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COVID-19 Essentials for Surgeons
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COVID-19 Essentials for Surgeons
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T00H59M55S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[narrator] Behind the Knife, the surgery podcast, where we take a behind the scenes intimate look at surgery from leaders in the field. [upbeat intro music] [music continues]
DR. KNIERY: Okay, and welcome back to Behind the Knife. Today, we really wanted to get out a breaking episode to you guys about COVID and how it affects us as surgeons and how we can prepare for this in our hospitals and how we can best take care of patients. We're going to start this episode off, we're lucky enough to have Dr. Sharmila Dissanaike. She is the professor and chief of the department of surgery at Texas Tech. And she's joining us today to talk about how she's preparing her hospital and the impact this has on surgeons.
DR. KNIERY: And later throughout the episode, we're going to hear from an ID expert. We're also going to hear from Dr. Christian Jones about actually treating these patients and what that entails. And then we're going to finish this episode with a telemedicine discussion. So, Dr. Dissanaike, thank you for joining us on Behind the Knife and welcome.
DR. DISSANAIKE: Thank you very much, I'm excited to be here.
DR. BINGHAM: So, Dr. Dissanaike, we're just kind of in the early stages of dealing with COVID and I think the reality is starting to sink in across the country that as surgeons, we're not immune to this process. Can you just kind of give us-- the ACS recently released a recommendation as far as what we should be doing with regard to elective versus acute care surgery cases. I know the CDC has a recommendation out there.
DR. BINGHAM: How are you at your facility dealing with these recommendations and how are you preparing for the pandemic that's happening?
DR. DISSANAIKE: Well, thank you, great question. And let me start by saying how I had intended and how I was planning to prepare for it and then let me tell you what actually happened. So, ideally, we are doing this for two reasons, right? We're doing it for social isolation to play our part in not bringing patients into the hospital, not increasing contact that doesn't need to happen. That's one reason. I think that was a big reason behind the ACS statement.
DR. DISSANAIKE: And then the second reason is to conserve resources because we know that the supply chains, many, many, many hospitals rely on products that come from China, which was clearly impacted by their COVID experience before anyone else did. So, those are the two factors. And I think most of the emphasis has been on the first, the social isolation. So, with that in mind, we have planned to have a triage process and a dial down process.
DR. DISSANAIKE: And that's what a lot of other institutions, I've been in contact with many, many surgical chairs across the country, and that seems to be the most popular approach where each division chief or chair or surgeon group leader gets three categories or two categories. You divide your patients into maybe urgent, elective and emergent or something similar. And when you're talking about elective surgery, basically saying that what is technically elective but probably needs to be done soon, perhaps a lot of cancer cases, some debridements of infected wounds, things that really do need to be done in a timely fashion versus something that's most would agree is purely elective, such as bariatric surgery or hernia surgery.
DR. DISSANAIKE: And you make those categories in each specialty, general surgery and its subspecialties, those leaders decide which of those cases fall into each bucket. And then you prioritize. And my plan had actually been to bring in my cancer patients early, actually start to front-load them because my big worry was when COVID hits West Texas, we will be an epicenter for those patients and we may not be able to get to our cancer patients at that point.
DR. DISSANAIKE: So, my hope was to actually get them done ahead of time, get them out of the hospital safe and then brace for what we knew was probably going to hit us at some point. So, that was the plan. What happened with that, I found out today that our supply we knew was concerning, we were watching it, but our supplier cannot get us anything more till April.
DR. DISSANAIKE: And we had a certain number of sterile gowns and gloves and masks in the hospital. And over the weekend, we did have someone break in and steal things from some of the supply carts and basically rampaged through the hospital. And this has happened not just at my institution, at doctors clinics, at hospitals across the country. And that brought us from very concerning to critical levels, to where we only had a certain number of days of supplies left.
DR. DISSANAIKE: And that took us from basically a nice orderly planned approach to DEFCON 10 by 9 o'clock this morning. So, now what we did at this point is that I am doing everything I can to make sure that none of us have to make the really heart-wrenching decisions of turning away patients who need care, lifesaving care, or having my team, my people have to operate without personal protective equipment.
DR. DISSANAIKE: I don't think either of those are acceptable scenarios and I want to do everything in my power to protect them from that. So, we have essentially had to do an emergency temporary shutdown of everything except true emergency cases at this point. And we'll go from there, we'll see when supply lines arrive, we are looking at state resources and other resources for help, because we need help and trying to get back online as soon as possible.
DR. DISSANAIKE: And when we, instead of a ramp down, we'll end up having a ramp up process that when we can hopefully resolve the supply issue, we will be going to cancer patients first and kind of going in reverse order and bringing those people in. Now, obviously, that's predicated on us not getting hit with COVID in the meantime. And that seems increasingly likely, and that will change the dynamic again.
DR. DISSANAIKE: So, I think this is evolving literally day by day in different centers, and it is evolving somewhat differently in different centers, but the truth is we're all finding that the bottleneck comes at that supply line, for surgeons this is probably the biggest issue that we will face. [Dr. Bigham] Now, I do have one follow-up question to that.
DR. DISSANAIKE: So, can you just maybe break down exactly what the thinking is behind the ACS recommendations? So, it seems to me like some people are getting it and some people in the community maybe aren't getting it. So, our local experience here, I'm in the Pacific Northwest and it seems like the big, like university centers were kind of quick to catch on like, okay, I get it, this is going to be a problem, it's going to be a resource allocation problem.
DR. DISSANAIKE: We have to get ahead of the curve, stop elective cases, preserve our resources. That seems to be a little bit slower to trickle out into the community that's maybe a little bit more RVU-based and delay in these cases really affects the bottom line. Can you just explain what the reasoning is, why it's so important to take these measures early?
