American Society of Plastic Surgeons
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Views from the front lines: Society members recount tales from the E.R. and ICU in COVID-19 battle

When the COVID-19 pandemic escalated in the United States, several ASPS members utilized the nationwide suspension of most plastic surgery procedures as a means to volunteer for E.R.s and ICUs. PSN asked several physicians on both coasts to discuss their experiences as they provided care and coverage.

Evan Garfein, MD
Chief of the Division of Plastic Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, New York

Dr. Garfein volunteered to treat COVID-19 patients in the E.R., in order to serve alongside Montefiore residents.

Prior to mid-March, we were doing normal reconstructive and general plastic surgery – then COVID-19 hit the region fast and hard. It quickly became apparent that elective surgery would be suspended and the need to redeploy manpower would ensue; that the E.R.s would be flooded; and that we'd need many more ICU doctors and beds. The Department of Surgery held planning calls over the course of a week to develop redeployment schedules. One of our core beliefs was that you can't ask residents to put themselves in harm's way if you're not willing to do it yourself. So, when our division made the decision to redeploy residents to the E.R., and later to ad hoc ICUs, we decided we would serve there as well. It was probably in the E.R., where we were charged with screening patients with COVID-like symptoms, that I contracted COVID-19, but I stand by the decision to help.

I was first redeployed as an attending to the E.R. Two sectors needed reinforcement – one for "procedural care" (e.g., treating lacerations, fractures and abscesses), the other took on patients who presented with COVID-19. We were stationed in a tent outside the E.R., which was visited by patients who presented with symptoms such as fever, cough and malaise. It took me back to my life as a medical student, doing general medical exams, listening to chests, taking histories and ordering chest X-rays. It was a great experience in some ways; it showed the fundamental truth of medicine and why we went into this field. The E.R. staff, nurses and P.A.s worked tirelessly through this. The real heroes are the midlevel E.R. staff who didn't take shifts but worked every day on the front lines. In my view, it wasn't that big a thing that we did; there was help needed and we provided that help. I don't know how we could've expected less.

The availability of PPE was always adequate for us; we had N95 masks, gowns and gloves. There were times in the early period when there wasn't a PPE surplus, but we never had a significant deficit at Montefiore. We were also fortunate that our network of friends from around the country, particularly those from my college days, stepped up and sent hundreds of Tyvek suits. We were able to hand these out to E.R. staff and ICU nurses.

We've never faced anything like this before, and I've been impressed and encouraged by the resilience of people in these months. I like to read history and I've been thinking about the Battle of Britain and the Blitz over London during World War II – a big city confronted by an existential threat – and people tended not to fall apart. They rallied around a common cause and became tough and resilient, and acted, in large part, in ways that were incredibly admirable. That's what we're seeing here in New York City. This is an environment where people could come unglued; kids are out of school, stores are closed, people are dying and we can't do anything to treat this disease. Nevertheless, those in the healthcare community rallied to the cause. That's good to see.

When you go back 1,000 years and follow infectious disease history, you'll see that these things end, so there's hope in that. Whether it's the Spanish flu or the bubonic plague that wiped out half of Europe, these things end. There will be a future and we'll go back to normal. That's the ray of sunshine; we just have to be resilient and tough, and do the best we can. We'll get through it.

Peter J. Taub, MD, MS
Program Director, Division of Plastic and Reconstructive Surgery, Mount Sinai Health System, New York

Mount Sinai officials began to plan its response as the pandemic progressed, with the EDs and ICUs shored-up for the coming surge.

The hospital administration recognized the impending shortage of personnel because the number of COVID patients was increasing. In addition, tents were erected next door in Central Park and the Navy ship Comfort was sent to New York. Our surgery department assembled teams of an attending surgeon, a resident or Fellow, a clinical nurse and a medical assistant to be deployed to areas of need. These teams were used to cover eight hospitals across the system. Each shift was 12 hours for three or four days followed by three days off. We've covered E.R.s, ICUs and COVID-19 units when called for duty.

Early on, we didn't know where we would be deployed, so I waited by the phone for orders. I'm trained in general surgery, so I have a greater variety and depth of experience – including critical care and ventilator management. Not knowing what I would be doing didn't bother me; I knew we could figure it out. But we were a little worried about being protected once we got there. We'd heard there may not be enough protective equipment. Luckily, we've had an adequate supply of PPE at each institution.

