We asked our customers and partners to share their experience from continuing the clinical practice in these unusual COVID-19 days.
The question was not just how to treat the COVID-19 patients, but how to keep on treating the regular patients under the heavy load and unique risks of the Corona pandemic.
We believe that sharing clinical experience, professional and personal perspectives by leading clinicians around the world could prove helpful, as the clinical community worldwide struggles to keep us all healthy while defeating this threat.
We will keep updating this page with newly received information.
April 14, 2020 – Interventional Cardiology
In regards to COVID-19 atmosphere, it feels like the silence before the storm. Our location seems to be a couple of weeks behind the east coast surge. I feel that our state of Ohio has done particularly well with preventative measures like closing the schools and gatherings early on and issuing stay-at-home orders. At the hospitals, we are preparing for all possible scenarios based on the experiences from places that are already facing a surge.
Elective and Procedural Volume
All elective procedures are cancelled, we are only doing urgent and emergent, lifesaving procedures. So, our overall procedural volumes are down by approximately 40-60%.
Surge Plans and Re-Purposing
We have surge plans made for repurposing the staff, physicians and trainees where in a fellow training in cardiology can work as Internal Medicine attending or Cardiologists well versed with critical care from CICU experience preparing to run COVID ICUs. The hospital has dedicated COVID units on medical floors as well as ICUs with ability to open new floors and man them in case of the surge.
Cardiac Injury in COVID-19 patients
Based on the data that came from Wuhan and now New York, 7-20% incidence of cardiac injury with troponin elevation in COVID-19 patients. The possible explanations for cardiac injury includes: Type 2 MI due to demand -supply mismatch in the setting of severe hypoxia, Myocarditis and Type 1 STEMI or NSTEMI due to plaque rupture. As per many case reports now available, significant number of patients with COVID-19 when brought to cath lab for ST elevations tend to have normal coronaries or with minimal non-obstructive coronary disease raising a suspicion for Myocarditis. There have also been reports of stress induced cardiomyopathy like presentations associated with COVID-19.
Diagnosis and treatment of Cardiac Event in the setting of COVID-19
If a patient is primarily presenting with respiratory symptoms of cough, shortness of breath associated with fever/chills and imaging findings are suspicious for pneumonia, then the associated cardiac injury is likely secondary to COVID-19 and less likely a primary cardiac event. In such presentations with elevated troponin, we request echocardiography to assist us in further decision making. In cases with hemodynamic compromise and/or shock we gather mixed venous O2 saturation, central venous pressure by transducing an existing central line and calculate Fick cardiac output and systemic vascular resistance. If these measures are suggestive of cardiogenic shock, we then proceed with bedside Swan-Ganz placement to guide the management of shock.
If the presenting complaints suggest a primary cardiac event and there are ST elevations in the ECG, a COVID clinical screen which includes history and chest X ray is performed in the ED. If negative, we bring them immediately to cath lab for primary PCI. If screen is positive or Xray is suggestive of pneumonia, ED physician and Interventional Cardiology will discuss the revascularization strategies; thrombolytic administration Vs primary PCI.
Difficult times bring in opportunities to innovate whether it’s using tele-medicine to do outpatient visits or teaching our trainees using webex and zoom applications while maintaining social distancing. There will be a time in near future when this crisis subsides the medical community will sit down to count the losses and the gains. This will bring us new knowledge, which I hope will change the way we practice medicine for the betterment of everyone. The medical world will never be the same again.
April 12, 2020 – Surgical Education
About a month ago, I recognized that many residents and medical students would be left without any access to didactic and skills education.
While larger programs have been able to overcome these hurdles, the disruption to our routine schedules has clearly impacted our ability to educate our trainees.
I launched Quarantine Surgical Education on twitter and YouTube to help meet this need.
Our goal is to provide high quality surgical education through curated expert videos. We have received donations from world experts talking passionately about their fields of interest. We have partnered with industry (Bard, Intuitive, Boston Scientific) to increase our reach. We have had journal access donated by British Journal of Surgery.
We are partnering with the Resident and Associate Committee of the American College of Surgeons to make a weekly curriculum based on our video content. We will continue the project as long as we have a pandemic disrupting schedules and content to curate.
April 7, 2020 – Interventional Radiology / Interventional Oncology
Interventional Radiology Department
The Interventional Radiology department staff was divided to two, working alternately in 24-hour shifts. We are still admitting patients and have not stopped treatments. For most patients we cannot postpone procedures. All life-saving treatments are conducted as usual – biopsies, embolizations and ablations.
