You might have seen headlines about the problem of clotting that comes with COVID-19 infection. This should set off alarms in your mind when thinking about massage or manual therapy. Blood clots are a sure contraindication for certain techniques. How can we sort out this risk when getting back to work?
At this point, our best understanding is that clotting happens from two mechanisms. The first mechanism involves the body’s immune response to damage the virus wreaks on lung tissue. Also known as a ‘cytokine storm,’ the immune response includes both an increase in pro-coagulants and a decrease in anti-coagulants. This is a clear set-up for blood clots. Scientists are finding a high number of micro-clots in lung tissue; in and of itself a cause for difficulty in breathing.
The second mechanism likely happens as the virus progresses within the body. Part of the initial phase includes a ‘porousness’ of the capillary bed. This porousness also allows the virus to travel into the blood stream. Then the virus can attack the inner wall of the blood vessels (a condition called endotheliitis). Blood clots within vessels themselves are an outcome. This happens in small or large vessels, with clots that are small or large. Once in the blood stream, the virus can travel to other organs, doing similar damage (heart, liver, kidneys, brain). More and more, clotting is understood as one of the primary threats of this disease.
Things to keep in mind
• First and foremost, there’s still a lot about this that we don’t know. Importantly, we don’t know much about the role of clotting in mild cases. (It is logical to assume that asymptomatic cases don’t include significant clotting; but we don’t know.)
• Significant clotting is seen primarily in severe cases. Most of the time, people with a high level of clotting are already diagnosed and usually hospitalized. That said, a very small number of patients present with stroke as their first sign/symptom and then being tested for COVID.
• As more people survive the critical stage of COVID, clotting is recognized as one of the long-standing side-effects of the illness. In recovery, people will be taking meds to decrease the risk of clots.
• As massage practitioners we have always been cautious relative to the risk of clotting. We need to refresh ourselves about those precautions and expand them to our general clientele, just to be cautious.
• Difficulty breathing, nausea, headache, fatigue can all be signs of poor physiological exchange.
• Do they exercise vigorously? If yes, how to they feel?
• Do they have other conditions that put them at risk for clotting? Are those conditions being actively managed at this time?
• Screen for standard COVID symptoms: dry/productive cough, fatigue, difficulty breathing, fever. (See previous post.)
• If they’ve had COVID, where are they in their recovery? Is the risk of clotting being managed?
If you have any concerns about their answers (or their candor in answering), it’s best to postpone the session. Ask them to get screened by their primary HCP before seeing them.
Adapting your massage in light of risk of clotting
Given the kind of massage or manual therapy you practice, you’ll need to do more or less to adapt your work. Here are some suggestions for what to avoid or how to alter your work.
• Avoid deep draining, vigorous petrissage, or heavy effleurage (Swedish style).
• Avoid deep compressive methods combined with long uninterrupted strokes (deep tissue/fascial release).
• If you want to access a deep structure, be patient. Go to 1/2 the depth you might ordinarily and then ask the client to engage the muscle. See how much change you can get with less.
• Avoid recoil or compression techniques (visceral mobilization). Engage the organs and blood vessels with motility (light touch) methods at least at first.
• Omit the thoracic pump-directed breathing technique in the sinus protocol taught in the Core Series (craniosacral therapy). Let the body’s regular breathing do the job of drainage for now.
• Avoid CV4 or other compressive techniques on the cranium or membrane system. In the cranial wave rhythm, treat only during flexion phase.
• If in doubt, use biodynamic methods; reserve biomechanical methods for later.
These are the adjustments that I’ve been making in my work. Given your skill set, how can you make your work as safe as possible for your clients?
Lastly: remembering signs of stroke and heart attack
Since it may have been a while since your last First Aid class, here’s a refresher on the signs of these two high-risk problems created by blood clots:
• Face: Does the face droop to one side when the person tries to smile/speak?
• Arms: If they try to raise both arms, is one arm lower/weaker?
• Speech: Can the person repeat a simple sentence? Is their speech slurred or hard to understand?
• Time: It’s important to act quickly. Call 911 immediately if you suspect someone’s having a stroke.
Other signs may include: weakness or numbness on one side of the body; dimness/blurred vision especially in one eye; severe sudden headache; and unexplained dizziness or dis-coordination.
Chest pain is the most common symptom for all people. Additional symptoms include nausea/vomiting; shortness of breath; jaw/neck pain.
Several symptoms differ between biological males and females.
• Females: upper back pain; (not always chest pain/pressure); pain/pressure in lower chest/upper abdomen; fainting; indigestion; and extreme fatigue.
• Males: mid-back pain; squeezing pressure in chest.
Staying educated about the risks with COVID is another aspect of practicing safely. It’s always better to err on the side of caution. Work as part of a team, letting your client’s HCPs do what they do best–tending the big stuff, like blood clots and life threatening conditions. When your clients are on the road to recovery, manual therapy can be one of the many complementary treatments and health enhancements they receive.