DR. DISSANAIKE: Absolutely. So firstly, just to be clear, while I am a governor of the ACS and hold some other roles, I'm not speaking officially on their behalf of the statement. So, just to clarify that.
DR. BINGHAM: Absolutely.
DR. DISSANAIKE: But it clearly is intended to set a bar for the surgeons to realize this is an issue. And I completely support that, they did the right thing and they came out with it, actually I think at the right time. They were looking down and saw what was coming and I give them full credit to that. They were looking ahead, shears the difficulty. So, a big academic center, no matter, we all have financial troubles these days, but they have reserves they can draw on.
DR. DISSANAIKE: There is usually a buffer zone and that buffer does not exist for critical access hospitals, we have had about 26 hospitals closed in the state of Texas very recently in the last few years because of this. There is not a lot of operating margin. So, you do have to understand that it's easier in a lot of ways for large academic centers to absorb this and large hospital systems to absorb this than it is for small hospitals.
DR. DISSANAIKE: So, I think it's important to realize that it's not just a matter of people don't understand, they do, but if a hospital goes bankrupt and closes, that doesn't do that community any service either. And so that is, I think what's made it so difficult for these community hospitals to do this. And for private surgeon groups, I do understand because they don't usually operate with a lot of buffer as well.
DR. DISSANAIKE: Now, I think that said, I have been very impressed, the private surgeons in my region, as well as in many other regions of the country, they do understand this and they're really concerned and really worried, but they understand why it's the right thing to do. So, I think that it's not a lack of understanding, honestly. I don't think that is the problem. I think the problem is they're balancing the short-term benefit of closing to elective surgery until this passes and let's face it, at this stage, we're looking at several months.
DR. DISSANAIKE: I don't think anyone thinks the U.S. is going to be in and out quick now because that train has already left the station. So, it's several months. And so, if a group goes bankrupt or if a hospital closes, that's a real consequence because those patients who are going to have their care delayed will still be there needing care. And so, I think it's just a very difficult situation and containment is absolutely essential because it isn't going to get better if this explodes everywhere.
DR. DISSANAIKE: But I think I do have a little sympathy and understanding for why it's harder for smaller groups to do that. That's it. I fully support the ACS guideline. I think we should all move toward adhering to it as quickly as possible. I think the one thing I would add is, I do think there is more emergency than even I realized a week ago and two weeks before that.
DR. BINGHAM: Yeah.
DR. DISSANAIKE: The emergency is here.
DR. DISSANAIKE: We're here now. We're getting close to the peak of that inflection curve. It's about to explode on us is my best guess. I think we do have to act right now. [Dr. Gupta] Very well said. Moving gears to something more about the measures that you are taking as being chair of the department of surgery, a lot of the hospitals are facing even with the PPE shortage and delayed testing coming back, most of these patients are coming to the hospital, getting discharged, but then you realize that the patient was positive.
DR. DISSANAIKE: And a lot of the medical professionals and staff that came in contact with the patients are being put in quarantine for 14 days. And so, that puts a lot of stress on people who are in the hospital working, but then their colleagues are quarantined for 14 days. What are your measures that you are thinking of in order to deal with the shortage of medical residents and professionals in light of the self quarantine period?
DR. DISSANAIKE: Well, I will tell you personally, and you may be aware in our state as in several other states, but in Texas, there are some very stringent requirements before they will approve a test. And those are state government mandated, and it's going through the state of health, but you need to fit a lot of criteria before they'll approve the testing. So, as a result, I have very few patients who are tested.
DR. DISSANAIKE: So, that particular scenario is not really a huge issue right now that I'm aware of in my region or in other parts of Texas. It is an issue in other places, I know. So, let me speak a little more broadly about how we manage our human resource which is really when push comes to shove our most valuable resource, both physicians, nurses, therapists, everybody, but to speak of surgeons specifically.
DR. DISSANAIKE: So, clearly in a COVID pandemic, surgeons are not usually considered frontline. We are sort of back and reserved. There are some surgical complications of COVID, we are seeing that, they do get surgery as well as some patients with COVID are going to have appendicitis and need surgery. And so, there is a global group and I believe the group at Boston is actually trying to collect data in the U.S. so that we have for the next go round, some really useful information.
DR. DISSANAIKE: So, that's going to be some exciting knowledge we get out of this. But the truth of the matter is the operating is going to be low. So, I think where surgeons really fit in and where we need to think through how we use our resources is on the backend. So, for example, at my institution, we've already agreed that when we do get COVID patients, they will go to the medical ICU and that'll be that quarantined off section.
DR. DISSANAIKE: And the medical ICU team will manage that as appropriate. But what we can do since we are also intensivist trained is we can help manage other patients that may have otherwise gone to the MI, but can be managed by other types of intensivists, anesthesiologists, surgeons, we can pitch in and help as well as helping with procedural needs. And in order to do that, we will probably have our general surgery colleagues step in and help manage the emergency general surgery that our ACS team usually did.
DR. DISSANAIKE: So, it's a domino effect because I really believe strongly that it is important, that it's all for one and one for all, we all are in this together, we're all doing the best we can. So, with that in mind, I do think it's important for institutions to start thinking about how to rotate their people. So, kind of like you alluded to it.
DR. DISSANAIKE: I don't think we should wait for someone to quarantine before we think this through. I think we just say that, okay, right now in my institution, for example, there's going to be sadly a bunch of residents who don't have much to do, not much operating, not much cases. Those residents should probably be furloughed to go home for a while and study, hopefully.
DR. DISSANAIKE: And then when the current group is tired, they go home and the new batch comes in. I think there are several centers that have done that or have started to do that successfully. And we should emulate that for both faculty and for residents to try to preserve the workforce. There's another factor, which is, should we make adjustments for faculty who are older than 60 or 65, who are at higher risk of consequences.
