Being one of the busiest hospitals in the largest and second most populous borough in New York City, New York–Presbyterian/Queens Hospital cared for hundreds of patients infected with COVID-19. Alexander Golant, MD, FAAOS, associate director of sports medicine at the New York–Presbyterian/Queens Department of Orthopaedic Surgery in Flushing, N.Y., and assistant professor of clinical orthopaedic surgery at Weill Cornell Medicine, transitioned from orthopaedic surgeon to frontline physician. Julie Balch Samora, MD, PhD, MPH, FAAOS, talked to Dr. Golant about his experience in New York during the peak of the COVID-19 pandemic.
Dr. Samora: Can you share your experience with being at the epicenter of the COVID-19 pandemic in New York City?
Dr. Golant: As soon as the first case of COVID-19 was diagnosed in the United States, we knew that it would come to New York sooner rather than later. What we did not anticipate is how hard and fast it would hit our city, particularly the borough of Queens. It hit us like a tidal wave. Although our hospital leadership did its best to prepare for the surge, we were quickly overwhelmed and exceeded capacity to accommodate the number of patients with COVID-19. Normally, we have 532 beds, but by early April, we had nearly 600 patients, almost all of whom were admitted for COVID-19. The critical care capacity was nearly quadrupled, with recovery rooms, presurgical holding areas, operating rooms (ORs), and even the cafeteria converted for intensive care unit (ICU) use. Nurses, technicians, physicians, physician assistants (PAs), and other physicians were redeployed.
As one of the surgical subspecialties, orthopaedic faculty were not formally mandated to redeploy to the front lines, but we all wanted to contribute maximally to the hospital-wide effort. The first case of COVID-19 was diagnosed in New York on March 1, and due to the rapid increase in cases, all normalcy of our regular workflow was abandoned by mid-March. We quickly pivoted to help other departments. Being a level 1 trauma center, we continued performing surgical cases only for life- and limb-threatening injuries. Not only were elective cases stopped, but due to the lack of space to recover patients, we had to transfer out hip fractures, ankle fractures, pediatric injures, and just about everything else. We kept the outpatient offices open, but only for the essential visits, with every one of those prescreened and verified by the attending physician.
Dr. Samora: Did your team work in shifts? How did you risk stratify?
Dr. Golant: We quickly divided the surgical faculty into two teams, which alternated between covering offices and hospital week by week in order to limit potential exposure to the rest of the staff and patients. We instituted an orthopaedic urgent care clinic in the hospital to help offload the emergency department (ED). Some of us volunteered to help out in the ICUs, where there was a critical need for additional staff. Our nonoperative doctors created and staffed a virtual respiratory follow-up program, helping monitor the condition of the COVID-19 patients who were seen and discharged from the ED. Despite the fact that we had very little musculoskeletal work to do, it was an all-hands-on-deck situation, and everyone was doing something, either on the front lines or in another capacity.
While the situation was definitely dire, what made it easier for my orthopaedic colleagues and me was that we had excellent communication among ourselves and a strong and engaged leadership that looked out for our needs and safety. Our chairman provided daily updates on the condition of the hospital in terms of the number of patients, which units were dedicated to COVID-19, and any new protocols being instituted. We held weekly FaceTime meetings, both for work-related issues and for socializing, and this helped alleviate anxiety and fear.
Four of us volunteered for the ICU. Pretty much all surgeons, including our chairman, participated in the proning team, coverage of the orthopaedic urgent care clinic, taking trauma call, doing virtual visits, and seeing essential patients in the office during alternating weeks. The nonoperative members of the department continued seeing patients in the offices, performing virtual visits, and staffing the respiratory follow-up program. Interaction between staff members was minimized to decrease the risk of transmission. Those who spent time in the hospital would avoid going to the office the same week. The days when surgeons were in the office, the nonoperative doctors worked from home. We had only one attending and two PAs exhibit symptoms of COVID-19, and they quarantined appropriately, recovered, and were able to return to work. As far as I know, none of the administrative staff or other members of the department contracted COVID-19.
Dr. Samora: Can you explain what a “proning team” actually does?
Dr. Golant: Early on, it was recognized that prolonged supine position is detrimental for patients with severe pulmonary complication of COVID-19. To help improve ventilation, patients who are awake and alert are encouraged to sit up or lie prone for a while. However, for patients who require invasive ventilation (i.e., those who are intubated), positioning them prone requires significant effort from the staff. These are patients who not only have an endotracheal tube connected to a ventilator, but also a myriad of other lines, including vascular lines (peripheral venous, arterial, oftentimes central lines), feeding tube, Foley catheter, etc. It takes anywhere from 10 to 20 minutes and a minimum of three to four people to reposition an intubated patient from a supine to a prone position, and when the nursing staff in critical care units have to do this, it takes away a significant amount of time from their other duties.
