SPECIAL REPORT: Reacting to virus in key locations across United States

Following on from part one of our June issue special report in which we explored global perspectives on how vascular surgeons were coping with the COVID-19 pandemic in its earliest stages, in part two we hear from specialists in cities dotted around North America.

AMERICAN GROUND ZERO

The realization of the pandemi magnitude was chilling here in Seattle. I remember the eerily similar feeling of being confused as I watched the twin towers on 9/11. There was an initial lack of comprehension, which led to a slow realization that we were under attack.

The first case in the U.S. was reported on Jan. 20 and we thought it was limited to a nursing home. Work proceeded as usual. The last normal I remember was a red eye flight from Seattle to Houston on March 5 in order to present at the Houston Aortic Symposium. It was a quick trip, and I returned that night. The airport in Seattle was eerily devoid of people.

That was the moment when I began to realize the magnitude of what was happening around me. The last elective operation I undertook, a third-time groin dissection and endarterectomy, was on March 10. A series of rapid changes then unfolded: a single visitor policy, screening at hospital entrances and all elective operations canceled. The pandemic led to a national emergency. Telemedicine and zoom conferences became the norm. At some point, I had a sore throat, myalgia and fevers. When the symptoms had abated, I was tested, with a negative result.

By the last week of March, Washington state had over 2,000 cases of COVID-19. During that week of call, I was consumed with rescheduling clinic patients and multiple complex urgent operations, including an infected graft removal, urgent aortic dissection repair and a complicated sarcoma resection.

While these operations were urgent, we were actively thinking of preserving our PPE and resources, worrying that we could deplete what we had. The entire pandemic experience remains surreal to date, including the lack of flour and toilet paper in the stores. For now, we continue to root for our colleagues in the hot zone. And we remain cautiously optimistic we have flattened the curve here in Washington.—Sherene Shalhub, MD, division of vascular surgery, department of surgery, University of Washington

PRIVATE PRACTICE AT US EPICENTER

As a private practice vascular surgeon in Seattle, I work at the multi-specialty clinic downtown, and operate and take call at a 340-bed community hospital nearby. We have an outpatient vascular lab and an outpatient-based lab (OBL) associated with our clinic. Our team of two vascular surgeons collaborates with the vascular group at the hospital. Lots of uncertainty and fear was in the air, as we were the first city in the U.S. affected by this quickly evolving pandemic.

Our hospital started officially limiting elective cases on March 17, seven weeks after the first positive case in Washington state. Prior to that, there was some confusion about what cases were allowed. We submitted operating room (OR) cases for committee approval and received weekly updates on OR status and PPE supplies, but had little information about COVID-19 patient burden.

Since our usual case conferences and meetings had been canceled, I felt somewhat professionally isolated, seeking more guidance and support from the community. We continued to see few patients at the outpatient clinic and transitioned to some telemedicine services. Two of our four vascular labs have remained open for more urgent exams.

We continue to utilize the OBL for thrombosed hemodialysis access and chronic limb-threatening ischemia (CLTI). I have treated some patients who were unable to get procedures done elsewhere due to limited hospital access. Overall, I am humbled and grateful to be a part of a community that is transforming in the face of this new changing reality.—Daiva Nevidomskyte, MD, vascular surgeon, The Polyclinic

ANXIETY IN NYC

March 2020 was the month that New York City and my vascular training ceased to function as normal. The first patient to be affected with COVID-19 in NYC was diagnosed on March 1; the second case followed two days later. The latter case was transferred to Columbia Hospital, initiating a chain of events that drastically altered my vascular training.

During the first week, the hospital suggested delaying elective procedures on patients over the age of 70, or with severe pre-existing conditions, but there was little change in practice as the COVID-19 cases slowly amassed in the medical wards and ICUs.

At the start of the second week, delaying elective cases became a requirement, and we were only treating patients with CLTI, dialysis maintenance and larger aneurysms. Moreover, a bypass patient developed a cough but tested negative for the virus, scaring us enough that only urgent cases were admitted to our service afterward. The rounding teams decreased from 10 people to just four in order to conserve PPE and reduce exposure. We moved all educational conferences online.

At the beginning of the third week, the ICUs were rapidly filling with COVID-19 patients and half of our 32 ORs were converted into ICU beds. The surgery residents became the emergency call team for difficult lines on coronavirus patients. A CLTI patient developed a cough postoperatively and was found to be COVID-19 positive. By then, there were so many staffing shortages in the system that we were told to only quarantine if we became symptomatic.

