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AANS Neurosurgeon Spotlight: The State of Neurosurgical Education

By AANS Spotlight, Burnout, COVID-19, GMENo Comments

Recent global circumstances have had considerable effects on neurosurgery. In the latest articles from AANS Neurosurgeon, the official socioeconomic publication of the American Association of Neurological Surgeons (AANS), authors discuss the state of neurosurgical education. Practices have taken steps to not only adapt to a multitude of changes due to the COVID-19 pandemic, but to thrive among them, while helping their patients do the same. Browse the Education issue for a scientific, artistic and realistic view from those tasked with providing and navigating valuable educational experiences during a time when there is no such thing as “normal.”

Article Spotlight

This Crisis is an Opportunity
Lola B. Chambless, MD, FAANS

Dr. Chambless explains how the pandemic has provided an unprecedented opportunity to study, learn and reform.

A Combined Spine Surgery Fellowship
Jason Savage, MD ꟾ Michael P. Steinmetz, MD, FAANS

Discover the makings of a successful spine fellowship – strong leadership, constant re-evaluation and a collaborative surgeon group.

Pen versus Penfield: A Proposed New Training Modality for Neurosurgery Residents
Erin N. D’Agostino, MD

Dr. D’Agostino describes how art “can serve a role in surgical skill building, learning and teaching of anatomy, patient education and combating burnout.”

Read More

Follow @aansneurosurg on Twitter, Instagram and like AANS Neurosurgeon on Facebook!

Reflecting on COVID19, the Death of George Floyd and the Need for Change

By COVID-19, Equity, Social JusticeNo Comments

“I want to touch the world.”
George Perry Floyd, Jr.

We are living in trying and turbulent times in our country. A global pandemic has claimed the lives of more than 100,000 people across America and has threatened to overwhelm our health care systems in some of the worst affected areas. On top of this health crisis, we are now facing the greatest civil unrest our country has experienced in over 50 years in response to a recent series of tragic deaths of black men and women — the cataclysmic event being the deplorable death of George P. Floyd, Jr. while in police custody.

While we look to our politicians for the political answers that will heal the strife in our country, we are all struggling with our personal feelings and response to these events. It has been extremely heartening, however, to see the expression and renewed commitment to inclusion and diversity, particularly within the medical community.

As voices cry out across the world underscoring the systemic problems of racism and inequality, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) have joined the chorus speaking out against all forms of discrimination and acts of violence — particularly that which is driven by intolerance and hatred. We reaffirm our commitment to inclusion and diversity. We reflect on the past and the messages of Dr. Martin Luther King, Jr. and Robert F. Kennedy. And we listen to our Black and Brown colleagues who provide a uniquely pertinent perspective on these issues, and we are thankful for their leadership and willingness to speak out.

We hope our readers will be inspired by the words of our colleagues from across the medical profession, which are reposted below in this piece. Millions around the world were horrified in disbelief at the killing of an unarmed man in police custody. As individuals and together as a society, we owe it to George Floyd and countless others to not let his death be in vain and to work to seek lasting change to stamp out racism, inequality and violence. We encourage you all to engage your patients, your colleagues and your communities in discussions as to how we can help heal our country and care for all who need us, including our most vulnerable.

In addition to the above message from the AANS and CNS, neurosurgeons and neurosurgical organizations spoke out.

A group of Black neurosurgeons who came together to publish an OpEd pointed out that as neuroscientists and surgeons, they see firsthand the effects of neurotrauma on those subjected to violence at especially alarming rates in the Black community. From the debilitating effects of blunt and penetrating trauma to the brain and spine to the “intangible neuropsychological effects stemming from fearing for one’s life on a daily basis,” there “is a slow but inevitable erosion of the state of health amongst Black people… This has culminated in a public health crisis shortening not only the lives of too many too early but diminishing the quality of life of those who remain to bear it.”

Reflecting on the shocking video depicting the death of George Floyd, neurosurgeon Fredric B. Meyer, MD, FAANS, the Juanita Kious Waugh Executive Dean for Education of the Mayo Clinic College of Medicine and Science and dean of the Mayo Clinic Alix School of Medicine, wrote to all medical students, residents and fellows. In his letter, Dr. Meyer reminded us “that although our country has made tremendous advances in civil and human rights, we all have significant work to do on so many levels to fight hatred, bigotry, and violence.” He recalled how Bobby Kennedy was one of his family’s heroes and how, as U.S. Attorney General, he was a strong advocate for civil rights. Dr. Meyer went on to note that in this time of terrible strife, anger, mistrust and hatred in our country, he is reminded of a powerful speech that Bobby Kennedy gave spontaneously on the back of a pickup truck when he learned of the assassination of Martin Luther King, Jr. He, along with his brother, President John F. Kennedy, and Dr. King, were all assassinated for the truth they spoke about human decency, civil rights, and a humane society. Dr. Meyer commends to the medical community the YouTube video of Bobby Kennedy announcing Dr. King’s death and to also listen to his speech on humanity, mindless violence and affirmation. His words are as relevant today as they were decades ago, and, as Dr. Meyer aptly stated, it is distressing that fifty years later, the same hatred that killed Dr. King continues to be pervasive in our society.

