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This COVID-19 Practice: The Things We Carry With Us. Neurologists on the Lessons Learned from a Pandemic

Neurologists, like physicians all over the world, had to change the way they practiced medicine—practically overnight—as the fast-moving COVID-19 pandemic—spread in the first months of 2020. But as practices begin to reopen, Neurology Today asked seven neurologists from the US, Italy, and France about what they learned from the COVID-19 pandemic.

Some of them were redeployed at their hospitals to take care of COVID-19, while others turned to telemedicine to care for their neurology patients during the crisis. Their interviews offer insights into how to adapt, work collaboratively, and challenge assumptions when confronted with a new medical challenge.

EvergreenHealth Neuroscience Institute, Kirkland, WA

When the first known US deaths from COVID-19 occurred at EvergreenHealth in patients from the nearby Life Care Center, it appeared to be a severe respiratory illness, said David J. Likosky, MD, SFHM, FAAN, FAHA, a neurohospitalist and executive medical director of EvergreenHealth Neuroscience Institute.

The thought was that "there were not a lot of neurologic issues," said Dr. Likosky. But as cases there and around the country grew, it started to become apparent that multiple organs and systems were involved.

"We were experiencing things as they were unfolding," including encephalopathies, strokes, and other neurologic issues, said Dr. Likosky. "It reminded me of when I was a resident in the 90s, when we had a lot of neuro-AIDS patients, and we were learning as we went."

Dr. Likosky said he and his colleagues recognized early on that a timely exchange of information was crucial as reports on COVID-19 emerged from around the US and other countries. They connected with physicians in China, and the hospital utilized email, twice weekly phone calls, and video chats to keep staff informed.

Dr. Likosky said the hospitalists decided to develop a written set of protocols and best practices based on current understanding. It included information on everything from how to correctly don, remove and conserve protective gear, as well as advice on putting patients in the prone position to reduce the need for mechanical ventilation. The document is still regularly updated.

What did he and his colleagues learn? "We recognize that things will continue to change from here on in and we need to be prepared for what is next around the corner," Dr. Likosky said.

Mount Sinai Hospital, New York City

It seemed like a daunting assignment when Stephen Krieger, MD, FAAN, associate professor of neurology at Mount Sinai Hospital, learned he would be among the neurologists redeployed as internal medicine attendants to care for COVID-19 patients. Dr. Krieger's specialty is multiple sclerosis and as a resident, he said, "I did one year of internal medicine 18 years ago. At the same time, I also wanted to contribute."

By the time Dr. Krieger finished two weeks on the COVID-19 floor, he had learned that his neurology training had prepared him well in many ways.

 "Neurologists in general are true clinicians. We practice a form of hands-on medicine and patient care that I think lent itself to the challenge of taking care of people with COVID. We think critically and take into account physical exam findings and clinical presentation," putting together clues to arrive at a diagnosis, he said.

However, his usual mode of taking time with patients and making collaborative care decision was largely gone.

 "We had to make decisions more quickly and spend little time in the room with a patient," he said. Physical exams were kept to a minimum.

"It was almost like seeing a field of medicine evolve in real time," Dr. Krieger said. "Usually treatments and strategies evolve over years, but with novel COVID-19, everyone had to be nimble."     

Dr. Krieger said camaraderie among staff quickly took hold. "One of the enduring things for me about the experience was seeing people of diverse specialties and skillsets working together for a unified purpose. Modern medicine is so fractured, and every specialty and subspecialty usually work in their little niches."

Dr. Krieger is back to treating his MS patients and is pleased to see that early concerns that patients on immunomodulatory therapy might be vulnerable to COVID-19 have not seemed to pan out. He said his MS patients still face "a common, long-term enemy" and his energy is refocused on how best to apply what is known in that field to their benefit.

University of Texas Health Science Center, San Antonio, TX

Carlayne E. Jackson, MD, FAAN, professor of neurology and otolaryngology and division chief for neuromuscular disease,

had no time to overthink when the decision was made to switch outpatient appointments to telemedicine. She cares for patients with neuromuscular diseases and "we felt very committed to figuring out how to provide their regular care."

"We really pivoted quickly from a clinic that did not do any televisits to one that during the pandemic had 1,000 telemedicine visits," she said.

At first, patients and caregivers were a bit hesitant and sometimes confused about using Zoom Health. Fifteen minutes or more of a one-hour appointment would be lost to figuring out what button to push or to position the camera, Dr. Jackson said. The clinic staff quickly discovered that doing a test run with patients the day before appointments led to more productive televisits.

Dr. Jackson missed her usual methods of assessing patients, "but I was amazed at how much information I could get without the (neurological) exam."

She conducted new patient visits, regular checkups and medication adjustments, and even delivered difficult diagnoses such as amyotrophic lateral sclerosis based on test results and other reports gathered pre-pandemic.

"With most of these diagnoses, there are treatments and I felt that it wasn't right to withhold therapies waiting for the pandemic to end," she said.

Dr. Jackson followed up with some patients she had not seen in a long time because their disability makes it hard to travel. It helped to get a glimpse of patients in their home environments because it offered insight into their level of functioning.

"I had one patient who I hadn't seen in four years," she said. "He's on a ventilator and bed-bound. I was able to connect with those patients, and that has been the biggest silver lining" of the pandemic.

University Hospital, Padua, Italy

"At the very beginning we had just a simple surgery mask. A simple surgery mask in front of a very aggressive virus doesn't help you much," said Angelo Antonini, MD, PhD, professor of neurology and head of the movement disorders unit at the department of neuroscience at University Hospital in Padua, Italy, one of Italy's COVID-19 epicenters.

