Andrew L. Rosen, MD
“Well, this is weird”
This was what I was thinking when I first did a video call for direct patient care after our office closed down. Although I’ve been connecting with friends and family with FaceTime for years, it was a new experience to use it instead of a medical office visit. Now, after over a month of a complete change in how we practice medicine, it has become pretty natural.
One of the few positive changes to medicine from the COVID epidemic has been the new ability for medical practitioners to utilize telemedicine. Prior to COVID, the government had placed restrictions on allowing doctors to communicate using easy and inexpensive technologies such as FaceTime and Zoom. Furthermore, the government and private health insurers would refuse to pay a doctor for any care that was not delivered in person. The pre-COVID system required all health care to be done only face-to-face. Limited interactions using telephone calls could be utilized for patients but without reimbursement and still required significant time to document the patient encounter.
Since COVID forced Medicare to ‘see the light’ that delivering medical care via telemedicine was not only safer, but worthy of their health care dollars, those restrictions have ended allowing doctors such as myself to now work with patients remotely and be compensated for it.
I’ve been able to reassure many patients and keep them at home
Since I started these telehealth visits, I have been able to remotely work with many patients and deliver the same level of diagnosis and treatment which I previously was doing in the office. I’ve been able to reassure many patients with minor disorders that they didn’t need emergency room visits or expensive tests. Getting a good history and a basic visual examination of the painful body part has been effective in determining that many conditions aren’t a big problem needing urgent treatment. Without x-rays and ultrasounds to check patients, it can be more challenging, but many conditions can diagnosed without direct testing.
I’ve found some real injuries
So far, I’ve seen several stress fractures due to excessive running, a torn achilles tendon from an over-aggressive home workout and a torn knee cartilage from a deep squat. Many patients require an MRI study performed at an outpatient radiology center that can be ordered and arranged without seeing the patient in person (now, thanks to telemedicine). These type problems can all be treated properly once diagnosed.
I’ve seen some interesting home environments
One of the more interesting parts of telemedicine has been getting to see patients in their home environments. I’ve seen lots of different living rooms, bedrooms and even a bathroom. Getting a look at existing and new patients at home brings back the old days of housecalls (long before my time of course). The presence of inquisitive toddlers and playful cats and dogs has added some levity to the visits which can make online visits more interesting and brings me more into the patient’s lives.
The not so good
Making a definitive diagnosis isn’t always easy when you can’t do a good physical exam or x-rays
Many conditions are fairly easy to figure out from a good history of the problem and a limited video exam. Some problems are more difficult to determine the origin of symptoms without seeing and touching the body part. Telemedicine patients should be informed that diagnoses can be a bit more uncertain with a telemedicine visits.
I can’t do procedures through the video
Barring new robotic injection machines delivered to a patient’s house (science fiction at this point), we still can’t perform procedures on patients with telehealth. Cortisone injections, suturing, application of braces, draining of abscesses are all very useful techniques that can be necessary and enormously useful for treating patients. Telehealth doesn’t allow these techniques but at least they can be discussed and planned as needed.
Insurance companies haven’t completely embraced telehealth yet
Although Medicare covers these visits without any extra effort for practitioners, many insurance companies take up to 30 minutes of staff telephone time to give us the information to tell a patient if they are covered and if there is a copay or deductible. This is just another disincentive for doctors to embrace these visits and could easily be removed with a quick online portal or simply universal coverage mandates.
It’s not always easy or time-efficient
One of the downsides to telemedicine is the (sometimes) lack of efficiency. It takes time to dial, connect with a patient, allow them time to get to a quiet, well-lighted spot. Glitches occur with connecting and sometimes video quality can get terrible depending on patient’s connection speed and location. Photobombing kids and pets are still fun but do distract and take up time. Even arranging post-visit treatments can be more time consuming when I have to contact one of my assistants to remotely get tests or medications ordered or sent to patients. Unfortunately, I can definitely see more patients in the same amount of time in my regular office setting. Telemedicine with any volume of patients will definitely be less productive for health care providers. Theoretically, health insurance should cover this inefficiency with increased reimbursements but that is unlikely.
