by Elizabeth Hofheinz, M.P.H., M.Ed., April 10, 2020
As Louisiana marches towards its COVID-19 peak, Ortho Spine News is in week two of its discussions with orthopedic surgeons from Louisiana State University. The surgeons, some faculty, some residents, discuss their challenges, treatment patterns, and predictions for the coming weeks.
Robert Zura, M.D., an orthopedic trauma surgeon, is the Robert D’Ambrosia Professor and Department Head at the Louisiana State University Health Sciences Center (LSUHSC). He states, “I think the theme of the past week has been settling into a new normal. That being said, it has been a roller coaster; as we’re building the curve of data in Louisiana. Early last week we had positive data and felt hopeful because the death rate had decreased, perhaps suggesting a flattening of the curve. Then, later in the week things started heating up again.”
“We have a daily influx of data and it is challenging to monitor your own response to your team. At times it can be hard to help as some people bring their own agendas to reading the data. The best we can do is to model safe behavior and continue to prioritize healthcare workers’ safety, patient care and the education of trainees. The most difficult part is protecting trainees, which comes down to a reliable and steady flow of PPE. We have a mild shortage at the moment, but frankly, it is unclear what PPE we should and should not be using. The messaging is inconsistent; on the same day last week the CDC and the World Health Organization gave opposite advice about wearing masks in public.”
“I can say, however, that I am proud of University Medical Center (UMC) because they are doing a superb job of conserving PPE. From what I can tell the appropriate PPE is available to those providing care.”
“I am proud that UMC continues to be a referral center for the region. We are taking transfers of COVID-19 patients, and our medicine, ICU, ED, and nursing teams are rising to the challenge. In addition, there are early indications that our treatments may be superior to what people are seeing nationally. We have a tremendously high extubation rate—around 40%—whereas nationally it is around 20-30%. UMC is taking the sickest people and providing world class care.”
“Both LSU and Tulane have gone to a stage 3 pandemic emergency per the ACGME. We are prepared to send residents when needed. One of our residents, Christina Terhoeve, volunteered to go to the ICU next week. If the current trends of improvement continue, perhaps we won’t have to redeploy our residents. While orthopedic surgeons are not on the front lines, we are impacted. More and more faculty and residents are being exposed…and finding out later. I operated on a patient who later turned out to be positive. Of course, that type of thing brings anxiety to everyone…and that is why we are operating in alternating teams.”
Looking forward, Dr. Zura indicates, “First, I would like to see the current positive trends continue. In addition, I am increasingly focused on the safety of my team as more individuals become positive—fortunately we have some people coming off quarantine. In addition, we will continue to treat time-dependent injuries and tumors in this difficult environment.”
Peter William D’Amore, M.D. is a third-year orthopedic resident at LSUHSC who has been taking call at the UMC emergency department and has seen potential COVID patients in the last few days. “I feel like at the moment we are riding up the rollercoaster. Hopefully, we can rise to the occasion and prevent deaths from a lack of resources. We should have taken precautions when we had early reports from China and/or when the first cases appeared in the U.S. We held our breath as a country hoping it wouldn’t affect us.”
“Here at UMC we are opening up a new unit equipped with ICU beds. It appears that at this time most ventilators in the facilty are being used. There are non-Covid patients who may also need ventilator support in addition to an influx of Covid patients that add to this growing need. For example, if the ED has 100 patients per day and 10% of those patients are in respiratory distress requiring intubation, then we have the resources to handle those 10 patients. But, if the ED sees 700 people and 10% need a ventilator, then we may not be able to meet that need. It’s not just the ventilators…it’s also the 70 anesthesia encounters, beds, nurses, medications, etc. If the situation is dire we may be forced to use our operating rooms to meet the ventilator needs.”
Vinod Dasa, M.D. is Associate Professor of Clinical Orthopaedics and Director of Research at LSU Health Sciences Center. He states, “I was on a call with multiple physicians yesterday and the Seattle surgeon said that they are finally seeing a flattening of their curve. Now that social distancing and all of the mitigation efforts are paying off, there is a lot of interest in looking ahead at the next steps required to ‘reopen’ the healthcare machinery. In trying to define what the new normal looks like, we need to determine who should be doing what, do we test all surgical patients preoperatively, and if someone is positive are, they allowed into the hospital. And how long should we wear masks around patients?”
