As the department leadership team planned for the outbreak of COVID-19 in Connecticut, they decided that action was needed to preserve the department’s most valuable resource: its people.
Department Chair Gary V. Desir, MD, Paul Beeson Professor of Medicine, announced on March 11 that all department in-person meetings would be cancelled through the end of March, including Medical Grand Rounds, the department’s weekly training forum.
Balancing the department’s educational initiatives with the overwhelming demands of clinical care proved to be difficult. Due to heavy clinical duties, the Section of Pulmonary, Critical Care and Sleep Medicine made use of opportunistic educational opportunities rather than formal events, but focused on ways for their younger physicians to excel. Because information was changing so rapidly, the Section of Infectious Diseases started daily virtual COVID didactic rounds to discuss treatment plans and educate other physicians involved with direct patient care. Along with delivering important information, the infectious disease specialists answered questions from across the hospital. Their expertise enabled them to relieve some anxiety expressed by clinicians. The section also held daily update calls because information was changing so quickly. Hundreds of people from across the university attended these educational calls. There were also concerns across VACHS about exposure, so Shaili Gupta, MBBS; Richard Sutton, MD/PhD; Brian Linde, MD, MPH; and Dan Federman, MD, set up information sessions for all facility staff to ask questions and voice concerns. Epidemiologist Louise-Marie Dembry, MD, MS, MBS, also provided guidance on the calls.
At both YNHH and VACHS, teaching conferences, morning reports, and firm conferences all converted to virtual meetings. Many other sections without such a heavy clinical load began virtual didactics, journal clubs, and grand rounds, which were more widely used than previously and run by many of the physicians who were considered high risk.
The teaching firms at YNHH were restructured as a result of the influx of COVID-19-positive patients. As a result of the changes, the education of trainees was focused on caring for patients with the disease. Department fellows were also affected. Infectious diseases fellows worked in the YNHHS COVID-19 Call Center answering questions from the community. They also still served as fellows, providing back-up on all ID services. Fellows from geriatrics and medical oncology/hematology served as residents on the firms. Endocrinology fellows filled in as extra house staff within General Medicine. Hematology/oncology fellows covered patients at both YNHH campuses, essentially performing residents’ duties. Advanced practice providers in hematology/oncology stepped up to cover services across both York Street and Saint Raphael campuses. General Internal Medicine, cardiology and nephrology fellows cared for COVID-19 patients.
Medical Grand Rounds
Medical Grand Rounds returned after a short hiatus to focus on the COVID-19 pandemic with virtual presentations. The presentations hit record numbers for attendance due to the desire for up-to-date information along with a sense of community.
The scientists and clinicians at YSM and YNHHS performed heroically, facing daunting obstacles as they worked to tame the COVID-19 pandemic in Connecticut. That was the message from a panel of Yale experts who gathered on March 26 for “COVID-19 Update: Caring While Keeping Safe,” a virtual discussion sponsored by the Department of Internal Medicine’s Office of Global Health (OGH). Asghar Rastegar, MD, was the moderator.
Yale’s work has included that of Marie-Louise Landry, MD. When tests for COVID-19 were lacking early in the pandemic, Landry and her lab developed one that met the exacting specifications set forth by the Food and Drug Administration (FDA), which were modified along the way as the pandemic grew and the need for testing became ever more urgent. In order to develop a test quickly, Landry and the laboratory staff adapted the Centers for Disease Control and Prevention test to the instruments available on site, established its accuracy, submitted their data to the FDA, and were able to fill an important need at YNHHS. Landry noted that a significant obstacle to attaining the desired testing levels at Yale as elsewhere is the sporadic supply of reagents—the substances that laboratory tests use to identify the contents of patient samples.
Richard A. Martinello, MD, described engineering controls designed to limit the spread of the virus. Many rooms were converted to negative pressure by YNHHS facility engineers in direct response to the COVID-19 pandemic. Martinello also described a constant need for more PPE for health providers, a problem plaguing medical facilities across the country.
Other aspects of protecting frontline health care workers included their monitoring their own health, according to Mark Russi, MD, MPH. Intensive care units are another point of great concern nationwide, including Connecticut. Charles Dela Cruz, MD, PhD, said the Yale system has developed procedures for determining who needs intensive treatment. There also is the need to treat patients with other conditions that are more typically seen in the ICU.