Certainly, telemedicine is here to stay for many months as the COVID epidemic evolves. For the long-term future, I hope that telemedicine will continue to improve and adapt as an evolution of the modern medical practice. Visits for routine patients, MRI reviews and some acute injuries could still be very useful and, of course, quite time efficient for patients by avoiding the trip to our office.
Rachel E. Bergang
To prevent the spread of COVID-19, many of us have been working remotely from home. As a result of this abrupt transition, most of us have a less than ideal “office” set-up. This sub-optimal ergonomic environment is causing many of us to experience increased aches and pains in our neck and lower back. We are more sedentary, slouching on our sofas/beds, or using our laps as a desk for our laptops. The stress of the COVID-19 outbreak, layered with a workspace that isn’t conducive to your well-being, can cause these problems to escalate.
Dedicate a Space for a Home Office
Now is a good time to prevent problems down the road. Make the effort immediately as it is critical to optimize your home office before these issues arise. If you don’t already have a full office setup at home, try to create a space in your home dedicated to working. With children and significant others all in the same home, this could be a challenge, however, a stress-free zone of solitude is crucial for higher levels of concentration and productivity. Creativity may be needed to transform corners of rooms, spare rooms or even closets into a brand new work environment.
Watch Your Posture
When we sit on a sofa, there is a natural tendency to bend or hunch forward. Numerous other locations can be better for working, including kitchen counters, bridge tables or dining room tables. I personally sit on a cushion on the floor, use the sofa to support my back, and my coffee table for a workspace. When sitting in a chair, try to sit in an upright, neutral position (preferably on a chair with a back). Your feet should be resting on the floor. A footrest can also help. Place a pillow or rolled up towel behind your lower back for added support. Raising your computer to eye-level can put less stress on your neck and shoulders. Use textbooks, boxes or an upside-down laundry basket to get the correct height. A stand-alone monitor and keyboard is another option.
Don’t Look Down!
We are all increasing our screen time on smaller devices. Using phones and tablets, we are frequently texting, emailing and video conferencing. These are all great ways to stay connected, but watch your neck! Make an effort to not look down at your devices. Hold them up to your eye-level when you can. Using headphones when talking on the phone can help avoid poor neck positioning as well.
Try to be less sedentary and mix up sitting and standing. A good strategy would be to start
slowly and set up a timer to stand for 30-60 minutes a day, and then experiment with different time intervals for the frequency that works best for you. Maintain a routine and set up a schedule. Plan out your meals and snacks ahead of time. Avoid eating at your workstation. Set up a cut off time every day to disconnect from your devices (especially the news!). This will allow you to relax and recharge your batteries.
Taking Care of Our Minds and Bodies is Essential in These Uncertain Times
Practicing self-care will help with both physical and mental health. Try to incorporate some light at-home exercises and gentle stretches. Avoid cabin fever, and if healthy, try to go outside for a walk. Remember to practice social distancing by staying at least 6 feet away from others.
Video-communication is a good way to connect with family, friends and colleagues, and reduce feelings of isolation.
This new reality is not what any of us planned, but it is imperative that we stay healthy, think positively and stay pain free, and remember that we are stronger together!
Andrew L. Rosen, MD
Although it's not a typical orthopaedic topic, I thought it would be useful to discuss a more important public health issue, the use of latex-type gloves to protect members of the general public during the current COVID-19 epidemic.
Yesterday I went to the pharmacy and observed a woman who seemed very careful and was trying to avoid becoming infected. She was wearing a surgical mask and stayed at least 6 feet away from all people in the store (all very good techniques). She was also wearing latex gloves for her entire shopping trip. I watched her pick up items, put them into a non-disposable (socially-responsible) shopping bag and then take them to the self-checkout. There she used the touch screen with her gloves, opened up her purse and wallet and put her credit card in the slot and paid for her pharmacy items. I then saw her put her card back in her wallet, her wallet in her purse and then carry everything to her car, entering it and driving home, all still while wearing her gloves!
There is no danger of COVID entering your hands
There has been no documented report of a known transmission of COVID through intact skin. The COVID virus needs to get to a person's mouth or eyes to infect them. Having COVID on the skin of your hands will not lead to an infection if your hands are cleaned before touching anything else.
