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The Fight Continues

COVID-19 S A N A N TO N I O

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COVID-19 – The Fight Continues

Medical and Business Ethics – Are They Compatible? By Rodolfo (Rudy) Molina, MD, MACR, FACP .......................................12

A Closer Look at PPP, EIDL and Other Relief Programs By Jim Rice, CPA, and Christopher Davis, CPA ....................................14 Cloth Masks: Public Defense Against COVID-19 Disease By John Menchaca, MD .......................................................................16 Exercise Like Your Life Depended On It By Jon Courand, MD and Ajeya Joshi, MD ...........................................17 Sanctity of Contracts By Mike Kreager and Trenton Brown .................19 Use of Cloth Masks by the Public: Good, Bad or just Ugly? By Diane Simpson, MD ........................................................................21 Loosening up the In-Home Sheltering Policy. What will happen next? By Bob Leverence, MD...............................24 Responding to Those Who Ignore Social Distancing Orders By Brittany Johnson, MS, MPH ............................................................25 COVID-19 Inspirations By Zahra Mohamed..........................................................................................................27 Whisperings from Solitude By Rajam Ramamurthy, MD ......................................................................................28 A Third-Year Medical Student’s Perspective on COVID-19 By Donald Egan ....................................................30 A Medical Student’s Perspective on the COVID-19 Self-Quarantine Experience By Katelyn Franck .............31 Why Medical Students (and everyone else) Should Learn Everything They Can About COVID-19 By Michael E. Walston, MBS..................................................................................................................................32 My Role as a Medical Student in the Era of COVID-19 By Michell A. Parma .....................................................33 The Effects of COVID-19 Social Distancing on Children: and Questions that Need Answers By Kalli R. Davis ....................................................................................................................................................34 My Coronavirus Retirement By Leon Ghitis, MD..................................................................................................36 STRAC, the RMOC, and Disaster and Pandemic Preparedness and Response By Ronald M. Stewart, MD; Joe Palfini, BSN; D. Eric Epley, CEM; Brian J. Eastridge, MD......................................38 Spanish Influenza From the Journal of the National Medical Association By T.C. Bracken, MD, Port Arthur, Texas................................................................................................................40 BCMS President’s Message .................................................................................................................................................8 BCMS Alliance ...................................................................................................................................................................10 BCMS Circle of Friends Physicians Purchasing Directory....................................................................................................42 Auto Features By Stephen Schutz......................................................................................................................................46 Recommended Auto Dealers .............................................................................................................................................48 PUBLISHED BY: Traveling Blender, LLC. 10036 Saxet Boerne, TX 78006 PUBLISHER Louis Doucette louis@travelingblender.com BUSINESS MANAGER: Vicki Schroder vicki@travelingblender.com ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@travelingblender.com

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JUNE 2020

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VOLUME 73 NO. 6

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Gerald Q. Greenfield, Jr., MD, PA, President Rajeev Suri, MD, Vice President Rodolfo “Rudy” Molina, MD, President-elect John Joseph Nava, MD, Treasurer Brent W. Sanderlin, DO, Secretary Adam V. Ratner, MD, Immediate Past President

DIRECTORS Michael A. Battista, MD, Member Brian T. Boies, MD, Member Vincent Paul Fonseca, MD, MPH, Member Danielle Hilliard Henkes, Alliance Representative David Anthony Hnatow, MD, Member Lyssa N. Ochoa, MD, Member Gerardo Ortega, MD, Member Manuel M. Quinones, Jr., MD, Member John Milton Shepherd, MD, Member Richard Edward Hannigan, MD, Board of Ethics Co-chair Nora Lee Walker, MD, Board of Ethics Co-chair Charles Gregory Mahakian, MD, Military Representative George Rick Evans, Legal Counsel Jayesh B. Shah, MD, TMA Trustee

San Antonio Medicine • June 2020

Ramon S. Cancino, MD, Medical School Representative Corinne Elizabeth Jedynak-Bell, DO, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Stephen C. Fitzer, CEO/Executive Director (ex-officio)

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PUBLICATIONS COMMITTEE Kristy Yvonne Kosub, MD, Chair John Joseph Seidenfeld, MD, Vice Chair Louis Doucette, Consultant Charles Hirose Hyman, MD, Member Tzy-Shiuan B. Kuo, MD, Member Fred H. Olin, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member David Schulz, Community Member Alexis A. Wiesenthal, MD, Member Tyler Adams, Student Member Chinwe Anyanwu, Student Member Darren M. Donahue, Student Member Donald Bryan Egan, Student Member Christopher Hsu, Student Member Aishwarya Devesh Kothare, Student Member Anirudh Madabhushi, Student Member Anjali Surya Prasad, Student Member Teresa Samson, Student Member Cara Jillian Schachter, Student Member Stephen C. Fitzer, Editor

PRESIDENT’S MESSAGE

Physician Leadership in a Pandemic By Gerald Q. Greenfield Jr., MD, 2020 BCMS President

The current pandemic points out, once again, the need for physician leadership, especially with health care issues. Fear of the unknown, guarded only by the knowledge and skill of physicians, is what can restore balance in a chaotic world. As is evident in reports and commentaries, the population trusts the word of physicians and medical leaders to a far greater degree than it does the word of elected or appointed political leaders. As COVID-19 rampages across this country and indeed across the world, medical professionals are at the vanguard. Nurses, physician assistants, therapists, medical assistants, and physicians are the frontline combatants against the “invisible enemy”. Instead of bullets, rocket-propelled grenades and bombs, the fighting forces utilize soap, alcohol, pharmaceuticals and mechanical ventilators. Rather than meet the enemy head-on in a frontal assault, the frontline forces use social distancing and asymmetric warfare techniques. The techniques are guerilla tactics reminiscent of those used by the American colonists and Francis Marion (The Swamp Fox). Wars of attrition are won by the side which can persist; with patience and taking the long view. When the tactics in use are successful, persistence offers the best chance of victory. It is only when change will provide a greater or more rapid chance to reach the goal, with less loss of life, that a tactical shift is reasonable. When bystanders in the population (the locals) seek to highjack the tactical role, danger and the risk of loss of life rise precipitously. It rises not only for them, but also for the front-line defenders. In the current pandemic the locals are the population. They are at the greatest risk of becoming wounded (infected). This will then obligate the medical professionals to rescue or save them. But in order to do so, the front-line, true medical professionals will put at risk their own health and lives. It is only when medical professionals (the generals in this war) are given the authority or seize the op8

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portunity to lead can political leaders be empowered to make prudent and appropriate decisions. Political leaders, however, also have a role to fulfill. The job of political leadership includes providing security for the population, financial support in case of disaster and maintenance of order in the society. In order to accomplish this, the political leadership must provide a safe living area, source of income and the promise of economic stability. When appropriate medical recommendations are offered as solutions to ongoing public health issues, political leadership must assure that they are instituted. The political leadership is responsible to the population to provide timely and accurate information based on objective evidence; only then can accurate forecasting for the health and economic well-being of the people be reached. The final level of responsibility lies with each individual member of the society. When appropriate public health information is provided by medical professionals, is transmitted accurately by political leaders, and finally is applicable to the ongoing problem, have all met their obligations. Should members of the population then choose to ignore those recommendations, they then accept responsibility for the outcome of their decisions. If those people then become ill, is it fair to then expect front line workers to now risk their lives in order to rescue them? Is it fair to ask those front-line workers to now be required to correct the poor decisions? If so, at what cost? Given the opportunity, the physician community will lead and meet the challenges facing medicine in our community in this pandemic. The solutions to health and good outcome require the population to support evidence-based medicine and listen to physicians who have dedicated their lives to keeping them well. Gerald Greenfield, MD, is an Orthopedic Surgeon in Bexar County and is the 2020 President of the Bexar County Medical Society.

BCMS ALLIANCE

San Antonio Medicine â&#x20AC;¢ June 2020

COVID-19 PANDEMIC

Medical and Business Ethics – Are They Compatible? By Rodolfo (Rudy) Molina, MD, MACR, FACP

The COVID-19 pandemic has forced the world to refocus its priorities. Whereas the health of a country’s citizens has always been important, so has its economic well-being. With what has been described as a draconian lockdown, our nations’ economic woes have skyrocketed, leaving millions unemployed. The medical community has been no exception. The stay-at-home policy, coupled with the closure of many businesses that were deemed nonessential and with the restriction of elective surgeries, all that has had a substantial impact on our human psyche. The 24-7 media coverage of this pandemic both frightens and depresses people, and many are afraid to go to emergency rooms or their doctor’s office. Small and single practices are seeing a dramatic fall in their revenue, which has resulted in lower salaries for some employers as well as furloughs and layoffs. We, the medical providers, are hearing and seeing on a variety of news media outlets a grateful public for our services, so, how is the business of medicine handling this pandemic? If self-employed, we understand the sacrifices will be tied to a loss of revenue. How are larger organizations dealing with this dilemma and how are employed physicians being treated by their employers? Atrius Health is a non-profit, self-owned corporation which has 5700 employees, 1000 of whom are physicians. Atrius is now asking its physicians to take a 20 % payment reduction. Atrius’ CEO, Dr. Steven Strongwater, who in 2017 reported a $834,201 annual salary, plans to reduce his salary by half this year. The average annual salary of an Atrius physician is $187,000 per year and a 20% reduction is 12

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substantial, especially for those physicians with a young family to support and who may also have educational loans to repay. Atrius Health is a physician, self-owned organization and pledges to return the loss of payment. What about the strictly employed? In an article from April 21, 2020 published by Becker’s Spine Review, it states the Michigan-based McLaren Medical Group furloughed around 500 providers, including orthopedic surgeons. The furloughs were announced April 15 and the group is considering keeping those physicians with lower work volumes laid off longer. Hospitals are also reducing salaries. Alteon Health, which employs 1,700 emergency medical physicians, has cut paid time off, 401(k) matching, and discretionary bonuses. The New York Times reported that physicians across the country are being asked to take 20% to 70 % pay cuts due to the pandemic. Fox News reported emergency room doctors in Los Angeles learned their pay would be reduced by 25%. A Texas urgent-care physician learned she would have a 10% cut in salary and that her two-to-three-week paid time off would be taken away. The importance of the bottom line was not lost on Dr. Keith Corl, an emergency room physician in Rhode Island, when his privileges were revoked in mid-March by a community hospital. He was informed that he would not be allowed to see patients until he helped the billing department determine if he could boost revenue on the

COVID-19 PANDEMIC cases he had seen. In business, success and profit is tied to perception. An emergency room doctor was fired by Bellingham Hospital in Washington State after he complained publicly of the failure of the hospital to protect its staff and patients from COVID-19. Dr. Kaarkuzhali Babu Krishnamurthy, assistant professor of neurology at Harvard, studies ethics and stated, “employers need to think more carefully about the ethics (of) asking doctors and nurses to live on less when many are working longer hours and putting the health of their families at risk.” With all these cuts in salaries, paid time off taken away, and laidoff medical staff, we should ask how competently run are these medical corporations? Cancelled elective surgeries are merely delayed. Will the staffing needs be met when surgeries are rescheduled? How about the emergency room visits. They should anticipate seeing sicker patients who stayed away from receiving their usual medical care for fear of this virus. Should our administrators be held accountable for not having a “Rainy Day Fund”? Should administrators expect their laid off physicians to return as loyal employees? And those who had pay cuts, how should they be rewarded? For those of us who are seeing our patients, we remain at risk of becoming infected by this virus and are also putting our families at

risk when we return home. COVID-19 is not the only illness we have to deal with, and our patients deserve our hands-on care for their existing or new-onset illnesses. Our salaries are tied to our sense of worth and to be asked or be told about a reduction in our salary is nothing less than demoralizing. If I were a dependent child living with my parents who have been providing my room and board and they came to me and told me to expect less because they have fallen on hard times, I would respectfully and graciously accept their request and would ask what more was needed from me. However, those who are CEOs, executive directors and administrators who have remained distant and not part of our “family”, I could not give them the same level of loyalty. This is basic human behavior not to be confused with “not being a team-player”. Patient-centered-care and optimized outcomes are and should always be our focus. Keeping our treating physicians on that aim, without the distraction of compensation, is paramount to that mission and our employed physicians may be the ones who are the most greatly affected. Rodolfo (Rudy) Molina, MD, MACR, FACP is a rheumatologist in San Antonio, Texas and is the President-elect of the Bexar County Medical Society.

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COVID-19 PANDEMIC

A Closer Look at PPP, EIDL and other relief programs By Jim Rice, CPA, and Christopher Davis, CPA

As we all try to deal with the COVID-19 crisis, several economic relief programs have gotten a lot of attention but still call for a closer look due to their complexity. Cases in point: The Paycheck Protection Program (PPP), the Small Business Administration’s Economic Injury Disaster Loan and Express Bridge Loan programs. All of these demand careful handling. This article addresses some of the most important aspects of these and other programs. PAYCHECK PROTECTION PROGRAM Many of us were able to get the Paycheck Protection Program (PPP) loan with the understanding that it could be forgiven if we continue to pay our employees their wages. The loan forgiveness is a very important financial benefit. The details on calculating exactly how much of the PPP loan will be forgiven are still many weeks away. But we know that wages, rent, utilities and certain mortgage interest payments that recipients pay out in the eight weeks immediately after receipt of the loan are the key. Retention of full-time-equivalent employees is also part of the calculation. Many documents must be gathered for submission to the lender to inform their decision on how much of the PPP loan will be for14

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given. Watch for additional information from your lender and the SBA on this required documentation. And be aware that the SBA recently announced that it intends to review all forgiveness applications for loans over $2 million. Tax deductibility It is also important to know that IRS Notice 2020-32 states that expenses paid (wages, rent, utilities and mortgage interest) on any PPP loan amount that is forgiven will not be deductible on the tax return. For many taxpayers, this seems to conflict with the intent of the new laws – to help taxpayers deal with the crisis. The IRS essentially is saying you cannot deduct an expense you did not pay for. There will be a lot of negative commentary on this IRS notice, but Internal Revenue Code Section 265 supports the IRS position. We shall see. Unemployment benefits For physicians and other medical staff who are being paid less than normal, potential unemployment benefits starting at $600 per week should be explored. Contact the Texas Workforce Commission immediately.

