Because people want to know before they make an appointment:
We wear masks and we will ask you to wear one too (children exempted)
We will wash our hands immediately before our visit and we will ask you to do the same.
We will open the windows, weather permitting or offer to meet with you on our deck.
We have been vaccinated but we haven't changed our precautions
We offer phone or Telehealth visits
We will arrange our schedules and ask some patients to wait in their cars our outside on our bench to minimize overlap
We will sit or stand 6 feet or more from you and each other when possible. 
We will clean high touch surfaces
​We welcome feedback

Melissa says: "I am a 25-year RN with a strong background in teaching and practicing hospital maternal-newborn care. I am in my fourth and final year of a graduate program to become a family nurse practitioner. I'm enjoying expanding my skills to provide primary care across the lifespan." 
Melissa will be joining us Tuesdays and Thursdays in March as a part of the last few months of her training to become a Nurse Practitioner.  Her time with us is supposed to be focused on Reproductive Health, which we are defining broadly to include hormonal health, menopause, bladder concerns as well as questions about contraception, genital health, and breastfeeding and newborns.  In order to celebrate having a learner with us (teaching is such a great way to learn and feel younger) we are offering our patients 50% off any visit Tuesdays and Thursdays in March if you are willing to welcome Melissa as a part of your care team. Schedule online or call the office with questions.  

It's been a week of a lot of intersections. 

In Columbia and Boone County:  Two workers at a grocery store and a hair salon and a child at a day care center tested positive.  I know many people want to know where the positive cases are so they can avoid getting sick, I don't think that is helpful.  First, a positive case just tells you who got exposed a 4-10 days ago, not where you might get exposed now.  Past information isn't always helpful.  It also presumes that every other place is safe and free of people with the virus.  With the level of testing we have now, (and honestly with any level of testing other than testing everyone every day) we just can't say that. What this says is that it is likely we can be exposed to folks who are shedding SARS CoV2 while shopping for groceries, getting our hair or nails done, or by having our children in day care. 

A resident of Boone County developed symptoms of COVID 19 while celebrating Memorial Day at several entertainment sites at the Lake of the Ozarks and tested positive this week.  We  could have predicted that at least one person was potentially infectious during that gathering.  This is a bit of a challenge for contact tracing and so the health department has resorted to issuing a press release listing the places this person visited so that others who were there at the same time can possibly be informed.

Around the country, people are out in public spaces expressing their outrage over the way police interact with the communities they serve.  These gatherings will almost certainly increase the spread of SARS CoV2.  The fact that they are outdoors reduces the risk, as will wearing masks, but not as much as if people stayed away from each other.  The risk is further increased by the use of tear gas by law enforcement (study showing a link between respiratory illness and tear gas exposure)..  I was surprised to learn that there are international agreements that outlaw the use of teargas by military forces, but allow its use by police on civilian populations and that the ACLU has concerns about the way it is used in US.  (Link to ACLU statement).  If you get exposed, here is a link to a decontamination procedure. 

Due to flooding in Michigan and storms in Bangladesh, people are having to evacuate. Housing displaced people during a pandemic is to say the least problematic.  

Sending you wishes of great health. 

Spring is here in Missouri and summer is close on its heels.  All the health challenges of a typical spring are still with us.  I'd like to offer a few ideas to help you through them

POISON IVY: I saw it yesterday in the woods, starting to leaf out.  I've already recovered from my first case this spring, so it is possible to get it on your skin before it has any leaves.  It's an oil that causes the reaction.  The higher your exposure (more oil for more time) the more of a rash you will develop.  Best to not get it on your skin at all, but if you do, the sooner you get it off,  the happier you will be.  Warm water and soap are your friends.  Wash like you got motor oil or something even more like wax on your skin.  Friction and lots of rinsing help.  If you get the rash, it is going to be there for about 3 weeks, cause that's how long it takes for you to make new skin.  It tends to develop slowly, getting more itchy and red over about a week, stays stable about that long, and then resolves over the third week.  I have found that hot water run over the skin for about 30 seconds really helps with the itching.  The water should be hot enough to sting but not hot enough to cause a burn.  Other home remedies that can offer relief are witch hazel and oat meal baths or soaks.  

SEASONAL ALLERGIES:  Like poison ivy, avoiding exposure is your best bet, but when that doesn't work, you might consider quercitin, probiotics, reducing inflammatory foods from the diet and my favorite herb; stinging nettles.  Spring is a great time to embrace nettles as a cooked green, raw in smoothies, or dried and made into a tea.  

SUN EXPOSURE:  The sun feels so good on the skin and the weather is really inviting right now.  About 10-20 minutes of sun exposure each day from April to October in Missouri is a great way to get our Vitamin D and the great benefits to mood and energy that sunlight provides.  It's important to be careful easing into sun exposure after a winter under clothes and inside our buildings.  Sunburn is no fun and isn't good for our skin.  The best sunscreen is a roof, shade, or dark clothing.  I wear a hat in the garden to protect my eyes and the skin on my face.  If you get burned, cool water, unscented lotions, and witch hazel can be soothing.  

