researched now because enough time has passed to understand very different effects after an infection or even after an asymptomatic infection. So some people are happy because they test positive but they stay home, they're symptomatic and nothing happens, but months later they develop all kinds of problems, so it includes multi-organ sort of issues, inflammation, even mental health problems, post-traumatic stress disorder, depression, anxiety, mood changes. And it seems that conditions could include weakness, brain fog, you can't remember things well, aches and pains, headaches, cough, depression, so many things. So there's still a lot we have to learn and I think as time passes we are going to understand more about what should I say, what has really happened during the pandemic. All right, now before we go to our presenter, we have a video from TVUP for our case, so TVUP, please go ahead. Last year, in August 2020, Gina, a 32-year-old nurse working in a Metro Manila Hospital, developed COVID-19. She was coughing for three days, had a sore throat and could not smell or taste anything and had a headache. She also experienced difficulty in breathing. At that time, she was pregnant and already had a one-year-old baby. She isolated herself but when the rest of the family was swabbed, her baby tested positive. This cost her a lot of stress and she was very emotional. She was not admitted to the hospital but on further work out, she was diagnosed to have anti-phospholipid, anti-body syndrome, APAS. It is an autoimmune condition where abnormal proteins are produced in the blood. This can cause the blood to flow improperly and can lead to dangerous clotting in arteries and veins and can cause miscarriage. She took a leave from work and delivered a healthy baby by cesarean section in February 2021. When she felt better, she decided to go back to duty at the hospital but noticed she continued to have difficulty in breathing. Okay, thank you very much TVUP. Of course, this is a dramatization of a case that's like the case that's going to be presented and it's our privilege and honor to welcome our presenter who is a resident at the Department of Family and Community Medicine at the UP Philippine General Hospital, Dr. Ian Gabriel-Hipol-Ion. Welcome to the webinar. Good morning pa. Hi, good morning. So did you see this patient Ian? Actually ma'am, I had the privilege of meeting this patient during our collection, data collection for our research because in the UPHS, what we are currently doing a study in the long term effects of COVID-19 in our PGH employees. So this was the only time that I met po this patient. Okay, Raymond, I think you were trying to say something. No, I was going to ask Dr. Suzy about follow up with the patient and how she has been constantly in communication with the patient. But that's probably right after the presentation of Dr. Hipol. Okay, so ma'am, we will ask Ian to tell us how the patient is now. Okay, Ian, go ahead with your presentation. I will just share my slides pa. Can you see my slides pa? Yes. So good morning. Good morning pa everyone. I am Ian Gabriel-Hipol, a third-year resident of the Department of Family and Community Medicine here at UPPH. So I'm here to present a case that I've encountered entitled the long haul since a lot of our patients who have long COVID are actually called long haulers right now. So my objectives for this presentation first is to present a case of a COVID-19 recovered patient who is currently still having prolonged symptoms 10 months after recovery. The second one is to demonstrate the psychological impact of having prolonged symptoms as well as to show the importance of having a multidisciplinary approach in the management of our long COVID patients. So what is a long COVID syndrome? This is just a short introduction but there are a lot of articles and studies right now coming up with different terms of having long COVID. Essentially, they are our patients who are experiencing prolonged symptoms beyond 12 weeks and this is recognized as an emerging cause of significant morbidity right now. A lot is still unknown regarding this syndrome but it is important to recognize that it is already an upcoming significant cause of morbidity in our patients. So for this patient, we have a 32-year-old female married from San Andres Bukit Manila who is currently working as a nurse for about six years already here at PGH. So this patient does not have any known comorbidities, only had one baby's surgery as a cesarean section for her second pregnancy and does not have any current allergies. As for the family history of this patient, it's significant for hypertension at the paternal side and her brother, rather, also has diabetes mellitus. There's no history of thyroid disease, bronchial asthma, stroke, myocardial infarction or cancer. This patient is a nonsmoker, a previous alcoholic beverage drinker. She actually stopped because she already is breastfeeding her children and she denies illicit drug use. At the time that the patient consulted with the UP Health Service, she was pregnant at the time with her third pregnancy. So her first pregnancy was actually obligated ovum and on her second pregnancy, she was able to deliver full term at 40 weeks age of gestation. At the time of consult UP Health Service, she was already at 10 weeks AOG and she has already delivered by a CES last February 8, 2021. So history of gestational hypertension or diabetes mellitus for this patient. So for the COVID-19 timeline of this patient, she's currently working at a non-COVID ward. But before she was diagnosed to be COVID positive, she had exposure to a COVID positive co-worker, but remembers wearing at least level 2 PPE on all her interactions with that co-worker. She usually travels to PCH for work via grab or tricycle and she is living in one house with her husband, her mother and her one year old child. But this house is actually situated at a compound for other family members from her family of origin. Unfortunately on contact tracing of this family, her daughter also tested positive for COVID. So on August 4 of 2020, the patient initially presented with cough, sore throat, rhinorrhea, nasal congestion, headache, anosmia, agesha, easy patigability and exertional dyspnea. So this prompted consult at UP Health Service on August 7 where she was found to be COVID positive. During the 14 days of isolation, this patient actually had resolution of all symptoms with supportive therapy. However, her easy patigability and exertional dyspnea resisted. And on August 27, which was 20 days after her diagnosis of being COVID positive, she requested another swab for her prenatal workup in her visit with her OB gynecology. And at this time, she already tested COVID negative. However, her easy patigability and exertional dyspnea was still there. So she had her workup in her OB gynecologist and on prenatal checkup, they deemed that it is important to test this patient for antipospholipid antivoggy syndrome since she had a first pregnancy loss on her first pregnancy. And of course, because of the easy patigability and exertional dyspnea which were persistent for this patient, she was referred to pulmonology. She consulted a private pulmonologist who ordered chest x-ray, which was normal at the time. So she was prescribed with BDS-9 plus for motorol as needed for dyspnea, but the patient was not able to use this since her dyspnea actually resolved with risk. She was also referred to cardiology and rheumatology for further workup. All workup done for this patient, but to the echo that well the DCG were all normal. However, on workup for APAS, she was found to have high DRVP. So she consulted with allergology and immunology who diagnosed her to have APAS. So in the interim, she did self rehabilitation with a progression of her exercise to improve functionality. And at present, June 2021, she still has easy patigability and exertional dyspnea. At the time that the patient had acute infection, she also had psychological problems. She had feelings of guilt of having exposed her family members as well as for her child being COVID positive. She also had depressive episodes due to isolation and anxiety of having her child be symptomatic and of course the problems as well as social problems with social stigma. Before the patient had COVID-19, she can go on eight-hour duties without difficulty at all. And also she can climb stairs without feeling out of breath. However, after having COVID-19, she feels patig two hours into her tour of duty, making her interrupt her workflow to have rest. She also feels out of breath after climbing one to two flights of stairs. Sometimes she also had limited physical activities with her kids because she feels that she hasn't recovered fully yet. When asked to evaluate her functionality, during the acute infection, she feels that her energy is only at 60%. However, after ten months after recovery, it has now climbed up to 80%. And these persistent symptoms actually have a psychological impact for her patient. So there are still feelings of anxiety on the exposure and the infection. And of course frustration that she feels that she has not fully recovered yet. However, for this patient, there is still hope of recovery. So she wants to still go back to being 100% healthy so that she can render the best care to her patients and also fulfill her duties as a wife and as a model. Moving forward for this patient, we would plan to have gradual progression of exercise to improve her functionality and to continue giving psychological support since these patients who have reviews mental health problems during the acute infection are also at risk for having psychological comorbidities in the future. We'd also recommend to have regular follow-ups for monitoring of symptoms. So further discussion for long COVID syndrome will be presented by Dr. Samwanti after this, but they would like to share my insights in this