COVID-19 PANDEMIC

ECONOMIC INJURY DISASTER LOANS The SBA’s Economic Injury Disaster Loan (EIDL) and Bridge Loan programs are intended to provide access to additional capital through low-interest loans. Proceeds received from an EIDL loan, unlike those of the PPP loan, may be used for most normal operating expenses. Businesses can borrow up to $2 million (reduced by any outstanding bridge loans – discussed next) at an interest rate of 3.75 percent. The loan can also have a term up to 30 years, although terms are determined case by case. It should also be noted that businesses with credit available elsewhere are not eligible for EIDL loans. As part of the EIDL, a business can separately apply for a $10,000 loan advance. This grant does not have to be paid back regardless of whether the EIDL loan is approved. As of this writing, the SBA is processing agricultural business applications, only. It is unclear when the SBA will resume processing EIDL applications for other impacted businesses but it is expected that they will do so. BRIDGE LOANS SBA Express Bridge Loans can be beneficial for emergency cash needs while applying for an EIDL loan. A business can borrow up to $25,000 at an interest rate not to exceed 6.5 percentage points over the prime rate, over a seven-year term. Only SBA Express lenders may process these loan applications. This loan is meant to be a short-term source of funds while a business formerly applies for the EIDL loan. Many other types of SBA loans are also available. While many businesses prefer other lenders because of the SBA’s extensive documentation requirements, all funding avenues should be explored in times like these. FFCRA AND CARES ACT Businesses should also carefully consider the potential cash liquidity generated by the payroll tax credits provided by the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security Act (CARES). The FFCRA expanded mandatory paid sick and family leave to employers with fewer than 500 but more than 50 employees. There also appears to be an exemption for healthcare providers regardless of the number of employees. However, there is some concern regarding this point. Wages paid from April 1, 2020 through December 31, 2020 under qualified sick or family leave provisions are eligible for a dollar-fordollar, refundable credit up to the limitations outlined by the law. Your business may also qualify for the new employee retention tax credit (ERC) if it was unable to secure (or decided against ac-

cepting) a PPP loan. This credit applies to qualified employers that saw a decrease of gross receipts of at least 50 percent compared to the same quarter in 2019 or had to fully or partially suspend operations due to a government order related to COVID-19. This 50-percent credit of up to $5,000 per employee is available to cover eligible wages paid through the end of the year. Determination of an eligible employer is done on a calendar-year, quarterly basis. Claim the payroll tax credits by either reducing the current payroll tax deposit or filing for an advance payment of the credit. If your business received a PPP loan, it is not eligible to take the ERC. A business cannot use the same wages to claim both the FFCRA credits and ERC. Also, you cannot claim any FFCRA credits on amounts that are forgiven under the PPP loan provisions.

This crisis has made it even more important to run your medical practice as efficiently as possible. That includes: • Employing the best staff and paying them accordingly, • Discussing morale with your staff and asking them for their opinions on how to make the office a better and more efficient place to work, • Clearly communicating with your team about your plans for handling the crisis, • Reviewing financial statements and other financial data frequently, • Cleaning up patient receivables, and • Continuing to negotiate for discounts and deferrals of payments to vendors and landlords.

Most importantly, show your staff that you are involved in the management/business of your practice, not just in being a great physician. Jim Rice and Christopher Davis are CPAs and shareholders at Sol Schwartz & Associates and lead the firm’s healthcare practice. The firm is observing its 40th anniversary this year and is a proud Gold Level Sponsor of the Bexar County Medical Society’s Circle of Friends. visit us at www.bcms.org

COVID-19 PANDEMIC

Cloth Masks: Public Defense Against COVID-19 Disease By John Menchaca, MD In December 2019, a novel form of the coronavirus family was first detected in a group of residents in the city of Wuhan, China, that initially presented with fever and cough, followed later by severe respiratory distress. At first, these patients were thought to have had close contact with bats that were being sold at the Hunan Seafood Market, but Zhang et al reported that only 8 of the 221 patients had any contact with the market.1,2 In another report, JF-W Chan et al reported on several family clusters in the same city to suggest a human-to-human transmission.3 In the ensuing weeks of January and February 2020, the disease became widespread throughout many of the Asian countries and later on into European countries and the United States. Initial recommendations from both the World Health Organization (WHO) and Centers for Diseases Control (CDC) specified only social spacing (six feet), frequent hand washing and cleansing of surfaces that might be reservoirs of the viruses.4,5 Cloth masks, used by the general public at risk for the coronavirus infection, were discouraged because they were thought to be ineffective in preventing the spread of the virus. In addition to the absence of controlled studies to evaluate the effectiveness of the masks, two other arguments were mentioned; usage of the masks would compromise the already inadequate supply for healthcare personnel and, there were a few studies on masks that suggested only a marginal effect on the transmission rates of avian and seasonal influenza and obviously none for the COVID-19 virus. During the early weeks of the pandemic, there were two studies that further complicated the original recommendations of social spacing and handwashing.6,7 Bourouiba, et al, demonstrated that droplets and aerosols (dried airborne residues from the droplets), produced by coughing and sneezing, could actually travel as far as twenty five feet. Furthermore, they showed that the aerosols may persist in the air for two-to-three hours, especially in areas with poor air circulation. 16

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There were two countries outside of China that, despite the paucity of evidence of masks being effective in preventing the transmission of the virus, chose to mandate mass cloth mask usage in public places where social spacing was not possible or practical – South Korea and Chechnya. On the other hand, Italy and Austria chose not to mandate masks. The two countries that mandated masks had dramatic lower rates of transmission.8 Incorporating the basic physiological behavior of viral droplets and aerosols in public places with the fact that patients who were already infected but not showing any signs of disease may be already shedding the viruses by their simply breathing without coughing or sneezing, brings up a very difficult disease management dilemma; how to manage these asymptomatic patients? Extensive testing and contact tracing only symptomatic patients will obviously miss many of the asymptomatic ones who are just as infectious as the symptomatic ones. The obvious solution is to consider universal, general public mask usage when in public places. Cloth masks worn by infected persons, asymptomatic or symptomatic, will trap the droplets before they are released into the immediate air space, thereby preventing the virus from spreading any further.9 Greenhalgh, et al, further expounded on the “precautionary principle” that in the absence of definitive results from controlled studies and the fact that we are dealing with a very dangerous illness, it is reasonable to proceed with universal usage of masks to prevent the spread of COVID-19 infections. In their most recent updates, both the World Health Organization and

COVID-19 PANDEMIC Centers for Disease Control now support universal masking when in public places to help control the COVID-19 pandemic.10,11 From a medico-legal basis, both the Texas Medical Association and Texas Medical Board agree.12,13 In authoritarian countries such as China and Russia, mandatory mask usage is readily accomplished by fiat or threat of punishment, if needed. Mandating in countries such as the United States, where individual liberties are immensely valued, is more problematic. For example, the reported failure to use masks is less than 2% of Chinese people, while it is 60-70% in the United States.14 In summary, it is reasonable to think that universal masking is necessary to prevent transmission of the COVID-19 virus in the United States, but it will be very difficult to assure adequate public cooperation for it to succeed. John Menchaca, MD is board certified in Pediatrics and in Pediatric Nephology, and is a member of the Bexar County Medical Society. References:

1 2 3 4 5 6 7 8 9

10 11 12 13 14

Zhou,P et.al.: Nature 2020 : 579 (7798) 270-273. A pneumonia outbreak associated with a novel coronavirus of probable bat origin. Zhang et.al. J Clin Virology 2020 vol 127 p104364. Clinical features and short term outcomes of 221 patients with Covid-19 in Wuhan, China. JF-W Chan et. al. Lancet 2020; Feb. (10223) 514—523. A family cluster of 2019 novel coronavirus indicating person-to-person transmission – a study of a family cluster. World Health Organization Public Advice April 6, 2020. Masks helpful for “source control “—prevents an infected person from passing on the virus. Messonnier, N. Director of Center for the National Center for Immunization and Respiratory Diseases January 30,2020 Press Briefing. Bourouiba, L.: JAMA published online March 26, 2020. Doi:10.1001/JAMA.2020.4756. Turbulent Gas Clouds and Respiratory Pathogens Emissions Potential Implications for Reducing Transmission of Covid –19. Setti, L.: Int. J. Environ. Res. Public Health 2020 17, 2932. Greenhalgh, T and Howard,J.: Downloaded from www..fast.AI/2020/04/13/Masks-summary. Masks for All? The science says Yes. Greenhalgh, T. et. al.: BMJ 2020 ;369: m1435. Face Masks for the public during the covid-19 crisis. World Health Organization advisory dated 6 April 2020. Advice on the use of masks in the context of Covid -9. CDC Coronavirus Disease Covid-19 updated May 4, 2020. Texas Medical Association website Covid -19 Resources, Queried May 7, 2020. Texas Medical Board web site Coronavirus Disease (Covid-19) Response, Queried May7, 2020. Clements, JM: Downloaded from http:// preprints.JMIR.org/preprint/19161. Knowledge and Behavior toward Covid-19 among US Residents During the Early Days of the Pandemic: Online Questionnaire.

EXERCISE

Like Your Life Depended On It By Jon Courand, MD and Ajeya Joshi, MD

This article, about exercise as great medicine, is the first of six articles planned for upcoming issues of San Antonio Medicine. Each article focuses on a different foundational area of “Lifestyle as Medicine: Exercise, Diet, Sleep, Stress Management, Avoiding Risky Substances, and Connectedness.” They follow last month’s article ‘Swimming Lessons for the Greater Good’ which framed the need for self-care now more than ever. For as long as I (JAC) can remember, I have enjoyed running. There is a certain aspect of running that is more a meditation in motion than exercise, and while I enjoy all the physical benefits, I think I value the mental aspects even more. As a trained pediatric intensivist and now hospitalist, I know that during those times of high stress in my life, I have always found relief by lacing up my running shoes and heading over to my favorite trail or track. I am not alone. In an article written in Runners World, approximately 50 percent of surveyed physicians under the age of 40 said that they run, the most popular leisure activity for that age group. Even for those over 60, a quarter of respondcontinued on page 18

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COVID-19 PANDEMIC

EXERCISE Like Your Life Depended On It continued from page 17

ing physicians also said that they run. There is a good reason for this. Research has proven that regular exercise and running in particular – about 30 minutes a day, five times per week – has important health benefits. Studies have shown that running can help prevent obesity, type 2 diabetes, heart disease, high blood pressure, stroke, and a host of other conditions. (1) Running can also improve emotional and mental quality of life. In a 2006 article entitled: Is Exercise a Viable Treatment for Depression?, researchers found that just 30 minutes of walking on a treadmill could instantly lift the mood of someone suffering from a major depressive disorder. Other studies have linked both walking and running to improved sleep quality, mood, and concentration during the day. A recent systematic review of 28 separate articles relating exercise and sleep quality suggested that sleep and exercise exert substantial positive effects on each other, with exercise increasing REM sleep, sleep continuity and sleep efficiency. (2,3) I have always been surprised at the sense of wellbeing that I get in those hours after a run. In his book Mindful Running, Mackenzie Havey recounts the experience of ultramarathoner Timothy Olson: “It’s about being in the present moment on the run, connecting with your breath and your senses and enjoying movement not based upon results, times or feelings. I focus on my breath and the rising and falling of my body and the thoughts, feelings and emotions that arise, but I don’t try to get rid of them. I stay curious. It’s as simple as that”. (4) I have only rarely experienced the classic “runner’s high” and there are certainly times that my body hurts both during and after a run, but regardless, the mental benefits are what always provide the lift for me, both in the short and long term. Great exercise options come in many other flavors as well. Some might prefer the yoga mat, the Peloton bike, or the community pool or martial arts studio (as social distancing is relaxed). HIIT (High Intensity Interval Training) may be especially efficient with sustained calorie expenditure after the actual exercise, and shows promise for weight loss, insulin sensitivity, and appetite control. (5) Scheduling time for exercise can be hard for some in a busy professional routine. This is understandable. It may be due to the perception that in a busy schedule, there’s no extra time for morning or evening exercise. It may be a factor of procrastination, thinking ‘I’ll get to it’ but that day keeps getting pushed back. Some people might perceive that you need a special place or specific equipment. The next time you feel burdened because there are still 20 encounters from clinic time to document in the EMR, it’s been a demanding overnight shift in the MICU, or there is a talk to prepare, the next most logical thing to do… is go for a run, or a swim, or a yoga session! These activities will probably lead to better focus and a method to help declutter and reduce the ‘to do’ list efficiently. Task pairing is a useful strategy most recognizable to us in the form of academic hospital rounds. The team walks from patient room to patient room and floor to floor, often with the help of gravity, but perhaps taking stairs to go upward on occasion for ‘reverse-gravity rounds’ would lead to more built-in exercise during the day. Corporate teams routinely conduct walking meetings. Other places to pair tasks include getting on the treadmill at home 18

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to read emails, and parking in the farthest spot from the hospital or grocery store. Other tips include enlisting the entire team at work to participate in an exercise challenge, with fun rewards for those accomplishing their goals. Virtual runs, lap counts in the pool or minutes on an elliptical are some examples. Finding an exercise buddy and holding one another accountable, at work at home or in the neighborhood, is also effective. ‘Start where you are’ is a quote some attribute to Teddy Roosevelt. It accurately sums up the approach to starting an exercise program or progressing to new goals in an existing one. Small goals within goals for frequency, duration, distance, and intensity, lead to success and sustained activity. Remember the four basic types of exercise: cardiovascular, resistance, balance, and flexibility. Try enjoyable activities in each category for long-term health benefits, variety and to avoid getting into an exercise rut. The current COVID-19 pandemic has prompted an unprecedented level of stress, uncertainty, fear and isolation throughout the population; however, it has impacted our physicians and other healthcare providers especially hard. For the cost of a good set of running shoes or a yoga mat, and a little investment of time, you can open up a world of physical, mental and emotional benefits to last a lifetime. Exercise truly is medicine; and this is one case in which it’s more than OK to self-prescribe!! Dr Jon Courand is a Pediatric Hospitalist and Assistant Dean of Wellbeing in GME at the University of Texas Health in San Antonio. He is a longtime runner. His favorite run is along the San Antonio river from the Pearl Brewery Complex to the Blue Star art complex and Southtown.

