During these unsettling days, we at OrthoSpineNews would like to provide a space for surgeons and orthopedic industry representatives to share their experiences, concerns, and ideas. If you would like to participate, please leave a comment or contact Elizabeth Hofheinz at email@example.com.
March 26, 2020
Update from Richard Iorio, M.D., Chief of Adult Reconstruction and TJA, Vice Chairman of Clinical Effectiveness, and the Richard D. Scott, MD Distinguished Chair in the Department of Orthopaedic Surgery in Brigham and Women’s Hospital:
“All resources are going to COVID, it is all encompassing. I would say other than NY, CA and LA which are poorly run states, things are going pretty well with good compliance and mortality rates pretty low, we will know a lot more within 2 weeks, then we will have choices to make.”
From Pierce Nunley, Director of the Spine Institute of Louisiana and Associate Professor in the Department of Orthopaedic Surgery at the Louisiana State University Health Sciences Center:
“We are only seeing patients in clinic that are essentially emergent. We are also only doing emergent surgeries. That leaves many patients that are in pain, need help, and need to be ‘seen’ and cared for. So we ramped up last weekend and rolled out telemedicine first thing Monday morning. A practice usually goes through months of research and then alpha and beta testing before deploying a complicated tool like telemedicine. We did it in 4 days! It is somewhat ironic that we would likely have never taken the time and energy in the near future to deploy telemedicine in our practice if it weren’t for this crisis.”
“My dad was an eternal optimist so I guess I got a heavy dose of his genes as I believe in many ways, we will be better when we get through this. We will have learned and will be facile at providing telehealth to our patients that need and will benefit from this valuable tool in the future. We will also be even more thankful for our health and this amazing country we are so blessed to live in.”
From a spine surgeon:
“Just before we stopped doing elective cases, there was a patient who had spine surgery and post-operatively tested positive. A fellow and an attending were exposed but so far are doing fine. We don’t have any confirmed cases in the ortho dept as of this am, fortunately. All elective cases and offices are closed for anything other than emergencies. Aerosolization of the virus during intubation and extubation is a significant risk. In a negative flow OR, it takes over 20 minutes to clear the virus from the room so it’s best for as few people as possible to be in the OR during intubation and extubation. We are running out of PPE so are only given 1 N95 mask per day when we come into the hospital. We will run out soon.”
“We’ll keep reusing the masks (I’ll spray alcohol on them and let them dry), putting sanitizer on gloves and eventually, if we run out of gowns, go without and shower frequently. We’re not seeing patients now, so I am not currently at risk but expect to be in the future, as we help support the medical docs taking care of patients.”
From an orthopedic surgeon:
“The response has been rapid and appropriate with frequent communication from Departmental and institutional leadership.”
“A growing concern is that of exposure during surgery. A Bloomberg Opinion piece, Why Surgeons Don’t Want to Operate Right Now, mentioned that operating rooms may be “viral labs in a wind tunnel.” We recently had an asymptomatic trauma patient expose surgical personnel to COVID 19. Now every trauma patient requiring surgery is being tested. This has added operational inefficiency but is necessary given the potential for an exponential increase in the number of cases. Taking care of those who care for traumatized patients is critical as we are conditioned to think their broken femur is the biggest issue when in reality it may be the least of their and our concerns.”
“We are also increasingly becoming aware of stress among the front-line providers, particularly residents. Many have young families at home. Several have pregnant spouses. It is critical for leadership to reach out, listen and provide support. This is a world-changing crisis and for many physicians, especially young and very busy, this is a new, uncertain and unnerving experience. Our department has set up a recall roster for residents and faculty to make sure we are staying connected in addition to email updates.”
