Ep 10 - “Supercharging Standard Precautions” with Massage Mastery Online’s Anne Williams

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"Supercharging” your practice protocols is an investment in practitioner and client safety during COVID. Join us in this latest episode of The ABMP Podcast’s "Conversations in Quarantine" as author and educator Anne Williams discusses actionable items practitioners can take to adapt their practices. We also check in with Ruth Werner regarding recent World Health Organization statements.

Note from ABMP: As you are aware, much still remains to be learned about COVID-19, and protocols and precautions for returning to work are constantly shifting as new information emerges. After this podcast was recorded, Anne Williams sent us this update to the facemask discussion included in the podcast. 

The CDC recently updated their guidelines for the reuse of N95 respirator masks based on a study showing that detectable levels of SARS-CoV-2 were present on the outer layer of a surgical mask after 7 days (Chin, 2020). The study suggests that the amount of detectable COVID was not high enough to cause infection. However, the CDC now recommends that each health care professional is issued five N95 masks. A mask is placed in a paper sack at the end of a shift and left where air can circulate around the mask for five days before it is worn again (CDC, 2020).   

As massage professionals we must reconcile a number of factors as we contemplate managing our personal safety and the realities of N95 facemask availability.

  • Perhaps we can get hold of five N95 masks and reuse them applying the CDC recommendations and feel a high level of protection.
  • It is more likely that N95 masks will not be available or we are only able to get hold of one or two masks. In this case we should opt to supplement our N95 masks with heavier surgical masks. However, we must understand that surgical masks will not protect us from small particle respiratory droplets.
  • How high is the COVID caseload in the community? If the caseload is lower than we are at less risk of encountering an asymptomatic client and we may feel safe enough in a surgical mask. If the caseload is higher than our chances of encountering an asymptomatic client are higher and we must decide if we feel safe enough in a surgical mask. 
  • Do we have underlaying conditions that place us at high risk of a serious case of COVID if we are exposed? If yes, we’ll want to be in N95 masks if we decide to open our practices.
  • Maybe we are willing to practice exceptional PPE safety and we put on and take off masks properly and clean our hands if we absentmindedly touch the surface of the mask. Maybe we feel safe enough simply treating the outer surface of the mask as contaminated and handling it with a high level of caution. 
  • Remember, when your mask shows wear or remains damp inside and no longer conforms to your face, or if you start to have difficulty breathing in the mask, it should be replaced.

1.     Chin, AH., Chu, JT., Perera, MRA., et al. Stability of SARS-CoV-2 in different environmental conditions. The Lancet. April 2020. www.thelancet.com/journals/lanmic/article/PIIS2666-5247(20)30003-3/fulltext

2.     Coronavirus Disease 2019. Decontamination and Reuse of Filtering Facepiece Respirators. Centers for Disease Control and Prevention. www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse...

Author Images: 
Author Bio: 

Anne Williams is the Director of Education and Cofounder with Eric Brown of Massage Mastery Online, specializing in digital textbooks for 21st century massage therapists. Anne has been a licensed massage practitioner for 23 years, and is a former esthetician, certified reflexologist, clinical hypnotherapist, former registered counselor, aromatherapist, spa consultant, author, and educator. She is the former Director of Education for Associated Bodywork & Massage Professionals (ABMP), former director of education for Ashmead College, and has served on the Federation of State Massage Therapy Boards’ (FSMTB) test writing committee, served as project leader for the Entry-Level Analysis Project. She is the author of Spa Bodywork: A Guide for Massage Therapists and Massage Mastery: From Student to Professional.

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist's Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Werner is also a long-time Massage & Bodywork columnist, most notably of the Pathology Perspectives column. Werner is also ABMP's partner on Pocket Pathology, a web-based app and quick reference program that puts key information for nearly 200 common pathologies at your fingertips. Werner’s books are available at www.booksofdiscovery.com. And more information about her is available at www.ruthwerner.com. 


This episode sponsored by Anatomy Trains and Yomassage.

Full Transcript: 

00:01 Speaker 1: Anatomy Trains is excited to announce the release of Anatomy Trains Fourth Edition. This new edition comes with a free enhanced e-book, including hours of video. Learn more at anatomytrains.com.


00:24 Darren Buford: Welcome to the ABMP Podcast in our series, Conversations in Quarantine. My name is Darren Buford and I'm the Editor-in-Chief of Massage & Bodywork Magazine and Senior Director of Communications for ABMP. Our goal is to speak with luminaries and experts in and around the massage profession to talk about the effects of COVID-19 on bodywork practitioners, the fears, the frustrations, and more importantly, to discuss next steps toward safely re-opening our doors when the time is right, how to pivot now, how to prepare for the future, and discussing what the new normal might be.

