All right. Hello, everyone. So thank you, Mary Beth. My name is Miguel Escalon, and we'll be talking to you today about SEI care during COVID and touch on several different things, ethical policy and systems-based challenges. So neither Dr. Davis nor myself have anything to disclose. And so we're going to talk, I want to bring up first medical considerations in persons with spinal cord injury and COVID. So there's one paper that came out you may be familiar with from Dr. Burns et al out of the VA system. So basically what this paper showed was within the VA system, 19% of veterans with spinal cord injury and COVID died compared to non-veterans without spinal cord injury, which was about 7%, 7.7. So more than double. So while I know that there are a lot of studies kind of ongoing, I know for example, Dr. Bryce here at Mount Sinai has a study that he has going to look into spinal cord injury, all the outcomes, mortality and morbidity that follow COVID-19 as places have surged and other places continue to surge. But this is one paper that has come out. So at least in this population of veterans, we see that persons that get COVID and have spinal cord injury are more likely to have higher mortality. And I want to start by just giving a little case. This is a real case, a patient of mine. So I had a 28 year old male, C5, age A, and he drives a power chair. He's got a baclofen pump, suprapubic tube, living his life. But during the COVID pandemic here in New York, I get an email. Gosh, probably in early February says, patient says, what would happen if I got COVID? So I emailed him back and I said, that would be really bad. And then a few weeks later I get another email says, Hey, I'm feeling kind of sick. I might have COVID. And so it gets you thinking, okay, what do we do for this patient population? We know they're super high risk if, or we think they are, if they have tetraplegia. He's C5. We know because of that, he has issues with respiration and lung volumes and mucus and all those things that we learn during residency and onward. And so one of the best, so we kind think about treatment, emergency management and treatment strategies. So the best strategy overall was prevention and education. So educate your patients on social distancing, wearing a mask, continuing their chest PT, which this patient was not doing. Maintain home care. We had a lot of patients in March and April and into May in New York that asked their home care not to come because they were worried about getting COVID. But because of that, they didn't get turned, they didn't get bathed, they didn't get kind of their regular care. So kind of finding someone that can provide that regular care who you also educate to follow these strategies is important. And monitoring yourself at home, understanding what the signs and symptoms of COVID are. Some patients aren't sure. One thing that if I had to do it over again, and we did this, but already in the midst of the surge here in New York was, and once we knew something was coming, maybe email blast and phone call everyone. Because there were times when I didn't hear from someone, I didn't know if that's because everything was okay or just or not. So I think maybe if you have patients that, especially those with spinal cord injury that might like mine, C5, or could have any respiratory issues for another reason, reach out to them proactively and educate them proactively. Don't be reactive and wait for them to send you an email. One way that we can leverage technology as a field, and I know a lot of institutions have done this, but I'll just use Mount Sinai as my home institution as an example, is by creating a remote monitoring program. So we see in the news every day hospitals are overrun, emergency rooms are overrun. A lot of those people need to be in emergency rooms and some maybe don't. And so one thing that we did at Mount Sinai was we already had a stroke monitoring program that was remote. And so you'd kind of monitor people to see if they were doing their exercises or what have you. But we pivoted on that and used it as a monitoring program for people with COVID. So if you had suspected COVID or you had positive COVID, or you even thought you had COVID yourself, you basically could text or email and you'd get monitored every day. A physician or some kind of practitioner would check on you, ask about your breathing, ask about your symptoms. Depending on the patients, we might mail them pulse oximeters so we could track their vitals. And then we would tell them, you need to go to the emergency room or no, you can stay home. And that was one way to kind of risk stratify and kind of help with the flow in the emergency room. This may be something particularly important for your patients with spinal cord injury that might be at high risk, those with tetraplegia or high paraplegia, given that we are worried about their breathing and respiratory capacity. Again, for prevention, a lot of things that we've seen kind of anecdotally are people stop going to PT and OT because those places close down. The home therapists don't come over and people stop going outside. They stop pushing their wheelchairs or they stop exercising. So educating people to continue exercising, continue cardiovascular exercise as much as they can to help their respiratory reserve and cardiovascular reserve is super important in this time. So to kind of get back to the case, the next email I got was from the patient and it's in this really broken English. So the best I can make out, he's saying that he's intubated in another hospital and that he has COVID-19. So at that point, I have no idea what's going to happen with this person. Are they going to pass away? You know, I know they have a baclofen pump refill coming up and gets you thinking, okay, well, what do you do for your patients with spinal cord injury that have COVID in the ICU? You know, normally for a patient with spinal cord injury in the ICU, there are specific things we might be doing and oftentimes they are acute injuries. You know, in this case, you're dealing with a chronic injury. You know, we might normally say higher tidal volumes. We're not going to do that necessarily in COVID because it's an ARDS-like picture. So there may be smaller tidal volumes. There may be, you know, different percussive elements to the ventilator that they're doing in different settings, but there