• Science Daily: Blood Clotting a significant cause of death in patients with COVID-19, 4/30/20.
• Web MD: Blood Clots are Another Dangerous COVID-19 Mystery, 4/24/20.
• New York Times: Coronavirus May Pose a New Risk to Younger Patients: Strokes, 5/24/20.
• MedRxiv: Etiologic Subtypes of Ischemic Stroke in SARS-COV-2 Virus patients, 5/15/20.
• MedScape: Kawasaki Disease, 7/29/18.
• New York Times: New Inflammatory Condition in Children Probably Linked to Coronavirus, Study Finds, 5/13/20.
• Medscape: Life After COVID-19: The Road to Recovery, 5/14/20.
• Ninja Nerd Science: Epidemiology, Pathophysiology and Testing, Update 4/20/20.
• Mayo Clinic: Stroke: First Aid
• Healthline: Everything You Should Know about Stroke
• American Heart Association: Heart Attack Symptoms: Men vs. Women
Here are the sources I’m following for guidance amidst the flurry of news (noise?) about COVID:
Pathophysiology and clinical implications
Science Daily — email newsletter with overviews and links to studies
Medscape — email newsletter with overviews and links to studies
JAMA — links to studies (no summary overviews)
Ninja Nerd Science/Medicine — excellent videos from a med school tutor
Television, radio and/or podcasts
BBC, CBC and NPR are doing good coverage.
Johns Hopkins Hospital/University has been running an excellent Q&A podcast since early March.
Two recent articles are worth checking out:
• Atul Gawande, MD: Amid the Corona Virus Crisis, A Regimen for Reentry, New Yorker, 5/13/20
• Eric Meyerowitz, MD and Aaron Richterman, MD, PhD: A Quick Summary of the COVID-19 Literature So Far, Medscape, 5/18/20
Taking all these steps can feel daunting. If you feel like you’re not sure it’s worth it, take a peek at what these birds are willing to do: National Geographic Birds of Paradise.
Thankfully, our work is simpler than that! After taking care of all the practical steps, we come to the moment of beginning again. It shouldn’t be surprising that returning to work is full of emotional peaks and valleys, just as being away from work has been.
I expected to feel a bit anxious when I saw my first few clients. I stumbled with the screening questions, feeling like I was reading a script. Once the client was on the table and my hands made contact, I started to feel more normal. Time went kind of slowly, though people’s bodies changed quickly. Ending the session was a relief.
What I didn’t expect at first was to have resistance to giving a session. Particularly on days when I would have just a single session, I found the inertia of being at home and secluded was strong. I didn’t feel like getting dressed for work, sorting out the space, or standing in my professional self. After missing work and worrying about not working, I didn’t expect to feel such ambivalence. Now that the number of people coming in has increased slightly, the inertia isn’t as strong. It’s easier for me to feel a bridge between my professional self and the new procedures that COVID demands.
Same as it ever was
Some sessions have felt like shining examples of why I do this work. People have come in with problems and with my presence and skillful touch, they leave feeling better. This is so gratifying. Several sessions felt okay: not great, not bad. I help, a bit, but not as much as I would like. It’s more like the time has gone by than we’ve had success. The slippery slope of uncertainty is just underfoot, immediate–and without a lot of sessions in a day, it’s easy to fall into mental traps. Is this the right thing to do? What’s best for them? Am I helping?
In the past, when this has happened, I recognized it for the countertransference that it is. Now, those dynamics feel more heightened: like being so-so or being ambivalent isn’t good enough. As if the unusual time must call forth the unusual in us. What does this even mean?
How to rise to this unusual moment
I’m beginning to see that we are balanced in a dance between holding onto the best of what’s been before, while also letting go in order to find a new way forward.
I appreciate how much we’ve all done to maintain a sense of center. “Keep calm and carry on.” Biologically, we’ve got homeostasis on our side: internal mechanisms that support our health and well-being. They guard us from being over-run by current events. Psychologically, these mechanisms include habits, memory, sense of Self, resistance and even a dose of denial. In trauma work of various kinds, we speak of resilience. To me, resilience is when all these internal mechanisms work together. It’s what helps me in the moment. Thank goodness for that, and yet.
When I wonder what I’ll need to move forward, I’m struck that it’s exactly the thing that I’ve resisted: to let this virus, this pandemic change me. To let life change me.
I’ve rewritten that sentence three times: from “you” to “we” to “me.” I am so resistant to feeling my own vulnerability. I want to learn and organize and keep good habits–do whatever I can to feel control in the moment. To believe that such control is the same as safety. It many ways it can be: learning about safe procedures, organizing my practice space to support the new habits of hygiene and client screening. These are all good pursuits.
And still, when working with people over the last few weeks, I have felt my own vulnerability as the practitioner again. Not for the first time, but in a fresh way. Am I willing, again, to meet my own not-knowing inside all the wise steps I’ve taken. Am I willing to surrender and meet the present moment?