00:55 DB: Joining us first today is Ruth Warner, author, educator, and frequent ABMP collaborator. Ruth, I just wanted to ask the... WHO released information about asymptomatic spread of COVID-19 being very rare. What's up with that?

01:13 Ruth Warner: Yeah, they did. And I went and looked at the who statement, and then I looked at an article that came out within hours of the same statement proposing basically exactly the opposite of that. And so, I'm glad that you asked me that question. [laughter] The WHO came out with it just the following day of saying asymptomatic spreading is very rare, to walk that back, and their final statement on this is that asymptomatic spread is "not determined". And it may well be that the World Health Organization was not doing a great job at separating out the difference between people who are positive for COVID and who will never develop symptoms versus people who are positive for COVID and who have not yet developed symptoms. And so that's not... It's asymptomatic in that they don't have symptoms, but there's a "yet" on that. So that's the difference between a symptomatic and pre-symptomatic, if that makes some sense. And what we know about pre-symptomatic people is that they can be highly contagious. They can be great vectors of transmission. And it seems the data suggests that people are most contagious one or two days before their symptoms really kick in.

02:45 RW: So, was the WHO, was the World Health Organization making a... Finding the right delineation between who's asymptomatic and who's pre-symptomatic? It's not clear. The statement was based on a whopping great four different studies that didn't have a huge number of participants, so it was really a relatively small sample size. And I think what they were trying to... I have to read into this because the statement itself is quite confusing. But I think what they were trying to convey is, "We are trying to figure out through really, really detailed contact tracing, how easy it is for this virus to spread from a person who truly is never test positive, but will never develop symptoms."

03:32 RW: And what they found in that small sample size is that it's not terrifically easy, either because they weren't clear about the way they stated this or because headline editors like headlines that make people click on the [chuckle] article. The message was... The message that got out somehow was, "So don't worry about asymptomatic spreading because it doesn't really happen." And so that made people start asking, "Alright, well, so is it safe to get back to my massage practice? Is it safe to work without a mask if nobody has any symptom? 'Cause the World Health Organization says it's safe now." And that is not the correct conclusion to take from this message.

04:22 RW: So on the same day, there was quite a detailed article in Time magazine that was basically reviewing an article, and I've read the Time article, I have not gone back to the Annals of Internal Medicine to look at the source material yet. But this was a much larger study that was international, it was all over the world, and looking at the possibility of asymptomatic versus pre-symptomatic spreading, and their conclusion was essentially exactly the opposite, and that even when they controlled for people who are asymptomatic and do not develop symptoms, their finding was that somewhere between 30% and 45% of new infections are being sourced back to those people, which gives us a very different picture of what the reality is.

05:19 RW: Now, that Time magazine article, and we'll point again back to the Annals of Internal Medicine, have some other findings and conclusions that we may have to start paying attention to, and one of them is that idea that if you are exposed and you self-isolate for two weeks and you don't develop symptoms, then essentially that's your get-out-of-jail free card. And their suggestion is that that might not always be true. That's not great news. So that's one of the things we're gonna have to watch really carefully. And the other big thing that we'll have to watch carefully 'cause nobody knows the answer is, how long is someone communicable? Right? If someone is exposed, asymptomatic or not, for how long can they transmit that virus?

06:15 RW: And typically, we think it's while... Nasopharyngeal samples come up positive because the main transmission is through droplets and aerosolization. So if you got no virus in your sinuses and in your upper respiratory tract, probably you're not very contagious. But again, we've had, what, five months to look at this. This is such a new phenomenon and we don't know the answers to all these things yet. So in that whiplash between the Annals of Internal Medicine and the World Health Organization, I'm coming down toward the Annals of Internal Medicine's side to say, yes, keep wearing your masks, that's a whole other debate we can talk about on another day. Yes, maintain physical distancing, not necessarily social distancing because we need our support groups, and yes, don't assume that because someone has no symptoms that they cannot share the virus, because that is probably not the case.

07:18 DB: Ruth, should MTs change anything? Because ABMP did a lot of work on the back of practice protocols, the FSMTB did a lot of work, a lot of people in the profession have done a lot of work. So we should still listen to that, right?