March 24, 2020
From Brian Cole, M.D., M.B.A., Associate Chairman and Professor, Department of Orthopedics at Rush University Medical Center in Chicago:
“While I am not on the front lines yet treating these patients, some physicians are being repurposed to meet the growing need. Televisits are up and running here at Rush and all elective surgeries have been stopped. I am hoping and praying that three months from now we will be able to offer a full complement of services. We are going to have a less active, uninsured, population when things start to return to normal. I am guessing that we will see no semblance of normalcy until August or October. And if the financial modeling is on track then it seems the world will look a lot different when we ‘reemerge.’ The leanest groups and practices will have a chance of survival…those with huge capital expenses and debt may not survive. It will likely be a new environment of consolidation and hopefully, opportunity.”
From Antonia Chen, M.D., M.B.A., Director of Research, Arthroplasty Services and Associate Professor of Orthopaedic Surgery, Harvard Medical School:
“As orthopaedic surgeons, we can do our part in battling COVID-19. We can take trauma call as needed to take care of truly urgent orthopaedic cases, we can cancel our elective cases and clinics, we can capitalize on the use of telemedicine to stay in touch with our patients, and most importantly, we can try to stay home to flatten the curve. We can set the example for our patients by social distancing and doing our part to keep COVID-19 from spreading even further.”
“I anticipate that we will try to increase our surgical and clinical volume each day from our baseline to accommodate as many patients as possible. We will also continue to embrace virtual visits more than before to meet patients where they are.”
From James Bradley, M.D. Clinical Professor of Orthopedic Surgery at the University of Pittsburgh School of Medicine:
“We are cutting office hours and only seeing acute and semi acute cases. While no sports are underway, we are still seeing ligament injuries and anything that could be time sensitive. If someone needs a total joint, it can wait but children who have knee or shoulder or elbow instability then they can do harm to themselves so that cannot wait.”
“If we find out that this virus is heat sensitive or if the Z-Pak and Plaquenil combination works then many people would not have to be hospitalized and the cases hopefully will be milder.”
“The other issue is that sooner or later we will have to open the economy back up. To shut everything down will lead to enormous joblessness and homelessness, etc.”
“We would have to open up semi-essential things first. These might include daycare centers, public transportation, banks, civil courts, etc. I am very concerned about those individuals who live from paycheck to paycheck. They are at great risk.”
“We also have to think of the massive mental health aspects of this crisis. I spoke to those in charge of mental health services at UPMC and they are just overwhelmed with the people who are in need of help. People need to be outside and getting back to some sense of normalcy. We are going to have to figure out ways for people to do sports together in a distanced fashion.”
March 20, 2020
From a hip surgeon:
“Our institution has come together and is working collectively. The orthopedic department has truly stepped up. Currently we are postponing all elective surgeries until further notice, and all non-urgent clinic visits until June 1.”
“This will definitely make the summer and fall months busy. Patients that are being rescheduled now will have to be rescheduled in the summer and fall.”
From an orthopedic surgeon:
“At UPMC we are hypervigilant about what is going on nationally and locally, and every day the highest levels of leadership are giving us updates regarding precautions, screening, testing, treatment, often several times a day. The institution has determined currently that we have a firm enough control that elective surgeries are still proceeding as usual. If, however, we see an exponential rise in cases and those who require critical care (respiratory machines, ICU level care), my overall thought is that elective surgeries will likely be cancelled as preoperative, postoperative, OR settings may be needed for intubation/respiratory care/acute care. What happens in 3 months will likely depend on how tightly this is controlled in the next several weeks. If the situation gets to the level of Italy, etc, then I predict elective orthopaedic practices (non-trauma, non-urgent surgeries) which comprise probably >80% of orthopaedics performed, will be cancelled and suffer in the short term for at least a 6-8 week period of time.”
From Izzy Lieberman, M.D., a spine surgeon at the Texas Back Institute (TBI):
“I am extremely disappointed in the highest levels of government. If we had shut everything down two weeks ago then two weeks from now our economy would be booming. When I started talking about shutting things down some people told me I was overreacting. But here we are with this new, frightening reality.”