There is no difference in these procedures – we use the same ultrasound and the same CT. The only difference is wearing the protective equipment.
Whatever we can do at the bedside is done at the bedside, and when higher resolution or patient safety are required, we operate in the interventional suite.
Oncological patients actually receive better care, given the reduced volume and pressure. Hospital occupancy is down by 50% in order to make space for the COVID patients.
We keep conducting ablations, as we need to treat patients with tumors. If the tumor is bothering the patient (if he cannot urinate for example), or tumors causing anaemia or hemorroids – we cannot wait.
Some patients wait longer at home before getting to the hospital these days, but if they are referred by an expert, we do not stop or postpone these procedures.
We implement different protection levels: normal patient, COVID-suspected patient and confirmed COVID patient. Protection wise, we are more protected in the hospital and the operating room, and we exercise caution during patient interaction, whether talking, examining or signing consent.
With respiratory patients, we exercise a higher level of personal protection.
With COVID patient, we have time to prepare, take him from the COVID department and perform the procedure as usual with protective gear. We clean the room later and the room is unavailable for an hour to admit other patients to avoid contamination.
The tough work is for the anesthesiologists, internists and ICUs. We radiologists have time to prepare.
Learning how to protect ourselves is key, regarding radiology there is nothing special. Protect yourself to protect your family, the medical team and the patients. Once you work according to the guidelines everything should be ok. Up until now, no medical staff member has contracted the virus from a hospitalized patient in our hospital.
March 31, 2020 – Bronchoscopy
The COVID-19 pandemic has significantly impacted bronchoscopy workflow and triaging of patients.
In order to minimize exposure-risk to patients and hospital staff, we are currently grouping patients into emergent, urgent, acute and non-acute.
Emergent cases include patients with symptomatic central airway obstruction, massive hemoptysis, acute foreign body aspiration or migrated stents.
Urgent cases include patients with fever and infiltrates in immunocompromised hosts, and lung transplant patients with worsening symptoms / drop in PFTs where a diagnosis of infection/rejection will change management. Ideally, these patients will have prior COVID-19 testing.
Patients in the acute category include those with a lung mass or adenopathy suggestive of malignancy, suspected drug induced pneumonitis where diagnosis will change therapy, lobar atelectasis unresponsive to chest physical therapy / airway clearance devices / bronchodilators and patients requiring stent surveillance.
Non-acute patients include those who do not fall into the above categories, such as most patients with suspected sarcoidosis and patients referred for bronchoscopic lung-volume reduction or thermoplasty.
Each institution’s categorization of these patients will clearly differ, as will the time-frame in which to perform the procedure. Our current recommendations are to perform bronchoscopy under “airborne” precautions in a negative pressure room.
March 31, 2020 – Surgery
The way we operate in my department did not change much, except for using masks, complete PPE, and washing our hands quite often. Certain patients are tested for COVID-19 prior to the operation, but it is not mandatory if they are asymptomatic. We have to consider the shortage of tests.
Some surgeons decided 2 weeks ago to completely stop all oncology surgeries.
As a thoracic surgeon, I think it is dangerous to just stop completely all surgery.
If it is feasible to keep operating in a COVID negative environment – we should do it.
Our patients are still ill, and await treatments. When we postpone certain surgeries, we are putting our patients at risk.
So, at present time, the way I am operating with lung cancer patients is as follows:
If it is a small tumor, and we think the patient is able to wait for several weeks – we postpone. But, when it is a solid, proximal, mass, we think it has to be operated – we try to do it in a private hospital (COVID negative environment) at present time.
Every day we discuss with the anesthesiologist and the whole team: “Can we operate? Should we not operate?” and we have difficult discussions such as for cardiac surgery: “What do we do for cardiac patient? Do we wait with surgery? But if we wait with certain surgeries we put the patient in risk”. Being the director of my OR, the whole team has to be convinced we should operate. If there is one staff member who thinks it is not a good idea – it is not very good for the team. So we have to have a clear discussion, and once we decided to operate, we perform to completion, and if the patient should go to ICU, he will to go to ICU.
We are at the time when there is ‘competition’ between COVID patients and non-COVID patients. And it is very important to be aware and consider this competition.
It is true everywhere I think. So an opened discussion is mandatory here because we have to take decisions. Probably at times it could be bad decisions and other times good decisions. No one knows the best way to perform in this situation, so we do our best.
We are struggling to find the optimal path between “nothing” to “everything” in regard to treating our non-COVID patients.
