 Good morning, CHWs and we're back on track. Thanks for being patient and hanging out with us here in this room Today at this time we're going to bring in Dr. Ellen Lenn and she's going to be presenting on chronic pain and COVID-19 Dr. Ellen is a graduate of the University of Texas Health Science Center at San Antonio She's board certified in physical medicine rehabilitation with subspecialty certification and pain medicine She's always had a strong desire to improve and maximize the quality of life for the patient. She treats She chose physical medicine and rehabilitation because the specialty emphasizes restoring patients quality of life By embracing a comprehensive treatment approach. Thank you guys again for being so patient. I'm gonna hand it over to Dr. Lynn Good morning Good morning everybody Can you see me? Good morning, okay. Thanks for having me here and I'll just wait until the slide comes back so we can talk about this So I hope everybody's doing okay. I know this is tough times right now And but I think we have a very strong community here in San Antonio and I'm really proud of ourselves for coming this far In fact, I was looking this morning online. I check it every morning almost like looking at the weather and now it's like the COVID 19 statistics every morning and so I'm trying to figure how to turn on my slides. How do I do that? So I can see it I've got your slides. I've got your slides and you want the slides to go live now They're going live now here. Go. Perfect. Okay. Okay, perfect. All right, and so we're doing really really well just FYI as say Community we're really flattening the curve and and so today I'm going to be talking about Chronic pain because this is a really important subject Obviously, I've been practicing here in San Antonio for 15 years and taking care of mostly chronic pain patients as well as acute pain and sports medicine but I'm happy to talk about how we can improve the outcomes of chronic pain patients and then while Doing this really tough times with our coronavirus outbreak How can we help these patients? All right, so do I just push return for the next slide? You should be able to advance your slides yourself. Yes Or maybe the arrow the arrow button on your keyboard Okay, the right arrow button Right arrow up down. I'm really sorry Oh 50-year-old Almost a 50 year old how to do this. This is a little challenging. I was like, do I go what right return? Hmm those video. Oh No Okay, all right, let's let's share your screen again. Okay. I'm gonna share my screen with oh No Starting in the moment It's not giving me back that screen again because I'm not in the speaker room again. So I don't see Do you see us? I see you and then on top of me and I'm gonna share that screen Share the lecture. Yeah, I'll share the screen with the lecture. Okay. Yay Okay Okay, can you can can you advance that slide? Can you see the slide that advanced? It advanced. Oh, okay. Interesting. Okay, all better. So it has to be it has to be done on my on my Computer, then yes, it does you're controlling it on your computer. So I'm gonna turn off I won't be able to see you guys anymore if I go into the slide Just keep doing what you're doing. Whatever you're doing is right. Okay. Good morning again I'm Dr. Ellen Lynn. I've been practicing here in San Antonio for the last 15 years in private practice We also have a nonprofit organization that we created about a year ago for chronic pain and It's called the global pain association. It's a nonprofit organization that we Try to put all the teams together that's missing in our traditional medicine to take care of chronic pain patients in a very comprehensive way So it's surprising to me when I when I was giving this lecture last year during our chronic pain summit looking up through the CDC website there are a hundred and sixty million people that suffer from chronic pain in America and that's more than cancer heart disease and diabetes combined and It's just tremendous number of patients They may not want to talk about it because it's a taboo and you know their families might be embarrassed and whatnot, but this is a very serious subject and with the opiate crisis the cost of The social economic cost of chronic pain is tremendous. So something like Five hundred and sixty billion with a B dollars per year is Engaged into taking care of chronic pain disorders from direct medical cause and loss of productivity as well as Disability programs that we hand out to these patients and so between the year of 2003 and 2014 They surveyed all of the suicide victims Data and they found out 9% of them actually have the co-mobility of chronic pain So what constitutes chronic pain? So if you go into the NIH website You'll find that the definition kind of varies from the NIH website to some international organization and then some national organizations in the US But somewhere around six three to six months the pain that lasts more than three six months is considered chronic pain and Or something that lasts longer than what the disease process should Constitute right if you have surgery things should heal up in a month or so But the pain persists after the recovery time of the typical surgery So there is a really good resource Like a task force around the the world actually so it's an international association for the study of pain or I a SP They put all the who's who's and the experts together and they study chronic pain So they came up with a whole bunch of categories, but Some might be a little bit too complex and so I don't want to bore anybody and put anybody to sleep so So here are some of the most common causes of chronic pain