My work–particularly craniosacral work–teaches us a lot about surrendering to whatever is presenting itself within the client. I’m familiar with that, I recognize the dynamic. Still, each moment I am given the choice to say ‘yes’ to that process, or not. I have had a couple of sessions where I knew I wouldn’t be able to say yes, so I rescheduled them. Honoring my own process of being ready or not to give a session has been both humbling and empowering. It’s a habit I want to cultivate more.
Letting myself be vulnerable is not the same as being reckless. It’s about managing the practical level, while being attuned to what my heart and soul are saying. It’s about letting myself feel the awkwardness or the fatigue that comes sooner in a practice day. It’s about being honest about who I do or don’t want to touch right now. This vulnerability is what allows me to stay present with myself and my clients–as humans first, then as partners in healing. For a while, I’ve believed that healing isn’t possible without a willingness to be vulnerable. We have to let go of what stabilizes to reach for something new.
A quote that stayed on my mirror through my cancer-time: “There is no healing without transformation, no transformation without healing.” I don’t know who said or wrote it–but it rang true in my heart when I came across it. At the time I couldn’t imagine a future where my breast cancer would be so woven into my life story that it wouldn’t be most prominent event.
I trusted that this would happen, but I couldn’t see how, not at that point. It was my biggest, closest life marker. By definition, events that become a thread in our lives are events that change us. They have significance. We have a sense of self “before” and “after” those markers. Clearly, the scale of COVID will be a marker for people all over the world. It is, perhaps, the first overt crisis event that joins us all.
(We know that our environment links us all and it’s in crisis, but somehow we haven’t responded with the same unified alarm or action. Perhaps our COVID-response can be a stepping stone on this front? What more will we be able to do–toward peace, social justice, ecological sustainability–moving forward from this united point?)
We can’t see the end of the tunnel on this, collectively or individually. But we can decide to participate with whatever arises during this time. For myself, I am trying to stay awake, not numb myself or hide. I’m re-committing myself to the passions I’ve had for so long: safe and healthy touch and to learning. I do believe we can help one another. Holding ourselves and each other with humanity, honesty, vulnerability and a fierce kindness, we’ll be alright.
This week’s best re-watch movie is the Best Exotic Marigold Hotel. (trailer) An ensemble story about a handful of retirees who decide to go to India for their elder years. It’s one of those lovely stories in which everyone maintains their dignity and has moments of humanity (messy or hard) as well as transformation. A favorite theme, from Sonny Kapoor, a young Indian man reaching for his dreams of love and success: “Everything will be alright in the end,….and if it’s not all right, then it’s not yet the end.”
For this idea of taking responsibility for our own health and keeping track of it, I can think of 2 moments in movie/tv viewing that really spoke to me. The first is a ‘cris du couer’ –a heart cry– at how challenging it can be; the second is a bit more fun.
First: in season 3, episode 9 of Elementary, Sherlock–here a sober heroin addict–explains to Watson (big shout out Lucy Liu!) about the tedium of tending one’s sobriety day in, day out. It resonates strongly with what I can feel at times about tending my health.
Do the little things–personal health log and self care
I have been tracking my own vitals, especially on days I’m seeing clients:
• pulse rate
• blood oxygen saturation
• blood pressure
Changes in the first three vital signs can be linked with COVID-19 activity. (See earlier post and/or Ninja Nerd Science’s excellent videos about COVID-19 pathophysiology.) I’ve heard of a practitioner who posts these stats in her office on practice days to reassure her clients that she is okay to be in the room. Nice idea.
I track my blood pressure because I have hypertension–one of the risk factors. It’s well managed; even so, it’s comforting to me to have a daily reminder that I’m doing well on that front.
I put them in my on-going health log which I started back when my health was really challenged. I track unusual symptoms, colds, medical visits, prescriptions and dosage levels. This way, when I see my providers for our quarterly to yearly check ups, I can remember what all has been going on. While I could cobble together this information if needed from each provider, I like the experience of being at the center of this conversation.
Other simple things:
• Stay hydrated! This is particularly important on practice days. Wearing a mask means we don’t drink as much through the course of a session. Remember to replenish your fluids in between (as your room airs out).
• Take care of your skin! It’s the simplest, biggest immune barrier you have. Think of how often you’re washing your hands — try to match that with lotion.
• While spreading the lotion, take time for some self massage. We know how good it feels to have our body map ‘filled in’ with good sensation.
• Self-hugs, self-squeezing all on the menu. In Iceland, the government has encouraged its citizens to go out and hug trees! (I can feel the eye-roll of some.) But really–getting to hug and feel the firmness of another living being is great. Especially if you’re sheltering alone. Don’t miss out.
• Colleague Bonnie Wong, DO suggests managing inflammation in our systems by “eating the right foods (lots of veggies/fruit), avoiding foods that cause inflammation (gluten, dairy, sugar/alcohol, etc.), exercising mild to moderately and getting good sleep.”
