Orthopedic residents share perspectives on redeployment to COVID-19 care

Last updated: 05-11-2020

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Orthopedic residents share perspectives on redeployment to COVID-19 care

The decision to become a physician may be motivated by numerous influences. However, at the core is the desire to care for people and the sense of purpose that comes with positively affecting the lives of others. Somewhere along the journey, the people, responsibilities and challenges stand out among all others as the place where we feel we belong. The day we matched to an orthopedic surgery residency will never be forgotten.

For the orthopedic surgery residents in New York City who have dedicated themselves to help fight the battle against the COVID-19 pandemic, their experiences reveal another moment in life they will never forget. Repurposing their efforts to support our frontline and critical care colleagues, in some cases working side by side with their professional mentors, has provided a sense of purpose, belonging and reassurance that they are in a profession they can be proud of, as well as thankful that their future as orthopedic surgeons will be focused on the improvement in their patients’ lives and quality of living.

Anthony A. Romeo, MD: You have transitioned from being an orthopedic resident into a new role to help with the COVID-19 pandemic. How has this experience been?

Nicole M. Stevens, MD: We deployed residents in four different areas of the hospital: ED, medicine wards, ICU and proning teams. I was assigned to the ED. Although I was excited to provide assistance on the front lines, I was also nervous about treating patients with COVID-19, especially as I have not managed medical patients in some time given I am in my chief year of residency. Fortunately, this transition was made easier by the overwhelmingly grateful and supportive ED staff.

Treating my first patient with COVID-19 was nerve wracking. I didn’t know the questions to ask to get a thorough history or the physical exam findings to check, let alone how to treat, anyone. This widespread uncertainty was disorienting, but the ED residents and attendings were wonderfully helpful, and I eventually got the hang of it.

Overall, I was happy to be able to offload to providers who have truly been on the front lines. I felt supported in my role and was given the assistance I needed. Still, I miss orthopedics.

Josephine R. Coury, MD: In the early stages of the COVID-19 pandemic at Columbia-New York Presbyterian Hospital, the ED was overwhelmed taking care of critically ill patients. Normally, patients requiring ICU level care are quickly whisked up from the ED to ICU, but when COVID-19 hit, we had up to 25 to 30 intubated patients in the ED awaiting beds. The orthopedics team volunteered to help bridge this gap in the care of critically ill patients awaiting placement in the ICU. The ED nurses needed our help the most, with an endless number of tasks for each patient. One of my shifts was an overnight 8 p.m. to 8 a.m. with Christopher S. Ahmad, MD, the “Tommy John” expert and team physician for the New York Yankees and New York City Football Club. It was a unique experience I will never forget: an orthopedics PGY-1 resident paired with one of the most famous sports surgeons in the world helping phlebotomists, nurses, patient transport and medicine residents in the ED overnight. Everyone in the ED worked together and collaborated – no duty too small or large, like an army with no rank. The whole dynamic changed from individuals with tasks to a dedicated team fighting COVID-19.

John D. Mueller, MD: This experience has been reminiscent of what it was like as a medical student on the wards, attempting to identify how we can be most helpful. We’ve transitioned from immersion in the world of orthopedics and management of relatively healthy patients to the foreign land of ICU medicine, where, at the peak of the COVID-19 surge, it was rare to find a patient who was not intubated and multi-death shifts were commonplace. This acute change has converted many of us from confident surgical trainees to at times helpless observers, wishing we could simply surgically excise the disease (preferably arthroscopically). During redeployment, there are no longer attending surgeons, chief residents or interns – rather, everybody is brought back to earth, and our greatest offering is our willingness to help. 

Nana O. Sarpong, MD, MBA: Our role as orthopedic surgeons may seem peripheral at best during this COVID-19 pandemic at first glance. The significant surge in the number of cases and the number of patients needing intensive care has taxed our hospital capacity, in both space and personnel. As a result, surgical specialists including orthopedic surgeons have had to take on new roles in not-so-familiar territory. Most of us who pursue a career in medicine are primarily motivated by altruism and thus the decision to redeploy, while voluntary, was an easy one.

In orthopedic surgery, we are able to fix and improve most things, often times dramatically and relatively rapidly, with immediate gratification. Furthermore, few of our patients die in orthopedic surgery. This new experience was initially daunting, as many patients were presenting in critical condition, some in arrest and requiring immediate intervention. The thought of having to run a ventilator and manage intravenous medications/drips in an intensive care setting was met with mixed emotions and trepidation, as I had not done this in years and frankly have had limited training in this area. Thankfully, there has been adequate orientation, supervision, adequate supply of personal protective equipment and extraordinary teamwork by all health care providers in our hospital system.

Robert M. Zbeda, MD: Our experience was slightly unique in that our residents decided ourselves to repurpose. In the middle of March, our elective case volume decreased significantly and the number of COVID-19 cases in the hospital were rapidly increasing. We could not accept the idea of sitting idle while our colleagues in other departments were getting pummeled. Under the leadership of one of our attendings, Teo Mendez, MD, we approached the director of critical care, Charles M. Carpati, MD, about how we might be able to help. We developed a multidisciplinary prone positioning team involving orthopedics, physical therapy and critical care. Our mission was to prone position patients on ventilators to hopefully save patient lives and also unburden our critical care nurses and doctors.

Approximately a week after we started our work, the hospital was going to repurpose our residents on COVID-19 units, but the director of critical care insisted that we continue our work with prone positioning in the ICUs and that became our official role. Since then, we have been working in the ICUs everyday turning patients. At the peak of the crisis in New York, we were turning 20 to 30 patients per day. Our team is now up to more than 30 volunteers and consists of residents, fellows, attendings, physician assistants, physical therapists and surgical technicians.

Daniel P. Murray, MD: This has been a whirlwind of an experience, especially in New York. I would have never believed you if you told me 6 months ago that this is what I was going to see. I certainly never could have envisioned this as part of my residency experience. The uncertainty has been frustrating at times. As the weeks go by, we grow increasingly anxious to return our work and our home lives to normal. However, there have also been some rewarding moments that have come from this crisis. Our residency program was always close-knit, but the upheaval of this crisis has brought an even greater sense of camaraderie to our department. We are living in an environment I never would have thought was possible and working in a capacity none of us could have foreseen. But we are in this together and I think this experience will be a bond that we share long after this pandemic has ended.

