Two leading orthopedic surgeons, Dr. Ira Kirschenbaum and Dr. Vinod Dasa, discuss what it will take for providers to reopen for elective surgeries. Guidelines by the CDC and governors are helpful, but it’s ultimately up to each medical team to make the final call on what patient safety should look like throughout the care process. Patients will be hesitant about having procedures, so providers will have to share details on what they’re doing to keep them safe.
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Michael: Welcome to the “Paradigm Shift of Healthcare” and thank you for listening. On today’s episode, we have two orthopedic surgeons, Dr. Ira Kirschenbaum, chairman for the Department of Orthopaedics at the BronxCare Health System, and Dr. Vin Dasa, vice chairman of Academic Affairs for the Department of Orthopaedics at the LSU Health Sciences Center. Host Scott Zeitzer spoke with both surgeons about when and how hospital and ambulatory surgical centers should be starting elective procedures in a post-quarantine environment.
Announcer: It’s time to think differently about healthcare, but how do we keep up? The days of yesterday’s medicine are long gone and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that healthcare is still all about humans. Many of those humans have unbelievable stories to tell. Here, we leave the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of healthcare together and hear some amazing stories along the way. Ready for a breath of fresh air? It’s time for your paradigm shift.
Scott: Welcome to the podcast. It’s really a pleasure having both of you available, Dr. Kirschenbaum and Dr. Dasa. By the way, everybody, Dr. Dasa is actually driving in to do a surgery as we talk about when is it best to start opening up the floodgate, shall we say, regarding surgery. So, I’ll open up the questioning. The first question that I’ve got for the team here is, irrespective of local government direction, when is a hospital ready to do elective cases?
Dr. Kirschenbaum: I’ll start off that a little bit. I think there’s two issues, first of all. A number of people on the internet have talked about “how could you even start talking about this while we’re in the middle of the COVID pandemic?” My answer to that is, had we planned for the COVID pandemic, it wouldn’t have been so bad. Had we planned for what to do during wouldn’t be so bad. Planning is an important stage.
I don’t think myself or Dr. Dasa are saying we’re ready to do full-blown elective surgery now, but we certainly have to plan for it. It would be irresponsible for any hospital right now not to plan what the recovery era is. And I think, irrespective of what the government may or may not say, the hospitals, and the doctors, and the nurses, and everyone who works in the hospital answer to a higher authority. That’s the oath to a patient: “do no harm”. The government could say one thing, but we have to take it up a notch at times.
I think it’s in two basic categories. Category 1 is patient issues and category 2 are hospital issues. Patient issues have to do with when to test patients before surgery, what to do if someone tests positive. That’s the first group of questions. The second is: how many COVID patients, how many patients under investigation do you have in your hospital? Those are the two broad categories. What do you think about that, Vin?
Dr. Dasa: Yeah, I would agree. I think, from my perspective, those categories are important. I think, is the hospital capable and able given the local circumstances? Because you may have one hospital at one side of town in a different set of circumstances… a hospital on the other side of town. Number two, “first, do no harm”, like you said, and that cuts both ways because, if we delay surgeries, we are potentially doing harm. The patients aren’t receiving appropriately timely care.
For example, I have a patient that I saw last week. Pre-COVID, she was scheduled for total knee and was using a cane. I saw her last week and now she’s decompensated to a wheelchair. In the vein of “first, do no harm”, where do we put that patient? Where does that patient fit in the general context of what’s going on? And then, number three, let’s be honest, there’s financial consequences here. If you don’t have a viable healthcare system on the backend of this with physician practices, hospitals that are financially viable, then we create more problems on the backend as well.
I think it’s got to be a marriage of different principles, and we have to pick and choose what risks we’re willing to accept and what risks are simply too high. Again, I think that speaks to kind of the individual dynamics each facility and do they have the ability and capability to handle elective cases. If they do, then I think it’s reasonable to step forward now that many of us are on the backend of this curve. But if you’re heading up the peak or at the peak, maybe it’s not the right time.