“TBI is coping very well. We have positioned ourselves well, and have protected our staff, patients and ourselves fairly early on. When we ran out of masks, we had people run out and buy all the bandanas they could find. The only patients we are seeing face to face are those in need of critically urgent spine care.”
“Looking ahead three months we should be over the worst of the infection and will be nursing some very sick people. The whole practice of medicine will change for generations to come. Social distancing will be the norm for a long time. And frankly, the fact that the government and health authorities are loosening the HIPAA rules just proves how they were obstructing medicine to begin with.”
“Two weeks ago I was joking about all of this. My family and I were on a big high from my daughter’s wedding and I wasn’t really paying close attention. But then I started getting calls from friends in Israel and Italy, who told me what was likely coming our way.”
“As healthcare professionals we must set the standard, go above and beyond…we need to be the most paranoid people out there now.”
From Captain Dana C. Covey, M.D.
“Institutions in this area (including mine) are curtailing elective orthopaedic surgery at this time. I suspect that in the months following control of the pandemic there may be a surge of patients who have experienced delays in treatment.”
“I concur with mobilizing the USNS Mercy (West Coast) and USNS Comfort (East Coast) hospital ships and moving them where most needed. Also, the Army, Navy and Air Force have mobile field hospitals with ICU beds that could augment civilian capacity, or military medical personnel could use buildings of opportunity to set up both critical and non-critical care hospital beds with wartime stockpile equipment.”
Update from Thomas Vail, M.D., Chair of Orthopaedic Surgery at the University of California, San Francisco:
“More COVID-19 cases are being diagnosed in our area. We continue to expand testing capabilities and ICU bed capacity. No plans to restart elective surgery at this point.”
Update from Richard Iorio, M.D., Chief of Adult Reconstruction and TJA, Vice Chairman of Clinical Effectiveness, and is the Richard D. Scott, MD Distinguished Chair in the Department of Orthopaedic Surgery in Brigham and Women’s Hospital.
“Anyone that hasn’t stopped doing elective surgery is in denial of the risks until we get widespread testing. Governor Charlie Baker in MA. has been an exemplary leader through this crisis. A huge distinction vs NY with Cuomo and DiBlasio. Almost 300 cases in MA, no deaths, extraordinary performance by Brigham and MGH under tough circumstances. Safety not finances have been the highest priority.”
March 19, 2020
From Gerald Williams, Jr., M.D., The John M. Fenlin, Jr., M.D. Professor of Shoulder and Elbow Surgery at the Rothman Orthopaedic Institute.
“As you can imagine, the Coronavirus pandemic is affecting our practice substantially. Most of the full-service hospitals we work in (eg. Jefferson, Mainline Health) have cancelled elective cases until at least 3/30. In addition, in our offices, we have instituted policies and procedures to minimize virus spread, including: rescheduling all patients over 65 to appointments at least 4-6 weeks into the future, instituting screening (not virus testing) of all potential patients entering our facilities, instituting rigorous hand washing, avoiding handshakes, using telemedicine for some office visits, limiting office visits to those that have clinically pressing problems. It is impossible to know what 3 months from now will look like, or even 3 weeks. Our information is constantly updated from appropriate governmental and institutional sources and we will respond accordingly.”
From Richard Guyer, M.D., Co-Founder of the Texas Back Institute
“On Monday we voluntarily halted all elective cases. Our staff has been cut back to the point where many of us are working from home. We are screening patients when they come in the door. This would be, for example, people coming in for postop checks or those with neurologic problems or wound problems. There is one entrance and one exit. If someone answers ‘yes’ to any of the questions we ask, we send the person home or to the ER (not the best option now). Everyone is wearing masks. We have been utilizing telemedicine visits when we can.”
“A friend form Beijing has told me that they are slowly coming out of it. They are still wearing masks and gloves, however, and if they have food delivered, they leave the package outside, spray it, and don’t bring it in their homes for at least 20 minutes. This friend told me about a predictive model by a Chinese epidemiologist said that the U.S. could peak in mid-April; other numbers from Cleveland Clinic say that it could be June. It will probably be somewhere between those predictions.”