Leaders of the Society of Neurological Surgeons (SNS) — M. Sean Grady, MD, FAANS, president; Karin M. Muraszko, MD, FAANS, past-president; and Nathan R. Selden, MD, PhD, secretary — wrote to SNS members, neurosurgery department chairs and neurosurgical residency directors. In their message, they called on “educators to exemplify the highest moral and ethical standards for our trainees.” They noted that as educators and leaders in neurosurgery, we must ensure “that the American principles of fair and equal treatment for all are the bedrock of our Neurosurgical community.” Reaffirming a commitment to be “an inclusive organization reflective of the ‘higher’ principles,” they pledged “to grow and adapt and to listen to those we educate and those we serve. Although we may not have walked in their shoes, we will remain open to the knowledge and experience of every colleague and trainee and will respect and acknowledge them for their character and skills rather than for their appearance. Like our society, we believe we can continue to grow towards a more perfect union of our ideals and the reality in which we live,” and to strive together to reach higher ground.

The AANS/CNS Cerebrovascular Section, the Society of NeuroInterventional Surgery (SNIS) and the Society of Vascular & Interventional Neurology (SVIN) joined together to issue a statement acknowledging the difficult and disturbing times that the country is experiencing. These neurovascular organizations pointed out that “acts of violence and racism cause psychosocial stress that leads to poor well-being and cerebrovascular health, especially for communities of color. Given that heart disease and stroke are the leading causes of death for communities of color, our organizations are extremely disturbed by violent acts that cut to the core of the lives in our communities. We denounce the incidents of racism and all violence that continue to ravage our communities.”

Beyond the neurosurgical community, leading national medical organizations also spoke out.

The American College of Surgeons stated that it “stands in solidarity against racism, violence, and intolerance, noting that its “mission is to serve all with skill and fidelity, and that extends beyond the operating room. Racism, brutal attacks, and subsequent violence must end. We will help any injured, and we will use our voice in support of the health and safety of every person.”

Leaders from the American Medical Association (AMA) reminded us that AMA policy “recognizes that physical or verbal violence between law enforcement officers and the public, particularly among Black and Brown communities where these incidents are more prevalent and pervasive, is a critical determinant of health and supports research into the public health consequences of these violent interactions.”  The AMA continued, noting that the “disparate racial impact of police violence against Black and Brown people and their communities is insidiously viral-like in its frequency, and also deeply demoralizing… Just as the disproportionate impact of COVID-19 on communities of color has put into stark relief health inequity in the U.S.”

Finally, the Association of American Medical Colleges (AAMC) pointed out that “the coronavirus pandemic has laid bare the racial health inequities harming our Black communities, exposing the structures, systems, and policies that create social and economic conditions that lead to health disparities, poor health outcomes, and lower life expectancy.” The AAMC statement goes on to address how the brutal and shocking deaths of George Floyd, Breonna Taylor and Ahmaud Arbery “have shaken our nation to its core and once again tragically demonstrated the everyday danger of being Black in America.” Issuing a call to action, the AAMC expresses that “as healers and educators of the next generation of physicians and scientists, the people of America’s medical schools and teaching hospitals bear the responsibility to ameliorate factors that negatively affect the health of our patients and communities: poverty, education, access to transportation, healthy food, and health care.”

The AANS and CNS echo this call to action and concur that we “must move from rhetoric to action to eliminate the inequities in our care, research, and education of tomorrow’s doctors.”

Editor’s Note: Neurosurgery Blog invites you to join the conversation for social change at #WhiteCoatsforBlackLives and #ChangeTheSystem.

 

John A. Wilson, MD, FAANS
President, American Association of Neurological Surgeons
David L. and Sally Kelly Professor and Vice-Chair of the
Department of Neurosurgery, Wake Forest School of Medicine

 

 

Steven N. Kalkanis, MD, FAANS
President, Congress of Neurological Surgeons
Chief Executive Officer, Henry Ford Medical Group
Detroit, Mich.

COVID-19 and Prevalence of Stroke: Making Sense of the Data

By COVID-19, Health, StrokeNo Comments

The current COVID-19 pandemic has been a singular event with far-reaching societal and medical ramifications. The enormity of the crisis and the alacrity of its spread across the globe has led to a rapidly evolving understanding of the disease. Current knowledge of the pandemic and the effect of the virus on the human body may become obsolete by week’s end. The COVID-19 crisis’s impact on the care of stroke patients is emblematic of these issues. Over the past few months, several data points have emerged that have been interpreted in divergent ways.

