On March 21, Peggy Peck, BreakingMED Editor-in-Chief, recorded a video interview with James D. Bowen, MD, Medical Director, Multiple Sclerosis Center, Swedish Neuroscience Institute, in Seattle. Dr. Bowen reviewed special considerations for management of multiple sclerosis during the Covid-19 pandemic. BreakingMED followed up with Bowen and asked him to reply to a series of emailed questions concerning the situation in Seattle three weeks after the initial interview. Those questions and Bowen’s answers are provided below, followed by the original video and a full transcript of that original interview.
What new challenges have you experienced over the last three weeks?
James D. Bowen, MD: As an outpatient clinic, we continue to support social isolation.
The greatest challenge is moving most of our visits to telehealth visits. We have to constantly reinvent workflows to accommodate the changes in requirements for this, and to try to assist our patients with the technology. Most of our clinic support team works from home and we have to be cognizant of communication since we are no longer seeing each other in person.
Hospitals in our region continue to be strained by the number of coronavirus cases, but the burden seems to be lessening. Even though we are outpatient, this still affects us because elective procedures, including surgery, MRI, and other outpatient procedures are still available only for urgent needs.
Have you had adequate access to PPE?
James D. Bowen, MD: Our clinic uses minimal PPE, and we have enough for our needs.
The region still has intermittent shortages of PPE, but the shortages are less severe now that cases in the community are decreasing. The hospitals and frontline clinics in our region have done an outstanding job of sharing resources, shifting PPE and equipment between facilities to help those with the most severe shortages.
Non-urgent dental procedures were restricted on March 19, which freed up considerable PPE. Also, several leaders in the region have been able to import PPE from overseas business connections.
I have a few questions about testing: Is there adequate testing available in your community? Have you been tested? Can you share the results? Have any of your family members or colleagues tested positive?
James D. Bowen, MD: The number of tests available in our region has increased in recent weeks but is not adequate for the demands. It is estimated that our state will need 3-4 times the current testing capability to meet the needs of opening our local economy.
I have not been tested. None of my family have been tested. Fortunately, none of our clinic staff have developed symptoms and none have been tested.
Are you enrolling patients in any of the FDA-approved clinical trials?
James D. Bowen, MD: Our institution is participating in several Covid-19 trials, but I am not involved in those. We have many trials related to MS, and those clinical trials continue. We see patients in person for those trials only if their treatment requires it (e.g. patients receiving IV treatments on a research study).
Finally, do you have any additional thoughts or comments to share?
James D. Bowen, MD: Washington State had the first Covid-19 case in the country and was among the earliest outbreaks of the disease in the US. Our state quickly adopted social isolation and our citizens have done an amazing job of adhering to social distancing.
We are fortunate that many of the jobs in our region are amenable to working from home, decreasing the risk of disease spread in the work environment.
We are also fortunate that our state has prepared the medical system for a number of disaster scenarios, and there is a well-functioning state-wide system of distributing patients and resources among our healthcare institutions.
We have flattened the curve the most of any state, with deaths now doubling every 3 weeks.
We continue to get new cases but are well past our peak. Deaths lag new cases, but even those are flattening now. Our initial severe resource shortages have lessened now.
Our next challenge will be to continue social isolation as much as possible, while slowly decreasing the constraints, without having a recurrent wave of the disease.
Peggy Peck: Dr. Bowen, here we find ourselves in the middle of the Covid-19 pandemic. You’re on the north coast of America. So, that’s where we’ve really seen some of the worst of it. I’m wondering what advice you are giving your MS patients in terms of Covid-19 and I think — especially patients who are newly diagnosed — what concerns they have and what advice you’re giving them.
James D. Bowen, MD: We get a lot of phone calls. We, of course, had the first Covid-19 case in the country here in Seattle. So, people have been thinking about this for a couple of months now and the MS patients are very concerned.
I think one of the issues that MS patients have is they have the misconception that MS is a disease where you’re immune suppressed but in fact, it’s a disease where the immune system is overly active. So, first, we have to reassure them that the MS does not put them at any increased risk of getting this virus, as far as we know.
A second concern that they have is that their treatments for MS may affect their risk of getting the coronavirus and we have developed protocols for each of the medicines, and most of the protocols I tell people to stay on their medicines. Some of this is because for most of our medicines, if we stop the medicine, the immune effects of that medication last for months. So, you’re not really helping them immediately avoid the risk of coronavirus, but yet at the same time you’re putting them at increased risk of having an MS exacerbation. So for the most part, they should stay on their medication.
Another factor that we have to work with our patients quite a bit on is how they themselves can decrease their risk of getting the coronavirus. There’s a lot of misinformation out there about this. One aspect that we’ve wrestled with in our region of the country, in particular, is that there are two levels of personal safety recommendations that have been going around. One is airborne and the other is droplet precautions.
Airborne are for diseases that have extremely small particles that can float in the air for days at times, and this is mostly measles and tuberculosis.
It is not the coronavirus.
An airborne precaution would require that you have an N95 mask and a lot personal protective equipment—face shields and so forth.
