I just want to welcome everybody to tonight's WNS webinar focused in on triage of neurosurgical cases during the COVID-19 pandemic. We have an outstanding panel of three different individuals. We designed this in a way such that we have chairs who've been dealing with the COVID pandemic at their own institutions, but we deliberately picked chairs from different regions of the country that are having different levels of cases of COVID and are at different points in the surge to just get a perspective on how you might handle triage in different stages of the pandemic. So with us tonight, we have Dr. Anil Nanda, who's the joint chair of the Department of Neurosurgery at Rutgers, Robert Wood Johnson Medical School, and Rutgers New Jersey Medical School. And in addition to Dr. Nanda, we have Dr. Aviva Abash, who's the professor, Nancy and Keegan and Donald Volpe chair, and the inaugural chair of the Department of Neurosurgery at the University of Nebraska. And then my name is Greg Zipfel. I'm the chair of neurosurgery at Washington University in St. Louis. We're going to start with Dr. Nanda, who's from New Jersey, as I stated, and is the furthest along in terms of the surge, and has had the most exposure to the pandemic and the most extreme kind of approach to triage. So we'll start with Dr. Nanda, and then I'll go after that, work on it in the middle part of the surge. And I'll tell you where we are in St. Louis in the Midwest, and then we'll complete it with Dr. Abash, who will talk about her experience, which is a lower caseload. And she'll also introduce the topic of reemergence after the COVID crisis and how hospitals are preparing. And there'll be kind of an introduction that leads into next week's WNS webinar, which will focus solely on how to prepare yourself for reemergence after the crisis begins to abate. So with that, I'll turn it over to Dr. Nanda. Thank you. Thank you so much, Greg, and welcome to all of you. If you told me eight weeks ago, we're going to have a COVID webinar, I would have probably laughed at you. Like, are you crazy? You know, we were just flying with our regular life, and that was sort of BC and AC after COVID and pre-COVID. So thank you again for this opportunity, and it's great to have two talented chairmen. And congratulations again to Aviva ascending the throne in Nebraska, and Greg taking the chair from inheriting it from the legendary Ralph Dacey. So this should be fun. And I think we have a nice lineup. So this is today's New York Times update, and it shows you worldwide almost 3 million cases, 200,000 deaths. And even if you'd said six weeks ago that we would lose a Vietnam in six weeks to this COVID crisis, most people would have said no way. So it's a serious thing. It's on us. We're really in the midst of it. We didn't think it would be as bad as it is, but it's really bad. And I think I might take a minute right now just to remember our colleagues from across the globe that have passed. Our dear friend Jim Goodrich passed from COVID. Dr. Vinatku was the first female neurosurgeon in Indonesia. She passed away. Lu Ziming was the director of the hospital in Wuhan itself. They passed away. And then Simon Hercules was an Indian neurosurgeon that passed away in Chennai from COVID. Unfortunately, his burial was the site of huge protests. And just to tell you the bigotry that does occur when you're COVID positive, especially in areas where the education level is not that great. So I think, you know, it's good to look at a public health crisis from a historical point of view. You know, John Snow, when cholera hit, everybody thought this was like miasma in the air. And John Snow went to the pumps and recognized that was the source of where it came from. And when we look at mortality, I mean, the person that came up with the pie chart was Florence Nightingale during the Crimean War. It's also the 200th year of her birth. And she was named Florence because she was born in Florence, Italy. But again, we should acknowledge our debt to these people. And I think with social distancing, you know, art, this was from the Wall Street Journal. Actually, I had it before Peggy Noonan used it as well, but this has become symbolic. And if you could look at social distancing with the creation of Michelangelo. And the latest slide was The Last Supper created by the Paris hospitals, almost giving divine status to health care professionals. Yeah. So just to give you a background on this, you know, March 1st, CDC says, you know, some guidance is March 13th. ACS says these are the things. AHA says various levels. March 16th, ambulatory care centers come in. And then just for us in the Northeast, Mayor de Blasio says March 16th. You know, this is postmortem, all elective surgeries, you know, White House echoes the same thing. And for us on March 27th, Governor Murphy transferred all elective medical, including an outpatient surgery center. So that's when we got it. And then I think the testing was that one of the things that we found was there was so much confusion. You should wear a mask. You shouldn't wear a mask. They were actually criticizing if you're wearing a mask and said, no, you should wear a mask. And PPE, as everyone realizes, is a national problem. And we were no exception to that. So I think some of the considerations for us was that, you know, you've got to remember the Imperial College said that two million Americans would die from this. So those are sort of the draconian predictions of, you know, how evil this thing will be. So we were looking at this hospital resources, financial ramifications. And most of you