From Constance Chu, M.D., Professor and Vice Chair Research in the Department of Orthopedic Surgery at Stanford University.
“Silicon Valley is a known affected area and we are in mitigation mode working to implement telehealth and rescheduling elective procedures. School has been canceled and everyone except those providing essential services is being asked to work remotely, stay home, practice social distancing, and wash our hands. This applies to the young and to those who seem healthy because we need to reduce potential exposures all across the board to decrease severe illness, so our hospitals are not overwhelmed.”
“Once this is over, I think a major positive impact will be the successful implementation of telemedicine, particularly to improve access for nonurgent or complex consultations and to facilitate routine follow-up care. We also have the potential to amplify our relationships with emergency room and medical colleagues by assisting with frontline and nonoperative injury and fracture care to offload the time and energy they likely will need to successfully treat the coronavirus.”
From a spine surgeon:
“We have shut down elective procedures and will be shutting down all office hours. Telemedicine is how we will conduct all visits until this is over. Three months from now, we will still be “locked down.” I doubt we will be doing elective procedures or seeing patients unless they are first tested negative for the virus. If we have a rapid test that is universally available, we can test people and then see them afterwards. Otherwise, we will be where Wuhan is today. After locking down on Jan 23, they are still locked down. The virus behaved the same way in China, Iran, Italy, France and every other country that didn’t take preemptive measures. In China, had they locked down on January 18, it has been estimated that only 20,000 people would have been infected, instead of 80,000. Had they waited till January 28th to lock down, there would have been 160,000 infected cases by now. So we need to test everyone (as they did in Korea) and lock down areas with a high density of infections.”
“Our political and medical leaders fear the economic and social consequences of locking down, so refrain from doing so when the numbers of new cases are small, in the misguided hope that it won’t grow. So they wait until the numbers reach about 60-100 new cases per day. Wuhan locked down at around 100 cases per day and they peaked at around 4,000 new cases per day. In NYC, we just closed schools. Subways are still open. This was done because schools provide meals, working parents need childcare and workers need subways. The delay will result in tens of thousands of additional infections and hundreds of deaths. It’s like the patient who delays surgery to remove a cancer on his hand in the hopes that it will miraculously go away. He rationalizes by saying that his kids need him and it’s incredibly inconvenient to have surgery. So when it becomes obvious that he has to have the surgery, the tumor has grown so big that he loses his entire arm instead of just his hand. Delay only makes the inevitable more painful. We all need to isolate ourselves, keep our hands clean and get tested as soon as the tests become widely available.”
March 18, 2020
From Alan S. Hilibrand, M.D., The Joseph and Marie Field Professor of Spinal Surgery and Co-Chief of Spinal Surgery at Jefferson Medical College / The Rothman Institute:
“We sometimes talk about how ‘disruption’ often leads to lasting change. At Rothman, where we have incubated several online technology platforms over the past 5 years, the disruption caused by the COVID-19 pandemic has pushed us to deploy all of these over the next week to transition from an outpatient office-based practice to a hybrid model where older patients and others at risk for COVID-19 will be evaluated through telemedicine. When the ‘smoke clears’ in a few months I believe that Rothman Orthopaedics will be a fundamentally different orthopaedic practice with enhanced national and global capabilities.”
From Wael Barsoum, M.D., CEO and President of Cleveland Clinic Florida, and the Robert and Suzanne Tomsich Distinguished Chair in Healthcare Innovation:
“The safety of our patients, visitors, caregivers and community is our paramount concern. That is why Cleveland Clinic Florida physicians and staff have been holding regular planning meetings, training and education regarding COVID-19 over the past two months.”
“We continue to work closely with local, state and federal government agencies to protect our patients and caregivers. We are devoting tremendous resources to this situation to ensure we are prepared to handle these types of situations and meet the needs of all our patients.”