osteoarthritis rheumatoid arthritis obviously diabetic neuropathy we have a lot of diabetics in this city and So it you know it probably somewhere around like 40% of San Antonio is a diabetic so you develop nerve damage, you know from diabetes and Cancer pain as well as a quantity low back pain, you know I'm a quite a low back pain suffer as myself and just because Athletes, you know when they get old things kind of break down Microwing headaches is also some of the common causes for chronic pain abdominal pain. It's interesting It's more common than we think most of us grosses. They have nerve damage. Sometimes they suffer from headaches shingles neuralgia or post-opratic neuralgia is another name for it and MPTs we have a large population of veterans here in San Antonio and Barrick County area then After the Iraq war golf war, this is what they suffer from and so there's a lot of Diagnoses that we need to consider when we're talking about what chronic pain patients look like, right? So it's a very complex Disorder or syndrome I would call it. So chronic pain not only have the part of their body that hurts They they also have issues with other, you know things right if somebody who's got an imputation pain for example They're their socket doesn't fit and then they have phantom pain syndrome They might get depressed because they used to run and now they can't run and they get anxious Because they don't know when the shooting pain is going to come again to their toe. That's missing and then the family member might be kind of distending them distancing because of Lack of connections and they make it insomnia anxiety and then there's a vicious cycle of like of Chronic pain become hopeless and loss of sleep and even loss of job and family members so because of the complexity of this pain we need everybody involved to help these patients so anxiety this and just Anxiety and depression is are probably the most common co-mobilities with the chronic pain patients, but it's not Because the patients depressed so they're faking the pain, you know, that's that's not what this is all about It's very complicated, right Some of the chemicals that's missing in a depressed patient also are this chemical that are missing in a chronic pain patient So like serotonin for example, right? And so if patients have Personality disorders, they're gonna have a hard time be able to cope with this chronic pain So it's really the chicken or the egg thing and and if they're suffering from pain They're gonna want to feel better even for just like that one hour that they're taking the painkiller So sometimes opiates abuse happens and there are other alcohol abuse and substance abuse happen as well in these patients and And so we need to look at these Chronic pain patients in a very complex way. So this is one of my friends from Johns Hopkins dr. Hassan a majid He put this diagram together. I know it's a little bit blurry, but Pain has many known Hormones and known chemicals that are associated with it. So the most common one being The endorphins your serotonin that that comes in when you're feeling good, you know when you wake up in the morning and glutamate is another chemical that actually Stimulates the pain and there's something that dampens the pain you have dopamine that makes you feel really good, right? so dopamine is Fascinating is not just for Parkinson's patients are missing dope dopamine, but there are patients with restless leg syndrome are associated with dopamine as well as Some kind of satiety like if you eat something that makes you feel good ice cream for example Dopamine increases so you may be for that moment that you are in pain You're eating some something that increases the dopamine. It will make you feel better just for a brief moment so these affective disorders are Well and alive in these patients brain in their chemicals in Hormones in their system so to talk about the complexity of These quantum pain patients We got to start somewhere first You got to have a team leader so these patients need help and they need to have a quarterback So either the pain physician can be helpful because we're trained to do this or you can have a primary care doctor if you're don't have resources and in a Area where there's less Pain physicians will not have a trained Pain physician to help but the pain physician with a primary care doctor can act as a quarterback to call in the Physicotherapist or help with patients walking the occupational therapist that's going to help with their Activities of daily living and then the vocational therapists can help and maybe get back to work psychiatrists psychologists to Counsel the patient on depression and give them give them some coping mechanisms and and The community health workers such as all of you here can get them back interacting and plug them in back into the family plug them into the society and the the nursing staff they're all very important and So now now you got these the team of people helping the patients right you're ready to go you get a plan from your pain doctor or from your Primary care doctor and we're ready to go. So now you put the patients in The center as the quarterback to help themselves empower them You have all these people that have resources that they're trained to do this you're passionate about this and Now the social worker and the the team leader is going to come in to integrate all this stuff together to help The patient recover and ultimately what we want to do is not just to treat the pain and it's not targeting or We preoccupied With that part of the body that hurts that that's not the point here, right? We got to make sure the patient