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COVID-19 and Neurosurgical Training: Impact on the Next Generation of Neurosurgeons (Part II)

By COVID-19, Faces of Neurosurgery, GME, Guest PostNo Comments

What started as a brief segment on the evening news has consumed our daily lives as COVID-19 spreads across the globe. As health care facilities became inundated with critically ill patients, the nation’s intensivists, internists, emergency medicine physicians, nurses and respiratory therapists took to the front lines to fight this invisible enemy. With years of education behind us and at the cusp of the most significant health crisis in recent history, many residents are apprehensive of the future. What would be our role? Would we have adequate personal protective equipment (PPE) and critical care supplies to care for the sick? How can we keep ourselves and families safe?

Life in neurosurgery changed in step with the sweeping changes across the medical community, necessitated by potential supply shortages and increased patient volume. As social distancing took effect, the coveted morning sign-out — the bedrock of day-to-day functioning of a busy neurosurgery service — was transitioned to video conferencing. Next was the cancellation of all elective cases, then semi-urgent cases, and eventually, in some hospitals, emergency cases could only be performed after chair/faculty committee approval. Clinic visits were canceled if deemed non-urgent or conducted as telemedicine visits to provide care while limiting disease spread. To protect residents from unnecessary exposure and maintain a reserve, call schedules were changed to limit the number of residents seeing consults at one time or available for cases. As these changes were implemented, unprecedented collaboration, flexibility and ingenuity was prevalent as everyone did their part to ensure care remained as safe and effective as possible.

All neurosurgery residents have been affected. The junior residents, who spend the majority of their time seeing consults in high exposure environments such as the emergency department, saw a significant decrease in volume. Many patients with non-life-threatening concerns were now staying home or triaged appropriately to outpatient follow up. When patients did require evaluation, proper PPE was a necessity, and focused examinations were performed with as minimal patient contact as possible to ascertain the most clinically actionable portions of the exam. The workup of neurosurgical patients was done with an extreme focus on critical data and imaging, necessitating a thoughtful and evolving approach in a resource-constrained environment. For off-call, junior residents, residency experience changed even more dramatically, with potential operating room time virtually eliminated in most programs and off service rotations as neuropathology or neuroradiology postponed. Junior residents turned towards productivity in different areas, such as pursuing research opportunities and reviewing neurosurgical literature. For many residents affected by the cancellation of the written portion of the American Board of Neurological Surgery board exam, the additional study time was a welcome opportunity for further preparation.

Senior residents, who traditionally spend the majority of their time operating or developing the next steps of their career, saw their world go on pause. Interviews for fellowships and jobs were delayed or canceled altogether. Apprehension about how these changes will affect the significant drop in case volumes has compounded their future. At our institution, there was a 95-100% reduction in weekly cases as compared to January of 2020. As a department, we implemented a weekly review of cases that were considered urgent, to identify the few that should be done. Difficult discussions involved patients without emergent indications for surgical intervention — including those with myelopathy, radiculopathy or brain tumors. Alternative treatments and management considerations were instituted as temporizing measures while maintaining close communication with these patients. This case review considered not only the patient’s course without surgery, but also the likelihood of the patient utilizing an ICU bed post-operatively, or the risk to their health if they were to contract COVID-19 during hospitalization.

Operative times increased as the operative team was required to vacate the operating room for a designated period during intubation and extubation to lower transmission risk. Universal testing protocols have been implemented to save valuable PPE and time. Room cleaning and turn-over times also increased. Operating room availability diminished in some institutions as anesthesia machines were utilized as ventilators, and the rooms turned into makeshift ICUs to cope with the surge of patients. The Accreditation Council for Graduate Medical Education began accepting COVID-19 patient management as approved cases to accommodate the drop in operative cases nationwide.

While not always called to the front lines, neurosurgical residents across the country sought ways to utilize their unique skillsets to help their colleagues and patients during this crisis. Using the spirit of innovation and ingenuity, some developed projects to 3D print ventilator parts, testing swabs or respirators. Others devised ways to manufacture face shields and other protective devices. The surgical suturing skillset took a twist as neurosurgical services turned to produce homemade masks from cloth and HEPA air filters. Others used COVID-19 webinars to increase their critical care skillset in preparation for possible time on the frontlines.

Neurosurgical education has also been altered. Traditional teaching methods have been abandoned for digitization. Much like the broader educational system, neurosurgery responded with unification over video platforms. Journal clubs offer opportunities to share screens and materials. Morbidity and mortality conferences continued via a secure connection. National organizations such as the Congress of Neurological Surgeons expanded their education platform to include virtual visiting professors and webinars. Information sharing through social media platforms have triggered unprecedented opportunities to communicate and learn with both the national and global neurosurgery community.