“We have been working closely across the Florida region and with the Cleveland Clinic enterprise. We are doing so with a shared sense of purpose and unity that will help us provide the best care possible for our patients, community and caregivers.”
“At this point, it is difficult to say what the effects of COVID-19 will be for orthopedics. There have been discussions at the national level whether elective surgeries should continue. That decision will have a profound impact in terms of orthopedics. If elective surgeries are discontinued, that could have detrimental effect for individuals in need of relief from pain. And it will be a challenge for orthopedic practitioners and their practices. That being said, this drastic step may be necessary to help mitigate the risks associated with COVID-19.”
“It is imperative that we continue to monitor the situation, do what is necessary to manage this disease, and then determine the best path forward once it has been resolved.”
From Michael Meneghini, M.D., Director of the Indiana University Health Hip and Knee Center:
“Indiana University and our Hip and Knee Center were very progressive and one of the first to implement unwavering travel restrictions, prohibiting any out of state business travel by any and all care providers and employees at Indiana University Health indefinitely. In addition, we are stopping all elective surgeries this coming week, but will continue to treat patients who have serious infections or orthopedic complications that put the patient at excessive risk or compromise patients if there is a delay in their surgical care. These are all efforts to preserve PPE (Personal Protection Equipment) for healthcare workers in the system to accommodate the surge of respiratory compromised patients with COVID-19 that are anticipated to start within the next 1-2 weeks.”
“We anticipate a backlog of orthopaedic patients 3 months from now, and are hopeful that we will be able to have expanded hospital access for decompressing the backlog of orthopaedic patients. In addition, I would anticipate that patients will be more amenable to having procedures like hip and knee arthroplasty in an outpatient setting, so they can avoid an inpatient stay in the hospital with much sicker patients. This may enhance and facilitate the difference between a ‘well patient model’ for treating elective orthopaedic patients, versus the ‘sick patient model’ that resides in a hospital setting.”
From a spine surgeon:
“There is likely to be a significant decline in elective spine surgery as a result of hospital mandates, as well as patient and provider concerns in the current uncertain environment. In addition, there is likely to be an embracing of telemedicine to better function in a world where one-on-one contact is set to diminish”.
From Edwin Su, M.D., Associate Professor of Orthopaedic Surgery at Hospital for Special Surgery (HSS):
“My institution made the decision to cancel all non-essential orthopedic surgeries and office visits for the foreseeable future. This was done in out of an abundance of caution, with the primary goal of ensuring safety for our patients and staff; secondarily, it is to be prepared for a potential influx of patients in the NYC area who may need our hospital’s resources.”
“It is something that is going to be continually re-evaluated, but the COVID-19 pandemic is certainly going to affect orthopedic care for the next several months, both because of the need to postpone and reschedule operations, but also because its overall impact on the economy. Academic and industry meetings have also been cancelled, so innovations and research in the orthopedic arena may also be delayed.”
March 17, 2020
From Alex Vaccaro, M.D., Ph.D., M.B.A., President and CEO of the Rothman Orthopaedic Institute:
“We are discouraging both work-related and personal travel for Rothman personnel. If they do travel, they must be examined and debriefed upon their return. We are constantly messaging our people, we have cautionary signs on all doors, if anyone is symptomatic, they must stay home and self-quarantine for 14 days. As for what will happen, frankly, I have no idea. This is obviously worse than the seasonal flu.”
From a spine surgeon:
“The elderly and infirm are a large portion of the orthopedic population, so this is hitting them particularly hard. A hospital is like a cruise ship as far as infection. I think that one month from now things will settle down and that we will have a treatment within a few weeks. The only difference between this and the flu is that there is no antiviral treatment.”
From Freddie Fu, M.D., the David Silver Professor and Chairman of the Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine:
“UPMC is doing everything in its power to institute testing and prevention with daily updates. Elective OR is still open now but that can change depending on cases. I hope it will return to somewhat normal in three months. We need 6-9 months to really know its effect.”
