by Elizabeth Hofheinz, M.P.H., M.Ed., April 17, 2020
With New Orleans hospitals admitting fewer Covid patients, local physicians are wondering if we have hit the peak. Ortho Spine News is in week three of its discussions with orthopedic surgeons from Louisiana State University. The surgeons—some faculty, some residents—discuss their challenges, treatment patterns, and predictions for the coming weeks.
Robert Zura, M.D., an orthopedic trauma surgeon, is the Robert D’Ambrosia Professor and Department Head at the Louisiana State University Health Sciences Center (LSUHSC). He states, “There was no one waiting in the ED at University Medical Center (UMC) today and I understand that there were only 115 total positive and pending patients in the building; even the tent outside the ER has been shut down. We never exceeded capacity at UMC, and we take transfers from all around the state. There is definitely a flattening of the curve here and we are beginning to discuss returning to some normal activities.” 
So where does that leave the 1000-bed popup medical facility at the convention center? Virtually empty, says Dr. Zura. “The criteria for admission to the convention center have been evolving quickly and overall it has been less well utilized than we thought it would be. UMC is the biggest Covid-19 caregiver in New Orleans and we have only sent 16 patients there.”
“The weather has been beautiful here and the mayor indicates that things are beginning to calm down…nice on the surface, but people may be jumping the gun on getting out. I have noticed more traffic on the roads in the last 48 hours—and we had a huge amount of trauma last weekend.”
Asked if this will change how he practices medicine, Dr. Zura states, “On the one hand I think we will just go back to business as usual. One positive aspect of this situation is that for most practitioners, any fear or anxiety that we had about telemedicine or non-traditional methods of care has been alleviated. It is challenging with orthopedics, however, and we cannot be ‘hands on’ or offer imaging via telemedicine.”
Peter William D’Amore, M.D. is a third-year orthopedic resident at LSUHSC who is rotating in Lafayette, Louisiana. “I can’t speak of what has happened at UMC since I left, but this hospital in Lafayette is doing a great job of helping the healthcare personnel. Getting a N95 respirator has been a chore at other hospitals. But to be fair, it is a much smaller facility here in Lafayette and they have no shortage of PPE largely due to the lower number of COVID-19 patients they have seen.”
“Case volumes are decreasing in the ‘hot spots,’ but there are some reports of more rural areas seeing cases pop up…and those are not the places that garner national media attention. What do you do if the small community hospitals in rural areas reach capacity?”
“I have had several people—including venture capitalists—reach out to me personally asking if my hospital needs N95 masks or ventilators. PPE remains an issue in some places, but the ventilator problem to my knowledge seems to be under control here. Ingenuity abounds…for example, I saw engineering students at UCF in Central Florida have devised a way to reuse the sterilization wrap to process instruments in a 3D printed reusable respirator device.”
Musing about the future, Dr. D’Amore notes, “I could see that the end of 2020 would be realistic for a vaccine. That is ambitious, however, we first must assess its effectiveness in trials and then comes mass production.”
This orthopedic resident is keeping an eye on a specific date in November 2020. “I don’t think we will be in quarantine for a year…I can foresee social distancing initiatives, such a limiting the size of gatherings, lasting until the end of 2020. My fiancée and I have plans to get married in November. We may have to cancel or postpone the event depending on the upcoming weeks and months.”
Vinod Dasa, M.D. is Associate Professor of Clinical Orthopaedics and Director of Research at LSU Health Sciences Center. He states, “I have seen a fair number of patients today as many people are struggling to manage their pathologies and are concerned about having their medical issues addressed. I saw a postop knee patient via telemedicine and was able to see her incision and see how she is moving her knee. The most substantial challenge for orthopedics and telemedicine is imaging. A large part of patients coming in to see an orthopedic surgeon require things like Xrays and MRIs.”
On the bright side, says Dr. Dasa, telemedicine is expanding the capacity to serve patients. “With postop patients, I can see them ‘online’ and don’t need to drag someone with limited mobility into my office. Seeing postop patients this way would probably open up roughly one-third of my schedule, which would help us fulfill our mission of serving anyone who walks in the door. For many of our patients, transportation and time off work are huge issues. Thus, if someone can do telemedicine from work from on their lunch breaks that is ideal.”
“There are a lot of discussions about restarting the healthcare system, which tells me that the medical professionals have relative confidence about this disease process. The trick is to open up but not send a signal indicating that ‘the coast is totally clear.’ The healthcare system needs to be several steps ahead of the general economy. It is vital that we get back to normal when appropriate as there are a lot of suffering patients who are turning to opiates and/or overmedicating with anti-inflammatories that create GI bleeds.”
Asked to reflect on the legacy of Covid-19, Dr. Dasa states, “I think it will have been an unnecessary harm that affected every segment of our society. We need to determine how to create a more resilient healthcare system so that we can avoid such a recurrence. I believe that we have spent 5-10 years of being too ‘lean.’ It has gotten to the point where we have removed redundancies because we thought they were ‘fat in system.’ All of the Six Sigma exercises that have been de rigueur, while driving value, they have also undercut existing safety mechanisms. There is a price to be paid.”
Andrew King, M.D. is Professor of Orthopaedic Surgery and the G. Dean MacEwen Chair in Orthopaedics. Dr. King says that while he is still testing positive for Covid, his wife is now testing negative. “I’m unsure of why there are such differences in the course of the disease. My wife had high fevers and the classic illness. I had a few chills, but never any fever…perhaps I am a carrier.”