know that this was the CMS recommendation, 1A, 1B, 2A, 2B, 3A, 3B, 3B was unhealthy, and the A's were the healthy ones. And this was pretty clear cut. You know, if you had a 1A, you had a carpal tunnel syndrome, you weren't going to do it. We shut down the Gamma Knife, even though it was outpatient, because one of the reasons was we wanted to protect PBRs and PPEs and gloves. So we said, maybe we shouldn't be doing that. You know, VP shunts were canceled. And then 2A, brain tumors, oligodendrogliomas, small petrous meningomas, we said, no, we will hold off. And then, you know, there's a bunch of T lifts. And, you know, I always I love my spine colleagues, but it's all with an emergency. So we had some issues and said, no, no, it's got a foot drop or something. So we canceled most spine surgery. And the thing is, this came from our governor. If there's no undue risk, the surgery should be canceled or postponed indefinitely. But there were 3A, 3Bs that we were doing. So if it was cancer, large tumor, shift. And again, if you saw this, it's obviously subdural hematomas, epidural hematomas. And the sad thing was, they were sort of almost EMTALA violations going on. People really didn't want to come into the hospital. And I mean, we had an epidural empyema that they sat on for six hours. So we got, you know, so it was just sort of morally ambiguous things were happening. The one thing I would recommend for all the places are going to make sure your documentation is really crystal clear and well done, because otherwise you have issues. So here's a low grade glioma, elective craniotomy. Surgery was canceled. He was not pleased. It was very poor documentation. And we got zinged for this. And then they said, this is the documentation. Governor Murphy and elective procedures can be postponed to protect the health and welfare of patients and clinicians to protect vital resources such as PPE. So the surgery will be rescheduled as soon as it is safe. I've scheduled a follow-up phone call with the patient in three weeks to reschedule this procedure. He understands that we advise to reach out with any worsening symptoms. So this is pretty clear-cut, again, legalese to make sure everything looks good. So one of the cases we did do, and we were completely shut down, it was like a ghost town. And we were specifically advised, like, you know, normally, historically, you go for rounds with the chief resident. So I was actually using WhatsApp and video chats a lot. So brain tumors, I would talk to the family, so they would have three-way conversations. And God bless technology, because, you know, at least you get some feel you're talking to them. So this was a 33-year-old at MCA, needed a thrombectomy. And the grandfather had expired of COVID. Mother was in the ICU with COVID. And our issue has been that the residents were really up in arms, because they felt some of the cases were 2Bs that shouldn't be done. So I'll talk about how we address that. But, you know, here's somebody with a broken neck. We couldn't wait. This was operated on. It didn't recover or anything. And this was the classic case, you know, 78-year-old, you know, bitemporal hemianopsia, giant pituitary adenoma. And the issue was endoscopic internasal decompression, craniotomy, bringing him back later. So we had an OR committee. So we had four faculty members on this OR committee, and we put all three chief residents on it. And I was not on the committee. I did not think as chair I should be ex cathedra and say, listen, this is what we're going to do now. So they made a vote. If there's some question, I would review it. But on this instance, if those of you read the paper that came out from Singapore, this is high risk. Endoscopic procedures are high risk. A lot of viral shedding. But, you know, after wearing extensive PPR for this, Dr. P.K. Erewol is our faculty person. He went ahead and did this, did a beautiful job. And I kind of agreed with the way to go on this. Some people said craniotomy, but we went transferably with a good outcome. So this was where we said, you know, we reviewed all cases because, you know, there's always going to be someone that's milking the system and says, you know, I need to do like, you know, T12 to S1 fusion because it's like a foot drop or something. So we wanted to bring some sobriety in this decision making process to be fair and transparent. And you realize a lot of the revenue for physicians is on their generation of RBRVUs. So there's always this thing, oh, no, I'll get it done here or I'll go to another hospital. But we were very clear cut and I thought we discharged it very fairly. But I can tell you at the peak, there was no beds in the hospital. It's all COVID. I mean, we had some strokes that were transferred from one hospital to the next. We took three hospitals in our system before we got a bed. The other thing I will comment that when you're that busy with all this, unfortunately, people that have chest pain, that have strokes do not come for medical care treatment. They were not. So I think collateral deaths from this were much higher. So here's another one. This was, we felt was a 2B. We didn't proceed on this. This was litiblation and we didn't do anything. These were my cases. This is somebody that I saw when the thing was pandemic was at his height. He had had this lesion was diagnosed a month ago. And you could argue this really should have been done. There was a shift. He was really intact. And I was worried bringing him in, you know, then he's immunosuppressed. He gets COVID. He could die from COVID. So we're doing him this week. We waited three weeks. And you could argue that was not a good decision. This really should have been a 3A. Here's somebody we saw last week that I'm going to do this week, a shift, some confusion. Again, we decided to wait. So sometimes, you know, you're not sure. Now, medical legally, you need to be very, very cautious on this. I was on the committee for ventilators. And the governor tried to give a special exemption in the state of New Jersey to all plaintiff cases that you couldn't be sued. This was the Wall Street Journal op-ed piece. Millions of Americans would lose their job, leave it to the plaintiff bar to make money off the misery. You know, the Wall Street Journal is about plaintiff attorneys. But they, you know, maybe they had a point on this. This is what happened in our hospital. 