What else is concerning you this spring?  

I can feel it in myself and hear it in the voices and social media commentary of others: this shut down is wearing.  Not all of us are taxed the same; we chafe at different pain points.  Anti-restriction protesters speaking up.  While not all of us agree with their methods or their proposed solutions, many of us share in the frustration. 

During my decades of practice, when I imagined the need to respond to a global pandemic, I presumed I would be led by folks who had thought it through, who had a plan, who had prepared equipment and technology.  I never imagined even in December and January when this virus began to spread that we would be so limited in testing, in PPE, in medicines, in plans. 

In various places, restrictions are being officially loosened.  And I can feel myself thinking that it's time to lighten up.  I can see even some of my cautious friends making some tiny steps towards more exposure to more people.  In Boone County, MO, we have very few active cases (that we know of, yet) and so it seems like it's time.  We have so far been spared the real tragedies, hardships, and staggering deaths that has been seen in Italy and New York City.  Does that mean we can safely expand our activities and contacts?  Or does it just mean that we have a lot of hardship ahead of us? We have flattened the curve.  We took action that was painful.   And we got really lucky. New York City with really stressed hospitals and hospital workers, refrigerated tractor trailers serving as morgues and increases in temporary mass burials has only about 13% prevalence of antibodies. How much more will they have to endure before the 60-90% prevalence we think might create herd immunity is attained? Will we follow them eventually? It seems clear that there is no easy way through this.  There may be, however, some saner ways to try. 

Many people will feel the need and the pressure to return to work next week in Missouri.  Without the protection of the government, there will be less unemployment benefits and no longer the cover of clear guidelines for those who wish to remain at home. Hair and nail salons, massage therapists, yoga studios, gyms, theaters, restaurants, retail outlets will certainly reopen for business. I wish that we were putting a higher priority on: 
1. resuming all non-emergency medical care.  Some folks got their surgeries and treatments postponed.  Some of these procedures can be safely put off for a bit, but not without a price
2. Educating our children.  I don't think it's time to resume regular indoor classrooms, but maybe some smaller groups outdoors? 
3. Allowing a bit larger gatherings for marking important life milestones such as funerals, weddings, and graduations.  
I think we might could have started to do those things carefully IF we had had more testing available, so we could have a better idea of what was really going on. 

Despite my preferences, Missouri is about to open back up its businesses.  I will be watching the apparent hotspots of nursing homes, jails and prisons, and meat processing facilities and hoping this will go better than I fear.

For me:  I am not going to change anything I am doing right now.  I will continue to see patients virtually, reserving in person visits for the infrequent circumstance where an in-person visit really just can't be wisely avoided.  I will dream of the day when I can once again welcome patients into the office  and when I can once again offer acupuncture, hyperbaric oxygen therapy and infrared sauna to my patients.  I will keep advocating for more testing of all kinds. My household will still obtain our necessaries through curbside and delivery.  I will continue to stay in touch with friends and relatives by phone or video. I will continue to wish I could get some really good body work.  For each of you:  I hope that you have all you need so you can make your own best and wisest decisions.  

This week we said goodbye to John Prine.  The last few days, his voice has replaced the podcasts that typically form my soundscape for gardening and housecleaning.  What a loss.  We lost him to a combination of tobacco addiction and COVID19 (in my opinion).  Two preventable illnesses.  The idea of having no more of his particular poetry because we didn't act courageously enough to these two public health scourges seems karmically fitting and yet tragically unmooring.  
This week also revealed mass graves to bury the unclaimed dead in New York City.  I read this article through tears with John's music in my ears.  What a gut punch.  Every casket just one bead on a rosary of horror.  Each one tells a story of a person dying without the comfort of a known loved one, of a family who lost a person they valued and counted on, of hospital workers witnessing a torrent of sickness, struggle, and death, of a nurse holding a hand while she also held her bladder and realized it would be another shift before she ate, because putting her needs ahead of the dying just wouldn't be any comfort to her right now. A pharmacist who turned over all the rocks searching for another supply of narcotics to make being on a ventilator survivable and worried about what torture would result when the supply ran out.  A doctor racing from one emergency to another, reading lab tests and interpreting thousands of pieces of information with a sleep deprived brain, wondering if the mistakes they were certainly making would be caught in time to prevent a bad outcome and if it really mattered.  A ward clerk watching the ward fill and overfill and staff falling apart and chaos reigning in what could on a normal day be almost kept orderly.  
I can't help but think that this was all unnecessary, that we could have prevented so much of this.  We have known for a hundred years that this could happen.  If it happened once, it could happen again.  Not just once has this happened:  Sure there was the influenza pandemic of 1918/1919. But there have been others.  As a medical student in the 1980's, I had a front row seat to the last major epidemic/pandemic of HIV.  A much more slowly unfolding health and vitality-robbing disaster we also botched.  Nearly every year or two there is another thing that makes public health leaders ask, "Is this the year?" Anyone in medicine or nursing who hasn't been watching for the next unfolding, at least with peripheral vision just hasn't been paying attention. There was SARS and MERS. And various strains of influenza. So many people preparing, making plans, stocking up with things we would need, speaking out.  This SARS Co-2/COVID 19 did not just come out of nowhere.  Public health folks have been watching this particular virus and shouting warmings since December, with increasing alarm and volume.  We could have been ready.  We could have mitigated the harm. 
It is so sad to me that we are actually paying a larger economic and social cost than we would have paid by doing things earlier. Is it possible that we  have the wrong kind of brains and social/governmental structures to respond effectively to challenges like this?  Will we learn enough from this to do a better job of responding to Climate Change?  The similarities of the situation, its seriousness and our resistance to changing our lives are pretty stunning to me.  

