First Katrina, Now COVID19: The Louisiana State University Perspective
Louisiana has famously weathered many storms. The psyche of the city of New Orleans, in particular, was forever altered by Hurricane Katrina. We learned that the impossible can happen and that the seemingly impossible—recovery—can happen as well.
A new storm has arrived and those at the Louisiana State University Health Sciences Center (LSUHSC) are doing their utmost to ensure that the city and state will recover from this new and disquieting crisis. OSN is talking with LSU orthopedic surgeons weekly in order to shed light on the evolving situation.
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 is an odd time distortion happening. While it feels like we have been dealing with COVID19 for a long time, in fact it has only been a short while. During the Mardi Gras period, roughly February 18 or so, I had no impression that this was going to be a problem for us. Then as things began to heat up in Seattle. It hit home for me when the mayor of New Orleans cancelled St. Patrick's Day parades and began to break up unsanctioned gatherings. It was evident that people were not taking the disease seriously. Note that New Orleans did invent the hurricane party. Cancelling these things was the 100% right move, but some would say that banning social gatherings took away our coping strategy.”
“I feel a very similar vibe to that of Katrina…except that was a finite event and, in a way, the bad occurrence happened all at once. Here the unknown is lurking, and we have no idea when it will go away.”
A surgeon, educator, and researcher, Dr. Zura is continuing to fulfill all three roles during this onerous time period. “You could say that my overarching responsibility is to build out the orthopedic infrastructure of Louisiana. That means that at this point I must be hyperfocused on the health and well-being of my faculty, residents, and staff. Our residents are likely most at risk, and they are young people who are not getting paid very much. I am thinking about their safety and the safety of their families. To address this situation, we have split them into teams in order to limit their exposure and to preserve a ‘bank' of other residents if some were to fall ill.”
“We are approaching the point where individuals from varying specialties can be reassigned as needed. Thus, we have developed new ICU teams to meet that patient demand. Most of our residents will possibly cover ED to allow other residents to cover ICU. But I have some very brave residents volunteer for ICU service as well. I'm incredibly proud of every single member of our team from staff to residents to faculty."
“We are still open for urgent orthopedic care and are covering five facilities in New Orleans, Baton Rouge and Lafayette. As for which residents were selected for the ICU teams, we have chosen six people by year and by our current needs. Fortunately, no one is a rookie in April.”
As for the overall picture, Dr. Zura states, “We really don't have the epidemiological data that we need. It is unclear how exactly those in Washington, D.C. are making predictions. I don't trust the models…and we don't fully understand this disease.”
On a slightly positive note, Dr. Zura adds, “The trend at University Medical Center (UMC), our community hospital that is the region's only Level 1 Trauma Center, is a bit positive as the percentage of inpatients has gone down somewhat. Perhaps we are nearing the peak.”
Peter William D'Amore, M.D. is a third-year orthopedic resident at LSUHSC who has been taking call at the UMC emergency department and has seen potential COVID patients in the last few days. “When the mayor of New Orleans cancelled the St. Patrick's Day parades and told everyone to stay home, I had a wakeup call. People didn't comprehend what was happening, they weren't seeing what we were beginning to see. It is hard to understand the gravity of this pandemic until it affects you or a loved one.”
“Starting the week of March 22, we tried to operate as much as possible, but all that changed pretty fast. We went from a normal situation where we were running all 22 ORs, down to four ORs, and then just down to just two. This was in large part because there was a concern about the potential need for ventilators. When I first walked into the ED on call it was a wall of blue, i.e., blue gowns were hung up everywhere so as to be reused for a single patient. I was hard pressed to find a patient who was not on contact precautions.”
“At this point I think we are probably one to two weeks behind New York. I saw a press release saying that Louisiana was even considering the advancement of medical licensure so as to meet the medical need.
“I will say in my brief visual assessments walking through the emergency department, that most of the people I have seen who are getting infected appear to be unhealthy to begin with. I have not seen the 25-35-year-olds who run marathons being affected. However, there are always outliers. For example, I have a friend in Denver, a medicine resident, whose 29-year-old colleague was about to be intubated due to coronavirus.”
“My biggest concern at this point is that we are not taking enough precautions for healthcare workers. A University of Nebraska study found than infected patients can spreads the virus everywhere in a room—on the TV's, curtains, windows, etc. Countries such as South Korea and Singapore are essentially wearing hazmat suits when they treat these patients. I only have a gown, gloves and a respirator.
Stating that we are having to deal with the “ugly side of medicine” as never before, Dr. D'Amore says, “Hospitals are even at the point of discussing issues like, ‘If a patient is so sick that they are not going to recover and require a ventilator…and you have a younger, healthier person that requires a ventilator, ethically who should the ventilator be allocated to?'”