Therefore, in our hospital, a special “proning” team was created, comprised of surgeons and PAs from the orthopaedic; vascular; and ear, nose, and throat departments. Depending on the workload, we would have one or two teams of four to five members in each, seven days a week, from mid-March to early May. The team would be contacted every day by physicians in charge of each critical care unit with instructions on which patients needed to be proned. For maximal effect, it’s best to prone the patient for 12 to 16 hours a day, so proning would take place in the afternoon to allow the patient to remain proned overnight. In the morning, the proning team would round on all the units and deprone the patients who were proned the previous day. Placing patients back in supine position tends to be easier than proning and usually took less than 10 minutes once the team became efficient. During this process, it was important to carefully pad all potential sites sensitive to pressure (such as the face), monitor all the lines and catheters (frequently needing to disconnect and reconnect them), protect the airway, and monitor the patient’s vitals, particularly oxygen saturation, for several minutes after the patient was proned or deproned. It wasn’t just the physical act of turning the patient over one way or another, but a collaborative effort that required careful attention to the patient’s hemodynamic status and continuous communication with the critical care team.
Dr. Samora: What was your role in the ICU? Did you have to recall your medical school training or open medical textbooks?
Dr. Golant: It certainly helped to review critical care medicine, which I did by going to online resources available through the Society for Critical Care Medicine. However, while I did learn a great deal about critical care, including ventilator management and hemodynamic resuscitation, in my short time in the ICU, as an orthopaedic surgeon, I was definitely not making any key decisions regarding patient care; decisions flowed through the senior residents and critical care attendings on the service.
After morning rounds, we began the daily tasks. We had similar responsibilities to those of interns, including writing daily notes, performing blood draws, intravenous line placements, obtaining cultures for microbiology, pulmonary suctioning, etc. Although these seem like menial tasks, doing them helped offload the severely overworked and understaffed critical care nurses and surgical residents, who were greatly appreciative. We also helped maintain contact with patients’ families (because they could not visit), doing daily calls to update them on patients’ conditions, as well as FaceTime videos for those who wanted to see and speak to their loved ones.
I recall a particular event where I felt I contributed the most to the well-being of the unit. I had just started in this ICU, and this was a unit freshly converted from a cardiac catheter recovery room to a critical care setting. As I mentioned, the surge was very quick and patient-heavy, so new units were being created to the tune of two to three every week, and staffing was a serious issue. There was a nursing shortage, and our unit did not yet have a nursing manager. After morning rounds, I realized there was a significant need for certain supplies and a better organized storage room. I called up the command center, which our leadership created to help address pressing concerns around the hospital 24 hours a day, seven days a week. I explained the situation, and within 30 minutes, we had additional staff sent over, as well as a temporary nurse manager and someone to help organize the stock room and bring more supplies. The nurses on the unit later told me this was critical in helping make a very difficult shift run smoothly and safely, because they now had what they needed to take care of their patients ready and well-organized. Sometimes, as this situation illustrates, the role you played on the unit was different from just patient care and was more organizational and logistical in nature.
Dr. Samora: Your group helped to offload the musculoskeletal patients who would normally have presented to the ED. Can you explain how your department created this system and worked with the ED to steer patients appropriately?
Dr. Golant: Our ED was overrun early and severely. The patient inflow was so high, there was literally no physical space to see patients. I took a photograph of the ED in early April, which has some semblance to a war-zone medical unit—beds with patients stacked along the hallways on both sides, with barely any space between them. The hospital created a special outside tent for patient screening, and other locations were utilized as well. We wanted to help offload the ED in any way possible and also limit COVID-19 exposure to patients presenting with musculoskeletal complaints. We turned our hospital-based outpatient clinic into an extension of the ED. We streamlined the triage process, whereby if a patient presented to the ED with a purely orthopaedic complaint (e.g., fracture, dislocation, sprain, etc.), they were quickly screened for COVID-19 symptoms, and if there were no symptoms, the orthopaedic attending in charge of the clinic would be called by the triage nurse, and the patient was quickly sent up to our clinic (with appropriate personal protective equipment [PPE] given to the patient). All X-rays were taken in the clinic, and all necessary procedures (e.g., wound sutures, closed reductions, splinting, and casting) were performed onsite. The visit was treated as an outpatient clinic visit, and patients were discharged with appropriate follow-up instructions. We also bypassed the ED by managing patients in ways we had never done before, such as performing direct admissions from the office to the OR and immediate disposition from the post-anesthesia care unit to rehabilitation centers.
Dr. Samora: You also mentioned that your group participated in a respiratory monitoring program for COVID-19 patients. Can you explain what this is and how it came about?