07:33 RW: Yes, I really do think that that's true. And I am a great admirer of the ABMP back to work guidelines. I helped to work on the FSMTB back to work guidelines. And the main things about those guidelines that are shifting now really is not so much about what we understand about the virus, but the availability of PPE to people who are not frontline healthcare providers. So for instance, it's conceivable at this point that a massage therapist could get their hands on a good quality N95 mask and not be taking it away from someone who needs it more than we do. And so those are the kinds of shifts I'm encouraging people to consider rather than that the virus is less impactful than we thought it was 'cause it's not.

08:20 RW: And we're making this recording on June 10th, so several states opened up about 10 days ago, and we are seeing not... Who could have seen this coming? Spike's not only and diagnosis, but in hospitalizations, and to me, that's really a much more important metric. I hope that diagnosis numbers go up just because that can be a reflection of better and more widespread testing, but it's... When those hospitalization rates start going up again, then we come again up against that need to flatten the curve because it's really about overwhelming the health care system.

09:00 DB: Excellent. Thank you so much, Ruth, for joining us and answering questions. I know this is really valuable. And I wanted to check in because, why not? [laughter] I know a lot of people read this information and were probably thinking, "What?" And they may not have seen the follow-up where the statement was retracted and... Or corrected.

09:18 RW: Clarified. It was clarified.

09:20 DB: There you go. Thank you so much, Ruth.

09:22 RW: My pleasure. Thanks.

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10:07 DB: Joining us next is Anne Williams. Anne Williams is the Director of Education and Co-Founder with Eric Brown of Massage Mastery Online, specializing in digital textbooks for 21st century massage therapists. Anne has been a licensed massage practitioner for 23 years and is a former esthetician, certified reflexologist, clinical hypnotherapist, former registered counselor, aromatherapist, spa consultant, author and educator. She's the former Director of Education for ABMP, former Director of Education for Ashmead College, and has served on the FSMTB test writing committee, served as project leader for the Entry-Level Analysis Project, and is the author of "Spa Bodywork" and "Massage Mastery". Hello, friend.

10:53 Anne Williams: Hey, how's it going?

10:54 DB: Good, good. I think our readers should know that... Our readers or listeners should know that you and I have worked together when you were an ABMP employee for quite a long time, and we have a long history and have worked with each other on numerous products, or projects and products, and it's always been a joy to work with you and work together. So I'm so glad that you're joining the podcast.

11:17 AW: Thank you so much for having me. And yes, I miss my ABMP family, so it's great to connect and have a chance to share sort of what I'm doing next, but also know that we're gonna work together in the future.

11:29 DB: Yay! Okay, so let me ask you a little bit. Tell me about... For those who are unaware, Anne Williams is the author of "Massage Mastery". Anne, tell me a little bit about the history of the textbook that you wrote, and leading up to where we are today with that product.

11:52 AW: Sure thing. So I actually have two textbooks, "Spa Bodywork", which is a guide for massage therapists, and "Massage Mastery: From Student to Professional". They were both published by Lippincott Williams & Wilkins, and they... And Lippincott, I just call them Lippincott, they went... They decided to discontinue their massage therapy textbook line and focused more of their resources on their nursing line. And as we all know, massage has sort of been going through this very slow contraction that is hopefully over now and it's gonna expand again soon, but they just weren't making enough money. And they stopped putting resources into marketing those textbooks, too. So all of us as authors for Lippincott I think were pretty frustrated. And then we got the great news that we were all getting our textbooks back. We got the rights back, they gave us the imagery that went along with our books. So that was a big exciting thing, and that happened in late 2018.

12:58 AW: But for me, I was fully engaged working at ABMP at the time. I really didn't know what I wanted to do with my textbooks. A lot of authors, they worked right away to find other publishers, and I sort of said, I do not wanna publish in the traditional way. I was crystal clear on that. As an educator, I feel like textbooks are going the way of the dinosaur. Students don't read them. They don't do what you really need a textbook to do. And I just felt that there had to be a better way to do what we need a textbook to do, which is deliver level one content to learners. And level one content is where a learner can understand what is being said to them or what is being presented to them, and they have an initial response to it.

13:53 AW: And the thing about learners are is this, when they are listening to a lecture, reading a textbook, listening to a podcast, watching a webinar, or whatever it is, a learner, and that means anybody, has one of two responses: A response might be, "Yes, I get this, I'm ready for more," or a response might be, "Yeah, I don't get this, I'm out." And textbooks so often leave a student feeling, "Oh, I don't get this, I'm out." So I really believe that we could do it better. And I started to discuss this with my husband, I had discussions with people at ABMP about it, like what could a textbook be? And when people hear digital textbook, they think PDF, and this is way more than a PDF. So what I'm trying to create is a digital multimedia textbook that engages the learner and pulls them into the content.