Dr. Kirschenbaum: I’d also like to add to that. That’s a great point. I agree with everything said. I’d also like to add to that. You constantly have to be making lists of the type of cases based on where you are in the curve. Early on, I posted—and Dr. Dasa added a lot to this post—on what were the time-sensitive, essential cases that needed to be done during COVID. There was a list of about 15 to 20 orthopedic procedures, from infections to certain fractures to locked knees to locked fingers to tumors that were risk for fracturing. You need that list. Now, going forward, you need the next list. Which of the people who are going to be most likely to go home the same day and spend less time in the hospital? What some people call the elective outpatient cases; I think that’s important. And then the next stage will be the list of cases that are in-patients but are lower comorbidity and a final group would be the regular patients of any comorbidity that you would do.
A lot of people have been trying to say, when you have one in a million people who worked 10 admissions of COVID over 10 days…some of those guidelines, I understand why some public health people use those guidelines, but I think more in terms of exactly what Dr. Dasa said. Where is your hospital in its volume of COVID patients? If you have, for example, 17 floors and you have one floor of COVID, that makes a good argument for opening up for more elective surgery. If you have a four-story hospital and two-and-a-half floors with COVID, you can’t. Your hospital situation is probably the biggest component in this.
Scott: I agree. I think the guidelines are important as a starting point, but frankly they’re being set up irrespective of a hospital and, in some cases, a medical doctor’s opinion and I really do think it does fall upon each hospital’s team to kind of figure that out probably on a daily basis. You talked about outpatient cases where the patient isn’t going to really be there for a long period of time and of course the risks post-surgery are lessened if we can get them out of the hospital, I would say from a COVID perspective I think, which leads to that conversation about ASCs. I think, in your state, Ira, the ASCs are tied to the hospitals if I’m not mistaken but not in every state. Do you think that that’s an appropriate modality of thinking?
Dr. Kirschenbaum: You’re only partially true in New York. There are many free-standing ASCs. We checked it out. A number of them have been purchased by health systems, so it seems that they are connected but they’re not necessarily. But ASCs are going to have the same problem because there’ll be COVID and non-COVID patients going in, and not every ASC patient goes home. Some need to go to hospitals so you need a target hospital to be able to send to. There’s a lot of criteria and we haven’t even talked about whether or not they will be tort reform for the idea of, if a patient who goes in for elective surgery happens to get COVID, is that a willful neglect type of situation? Is someone going to address that elephant in the room as well?
Scott: Yeah, especially with the state of testing or lack thereof. How do you know when they had the COVID? I mean I know antibodies, antibodies, antibodies, but any good testing and reliable testing out there is going to be a major part of that conversation.
Dr. Dasa: You brought up an interesting point. The challenge that we’re having is, around testing, number one, the sensitivity and specificity is suspect based on what test you’re looking at and then, number two, we have no real clear guideline on who should be testing and who shouldn’t. In fact, Louisiana Department of Health released some guidelines a couple days ago and said, “We should only test preoperative patients if they have symptoms.” In other words, the official state guidelines say, “No need to test every patient if they’re healthy and asymptomatic.” Whereas our hospital and myself agree that we probably should be testing every patient. We have no national standard. We have no game plan. It’s kind of a hodgepodge of rules that we’re seeing. There’s really a lack of leadership in terms of giving us a clear, consistent game plan to make sure we’re taking care of the patients in the best way possible.
Scott: Ira, I’ll let you know chime in on that. That’s a good point, Dr. Dasa.
Dr. Kirschenbaum: I agree. The testing, if you ask one infectious disease doctor or another one, they’re going to tell you a different story. As I said from the beginning and Vin’s comments reflected this as well, each hospital has to answer to the “do no harm to the patient,” “do no harm to the staff” motto. Every hospital is set up quite differently. Some have multiple ICUs, multiple areas for PACUs. Some are very small and limited spaced. Some have the ability to do social distancing better than others. Each one has to really give some thought as to their own unique plan. If you’re sitting around and you’re waiting for the governor of your state to give you an actual roadmap of what to do when bringing back elective surgery, then you are in the wrong profession because you should not be in healthcare management if you are waiting for the governor to give you a roadmap. They will give you guidelines and public health guidelines and rules, but you will need to apply them in your specific situation.