For example, early on, there was speculation from New York City — one of the regions hardest hit by COVID-19 — that COVID-19 was associated with an increased risk of fatal ischemic stroke in young adults. Several physicians from New York authored a report of their experience with five stroke patients infected with SARS-CoV-2, aged 33 to 49. This study received significant attention in both the press and academic journals. We currently understand COVID-19 to be a mild disease in most people. However, occasionally it progresses to a more severe process, including acute respiratory distress syndrome (ARDS), multi-organ dysfunction, cytokine storm, inflammation, coagulation and death. Coagulopathy and vascular endothelial dysfunction have been proposed as complications of COVID-19. Although the authors shed light on the clinical characteristics of young adults with these two pathologies, they were not able to explain the possible association between stroke and COVID-19 fully.

On the contrary, several researchers have indicated a decreased incidence of ischemic stroke across the world during the COVID-19 pandemic. The drop in the rate of stroke presentations has been so dramatic that various medical societies and advocacy groups have issued statements urging patients not to delay stroke care out of fear of being exposed to SARS-CoV-2, the virus causing COVID-19. While this a plausible explanation for the decreased incidence of stroke during the height of the pandemic, we believe it may be too early to tell whether this is, in fact, the case.

Another data point suggests that patients are seeking care for stroke symptoms in a delayed fashion, resulting in suboptimal outcomes. Most stroke experts have attributed this phenomenon of “vanishing strokes and heart attacks” to the unwillingness of patients to be exposed to COVID-19 in an already overwhelmed emergency room. By contrast, researchers from Italy have hypothesized a pathophysiologic mechanism behind the decreased incidence of stroke in COVID-19 patients based on the controversial role of Interleukin 6 (IL-6) — a protein involved in inflammation — in stroke. There is experimental evidence that IL-6 — which is elevated in patients with more severe forms of COVID-19 — has a neuroprotective effect and enhances angiogenesis (formation of new blood vessels). Another possible explanation offered is the thrombocytopenia (low platelet counts) encountered in patients even with mild cases of COVID-19, as low platelet levels may prevent the formation of large clots in the intracranial circulation. Lastly, the widespread mitigation measures, which have minimized the prevalence of influenza in the community, may have attenuated the typical negative impact of the flu on cardiovascular disease and stroke. Further research into the effects of these various associations is warranted.

In these times of crisis, we remain dedicated to offering the highest level of care for stroke patients focusing on the following principles:

  • Clear identification of Comprehensive Stroke Centers (CSCs), which can offer all stroke-related services even during the pandemic;
  • Information for emergency medical services and the public that CSCs will be protected and will remain fully operational during crises; and
  • Education for health professionals and the public — especially those who are at high risk of stroke — leading to early recognition of stroke symptoms and contacting emergency medical services immediately to be taken to a CSC to avoid significant delays in transferring patients between hospitals.

A full picture of how COVID-19 influences the phenotype, incidence, and demographics of acute ischemic stroke patients has yet to emerge and may not for many months. Until then, it remains paramount to focus on measurable outcomes and continue to leverage the proven components of our stroke system of care to the benefit of our patients. Education — as was emphasized throughout May’s National Stroke Awareness Month — needs to continue and must be the cornerstone of engagement of the health care system with the public to reassure that we are able and ready to take care of our patients safely.

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.

Kimon Bekelis, MD
Vice-chair, AANS/CNS Communications and Public Relations Committee
Director of the Stroke & Brain Aneurysm Center and co-director of the Neuro ICU at Good Samaritan Hospital Medical Center
Chairman, Neurointerventional Services at Catholic Health Services of Long Island
Director, Population Health Research Institute of New York at CHSLI
Assistant Professor, The Dartmouth Institute for Health Policy and Clinical Practice
West Islip, N.Y.

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

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

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.

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.

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.

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

The COVID-19 Challenge from a Health System Perspective

By CNS Spotlight, COVID-19, Guest Post, HealthNo Comments

It’s hard to believe that just over a month ago, the first case of COVID-19 was reported in Michigan. We were all aware that it was coming, but really couldn’t imagine the profound impact this virus would have and the rapidity of the viral spread. Many reasons have been postulated for why Detroit in particular turned into one of the country’s most serious COVID-19 hotspots, including the fact that our international airport, Detroit Metropolitan Airport, is one of the 5 busiest hubs in the country. The resurgence of Michigan’s economy in the last few years also resulted in a dramatic rise in international industry business travel, including to China, Korea, Japan and Italy.