We began testing every preoperative patient, and all remaining ORs—save three—were converted to ICU beds. Now into the fourth week, we have multi-institutional educational conferences over Zoom, we watch and discuss operative videos, and we wait anxiously for daily updates. We have two patients on service, with only the fellow and a service-shared intern rounding on them.

We make every effort to not admit anyone or to discharge as soon as possible—we are not even carrying out completion amputations after guillotine amputations for septic feet—because the COVID-19 census in the hospital is so great and our vascular patients are so vulnerable. There is a general concern among fellows that our fellowships have been functionally terminated early.—Matthew Smith, MD, division of vascular surgery, Weill Cornell Medicine/New York- Presbyterian Hospital

CAUTIOUS OPTIMISM IN MICHIGAN

From Bay City, I started to see the cases grow exponentially in New York and felt it mandatory to push the pendulum aggressively in mid-Michigan to help flatten the curve. So, prior to our first confirmed case, even before the surgeon general put out his notice to defer elective cases on March 16, I had already implemented a plan to defer all non-urgent referrals in the clinic followed by deferring non-urgent or emergent cases in the OR.

Clinic patients were reviewed for acuity, and the clinics were downsized to a skeleton crew for only urgent referrals including CLTI, symptomatic carotid disease and all AAAs, later revised to just include AAAs over 6–8cm.

There was pushback from the administration as they wanted it to be “business as usual,” but I felt strongly that this clinical decision superseded the business decision, and difficult times require difficult and drastic measures.

Initially, cases were reviewed by the chief of vascular surgery for appropriateness; however, by week two, only emergent cases were allowed. Initial challenges involved explaining to the rest of the staff that this pandemic was in fact real. Hourly- paid staff and techs were worried about their jobs; sharing the science behind the flatten the curve model was crucial.

It was essential to keep everyone informed of the plans, and, as such, changing our behavior was a team effort. The other critical aspect to our new treatment paradigm was to inform the patients that we were not “canceling” their operations, but rather “deferring” or “postponing” their cases until it was safe to operate again. Our initial aggressive approach has been helpful in guiding the other 13 facilities in our healthcare system.

Our prompt decision-making elevated us as the health system flagship. We continue
to be optimistic these efforts helped to curtail the curve and, importantly, save the lives of our community.—Nicolas Mouawad, MD, McLaren Bay Heart and Vascular

PROGRESS BEFORE THE SURGE

A state of emergency was declared on March 10, the same day of the first two confirmed cases of COVID-19. Despite being located over 140 miles from the index case, between March 10–20, in Grand Rapids, Michigan, we became trained in virtual visits, all scheduled cases were reassessed and stratified, with elective cases canceled, satellite offices closed and imaging services significantly curtailed.

Our hospital set aside 10% of bed capacity to accept patients from the Detroit area if needed. We were asked to complete an online critical care refresher course. On March 23, the state governor announced a shelter-in-place order as we watched our colleagues in Detroit, Royal Oak and Ann Arbor report rapidly increasing cases.

We created two separate vascular teams that would rotate, spending seven days in clinical work at the hospital, clinic and covering call. The second group worked from home to prevent a single exposure spreading through the department.

On March 27, one of our integrated vascular residents felt ill and was confirmed COVID-19 positive the next day. Thankfully, he was able to self-quarantine at home and recovered quickly over the next 10 days. Realizing we had many patients who needed vascular lab testing to appropriately stratify them, we launched an in-home vascular testing program for high-risk patients on April 1.

In the first 10 days, more than 30 patients had testing in their homes followed by a virtual visit to discuss the results. Fortunately for us, the national social distancing program, state shelter-at-home order and efforts of our colleagues to educate us— combined with the implementation of our early reduction in cases—appears to be paying off in west Michigan.

We have been seeing a steady number of cases but continue to have adequate PPE, ventilators, and ICU and general beds. Our time to peak surge has been successfully pushed back by weeks, and we have had limited healthcare providers infected at this point. Due to these successful measures, we are now looking to offer surgery to some of our previously postponed patients during this new window prior to the expected surge.—Robert Cuff, MD, division of vascular surgery, Spectrum Health Medical Group

WORKING THROUGH CONFUSION

I returned from vacation in the second week of March to a packed schedule over the three proceeding weeks, with a large CLTI patient load. Reading about the case numbers on each coast created a lot of anxiety but workflow remained normal until March 18, which was the day the first COVID-19 patient tested positive in St. Louis.