We need to assume that every object of any kind could be contaminated
For the last few weeks, I've been explaining the principles to my non-medical friends to make them understand the principles of reverse-sterile technique. When we leave our clean, protected houses (hopefully), we need to assume that every solid object of any kind could be contaminated by an unknowing COVID-carrying person that touched, coughed or maybe even just breathed on the object. That includes door handles, self-checkout machines, credit card readers, items on a pharmacy shelf, cans of food at a supermarket. COVID can live on objects for over 3 days for most common substances.
Gloves can carry COVID just as easily (or possible more) than bare hands
As soon as you have touched the door handle that has been exposed to a COVID patient, the gloves you wear are now contaminated with COVID! Touching objects such as wallets, credit cards, car keys will easily transfer the virus to those as well. Holding the same objects with bare hands later will allow the eventual transfer to your face and can lead to infection. The risks are low but still possible.
Use hand sanitizer instead of gloves
My personal recommendation to friends is to skip the latex gloves and instead, watch carefully what you touch and ‘pretend’ that your hands are contaminated after holding or touching any objects. Hold your hands in front of you and avoid touching your face, clothing, phones, wallets or car doors. Sanitize your hands fully with an alcohol-based product the second you have left a store, used a door or touched any objects outside the home. Try not to carry a wallet, but if you do, sanitize any area that you touched immediately afterwards. When you get home, wipe items purchased with cleaning wipes or approved cleaning products on rags and wash your hands carefully!
If you do choose to use gloves, be very careful with removing them
The act of removing gloves that have COVID can actually contaminate your hands or send COVID viruses into the air! The proper way to remove gloves is to grab the glove near the wrist (avoid touching the wrist with your other gloved hand) and carefully, slowly, peel it inside-out down the hand. Hold the inside-out glove and throw it in the trash immediately! Sanitize with a Purell-type product as soon as the gloves are off to be double safe and wash your hands as soon as you get home.
Avoiding direct exposure to a person with COVID is still the most important way to prevent infection
'Hand hygiene' is very important but the most effective way to avoid COVID-19 infection is to stay at least 6 feet away from other people and wear a cloth surgical-style mask whenever you get into enclosed areas where people have been (elevators, small rooms, hallways).
Stay safe out there! I can't wait to get back to sports medicine topics soon.
Andrew L. Rosen, MD
I certainly never thought I would be writing a blog post of this nature. Overnight, the way our society deals with exercise has been completely altered. With gyms closed, no access to yoga, pilates studios and kickboxing studios, running has become one of the safest forms of aerobic exercise at this point. Here are a few pointers on how to do it safely.
Run only if you feel well
If you don’t feel perfect, don’t run! Don’t put yourself or others at risk if you have any upper respiratory symptoms at all. Seek proper medical help and testing if needed before pushing yourself and potentially risking your health.
Respect social distancing guidelines
Running outside is a great way to get a small escape from home confinement and get some exercise. Running in a large group is no longer an option but solo running or with an appropriately distanced friend should still be safe and fine for weekly exercise. Be sure to give all runners (friends included) a wide berth when passing or crossing each other. Pretend that every person you see has the infection and stay away while exercising. There is no direct evidence that COVID spreads through sweat but do your best to steer clear of direct contact with other runners.
Practice good ‘sterile technique’
The best rule is to pretend that every solid object has been contaminated with COVID. Try to avoid touching doors, park benches, water fountains, etc…. Avoid touching your face or mouth when you run. When you arrive home, throw your clothing into the washer for a hot water wash and give the bottom of your shoes an appropriate antiseptic wipe and then
wash your hands carefully.
Most of us have time limits on our weekly running that have now sadly vanished. With lots of extra time on our hands it’s challenging to avoid the temptation to push our running to 7 days a week and hit some extra mileage. Long distance training at this point can potentially decrease our immune strength and increase the risk of COVID infection. Pushing too hard could also potentially risk an overuse injury such as tendonitis or a stress fracture which could be difficult to treat with physical therapy or MRI studies which should be on hold to keep social distancing. With all races cancelled for many months to come, watch your training carefully and use the time to build some nice safe base training mileage.