• On his Facebook feed, Dr. Fernado Vega, MD suggested a daily course of vitamin supplements “to mitigate the oxidative stress in our cells.” I’m passing this along as something you can check out with your own care provider to get the daily levels that are appropriate for you: Vitamin C, Vitamin D, Vitamin A, Zinc, NAC and Quercitin. Again, this is immune and stress support — not itself a treatment for COVID-19.
• As we understand the relative risks of inside/outside, meeting up with friends outside (keeping 6′ apart, wearing masks) has been big medicine for us. Taking garden tours, giving garden tours, sometimes just checking out a new park in our area.
Taking good care of ourselves is always important–these days, as we get back into practice, it’s non-negotiable. We have the chance to reimagine our practices and begin again toward our best practice. One that supports us as we support others.
To celebrate the practice of keeping a log, watch the first Incredible Hulk movie. (Shout out Edward Norton! Much as I love Mark Ruffalo’s Hulk too.) Bottom right hand corner: # of days since last incident. Excellent.
For appreciating the ripple effect, we could start with the beginning of Love Actually: the evidence is all around us. Our partners in beating this pandemic is all around us. What we each do individually is as important as ever.
Contract Tracing — building a web, creating a safety net
Like using PPE and washing our hands regularly, becoming familiar with contact tracing as a public health strategy will be important for all of us. As LMT’s in particular, it’s good for us to understand because our work with clients constitutes “contact.”
Terms and Times Frames
Let’s remember the terms used for difference phases of any disease and how they relate to each other. Here’s a nice graph that helped clarify things for me:
We know COVID-19’s longest incubation period is 14 days (average is 5 days). Also, people are most contagious just as symptoms begin. That is when our contacts are most risky. When our measures of social distancing, wearing masks and hand washing are most important. Because of this, contact tracing orients around the time you were exposed and when your symptoms arose.
Steps of Contact Tracing
There are several phases to successful contact tracing:
• start with a new suspected or confirmed case (initial layer); then…
• ask that person to identify anyone with whom they had contact in the last 14 days (second layer); then…
• inform the second layer that they have been exposed (the identity of the first layer person is kept confidential); then…
• complete a health screening, resource screening and education of these second layer people
• require them to self-quarantine for 14 days, while being monitored at home (temperature and symptom checking); then…
• ask the second layer people who their contacts were in the last 2 weeks. And on, and on.
If a person in the second layer develops symptoms, they are already engaged with public health officials. Getting them appropriate testing and care is an easy next step.
To make this self-quarantine viable, contract tracing is part of a multi-pronged strategy that includes what are known as ‘wrap around services.’ These services include public health sector support to navigate quarantine with land lords, employers, family members, etc. This is standard public strategy that has proved successful against other diseases like ebola, MERS, earlier SARS viruses, and small pox.
The important thing: what constitutes a contact?
I’ve seen 2 definitions of a ‘contact’:
• being within 6′ of someone known to have the virus for at least 10 minutes
• being within 6′ of someone known to have the virus for at least 15 minutes
My take on the difference: if the space we share is quite enclosed with poor airflow, 10 minutes is my comfort zone. If I’m in a very large with great air flow, 15 minutes is my max. (Of course, as this is implemented and/or you are contacted the public health officials will have their own parameter. Do what they ask.)
In either case, my memory is fuzzy at the best of times. These days I’ve noticed that it’s harder for me to stay clear about what happened on which day. So, I’ve started a simple log of when I see people–friends coming over for a garden tour, dropping off a jigsaw puzzle and saying hello, etc.
What doesn’t need to be tracked: grocery store, getting gas, or most errands. The spaces are large and mostly managed for 6′ distances. Outdoor meet ups, walking together, or casual interactions with strangers. (Evidence is quite consistent that being out of doors significantly decreases the risk of transmission.)
So far, most of my events wouldn’t constitute a “contact.” But I’m hoping to get into the habit of noting my contacts before we open up. We’ll all be doing more things that constitute contact (hair cut please!) so naturally our risk of transmission will go up. I want to make sensible containment decisions and be ready to participate in contract tracing as effectively as possible.
We might as well press ‘play’ and finish up Love Actually, because if you haven’t had a good cry in a few days, the final moments of the film are another reminder: “Where would I be without you?”
Amid the Corona Vira Crisis, A Regimen for Reentry, Atul Gwande, New Yorker, 5/13/2020.
Experts Explain How Contact Tracing Will End the Coronavirus Pandemic, Nina Bai, University of California San Fransisco website.
Also: CDC website has downloadable flyers about contact tracing.
What seems like ages ago, this video was making the rounds: how we were making it through self-quarantine. Day 22 remains my favorite — and might reflect your mood at this point!
A New Routine for Our Sessions and Our Clients
Given these new protocols, safety equipment and pared down environment, it’s likely that our sessions won’t feel like they used to. At least at first.