case. So caring for COVID patients extends way beyond acute infection. Since then, there is an emerging trend of having long COVID patients, so we should be ready to care for these patients even after they have recovered and even after they have been discharged from the hospital. It is also important to note that addressing the psychological impact of having persistent symptoms is as important as managing as the physical ones. And there is also importance of multidisciplinary collaboration, especially for us primary care physicians. We would need a network of specialists whom we can refer our patients to have a holistic approach in managing these patients. And with that, I end my presentation. Thank you very much. Thank you so much for that very brief, but also concise presentation. Dr. Ian will call you back for our panel discussion, ma'am, and we hope that you could join us for that. Meanwhile, we are moving on to our next presenter. She will be our main discussant. She is essentially the head of the UP Health Service, also the clinical associate professor of the Department of Family and Community Medicine at the UP Philippine General Hospital, none other than Dr. Marichelle Mejia Samwanti. Dr. Samwanti, welcome to the webinar po. Yes ma'am. Good afternoon everyone. So I'll just share my slide. Okay. Just go to presentation view, ma'am, and then we can go. There we go. Okay ma'am. All right. So Dr. Ian yung ating resident about the case. So being the head of the UP Health Service, we encountered several cases of patients. Just for context, yung patients, if it's COVID related consult, we don't see them face to face. So we initially saw them face to face, but after to minimize the risk of infection also for our staff, we started doing the consultation virtually. So tele-console tarin yung platform namin for COVID related consults. Okay. So even yung follow up, pag-recovered lang sila, that's the only time that we see them at the UP Health Service. So yun. So COVID in healthcare workers, more than 14,000 healthcare workers yung infected na with COVID-19 in our country. And majority, I think everyone knows naman na majority, mild lang yung presentation of infection, but approximately 10% had moderate to critical conditions dun sa mga patients natin. Now, for PGH, as of yesterday, 1,222 patients tested positive out of the 15,537 patients. Yung employees na PGH is roughly around 4,000 in regular and around 2,000 na, I'd call them irregular, pero, yung know, these are possessions that are not really under the panthilia of PGH. So some of them would get multiple tests already because of the current exposure from their co-workers yung or for some other reason. And out of these individuals that were tested, so majority of them are close contacts or symptomatic cases. So 7.86% of them tested positive. And majority of these confirmed cases were allied healthcare professionals, meaning these are the, because if you look at our sensors, naka-breakdown siya into physicians, nurses, and then others. So yung others kasama po dito, yung admin, kasama dito, pati yung allied health professionals like yung sa rehab. So dun sila lahat nakalam. So for the case that was presented by Dr. Hippol, so it's a 32-year-old female who tested COVID positive last April 2020 na puntis siya at the time of diagnosis. She was 10 weeks pregnant at that time with the third pregnancy. Unfortunately, she was also diagnosed with a past during this pregnancy. The personal social history is unremarkable but the patient is mildly symptomatic for COVID. Sinabing mildly symptomatic, tolerable yung symptoms niya. However, the list of symptoms that she experienced really medyo madami po. Almost lahat nung checklist dun sa symptoms at least three kong non-fever or non-coff. Pasok siya lahat dun, meron siya almost all. And then mental health issues na na encounter niya upon diagnosis. And this patient underwent home isolation only so hindi siya nagpa-admit yun. Although there was a protocol to really have the patients admitted or placed in a quarantine facility, the patient underwent home isolation only. But yun ang problem nagkaroon siya na exertional disneya and e-safetability post COVID. So what happens recovery after COVID? Kanina nagbabasta ako ng questions. May mga nakikita na akong questions kanina dun sa Q&A section and I think some of the questions will be answered already with the slides. So there are short and long-term effects and sabi nga kanina sa intro ni Dr. Raymond. There are increasing reports nung sequelae after recovering parang anong mga yung yari dun sa patients after ng COVID. What will they experience? And there are reports that 23% of these patients, they will experience one or more health issues one month even after one month after the COVID infection. So kahit na technically recovered na yung status nila, 23% of them will still experience some problems.  They have prolonged ventilation especially those yung mga yung nasa ICU natin and then yung social isolation kasi yun na parang dito pa lang na nagkaroon tayo ng pandemic di ba parang yung physical distancing or social distancing na recommend natin all the more if you are confirmed COVID positive case and of course the impact of pre-existing conditions. So when we talk of post-COVID conditions very wide yung range nya. So ang sabi dito new returning or ongoing health problems so pweding bago bumalik na problem or ongoing health problems that people can experience even a month after the infection. And long term complications are they include the post-COVID syndromes marami po yan I will show you later and then the post-COVID astin nya and issues related to mental health. So this can happen in a symptomatic to severely symptomatic confirmed COVID patients. So meaning kahit na nag-COVID positive ka pero wala kang naramdaman na symptoms pwede ka pa rin magkaroon ng COVID conditions. So in other words nga lang correlation between kung gano kalala yung COVID mo kung ikaw ay asymptomatic or mild lang yung symptoms moderate yung symptoms or severe yung COVID wala yung relationship direct relationship or clear relationship dun sa long term sequela na may experience ng patient and yung din there's no definite criteria for diagnosis and assessment of severity. Sabi sa poll kanina how will you know if you are a COVID a long-hauler di ba yun yung question but yun na if you look at the text wala siyang kailangan ng necromatic fever alamong ito yung criteria pneumonia alamong ito yung criteria sa post-COVID syndrome wala pa tayong exactong ganun. So because of this dahil wala tayong criteria there's actually no support or planning to operate services for them because how can you plan for something that you don't know yet? So this long COVID patients yung mahabang term kanina nidok and we call them also as long-haulers na. So weeks two months na yung persistence nyan and different types and combinations of health problems ang may experience ng patient at varying degrees and varying periods of time so hindi nalaga siya pare-pare-eho however yun na unknown how long this will be experienced by the patient kung ganun ka tagal siya mag-pursist and of course if this is something that will be a chronic health condition already of the patient meaning nandyan na talaga siya parang laga na ba talaga na pasyente yung ganito symptoms niya for life nyan so chronic condition na siya. So if you look at this list provided by CDC so andaming symptoms na pwedeng ma-experience ng patients multi-organ effects na kung tawagin nila because it targets the different organs. So may tiredness, fatigue, yung brain fog na may mention headaches, loss of smell, dizziness, palpitations yung kumun kumakabung teragay yung dib-dib nila, chest pain, difficulty breathing or shortness of breath, cough, joint or muscle pains, depression or anxiety, fever and symptoms that get worse after physical or mental activities. So kanina I mentioned about the post-COVID syndrome so somebody actually attempted to categorize them multi-organ effects kasi siya but if you look at the list ayyan so it's more of a description of the syndrome for particular system na na-affectohan niya and if you will look at the predominant clinical features not all of them are measurable example post-COVID-19 syndrome patin parang it's so subjective na you wouldn't know nirong time na we were clearing the patients, we were monitoring them daily sa PGH every time we have a patient the health service monitors them daily once na diagnosed nila ng COVID-19 tapos at a certain point pag for clearance na nila we advise them na cleared na nila but there are people na who would complain na 3 weeks na namin ang monitor pero still complaining na may fatig pa ako so parang we were at a loss can we actually let this patient return to work parang how would we know if the patient is madingaring or actually experiencing the fatigue it's difficult so kasi not all of them are measurable even the pain itself when the patient is complaining of pain parang pain is somehow subjective no matter how much you quantify it iba-iba ang tolerance ng tao in terms of pain so may hirap talaga siya i-manage or i-detect or i-confirm so yun siya but the reality is all these syndromes are real they are happening to our patients so sino po ba yung mga nakikita namin at the PGHUP Health Service yung nakita niyo kanina na mga syndromes well not all of them will come to the UP Health Service yun majority makikita namin ito yun ang ko complain headache that is so severe remember kasi parang person or for a patient to consult there is a certain level of anxiety attached to the symptom or the illness of the patient that they are experiencing before they actually seek to consult and also since na sa hospital setting I'm sure the other hospitals experience this also new employees they are not always at the occupational health clinic sometimes they go straight to the specialist dahil the specialist is really accessible so they just