Roy Exum
There is a website known as Medpagetoday.com that correctly identifies itself as “a trusted and reliable source for clinical and policy coverage that directly affects the lives and practices of health care professionals.” It is a very popular website for people like me who write about health-related matters, particularly in the COVID-19 era where the key is to distinguish between truth and Internet hogwash. On Tuesday, there appeared a question-answer piece about the effect of the coronavirus has had on trauma medicine in emergency rooms.
It featured Dr. Manny Sethi’s views on how the ravaging disease has affected our nation’s trauma efforts.
The question-answer project was done by two post-graduate medical students at the University of Missouri, Sarah Townsley and Audrey Wagner, under the direction of medical school professor Albert Hsu, MD. Dr. Sethi, obviously, is acknowledged as an expert in orthopedic trauma.
Ironically, Dr. Sethi has just taken a two-month leave of absence to pursue a “surgical approach” to become the next senator from Tennessee, replacing the retiring Lamar Alexander. Manny, who was born in the United States to husband-wife immigrants from India, has a Tennessee heart. His parents moved to Hillsboro, Tn. (pop. 240) in Coffee County (county seat Manchester), as rural physicians where, in the next 30 years, they became legendarily loved. Manny attended high school in rural Coffee County High School and, due to his upbringing, founded a nonprofit “Healthy Tennessee” long before he had political aspirations. “Healthy Tennessee” has now benefited all the state’s 95 counties with its preventative medicine approach. Manny has our state in his soul and in his heart, believe me.
Here is the question-answer from a physician’s view of COVID-19 from the frontlines, as it appears on Medpagetoday.com:
* * *
“YOU’RE A SOLDIER, YOU KNOW THE RISKS”
In an interview conducted about two weeks ago, this is Dr. Sethi’s discussion on his vantage point and hopes for the future:
Question: We are very curious, in light of the coronavirus pandemic, how has your practice and your patient care changed?
Dr. Manny Sethi: Honestly, for me, I'm an orthopedic trauma surgeon and Vanderbilt is the third-busiest level 1 trauma center in the country. So, for us, what I've seen around me, most elective orthopedic surgeons have had their surgeries canceled. But our volume, in fact, has gone up because most rural hospitals around us are not doing cases. I'm noticing an increase in violent crime here, we're seeing more stuff come in -- robberies, etc. So, it's busier, but obviously the "cold trauma" is less. So, a thing like bones that are not healed or things like that -- we're only doing what we call “hot trauma.” (NOTE: A ‘hot trauma’ involves an urgent, life-saving procedure; a ‘cold trauma’ is a surgery that can be put on hold without the patient being endangered. Think: a broken ankle where surgery has been performed and must be repeated.)
What are your thoughts on what the hot trauma is related to? Perhaps financial motivations, or a general state of panic?
I think people are just at home, and you know ... could it be related to the economy? Sure. But I just think there's more time for altercations and more time for different bad things to happen than when we have a normal bustling world.
That makes sense. So, when you are taking people to the OR for hot trauma, how have the protocols in the OR changed in terms of intubating the patient, number of people in the OR, staff, etc.?
The anesthesia folks are taking increasing precautions when they are intubating. We have a policy here of N95 masks, protective gear. Our problem is, when I'm in the operating room, or on Saturday at two in the morning when I got called in to an acute trauma, I'm running into an ER bay trying to control bleeding out of a near-complete amputation above the knee. The problem is you just don't have time for protective gear. You've got like 30 seconds, and you have to intervene. From our standpoint, when you have a minute to do that, it's good, but it's a problem because [when] you're in the heat of the moment, it's hard to stop for protective gear.
Have you received any guidance from your hospital system or the national organizations like AAOS [the American Academy of Orthopedic Surgeons], or other state or national organizations about how to handle surgical patients? For instance, like who to take back to the operating room or not?
My chairman and our CEO of the hospital are acutely involved in reviewing the cases that we're doing, that everybody has a sense of what's going on. I think it's to our discretion about what is reasonable to take to the OR. And, I haven't really seen much guidance from the academy or others. But, within our department, we're having active, ongoing discussion about what cases are critical.
As a trauma surgeon right now, what are some of your biggest worries about this pandemic? And, have any of those worries that have developed over the past few weeks actually started to come to life?
Yes. My biggest worry right now is that I get this thing and get very sick. And, I'm seeing that happen in my trauma colleagues. I have one colleague in Atlanta that is very sick right now, who was hospitalized. I believe he got out of the hospital now and is home. My mom is elderly, and she lives with us, I've got two very small children. But I think we are soldiers in a war right now, and when you're called to war you know the risk. When you're a soldier you know the risk. I think this is the battle of a generation for our doctors, nurses, healthcare providers. We're on the frontlines, it's an occupational hazard.