Jessica Morton, MD: As an orthopedic resident, I switch weekly between orthopedic responsibilities and COVID-19 ICU responsibilities. Transitioning from an orthopedic resident to a resident in one of the expanded COVID-19 ICUs has been humbling to say the least. Many of the clinical situations we face are far outside our orthopedic comfort zone and what we typically see in our patients. While the learning curve has been steep, the collegiality of the ICU team including our medicine colleagues, critical care attendings, nursing staff and respiratory therapy, has been inspiring. They have softened the transition with clinical pathways and guidelines, medical refreshers and case-by-case learning points.

Matthew R. Boylan, MD, MPH: It was a big change for me and my co-residents at the beginning of the crisis, but we have quickly adjusted into our new roles. Fortunately, I’ve been able to help with the pandemic response while continuing to provide orthopedic trauma care at Bellevue Hospital, a level 1 trauma center in lower Manhattan.

Stevens: I was deployed to the emergency room at a public hospital. They had redistributed their physical space into a COVID-19 unit and a non-COVID-19 unit. I worked in the two different units in the junior resident role. I would see a patient primarily, begin the initial work up, and then discuss the case with a senior emergency resident or attending. I mostly took care of the lower acuity patients, but also took part in a myriad of codes. As the main referral center for the surrounding hospitals, the ED was accepting many transfers from other severely overcrowded EDs, and many of the transferred patients would come in very decompensated. These were some of the most frightening patients to take care of as some of them would code almost immediately on arrival.

Coury: Typically, we start our shift by rounding with the ICU doctors. We review the patient history, clinical course, labs, ventilator settings, vital signs and “ins” and “outs.” At the end of rounds, we have a list of tasks to complete including: drawing basic labs and blood cultures, placing IVs, femoral and radialarterial blood gases (ABGs) (sometimes ultrasound guided in difficult patients), placing foleys, placing nasogastic tubes, transporting patients for imaging studies, refilling oxygen tanks, monitoring ventilator settings, reassuring patients, calling families and, unfortunately, CPR if a patient coded. In the ED, patients are spread through several areas, so hourly we would walk by the patients to monitor their clinical status. As the ED volume decreased, the ICUs became full and we transitioned to shifts in the OR-ICUs. Our role and the shift format were essentially the same. 

Mueller: Our role has been fluid and dependent on which team we are assigned to at the time. While in the ED, we’ve rotated between functioning as ED residents (seeing lower-acuity patients, expediting discharges, coding patients) to helping run ICU-extensions (drawing ABGs, monitoring patients and calling consults) to accomplishing general tasks (transporting patients, helping overworked nurses with vitals and running samples to the lab). 

Sarpong: My responsibilities have varied as we have redeployed from the emergency room to new intensive care units that have built in previous operating rooms, as the needs for the ER had changed. The shift begins with walk-rounds with the attending physician and ER/ICU fellow to orient ourselves to each patient. Thereafter, tasks for the shift begin, and range from physical (placement of peripheral IV lines, drawing blood gases, transport of specimens to laboratory and patient transport) to administrative (phone calls to families, radiologists, consultants and following up on studies). I have also participated in multiple rounds of advance cardiac life support, including chest compressions, unfortunately.

Zbeda: Our main responsibility is to prone position intubated patients to improve lung oxygenation and hopefully help patients wean off mechanical ventilation. By taking over this time-consuming and labor-intensive task, we enabled our critical care staff to focus on the most essential matters and reduce their daily viral exposure. The actual process and steps of prone positioning is described in our article published recently in JBJS Open Access by Rahman and colleagues. 

As we gained experience in the ICU working with our critical care staff, we performed additional tasks to offload the staff as much as possible. This included chest physical therapy, oral suctioning, endotracheal suctioning, inserting/exchanging foley catheters, cleaning/dressing/flushing central and arterial lines, hanging medications, wound care, decubitus ulcer prevention, changing soiled linens, patient hygiene, titrating oxygen intake and picking up trash. No task or job is beneath our team and we are prepared to do anything to help.

Murray: The postponement of elective surgeries and outpatient office visits freed our residents, fellows and attendings from most of our typical clinical duties and left us with excess manpower. Early in the COVID-19 surge in New York City, some members of our department asked our intensive care colleagues how we could best help them. The results were the creation of a unique role for us during these times. We developed a prone positioning protocol, where our department provide teams of people to help to reposition intubated patients twice per day. This idea was borne out of evidence seen in the critical care literature for the efficacy of prone positioning for other causes of acute respiratory distress syndrome. The intensivists managing the care of these patients determine who may benefit from a trial of prone positioning. Our duties are to safely flip these patients while maintaining their endotracheal tubes, arterial lines, urinary catheters and all other monitoring devices. We gathered a group of roughly 25 department members who participate strictly on a volunteer basis and we have been working in this capacity since March.

Morton: As part of the COVID-19 response, I have been working night shifts in the ICU under the close supervision of a critical care attending. I assist in the management of patients who have been placed on ventilators for COVID-19-associated pneumonia and acute respiratory distress syndrome. These are some of the sickest patients in the hospital and require frequent monitoring and intervention, whether it is drawing an ABG, managing electrolytes, adjusting ventilator settings, titrating vasopressors or coordinating consulting services. One of the most important responsibilities in this new role is communicating with the families on patients’ status while they are in the ICU and discussing their goals of care.

Boylan: During the past 2 months, I have been a member of the prone team. Proning is utilized to improve oxygenation for intubated patients who are not responding to standard ventilator protocols. Each afternoon, a team of orthopedic surgery residents and attendings is deployed to the ICU with an anesthesiologist to place patients in the prone position and return them to a supine position the following morning. It is a fairly straightforward task but is time-consuming because of the sheer number of patients who need it done. Our department’s involvement has allowed the intensive care doctors and nurses to focus on medical management of these complex patients.

Stevens: My biggest takeaway from this experience is the overall resilience of the ED. I was deployed a couple of weeks into the pandemic, so the physicians and staff in the ED had already been on the front lines for several weeks. Despite high mortality rates and feelings of frustration at their inability to help, the providers still came to work every day, supported each other and maintained an excellent level of care.

