The Emotional Journey of COVID-19: An Interview with Dr. Jonathan Whiteson
In this issue, we talked to Dr. Jonathan Whiteson of Rusk Rehabilitation in New York, NY. Dr. Whiteson has been working on the frontlines during the pandemic, helping to reshape his department, and educate others on Rusk's learnings through this time, as is their mission. The following article is based on his experience as of late July 2020.
Jonathan Whiteson, MD, FAAPMR
Vice Chair, Clinical Operations
Medical Director, Cardiac and Pulmonary Rehabilitation
I don't think anyone across our country can say that COVID-19 hasn't affected them. It's brought a rollercoaster of emotions and the ride hasn't ended yet. Personally, as physicians, we've had to worry about our own health and that of our families; professionally, we've worried about the health and well-being of our patients. Not only are we concerned about our existing patients, but also our new patients coming through due to COVID-19 and access to future patients who need us.
And of course, we worry about the health care system. Can it survive? Can rehabilitation medicine survive? How do we evolve through this time and learn lessons or take lessons from prior disasters and know how to respond?
I'm going to take you back to essentially the beginning of March when things started to take off here in New York with sporadic cases. We had a sense that we were going to be, along with California, the hotspot but we had no idea what was going to come in the middle of March, when the caseloads started to take off and lockdown orders were put in place. Everyone had to shift into high gear in terms of how we functioned, personally and professionally, and how we coordinated and structured our department. It was exhilarating, terrifying, and satisfying all at the same time.
I still think back on it with some degree of shock, but it was not a paralysis. On the contrary, it mobilized us. We became so efficient and fluid by need, necessity, dedication, and adrenaline.
We weren't used to working at that breakneck speed and in that kind of way — with the type of background fear and concern for our own safety and our patients' safety. At that time there were no orders for masks in public, no precedents, and a lack of PPE, so we were sort of walking blind.
Adding to that, it reached a point very rapidly where whatever you were thinking, your thoughts were no longer valid by the time you spoke them. What was true and relevant in the morning, was old news and irrelevant in the afternoon. When before has the practice of medicine changed at such break-neck speed? For our department, we instituted daily discussions where we would cover all the changes we were seeing. It was non-stop communication and I think that was the key to our ability to adapt and morph from the pre-COVID-19 era to the COVID-19 era and take care of our patients.
It was emotionally very challenging yet motivating because we went into rehabilitation to honor individuals with disabilities. Honor them with our dedication, our expertise, and our commitment to enhance their lives and level the playing field. That sense of service overcame our sense of self-preservation or fear for ourselves or our families. That's why we were able to respond as the number of cases rose exponentially.
For example, very quickly we started to notice that there were patients who were becoming COVID-19 positive on one of our inpatient rehabilitation floors and no matter how hard we tried to transfer those patients off and reduce the spread, we weren't able to succeed.
This facilitated the creation of COVID-19 positive and COVID-19 negative units. We created criteria for admission for our COVID-19 negative-never-positive unit and worked to ensure that it remained that way by coming up with a set of criteria for monitoring patients on the inpatient rehabilitation unit. This criteria indicated deterioration and therefore transfer back, and also signified safety for discharge home, which all related to the COVID-19 pathology we were learning about.
Against all odds, one of our COVID-19 negative units remained so throughout the surge of the pandemic, ensuring that our rehabilitation and transplant patients were safe.
COVID-19 has further proven the value of physiatry. Physiatrists have always been the best physicians and the best team for the recovery phase because we see the whole person. We don't just treat the broken leg or the injured spinal cord or the damaged brain. And this disease impacts the whole person as we've discovered. COVID-19 affects every single organ system and there's only one specialty that deals with every single organ system. We may have a specialty in spinal cord or brain injury, but we are skilled in the multi-disciplinary approach to the management of patients. We understand the physical, functional, medical, emotional, and cognitive — what it takes to make a whole person. And that's our passion.
There is no physician and no training program that provides our perspective better than physiatrists. And the value of physiatry is not just to the individual patient, but it's to the health care system in general. We know that the sooner rehab services are involved in patients, the patient's trajectory changes in a positive way, and that has great impact on the Triple Aim.
Telehealth is a boost to our field as we face this new normal. Having continuous access to patients is critical. Telehealth opens access to patients that we didn't have before, whether because of limitations due to location or a patient's inability to physically get to us.
