03/23/2020    Lawrence Oloff, DPM

Podiatrists and COVID-19 Pandemic (Janet Kail, DPM)

Everybody wants to help during this unprecedented
crises. Everybody wants to fulfill their duties to
their patients. But it is also important that this
duty extends beyond foot care. When I read the
posts about the coronavirus, I am getting the
sense that many are not appreciating the
seriousness of what is going on. Of course,
maintaining social distance in the waiting rooms
and doing an extra good job of cleaning is
important, but the best thing you can do is keep
patients out of your waiting rooms and your
offices in this critically important time. The
economics of what I am suggesting are dire, but
the risks are worse.

Coronavirus is an untreatable condition and is
spreading rapidly. It is affecting some areas more
than others, but it will affect everybody
eventually. There is no treatment. Antivirals are
in early testing to curb the severity of the
disease. Vaccinations are at least a year off. The
numbers are going up exponentially. The ICUs where
I live are filling up all the time. Many are on
respirators. The resources can handle things now,
but this is only going to get worse.

This disease will impact all of us. The CDC
recommendation went from airborne precautions down
to droplet precautions. OSHA has maintained its
airborne risk precautions. It is hard to tell if
the downgrading was driven by supply concerns.
Droplets come out of mouths when we talk. It is
not about cleaning when you come to work, it is
about cleaning and extra precautions after each
patient. Hard surfaces like counters are concerns
for transmissions.

The bottom line is that you need to keep patients
out of your office for the foreseeable future. You
need to utilize technologies that are out there to
treat patients remotely. CMS lifted HIPAA rules
that allow us to use Facetime, Skype and other
technologies for virtual visits. Telephone visits
too. Both are billable services. I just scheduled
a patient for a bunion procedure by phone visit
and by accessing her X-rays on line. She
understands it may be months for elective
procedures to get back on board.

Everyone needs to face the sobering reality. When
you have patients come to your office, there is no
way to protect these patients from other patients,
staff, and doctors. Offices do not have those
resources. Many carry this disease with mild or no
symptoms. How can you tell who is a carrier? The
present strategies are not designed at
eradication, but to slow a surge that will overrun
the healthcare system. Now the version of the
virus showing up in Europe is creating more
devastating disease in some young people. This was
not the case in China.

Lawrence Oloff, DPM, Burlingame, CA

Other messages in this thread:

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03/24/2020    Denis LeBlang, DPM

Podiatrists and COVID-19 Pandemic (Janet Kail, DPM)

I practice in Rockland County, New York and so
far we have had a small number of Coronavirus
cases but we are told it is coming and it can be
a large percentage of people living here. I have
closed my office to everyone except emergency
patients and some post-operative patients from a
few weeks ago. We have a mind set to treat and
help our patients so most of us will stay open
for these patients. I spoke with PICA and they
told me if you close your office you could
suspend your coverage for as long as you are
closed as long as you are not seeing patients

We also feel that we have to make a living to pay
our monthly bills. Our normal patterns have been
radically altered and for the next three months
we all probably will have to honker down and
hopefully the virus will peter out and life will
again be normal.

So for the next three months I am advising all of
us to contact the companies or institutions that
we pay our monthly installment loans like
mortgages, car payments, home equity loans and
other various monthly notes and they will freeze
the payments for three months with no interest or
late fees. I have done it and I was granted a 90
day grace period for these monthly payments. They
will extend the schedule of payments for three
months. Credit card companies will accept partial
payments without interest.

The essential payments like utilities, cable,
telephone, medical insurance, have to be met but
you can hold off and pay them when you can. We
should pay our employees partial salary to help
pay their essentials. We are all in this
together. Eighty percent of the cases are very
mild. None of us want to be in the remaining
twenty percent but it could happen to any one of
us. We have to get through the next three months
and hopefully we will be able to joke about it
when we get together for our clinical conferences
later this year or next year. So the bottom line
is hold your money as long as the emergency lasts
and only pay for your essentials.