are still things we can do and educate on and remind physicians about positioning, bowel, bladder, all these kinds of things and the risk of the patients might still have of dysautonomia. You know, a lot of them may be sedated or paralyzed, which might help that, but these higher level injuries, hypera and tetra will be at risk for those things. So I think, you know, in my experience, that was some of the best ways we could help, especially a lot of the patients get position prone to help. So remembering that they need to be turned and even if position prone, trying to offload weight, trying to remind people that a bowel routine and other things are still important, especially when you're talking about breathing, if somebody gets constipated, that's certainly not going to help them wean from the vent. Treatment options, you know, there's still a lot kind of ongoing here. So I just wanted to kind of throw this out there that there are some treatment options, steroids, plasma exchange. We've all heard about a preventative option. Hopefully that will be out sometime next year and the vaccine, you know, that would still be to come. But there's a lot to kind of think about and sort of how we triage these treatments and who gets them and when. So we'll touch on that a little later. So medical complications in COVID for people who have spinal cord injury, this would be more post-ICU. Critical illness, polyneuropathy and myopathy. We've seen brachial plexopathies from prone positioning, which if you have paraplegia or have tetraplegia could be devastating to your independence. Pain, pressure injuries, you know, a lot of just really severe debility and other things that kind of come with prolonged ICU stay, including psychiatric psychiatric signs, depression, even PTSD from the ICU stay and cognitive decline, which has also been shown in other ICU populations, which we've seen as well. And also there's been certainly reports of COVID in the CNS. So something to consider. And this is, again, along those lines, this is a smaller case study in the New England Journal of Medicine. Certainly there's been stroke associated with COVID-19 directly. And there's also been, you know, there are numbers, I don't know that I have them handy, but I know there are numbers from New York and kind of people that had strokes or other illnesses that did not present to the ICU for fear of COVID. And that would be kind of any population, but something to consider in your patients with spinal cord injury as well, since they can get anything else that anyone else can. Re-educating not only on signs of COVID, but when might be important to go to the ED for anything else so that somebody doesn't stay home and get really sick when that could have been prevented from something else. So non-ICU acute care. So this would be a step-down unit or just a medicine floor. So it would be important to continue following again, all the things we kind of talked about in ICU care, skin, bowel, bladder, spasticity, pulmonary toilet, just to kind of, and at this point, often they, if they haven't in the ICU already due to some other reason, they could start PT and OT. So, and speech oftentimes they might have dysphagia or other issues from the prolonged intubation, or maybe they've been trached. So kind of starting all those kinds of things, you know, there may not be a lot to do from a physiatry perspective in terms of the treatment of the COVID itself, but there's a lot we can do to expedite everything that follows spinal cord injury after any pulmonary illness. And we know how to do that well. So debility and critical illness, myopathy in patients with prolonged ICU stays. Again, we've seen anecdotally, I heard that there probably will be some papers coming out kind of on this topic within COVID soon. I think there was also one from Italy recently. I don't know if there'll be one specific to patients with spinal cord injury, but something super important to consider is what happens down the line. So when these patients, you know, if they, do they come to acute rehab? Hopefully they do. If they don't, what needs to be done before they go home? Presumably they might not be as independent as they were. Maybe they need more home care hours, you know, maybe before they popped over with their transfers and now they might need a sliding board. There's a lot to kind of think about just from a physical and strength perspective, but also sensory changes that could accompany critical illness polyneuropathy. You know, sometimes you can have changes in your reflexes that are temporary, you know, could that affect bowel and bladder? You know, if it's a severe enough case, maybe. So these are all things to kind of think about when you're looking and reviewing your patients with spinal cord injury, just to kind of keep in mind because someone was reflex voiding before may not mean they are now. So kind of just double checking everything and making sure everything is good to go before that person leaves the hospital. So we'll touch on some ethical and policy implications. So hospital and health, it's complicated in COVID, especially when we hear about hospitals kind of being overrun and what resources we have. So, you know, kind of in routine clinical medicine, you know, there's an ethical principle for patient autonomy and also for physicians to have an ethical duty to provide care. And so usually if a patient requires life-sustaining treatment, we do that unless that patient or surrogate says no. But we've seen instances in the news and certainly there were times potentially in the hospital that you've worked at or in hospitals in New York, I know that this was discussed a lot early on in the pandemic was, what's fair? You know, do we have enough ventilators? Who gets what care? Do we have enough treatment, enough steroids, you know, whatever it is. And so that's something that to really kind of think about and to decide, you know, there's different levels of this. There's a hospital system level, there's kind of the personal physician level, there's your unit or where you're working. But how do we provide the best care to the most number of people while maintaining these ethical principles? That's kind of physicians in general. We have a subset of patients as physiatrists and in this talk in particular, as physiatrists or people interested in the care of persons with spinal cord