Second, I learned about facing sick patients. Given the risk of transmission, family members were not allowed at the bedside in the ED. This left patients alone and short of breath; you could see the fear etched on their faces. As orthopedists, we often take care of hurt and upset patients, but we do not often encounter sick and dying patients. In my early shifts, I watched as emergency physicians and nurses provided comfort to their patients, despite their own fears. I emulated them and got better at being present for the sick and dying. While I hopefully will not need to use this skill frequently in my career, I think it is a skill that I can take forward into my orthopedic practice.

My final takeaway is the significance of fighting something new. No one in our generation, has ever seen anything like this. As such, treatment strategies are evolving constantly. Even through my several weeks in the ED, protocols were changing daily. There was a monumental shift from early intubation toward preferentially using high flow oxygen. This knowledge came several weeks into the pandemic, as providers learned that it was extraordinarily difficult to wean patients off the ventilators. While I was there, the medical community recognized the hypercoagulable state the coronavirus created, so we began changing anticoagulation protocols. We discussed the role of the antivirals being tested and the myriad of trials underway at our own institution. Despite the fear of managing the unknown and the distress of the casualty rate, I will also remember this as a time of discovery.

Coury: I absolutely have a new appreciation for the ED and ICU staff. On my shifts, I saw several of the same ED attendings who had been working 7 days a week, for weeks on end. I also saw the resilience of the nurses, many in the OR-ICUs who were previously ambulatory preoperative or post-anesthesia care unit nurses who stepped up to the challenge. Even employees not directly involved in patient care – food services, unit assistants, security guards or patient transport – came in dedicated to serving patients on the front line. This included my favorite security guard, Spyder, who always tries to lift my spirits with kind words and coffee. I have a deeper appreciation for the expertise and hard work of the ED, medicine and ICU doctors. I feel a new sense of camaraderie with those I met on my shifts. We will never forget what happened, what we went through together and the patients we lost.

Mueller: This experience has given all of us a massive appreciation and admiration for everyone who has been facing this crisis daily. From the janitorial staff to the nurses to the ED attendings who have had to witness a seemingly non-stop flow of illness and death, we are all amazed at the drive they have to show up and keep on fighting. We’ve also stood in awe as our colleagues in anesthesia, ENT and general surgery have sprinted around the hospital, intubating, traching and placing central lines with barely any time to stop and reflect. This experience has shown us overall what amazing things we can accomplish when we put our heads and efforts together.

Sarpong: From this experience, I have developed an even stronger appreciation for the nursing staff, assistants, phlebotomists, physical and occupational therapists, X-ray and ultrasound technologists on the front lines in the ED and ICU who are the ones spending countless hours during the day and night with these patients, fulfilling doctors’ orders for clinical tests and interventions to these patients. I recognize that all health care providers are practicing at the edges or beyond the scope of their training during this crisis, yet strive to learn more about their new roles and continue to provide high-quality and compassionate care to our patients. I have witnessed a new appreciation for one another that has been refreshing.

Zbeda: The most important thing we learned was how to be adaptable and keep an open mind. This mental flexibility enabled us to be successful in whatever role or situation in which we were thrown. When we started our repurposed role, there was no roadmap or instructions. We worked together as a team in a trial-and-error fashion by constantly providing feedback and training each other to achieve more efficacy and efficiency. We figured out which essential items were needed in the rooms and mastered the step-by-step process. All traditional hierarchy went out the window. Junior residents were giving advice to senior residents and residents were training attendings.

Regarding our critical care colleagues, I cannot speak more highly of the level of dedication, bravery and mental fortitude they exhibited daily during this crisis. Along with the ED and medicine teams, the critical care staff should be heralded as the true heroes of this pandemic. Our mission was to merely support them. They certainly have all our respect and we hope that through this crisis they gained a new appreciation for the orthopedic staff as well.

Murray: I have gained a great amount of respect for the critical care physicians and nurses who are overseeing the care of these patients. I am struck by the complexity of care the patients need whenever I enter a room. Their clinical courses have been unpredictable, and their illness extends far beyond the respiratory system. These patients require constant, delicate management of ventilator settings, fluid balance, circulatory support, anticoagulation, sedation and meticulous nursing care. It is rewarding to know we are assisting the intensive care teams in some small way by reducing their physical workload.

I think our willingness and enthusiasm to help in this way has also instilled the sense of a united front at our institution. We are all familiar with the occasional adversarial relationship between medical and surgical subspecialties. I believe this experience has reminded us that we are all on the same side when it comes to looking out for the best interest of our patients.

Morton: I believe I will be a better and more well-rounded physician due to this experience. Not only is my knowledge of medical conditions and treatments deeper and more practical, but my appreciation for the challenges my colleagues and others face are greatly increased. This experience has broken down traditional hospital roles and service-based differences with all staff working together toward the common goal of recovering patients. It is “all hands on-deck” and the staff I have worked with have responded to the challenge with grace and compassion.

It is hard to put into words the appreciation I have for all the staff I have worked with through this crisis the critical care attendings, critical care nurses, traveling critical care nurses, respiratory therapists, pharmacists, and residents from other services also volunteering in the ICU. I am surely leaving out so many members of the team but remain in awe of what they do and will never forget this experience and their help.

Boylan: From doctors to nurses to ancillary staff, everybody has a role to play in the pandemic response. We’re all in this together. In a time of crisis, there is no substitute for effective leadership. Our residency is fortunate to have a great team of leaders who have kept us informed of the latest developments and ensured our safety and well-being.

Stevens: From a technical standpoint, I had the benefit of working in the ED as an intern, so I had some idea of the general workflow before I got there. Otherwise, I think treating geriatric fracture patients helped prepare me for interacting with the sick patients I was seeing daily. My consult work in the ED was a good model for taking the histories and physicals of the patients I was seeing, although the content was certainly different.

Coury: I think the nature of an orthopedic resident is a doctor who is ready to work hard and do what it takes to get a task done, no matter how many hours or days. We aren’t afraid of much and are eager to learn what we can. My hospital provided educational seminars/trainings about the latest guidelines for COVID-19 treatment at Columbia and I, among many of my co-residents, watched and read all the provided material to be best prepared. When our attendings also volunteered to participate in the battle against COVID-19, it inspired the residents to do our best and be our best.