The future remains uncertain for now. While there is talk of restrictions being eased in some parts of the globe, the U.S. still has difficult days ahead. We are grateful to the intensivists, internists, emergency medicine physicians, nurses and respiratory therapists who are bearing the brunt of this war. They are the true heroes. The silver lining of this experience is what we have learned about ourselves and what we have achieved with our ingenuity.

As will be the case in other specialties, telemedicine has shown its utility in neurosurgery and is here to stay. Although lacking the personal connection many of us hold sacred, telemedicine has proved to be a suitable alternative for patients in rural settings with long travel distances or those with debilitating conditions that make travel a stressful experience. This creates new opportunities to provide highly specialized neurosurgical care from a central location with patient experience and convenience at the forefront. Virtual video meetings have changed how we share information, collaborate on research and learn. The ability to 3D print ventilator parts and PPE has shown us the promise of technology. With time, the focus will shift away from the needs of the pandemic and to newfound innovations with relevance to neurosurgery. As a profession will come out from this with a renewed focus on the improvement of patient care.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following and using the hashtag #COVID19.

Redi Rahmani, MD
PGY-4 Neurosurgery Resident
University of Rochester Medical Center
Rochester, N.Y.

 

 

Nathaniel R. Ellens, MD
PGY-2 Neurosurgery Resident
University of Rochester Medical Center
Rochester, N.Y.

 

 

Tyler M. Schmidt, DO
PGY-7 Neurosurgery Resident
University of Rochester Medical Center
Rochester, N.Y.

May 20, 2020
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COVID-19 and Neurosurgical Training: Impact on the Next Generation of Neurosurgeons (Part I)

By COVID-19, Faces of Neurosurgery, Guest Post, HealthNo Comments

In early March, our neurosurgery team at Mount Sinai Medical Center noticed a handful of COVID-19 cases admitted to our medical intensive care unit (MICU), which is just down the hall from the neurosurgical intensive care unit (ICU). The daily news from Asia and Europe was certainly not encouraging, but we proceeded with our normal routine — morning rounds, surgery and academic conference.

Then, for one-week, cases of COVID-19 filled the MICU. Shortly after that, our neurosurgical step-down — followed by the neurosurgical ICU — were rapidly converted into negative pressure rooms for COVID-19 patients. That same week, our hospital system placed a hold on all elective, non-emergent surgeries. By Friday, March 20, at a time when there were 7,102 confirmed cases of COVID-19 in New York (with 46 deaths), Governor Andrew M. Cuomo ordered all non-essential businesses closed and their employees to stay home. The following day, our department leadership held an emergency town hall video conference discussing a re-organization of the department. As of the writing of this article, our 18-bed neurosurgical ICU is at double capacity and frequently caring for more than 40 critically ill, ventilated COVID-19 patients every day — accounting for new admissions, discharges and mortalities.

As health care providers and citizens of New York City, my colleagues and I have witnessed our home become the U.S. epicenter of the COVID-19 pandemic — surpassing all other regions in terms of the number of confirmed cases and deaths. What has transpired over a month here in New York City has completely shifted the way we provide health care — in general, as well as the practice neurosurgery — and how we learn as resident physicians.

There has been a city-wide diversion of health care resources to care for critically ill patients with COVID-19. From the conversion in operating rooms and post-anesthesia care units (PACUs) to ICUs, to the transition of neurocritical care faculty and providers to staff these units, all have led to a shift in focus for residents of neurosurgery. With elective surgeries on hold, our daily routines have changed dramatically. In addition to caring for neurosurgical emergencies, many residents have assumed a greater role in providing critical care — staff both the neurosurgical and respiratory ICUs. This has meant — particularly for more senior residents and neurosurgical attendings — a deep dive into critical care medicine, ventilator management and the latest therapeutic strategies for COVID-19. One piece of expertise that neurosurgery residents can bring to the respiratory ICU is turning patients into the prone position. This maneuver can salvage some patients with significant respiratory compromise. One commonality for all health care providers during this time is the feeling of being outside one’s zone of comfort. Whether this takes the form of a neurosurgical resident staffing the respiratory ICU or a general sense of uncertainty over when this crisis will end, this unified sensation has led to individual and interpersonal growth.