One of the missions here at Rusk is education. We feel there's no point in just educating ourselves, we want to share that education and we want the same back from our colleagues. We want to learn from them. Great research is only great if it's shared and published and great learning is only impactful and helpful if it's shared with others. We've been fortunate enough to spread the word on what we are doing through podcasts, webinar series, and short soundbites.
COVID-19 is devastating, there's no minimizing that. But as a specialty, this is an opportunity to learn, evolve, build new programs and to recognize different approaches to care. Out of the ashes the phoenix rises.
Hitting the Pavement During COVID-19: An Interview with Dr. Michele Arnold
In this issue, we talked to Dr. Michele Arnold from Swedish Spine Sports and Musculoskeletal Medicine Center in Seattle, WA. Dr. Arnold volunteered to work in mobile testing units on the streets of Seattle when COVID-19 hit. The following article is based on her experience as of late July 2020.
Michele Arnold, MD, FAAPMR
Chief Medical Officer
Swedish Spine Sports and Musculoskeletal Medicine
When COVID-19 hit in March, there were countless changes happening in our institution. When leadership started discussions about various redeployment opportunities, I assumed (having some limited experience with ventilators) I would be in the ICU helping manage ventilator-dependent patients, or that I would be in the hospital. I never expected I would be spending two months on the streets of Seattle serving people in transitional housing and homless shelters, swabbing patient noses. And yet, it turned out to be the most impactful experience of my 18-year career. For the short-term, I turned in my "physiatrist hat" for a "COVID-19 physician hat," and dove right in.
We developed what are known as Community Response Clinics (CRCs) at several campuses throughout the greater Seattle area. Our set-up included a triage team stationed in a mobile trailer in our parking lot, where people could simply drive up and be screened for COVID-19. The triage team would then radio down to the underground parking garage where we stationed tents and staff for drive-through testing. This worked great for these communities, but we realized we were not reaching our most marginalized and vulnerable populations.
We chose to leave the building and hit the streets. We repurposed a mammogram unit into a mobile testing office, which gave us the chance to go out into at-risk communities. We functioned as a pressure release valve for our emergency departments and this provided a means to offer greater education efforts. A typical day consisted of pre-clinic planning followed by field clinic assembly, clinic operations, and the subsequent tear-down and disinfection. We would then follow-up afterward with results. Over the course of a clinic day, our team of about 15-20 people would typically see about 50-100 patients. Between March and May 2020, we conducted more than a thousand patient screenings with around 700 tests. In the two-month timeframe, we reached 25 different sites throughout the greater Puget Sound area, primarily targeting homeless shelters and transitional housing as well as cultural centers. In hindsight, mobile testing units identified 60% of the COVID-19 positive cases found in our homeless population. None of this would have been possible without our teams.
This is where PM&R truly shines. We work in teams extraordinarily well. We know how to build a team, connect cross-functionally, and keep the power differential low. Whether good or bad, shared suffering brings people together. We experience this on our inpatient rehab units, but I think we miss out on this culture in our clinics. With COVID-19, we ultimately grew more than a team — we grew a family — bonding with one another around the common resilience to withstand the adverse conditions we were working in. The beauty and the glory of the opportunity far outweighed any of the challenges we faced.
In a normal ambulatory practice, focusing on production expectations and seeing patient after patient can lead to feeling like we're on the treadmill. In the clinic, it is easy to lose sight that we're on a team. My next goal is to recreate that same feeling of camaraderie, that same culture that we were able to develop in the CRCs, and plant that in my own clinic.
My final takeway that I want to share with you is this: Don't be afraid to look for and lean into opportunities. We're proud of being physiatrists. We love our specialty and will defend it to the ends of the Earth. But we don't know everything. No one in my residency program taught me how to do health screenings for an infectious disease on a busy city sidewalk during a pandemic (that's not a typical rotation in your PM&R residency!). We must be willing and open to meet the challenges of new opportunities that COVID-19 is presenting to us. I am a firm believer in that if you are being called to do something revolutionary, you're going to be equipped.