Mueller: Solid team dynamics are crucial in orthopedics, and our experience in working as an orthopedic team from day one of residency translated seamlessly into the ability to integrate with teams all over the hospital, wherever we were needed.

Sarpong: Orthopedic surgery residency demands a commitment to proper time management, the ability to triage and prioritize tasks, and see these tasks to final execution and completion, regardless of any barriers along the way. Many of us have this “grit” innate in us or develop it along the way in our long training. Is a nurse struggling with a peripheral intravenous line? No problem, I will try it myself and if I am unsuccessful, I will find an ultrasound and find a way into the vein. Are the patient transporters being inundated with the surge in patient volume with transfers in and out of the ER, procedure rooms, ICU? No problem, I will transport the patient myself to free up the bed for the next patient coming in. Is the ICU fellow stuck in the next room doing a procedure? Sure, I can draw this femoral arterial blood gas! The patient’s daughter is on the phone and needs an update on her father’s medical status. No problem, I am happy to chat with her and answer her questions and FaceTime her on my phone so she can see her father since she cannot be here in person. It is this “can do and will do” spirit, working well under pressure and perhaps with limited resources that has prepared me best for this new role.

Zbeda: I don’t think anything can prepare you for a pandemic on this scale. However, I did find some similarities in prone positioning and being on a busy orthopedic service. For example, on a joints service, you are essentially doing the same procedure repeatedly and your goal is to constantly figure out how to make the process more efficient. This attention to detail and self-awareness helped us constantly improve.

Additionally, we also tapped into our experience positioning patients prone and in other various positions for surgery. We often obsess over making sure all prominent areas are well padded prior to surgery and we were able to transfer this skill to our new role. Our patients are prone for 16 hours a day so proper positioning is crucial.

Lastly, I think one of the goals of residency training is to become resilient so you can become grounded during difficult and stressful scenarios like these. Orthopedic surgeons may not be the most knowledgeable about medicine, but we are hard workers and trained to grind it out even when we are stretched thin. I think the 24-hour calls and busy months on a trauma service have helped me develop the resilience needed to make it through these difficult times.

Murray: My residency experience has prepared me well for this new role because orthopedic surgeons are constantly thinking about patient positioning. This applies across the field of orthopedics from physical exams during office visits to emergency department reductions to repositioning intubated patients in the operating room. We understand how we can safely use patient positioning to our advantage on a daily basis. We have completely changed the context in which we do it during the care of patients with COVID-19, but the concepts remain the same. I also believe the mindset of orthopedic residents and surgeons is well-suited for this role. We are always searching for ways that we can be more effective and efficient in our everyday practice and this outlook has carried over into our new responsibilities. Team members are constantly thinking of minor variations to our protocol that can help us be more efficient. This has allowed us to expand the capacity of our proning team tremendously since we first started, allowing us to turn more patients faster and in the safest way possible.

Morton: I believe my ED and ICU rotations as an intern prepared me for the medical aspect of this new role. However, I think the overall culture of our residency best prepared me to transition into a new role, our program emphasizes professionalism and communication amongst staff. Communication has been key and our residency has encouraged me to ask questions when I don’t know something, to listen to your nurses, to speak up if you or the nurse has a concern and above all to have the best interest of the patients in mind – all of which has been valuable in adapting to new clinical responsibilities. Beyond communication, the time management and organizational skills you cultivate as an orthopedic resident are helpful in accomplishing time-sensitive tasks on critical patients.

Boylan: We routinely prone patients for spine surgery, and the basic management of lines and monitors I learned during my intern year. Communication is also extremely important to safely position these medically fragile patients, which is something that I work on every day in clinic and the OR.

Stevens: My first piece of advice would be to rely on the expertise around them – whether that be the internal medicine or emergency medicine physicians, residents and/or nurses. We, as orthopedic surgeons, are out of our element when it comes to the disease we are fighting. Some aspects of treatment, like oxygen titration, are more easily learned, but many components of COVID-19 patient care are nuanced and complex. Ask questions and don’t make assumptions.

My second piece of advice would be if there is time, residents should try and learn something that may be beneficial to their practice. The ED doctors are experts at utilizing the ultrasound as a point of care device. I learned how to put in IVs under ultrasound guidance and while I may not be placing lines, learning how to use the ultrasound machine may be helpful for my future orthopedic practice.

Coury: Being redeployed was a rewarding experience. All the ED and ICU staff were so grateful to have our help. On each volunteer shift, I received a heartfelt thank you from at least five different providers. In terms of specific advice, I recommend familiarizing yourself with basic tasks, ventilator settings and ideally COVID-19 guidelines (if your hospital provides them). The best advice I can give is to come into every shift with the orthopedic mentality of dedication, hard work and eagerness to learn. 

Mueller: While redeployed, it is easy to feel frustrated that your role is not defined, that you aren’t offering much help or that your current job could be performed by someone without any medical training at all. However, in walking around and seeing the weary faces of the workers on the front lines, you quickly realize that your presence alone is a huge morale booster for those who need it most. It is ironic that when encountering colleagues who know us from calling consults, we are met with an enormous outpouring of gratitude for coming to help them out; those who have been on the front lines since day one are the true heroes and we will be forever indebted to them for their efforts.

Sarpong: My advice to orthopedic surgery residents being redeployed is to remember to not lose sight of the “3 As” of being a successful physician — to always be able, affable and available. While we are often not considered frontline doctors in a time of medical crisis, our ED and ICU colleagues are struggling and need our help now more than ever and the rigor in our training has prepared us for this. We have an opportunity to support our colleagues and make a difference in these unprecedented times. It is okay to feel a sense of fear and trepidation but be reminded that you have an honorable skillset to offer that is held to the highest esteem by society. You have the ability to save many lives. Lastly, take care of yourself and please be safe.

Zbeda: Make no mistake – this is a war. All hands are on-deck. Be prepared to help as much as possible. This disease is unrelenting, so you must be unrelenting. You will take care of many patients who will die, sometimes right in front of you, but you will also take care of many patients who will live. Those experiences are the ones you need to hold onto to keep going.

You don’t need critical care training to be effective in this pandemic. You merely need to have an open mind. Check your ego at the door. Prepare to learn from others. Embrace any task that may be helpful. If everyone adapts a similar mindset, there is nothing that can stop us.