“At this point it wouldn’t be prudent for me to go work at Children’s Hospital, so I am taking my third week of sick leave and keeping in touch with patients online.”
And he is well enough to whittle down his backlog of tasks. “I have never kept up a CV and am taking this time to log every book chapter and article that I have published…20 years’ worth. In addition, I am taking time for a research project that has been on my to-do list for over a year.”
Dr. King is taking advantage of the old and the new during this time of relative repose. “We gathered about 25 of our friends and had a zoom cocktail hour the other night…it was a blast!”
And the traditional part? “My wife scored us some of the first crawfish of season as our Easter meal.”
Peter Krause, M.D. is the Elaine A. Doré Endowed Chair in Orthopedics at LSUHSC and the Director of Orthopaedic Trauma at University Medical Center. “I am cautiously optimistic that we will continue to see a steady decline in hospitalizations and intubated patients. We can’t rely solely on lab testing because that has not been widely available until recently; my understanding is that direct viral testing is now available via multiple labs at UMC. The FDA has approved one antibody test for us, and we anticipate that this testing to be available in large numbers within a few weeks.”
“I would say there are approximately 50-60% Covid-related patients in our hospital now. The overall census is down…and while we continue to see gunshot victims on a regular basis, even those are down.”
“My primary concern is what will happen once we start allowing people to go back to work. How do we safely resume life until a vaccine is available? I think this time in history will be remembered as a wakeup call, as it should be. Just imagine if this had been something even more horrible…like EBOLA.”
Christopher Marrero, M.D. is Associate Professor of Clinical Orthopaedic Surgery at LSU. Dr. Marrero, who says that he has had no contact with Covid patients over the last week, notes, “I did do clinic at UMC this week, but it was very light and scaled down. Patients were screened and given masks, and the staff had adequate PPE.”
“I know more than 20 individuals who have had Covid, three of whom have passed away. There has been an increased focus on the fact that this disease disproportionately affects African Americans. This effect is not surprising…it is just a manifestation of the longstanding healthcare disparities in this country. It is a function of society…and this disease is just exposing the problem.”
Asked about the likelihood of this crisis eventually improving health disparities, Dr. Marrero states, “Honestly, I am not feeling optimistic about that. There are so many social determinants of health: what people eat, where they shop, live, go to school…all of that and more plays into someone’s health. And there is the lingering shadow of mistrust between the African American community and medical community. Even recently, two French doctors suggested on live TV that experimentation using the BCG tuberculosis vaccine against Covid testing be undertaken in Africa.”
Elucidating plans for his role as Diversity Officer, he says, “I am developing a structure for the position and then will begin creating a plan. We are defining goals with regard to inclusion in the LSU Department of Orthopedics. It is in its infancy stage, but I am pleased to see that some faculty and staff have already stepped up to join in these efforts.”
Paul Phillips IV, M.D. is Assistant Professor of Clinical Orthopedics at LSUHSC who states, “The stay at home order has had a tremendous effect in letting us get a handle on this disease that was spiraling out of control.”
And how might he see things one year from now? “I could see reflecting on the fragility of our health and how fast things can turn from a happy, healthy country to a country that is up in arms, frightened, and with so many people dying daily. We should not take for granted the days we get where we are healthy and happy.”
“Looking forward, maybe the best use of telehealth is for followup patients with chronic pain. And if you have sent a patient for PT or given them an injection at the last office visit, telehealth can work very well.”
Turning to the issue of elective cases, Dr. Phillips states, “Hospital administrators draw up the rules and use keywords like ‘elective case’ without knowing that the meaning of ‘elective’ changes with the condition.”
“I do need to treat a tibial plateau fracture very soon, as waiting would put the patient at risk for long-term knee problems. I have to bump it up the chain of command and advocate for the patient.”
Daniel Plessl, M.D., chief resident at UMC, is hunkering down for exams. “I have worked from home over the last week, which has been quite helpful as I have Board exams in the summer. My whole class was scheduled for a board review class in Chicago this week, but now it is a week-long webinar.”
And what fills his musings about the ripple effects of this crisis? “I think that as a country/society we may see some permanent changes. After 9/11 we experienced a change in security and now it may very well be the end of the handshake. At least in the future, hospitals will be prepared with excess ventilators and respirators.”
Opining on how medical training might be altered, he says, “Perhaps we will be more economical with our resources. For example, now we see how precious a surgical mask can be. In the past it was no big deal to stick your head in the OR and then leave and toss out the mask…definitely not ok now.”
Cristina Terhoeve, M.D. is a third year orthopaedic surgery resident at LSUHSC. Dr. Terhoeve is gearing up for her ICU shift this week…she is studying and she is thinking about her field. Dr. Terhoeve told OSN, “In orthopedics, we think that our jobs are incredibly import…but in fact ours is one of the few specialties that is not life or death. In a situation such as Covid where people are getting sick and dying you feel a little helpless because you no longer have the tools to take care of those people.”
Asked how she is dealing with the helplessness, Dr. Terhoeve says, “I am dealing with it by volunteering to work in the ICU.”
“At UMC they have created a new ICU just for Covid patients. I have spent extra time reading about how to manage these patients and watching videos about critical care management so that I can be as prepared as possible. Fortunately, I recall more than I thought I would. I did have to learn certain things, of course, like at xyz level of elevated blood pressure, what dose of BP medicine should I prescribe.”
Please stay tuned for next week when we learn how LSU continues to evolve its response to COVID19.