Healthcare disparities are showing up in this crisis.
“One of my substantial concerns is the emergence of healthcare disparities in this disease. It appears in Louisiana that roughly 70% of those who die from Covid are African American. A significant portion of the population has been affected more than others, perhaps because of worse access to care. It is complicated and is going to require more thought than just flipping a switch.”
“This past week I only saw a handful of patients—fewer than 20. Like my colleagues are seeing, many individuals are struggling with technology…either they have no access to hardware, or they don’t know how to use it. It is a lot of phone tag…you call, they don’t answer, they call back, but you have had to move on to the next patient.”
“As for PPE, here at Ochsner Kenner we have a stable supply of PPE as they have done an awesome job of managing supplies.”
And the peak? “I would say we are a week or two behind Seattle and they are projecting to start elective surgeries starting around May 18. We will have to be ready to ‘go’ a week or two later.”
Michael Hartman, M.D. is Associate Professor and Residency Program Director at LSUHSC. He says, “Things have been relatively stable this week, with no significant news from the residency front. Inpatients at UMC are down and one of the local trial drive-through sites has closed—although I think that was because it was not working efficiently. Most local testing has been brought in-house and our residents continue to work in teams, i.e. ‘platooning.’”
At this point, says Dr. Hartman, the toll is largely emotional. “Residents are very concerned about their personal safety because there is always the threat of insufficient PPE. Logistically, things are going well, and we have established a daily didactic online schedule. For example, one day the residents will review information on tumors and do a 50-question test on their own. The following day we will review their answers with two faculty members via Zoom. I am also telling residents that if they have any research projects to work on, then now is the time. And given that the chief residents are taking board exams in the summer, I told them to buckle down and study.”
And what is a residency director doing with his time during this crisis? “Today I spent 8 hours completing end-of-year reviews for our 20 residents—examining all of their evaluations for the year, case numbers, in-training scores, research projects, quality improvement projects—and then having a Zoom meeting to go over everything with them.”
“The University of Washington Institute for Health Metrics and Evaluation (IHME) is now projecting that New Orleans may have already peaked, but this is hard to confirm. The initial projections were based on Chinese data and the latest ones are based on data from Italy and Spain.”
Andrew King, M.D. is Professor of Orthopaedic Surgery and the G. Dean MacEwen Chair in Orthopaedics. Last week Dr. King let us know that he had tested positive for Covid. “And this week,” says Dr. King, “my wife finally got her results after nearly two weeks…she too is positive. Fortunately, we are both on the mend, but staying home out of an abundance of caution.”
Peter Krause, M.D. is the Elaine A. Doré Endowed Chair in Orthopedics at LSUHSC and the Director of Orthopaedic Trauma at University Medical Center. “I am assuming that all patients are Covid positive and contagious, so I am wearing a mask at all times. A paper from China has just shown that regarding the infection rate among orthopedic surgeons in Wuhan, what made the most difference as far as those who were infected and those who were not was the use of N95 masks.”
“Infectious disease experts say that we are unlikely to get the virus from blood, so I am not so concerned about getting it from aerosolized blood. The biggest risk with any procedure involves the airway—intubation and extubation. Thus, our team is staying out of the room during those periods.”
Dr. Krause: “My biggest concern is PPE. The administration has told us that additional supplies are coming, but as of now we are reusing masks. We are going to start sterilizing masks with UV light soon. As bad as it is here, New York is worse. One colleague at Bellevue had to use one N95 for an entire week.”
“As we approach the peak, I think we can move patients who are not quite well enough to go home, over to the convention center. And although the national news is reporting a high per capita mortality rate, UMC has an extremely high rate of extubation. Why? Perhaps the protocol they are using is more successful.”
And once the healthcare wheel starts turning again? “Yes, there will be a large volume of patients who must be tended to who have deferred their care.”
Christopher Marrero, M.D. is Associate Professor of Clinical Orthopaedic Surgery at LSU. Commenting on the current time warp, Dr. Marrero says, “Time, hours, days do seem different now…it’s hard to know how many days have gone by since this crisis began. I was here during Katrina, another time where life as we knew it was completely disrupted. The difference with Covid is that we have electricity, amenities, grocery stories, etc. But you could say it’s worse because there is nowhere to run.”