During this time, neurosurgeons have also witnessed the redefinition of a neurosurgical emergency. As providers, we have had to make difficult decisions on both ends of the emergency spectrum — for example, from purely elective spine surgery to active herniating discs. In the current pandemic, physicians worldwide have been needed to decide which COVID-19 patients should not be intubated, given their overall poor prognosis to save the ventilator for a patient with a better chance of a good outcome. We have had to discuss end-of-life care with certain neurosurgical patients who, in other times, would be surgical candidates. Non-emergent but urgent surgeries, including brain tumors, have been pushed back for months — another indirect consequence of COVID-19 that may significantly affect a patient’s overall outcome.

Despite a lack of standard surgical experience, neurosurgical residents have continued to learn during this crisis. Beyond the critical care knowledge, we continue to have didactic sessions, with one significant change — video conferencing. To uphold the sanctity of social distancing, we have been logging in from separate computers in distant locations to participate. We are fortunate to be able to continue our didactic learning. At the same time, our colleagues in internal medicine and other specialties beleaguered by the present pandemic, do not have the capacity for anything besides direct patient care.

Beyond these changes to the health care landscape, we in New York City have experienced an incredible shift in the mentality of daily life. The defining features of the “City That Never Sleeps” — restaurants, subways, cultural landmarks — have been shut down. However, the New York City spirit continues to thrive. We have seen an outpouring of philanthropy, from donations of handmade personal protective equipment (PPE) to deliveries of meals to entire medical units. Like other cities around the world, every night at 7 p.m., one can hear clapping and cheering from apartments and skyscrapers city-wide, an homage to the essential personnel and health care workers keeping New York City on its feet and preparing for a successful emergence in time.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following and using the hashtag #COVID19.

Kurt A. Yaeger, MD
Mount Sinai Medical Center
New York, N.Y.

May 18, 2020
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CNS Launches Town Hall Xperience to Cover COVID-19 and Timely Neurosurgery Topics

By CNS Spotlight, COVID-19, HealthNo Comments

To address the need for neurosurgeons to rapidly share experiences and insights during COVID-19, the Congress of Neurological Surgeons (CNS) recently launched a complimentary Town Hall Xperience for CNS members.

The CNS Town Hall Xperience provides an informal and interactive format, where experts discuss their experiences and answer questions from members. Members can submit topics and questions in advance of the session, as well as during the session. Sessions are facilitated by preeminent faculty.

Multiple sessions each week ensure the latest timely COVID-19 and neurosurgery topics are covered and discussed. Summaries of the sessions will be available following the session, along with other helpful links and resources.

Topics will cover a variety of information helpful to practicing neurosurgeons and residents, including:

  • Managing a Neurosurgery Practice in the COVID-19 Crisis;
  • Fellowship Speed Dating: Subspecialties, Timelines and How to Make a Choice;
  • Subspecialty-specific topics; and
  • More.

Throughout the pandemic, publications, including Neurosurgery, are working to expedite breaking research, but there is a limit to the speed in which peer review can be accomplished.

Currently a CNS member? Learn more here.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following and using the hashtag #COVID19.

May 15, 2020
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Telemedicine During the COVID-19 Pandemic and in a Changing Health Care System

By COVID-19, Faces of Neurosurgery, Guest Post, HealthNo Comments

The COVID-19 crisis has produced seismic changes in the practice of neurosurgery. For weeks elective surgeries have been eliminated and shelter in place orders implemented. Patients still develop herniated discs with neurologic deficits, present with brain tumors and need neurosurgical treatment. Telemedicine has provided one option for remaining connected to our established patients and caring for new patients during the pandemic.

CMS Changes

The Centers for Medicare & Medicaid Services (CMS) has been nimble in issuing rules and guidance around the use of telemedicine. CMS is now paying for telehealth visits at the same rate that they pay for an in-person visit. Documentation requirements have been modified and now focus on medical decision-making. Now you can bill based on time spent during the visit or on the complexity of medical decision making required in your assessment. CMS will pay for telemedicine if the physician is licensed in the state where the services are provided — regardless of where the patient is located.

There are several video conferencing and chat platforms that physicians may use. Setting up Health Insurance Portability and Accountability Act (HIPAA) compliant solutions may be beyond the capabilities of small practices, especially when they are trying to see patients now. If physicians act in good faith, CMS is currently allowing physicians to use other platforms without worrying about triggering an Office of Civil Rights audit for the failure to comply with HIPAA during this national public health emergency.

CMS has also issued specific guidance for teaching hospitals and addressed numerous questions about how learners may fit into the broader utilization of telemedicine. The agency has stated that teaching physicians can provide services with medical residents virtually through audio/video real-time communications technology, with the caveat that this does not apply in the case of surgical, high-risk, interventional, or other complex procedures, services performed through an endoscope, or anesthesia services.