injuries or other disabilities, how do we make sure that our patients are not discriminated against? Because it could be that people perceive that our patients have a lower quality of life, but in fact they may not. They may be perfectly happy with their life and living fulfilled lives, have families, have everything, and maybe not get the care that somebody else would just because a doctor perceives that their quality of life is less or that their odds of getting off the vent is less. So, you know, we might have to advocate for those things. On the flip side of that, there will be potentially hard decisions that have to be made if there aren't enough ventilators, for example. So there aren't really national guidelines for this. Most every hospital system or hospital or care system is kind of making their own and figuring it out. The VA does have guidelines and so that's a place for somebody to start. These are nationally kind of standardized in terms of like how, when there are scarce resources, how they're allocated in kinds of times of need. And so there's kind of an overarching criterion there in terms of medical success or survivability as determined by safe SOFA scores, which are severity of illness scores when you're admitted to the ICU. So there's a SOFA score would kind of predict your mortality. So kind of actually using established criteria to say, okay, if we have five patients and three ventilators who gets them based on the best kind of stats and criteria that we have, as opposed to kind of individual practitioners making that decision, there's a protocol. But again, the SOFA score is not necessarily validated in people with spinal cord injury or people with COVID. So a lot to think about. And there are different kinds of models in terms of like how you might allocate resources. We just kind of touched on predictors of morbidity and mortality. There's egalitarian philosophies and other ways to kind of think about this. So there's no one way. But all that being said, I just want to kind of come back to our patient population and how we should know those patients, who's coming in, check on them. If we can communicate with them, find out what their wishes are and advocate for them if they don't want to be made DNR, DNI. I know there were patients in New York, not necessarily at Mount Sinai per se, but in the New York City area that were made DNR, DNI, not necessarily even spinal cord injury, but maybe they were a certain age or they had really severe COPD. They were made DNR, DNI, even times against their wishes. So it's incumbent on us as physicians who understand this population to advocate. And again, we just touched on this, right? So it would be important, again, even when you reach out to your patients, if they're not in the hospital, we talked about kind of reaching out to everyone that might be at high risk and talking about this with them too. What would you want? Would you want to be intubated? Would you want me to advocate for you and do all those things? So maybe, you know, ahead of time before they're sedated in an ICU. We'll touch on some systems-based challenges and specifically kind of longer term rehab considerations and COVID. We touched on this a little before. So, you know, this is an issue that will affect a lot of patients and will more in a downstream affect a smaller population of patients with spinal cord injury, but there's going to be a lot of extra need in general for subacutes or home care, outpatient, psych and PT, OT speech. And you could imagine that if there's more of a need for that and potentially a decreased workforce, you know, maybe people don't go to work because they have, you know, they are particularly susceptible to COVID. Maybe they're immunosuppressed or maybe they have children at home. They decide to pull back from the workforce. So in theory, there could be less PTs, OTs, less home attendance and home aides, more people that need those, you know, patients with spinal cord injury could be affected. And so kind of planning for this as a department or as a community would be important. So when do we decide how to open PT, OT? Who gets virtual therapy if we can offer that? And how do we plan for the surge, the overall surge, and then to make sure that those patients that are going to need these like home care, for example, long-term, how do we make sure that they really get that and that they're not lost in the shuffle, in this mad scramble to just get everyone home care because so many more people need it. So I want to touch on, I think I have maybe a couple minutes, just a little bit about what happened here at Mount Sinai and I'll kind of go through this quickly. This little purple arrow at the bottom left is Mount Sinai. And so the reason that I'm pointing out this picture is because this kind of green space at that bottom left was turned into a field hospital. So the hospital was overrun. There were beds in the cafeteria, there were beds in the lobby, there were beds in Central Park. And just some numbers, and I know there are a lot of numbers now across the country, but just to give an idea how quickly things can spread if they're not controlled appropriately. So the first case in New York was March 1st. By March 16th, there were 2,000 new cases a day in New York. From March 16th to April 10th, so this is about a month, there were 20 days, this is New York City now, of more than 3,000 new cases per day. And 12 of those days with more than 4,000. So we're talking about an insane amount of people, a large chunk of which are coming in through the ED and being admitted to the New York City and Metropolitan Area Hospital system. So, and that's why we had to put hospital, basically build ICU beds in Central Park. Those were not regular beds, those are ventilated ICU beds. In terms of the department itself, March 23rd, we closed outpatient. And that same week, we basically got everyone off the inpatient unit as fast as we could to make room for the medical need that these COVID patients were requiring. So some people were discharged to other acute rehabs or discharged home, maybe what we might think is prematurely, but with home care. And what we did, these are numbers that you can kind of read as I talk, but kind of what we did as a department was, we kind of manned those units. So the rehab units converted to medical units and the rehab team ran those medical