Dr Ajeya Joshi is an Orthopedic Spine Surgeon at South Texas Spinal Clinic. A Diplomate of the American Board of Lifestyle Medicine, he promotes population health using lifestyle measures at Hill Country Lifestyle Medicine Center. He also enjoys running, and is a yoga practitioner as well. References

1. Alison Wade, Half of Young Doctors are Runners, Runner’s World, Jan. 2015. 2. Blumenthal et al. Is Exercise a Viable Treatment for Depression? ACSM Health Fit J. 16(4) 14-21, July/August 2012. 3. Dolezal, C Cooper et al. Interrelationship between Sleep and Exercise: A Systematic Review, Adv Pre Med 2017: 2017: 5979510. 4. Mackenzie Harvey, Mindful Running, How meditative running can improve performance, and make you a happier, more fulfilled person. Bloomsbury, Oct 2017. 5. https://www.healthline.com/nutrition/benefits-of-hiit#section8.

COVID-19 PANDEMIC

Sanctity of Contracts By Mike Kreager and Trenton Brown Contracts are unpleasant, but necessary. Every medical practice has contracts: employment contracts, office and equipment leases, equipment and software maintenance agreements, supplier and vendor agreements, patient agreements, buy-sell agreements... In a contract, each side promises something in exchange for the other side’s promise. A promise to make an office available in exchange for the promise to pay rent. Or, a promise to work in return for an agreement to pay a monthly salary. But what happens when uncontrollable events occur that prevent one side from completing its promise to the other side? Consider this — a pandemic. Schools are closed by executive order. The schools relieve the teachers from duty. But the teachers have a contract to teach and are available and willing to teach. The schools don’t want to pay the teachers because the epidemic closed the schools. Sound familiar? Similar situations are occurring daily with COVID-19; this event likewise occurred during the 1918 Spanish Flu epidemic. A 1918 contract entitled the teacher to $50 per month. The court awarded the teacher the contracted rate for the duration of the school’s closure. The case went to the Illinois Supreme Court for review, where the court surveyed the judicial decisions of similar quarantines during the epidemic and noted a marked dichotomy of legal principles. On one side, cases showed schools were excused from paying the teacher’s salary during the closure because the epidemic was beyond the schools’ control and the closure was a government action. On the other side, the cases showed the school was compelled to pay the teacher’s salary because the epidemic could have been foreseen and the school could have added a contingency to excuse its obligation to pay if an epidemic, acts of God and similar events occurred during the contract. The current “shelter-in-place” orders by state and local authorities have forced non-essential businesses to close. If these orders affected your practice’s revenue, how does that affect any related contracts? There are two legal principles to consider. As legal principles, though, they do not automatically present definitive results. Their application is often “maybe” and it “depends upon the particular situation.” Force Majeure. From the French, “superior force,” but in legal parlance, it means extraordinary events, like Acts of God, terrorism, acts of governmental bodies or authorities, civil strife and labor strikes. It is quintessential boilerplate. It often will include “epidemic” — certainly a pertinent contract word for today’s environment. Force majeure provisions are included in a variety of contracts, including some employment contracts. If a contract is unable to be performed because of current economic distress, it

may result in being excused for the duration of the event, if the contract includes a force majeure clause. Remember, the clause is usually buried at the end of the contract. If it’s there, look for anything referencing government action or, better, epidemic. If those references are included, it may give a basis to suspend delivering on the contractual promise. But, the courts have not interpreted force majeure as a get-of-jail-free card, but as a mitigation measure. In other words, the practice must take the necessary steps to be able to perform. That’s where the cloudiness enters the picture. If the practice can see patients via video (i.e., telehealth and telemedicine options) or in limited numbers, thereby complying with current safe-distancing guidelines while keeping its doors open, is the practice excused from contractual performance? While there is no clear answer, there is at least a basis to justify a reprieve. Again, force majeure is only a reprieve. When the disaster ends, performance begins. Impracticability. What if the contract is silent about force majeure? Fortunately, another legal principle may allow a practice to interrupt performance. Recall the teacher ready to teach. Other courts likened the epidemic to the school house having burned to ashes, in which case the school would have been excused from paying. The absence of students excused the school from paying the teacher because it was impractical for it to perform the contact without students. Essentially, impracticability inserts an excuse into the written contract as an implied condition. If, without fault, a supervening event occurs that makes it impractical for the practice to perform the contract, then the practice should be excused from performing. As can be imagined, the courts are widely divided on the application of impracticability. Hence the name of this article — sanctity of contract. In other words, under the sanctity principle, the contracting parties should perform their respective promises or include a force majeure clause to allow a temporary interruption. The defense of impracticability, or its more widely-known name, impossibility, of performance is a high bar to clear and has scarcely been applied to employment contracts. But this excuse rests on two critical aspects. First, at the time of contracting, the parties must have shared a basic assumption that a certain event would not occur to make the contract worth entering. The event must occur unexpectedly after the contract was signed. A common example of a supervening event involves a supplier and a practice entering an exclusive, one-year supply contract for PPE that the supplier manufactures to FDA standards. The practice and supplier inherently assume the supplier’s plant will not be destroyed during the term of the contract. The continued existence of the plant is the basic assumption on which the contract is made, even if it is not explicitly continued on page 20

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stated in the contract or discussed by the parties during negotiation. Second, the event must make performance impracticable — not simply impractical, a lower threshold. A mere change in difficulty or expense will not do; the event must be far outside the normal range. Contracts are sanctified because parties can allocate their risk prior to entering the agreement. Courts will likely assume the parties intentionally chose who would bear certain risks. The event must be extreme and pose unreasonable difficulty, expense, injury, or loss if the party was forced to perform. As an additional requirement of impracticability, reasonable efforts must have been made to overcome the event’s obstacles to perform the contract. Like force majeure being a measure of mitigation, impracticability must be present in spite of reasonable efforts to perform. A pandemic may prohibit patients from coming to the clinic, which may affect the practice’s ability to provide patients for the employed physician to see. Telehealth, staggering patient appointments, health screenings upon arrival, and limiting clinic occupancy are all measures that help the parties perform despite the event and might defeat the excuse of impracticability or shorten its reprieve. Returning to the employment relationship, impracticability might apply. A physician may be employed as a staff physician under a contract with a fixed term, a monthly salary and an obligation to give 90 days’ notice before terminating the employment relationship without cause. If COVID-19 caused the closing of the practice, does the employer have to keep paying the employed physician or can performance be suspended? Texas is an “at will” state that allows an employer to fire an employee without cause and without notice. But the employment contract requires notice to end the employment relationship. If the contract has a force majeure clause, it may excuse the payment but not excuse the obligation to give notice. If the contract is silent on government action or epidemics, the government closure could create a pay holiday while the clinic is closed. When the clinic reopens, it is 20

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likely the obligation to pay salary payments resumes even though the patient volume cannot bear the expense. Permanently losing good employees or falling into legal disputes are among the last things we want to face while addressing the pressures of a global pandemic. Though it may be difficult to avoid disruptions in a practice’s revenues, when an employment contract does not contemplate force majeure, the next best step may be negotiation. While not universally applicable, what is working among practices to maintain the business and avoid acrimony is the employer and employee agreeing to interim changes to the employment agreement. The physician-employee’s workload in many practices will obviously be reduced during quarantine. Similarly, the practice’s reduced revenues will make paying the physician’s salary much more challenging, if not impossible. Coming to the table with this understanding may allow the employee and employer to agree on a temporary amendment to the contract where the employee will accept a reasonable reduction in pay until the crisis has passed. Keeping in mind that everyone is enduring the COVID-19 crisis together may help practices avoid losing valued employees and create legal disputes. But contemplation of these events in future contracts with thorough force majeure provisions will help insulate from further loss without having to rely on the “maybes” and the “it depends on the situation” legal principles. Michael Kreager and Trenton Brown are attorneys at the Kreager Mitchell Law Firm in San Antonio, and are members of the BCMS Circle off Friends Program.

COVID-19 PANDEMIC

Use of Cloth Masks by the Public: Good, Bad or just Ugly? By Diane Simpson, MD

Earlier this year I hosted a foreign exchange high school student from Thailand. As concerns about Coronavirus in the US started to increase, she asked if she should wear a mask to school. I informed her that, unlike parts of Asia, we in the US didnâ&#x20AC;&#x2122;t wear masks in public except in rare circumstances and that the other kids at school would think her either very ill or strange. Fast forward 2 months and the use of masks is not only recommended but required in some settings as the COVID-19 pandemic sweeps the US. What evidence is there to support this change? Most of our pre-COVID-19 virus respiratory disease pandemic planning focused on controlling a novel influenza virus and the use of face masks was considered. CDC recommended that persons who had flu-like symptoms use surgical face masks as a non-pharmaceutical intervention during severe, very severe or extreme flu pandemics, but noted little evidence supporting the use of face masks by well persons in community settings. (Qualls et al, 2017). The situation we are in now, the use of cloth face masks by the general public, was not addressed in the planning document. A few studies around the time of the H1N1 2009 influenza pandemic did try to assess the ability of cloth facemasks to prevent respiratory virus transmission either from the standpoint of infected persons wearing a mask to stop virus transmission or non-infected persons wearing a mask to prevent virus acquisition. One study conducted prior to the 2009 influenza pandemic compared FFP2 masks (N95 equivalent) with surgical masks with tea cloth (a flat, woven linen or cotton cloth). FFP2 masks provided 28 adult and 11 child volunteer wearers 50 times more protection than tea cloth and 25 times more protection than surgical masks in an environment containing at least 10,000 particles per cm3. Particles ranged in size from 0.02-1 micron. Surgical masks provided about twice as much protection as the homemade masks. Evaluation of the different types of masks, capability to prevent particles from passing from an adult-sized artificial, head into the environment showed similar protection capability between the FFP2 masks and the surgical masks and only marcontinued on page 22

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Use of Cloth Masks by the Public continued from page 21

ginal protection by the homemade masks. Children (5-11 yrs) were shown to have less inward protection from masks than adults but there were no differences between men and women. The authors concluded overall that any type of general mask use is likely to decrease viral exposure and infection risk on a population level (van der Sande, Teunis, and Sabel, 2008). A later study tested a variety of materials (e.g. tea towels, pillowcase, cotton T-shirt, linen and silk) against surgical masks for their ability to block transmission of micro-organisms when a person coughed. They concluded, unsurprisingly, that surgical masks were at least 3 times more effective than any of the other tested materials and that homemade masks, while not useless, should only be considered a last resort. (Davies et al, 2013) Concern for healthcare workers in developing countries who may only have cloth masks, prompted one large prospective randomized study of cloth masks vs. surgical masks while providing medical care. Just over 1600 healthcare workers in wards within 15 hospitals in Hanoi, Viet Nam volunteered to participate. Depending on the ward, the staff wore cloth masks exclusively, surgical masks exclusively or either a cloth mask or surgical mask (i.e. standard of care) while working their shifts. They were evaluated over a five-week period for development of influenza like illness or a laboratory confirmed respiratory viral illness. Surgical masks were much more protective than cloth masks and provided better particle filtration. The authors concluded that cloth masks should not be used by healthcare workers especially in high risk situations. (MacIntyre et al, 2015) Not all cloth masks are created equal. A recent article published on-line in ACS (American Chemical Society) NANO evaluated the ability of several different materials and material hybrids to filter particles ranging in size from 10 nanometers (nm) to 10 microns. The authors determined that the filtration efficiencies for a single layer of various fabrics ranged anywhere from 5 to 80% for particles <300nm and 5 to 95% for particle >300 nm. Filtration efficiencies of multiple layers and specific combinations of fabrics such as cotton−silk, cotton−chiffon, and cotton−flannel were better with >80% filtration efficiency for particles <300 nm and >90% for particles >300 nm. (Konda et al, 2020) Another very recent evaluation by the US Army Combat Capabilities Development Command looked at different fabrics for use in cloth face masks. This group found that the best, easy-to-find material to protect against coronavirus transmission is four-ply, microfiber cloth. This material, found in the cleaning section of most big box stores, filters out more than 75 percent of particles 0.2-0.3 microns in size. (Rempfer, 2020) These studies neither provide overwhelming evidence in support 22

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of cloth masks in the general public nor do they refute the idea that there is no protective value. None of the studies cited considered an environment with masks worn by both persons who were infected and persons wishing to avoid infection. Much also may depend on the type of material and numbers of layers being worn as a mask, the tightness of fit and the user’s adherence to consistent wear in risk situations and cleaning before the next use. Perhaps enterprising researchers are gathering good data from our current experience to better inform us in the future. However, I think two things are clear. The first is that cloth mask use is inferior to social distancing as a means of preventing community spread, especially to the most vulnerable. The second is that healthcare workers deserve the quality of masks, either surgical or N95, recommended for their level of care. We shouldn’t lose sight of either. Dr Diane Simpson retired in late 2018 after over 30 years of work in public health. Her career focused on the control of communicable diseases at the local, state and national levels. Dr. Simpson is a member of the Bexar County Medical Society. References

Davies, A, Thompson, K-A, Giri, K, kafatos, G, Walker, J, Bennett, A. (2013). Testing the Efficacy of Homemade Masks: Would They Protect in a Pandemic? Disaster Medicine and Public Health Preparedness 7: (4) 413418. DOI: 10.1017/dmp.2013.43

Konda, A, Prakash, A, Moss, G.A, Schmoldt, M, Grant, G.D, and Guha, S. (2020). Aerosol Filtration Efficiency of Common Fabrics Used in Respiratory Cloth Masks ACS Nano 2020, Publication Date: April 24, 2020, https://doi.org/10.1021/acsnano.0c03252. Copyright © 2020 American Chemical Society

MacIntyre, C.R, Seale H, Dung, T.C, Hien, N.T, Nga, P.T, Chugtai, A.A, Rahman, B, Dwyer, D.E, Wang, Q. (2015). A Cluster Randomised Trial of Cloth Masks Compared with Medical Masks in Healthcare Workers. BMJ Open 2015; 5:e006577. DOI:10.1136/bmjopen-2014-006577

Qualls, N, Levitt, A, Kanade, N, Wright-Jegede, N, Dopson, S, Biggerstaff, M, Reed, C, Uzicanin, A. (2017). Community Mitigation Guidelines to Prevent Pandemic Influenza — United States, 2017. Morbidity and Mortality Weekly Reort, Recommendations and Reports. 66(No. RR-1):1–34. DOI: http://dx.doi.org/10.15585/mmwr.rr6601a1external icon.