Denis LeBlang, DPM, Rockland County, NY

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03/23/2020    Tom Silver, DPM

Podiatrists and COVID-19 Pandemic (Janet Kail, DPM)

As of this week, we have instituted new safety
practices in my clinic which may change from week
to week or day to day. We are also letting
patients know that we are offering telemedicine
visits.

Our current practice (as of this week) in my
clinic is:
1) Asking patients if they have or been in contact
with anyone that has a cough/fever & if, so to not
come in at this time.
2) Asking patients if they (or someone they've
been in contact with) have been out of the country
recently or have been (or been in contact with
someone) on a flight recently. If so, reschedule
if not an essential visit. Limited amount of people in the reception area at any given time. This can be accomplished by staggering appointments and asking patients to
come alone or with only one other individual.
3) Hold off on scheduling any non-essential or
routine foot care patients, especially for the
elderly...until further notice.
4) Limit the amount of patients seen in a day or
expand office hours to stretch out the patients so
there aren't too many in the office at any given
time.
5) Wipe down reception room chairs, entry
doorknobs and any other surfaces patients have
been in contact with after each patient leaves
reception area, treatment room & entry door.
6) Don't allow any employee to come to work if
they or anyone they've been in contact with
(especially at home) has a cough or fever.

In my area, all elective, non-essential surgeries
have been cancelled until further notice. Dental
offices in my area have closed or sent out notices
that they are only seeing people for essential
care & no routine care at this time.
Chiropractors in my area have closed their doors
too.

There are many challenges that we must face with
this pandemic and we can't take things lightly.
The best we can hope for is that this won't last
too long and the economic fallout from this won't
be too devastating.

Tom Silver, DPM, Minneapolis MN

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03/23/2020    Richard A. Simmons, DPM

Podiatrists and COVID-19 Pandemic (Janet Kail, DPM)

When I submitted this letter for discussion on
March 12th, one week ago, none of us had any idea
that we would be facing what we are facing today.
When I heard the request to isolate/quarantine for
two weeks, I took it seriously. I have not seen
patients this past week nor will I see them next
week.

Mine is a house call practice and I can appreciate
the difficulties my practice faces going from
house to house, yet mine pale in comparison to
what many of my office-colleagues are facing.
From the New England Journal of Medicine, March
18, 2020 “If protecting patients is difficult, so
is protecting healthcare workers, including
nurses, respiratory therapists, and those tasked
to clean the rooms between patients. When we
spoke, Dr. D. was one of six physicians in his
division to have suspected COVID-19 infection.

Given testing lags and the proportion of infected
people who remain asymptomatic, it’s too soon to
know the rate of infection among caregivers. And
it is precisely these circumstances that make
infection control so difficult. “The infection is
everywhere in the hospital,” Dr. D. told me.
“Although you wear protective gear and do the best
you can, you cannot control it.”
[https://www.nejm.org/doi/full/10.1056/NEJMp200549
2?query=TOC&fbclid=IwAR2o-
Rx4c8E5C1irAHI9xwtuP5PQQeVOJeW6KaVaKP6zIj4VA6zue4C
SBLM#.XnNVOnJT64I.facebook] Once it gets into your
office there is no control.

My dear podiatric colleagues, we have no idea what
we are up against MOSTLY because we have no
empirical data. I am fortunate that I have no
employees who have direct patient contact, only I
have direct patient contact. All of my employees
have always worked remotely from their homes. I
have no fear that the persons in my employment can
come in contact with this virus because of work.
Right now we have to think not only of ourselves
and families, but also our employees, their
families and our patients and their families.
That said, I am sure most of you are also working
with narrow financial margins: how long can you
pay your staff to do nothing? What does your
business insurance offer to pay?

So far the best model for containing this virus is
quarantine/isolation. We should look at New York
City and San Francisco as models as it appears
there is no reasonable federal guidance at the
current time. Each of us will have to decide what
is best until there is guidance.