“You know, we wake up and see clear blue skies and life looks normal. We are used to hurricanes here. What no one is seeing are the people gasping for air or an ICU with every patient on a ventilator. We don't have a particular face to attach to this crisis…even the 3D rendering of what this virus looks like—the almost cute circular virus image—isn't reflective of the seriousness of this situation. People need and deserve to understand the gravity of what is happening.”
Vinod Dasa, M.D. is Associate Professor of Clinical Orthopaedics and Director of Research at LSU Health Sciences Center. He states, “Two weeks ago, we began taking cues from Seattle. As they were shutting down those dynamics reverberated across the U.S. It was about that time I noticed our rates were going up whereas the rates in the rest of the country were not. It was beginning to be apparent that this would go beyond being a critical care issue and would impact the broader healthcare system. That was at the end of February to the beginning of March. In mid-March Seattle was overwhelmed and began questioning their ability to handle nonemergent patients in addition to those with COVID19.”
“At this point I have yet to directly treat any COVID19 patients. My biggest short-term concern is public health and safety. In the midterm it is the hospitals and the safety of all of health care workers. In the long-term it is the system itself. We are seeing a lot of progressive thinking, i.e., what types of things do we have to do to set the stage to create a more resilient health care system?”
“When social distancing goes away, I think the ICUs won't necessarily be overrun, but they might be at 90% capacity. This will burden us for months so we will have to negotiate this new landscape. Part of this will be determining how to reduce exposure to pathogens overall. Implants and instruments typically move from hospital to hospital, for example. Do we want to maintain this logistics model? will device reps move from hospital to hospital and potentially be exposed or expose others to the virus? ”
“Sterile processing departments, often an overlooked and underappreciated part of a hospital, are going to be one place where resiliency is vital. I am also concerned about competence in the OR. If staff members have not done surgery in two months, will they struggle? And specialties will be competing for OR time. Maybe we will find that ASCs are the relief valve—if they have not gone bankrupt.”
Michael Hartman, M.D. is Associate Professor and Residency Program Director at LSUHSC.
He says, “Things are rather dire for residents. The first thing we did was to take a team approach for clinical duties. We have set it up so that each one of our clinical sites has a resident off duty and one on duty. At UMC we have trauma teams, so we have four on/four off so that we have a backup team. Trauma has slowed down, fortunately. That is good news as far as helping us to conserve PPE.”
“What makes it hard as residency director is that I have no control over hospital policies. Our residents serve eight different sites, so they are at the mercy of each hospital. As it stands now, it seems that most hospitals are able to meet the PPE demand—but I think that is rapidly deteriorating. When I saw things were heating up, so to speak, I was able to secure additional PPE for residents in case they had none.”
“I will admit that I thought some of the initial precautionary moves being made were an overreaction. Then I started to ask residents if they were seeing patients with respiratory problems. When they started saying ‘yes' I began to pay attention.”
Andrew King, M.D. is Professor of Orthopaedic Surgery and the G. Dean MacEwen Chair in Orthopaedics. Dr. King: “I saw this coming fairly early on because I could tell this was going to be an international pandemic. I knew our area would play it down a little. On the personal side, we had a 250-person wedding for our daughter on February 29 and had a number of people fly in from New Zealand. Despite the 14-hour flying time, none of our international guests have contracted the disease.”
But Dr. King and his wife were not quite so fortunate.
“While I have not seen any COVID19 patients, my wife and I started feeling poorly around March 20. She was feverish and had chills, so we went to get her tested. The next day I got tested. Touro sent both my wife's specimen and my own to a private lab based in California. I got my result after a week (positive), but my wife's is still in process in its 15th day! We have assumed she is positive and have quarantined in our home.”
But they have not been waiting around…
“Her temperature was very high, so I phoned her internal medicine doctor at LSU and someone said that the clinic was closed…there wasn't even any healthcare provider onsite. My wife's temperature came down and we were advised by a virologist to give her hydroxychloroquine if she continued to have symptoms. All of the local pharmacies were out, but I procured some from another source.”
“My wife is improving…I can tell because her sarcasm has returned.
And his overarching concern? “It goes beyond medical,” says Dr. King. “How will this country not be severely discombobulated by all of this? For example, what if the medical school runs out of funds and we have to let go of a lot of employees? Each of those people pays rent, a car note, etc. I think there will be a big lag phase when it comes to bouncing back…and there will have to be a lot of preemptive money poured into getting us back on our feet.”
Asked what he thought when he got word of the first case in Louisiana, Dr. King said, “You know, the lifestyle that the Italians and the Spanish lead—gregarious, big family dinners, etc. I thought, ‘If any place in the U.S. replicates that lifestyle then it is Louisiana.”
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. “This has all been quite a surprise. Years ago, we saw SARS and MERS brewing in China and Saudi Arabia, but they never made it here. It didn't dawn on me until about a week ago that this was going to explode here in Louisiana.”