In anticipation of the surge in Michigan, Henry Ford Health System (HFHS) took many key steps at early points in the crisis. A month prior to the first detected COVID-19 case in the state, HFHS began holding daily infection prevention calls to start COVID-19 related education and training amongst the staff, and we activated our Incident Command structure where all physician and administrative teams across all business units were included. In an effort to keep staff and patients safe, business travel and HFHS events were cancelled prior to the state’s mandates.

At the onset of increased COVID-19 admissions in mid-March, HFHS stopped all elective surgeries, which helped create the immediate and much-needed capacity to accommodate any surge. We temporarily closed many ambulatory clinics and redeployed resources — including not only supplies but also over 550 physicians, nurses and staff — to the inpatient settings. In accordance with Accreditation Council for Graduate Medical Education (ACGME) guidelines, HFHS declared a Stage 3 Pandemic Crisis, transitioning most residents and fellows to patient care areas in the most immediate need of clinical support. In taking these steps, we were able to quickly create ICU and general inpatient capacity.

To expedite diagnosis at the HFHS’s five acute care hospitals, the laboratory services became Michigan’s first same-day results lab for COVID-19, having the ability to process 1,000 tests per day with 93% processed in 12 hours or less. We also chose to be very proactive in testing our employees to safeguard our patients and our community, and we were also very transparent in our reporting of employee COVID-19 positive results to highlight the need for testing, and the need for aggressive prevention measures, throughout our region and beyond.

Like hospitals throughout the world, we experienced some supply disruptions for personal protective equipment (PPE) as global demand far exceeded production capabilities. Maintaining the safety of our health care professionals on the front lines remains a critical focus for the System. Thus, our supply chain team aggressively responded to the global constraints for these items by actively sourcing PPE from alternative sources, like TD Industrial Coverings, Inc., and we received more than 250,000 PPE donations from area businesses, including Ford Motor Company and the DTE Energy Foundation. The HFHS also implemented conservation policies aligned with the Centers for Disease Control and Prevention (CDC) recommendations to ensure the frontline workers continued to have the protection they needed. To help address the high demand for PPE, the photomedicine and photobiology unit in our Department of Dermatology rapidly developed an innovative process to sterilize N95 respirators using a special form of ultraviolet C (UVC), so the respirators can be reused. Ultimately, we were able to secure adequate PPE supplies to mandate a universal mask policy for all staff, employees, patients and visitors to any Henry Ford facility, and N95 respirators were made available to all staff in contact with suspected COVID-19 patients and for those performing any procedure at risk for aerosolization of bodily fluids.

The Henry Ford Research Team also embarked upon dozens of studies either underway or under development to understand disease progression and outcomes, and to treat or prevent COVID-19. With assistance from Vice President Michael R. Pence and Food and Drug Administration Commissioner Stephen M. Hahn, MD, Henry Ford launched the country’s largest randomized controlled, double-blinded study to determine the effectiveness of hydroxychloroquine in preventing COVID-19 in health care workers and first responders. Another study is underway on the antibody assessment and treatment in preparation for a potential vaccine that focuses on collecting convalescent plasma and using it in a clinical trial format for newly infected patients. We are also testing anti-viral agents, agents that inhibit the cytokine storm, convalescent patient serum and other novel approaches to treatment.

As the number of new COVID-19 cases decrease in Michigan and we extubate more patients from ventilators than we intubate, we’re beginning to perform time-sensitive ambulatory surgeries and procedures that were postponed due to the pandemic. We are starting with cases that can reasonably be accomplished on an outpatient basis using existing and available staff so as not to overburden the current inpatient needs for the hospitals. In our first week of restarting these ambulatory procedures, 80% of patients called were willing to be scheduled, while 20% preferred to wait given ongoing fear in the community of exposure. We have designated COVID-19-free operating rooms and teams, specifically assigned to these time sensitive non-COVID-19 cases to help reassure patients and families. Of 8,000 cases postponed since the start of the pandemic in mid-March, we hope to reschedule and perform 2,000 prioritized cases by mid-May in a staged way, taking great care to guard against another surge. All along we have been performing emergency cases with immediate threat to “life and limb,” but as we look to expand our inpatient surgical readiness in the weeks ahead, we plan to prioritize cancer, cardiovascular, neurosurgical and transplant cases given the risks of further delays to those patient populations.

The COVID-19 pandemic has challenged us to navigate through unprecedented circumstances, but it’s a challenge I strongly believe we will overcome together, and emerge even stronger as a profession, and as a 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.

Steven N. Kalkanis, MD, FAANS
President, Congress of Neurological Surgeons
Henry Ford Medical Group
Detroit, Mich.

We believe we’re through the peak of the surge, but we’re not ready to declare victory yet.

Steven N. Kalkanis, MD, FAANS