Ultrasound experts – Ask a family medicine doctor: Interview with Dr. Daphne Rosales Barragan

In our series of interviews with experts to understand the Covid-19 crisis and the context of women’s health better, we speak with family medicine provider, Dr. Daphne Rosales Barragan, family medicine at El Rio Health in Tucson, Arizona.

Dr. Daphne Rosales Barragan, Family Medicine Physician at El Rio Community Healthcare in Tucson, Arizona provides her perspective about women’s health and how to have a safe, healthy, happy pregnancy during the Covid-19 crisis.

Dr. Rosales Barragan is a graduate of the University of Arizona College of Medicine. Her clinical areas of interest include Women’s Health, Geriatrics, Education, Research, and Border/Refugee Care.     

Our team sat down with her for an interview to ask her, as a health expert, what she wants the public to know about the Covid-19 crisis from a family medicine and women’s health perspective.  As both a physician and at the same time a person in the third trimester of pregnancy, she is able to provide a unique perspective about how women’s health has been affected by the crisis and how patients, pregnant or otherwise, can take care of themselves during this pandemic.

CW:  I just want to start by saying thanks so much Dr. Rosales for spending some time with me.  I really appreciate it.

Dr. R:  You’re welcome.

CW:  For the benefit of others, this is Dr. Daphne Rosales Barragan.  She is a family medicine doctor at El Rio Health here in Tucson.  I’m really excited to connect to learn about family medicine care and also pregnancy care during the time of Covid.  So to start off, how are you doing and how are you feeling?

Dr. R:  I am doing great, actually.  I am currently working from home because of the Covid pandemic.  But I was enjoying working at the clinic, with the proper protection of course, to stay with that human contact at least. 

CW:  So for the benefit of other people, can you tell us a little about your daily work, both before and now?

Dr. R:  Before the pandemic I was working both in the outpatient and inpatient setting.  That means we do some clinic work, but the majority of my work is in the clinic.  I have my patient panel and we follow up longitudinally and we form really nice relationships with the patients. I work in the south part of Tucson and we serve the underserved as I work for the community health center. Then besides that, I rotate through the St. Mary’s Hospital in the inpatient adult medicine service, and that also would be serving our El Rio patients.  As a family doctor, I’m able to see, at least in the clinic, the full spectrum of family medicine, which as it says, is babies, newborns, pediatric patients, women’s health, adult health, and geriatrics.  In my case, I do have a wide range of them.  But I would say about 50% are geriatrics, and there are also a lot of newborns. 

CW: How have things changed?  Are you able to do telemedicine at all?

Dr. R:  Yes, so now since the pandemic, we are still in clinic as family medicine doctors.  The patients that are high risk for complications if they were to get an infection, those are the ones we are trying to target through the phone visits, video and audio visits, to keep them at home and help keep them out of unnecessary exposure.  Those patients would be pregnant patients, or those who are elderly or have diabetes that is uncontrolled or heart failure that is not well controlled.  That way, the patients are in the comfort of their home and then we can continue to follow them longitudinally.  So at the end of this pandemic, we don’t end up with all these other clinical conditions that are out of control – or while the hospitals are busy taking care of all these respiratory issues related to the virus they also have to take care of these patients that maybe have complications from their chronic heart conditions or their diabetes.  I think at least at El Rio, we have been very fortunate that our clinical leadership has definitely taken a step ahead and we have been able to prevent and target that early on. 

For me because I’m pregnant (I’m 32 weeks pregnant), I was advised to stay home and do all of my visits now from home.  I have been home for almost two weeks now.  I do miss going into the clinic and interacting with my medical assistants and other physicians, but I do understand that it’s safer for me and my baby to be home. We can still serve the patients via video or audio. It’s both my panel as well as other providers’ panels.  The doctors that are at the center, they do serve, like I said, we do limit the exposure in the clinic, but we do have a specific space in the clinic for “sick patients.”  That means patients that are showing some signs or symptoms of the respiratory infection related to the Covid virus.  Of course, those visits are with protection.  I am forever in debt to those doctors doing those sick visit service to the patients. I am very grateful to them that they are serving the community still.