Droplets are the way that coronavirus is spread. So, this is basically mucus droplets and to protect yourself from that you generally need a regular surgical mask, not an N95 mask. There has been a real run on N95 mask sales at all the stores in the region, so all the hardware stores are out of them for example. But you really just need a surgical mask. So, we’re having to tell people that, that’s more what you’re talking about.
Another aspect that we have to educate patients about regarding the droplet precaution is there’s this 6-foot rule where you should stay 6 feet from people around you, and I think people don’t understand what the purpose of that is. If you sneeze or cough, the radius at which these globs of mucus will land is about 6 feet so you really want to stay 6 feet away so people aren’t sneezing or coughing right on to you.
It’s rare that a patient would be so rude that they would just cough right at you like that so, we also had to educate our patients that the biggest risk of catching this disease is not the 6-foot radius but that people will touch their face, wipe their nose, then they’ll touch a desk or another surface and then you will come along, touch that same surface and scratch your nose.
It’s really not the classic respiratory precautions that you think of —it’s actually hand sanitation, that you’re trying not to pick up a droplet on a surface and then put it on your own face. So, we really spend a lot of time also talking about hand sanitation to try to prevent this illness.
Peggy Peck: Let me ask you, since you are in Seattle and you’ve made a lot of news in Seattle, about Covid-19. What exactly are your supply chain issues there now?
James D. Bowen, MD: We are, we have about 5,000 hospital beds in the greater Seattle area and our hospitals are currently running at capacity and there’s concern that we will exceed our hospital bed capacity.
So, currently, they are putting up temporary hospital beds in a soccer field in one of the northern suburbs of the city.
In addition, one of our biggest supply chain issues is personal protection equipment for medical providers. This is just basic surgical masks for healthcare providers. There’s also a shortage of N95 ones because if the patient is on a respirator or getting nebulizer treatments, something like that, it can aerosolize and then it becomes airborne precautions instead of droplet precautions.
So, some of our hospitals in the region have less than 2 days of a supply of these masks on hand, and it’s unclear what will happen when we run out of those masks.
A third real supply chain problem is that we have not been able to run down the contacts of patients that have this virus because we do not have adequate access to the coronavirus testing.
And, one of the challenges, of course, is that about 80% of people with this virus are either asymptomatic or minimally symptomatic, so it’s not only people that have severe respiratory failure that can spread this virus. It’s the asymptomatic ones that are probably spreading it more because they feel well enough to be out there in the community and we do not have the capacity to test those.
So the number of people that have been tested in our region is limited, not only because the test, the agents that we have are in short supply, so they can’t run the test, but we’re also running short on nasal swabs to even take the specimens with.
Peggy Peck: We’ve been hearing a lot about a shortage of ventilators. What is the situation in ICU beds in addition to just hospital beds?
James D. Bowen, MD: Seattle has a very sophisticated medical community and somewhere between a quarter to a third of our hospital beds are ICU capable, so right now my understanding is we’re doing okay on the number of ventilators in the city, but there is concern that if there’s a surge in cases that we could strain our ventilator capacity.
But right now, it’s personal protective equipment that is the biggest limitation.
Peggy Peck: And then finally, I wanted to ask about, and you mentioned this earlier, that you’re converting to telemedicine visits versus in-person visits. I’m wondering about patients and their acceptance about it. I mean, how do you sort of talk a patient into agreeing to a telemedicine visit, and setting up and being comfortable with that?
James D. Bowen, MD: Yeah. I might expand that question a little bit and, if I could give recommendations to some of my colleagues, very early on—in late January, for example—our clinic anticipated that we might be struggling with this so we developed very comprehensive protocols for how to deal with patients, either calling about questions with this virus but also what happens when someone shows up at your front desk with a potential symptom.
And we have a very detailed outline of what should be done, who should greet the patient, where should they be seated, depending on the ventilation of your building, what exam room you’re going to put them in and things like that.
The other thing is, as you said, we are shifting toward doing only urgent cases in person in the clinic and, have converted most of these to telehealth visions or telehealth visits, and I have to say that every single person that I have contacted in this way has been very pleased with this.
They are concerned, but of course, with multiple sclerosis clientele, a lot of them have disabilities and they would prefer a telehealth visit anyway, regardless of coronavirus. The reason we’re able to shift to this now is, in the past, you really could not effectively bill for a telehealth visit but on an emergency basis, the insurance is covering this now to prevent exposure of these patients. So, the acceptance from a patient standpoint has been very high.
Peggy Peck: And, CMS has a code now—there is a billing code now that they’ve added.
James D. Bowen, MD: Yes, and they reimburse at the rate of a normal office visit. In the past, you could only do telehealth facility to facility, which kind of defeats the purpose for a disabled person. They’re having to leave their home and go to another facility but then the other facility gets the facility fee so they get a big chunk of the amount of money, so you would get perhaps 60% of the fee. Now, you can telehealth right into the patient’s home, and you can get a normal charge for that visit.
Peggy Peck: This information is so helpful, and I really appreciate it. I know your colleagues will appreciate it as well. I want to thank you and I hope you continue to be safe and your patients continue to be safe.
James D. Bowen, MD: Thank you.
Peggy Peck, Editor-in-Chief, BreakingMED™
Cat ID: 130
Topic ID: 82,130,791,932,190,926,130,36,192,927,151,928,925,934