14:51 AW: And I'm trying to use everything that I've learned about instructional design to make the process of level one content learning much more efficient, engaging and exciting for the learner. So I'm using, hopefully, we're not there yet, but I'm moving towards an instructional design model that is, read it, see it, hear it, watch it, apply it, and own it. And so when you can do those things as a learner, your learning is much richer, and you're moving way beyond level one of learning. You're moving to level two, which is where you could take information and apply it in new ways or in new settings, which is what you have to do to practice massage. At level three, a learner uses content to solve problems. So with a digital textbook, I could take you all the way to level three of learning, and that's not always necessary, but I can do it if I want to.

15:56 AW: And with a traditional textbook, I'll be lucky if I can get you through level one. So this was a way for me to teach better, to provide better content, richer content, content that's gonna serve schools and students and professionals more effectively. So what happened then was Massage Mastery was going to be launched in this new digital multimedia edition in late February of 2021. That was my plan for it. And what happened was schools ran out of the printed copies. And they ran out of those printed copies in December of 2019. And they started writing to me, "You've gotta do something." All of the used books were gone. People had bought them up. Barnes & Noble and Amazon were selling the copies that were still available for $89-$120 per copy. So it was just too expensive for schools.

17:01 AW: So Eric, my husband and business partner, moved Massage Mastery into an online digital format. It's plain Jane. It's got some of the features of a digital textbook, but it really is just to make that product available. And we're letting schools have it for a nominal fee per student, just $19.99 per student, which is great. But then COVID strikes, and that transitioned us to where we are today. Because I had already re-written "Preventing Disease Transmission In A Massage Practice", which was a number of sections for Massage Mastery in the future. So I had chapter one through seven written, and I added a chapter eight.

17:49 AW: And Eric went to work, turning around our website, making our website happen. We had all this custom programming for schools planned. We accelerated the timeline on that, and we did it in a month. While I wrote the chapter, he did everything else. And we launched "Preventing Disease Transmission In A Massage Practice" with a whole chapter and a whole lot of resources for people, massage professionals and students related to COVID-19.

18:23 DB: As somebody who went through... I actually went through Preventing Disease yesterday, I loved it. It was interactive for somebody who was not as knowledgeable on the topic, it was really easy for me to understand because of the imagery, the interactivity of the product, the way you did summaries at the end, it was micro-learning and it was chunking of materials, it was all those things that I think help learners. Correct.

18:47 AW: Yeah, yes, I'm able to take what I've learned about instructional design and apply it in a totally new way, and I definitely have made some mistakes, like this is the first try. And I can sort of see how some things need to work a little bit differently in our next product, but that is the beauty of it, and I can change this product too at any time, and that's been absolutely essential with COVID-19, I update that COVID Chapter every single week religiously on Fridays, because every single week there's something new that I either learn that sort of shifts my thinking or that has sort of come out. And this is a good time with COVID, things are settling out a little bit, and the CDC is able to make much more directive recommendations to healthcare providers.

19:41 DB: Let me ask you a little bit about Preventing Disease, which you've made available for free for practitioners to download. In the opening to the new piece, you mentioned that the material may be important for EMTs, obviously because of COVID, but also because of potential knowledge gaps in their training. Do you find that to be true? And what I mean is, when you think about an EMT's basic training in school, how does that fare in a COVID world, will this be material be new to them, "Oh yeah, I remember that." Or, "Oh my God, I didn't learn this in school." Or, "Yeah, I've been doing this all along."

20:16 AW: I've had people responding all of those ways, and one of the things that's been really interesting is... And one of the things I know just from my work at ABMP is how consistent and inconsistent education is. And sometimes people are getting a great education and this will feel like a refresher, and sometimes they are saying to me, "I never learned that in school, I've always been confused about what is standard precautions, I've never really gotten this." And then some people say, "Well, I learned it as universal precautions." And it's like, "Yeah, it's all been updated since then by the CDC, and it's different now."

20:57 AW: So I think that sometimes just being in the profession for 25 years or however long people have been in it, you've missed some upgrades that have happened, you've missed some shifts that have occurred, so that might be a knowledge gap that you have, or you've fallen into some habits which seems safe enough to you and maybe they were. But they're not safe enough now because COVID is a whole new animal. Our society is very comfortable with passing back and forward the common cold, we're comfortable with sort of saying, "Nobody is gonna die from this. It's okay." We're in a whole new world now. It's a different reality, and that's why I use the terminology in the book of Super Charge It, we have to super charge our knowledge, our cleaning and sanitation, we have to super charge our policies and practices. We have to bring a whole new level to the game. It's a whole new game. We gotta be a whole new therapist.