as a whole comprehensively can be reintegrated into the society Right and as a physician at this point the patient is going through the rehab phase and Recovery phase I'm only here as a little reminder and to connect the team together But we're equally important in taking care of this chronic pain patients needs So this is one of the 12c approaches that I have borrowed from rehab Institute of Chicago and I thought this is really interesting right we can talk about the mechanism of actions and Chronic pain, you know diseases and how it would cause that but I I really personally don't think after 15 years of taking care of pain Ponypain that's not that that's not the that the the Ideal situation here again my emphasize on the team. It's a comprehensive approach you must take care of the patient communicate with your team whether as a Community health worker social worker you got to communicate with your doctor talk to the physical therapist You know, do they need to have a walker? Do they need to have a ramp on to into their house or into their car? So they can be a community Mobile person so we care about these patients. We have to make the commitment to these patients we have to coordinate all this care and and then Confirmed some of the difficulties that these patients are voicing or their families are voicing You got to have a team meeting almost in ideally with a meeting like this for the families and Many of your rehabilitation doctors as well as some of your pain physicians who are trained in this and are familiar with it the 12c approach is very effective and you can go to the the RIC website org and Look at their statistics and their research on this very comprehensive rehab for chronic pain patients So Ideally, this is what we want. We want to make sure that the patients recover from their chronic pain not just from Decreasing the part of the body that hurts but we want to make sure that they get plucked back into the community and to be able to be a mom or be a husband be a grandpa and And going back to be a policeman or a nurse or whatnot Okay, so here are some of the resources for chronic pain I'm gonna be shameless and put the global pain association because we are Probably one of the only few in the country that do a comprehensive Non-profit free care, you know for patients in who suffer from chronic pain there's also a local organization called Hope Weiss and that's organized by a bunch of psychologists and counselors and they do have free sessions Counseling sessions. I believe four times a month if you go to their website Hope Weiss a calm and look up the schedule for free counseling and they actually are unique because they offer For teens and that's their subspecialties and teens with depressions and chronic pain. There's five national fibromyalgia network Also, there's nursing American Society of pain management nursing chronic pain association so so forth and so on and Most importantly, you know, we don't want to think about this and but not to avoid the subject But chronic pain patients have higher suicide rates and there is providing that hotline Prevention line to the chronic pain patient at the 800 number is I think it's really important you just you just never know and We locally here have something called the near me San Antonio. They also have It's like a suicide hotline and crisis care Clinic and the 210 223 7233 number is down in the bottom Okay, so I can't I changed it this whole lecture completely just because in the last four weeks I've been talking about what reading about COVID-19 and then I was starting to worry about my patients will have a chronic pain because they have less resources and They also have other cold mobilities in their health That might predispose them to contract COVID-19 and have worse outcomes in the general public So then I started thinking Why and how was I coming to the idea that chronic pain patients might have a worse outcome? So there it is. Dr. Light in China between the month of January I think she took about a week and surveyed 1250 healthcare workers in China and 50% of them have already just within a month or two suffer from depression And they didn't have any signs of depression prior to to the the survey 44.6% have anxiety. Remember that circle of chronic pain patients with depression anxiety and You know the the vicious cycle of a chronic pain. I call it they have insomnia also So you kind of see the resemblances of COVID-19, you know, healthcare workers, right? Okay, so 71.1% have also distress So now these are the people that could be taking they're taking care of COVID-19 patients But but you know, could they become chronic suffering, you know, chronic pain sufferers themselves or they become Caretakers for for a chronic pain patients. So So these are things to kind of consider and you know ponder and maybe research about so How can we prevent these frontline? healthcare workers from becoming depressed or going into a chronic illness or chronic pain state Maybe there is a way to prevent them from becoming my patients, right? So now I would I don't think anybody in this audience Unless you're younger than 20 years old would forget the day that we 9-11 happened at the World Trade Center So interestingly I went back and look at the the literature on this 17% of the responders who were at the World Trade Center They were trying to compare the people that were inside of the World Trade Center That were taking care of the first I mean the first responders that were there Compared to the first responders who were in the hospital, for example, right some way else 70% of them have depression and then 7% have PTSD and 