From PM&R Consults and EMGs to Treating COVID-19 Patients: An Interview with Dr. Carla Watson
During these challenging times, we continue to be inspired by the work you do as physiatrists. You are sharing your stories with us, of working in your communities, helping treat COVID-19 patients, innovative ideas you have started, and more. We’re speaking with a variety of AAPM&R members who are making a difference in our specialty so that we can share their stories with you. Look for additional stories from your peers in future issues of The Physiatrist and our other communications.
In this issue, we talked to Dr. Carla Watson of the OSF Little Company of Mary Medical Center in Evergreen Park, IL. Dr. Watson made a big transition when COVID-19 hit and directly treated patients that tested positive. The following article is based on her experience as of late June 2020.
Carla Watson, MD, FAAPMR
OSF Little Company of Mary Medical Center
As a board-certified physiatrist within the OSF Little Company of Mary Medical Center in Evergreen Park, IL, I wear several hats on a day-to-day basis. 50% of my time is spent doing clinical work, which usually involves in-patient consults for anyone needing to have a rehabilitation consult as well as outpatient EMGs and nerve studies. The other 50% deals mostly with case management in terms of discharge planning of difficult cases, utilization reviews, length of stays, and more.
As COVID-19 swept through the state of Illinois, our number of cases accelerated daily. The Chicago zip code we serve was labeled a “hotspot.” Our daily goals changed from seeing patients to securing the hospital as ICU and PCU wards overflowed with COVID-19 positive patients.
Instead of performing EMGs, my focus shifted to evaluating patients with COVID who potentially qualified from in home monitoring to create available beds which were scarce. A lack of PPE and the need to limit access to patients, meant coming up with a plan to restructure how we performed our duties.
We even restructured how our practitioners entered the building in order to decrease contact and flow of people entering the hospital.
Naturally, there was a pause in the need for inpatient rehabilitation consults. Our referring IRFs and SNFs weren’t yet prepared to accept COVID-19 patients early on. There were no guidelines on how to proceed. As an advisor to case management, our big issue was where to send these patients that needed to transition out of acute care but could not go home.
Collaborating with the SNFs, we were able to help develop rules, regulations, and guidelines with the state to say, “Okay, if you do this, this is how you would be able to safely accept the patient.” While this has helped, it’s still an ongoing process to direct people to care and get them access to care. The care that we, as physiatrists, are seeing develop before our very eyes.
In PM&R, usually by the time they get to us, we have a fairly clear rehab diagnosis, whether it’s stroke, amputation, TBI, etc. We have enough experience and data on just how hard to push these patients for desired outcomes.
With COVID-19, we’ve had to take a more cautious approach. Patients could take three steps forward only to take another five steps back.
At OSF Little Company of Mary Medical Center, the majority of COVID-19 patients were too sick for rehab. We saw two extremes: those who were on and off the ventilator fighting for their lives and those who were really sick but needed to move a little bit. For the latter, it was about finding a balance of how much we push them to move safely.
The scary element of it all was that we didn’t know.
As physiatrists, we need to get a handle on long-term effects of this disease. At this point we have some recommendations for early recovery stages but have yet to discover what late recovery truly looks like.
Although it is definitely a challenge, it provides us with an opportunity because people do not know what is needed. It’s an opportunity for us to say, “You need us!” Once you get a patient to this level, you need to be able to transition someone’s care to those who can coordinate care with those who treated them initially, such as the pulmonologist or the infectious disease doctors. People underestimate the value in that and the amount of care.
Physiatrists are uniquely specialized to be the best-suited clinicians in treating patients in COVID-19 recovery because this is what we do. Physiatrists restore function to life.
We truly look at our patients, not just their physical being, but also their emotional well-being. Their life after rehab. What we’re seeing now is that once people have recovered from the acute infection, there are some lingering effects. This has primarily been anxiety and its related symptoms, such as sleep disorders and panic attacks. Also, addressing the various skin effects associated with the disease and caused by immobility with prolonged mechanical ventilation. Those are the things we treat innately and that we pay attention to.
So, what can we do moving forward? We need to advocate for people to be tested. As more testing becomes available, we need to inform not just our patients, but our loved ones. A way to limit spread is by being more knowledgeable about our own status.
Finally, you need to be protective of the people around you, whether you’ve had the disease or not. I think everyone needs to recognize that although being in close contact with other humans, and especially our family members, is what we crave, we have to recognize that in loving them in too close contact, in this climate, we could literally be loving them to sickness.