21:58 DB: To add that practitioners are gonna feel safer, clients are definitely gonna feel safer, they're gonna feel more comfortable, and if they see a practitioner who's following the standards of the chronology that you set up in your digital textbook. If I knew that my practitioner was following these guidelines, I just immediately buy-in. I'm like, "Yes, look at... This is what I was looking for." If I see somebody not following protocols or it's sub-standard, the amount of work that they're doing or that they're showcasing for me, well, 'cause it is a little bit of show and tell it. Here's what I'm doing. Oh, I see what you're doing, you've done an intake before I've walked in. You're calling me, I'm waiting in my car, I'm not going into a waiting room, and then you'll text me when I come in, maybe using touchless payment. There's any number of sequence of things that are gonna make clients feel comfortable right now in this challenging time about continuing to receive massage.

22:55 AW: Yeah, there's the whole level of comfort for the client, but for me, my biggest concern is not the client, it's really the therapist. You're the one at the most risk. You're the one who is being exposed to a whole lot of new people, and obviously that puts your clients on down the line, at risk, but you're the one who could take this home to a family member. That's such a big concern for me. So I keep saying to people who tell me I'm a fear-monger and that I want them to do too much. I keep saying, "Well, in a month's time or two months time, or when we have a vaccine, or when this is all over, if we look back on this time in our lives and we say, 'I didn't way too much, I was too careful. My place was spotlessly clean. I worked so hard. But we're alive. Our parents are alive. Our children are safe. Our grandparents are safe.' We're just gonna say, 'Well done me, I super charged, I kicked some butt and COVID didn't get me and my clients are all safe.'" So for me, I'm like, "Just show up." Take every precaution you can. Protect yourself, protect your family. Protect your clients. Do the right thing.

24:12 DB: Let me ask you a couple of... Let me ask you several rapid-fire questions here because I really want people to be able to go check out Preventing Disease on online, and I don't wanna give away all the great material that's in there. So maybe just some things that I picked up on that I thought were fascinating. Can you tell me a little bit about massage practitioners right now who have back bar or retail sales? How do they do that?

24:35 AW: So that's really tricky. The first thing you wanna do is promote social distancing in a retail area, so you don't want people crowding the retail salesperson, so place tape where you want people to stand, make sure that they can maintain six feet of distance between them. Ask people to sanitize their hands upon entry so that their hands are clean with an alcohol-based hand sanitizer, they should be wearing a mask at all times when they're in your facility, and then ask them to only touch those things that they intend to purchase. If they touch something, you're just gonna need to know that you'll need to go in and sanitize really well in between client visits, so maybe that's six or seven times a day, you're in there wiping down surfaces.

25:26 AW: The other thing is, think about the ventilation. How ventilated can you keep that space? If it's a really small enclosed space, one person at a time, and then you're really ventilating it in between uses that's the biggest thing, is ventilation and keeping down the number of people on your facility or in a particular space at one time.

25:48 AW: For me, the thing is, the studies on this are a little inconclusive, and one thing that's definitely happening right now with research is people are trying to get out ahead of this, so they're publishing research without careful peer review. So even like the World Health Organization and the CDC, they're publishing stuff that doesn't get vetted the way that it normally would. So I'm hesitant about this because I felt a little uncertain about some of this research, but we know respiratory droplets can land on dust and when they land on dust, they are re-dispersed into the air with dust particles where they can be inhaled. Now how much live virus is there on the dust particle will matter and who can measure that at this point, but because of all the extra ventilation, we wanna be dusting a lot more, we wanna keep our places dust-free so that all that circulating air isn't working the dust up, throwing it into the air where people are going to breathe it in if it becomes contaminated. So keeping your retail area super dust free is another sanitation burden.

27:03 AW: And one of the things I talk about in Preventing Disease is decrease de-clutter, de-junk, get rid of anything that becomes a sanitation burden. This is not the time to have magazines on tables, they need to be wiped down in between every client. Get rid of that stuff, just get a really pristine. It's time to go minimal.

27:25 DB: You mentioned also in Preventing Disease about potentially eliminating 90-minute massages for the time being, can you elaborate a little bit there?

27:33 AW: I will and I will just say that there's no conclusive research on this, we're still in the dark, but we have... We can make some assumptions, I think some safe assumptions about COVID-19 and the fact that the amount of time that you were exposed to someone who has it factors into you getting it or not. And originally, I was saying, get rid of 30-minute sessions, you're doing so much cleaning in between clients who wants a 30-minute session, but now I've changed that because it's digital and I can. Now, I'm saying get rid of longer sessions, 60 minutes is your maximum session that you were exposed to one person.