DR. DISSANAIKE: And I think that is something I'm working through right now and will be discussing with faculty as to how we approach that. But that has been raised, if you have people who are perhaps at increased risks, because they have an immunocompromised condition or are older, should we try to protect them? Because I do feel very strongly that protecting your team is for me as chair, one of my fundamental responsibilities.
DR. DISSANAIKE: And that's something that I'm trying to work through best I can right now.
DR. BINGHAM: Great. So yeah, 100% agree. And that's the similar stuff that we're kind of experiencing out here now is that we have to start planning for a space for the patients and you have to start kind of gathering your tools like how many ventilators do we have, but that's not always going to be the limiting fact, as Shreya alluded to. A lot of times the stress isn't going to be how many ventilators we have, but you don't have enough people to run those ventilators.
DR. BINGHAM: So, we're doing things at our hospital, like making sure that everybody is refreshed on their ventilator management and understanding that sometimes we're going to have to step into roles that we don't normally do. It's to kind of help out our medicine and our intensivist colleagues. You mentioned it a little bit, but how are you dealing with trainees?
DR. BINGHAM: So, residents, fellows, medical students. We've had some medical schools tell us, the med students are a critical part of the team. They need to be there taking care of these patients. And we've had other medical schools say we're pulling our students out. We don't want them exposed. So, how are you dealing with trainees in this resource limited and somewhat dangerous for exposure environment?
DR. DISSANAIKE: So, currently to my knowledge, and this may have changed today, because I haven't had time to check, but the Council of Deans has not mandated that third and fourth year students be pulled from clerkship. So, third year students are obviously more relevant since Match Day's upon us. So, right now they're still rotating. However, the main issue that is hindering their experience right now is the shortage of PPE.
DR. DISSANAIKE: So, clearly we're not going to put them in danger, but we cannot afford in this extremely dire situation in the hospitals that I work at to use it on non-essential personnel. So, it's limited their ability to be in the operating room or at least to scrub in on a case. However, we are still having them see patients. But remember that's in the context of a center that doesn't have documented cases yet.
DR. DISSANAIKE: If we had documented cases, we would not have a student on that service. And that actually has come through from the LCME that medical students are not supposed to work with COVID patients. And so, that is actually non-negotiable, but the rest of it is up to each medical school. And as you point out, each one of them is doing it perhaps a little bit differently.
DR. DISSANAIKE: And I think that's to some extent okay, just reflects the local concerns of that region. And I think something that is important to understand is even though we do rise or fall as a nation, it is a very large, very diverse, very geographically spread nation. And so, I think some of the problems we're seeing is that it's very hard to take a one size fits all remedy on any aspect, and we do have to-- It is different if you are in a crowded metropolitan city with five hospitals in a block practically, that's different from where I'm at, which is where we are the only academic tertiary referral center in this region.
DR. DISSANAIKE: That's a very different scenario and we really, it doesn't cross-pollinate as well as maybe some people would think it did.
DR. BINGHAM: And that leads to kind of my final question is how are you coordinating? Is there any talk there locally among the other hospital systems in your region about sharing resources or what to do if you reach capacity or if another hospital reaches capacity, who's going to overflow to who, have you started those discussions yet?
DR. DISSANAIKE: So, absolutely. I do know that the CEOs and the CMOs of the hospitals in the region are communicating and that happens mostly at that level. I will say that that is not usually happening at the surgery department level, that's happening at the hospital system-wide level. But I do know that in my region and most other regions, there is this kind of coordination. And the problem, of course, is that almost everyone has the same problems.
DR. DISSANAIKE: And so, if you're short of PPE, it's not like anyone else is going to have extras sitting around. So, that is the difficulty that we're all in the same boat, but it also means it limits what we can do to help each other out. However, I do know that in general, in most regions, I do think that hospitals are working together as best they can to pool the resources and serve the community.
DR. DISSANAIKE: [Dr. Gupta] Dr. Dissanaike, this was great. This is definitely a lesson in flexibility, if nothing else, and we appreciate your leadership and the measures that you've talked about, and hopefully, that will help the other leaders and other leaders in the field of surgery take similar measures to help our entire community. So, thank you so much.
DR. DISSANAIKE: Well, thank you very much. And I do want to say actually, since it didn't come up earlier, that one of the biggest resources for me has been email chains with other surgeons, surgical chairs. We have a lot of communication going, and frankly, that has been immensely helpful. My strategy for example, was modeled on the template of Dr. Rebecca Minter that the University of Wisconsin shared with me.
DR. DISSANAIKE: And I have many, many, many other friends who are chairs and we've all been sharing data and helping each other out. So, I do hope your listeners realize that nationally the surgical leaders are in very close communication with each other and we are all doing the best we can to help each other out.
DR. BINGHAM: Great. Communicate, collaborate. Yeah. Communicate, collaborate and dominate, that's one of the themes of Behind the Knife. So, that fits in perfectly. Thank you so much. [all participants chuckle]
DR. DISSANAIKE: That's awesome. Thank you. Bye.
DR. KNIERY: All right, and we're lucky enough today on Behind the Knife to have Dr. Angela Hewlett who is an associate professor in the division of infectious diseases and the medical director of the Nebraska Biocontainment Unit. Dr. Hewlett came on the podcast last minute to help us out with this breaking episode on Behind the Knife. So, thank you Dr. Hewlett for your time, and we really appreciate you joining us.
DR. HEWLETT: No problem. Happy to be here.
DR. KNIERY: So, can you just break down where are we right now as far as the number of cases in the U.S?
DR. HEWLETT: Well, currently today, and this is obviously a rapidly changing situation, but we have about 4,100 cases currently confirmed in the United States today.
