Article In Brief
Nearly nine months into the pandemic, neurologists discuss their most valuable lessons learned about treating infection with SARS-CoV-2 and public health management, crisis leadership, the delivery of neurologic care, and how to navigate the professional and emotional crises wrought by COVID-19.
Over the past eight months, neurologists have learned a great deal about the diagnosis and treatment of infection with SARS-CoV-2 and public health management, crisis leadership, the delivery of neurologic care, and our remarkable medical workforce. While the number of those lessons will one day be able to fill textbooks, Neurology Today asked several experts in those fields to share their singular most valuable lesson from COVID-19 thus far.
James J. Sejvar, MD, neurologist, and epidemiologist at the Centers for Disease Control and Prevention (CDC)
“The virus is more infectious than we initially understood. Many of the features of the spread, health impact, and transmission of COVID-19 that we identified during the spring of 2020 have held relatively constant. It still remains that the persons at greatest risk for getting very, very sick from COVID-19 are persons of advanced age (over the age of 65 years); people with co-morbidities, including obesity, cardiovascular diseases, and diabetes; and those who are immunocompromised. There are also new things that we have learned about the virus, and its spread, during the ensuing months.
We now know that this virus, SARS-CoV-2, is much more ‘infectious’ than we originally thought—one person with COVID-19 is able to spread the virus easily to up to three or four additional people. We have also come to understand that children are not entirely immune from serious effects of the virus, as demonstrated by multisystem inflammatory syndrome in children (MIS-C), which can cause grave and life-threatening diseases in young children.
Finally—as debate ensues regarding sending children back to school, re-opening restaurants and bars, and other efforts to return to a sense of normalcy—public health professionals are trying to determine how to balance the clear and present danger of the ongoing spread of the virus from persons at a lesser risk to those at higher risk, with going back to an ‘ordinary life.’ However, coming up into the winter season when all respiratory viruses tend to cause their greatest impact, the public health messages remain clear and simple: Wear a mask; avoid social crowding, particularly indoors; wash hands often; and maintain at least a six-foot separation between yourself and others.”
Kenneth L. Tyler, MD, FAAN, neurovirologist and chair of neurology, University of Colorado School of Medicine
“It is far more than a respiratory disease, and in fact, has major neurologic complications. In the acute phase, we can divide these complications into the effects of systemic disease, including hyper-inflammation, enhanced coagulation, and multi-organ system failure that often results in ‘encephalopathy’ or cerebrovascular events. We also know that COVID-19 can be associated with encephalitis and that this can include direct infection of the brain by SARS-CoV2, but also, more commonly, with an inflammatory state in which we don't typically detect direct evidence of the virus in CNS.
Furthermore, the virus can trigger a variety of post-infectious immune-mediated conditions that can include Guillain-Barré syndrome and its variants, acute disseminated encephalomyelitis, acute necrotizing encephalopathy, and MIS-C, but also, less commonly, in adults. In addition, we are now just beginning to identify and understand the potential longer-term neurologic sequelae of infection, as many patients report they have not fully returned to their prior level of cognitive functioning or continue to experience symptoms many months after ‘recovery’ from their acute infection.”
John M. Murphy, MD, neurologist, and president and CEO of Nuvance Health
“We often need to reassess our facts. As we tracked data and clinical reports from around the world, we built protocols and policies based on what we believed were established certainties. It became important for us to recognize our understanding would evolve, and our communications needed to reflect that. Early on in the pandemic, we believed the following statements were accurate: people without symptoms don't spread the virus, children don't get sick with COVID-19, the virus is spread purely by droplet transmission, steroids should be avoided, and masks only provide benefit to others. As a learning organization, we tried to honestly share what we knew but, at the same time, invited a questioning attitude without creating unnecessary confusion. As a result of being guided by an evolving consensus that was widely believed to be evidence-based, we quickly established standard clinical approaches across our seven hospitals in New York and Connecticut. We also freely shared what we learned with others, both near and far. As I look back at the past eight months, I'm proud of the many heroes who work in our health system and grateful to our communities for their support.”