Rempfer, K. Army Times https://www.army times.com/news/yourarmy/2020/04/24/army-researchers-say-this-is-the-best-material-for-ahomemade-face-mask-theyve-found-so-far/

Van der Sande, M, Teunis, P, Sabel, R. (2008). Professional and Homemade Face Masks Reduce Exposure to Respiratory Infections among the General Population. Plos One 3(7) e2618. DOI:10.1371/journal.pone.0002618

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Loosening up the In-Home Sheltering Policy. What will happen next? By Bob Leverence, MD As of this writing, the nation is focused on concerns over a COVID-19 resurgence in the face of many states reopening despite not meeting CDC criteria. Economic pressures for reopening are certainly valid and compelling, however they come at the risk of one or many resurgences. This would not only lead to more loss of life but more harm to the economy as well. One way to help guide this reopening is by using predictive models, and so there are many in use today.1,2 These models quantitate and incorporate the many factors which influence the spread of COVID-19 — climate, urban density, age distribution in the community, social distancing mitigations used, population immunity, etc. Since the results or predictions from these models depend on a host of assumptions related to these factors, it is not surprising we see a broad range of outcomes. In other words, despite the fact these models are data driven, forecasting the future will always be plagued with uncertainty. With that said, higher quality data leads to more accurate assumptions which reduces that uncertainty. Many critics state these models have not been very useful thus far. One reason being that early in the pandemic good data just was not available — after all, a pandemic like this has never happened before. So, the models have been learning with us. Then again, one might argue this is not our first pandemic, and so should not models already be sitting on the shelf just needing calibration for this virus? Well, we could use that same argument for greater stockpiles of PPE, more reliable supply chains for swabs, and better public health infrastructure for crisis management and contact tracing. But that is a whole other subject. If we learn anything from this pandemic, I hope it is the need for better pandemic preparedness. So, getting back to the predictive models, ideally, they should be applied to local environments since that is where outbreaks occur and much of the mitigation happens. Stated differently, predictions which are modeled at the state or national level can mislead a community since micro-environments can be so different. Likewise, models should include an analysis of supply and demand for resources such as hospital bed capacity. Finally, results should be displayed in a way that non-scientists can readily understand them. So that is a tall order few models have achieved and why multiple models are used. In my view, the predictive models help most when we report them in a balanced way. I like to call this the “Hope for the best, but plan for the worst” approach. I say that because if each half of the statement were to stand alone, we would be in danger. If you only hope and report on the best-case scenario, this denial of the worst case would leave you ill-prepared. Alternatively, if you are the kind of person who only prepares for the worst without a vision for how good it could be, then people will avoid or not even listen to you. 24

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Let me try to explain. We certainly have good reason to hope the next surge will not be so bad. Warm weather has been shown to slow the spread of this virus, people are now behaving more prudently regardless of easing community restrictions, testing is more available, we have at least one effective treatment (Remdesivir) and there is at least a low level of population immunity. All these factors weigh in favor of a lighter resurgence. So, let us hope for the best. Alternatively, government officials, civic leaders, scientists, and the press all have the obligation to plan for the worst. Unfortunately, it is hard to listen to them night-after-night and now month-after-month, prophesying devastation and gloom. But again, that is their job and I am thankful for them. The factors which most dial up the likelihood of a bad surge are the lessening of social distancing and a reduction in infection control practices. If people congregate closely in public places and shops, if they do not regularly sanitize their hands, or if they do not wear masks and stay home when ill, then we are likely to see a repeat filling of our hospital beds with COVID-19 patients and another round of in-home sheltering measures. We are still in the thick of this pandemic and will be until a highly effective treatment or vaccine becomes available. Until then, patients will continue to delay needed care out of fear. Many will also lose their insurance due to unemployment. All of these factors mean the health of our communities will certainly suffer. As physicians, we need to reach out to our patients to assure them our clinics and procedure centers are safe so they will feel comfortable seeking the care they need. In the spirit of social distancing, we also need to use telehealth wherever possible. Since COVID-19 will likely be here for the next year or so, this will be our new normal. But COVID-19 will someday pass, and we will eventually start thinking about other things. So, what will happen next? Maybe we will see sustained reductions in greenhouse emissions. I hope we celebrate the new breed of hero we have found in our healthcare workers and civic leaders. I myself have certainly come to a new appreciation of what is important. Bob Leverence MD, is Professor of Medicine and CMO UTHSA and is a member of the Bexar County Medical Society. References 1. Jewel, Nicholas P., Predictive Mathematical Models of the COVID-19 Pandemic. jamanetwork, April 16,2020. https://jamanetwork.com/journals/jama/fullarticle/2764824 2. Centers for Disease Control and Prevention. COVID-19 Forecasts. Updated May 6,2020. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/forecasting-us.html.

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Responding to Those Who Ignore Social Distancing Orders By Brittany Johnson, MS, MPH In late April, as COVID-19 continued to spread throughout the United States, a video emerged showing an alleged gathering of hundreds of attendees congregating at a house party. The city’s mayor subsequently rebuked the partygoers, calling the celebration “foolish and reckless.” The governor similarly condemned the attendees for putting themselves and their families in danger. In the midst of a global pandemic, where an infectious disease can be easily transmitted through close contact, it is not hard to imagine why blatant violations of social distancing orders would elicit widespread contempt and ire. While the urgency of social distancing cannot be denied, we have a choice in how we “sell the danger” to violators. Berating those who neglect precautions to prevent the spread of COVID-19 is more often than not incompatible with inducing behavioral change. People tend to respond better to empathy. If your family or friends are leaving their homes frivolously, try to uncover why and respond to that problem. Follow-up stories to the above-mentioned large party revealed that the host initiated the gathering in memory of two friends he lost to gun violence. Grief, rather than indifference to people’s health or public policy, was the root of this gathering. Sometimes, when rushing to judgment concerning those who violate social distancing policies, the bigger picture is missed. People and governments can overlook the issues that drive people to seemingly violate edicts. In some communities, people’s personal actions can be driven by an unstable home life, food insecurity, mental illness, loneliness, financial insecurity, and/or a host of other complexities. Before being able to change actions, it is necessary to acknowledge the underlying conditions that push violators towards the undesirable, even risky, public conduct. Under the CDC’s tips for social distancing, there is a recommendation to “avoid gatherings of any size outside [of] your household, such as a friend’s house, parks, restaurants, shops, or any other place.” While staying home is certainly inconvenient for nearly

everyone, for some, the call to isolate can be uniquely confounded by a harmful domestic environment. If you know someone who seems to unnecessarily defy stay-at-home orders, ask them “what makes it so challenging for you to stay home during this time?” and offer help or counsel based upon the information received. If the isolation is triggering someone’s feelings of loneliness and depression, for example, it may work to engage them in virtual games via social media or offer to host a virtual party on a video conferencing app like Zoom or Skype. If the cause is that someone’s food resources are bland or scarce, consider referring them to the area food bank, church, or even purchase a contactless delivery meal to be sent to their residence. These contactless services are currently being offered by many pizza chains and delivery services like Grubhub and Door Dash. No-contact delivery is also available for flowers, groceries, and prescription medications. Assume that violations of social distancing are a consequence of a solvable issue, and if you are able to, help fill that void. Health behavior may not be an extension of a character flaw, but rather a manifestation of one’s social condition. If we treat the social condition, the behavioral change may follow. When strangers violate the tenets of social distancing, keep a consistent approach, and cloak it in compassion. Subsequent reporting and public discourse about this house party attempted to correlate non-compliance to policy with stereotypes of those who seem to be more susceptible to COVID19. It seems to be human nature for people to dismiss events based upon unfair or incomplete knowledge. Consider the media coverage regarding the recent wave of protestors who have begun to gather en masse to demand reopening of the economy and lifting stay at home orders. Much of the verbiage assigned to these occurrences focuses on political affiliations, impact on the economy, and other motivations driving the protests. There are no clandestine or outright slogans that the protestors’ violations of social distancing orders are continued on page 26

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directly responsible for the spread of COVID-19 in their respective communities. Demonizing and admonishing the behaviors of one group of people while simultaneously promoting a different narrative surrounding identical behavior performed by other groups is unfair, dangerous, and a tributary to the cycle of bias and discrimination that pervades medicine and society. Defiance of social distancing is a widespread obstacle perpetrated by individuals of all creeds, colors, and nationalities. Whether it’s encroaching upon the six feet barrier or failing to wear a face mask in public, as Texas and other states begin to reopen, it is inevitable that we will soon observe an increase in the number of people whose public performance violates measures to prevent COVID19 spread. This behavior is problematic, regardless of who the offenders are. In place of admonition of these offenders, we could position them as the subjects of our concern. Demonstrating compassion and concern for another’s wellbeing is more likely to result in a favorable outcome. Rather than adopting a “do as I say” approach, join forces with communities to make the fight against COVID-19 collaborative. Fighting COVID-19 at the community level necessitates that members of the community have ownership and investment in the health promotion and prevention activities that target them. Social

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distancing orders are more likely to be followed when there is participation and buy-in from the community. Encourage people to be stakeholders in their own health and the health of their neighborhoods to foster the flourishing of productive behaviors during this pandemic and beyond. Entreat neighbors to hold other neighbors accountable rather than threatening police involvement. Encourage the placement of pre-printed or custom-made lawn signs, which can be used to show support and unity in shared struggle and triumph. If you or your neighbor has a mask-making kit or the necessary supplies to sew fabric masks, make masks for neighbors who may need one and leave it on their doorstep. Free instructions and sewing patterns are widely available online. And last, but certainly not least, model appropriate behavior. Whether it is taking a walk around the block with a face mask on or having a chat from a recommended minimum distance of at least 6 feet, visible adherence to social distancing guidelines encourages community backing of these policies. It is easy to become frustrated with people who exhibit nonchalance about preventing the spread of COVID-19, potentially prolonging the return of life as we once knew it. Nonetheless, we must fight the urge to belittle and instead respond with unbiased empathy and a spirit of collaboration, the true catalysts of change. Brittany R Johnson, MPH, MS is a DO Candidate, Class of 2023, at the University of the Incarnate Word Medical School.

COVID-19 Inspirations

COVID-19 PANDEMIC

By Zahra Mohamed When the new decade rang in, no one could have anticipated what the year was about to bring. Only three months into 2020 we were all faced with the reality of a major pandemic. Americans and people around the world have been asked to take drastic measures to contain the virus. These preventative measures include maintaining social distance and not leaving our homes except for essential needs, such as medical care, groceries, or outdoor exercise. These new provisions greatly reshaped the way we organize our lives. As the news changes by the hour concerning new discoveries of the novel corona virus, fear, worry, and uncertainty continue to be a consistent theme in each story. However, with the bad, comes the good. If you filter through the negative news, you'll read about the everyday heroes. Here are a few of the heartwarming stories that we have witnessed in our communities amid the corona virus pandemic. Healthcare workers: The popular phrase “Not all superheroes wear capes; some wear scrubs” is an expression that right now couldn’t be any more fitting. Every day we are witnessing the sacrifices healthcare workers are making during this pandemic. They truly are at the forefront of stopping this deadly virus and their efforts to help patients and their communities are deeply appreciated. This gratitude also extends to the hospital cleaning staff whose valuable work and contributions to the health and safety of others are very important and deserve recognition.

Teachers driving through neighborhoods: A group of teachers in San Antonio, Texas, made a surprise visit to their students under quarantine during the COVID-19 pandemic. Teachers drove through a neighborhood in a Photo credit by Becky Inocente via Storyful parade of vehicles decorated with balloons and handmade signs reading “We miss you!” and “Wash your hands!” Making face masks for Healthcare workers: As many hospitals run out of personal protective equipment, many local residents are stepping up to help fill this need. Many individuals have been making handmade, reusable masks for medical professionals on the frontlines and for other people in their communities.

Photo: Bob Owen, Staff-photographer/San Antonio Express News

Photo credit by (Photo: KEYE)

H.E.B Meal drive: HEB workers have been distributing food as their way of saying thank you to health care workers. The company vouched to deliver fresh chefinspired meals for the next five weeks, to doctors, nurses and other healthcare workers engaging directly Photo courtesy H-E-B with COVID-19 patients. They are also providing meals to individuals working in emergency rooms. Simple acts of kindness like providing meals to those who are directly battling the coronavirus can help ease the providers’ busy days.

Just like the previous pandemics in the world, the corona virus too shall subside. The world is changing and the crisis is showing us the importance of leading with empathy and humanity. It is necessary to remember that there is light at the end of the tunnel. Before then, let us all remember to wash our hands, keep our distance and remember that we are all in this together. Zahra Mohamed is a first-year medical student at UIWSOM and is a member of the Bexar County Medical Society. She is a public health advocate with a special interest in infectious disease control.