28:20 AW: And I just wanna remind everyone, you know all of those face coverings that people say are fine, they're based on the idea that you're maintaining six feet of distance between you. We are in each other's air space, I am right above you as a therapist working over the top of you, and when you're face up on the massage table, when you're supine on your spine, you are breathing into my air space, so you must have a mask as a client. And a face covering, I do not believe is good enough, so this is another place where people tell me I'm a fear-monger.

28:56 AW: But I believe massage therapist should be wearing N95 respirator face mask. And these are the kind of face masks that health professionals are using in a hospital, but we are having one hour a full on contact with another human being. Now, If we've picked it up and we don't know we have it, or if they have it and they don't know they've had it, we are in contact with somebody who's potentially infected for an hour, we need the best possible face mask for that situation.

29:29 AW: Now, originally, I would say, "Oh, there's this huge ethical decision because we're taking it away from healthcare providers," but honestly, the stocks have come up, you can get them all over the place now on the Internet, so that must mean that there's enough for healthcare providers and we haven't heard about this in the news for a while. So I was just looking into this this morning, and I can't find evidence that people are still having problems with getting enough respirator masks.

29:55 AW: And as a massage therapist, you need two masks and you're gonna recycle them and this is approved by the CDC. What you're gonna do is you're gonna wear one mask for a full day of shifts, that doesn't mean you can't take it off, just remember, because these things are hard to breathe in, I think. You're gonna take it off using the straps, you're not gonna take it off sort of touching the surface. If you touch the surface of the mask, your hand is contaminated, you need to wipe it down with an alcohol-based hand sanitizer. But when you're taking a break and you wanna take that heavy duty mask off, just take it off and put it right into a brown paper sack and use the little straps to sort of hang on to it and hold it and manage it.

30:43 AW: De-contaminate your hands with an alcohol-based hand sanitizer. When it's time for your next shift put it back on and go again. You're gonna use one for one shift and then you're gonna put it in a paper sack on a shelf for at least 17 hours, 24 is better. And the next day you wear your second mask and you just flip-flop them like this every 24 hours because COVID only last 17 hours on the type of fabric made to create those masks. So the mask is de-contaminating itself basically.

31:19 AW: The other thing to know is if you've worn one of these masks for a full day of sessions, don't wear at home, leave anything potentially contaminated at your office. Home is a safe space, so you don't wanna take that mask in the car with you and put it in the seat beside you where it might be off-gassing COVID-19 in the small enclosed space of your car.

31:44 DB: Speaking of clients, can you walk me through mid-session or three quarters through the session when you have now asked a client to flip to turn over from prone to supine, meaning, I'm assuming you've used a towel hamper for the face cradle, and so they've removed a face mask to lay on the table prone. But when it's time to flip over, are you suggesting that they put a face mask on then, and how do you kind of do that during the routine of a massage without losing that flow?

32:21 AW: Yeah, you're gonna lose some flow, and it's just the world we live in, and it's okay, so you can use like you say, there needs to be something under the face cradle and it can be a pillow case that you've created to work like a hammock, and the reason that you're using that is those respiratory droplets, even from breathing or talking. They're not gonna float up and around you in this scenario, but you wanna keep them off your shoes, you wanna keep them off your carpet, 'cause you're walking around on your carpet and that redisperses them into the air. So you do wanna capture them, but they shouldn't be in a face mask, it would just be way too claustrophobic.

33:04 AW: So now let's say it's time to turn your client from being in a face rest to out of the face rest. Just have the client go ahead and sit up on the massage table and just hold their drape across their chest, and then they're gonna put on a surgical or better face mask. The minute that face mask is on, you wanna hand the client some hand sanitizer so that they de-contaminate their hands 'cause they've more than likely touched the surfaces of the mask.

33:36 AW: And I would say don't let your clients just wear a loose face covering like a bandana or a homemade cotton mask, purchase disposable surgical face mask and if they show up with something that's not at least a surgical face mask or an N95 or something better then you're handing them one of these disposable mask to where on your facility. You are in close contact with that client, and they just did a study... Who did the study? I meant to look this up 'cause I have only seen it in passing in the news, six layers of cotton to be a reasonable face mask, cloth face mask, not two layers of loose bandana, allowing stuff to float out the sides, so I want my client in a real face mask.