Murray: The first thing I would say is to try to develop a prone positioning protocol in your own hospital. Our evidence is only anecdotal at this point, but our intensivists believe it makes a significant difference in the care of the most critically ill COVID-19 patients. Orthopedic residents are well-suited to assist overburdened ICUs in this capacity and I think it is an innovative way to utilize our skills. Other than that, the best advice I can give is to recommend you maintain an open mind. It is easy to view this entire experience negatively because we are being removed from our typical roles and are no longer focused on learning what we intended during residency.

The word “unprecedented” is overused but we are living through a truly unique time in the world of medicine right now. We became orthopedic residents because we are hard-working, motivated and enthusiastic people. We should continue to apply that same mindset to any new roles we have. It will help to create a better work environment at a difficult time and, most importantly, it will benefit any patient you care for.

Morton: My advice as a resident is to try to brush up on your medical knowledge, review your institution’s guidelines for treatments, keep an open mind, listen to those around you with more experience in critical care settings and to ask for help when you need it. My advice as a person is to stay connected with family, friends and your co-residents. It is important that you have a support network you can talk to and process this experience with. As orthopedists, we generally have the unique privilege to care for relatively healthy patients, with stabilized chronic conditions or the acutely traumatized, resulting in relatively few patients expiring while under our care. An unfortunate reality of the COVID-19 pandemic is despite your and all of our current treatment’s best efforts, you will be confronted with more critically ill patients and death than you likely have been as an orthopedic resident. Having a support system in place or reaching out for support during this time is crucial. Take care of your patients and take care of each other.

Boylan: This whole experience has been surreal and is something I never could have anticipated. Keep an open mind, and approach it with the same effort and enthusiasm as any other aspect of residency. Ultimately, I am proud our department has been able to contribute to the response in a meaningful way to help those in need.

Matthew R. Boylan, MD, MPH, is a PGY-4 resident in the Department of Orthopedic Surgery, for NYU Langone Health. Josephine R. Coury, MD, is a PGY-1 resident in the Department of Orthopedic Surgery, New York Presbyterian, Columbia University Medical Center. Jessica Morton, MD, is a PGY-4 resident in the Department of Orthopedic Surgery, NYU Langone Health. John D. Mueller, MD, is a PGY-1 resident in the Department of Orthopedic Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center. Daniel P. Murray, MD, is a PGY-2 resident in the Department of Orthopedic Surgery, Lenox Hill Hospital. Nana O. Sarpong, MD, MBA, is an executive chief resident in the Department of Orthopedic Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center. Nicole M. Stevens, MD, is a chief resident in the Department of Orthopedic Surgery, NYU Langone Health. Robert M. Zbeda, MD, is a chief resident in the Department of Orthopedic Surgery, Lenox Hill Hospital.

The decision to become a physician may be motivated by numerous influences. However, at the core is the desire to care for people and the sense of purpose that comes with positively affecting the lives of others. Somewhere along the journey, the people, responsibilities and challenges stand out among all others as the place where we feel we belong. The day we matched to an orthopedic surgery residency will never be forgotten.

For the orthopedic surgery residents in New York City who have dedicated themselves to help fight the battle against the COVID-19 pandemic, their experiences reveal another moment in life they will never forget. Repurposing their efforts to support our frontline and critical care colleagues, in some cases working side by side with their professional mentors, has provided a sense of purpose, belonging and reassurance that they are in a profession they can be proud of, as well as thankful that their future as orthopedic surgeons will be focused on the improvement in their patients’ lives and quality of living.

Anthony A. Romeo, MD: You have transitioned from being an orthopedic resident into a new role to help with the COVID-19 pandemic. How has this experience been?

Nicole M. Stevens, MD: We deployed residents in four different areas of the hospital: ED, medicine wards, ICU and proning teams. I was assigned to the ED. Although I was excited to provide assistance on the front lines, I was also nervous about treating patients with COVID-19, especially as I have not managed medical patients in some time given I am in my chief year of residency. Fortunately, this transition was made easier by the overwhelmingly grateful and supportive ED staff.

Treating my first patient with COVID-19 was nerve wracking. I didn’t know the questions to ask to get a thorough history or the physical exam findings to check, let alone how to treat, anyone. This widespread uncertainty was disorienting, but the ED residents and attendings were wonderfully helpful, and I eventually got the hang of it.

Overall, I was happy to be able to offload to providers who have truly been on the front lines. I felt supported in my role and was given the assistance I needed. Still, I miss orthopedics.

Josephine R. Coury, MD: In the early stages of the COVID-19 pandemic at Columbia-New York Presbyterian Hospital, the ED was overwhelmed taking care of critically ill patients. Normally, patients requiring ICU level care are quickly whisked up from the ED to ICU, but when COVID-19 hit, we had up to 25 to 30 intubated patients in the ED awaiting beds. The orthopedics team volunteered to help bridge this gap in the care of critically ill patients awaiting placement in the ICU. The ED nurses needed our help the most, with an endless number of tasks for each patient. One of my shifts was an overnight 8 p.m. to 8 a.m. with Christopher S. Ahmad, MD, the “Tommy John” expert and team physician for the New York Yankees and New York City Football Club. It was a unique experience I will never forget: an orthopedics PGY-1 resident paired with one of the most famous sports surgeons in the world helping phlebotomists, nurses, patient transport and medicine residents in the ED overnight. Everyone in the ED worked together and collaborated – no duty too small or large, like an army with no rank. The whole dynamic changed from individuals with tasks to a dedicated team fighting COVID-19.

John D. Mueller, MD: This experience has been reminiscent of what it was like as a medical student on the wards, attempting to identify how we can be most helpful. We’ve transitioned from immersion in the world of orthopedics and management of relatively healthy patients to the foreign land of ICU medicine, where, at the peak of the COVID-19 surge, it was rare to find a patient who was not intubated and multi-death shifts were commonplace. This acute change has converted many of us from confident surgical trainees to at times helpless observers, wishing we could simply surgically excise the disease (preferably arthroscopically). During redeployment, there are no longer attending surgeons, chief residents or interns – rather, everybody is brought back to earth, and our greatest offering is our willingness to help. 