Dr. Golant: As the volume of patients presenting to the ED with COVID-19 symptoms surged, there was concern that those discharged would be lost to follow-up. The hospital created a virtual follow-up appointment system, instructing these patients to reach out to a primary care physician within two weeks for reevaluation, but there was still concern about short-term worsening in these patients’ conditions. In response to this concern, spearheaded by the orthopaedic and ED chairmen, our nonoperative doctors helped create a virtual respiratory monitoring program, which became key in helping ensure the safety of those patients, minimizing unnecessary bounce-backs, and guiding the patients through their recovery process. The ED provided us with a daily list of patients who were seen and discharged, and we called them two to three times for the next 48 to 72 hours using a variety of telehealth platforms. During these visits, we assessed their respiratory rate, heart rate, use of accessory respiratory muscles, and response of the respiratory status to mild to moderate exertion. Eventually, patients were also given pulse oximeters, so their oxygen saturation could be monitored as well. We were able to identify patients who had worsening respiratory status and required a reevaluation in the ED. Alternatively, we were able to help reassure patients who were concerned but did not exhibit any evidence of respiratory worsening.
Dr. Samora: Did your team have access to PPE?
Dr. Golant: We were never without PPE, although we were instructed to preserve and reuse whenever possible. In each medical and critical care unit, the nurse manager had a set of protective equipment under lock and key (to avoid theft). In the ICU, this included N95 masks, surgical masks to go over the N95, a full-body suit, head cover, face shield or googles, and gloves. Our system supply chain stayed in tight control, but there was never a day that my team did not have what it needed. Additionally, our chairman checked in every single day with every member of our department to ensure everyone had what they needed and would procure any additional equipment needed.
Still, we were well aware that overall there was a shortage of PPE around the New York City area, so my colleagues and I actually started a campaign to raise funds and procure additional equipment. This was well-received, and we actually got some excellent and generous donations from around the country, which we distributed both within and outside our hospital.
Dr. Samora: Can you provide any advice for other groups who may wish to provide similar medical assistance?
Dr. Golant: I think first and foremost, everyone has to be cognizant of their safety and the safety of their loved ones. To volunteer for the front lines is a difficult choice, and those of us who made it did not do so carelessly. But if you are in good health, relatively young, and capable of doing this kind of work, it’s one of those rare opportunities where we are afforded the ability to serve the community in a time of crisis. My advice to those who want to do this is to carefully assess your risk profile, speak to your significant other, consider yourself, and explain to them what it would entail—what kind of sacrifices you will all have to make. I moved my family away, taking my wife and three kids to stay with my in-laws, and I did not get to hug or kiss them for seven weeks. Many other folks serving on the front lines had to do something similar or maintain distance from their spouses and kids when returning home from the hospital. Also consider what effect the volunteerism will have on your practice—if you are still seeing patients and performing surgeries. Serving on the front lines is definitely not for everyone; but if you are able to do it, it is an action that is greatly appreciated and valued.
Dr. Samora: Do you think this experience has prepared your group for a future disaster or mass casualty event?
Dr. Golant: Absolutely. There is no doubt that we all—whether serving on the front lines or in other capacities—learned valuable lessons about working together in a time of crisis, including putting aside disagreements and pride, stepping out of our comfort zones, and thinking outside the box. Not to sound cliché, but this was a bonding experience, both within our department and with those from other services and positions. It also taught us the importance of being better prepared for the unexpected, staying updated on issues both within and outside our specialty, and participating actively in the hospital and our healthcare system at large.
Dr. Samora: What advice would you give those who are in areas that are less affected by COVID-19 than New York City?
Dr. Golant: This is definitely only the beginning. Although the surge was unprecedented in New York City, and hopefully will not be as bad in other areas (or may not happen there at all), I think we will all have to deal with the new reality of taking care of patients while COVID-19 is active. Even in times of crisis, with attention focused on this coronavirus, we have to ensure access to and continue providing non-COVID-19-related musculoskeletal care. This means we have to be prepared in a number of ways, including ensuring adequate PPE availability, standardizing protocols for testing patients preoperatively, providing a safe environment in outpatient clinics, and being prepared for a disaster-type situation, akin to what we experienced here. This latter preparedness requires regular communication within the department, both vertically and horizontally within the healthcare organization and with the local and state governments, as well as alternative plans for chain of command, staffing, and workflow. It is also essential to not forget about emotional and physical well-being of the physicians. It is key to maintain open lines of communications with each other, support each other, and ensure that, even as the acute phase of this virus subsides, we are ready for whatever challenges lie ahead.
Julie Balch Samora, MD, PhD, MPH, FAAOS, is a pediatric hand surgeon at Nationwide Children’s Hospital in Columbus, Ohio, where she serves as associate medical director of quality for the hospital. She is also the deputy editor of AAOS Now. Dr. Samora can be reached at firstname.lastname@example.org.