In the E.R., we helped admit walk-in patients, deciding what level of care they need. We ordered chest X-rays and EKGs and drew blood if there was no one around to do it. We generally provided some disposition for the conditions diagnosed. In ICU, we would take over for the day team. Overnight, we carefully watched patients' oxygen levels and increased the acuity of care if needed. If they started to drop, we'd switch their mode of oxygen delivery. If they became critical, we'd arrange to have them intubated and transferred to ICU or monitored on our floor as an ICU. We even intubated patients if time was critical.

We're seeing people of all ages – usually sicker than the average – coming in with respiratory distress. It seems that the chest X-ray images are similar: bilateral fluffy infiltrates. Some patients are stable on room air and are able to go home. Sicker patients start with oxygen via a nasal cannula. Some decompensate and need a non-rebreather mask. Those that decompensate further are put on a bi-level positive airway pressue (BIPAP) machine. Those that fail BIPAP are intubated. We weren't in any one place long enough to see patients whom we intubated get extubated, but many have. We have also seen death in every area in which we worked.

I take the stress in stride, but it's a little harder on my family, as I go into a difficult environment, work with COVID-19 patients and then return to an apartment. We have a routine in which I undress in the hallway (note that our neighbors decamped to the suburbs), put a towel on, go straight to the shower and change into clean clothes.

I just wrote a small piece for PRS, with the premise being there are a lot of roles for plastic surgeons in the face of pandemic. Plastic surgeons are very well-trained in what they do, but they also do a lot of things that can be helpful during a pandemic. We're used to surgery, to medical care and to thinking and reacting on the fly and facing situations where the best resources aren't available. Plastic surgeons and our residents are well-adaptable to a pandemic situation.

Amanda Gosman, MD Plastic Surgery Division Chief and Plastic Surgery Residency Program Director, University of California-San Diego School of Medicine
Dr. Gosman's early reaction to the international crisis dealt with efforts to procure PPE, which was in a critical shortage in Tijuana, forcing her to personally order masks from China.

Our response has been relatively well-managed, both in terms of the number of cases and incidents, and in our preparation. It was challenging at first to shift gears, but when the ACS came out with its "stop" recommendation, the academic center at UCSD immediately stopped. We arranged in the surgery department to have a global redeployment plan if we were needed in an emergency and created an inventory of our personnel's skillset. We also instituted a lockdown and organizational-hold mode, where we created a platoon-type system with residents to limit their exposure to keep them safe, and to preserve our workforce. We also limited the number of residents at each institution, which was acceptable, due to the lower clinical volume created through the elimination of elective surgery. We took a somewhat similar approach to our clinic and office staff as well; everybody transitioned very early to working from home.

We were ready for a surge – UCSD has a fairly extensive capacity to provide ICU beds and ventilator support, although that plan evolved rapidly. San Diego was very aggressive in instituting its stay-at-home order, and we've successfully flattened the curve. We haven't experienced a large increase in cases throughout the metropolitan area – most of the cases we're seeing originated in nursing homes, where there are several significant clusters. Although the curve is flat, we're still seeing cases arise – just not in large amounts or rapidly.

We've had somewhere between 20-30 inpatients and about 10 on ventilators in the UCSD health system; in the county, there have been about 222 deaths and about 1,200 hospitalizations, 350 of which are ICU hospitalizations. We hadn't met the lower-curve criteria for decreasing caseloads before we reopened, but it looks like we'll stay at that relatively low-but-steady increase.

Our major concern is what's happening in Tijuana (approximately 20 miles from San Diego): Mexico was very late to embrace a stay-at-home order; their government and president were in denial in the beginning. Tijuana has been huge hotspot, and healthcare workers represent about 50 percent of COVID-19 victims because of the lack of PPE, which has been devastating for their community. Approximately 250,000 U.S. citizens live in Tijuana and work in California on a regular basis – with that cross-border traffic contributing to the largest surge of cases. The southern part of San Diego and the hospitals nearest to the border have seen a steady and significant increase in cases.