Nana O. Sarpong, MD, MBA: Our role as orthopedic surgeons may seem peripheral at best during this COVID-19 pandemic at first glance. The significant surge in the number of cases and the number of patients needing intensive care has taxed our hospital capacity, in both space and personnel. As a result, surgical specialists including orthopedic surgeons have had to take on new roles in not-so-familiar territory. Most of us who pursue a career in medicine are primarily motivated by altruism and thus the decision to redeploy, while voluntary, was an easy one.

In orthopedic surgery, we are able to fix and improve most things, often times dramatically and relatively rapidly, with immediate gratification. Furthermore, few of our patients die in orthopedic surgery. This new experience was initially daunting, as many patients were presenting in critical condition, some in arrest and requiring immediate intervention. The thought of having to run a ventilator and manage intravenous medications/drips in an intensive care setting was met with mixed emotions and trepidation, as I had not done this in years and frankly have had limited training in this area. Thankfully, there has been adequate orientation, supervision, adequate supply of personal protective equipment and extraordinary teamwork by all health care providers in our hospital system.

Robert M. Zbeda, MD: Our experience was slightly unique in that our residents decided ourselves to repurpose. In the middle of March, our elective case volume decreased significantly and the number of COVID-19 cases in the hospital were rapidly increasing. We could not accept the idea of sitting idle while our colleagues in other departments were getting pummeled. Under the leadership of one of our attendings, Teo Mendez, MD, we approached the director of critical care, Charles M. Carpati, MD, about how we might be able to help. We developed a multidisciplinary prone positioning team involving orthopedics, physical therapy and critical care. Our mission was to prone position patients on ventilators to hopefully save patient lives and also unburden our critical care nurses and doctors.

Approximately a week after we started our work, the hospital was going to repurpose our residents on COVID-19 units, but the director of critical care insisted that we continue our work with prone positioning in the ICUs and that became our official role. Since then, we have been working in the ICUs everyday turning patients. At the peak of the crisis in New York, we were turning 20 to 30 patients per day. Our team is now up to more than 30 volunteers and consists of residents, fellows, attendings, physician assistants, physical therapists and surgical technicians.

Daniel P. Murray, MD: This has been a whirlwind of an experience, especially in New York. I would have never believed you if you told me 6 months ago that this is what I was going to see. I certainly never could have envisioned this as part of my residency experience. The uncertainty has been frustrating at times. As the weeks go by, we grow increasingly anxious to return our work and our home lives to normal. However, there have also been some rewarding moments that have come from this crisis. Our residency program was always close-knit, but the upheaval of this crisis has brought an even greater sense of camaraderie to our department. We are living in an environment I never would have thought was possible and working in a capacity none of us could have foreseen. But we are in this together and I think this experience will be a bond that we share long after this pandemic has ended.

Jessica Morton, MD: As an orthopedic resident, I switch weekly between orthopedic responsibilities and COVID-19 ICU responsibilities. Transitioning from an orthopedic resident to a resident in one of the expanded COVID-19 ICUs has been humbling to say the least. Many of the clinical situations we face are far outside our orthopedic comfort zone and what we typically see in our patients. While the learning curve has been steep, the collegiality of the ICU team including our medicine colleagues, critical care attendings, nursing staff and respiratory therapy, has been inspiring. They have softened the transition with clinical pathways and guidelines, medical refreshers and case-by-case learning points.

Matthew R. Boylan, MD, MPH: It was a big change for me and my co-residents at the beginning of the crisis, but we have quickly adjusted into our new roles. Fortunately, I’ve been able to help with the pandemic response while continuing to provide orthopedic trauma care at Bellevue Hospital, a level 1 trauma center in lower Manhattan.

Romeo: What are some of your responsibilities in this new role?

Stevens: I was deployed to the emergency room at a public hospital. They had redistributed their physical space into a COVID-19 unit and a non-COVID-19 unit. I worked in the two different units in the junior resident role. I would see a patient primarily, begin the initial work up, and then discuss the case with a senior emergency resident or attending. I mostly took care of the lower acuity patients, but also took part in a myriad of codes. As the main referral center for the surrounding hospitals, the ED was accepting many transfers from other severely overcrowded EDs, and many of the transferred patients would come in very decompensated. These were some of the most frightening patients to take care of as some of them would code almost immediately on arrival.

Coury: Typically, we start our shift by rounding with the ICU doctors. We review the patient history, clinical course, labs, ventilator settings, vital signs and “ins” and “outs.” At the end of rounds, we have a list of tasks to complete including: drawing basic labs and blood cultures, placing IVs, femoral and radialarterial blood gases (ABGs) (sometimes ultrasound guided in difficult patients), placing foleys, placing nasogastic tubes, transporting patients for imaging studies, refilling oxygen tanks, monitoring ventilator settings, reassuring patients, calling families and, unfortunately, CPR if a patient coded. In the ED, patients are spread through several areas, so hourly we would walk by the patients to monitor their clinical status. As the ED volume decreased, the ICUs became full and we transitioned to shifts in the OR-ICUs. Our role and the shift format were essentially the same. 

Mueller: Our role has been fluid and dependent on which team we are assigned to at the time. While in the ED, we’ve rotated between functioning as ED residents (seeing lower-acuity patients, expediting discharges, coding patients) to helping run ICU-extensions (drawing ABGs, monitoring patients and calling consults) to accomplishing general tasks (transporting patients, helping overworked nurses with vitals and running samples to the lab). 

Sarpong: My responsibilities have varied as we have redeployed from the emergency room to new intensive care units that have built in previous operating rooms, as the needs for the ER had changed. The shift begins with walk-rounds with the attending physician and ER/ICU fellow to orient ourselves to each patient. Thereafter, tasks for the shift begin, and range from physical (placement of peripheral IV lines, drawing blood gases, transport of specimens to laboratory and patient transport) to administrative (phone calls to families, radiologists, consultants and following up on studies). I have also participated in multiple rounds of advance cardiac life support, including chest compressions, unfortunately.

Zbeda: Our main responsibility is to prone position intubated patients to improve lung oxygenation and hopefully help patients wean off mechanical ventilation. By taking over this time-consuming and labor-intensive task, we enabled our critical care staff to focus on the most essential matters and reduce their daily viral exposure. The actual process and steps of prone positioning is described in our article published recently in JBJS Open Access by Rahman and colleagues. 

