AAC To The Point - Lorne Brown

Best Practices for Starting Up After COVID-19

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And again, thank you to the American Acupuncture Council for inviting me to host the practice management sessions on their webinars. Today we’re going to be talking about COVID-19, best practices for starting up after a full stop. I’m your host, your moderator Lorne Brown. I’m a doctor of traditional Chinese medicine, founder of healthyseminars.com, the clinical director of Acubalance. I’m a doctor of Chinese medicine in Vancouver and I’m also a CPA. And I got some impressive guests with me today as well. I got the chair and vice chair of the ASA, the American Society of Acupuncture. David Miller is a medical doctor and a licensed acupuncturist and Amy Mager is a licensed acupuncturist and they have been a voice for our profession. And since we have been in isolation, some of us are maintaining isolation, some of us are starting to go back to work part time, et cetera. There’s lots of moving pieces and we thought it’d be a great opportunity to have two great resources, Amy and David come here and answer some questions for us. Thank you both for taking the time out of your busy schedules to be on my show.

Thank you for the opportunity to encourage people to find the best resources for going back to work at our website, www.asacu.org. On the top there’s a COVID-19 resource page. You can click that. It’s updated regularly by our webmaster Z Elias and he’s happy to do this and we’re happy to have you go there. One of the most important documents we have there is one created by the board entitled, Contextualizing Essential Healthcare Providers and Essential Healthcare Services During COVID-19. And it’s an extensive document and we invite you to go there and find it at asacu.org.

On the ASA website that’s an important thing to kick off. There’s some resources that have been collected and is being updated daily. Now, first question I have because I want to get some practical tips for our group. You have the ASA website where you can check out these resources. David, we’ve been chatting a bit and I just want you to kind of elaborate and go back into what’s it going to look like for practitioners as we ease off these restrictions and return to work? What are you aware of for all the different states right now?

Right, I think that’s a great question, Lorne. Thank you. I think what’s important for people to understand is that this is not a stop or go kind of situation. This is not a you can’t practice or you can go back to full practice just like you did before any of this happened. This is a staged process and as people return to work, they are expected to take significant precautions in practice if they do return to practice.

And so the first piece of that is, when do you return to practice? And it’s important to pay attention to the guidelines put out particularly by your local authorities. Start with your local authorities, then go to your state authorities, then go to the national authorities in terms of when you should start to open up your practice because the distribution of cases of coronavirus are different depending on your location. And the thought from the governmental level is that in areas that are less densely affected, that it’s more appropriate for those people to start opening up their doors a little bit more. Whereas in places where it’s highly concentrated, it makes less sense to do that.

They’re watching for a number of factors surrounding that, including a decrease in the number of new cases, particularly occurring in the area and a decrease of the slope of the curve. But remembering that just because the curve is starting to go down, that’s just reflecting a decrease in the number of new cases occurring each day. But not that no new cases are occurring. If you have a 100,000 cases occurring on the peak, and as one doctor said, then the day after the peak, you might only have 90,000 new cases, but you still have 90,000 new cases on top of that 100,000 cases. And so don’t get over comfortable with opening your doors like everything’s fine.

What it’s going to look like is there’s going to be an expectation that you’re still screening your patients, that you’re checking to see whether they’re symptomatic, whether they should be dispositioned somewhere else, whether the condition that you’re going to treat them for really needs to be treated right now. And whether or not that patient themselves is a high risk person. Do they have diabetes? Do they have a congenital heart problem? Do they have immunosuppression? Things like that. Those kinds of patients, it’s more risky for them to leave the house and come out. There should be a relatively greater threshold to starting treatment with them. Think of this as a staged approach and it’s not all guns forward, just we’re going back to it. It’s going to be a gradual process that’s done very cautiously and is different location by location.

And is there a risk then that we go back to work and could this all happen and we get shut down or get pulled back?

Absolutely. That’s a yes. That’s a great point. And I actually really want people to take that to heart. All the predictors are that we will have a second surge. Because we have a decrease in our surge because we have done this isolation technique that lowered the number of new cases. But because this is so widespread, once we start interacting with each other again, we’re going to see a rise in the number of cases. And the question is, how high will that rise go? And one of the big reasons we have to do such an extreme sort of isolation in this case is because no one has any immunity to this. We were under prepared or under stocked in resources. And so it caught everybody essentially by surprise and we weren’t ready to manage it. But we should anticipate, we’ll be happily surprised if it’s not true, but we should definitely anticipate that there will be a second surge.