CW:  You are as well, so thank you for continuing to do the work you do.   So how do you then take care of yourself?  Being pregnant and being a provider right now, and what advice do you have for your pregnant patients and anyone else who is pregnant during this health crisis?

Dr. R:  Well, being pregnant in the third trimester it’s a little hard to stay sitting for long periods of time, which is required during virtual visits.   I make sure I have a water break every other patient and walk, go to the bathroom and at the ends of my sessions I definitely stretch. I do yoga and is a big part of my life and I do incorporate it in my patients’ visits and my patients’ treatment plans.  Yoga has been very helpful not only for the muscle and ligaments stretch necessary after 8-9 hours of work at the desk but also mindfully, putting your mid at ese, not getting your mind lost in the details.  As a pregnant woman you’re planning for your baby to come and of course it’s very, very exciting. But with the current Covid status, you can get lost in the details of “how is it going to look when my parents come in, when my in-laws come?  Am I going to let them see the baby?”  All the things that are very uncertain right now that just create more stress and then of course your baby is going to feel the stress. Even if maybe you are not conscious of it, it does generate a reaction in your body that of course is transmitted to the baby. 

I try to stay on a day-by-day vision.  For instance, daily goals like going out for a walk.  Our neighborhood is pretty far away for other homes, but even if it wasn’t, wearing appropriate protection, going for walks around sunset.  When my husband comes in, staying supportive with him.  Even the daily meals.  It’s the little accomplishments.  Otherwise, life currently would be very monotonous and it would just feel dull.  Sleep of course is very important.  In the third trimester it’s very difficult to sleep throughout the night, at least for most of us. But I try to make sure to get at least 7-8 hours of sleep per night. Staying hydrated is very important too throughout pregnancy to prevent those contractions that might be the false contractions, Braxton Hicks as they’re called, or to prevent cramps, low blood pressure, headaches, all of those things that come from dehydration that can be very, very well prevented.  In this case I would tell my pregnant patients, do as I do, instead as do as I say.  I am trying to practice what I preach also.  Stay focused on right now, the day that’s coming ahead of you.  Don’t get lost in the details.  Maybe things might get better if they’re due in August or September, and hopefully things will get back to normal by then and all of this uncertainties and stress wasn’t necessary. 

But currently, staying in the now and stay home as much as possible.  Whenever you go out, because the CDC and WHO do recommend for us to be protected and our mouth and nose to be covered with a face mask, and make sure that people are staying at least 6 feet away from you, especially strangers.  Like when you’re grocery shopping, which you can, and I actually find that very therapeutic for me, try to go with someone else that’s going to help you because you do need some help lifting some things.  Keeping your nose and mouth covered and washing your hands as soon as you get home. The mask I have found is helpful for protecting yourself from yourself.  Sometimes we tend to touch our noses and mouths.  Use a mask, a bandana or a scarf.  If it’s cloth I do recommend that as soon as you come home from visiting or very close family members in close quarantine or coming back from grocery shopping you wash the mask so you can use it again.  It does need to be washed after being exposed or technically being exposed to the outside. 

CW:  Awesome advice.  Need to be taking some of that advice actually….  Are there any changes to the types of screenings you’d recommend for patients right now?  Or keep everything as normal?  What are your thoughts?

Dr. D:  Screening for the virus and particularly to pregnant patients?  So, we are considered high risk patients because we’re pregnant. The reason is that our immune system is considered to be a little less active.  Your immune system is going to identify something that doesn’t belong and try to attack it. In pregnancy, you’re growing another human and technically it doesn’t belong to you so your immune system sort of needs to tune and calm down so the baby continues to grow.  Because of that we have that relative immunodeficiency or weakened immune system, so that’s why we’re considered high risk patients.  AS with any other high risk patient if you start feeling like you get the flu, you’re having a very bad cold, you have a cough, you have a runny nose, it’s hard to breathe – and I know that’s that hard to gauge in pregnancy because when you get to the third trimester, it’s hard to breathe because your belly is getting bigger – but if it’s not just sporadically, if it’s all coming together, hard to breathe, developing a cough headache body aches, and you have a low grade temperature, and you feel hot and having a fever, that sounds lie the flu for most people.  Maybe a sore throat too, because the flu comes with a sore throat.  If you’re feeling not yourself, under the weather, and it’s not just for a few hours or for one day, the definitely there’s a recommendation to call your OB or your family medicine doctor or primary care provider. 