From a shoulder surgeon:
“We have only a few cases so far in our city, so resources are not burdened. The expectation is for the numbers to increase. There is concern over PPD supplies – particularly the recommended masks. As for cases, none have been canceled so far. The surgeon general and the ACS (American College of Surgeons) has recommended cancelation of elective cases. What would make sense is allow individual states and cities to monitor the situation and make sure resources are available for if and when they are needed. If cases are to be canceled, it would make sense to consider first canceling the elective, same-day admit cases (ie larger cases such as spine or joint replacements) and continue with outpatient cases (ie scopes and smaller cases as patients will essentially self-quarantine while recovering from their procedure). The economy hit on hospitals may be significant and IF the outpatient cases can be safely done for as long as possible, this may lessen the financial impact on an already razor thin profitable enterprise where in general surgical care reimburses more than non-surgical care.”
From Thomas Vail, M.D., Chair of Orthopaedic Surgery at the University of California, San Francisco:
“We are dealing with a constantly changing environment, doing our best to interpret what is happening around the world and in our own community as we make decisions. The primary concerns are the well-being of patients, and the safety of staff, providers and the community.”
“There has been a lot of messaging to patients to eliminate surprises regarding cancellation or postponement of scheduled clinic visits and surgery. At this point, we are seeking to eliminate elective cases and visits that can wait. As a hospital and health system, we need to be able to respond quickly and maintain available resources in the event of a surge in inpatient bed usage for COVID 19 patients.”
“We are committed to the practice of social distancing, recognizing that we must be present for our patients and cannot simply close. The net effect is that some care is being delayed and postponed, which will impact care in the weeks to come. We do not know with certainty the course of events, including the magnitude and length of the impact on orthopaedic care. We are taking advantage of telehealth to communicate with patients, and video conferencing internally.”
March 16, 2020
From a spine surgeon:
“I can say that the travel restrictions imposed on many faculty from their universities has led to a plethora of recent cancellation of meetings on an international basis. Folks are looking for innovative ways to still communicate, collaborate, and proceed with regular business from a remote location. Although it is having many negative effects on meetings and collaborations, it is stimulating us to think differently about the need for meetings, and how to do these in innovative ways. These are very interesting times.”
From a spine surgeon:
“If Italy is what will happen to the US and other countries around the world, we are projected to have a major influx of patients to our hospital systems in the next 2-4 weeks. Depending on the hospital systems and the bed availability, I suspect most elective orthopaedic surgeries will need to be halted for resource allocation reasons. All ventilators may need to be used for COVID-19 patients which will stress anesthesia departments, and other hospital beds will be needed to care for the hundreds of patients that develop respiratory distress/sickness requiring oxygen therapy In addition, most patients considering elective orthopaedic surgeries will be reticent to come into the hospital where COVID-19 infected patients are being treated. All in all, if the infection rates climb in the coming months, we will be stressed to the limits making orthopaedic surgeries difficult to perform (other than acute trauma surgery).”
From Richard Iorio, M.D., Chief of Adult Reconstruction and TJA, Vice Chairman of Clinical Effectiveness, and is the Richard D. Scott, MD Distinguished Chair in the Department of Orthopaedic Surgery in Brigham and Women’s Hospital.
“No more elective surgery.
We are ahead on precautions behind on testing.
Symptomatic patients increasing in ERs.
Death rate is less than anticipated but worst is yet to come.
I think level of preparedness and precautions are now appropriate.
We are in adequate shape to blunt the first wave as long as it’s not too high.
Docs are starting to convert to positive and others are stepping in to fill their roles.
Americans are best in a crisis.
We are at last getting appropriate direction and messaging from above.
Media not helping as they politicize the process.
Fauci is a rock star and understands the way to communicate and measure his responses to a serious problem.
hope we have overreacted, but I don’t think so.”