And being trapped, as it were, we have probably all been exposed at some point.
“On March 18 I was told that I was potentially exposed in the OR on March 10. I was told that it was one of the staff members in the room with me during surgery who ended up testing positive. They would not release the name of the initial person who tested positive, of course. I reached out to the administration for guidance and was told to monitor myself for symptoms and that I might want to wear a mask. I am fine but I suspect that because Covid is so prevalent most of us have been exposed. Around Mardi Gras I was sick and I had a fever for a couple of days, but I got over it.”
Dr. Marrero, who works at UMC and the VA 2-3 times per week, says he would feel much more comfortable going to work if he knew he had the antibodies.
“I do take call, I keep an N95 mask with me at all times, and I’m trying to hold out long enough to where we can test everyone for antibodies. In addition, I have recently been named Diversity Officer for the department. This is particularly relevant nowadays given the disproportionate number of African Americans who are being affected by this disease. Now that I have some extra time, I can devote additional attention to our diversity program.”
“New Orleans is a tightly-knit community and it seems that everyone knows someone who is infected…I know at least ten people who have had it or have it now. My sister is a pharmacist and she was tested and is awaiting results.”
Paul Phillips IV, M.D. is Assistant Professor of Clinical Orthopedics at LSUHSC. “Although telemedicine is in full gear, we have numerous patients who have not yet adjusted to it. People are either having difficulty understanding what steps are needed to access the technology or they just don’t have resources for a laptop with a webcam or an updated cell phone with a camera. Trying to use high technology with a portion of the population that doesn’t have access isn’t so easy. We are doing what we can and spending a lot of time walking patients through things or finding workarounds. If all else fails, telephone calls are now HIPAA compliant.”
“For about 80% of all patients, you can get all the necessary information for a diagnosis and treatment plan just by listening to their story; with the other 20% you need a physical exam in order to do a treatment plan. Orthopedics falls into that 20%, so we are making do. To know how swollen or how red something is, the patient has to take pictures or have patients on video so you can say, ‘Show me how much you can bend your ankle’ for example. While it is a monumental struggle and is stretching our staff in a lot of ways, patients are so appreciative of our efforts to reach out.”
Dr. Phillips says that he has seen fewer than 10 patients this past week, none with COVID-19. “While we try to restrict unnecessary contact, I did have a patient who supposedly had a wrist fracture (per the referring office), but when I saw him it was apparent that someone just quickly perused his file and thought he needed an ortho appointment. It was a longstanding injury, but it was not a fracture. So situations like that can result in possible exposure.”
Daniel Plessl, M.D. is the chief resident at UMC. “I am at LSU in Baton Rouge, where I am taking call as usual—but we are only seeing acute fractures or other urgent things like infections. In a typical week I have three days of clinic…now I’m trying to combine all patients into one day. I’m also spending a lot of time calling patients to reschedule their surgeries.”
“As for the OR, tendon ruptures are one time-sensitive problem that we are addressing. If you fix these injuries early, then you are typically able to get a better repair with less stiffness and better long-term results.”
“Going into next week there is some uncertainty regarding surgical patients with fractures or acute issues. We lost block time at the hospital we cover in Baton Rouge. Normally you would post the case for a given day and then it would fill up that morning and the board would just get triaged. I don’t know who will be in charge of triage here. Maybe we will be telling patients to show up and then they find out they can’t have surgery that day and so they have to try for the next day.”
Cristina Terhoeve, M.D. is a third year orthopaedic surgery resident at LSUHSC. Dr. Terhoeve is off this week but is gearing up for her ER shift next week. She told OSN, “While I was off last week, another resident with whom I share call told me of a Covid patient with a distal radius fracture. Normally, we would consider injecting lidocaine and putting the bone back in the right position and splint it. But this patient is older, has COPD, and is on oxygen. How would going in and performing that injection, etc., enhance her quality of life…and there is the issue of healthcare worker safety.”
“I am getting messages from staff saying that the curve is starting to flatten a little. Our patients, so many of whom are hurting, will probably not be able to have their surgeries until June. I’ve spent a lot of time on the phone with these people dealing with chronic pain. “Normally, we would consider injecting lidocaine and splinting the bone in a better position.”
Please stay tuned for next week when we learn how LSU continues to evolve its response to COVID19.