And as doctors at the national level, Dr. Fauci and other people have said, when you start mixing that with seasonal influenza, then it gets really hard because seasonal influenza is hard enough. And then you add this on top of it that when we get into September, October, November when influenza starts to rise and you can’t tell whose symptoms are from which illness, and you’ve got this compounded situation of two illnesses that are significant occurring at once, we don’t know whether or not there’s going to have to be a second isolation order.

But I think it’s really important for the practitioner community to not get caught twice, in being not prepared. I absolutely do not encourage people to hoard supplies. Don’t hoard things. Make sure there’s good distribution of supplies for people, but plan ahead also. Have a store of masks on hand. Have your gloves on hand. If there are herbal formulas that you prize more than others, have those on hand. Gradually build up your storehouses and calculate if you see this many patients per day or this many patients per week, how much of that do you actually need to to practice on a limited basis, most likely? But even on full force, how much do you need to practice? So that we’re prepared for that next time and don’t get caught without the personal protective equipment.

And then either of you or both of you, what can we do to prepare our clinics? What are some of the supplies and procedures that it looks like we’ll have to be doing? And I’ll add this that for the listeners, this can change on a day by day basis. What is it that you are seeing that is going to be kind of required? And then in your own personal thought process, what are you planning to do? Because there may be a minimum you have to do, maybe you want to do more. And so that’s kind of a two part question is, kind of what do you think is going to require of us? Their mask, patient mask, us mask and the distancing, so can you kind of walk us through what it would look like in a clinic daily?

It’s going to depend. I’m in a private clinic, David’s in a hospital and many of us practice in private clinics. In a private clinic, you’re going to want to have your gloves on. You’re going to want to text your patient to come in because normally we might have two, three, four people in our waiting rooms and that’s not going to be allowed to happen. You text patient when somebody’s in a room door closed, you’re ready for the next person to come. You preferably you open the door with a gloved hand, let the patient in, patient washes their hands and patient, if they’re not wearing a mask, you hand them a surgical mask. That’s one of the things we have to have on hand.

We’re going to need surgical masks, gloves, we’re going to need KN95 masks for us or N95 masks if you have them or can get them. We’re going to need hand sanitizer. We’re going to need Clorox bleach, things that kill COVID-19 because after your patient has washed their hands and you washed your hands, practitioners are deciding whether or not to use gloves. Then you take them into your treatment room. We are now in a situation where there’s no table warmers, no sheets. You can, unless you have a table warmer and a vinyl sheet on top of it, and you’re not going to put the vinyl table warmer on fire if you put it on top of your table warmer, no table warmers. Paper only. People often put paper in the middle of the table. Research demonstrates that if you cover the whole table, you’re better off. Instead of using a sheet, you’re going to cover your table with paper. You’re going to use a either a plastic backed paper pillowcase, or you can have plastic pillowcases and the paper plastic back ones on top of that.

You get your patients situated. It’s recommended that you not be in the room for more than 15 minutes, which is going to change our billing and coding and how many units we can apply for. When your patient leaves you, escort them out, preferably with your washed hands, gloved hands, and you open the door again so you have control over what’s going on with the doors in your space and what’s being touched. Once that patient leaves, you cannot bring another patient in until you thoroughly wipe down the table and every space with COVID-19 killing disinfectant. Make sure when you take, when you roll up the paper, you roll it up into the center so you’re not putting things into the room. When you take off your gloves, roll them inside before you throw them out. When you take off the pillowcases, roll them inside.

Make sure you have sanitation stations because your patient may or may not come in with a mask. You want to have a safe, clean place where you have surgical masks, where you have wipes, where you have gloves. What’s your patient’s comfort level? Do they need gloves on to feel safe? These are the things that I’m going to be doing and that Valerie Hops and Steve Shomo are going to be speaking to, from the CCAOM at our webinar next week. That ASA town hall next Wednesday night will be about this. We’re encouraging people to go to our website, asacu.org or our Facebook page, American Society of Acupuncturists to register for that link where you will not only gain knowledge, you’ll earn two CEUs and you’ll get to be a part of the greater discussion.

David, what do you have to add to that?

Well, I think that’s a great explanation, Amy, and it’s a really thorough picture of the types of precautions that we believe will be expected. That that level of mindfulness really will be the norm, we hope. And so, there’s just to generalize, there’s the patient flow questions that have to be managed, the patient spacing questions. There’s the sanitization questions. And so groups that are, practitioners who are used to seeing two, three, four people at a time and running from room to room, that’s going to be tricky. That’s really probably not going to be possible. You’re going to be doing more, maybe two rooms at a time maybe. But even more likely just one room.