ask them about this but for our case at the UP Health Service these are the people that we see headache, depression or anxiety hypertension so mga ato maasang BP nung nagkaroon ng COVID and then persistent palpitations and then difficulty of breathing or shortness of breath tiredness or fatigue difficulty of breathing or shortness of breath ano sila ay parang more of minsan may ibang may ibang reason for consult and then they just mention na they are experiencing the symptoms and then joint or muscle pain and we also encountered some people with irregular menstruation sometimes 2-3 months post COVID nakakaruna amenorrhea so we had some cases of that also so for our patient ito yung predominant yung nang lingers na kanya na symptom difficulty of breathing, shortness of breath tiredness or fatigue and as mentioned by Dr. Hippol it's 20% less than her usual function kahit na nakat 10 months na siya after nung COVID niya so medyo ano siya nakita yung battery kanina yung Dr. Hippol 60% lang siya nung na during acute phase ng COVID pero post COVID 80% functionality lang siya and I think that's quite important especially na yun na this patient is a nurse na parang medyo bata pa siya she has young children so yun so what are the risk factors for dung COVID so it's twice more common in women versus men in one of the study done by the group of Ravindran so it's more common in women versus men the presence of more than five symptoms pagmasyado siyang maraming symptoms at the onset risk factor din yun and then presence of comorbidities and increasing age of the patient so for our case pasok siya dun sa unang tatlo andami niya talagang symptoms na experience female and yun na na diagnosed siya eventually na meron pala siyang autoimmune disease which is yung apas so the question now is why why do people develop this I cannot state the reason why but in other studies they are saying that the presence of the virus is not actually a prerequisite to say that this patient will experience persistent disease and there are also presidents of other diseases having autoimmune and inflammatory responses that would persist and would have long term an example of this would be your symptoms ang sasakit pa rin ang joints nila so this is a proposed pathophysiology of what is going on it's actually an attempt I don't think it's a proposal it's an attempt to explain of what is going on and they are saying that during the acute infection once you get the treatment so there are instances that some patients experience drug side effects or interactions especially if they have comorbidities and they are taking other medications so sometimes these need to prolong symptoms or when they develop complications during acute infection sometimes there is organ damage experienced by the patient and this organ damage persists leading to prolonged symptoms and during the inflammatory phase they have cytokine storm so there is inflammation and this persistence of inflammation in the different body parts especially if the patient has altered immune status like the case of our patient so ang kakarondin siya na prolonged symptoms for patients who were admitted in the ICU or hospitalized for long periods they are also believed to have some prolonged symptoms but whether it's a sequelae of a critical illness per se kung the actual medical condition or it's just a nonspecific effect of the hospitalization or the conditioning of the patient well they're not yet sure of that yet but definitely it's a possible reason for development of prolonged symptoms and of course the psychological issues attached to having COVID so for the respiratory symptoms 43% of patients who had COVID will experience difficulty of breathing so they have residual pulmonary involvement some will even have CT scan or MRI findings if you do the test on them so fatigue experienced by more than 53% so that is quite significant and the chest pain can persist in 72% of patients for the neurologic symptoms yung headache, tremor and brain fog due to possible disruption in the microstructural and functional brain integrity still being linked to inflammatory response to the infection for the psychological impact so high levels of emotional distress, alam natin pagtakovid hindi kang amag kakovid matas na yung emotional distress nulot yung satin when the pandemic was announced so all the more, pag nagkaroon ng COVID yung patients so number one, there is stigma from the community there are patients that once they disclose na min or your result turned out to be positive but you have to inform your barangay for proper contact tracing so things like that sometimes they would beg us to guide or sometimes they would just wait for the information to be disseminated to their barangay through the system of the government but it takes time it takes time because they don't want to be incriminated by their neighbors so in the same stigma exist among their co-workers so even in the healthcare setting ano ninyari pa rin nyo na technically kung ngisipin mo dapat mas may pangunawa dahil na sa healthcare setting or mas naiintindihan yung scenario but unfortunately, that is not the case and then nakakontribute doon yung evolution of protocols kasi nagbago-bago nalagay yung protocols because this is something new so every time there is a new idea or new concept na nalil-discover yung po doon sa illness so kailangan talaga mag-evo ng photoadap kung doon sa recent knowledge kung po doon sa disease and then there are individuals na persistently positive PCR tests so compared to our patient nagkataon, actually hindi naman talaga kailangan niya mag-test repeat a few days after niya maging recovered because of the other things that she needs to do for clearance or for OB consult niya, it's so happen and negative but we know that since nung start ng pandemic the requirement is two consecutive negative tests and we've heard of cases na three months nakagmits sa hospital because hindi talaga mag-negative yung PCR nila so nangyari yun and with that, there's long period of isolation from their family from their community especially if you're that person eko kung patient natin nilang siyang anak yung isolation na yun from her family kahit na sabi mo nag-home isolation siya, it's different if you can really be beside your family kahit na all the more kung nakakadmit yung patient sa hospital because they're not allowed to have visitors ang Filipinos kasi diba yung habit natin para ginagawa natin reason yung admission for mass gathering yung setup natin but in the case of COVID hindi ba walang bantay so ganan yung nangyari sa kanila so this adds to the emotional distress of the patient and then of course yung fear of survival kasi kuro deaths talaga yung naririnig nung una parang walang nakasurvive sa COVID when in fact it's just a small percentage pero for some reason yung nga highlight natin sa media so I think it contributed to the emotional distress of the patient yung fear na mabubuhay bako, mayaldang bako o kasama ako sa listahan ng mamamatay yun siya and then the fear of infecting others baka nahawa ko yung family ko diba kasi by the time diba by the time nagkasymptoms naman yung pabakonsot but we know that two days prior to that pweding nakakahawa na yung patient and of course yung financial worries mag-stop yung work tapos pati yung close contacts mo mag-stop yung work so definitely meron talagang financial burden attached to having COVID and lastly yung risk of reinfection kasi hindi siya kagaya ng chicken packs na pag nagkarun ka na yung misals pag nagkarun pala na ito hindi you never know if you'll be re-infected again and experience the same problem or have mild symptoms again so you on yung problem sa kanya so post-traumatic stress symptoms in another usually may studies more than four years sabi kong yung COVID pa lang not even two years old mula nung in-announce na pandemic but it's been several months already but we are seeing a lot of patients with post-traumatic stress symptoms I guess the psychiatrist later can share his experience and then yung pa plungs waiting yung symptoms so sabi ng relapsing remating for a time parang pili mo okay ka na kailang mararamdaman mo na naman siya parang gusto mo tanong inang anong bang mayroon kaya ngayong tanong na gagaling pa ba ako so other symptoms by the patient there are gastrointestinal symptoms there are joint pains and because of everything that I've shared doon sa long COVID yung reduced quality of life because they don't know what to expect they don't know what to do they don't know how long it will last or when it will attack what will trigger all these symptoms that they are experiencing kutikong mild siya lahat but what if it's really bothersome symptoms severe headache or severe joint pains and debilitating if the patient is a nurse and is on duty and then suddenly yung bigla nagka-attack pano yung gagawin niya so mayang talagang effect in terms of quality of life of the patient so in terms of management multidisciplinary approach why? because as you can see yung na multiple organ systems yung affected so lagin ganon yung nai kita I haven't seen one actually na isa lang yung talagang complaint niya niba so kadalasan yung one or more and then 50% will need rehabilitation post-COVID so whether it's fisiotherapy, occupational therapy or psychological therapy it's needed by the patient so yung tanong natin kanina gagaling pabaakodok pang matagal ang complication ng COVID ang ating issue dito ngayun so sabi ko I don't want to be the deliverer of bad news pero nabanggit na rin naman kanina ni Doc I think the question is unanswerable with yes or no at the moment hirap niya sagutin because we are still learning about COVID perhaps in the next few months pero yung know our patients are suffering this illness sabi ko nga ok lang if they are mild symptoms but for those experiencing severe symptoms in affecting their functionality with reduced quality of life I hope we get an answer soon yun lang