At least at El Rio, what we’re trying to do is catch those patients over the phone so that we can say, “Ok, no it doesn’t sound like it, it sounds more like a cold or a sinusitis or something else.  Stay home and we’re going to follow up with you over the phone in a couple of days.”  Or, “Yes, you definitely need to come and get tested.”  We’re trying to reach our patients first via a way that is not going to expose them to even more sickness in the real world, but that we’re still going to provide them with care and very close follow up.

Of course, if it’s the middle of the night, and there’s a high-grade fever and you have chest pain, you of course need to call the paramedics, which is the first thing I’d recommend, or go to the ER.  Also, it’s important to say hydrated as I said before, because you could be having body aches because you’re dehydrated, that will of course cause more contractions.  Those would be initially false contractions, but that could predispose you to a preterm labor. 

Tylenol is your best friend if you have back pain.  Tylenol is the best thing to take.  If you’re taking it to consistently feel better because you’re getting a fever or pain everywhere in your body, or getting a headache consistently, that’s when I would say reach out to the primary care provider, ideally first through phone or video and audio services to prevent exposure.  Just imagine, in the ER everyone there really, or even by statistics, at least one person there is going to have some sort of virus. Not necessarily the Covid virus, but some sort of disease or infection that gets transmitted via droplets or being in close proximity.  Of course we don’t want a pregnant patient to be sick.  Every physician or practitioner should have the current guidance and criteria to check pregnant patients.  Also if you don’t have symptoms but you know that you have been in very close contact with someone who has a positive Covid test, and close contact means within 6 feet from you (maybe you were just talking or it’s your partner), that’s another reason to call your provider.  Under some circumstances it would be recommended for you to be tested.  On the bright side, some of the patients that unfortunately have acquired the virus that have been pregnant have delivered in the majority healthy babies and they have had good outcomes in the third trimester.  That’s good news too.

CW:  It’s amazing to actually have good news in span of all this.  I have two more questions for you.  One, do you have any visibility into how the delivery process is changing or what people have to be aware if they have to deliver in the near future or even in the next several months?

Dr. R:  I know that in Tucson they’re only allowing one guest or one companion with the patient.  Normally, we’d allow two or three or as many as the patient would feel comfortable with but right now it’s only one.  I know that could change if our numbers rise or if we see a ramp up of the rate of cases.  At least right now for Arizona we’re getting more cases.  But that’s because we’re testing more and we weren’t testing a lot before.  If we see an increased rate of cases or locally at the hospital there are more cases, then they may actually not even let the companion go into labor with the patient. That’s nerve-wracking in a way for us as pregnant patients.  It’s also a bit discouraging for the partner, that other companion that was going to be there.  I would assume they would allow an iPad or some sort of technology so that the partner could at least be there for part of the laboring process. 

Also I see some of the patients and the community are thinking about laboring more at home I that early stage of labor when you’re just getting comfortable and your contractions are coming, but not too often.  Normally as a physician that’s what we tell our patients.  The reason to come to the hospital is when your contractions are happening every four minutes for a minute, for an hour, (4-1-1 rule).  You need to have a timer with you. It sounds over the top but it helps you gauge things better.  That’s when generally that’s the start of active labor, when your body starts making those changes more rapidly to help baby come down the birth canal and eventually for you to deliver.  So before that, we just say, ok, stay at home, keep track of things, drink water (maybe they’re not real contractions), relax, practice ways of coping with pain, anxiety or stress.  A lot of pregnant women in community, that’s what they’re trying to practice more now.  Of course that should not be a decision you make before touching base with your OBGYN or family medicine doc, or your midwife. You should reach out to them and tell them, hey, I’m thinking about doing this, are you ok with that as my provider?  Of course your situation may be different.  Not everyone’s situation is the same.  I personally think that’s what we would do. We’d practice our pain management and breathing techniques at home before the doctor tells us to go to the hospital. 