As we gained experience in the ICU working with our critical care staff, we performed additional tasks to offload the staff as much as possible. This included chest physical therapy, oral suctioning, endotracheal suctioning, inserting/exchanging foley catheters, cleaning/dressing/flushing central and arterial lines, hanging medications, wound care, decubitus ulcer prevention, changing soiled linens, patient hygiene, titrating oxygen intake and picking up trash. No task or job is beneath our team and we are prepared to do anything to help.

Murray: The postponement of elective surgeries and outpatient office visits freed our residents, fellows and attendings from most of our typical clinical duties and left us with excess manpower. Early in the COVID-19 surge in New York City, some members of our department asked our intensive care colleagues how we could best help them. The results were the creation of a unique role for us during these times. We developed a prone positioning protocol, where our department provide teams of people to help to reposition intubated patients twice per day. This idea was borne out of evidence seen in the critical care literature for the efficacy of prone positioning for other causes of acute respiratory distress syndrome. The intensivists managing the care of these patients determine who may benefit from a trial of prone positioning. Our duties are to safely flip these patients while maintaining their endotracheal tubes, arterial lines, urinary catheters and all other monitoring devices. We gathered a group of roughly 25 department members who participate strictly on a volunteer basis and we have been working in this capacity since March.

Morton: As part of the COVID-19 response, I have been working night shifts in the ICU under the close supervision of a critical care attending. I assist in the management of patients who have been placed on ventilators for COVID-19-associated pneumonia and acute respiratory distress syndrome. These are some of the sickest patients in the hospital and require frequent monitoring and intervention, whether it is drawing an ABG, managing electrolytes, adjusting ventilator settings, titrating vasopressors or coordinating consulting services. One of the most important responsibilities in this new role is communicating with the families on patients’ status while they are in the ICU and discussing their goals of care.

Boylan: During the past 2 months, I have been a member of the prone team. Proning is utilized to improve oxygenation for intubated patients who are not responding to standard ventilator protocols. Each afternoon, a team of orthopedic surgery residents and attendings is deployed to the ICU with an anesthesiologist to place patients in the prone position and return them to a supine position the following morning. It is a fairly straightforward task but is time-consuming because of the sheer number of patients who need it done. Our department’s involvement has allowed the intensive care doctors and nurses to focus on medical management of these complex patients.

Romeo: What have you learned from this experience? Do you have a new appreciation for the non-orthopedic staff who you worked with?

Stevens: My biggest takeaway from this experience is the overall resilience of the ED. I was deployed a couple of weeks into the pandemic, so the physicians and staff in the ED had already been on the front lines for several weeks. Despite high mortality rates and feelings of frustration at their inability to help, the providers still came to work every day, supported each other and maintained an excellent level of care.

Second, I learned about facing sick patients. Given the risk of transmission, family members were not allowed at the bedside in the ED. This left patients alone and short of breath; you could see the fear etched on their faces. As orthopedists, we often take care of hurt and upset patients, but we do not often encounter sick and dying patients. In my early shifts, I watched as emergency physicians and nurses provided comfort to their patients, despite their own fears. I emulated them and got better at being present for the sick and dying. While I hopefully will not need to use this skill frequently in my career, I think it is a skill that I can take forward into my orthopedic practice.

My final takeaway is the significance of fighting something new. No one in our generation, has ever seen anything like this. As such, treatment strategies are evolving constantly. Even through my several weeks in the ED, protocols were changing daily. There was a monumental shift from early intubation toward preferentially using high flow oxygen. This knowledge came several weeks into the pandemic, as providers learned that it was extraordinarily difficult to wean patients off the ventilators. While I was there, the medical community recognized the hypercoagulable state the coronavirus created, so we began changing anticoagulation protocols. We discussed the role of the antivirals being tested and the myriad of trials underway at our own institution. Despite the fear of managing the unknown and the distress of the casualty rate, I will also remember this as a time of discovery.

Coury: I absolutely have a new appreciation for the ED and ICU staff. On my shifts, I saw several of the same ED attendings who had been working 7 days a week, for weeks on end. I also saw the resilience of the nurses, many in the OR-ICUs who were previously ambulatory preoperative or post-anesthesia care unit nurses who stepped up to the challenge. Even employees not directly involved in patient care – food services, unit assistants, security guards or patient transport – came in dedicated to serving patients on the front line. This included my favorite security guard, Spyder, who always tries to lift my spirits with kind words and coffee. I have a deeper appreciation for the expertise and hard work of the ED, medicine and ICU doctors. I feel a new sense of camaraderie with those I met on my shifts. We will never forget what happened, what we went through together and the patients we lost.

Mueller: This experience has given all of us a massive appreciation and admiration for everyone who has been facing this crisis daily. From the janitorial staff to the nurses to the ED attendings who have had to witness a seemingly non-stop flow of illness and death, we are all amazed at the drive they have to show up and keep on fighting. We’ve also stood in awe as our colleagues in anesthesia, ENT and general surgery have sprinted around the hospital, intubating, traching and placing central lines with barely any time to stop and reflect. This experience has shown us overall what amazing things we can accomplish when we put our heads and efforts together.

Sarpong: From this experience, I have developed an even stronger appreciation for the nursing staff, assistants, phlebotomists, physical and occupational therapists, X-ray and ultrasound technologists on the front lines in the ED and ICU who are the ones spending countless hours during the day and night with these patients, fulfilling doctors’ orders for clinical tests and interventions to these patients. I recognize that all health care providers are practicing at the edges or beyond the scope of their training during this crisis, yet strive to learn more about their new roles and continue to provide high-quality and compassionate care to our patients. I have witnessed a new appreciation for one another that has been refreshing.

Zbeda: The most important thing we learned was how to be adaptable and keep an open mind. This mental flexibility enabled us to be successful in whatever role or situation in which we were thrown. When we started our repurposed role, there was no roadmap or instructions. We worked together as a team in a trial-and-error fashion by constantly providing feedback and training each other to achieve more efficacy and efficiency. We figured out which essential items were needed in the rooms and mastered the step-by-step process. All traditional hierarchy went out the window. Junior residents were giving advice to senior residents and residents were training attendings.

Regarding our critical care colleagues, I cannot speak more highly of the level of dedication, bravery and mental fortitude they exhibited daily during this crisis. Along with the ED and medicine teams, the critical care staff should be heralded as the true heroes of this pandemic. Our mission was to merely support them. They certainly have all our respect and we hope that through this crisis they gained a new appreciation for the orthopedic staff as well.