There was a lot of confusion and no affirmative government action at first. I packed all the important cases left on the schedule into 7- to 10-day span and decided to cut back significantly on case volume and clinical work at this time. The following week, we had a citywide, stay-at-home order; we started to see PPE was in short supply; there was a lot of concern for our own safety; telemedicine was an emerging uncharted concept; and a couple of surgeons got infected.

Testing became more widespread, we pulled our resources from two sister hospitals and adjusted our trainee schedules to protect them. For attendings, we were down a few providers, as some of us were benched or quarantined. We have been taking call once a week, but our case volume is two to three cases per day compared to our baseline of eight to nine fully-packed rooms running daily for 11 surgeons. Now we await the surge, prepare to be redeployed, or contribute in any way possible.—Vipul Khetarpaul, MD, division of vascular surgery, department of surgery, Washington University in St. Louis

SPARKING GROWTH

On March 13, four days after the first COVID-19 case in our hospital in Evanston, Illinois, and six weeks after the first case in the state, our chair here called an emergency meeting as the pandemic started to blossom. A dozen conference calls later, there were guidelines on restrictive surgery, including the cancellation of elective surgeries and clinic reorganizations.

A cardiology colleague with whom we worked closely came down with the virus, prompting immediate decontamination of the office. All my partners volunteered for the physician labor pool in case of overwhelming need. Then came the second week. I felt a bit sick, and quarantined myself in a hotel for two days. My only symptom was fatigue—no fever and no cough—so I returned home.

We preemptively canceled cases through May, and I had to talk partners and office staff off the ledge as they were anxious about losing their jobs and being redeployed into the “fire.” I performed a complex oncologic resection case that week, along with urgent revascularizations and my last vein case for a good while.

Saturday, March 21, Illinois declared shelter in place. I was on call that week and noticed a steady increase in COVID-19 patients. There were multiple emergencies—a devastating aortic arch dissection, limb and mesenteric thrombosis, and several intraoperative arterial injuries.

By the fourth week, we had reduced our clinic to just one provider per week. I enjoyed the change of pace, doing WhatsApp and FaceTime clinic visits, though they were more laborious than in-person equivalents. I have been trying to stay positive, and now spend quality time with family, attending family gatherings via Zoom. I am also trying to look ahead to divisional growth at the conclusion of this pandemic with regards to recruitment, incoming fellows and research funding.—Cheong Jun Lee, MD, division of vascular surgery, Northshore University Health Systems

FLATTENING THE CURVE IN TEXAS

In Houston, the effects of the pandemic became clear on March 4, the week of the Houston Aortic Symposium. We had participants from all over the world, except from coronavirus-affected countries like Italy and China. A couple of days later, our institution issued a ban on travel.

As a division and an institution, we started reducing our clinic visits, determining emergent surgeries and adjusting call schedules to protect our patients and ourselves. I took the first week of call; no elective cases were performed but emergent cases did not stop.

That week I had two ruptured infrarenal aortic aneurysms, one submassive pulmonary embolism (PE), a few infected arteriovenous grafts and CLTI cases. During that week, I did not have much time to catch up on local news, and barely had time between operations to eat, sleep and finish paperwork. On top of this busy schedule, I learned my brother was ill with suspected COVID-19. Eventually, he tested negative and recovered quickly, but it was unsettling being thousands of miles away, worrying about him, his family and my parents.

Week three started, and I was mostly working from home. A stay-at-home order was issued, and the models started predicting a surge in Houston in mid-April. It sunk in that this may be the reality for the coming few months, so we started planning out our educational conferences and meetings for the next few months.

Week four, I operated on a couple of urgent outpatients and finished telehealth training. For now, I am playing my part to flatten the curve and prepare for the surge in Houston as it comes.—Rana Afifi, MD, department of cardiothoracic and vascular surgery, McGovern Medical School at The University of Texas Health Science Center at Houston

LOW NUMBERS IN THE HEARTLAND

In the middle of the country, Oklahoma has had an interesting run-in with COVID-19. Week one of the pandemic we watched the world get taken by surprise. China. Japan. Italy. But nothing to report here. By week two, New York starts to get hit hard. Still not much going on here in Oklahoma.

However, my partners and I start to notice an odd increase in large clinically significant PE consults from the ICUs. We were business-as-usual until recommendations from the surgeon general and the American College of Surgeons were announced regarding the cessation of elective surgery.

That same March 21, we had our first case at our hospital in Tulsa: a young medical professional who deteriorated quickly, requiring ECMO. Now COVID-19 had hit close to home, and alarms began to ring throughout the medical community in the area. Our group decided to cancel all non-urgent cases on the Sunday night—hours before the work week began.

