Letter to the Editor: Coronavirus Disease 2019 (COVID-19): A New York City Intern's Perspective

Letter:

By the time January arrives during intern year, most first-year neurosurgery residents begin to settle in to their roles as junior residents; we learn how to triage consults, become more comfortable with bedside procedures, and begin to gain some technical abilities in the operating room. My program was no exception; however, every other day I would quickly glance at a broadcasted e-mail from our health system about a “novel virus” in China, instructed not to worry, but that we should avoid traveling to China on vacation, at least for now. For several weeks it was elevator music—a faint noise in the background that could easily be overcome. Unbeknownst to me or my co-residents, it would set the tone for the remainder of our year of neurosurgical training.

On March 1, 2020, the first case of the novel coronavirus, which in the coming weeks would be colloquialized as coronavirus disease 2019 (COVID-19), hit New York.¹ The patient had mild symptoms and did not require hospitalization. Within a week, there were 100 confirmed cases in the state.² By March 14, 2020, New York City had its first fatality, which would be one of more than 16,000 deaths in our city over the following 2 months, in the setting of more than 200,000 confirmed cases. At this time, I was in my final month as the junior resident at Elmhurst Hospital Center, our affiliated New York City public hospital and level one trauma center, which would quickly be known nationally as “the epicenter of the epicenter.”³ Struggling with funding and resources before the COVID-19 era, Elmhurst was quickly over capacity and out of supplies. All elective cases were put on pause, our surgical intensive care unit (ICU) and postanesthesia care units were converted to overcrowded COVID-19 ICUs, and the emergency department because an overflow ICU, with the remaining hundreds to be admitted to the emergency department having to wait in a barricaded line outside on Broadway Avenue.⁴ Due to shortages, we were reusing our masks often for over a week at a time, and with only one gown for the team to enter patient rooms between our team of 4 (junior resident, chief resident, and 2 physician assists), we had to decide before rounds who was going to enter the COVID-19 rooms for the day. At this time, it was the new normal to have double-digit deaths in a day at Elmhurst,⁴ and for the first time in my medical career, I was scared to go to work. Soon I would realize my next rotation would come with even more uncertainty.

To end my intern year, I would be spending my final rotation at our flagship hospital, helping where needed during this pandemic in lieu of my previously scheduled research elective. Our department, as many others in our health system, stepped up to the challenge, with an all hands on deck approach. Every practitioner in our department—from our chairman down to me—was working on the front lines taking care of patients with COVID-19. For the first time in residency, I was taking in-house neurosurgery call. Our junior residents, including myself, were staffing our neurointensive care unit with a neurosurgery attending as backup, as our neuro-ICU attendings, fellows, and advanced care practitioners were working in various COVID-19 ICUs. Our chief residents were splitting time between neurosurgery call, operating room duty (as we were only operating on emergencies), and in the COVID-19 ICUs with an assigned neurosurgery attending. During the first couple days in the ICU, we were sent learning modules on ventilatory management and acute respiratory distress syndrome, to provide a refresher, or primary learning course in some cases, on ICU management. Although our elective case volumes drastically declined, what we did not anticipate was the surge in cerebrovascular cases, particularly strokes, in patients positive for COVID-19. In the literature, this hypercoagulable state associated with COVID-19 has now been well reported,⁵ but on the front lines, it meant multiple strokes daily, several consults a day for intracerebral hemorrhages in heparinized patients with severe COVID-19, and regular emergent trips to the operating room for hemicraniectomies on patients positive for COVID-19. Learning from European neurosurgery leaders, we quickly developed protocols for operating on patients positive for COVID-19 and how we can best protect ourselves and our staff while caring for these critical patients.

During this time, we saw changes to neurosurgery resident education like never before. Grand rounds were now conducted remotely, which allowed for not only broader engagement but broader speaker panels. On a weekly basis, our department's newly-branded “Global TeleRounds” would host world leaders in neurosurgery in pediatrics, tumor, spine, and cerebrovascular, access to panels we had not received during in-person grand rounds. Case conferences and morbidity and mortality presentations were now conducted remotely as well, and it quickly became rare to see faces in the department who we were not directly working with in the hospital.

However, the impact of the COVID-19 era on neurosurgery training has not been all positive. The medical student experience has been incredibly thwarted; third-year neurosurgery rotations have been cancelled, and for the first time in the modern neurosurgery era, sub-internships have been prohibited, leaving aspiring neurosurgeons with limited hands-on experiences to explore clinical neurosurgery. For junior residents, intern boot camp was condensed into a several-hour webinar, and the American Board of Neurological Surgeons (ABNS) primary exam was delayed and converted to a virtual, “take-home” exam. The American Association of Neurological Surgeons (AANS) annual meeting was cancelled for the first time since 1945, marking the end of WWII. Senior resident fellowships were delayed or cancelled, research grants have been affected, and basic science investigation has been put on hold. While we aspire to return to the previous normal in the coming months, it is without doubt that this time will have a lasting impact on academic neurosurgery.

There are several concluding messages that this pandemic has taught us about ourselves, our colleagues, and the field of neurosurgery. The first lesson is that we are doctors and healers before all else—when our ability to take care of patients is needed outside the scope of neurosurgery, we are there to do our part. Next is our collaborative spirit; neurosurgery programs have joined across the United States and the world to share patient care experiences, take part in educational platforms, and spread neurosurgery as widely and deeply as possible. Finally, the largest lesson is resiliency. Our indomitable spirit runs deeper than our stamina in the operating room, and no matter the task we are asked to perform, we will rise to the occasion and set an example for others in medicine. My hope is that we carry these tenets long beyond this time.