beds. We had a hospitalist buddy, but we ran them. And so we chose to kind of keep our department together as opposed to be spread out amongst different hospitals or units. And that's kind of how we did it. So our residents and attendings ran codes and they treated patients that were not rehab patients, but just COVID patients. But you can see the kind of just in one city, how quickly things happened and how they continue to lesser numbers, knock on wood, but at least in New York City, but things can really ramp up fast. And our patients, people with spinal cord injury can be swept up into that and easily lost in the shuffle when everyone else is so overwhelmed. So part of the reason to show these slides is to just say, it can be really easy to lose track of those patients when you're pulled in so many directions. So kind of that preparation, calling them beforehand before it's a problem, maybe hopefully it will never be a problem where you're at, but understanding that even beforehand is super important. This is just to show the number of hospitalizations at Mount Sinai. So you can see there was many days in a row, basically the entire month of an entire month worth of like 2000 patients hospitalized with COVID, which is the entire capacity of the hospital really more than ever was. So just to touch a little bit on repurposing of units and redeployment, I did talk about this some already, but you have to kind of think about what's best for you. We mentioned what was best for us. There will be potentially some attendings, fellows of residence that we had some that have their own medical issues that maybe were at high risk. So we assigned them actually, if you think back, we talked about that virtual monitoring program, we assigned them to that or to different things where they could still be helpful. Some of them called families and helped us communicate with families, even if they weren't on the inpatient units. But in other places I know of have actually kind of been redeployed. So there are different kinds of things to think about. There's no one right way, but kind of having that plan in place is good. Cause I can tell you from personal experience kind of scrambling, which you may have to do kind of real time decision making, but kind of scrambling in the moment is not where you want to be in the midst of a surge. Things to think about, we mentioned personnel with medical considerations, issues with safety and PPE, education on PPE is crucial. A big thing is, if I'm gonna be seeing COVID patients, how do I keep that at work? How do I not bring it home with me? There's a lot of uncertainty that follows a pandemic. And so as much as possible, educating people and being in constant communication from a leadership perspective, is super important. So, and most of the things I've kind of touched on already, the education, the flexibility, and even if you have a plan, being willing to pivot and change course, taking feedback, and that's a big part of communication. Somebody might say to you, listen, we can accept more COVID patients, or hey, we have too much, we're running too many codes, this is too much for us. And maybe you change the rotation or you talk to the hospitalist team or whatever it is that you're doing, redeploy them so that they can be there for you. Redeploy them somewhere else. Having that flexibility is important and innovating in the ways that we've kind of discussed. Video visits and kind of finding ways for patients to communicate with their families, if possible, through iPads or iPhones and things like that. Physical health of employees. This is practical stuff. I won't go through every single point, but basically screening your employees is important. Again, the PPE and the staff with medical concerns. Emotional health of employees, I've touched on some as well. Showing appreciation is really important. One thing that we were able to do, because a lot of our psychologic, at least like our neuropsychologists, weren't seeing patients in the way they were, so we were able to leverage them to support our faculty and our residents and our nurses. But one thing that we could have maybe prepped better was maybe working with palliative care or someone else before and educating everyone on how to deliver bad news and be mindful and how to kind of deal with that. That was a big recurring theme with us was, in physiatry, we expect maybe to deal with people that are in a really low place, but most of the time they get better. And so that's a certain, oftentimes a certain personality of person where you have a certain expectation of what your job is gonna be. So when that changes to dealing with people that may die, may not get better, and that happens more often than not, it takes a toll. And it's not just that the patients pass, it's the talking to the families. And so that's also something that you could prepare for ahead of time. Hopefully you'd never have to use it, but there are usually resources you can use to educate. So I just wanna say thanks to all of you for the time. With all that being said, I'm gonna hand it over to Dr. Davis to take it from here. Okay. Let's see here. So greetings from Houston. That was really eye-opening account to hear from Dr. Escalade. In Houston, we had our own surges. They were not as extreme as what New York experienced, thankfully. But just a little bit of perspective from what I went through. I'm gonna be going through a series of really stories about various things that happened in the first few months. And the first thing that really came to mind was, late March, for those of you who don't know, I serve on the Advocacy Committee for ASCIP, the Academy of Spinal Cord Professionals. And we were really thinking about, what can we do to help our patients or just our colleagues during this time, this unprecedented time. That's become kind of a buzz phrase, I guess. And so we said, we're having our monthly conference call. I said, maybe we should put together a webinar. Maybe we should put together a talk to kind of help inform people. And at that time, there were a number of, a number of kind of medical media outlets that were putting out kind of pieces on, what would you do two weeks ago? What would you do? What do you know now that you wish you had known two weeks ago? And how should we be preparing? How should the rest of the country be preparing? Because we knew that