48-year-old male went to an outside hospital, came back several days later with severe back pain. And he was told he's not having COVID symptoms. He should come back. Symptoms are worse. Two days later, he comes back and he's paraplegic. He turns to the air. He is unable to urinate. And they transferred to us. He had a big thoracic disc. And he never got anything back. So, you know, this is sad. But this is the truth of what's going on. There are real risks. And people get, you know, you have to be really cautious. Now, PPE is something I can't overemphasize to everybody. There's a great poem by this woman who was a nurse during the Ebola crisis and said, they'll tell you go in, save lives. No, you don't have PPE and you could be out and then they've lost a professional and all your experience. So, this is something, this is one take-home lesson take from this. Treat every patient that comes in as COVID. Be extremely cautious. Our residents were really cautious. We, very early on, when before the spike happened, we had somebody came to the Subarachnoid Hemorrhage, wanted to need an EVD. And our residents insisted they wanted an N95 mask and PPR. They got it. Put the EVD in. Two days later, the patient was positive for COVID. So, they were cautious. And I think it was the right thing to do. And this is just to show you historically, you know, PPRs haven't changed much. This is the 17th century for the plague. In fact, I think the Cleveland Clinic CEO said we're using 14th century techniques for 21st century disease, but that's the only thing we have. What are we doing in our hospital now? Everybody, this was Institute April 1st, everybody wore a mask. We had to wash our hands, social distancing, proper hand hygiene, and no food or drink in clinical areas. And I think the big metaphysical slash existential issue with this crisis was I was on the committee for ventilators for the whole system. And this was the Kafka's dilemma. I mean, you know, how do you decide if you run out of ventilators, are you going to take the 90-year-old that's been on a ventilator for three weeks and give it to the 18-year-old that just comes in? So, it's almost like the ethics of trolleyology, you know, where you bush one trolley this way, you can save five lives. And we had multiple debates on this, and, you know, this was like Sophie's Choice. Who was going to protect us? What was the medical legal protection if a ventilator shortage happened? Now, with the grace of God, there was no ventilator shortage in both New Jersey and New York, but it could happen wherever you are if it gets out of control, and it's a difficult situation to be in. Our volume dropped over 80 percent, basically, when we were in the hospital. Our volume dropped over 80 percent. Basically, we were just doing 3A, 3Bs, that's it. And I felt it was a safety issue. We were on a skeletal staff. We had very few people. We did a lot of WebExes. I really have WebEx-itis now. Every day, we were like WebExes for 70, all our M&M was on WebEx, resident meetings were on WebEx, and our PA, head PA, organized CME meetings for all the staff, and I think telemedicine took off. We've seen over 200 patients by telemedicine, and I think that's going to be the future. And we were testing all physicians to make sure that if they are positive, they can operate. And I think the financial effects are reopening the economy. I mean, is it true the only way to improve public health is by shutting down the economy, and the only way to improve the economy is by sacrificing public health? And I don't think that's true. So, this is a state of quarantine. Somebody sent this to me, and I think it's had a big impact. I mean, arts, Rutgers University will lose $200 million. I know Columbia-Presbyterian is looking at a billion dollars in four months. And what will this do in the post-COVID era? You know, the Handshake will probably be banned. This was an editorial in 2014. And we were all travel-banned, and you know, academies canceled, double A&S has been canceled, so it's a huge ripple effect. And I think, you know, to a certain extent, we've not been, you know, people have said you can't speak out, don't say you have no lack of PPRs. So I'll sort of end with this, you know, Hurricane Katrina, I didn't think I'd lived through another event. Hurricane Katrina, they defined as an event when the truth defied imagination, and it was a failure on multiple levels. And I think, you know, this is like the Kennedy assassination or September 11th. You know, Don DeLillo described what has become unraveled since that afternoon in Dallas is the sense of a coherent reality most of us shared. We seem from that moment to have entered a world of randomness and ambiguity. And that's, it is, it's the post-COVID state. This Franco Cerverdea was on the double