po thank you hey thank you very much that's Dr. Marichelle Samonte thank you for your presentation which was really very comprehensive covered a lot of ground we've got a couple of reactors and it's my pleasure to reintroduce somebody who's always been with us on the webinar in fact was one of our first presenters in stop COVID deaths we'd like to welcome Dr. Lenny Fernandez who is the chief of the division of pulmonary medicine department of medicine of the Philippine general hospital Lenny, welcome good afternoon Susie so I'll be starting my reaction so thank you Dr. Schill you know I think that patient was the patient that I saw before so I remember now you know I suspected there was somebody in the audience it's antiphospholipid anti-bodies syndrome so it's like an autoimmune disease you produce anti-bodies in your own body for no reason at all and it usually happens among females in the reproductive age and then it causes blood clot formation in your body so there's a famous movie star she also sings who had APAS and she was the one who had heparin during her pregnancy so that is what APAS is so it's like an autoimmune disease and then I suspected that for this patient because even after the COVID and after her delivery she had the persistent symptoms of Disneya and there was also I think a diagnosis of pulmonary embolism during her stay so that's why it's incumbent on us to work up for autoimmune diseases and discover the APAS for this patient so ang question ngayon which came first in terms of prolonging her symptoms was it the APAS kasi paraeho silang increase in inflammation sa katawan so it was really a bad combination both for this patient and she was probably really prone to have the long COVID or the long whole symptoms of COVID so this brings me now to the pulmonary complications one year na po kami ng front line po buti na lang nakabakasyon ako ito nakarang dalawang araw so that was my first break after one year and we've really seen patients dying so kahit sinabingan ni Dr. Rachelle na masyado na hype up probably or na hype up yung mortality but it is really very real to our patients and sa mga paciente po nating they end up with severe na COVID na meron silang ARDS ang adult respiratory distress syndrome they end up in the ICU kinakabitan namin nung machine it's either in intubate namin at kinabit sa mechanical ventilator or if not naririnig na yung high flow nasal cannula na pagusapan na po yan it's a method to deliver high flow oxygen very high flow oxygen so that at least na avoid namin yung intubation so in this group of patients na na sa ICU po sila talaga po yung actress of having more pulmonary complications or symptoms after they are discharged of course if they are discharged kasi sa tuto o lang po hanggang ngayon medyo mataas pa rin na mortality rate natin sa mga paciente if they have ARDS and they end up on a mechanical ventilator so each time we are able to extubate and COVID patient po talagang celebration po siya second life po talaga sa mga paciente and as mentioned by Dean Chong it doesn't end there their suffering actually continues after they might have survived they might have lived pero yung quality of life po nila after talagang doosap po talaga not only them but their family also so overall sa lahat na mga nagkaroon ng COVID be they mild, moderate or severe so bobo po tahit na admit man o hindi ang sabi ni Dr. Rachelle kanina 50% among all COVID patients would have a pulmonary symptom one way or another and that would be shortness of breath or coughing and many times actually especially among the mild patients if we do a lung function test on them yung pinapabuga na namin sa isang machine to check how much lung function they have if we do even a CT scan on them and if we do let them have like an exercise testing we don't see any abnormality but they still complain of this especially among the mild patients so Dr. Rachelle mentioned that there seems to be no strict correlation between the two that's why we always still regarded as something serious it is not malingering they do feel it so I just discharged a friend of mine a doctor she came from the province flew into Manila just to have herself extensively worked up after she developed COVID and everything was normal but she still felt really the shortness that was two months after she contracted COVID so it is something real and is experienced among people now among patients now who would have these symptoms in many cohorts already in China, in the UK they found among those who have been discharged for example from the hospital around 20% would have abnormal x-ray or CT scan findings iba-iba po yan if na sabi namin in ground glass opacity or may fibrosis na po so there would be around 20% among patients who would have that and in that segment of population I mentioned na yung galing sa ICU apos the discharge tila probably 80% among them would be on oxygen and they would still be very debilitated going home and that's why we need the multidisciplinary care for them we call them the rehab a lot so dito po ito mga patienting ano ang sakit nilang dala or what do they have inside them that is still making them very debilitated so doctor shell mentioned the post or the ICU syndrome we call it the PICS post ICU syndrome because it's very deconditioned imagine you've been lying down for 21 days sinidate, binigyan ng paralytics so talagang destroyed kung baga pa lahat ng muscle they're very deconditioned and that's a bulk of the reason why they would end up to be debilitated and have abnormal function but there is that 4% among our patients whom we see on CT scan and X-ray na naguwers and this is what we call now the post COVID pulmonary fibrosis so as we mentioned iba-iba ang terminology kasi wala pa tayong fix na terminology for that I look into ICD-10 ang nakalagay pa po sa ICD-10 is COVID infection at ang label ng COVID infection ay U07.1.G pero walang anything mentioned about follow-up care or the post COVID state there is no ICD-10 terminology now the UK people were quite smart enough to have their moment lecture in place because there's a lot as mentioned by Dr. Schell a lot of implication in terms of reimbursement and insurance compensation and all those things they would label patients who are still symptomatic for the first 4-12 weeks as ongoing symptomatic COVID-19 hindi a post COVID-19 syndrome it is only 3 months after if you still have the symptoms particularly the pulmonary symptoms that you will label it now as post COVID-19 syndrome and for the lungs as well if the findings on the CT scan or the X-ray would persist 3 months after then we could technically label it that really this is post COVID pulmonary fibrosis now there are two schools of thoughts there because if for example if we look at now how the pathophysiology is at fibrosis yung pagkaskar po ng lungs would take place even way before so they've seen also the autopsies studies na 43% even at the second week of illness nagsa start na po yung scarring together pa with the COVID pneumonia so we should hit that fibrosis right from the start you mitigate the risk right from the start so that sana it won't proceed on the fibrosis so there's that school of thought at the start now your medications to combat the fibrosis that can go on in 4% of patients right from the start when you see signs of it or when you now are really able to establish it some would put it at 4 weeks some would put it at 3 months kanya kanya din po yan because there is still it's still being learned now what the experts did now is to look at our experience with the MERSCOV before MERSCOV 1 epidemic how did fibrosis happen among these patients na kita po nila na 2 years down the line most recovered but there is still 5% who still had fibrosis 2 years from now so sa question na gagaling po ba ako if you are one of those who would have the fibrosis that happens in around 4% of patients gagaling ka pa ba most likely yes but the problem is so 2 years down the line you might still have it and then the longest na cohort po nila na kita was 15 years and they found that in 15 years again around 2% still had some fibrosic infiltrates there but functionally they were already able to recover so in terms of pulmonary fibrosis 4% would probably have it silo na ang may risk factor to have that those who were in the ICU those who were on mechanical ventilation or had high flow nasal cannula older age group patients with comorbidities and a pinpoint nga nila hypertension is one of them now if you know yung overall na post COVID state it was there was a preponderance for females for the overall post COVID state but for pulmonary complications from COVID patas po yung gender there was a bit of a male preponderance in the UK cohort because they had more males there who succumbed to ARDS from COVID so ito po yung mga risk factors na nakita nila for us now having fibrosis so ngayon po I mentioned we tried to prevent it mitigate the risk tried to aggressively manage it right from the start the COVID infection per se so ano na ngayon is how did fibrosis happen and most would still believe it's due to the hyper inflammation and then the aberrant response of your body to that inflammation na ang repair mo naman exuberant masyado so there is an over repair that happens in the lungs that now leads you to fibrosis so the bottom line now would be treatment what do we do we give immunosuppressants there was one study that was published last month which showed that giving steroids at 0.5 mkd four weeks after the patients were discharged and were diagnosed to have pulmonary fibrosis it showed that there was an improvement in lung function with that study it was not a controlled study there was no placebo there there was no placebo arm or control arm and the patients were well monitored so we don't know whether the improvement in lung function was due to the overall good care that the UK people did or was it really due to the steroids now