We also have to consider that in 2 months (of course no one knows exactly, but 2 months from now we think the situation might go back to normal), we will have accumulation of surgical patients, and again we will have a competition between patients.
Then the question will be – are we able to work more? We do not currently have
March 30, 2020 – Surgery
Here is what we are doing and how we change our practice during the COVID situation:
- These are certainly extraordinary times that require extraordinary measures. At NorthShore University HealthSystem we have cancelled all elective surgery for 90 days and are performing as many clinic visits as possible through remote telehealth visits. This is an effort to social distance and decrease the use of personal protective equipment (PPE).
- We are following the American College of Surgeons Guidelines for emergency surgery which are thoughtful guidelines in how to approach patients during these times of resource allocation while also still needing to address life-threatening emergent and urgent surgical disease.
- We are following the SAGES guidelines as it pertains to managing capnoperitoneum and the possible viral transmission (not known) that occur. We are employing filtering devices when available and at the very least, suctioning the capnoperitoneum out before opening ports, removing ports, or enlarging an extraction site.
- We are approaching all patients that are COVID positive or unknown as if they are positive and employing N95 masks in the operating area. The surgical team and non-essential staff are leaving the operating room during the intubation. There is certainly a balance between preserving PPE and protecting the surgical team.
- We are constantly practicing good HAND HYGEINE.
- We are practicing social distancing. Medical students are not rotating in the hospital. We have pared down the surgical residents to the minimum needed and allowing them to rotate one week on and one week off. We are limiting the number of caregivers into a patient’s room for examination and maintaining a six foot distance except when examining the patient.
- We are still reaching out to our trainees and making sure they are doing ok. We discuss cases and research and we will sometimes go over videos of cases. There is still education that can be done!
- We have recommended mindfulness exercises for our surgeons and trainees.
March 29, 2020 – Intensive Care
On COVID-19 relevant training
All physicians encountering patients from the community, ER though ICU, undergo complete PPE training, as well as care providing to the mechanically ventilated with PPE. This is done in the simulation center.
Most, if not all, of the Internal Medicine physicians in our hospital participate in a POCUS course at Soroka Medical Center as part of their medical training, including echo, shock, lung, vascular and FAST.
Recently, under the new circumstances, we have created and distributed two video tutorials, half an hour long, summarizing the current knowledge on lung manifestations in COVID-19 patients and the anticipated findings in a focused lung ultrasound exam.
On ultrasound training during COVID-19 time
We have built a team of trainers, all sixth year medical students so clinical duty in our hospital does not suffer. They voluntarily teach focused lung ultrasound, with and without a simulator, at Soroka Medical Center and other hospitals in Israel.
On how diagnosing and admitting patients differ from normal
Patient examination is a challenge with COVID-19 patients, given the risk of medical staff infection. Thus, the physical examination is limited, the statoscope cannot be used, and CT or CXR exposes additional staff members to the risk of infection. In addition, accounts from China and Italy claim that CXR sensitivity is lacking in the timely diagnosis of lung infiltrates and ARDS (Acute respiratory distress syndrome).
Considering the above, a focused ultrasound examination becomes crucial, being the eyes and ears of the physician in this complex condition. We therefore encourage the use of ultrasound and remind physicians of its relevant findings connected with this disease.
March 29, 2020 – OB/GYN
Today, it is the 10th confinement day in France, as my kids reminded me this morning.
I live in the center of France, in the middle of the Loire Valley area. I work in the University Hospital Center of Tours, as a Gynecologist and Obstetrician.
So far, this area has been quite spared by the Corona virus spread and we are expecting the worse part of the epidemic in the next few days/hours.
We saw from our Italian and Spanish friends and even from the eastern part of France (Mulhouse and Strasbourg mostly), how big and challenging the number of severe COVID 19 cases could be for the population, and health institution.
As all the rest of the French health system, we have been preparing ourselves and institution organisation since 3 weeks now.
Usually, my daily work is mostly oncologic and complex benign surgery, and I lead the robotic program in my unit. 3 weeks ago, we decided to cancel every non oncologic, non life threatening case in the OR, expecting to schedule again our cases in a not so far future.
Oncologic surgeries that could be postponed by using near adjuvant therapies (chemo or hormonal) had been cancelled.
Outpatient clinic has been restricted to urgent cases that needed clinical examination.
Our institution developed a Remote Clinic activity in less than a week to be able to assume our health mission for other patients. Our national health insurance took decisions to facilitate this organisation.