Scott: I heartily agree with that whole statement. I do think it’s a good starting point conversation, but I don’t think they’re ever going to get down to the some of the necessary details required by the surgeon, the staff to make sure that that patient is safely taken care of. They’re not going to go into what type of testing you’re going to do, who gets worked on. Dr. Dasa, you brought up the fact that our governor in the state of Louisiana is basically just saying you don’t need to test if they’re asymptomatic and we all know that there are a lot of people with COVID who are asymptomatic. It is almost like saying you don’t have to test.
Dr. Dasa: That’s right. If we’re going to treat everyone as if they have COVID, because we know again 70% sensitivity, 80% sensitivity of these tests, it’s been fairly high false negative patients where you actually have it but the test is saying you don’t. So then, if it’s that high, then do we simply treat everybody as if they have it? Which is a whole different pathway, workflow, and process in terms of intubation in one room and then wheeling the patient to another room and who needs to be in the room and who’s got N95s and who doesn’t. The list goes on and on and on versus if they test negative and we just treat them as negative and we go about our business.
So, again, the science is really not there. Remember most ASCs don’t have real robust testing capabilities, if any. And so, are we going now force them to get rapid testing if we do it at the day of or do we do it 48 hours before a lab somewhere? And then we have to make sure that information gets there. Let’s say you’ve got a Monday surgery and it’s 48 hours before. That means they’re getting tested on a Saturday. Who’s going to be able to get that paperwork to whoever it needs to get to? A lot of logistical challenges when we talk about testing, and when, and how, and why in addition to just the basic science around it.
Scott: I’m not aware of any ability really, even if you wanted to do that type of testing of being able to get enough kits out there to do good, reliable testing. Not that I’m aware of right now today.
Dr. Kirschenbaum: Yeah, one last thing, Scott. I think that a lot of people have not put enough into, once they’re in a hospital, what does the episode of care look like? So, after surgery, is your PACU completely clean? Do you have an opportunity to have two areas of a hospital, a COVID PACU, a non-COVID PACU? Are your ICUs mixed? Are they separate rooms? Because any one of these patients could decompensate. As I like to say, even if you do wholly unnecessary sports medicine surgery, which is generally what it is, you still can go to an ICU afterwards. If your ICU is filled with 25 beds of COVID and 5 open beds, maybe you’re not ready. You have to look at that whole episode of care and all the contingencies of every possible patient who is going to go into that operating room. They’re all not going to be simple, “Clark, go to the holding area. Go home.” Even if you’re adept at outpatient joint replacement surgery, if you have 2 out of 100 to get admitted, what if one decompensates, has an MI, has to go to the CCU and the CCU is being used as a COVID ICU? You really have to analyze the episode of care in your entire hospital for a patient for multiple, multiple contingencies to be fair to the patient and fair to the staff.
Dr. Dasa: I think everyone’s under such tremendous financial pressure to open the doors and get the ball rolling. It’s a balance between all these dynamics and what’s the best path forward.
Dr. Kirschenbaum: I agree with you, Vin. I think the financial pressures are very important to keep in mind, and I agree. Their best handle through thorough planning, which doctors historically plan like this. I plan to wake up, have my coffee, go to the operating room, and do six cases. Now they’ve got to plan the whole episode of care all the way through for each patient. It’s doable. It’s doable. And I think we’ll fix the finances when we concentrate on the planning because a well-planned episode of care post-COVID will allow you to safely do more surgery.
Scott: Yeah, I think planning is going to be a critical part. I agree regarding the balance. I agree don’t do any harm and you’re going to have to have the appropriate balance in terms of moving forward. As we all know, it is not a post-pandemic environment. It’s simply a post quarantine environment, so the quicker that hospital management and doctors get together as quickly and efficiently as possible to come up with their own internal guidelines and specifics. I question the judgment of not doing that…poor job explaining that, but that’s kind of what I’m thinking.
Dr. Dasa: No, and I think that’s a very important distinction post-quarantine versus post-pandemic because I think your initial gut reaction is to say post-pandemic emotionally but you’re right. We’re still in the thick of it. Chapter 1 is finished. We’re now on to Chapter 2.