DR. KNIERY: And do you have a favorite resource you use that is reliable to find this information?
DR. HEWLETT: So, actually they have a really great resource available on the Johns Hopkins website, which is actually a group of engineers from Hopkins who have been really great about updating current numbers, not just in the United States, but around the world.
DR. KNIERY: Great, that's also what I have been using. And so, what has our mortality rate been in the U.S. in these patients? And then how does this compare to the international rates that have been reported?
DR. HEWLETT: Well, I'm not sure we can really calculate a mortality rate at this point. I mean, we've had over 40, I think, 42 deaths reported in the United States as of today, but that being said, this again, this is a rapidly changing situation. And so, it's very difficult to really calculate an actual mortality rate based on the fact that these numbers are changing so dramatically every day. The other reason is that not only with the rapid evolution of the outbreak, but also just the issues that we've had with testing, and that we really don't know a good denominator for how many cases we actually have out there.
DR. HEWLETT: And so, any mortality rate would be very difficult to estimate at this time.
DR. KNIERY: Great. So, perfect lead in. Why is testing so difficult? I've heard South Korea has tested as many as 20 million people, and this is a month ago that they were doing this. What's the holdup and where do we go from here with that?
DR. HEWLETT: Well, so in the beginning, there were some issues with the test kits and some problems with the results actually generated from these testing kits at the CDC. And so that caused a delay with deploying those test kits to the state public health labs, which is typically how things are done here in the United States. The issue that we have with that is that the public health labs are only capable of running a certain number of tests.
DR. HEWLETT: And if you think about how we're set up here as a country, there may be that the state public health lab is located in an area that is hours away from a hospital or that sort of thing. And so, it's just a difficult system to work within. That being said, there have been some improvements, especially in the last few days as far as the number of tests that are available, mainly because the commercial labs are starting to test now, which hopefully will increase our capacity to test.
DR. HEWLETT: But yeah, there were delays and not only the test itself and the actual test kits that were required to perform the testing, but then also the processing of specimens was initially just done through the CDC with a longer turnaround time, and just a lot of difficulty actually obtaining those results.
DR. KNIERY: I hear these things of drive-through testing, is that a reality in the U.S., and if so, how long?
DR. HEWLETT: So, there are places that are doing drive-through testing. Washington State is a good example of that. I believe that this is happening in Colorado as well. We're all thinking about ways to try to test individuals in the community to really get a better idea of how widespread this illness has progressed. And as I mentioned, with limited testing capabilities, it is very difficult to test people in the community that are not in those distinct high risk groups that were initially identified by the CDC.
DR. KNIERY: Great. Can you speak quickly to just the virulence of this and how it compares to the flu and kind of incubation time and things like that?
DR. HEWLETT: Well, the virulence is I would say yet to be determined, it does seem like it's fairly easy to transmit this from person to person, just based on the rapid spread of this illness throughout China, Italy, Iran, we're obviously seeing this in the U.S. now. And so it does seem to be pretty capable of transmission person to person especially with close contact and with prolonged contact.
DR. KNIERY: Do patients develop immunity to this once they get through it?
DR. HEWLETT: Well, there's likely some immunity that develops. I think all of us think that there may be at least a transient immunity, but this is really yet to be proven and it's really unclear how long this immunity will last. I think that in the coming weeks and months, we'll have a much better idea of the immune system we'll have a much better idea of the immune system and how it reacts to this illness. There have been a couple of studies looking at the immune system and just showing some of the dysregulation that occurs with immune response in response to this illness.
DR. HEWLETT: But as far as actual immunity, we really don't know that yet.
DR. KNIERY: And then if you had a crystal ball, when do you expect to have clarity on the impact this is going to have as far as disease throughout our country?
DR. HEWLETT: If I had a crystal ball, and I really wish I did at this point, I think we all probably wish we did, I would say that this would last several weeks to a couple of months, and we're going to see a peak, and then hopefully we'll start to see cases taper off. If China is any indicator, they have a very, kind of a dramatic decrease in their cases that has been occurring recently.
DR. HEWLETT: But if you think about it, this outbreak actually began in China a couple of months ago. So, we're really talking probably weeks to a couple of months before we really know. And the other issue is that we also don't know, will this be a peak and then will taper off and go away like SARS did in 2003? It essentially disappeared off the face of the earth, and we never saw it again.
DR. HEWLETT: Or is this going to be something that will be more like the flu, where we see a seasonal resurgence of this illness?
DR. KNIERY: Great. And just to close out our podcast, if you could end it with telling us one thing that scares you the most about this, and then one piece of good news.
DR. HEWLETT: The thing that scares me the most about this is just the novelty of it. We've had several outbreaks in my lifetime and the lifetime of others, but actually, there really hasn't been anything like this since the 1918 influenza pandemic. And so, this is something that I'm less scared about the virus itself and more scared about our response capabilities and the concerns with providing the healthcare system, with having to ration supplies and medical equipment, beds, these are things that we really have not encountered in a real way.
DR. HEWLETT: We definitely have had some experience with pandemics, like H1N1 in 2009, as well as other emerging infectious diseases, but this is new. And I would say that that's what scares me the most, is just the novelty of this and concerns for the difficulties that the healthcare system will have as a result.
DR. KNIERY: And do you see any positives?
DR. HEWLETT: Yeah. So, there are a couple of things that I believe, are positives in this scenario. And one is that we are conducting a randomized controlled trial in the United States and around the world, looking at investigational therapeutic agent, specifically remdesivir for this illness, which this is the fastest randomized controlled trial I've seen come to fruition, at least in my career. And I would say that, to credit the NIH with bringing that trial very quickly and allowing us to start enrolling patients very quickly so that we can really see if this therapeutic agent does have a positive effect on this illness.