Yale worked diligently on tracking the transmission of COVID-19. Saad B. Omer, MBBS, MPH, PhD, said most current transmissions in Connecticut come from domestic sources, as they do in New York City and Boston. Omer said the ultimate goal is a safe and effective vaccine for the novel coronavirus.
The April 23, 2020 Medical Grand Rounds was titled “COVID-19 Clinical Management at Yale: What We’ve Learned So Far.” It was presented by Merceditas Villanueva, MD; Maricar Malinis, MD; and Mayanka Tickoo, MD. This event had a record-breaking 1375 people on the virtual seminar.
Villanueva started with the natural history of the disease, its epidemiology, clinical presentation, and testing. She was involved in the first diagnostic case at YNHH and couldn’t believe how much the world had changed in six short weeks. Malinis highlighted treatment options and the treatment treatment guideline, which is frequently revised on the basis of the most up-to-date clinical data, local clinical experience, and expert opinion. Tickoo presented management of critically ill COVID-19 patients in the intensive care unit (ICU). She discussed respiratory support modalities, mechanical ventilation, the use of extracorporeal membrane oxygenation (ECMO), and such surge strategies as ventilator splitting.
Hannah Oakland, MD; Jonathan M. Siner, MD; Alfred Lee, MD, PhD; Charles Dela Cruz, MD, PhD; Elaine C. Fajardo, MD; and Margaret Pisani, MD, MPH presented at the April 30, 2020 event on “Critical Care in COVID-19 Patients.” This virtual seminar was attended by 784 people.
Oakland presented the case of a 33-year old man that was extraordinary but had become commonplace in the MICU. Dela Cruz discussed critical illness from the coronavirus pneumonia standpoint as compared to SARS in 2003 and MERS in 2012, and reviewed data from Wuhan, China; Lombardy, Italy; and Seattle, Washington. He highlighted the potential long-term health care complications in individuals recovering from COVID-19 and discussed ongoing research findings. Siner’s talk covered acute respiratory distress syndrome (ARDS) outside of and during a pandemic like COVID-19. He reviewed the treatment for ARDS and noted that the focus should be on low tidal ventilation, prone positioning, and sensible use of positive end-expiratory pressure (PEEP). Lee reviewed COVID-associated coagulopathy (CAS), which is characterized by such unique features as high D-dimer and fibrinogen levels. Fajardo explained the concern regarding a potential ventilator shortage during the surge in critically ill COVID-19 patients in Connecticut. She explained the principle behind expanding ventilator capacity as well as the limitations of using ventilators that were not designed for critical care in patients with ARDS. She also described two Yale solutions: the Vent Multiplexor and PreVentS devices. Pisani described the impact of the disease on the management of critically ill patients. She explained why COVID-19 has altered patient care, and finished by emphasizing the important issue of the long-term effects of critical illness on health.
As the last Medical Grand Rounds of the academic year, the department held its special event focused on sharing stories on June 1, 2020. The fourth annual “Stories of Yale Internal Medicine” focused on seven clinicians sharing COVID-19 stories. Participants included Bethany Canver, MD; Manisha Juthani, MD; Elizabeth Y. Li, MD; Christina Demopoulos, MD; Cynthia Frary McNamara, MD; Hafsa Nawaz, MD; and Sharon Ostfeld-Johns, MD. Juthani’s piece, titled “Nanima,” is about her relationship with her resilient grandmother whom she called Nanima; her health challenges; and her passing during the COVID-19 pandemic. “Nanima” was published in The New England Journal of Medicine in October 2020.
IM Inpatient Telehealth Elective
YSM suspended medical and physician associate student clerkships and electives in mid-March 2020. These students received a concentrated eight-day didactic course in June called the IM Inpatient Telehealth Elective to prepare them to go back to the wards in July.
When the COVID-19 crisis hit, Mark Siegel, MD, and Ethan Bernstein, MD, were eager to engage students in supporting their team. They asked for student volunteers to help design a pilot project for a possible elective involving remote support. Rising fourth-year MD student Fouad Chouairi, and rising fifth-year MD students Lina Vadlamani, Amanda Zhou, and Isaac Freedman, all of whom were one week into their IM sub-internship when COVID-19 interrupted their work, raised their hands. They hoped to continue as much of their sub-intern role as they could remotely and were eager to help with patient care related to COVID-19.