34:28 DB: Are surgical mask, one step above cloth masks?

34:32 AW: Oh, for sure, they're definitely. So a surgical face mask like there are one-time use disposable surgical mask, you can buy a little heavier one, but I wouldn't get these for the clients because they end up being kind of expensive. They protect you from large particles, airborne particles. The N95 respirators, protect you from 95% of small particles, that's why their name is N95. N means not resistant to oil, and 95 means protects against 95% of the smallest airborne particles, that's what you wanna wear during your massage.

35:14 DB: Do you recommend practitioners work with gloves or no gloves?

35:18 AW: No. No gloves. You don't need gloves. So the reason we wear gloves in standard precautions is to prevent infection from blood-borne diseases like Hepatitis B or C, or HIV Aids, if it's in a contagious stage. And the reason for that is, if you are a therapist and you have cuts all over your hands, like I was a rock climber, I used to get... My hands used to get so beat up from that I would need to be love if I were practicing massage. Or if you are prone to a lot of hang nails and you have little microscopic even cuts in your skin, and then the client also has a microscopic cut in their skin, or they get a bloody nose or they vomit and it's got some blood in it, or even they cough and it's got a little bit of blood in it, like body fluids can have blood in it, sometimes. Even microscopic amounts of blood can transfer Hepatitis B, so we wanna be just whenever we...

36:19 AW: There's the opportunity for blood or body fluid to come into contact with our hands, we wanna wear gloves, whether that's because of the client or because of us. We always treat every client as if they are potentially infected with a blood-borne disease, and now we treat them as if they are potentially infected with COVID-19. But COVID-19 is spread through respiratory droplets, it's not a blood-borne disease. It's not gonna enter a small cut on your hand and infect you. If you do get it on your hand, you're touching your face, your nose or your eyes and infecting yourself that way, and that's just as easy to do with a glove.

37:00 AW: So if the outside surface of your hands get contaminated, it's the exact same thing as the outside surface of a glove getting contaminated. The difference is, if a glove gets contaminated you have to remove it, throw it away and get a new pair of gloves. If your hands get contaminated, you use an alcohol-based hand sanitizer, and de-contaminate them. And protect the environment from lots and lots of vinyl gloves. [chuckle] So gloves are not necessary.

37:30 DB: I know that you have a list of potentially high risk clients. Do pregnant clients fall into that list, or no?

37:40 AW: So the list of high risk clients is the CDC's list. And the reason that they're high risk, is the current numbers show that 88% of people who end up in the hospital with Covid-19, end up with... Have one or more of these underlying conditions. So the high risk conditions are things like they're smokers, or they have emphysema, or asthma... They have a lung condition, or they're diabetic, or they're obese. Obesity is one. Or they're over age 65, even if they're a great health. So 88% of the people who end up in the hospital with a serious case have one or more of these underlying conditions. They're at high risk for a serious infection.

38:32 AW: Now pregnant women, the CDC does not have pregnant women on this list at this time, but they do point out that pregnant women are much more likely to get a serious viral infection. So when they get a viral infection, pregnant women tend to get a worst viral infection, like the cold or a flu than most people. So the CDC doesn't call them high risk, but does warn them that they're more likely to get a more serious infection.

39:04 DB: I found it really interesting in a portion, in a section, when you talked about contact tracing, and following up with clients. Can you tell me your suggested protocol there? Because you had suggested certain check-ups, and certain periods in which to do so, after the massage session.

39:20 AW: So one of the things that I've done in preventing diseases, I've created a document which goes beyond typical informed consent that people can download, and it's free. And it's a high... It's like a Covid-19 informed consent. Like you understand that because we're in close contact, there's still a risk, even though I've taken all of these precautions. I'm gonna sign off as the client on that. Then I'm gonna sign off that I understand that people at high risk, because they have one or more of these underlying conditions, are at higher risk for a serious infection. I'm gonna sign off on that. And then I'm gonna sign off on the fact that my State Department of Health may follow up with you, in the event that there's an outbreak of Covid-19 that originates here, at this clinic.

40:12 AW: So in the event that another client... You, yourself as the client, me as the therapist, or another therapist or staff worker here, if within two weeks of your session somebody tests positive for Covid-19, the health department's gonna track you down. So as a therapist, you need to keep really good records about who's on your premises, on what dates and times? And then you wanna let your clients know, and have them sign off that they understand that in the event of an outbreak, their contact details will be shared with the State Department of Health and that the State Department of Health may follow up with them. But then I'm also suggesting to therapists that we remind clients to call us if they experience any health symptoms within two weeks of their session.