DR. HEWLETT: And the other thing is that the vaccine trials have started on healthy volunteers, actually today. I believe they enrolled the first healthy volunteers looking at a vaccine for this illness. And so, those are both things that hopefully will generate a therapeutic agent and potentially a vaccine as well. The vaccine, since we're just enrolling healthy volunteers currently, the vaccine actually coming to the general public is still pretty far off, I would say, within a year is the estimation, a year to 18 months, just because of the amount of time that that process takes.
DR. HEWLETT: But the positive is at least it's gotten started.
DR. KNIERY: Definitely. Well, Dr. Hewlett, thank you so much for your time. And this has been very helpful.
DR. HEWLETT: Okay. Thank you very much.
DR. KNIERY: Now, I'm here with Shreya and we're lucky enough to have Dr. Christian Jones. He's the director of acute care surgery fellowship, the assistant professor of surgery at Johns Hopkins. And he's going to talk to us about how to get these patients to the OR safely, if you are consulted on a COVID patient and they need surgery for whatever the reason, we're going to talk about ways to protect ourselves and to safely perform an operation on these patients.
DR. KNIERY: Dr. Jones, welcome for the 10th time, at least to Behind the Knife. Thank you for all your work you've done and please tell us, how do we do this safely? [Dr. Jones] Well, it's great to be here. Thank you both for having me. It's always a pleasure to be on the show and to still be an active listener as well. So, I should say before I get started, that all of the information that I'm going to give you is still very much in development, very much anecdotal, and owes a huge debt to the physicians who've treated patients in China, in Italy, in Iran as well as a lot of people on social media.
DR. KNIERY: And then, of course, most importantly, the University of Washington experience here in the Seattle area. The resources that are available are constantly being updated. So, I apologize greatly if something I tell you now ends up not being quite right in the next two weeks, but what I can say is that what we'll talk about is principles of ensuring that you're doing the right thing for your patient as well as the right thing for your team.
DR. KNIERY: So, the first and probably most important point of emergency surgery on a patient with COVID just like with any other severe, easily transmissible critical illness, is to ensure that you're doing the right procedure or filling the need properly in the first place. Some patients that many of us in acute care surgery are accustomed to treating operatively may not need a formal operating room procedure.
DR. KNIERY: may not need a formal operating room procedure, again, just like the critically ill patients that we see in our consult from time to time. For instance, if a patient, for whatever reason, develops cholecystitis while suffering from multiorgan system failure secondary to COVID, it's almost certainly more appropriate to place a percutaneous cholecystostomy tube in that patient rather than taking them to the operating room.
DR. KNIERY: So, ensure that you're doing the right thing in the first place. If you do end up having to take the patient to the operating room, there are a few items that you can ensure give both you and your patient as well as the rest of your team, the best options for recovery and prevention of exposure. Again, these are anecdotal, but they make sense.
DR. KNIERY: Some of them are from current experiences with COVID, Some of them are from current experiences with COVID, and some of them are from back a few years ago when we were preparing for a larger number of patients with ebola. The mandate of course, is minimize exposure as well as minimize the exposure of the patient to the environment. So, most of the recommendations that are coming out, of course, include the same airborne precautions that you're going to do at anytime that you're interacting with COVID patients in an aerosol fashion.
DR. KNIERY: So, you're going to have full body coverage, you'll have the big OR boots on, so even your feet and your pant legs aren't getting exposed, you'll have obviously a gown, an N95 mask or PAPR respirator, eye protection, head protection, and so forth. And again, we've talked about this quite a lot on social media and here on Behind the Knife, but a big part of that is learning how to properly apply to doff and don as it were, that protective equipment.
DR. KNIERY: And it's a really, really boring, dry thing to think about And it's a really, really boring, dry thing to think about practicing putting on and taking off PPE. practicing putting on and taking off PPE. But at the same time, it's not boring at all when you actually have to do it in order to prevent contaminating yourself. So, there are a lot of videos out there, there are a lot of recommendations from the CDC and other groups on the exact order to put things on.
DR. KNIERY: And we can talk about that more, but again, using that PPE is obviously imperative to any interaction that you're going to have from a surgical standpoint with such patients.
DR. KNIERY: Great. I think that is videos that I can put up and load on the show notes so people can watch. It's one of the things they may not watch right now, but when they get that consult, they may think of it and go watch these videos beforehand. So, Dr. Jones once these patients are intubated, is there any less risk of transmission given that they're breathing through a circuit or do we not know yet?
DR. KNIERY: [Dr. Jones] Well, we think that there's less risk. In fact, some of the patients who are already intubated, already on the ventilatory circuit seem to have less disease transmission. The problem is that we're not just getting them intubated, The problem is that we're not just getting them intubated, which that the process of intubation can still expose a great deal of viral load, we're doing something else to them as well, which almost certainly ends up making things worse in terms of exposure.
DR. KNIERY: So, having the patient ventilated, having the patient with the tube and the circuit in place is great. Unfortunately, you're also then going to cut them open, or in certain circumstances, you might end up performing tracheostomies or otherwise getting into the airways. We know that the virus does present in fecal matter.
DR. KNIERY: So, perhaps bowel surgery increases the rate of disease transmission. We have absolutely no data regarding disease transmission via surgery, but people are trying to keep track of the surgeries that are done. There's a great global movement happening called COVID Surg, C-O-V-I-D S-U-R-G that has a huge number of centers enrolled for keeping track of surgeries that are done on patients with COVID.
DR. KNIERY: But again, that's all very early, we don't know the actual risk at all. So, we're again recommending simply to be as cautious as possible. One of the items that has come up is the question of laparoscopic surgery, does insufflating the abdomen, causing that positive pressure in the abdomen end up aerosolizing virus that then goes into the air around the surgeons in the operating room, and maybe even out of the operating room.