12% have Reflex gastric reflux and 12% have airway disease. And so compared to the rest of the first responders Away from the World Trade Center these First responders inside of the World Trade Center have seven times more likelihood to have PTSD and two times more depression So, how can we learn? What do we learn? So I was thinking about how do we learn from 9-11? Because you know, they're both catastrophic events 9-11 I will never forget because my I was pregnant with my daughter She's now 18 years old and I was thinking wow, you know, what is the world's coming to an end, right? And so Same thing I'm like thinking again. Okay. I can't believe this, you know, 18 years later We're gonna have another Problem, but it's not terrorism. It's like viral pandemic. So how can I Help as a healthcare worker as a provider to Think about what happened 18 years ago To maybe decrease decrease the the consequences or the impact that COVID-19 can have not just as a physician But also as a community Person and a leader, right? So can we identify? What are the common symptoms in these cohorts the nurses and doctors and your firefighters and your first responders in the field taking care of the COVID-19 patients and And some of the quantum pain patients are isolated at their homes already and they don't have resources So find the common symptoms of these cohorts these people and then you monitor them So at the University of Stanford Interestingly, this just happened a few days ago. Maybe a week ago. They actually have a web link if you look up Stanford University You can go into their Website it's it you could click on they they have a daily reminder to ask you questions about COVID-19 and Measure your temperature and all that so they're keeping track of these patients and you know, that's voluntary obviously and It's HIPAA compliant. And so I think that's a really good idea moving forward from here so that you don't have You can monitor these people who may become chronic pain sufferers or chronic illness sufferers So so these are task forces that the community is putting together To provide Emotional care and physical care and maybe later on to develop some kind of protocol for safety and to prevent the the horrific impact That this pandemic is my Present later on so so again, I Was really worried about Quantum pain patients my patients who suffer from chronic pain and they're gonna have equal Opportunities to be infected with the COVID-19. So the higher the incidence of autoimmune disease and they also have Comorbidities such as a diabetes thyroid heart conditions obesity and Maybe their bodies are deconditioned because they can't walk around as much because they heard and cardiac problems and hypertension and all that Right. So how do we lower the risk of the COVID-19? virus in affecting the chronic pain patients as well as all of us who are in Healthcare so These are the same recommendations from the Bayer County and CDC and WHO so you know cover your mouth when you sneeze and don't get anywhere in the bubble of Somebody I think about bubble is not just six feet But you know behind them as well right social distancing is it's becoming very effective and I'll show you a slide later on how They're counting is doing we're doing excellent by the way in the state of Texas and in the Bayer County so cling surfaces when I come to work I actually have Clorox wipes and I wipe down my monitor I don't know who was there the night before the cleaning crew, you know, I just don't know that so Clean the door knobs I tell my kids to wipe down their door knobs and clean their desk and There are tables and kitchen and all that and 20 seconds of hand washing It's really more important than you can ever believe it actually works better in some ways than The wipes if you have a chance to use a soap the soap actually spices the the virus open so from what I have read and Once you have touched something definitely do not touch your face. That's how things get infected So this is just like a cartoon. It's this Talking from your left screen to One meter one meter is about one yard and then four meters about 13 feet or something like that Okay, so there are big droplets and little droplets when you cough when you sneeze when you talk and you know that this gives you like a diagram of how far your plume of Droplets and well was spread. So just keep that in mind. This is not necessarily COVID-19 There are different sizes of viruses and germs and stuff that's different But but if you put this picture in your head like one yard, okay, there's a bunch of big droplets and then going out to like 10 That is 13 feet four meters is about 13 feet. There's a whole bunch of little droplets still All right, so things to consider if you are in the front line taking care of patients in their homes and in the community and the Clinics and whatnot, you know, please I would recommend I know this is not recommended by the state of Texas yet and it's not mandated but where a mask when you go to your patient's homes and clinics and When you go to the public grocery stores and I put your mask on and and there is actually a study in Asia where they looked at different groups of Healthcare workers one where N95 and the other group wore just regular surgical mask and apparently the surgical mask which it's a little bit flimsier than the N95 actually does not make a difference whatsoever whether you wear N95 or not So this is in the hospitals where they're taking care of COVID-19 patients. So anything will be helpful I think so don't share your food and drinks the common sense, you know common sense Wash your fruits and vegetables and if you come into