Even with the few sessions I’ve done in the last several weeks, I can say that a new routine is easier to establish than I feared. Once the client is in and we’re doing our work, the treatment itself takes center stage. All that is gratifying in the work resurfaces: relating to the complexity of the human body, the presence of health, helping someone feel better, the learning, the quiet. That is not lost, not at all.
Here’s a bit of a checklist to make sure we’ve covered the bases:
• Leave 30 minutes between sessions to allow for hygiene turn over and more self care. Better to have more time to center ourselves than too little at this stage (ever?).
• I’m also telling clients that I’ll work on them until I feel that useful changes have been made (rather than for a pre-set # of minutes). So far, most sessions are running about 2/3 of the time that they would in the past. I like the added focus this time is bringing.
• I’m scheduling fewer people in a day, so that I can be flexible about rescheduling as needed and I can learn as I go.
• Fewer clients also means less risk of transmission should one of us be exposed to COVID-19. We and our clients can do everything “right” and still there’s a small risk of infection. I’m expecting to keep a light schedule at least until contract tracing is up and running in my community.
• We’re trying to cluster our clients onto the same day(s) to allow the possibility that the room could go unused for 48-72 hours at a stretch. It’s relieving to come into the space knowing that the risk of active virus is extremely low to nil.
• Remind your client about wearing their own mask, leaving extraneous items in the car/at home, and if possible, coming at the start of their time outside the home.
• If needed, shift your practice policies to allow for late cancelations without penalty. (As ever, if a clients habitually no-shows or cancels late in the day, you’re not required to reschedule with them.) The goal is to empower clients to be as honest as possible with you about their status.
• I have ‘fired’ two clients because they were non-responsive or resistant to the new protocols we’ve implemented. I simply let them know that this is how we need to run our practice right now, so I won’t be able to see them for the time being.
Greeting the client outside the treatment room:
• I’ve been leaving my door open so I can see them arrive (they don’t have to knock/touch the door).
• Ask them to leave their shoes outside.
• I put my mask/goggles in place before I step out of the room. I give them a cloth mask if they’ve forgotten their own.
• Wiping down my thermometer/blood ox monitor in their presence gives them peace of mind. I take their signs and relay the findings.
• Stepping aside to let them pass, I welcome them in and close the door behind us.
•• See an earlier post for health screening strategies. ••
• Before the session or in person, it’s important to ask them how they have been managing this stay-at-home time. Have they been using appropriate protocols or has their behavior been more risky? Do I trust that they’re being candid about this?
• They sign it with a newly-wiped pen while I hold the clipboard. I receive the pen and wipe it down again.
• First thing is to open the window and door to air the room out. This helps to disperse possible contagion and the fumes from the disinfectants.
• Alongside changing over the linens, I’m wiping down the chair where the client sits, the floor between that chair and the table, my computer and phone, door knob/surfaces — anywhere we have touched during the session.
• Remove my mask/goggles and place them, carefully, in a paper bag specifically for this use.
• Wash my hands. Put lotion on them so they don’t get too dry.
• DRINK WATER! Wearing masks means we’re not taking in water during sessions. Actually this has been one of the biggest changes!
By far, my favorite show that has an element of on-going negotiation about physical contact is Pushing Daisies. If film noir and musical theater had a baby, it would be this show. Private detectives, requited and unrequited love, campy design, pies, a musical number or two and great big heart at its center. How did it get canceled after only 2 seasons?! Why is it no longer available streaming?? For your birthday, ask for the DVDs. Try the library. Come to my house.
So in lieu of that, still in a light-hearted, comedy of errors meets detective story vein: watch Pink Panther. The original with Peter Sellers — fabulous. The remake with Steve Martin — wonderful.
To get ready for this, I’d suggest 2 or 3 episodes of Monk (anywhere in the first season definitely). What makes Tony Shalhoub’s performance so poignant is the tension between his anxieties and his desire to continue his life despite them. My tears of laughter are in recognition of his, our humanity at the center of that dance.
Day to day: Keeping it clean
There’s great information on the professional sites: WSMTA, ABMP, IASI. Next there’s seeing what’s available — sometimes the thing that seems easiest, isn’t to be had. Clorox products–anything with bleach, for example, is tough to find. There’s a reason for that: my sister-in-law works for Clorox, helping with distribution management. The general public isn’t seeing Clorox products on the shelves of super markets because the company decided to prioritize shipments to hospitals, nursing homes and care facilities. I’m okay with that.
Remember: this virus is very very nasty on the inside, but relatively easy to kill on the outside. Lots of strategies work; use as many as is practical.
Our plan consists of several levels of disinfection:
• Good ol’ soap and water: It’s simple and effective. Soap and water, doesn’t even need to be hot water, will kill it. 20 seconds of hand washing–all the nooks and crannies–is enough. There are dozens of ‘how-to’ videos around; watch a bunch.
• Sani-gel: mostly for clients to use before/after and for us to use during the session. We’re just about out of our pre-COVID stock (thank you classroom supplies). We’re making our own with 80% alcohol and aloe vera gel. Keep the dispenser bottles!