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COVID-19 PANDEMIC

Whisperings from Solitude By Rajam Ramamurthy, MD

The unexpected abundance of time, the unprecedented break in routine, and a measure of solitude could render the mind blank like a clean chalkboard. One day I was walking up and down our driveway trying to accumulate steps. Thoughts began to form a picture on the blank chalkboard. How do you console a mother who has lost a child to COVID-19? What does a woman with three children do whose physician husband is fighting for his life hooked up to a heart-lung machine (ECMO)? What do you say to a high school senior, valedictorian, who will not have a graduation ceremony? How do you explain to a six-year-old, the vice president of the country, not wearing a mask when visiting a hospital while she is not allowed to play with her friends without it? When do we get back to the baseline? What is the baseline? What could be the new baseline? These and other thoughts keep me, and perhaps many of you awake at night. Pandemics have occurred throughout man's history, COVID-19 is the first in the age of digital media that is both a fantastic tool and a curse. The instantaneous communication that is possible through today's digital media is unprecedented and is partly responsible for the containment of the spread of the virus, the 'flattening of the curve.' Conversely, the constant bombarding of the mind with news local and global has a tremendous effect on the psyche of people. What have we learned from past experiences? It is fascinating to read an article that chronicles pandemics as far back as 165 A.D, which was a pandemic that affected Asia Minor, Egypt, Greece, and Italy, was thought to be caused either by Smallpox or Measles. It was brought to Rome by the returning Roman army from Mesopotamia, and it decimated the Roman army. The death toll was 5 million, with a world population of about 160-300 million. The most recent pandemic before COVID-19 is the HIV/AIDS infection. It peaked between the years 2005-2012, claiming 36 million lives worldwide. A 2004 study from Canada, following the 2003 SARS (Severe Acute Respiratory Syndrome) epidemic, found a high prevalence of depression and PTSD (Post Traumatic Stress Disorder) among the quarantined population. It is essential to keep this in the equation as we move from the phase of response to that of recovery. Following other catastrophic events like hurricanes, forest fires or mass 28

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protests and riots, depression and PTSD are seen at a heightened level not only with those directly affected, but also as a spillover effect on those not involved. Economic stress adds to the problem. Drops in the stock market are devastating, however, more impactful are the economic effects on a larger proportion of the population who depend on their daily earnings to sustain life and health. The pandemic is a psychological crisis as well. Sherry Cormier, a psychologist who specializes in grief mentoring says that in addition to individual losses of a loved one or a job, even people who have not lost anything are in a phase of "communal grief as we watch our work, health-care, education and economic systems…destabilize,". These losses include our loss of control, predictability, fairness and belief that we can protect our children, our elders, and ourselves. The loss is not only of lives but dreams as well. It can include the loss of home — our income plummets, and as a result we don’t have the resources to invest in that first house we dreamt of or worse, we are evicted. It impacts our profession — suddenly, the research project stops for lack of funding. Aspirations are washed away — the gymnast who is training for the club trophy or the Olympic gold medal. These and numerous other situations could all be such profound losses. Grief is turning inwards and recalibrating. It is natural and beneficial, even while grieving, to experience moments of acceptance, even happiness, laughter, and the most healthy grieving involves going in and out of these phases. Mental health professionals talk about 'Naming and Claiming Grief.' It is an organized way of helping oneself cope. Some suggest writing or keeping a journal as a way to relieve stress. I can personally vouch for the power of writing on grieving and healing. The writing was my mantra when I faced a family health crisis. Staying home, especially with children of different ages, has made parents learn so much about their children. The American Psychological Society (APS) has guidelines for helping children cope. A preschool child fears being alone, regresses in bowel and bladder control or may lose appetite. There could be an increase in temper tantrums, whining and clinging. On the part of the caregiver, increased tolerance, short-term changes in sleep arrangements, maintaining regular routines like bed and mealtime, and avoidance of

COVID-19 PANDEMIC media exposure with news about the disaster are helpful. Children 6-12 years of age may be irritable, withdrawn, aggressive, or clinging. They may have physical symptoms like stomachaches. Children may forget the information learned in school. Parents must follow a routine; make the child participate in setting up rules about hygiene, encourage expression through play and conversation. Keep up the habit of school time by ensuring school work is done during those hours, be firm and gentle. Play session online and telephone time with friends is helpful. For children aged 13-18, it is even more important to follow a routine, particularly keeping up with school work. While encouraging awareness of what is happening is good, don't force it. A teenager may understand numbers and statistics, so take advantage of this and encourage creative thinking. The dance school I am involved in has continued all classes online. We challenged the senior students to choreograph a dance to music that we provided, and the result was a beautiful dance fit for a large audience. Addressing stigma and discrimination and potential injustices in a healthy discussion are also important. One thing we have to be grateful for is the social media that has kept us connected. Social connectedness is so critical for psychological wellbeing, which is difficult while distancing six feet apart. Connecting via social media is one thing I would recommend carrying forward as we transition. I am connected with ‘Care for the Caregiver’ program at UTH that was in place before COVID-19. The uniqueness of this program is that it sends a personal message to me in the place of a generic newsletter that many heads of organizations send. The American Psychological Association recommends that therapists and psychologists connect with patients in the aftermath of the pandemic, which appears to be a vulnerable period. The epidemic also has broadened these connections. Many people have also received and made connections with friends and relatives that they had lost touch with. While many people will be resilient to the changes wrought by COVID-19, this global crisis will test others in significant ways. Erika Felix, a psychologist at U.C. Santa Barbara, says, "As things return to normal, most of us will also return to a kind of normal, albeit changed by going through this experience. But there is a subset of people who will be chronically disrupted and will need support in recovery". Physicians, health care professionals, administrators, parents, and caregivers must take care of themselves. There is a saying in Tamil (Language spoken in south India) 'Sevir irundhalthan Chithiram' meaning without the canvas you cannot paint a picture. You are the canvas, and you are the artist as well. Make time to do things at home that have made you and your family feel better in other stressful situations. These could be reading, watching movies, listening to music, playing games, exercising, or engaging in religious activities (prayer, participating in services on the Internet). The other day I did something spontaneously; I read to my husband the 'Upanishad', a very complex Vedic literature. He listened to it as a child would to a storybook. Reading to others

is certainly a calming activity for both the receiver and the giver and applies to all ages. At the other end of the spectrum are the elderly. Recognize that feelings such as loneliness, boredom, fear of contracting disease, anxiety, stress and panic are normal reactions to stressful situations such as a disease outbreak. Between March and April, five people we have known since we moved to San Antonio, all well past seventy years, most with chronic illness, passed. None due to COVID-19; but none could have traditional last rites. The isolation of the surviving family members is heart-wrenching. Communication through email, telephone or just, a card is all helpful. Social connection is critical. Are we all in this together? The 'Vedas', the oldest known trove of knowledge, speaks about the connectedness of all humanity to higher consciousness. The great seers of yonder times meditated for all humanity because we are all interconnected. It is a practice I find useful. Twelve to fifteen minutes of meditation at any time of the day and anywhere you are could be a source of energy and replenishment. Please be with me while I meditate seated comfortably on a chair, feet planted firmly on the floor, spine erect, face slightly turned up, shoulders and arms relaxed, palm turned upwards resting on thighs. Inhale deeply as your abdomen protrudes; exhale, so it becomes flat. Do this 2-3 times and then begin to breathe easily. As you inhale, think I am not just a body. As you exhale, think I am not even just the mind. Focus on a point between your eyebrows. Do this for 4-5 minutes. Let your thoughts wander; don't fight them, gently come back to the focal point. Follow this with exhaling with the sound 'Aaah' coming from a point below your naval and 'Oooo' coming from the xiphoid and ending with 'Mmmm" at the throat, which should send vibrations throughout your body. It takes practice to do this. Do this seven times. Follow this with easy breathing, mindful of just the breaths going in and out. Now gently open your eyes. You may have briefly connected with universal consciousness. With practice, you will be able to get into the phase faster. It has taken me four years to get a glimpse of it. When life gives you a handful of lemons, always remember that what you do with them is up to you — and your choice might not be to make lemonade. You could grumpily sit by and watch them rot, or even lash out at others by throwing lemons at them. Or you could make the best of the sour fruit and whip up some delicious lemony treats or squeeze a little in your tea. Remember that with the right mindset, you can make the best out of the sourest situations. (Source unknown) Additional resources can be accessed at: www.NCTSN.org www.healthychildren.org www.cdc.gov/coronavirus/2019ncov/specific-groups/children-faq.html https://www.mphonline.org/worst-pandemics-in-history/ Rajam Ramamurthy, MD is Professor Emeritus, UTHSA Department of Pediatrics/ Neonatology, Peace Laureate S.A. 2017, and is the 2005 President of the Bexar County Medical Society. visit us at www.bcms.org

COVID-19 PANDEMIC

A Third-Year Medical Student’s Perspective on COVID-19 By Donald Egan

I was at the bedside of an 11-year-old patient who was recovering from a motor vehicle accident when I felt my phone vibrate twice in my pocket. This notification felt different. Once the patient encounter was finished, my colleague pulled me aside in the hospital corridor and told me the news that we were dismissed from our clinical duties because of the novel coronavirus, COVID-19, outbreak. Over the course of the previous week, medical schools across the country were pulling students from clinical sites and moving to online curriculums when available. Our administration had remained transparent with our student body during this time and ultimately made the difficult decision to pull us out due to the escalating threat. The ensuing days were filled with more questions than answers. As a third-year medical student, I am quickly approaching the crucial time of my education where I will be finishing my clerkships, taking Step 2, completing away rotations, and applying to residency. For years, students in my same position have been working towards the common goal of completing medical school to become doctors and help our communities. However, now it is hard to not feel sidelined. As third-year medical students, we find ourselves in the difficult position of wanting to help by applying the training we have learned in clinics and hospital settings but lacking the experience of our more senior colleagues. In response to the growing burden of COVID-19 on Bexar County and the volume of students expressing to the administration at UT Health San Antonio their desire to help, The Long School of Medicine Medical Student Response Team was created. The team is a partnership with Metropolitan Health District’s (MetroHealth) COVID-19 Epidemiology and Crisis Hotline and its mission is to conduct phone screenings, assisting health care professionals across the city and surrounding areas, as well as answer general questions from the public. The phones are manned by a team of medical students, nurses, and employees of MetroHealth. On average, the hotline receives approximately 100 calls an hour with an increasing 30

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number of calls as the virus continues to spread. I am one of the team leaders, helping to answer questions from callers and acting as a liaison between the medical student volunteers and the MetroHealth staff. While our hotline was intended to be for healthcare providers asking questions about testing criteria and specimen collection, a large portion of our calls now come from community members without primary care providers (PCPs) or those who cannot see their PCP because they were either turned away or their PCP lacked resources. In cases like these, we screen the individual for signs and symptoms of COVID-19 to determine if they meet criteria for mobile testing. Many of the calls we receive are from scared members of the community who know someone who has tested positive or is suspected positive for the virus. Thus, a fair share of our time at the hotline is mitigating fear and disseminating health promotion and education to the community. I chose to volunteer because I could not sit idly by and do nothing while my community suffered. In this time of crisis, healthcare workers are desperately needed and the hotline is one way to apply my training for the good of public health and safety. I will continue to help in ways that I can, and I encourage other healthcare students and trainees to do the same. No one is quite sure how long the current restriction on daily life will last or when life will go back to some modicum of normalcy. In the meantime, the growing opportunities to serve borne from the current pandemic offer a sense of direction and purpose. More importantly, these opportunities serve as reminders of why we joined the healthcare field in the first place. They offer a chance to renew our commitment to the service of others when they need us the most. Donald Egan attends University of Texas Long School of Medicine and is a Doctorate in Medicine Candidate, 2021; he also attends University of Texas School of Public Health and is a candidate for Master of Public Health Candidate, 2021. Mr. Egan is TMA MSS, and AMA Delegate Co-Chair.

A Medical Student’s Perspective on the COVID-19 Self-Quarantine Experience

COVID-19 PANDEMIC

By Katelyn Franck Spring is a uniquely challenging time for 2nd year medical students like me. The majority of us are in “dedicated board prep”, studying primarily on our own for USMLE Step 1 and COMLEX Level 1. Many of us had already been doing “social distancing” to some extent. Prior to writing this, I attempted to find articles on “social distancing” and couldn’t find anything on its implications. This is uncharted territory. We all hope this is effective in slowing the disease spread. Maybe this will be a tool to be applied with future disease outbreaks (to a lesser extent)? The COVID-19 pandemic has disrupted the lives of nearly everyone in the world and has created unique challenges for individuals. Most likely, the stress or burden will be somewhat dependent on the level of disruption this has caused to one’s daily life. Even though my cohorts and me were planning to spend a lot of time alone, we certainly did not expect it to look like this. Med students rely on each other for support and it has been challenging not being able to see each other, to study in the library, or continue our regular workout routines, among other things. Our school outlined a very specific number of weeks for us to exclusively study for boards based on data showing that, after a given number of weeks, one’s performance starts to decline. Right now, we (UIWSOM students) have our exams scheduled for May, so we are trying to find the balance of study vs. other pursuits. We don’t want to risk being underprepared, but we likewise don’t want to study really hard, have our exams moved back, and as a result not perform well. Many of us medical students have struggled with feelings of helplessness. Naturally, we all want to be able to help right now; unfortunately, we are not at that level of training yet. Even third-years have suspended rotations for now. As a result, many med students across the country have been reaching out to physicians they personally know to offer help and assistance in any way possible. Just as this pandemic has forced our healthcare system to be “creative”, it has likewise forced the creativity of society in general to come up with new ways of doing things. I see this as a positive, using things like home workouts, learning how to work more productively at home, and finding new means to connect with friends through technology. For med students, being forced to communicate with friends largely through social media may aid us in maintaining our friendships after med school is over, when we have all gone our separate ways. Even with negatives that have been widely proclaimed about the shortcomings of social media, its rise has been beneficial in education; not only for dispersing COVID-19 facts, but also to shed light on some of the challenges that doctors, nurses and other healthcare

workers face. It demonstrates how important other professions are in keeping society functioning, such as those that teach, sell groceries or whatever. This virus pandemic has also shed light on the fact that we need to better educate patients on basic disease prevention, healthcare delivery and the complexity of vaccines/new medications. It will lead to some changes for the better. I feel it has reinforced the importance of patients having a primary care provider (PCP). It points out that patients need a doctor they know and trust and who knows them as well because despite the healthcare needed to treat the virus that plagues us now, acute, minor illnesses/ injuries that don’t require an emergency department (ED) visit obviously still occur as well. Many individuals are likely going to be needing mental health treatment as they face these unique challenges. Both now, and when we eventually see the decline in COVID-19 cases, there are potential opportunities to work on increasing mental health awareness and hopefully further propel us in the direction of improving accessibility for mental health care. The BCMS LifeBridge program for member physicians and their staff and families provides free counseling any time of day or night, from anywhere. Finally, in the spirit of improving healthcare, this as an opportunity to consider working toward additional major legislative changes. For me, this all just reinforces the importance of being an active advocate for change – both as a med student and as a future physician.

directors.