Watch your spit!
It may seem silly, but many runners need to clear their oral or nasal secretions with spitting while they run. Just watch carefully on where you aim and respect the 6 foot rule when doing what you need to. If you are the victim of poorly placed saliva, don’t wipe it off your clothing but strip down when you get home and wash the clothing carefully in hot water, use alcohol-based hand sanitizer and then shower with hot water and soap.
Build core strength and work on flexibility
Use the extra time on your hands and rest days (at least one or 2 per week is best) to focus on home exercise that can improve your running and get you stronger for future training. A simple google search for ‘home exercises for runners’ can provide lots of great options for simple stretching and strengthening workouts that don’t require a gym.
I can't wait to write another post on how great it is to hear people complain about filled-up running classes, crowded races, race fans insisting on high-fives and getting locked out of their favorite races. That looks like along way away but if we all do our part to prevent transmission, we can certainly help our future.
Andrew L. Rosen, MD
Although the return of cold weather for the winter season is often a source of dread, these low temperatures do mark an opportunity to return to the slopes for many of us. Ski season is here and unfortunately, we do treat a multitude of skiers and snowboarders each year. Here are some tips to try and avoid the need for medical treatment on or after the ski slope (especially the much-dreaded trip down the mountain in a ski patrol sled!)
Build strong legs, improve overall fitness
Snow sports require different muscles than summer activities. Spending the time to build strong quadriceps can make a big difference for improving ability and reducing the risk of knee injuries. Squats, lunges, box jumps, stair climbers are common methods used to get legs ready for the slope. Building core strength with abdominal and back exercises can help to keep you more stable on a ski slope and should be a big part of a ‘pre-hab’ program to get ready.
Check ski bindings and tune skis regularly
Getting your ski edges sharpened each year (or even more frequently) can improve stability drastically, especially on the icy conditions we can often get on the East Coast mountains. Binding pressure can change as well and having the bindings re-adjusted for boots can prevent skis from accidentally releasing or failing to release in a fall. Many tears of the anterior cruciate ligament (ACL) in the knee occur when a skier falls and the binding fails to release. Even low speed injuries can create these often surgically-treated injuries.
Wear a helmet
It has been well-established that the use of helmets in snow sports has dramatically decreased the number of skull fractures, fatalities from head injuries and scalp lacerations. Helmets are generally inexpensive ways to avoid many of the most catastrophic injuries on the slopes. Over 80% of all skiers/riders wear helmets regularly. The remaining few holdouts certainly look rather foolish and archaic in the lift lines!
These alpine activities are true ‘sports’ and are no different than other sports that generate loss of fluids which can affect the body. Dehydration can affect muscles in ways that promote muscular fatigue, injuries (pulled muscles) and decrease performance. At high-altitude mountains it can also promote symptoms of ‘altitude sickness’ which can be uncomfortable or even serious. Taking the time to hydrate (rest stops, hydration packs or bottles) is well worth the effort to improve performance and avoid injury.
Avoid pole straps
When a skier falls with the pole strap looped around the wrist, it forces the thumb into a position that can tear an important ligament. ‘Skier’s thumb’ or ‘Gamekeeper’s thumb’. These injuries can be painful and even require surgery if they are severe. By keeping the poles straps off of the wrists, the ligament injury can be avoided in most cases. Although a dropped pole in a fall can be an annoyance, it’s much preferable to an injury that could even require surgery!
Avoid the too common ‘last run of the day’ injuries
It’s a well-established ski-patrol fact that there is a significantly increased rate of injuries that occur towards the end of the day. This ‘last run’ injury phenomenon is likely the combination of poor lighting (flat light), icier ski conditions and generalized fatigue from a day of hard activity. Always keep this fact in mind at the end of the day and keep the runs less challenging and be more vigilant to stay in good control.
Alpine sports can be a fantastic way to get out and enjoy the winter but even with the best intentions, injuries can occur. A little care and training at the beginning of the season can go a long way to keep the sports safe!