By the time the COVID patients stopped filling the hospital, Dr. Antonini had been tested seven times for the virus, a number he offers not as a badge of honor but simply as evidence of his role as a doctor in helping his community get through the deadly pandemic.

"We always have the impression, we know everything and that everything has already been written. But with this virus we knew very little," said Dr. Antonini, who normally takes care of patients with movement disorders.

One COVID-19 case in particular has stuck with him: That of a middle-aged cardiologist who, five days after seeing in his office an older patient who initially tested COVID-negative, lost his sense of smell and taste and within 48 hours, developed seizures and was in the ICU on a ventilator. The doctor had inflammation throughout his body. His acute course was difficult and unpredictable, including multiple organ failure, encephalopathy and generalized seizure.  

It took three weeks for the cardiologist to come out of a coma and he is now in a rehabilitation center.

Dr. Antonini said a key question to answer going forward is whether the SARS-CoV-2 virus is neurotrophic or whether the neurologic symptoms are secondary to the inflammatory aspects of the disease. (He thinks the latter.)

An autopsy he was involved with before autopsies were halted due to safety concerns showed blood clots all over the body, but no damage to the brain, Dr. Antonini said. He is in contact with Columbia University researchers to study autopsies done on other COVID-19 patients trying to understand possible brain damage from the virus.

Dr. Antonini has returned to caring for his usual patients, some of whom suffered unintended consequences of being ordered to stay home. A woman with dystonia got so confused that she took an overdose of benzodiazepines. A man with Parkinson's disease became severely psychotic and had to be admitted to a psychiatry ward, likely due to being isolated for so long, Dr. Antonini said.

Dr. Antonini wonders whether the memory of the pandemic and how people joined in solidarity will fade.

"We as humans tend to forget," he said. "We might get back to business as usual very soon."

 

Salpêtrière University Hospital, Sorbonne University

Paris, France

Marie Vidailhet, MD, a professor of neurology at Sorbonne University and a movement disorders specialist at one of the largest public hospitals in Paris, refers to the past few months as the "dark time of COVID."

"We were overloaded with work, some of our colleagues and staff got COVID-19 disease, and some of them were admitted in serious condition to COVID wards and that made us sad and anxious, hoping for a rapid recovery. We saw the exhausted nurses and residents; people locked in their houses to prevent contamination; and patients afraid to go to hospital even though they were suffering from transient ischemic attack. For them, there was a lost chance to get better or to prevent worsening of the symptoms. We perceived the anxiety, distress, and loneliness of our patients and could not comfort them as much as they would have needed." 

There were gratifying moments as well.

"We (neurologists) realized that we had a rapid adaptability and could invest our energy in a large number of missions that were beyond our usual expertise and routine and that we did it willingly, with enthusiasm, motivation and tirelessness. We saw that we could learn quickly about new things far from neurology and that we were happy to do so. We spent more time with other colleagues from different horizons in an impressive surge of energy and with a common goal and urgency to save and treat as many patients as possible."

"This pandemic outburst changed a little of our humanity," Dr. Vidailhet said, "and it was intense and emotional."

Johns Hopkins University, Baltimore, MD

Charlene E. Gamaldo, MD, FAAN, professor of neurology

and medical director at Johns Hopkins Center for Sleep, said she can't imagine a better teaching tool than the COVID-19 pandemic.

"We are living history," said Dr. Gamaldo, vice chair for faculty development for Hopkins' neurology department. Not only is there the still unfolding science and medical understanding of the coronavirus, but the pandemic has revealed a lot about how people deal with a crisis, she said.

"I think it's a time to teach future (medical) leaders that they need to be adaptable in times of uncertainty," Dr. Gamaldo said.

In her own field of sleep medicine, she had to adapt to using telemedicine for consultations and rely even more on in-home monitoring instead of lab monitoring to make diagnoses. She had to think more about a basic tool of sleep specialist—CPAP used for sleep apnea—including questions about how the machine could be safely delivered to sleep patients and whether the device could potentially spread COVID germs to others in the household.

Dr. Gamaldo said her thinking evolved on whether it was wise to keep known COVID-positive patients on CPAP, deciding in the end it was better to keep their airways open to provide a good night's sleep as they dealt with their symptoms.

Dr. Gamaldo said the COVID-19 pandemic reminded her of the importance of keeping communication flowing among faculty and staff "to remind each other that we are here to support one another in our mutual goal to provide excellent care to our patients."

Also, she said, she learned how important it is to turn to colleagues "who are high in positivity to lift the team up when we are feeling low."

University of Turin, Turin, Italy

Riccardo Soffietti, MD, professor of neurology at the University of Turin and chair of the neuro-oncology department at the City of Health and Science University Hospital, said although he did not take care of COVID patients, the pandemic was constantly on his mind.

 His regular patients wanted assurance that their health would not be negatively impacted by changes in clinical care necessitated by the pandemic, including switching to telemedicine and delaying surgery for benign asymptomatic tumors. He also worried about colleagues caring for COVID patients.

"Basically, we tried to survive (in a larger sense) during March and April," Dr.Soffietti recalled. "The most negative things were the reduction of relationships with patients, and, on the other hand, the risk for the staff members to become ill."

As normalcy returns, Dr. Soffietti has a heightened appreciation for the very essence of being a caregiver. "Human contacts are still important even in modern medicine," he said.