• Alcohol (between 70-90%): We’re wiping down commonly touched surfaces between clients with 80% alcohol right from the bottle. Check your local supermarket in the booze section: many distilleries have started bottling 80% alcohol and labeling it “Hand Sanitizer.” This isn’t a scam; this is how they are contributing to our safety at this time. It’s cheap and easy to use. It’s also not too harsh and doesn’t leave a big chemical trail like bleach can.
• Spray disinfectant: Then at the end of the day, we’re spraying down with a disinfectant to reach the uncommon places. Walls, under the table, base of the chairs, the hinges on the face cradle, etc. We’ve found a spray I’m excited about: Anti3. The name relates to its potency: anti-viral, anti-fungal, anti-bacterial, utilizing several of the EPA approved active agents. It’s made for sporting equipment, which means it’s gentle on vinyl, leather and wood. It’s not expensive and is readily available — probably because you need to leave it to air dry to be effective. This air-drying aspect means Anti3 is not so good for between sessions, but it’s great as an all-over, once a day thorough treatment. And it doesn’t smell bad.
So far so good. I do like to repeat clean anything I’m asking client’s to touch, like the devices I’m using to check their signs of health (see previous post on client screening). Or my phone for credit card swiping. (I know many LMTs are asking that clients only pay on line, but some forget. We’re using the in-person method as back up.) Clients are absolutely on board and grateful for all the attention to safety.
If you have kids at home, you could follow this up with Mary Poppins, “A Spoonful of Sugar.”
Or if you can have some adults-only streaming, pick your favorite steamy kissing-when-wet scene: the first Spider Man upside-down kiss, the Ross-and-Rachel-finally-kiss scene, the back-together scene from The Notebook, the almost-kiss in either version of Pride and Prejudice, the shower scene in Something New, and on, and on. Enjoy!
The only way to get through one more conversation about PPE is to be re-inspired. How about Fred Astaire singing “Putting on the Ritz”? Or if you want a campier version, you can watch Gene Wilder and Peter Boyle in Young Frankenstein (jump out of it before the end which is a bit chaotic). Now that we’re ready to get dressed up, let’s look at what we’ve got PPE-wise.
We’re using a small stash of N95 masks we bought years ago when we were doing a lot of painting. (This might be the one time that having chemical sensitivities has seemed to pay off.) We are reusing them by putting them in paper bags, marked with the date so we can keep them there for 3 days between uses.
We also have homemade masks that we are using around town ourselves and to have on hand at our practice space in case clients forget theirs. (Recently, the few clients we’re seeing are all coming prepared.) To address the risk created by ‘voids’ in the masks–places that gap where air escapes–we are using nylons on top of them as recommend by CDC and WHO. Here’s Richard modeling the new style!
We’ve ordered goggles that seal, but not ones that need to go over our glasses. (Looking at the options, be mindful that lots of goggles advertise ‘anti-fog’ capacity. This means they have venting to reduce condensation; that venting becomes a risk factor in this instance.) We’re waiting for them to arrive, so we’ll see how they fit. It may take a few tries to get something that suits us.
For clients’ eye protection when they are on the table, we’re going to use hand cloths, folded over. They’ll be easy to place and to wash between uses. They won’t provide a complete seal, but if the client has their eyes closed underneath the cloth their body accomplishes that.
While simply touching COVID-19 poses no risk of infection through the skin, we want to be more cautious if we have cuts or openings on our hands. OSHA and other agencies haven’t given guidance about 1 versus 2 layers, except in medical/work situations where likelihood of tearing is high. That’s not us.
Some folks are counseling to use gloves while working on the feet or relatively dirty areas. Then you can take them off before working on other areas of their body without needing to clean your hands yet again. This can give you more flexibility about the sequence of how you move from one body area to another. I figure I’ll experiment with this once it’s sandal season.
For many of us, we are accustomed to using gloves for intraoral work. If you choose to do intraoral work now, remember that inherently it poses a much higher risk because the client must remove their mask. You’ll need to take this on a case by case basis–and only do the bare minimum needed. It’s not the time to go all out doing everything that’s possible.
The gist of this is to have a clean layer of clothing for each client. Rather than invest in new wardrobes, we’ve decided to bring a change of layers: Hawaiian shirts, long t-shirts and/or sun dresses (for me!). Clearly we’ll be doing more laundry anyhow, so we might as well.
Something to consider: how far up your arms do you contact the client; does their body touch your torso (say with an arm ROM)? Remember to account for all those surfaces. For reaching under the client, I tend to go under the sheet — I may expand that practice to more areas of the body. We’ve also discovered that the hand towel we’re using to cover our head extension on our table can be used as a layer. Here’s me working on Richard’s head through the hand towel.
Donning and Doffing:
First of all, when have we used these words except in Christmas carols? To learn about this, there are several good videos on line. One day, it will become habitual, but not yet. Every few days I watch one, just to refresh my understanding and skills. I’m getting better and more consistent about this.