DR. KNIERY: And again, we really just don't know. Most of the recommendations are to do what you're comfortable with. So, if you're going to do a cholecystectomy in a patient for whatever reason, and you're more comfortable doing laparoscopic surgery quickly compared to an open surgery, by all means, you should probably do that to again keep the patient as safe as possible while providing whatever safety you can for the entire team.
DR. KNIERY: Not to dive too much into the nuance, but so when you scrub in for these cases, you're going to have the shoe, booty protectors on, you're going to have your whatever your head covering is, your standard head covering, and then it should be an N95 masks that you're operating with, is that what you said? [Dr. Jones] So, there are still two schools of thought that the N95 mask is entirely appropriate for the operating room, or the PAPR, the positive air pressure respirator.
DR. KNIERY: the positive air pressure respirator. The numbers are basically equivalent. There may be a slight decrease in exposure with the PAPR, There may be a slight decrease in exposure with the PAPR, but most people who have had what little experience we've had, say that it's harder to operate wearing a hood with a fan running near your head. Either one is perfectly acceptable from a disease transmission standpoint and from an exposure standpoint, I think as we end up doing more and more emergency surgeries in patients with COVID, people are going to end up having their preferences one way or the other.
DR. KNIERY: Some people are going to find the PAPR difficult to work with, and some people are going to find the N95 masks terribly uncomfortable. In fact, it may end up simply being a moot point if we end up having access to only one or the other as could certainly arise, the PAPRs are reusable, but do end up taking quite a bit of processing to make reusable, the N95 masks as everybody has already talked about could very well be in shortage.
DR. KNIERY: From the pure safety standpoint, it's either one that you have access to and can work comfortably and appropriately from the standpoint of surgeon preference. I've tried both, not in an actual case, but I've fitted and worn them for some time, and I tend to prefer the PAPR myself. But once again, I don't think there's any data suggesting that you really should be wearing one or the other, especially for an extended surgery.
DR. KNIERY: [Dr. Gupta] Shifting gears from like actually being in the perioperative period for these patients, could you talk to us about what are some of the basic principles of management of COVID-19 patients, especially for the residents who are taking care of these patients that we've outlined? [Dr. Jones] So, as might be somewhat expected for those who have a significant amount of experience with critical care, then somewhat disappointing, perhaps, [chuckles] believe it or not, it's mostly supportive care.
DR. KNIERY: There is a great deal of information coming out about particular maneuvers and particular treatments that may be somewhat more effective in patients with COVID as opposed to patients with otherwise severe pulmonary failure and ARDS, for instance, there's anecdotal data suggesting that for patients who are deoxygenated and having difficulty with recruitment, that proning may work well for such patients.
DR. KNIERY: But again, there's no strong data to say so. Similarly, early use of steroids may be appropriate. It's really impossible to know at this point, whether the treatment of COVID-based ARDS whether the treatment of COVID-based ARDS is really any significantly different than the treatment of ARDS that we've been doing for the last 10 years. And the problem, of course, is that there've been so many different potential treatments and potential interventions for acute respiratory distress syndrome that have over the years gone into and out of fashion as more and more data becomes available, that we're sort of revisiting every one of those with COVID patients hoping that in this select subset of patients, some of those things that don't work in general, may work better.
DR. KNIERY: Complicating all of this issue, most of the anecdotal tales we have of patient course in the ICU from the critical illness associated with COVID shows that yes, there is some incidents of multiorgan system failure, but at the same time, there is this coincident syndrome of having severe ARDS there is this coincident syndrome of having severe ARDS that then gets better for a couple of days, followed by a terrible cardiomyopathy.
DR. KNIERY: And in fact, many patients appear to be dying more of the cardiac failure, again, in these anecdotal series. So, in that sense, again, we're dealing mostly with supportive care. There are a few stories of patients going on ECMO and surviving. And I have heard talk, though I've seen no official report, I've heard talk that there has now been a double lung transplant for a patient who was actually recovering from COVID with terrible lung disease.
DR. KNIERY: So, from the critical care standpoint, as is often the case, we don't know exactly which treatments shorten the course or improve the outcome. We know that the standard supportive care of the patient in multiorgan system failure arising from acute respiratory distress syndrome seems to be important and seems to work well at its standard, and that's for the moment what I would advocate doing for our patients that we end up seeing in the ICU.
DR. KNIERY: Great. That's very helpful. I was actually listening to a podcast earlier today called The Journal, and they have a race to the cure of coronavirus, and they were actually interviewing some pharmaceutical companies that are trying to find this gold rush for cure. that are trying to find this gold rush for cure. And two things that they're looking into closely is there's an antiviral that had been made for a different coronavirus that they're trying to modify to work for this.
DR. KNIERY: And then there's also, in China, apparently they had some luck with arthritis drugs, and the thought being is it decreases the immune response. Apparently some of these patients are having relatively low viral loads but having these extreme immune responses and I guess, similar to how steroids work, and potential effects of that maybe helping. None of these are anywhere near approved, and they just have eight patients in the U.S. on it, on the antiviral, but it's at least a start.
DR. KNIERY: [Dr. Jones] That's great, absolutely. And again, the idea of the anti-inflammatory or the anti-immune response goes back to that standard or the anti-immune response goes back to that standard acute respiratory distress syndrome treatment that we've talked about and have had treatments going in and out of fashion. When it comes to the actual antivirals that are being used, this is probably a good time to ensure that you are engaging your infectious disease colleagues and other experts.
DR. KNIERY: I am not going to, in any way, suggest that I'm an expert in antivirals.