Katelyn is a 2nd year medical student at University of the Incarnate Word School of Osteopathic Medicine and is from San Antonio. She is an active member of BCMS and this past year, served as the UIWSOM student representative to the BCMS board of

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COVID-19 PANDEMIC

Why Medical Students (and everyone else) Should Learn Everything They Can About COVID-19

By Michael E. Walston, MBS

Respectfully acknowledging and setting aside for a moment the enormous human toll of the disease, for medical students the COVID-19 pandemic represents a singular educational opportunity. Truly, regardless of where you are in your medical education, those interested should dive into the research to learn all they can about this disease, its treatment, and the relevant healthcare policy and systems. This is a rare moment when it is possible for an individual to learn everything currently known about a single disease entity, its treatment, and critically evaluate new evidence and studies. As scientific information about this novel coronavirus emerged, this was of course the first area to focus as a learner. What we initially understood to be a relatively straightforward respiratory virus has, however, developed quite a few more interesting wrinkles, (coagulopathy, stroke, dermatologic) which the medical and scientific communities are still working to fully comprehend. That is one reason this pandemic is an excellent educational opportunity: if one is sidelined and cannot participate, there is the chance to witness the development of scientific understanding. The evidence-based medicine pyramid, outcome measures, statistical power, p values and so forth are often studied in abstraction or historically as evidence for current treatment guidelines, for example. In this setting, the subject might seem to have less real-world importance to learners than established biology and pathophysiology, proven treatments and gold-standard tests. But when none of that is available, what are we to rely upon? For those early in their medical careers, we are provided in the current crisis an opportunity to critically appraise publications, study new therapies, follow epidemiological data and make our own decisions in real time. Tracking the therapies which have been used in the treatment of COVID-19 would obviously be a valuable real-time object lesson: hydroxychloroquine, remdesivir, patient proning, ventilation strategies and so forth. While the purpose of this article is not to explore these therapies, using the experience of reading and critically evaluating the studies as well as digging into the data is an excellent ed32

San Antonio Medicine â&#x20AC;˘ June 2020

ucational opportunity. Following the therapies deployed against COVID-19 continues to be instructive and should be of benefit to learners at any stage of their career. It goes without saying that the COVID-19 pandemic has stressed our healthcare system in ways not seen before and has spurred innovation that will continue to change the landscape of healthcare. Whether it was the cancellation of nonessential or elective surgeries, changes to reimbursement or the logistics of resources, this is the bureaucracy of medicine. Studying the convoluted forest of acronyms that comprise these systems is not appealing to most medical students, let alone practicing physicians, and often only garners a passing survey in medical school. COVID-19 offers an impetus as well as a framework to begin to learn more about these issues and perhaps work to improve them or at least navigate them more effectively. Lastly, the pandemic reinforces and makes real and urgent the importance of the social determinants of health, such as employment and economic stability, education, food security, healthcare access and social resources. It has been established that chronic diseases are risk factors for worse outcomes with COVID-19 as well as the development and severity of many chronic diseases are linked to social determinants of health. For the interested learner, this can be a valuable reminder of what has been established: the strong association between the social determinants of health, disease, and health outcomes. To conclude, this is certainly a unique moment to be in medicine. For learners, we can make the most of the tragedy of a global pandemic by learning all that we can about this emerging disease and then use this educational experience to refine and improve our own skill set for understanding a disease process, to evaluate data and to better know the larger healthcare system. Michael E. Walston, MBS, is a DO candidate, Class of 2021, at the University of the Incarnate Word School of Osteopathic Medicine and is a member of the Bexar County Medical Society.

COVID-19 PANDEMIC

My Role as a Medical Student in the Era of COVID-19 By Michell A. Parma

If medical school is a high-speed train, barreling toward the destination of residency, the current global pandemic is the unforeseen debris sprawled out on the train tracks, pulling everything to a screeching halt. For almost three years, I have been constantly moving forward. I have studied for exams, perfected patient history-taking skills, adjusted to new teams in a variety of specialties, and grown as an aspiring physician. All the while, I have paid no mind to the blur of scenery surrounding. This fast-paced schedule progressed like clockwork. While tiring at times, I reminded myself that this was a shared medical student experience. This was the tried and true formula that would someday mold me into a successful doctor. Then I received an email from our dean of student affairs. Due to safety concerns around the growing number of COVID-19 cases in Bexar county, UT Health San Antonio students were to be pulled from clinical duties immediately. I jolted to a stop. And after recovering from this whiplash, I remember thinking, “I guess I don’t have to set my alarm tomorrow morning.” I woke the next morning at 6:00 am, no alarm necessary. Now that the train had stopped, I could finally look out and see how still life had become. And that made me immensely uncomfortable. If my role as a medical student was to be suspended indefinitely, in order to make some sort of progress, or the illusion of progress, I needed to reconsider my role for the time being. If I could not learn in a clinical environment, then I was determined to simply be helpful. Soon my email flooded with volunteer opportunities from our school. I jumped on the chance to serve the City of San Antonio’s Metropolitan Health Epidemiology COVID-19 Hotline. The hotline was originally intended for health care providers looking to receive up-to-date guidance on testing guidelines and the PUI numbers for patients being tested. But unexpectedly, it expanded into a community hotline. We answered questions from “How long should I quarantine if my co-worker tested positive?” to “Can my mother drive down from New Orleans to help me with my newborn baby?” to “How do we dispose of a body suspected of being COVID-19 positive?” The unprecedented nature of the pandemic evoked widespread fear in my city. By helping ease com-

munity anxieties and answering questions the best way I knew how, I began to carve out my new role as a medical student in the time of a global pandemic. During my month-long volunteer experience, one of the most memorable calls I received came from an elderly grandmother seeking guidance on self-testing. Her husband was a cancer survivor with COPD. Her daughter was a single mother of four. When the grandmother’s daughter started showing symptoms requiring her to selfisolate for fourteen days, the grandmother worried for the grandchildren. “Who will take care of them if she becomes hospitalized?” she cried. “My husband and I can’t because of his medical conditions, and I’m afraid all of the burden is going to fall on her oldest son. He’s only twelve.” There was so much out of her control. I confessed to her that we are in control of very little at this time. But for the few things that we can control, I assured her, we can act with deep intention and grace. I hope she took solace in that fact. I know I did. I think it was the feeling of losing control that woke me early that first morning after being pulled from clinicals. I made a mental list of what I could control: the hours I put into volunteering, the grace I give towards others and myself, and the way I bear witness as a student during this pandemic. This may well put me behind schedule for what could have been a conventional season of residency applications and interviews. Or this may well be the most formative reflective pause of my medical education. For the first time, the train has stopped. I can see the scenery around me more clearly. And I can step off and help others, without the fears of limited time or of being left behind. For the first time, I can simply take on the role of reflective service. And that has been the closest role to a physician that I have practiced so far. Mitchell Parma is a third year medical student at the UTHSA Long School of Medicine, is a member of the Bexar County Medical Society and is interested in pursuing a career in Internal Medicine. visit us at www.bcms.org

COVID-19 PANDEMIC

The Effects of COVID-19 Social Distancing on Children: and Questions that Need Answers By Kalli R. Davis

San Antonio Medicine • June 2020

COVID-19 has drastically altered the day-to-day life of the majority of the citizens in the United States, from young to old. Nursing homes are closed to visitors and women are delivering babies without their husbands. Working from home has become the new ‘norm’ and, for children and adolescents, learning from home has become the only option for completing the 2019-2020 school year. While online classes offer challenges to student’s educational advancement, social distancing could also be creating other barriers for childhood development. The school environment and peer-to-peer interactions provide the necessary platform for many aspects of psychosocial and biological development. It is important to consider the effects of social distancing on children ages 2-11, particularly concerning their psychosocial development and mental health. For infants and children 2-4 years old, stay at home orders may actually be beneficial, allowing them to establish necessary relationships with caregivers. At this age, children begin to develop spoken language and initial language development can easily occur within the household. Studies have shown that when encouraged and provided opportunities to learn, preschool isn’t necessary for them to reach developmental milestones and it is even believed that the home learning environment may be less stressful for children at this age. They are likely to successfully learn at home with proper encouragement and activities facilitated by family members. These children can also entertain themselves relatively well within the home environment, and may play with blocks, a ball or colors by themselves. The question to

COVID-19 PANDEMIC ask in regard to children 2-4 years old are: 1) are they being adequately cared for, 2) is their home environment safe, and 3) how can we help parents to provide their children with the necessary stimulation to remain on track for learning and development? Consider now the effects of social distancing on children ages 46, recognizing the importance of peer-to-peer relationships in school age children. Children at this age begin to understand meaningful interaction through social play. At this age, children require active play involving the physical activity necessary for muscle strength and control. Through active play with peers, children learn to regulate emotions, partake in competition, and can even develop empathy. It is believed that these types of play may facilitate development of the prefrontal cortex. Another common form of play is Drama and Pretending in which children assume different roles and act out various plots. This type of play teaches children to explain their ideas, formulate persuasive arguments (through convincing playmates to agree to engage in their suggested plot/role), and even allows children to explore emotional regulation through pretending to feel a certain way or act a certain way based on their assigned role. A lot of these activities are lost with the current social distancing regulations; children are not able to play with their friends and, while siblings can be a good playmate, they are not always close enough in age to allow for the formation of peer-to-peer relationships that facilitate some of these developmental milestones. While we are all hopeful COVID-19 will only pose a short-term challenge for our youth, it is important to foster ideas to overcome these challenges if this crisis is prolonged. Children require the proper stimulation to foster development and reach psychosocial milestones. Middle childhood occurs from age 6-11, during which children have slower growth but develop greater strength. Physical activity is crucial for children at this age, and Active play is extremely important as it promotes better overall health, lessens obesity, improves their problem-solving abilities and teaches them to appreciate cooperation and the benefits of fair play. Children normally partake in active play in their neighborhoods, schools and sports leagues; none of which they do not have access to while practicing social distancing. It is believed that students can learn outside of the classroom, through peer-to-peer interaction, watching television, eating dinner with their families and observing people on the street; basically, every daily activity and experience can offer children some form of education. The question we must ask going forward as parents, educators and healthcare providers is how to continue teaching children at home? How can we utilize a variety of teaching platforms to keep them engaged and excited about education? It is also important to teach parents about the benefits of physical activity for their child’s physical health, mental well-being and normal development. What are activities that may allow the child to be active as well as engaged? Mental health of children should never be overlooked, especially during extreme circumstances such as COVID-19. Children as young as 2 years old can sense changes in the environment around them. They are able to understand that “something isn’t right” and

it is important for parents and caregivers to allow them to talk about their feelings during the changing times. (Dalton, Rapa, and Stein; 2020). It is also important to provide children with honest information that is consistent with their level of understanding and cognitive processing. Dalton, Rapa and Stein elucidate the importance of prioritizing appropriate communication with children regarding COVID-19 as part of the community-led response to the pandemic. How can we contribute to this response and ensure children are provided information that is appropriate for their level of understanding in order to help them cope with the rapidly changing tides of COVID-19? The World Health Organization offers some recommendations that may be helpful for parents, educators and healthcare providers when considering adolescent mental health during this time. They recommend that parents encourage children to express their feelings in a positive manner, through activities such as drawing and playing. The CDC also recommends that caregivers stay close to their children and avoid separation as much as possible; regular contact with parents can provide children with stability and comfort. It is also recommended that a daily routine is maintained, even if it may need to be adapted slightly — consistency is key. It is also recommended that parents encourage play time and socialization with others. This is where creativity may need to come into play. A question to ask is how can we facilitate the critical types of play previously discussed while maintaining social distancing? How can this lack of social interaction negatively impact the mental health of the children in our community? What is MY role [as it applies to you individually] in ensuring the needs of the children in our community are met? Kalli R. Davis, B.S. / M.A. in Biology, is an Osteopathic Medical Student at UIWSOM, and is a member of the Bexar County Medical Society. Works Cited Berger, K. S. (2014). Invitation to the life span. New York, NY: Worth , a Macmillan Higher Education Company. Dalton, L., Rapa, E., & Stein, A. (2020). Protecting the psychological health of children through effective communication about COVID-19. The Lancet Child & Adolescent Health. doi:10.1016/s2352-4642(20)30128-0 #HealthyAtHome. (n.d.). Retrieved May 12, 2020, from https://www.who.int/news-room/campaigns/connecting-theworld-to-combat-Coronavirus/healthyathome/healthyathome--mental-health?gclid=CjwKCAjw7-P1BRA2EiwAXoPWA_V_3uUe _-pCBqxdiPcn7D2JqbFjWx5_cQO67fWNIg1vyyOoXVXLPRoCpjkQAvD_BwE

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COVID-19 PANDEMIC

My Coronavirus Retirement By Leon Ghitis, MD

I am writing this at the beginning of the COVID-19 pandemic, one of the greatest challenges human civilization has ever seen, where probably millions of people will be affected and hundreds of thousands of lives will be lost. I hope we survive it and that soon we may easily diagnose it, measure immunity, have some type of effective treatment, and a vaccine available. Before the holocaust, where millions of people were killed by humans, of them 6 million Jews, my maternal and paternal grandparents had a good life in the â&#x20AC;&#x153;old countryâ&#x20AC;?. Everything around them suddenly collapsed. They made the decision to flee from Europe to Colombia at the end of 1938 saving their lives but leaving and knowing that other family members would perish. In 1978 in Colombia, under totally different circumstances, 40 years after my grandparents came to Colombia from Europe, my wife and I decided to make the move from Colombia to the US, looking for better opportunities and a safer place for us and our 2 children. I had just finished medical school and the situation in Colombia started to get difficult and dangerous with the rise of Narco-trafficking. Fortunately, I was able to meet the medical requirements to come to the US and, after my Anesthesia training in Houston, my family and I moved to San Antonio in 1982. I started my private practice with a small group of anesthesiologists. In 1997, my partners and I decided that with a consolidation of smaller anesthesia groups into a big one, we could function more efficiently, provide better service, and decrease our operating expenses. After multiple exhausting meetings with lawyers, several groups merged. We founded Star Anesthesia which became the largest Anesthesia group in the city. The integration was interesting and challenging, because each group or division had their own way of practicing. Some groups worked the old-fashioned way where anesthesiologists followed their surgeons around to different hospitals, others were basically hospital based, and others functioned both ways. Slowly, we expanded our anesthesia group in the city. Around a year ago, Star Anesthesia group started talking about a possible sale of the practice. Finally, at the beginning of September of 2019, Star was acquired by USAP. We were offered two different options: Remain as a Partner (either full-time or part-time) or become a "legacy member" and work as a contractor. As a legacy part36

San Antonio Medicine â&#x20AC;˘ June 2020

ner, you would give up a large part of the compensation in the form of bonus and shares in the company, but you were free to work as much or as little as you wanted, with no obligations and relatively low compensation. As a partner, depending on the age, you would be required to take call and sign for a minimum period in order to qualify for the shares and the bonus opportunity. It was a very difficult decision for me to make. I enjoyed my practice very much. I had been privileged and over the years I had enjoyed a very nice "gourmet" practice; I worked only with the surgeons I liked and kept a decent schedule of hours. After going back and forth for weeks, my decision was to go legacy, as a preliminary step to retirement and sacrifice a significant amount of money for the sake of a good quality of life with family and especially with my grandchildren. Initially, I was working once or twice a week, then once a week or once every two weeks, and eight weeks ago I stopped working completely. I thought it was a great decision. The stock market was doing great, and I had more time for myself and time to enjoy my family and friends. Then, the COVID-19 came into our lives as a surprise: the stock market collapsed, and we are facing a very scary situation that we don't know how and when is going to end. It feels as if our world is collapsing around us again. We lost our freedoms to live normal lives and to see family and friends. The number of people getting sick is exponentially growing and the economy of the USA and the whole world is collapsing. In the meantime we, my wife and I, are doing the most we can with physical, social distancing, so that we minimize the risks and help flatten the curve so that in the event any of us gets sick, it would not be at the peak of the curve and we would hope to get appropriate treatment without restrictions. Even though I stopped working and soon will be 70 years old, I have decided not to resign from the company and to maintain my active privileges, so in the event this pandemic gets to an extreme situation and my services are needed, I can go back and help. Leon Ghitis, MD is an Anesthesiologist in Bexar County and a member of the Bexar County Medical Society.