To round out this subject, it would be easy to list an epidemic/biohazard/pandemic movie. Rather than that, I’m going to give a BIG SHOUT OUT to my brother, Tom. He’s one of a team of engineers working for GE Health to produce ventilators. Alongside tripling production of the high-end and mid-range ventilators, they are working on adapting simpler ‘transport ventilators’ for mass production. (Think of the kind of ventilators used on helicopters.) They’re taking a plan from a small company that’s produced about 150 ventilators a year–and upscaling it to be produced by Ford at the rate of 10,000/week. Not an easy task.
So, to honor them, I’ll suggest one of his favorite science movies: Apollo 13. Remember the part where the engineers on the ground need to design an air scrubber out of supplies on board? “You, my friend, are a steely-eyed missile man.” Love you, bro.
Needless to say, it’s easy to be overwhelmed when considering all the logistics of getting back to work. Through this series of posts, I’ll explore one mode of preparation and share the steps we’re taking.
Some of these steps may fit for your practice as well; some might not. You might have needs based on the configuration of your practice that aren’t listed. Please review the resources provided by the WSMTA , AMBP and IASI— they have compiled great overviews for massage therapists, with links to larger organizations such as OSHA, WHO, EPA and CDC.
These posts aim for a distilled example, with a bit of light-hearted support. Since we’ve got time for some movie/youtube watching, I’ll include a couple of suggestions with each post. Enjoy!
Part one: Preparing the Office
First step: watch at least 3 episodes of Marie Kondo’s “The Magic of Tidying Up!”
This should get you in the mood to clear all the clutter from your shelves, cubbies, and closets. It’s been a wonderful exercise to ask ourselves: what is absolutely needed for us to massage in this space?
We’ve learned that over the months and years, we’ve gathered a lot of clutter. Supplies we once used or thought we would use — oils, self-care props, over used linens that sit at the bottom of the basket, etc. And then there’s the decor: Lots of little objects, some are gifts from clients, some are an object of beauty to set a tone. While lovely and comforting on one level, what if we picked just one?
It’s been refreshing and empowering to remember that the work we do is genuinely about how we touch another person. No props, no gimmicks.
Swap out non-wipeable surfaces
We had upholstered chairs for our clients to sit on — we’ve swapped them out for wooden chairs. We had cloth or mat runners on top of a set of shelves; we’ve removed them. We’ve included plastic liners on baskets that hold our linens — both clean and dirty. Scan your room: how can you switch things out?
Add in wipeable covers
We use a foam topper on our tables; I’m not ready to let that go. We’re swapping out the prior (very old) lambs wool cover for a new, wipeable cover. My first attempt will be a bamboo cover that is water proof and washable, 100% hypoallergenic and also protects against bed bugs. (Remember when we were all worried about bed bugs?!) Same for pillows and bolsters.
We’re using small garbage bags (12″ size — which also happen to have twist ties that can be used in masks) over the frame of the face cradle. OSHA’s information makes it clear that the hardest equipment to clean are things with hinges. Think of that oblong overhead light at the dentist office: for years they’ve been slipping little plastic bags over the handles. Our turn.
Reorganize the space
How can the client come in, have a place to keep their things, and get to and from the table with as little chance of touching surfaces unnecessarily? We’ve got a spot that includes easy reach for kleenex, sani-gel and our health screening items (more in a later post). It gives the clear message that our shared hygiene is a priority. Be willing to shift how you live in the space as well. This rearranging might take some imagination about how you think of the space. Think of it as the biggest, baddest spring cleaning ever!
Air Turn Over
Since the risk of transmission is way higher in enclosed spaces, we need to think about air quality. We’ve had air purifiers already; now we’re double checking them to make sure they’re working well. We’re also opening windows and doors to air out the room between clients. This also helps to clear out the scent of the disinfectants we’re using. (More on disinfectants in part 3.) What’s great about airing out the room between clients is that the door is already open–they don’t have to knock or touch the treatment room door to enter!
Keep shoes–and unneeded items–outside
We’ve got a place for our shoes and the clients shoes to be that’s outside the treatment area. We’re also asking that clients leave unneeded items at home or in their cars. If they can make our session the first outing of the day, it’s less likely that they’ll bring a chain of exposure with them.
It’s recommended to consider not using blankets during this time. Turn up the heat, use double folded flat sheets, use a table heater below the client–there are lots of strategies. In general, because we work with people clothed, folks are usually warm enough. Still, we’ve decided to repurpose our stash of fleece blankets for use in our practice. They are washable and not too bulky going into the hamper.
We’ve invested in a few more sheets, as well as hand towels and face cloths. Extra sheets can be used for blankets and for floor coverings (especially as the weather warms up and people aren’t wearing socks). We’re using face cloths as eye shields when people are laying face up, Hand towels go over the extension portion of our table — and bonus! You can work through them for scalp massage, just like our hair dresser does between washing and cutting at the salon. We’re taking them to and from in sturdy/exterior plastic bags; to not create excess plastic waste, we’re rotating those bags on a 5 day cycle.
