Article In Brief
Virtual happy hours, town hall meetings, and email blasts are some of the ways medical teams across the country are managing their patients amid the COVID19 outbreak.
As of April 13, about a third of the residents at NYU Langone Health14 individualshad established COVID-19 or symptoms, although not formally tested.
They were just sent home assuming they had COVID-19 until their symptoms abated and they were afebrile for three days, said Steven L. Galetta, MD, FAAN, professor and chair of neurology. A few attendings had also fallen ill. Everyone in the neurology department was working from home unless they were needed for inpatient care or part of a skeleton crew conducting urgently needed outpatient care that could not be handled via telemedicine. At least 80 percent of hospitalized patients were being treated for COVID-19.
As the pandemic bore down on New York City, Dr. Galetta quickly grasped that he needed to address the emotional toll of the crisis. People are exhausted and fear is understandably a big factor in this situation, he said. But we know that we are in this together and that we just have to find a way to do this.
His strategy: Remind everyone in the department they are part of a community. Each neurology division started scheduling weekly virtual happy hours using Zoom, and Dr. Galetta attends as many as possible to stay connected. They last an hour and we usually have 10 to 15 people, generally all attending from the confines of their homes, he said. And we have great conversations about medical and nonmedical aspects of what's happening.
In addition, the department collected money to buy meals to be delivered to their colleagues working in the hospitals. We raised $14,000, as a department, from attendings and other donors, to feed the front linesour neurology residents working on medical units, the advanced care practitioners and other nurses, he said. They don't have time to go to the cafeteria so we supply them and that's a morale builder.
A weekly group counseling session, conducted via Zoom, is being led by several neuropsychiatrists.
Dr. Galetta started sending a daily email to residents and faculty, summarizing the latest informationthe number of COVID-19 cases, the train schedules and whatever else. Each day's note includes a music videoan inspirational song or even a concertand a bit of COVID-19 humorIt's impossible to touch your face if you have a wine glass in each handsent to him by attendings or residents to share with their colleagues. We are trying to balance the reality of this crisis and the sadness of it with other things that are important in life, he said.
As of April 8, Johns Hopkins Medicine was deep into preparation for a COVID-19 surge that everyone hoped would not come. There were 109 COVID-positive patients in the hospital on that day, and several neurology residents had volunteered to be redeployed to the department of medicine if needed. To alleviate the residents' burden, neurology faculty members and fellows were handling all outpatient activities and prepared to take over some of the residents' inpatient work if necessary, said Justin C. McArthur, MD, MPH, FAAN, professor and director of the neurology department.
The residents are stressed and working quite hard, so we have changed the rotations, he said. People basically have six days on, six days off, so they have a block of time away to recoup.
Faculty members were bringing home-cooked food for the residents, and Dr. McArthur was reinforcing the community spirit through weekly department-wide Zoom meetings. Operational information is discussed, followed by a brief concert. The idea came from Alexander Pantelyat, MD, assistant professor of neurology and co-director of the Johns Hopkins Center for Music & Medicine.
He's very well connected with the Baltimore Symphony Orchestra (BSO), which is of course not playing live concerts right now, Dr. McArthur said. So we have lined up a number of the BSO musicians to do these mini-concerts once a week for us.
Meanwhile, another faculty memberSusan Magsamen, executive director of Johns Hopkins' International Arts + Mind Labcompiled educational and arts resources that department members can use with their children during the COVID-19 lockdown.
We are trying to do things to take care of our own, Dr. McArthur said.
His tip for other neurology leaders: Develop a communication strategy that makes it easy for department members to find the information they need. There's a balance between over-communicating and under-communicating, he said. Rather than sending out 20 emails every day, we send out one that is curated and has all of the information in one place.
The department also developed a Wiki-page that archives all information so people don't have to search through lots of email messages to find something they need.
New York City Health and Hospitals Corp. operates 11 public hospitals, including Kings County Hospital in Brooklyn, that on average have a total daily inpatient census of about 3,500 patients. On April 13, those hospitals were treating 3,000 COVID-19 patients, including 950 who were intubated.
I think we all had to come to terms with our own mortality and go through the Kubler-Ross stages of mourning for the loss of our previous state of complacency, said Helen A. Valsamis, MD, chief of neurology for Kings County and professor and vice chair of neurology for SUNY Downstate Medical Center. As physicians and educators, we are particularly stressed because we are on the front lines and responsible for the safety of our residents and fellows.
