Skip to main content
search
Tag

COVID-19

Stroke Month: Continued Progress in Research and Patient Care

By COVID-19, Faces of Neurosurgery, Guest Post, HealthOne Comment

On average, someone in the U.S. has a stroke every 40 seconds. Acute ischemic stroke remains one of the leading causes of death and disability in the U.S. and around the world. The American Heart Association (AHA) estimates that in 2016 there were 5.5 million deaths attributable to cerebrovascular disease worldwide — 2.7 million of those deaths were from ischemic stroke. May is National Stroke Awareness Month and provides the opportunity to remember patients who are survivors of this dreaded disease and highlight the physicians and researchers at the forefront of progress to improve care and outcomes in stroke.

Over the last five years, there have been significant advancements in the treatment of acute ischemic stroke secondary to large vessel occlusion (LVO). LVO is an especially disabling form of ischemic stroke because a large territory of brain tissue and function is typically affected. Five landmark clinical trials published in the New England Journal of Medicine in 2015 and 2016 (MR CLEAN, ESCAPE, EXTEND IA, SWIFT PRIME, and REVASCAT) all demonstrated overwhelming benefit for mechanical thrombectomy for LVO. In summary, the studies suggested that only three patients need to be treated with thrombectomy to improve the functional outcome of one patient (number needed to treat (NNT) of 3). This makes mechanical thrombectomy one of the most effective treatments not only in stroke but in all of medicine. The AHA quickly amended its guidelines to recommend thrombectomy for ischemic stroke patients. However, the recommendation was reserved for a select number of indications, including:

  • occlusions of the internal carotid artery (ICA) and proximal middle cerebral artery (MCA) segments of the cerebrovascular tree;
  • those who had received intravenous (IV) tissue plasminogen activator (TPA);
  • those with good baseline functional status; and
  • those being treated within 6 hours of symptom onset.

These were significant steps in the right direction; however, there are still many patients who fall outside these indications which might benefit from mechanical thrombectomy.

Since then, indications for thrombectomy have expanded. In 2019, two additional trials were published in the New England Journal of Medicine (DAWN and DEFUSE3) that demonstrated similar positive outcomes in select patients being treated up to 24 hours from symptom onset. Research to establish the role of thrombectomy in several other groups of patients is ongoing, including studies involving:

  • pediatric patients;
  • the elderly;
  • more distal occlusions in the cerebrovascular tree;
  • posterior circulation occlusions;
  • patients with mild stroke symptoms despite evidence of large vessel occlusion; and
  • other conditions.

There remains much to learn about this powerful treatment, and hopefully, the indications for mechanical thrombectomy will continue to expand.

Another active area of research is the improvement in stroke care delivery. Researchers are developing new systems to administer care for stroke patients as quickly and efficiently as possible. Emergency medical services (EMS) and stroke triage systems are being redesigned, often across hospital systems. In some cases, the stroke care team is coming to the patient rather than the patient to the team. In other cases, patients with a high likelihood of LVO bypass closer primary stroke centers and are brought to comprehensive stroke centers for thrombectomy. Artificial intelligence-based tools help identify and select patients earlier for these advanced therapies. New diagnostic tools are being developed that can be utilized by EMS providers in the field. Robotic mechanical thrombectomy and the potential of tele-mechanical thrombectomy are exciting advances on the horizon.

Finally, stroke, large vessel occlusions and mechanical thrombectomy have become an area of interest amid the COVID-19 pandemic. Evidence is emerging from epicenters of the crisis — like New York City — that patients, whether afflicted with COVID-19 or not, are seeking medical attention later in their stroke course due to fears regarding COVID-19. We expect many studies to be published in the ensuing months evaluating stroke and mechanical thrombectomy in COVID-19 patients. We are excited about what the future holds in cutting edge research to bring the best available care to stroke patients everywhere.

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.

Justin R. Mascitelli, MD
University of Texas Health Science Center at San Antonio
St. Luke’s Baptist Hospital
San Antonio, Texas

 

 

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

May 29, 2020
Love0

Providing Comfort and Mercy: The U.S. Military’s COVID-19 Response Effort

By COVID-19, Guest Post, Health, Military Faces of NeurosurgeryNo Comments

Editor’s Note: Since the onset of the COVID-19 pandemic, neurosurgeons have helped bring aid and comfort to neurosurgical patients and those suffering from the novel coronavirus. Today, on Memorial Day, we wish to salute the efforts of the men and women serving in our U.S. Military, who, too, have provided comfort and mercy during this national emergency. On this day and always, you have our unwavering gratitude for your dedication and service.