Steven L. Galetta, MD, FAAN, neuro-ophthalmologist and chair of neurology, NYU Langone Health
“It is critical to be timely about communicating ever-changing directives and data as the pandemic evolves. The most important thing I learned during COVID-19 was the need for bidirectional communication. It was essential to be a good listener and ask people what they were most comfortable doing during a crisis; playing to people's strengths proved to be the best approach. The pandemic affected individuals in so many ways, so one prescription did not fit for all.
There were some very challenging circumstances. Some neurologists had to see patients for virtual visits while simultaneously being mom and dad. It became clear that we need better solutions for child care going forward. At the same time, the residents, intensivists, and stroke specialists saw a lot of people die, and that was traumatizing. The psychosocial aspects of this pandemic have been enormous. In the future, I would want to make sure that our teams were hearing from me and that I was listening to them. We needed people to know that we were out there for them in this period of social and physical isolation.”
James C. Stevens, MD, FAAN, neurologist and AAN president
“Never underestimate the resourcefulness, creativity, and resilience of human beings. For a leader of an organization, calm and clear-headed thinking are essential when faced with a sudden, unexpected challenge. My initial assessment consisted of gathering the most reliable information available at the moment concerning the pandemic's potential impact on individuals and the organization, then prioritizing the actions required, and adjusting as more information became available.
Communication proved equally critical: messaging concerning our planned actions—cancellation of the annual meeting, telehealth, personal protective equipment (PPE), financial support opportunities, the latest science, and more—by maintaining ‘contact’ in our physically distanced/quarantined environment.
This entire organization came together to ensure the delivery and support of science and educational content, telehealth instructions, advocacy, PPE, and financial resources through our web and SYNAPSE sites and via virtual meetings. Since the public health emergency was declared in March, I have been impressed each day by the accomplishments of our AAN staff, committees, volunteers, and members. Everyone's willingness to adapt and find solutions to our dramatically changed environment has been nothing short of astounding and has been a profound lesson that I will carry with me always.”
Jennifer Bickel, MD, FAAN, headache section chief in the neurology division at the University of Missouri and COVID employee wellness officer at Children's Mercy Hospital
“Through this time of crisis, we have learned that we have the power to choose how we respond. The first eight months of the pandemic drastically altered our jobs, our communities, our families, and ourselves. Many of us were suddenly confronted with the fact that our mission to serve others could endanger ourselves and our loved ones. Some of us worked countless hours on COVID-19 units in roles way beyond our comfort zones. Some of us lost our jobs. Some of us watched our academic productivity slump as we balanced being a parent with being a researcher. And most of us could not spend time together after our beloved conferences were canceled one by one. However, we have all used our values and our mission to guide how we will navigate this changed world. We have found inspiration and pride in our colleagues on the frontlines. We have been comforted by the neurologists who found ways to entertain us through virtual trivia, Zumba, mindfulness, and so much more. We have realized that we must take care of ourselves to take care of others. None of us know what the next eight months will look like, but we all know we are stronger than we were prior to the pandemic.”
Neil A. Busis, MD, FAAN, associate chair of neurology for technology and innovation and clinical director of the telehealth program for NYU Langone Health
“Telemedicine transformed the practice of neurology and was demonstrated to deliver care without compromise. Conventional wisdom dictated that the teleneurology examination would subsist of a very small subset of the in-person neurology examination. With a shift toward examination by observation, functional testing, and use of household objects, the virtual neurology examination was found to be far more comprehensive than one might have expected before the pandemic. The old cliché that ‘necessity is the mother of invention’ holds true for the remote general neurological examination. First came the need to switch to virtual neurology encounters due to the pandemic; next came a flurry of creativity that dramatically improved what we all thought the virtual neurology examination could accomplish. Future research is likely to reveal that quality of care is akin to that of traditional face-to-face visits and, in fact, exceeds it in providing opportunities to evaluate and address the social determinants of health since patients can be examined in their homes.”