DR. KNIERY: Definitely. And so Dr. Jones on Twitter, when we were talking about this, people were asking what acute care GI issues are occurring in this, what surgical issues are most common? And I promised that I would ask you that question. And so, have you heard anything, is there any reports out about what acute care surgeons might be facing with this disease? [Dr. Jones] Yeah, absolutely, Kevin.
DR. KNIERY: The biggest thing that we have to assume is that they will mostly have the same diseases that any critically ill population has as a secondary presentation. So again, for instance, one of the more common diseases that we find in the critically ill population who may or may not have had surgery is acalculus cholecystitis. Once again, that's something that you're going to be consulted on as an acute care surgeon or a general surgeon not treating COVID patients, and again, as usual, depending on the level of illness, most such patients are going to end up with percutaneous cholecystostomy, too and deferred management over that cholecystitis.
DR. KNIERY: There are a few stories of patients having other diseases associated with the COVID multi-system organ failure, and again, those are things that you might expect, such as mesenteric ischemia, or otherwise, small bowel ischemia. As it happens, a great deal of these patients don't seem to be receiving high dose vasopressors, at least not during the pulmonary section of their illness.
DR. KNIERY: And therefore, they may not have quite the same level of acute abdomen presentations as some of the MICU patients that you're more accustomed to seeing. There's always going to be a small portion of patients who develop coincident acute care surgery problems, such as appendicitis or true biliary cholecystitis or pancreatitis, but we don't even know exactly what that incidence is.
DR. KNIERY: I think, as with any critically ill population, the big question is going to be what the physiology of the illness has been, what's the pathophysiology that this particular patient has presented with? Have they had episodes of severe hypotension? Have they been on high dose vasopressors? Have they had previous complaints of gallstones, Have they had previous complaints of gallstones, biliary, colic, and so forth?
DR. KNIERY: I would expect that as we have gotten better at treating coincidental or associated problems in the ICU over the last several years, if we do become particularly overwhelmed on the patient side, and especially on the intensivist side, there are likely to be things that do end up getting missed, and perhaps that we haven't dealt with in some time like significant stress ulcers, because the patient hasn't been on a prophylaxis.
DR. KNIERY: We may be dealing with GI bleeds from a surgical standpoint, again, slightly more often. Unfortunately, that'll greatly depend on the course and epidemiology of the illness over the next several weeks or months. [Dr. Gupta] Well, thank you Dr. Jones for taking time to talk to us, we know that the situation is evolving and there's a lot of anxiety and likely so in the medical community.
DR. KNIERY: So any and all education on this topic is very much appreciated by our listeners. So, we appreciate you taking time. Thank you. [Dr. Jones] It's always my pleasure, Dr. Gupta. Thank you so much.
DR. KNIERY: Okay. And we are lucky enough to have Dr. Vahagn Nikolian, he's a fellow at Columbia in abdominal wall reconstruction, and he helped start the surgery e-clinic at the University of Michigan, and he also has worked on telehealth at New York Presbyterian and will be joining OHSU, which is known for their strong telehealth presence in the Pacific Northwest. He's joining us today to obviously talk about telehealth and how we can use this in the situation of a pandemic to serve our patients and protect them.
DR. KNIERY: So, welcome, Vahagn, you've been on the podcast multiple times before. We're excited to have you. [Dr. Nikolian] Thank you again for bringing me back, I wish we weren't sort of meeting on these circumstances, but I'm happy to discuss how telehealth can help our patients and our providers. So, why don't we get started?
DR. KNIERY: Yeah. So, what is telehealth? [Dr. Nikolian] Sure. So, I guess in its simplest form, it's the use of audio and visual communication to practice medicine. It's been around for decades, but obviously over the course of the last maybe 10-15 years, it's really taken off, people are recognizing it as a viable approach to seeing patients. Modern telemedicine is using telephone calls, broadband, text messages, smartphone apps, and even wearable devices to connect us with patients like we've never had the opportunity to connect before.
DR. KNIERY: I also tell people telemedicine essentially lets us practice medicine irrespective of geographic barriers, so things to remember whenever you think about telemed. [Dr. Gupta] Now, how does this apply to surgical population, our surgical patients? [Dr. Nikolian] Great, great question. Yeah. So, surgical patient populations have actually had some opportunities to work with providers in this setting.
DR. KNIERY: The role of telemedicine is expanding quickly. Over the last decade, more use of pre and postoperative evaluations has been done. In surgical patients, I think the goal should be to consolidate their experience to as little time spent at the medical center, essentially just center it around the hospitalization or the operative visit, and then try to do as much of it away so that the patient doesn't necessarily have to travel so many times for a single service.
DR. KNIERY: Most commonly, it's been applied in the post-op period. It's also been applied successfully in a variety of subspecialties, so vascular surgeons, orthopedic surgeons, neurosurgeons, and general surgeons have shown that it's safe, it's feasible and there's higher rates of user satisfaction, both on the patient side and the provider side. [Dr. Gupta] That sounds like the perfect solution in the advent of the surgeon shortage that we face now.
DR. KNIERY: in the advent of the surgeon shortage that we face now. But at the same time, there are definitely some situations that are not ideal for telehealth. Would you like to comment on that? [Dr. Nikolian] Sure, yeah. So again, I always tell people telemedicine is centered around the patient. So, I always present it, and most people would obviously present it as an option for patients.
DR. KNIERY: Clearly, if a patient's not comfortable with that modality of interaction, then we would offer them a more traditional follow-up or a more traditional approach to their care. Patients with postoperative complications, patients with drains that need to be removed, permanent sutures, or those that need other diagnostic workup at the hospital probably won't benefit as much from telehealth postoperative visits.