I think unfortunately I think group treatments are going to be really hard to navigate for a little while because there’s just no way to control the airflow. There’s a sort of, almost a meme now, but a gif I guess was in the Washington Post of how a cough circulates in an airplane and, but even if you look at pictures of coughs and sneezes that they take, it just takes one person with a good sneeze or a good cough to fill the room with enough particles to infect everybody in a closed space.

Multiple people in a closed space together, it’s going to be very much counter to the efforts of limiting the spread of disease, which is, it’s a problem. It’s a real shame and a problem that I hope we can figure a way out of because that’s an amazing service. And yeah, so if you look back also too at the original ASA document that we produced on this, I think it’s still a very good resource, but we’re very much looking forward to in partnering with the, there it is, the CCAOM. Amy’s holding it up. The CCAOM document that that Valerie and Steve are putting together, which is an excellent, an excellent resource. And we’re doing that at the the ASA NCCAOM town hall, as we said a week from today. There may be some other opportunities to see them as well.

Thank you for that. That’s a great resource on ASA. I will share also that healthyseminars.com/resources. We have sections on COVID-19 and it’s more about the acupuncture and herbal approach in response to COVID-19. What practitioners are doing when people are, how they’re presenting. We’re not saying they’re treating COVID-19 but using the principles on how people are presenting. Still using Chinese medicine principles. If you’re looking for that kind of information, that’s at healthyseminars.com/resources.

If I could jump in Lorne, just for one sec. I do want to underscore that from the ASA perspective, it’s not appropriate for us to be sort of teaching you how to treat people on this. What we’re trying to focus on is really the practice dynamics of that and the sort of nuts and bolts about just how to do the practice. The actual treatment of these things, either with acupuncture and herbs, there are excellent resources and excellent lectures on this, but we can’t vet them all. We can’t endorse from a public health standpoint, some of the ideas. And so it’s just not our role as a professional organization. And we also don’t need to do it because there are excellent, excellent resources like Healthy Seminars has quite a few and others have done amazing lectures. Site for integrative oncology, has done some great lectures with Dr. Lu. We’re going to have Dr. Lee on. He’s going to be sharing more his experiences on the town hall tonight, I believe. Oh no, also a week from today with Valerie and Steve. And other vendors also have particular some really fine lectures.

It’s nice. Everybody’s coming together trying to figure out how to support the individual and again at Healthy Seminars, we’re not addressing the disease as much as we are working on the individual basis. David, so what are your thoughts on the safety for the practitioner? And so a couple of part questions here is, are we at risk of as practitioners, since there’s a lot of asymptomatic patients, is it possible we as practitioners can get it even though we’re doing these safety measures, washing your hands, wearing masks? And if a practitioner becomes diagnosed positive, they get sick, what should they do if they feel a fever, they feel a little off? What should they do? And if they test positive, what happens to the clinic? What kind of communication needs to happen? Because I think it’s likely that some practitioners are going to catch COVID if they’re treating the public.

Absolutely. And so, and this is the thing that makes this tricky is the long silent carrier stage with this too. That people can be walking around asymptomatic and be silent carriers. That it’s estimated that up to 50% of people who catch coronavirus will not develop symptoms but may spread it anyway. The chances of our contracting it are high. There’s no difference for the practitioner than the patient. We hope we’re being more vigilant about the things that we know spreads COVID virus 19, like we’re washing our hands better. We’re not touching our faces in between more. We’re being, more cautious in our interactions, in our physical distancing. But there’s nothing special about being a practitioner that should lead anybody to believe there’s not a high risk for them catching it just like there is any member of the public.

The bigger concern would also be that someone becomes a silent carrier and then also transmits it to many, many patients. Which gets to the part of your question that if you are diagnosed with COVID-19, you need to be prepared to contact every patient that you have seen over at least the past 14 days, ideally probably the last 21 days, and inform them that you have tested positive or developed symptoms. Now does that mean you gave it to them? Absolutely not. You could have picked it up five days ago, someone you saw 14 days ago, but we don’t know. If we’re being really rigorous and doing best practices, then we would contact everybody we’d seen for the last 14 to 21 days to inform them that this is what’s going on.

If a practitioner becomes ill, how they care for themselves of course is beyond scope of what we can advise. But certainly they want to do it in conjunction with their medical team and they want to be really aware that, while most people end up doing okay after infection, there are people who get very sick and decompensate very quickly and so just to not take it lightly. Don’t take it for granted, do do your self treatment, do do your self care, but make sure you have access to a medical team who can support you if things start to go south. And Amy, I know you’d like to say a few things about that.

