COVID-19 fundamentally changed society. More than 18 months into the pandemic, schools have implemented a range of remote, hybrid, and in-person models to educate students, employees in many business sectors have worked remotely, and various lockdowns and mask mandates have been instituted over time. Notably, the health care systems nationwide have been stretched beyond capacity during peak waves. As a semblance of normalcy appears to be within reach, at least in places with high vaccination rates, one Orthopaedics faculty member at Yale School of Medicine paused to reflect.
Lee E. Rubin, MD, is an associate professor and division chief of Adult Reconstruction with the Department of Orthopaedics & Rehabilitation as well as chief of the Total Joint Replacement Program at Yale New Haven Hospital. He offers an inside look, not only to what physicians and surgeons have experienced, but what he has done personally to keep focused and prioritize mental health.
“The onset of COVID in March 2020 had an enormous impact on our clinical activities,” Rubin said. “Based on the public health crisis and the governor’s orders, we had to immediately wind down and stop all elective surgeries, and simultaneously determine how to care for patients needing urgent or emergent surgical care.”
One of the most critical shortages in the early stages of the pandemic was personal protective equipment (PPE). Suddenly, there was an immediate lack of PPE and sterile supplies for the operating room, as existing materials had to be diverted to COVID care in the emergency department, medical wards, and intensive care units. During the initial months of COVID, additional supplies were difficult or nearly impossible to obtain.
Lisa Lattanza, MD, chair of orthopaedics & rehabilitation, spearheaded efforts to organize collections and donations to increase PPE supplies. Lattanza worked with suppliers across the Northeast to secure more gowns and procure masks for physicians at sites across Yale New Haven Health. Through friends of Yale in China, Frontline Heroes, manufacturing companies in Connecticut, and thanks to local and national innovation and community support, more than 30,000 masks and over 100 hazmat suits were delivered within the first few weeks of the pandemic.
The highly contagious nature of COVID-19 presented barriers beyond PPE, which required health care providers to quarantine given their frequent and direct contact with patients. “Our attending surgeons took turns staffing the total joint service each week, so that we could care for patients with urgent needs while also sequestering the other surgeons and staff from COVID exposure to protect them if anyone was to become sick or incapacitated,” Rubin said.
Academically, many clinical research projects in the Department of Orthopaedics & Rehabilitation were also impacted. Rubin added, “For example, Dr. Jinlei Li, Dr. Michael Leslie, and I were working on a prospective randomized controlled trial evaluating the effectiveness of different peripheral nerve blocks for hip replacement, but we could not continue this for months as no elective hip replacements could be performed during that time, forcing a major delay in completion of this project.”
He continued, “At that same time, I also was working with Dr. Jodi Sherman, Dr. David Gibson, and Dr. Dan Wiznia on a semester-long seminar and research project in partnership with the Yale School of Public Health and Yale School of the Environment to understand and evaluate the environmental impact of joint replacement surgery, and that work also had to be completely suspended.”
Additional collaborative endeavors were adversely impacted. The adult reconstruction division is fortunate to have a unique program that enables the department to host international surgeon visitors and scholars during the academic year, funded by Dr. Kristaps Keggi via the Keggi-Kimball International Surgeon Education Endowment Fund at Yale University. Prior to COVID, plans were in place to host orthopaedic surgeons from Latvia, Egypt, Singapore, Brazil, and Costa Rica. All were postponed indefinitely.
While lockdowns affected much of the nation, the likelihood of contracting COVID felt imminent for many health care providers. Mental health quickly came into focus as physicians and hospital staff navigated an overwhelming number of patients, the stressors of a highly contagious virus, quarantine protocols, and PPE shortages.
“The threat of illness or death has been real for everyone during the pandemic, and anxiety about this impacted physicians to a very significant degree, as health care workers were at the highest risk of exposure during the initial waves of COVID prior to the vaccine,” Rubin said. “I wanted to keep my patients, residents, faculty, and staff safe, but I also spent a great deal of time and energy working to keep my family safe. My wife and kids were quarantined at home, but I continued working in the hospital and our office to a limited degree. I felt an obligation to do everything possible to embrace and advocate for the best possible public health practices and protect my patients, my community, and my family from exposure.”
The threat of illness or death has been real for everyone during the pandemic, and anxiety about this impacted physicians to a very significant degree, as health care workers were at the highest risk of exposure during the initial waves of COVID prior to the vaccine.
Lee E. Rubin, MD
As the pandemic progressed, so did the need to adapt in other areas of family life, such as education. Rubin added, “Having our two kids stay at home for elementary school, which was conducted via Zoom, was a sudden change and another unique challenge, as my wife and I both tried our best to continue working our full-time jobs while also supervising their transition to remote learning.”
Elective operations began to resume in July 2020 after COVID restrictions lifted. The Department of Orthopaedics & Rehabilitation immediately began to manage a backlog of more than three months’ worth of elective hip and knee operations from patients whose surgeries had been cancelled during that initial wave.
To accomplish this, total joint surgeons worked six days a week and performed cases on Saturdays for two months to accommodate those patients. Yale physicians ran office clinics at upwards of 120% capacity to see patients, working tirelessly to help them.
Since that time, Rubin has observed a trend of older, vulnerable patients who chose to completely avoid any contact with the medical system during the first year of COVID. The patients only began to visit physicians again in the spring of 2021, after vaccines became widely available to the public. By the time some of these patients saw a doctor, many had severe, disabling arthritis symptoms that had significantly advanced, making their surgical care much more complex and challenging.
“We also have seen many patients with neglected joint replacement failures, who have allowed their hip or knee to wear out to an alarming degree because they did not want to seek care during the COVID era,” Rubin added. This, in turn, makes interventional and surgical treatments more complicated, which can ultimately contribute to a slower recovery time or yield a clinical result that may not be as optimal as if the patient had sought care at the onset of a problem.
For Rubin, living and working through the pandemic has allowed him to find deeper roots in communities with common interests. Social media has been an incredibly helpful outlet, especially Twitter. Tweeting under the handle @DrLeeRubin, he is actively involved with current events, public health, and health care policy, as well as regular discussions about cases and surgical concepts with colleagues from around the country and all over the world.
In fact, as Dr. Rubin became a more active participant in the online #OrthoTwitter community, he became ranked by the Medical Device Network as being one of the 10 most influential orthopedic specialists on Twitter.
“I have also become very active with my Peloton bike, which has allowed me to exercise and productively engage with other physicians, nurses, and fellow orthopaedic surgeons online, often in real time,” he said.
“We use the group #SkeletonCrew to ride together, push each other, and hold one another accountable to exercise,” Rubin added. “I have now completed over 900 rides and close to 1,000 workouts overall, many of which have been in the past 18 months. These workouts have helped me work through the stress, emotional exhaustion, and social isolation of the pandemic.”
Embracing the concept of “movement is medicine,” Rubin has found his strength and built newfound resilience through these outlets. Today, he continues to lead his division forward with hope for a new post-pandemic era ahead.