In an email, Dr. Valsamis said her department has changed its call-duty protocol during the COVID-19 crisis. Because being on clinical services is now more stressful, we now have a daytime attending and our high-risk attendings take night calls from home, she said. That way, the daytime attendings are well-rested and better able to function safely during the day. With the help of our SUNY Downstate colleagues, we set up a telestroke cart that we can use if the residents need additional attending support at night.
Although many hospitals around the country are reporting a lower volume of strokes than usual, Kings County has seen an increase in strokes. For stroke codes, we have created pre-packaged, readily available PPE (personal protective equipment) kits so that the resident can don and go, she said.
Clinicians were trained in how to perform a targeted neurologic exam with minimal patient contact. For the neuro exam, we stopped doing fundoscopic exams and the face shields enable us to evaluate pupils safely, she said. We made copies of the NIHSS (National Institutes of Health Stroke Score) cards that were on letter-size paper. That way the residents can stand farther away while administering the aphasia testing portion of the NIHSS and discard the papers after use.
The Detroit area had more than 21,000 confirmed cases of COVID-19 and 1,340 deaths as of April 13. Detroit Medical Center, the largest health system in the metro area, has attracted national media attention for overwhelmed emergency departments. Jun Li, MD, PhD, professor and chair of neurology at Wayne State University School of Medicine, said the serious shortage of personal protective equipment (PPE) has limited each clinician's use to one mask per day.
In an interview with Neurology Today on April 10, Dr. Li said a few neurology residents have tested positive for COVID-19 and one attending who was infected has recovered. He counsels faculty and residents to focus on reality: the majority of COVID-19 patients experience mild symptoms and recover quickly.
During a crisis, people tend to overreact, Dr. Li said. Everyone should constantly evaluate themselves to differentiate their emotional reaction to the situation from the real risk.
Like most neurology departments, Wayne State has pivoted to telemedicine for the vast majority of outpatient care. While everyone is displaced from their normal work setting and typical routines, Dr. Li wants to limit discombobulation by staying productive.
Keep every attending and resident as busy as possibleotherwise, people feel anxious, he said. I find it is important and quite effective to reduce anxiety and fear by restoring normal activity as much as possible.
To that end, his department is finding ways to implement telemedicine clinics quickly and restore routine educational activities. For example, grand rounds lectures are being conducted through Microsoft Teams technology. When people see normal activities, they feel normal, he said.
Focusing on the future, which will present another challenge, reinforces the reality that the COVID-19 crisis will eventually end. Unable to perform elective procedures for months, health systems are seeing revenues plummet. Dr. Li estimates that outpatient care delivered via telemedicine will save only 30 to 40 percent of his department's budgeted revenue. We have to start thinking about the post-COVID phase now, he said. How are we going to recover financially? All leadership needs to be working together on the plan.
Ronald Reagan UCLA Medical Center had 44 COVID-positive inpatients on April 8, and members of the neurology department at the David Geffen School of Medicine at UCLA were caught between their professional preparations for a possible surge and their personal vulnerability. That is creating a dynamic that has destabilized a lot of health care workers and staff, said S. Thomas Carmichael, MD, PhD, chair and professor of neurology. They feel the obligate healthcare duty to control the safety of their patients as much as possible and at the same time feel an uncontrolled risk to personal infection.
He is using three strategies to keep communication about the fast-changing situation flowing. In addition to a daily staff newsletter, written by Dr. Carmichael and the department's clinical directors, he is scheduling town halls on Zoom. We had 120 participants on this last one, he said. We have a really modest agenda because the main thing is for people just to fire questions and we answer them.
Residents get more attention than ever. I meet with the residents because they are the tip of the spear, he said. I need to make sure that they feel like they're heard and often their ideas are great and presage ideas that we would normally have but a day or two ahead of the rest of us.
The third strategy: Show up for every type of clinical scenario that clinicians and staff are dealing with. I'm in the clinic daily; I'm in the hospital daily; and I respond to emergency situations in the emergency department, he said. It helps me be more effective in revising how our protocols are we move forward. And I think it relieves stress and anxiety when others see me in the middle of it, willing to provide health care right on the front lines.