A&S with us, and he said, you know, that when the virus came through China, they said it was Wuhan. When it spread through Italy, they said, oh, you got older people there. When it came through Spain, it was because of the healthcare system. But in the end, this virus came for us all. It was like Niemöller's line, you know. When they came for the unions, I don't speak out. When they came for me, there was no one left for me to speak. So I think, this is Seamus Haney, if we win this one out, we can summer anywhere. So I think we'll get through this, and I thought I'll end with this beautiful rainbow that appeared in New York City. My dean said it's from New Jersey to New York City to the World Trade Center. And I think that gave us a beacon of hope. I think the worst is behind us. My only advice to everyone is that don't take it lightly. Be extremely serious. PPE is the whole bit. You're better safe than sorry. Thank you. Okay. Well, thank you, Dr. Monda. I'm going to move on. And we are in a different stage, and it looks like we will never be where Rutgers in New Jersey and New York were. But I'll give you our experience. If you are in a region of the country or the world that has, you know, in a similar place, I think some of what we've gone through hopefully will provide some guidance and some help. I'm just going to talk about where we are on the curve. Dr. Monda already introduced the elective surgery acuity scale, but I'll briefly review that. And I kind of see our response in three different phases. There's the initial response, which is, you know, a few weeks after Washington State and New York and New Jersey were really starting to get hit. And so we were kind of a few weeks behind that. And I think that got our attention, you know, very quickly, and we, you know, responded, I think, very rapidly. And I'll tell you about a lot of that. And then there was a time, a secondary response, where, you know, the cases were increasing and we were really preparing for the worst. And then the worst never really came. And then I will describe where we currently are, which includes just real brief comment on reemergence and what we're planning after this immediate crisis has passed our region. You know, this is where we are in terms of the U.S., you know, certainly a plateau, but not a clear-cut decline in overall new cases as yet. That's for the U.S. This is for Missouri. And what I think you can see is that we have certainly plateaued, and I believe even we interpret this as a reduction in cases in all of Missouri. There's one day about a week ago that really flipped up, but that was an artifact. Really, overall, Missouri cases overall are going down. This is a graph from our St. Louis MSA region, which also suggests that we're certainly plateaued and more likely on the downward swing. But importantly, for our hospital, we're not on a downward swing. We are probably plateaued, but we certainly have not hit where our St. Louis MSA in Missouri has in terms of reduction. And that's impacting our decision-making and really probably slowing down the beginning of reopening for elective surgeries to some degree. This is just as of yesterday, our particular hospital, Barnes-Jewish Hospital, where we are in terms of available beds, which are in gray for ICU or floor for the COVID units, and we still have capacity. Where we are for non-COVID ICU beds, we still have capacity. And to the right, you see where we are with ventilators, and a gray area is available. So we never really even got to a 50% utilization of our ventilators. So really, we were preparing for the worst, but thankfully the worst really didn't hit upon us. I think that's in part because although our state was late to stay-at-home orders and other precautions, our city and county were quite active very early on. We already went through this, and so I'll skip over this elective surgery acuity scale. But I'll just say that our initial response, and this is the Missouri, down to the right is, again, the new cases in Missouri. And what you see is our initial response was really in the first, I mean, the second week of March. And we were just having very few cases. I remember having these conversations, and literally when they first started in our institution, there were five total cases in St. Louis. And yet you see what happened on the upswing, and we prepared as if the surge was gonna be upon us, and we could enter a state where we had issues about ICUs and ventilators. We were preparing for that. And what did we do? We converted all of our educational conferences to video. Many of the return visits were postponed. Early on, when you're first trying to figure this out, you're focused more on PPE and things within the hospital and taking care of COVID patients and converting. And we really didn't understand where we were gonna be with telephone visits and video visits, which turned out to be very soon thereafter, in terms of actually seeing patients in a regular way, getting our technical aspects of being able to do these visits, and also realizing that you could be reimbursed for these. And so, but early on, we didn't know that. And so, some were converted to telephone visits. Most were postponed. Almost all new clinic visits were postponed unless there was some urgency or emergency to them. And then all elective surges were canceled, as Dr. Amanda had mentioned. And that really focused in on Tier 3A and Tier 3B. But I personally don't think it's as clear cut about what Tier 3A is. And even Tier 3B, which I'll mention here in a second, is not entirely clear. And it really took, at least