I think one thing that people forget about is that traumas, heart attacks, even things like bowel obstructions -- they still happen even though the coronavirus is going on.
That's right. I think this is really our time to shine as a profession right now. To remind America and remind the world of the power and the compassion of American medicine.
That's a great perspective. You mentioned you are nervous about possibly getting the coronavirus and what might happen if you brought it back to your family at home. Are you taking any extra precautions when you do go home? And, is there anything set up in the hospital or in the community to help prevent that?
What I'm doing is that when I'm coming home, I'm taking all my scrubs and everything, putting them in a plastic bag, and then changing before I walk in. In terms of the hospital or the city, nobody is really trying to help out -- they've got bigger problems! I can't reasonably expect that. I think it's safe to say -- I was talking to one of my partners this morning -- one or two of us is going to get this thing. You got to ‘keep on keepin' on.’
As a trauma surgeon working closely with the emergency departments as well, how has the trauma surgery team and then the emergency department been coming together or even been divided over this pandemic?
I think we're working smarter. So, for example, all of our rounds now are done via Skype. And, we're trying to stay away from -- I have five partners -- and we're trying not to be in the same area at the same time. We have two fellows, now we've kind of separated them. And, we have a PGY5 (5th-year resident) and a PGY2 (2nd-year resident) and they are basically taking a week on, a week off. Obviously, the physical or social distancing, all those things we are doing. I am trying to limit going down to the ER myself. But, in the settings of an acute trauma like the one on Saturday morning, you've got no choice.
What is the personal protective equipment access like? You said previously sometimes there just isn't time to use gear, but is this being compounded by a lack of access as well?
It's difficult to find N95 masks. We're being very thoughtful and careful about the gowns and gloves situation here. There is a national shortage. So, by us shutting down all the elective surgery I think that's going to help us. But the key thing I think that this shows you, is our dependence on the Chinese government or foreign sources for our PPE. I think, once this thing is over, we gotta bring all that stuff stateside -- immediately.
That's an interesting perspective. I really hadn't thought about that before, about where our sourcing is coming from.
I think it shows you how our entire healthcare system is sort of predicated on this supply chain that is in another country. And, that's insane. We gotta change it.
What do you think could be done to change that?
I think, I'm a strong supporter right now of the Defense Protection Act (DPA), to make sure that we're producing these things [masks] here immediately. You're seeing with masks, that people are coming to the conclusion that South Korea has such a lower rate of transmission because they did have masks and were all using masks. You see us pivoting that, where we don't have enough. I think with the Defense Protection Act, we will be doing that [making Personal Protection Equipment domestically]. But I think in the longer term, there is an opportunity in our country to have a second industrial revolution. This time it's going to be around healthcare tech. And that we make gowns, masks, the 20 vital drugs that you cannot make in the United States because of the compounding or what have you, that we need to make that stuff in America.
Absolutely.
And, I think the way we do that is we tax incentivize for any company that's willing to do this. We don't pick winners and losers, but we offer every corporation the opportunity to come back to America and produce stuff.
That is interesting. I think in light of the pandemic, if we could do that, that would be a positive that would come out of this and help us to be more prepared next time.
In my world of trauma (I gave this speech on Saturday afternoon to somebody), and you'll see this in your residency, some of these trauma patients -- they really get mangled. It's hard that first day of what you're gonna’ say. After 10 years, I've kind of got a speech I give to everybody. "This is probably the worst of your life. But the thing is, you're going to look back on this in 6 months, a year -- and it's going to be a turning point for you. Did you spiral downward? And did you use this as a point where everything went bad? Or, is it where you took a turn to be uplifting? And, to move forward?"
I think in our country, this coronavirus issue has devastated our economy, it's going to kill a lot of people. We've got to determine what it's going to do to us as a nation. I believe one thing: that it could teach us that this is the moment where we realized our dependence on China and others was too much. And that we brought a lot of our manufacturing back in-state.
In the event that additional providers are needed to fulfill critical care and ICU roles, what training or preparation are you and your colleagues undertaking to fill those roles, if needed?
I am doing modules right now for ventilator management. I am reading a couple of chapters about ICU management, vasopressors, and a couple of things I did as an intern. At Vanderbilt, we have a closed trauma ICU, we're one of the few in the country who have that. The general surgeon is responsible for managing those patients, but after being around it for so long, you have a gestalt for what to do. So probably, what I would imagine is a lot of us will end up doing more critical care management. But having said that, the trauma is not going to stop. So, I think we are in a little bit of a different place. (Definition: GESTALT is a word used in psychology circles that means “a unified whole”)
From a resident standpoint, are you maintaining the same number of residents on your trauma service, or are you taking more from other elective services?