the Northeast was being hit hard and the rest of the country was maybe about two weeks behind. And so, I emailed one of my colleagues and I asked if he would be interested and available to help present this kind of webinar. And his response to my inquiry really captured the environment of the day. A better question, what have I learned at this hour that I wish I knew this morning? That was a very sobering reply. I really, in retrospect, I think I really should have, or could have anticipated that when I had seen what my own chief medical officer was going through and my department chair. He was in meetings every hour and was sending constant email updates. It was a crazy, crazy time. And there were a lot of decisions that were needing to be made very quickly. And I think one thing that occurred to me, we eventually abandoned the webinar idea. I realized whatever time it took for us to put together a set of PowerPoint presentation, set of PowerPoint slides to put together, to get everybody's schedule together to be able to prevent something, whatever we would be presenting would probably be out of date. And so that was March, right? We were, people were making decisions very quickly and they were made with very little information. And so anytime that that happens, you're going to make mistakes or you're going to have to go back and revisit what's working and what's not. What's working and what's not working. So it's several months later now, we've learned a lot. We still clearly have a lot to learn, but it's not a bad time to look back and say, what can we learn from our experience in the early days of COVID? And what policies do we need to change? So probably you folks, everybody knows who these people are, right? This is Anthony Fauci and Robert Redfield. And in this picture, this was during the meeting in mid-March when they were talking with the House Oversight and Reform Committee. It was a very uncomfortable committee meeting for these two gentlemen. They were discussing why the CDC had been unable to produce widespread testing, widespread screening, testing the way that other countries had been doing. And I watched this video and it really struck me. At one point, Robert Redfield kind of looks over at Anthony Fauci and he almost seems to be saying, come on, help me out here. He was just really getting grilled. And at that point, Dr. Fauci steps in and he made a statement that really, really won my respect. And I think, you know, he said, it's a failing. It is a failing, let's admit it. And if I had to point to one time, one point in time where I feel like the American people really started to really trust Anthony Fauci and maybe the CDC kind of took a little bit of a back seat in this, I would point to this moment here. You know, Anthony Fauci had the courage to admit that our system just wasn't prepared, wasn't set up to meet this challenge as quickly as we would like it to have been set up. And so that really helped him to be kind of established as a leader who can be trusted. You know, he acknowledged when, he acknowledged mistakes. You know, during this time, people are working really hard. They're putting in long hours to put together policies, procedures to try to keep everybody safe. We all have a tendency to get defensive when people point out potential gotchas. No plan's gonna be perfect. We know that. You simply cannot learn from your mistakes if you refuse to acknowledge them. So kind of moving forward, I wanna focus on a couple thoughts here. First of all, when we're talking about lessons learned, one, people are already doing the best. The problems are with the system, right? The people are not the problem, or at least they're rarely the problem. It's, you know, when we have suboptimal patient outcomes, it's usually a problem with the system. And, you know, we need to think in terms of improving the system. This is a quote from W. Edwards Zimming. He's known as the father of modern quality. You may recognize he's the person who came up with the PDCA cycle. So those of you who've done your residency fairly recently, probably had to learn this as part of your QI curriculum. Plan, do, check, act. And at this point right now, we're at the check part. So, you know, we have planned, we've put in some of these procedures. It's time to go back and just normal quality improvement means you go back and look at what's working, what's not working. So then the other item I'd like to point out, and this is a quote from Sophocles in his Greek tragedy, Antigone. All men make mistakes. A good man yields when he knows his courses wrong and repairs the evil. The only crime is pride. You know, I think there are two parts to this quote, really. You know, everybody makes mistakes. Another way I've seen this expressed is if you're not making mistakes, then you're not trying. You're not doing anything. And that also is a failure. But also, the only crime is pride. Pride is a crime, right? So if you dig in your heels and say, no, we don't have any room to improve. We've done the best that could possibly be done. And then you run into the same problems again. Well, at some point, it does fall on you. So yeah, let's, you know, these are desperate times. We're all working hard to make things better. It's, you know, we can circle around and reevaluate some of these things. So I'll start off with really a case that was a big learning experience for me. And this was one of the hard lessons that I had to learn early on in the pandemic. He was a 76-year-old gentleman. He was admitted to my service in, I think it was early May, in complete paraplegia asia-C. And he was still pretty significantly impaired. And at that time, we had very limited test kits in the Houston area. And so we didn't have COVID testing available at TIER at that point. We had a certain limited number of tests within the Memorial Hermann Hospital system. And, you know, we had heard of people kind of squandering tests for frivolous causes, people with low likelihood exposures, that sort of thing. And so, you know, we had no testing in our hospital. And I agreed with this policy at the time. I thought, you know, we have very sick patients at TIER. We really cannot afford to have an outbreak in our hospital where I have vent-dependent tetraplegics, you know, 10 days out from their spinal cord injury. So yeah, if you think that somebody might have COVID, you should