I'm sure you've heard that maybe antifibrotics can be used these are now medications which will lessen the repair response to our body and we have two such drugs that we use for idiopathic pulmonary fibrosis or ITF ang pangalan po nung mga gamut na yun nintedanip atirfenidone eto na po ang aming yunaggamit na mga pulmonologist sa mga patients whom we believe have really post-COVID fibrosis but it's so expensive it's 100,000 pesos per month and if you're feeling don't you can't get it from here in the Philippines so that's how bad it can be that would be the bad use in terms of patients who would develop post-COVID fibrosis who would be oxygen dependent what the good use is is that it happens only in a few patients but we as pulmonologists have to be on guard if our patients would end up like this and then as we've seen in the SARS-CoV-1 and the MERS-CoV epidemics before if ever fibrosis happen it doesn't worsen hopefully further so that would be the good use so may gagaling ka ba daw? yes gagaling ka kung kelan hindi ko po anong kung kelan it's just a simple debilitation from pigs or your very decondition kalang from hospitalization then definitely rehab will help and if they would just be the mild symptoms like cough and dyspnea yes it is real it's present we still don't know it might be the inflammation that has led to those complications but those also disappear usually within three months thank you pa okay thank you very much Dr. Lenny Fernandez for a brilliant analysis of what could what is happening in long haulers or long COVID Raymond over to you for our next reaction thank you Dr. Lenny thank you Dr. Susie I did not expect that we will be getting updates po very very based on the evidence and up-to-date science that we have been receiving so thank you so much Dr. Lenny our next reactor po is the chair of the department of rehabilitation medicine of the Philippine General Hospital other than Dr. Sharon Ignacio Mam Sharon Good afternoon everyone Dr. Raymond and everybody else Chancellor Padilla so it's nice to see you again so let me just comment and leave my reaction to Dr. Asamonte's presentation thank you very much so from the rehab standpoint long COVID rehabilitation what do we know so even minimally symptomatic patients exhibit abnormalities after recovering so COVID can lead a variety of symptomatology ranging from mild moderate severe symptoms and we end up having late convalescence persistence of symptoms and emergence of symptoms related to organ damage so the long COVID state is neither well defined nor well understood as of now so the COVID complaints have been described by Dr. Asamonte and what of course now we realize the vital role of rehabilitation place in long COVID we very well know that in rehabilitation we assess the patients we include the medical condition the comorbidities signs and symptoms and the various altered body structures and functions that relate to activities of daily living and performance at work, at home and of course we always include the various contextual factors such as psychosocial and environmental factors that can influence recovery we can be barriers or facilitators of recovery so because of the myriad of problems that may beset long COVID patients it's important as mentioned earlier to have poholistic and multidisciplinary approach in the care of these patients the PGH actually is a recover program it's called the rehabilitation of COVID patients for early functional return this program was set up in collaboration with a section of pulmonary medicine of the IM department last November 2020 and in May of this year plans for the phase 2 of this program was initiated to address the problems of long COVID and we've seen so far so from November to June we have seen 239 inpatients and for those and follow up via the teleplatform from March to June of 2021 we have seen 52 of these patients so the general characteristics of these patients and follow up most of them have improved using the QAT or the cut assessment tool that we have developed mostly on exertion but much improved than the state that they were just before they left the hospital but some remain status quo and some were re-admitted maybe some have poor follow up because they have had improved status even after discharge so what do we do with these long COVID patients we usually provide an individualized program it has to be individualized because we know that these patients have varied medical problems they have different problems it differs from one patient from another was mentioned earlier that patients can undergo an exercise program but let me tell you also that we also have such programs like work simplification and energy conservation programs and even we teach patients relaxation techniques depending on their I think this patient our nurse can benefit from it she has gone back to work so she can taught the proper techniques on how to minimize exertion so maybe she can come to us for consultation and we can teach her these techniques and relaxation techniques this can help her especially when she is quite anxious and again we also have speech and dispatch programs especially for those who have been intubated for a long time and we also include educational programs for our patients and their families appropriate referrals are given to our paramedical staff PT, OT speech, psychologists as well as other MBS if they are warranted so since medical our medical knowledge on long COVID is still evolving and the patient is left with what COVID leaves him with presently though there is nothing we can do to prevent the symptoms coming after COVID we can still work with whatever the patient presents to us to improve their quality of life and that is the role of rehabilitation let me just share with you the else in long COVID so I just point this plus clinicians what do we do let's look and review at literature but let's keep listening and observing well our patients for we may get to learn and understand this long COVID condition better from our patients as clinicians it cannot just be let it be and for our patients we hope that they can learn to leave the present moment knowing that there are doctors there's a team to help them deal with the COVID symptoms and for family and the rest of the team let's all be one in this journey let me take a long while helping patients to move on for the care that we may give at breathlessness and symptoms away thank you thank you so much Dr. Sharon Ignacio it's really just a continuation of what we heard from last time and thank you so I hope you can join us ma'am in the panel discussion over to you Dr. Susie thank you Reymond so all of our panelists have talked about mentally and psychosocial reactions so it's only fitting that we have with us the chief resident of the department of psychiatry and behavioral medicine at the Philippine General Hospital Dr. Cedric John Factor who will discuss the longer term effects on psychosocial and mental health Cedric welcome to the webinar good afternoon pa Dr. Susie and good afternoon everyone first I'd like to thank the organizers for inviting our department to this multidisciplinary discussion it is an honor to represent our department to discuss the psychiatric sequel of COVID-19 when the COVID-19 pandemic adopted last year psychiatrists all over the world have already anticipated the possible long term psychiatric effects of COVID-19 for us in the department of psychiatry and behavioral medicine in the past year and a half our service would regularly receive referrals from the COVID floors for co-management after seeing patients being depressed anxious, frustrated and would sometimes act out during their admission as a consequence of their COVID-19 diagnosis when I would assess patients na nang karong datan ng COVID-19 ramdam naramdang ko pa rin yung impact sa kanila ng pagkakarong ng COVID-19 na ito may magtagal na silang negative minsan, tuloy-tuloy pa rin yung hirap nila sa pagtulog na una nila ang napansay nung nakakwarantin sila minsan, especially with yung frontliners na kausap ko nagsusabi pa rin sila na may unting pangamba pa rin sila sa pagbalik sa trabaho dahil na nandon pa rin yung tako at yung pangamba pa rin sila sa COVID-19 Speaking of frontliners I would like to express my appreciation of Dr. Hippol and Dr. Samonte highlighting the mental health struggles of COVID-19 patients especially those who are healthcare workers consistent actually yung kwento ng patient ni Dr. Hippol and Dr. Samonte sa nangyari nung SARS na natin a last major pandemic of this level nung SARS ng 2003 na identify ang mga healthcare worker ay mas higher risk to experience mental health issues even on a long term basis when I was reading studies on COVID-19 and its long term psychiatric impact I found a study na nung SARS even two years after the SARS pandemic is over isang study sa Hong Kong showed na healthcare workers in hospitals handling SARS patients reported higher levels of psychological distress compared to those who are not exposed to SARS patients I think sa kwento na na share ng patient natin this morning kitang kita yung takot na naidulot ng COVID-19 kong ikaka matay ba nilin COVID-19 yung takot na maaari silang na makapag-infect na ibang tao nako anong mga iyari sa kanila pag atapos ng COVID-19 diagnosis nila in treatment unfortunately on a less positive note na I think this case presented today will be more common in the near future ito siguro ang isa sa mga makigin long term problems ang ating mga na-infect ng COVID-19 even years after the COVID-19 pandemic is over lalo ang lalo na sa mga healthcare workers kitang kita na sa case na ito na mental health ng mga healthcare workers ang isa sa kailangan ating bang tayan lalo na sa mga naging COVID-19 referral centers tulad ng PGH so with that, maraming salamat for inviting us in ngayon ng hapon very much Cedric Faktor from the department of psychiatry and behavioral medicine of the Philippine general