You covered the most important pieces. The only other thing I would say is we really need to advocate for testing because when people are treating in the hospital, they are tested on a regular or semi regular basis. And we need to find that and make that available for acupuncturist because if we’re going to be seeing patients, we need to be able to be tested to verify that we are not passing the virus or carrying it nor passing it on to others.

Right. And I think it’s also important to know that testing is in a state of development right now. Tests are not 100% accurate by any stretch of the imagination. And so that repeated testing will be important when it becomes available. And the other thing is as another practitioner had pointed out or somewhere that if you’re right now using the test and you’re being tested and they’re swabbing you, if it was not terribly uncomfortable, it wasn’t done correctly because you’re supposed to swab the posterior nasal pharynx. The way back of your nose. That swab’s got to go up there and you’ve got to twist it and you got to do back of the throat, there should be some gagging, some discomfort. It was a little bit of a ni, ni, that’s not accurate testing.

Many things to look forward to. I want to play some scenarios with you guys. And again I just want to caution or put this out to our listeners is that you got to check in with your state health authorities and your state boards. And so these are just scenarios that I’m playing with and we haven’t rehearsed this. I want to know kind of your thought process.

I’m a practitioner and I get a call from a patient that says, “You saw me four days ago, Lorne and I just found out that I have COVID. I tested positive.” Do I have to go call my patients I’ve seen since I’ve seen that patient? Do I have to close my clinic until I’m tested? What would you think some of the scenario is? Because this is one of the scenarios that likely will happen and a patient’s going to call you because they’re supposed to, I just found out that had COVID. What do we do as a practitioner that are not experiencing any symptoms but know that we had treated a patient with COVID-19 five days ago?

That is a great question.

This is how my brain thinks. That’s the problem.

Yeah, absolutely right. Amy, did you want to speak to that?

Just to say that you’re going to have to do all of the things that David just spoke about. Because whether it’s you, whether it’s a patient, it’s called due diligence. And we can’t control this and we don’t know where it came from, and nonetheless we need to do our due diligence. What David said is what I would repeat.

Right. And what I would also add too, if I could, is that before you find yourself in that situation, it would be ideal to have a special consent form that you’re using during this time that explains to patients, here’s the deal. If I’m treating you and I turn positive or I am exposed or I develop symptoms, I’m going to contact you and tell you that this is what happened if I’m aware of it. And it doesn’t mean you caught it from me, it doesn’t mean this or that. But I want you to be aware that I’m being very transparent in what’s going on. And that if you’re going to accept coming to my clinic and if you’re going to accept a treatment during this window of time, you are implicitly understanding that there is a risk to doing that.

The only super complete safe thing is stay at home, complete isolation. Which is hard for anybody to do and maybe not always necessary. But otherwise, the more upfront you can be with people about what you’re going to do, then they won’t be surprised when you have to do it.

Right. Thank you, David. And Amy had to jump off. We knew she had a call, so her technology is good, but we knew she was only here for the beginning of it. What about, maybe we’ll finish off with a few couple comments or questions, but what about if you’ve had it already as a practitioner? You feel that you’re in the clear you’re immune or is there a chance that you still could catch it again possibly?

Right. Yeah, that is another one of the million dollar questions right now and the reason for that is, clearly we do develop some immunity to COVID, many people do when they get it. Because that’s the whole serum that we’re trying to gather from people to give to other people to help them get better quickly. You absolutely can develop some immunity when you have it. The problem is different people develop different levels of immunity, how robust that immunity is. Someone may get COVID and end up really not developing any lasting immunity. Another person may get it and develop a robust immunity, but you don’t know who you are in that process.

The other thing that we don’t know about is how long will that immunity last? Generally speaking, immunity is of duration because you get re-exposed to the critter over and over again throughout your lifespan. As we said with chickenpox for example, you get chicken pox, it actually lives in you, but your immune system keeps it under control because you get periodically re-exposed to it and it reminds your immune system to stay robust and so it stays under control. And when you stop getting re-exposed to it over and over again, then you start getting outbreaks of things like shingles because your immune system starts to forget to pay attention.

How our immune systems are going to end up behaving in the area of COVID, in the era of COVID, we don’t know because we don’t know if this organism is going to be around enough to reinforce natural immunity if it occurs. We don’t know if it will mutate. That can be another thing that happens is that you get immunity to a certain pathogen and then that pathogen mutates and finds a way around that. I think there may be some short term comfort in having had COVID and recovered, but don’t bank on it. We don’t know how long that immunity is going to last. We don’t know which one of us developed robust immunity versus really no immunity to it. Those questions are being studied right now by public health authorities, but it’s too new to know any longterm answers because this has only been around for a short period of time.