“On March 20 we began cutting back on our OR schedule. The ORs normally run about 16 rooms plus one reserved for trauma; on the 23rd we were told that we would go to 4 plus 1 trauma room. We had heard rumblings during the week about East Coast hospitals canceling all elective surgeries. On March 16 I canceled my elective surgery, but I did continue to do acute fractures and emergency cases. One patient emailed me around March 17 and asked me about his upcoming surgery. We had just received a directive from UMC to move elective surgeries and he asked if this would affect his April 1 surgery. I had to tell him, ‘Probably so.'”
Asked about what he can do these days, Dr. Krause notes, “. Last week I did several trauma surgeries and since we found an additional team, we had 5 rooms plus one trauma room. I even did a trauma case on Sunday because the patient was in the hospital and I was afraid that if I waited, then I wouldn't be able to get him on the schedule.”
“There are definite echoes of Katrina in the air. We didn't think she was going to hit us, and she did…and we didn't think that this would hit us either…until it did.”
Paul Phillips IV, M.D. is Assistant Professor of Clinical Orthopedics at LSUHSC. “About a week after Mardi Gras it was evident that something odd was going on. There was an uptick in media attention and then once mid-March hit there was a substantial change in our day to day functioning when the surgeon general recommended that all elective cases be cancelled.”
“The only patient I have seen in person was a postop appointment. The gentleman thought that his shoulder had become dislocated. He was screened for fever when he entered the building and then the front desk staff screened him, and then our nurse screened him. However, I have had contact with some of my operative patients who subsequently tested positive for COVID19.”
“I have heard from colleagues across the U.S. that while specialty surgeons are at a standstill, general surgeons are being pulled into ICUs because they are trained in intensive care management.”
“I am supremely concerned about the hospitals being overwhelmed by patients. We would be able to manage provider shortages by shuffling people around, but you can't shuffle space around. The real question is, ‘If that happens, would a patient be sent from this 110-bed facility to another hospital, or would they be sent to ancillary centers like nursing homes or short/long term care facilities?”
Daniel Plessl, M.D. is the chief resident at UMC. “I've been at UMC the past three months and have just headed to Baton Rouge for my next rotation. When the national sporting events started getting canceled, I really started paying attention. The reality of Washington state sunk in and then everything just started to rapidly change.”
“UMC has limited the number of entrances to two and is not allowing any visitors. All staff are temperature screened upon entry. The PPE shortage is widespread; all medical students were sent home a couple of weeks ago. When we do perform surgery, we are only using one resident and one attending in order to conserve PPE. We have been instructed to reuse N95 masks, which is essentially off label. There have been emails flying around about how to sterilize them, some saying to spray them with Lysol and others saying to heat them in the oven above 137 degrees to kill the virus. We have not had to take these measures as we in orthopedics are not—as of yet—seeing these patients daily.”
“It is possible that our junior residents are being exposed because they are in the ER more and are sometimes on the floors seeing patients. One intern I know of consulted on a COVID10-positive patient and tried to get an N95 mask from the nursing station—and was told they were not necessary for that patient. You can imagine the angst.”
“At this point even if we have been exposed to someone with COVID19 we are expected to work. I do think it is necessary because at this point almost all of us have been exposed to the virus. Apparently, I was in a room with a COVID19 patient and didn't know. I got an email telling me so 16 days later.”
“UMC is building rooms to host new ICU beds. Before all this there were two main ICU floors; now they are building a third, thus expanding it by about 30-50 beds.”
And Dr. Plessl's primary concern? “The health of my family…my wife is a family medicine doctor and sees patients with respiratory illness.”
Cristina Terhoeve, M.D. is a third year orthopaedic surgery resident at LSUHSC. She says, “From January to March I was at a hospital in Lafayette, which is much smaller than UMC. I was in my last two weeks of rotation when the COVID19 situation began to heat up. I went on vacation and was getting texts from one orthopedic resident and two general surgery residents with fevers. The administration of that hospital panicked and sent the New Orleans residents home. When I got back from vacation the Lafayette hospital said, ‘OK, now we have a COVID19 patient so you can come back.'”
“I was shocked to see that of the 25 patients in the ER the other day, 17 of them were for suspected COVID19. I didn't realize it was going to be like that and I only had a surgical mask; on the way home I picked up an N95.”
“If a stage three pandemic is called, then they will start pulling residents from all different specialties. I will be one of them.”
Dr.Terhoeve's primary concern? “I'm not so concerned about myself. I am in my 20s and in good health. I am more concerned about passing it on to other people. I live in a condo complex with a lot of elderly people…I make sure to use hand sanitizer before I press any elevator buttons.”
Please stay tuned for next week when we learn how LSU continues to evolve its response to COVID19.