hospital thank you for sharing that we are now going to pull our panel back but while we're doing that and asking our doctors to open their screens we have a public service announcement from TVUP so let's go to that okay are we going to do the public service announcement I'm not saying it TVUP meron time public service announcement ano po ba tayo it will display okay, alright so let's go to the and we'll see if we can do the public service announcement later just let us know in the chat so let's have everybody back Ian, Marichelle, Lenny Sharon and Cedric and please open your cameras we are going to have panel discussion but first Raymond is going to get answers for our opinion po Raymond over to you okay, thank you doctor Susie as we are seeing po as displayed on the zoom but we may ask TVUP there we go, okay so doon po sa mga nanonok po sa ating mga YouTube at Facebook pages we'll try to answer these questions so I'll get answers from our panelists po questions and answers before we go through the feedback from our speakers first question, what are the risk factors that will make a person a COVID-19 long hauler, is it age ICU admission, comorbidities or all of the above majority po ay pinili ay all of the above and then for our second question ang second question po natin ay, thank you po what will make you a long hauler so option A persistent shortness of breath option B, depression option C, brain fog and option B all of the above okay, doctor Susie okay, so si nung sasagot nito first question po mo na yung ano po ba yung mga sin Tomas first, Marichelle or Lenny or Marichelle in answer okay, doctor Lenny na yung answer kanina di ba ICU admission, comorbidities yes, especially sa pulmonary pero sa lahat din yung possible na symptoms of post COVID po nipo sila, yun lang gender it's quite unique na sa post COVID na overall nakita nila na mas madami sa mga females ang affected over all for our second question po what makes you or will make you a long hauler po wala po dito yung time element mam Lenny pero in terms of symptoms ito po angan mo for the most part in terms of symptoms well, all of those things as I mentioned di ba ang dami isang mong pay na kaisan if all those things na nalipopersist kahit na anong symptom na nalipopersist after COVID so matatawag natin siya na anong long hauler so the answer is all of the above okay, all of the above okay okay, I think Dean Charlotte is still here Charlotte if you're still around and you can still stay we'd like you to be in the panel here are our discussion I think maybe the first question is you know, our audience are really frontline workers nurses, doctors all over the country in district hospitals, tertiary hospitals private practice people watching us from schools I think the first question is what advice do we give to somebody who has recovered from COVID but now experiencing persistent symptoms so anybody? siguro from the patients that we see sa health service so number one the spectrum of symptoms it's very varied so there is an opportunity to do something about it like there are interventions in rehab that are being done and sometimes people are just not aware and some of them can be done sa kanila lang they can do it on their own actually they just need to be aware and it's something that you have to observe kung talagang meron ba siya talagang and if it's manageable and I think for any busy especially like this parang acceptance of what you have and learning how to cope doon sa meron and existing condition would be very important to maintain yung wellness but I hope in the future parang just like any busy we have primary prevention secondary prevention my tertiary prevention yung long term complications hopefully we really matutunan natin ma figure out kung pano ba talaga if you prevent or if you control yung long term complications na ito what would be some Lenny go ahead you wanted to say something go ahead then so we're trying to build as mentioned by Dr. Rachelle ninsan kasi hindi mo volunteer ng patient so first and foremost we're coming up with a checklist na at least it's easy to take off at least to see which are the complaints of the patients kasi parang ang bottom line then it's symptom based then yung ating care kasi as of now wala nga tayong terminology pa for that so it's like a multidisciplinary thing targeted at decreasing what the patient is complaining of kasi nga it's a constellation and it's quite varied now the rehab department and Sharon can share that they have a very nice na simple na scaling as to how you will now assess how the functionality of the patient is and from there dapat may baseline kang nga talaga and then you work on kung ano yung main complaint ang patient do na ka target na kung ano magiging intervention so like for example dito sa pulmunari part nakikita ko talaga this is one observation of mine na there's a turnaround after three months so I've seen that happening among the patients who consult with me na they do have a lot of symptoms the first three months tapos I just tell them also na we just have to weather this out we'll try to target whatever symptoms you have and then there's usually a turnaround after three months and things will get much better is there something practical that we can do to help patients like should they keep a journal or a diary of what's happening to them and then I think the second thing is at what point because actually patients don't really consult unless di na nilakaya parang okay there are patients who will you know run to the doctor or call right away but I think in general patients will kind of titiisimila tiba so but at what point what point in long COVID do we really advise patients to seek care so anong si Dinyong nakakatakot talaga supposedly for all hospitalized patients they should be seen by their doctor for follow up two weeks after so parang yan ang victim two weeks, abroad four weeks nga sila tele consult or face to face usually it's just tele consult and then the rehab people have a nice pamflip that they now give to also recovery program nila na they give it to all COVID patients na sana kahit di na refer sa kanila so there are all the tips the H.O. website has a very nice na patient pamflip napos nandun yung simple exercises for example that you can print out and use in your own hospitals it's so simple and very practical okay I think that's a great piece of information for our practitioners or listening. Raymond did you have a question or do we have somebody coming from the audience to ask a question, go ahead. I think we have one Mr. Ryan James Kaspar has been selected to ask his question and I think Mr. Robert Dave so I will if you are already okay Ryan can you open your video and ask your question feel free to unmute yourself and open your go ahead with your question Ryan. Hello sir I guess the question was already answered ang part na lang po na hindi na sasagot is yung how were the scientists or what were the studies how were the scientists able to ascertain the causation and the correlation of long COVID of the syndrome to the pathophysiology of the COVID itself. Okay who would like to answer that? I think Mr. Ryan Thank you for your question. Hindi ba sabi ko nga kanina what I presented a while ago is actually an attempt to explain what is going on and we are still learning yun but to really establish everything that is going on like anunitiglity like how we explain other diseases we don't have that yet yun yung problem sa kanya so just like NDCs we start out with case reports yung mga testimonials na patient na after kung nagarunang COVID ito na yung naramdaman ko and then pag-isa lang kasi yun nimo siya papansin na hindi but when you're getting multiple patients already having the same complaints na related to the same illness then you start suspecting and then you start trying to answer the questions and we are at that phase and we are trying to answer the questions slowly nandun tayo sa stage na yun so we're trying to figure it out so I think yun yun siya these are multiple observations sa ngayon reports not only in our country but also in other countries so that's what we have right now and that's what we're trying to do and explain and address for these patients Lenny did you want to say something about that? For example for the pulmonary part they've done also yung association ng mga inflammatory markers and how the CT scan and the others would look now they also do lab work so yung SARS-CoV-2 na virus nilagay nila sa mga rat models to see how the physiology in the non-human models models are and that's how they would actually discover so nakita nila yung mga TGF beta and all those inflammatory markers are kind of increased also in the post-COVID state so that's how they're looking into the causation in terms of the pathophysiology pero mahirap talaga siya lalo na par example sa muscle kasi hindi mo alam kundeconditioning ito or it's really the effect of the inflammation or the repair thing so mahirap talaga na Okay, thank you Lenny. Raymond, did you have another question? The most upvoted question ko kasi was already tackled but I think there are a couple of questions in the middle po ng mga Q&A na that several people have also chosen I'll just read them off the list so very interesting po this one from Dr. Joseph Cortona Will vaccination prevent long COVID? Is that something po na has been studied and then the next question po and I'll mention this also if you were an asymptomatic COVID case will it be pa, will you all what are the chances that you'll develop for long COVID? Siguro, those are two separate questions sa vaccine related and then yung asymptomatic case the actual numbers I don't have but they know na yung asymptomatic cases can also develop post COVID minsan kasi we've seen patients na symptom-free talaga siya and then after a while big lang mayroon siyang complaint mayroon siyang sasabihin na nararam daman these are a small group of patients na