Initially, when we began the shutdown and didn't know what the surge would be like, we had a hard time at our hospital in getting N95 masks. We weren't able to get any testing, and we were still doing a lot of high-risk aerosolizing cases, such as facial trauma and aggressive head and neck cancer. I personally bought a shipment of k-N95 masks from China for my plastic surgery division and all of our residents because we didn't have adequate PPE and I was concerned about the protection of our workers. We've shared some supplies with our international partners in Tijuana, but now most of them are shut down.

However, positive developments have arisen that will permanently change healthcare. After creating our resident "platoons," we shifted our focus off traditional resident education. We assigned each resident a quality improvement project, for instance. In addition, for the last few years we've held many "virtual" grand rounds and didactic conferences – and we frequently employ telemedicine internationally. The recent explosion in video-consultation is a great thing for patient care, from eliminating long-distance travel for care or helping those with anxiety who may have a lot of difficulty interacting in person. I believe we've reached a new era in virtual education for medical students and residents, and for patient care.

C. Scott Hultman, MD, MBA
Burn Center Director and Vice Chair of Strategic Planning at Johns Hopkins Medicine, Baltimore

Dr. Hultman was notified that medical personnel at Johns Hopkins would soon redeploy, so he opted to volunteer rather than wait.

The COVID team structure was based on deploying a full staff and creating multiple teams; in case one team got sick, the other team could come in. Teams consisted of one bedside physician for every three patients in the ICUs; one pulmonary "junior intensivist" for running each unit and one attending. The attending would round during the day and offer guidance. As the junior intensivist, I was on a 12-hour shift. We have two shifts: 7 a.m.-7 p.m. and 7 p.m.-7 a.m. We had the bedside intensivist. We had a training period of three-tour days, learning how to care for the patients – then we were on our own. I did three night-shifts, 36 hours and it was hard work.

Contrary to what some might believe, taking care of the patients – the "medicine" – isn't the hardest part of the job. It's the physicality of pushing your body, going without sleep or a break. In addition, wearing PPE is brutal; once the N95 mask is on, you can't take it off. Neither can you breathe very well and your whole face is itchy but you can't scratch it. At the end of the shift, the masks have worn their way into your skin – people we've replaced had pressure injuries on their faces and ulcers from their masks. They had to apply Duoderm because of open sores.

Our PPP isn't standardized. Even though all three face/head protections can effectively decrease or eliminate the viral particles, the PAPR hoods are clearly the best solution – but I was given the N95 mask, as were many others. PAPR hoods not only protect the healthcare provider, they also allow for much better communication between members of the team and are more comfortable – a necessary concern given these long shifts.

Even though I had volunteered, my stomach turned when the email notice of my selection arrived. I remember thinking, "This is real; not only will I get community exposure to the coronavirus, but I'll be in the trenches taking care of patients who are covered in this." My thoughts centered not on myself, but on my family: My wife has a weakened immune system and my mother-in-law is age 87. Fortunately, I developed a system: Change scrubs as soon as I leave the hospital, put on another pair of shoes and get myself clean before I get in the car. At home, I make sure I maintain distance, and I'm completely removed from my mother-in-law. But psychologically, I was very anxious.

One of the saving graces is that we're meeting the surge in most U.S. healthcare systems, probably because we're doing social distancing. There's been a huge hit to our economy, freedom and our lifestyle, but on other hand, we're slowing the rates of infection – so if you do get sick, you can get adequate care at a hospital.

We had about 200 patients admitted to our system; at Johns Hopkins Bayview, we had 18-20 patients. We're now down to 14-16. We hit the surge and things are looking better now.

The "light at the end of the tunnel" is that we've undertaken a massive experiment in behavioral modification in this country, and even though tragedy is all around us, it could've been much worse in terms of deaths. Maryland was expected to run out of ICU beds according to the early models, but we haven't. We adapted and slowed the number of new cases. We've learned so much on how to manage viral infections in populations. This is a great population health experiment – and we can apply the lessons learned to the next pandemic.

David Song, MD, MBA
Plastic Surgery Department Chair, Georgetown University; Physician Executive Director, MedStar Plastic & Reconstructive Surgery, Washington, D.C

The Georgetown health system paused all elective surgeries the week of March 16 and prepared for a surge of COVID-19 patients.