DR. KNIERY: I think for us there's a lot of factors that limit the increase in utilization, and most of that is related to reimbursement. Every state and every insurance company is different, so when you're working in a setting with a lot of different insurance providers, it's important to understand the rules and regulations for each. And then finally, one of the settings that you have to be careful about as a doctor is making sure that the patient and you, or at least the patient lives in a state that you're licensed to practice in.
DR. KNIERY: If patients are crossing state lines to see you, you can't see them at their origination site, which would be their home.
DR. KNIERY: Yeah. So, Vahagn, this makes a lot of sense. And I think this is, like Shreya said, a perfect opportunity to use this in the setting of this pandemic and after that also. So, we have providers that are listening that have clinic set up for this week and they want to know how do I implement this, this week? What do I do? So, what is the software? What are the platforms that you recommend for using this technology?
DR. KNIERY: [Dr. Nikolian] Great question. And so, most EMRs right now do provide you the opportunity to do what's called the video visit, which is going to be a synchronous real-time interaction with your patient. That can be a little difficult to set up right now to have it go because the patient has to download usually an app to get them on the interface. You have to coordinate with your team to have a visit set up, and then the patient has to be able to use the app.
DR. KNIERY: It's not difficult but I think in this setting, when we're talking about implementation in the setting of coronavirus, I think that would be difficult. What you can remember is that telemedicine has been shown to be effective in the post-op period, just using simple telephone calls. So, if you want to have a telephone call with the patient, that is also very safe.
DR. KNIERY: If you have questions about how the wound looks, you can ask them questions through a checklist. You can also ask them to take a video or a photograph and send it to you and then make your assessment in that manner. A lot of people ask whether or not you can use other things, such as Skype or other things, like FaceTime and that's been used before, it's safe. A lot of these programs now are developing HIPAA compliant mechanisms.
DR. KNIERY: One of the other questions people have is with regard to platforms and video visits, are patients that are older going to be comfortable using it? And I always remind people that older patient populations are actually using this all the time when they're connecting with their families from across the country or seeing their grandchildren via FaceTime. So, a lot of my patients are even pushing up into their mid and late 80s and are still able to communicate and connect with us via video visit.
DR. KNIERY: [Dr. Gupta] So, what are some tips that you have in order to make this new platform of telemedicine go smoothly for both the patients and the providers? [Dr. Nikolian] Great. Yeah. So, most importantly, it's about planning. And so, it's about coordinating with your administrative staff to help the patients either set up their smart devices. You want to make sure that patients are recognizing that these are true appointments.
DR. KNIERY: So, when you schedule them for their appointment, we always tell them to plan sort of be somewhere quiet for 15 minutes before your appointment time until maybe 30 minutes after so that you can have time to check them in, talk to them, address any questions that may come up. And so, setting expectations is essential. After you do that, then you have to figure out whether you're seeing the patient in the preoperative setting or the post-op setting.
DR. KNIERY: For preoperative patients, you want to make sure that you've collected as much data on them before the interaction as possible. That includes getting all of their images if you need that uploaded into your system, their laboratory is uploaded into your system. And then if it's possible, sending them just a simple questionnaire so that you can know what's going on in their past medical, past surgical history, what medications they're on, so that your interaction with them can be more effective.
DR. KNIERY: I think most providers are going to be more comfortable in the post-op setting. And again, you set that up by giving them the option after their surgery of seeing you in the video visit format. When you do that and you see them, it's usually a straightforward checklist of making sure that they're progressing as you would expect.
DR. KNIERY: And if they are, then I think you're safe to consider them doing well postoperatively. [Dr. Gupta] So, you mentioned this really salient point in all of this is that you want to make sure that your patients know that this is an appointment. How does this fare with like the insurance companies? Do they consider this a full appointment? And is this qualified for their post-op clinic visit?
DR. KNIERY: [Dr. Nikolian] Yes. So, for postoperative, in most cases, you're working in a setting where you're talking about bundled payments, and that's really why post-op visits are taking off because the payment is bundled into their operation, you're not necessarily having to deal with as much issues. Preoperatively, it can be more difficult. A lot of people have started billing based on time-based billing.
DR. KNIERY: So, you can circumvent some of the challenges in terms of reimbursement. Again, as surgeons, I think we have an advantage in that our reimbursement is not necessarily tied to how active we are in the clinic, but it's something that's evolving, we definitely have to work on. I think in these circumstances, a lot of providers and payers have lifted some of the restrictions they had.
DR. KNIERY: So, this may be a good opportunity to get involved in this realm without some of the restrictions that have previously been there. [Dr. Gupta] That all sounds really good. Is there any last minute comment that we have not covered in our questions that you would like to add? [Dr. Nikolian] Sure. So, every time I talk about telemedicine, one, I get really excited.
DR. KNIERY: I think it's something that's evolving, it's going to definitely become more common as we practice medicine and surgery. When you're seeing your next few patients in just a traditional clinic, consider asking them a few questions, just to get a sense of how useful it could have been for them. Specifically asking them how long they had to wait to come for the clinic visit and how much time they dedicated to the encounter.
DR. KNIERY: And then ask yourself after the encounter, whether or not you knew the recommendations that you were going to provide them prior to meeting the patient, and whether or not the actual physical exam based on touching the patient altered your final decision-making. I think when you ask yourself these questions and talk to the patient, you may realize that you can actually use telemedicine more than you were previously thinking you could.
DR. KNIERY: [Dr. Gupta] I think that's really great advice. Thank you so much for taking time to discuss telemedicine with us. We really appreciate it. [Dr. Nikolian] Yeah. I hope we all are able to work to continue to flatten the curve. And I think telemedicine can give us an opportunity to do that for our patients. Thanks, guys.
DR. KNIERY: [Dr. Gupta] Absolutely.
DR. KNIERY: Absolutely. Thank you, Vahagn. [narrator] Until next time, dominate the day. [upbeat outro music]