That’s another thing.  The positive of this time is that it expands your spectrum of resources and as a woman, a pregnant woman, it really makes you dig into that powerful and positive side of yourself.  Yes, I can do this.  At least that is what I envision and what I hope a lot of women have.  Yes, it’s scary, intimidating to be delivering in this time.  It’s almost a challenge to reach out to that strong, powerful raw woman that has that power within us. Our body knows how to grow babies.  We don’t tell it how to grow babies.  It challenges you to reach out to the things and people you have around you and the techniques you have developed within yourself like breathing techniques or positions or yoga or the birthing ball or warm water.  All those methods that are not invasive are very powerful and accessible to a lot if people.  These times make you reach out to those techniques more.  And of course, communication with your provider. I think it’s a beautiful thing. 

CW:  Wow, that’s amazing.  You kind of touched on it already, but I wanted to end on an additional positive note.  What gives you hope right now?  There are many people that are so stressed out, pregnant or not, with medical conditions or not, and it can be really overwhelming to be in a pandemic, or isolating.  What personally gives you hope?  What can you share with your patients or the general public that might give them hope too?

Dr. R:  I think we’re very fortunate because we have this life coming developing inside of us.  Us as pregnant women, we bring joy in this area of crisis.  When I go out (with my mask of course), everyone smiles at me.  Before the pandemic, I would be like, “Oh that’s nice.  How cool.  Okay.”  But now, it still feels good, but taking it from their perspective, we bring joy and bring up a smile to strangers.  Really, people need, in this time, even more of a reminder of the kindness of the world.  How amazing that you as a pregnant person, a pregnant woman, can inspire that in a stranger. That’s just amazing.   So that keeps me in a positive light. Also, focusing on my baby, the near future.  How I am going to name my baby, what outfit or what clothes.  Washing and organizing the clothes.  Seeing more kids around you, envisioning your child.  Just focusing on the baby keeps me really positive.  I think that hopefully will bring that positive note on the pregnant patients. 

Also, I generally thrive on negative things but when there is a lot of uncertainty, the thing that keeps me going is that every day that passes by, we are a day closer to the end of this pandemic.  It’s a very general statement, but if I remind myself of that and that also helps me stay positive. 

For patients that aren’t pregnant or don’t have a pregnant family member around them, things I tell my patients to keep them positive, to be present in the moment, to realize all the things they already have is actually what they need.  With that, it’s helping them healthy, it’s keeping them alive, and grateful to be alive.  I invite them to be mindful and grateful of what they have already.  Maybe before they had plans to get a new car or something else – that’s actually not what they needed.  What they have around them is enough. 

I do recommend that when we watch the news or read the news that we are selective of what we read, and like everything, that it’s the right amount.  Don’t watch the morning, afternoon, and evening news, because they’re all saturated with Covid.  Just pick your source and do that once a day because it’s important to stay informed.  Other than that, find a new hobby. 

It could be writing, journaling, drawing (doesn’t have to be good), gardening, or something new that is going to help cope with the dullness and anxiety provoking time.

A lot of my patients they’re knitting, watching cooking videos, in the garden, some of them are fortunate enough to have a stationary bike at home so they’re doing that.  I have one patient who recorded herself to show me she was doing that.  If they have access to social media to use it on a positive note.  You can work out with your friends, you watch a video together everyone with their phones or on TV and you can debrief at the end and hang out.  If you keep that consistently, it won’t feel like such lonely times. 

CW:  Great suggestions.  Seriously thank you so much for sharing them.  It is true.  Every one day, we are getting closer to the end and that is super powerful to keep in mind.  Thank you.  Thank you for spending time with me today and sharing medical expertise and life expertise with us. Really appreciate it. 

Dr. R:  It’s nice.  It’s enjoyable.  I’m very happy you asked me to talk.