Murray: I have gained a great amount of respect for the critical care physicians and nurses who are overseeing the care of these patients. I am struck by the complexity of care the patients need whenever I enter a room. Their clinical courses have been unpredictable, and their illness extends far beyond the respiratory system. These patients require constant, delicate management of ventilator settings, fluid balance, circulatory support, anticoagulation, sedation and meticulous nursing care. It is rewarding to know we are assisting the intensive care teams in some small way by reducing their physical workload.

I think our willingness and enthusiasm to help in this way has also instilled the sense of a united front at our institution. We are all familiar with the occasional adversarial relationship between medical and surgical subspecialties. I believe this experience has reminded us that we are all on the same side when it comes to looking out for the best interest of our patients.

Morton: I believe I will be a better and more well-rounded physician due to this experience. Not only is my knowledge of medical conditions and treatments deeper and more practical, but my appreciation for the challenges my colleagues and others face are greatly increased. This experience has broken down traditional hospital roles and service-based differences with all staff working together toward the common goal of recovering patients. It is “all hands on-deck” and the staff I have worked with have responded to the challenge with grace and compassion.

It is hard to put into words the appreciation I have for all the staff I have worked with through this crisis the critical care attendings, critical care nurses, traveling critical care nurses, respiratory therapists, pharmacists, and residents from other services also volunteering in the ICU. I am surely leaving out so many members of the team but remain in awe of what they do and will never forget this experience and their help.

Boylan: From doctors to nurses to ancillary staff, everybody has a role to play in the pandemic response. We’re all in this together. In a time of crisis, there is no substitute for effective leadership. Our residency is fortunate to have a great team of leaders who have kept us informed of the latest developments and ensured our safety and well-being.

Romeo: What part of your residency best prepared you for this new role?

Stevens: From a technical standpoint, I had the benefit of working in the ED as an intern, so I had some idea of the general workflow before I got there. Otherwise, I think treating geriatric fracture patients helped prepare me for interacting with the sick patients I was seeing daily. My consult work in the ED was a good model for taking the histories and physicals of the patients I was seeing, although the content was certainly different.

Coury: I think the nature of an orthopedic resident is a doctor who is ready to work hard and do what it takes to get a task done, no matter how many hours or days. We aren’t afraid of much and are eager to learn what we can. My hospital provided educational seminars/trainings about the latest guidelines for COVID-19 treatment at Columbia and I, among many of my co-residents, watched and read all the provided material to be best prepared. When our attendings also volunteered to participate in the battle against COVID-19, it inspired the residents to do our best and be our best.

Mueller: Solid team dynamics are crucial in orthopedics, and our experience in working as an orthopedic team from day one of residency translated seamlessly into the ability to integrate with teams all over the hospital, wherever we were needed.

Sarpong: Orthopedic surgery residency demands a commitment to proper time management, the ability to triage and prioritize tasks, and see these tasks to final execution and completion, regardless of any barriers along the way. Many of us have this “grit” innate in us or develop it along the way in our long training. Is a nurse struggling with a peripheral intravenous line? No problem, I will try it myself and if I am unsuccessful, I will find an ultrasound and find a way into the vein. Are the patient transporters being inundated with the surge in patient volume with transfers in and out of the ER, procedure rooms, ICU? No problem, I will transport the patient myself to free up the bed for the next patient coming in. Is the ICU fellow stuck in the next room doing a procedure? Sure, I can draw this femoral arterial blood gas! The patient’s daughter is on the phone and needs an update on her father’s medical status. No problem, I am happy to chat with her and answer her questions and FaceTime her on my phone so she can see her father since she cannot be here in person. It is this “can do and will do” spirit, working well under pressure and perhaps with limited resources that has prepared me best for this new role.

Zbeda: I don’t think anything can prepare you for a pandemic on this scale. However, I did find some similarities in prone positioning and being on a busy orthopedic service. For example, on a joints service, you are essentially doing the same procedure repeatedly and your goal is to constantly figure out how to make the process more efficient. This attention to detail and self-awareness helped us constantly improve.

Additionally, we also tapped into our experience positioning patients prone and in other various positions for surgery. We often obsess over making sure all prominent areas are well padded prior to surgery and we were able to transfer this skill to our new role. Our patients are prone for 16 hours a day so proper positioning is crucial.

Lastly, I think one of the goals of residency training is to become resilient so you can become grounded during difficult and stressful scenarios like these. Orthopedic surgeons may not be the most knowledgeable about medicine, but we are hard workers and trained to grind it out even when we are stretched thin. I think the 24-hour calls and busy months on a trauma service have helped me develop the resilience needed to make it through these difficult times.

Murray: My residency experience has prepared me well for this new role because orthopedic surgeons are constantly thinking about patient positioning. This applies across the field of orthopedics from physical exams during office visits to emergency department reductions to repositioning intubated patients in the operating room. We understand how we can safely use patient positioning to our advantage on a daily basis. We have completely changed the context in which we do it during the care of patients with COVID-19, but the concepts remain the same. I also believe the mindset of orthopedic residents and surgeons is well-suited for this role. We are always searching for ways that we can be more effective and efficient in our everyday practice and this outlook has carried over into our new responsibilities. Team members are constantly thinking of minor variations to our protocol that can help us be more efficient. This has allowed us to expand the capacity of our proning team tremendously since we first started, allowing us to turn more patients faster and in the safest way possible.

Morton: I believe my ED and ICU rotations as an intern prepared me for the medical aspect of this new role. However, I think the overall culture of our residency best prepared me to transition into a new role, our program emphasizes professionalism and communication amongst staff. Communication has been key and our residency has encouraged me to ask questions when I don’t know something, to listen to your nurses, to speak up if you or the nurse has a concern and above all to have the best interest of the patients in mind – all of which has been valuable in adapting to new clinical responsibilities. Beyond communication, the time management and organizational skills you cultivate as an orthopedic resident are helpful in accomplishing time-sensitive tasks on critical patients.

Boylan: We routinely prone patients for spine surgery, and the basic management of lines and monitors I learned during my intern year. Communication is also extremely important to safely position these medically fragile patients, which is something that I work on every day in clinic and the OR.

Romeo: What advi


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