Phew! After all that, I can share 2 really important things:
- In the sessions we’ve had during this time, we both have realized something consistent: clients don’t actually touch that many surfaces in our offices. Their behavior is pretty contained–at least the adult ones!
- It’s REALLY important to remember that touching the virus, in and of itself, doesn’t make you get the disease. Transmission requires the next step of then touching our eyes, nose or mouth. So, if you or your client touch something that you’re not sure is free from risk: just WASH YOUR HANDS!
And, after all that, if you need an epic movie to captivate your imagination: try Lawrence of Arabia. Memorable line–from real life: When asked why he loved the desert enough to leave his home in England, utterly uproot his life to be in such a harsh environment, Lawrence replied, “It’s clean.”
Once we have confirmed that people’s need is critical enough to come in for a massage (earlier post), and we’ve created a clean-as-possible clinical environment (next posts), we can further check their health to make sure it’s safe to continue.
We are checking that the client is healthy on the day of the session — healthy enough to receive massage. We are not screening for particular diseases. This may seem like two sides of the same coin. But it is critical that we, and they, understand the difference. The goal is to confirm that people are presenting with both a lack of common symptoms and signs of body function within normal range.
Symptoms are assessed through intake questions. This requires trust in the client’s honesty: fever, cough (dry or productive), shortness of breath/difficulty breathing, and sudden loss of taste/smell. These are the most common early symptoms that people have. Even though a small number of cases remain asymptomatic throughout the course of the disease, most people DO have symptoms — even mild ones. So invite them to be thorough; better to over report than under report or minimize what they feel. Add to this: known exposure to COVID-19 or to people with COVID-19 (travel, work, family, etc.).
Signs we can check easily with simple, low-cost equipment: temperature, blood oxygen level coupled with heart rate, and breath rate. Each of these vary, within homeostatic range, at time of day, activity level and from person to person. Ask your clients to arrive 5 minutes early to allow heart and breath rate to normalize after the activity of arriving at your door.
We can encourage our clients to get to know what their baselines are. Home monitoring is easy or they can get this information from their HCP’s office/health portal. These signs are part of a standard health check up, so the data should be in their charts.
Here’s what we’re looking for:
• temperature: “fever” is defined as anything over 100.4° F Using an ear, forehead or infrared thermometer. Clearly, devices that touch them need to be disinfected between clients.
• blood oxygen level: normal range is 95-100% (perceivable “difficulty breathing” generally happens with levels of 88-92%). Using a fingertip device, easily available for home use. Also disinfect before each use.
- pulse rate: 60-100 beats per minutes (over 100 is high). Count the beats in a 12 second period, then multiply by 5; or count the beats in a 6 second time and multiple by 10.
- breath rate: 12-20 breaths per minute (over 22 is high). Similarly, count the breaths over 15 seconds then multiply by 4; count breaths over 20 seconds then multiply by 3.
We include pulse and breath rate because they are the initial compensations that the body makes when lung volume is compromised. If the alveoli are not able to continue with O2/CO2 exchange in a healthy way, we adapt by either breathing more or pushing more blood through the lungs. The client may or may not perceive these changes — but they are changes that happen as COVID-19 attacks the lungs, even before the body’s immune response kicks in (creating fever, coughing, fatigue, etc.).
Keep in mind that many conditions can create these signs. If the client has chronic, well-managed conditions that can create these signs — and they know where their baselines are — we adjust our screening to rapid or severe changes in those levels. Also keep in mind, the more risk factors or vulnerabilities the client has (age, high risk diseases such as hypertension, lung compromise, cardiac compromise, etc.), the more conservative your appraisal should be. Always err on the side of caution.
Again, we are not screening to see if they have a particular condition (COVID or otherwise). We are checking to see if their cardio-vascular physiology is within healthy parameters. It is not our responsibility, nor in our scope, to diagnose disease.
How the findings guide our decisions:
Any symptoms or uncertainty on your part about the client’s self-reporting is reason enough to postpone. An out-of-normal-range sign in these areas is cause enough to postpone the massage. At the least. Multiple signs and symptoms require us to urge them to contact their HCP for active disease screening (COVID-19, pneumonia, bronchitis, etc.).
If the client reports no known recent exposure or symptoms, and the above vital signs are within healthy parameters, we can conclude that they have a high probability of health. We can welcome them into our practice, while still protecting against the possibility of contagion by using all the PPE and disinfecting protocols outlined for our profession.
So far in my practice, the few clients I’ve seen have been more than willing to be screened and are thankful for extra measures and conscientiousness that these measures show.
Thanks to Bonnie Wong, DO and Robbin Blake for helping me clarify my thoughts.
4000 Aurora Ave N, Suite 114
Seattle, WA 98103
116 NE 194th St.
Shoreline, WA 98155