Outpatient and Inpatient Visits

These new rules are not just for outpatient clinic visits. Inpatient consultations and emergency room care are also included in the list of services where telehealth is an option.

The use of telemedicine carts has been widespread in the evaluation and management of stroke patients. This same platform could be used to conduct consultations and rounds, supported by colleagues at the bedside. Some of the challenges around this concept require novel solutions, such as the creation of a tele-presenter role to:

  • Be onsite and available through the paging system;
  • Deploy the telemedicine equipment as directed by the physician;
  • Introduce and explain the telemedicine process to the patient;
  • Stay in the patient’s room while the consult is performed to assist with the exam;
  • Interact and coordinate telemedicine deployment across multiple specialty teams; and
  • Basic troubleshooting of any equipment malfunctions.

Potential Issues

Technological innovations have enabled practices to continue to see patients while maintaining social distancing. While telemedicine may have a long-lasting and impactful future, and the health care system may not have explored all potential avenues of virtual health care delivery, there are some potential issues. For example, how are physicians who are currently working from home enabled to respond to the occasional inpatient consult that may arise during the day? Physicians working remotely may produce unique challenges.

Additionally, patient consent specific to telehealth is required for all visits. The consent needs to specify the unique risks of providing care virtually with a patient. Unauthorized access, breach of patient privacy and the inability to provide a thorough physical exam are limitations of telehealth.

Finally, the lack of a physical exam cannot be understated. Some aspects of the physical exam can be assessed, including height and weight, pulse, respiratory rate, observation of motor status and gait/balance, extraocular muscles, and facial symmetry. Many aspects of our examination simply do not translate to a virtual platform such as deep tendon reflexes, pathologic reflexes and a thorough sensory exam. Furthermore, direct patient contact is essential for fostering trust and in developing the doctor-patient relationship. The feeling of partnership with your patient when facing a difficult diagnosis may be challenging with a visit conducted through a smartphone screen.

Looking into the Crystal Ball

During the COVID-19 public health emergency, we have incorporated telehealth visits into our practices. In our experience, the move to telehealth has improved clinic efficiency and increased clinic throughput. Telehealth visits are an effective way to screen patients and provide an easy way to quickly assess whether a patient needs to be seen in person to determine the need for surgery.

While Medicare (and other third-party payors) has adopted these changes for the duration of the COVID-19 public health emergency, it is safe to say that telemedicine in neurosurgery is here to stay — and will have even further impact on our practices in the future.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following and using the hashtag #COVID19.

John Ratliff, MD, FAANS, FACS
Chair-elect, AANS/CNS Washington Committee
Stanford University Medical Center
Palo Alto, CA

 

 

Clemens M. Schirmer, MD, PhD, FAANS, FAHA
Chair, AANS/CNS Communications and Public Relations Committee
Geisinger
Wilkes Barre, PA

May 13, 2020
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Neurosurgery, COVID-19 and Health Disparities: Perspectives from a Minority Provider

By COVID-19, Faces of Neurosurgery, Guest Post, HealthNo Comments

COVID-19 has had a tremendous global impact and has taken the lives of many people. It has halted economies and disrupted our educational system. It has strained health care resources and has expedited health policy reforms. One particular impact of COVID-19 that troubles me as a minority provider is the disproportionate burden of illness and death among racial and ethnic minority groups. COVID-19 has further illuminated existing health disparities in our society.

Before becoming a neurosurgery resident at Massachusetts General Hospital, I played football at Florida State University and with the Tennessee Titans. My athletic experience taught me valuable lessons that apply to my life as a physician. One of those lessons is awareness. If an offense breaks the huddle with a new personnel grouping in a never-before-seen formation, as the safety on the defense, I have to be aware of this new wrinkle and call it out, so my teammates are ready to make a play.

If there is a new highly contagious infectious disease disproportionately disrupting and taking the lives of a specific subset of people in a never-seen-before fashion, as a black neurosurgery resident volunteering to help fight COVID-19, I have to be aware of this fact and call it out, so my health care and public health teammates are ready to make a play.

In my opinion, the delivery of hospital care is not the principal problem. Regardless of race, you will be treated with quality outstanding care if you enter the Massachusetts General Hospital doors of most hospitals in the US. Hospitals have the resources and providers to treat patients with COVID-19. Unfortunately, the problem is further upstream before a person becomes our patient. Here are some key points to consider:

  • Emerging non-communicable diseases like hypertension, obesity, and diabetes are prevalent in minority communities, and these pre-existing conditions place this population at higher risk for contracting COVID-19 and developing life-threatening complications of infection;
  • Living quarters are tighter in poor neighborhoods, which limits social distancing in these communities;
  • Getting to work often involves public transportation, another close-proximity activity permitting easier human-to-human transmission; and
  • Access and affordability of primary care physicians often are out of the reach for many of these families; thus, diagnoses can be missed, and the costs/effort to manage medical problems may be too much to bear given other financial demands.