COVID-19 PANDEMIC

STRAC, THE RMOC, AND DISASTER AND PANDEMIC PREPAREDNESS AND RESPONSE By Ronald M. Stewart, MD; Joe Palfini, BSN; D. Eric Epley, CEM; Brian J. Eastridge, MD

History of Texas Regional Advisory Councils In May of 1989, the 71st Texas Legislature passed an Omnibus Rural Health Care Rescue Act (HB-18). This bill provided the foundation of the modern Texas EMS and Trauma System. Following this legislation, the Texas Department of Health approved rules which divided the state into 22 geographic trauma service areas (TSAs). These geographic areas were based off of natural referral patterns and were sized to include at least three counties in a region that could support at least one Level III trauma center. In turn, each of these areas were directed to establish a Regional Advisory Council (RAC) as a 501 C3, non-profit corporation. The original purpose of the RACs was to administer the regional EMS and trauma systems in Texas. Over these three decades, regional EMS and trauma systems first developed then flourished and subsequently grew to encompass the full spectrum of emergency health care, including regional disaster response. Southwest Texas Regional Advisory Council The Southwest Texas Regional Advisory Council (STRAC) leads and administers an integrated military and civilian trauma and EMS system encompassing a 22 county, 27,000 square mile region. The STRAC held its initial meeting in 1993 at the UT Health Science Center’s Library. In 1998, the STRAC was established as a 501c3 non-profit, tax-exempt organization chartered in the State of Texas. The first Chair of the STRAC was Charles Bauer, MD, past president of the Bexar County Medical Society (BCMS) and chair of the BCMS Emergency and Disaster Preparedness Committee from 1985–2006. From 1993 forward, the principal goal of the STRAC was to establish a regional trauma and EMS system designed to maximally reduce trauma related death and disability. Trauma system development is inherently multidisciplinary, and the principal goal of a trauma system naturally extends to encompass all emergency health care and disaster response. The STRAC has benefitted from an incredible regional team of physicians, nurses, paramedics, first responders, educators, public health, emergency management and IT professionals. Through the development of STRAC systems, important lessons have been learned that are relevant to addressing all complex health problems. Implementation of STRAC systems is based on the following five key principles: 38

San Antonio Medicine • June 2020

1) be maximally inclusive with engagement of all stakeholders, 2) encourage dialogue and consensus decision making centered on what is the right thing to do for the patient or population being served, 3) establish systems that ensure timely and structured cooperation and communication, 4) develop data systems with strong support for research and quality improvement, and 5) cultivate a bias for action. This approach naturally fosters civility, professionalism, humility, mutual respect and timely, evidenced based action. We believe these processes and values resonate with the culture and values of South Texas health professionals. Managing South Texas emergency health care and disaster response is multifaceted and complex, but for clarity we will focus on things we believe are relevant to physicians and patients related to the COVID-19 pandemic in South Texas. STRAC Disaster and Pandemic Response Following the attacks of 9-11 and the anthrax incidents of October 2001, the Joint Emergency Preparedness Committee of the Bexar County Medical Society (BCMS) and the Greater San Antonio Hospital Council (GSAHC) formed the Regional Emergency Medical Preparedness Steering Committee (REMPSC) to organize local hospitals, physicians, pharmacists and other stakeholders for the best response the area could provide with existing resources. This effort led to the realization that we, similar to almost every other region in the United States, had some key vulnerabilities. Many of our existing plans were untested and unworkable in real-world conditions. Communication and data sharing capability across the health care and public health systems were virtually non-existent, and ultimately there was no mechanism to rapidly coordinate a complex health related disaster, especially one that required the integration of acute health care, public health and emergency management. This situation contrasted starkly with the public safety (police, fire and EMS) and military communities which had far more robust communications and coordination systems. This led to the development of the STRAC Regional Medical Operations Center (RMOC) concept.

COVID-19 PANDEMIC

The RMOC arose from several converging experiences, including multiple large exercises which demonstrated the need for a higher level of integration of medical operations, the desire of local governments for a single point of reach back to the large and diverse health care community, and the positive experience of STRAC and military medical planners with medical command centers. The STRAC led the conceptual development of the RMOC, which was implemented in Hurricane Katrina and tested in every disaster in South Texas since that time. It has been proven to work in natural disasters, mass casualty events and currently is critically important in coordinating the regional and state response to the COVID-19. The RMOC leads to improved 1. Coordination between governmental agencies, stakeholders and health care institutions 2. Communication between agencies and stakeholders 3. Distribution of resources 4. Understanding of local need 5. Information sharing 6. Real-time, patient-tracking hospital bed capacity 7. Deployment of medical assets to the scene of a disaster 8. Deployment of EMS strike teams 9. Deployment of regional mobile medical unitsâ&#x20AC;&#x201D;field hospital 10. Convening of experts and coordination with agencies, health care institutions, professional organizations and other stakeholders.

In the COVID-19 response the STRAC RMOC has led to dramatically improved (compared to other regions) situational awareness, integration of public health, acute health care and disaster management functions in an unprecedented fashion, actionable data consolidated from public health and acute health care data sources, identifying, controlling and coordinating hot-spots, drive through testing management across the entire State, load balancing across multiple health systems and organizations, and distribution of personal protective equipment for clinics, hospitals, private practices and congregant care facilities. In the past 60 days the RMOC has processed over 6,000 unique line item requests from over 1,200 request forms submitted by hospitals, clinics, physiciansâ&#x20AC;&#x2122; offices, long term care facilities, dialysis centers, hospice providers, funeral homes, EMS, first responders and critical infrastructure organizations such as power companies and cell providers. Through a partnership with BCMS, the STRAC has served over 232 primary care providers or 6,000 caregivers. The STRAC and the BCMS have a long history of partnership in coordinating South Texas disaster response, and in the COVID-19 era that partnership is more important than ever.

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COVID-19 PANDEMIC

From the Journal of the National Medical Association, Vol. 11, No. 4 *Read before the 21st annual session of the N.M.A., Newark, 1919.

Spanish Influenza By T.C. Bracken, MD, Port Arthur, Texas

The recent pandemic of influenza originated probably in Spain, and thence spread rapidly, within a few months to practically every part of the known world. The Term “Influenza” is Italian in origin and literally translated means influence. It must be confessed that all the influences governing this disease are not yet definitely known. The term “La Grippe” was introduced by the French in about 1712 and has been accepted as the popular name of the disease. With more than 400,000 human lives snuffed out by this scourge in the United States, the very name “Spanish Influenza” strikes terror to the entire country. Periodic outbursts of influenza epidemics have been recorded through the centuries. Hippocrates refers to an epidemic as early as 412 BC. The severity of the recent outbreak of influenza is not unique. The first epidemic of La Grippe to appear in the United States occurred in 1647, and four great pandemics of influenza during the last century (1850-1833, 1836-1837, 1847-1848, 1888-1890). The last world-wide outbreak of 1889 is said to have originated in the Far East, and within a year had visited practically every part of the known world. Just what is responsible for these epidemics is not definitely known. These outbreaks of disease have differed in severity and have spread according to the speed of human travel and intercourse. Influenza is caused by a specific germ and is highly contagious at close range. Early in the year 1892 Pfeiffer discovered what he believed to be the influenza bacillus. This organism has been generally accepted as the causative agent of the disease since that time. Observers have about decided now that Pfeiffer bacillus is not the cause of influenza. Reports from the various army camps during the recent epidemic show that the Pfeiffer bacillus was present in less than 1 per cent of all cases reported. It is fair to predict that with the attention influenza has claimed the causative germ will soon be discovered. Influenza attacks the old and young of all walks of life. Exposure to the disease is universal. It is particularly to the young – ages ranging from twenty to thirty-five – but it is no respecter of ages, locality or previous condition of health. The large number of deaths incident to an epidemic of influenza is not due to the influenza, but almost entirely to a virulent type of pneumonia which accompanies it. The pneumonia does not exist as a separate epidemic, but exists as a complication. There seems to be no doubt that there is some unexplained or peculiar relation between these two diseases. The causative organisms are spread from the sick to the well by a droplet or spray infection; that is, when one sneezes, coughs or 40

San Antonio Medicine • June 2020

talks loud, a fine spray of mucus is thrown from the nose and mouth. This fine spray consists of globules or bubbles of mucus containing large numbers of mouth, nose and throat bacteria. From this you can see it is necessary for those who are infected to wear a gauze mask, it is also essential for the attendants to frequently wash their hands. Steps used to combat the disease in some of the training camps were threefold – isolation, sanitation and education. Because of the abnormal condition incident to the war, not only as regards food, exposure, etc., but also as regards the congregating of large numbers of individuals within relatively limited spaces. We can, perhaps, picture the situation in this way. The bodies of certain individuals whose resistance was lowered by the vicissitudes incident to war, may have offered a particularly favorable breeding for the germs which set up influenza. The congregating of large numbers of individuals within camps, munition factories, etc., afforded the most ideal condition for the spread of the germs. During their passage through a large number of individuals their virulence may have become raised. And the possibility this increased virulence of the attacking germs may be the main reason for the severity of the symptoms as manifested in the United States. A certain air of probability seems to be lent to this by the fact that the resistance of the individual does not appear to be a dominant factor with us. Because Spanish influenza impartially attacks the weak and the strong. It may be a case of strong individuals being attacked by still stronger germs, which acquired their high degree of injury wreaking power by first passing through the bodies of a large number of somewhat weakened and susceptible individuals in Europe. In the future we will look back on this epidemic of influenza with wonder and surprise; yes, in spite of our vaunted advancement, we have utterly failed in the recent crisis. The cause of this failure of the medical profession is our ignorance of preventive medicine. Our medical schools have taught diagnosis and treatment, but not prevention of disease. Certainly the old quotation is most appropriate to be used in this connection, “In time of peace prepare for war.” It goes without saying the United States was quite unprepared for the recent epidemic of influenza. Like smallpox of the middle ages and typhoid fever in modern warfare, influenza is the scourge bred o n the latest battlefields of Europe and when the history of war is written the losses in the American military cantonments from this scourge will be ten times greater than American deaths in European warfare. The experience gathered from past epidemics of influenza clearly demonstrates the fact that for at least one or two years following an outbreak of this disease we can expect a marked increase in the

COVID-19 PANDEMIC mortality following either the influenza per se, or some of its characteristic sequelae. There is no question in our mind that we must look forward to seeing a decided increase in kidney and heart lesions, a marked increase in tuberculosis and other complications – and how to become prepared to meet a new epidemic is a question that looms up before our vision in an importance – how to prevent, as far as possible, a new influenza outbreak and spread – how to obtain the largest percentage of recoveries, following attacks of the disease – these are all pressing problems of the moment, to engage the serious thought of the best members of the professions; and now is the time for this task to begin, so that its better solution may be reached and preparedness against what may await us in the future be the more assured. PAPER Discussion opened by Dr. G.W. Bowles, of York, PA, as follows: “There are one or two classes of influenza; one is gastro-intestinal type. I am of the opinion that the influenza epidemic we have experienced recently is only a certain intensified form of the regular influenza. The best way that I could state for a patient’s treatment is to treat the complications before they occur. Upon the first symptom, jump right on him as though he has pneumonia. After that the nervous type almost invariably recovers. During the whole epidemic I only lost two patients. The most serious and the most fatal type is the pulmonary type. After all, the secret of your success is, holding on to the patient until the ninth day.” E.A. Carter, MD, of Buxton, Iowa: “First I wish to compliment the writer on the paper for the scope in writing and reading. I want to take some issue with some of the things in the discussion. It was my privilege to use vaccine both as a prophylactic agent and as a curative; yet I believe one of the potent factors is absolute rest in bed. I could not agree with blistering the patient; for the cure would be almost as bad as the pain itself.”

Dr. Boyle, of Maryland: “It was not the influenza that we contended with in the times past. I do not believe that it is the concensus of opinion that it was. As for digitalis, it would do the heart no good at all. This blistering, of course, we could get rid of by using codeine sulphate; but if we make trouble ourselves we will kill out patient.”

Dr. C.W. Childs, of Washington, DC: “I have been practicing medicine about twenty-five years; I believe that influenza is an intensified form of the old time grip, given the name of Spanish Influenza for the purpose of making money. I had a large number of patients, and not one of mine died, not because I was a mighty powerful doctor, but because my patients were too tough to die. You keep on treating them; you can’t cure them, but nature will take care of the matter. Codeine is a powerful drug and seems to make you unconscious of the pain. I believe my patients got well because I knew how to ‘don’t’. Don’t give the patient digitalis until you find out that the heart is flagging, and the patient will do well. Ice will do a world of good and keep that temperature down; keep the patients quiet; don’t give too many drugs. I have tried them all, and about a dozen of them will

answer my purpose; the more drugs I use the more patients will die; the more I don’t use the more will live.”