just send them out, send them to the ER to get tested. Made a lot of sense. So what happens next? Well, he was admitted on kind of late in the week, Wednesday, Thursday. I got to see him just a couple of times before I rotated off service. At that time, we had about half of our attendings working from the hospital, and then the other half were working from home, basically just to minimize exposure to the virus. And so I saw him for a couple of days, and then we had a transition of care. He was seeing one of my colleagues for the next week. And so during that week while I was gone, he started having low-grade temperatures, a little bit of a cough. He had some nausea, bowel incontinence, and kind of an equivocal urinalysis. Okay, so let's look at these symptoms here. Cough, not a very prominent symptom for this particular gentleman. Bowel incontinence, I mean, who with neurogenic bowel doesn't have bowel incontinence? So I didn't really think much about that. As far as the low-grade temperatures go, I mean, once again, he has an equivocal UTI, or equivocal urinalysis. Well, it's pretty common for just about anybody with in-and-out coughing. And so should we order a COVID test? I guess at this point I could have put voting buttons here, but that was the question that was before us. Should we order a COVID test? You know, keep in mind, you know, ordering a COVID test meant sending him to the emergency room, and that's not the most benign thing, right? I've had patients who go to the ER and spend 10 hours on a gurney, not getting turned, and they come back to me with a deep tissue injury that is just waiting to evolve into a stage four pressure ulcer. And so we did not order a COVID test at that time, during that, you know, first week. The next week, I was back on service seeing my own patients again. The cough and low-grade temperatures had resolved, so it seemed like a good decision. Tuesday through Thursday, his nausea and bowel incontinence got worse. I mean, we did a bowel clean-out, we did x-rays to see how much stool burden does he have. He was not full of stool. And then he had this abdominal CT, eventually we ordered it, and it showed proctitis. So his antibiotics were broadened. He was being followed by an infectious disease consultant, also an internal medicine hospitalist. Most disturbing was Friday. Friday, the end of that week, he had altered mental status, and he had oxygen desaturations. So, do we order a COVID test now? Once again, do I send him to the emergency room for this? Well, oxygen saturations, that's a little more problematic. At the very least, I said let's order a chest CT. I ordered a chest CT, and it showed bilateral patchy ground-glass opacities, which is pretty characteristic for COVID. So at this point, okay, we sent him out, and his tests came back positive. He tested positive for COVID. He spent about a week in the acute care hospital and was discharged home. We still have not taken, to this day, we've not taken any actively ill COVID patients into our hospital. So, what do we do with that, right? Hindsight is 20-20. This patient spent two weeks at our hospital with really, really ill, susceptible patients, and he was shedding virus at tier. Fortunately, I can say that we didn't have anybody, any of our other patients or any of our staff get sick from this. I think that really, that makes me proud of our ancillary staff for, you know, gowning and gloving and really using their infection control procedures, but things could have turned out very differently with this case. So, was it the right decision to wait two weeks to order the test? I don't know that there's a right answer to this, to that question. I mean, I don't know how many tests we had available in Houston. We certainly, and, you know, this is a gentleman who came to us from Longview, Texas, right? This is, that was not a, not exactly a hotspot. So, it was a kind of a strange case, but I think that, you know, what I learned from this case was, as soon as we have enough tests available, I need to start ordering tests, COVID tests on patients as soon as I start to have suspicion. I asked some of my colleagues, I said, you know, over the last, you know, couple of months, this was, you know, once again, back in May, I asked them, I said, over the last couple of months, how many patients have you had that you would have ordered a COVID test on if it had been as easy to order a COVID test as it is to order a urinalysis? And most of them said that they'd had about three or four patients in that past month that they would have ordered a COVID test on. So, you know, I kind of started bringing this case up to our hospital administration and saying, look, as soon as we have available tests, we really need to lower our threshold for ordering tests to where it's the same threshold as we would have for, you know, somebody with loose stools, we'd think about ordering a C-diff or urinalysis. We, you know, and so that was, that was the learning that I had from this case. Next case, this was a gentleman, 54 year old gentleman, cervical spinal cord injury, depression, anxiety, and he had a history of MRSA colonization. So he was on contact isolation, not for COVID, but for an MRSA infection he had had two years previously. He had had a spinal cord injury for a while. And so, you know, we had to come up with a whole set of policies for patients on contact isolation because they use up PPE. And, and so, you know, once again, paying attention to the context of that time, in Houston, we, you know, the PPE shortage was never, we never had a PPE shortage. We did have that shortage of tests that everybody had early on, but with PPE, we knew that we needed to be judicious in how we used it. We needed to not squander our resources, but, you know, we, we, you know, I never had to reuse gowns or gloves. I never had to use a trash bag as a gown. Things that you heard about coming from other hotspots, I guess. And so to preserve PPE, we, we developed a policy that said, you know, patients that are on contact isolation, they can't have visitors because the visitors are going to use PPE during their visit, and they need to do their therapy inside the hospital room instead of in the therapy gym. And that was, you know, once again, so that our therapists would be using less PPE. This particular gentleman really did not thrive under that system. He really