Honestly, it feels a little bit like the conversations we have around safer sex.  Who have you been around?  And who have they been around?  And can't I make this thing I want to do with you safe enough that we can break the rules? 

The First Rule of Social Distancing = Essential Activities ONLY
Stay home.  Anything you do in your home, in your yard, and with your household members is good.  Walking outside in a public space (or on private land with permission) by yourself or with other members of your household is also fine.  

Getting food, medicine, essential household items, and health care are considered essential activities.  It is best to do that with minimal contact. Use curbside pickup or delivery for groceries or other consumer products.  Take out (stay outside) or delivery is the only option for prepared food.  Reschedule routine health care visits or do them by phone or video conferencing.  Ask if labs, X-rays, ultrasounds or other studies can be rescheduled. Rarely, folks will need emergency home repairs, will need to sign papers, will need to make a larger purchase like a car or an appliance. Limit this to the essentials and be creative about reducing your time in a building you don't live in and contact with anyone not in your household (even at a distance). 

Only Household Members.

Whatever contact, even distant, you have is to be with members of your household only. Some folks have gotten clever and decided to make one household out of two and agreed to limit ALL their contact to just the members who live in those two households.  This doesn't work if someone  leaving the house to go interact with others on a regular basis, like for work or is going into stores to get supplies. 

Wash your hands. 

After using the restroom of course, before eating. Before and during food preparation.  Before and after touching shared surfaces. Use soap and water.  No need for antibacterial soap. A second choice (not as good as soap) is alcohol-based hand sanitizer with 60-70% ethyl or isopropyl alcohol. Stronger isn't more effective.  Avoid touching your face. 

Cover your coughs and sneezes.  

Wear a mask. If you need to cough or sneeze while wearing the mask, lower your face, use a tissue or catch it with your elbow.  
A mask will reduce (but not eliminate) the amount of aerosols you spread into the air.  If you have an infection, it will reduce the amount of virus that floats in the air for hours after you pass through a space.  
No mask works as well as staying out of the space in the first place.  Talking, laughing, and singing all seem to increase the amount of aerosols and droplets you send out.  

Distance= 2 meters of distance determines our existance
If you have already determined that your errand is essential AND that you can't do it without crossing paths with others, THEN please make every effort to stay 6 feet (2 meters) away from everyone else.  Current recommendations advise that  you cover your mouth and nose with a mask, wash your hands, use hand sanitizer, don't touch anything you don't have to,  and get your business done quickly so you can return home. 

Intentionally getting together socially and staying 6 feet away or wearing a mask is NOT on the current guidelines.  Taking a walk with a friend but staying 6 feet away?  NOPE.  Having a neighbor over to garden outside?  NOPE.  Having friends over for a campfire?  NOPE.  Having a community work day to pick up trash/pull out invasive?  NOPE.  Stopping by to see your grandchildren and sitting out in the driveway 6 feet or more apart? NOPE.  Why?  because none of these things fits into the above definition of essential activities.  And they all include folks who aren't in your household. 

Clean surfaces. 
Use the same soap for wiping down surfaces and objects.   For surfaces a third choice is bleach, 10% solution   Stronger doesn't work better.  Do not apply bleach to your skin. We have all read about how long the virus lives on various surfaces--from a few hours to a few days.  If someone outside of your household has touched a surface, it's wise to either leave it alone for a day or two or wipe it down with soap and water, alcohol, or a dilute bleach solution.  As you do this, remember that the PRIMARY way SARS Co2 is spread is by respiratory droplets and aerosols.  The most important things seems to be to stay out of buildings that you don't live in.  High exposure folks like health care workers and emergency responders should probably launder their clothes on returning home and shower before touching other people or surfaces.  We don't know if there is any benefit in doing that after a trip to the store.  There is no need to even consider that if you picked up curbside or had your items delivered. 