Dr. Bailey, of Germantown, PA: “Unlike the former speaker, somehow or other I am still holding on to the drugs. We will have cases of grippe this year. I have found out that I could more or less tell when my patients are going to have pneumonia. Watch the pulse diminishing, and as soon as it is found, I throw my nitroglycerin; the next, I watch the result of my treatment. I have an idea that the liver plays a very important part and I believe that that is where we get a great deal of our poisons manufactured. When it comes on to the point where you have been able to check your pneumonia conditions, you have easy sailing. This thing about keeping the patient cold – when your are cold you are dead, and when you are hot your are alive; when you throw the windows open the cold winter air comes in and the patient gets cold. Put a thermometer in the room and fresh air, but keep the temperature about 60 degrees.”

D.A. Bethea, MD, of Terre Haute, Ind.: “I like the thoughts brought out that all of us have brought out along these lines of treatment. There is a doctor in my state who has as large a practice as anybody in the state. He said that one reason why no more colored people die from this disease is becase they get plenty of air, because of the construction of their nose which enables them to breathe more air than any other people. That might seem a little simple, but I have been thinking about it and I am inclined to believe there is something in it. The next point along the line of treatment. My treatment is different from others, but I have gotten results. I don’t like the idea of quinine doses. Sometimes a blister does good. No matter how old fashioned a remedy may be, get results.”

Dr. Bowser, of Richmond, VA: “I listened to the papers with a great deal of pleasure. Have had cases of this kind last winter. This pneumonia-grippe was not characteristic of lobar pneumonia, it is septicemia pneumonia. I don’t see that we have anything to blister for. In Richmond, too, we had grippe last year; and in my work I had some 600 cases; I had a charge of one of the pneumonia wards – had a very good success with patients. In none of my wards was the blister used. I was hoping that the writer would bring out the idea of the septicemia grippe.” Dr. Johnson, of South Carolina: “I wish to emphasize the vaccine part of it. In treating this disease many of the patients get sick from pure nervousness. At the time I think you can do a good thing by using a little phophylactic vaccine.”

Dr. Bracken closed the discussion as follows: “You can use a drug for one patient, and use the same drug for another, and it just the same as if you have not given any medicine. Some times I use ice pack, but not very often. If I had a very big strapping fellow I used ice, because I thought he was big enough to stand it. Concerning the septic variety of pneumonia which we find – some said we had a catarrhal form and some of the gastric form, but I used the symptomatical treatment. I had 1,500 cases and lost 9.”

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San Antonio Medicine • June 2020

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development tactics, we create a plan tailored to your needs! Michal Waechter, Owner (210) 913-4871 Michal@WaechterConsulting.com “YOUR goals, YOUR timeline, YOUR success. Let’s grow your practice together”

COMMERCIAL PROPERTY MANAGMENT

Investment Realty Company, L.C. (HHH Gold Sponsor) We act as Trusted Advisors leveraging our expertise as we assist Physicians in making the best commercial real estate decisions for their practices whether it's leasing, purchase or asset acquisiton. Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

DIAGNOSTIC IMAGING

Touchstone Medical Imaging (HHH Gold Sponsor) To offer patients and physicians the highest quality outpatient imaging services, and to support them with a deeply instilled work ethic of personal service and integrity. Caleb Ross Area Marketing Manager 972-989-2238 caleb.ross@touchstoneimaging.com Angela Shutt Area Operations Manager 512-915-5129 angela.shutt@touchstoneimaging.com www.touchstoneimaging.com "Touchstone Imaging provides outpatient radiology services to the San Antonio community."

FINANCIAL ADVISOR

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney, Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabetholney "Making Sense of Investing"

FINANCIAL SERVICES

Bertuzzi-Torres Wealth Management Group ( Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help

you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing" Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

HEALTHCARE BANKING

Amegy Bank of Texas ( Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

BBVA Compass (HHH Gold Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive

advice, and customized solutions in cash management, lending, investments, insurance, and trust services. Josh Collins SVP, Global Wealth Executive 210-370-6194 josh.collins@bbva.com Mary Mahlie SVP, Private Banking 210-370-6029 mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"

HEALTHCARE CONSULTING

CareAllies (HHHH 10K Platinum Sponsor) CareAllies works side-by-side with health care providers to accelerate the transition to valuebased care, helping improve the quality, value and experience of care for patients and make health care better for everyone. Sabrina Moreno, Network Operations Senior Manager (713) 437-3088 X 523088 Sabrina.Moreno@careallies.com info@careallies.com https://www.careallies.com/ “For Better Health and Better Business”

HOSPITALS/ HEALTHCARE SERVICES

Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research. Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com

continued on page 44

visit us at www.bcms.org

PHYSICIANS PURCHASING DIRECTORY continued from page 43 INFORMATION AND TECHNOLOGIES

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

OSMA Health (HHH Gold Sponsor) Health Benefits designed by

San Antonio Medicine • June 2020

Physicians for Physicians. Fred Cartier Vice President Sales (214) 540-1511 fcartier@abadmin.com www.osmahealth.com “People you know Coverage you can trust”

INSURANCE/MEDICAL MALPRACTICE

providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior). Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

MEDICAL BILLING AND COLLECTIONS SERVICES Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare

Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more efficient and profitable, and aims to accelerate their growth with proven successes and systems Christiane Escobar, CMRM Certified Medical Revenue Manager 210-687-5506 cescobar@acumen.systems Angeles Hubard Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a check-up? Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL FURNITURE

CBI Group (HHH Gold Sponsor) From reception to waiting rooms to workstations, CBI Group is your trusted partner for turnkey office furnishing solutions. Our culturedriven approach and unique access to factory-direct pricing allow us to work within any budget/timeline. Brent Warrilow 210-504-3740 brent.warrilow@cbi-office.com Brody Whitley 210-741-0438 brody.whitley@cbi-office.com Craig Hewines 210-941-1257 craig.hewines@cbi-office.com www.cbi-office.com

MEDICAL PRACTICE

IntegraNet Health (HHHH 10K Platinum Sponsor) Valued added resources and enhanced compensations. An Independent Network of Physicians with a clinical and financial integrated delivery network, IntegraNet Health serves as your advocate and partner. Margaret S. Matamoros Executive Director, San Antonio 210-792-2478 mmatamoros@integranethealth.c om Nora O. Garza, MD Medical Director, San Antonio 210-705-3137 ngarza@garzamedicalgroup.com www.integranethealth.com “We encourage you to learn more about how IntegraNet Health can help you “

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHH Gold Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”

MOLECULAR DIAGNOSTICS LABORATORY iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases. Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

MORTGAGE

PrimeLending (HHH Gold Sponsor) Doctor Loans, Construction Loans, VA Loans, Conventional and FHA Loans. Cleo Garza Sr. Loan Officer NMLS#218858 210-483-4907 cleo.garza@primelending.com www.lo.primelending.com/cleo.garza Home Loans Made Simple

OFFICE FURNITURE

PRACTICE SUPPORT SERVICES

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Tom Tidwell, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

KW Commercial (HHH Gold Sponsor) We specialize in advising Medical Professionals on the viability of buying & selling real estate, medical practices or land for development Marcelino Garcia, CRE Broker Assciate 210-381-3722 Marcelino.kwcommercial@gmail.com Leslie Y. Ayala Business Analyst/ CRE Associate 210-493-3030 x1084 Leslie.kwcommercial@gmail.com www.GAI-Advisors.com “Invaluable Commercial Real Estate Advice for The Healthcare Professional”

TELECOMMUNICATIONS ANSWERING SERVICE

TAS United Answering Service ( Gold Sponsor) We offer customized answering service solutions backed by our commitment to elite client service. Keeping you connected to your patients 24/7. Dan Kilday Account Representative 210-258-5700 dkilday@tasunited.com www.tasunited.com “We are the answer!"

For questions regarding services, Circle of Friends sponsors or joining our program please contact August Trevino, Program Director at 210-301-4366, August.Trevino@bcms.org, bcms.org/COF.html

STAFFING SERVICES

CARR Healthcare (HHH Gold Sponsor) CARR Healthcare is the nation’s leading provider of commercial real estate services for tenants and buyers.Our team of healthcare real estate experts assist with start-ups, lease renewals, expansions, relocations, additional offices, Purchases and practice transitions Matt Evans Agent 210-560-1443 matt.evans@carr.us www.carr.us “Maximize Your Profitability Through Real Estate”

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Donna Bakeman Office Manager 210-301-4362 dbakeman@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

Join our Circle of Friends Program The sooner you start, the sooner you can engage with our 5700 plus membership in Bexar and all contiguous counties. For questions regarding Circle of Friends Sponsorship or, sponsor member services please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366 www.bexarcv.com/secure/ bcms/cofjoin.htm

visit us at www.bcms.org

AUTO REVIEW

Automotive Features

By Stephen Schutz, MD

San Antonio Medicine â&#x20AC;¢ June 2020

AUTO REVIEW

It’s COVID-19 time, which means, I recently discovered to my chagrin, that I can’t get press cars for a while. That’s life, but the show must go on, and I’ve decided to write a column I’ve been thinking about doing for a while: a discussion of automotive features that I either like or dislike. So, in no particular order, here we go.

Backup Cameras: these wonderful devices have been around for more than 20 years and have been mandatory on new cars since 2018, but I still feel gratitude every time I use one. How many bumper dings have they prevented? The number has to approach infinity.

Smart Cruise Control: if you have a stop-and-go commute on the freeway these features are a godsend. The most sophisticated ones now use radar, GPS, and cameras so that, literally, all you need to do is steer the car. And they’re as smooth as you are, if not smoother. Stress Reliever.

Lane Keep Assist: maybe the most annoying automotive party trick ever, this “driving enhancement tool” pulls you back into your lane when you want to leave it and seems oblivious to the fact that meandering backcountry roads aren’t the same as gridded city streets. Unless you hate driving and enjoy being pushed around by your tech this is an option to avoid.

Touchscreens: I’m mostly fine with these, but I’m becoming concerned that they’re going too far (I’m looking at you, Audi and Porsche). Audio volume and cabin temperature should always be controlled by a knob, and opening the rear hatch should always involve pushing a physical button, not scrolling through menus on a screen. Sometimes engineers need non-engineers with the authority to say “Stop!” overseeing their work.

Sports Exhaust: many sporty cars and SUVs have this feature, which I mostly like. In Normal (neighbor friendly) mode the exhaust note is hey-it’s-just-little-ole-me quiet, but when you’re pushing the car in Sport mode it releases its aural Tiger King and lets the good engine sounds out. In general I enjoy this feature, but shame on Porsche for charging around $3,000 for it. There’s no way it costs more than $30 to do.

Heated Steering Wheels: OMG gurl is this not the greatest thing ever invented?!! When I first heard about it I thought it was stupid. And then I tried it, and my life changed. Like right then. I don’t care if you live in the hottest place in the world—and south Texas is pretty close to that sometimes—this wonderful feature is a must have. Early mornings will never be the same.

Blind Spot Protection: like backup cameras these are ubiquitous, and I appreciate them almost as much. I’ve always been good about checking my blind spot, but seeing that little light on the mirror somehow makes me feel just a little bit safer.

Apple Carplay: if you have an iPhone this is so great. All of your music, podcasts, contacts, etc. magically appear on your car’s main screen. And your phone’s Waze app is better than any OEM navigation system anyway. Plus you can access it all so easily. Just make sure your phone connects to the system via Bluetooth, otherwise it’s pretty lame. To get your best deal on a new vehicle, call Phil Hornbeak at BCMS at 210-301-4367. Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit us at www.bcms.org

RECOMMENDED AUTO DEALERS • • • •

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave New Braunfels, TX 78130 Matthew C. Fraser 830-606-3463

We will locate the vehicle at the best price, right down to the color and equipment. We will put you in touch with exactly the right person at the dealership to handle your transaction. We will arrange for a test drive at your home or office. We make the buying process easy! When you go to the dealership, speak only with the representative indicated by BCMS.

11001 IH 10 W at Huebner San Antonio, TX Esther Luna 210-690-0700

Northside Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Northside Ford 12300 San Pedro San Antonio, TX

David Espinoza 210-912-5087

Marty Martinez 210-525-9800

GUNN AUTO GROUP

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Honda 14610 IH 10 W San Antonio, TX

Coby Allen 210-625-4988

Eric Schwartz 210-680-3371

Northside Honda 9100 San Pedro San Antonio, TX 78216

Cavender Audi Dominion 15447 IH 10 W San Antonio, TX 78249

Sean Beardsley 210-988-9644

Rick Cavender 210-681-3399 KAHLIG AUTO GROUP

Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Mazda 9333 San Pedro San Antonio, TX 78216

William Taylor 210-366-9600

James Godkin 830-981-6000

Scott Brothers 210-253-3300

KAHLIG AUTO GROUP

North Park Subaru 9807 San Pedro San Antonio, TX 78216

North Park Lexus 611 Lockhill Selma San Antonio, TX

North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX

North Park Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257

Mark Castello 210-308-0200

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

KAHLIG AUTO GROUP

North Park Toyota 10703 SW Loop 410 San Antonio, TX 78211

North Park Lincoln 9207 San Pedro San Antonio, TX

North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257

Justin Boone 210-635-5000

Sandy Small 210-341-8841

James Cole 800-611-0176

Cavender Toyota 5730 NW Loop 410 San Antonio, TX Gary Holdgraf 210-862-9769

Land Rover of San Antonio 13660 IH-10 West (@UTSA Blvd.) San Antonio, TX Ed Noriega 210-561-4900

Porsche Center 9455 IH-10 West San Antonio, TX Matt Hokenson 210-764-6945

Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org

THANK YOU to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA

MEDNAX

Dermatology Associates of San Antonio, PA

Peripheral Vascular Associates, PA

Diabetes & Glandular Disease Clinic, PA

San Antonio Eye Center, PA

ENT Clinics of San Antonio, PA

San Antonio Gastroenterology Associates, PA

Gastroenterology Consultants of San Antonio

San Antonio Infectious Diseases Consultants

General Surgical Associates

San Antonio Pediatric Surgery Associates, PA

Greater San Antonio Emergency Physicians, PA

South Alamo Medical Group

Institute for Women's Health

South Texas Radiology Group, PA

Little Spurs Pediatric Urgent Care, PLLC

South Texas Renal Care Group

Lone Star OB-GYN Associates, PA

Star Anesthesia (USAP Texas-South)

M & S Radiology Associates, PA

The San Antonio Orthopaedic Group

MacGregor Medical Center San Antonio

Urology San Antonio, PA

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of May 21, 2020. 50

San Antonio Medicine â&#x20AC;¢ June 2020