41:12 AW: And I'm also suggesting that we are proactive and call our clients. And that means we're calling a week after their session and we're saying, "Hey Judy, this is Anne. And I'm just calling to follow up, it's been a week since your session. Can you verify for me that you haven't developed any sort of strange symptoms of illness that are not normal for you?" Or, "Judy, have you tested positive for Covid-19?" Or "Have you gone to be tested for Covid-19, and are you awaiting results?" And then at week two you're making that exact same phone call. "Hi Judy, it's Anne again. And I'm just checking, still no symptoms of any illness, still no positive Covid-19 test? And don't you feel good that I'm calling all of my clients to make sure that I'm keeping you safe? Okay Judy, it's two weeks, you're in the clear, I won't be calling you again. It's time for you to come back for another session."


42:09 AW: So we can do this process all over again. But in the event that you do have an outbreak. Like let's say a client calls you as the therapist, and says, "Hi, this is Judy. I just tested positive for Covid-19, and I had my session a week ago." Now you're not trying to make any decisions around this, you only have one thing you have to do. You're calling your State Department of Health, or City Department of Health, and you're saying, "Here's my situation. This is what's happened. I have great records, I'm following up with clients. What would you like me to do?" They're gonna take it from there.

42:48 AW: Contact tracing. I've heard some massage therapists suggest that we should be contact tracing. But you have to do a whole training protocol, it's a big training to do that. We're not contact tracing, we're following up and then we're calling the health department if we identify that there's a problem with something that's happened at our clinic.

43:10 DB: And where can listeners find your resource and Massage Mastery on line?

43:16 AW: So you go to massagemastery.online, and you just scroll down from the really pretty picture. And you'll see the very first textbook is "Preventing Disease Transmission in a Massage Practice." You click on the Access button. It takes you to a sales page, which is not a sales page, because it's free. And then you click on the Access button. Now, I like to warn people that you have to go through our process, because it's how our website gives you access. So you'll go through a whole process, almost like you were gonna buy a book with a credit card, but you don't have to give us your credit card number. And some people I know have been put off by that, but that's just the way our system works, and it's the only way for us to give people access. So be aware that that will happen. You'll do that, and then you'll instantly have access to the textbook. And whenever you go back, the system will ask you to log in. And then you'll go to "My textbooks," and access it from "My textbooks."

44:22 AW: The other thing I like to tell people, is I just completed maybe 10 days ago, maybe it was just last weekend, the time is blurring. Four safety training videos, for people who just don't have time to read a textbook right now. And the safety training videos literally walk you step by step through the most important pieces. And I kinda walk people through this whole protocol and put it into a chronology, so that it makes it a little easier to adopt. And I created a document that you can download, it's almost like a check list, so you know you've done it all with a client. And it sort of helps you develop those habits, those supercharged habits we've been talking about. So if you don't wanna read the textbook, watch the video. And also, you can always just jump directly to Chapter 8, which is the chapter that deals specifically with Covid-19.

45:22 DB: Anne, is Preventing Disease available? Does it offer CE's... CE hours, CE credits?

45:27 AW: You can get CE, it's not through us. We were getting lots of requests for CE. People who had worked their way through the whole textbook, and they were like, "Please give us CE." We're not CE providers at this time. I don't know if we ever will be. So what people can do, is Eric Dalton, whose a good friend of ours, is willing to offer the CE. You'll wanna take all the quizzes in the textbook, and practice, because you'll have to pass a final exam of 40 questions. And the 40 questions come from a test bank of 80 questions. And every time you reset, it's impossible to game this exam, you'll have to know your stuff to get through it. You'll take this exam. And once you pass the exam, you'll get a nice certificate that you can post on your wall, letting your clients know that you've passed this content and you get eight hours of NCBTMB approved CE, so it's a good deal.

46:28 DB: Excellent. I wanna thank our guest today, Anne Williams for joining us. Thank you friend, this was really enjoyable, to connect again.

46:36 AW: It was really fun for me too. And thank you for helping the ABMP audience find out about preventing disease transmission in a massage practice.

46:49 DB: This has been a production of Associated Body Works in Massage Professionals. ABMP is the leading association for massage therapists and bodywork professionals in the United States, and beyond. From liability insurance to professional advocacy, award-winning publications to the world's largest continuing education library for massage to this podcast, no organization provides more for its members and the profession than ABMP. ABMP works for you.

47:21 S1: Thank you for listening. If you haven't already done so, please subscribe to the ABMP Podcast on iTunes, Google Play, or wherever you find your favorite podcasts.


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