deteriorated psychologically with, without being able to see his, his family face to face. He was not making a lot of progress in therapy, not just because of the psychological side of things, but he couldn't use the therapy equipment that we had available. And, and so it was in some ways a wasted visit. He was very dissatisfied with his stay in rehab. Fortunately, it was a safe discharge. He, you know, had had a chronic injury, but he spent about two weeks on our unit without making much progress at all. And so while I was mulling over this challenging patient, I happened to listen to a couple of my therapists talking about how many gowns and gloves they were using doing therapy in the patient's rooms as compared to in the gym. And, and so, yeah, I realized they're using a lot of gowns and gloves. So what we did is we did some process mapping. We just figured out, okay, so when you have a patient doing their therapy in the room, how many gowns are you using? How many gloves, how many antibacterial wipes are you using? And after, and then how do we, how does that compare to when we have somebody doing therapy in the therapy gym? We realized we were actually using just a little bit more PPE, having patients do the therapy in the rooms. So that little bit of process mapping made it a very, you know, made this a very simple decision, right? I mean, if the whole reason for this policy was to preserve PPE, well, let's, let's get rid of that part of the policy. And this was a policy that was our hospital's policy. We actually had control over that. And I think that's a, you know, important thing to pay attention to is, you know, where, whenever you're looking at hospital policies, where are they coming from? Is this the main hospital system? Is this coming from your branch of the hospital? Is this a joint commission requirement? I will say that even regarding things like joint commission requirements, before COVID came, I had had a number of instances where I'd be asking questions about various policies that we've had. And a lot of our policies, you know, they were written to help us comply with joint commission requirements. But if you went back and actually looked at what those requirements said and how the joint commission requirements were worded, there was flexibility. And so it never hurts to go back to the original source document and ask, you know, is this the best way to do things? Do we have to do it this way? Is there a way that we can tweak things a little bit? And then this last case, actually, this was not a real case, but it could have been one. I had a couple months prior to COVID, I had a 50 year old gentleman with chronic C5 tetraplegia, who got pneumonia, he was on a ventilator. And this was in December, actually. And, you know, since then, we found that there have been some COVID cases in the US, maybe he did have COVID, I don't know. What would have happened to him if he had been hospitalized during the surge? So this gentleman, he was in the ICU for a couple of weeks on a ventilator. And my patient, he was on in December, but what would have happened if he had been admitted in, you know, April, May during the surge in Houston? And this gets back to a little bit of what Dr. Eskalon was talking about, allocation of resources, right? So during a public health emergency, how do you decide who gets a ventilator who doesn't? There have been a number of states that have come up with policies on this, and some of them can be controversial. This was a resource that was forwarded to me, as part of my advocacy work with ASCIP. And so it was put together by an Institute for Disability Policy, you know, Evaluation Framework for Crisis Standards of Care Plan. So you can Google this term, and you can find this document, it's downloadable online. And it has some principles that get back to some of the things that, once again, Dr. Eskalon was talking about. And kind of a quick summary of the main points in this document. I mean, there are six questions to ask when you're looking at these kinds of policies. One, does this policy, or does the plan include categorical exclusions on the basis of diagnosis or functional impairment? So, you know, would the policy say something like, you know, people with quadriplegia will not be considered for ventilators? That's a very broad statement. There, you know, tetraplegia can be anything from Asia A to Asia Impairment Scale D. You know, anything that paints such broad brush strokes generally we wouldn't be in favor of. Does the policy, number two, does the policy include explicit quality of life assessments? We know from published literature that healthcare providers have a tendency to dramatically underestimate the quality of life of people with severe neurological impairments. And so that is something that needs to be factored into the equation. Ultimately, some of these policies incorporate decision-making teams to make these kinds of decisions. And I think that makes a lot of sense, you know, especially if you have members of the team who are aware of the literature on things like quality of life. Number three, does it include long-term survival beyond the acute care episode? So this is another one where a lot of people have, you know, inaccurate ideas or only partially accurate ideas of what the life expectancy is for somebody in a wheelchair. Yes, a number of our patients, you know, a lot of our patients with the most severe impairments have dramatically altered life expectancy. But overall, a lot of patients with spinal cord injuries live near normal lifespans. I think that's something that's not well appreciated by a lot of our non-physiatry colleagues. Does the plan include allocation based on anticipated documented duration of need? How do you determine how long you expect somebody with tetraplegia to be on a ventilator? That's kind of a tough call to make. So same thing with short-term survival probabilities. And then, you know, what do we do with patients who are on ventilators at home? And this is, I have not heard of this happening, but there is some concern among people with independent tetraplegia. What happens if I get sick and I go to the hospital, I'm on a ventilator and it's my ventilator. It's one that my insurance has purchased. And yet somebody wants to try to use it for a patient who is deemed to be younger, healthier, have a better quality of life. These are all