  
Everyone has to make their own best decisions of course.  Each person knows what is essential for themselves.  We are all in this together.  We are being asked to do the really hard things so that hospital workers and emergency responders don't have to do so many horrific things.  

 Three weeks ago, I stepped out of my usual routine and into a new world of testing for COVID19. Monday, March 16 I found tests were available for me to order through Boone Hospital.  I swabbed noses and submitted 10 samples in the next few days. Wearing my home made PPE was sobering.  Looking into the eyes of people who were so sick and so afraid is something I will not soon forget.  Sadly, those samples went to LabCorps and took weeks for the results to return.  Those weeks were forever for me and even longer for the people waiting for those results. Since then I have been ordering the tests and having the swabs be collected at Boone Hospital. Results are coming back in a day or two. Right as I started testing, local officials recommended I have my office manager work from home and I then hired my daughter to work in person in my office.  Lots of shifting.  Learning to manage health care with a new staff arrangement, over the phone first and now also by secure video, responding to shifting requirements for testing.  Friday March 20th, I posted about testing on a local FB community group and within an hour, there were hundreds of likes and shares.  My sleep that night was disrupted by dream and waking fears of being overwhelmed. I woke the next morning to internet and phone lines down.  An hour later, the phones started ringing and didn't stop for days.  I haven't counted, but I am guessing I have ordered testing on 50 people and talked to another 25 who didn't meet the criteria from the lab. There has been so much grace in the overlapping of a slowing of need from my regular practice just when the testing was so busy.  Now that the testing system is streamlined and the demand for testing has slowed, I am ready to get back to seeing my patients.  If you are one of those people who had to wait a little longer to get your medication prescriptions refilled, I am so grateful to you for your patience.  If you have been waiting and hoping to get to see me soon, now is your time. 

In response to questions about how to prepare for and to provide home care for those who are sick:
First, just know that you probably know more than you might think.  Most of us have had a cold or a fever or a respiratory illness.  This one might not be any more severe than the ones you have had before. What you have learned in previous illnesses is relevant and applicable.   
For the sick:  rest is so helpful.  Rest for the body, yes, but also rest for the mind.  Avoid social media, screens of any kind, disturbing stories, harsh words.  Surround the sick with beauty, soft light, quiet, peace, comfort, and of course, drinks and foods to appetite. Speak with a cheerful confidence of their body's healing journey.  Soups with lots of onions and garlic, ginger, turmeric, chicken broth, astragalus, and savory herbs are comforting and healing.  So many plant medicines can come to our aid when we feel unwell:  echinacea, astragalus, olive leaf extract, yarrow, mullein, elder, garlic, . . .  Of course each person's reaction to any plant should be considered and adapted.  
Sugar and flour, processed foods, alcohol (in excess of what is in herbal extracts--taken in the fractions of ounces), and worry are to be avoided. 
Supplements like fish oil, zinc, vitamin C, and vitamin D support healing.  Always customize the regimen to the person.
For the caregivers:  Care for yourself first.  Sleep is so important, as is being well-nourished in body and soul.  Asking for help is hard even in the best of times.  Notice if the obstacle to getting help is inside of you or external.  Who is your support--both physical and wise guidance?  Hygiene is important.  Separate the sick person's toothbrush, towel, washcloth, etc from the rest of the household.  Can the sick person have their own room and dedicated bathroom?  If so, that's the easiest.  Of course washing hands and surfaces is important. Soap and water is our oldest and most effective ally for hands and surfaces.  Use products that have your confidence and make you happy.  
We are asking people to practice social distancing, and once people are sick to practice isolation (for the sick) and quarantine (for the exposed well). It is true connection with people is so important to health.  (This applies mostly to the caretakers.  The sick are generally internally focused as is right and have little energy or interest in social interaction--this is to be respected)  Use technology to communicate as regularly as you can. Stay honest with yourself.  Connection with nature and the divine are also health-giving, as is movement.  

In an effort to be available to my patients in a way the reduces the chance of spreading COVID19 (and other infections as well), I am asking that my patients who have fever, cough, shortness of breath or otherwise feel unwell call the office rather than coming in.  I will be making myself more available by phone and by videoconferencing.  In addition, I am making greater efforts to see sick folk at their homes.  

I am exploring ways to get testing for COVID19.  The state makes that testing available, but due to limited supplies, they are only testing people with symptoms and with high risk exposure (contact with a documented case or travel to an area with documented community spread).  Others will need to pay for testing, either themselves or through their health insurance.  That testing should be available any day now.  
I am fielding questions about the specifics of social distancing.  It's new to all of us.  Sharing perspectives is so important. 
Are there ways I can be more helpful to you?