yung big lang hindi namin sometimes period of clearance na niya meaning clearance return to work because we monitor them daily return to work na big lang maysaden onset na ay big lang may ganito ako big lang ako inubo so ano to niyo COVID ba to pa rang pero weird kasi di ba sabihin natin 3 months eh di ba so parang yun so we monitored or nagkaromba siya na bacterial infection and then it persists na parang if it's bacterial infection we've already given the antibiotics doon pa pasok ngayon siya yung mga referrals for further assessment or diagnostics kung kailangan di ba para malaman nga natin kung ano what to do next yun on and then for the other question naman ang vaccines kasi natin ganoon din nasa parang trial phase din kasi di ba ang vaccines matagal yan may establish nabi ko even yung establishing kung hanggang san siya effective ano eh di pa natin alam di ba parang we do not know yet we need to be vaccinated year to be every 3 months every 6 months it's not yet known so yung doon sa question ni sir parang mahirap din sagotin yung part na yan if it could really prevent that but you know pag titingan mo kasi yung usual vaccine ang usual vaccine walang 100% eba it doesn't guarantee 100% protection but we don't know if you are vaccinated and you have lesser chances of getting infected and if you do get infected you have milder symptoms di ba so yung kinatakutan natin na severe kiniklaim nga nila 100% protection against severe e di ba so we do know that you'll get milder symptoms pero although more na medyo mahirap sagotin kung mapprevent niya yung long term complication ng long COVID so maybe in the future kasi ngayong pala yung batch na nakikita natin ng protected or yung protected na hindi magkaroon na hindi magkakaroon ng long COVID in the future so ngayon palang sila mga anak or ngayon palang sila ipapanganak sige Thank you very much Doctor Samonte I think one of the more difficult things to manage and both Ian and Cedric have alluded to this but I want to ask this question because it's more difficult because it's actually quite difficult to deal with mental health issues in general even without COVID so what is our advice so family medicine, psychiatry what is our advice for families when you have patients who have recovered but are anxious have PTSD they're depressed what should we be doing so Ian you might want to start kasi you opened with it I thought it was great that you you talked about that but I also want to ask Cedric what's the role of the family, of friends et cetera okay go ahead Ian please so actually for the patients that we've had were dealing with mental health situations especially now that we have COVID or they have past experience with COVID what we do is actually to involve the family in the care of this patient so aside from the doctors kasi that they can talk to it it's actually easier for them to open up to family members so if possible we can talk to the family members and give advice on how to support even just yung talking to yung family members with their feelings and how not to invalidate the feelings of the patient para at least mas open po yung lines kasi it's very important for the family members to provide support aside kasi from yung friends and of course yung colleagues na mas nakakainting din yung pinag-dadaan ang po yung patient iba din kasi yung relationship and yung connection nila with family unfortunately there are also times kasi na yung stigma actually can also come from family members so we have to educate also the family members on how to parang hindi naman siguro nila sinasa na yung imposing stigma it comes from fear also of being infected kasi in nature naman nang tao yung na matakot for yourself but siguro yung kausapin yung family and of course educate them well para po maiwasan nang mabawasan yung ma-impost na stigma din sa patient so that they can feel safe at home also not only physically but emotionally mentally as well. Iyan before I give the fur to sir I thought when you said not to invalidate what the patient says what does that mean concretely because we're talking to thousands of people of this webinar who are counter so what do you mean by invalidate kasi baka ano ay di ba oh kaya-kaya mo yan bala naman yan di ba yung naman yan problema yung positive thinking nangang kailangan yan yung bang anong big sabihin natin ng invalidation and what is the correct response and maybe Cedric can also answer that so ikaw mo na iyan so for me yes mam the invalidation mam actually parang it's more of not giving importance to what the patient is feeling so sometimes actually that's the reason why there's a delay in consultation for the patient kasi feeling nila may very minor yung symptoms nila as you've mentioned na dumadating nalang yung patients to the point na sobrang nakikirapin na sila saka sila mag-consult and at that time at that point and time na yung intervention if ganun po nang nagsasabi yung patients sa family members na parang hinihingala ko parang ganito we encourage them to see consult agad para at least alam nila na itong nararam damang ko is actually something that I should consult for or even yung feelings po thoughts and feelings na with relation to psychiatric problems din yung depression and depression and anxiety kahit mahirap ko kasi lay person to validate or at least to acknowledge kung ano yung pinagdadaan and but actually what we can teach them is what not to say to the person para hindi po sila magkaron ng wall dun sa communication so it's more of allowing the other family members or allowing the patient to actually just air out or parang ventilate lang kasi sabihin lang kung ano yung and not to say anything na parang sa sabihin yun sometimes kasi our tendency is sabihin nga po na okay lang yun parang kaya mo yan siguro magdasal o kaya parang mag-relax ka lang ganun so sometimes kasi yung statements po na ganun actually na hihirapan silang parang even for themselves hindi na nila ina-acknowledge na ah o nga baka sa aking lang to parang kung ibang tao to hindi naman ganito yung nararamdaman so that's when parang self-questioning starts for the patient so na mas na hihirapan tayo to reach out to these patients kapag nagkaron ng instances even in their safe space with their friends and their family members nagkakakirot ng ganun statements po Okay, thanks yun. Cedric go into more details on what you shouldn't say and how should you respond? It says na lulung ko tako o parang baka hindi ako gumagaling o parang ayaw ko ng mabuhay whatever it is what should the response be and what should you not say? Sigurom sigurom ang start of first with the previous question kung ano yung invalidating statements invalidating statements are primarily statements na well-intention po pero are actually preventing the patients who may need psychiatric or psychological treatment from seeking help. Kanina you were able to share some examples yung kaya mo naman yan ipagdasal natin yan manalig sa Jaws may mga pinagdaan ang kanaman mas malalada tilito these are very well-intentioned statements na in the person who said it ang tingin nila is actually helpful pero ang dating noon is that ang dating dun sa nakakarinig ay hindi pala important yung sinasabi ko na malungkot ako na may hirapan na kung bumangun sa umaga it comes across as pinapawalang bahala yung sinasabi and to answer the main question I think yung pinakaemphasis just like Dr. Heaple said earlier is for families to maintain an environment sa pamily nila we're in the patient who underwent COVID-19 is comfortable enough to share yung nararamdaman nila I think we have to remind ourselves that we are living in a very unusual situation already living through a pandemic it is even more unusual and stressful to get COVID-19 and that is an experience na mahirap icommunicate especially to those na hindi naman nakaranas noon and we need to remind ourselves that kung may sinabi sila na nang hihirapan sila or malungkot sila because of what they're experiencing allowing them to share and to listen and to instead of expressing and validating statements to collaborate with them and to approach them how you could solve the problems if the patient says na lulungkot ako offer your help na paano ka namin pwede matulungan nakikita namin na nahihirapan ka ngayon masakit makita na nakikita ka malungkot sa tingin mo paano kami pwede makatulungan because I think in times like this not everyone can go to a psychologist psychiatrist and if we can empower the families with these statements paano baka makatulung nga ikita kung may hihirapan ka these examples of how to respond is very important at the level of the family kasi sabi nga nila judgmental meron nagsabi sa chat toxic positivity ay wala lang yan anong kumain ka nang mga masarap okay ka na these are very real feelings that our patients are experiencing so I think this is very helpful these points that you have raised I think Lenny is nodding your head Lenny you wanted to say something so I was amazed by that term na toxic positivity so na tutunan ko sa smoking sensation ganito din your motivational interviewing part na open-ended questions again with the empathy and then just let the patient express themselves tapos kami naman as healthcare workers we do have to perform objective tests to see also if there's really also something that we can specifically target but again Dr. Shell mentioned marami din now negative sa mga tests but they still feel it that it's still very real I think for our webinar today talagang lumalabas yung ano what patients report we have to take it seriously nga kasi tarang marami tayong hindi alam tungkol sa sakit Raymond did you have any other question before we come to a closer coming to the top of the hour that's one last question po thank you to everyone very very important as a psych graduate that's something that we try to be able to put an emphasis on really we'll give it a thumbs communication softeners but sometimes it's not really softening anything in that