When it was clear after four days that the students’ involvement was beneficial to the IM team and to student learning, the pilot was converted to a two-week elective. Students were paired with the same resident and intern on COVID-19 teams for the two weeks. Their roles included writing progress notes; participating in rounds remotely; engaging with patients and their families remotely; and conducting literature reviews based on clinical questions that arose during rounds. The aim was to enable students to learn about the COVID-19 pandemic and gain experience with ICU rounding and documentation while also reducing the residents’ workload.
Educational Challenges
Cardiovascular Medicine Fellow Jennifer M. Kwan, MD, PhD, led efforts to understand how the pandemic affects physician-scientists. With the support of the American Physician Scientists Association (APSA), Kwan conducted a national survey this spring of more than 2,000 members in the field, ranging from current MD-PhD students to mid- and late-career researchers. Her preliminary analysis indicates
that the research of women physician-scientists is the most threatened. Young physician-scientists are also bracing for the impact of COVID-19 on their mental health, with post-traumatic stress disorder a potential concern. Fotios Koumpouras, MD, co-authored, “Stand Together and Deliver: Challenges and Opportunities for Rheumatology Education during the COVID-19 Pandemic,” an article published in Arthritis & Rheumatology on how rheumatology education can and should continue during the pandemic. He emphasized the need for flexibility, innovation, and safety as the fellows continue their training.
Other Educational Events
The eighteenth year of Research in Residency Day was altered in April due to the pandemic. With the assistance of the department’s communications team, the poster presentation was held online on a special website so that presenters could interact with virtual attendees.
The Office of the Dean began Dean’s Workshops in late March that focused on the pandemic and featured many department clinicians and scientists.
The department’s Advanced Therapies Group hosted virtual seminars that focused on COVID-19. These included the institutional clinical care experiences from such overseas centers as those in Beijing, China; and a Grand Rounds by Stanley Perlman, MD, PhD, from the University of Iowa, a leading authority on coronaviruses.
The department’s chief residents created a House Staff Educational Series on COVID management. They held six seminars, ranging from palliative care and various therapeutic trials to a webinar with Tehran University of Medical Sciences, in which residents in Iran shared their experiences and insights. VACHS researchers and clinicians shared their findings in numerous publications during and after the first wave of the pandemic. Four major publications are listed:
- Gupta, Shaili, Federman, Daniel G. “Hospital preparedness for COVID-19 pandemic: experience from department of medicine at Veterans Affairs Connecticut Healthcare System.” Postgraduate Medicine. DOI: 10.1080/00325481.2020.1761668
- Spelman, Juliette F.; Brienza, Rebecca; Walsh, Robert; Drost, Paul; Schwartz, Amy; Kravetz, Jeffrey; Pitkin, Patricia; Ruser, Christopher. “A Model for Rapid Transition to Virtual Care, VA Connecticut Primary Care Response to COVID-19.” Journal of General Internal Medicine, July 2020. https://doi.org/10.1007/s11606-020-06041-4
- Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT, Skanderson M, Hauser RG, Schultze A, Jarvis CI, Holodniy M, Lo Re V, Akgun KM, Crothers K, Taddei TH, Freiberg MS, Justice AC. “Covid-19 Testing, Hospital Admission, and Intensive Care Among 2,026,227 United States Veterans Aged 54–75 Years.” medRxiv [Preprint]. 2020 Apr 14:2020.04.09. 20059964. doi: 10.1101/2020.04.09.20059964.PMID: 32511595; PMCID: PMC7276022.
- Federman DG, Gupta S, Stack G, Campbell SM, Peaper DR, Dembry LM, Fisher A, Tarabar AF, Kozal M, Ruser CB. “SARS-CoV-2 detection in setting of viral swabs scarcity: Are MRSA swabs and viral swabs equivalent?” PLoS One, 2020 Aug 5;15(8):e0237 127. doi: 10.1371/journal.pone.0237127. PMID: 32756602; PMCID: PMC7406068.