issues that are, you know, obviously very challenging. I think that, you know, we need to be involved in these kinds of decisions. Otherwise, they'll be made without us. So I guess take home points from, you know, my portion of the discussion, crisis management in any situation is going to require a lot of rapid decision-making with very limited information. So really you have to go back and re-evaluate, is this the best way to do things? And that's just basic quality improvement concept there. And then also everybody has a role to play in process improvement. I think this was something that my department chair really helped me understand when I was early on in my career. He was suggesting that I join, you know, various hospital committees. And, you know, at that point, at that time in my career, I really didn't see myself as being, wanting to be involved in hospital administration. I didn't want to see my, I didn't really see myself as being involved in academics per se. I certainly would not have envisioned myself presenting at a national conference. I just want to be a clinical workhorse. But, you know, as you see these policies being put into place for all sorts of reasons, you start to realize that, you know, they need help. People need input from frontline clinicians to really make these processes the best they can possibly be. And so, you know, now that I am the one who's talking to some junior level faculty in my post, I talk to them about it like it's almost like clinical work, right? So in clinical work, it's, you know, you need to be a team player. There's a certain amount of work that needs to be done, certain number of patients that need to be seen, and we just need to make sure we take care of the patients. Well, the same is true with this kind of administrative work. There's a certain amount of, certain number of decisions that need to be made, policies that need to be written. They need input from frontline clinicians in order to do the best they can. And so, you know, if everybody gets involved and everybody pitches in, then nobody has to do all the work. And so that's my take on that. I guess we have time for some questions now, about five minutes. I guess I'll start off the questions. So if you, going forward with any other potential surges, what would be one thing that you would change from previous experience? Is that for both of us? I'll let Miguel go first, because he dealt with the biggest surge. Yeah, I think I touched on some of those. A lot of it was just kind of prep in terms of education and keeping track of our patients in a different way. I think that depending on, it all depends on the size of the surgeon, like what you're going to need. There was no way our rehab unit could have stayed open, for example. But in another world where maybe we were teetering, could we stay open and maybe help the flow of patients like through the hospital, get them home sooner? Then in that world, we would have maybe accepted people we don't normally do, gotten people home much faster. We usually want to get them as close to Mariah as we can, but no, we would have changed focus and just been like, okay, family education training. That's a whole other thing is like, how do you even do that during COVID? But I don't know that we could have done anything differently at the time. I think if now moving forward, we have plans in place and that goes all the way from like attending scheduling to like, what do you do with the residents? We instituted a night float system because we thought 24 hours straight was too much, too intense and too much. So kind of things like that, that basically we found out what worked and what didn't. So I know I'm being a little bit vague, but if anyone has specific questions, I'd be happy to kind of hash those things out bit by bit because that's the whole talk. I think in and of itself, what would I would have done different? Yeah, I would say from the, you know, from our perspective, we actually, you know, some of the things that Miguel was talking about, our surge was not as severe and we actually served in that role. So we were kind of the safety outlet. We didn't have to close our rehab unit, but we did, well, we closed a couple of rehab units within our system actually. And so we had patients who were coming to kind of tier central that normally wouldn't have come to us. They, you know, yeah, for whatever reason, they normally wouldn't have come to us, but they needed some place to go before they went home. We were able to do some training, kind of help them get ready to go home and we were kind of a pressure outlet valve for the hospital system. I think that was really helpful to the hospital system. Staffing was a real challenge, even figuring out things like staffing. You know, we just had, we had staff members who couldn't come to work because they had a runny nose and it, you know, once again, in the first few months, sometimes it would take five or six days to get a negative COVID test back when you knew the person probably had a cold. And so we spent a little more time, I think, figuring out the staffing and also how do we do patient education? You know, I think we've had more time to put into learning how to do patient and family training before people go home. Okay. So Dr. Burns asked, we have about a minute and a half left. Did you put any spinal cord injury patients on prophylactic antibiotics? I did not. I think just the emphasis on the good, like pulmonary toilet and home care at home, you know, hydrate well, it's probably the best thing. You know, if you have someone that's not, you think maybe wouldn't need NEBS, I don't think I even did that. But I didn't do any antibiotics. I don't, I don't know that they've shown to help in COVID at all. Yeah, we didn't do antibiotics either. Okay. Any closing remarks in the last minute here? Thanks for watching. Yeah. Good luck. We'll see how this plays out in the next six months to a year, I guess. Yeah, I'd say this, I'll say the same. And again, I think probably any of us that you see on the screen would be willing to answer more questions later if any come up. Well, thank you so much for taking your time this morning and educating us on your experiences. Thanks again.

spinal cord injury

SCI care

COVID-19

mortality rates

prevention

education

personal protective equipment

isolation precautions

resource allocation