I’ve been asked to comment about my experience mobilized in the military reserve in response to the COVID-19 pandemic. I do so without named authorship secondary to the fact that the mission is ongoing, and the focus should be on a genuinely profound group effort.

Bluntly, the United States military responded in a big way with a large and immediate tri-service response. It’s truly been incredible to see, and it’s been an honor to play a very small part. Nearly 1,600 U.S. Navy Selected Reserve Sailors have deployed globally to fight COVID-19.

The U.S. Navy has developed a neurosurgery presence on both the United States Naval Ship (USNS) Comfort and the USNS Mercy. The USNS Comfort has aided the effort in New York City while the USNS Mercy has helped in Los Angeles. Both undertook evolving missions to best help the civilian hospitals. The mission morphed as necessary from off-loading non-COVID-19 patients, to acting as a trauma and emergency surgery center, to ultimately focusing on treating COVID-19 patients. The leadership has been adaptive to the needs of the community. There are a lot of good people who are doing very impactful things with both missions. Navy Reserve neurosurgeons aided in neurosurgical coverage and general surgical call responsibilities on each of the ships with excellent mentorship from their active-duty counterparts as well as the Navy Reserve neurosurgery specialty leader.

The United States Army has also helped create a field hospital at the Javits Center with an ideal maximum capacity of up to 2,500 beds. This was mostly to off-load more stable patients with COVID-19, but the facility also had intensive care unit (ICU) capabilities. The Navy Reserve Expeditionary Medical Force Bethesda supported the medical relief efforts at the Javits Federal Medical Station with a top to bottom 400 sailor hospital staff unit. There was no neurosurgery occurring at the Javits Center, as the focus was on COVID-19. Other similar sites throughout the U.S. were also established.

Other Navy Reserve doctors and nurses are embedded into the New York City public city hospitals that have been decimated with COVID-19. Navy Reserve doctors and nurses are joining their civilian counterparts in treating COVID-19 patients in hospitals where they are most needed. Many are acting in new and expanded roles due to the dramatically increased ICU needs. The shortage does not call for additional neurosurgeons to perform neurosurgery but for additional coverage in overflowing ICUs. These are very sick patients, and neurosurgeons have a tremendous possibility to do some good within this structure. As our medical critical care colleagues take a pounding, neurosurgeons are very comfortable in the ICU, in treating critical patients, in dealing with mortality and in leading large health care teams to make pragmatic, direct and impactful decisions. Indeed, the Joint Section on Neurotrauma and Critical Care of the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) issued guidelines to help neurosurgeons managing COVID-19 ICUs. The Navy has been tremendous in organizing teams across multiple specialties to do just that work.

Neurosurgeons who no longer desire the ICU could also consider joining their hospital’s prone team to help flip acute respiratory distress syndrome (ARDS) type patients with COVID-19 throughout the hospital. These teams generally travel from unit to unit to supine and prone the sickest of the respiratory patients in the hospital. Anesthesiologists head these teams due to airway concerns, but they also include orthopaedic, spine and other surgical specialists comfortable in positioning complex patients. It is truly a service that makes a tangible difference when managing these patients within the ICU.

It goes without saying that service in the Navy Reserve rests upon the service of others. Colleagues back home have taken additional emergency call, increased their workload and served the local community in similar ways. Even more so, spouses have to work overtime at home, especially those with small children and those juggling their own virtual careers. Multiple people have come together in numerous ways to serve the people of New York City. And, the welcome in New York City has been one of deep gratitude both inside and outside the hospital.

The objective impact of the Navy Medical Response Team will be measured in patients treated, intubations and central lines. However, the subjective impact has been even more important. The military members here have truly made a difference fighting an invisible enemy.

*This is the author’s opinion only and in no way reflects the thoughts or opinions of anyone else in the United States Navy. It does not represent the official policy of the United States Navy, the Department of Defense or the United States Government.