contact with the patient, please Please consider changing your clothing and stuff like that. And so now it's a really good time to practice telemedicine and even old people You know, I actually am impressed with some of my patients where it was able to Talk and be talking to doing this and walk them through the telemedicine Process and we can see them and kind of check up on them. So reach out to your family members as well who may be suffering from chronic pain or maybe a little more isolated and Take care of yourself. That's your number one if you don't fill your cup I always say if you don't fill your cup, you cannot give to somebody else So take care of yourself as we all are healthcare workers. We're gonna get burns out and So your well-being is very very important. So this is a quote by Benjamin Franklin by failing to prepare You are preparing to fail So I've been looking at this website. This is well, this is the the website was telling you about It's by the University of Washington. You can go to just Google University of Washington or COVID-19 health data Okay, I'm sorry. I misspelled it should be health data not how date health data and It will have a drop down menu if you haven't seen this already It says United States on the top and then you can scroll down To Texas and then you will find This okay. Well, okay. I'm sorry. This is uh, I'm I'm showing New York first Okay, so you go down to New York they had their social distancing and isolation order from their state March 22nd, which is just about a week or so before we did okay They had the outbreak form a couple of months already, but they did it about a week before Texas did and look at the peak So the dotted purple line is the peak of the COVID-19 Beds that that they need and then the shaded the shaded graph if you see the shade of graph right here That shaded graph is the beds they have available But you know, you can see that they're not going to run out of beds. It's it's going to be okay But on the other hand It's this is Texas. We're doing so much better because on April 2nd Governor Abbott put stay-at-home order and look at how flat Compared to New York the curve is so whatever we're doing. We're doing a great job. So keep emphasizing that reminding your loved ones and your patients and everybody around you This is what we need to achieve and maintain that and this is a mean that we're safe Because the peak is coming about end of april maybe into may and what my fear is For easter we might want to really struggle hard. We want to go see our family members Even though the parks are closed. We want to go and hang out, you know at some You know our grandparents house or whatnot that peak is going to go back up again We're going to have a second wave of this COVID-19. So I would like to make sure that we remind each other and to take care of each other and that's how we love each other Okay, and so the dotted line is way down flat. So I I expect in the state of texas and in bear county We're going to be fine and the death rate is going to be very minimized so These are the resources for Texas and beyond so the the state office governor has a website just texas.gov and you can look at the department of health And cdc and the bear county website has many many great resources on COVID-19 and to help how you help your patients and the COVID hotline if somebody If any of you or your loved ones or your family and your patients are Exposed or I worried About their symptoms. The hotline is right here. It's 210 207 5779 I'm not sure what their hours are but they I know they have At least nine to eight o'clock in the in the in the evening. They're expanding their they're Trying to expand to like 24 hours. They have weekend hours as well. So go into the cobit hotline bear county Website and and call them and be prepared when you have problems and you can call them All also all of texas med clinics now Which I believe they have 20 clinics around the bear county as well as austin They have testing kits readily available to go Okay, so Thank you. I would take some questions. That is wonderful information. I appreciate all your expertise and your knowledge that you've contributed We have about two minutes. I see a question here. Uh, do you treat pregnant women with chronic pain as well? Uh, this participant has a client who's suffering from back pain, but unable to get medication because she's pregnant So I want to offer a quick platform for you to maybe address that But if we also need to take this offline and connect you guys via email, we can do that as well Um, okay. What are your debony thoughts on that? I will take questions for the next minute and a half and then I'm happy to do emails as well so I hope everybody stay well And uh, I know we're really at great. I think we're the best county of all of texas um, but remember For the next week. So this weekend. Holy week. Easter is coming. I just emphasize. Please. Please Stay at home. That doesn't mean that you stay at home. You do nothing. You know, there's a lot of uh Backyard you can go to and you know, uh, you can run on the streets and just take care of yourself Take care of your mental health as well as your physical health. And this is how we best fight And to remind everybody that we should Not trying to expose ourselves with we could be factors or Silent carriers and you definitely love your family and friends and your patients in the community this way. Just just just to hunker down Thank you. Dr. Lynn. Thank you so much We'll go ahead and send you some uh questions via email and we'll be in touch with you. Dr. Lynn And thanks so much. Thank you. All right. Stay well