Richard A. Simmons, DPM, Rockledge, FL

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03/20/2020    Dean Clement, DPM

Podiatrists and COVID-19 Pandemic (Janet Kail, DPM)

I realize that in every locality things are a
little different, but I find that our
responsibility as foot and ankle specialists is to
absolutely remain open. I believe our role in a
situation like this is to make sure that our
patients with medically necessary needs are cared
for in our clean, uncrowded offices instead of
being left to go to Primary Care, Urgent Cares or
the ER, where they will run the risk of being
exposed to sick patients and add to the overall
volume burden of primary care, urgent care and ER.

Our practices have to change how they operate for
a while to support social distancing, but that can
be done. My office is asking elderly or
compromised "routine care" patients to postpone
their appointments for the next 2-3 weeks. We made
workflow changes to decompress the waiting room.
For example, our hospital has temporarily
cancelled elective surgery. This frees me up to
have the office open that extra half-day, which
allows my staff more flexibility to spread out
appointments. We ask our patients to only bring
one escort if possible to decompress the waiting
room. I prioritize with my staff the need to run
on time to decompress our waiting room. We ask
younger, able bodied patients to wait outside if
the waiting room get more than a few people in it.
We double our frequency of sanitizing doorknobs,
etc.

I also find myself discussing coronavirus with my
patients to help them understand what it is, why
precautions are necessary and how they can be safe
and part of the overall solution. I couldn't
contribute in that way if I was closed.

We definitely need to stay engaged in this
pandemic by simply doing what we do, with workflow
process changes and perhaps less routine care
volume. Nobody else does what we do better.

Dean Clement, DPM, Casa Grande, AZ

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03/20/2020    Vincent Marino, DPM

Podiatrists and COVID-19 Pandemic (Janet Kail, DPM)

In addressing Dr. Kail’s query, I can respond from
the front lines here in Marin County where the
country’s most stringent “Shelter in Place”
precautions have been instituted. The order from
the Governor and the Sheriff offices that is
effecting 9 Bay Area Counties specifically
EXCLUDES Healthcare businesses and that includes
all medical offices. We have a service and
responsibility to our patients.

I will tell you that the hospitals and most
surgery centers here in the Bay Area have
cancelled ALL elective surgical procedures until
further notice. So the question becomes - What do
you consider “non-emergent”? Our office is giving
our patients the option to reschedule, especially
our seniors. But most are not willing to wait and
are actually thankful that we are open for
business.

Let’s say you forcibly reschedule a palliative
patient who comes in every 9 weeks routinely. And
what if this patient who is forced to wait an
additional 3 weeks develops an ingrown toenail
that becomes infected due to the nails being too
long and/or dystrophic. And what if this leads to
hospitalization for cellulitis and results in loss
of the toe or even a limb due to vascular
compromise. ( I have actually seen this when I was
a resident 30 years ago). So I think it depends on
each practitioners situation. But remember, our
oath is that our patients come first. What we have
done is the following:

1. All rooms, phones, desktops, keyboards, mice,
and chairs are wiped down with Clorox wipes in the
am before patients begin; 2. Give the staff an
option to wear a surgical mask throughout the day
if they want; 3. Have eliminated double booking
patients so that there are never any patients in
the waiting area and if so, they are separated by
6 feet; 4. all treatment chairs are wiped down
after each patient with Clorox wipes; 5. We have
set up a “Pen Bin at the front desk- once a
patient uses a pen it goes into a bin and then the
pens are all wiped down with Clorox wipes before
being put back in the “Clean” pen cup for others
to use; 6. allowing the staff to notify the
treating doctor if a patient comes in ill- the
treating doctor will then decide if the need to
see the patient and if so, a mask is given to
them. If the patient does not need to be seen (up
to the discretion of the doctor) then they are
rescheduled.

Of course, if any of you or your employees are in
the high risk group, whether it is due to age,
them having a systemic condition putting them at
risk, or if they live or regularly have to have
contact with another who is high risk, then they
either can work from home or, if not possible, are
encouraged to use their sick time and PTO. If none
is available then they take unpaid leave but we
leave this up to them.

We are all in uncharted waters but remember we are
still healthcare practitioners and have a
responsibility to our patients.

Vincent Marino, DPM, Sacramento, CA