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 25, 2020
Love0

Life as a Medical Student During the COVID-19 Pandemic

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

The COVID-19 pandemic has caused sweeping systemic changes to the landscape of medicine and society as a whole in the few short months since the virus arose. The pandemic has impacted all medical specialties, and those still in training have experienced significant disruptions to their education. Medical schools were quick to respond to the spread of the virus to keep medical students safe. The first warnings from the University of Rochester School of Medicine and Dentistry (URSMD) administration came in early March — students were informed that those who intended to travel during spring break might be required to quarantine upon their return. At the time, the magnitude of the impending pandemic was unknown, and social distancing measures were still on the horizon.

Initially, physical classes were canceled until late March, by which time any students who had traveled to a COVID-19 hotspot would have completed a 14-day quarantine. The plan was to resume regular classes and clinical experiences following this disruption. However, it became clear within a matter of weeks that this would be impossible. For the safety of students, faculty and patients, it was eventually decided that all physical classes and clinical experiences would be canceled for the foreseeable future. Students at all levels were placed in an uncertain position as it became increasingly clear that in-person learning would not be possible for the remainder of the year. This uncertainty fostered fear and anxiety among students — many of whom were also dealing with the stress regarding their safety and that of friends and family.

For preclinical students like myself, we have been utilizing remote learning for the remainder of the year, which has been a significant disruption to our training. In particular, clinical learning has been impaired due to the difficulty of mastering medical history taking and physical exam techniques over Zoom instead of in-person practice with classmates and standardized patients. Another challenge has been coordinating exam proctoring for students who are in different time zones. Some students who have been planning summer research at other institutions or projects involving clinical or volunteer work have had their plans canceled.

Second-year students have been particularly concerned about the logistics of their upcoming United States Medical Licensing Exam (USMLE) Step 1 exams, given that social distancing measures preclude the use of physical test sites. Third-year students have been unable to complete their clinical rotations and have experienced considerable stress due to the ongoing uncertainty in scheduling away rotations for their fourth year. Fourth-year students have had their graduation and Match Day celebrations converted to online events. Graduation has also been moved up. Depending on their specialty of choice, some newly minted physicians have been called upon to begin their residency training early to respond to the COVID-19 pandemic.

Many student doctors have been frustrated because they are unable to contribute to patient care during this crisis. It has been challenging to find ways to help without potentially compromising patient safety. Despite these challenges, medical students at all levels and from all over the country have stepped up to do what they can to support the medical community during this crisis. During the initial stages of the pandemic, students volunteered their time to provide childcare for physicians called to the front lines and organized efforts to produce personal protective equipment (PPE) for health care workers. Additionally, students have made an effort to publicize clinical trials that need healthy volunteers, and the University of Rochester Medical Center (URMC) has initiated a program to recruit volunteer lab techs to help with COVID-19 research. The administration at URSMD has also sent out a request for medical student volunteers who might be called upon to assist in patient transport, ventilator preparation, and supply transport, as well as serving as respiratory care assistants if needed.

Medical education faces challenges moving forward. At this time, it is unclear when or if in-person education can resume. There have already been substantial efforts to promote methods of distance learning for medical students and residents, including Zoom-based lectures and an increased emphasis on online resources. However, this leaves something to be desired for hands-on clinical education, which does not lend itself well to remote learning. It is not clear when clinical rotations can be safely resumed, or when students will once again be able to schedule away rotations. The uncertainty surrounding away rotations is of particular concern for those students who are preparing to apply to residency in the coming year. It also remains to be seen how this crisis will affect the residency match process in the future. Many students have also had research or volunteering opportunities canceled due to the pandemic, and the future of USMLE board exams remains in doubt for the time being.

As a whole, medical educators and students have risen to the challenge of COVID-19. Medical educators have dedicated extra time and effort to minimize disruptions and to maximize students’ learning experience. Many medical students have helped their communities wherever possible and are responding admirably to the unprecedented disturbance in their education. Reactions like these foster hope that both students and educators will continue to work tirelessly to respond to crises as they arise.

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.

Stephen Susa
First-year Medical Student
University of Rochester School of Medicine and Dentistry

May 22, 2020
Love0

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
Love0

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
Love0

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
Love0

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
Love0

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
Love0

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
Love0

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
Love0