Great. Thank you very much. For information, I just want to remind people, first of all, actually let’s summarize a bit. Keep going back to your local health authorities, what you’re suggesting. they’re the ones that are really putting down the policies. The American Society of Acupuncture has information, healthyseminars.com/resources, we have a section on COVID as well for you guys. And just any last words? Oh, actually I do have a good question for you. What happens in my state or province if an allied health profession is being told that they can go back to work, but as an acupuncturist I cannot, should I be taking that personally?

Right. Yes and no, I guess I would say to that too. No, you shouldn’t take it personally and I think it reflects a certain, evolution of the field in terms of what people think of us for. I also want to add to your list, the NCCAOM has a great list of resources too. We’ve been collaborating with them, the ASA and then CCAOM is developing great resources as well and we’ll be releasing those shortly. Those should also be on your list of organizations to check with. This gets back to that question of am I an essential health provider? And am I providing an essential health service? And I think the particularly difficult thing with acupuncture is that we offer a very wide range of product so to speak. We offer everything from feel good relaxation sessions, which are absolutely not critical, although we want to lower our stress. We all know there’s just relaxation sessions and then we offer really critical pain control that keeps people out of the emergency room. We offer help for mood and emotional disorders that could otherwise end up in self harm or harm of others.

We really offer the range of services from sort of mild to severe. And so as you assess patients, that’s kind of the consideration you have. Now whether in your area you are considered this or that, is also, that was what was in place before COVID. And I encourage our state associations and for people in the US to join your state association and become involved in the process of advancing the field at that legislative and regulatory level. To some degree, I think the field wasn’t completely aware of before this crisis.

We are in this intersection of times where we have an extreme circumstance that has revealed chinks in the armor, so to speak. But we also need to be honest with ourselves about what service am I providing? Is it truly critical? Even if I am an essential healthcare provider, it does not mean that everything I do is essential right now. That’s just hubris. It’s nothing else. But some people are providing services that really are critical. They’re keeping people out of the emergency room, they’re helping them with mental and emotional health, they’re helping with fertility, they’re helping with things that just can’t wait. And then those services are at a higher tier of reintroduction.

I think one of the things that we’ve seen in some of the documents coming out, like from the Medicaid services is acupuncture is sort of a knee jerk reaction listed as a tier one not critical. But they are also thinking of acupuncture, they don’t know the level of patients that is often treated. And so they’re giving a very general recommendation that is a recommendation and a guideline and not a law or a strict rule. And so we just need to understand that. And that’s part of the educational process for the rest of the healthcare system in terms of the services that can be offered through our providers.

As we come to the end of this interview, and again, I want to thank you David for making the time and Amy who will be watching the rest of this later. Thank you, Amy. Basically it’s a new, it’s no longer, it’s a new normal that we’re going to be going into and I wouldn’t even think the word normal is correct. And so our expenses of treating, and this goes to everybody now who’s into health services has changed. There’s going to be increased costs to treat your patients. There’s going to be new regulations and policies are going to be changing regularly as we learn. And so it’s not like it used to be. How you treated before, be prepared to adapt and pivot and shift because it’s going to change. The volume of patients that you’ve seen may change also, be reduced because to do it safely you may not be able to do that volume until we figure out a way to do it safely.

That’s one thing because we talked about today is COVID-19 best practices for starting off after a full stop. I think one is getting your expectation set that it’s different and it’s going to be a little bit more effort and work to play safe and your volume is going to be down a bit. But priority safety, everybody. And then keep staying informed and educated and so you can do this practice safely. And so the ASA has put out great resources. You said the NCCAOM has some great resources. The California Acupuncture Association has put out great resources and at healthyseminars.com we keep putting out resources. And it’s healthyseminars.com/resources. Please keep checking these resources, get informed, and it’s changing on a daily basis.

David, thank you very much for your time. I really do appreciate you.

Thank you for having me.

Taking the time. And then everybody stayed tuned for, To the Point the American Acupuncture Council’s next webinar. I apologize. I actually don’t know who the next speaker is, however you can check out that website and you’ll see who’s hosting the next To the Point webinar. My name’s Lorne Brown. You can find more about me at healthyseminars.com and I look forward to you guys when we do our next practice management webinar. Thank you very much.

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