The week of March 23, we split our department and system service line into two teams to staff our clinics/consults, one week on and one week off. I initiated this in order to minimize mass exposure and illness. This proved to be beneficial; we've had several team members contract COVID-19 and were forced to quarantine for two weeks. Splitting our service and moving all educational offerings to virtual online meetings also helped mitigate the spread within our department. This has been the reality since.

Our department started telehealth two years ago, so we were well-prepared for video consults. We moved to only performing essential surgery and transitioned microsurgical DIEP flaps into all tissue expanders as an outpatient procedure after mastectomy early-on, to minimize potential exposure to patients and team members – and to preserve hospital beds for potential COVID-19 patients.

Our department unanimously decided to volunteer to cover the E.R. at Georgetown, as the strategy was to build an emergency triage area for COVID-19 cases and patients under investigation (PUI), where E.D. doctors would staff along with pulmonologists. We were to staff the non-COVID E.R. We trained in the E.D. software (different from our routine EHR) and went through scenarios. There were online refresher courses on how to work-up acute headache, abdominal pain, etc., that we all spent time reviewing online and in virtual meetings.

The plan still remains for us to rotate coverage in the E.D. for these purposes. Fortunately, the strict social distancing and lockdown here in D.C. has worked; although we're seeing 2 to 3 percent daily increases in COVID-19 cases, we've yet to be activated in this role and we believe the plateau is near.

This redeployment is filled with anxiety; I hadn't worked up headaches or even abdominal pain since I was a general surgery resident. Confession: I don't even own a stethoscope anymore (I donated my last stethoscope during my mission trip to the Dominican Republic in 2000). Many of us brushed-up on our ICU skills, as some of our residents may be deployed into the ICUs. The overall motto has been and continues to be one of vigilance and overpreparation with the hope that our services won't be needed.

Gregory Greco, DO
General Surgery Residency Director, Monmouth Medical Center-Robert Wood Johnson Barnabas Health, Long Branch, N.J.

Dr. Greco oversees 26 general surgery residents at two New Jersey hospitals, with one – Newark Beth Israel Medical Center – retrofitted entirely into COVID-19 units.

On March 9, I put our residents on a protected, non-exposure schedule where they had to quarantine at home. No other department had done so, but I felt it was necessary – we needed to protect a portion of the workforce in order to handle the mass infection. All surgery was suspended, except for extremely urgent procedures. Then I put the residents on a five-day-on, five-day-off, 12-hour night-and-day shifts. We rotated the residents; they managed ventilated patients and took care of the critical-care patients by putting in central lines and chest tubes, for example. Three residents became infected, but fortunately, they all recovered.I expected pushback for their schedule suspension, but the week before I'd communicated in depth on this. What helped was that I'm on the ASPS Executive Committee, so I was fully aware that we had cancelled our Spring Meeting because of COVID-19 concerns. We had national minds thinking ahead, and that awareness influenced my decision-making.

The institutions were very good in securing PPE for the residents. There's not an abundance of disposables, but they were never put at risk, thanks to the stockpiling by the health system. They had N95 masks which they re-sterilized per protocol and face shields – full PPE.

One thing residents must understand is the entire team is necessary for an optimal patient outcome. They now understand what we mean when we say that we are not, as physicians, capable of doing this by ourselves.

There's been an emotional toll for all the residents – emotional limits have been tested watching patients who've been well die within hours. When you're surrounded by high-acuity patients, you realize how every decision is critical. The health system has been very appreciative; a lot of emotional and psychological support is available to residents and staff.

I wasn't on the front lines; I was their caretaker if you will, and I felt very paternalistic during this crisis, making sure that they were protected, had PPE and were not going to be harmed while caring for patients. I care about them and I'm concerned; I'm doing this from a "situation room," where I feel helpless. They're truly on that "island," so I support them in every possible way.

I give a tremendous amount of credit to my residents; they performed amazingly well and I tell them that. I saw people who I thought could never perform so admirably exceed expectations. Everybody stepped up their game. I had residents volunteering to go to Newark to relieve their colleagues. It showed their altruism for each other and for their profession.