Scott: I agree wholeheartedly and I think that kind of lends to what the landscape looks like in that post-quarantine world where you’re, as a patient, looking to go and get a surgery that they really need. They’re in a lot of pain. I may need to get some surgery. They’ve got to make some decisions. I do think understanding what the practice’s office looks like, what kind of social distancing they’re doing in that waiting room and/or clinic, how quickly and efficiently you see patients in the clinic, how quickly and efficiently you get them the heck out, and then get them into the operating room, which you surgeons are… It’s the only thing you guys care about is the OR but I’m kidding.
But, yeah, there’s going to have to be a whole change in process. I was talking to a surgeon a few days ago and they were going over just how they were working out their entire change for their whole group, the entire building. It was a group of about a dozen surgeons, and how they were redoing their entire walk through for their office, and which hospitals they were going to go to and operate at. A lot of it, Ira, was based on some of the thoughts you had and you as well, Dr. Dasa. I think this balancing act is going to be going on for some time. Do you guys think you’re going to be changing…? Ira, you’re in South Bronx, a very large clinic. I remember from a previous podcast, you see more people than the city of Cleveland in a year. Are you starting to walk through, in your mind, what that clinic’s going to look like and how you’re going to process…?
Dr. Kirschenbaum: I just had a big meeting with a planning group on what opening the clinics is going to look like. It doesn’t mean we’re opening, but it means what the clinics look like. We review all our patients the day before and sometimes a week before and decide which patients must be seen in our opinion. Some people may have open wounds and other things that need to be seen and make sure we’re good for telehealth. Certainly this pandemic has accelerated our telehealth program significantly, but we are planning for opening the clinics. Now, when I say we’re planning, it’s not like we’re opening this coming Wednesday but again, we need a plan for when they open up.
Last year, our system, which is a single health system, not affiliated with anyone else in New York, just in the South Bronx, we saw 1.15 million clinicless. I think that’s almost 100,000 a month. We think it’s going to be slow for patients to get away from the fear of coming to clinic and hospitals but it will be grow and we’re going to need to be ready with a combination of face-to-face and telehealth. It’ll be a real bumpy ride in the beginning I think.
Scott: I couldn’t agree more. Dr. Dasa, on your end with your hospital system, are those conversations taking place as well?
Dr. Dasa: Yeah, exactly. And so what does the waiting room look like? What does the recovery room…? Ira kind of alluded to having non-COVID and COVID recovery rooms, and floors, and all that kind of stuff. Those discussions are starting. Telemedicine. So many different things that we have to think about—workflow, processes, physical plans. A number of things. So, yeah, I think everybody is having the same discussions.
Scott: We often complain about the insurance companies probably for good reason. This conversation regarding telehealth is an entirely different podcast that we could have about making sure that frankly all physicians are reimbursed appropriately for a telehealth conversation. It is not going to be some sort of cute add-on anymore. It is going to be part of the process of taking care of patients, and the physician community will need to be reimbursed appropriately.
Dr. Dasa: Yeah, absolutely. I think Ira and I probably share similar issues around telemedicine, and disparities, and resources and things like that. There’s going to have to be a lot of work. Coming from New Orleans for example, we know we’ve got the highest…we were close to the epicenter. One of the hot spots in the country. On top of that, had a the highest number of deaths in non-white patients. And then later, on top of that, many of those patients were under-resourced. How do we take care of these patients? We have basically a bottleneck now just in our waiting rooms, the number of chairs we have, let alone all the other issues. Telehealth or telemedicine is a potential solution but, for a lot of these patients, it’s unrealistic for them. A lot of things we have to think through.
Scott: Guys, I think we’re hitting on our 25 minutes, and I knew that this was going to be an issue because we probably sit for an hour and talk. Dr. Dasa who’s going off to do surgery, thank you for squeezing us in before you take care of that patient. Dr. Kirschenbaum who I refer to Ira all the time because he is my brother from another mother, thank you for your time as well. I sincerely appreciate it, guys. You all have a great day.
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