Urologists Pivot to COVID-19, but Struggle With the Aftermath

M. Alexander Otto

July 16, 2020

The call went out on March 25 from hospital leadership at Columbia University's Irving Medical Center, in New York City, for volunteers to help with the crush of COVID-19 patients in the Emergency Department (ED); a little over a week later, makeshift ICUs were popping up in operating rooms.

The Department of Urology was in the thick of it; ultimately, 16 residents, 14 attendings, two nurse practitioners, and three medical assistants volunteered to help beat back the onslaught ― well over half the department.

They relate their experience in an article that was published on July 12 in Urology as a journal pre-proof. They hope their tale will help guide others "in the response to this and future pandemics."

Dr Jamie Pak

Things have calmed down since April, and urology services are slowly ramping back up, but there's "uncertainty of when, if ever, we will return to 'normal.' " For cancer patients in particular, "the downstream effects of delay in surgical care will be much more difficult to ameliorate," say the authors, led by fifth-year urology resident Jamie Pak, MD, one of the volunteers.

Urologists at Columbia are now operating 6 days a week, including Sundays, to work through the backlog of surgical cases.

Through the Looking Glass

It was clear by mid March that trouble was brewing. The ED was overrun; many frontline providers were in quarantine; and all elective surgeries had been canceled. Clinicians sensed that redeployment was imminent.

Urology was one of the first services to volunteer. "There was definitely anxiety about volunteering," including concerns about personal safety. "There was no way to predict what we would encounter. It was a bit scary," Pak said in an interview.

Pak and colleagues were met with an overwhelming number of patients in the ED, many on ventilators and some on beds in the hallways. Virtually every patient had suspected or confirmed COVID-19.

Pak and his colleagues helped in whatever way was needed, including changing oxygen tanks, placing lines and Foley catheters, performing chest compressions, and keeping an eye on vital signs, all under the supervision of trained ICU physicians.

"It was bizarre. In urology, we do sometimes encounter very sick patients, but it's definitely not routine," Pak said. He noted that as a urology resident, the ICU training only lasts 1 month.

It was immediately clear that there wasn't enough ICU capacity, so urology volunteers set up a 16-bed ICU in the ED in early April. "Attending/resident pairs were responsible for entering orders, reviewing labs and imaging, adjusting ventilator settings, contacting consultants," and bringing volunteers from other services up to speed, the team writes.

Soon, 16 beds weren't enough, so several operating rooms at the university's Milstein Hospital were converted to four-bed pop-up ICUs, and a makeshift six-bed ICU was set up in the pre-op waiting area at Allen Hospital, Columbia's satellite in northern Manhattan.

Keeping in Touch With Families

With critical care attendings and other attendings inundated, it sometimes fell to Pak and other residents to keep families up to date. "There was a lot of stress and anxiety from them because they could not witness what was going on," he said.

"It was hard to convey the severity of the situation and to ask them to withdraw care from a family member to whom they could not even speak, see, or touch. It was really difficult to have these conversations," Pak commented.

"My maternal grandmother was in a nursing home and passed away from COVID; I was not able to go to the funeral. I feel for these families," he added.

Through it all, the team writes, "we encountered the dark realities of critical illness and death from COVID-19 in our patients, colleagues, family, and friends. Emotions such as guilt, helplessness, and grief accompanied our anxiety." Mental health experts at Columbia held virtual group sessions to help.

A Changed Service

The wave started to subside in mid April, and by early May, things were enough under control that urology was no longer needed in the makeshift ICUs. A week later, they were dismantled.

Since then, the Columbia urology department has tackled a new task: getting a derailed service back on track.

Inpatient urologic consults at the main hospital fell from about 15 a day to sometimes none during the crisis and were limited mostly to Foley placements in critically ill patients and gross hematuria that was often related to COVID-19 anticoagulation. Weekly surgical volume fell from about 40 endourologic and 20 open/laparoscopic/robotic cases before the pandemic to just a handful, if that.

Outpatients had been switched to televisits by phone or video, and emergent urology problems were seen in the outpatient clinic to minimize contact with the ED. To keep up with resident education, the department launched daily virtual lectures on Zoom. There was a competition among residents to see who could score the highest on the da Vinci Skills Simulator.

The surgical delays were "particularly worrisome for patients with high-risk cancers that can and do progress within weeks, such as high-grade bladder cancer and large renal masses," Pak said.

Patients with the most pressing needs come first as the urology team catches up on surgery cases. Pak estimated that surgical volume has returned to about 75% of pre-COVID levels.

But patients are hesitant to go to the medical center, so clinic visits and operations are booked for later dates or at the satellite hospital. Mandatory precautions include symptom and temperature checks for both clinicians and patients.

Televisits now account for at least 40% of outpatient urology volume, a trend "we foresee will continue...even once the pandemic has subsided," Pak and his colleagues say.

Urology. Published July 12, 2020. Full text

M. Alexander Otto is a staff journalist on MDedge, now part of the Medscape publishing group. He has a newspaper journalism degree from Syracuse University and a master's degree in medical science ― a physician assistant degree ― from George Washington University. Alex is based in Seattle and can be reached on aotto@mdedge.com.

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