In less than a week, IT solutions to teleworking and TC meetings has been widely adopted, thereby accelerating a process that was meant to take ages.
During countless crisis meeting (by videoconference), we decided to reorganize physicians activity, reinforcing Obstetrical activity and doubling the staff in order to manage COVID and non COVID cases in the same time.
We decided to dedicate 2 OR to COVID + cases in order to be able to manage Obstetrical and Gynecological emergencies. We dedicated a part of our hospitalization unit to COVID + cases.
Our physicians who don’t do on-call activities, are participating in emergency activities or reinforce activities were their skills could be best used. The rest of us are dedicated to doubling the on call list, to face dual activities and rely on if any staff gets ill.
In our institution, ICU beds had been reassigned for COVID for 80%. The rest 20% remain for current ICU activities (decreased but not stopped because life still goes on and people still endure other diseases…)
Plans have been made to face an overwhelming arrival of severe cases with the reassignation of OR ventilation machine to recovery, in order to double our ICU beds capacity. And in that case, all surgical cases, appart from immediate life threatening emergencies, would be canceled, as it had already been done in Strasbourg and many other places in southern Europe.
Since yesterday, hospitals from eastern France and Paris are sending us by train some of their ventilated patients in order to be able to face the increase of severe COVID forms in their area.
We are now ready to face the battle and are waiting for it.
We face a certain concern and fear, because some physicians, nurses and other hospital staff have been severely impacted and some died, but that is certainly the reason why the whole population clap hands overnight at 8pm, we need to deserve this consideration…
I know how game changing this epidemic episode could be, it is now war and we are ready for it.
But, thanks to this critical situation, we already made some tremendous changes in our practice.
Eventually, we will get through this sanitary crisis and I hope we will be able to learn from it and reconsider our way of living.
People in my area and institution, are lucky enough to have time to prepare for this upcoming wave, and to live in a wealthy country with, whatever some may say, a very solid health system.
My thoughts go towards people all over the world who don’t share that chance, only due to the place they were born in.
May all of you and your families stay safe
March 27, 2020 – Urology
In fact, there is little change in the environment around me so far.
Scheduled operations and volume of outpatients remain the same as pre-CoV pandemic.
But, we are full of cancellations and self-restraints of gatherings and events in the public space.
My daily practice is solo, so that I am doing my routine RobotiX Mentor training as usual.
Our RobotiX Mentor console is in the OR, and I can practice on it even if the outside is in danger of CoV scattering. I am afraid of the CoV impact on the global economy, which is not so small.
March 26, 2020 – Colorectal Surgery
I work in a 1,200 beds hospital, with approximately 35 operating theatres, nine of those are general surgical. In the UK we have not seen the peak of COVID-19 yet but expecting it around 2-3 weeks away. Despite the testing and PPE are extremely important, we did not have sufficient resources to deal with these two aspects at the beginning of the pandemic. However, we are expecting more supports in the coming weeks.
Since last week, we have cancelled all the planned operations, including cancer surgeries, planned endoscopies, and out-patient clinics are limited to telephone consultations.
We have revised the working rota for junior and senior surgical members to cover this period, to allow numbers that are safe to manage the in-patients and emergencies. This would enable some staff to be at home and on standby just in case of colleagues are becoming ill or increase demand from the hospital, we don’t want too many of us getting sick at any one time.
Colleagues are prepared to perform tasks that they don’t normally do. For example, junior surgical teams and nursing staff are being trained in an ICU setting. Before the COVID-19, we had 12 ICU and 12 HDU beds. We are converting recovery areas, theatres, and potentially surgical day ward to ICU beds, with a maximum capacity of 80 ICU beds in our hospital. We might need these in the next few weeks!
Apart from preparing the increasing demands of patients with COVID-19, there are uncertainty and anxiety amongst patients with surgical conditions awaiting treatments. We would want to keep them posted on our latest updates.
More importantly, we need to help and care for each other, and the general public is aware of the situations. A plea from the government recently for help and received tremendous support from volunteers.
It is a challenging time, and we are all learning and adapting! Hope we can get over the peak soon!
Prof. Tingbo LIANG Editor-in-Chief, Chairman of The First Affiliated Hospital, Zhejiang University School of Medicine: “Faced with an unknown virus, sharing and collaboration are the best remedy. The publication of this Handbook is one of the best ways to mark the courage and wisdom our healthcare workers have demonstrated over the past two months.”
See complete handbook: Global MediXchange for Combating COVID-19 (GMCC)