How do we solve these problems? That is a complicated question. Key elements include evaluating social determinants of health, providing education and development to children and families, as well as income enhancements in these communities. Tracking equity measures, implementing quality improvement initiatives, building a culturally competent health care system and fostering and encouraging better relationships between clinicians and patients may also be solutions. No matter the methodology, a multi-layered approach between the health system stakeholders and affected communities will be at the core of the answer to this problem.

COVID-19 is hurting all of us; it just has shown a propensity to target more impoverished, underserved populations more. As in football, we see the COVID-19 opponent lining up to attack us with an offense we haven’t seen before. It’s our responsibility to be aware as a team, to respond to that attack, and defend our goal — in this case, the health of the most vulnerable members of our community.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following and using the hashtag #COVID19.

Myron L. Rolle, MD, MSc
Massachusetts General Hospital
Boston, Mass.

May 11, 2020
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COVID-19 Perspectives, News and Insights in Neurosurgery

By CNS Spotlight, COVID-19, HealthNo Comments

Neurosurgery, the official journal of the Congress of Neurological Surgeons (CNS), publishes top research on clinical and experimental neurosurgery covering the latest developments in science, technology, and medicine. As the COVID-19 pandemic evolves, Neurosurgery continues to publish the latest COVID-19 news and insights.

Recently, Neurosurgery published 15 articles covering a variety of COVID-19 related topics:

Explore the COVID-19 Information Hub and online education offerings for the latest research, knowledge, and expert insights in the weeks and months ahead. The Neurosurgery Perspectives section of the hub will be updated regularly as new COVID-19 content publishes.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following and using the hashtag #COVID19.

May 8, 2020
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Answering the Call: From Neurosurgeon to Critical Care Physician During COVID-19

By COVID-19, Faces of Neurosurgery, Guest Post, HealthNo Comments

With the coronavirus pandemic sweeping the nation, some regions of our country are encountering a shortage of health care providers to look after the surge of hospitalized patients. As personnel resources are strained, neurosurgeons are being asked to care for critically ill patients — including ones that do not have neurological diagnoses.

Beyond a robust foundation in neurocritical care during training and daily practice, some neurosurgeons have additional training in critical care to become full-time neurointensivists. As such, neurosurgeons of all subspecialties may be tapped to care for patients in the intensive care unit (ICU). This is not surprising because of the skills all neurosurgeons develop to monitor patients closely and act swiftly and decisively when the need arises. The complexity of neurosurgical patients demands an extensive understanding of how the body’s organ systems interact and must be treated when acute multi-organ dysfunction exists. Patients with ruptured aneurysms, traumatic brain injuries, strokes and spinal cord compression may also have respiratory failure, cardiac disease and acute kidney injury.

While learning about critical care is a part of neurosurgical training, many neurosurgeons have not been practicing critical care medicine since leaving training. One strength of organized neurosurgery is its ability to draw neurosurgeons together for a common purpose. To aid neurosurgeons in their new mission, the Joint Section on Neurotrauma & Critical Care (Trauma Section) of the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) developed A Neurosurgeon’s Guide to Pulmonary Critical Care for COVID-19, a presentation that includes:

  • A review of pulmonary physiology;
  • Protocols to promote the safety of caregivers;
  • Basics of ventilator management;
  • Recommendations from multiple professional societies for the care of COVID-19 patients; and
  • A review of techniques to optimize patient care.

This presentation is available on the COVID-19 resource hubs of the AANS, the CNS and the American Board of Neurological Surgery.

The Trauma Section has also developed additional guidance, A Neurosurgeon’s Guide to Cardiovascular and Renal Critical Care for COVID-19, which is available from the AANS and the CNS.

While our nation faces a new challenge in the COVID-19 pandemic, organized neurosurgery is rising to meet it. The educational efforts of the AANS and the CNS, along with health care policy advocacy from the AANS/CNS Washington Committee, are helping to prepare neurosurgeons in all stages in their career to answer this call.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following and using the hashtag #COVID19.

Alan Hoffer, MD, FAANS
Chair, Critical Care Committee of the AANS/CNS Joint Section on Neurotrauma & Critical Care
University Hospitals of Cleveland
Case Western Reserve University

May 6, 2020
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