Reconstructing a Knee One Day, Working on COVID-19 the Next

Laird Harrison

May 28, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

When New York Governor Andrew Cuomo called for licensed healthcare workers to help hospitals overwhelmed with COVID-19 patients, orthopedic surgeon Haydée Brown, MD, answered his appeal.

Brown volunteered, as part of the New York City Medical Reserve Corps, at Lincoln Hospital, which is located in one of the poorest parts of the city. She soon found herself filling in for physicians inundated in the emergency department, evaluating COVID-19 patients, prescribing labs, x-rays, and treatments. "It was harrowing," she said.

"The system was overwhelmed," Brown told Medscape Medical News. Sometimes it was difficult just to make sure patients got the x-rays and oxygen they needed. And when the condition of a patient rapidly worsened, there was often little she could do to help.

"One driver from a car-share service walked in talking normally," she said, and 6 hours later, "he was on a ventilator."

This experience was new to her because in orthopedics, Brown was accustomed to solving the problems of most of her patients.

And fear of contracting the virus was constant. She kept a mask on for her entire first shift. "I did not eat or drink or go to the bathroom," she said. "I just wanted to be safe."

Before volunteering, Brown said she was feeling burned out and already planned to leave her private practice as an ankle specialist around the time Governor Cuomo issued the order for New Yorkers to stay at home. "I feel like this pandemic renewed my love of medicine and taking care of underserved people," she said.

But then her brother-in-law, a telephone-company employee, died from the virus. "He called me right before they put him on a vent," she said. Brown promised him she would take care of her sister, effectively ending her volunteer service. "My family needed me."

Tough Times

There is a disparity in the way the virus has affected different healthcare systems, so "many of my colleagues cannot even fathom what's going on here," said William Levine, MD, chair of orthopedics at Columbia University in New York City. Levine was there for the height of New York City's surge. He helped transform the hospital's operating rooms into intensive care units (ICUs). He organized orthopedic residents so they could help. And then, as internists were besieged, he worked shifts in their place: testing arterial blood gas, administering medicine through nasal gastric tubes, getting chest x-rays, and transferring patients to the ICU.

The pandemic makes it so you're not able to do what you're trained to do and then puts you potentially in harm's way.

"We all went into medicine to help people," Levine said. "But it's such a bizarre and cruel twist of the world that we're living in. The pandemic makes it so you're not able to do what you're trained to do and then puts you potentially in harm's way."

Yet he too gained something valuable from the experience, he said. "It was heartwarming to see how incredibly grateful every single person in the ER was just to see us there — orthopedic surgeons not setting fractures, not reducing dislocated shoulders, not replacing dislocated hips as you normally would — but just being there at a time of incredible need."

The same sentiment was described by Dustin Schuett, DO, an orthopedic surgeon who stepped up when hospitals in San Diego deferred elective surgeries to conserve resources and decrease the risk of spread.

He began testing people for COVID-19 in a tent outside the Naval Medical Center San Diego, where he normally works. There, he found himself swabbing and then reassuring a woman whose cousin had died that morning from the coronavirus.

"A lot of people are scared and concerned," Schuett said. In the tent, a nurse recorded patient vital signs then Schuett — wearing a gown, N95 mask, gloves, hair covering, and eye protection — took their histories and examined them. If they fit the criteria for testing, he administered the test on the spot. If they were sick enough, they were admitted directly to the emergency department.

While he was there, the protective equipment stock remained adequate but he was asked to save his masks, in case supplies ran low.

Most of the people Schuett saw had routine upper respiratory infections and he prescribed over-the-counter medications and inhalers. Many presented with high blood pressure and heart rates, but he usually saw a decline in these measurements after he assured them that San Diego has not been a hotspot for the virus, and that only a small fraction of those diagnosed die from the infection.

Of all the people Schuett tested in April, only 50 had positive COVID-19 results. He expected the percentage of cases to climb as the virus surged, but so far that has not happened at his facility.

In fact, by May, the demand for testing there had dropped and Schuett is currently preparing to return to replacing hips and knees.

"When you don't get to do what you know how to do best and then get to do it again, it's a relief," he explained.

But it's not yet back to business as usual. Although his hospital has only a few coronavirus cases, many people are afraid they might become infected if they come in for orthopedic surgery.

Reducing Risk

Schuett had to contact seven or eight patients before he found one willing to schedule surgery. "I'm trying to find patients who have the ideal combination of heavy arthritis symptoms but can recover quickly and get out," he explained.

Naval Medical Center San Diego has implemented measures to reduce the risk for infection, limiting surgeries to two per day, using only half its operating rooms, and introducing mitigation measures, such as negative-pressure air flow.

And when patients must be intubated, the anesthesiologist is the only person present. "We're kind of doing the cautious approach, gradually wading back into normal healthcare," Schuett said.

In New York City, where many operating rooms were transformed into ICUs for COVID-19 patients, a return to normal looks far off. "We're still trying to figure out what it means to say someone should have surgery now," Levine explained.

The number of COVID-19 cases is still ticking upward in many areas of the country and Levine cautioned his colleagues there not to become complacent.

"It's okay to think about doing elective surgery in places that aren't hit but, out of the corner of your eye, you have to have a plan. How do we test healthcare workers? How do we test the patients? There are still so many unanswered questions," he said.

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