Because all the elective cases are canceled, a lot of residents are volunteering to do COVID diagnosis clinics and volunteering in the ER to help out. Residents are also available to do trauma cases if there is need. We also have one fellow. So, we have a good amount of manpower and residents are able to participate in trauma cases if they so desire.
How have mid-levels, like NPs and PAs, been contributing to the workflow during the pandemic?
I cannot speak enough to the quality of our advanced practice nurses and physician assistants. They carry the ball for us in the management of patients. We could not do it without them. They have been key. Overall, in Tennessee, as our numbers of COVID increase, I think you will see more of the advanced practice nurses get involved. So, I cannot say enough about them. Our nurses are on the frontlines, they really are.
In your experience, how have patients adapted to this?
We are doctors and medical students but imagine most people don't know and understand what is going on here. All they can do [to inform themselves] is watch TV and listen to the radio, so people are really freaked out. With my patients, I am trying to explain it to them. But I'm also getting tons of calls, as I'm sure you are, from friends for whom I am their "doctor in the family" [so to speak]. [They're asking me questions such as] "Hey is this a real problem? What is this?" I would say in the hospital also, people are really worried, people are on edge.
In an effort to keep people away from the hospital itself, what have you and your colleagues been doing in terms of telehealth or telemedicine from an outpatient standpoint?
I did five telemedicine visits today out of 20. Our problem in Tennessee is that rural broadband is an issue and some of our trauma population is not the most tech-savvy. We are increasingly doing that. One of the positives is that you are seeing different states reduce barriers to telemedicine that we have been trying to deal with for a decade, and overnight, they've fixed them! I think that's one thing you'll see is more virtual visits from now on. And I think that's a good thing. Our problem in orthopedics, specifically, is that with telemedicine we cannot get x-rays. For a lot [of the telemedicine] people today, it's more like: "Hey, how are you feeling, how's your leg doing?"
The five visits that you did today, were they convenient for you? Did you find that they were effective enough in terms of diagnostics and plan management? Or were you still kind of thinking, I really wish I had X, Y, and Z to be able to do this effectively?
You know the x-ray part is hard. And when you're in a room with a patient, you can get a feel for how they feel by their body language. I tend to notice how someone walks into a room. So, I am missing those things.
Do you feel like there are areas where you are liking telemedicine?
I think the visit is faster and patients tend to address their problems more quickly. It centers them more quickly to discuss the issue that they're seeing you about. And maybe it's because they're more comfortable or because they're at their house.
Beside changes to medical supply chains, how else do you think healthcare will change as a result of this pandemic?
I think we're going to do more virtually. I think that we are going to be facing an overload. People are talking about overloading hospitals with this coronavirus. I'll tell you where another overload is about to happen: it's going to be after this quarantine is over. Because you have millions of people who have delayed procedures, mammograms, colonoscopies, or their total knee replacement. So, we're going to have to figure out as a healthcare system, how are we going to deal with this onslaught? And then I think we're going to have a real resource limitation in the months to come, and that's going to impact how we deliver care. I think we're also going to have to change our ability to respond to a pandemic. For example, our ability to adapt to rapidly changing health conditions in a surrounding population, our ability to effectively quarantine, etc.
As more rural hospitals close and telemedicine becomes more widely adopted, what can we do to ensure that rural populations are not left behind?
I think it shows you, number one, how integral a role internet plays in society, and I think we have to focus on the national structural broadband issue. But then I think we have to also give thought to how important rural hospitals are in our statewide healthcare system and our national healthcare systems. I don't think that we reflect that in terms of our federal policy towards reimbursement. The Medicare wage index gives places like San Francisco 1.5-2 times the amount of money for the same thing that's done at a hospital in Grundy County, Tennessee, 20 minutes from where I grew up. I think we're really going to have to think about that.
Tennessee recently suffered a natural disaster when a tornado came through. How has the COVID-19 response been similar and different?
I think with the tornadoes, you saw communities across the state come together. I was on trauma call the night the tornado happened. I think you're seeing the same level of community togetherness. What's different is, that tornado hit Putnam County. It was devastating; you lost lives, you lost kids, it was horrible. That was a disaster that we had to recover from and are still recovering from. This virus is a disaster that we are still in, and do not know when we will be able to start recovering from.
The question-answer session was conducted by two medical students at the University of Missouri, Sarah Townsley and Audrey Wagner, and medical school professor, Albert Hsu, MD, who is a reproductive endocrinologist.
royexum@aol.com
Dr. Manny Sethi