sense but the last question will be about rehab medicine po for Dr. Sharon Ignacio po I hope ma'am is still here ma'am Sharon the question po and this is something that we saw po outside of the zoom the question po with regards to for those who have been previously shall we say more on the athletic side did not have any problems and then na kamaan po ng COVID and then four months, six months thereafter they are still tingal when they are climbing three flights of stairs compared to before they were marathoners kung adakbuku sila what advice do you normally say to these patients po Dr. Sharon? Actually I have one patient who is like that he had COVID no he was riding the bike several kilometers and all young individual so just like what others have been saying of course we listen to them we have to learn to listen what are their complaints and all so we analyze their activities what is it so we still encourage exercise okay but not to the point that they will be hingal na hingal okay because you are asking about an athletic patient so yes we encourage exercise but of course not to the point that they will really collapse so what is that intensity at the start you build their endurance you build their strength but for these athletic patients kiba kasi mentality nila to immediately go back to their usual but you really need to explain to them what is this what is this that they are feeling why are they feeling this so it's really a must for you to explain that they might not be able to reach that point easily they have to wait they have to learn to be patient so I tell this to the patients actually learning to be patient learning to deal with what they can manage at that point in time and then we slowly build up the intensity of the exercise exercise that they can manage so hindi kasi pwedein bigla e maraming athletes gusto kasi bigla ka agad but that cannot be the way as of now okay thank you very much thank you very much Sharon okay so Raymond we'll go to our closing statements go ahead Raymond no we'll just do reverse chronological order but before we go into that tbup may we have the our assessment poll really a staple for all webinars read through the questions and then we'll try to move forward with closing statements as more and more try to answer for the questions the panelist demonstrated total knowledge of the topic second question the panelist were well prepared and organized third question the panelist spoke clearly and audibly fourth question the panelist used appropriate language with technical medical jargon adequately explained and number five the panelist contributed to new perspectives and knowledge on managing various key COVID-19 health issues okay as our attendees who are still numbering 200 in the zoom are key in their answers may we call on Dr. Cedric Paktor may be 30 seconds to one minute brief closing statement Dr. Cedric what is your last message to our audience oh siguro as more of a parting message lang po na I do appreciate and this is one of the interventions that we're already doing this particular webinar is that we need to make mental health psychological and we need to make mental health a major part of interventions when it comes to illnesses even illnesses that are still difficult to explore such as COVID-19 so I'm very happy na we were included in this multidisciplinary webinar thank you so much for closing statement we'll have Dr. Sharon Ignacio last message to our audience okay so there's more to rehab than just exercise we have to have a multidisciplinary approach find out what the problems are of the patients and tackle these refer to our staff we have our paramedical staff we have a holistic program so remember here and in PGH we have the recover program thank you thank you po for Dr. Lenny Fernandez mam Lenny so the pulmonary complications in post-COVID are very real and gagaling pa pa sila yes gagaling sila unfortunately the bad news if you're one of those 4% it might take time thank you Dr. Lenny to Dr. Rochelle yun nang sabi ni mam Lenny mam Lenny long COVID is real na ibanan doon siya it is existing but it is not the end of the world yun siya it's not the end of the world so there's still new things to learn there is interventions available and sabi nga laban lang but if this ever happens to you hindi naman masama ako patingin ka just to verify if it's really the long hauler you're a long hauler or not okay and then finally our presenter po Dr. Ian current people we live in very uncertain times and we still have a lot to learn from what is happening but we would like to take this opportunity to collaborate with our co-leas and other departments so that we can holistically take care of our patients especially since medyo mahaba pa ang road to recovery so it doesn't stop at acute infection but later on we still have to take care of our patients okay thank you so much Dr. Suzy you'd be the one to close our webinar po it seems okay so I think since the start of the pandemic 178 million people in the world have developed COVID and I had mentioned earlier that Time Magazine came up with one of the studies that it's estimated that 25% of individuals who develop post-COVID conditions or long haul COVID whatever we call it are going to be with us and I think this has many many implications for care, diagnosis because it mimics so many other conditions in the case of this particular patient Lenny asked a good question right did she have anti-phospholytic antibody syndrome before COVID or after COVID so there are so many so many implications of long haul COVID on the way we are going to manage patients in the future because if there are 178 million people who have had the disease 25% is about 45 million 45 million people who will be having some kind of a chronic condition which we still do not understand and truly we are only scratching the surface of this problem as there are new variants and new information is coming about this so there are implications about returning to work when can one return to work about financing can this be covered by insurance if you are post COVID and then you get sick again and then the mental health part of it the anxiety, the stress some people think they have paranoia because of it but actually what I think I heard everyone say was these conditions what the patients feel their symptoms are very very real and as healthcare providers we have to respond in the right way so that we don't make it worse and what it is and I really like this discussion on how to respond and again sometimes we think we are being helpful by saying oh positive thinking lang or magdasal nalang tayo mawawala rin nyan suerte ka nga na buhay ka I mean we have to learn how to do what is called reflective listening meaning if somebody says something you don't judge, you don't jump and sometimes when you don't know what to say what you can say is parang nahiirapan ka talaga what I'm hearing you say is you can't sleep, you can't eat and once you repeat what a person has said what a patient says they experience they actually feel good about it because it meant you heard them you don't say don't feel that way or wag kang ganyan you can say parang nahiirapan ka talaga ano pang ano kumahakatulong sayo gusto ko yung kisedya kaya kumahakatulong because they might have an idea they might be able to tell how to progress in this pandemic we really all have to have an open mind we willing to learn and I think most importantly we need to learn how to listen to listen well to our patients to be respectful, to have empathy and to always consider that I learned this many many years ago when I was a student that patient will not complain to you because there really there's really something going on of course there will be a couple of one or two there that will make things up for different reasons but most of the time when people seeking out they really need ya particularly Filipinos where mati isin we don't usually complain but if someone is saying something so I'll end on that note and thank you everyone for our great webinar go ahead Raymond thank you po maraming salamat po to all of our well excellent set of resource speakers we hope to be able to invite you in our future webinars and we look forward for your attendance in our future webinars and maraming salamat po we are showing po the poll for those who will want to take a post test as it relates to the questions po two questions are what are the risk factors na isang taong COVID-19 long hauler and number two what will make you a long hauler so be very very well perceptive po that just on the symptoms but also for number two time element po which is the three month mark for COVID-19 long hauler and that ends webinar number 57 po ating fifth season of the stop COVID-19 webinar series maraming salamat po and we hope to see you again next week Friday for our regular lunch date magkita kita po tayo from 12 noon to 2pm it's a date okay Raymond before we get the closing line our topic next don't miss it magandan tapik natin who gets the last ventilator we hope we never hope we never get to that but ang discussion natin is about ethics COVID-19 crisis level hospital care so harinoa hindi na maulit yung surge na na puno yung mga hospital although there are some hospitals outside Metro Manila that are experiencing this so we are going to have a discussion on the ethics ang pagkanagpulang na yung mga ventilator natin paano bang pipiliin po sinong nag-amit ng ventilator so join us next Friday okay so someone who is from a patient advocacy group I think we will also have an ethicist also because it's an ethical legal aspect will have a lawyer to join us and also the proponents of that set of protocols but I believe has been adopted in select few hospitals at least in the European Union so yung po, the crisis okay together we can stop COVID deaths thank you and keep safe, keep healthy and see you online thank you I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I