Outside of a few suspected patients who had traveled to Italy, things were noticeably quiet in town. We contacted the other vascular surgeons locally and made a unanimous decision to hold off on elective surgery, despite the low numbers. It was evident we were several weeks behind others, so we prepared for an enemy that had not yet arrived.

Several more cases were admitted to our hospital in week three. As vascular surgeons, we did inpatient procedures and emergencies but for the most part we left early and waited. Week four, we entered a COVID-19 surge. Case numbers were now drastically higher in the state, along with hospitalizations.

Our first coronavirus consult was a cold limb on ECMO. Several COVID-19 ECMO cannulations followed. But, again, at this point we were not yet a New York or New Orleans. My family all became sick with flu-like symptoms. As they recovered, I became ill. I then received an email informing me that a patient on whom I did a PE embolectomy two weeks prior was COVID-19 positive. As I write, I am to be tested tomorrow, so we will see what happens.—Adel Barkat, MD, Oklahoma Heart Institute

ACCLIMATING IN COLORADO

The first person in Colorado to test positive for COVID-19 came on March 4. I did an angiogram and ray amputation that Friday, and we had friends over for dinner. Life felt normal in Aurora. The first week, we held fellowship interviews, regular clinic and Journal Club, I with an article about the importance of social distancing. Then we saw the first COVID-19 patient at our hospital, and, by the next day, all the healthcare workers were wearing masks.

Two days later, we had postponed all elective operations. The second week my daughter had a cough and a fever to 103. I performed a toe amputation on a patient with dry gangrene following revascularization the week before. I postponed an arteriovenous fistula creation as elective. Luckily, my daughter started feeling better as I balanced call and worked from home with my wife and three kids.

About half my clinic patients canceled, especially the elderly and those in assisted living facilities, and I had my first virtual clinic. On the third week, a stay-at-home order was issued. It has been a whirlwind 30 days since the first person tested positive in Colorado. I look back at that dinner with friends, and it seems like an eon ago. It has been challenging to stay up to date with information given the speed at which the pandemic spreads. Another challenge has been finding ways to overcome the isolation that comes with physical distancing.—Max Wohlauer, MD, division of vascular surgery, department of surgery, University of Colorado School of Medicine

CONFLICT IN CALIFORNIA

California declared a state of emergency March 4 and shelter-in-place by county March 16. By March 19, the order was statewide. As a private practice vascular surgeon at a community, non-teaching hospital in Burlingame, near San Francisco, our awareness of the coronavirus epidemic was initially one more of empathy and wariness, watching what was unfolding in China and knowing we were on the “near coast.”

After the cluster outbreak in Washington state, the hospital began screening patients upon arrival. When I proposed screening patients at our office, my partner disagreed, not wanting to “scare patients away.” Less than a week later, the shelter-in-place order came down and, just a few days after that, my partner agreed to a screening protocol for our patients and staff.

The conflict in a small private practice between patient and staff safety, and financial stability and viability, has continued to be a struggle as the weeks have slowly passed. While elective cases were stopped early at the hospital, my partner continued to do cases at our OBL for “critical” disease, though I had decided to postpone my cases. Witnessing the crisis flare out of control elsewhere but from the relative quiet of California, I feel guilt and helplessness.

Hearing about struggles with central access and ECMO on group chats, I reached out to the critical care and cardiology groups at the hospital and offered to help. To my surprise and dismay, there was no organized plan. Despite multiple emails daily, true information transparency and logistical support have been sore points between medical staff and hospital administration.

During week three, I realized how much I missed interacting with colleagues at the hospital. Without the socializing typically done between cases or at lunch, I found limited interpersonal crossover for a physician who is not hospital-based. Social contact is still a fundamental part of the human psyche—enough that even as an admitted introvert I found myself looking forward to being on call.

Now, almost at week four since shelter-in-place, the irony of hand-sewn face masks and civilian N95s juxtaposed with rationed surgical masks has become the norm. Before, I had never disinfected my desk, phone or keys, and now I do it at least once daily. Our office and vascular lab run an abbreviated schedule.

Worries about being able to pay the bills are a constant presence in a not-so-small corner of my brain. While right now I feel undeservedly lucky our area has mostly avoided the first wave of disease, I know that the concerns of this last month will continue, and that our risk remains looming and real.—Stephanie Lin, MD, Bay Area Vein and Vascular Center

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