Tips for his colleagues: Use GoPro technology to allow residents and medical students to learn even when they are not in a patient's room. His department is using a one-plus approach to inpatient care; only an attending and either a resident or fellow go into a patient's room. The resident or fellow wears a GoPro, which beams video in real time to other members of the care team so everyone can see what's happening.
As the COVID-19 surge hit New Jersey on April 8, the neuro-intensive care unit (ICU) at the Robert Wood Johnson University Hospital in New Brunswick became part of the COVID-19 surge plan. Stroke patients who needed critical care services were moved to a separate unit. The neuro-ICU faculty are fully credentialed to take care of patients with acute respiratory distress syndrome and complications of COVID, said Suhayl Dhib-Jalbut, MD, professor and chair of neurology at Rutgers-New Jersey Medical School and Robert Wood Johnson Medical School.
So they are doing bothtaking care of neurological patients with critical conditions and COVID patients, he said. You can imagine that their hours have been stretched.
The long hours that some clinicians are experiencing during the pandemic are one of many stressors that Dr. Dhib-Jalbut is dealing with. His colleagues are worried about being infected with COVID-19 and spreading it to family members who might be vulnerable to COVID complications. They are worried that the health system might be overwhelmed above capacity to deal with COVID-19 patients. Non-essential staff are worried about possible furloughs because outpatient volume has fallen sharply.
Beyond that, clinicians are worried about indemnification. One concern is the possibility of being redeployed to care for patients outside their area of expertise, Dr. Dhib-Jalbut said. Another is the challenge of diagnosing and treating new patients via telemedicine. The department is only accepting new patients if they have an urgent or unique need because, without an in-person examination, it might be difficult to commit to a diagnosis and treatment plan.
Communication and transparency with faculty, with trainees and with staff are going to be key to keep everybody engaged and informed, he said. We are doing many meetings, sometimes daily.
He encourages colleagues to take advantage of counseling hotlines that Rutgers has set up for faculty, staff and students and temporary housing being offered to physicians who live in New York or far away from work. Providing housing arrangements for those faculty who have duties in the hospital is very helpful, he said.
His tip for colleagues: Neurology departments need to pitch in to help their colleagues during a COVID-19 surge. We may be deploying some residents to be part of the Medicine Service team, and to the emergency department so they can be first-responders for patients who present with neurologic symptoms, he said. We know that emergency department physicians are overwhelmed.
At the start of April, Jackson Memorial Hospital in Miami had at least 120 COVID-19 patients and University of Miami Hospital had more than 80 patients who had tested positive and or pending results. Two Jackson Memorial employeesa radiology technician and an intensive care nursehave died from the disease.
We're not at the surge peak but we are getting closer, said Ralph L. Sacco, MD, MS, FAAN, professor and chair of neurology at the Miller School of Medicine at the University of Miami.
The numbers have likely changed since then as is the way the neurology department has had to adapt in the face of COVID-19.
Most faculty members are learning how to conduct outpatient care via telemedicine on the fly and almost everybody is working from home. Sometimes that can increase isolation and it also makes it harder if you have children at home that you're trying to attend to, he said. So stress definitely has gone up in a big way.
Dr. Sacco emphasizes that physical distancing does not require social distancing. We can connect with one another from FaceTime and other ways so we can still see each other, he said, adding that faculty meetings and executive leadership committee meetings, now via Zoom, have been moved up to weekly instead of monthly.
To cope with the anxiety caused by the pandemic, he encourages department members to take advantage of the university's new pandemic counseling service for employees. Anybody can call in and get a virtual visit with a psychologist or psychiatrist, he said.
Meanwhile, a psychologist who has been working to help neurology residents with wellness during their training years has offered to provide group or individual counseling sessions to members of the department during the pandemic.
Tip for his colleagues. Create a three-deep backup list for inpatient care if residents are redeployed to medical units or get sick. We cover a lot of inpatients across two hospitals, so if somebody goes out, we need to have one, two, three deep in terms of coverage, Dr. Sacco said.
For more on how neurology departments have responded to the emotional toll of COVID-19 on their faculty, read more of the stories online: https://bit.ly/COVID-WeillCornell (Weill Cornell) and https://bit.ly/NT-COVID-UCLA (UCLA).
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