for us, some interpretation and some discussions across the surgical chairs and other leaders across the institution about even what a 3B case was. So what we did, similar, it sounds like to Dr. Nanda, is we developed a panel. In our particular panel, we assigned the chiefs of divisions, either the pediatric chief, the spine chief, or a designated leader of the cranial service. And they did the initial pass of cases that our faculty felt were 3A or 3B and needed to be done. Then that passed to, initially, Dr. Casey, my predecessor, who volunteered his time to review all these cases. And then I was the last review of the cases. And if it passed through this series of three people and was felt to be 3A or 3B, then it would go on to the non-urgent, non-elective case schedule and be booked in our ORs. There was a, not the first week, but within a week or two, we started realizing and started seeing reports out of Wuhan about the importance and the risk related to any manipulation of the nasal and oral pharynx. For a neurosurgeon, that primarily involved the intubation of your patient itself, as well as the transpinodal procedures. And we developed a process very quickly. ENT led this effort to get preoperative COVID testing on any patient that was going to undergo a transpinodal procedure. And we required the sample to be taken by an ENT surgeon to make sure the sample was truly from the back of the nasopharynx and we didn't get a false negative, which at the time had been reported to be as high as 30%. Many people believe a lot of that had to do with not getting appropriate nasopharynx samples. And we wanted to get around that by having the ENT experts obtain the sample for testing. So we implemented this and all transpinodals go through this process. You really need to be COVID negative to have your procedure. We also developed a policy that if a patient who is COVID positive was going to have to have surgery, that we wanted to have a very high level of approval that that would happen based on the risk of aerosolization, a risk of transmission to healthcare workers and the like. And that included approval from the anesthesiology in chief, the chief of service, the chair of the department, as well as the general surgeon in chief. So a high level of approval to get COVID positive, known COVID positive patients their operation. And it sounds like similar, but not quite as severe as what Dr. Nanda stated. Our case volume was reduced to really about 25% of what we normally have done. And that persisted for the first few weeks, although it has come up and I'll talk about that as it relates to kind of our current state, but a dramatic reduction in our elective cases. And then what happened is as we got further out in the surge and the arrow depicts kind of where the secondary response occurred, we were seeing the uptick in cases in our region and in our hospital, and we didn't know when it was gonna stop. And so we were prepared for the worst and felt that we needed to understand and put in processes by which, is there a time that we would only do 3D cases? Is there a time that we would stop doing 3A cases? And we had a process by which that would be approved. And here is what we developed. And I underlined a part that's particularly important for neurosurgeons, because this was not originally in this definition of when we would only go to 3D cases. And so first of all, you had to define what a 3D case was. And what we said was it's a surgical procedure that if not performed will result in high probability of patient death or permanent life-threatening morbidity within the next seven days. It turns out that phrase was not part of the original phrasing from our general surgical colleagues and our faculty practice plan, but ophthalmology and neurosurgery viewed it as that need to be put in place for someone who's, if someone comes in with a thoracic fracture or the thoracic disc as the one that Dr. Nanda stated, they may not die from this, but they certainly will have life-altering paralysis and morbidity associated with it. So we included that and that was approved by our oversight committee. And then solid organ transplants were also included. So that was our definition of what a 3D case was. And the plan was if patient census ever exceeded 80%, and if the daily trending statistics suggested that the number of COVID positive patients in our hospital continued to increase, these were the triggers that would change us from performing 3A and 3B to only performing 3B. Now, thankfully, we never got to that position, but during that secondary response, I did another pass through of cases that we had initially interpreted as 3A and were scheduled for surgery. And we all did this across the different surgical departments, looking for cases that if it was going to use an ICU, and there was an alternative approach to treating that patient, perhaps we should not be operating on that patient. And this is just an example of a 33-year-old gentleman who had a history of ocular melanoma, had a right brain metastasis that was identified after a seizure, about two and a half centimeters in diameter, initially was scheduled for surgery. But in the secondary response, we looked back at this and felt that we could certainly do gamma knife, avoid an ICU stay. And so we accomplished the surgery and proceeded with gamma knife because of where we were in terms of our case incidents in the hospital and in our region. So that's just an example of how we converted to a different treatment approach. Here's another case. This is a patient who also had a seizure and was found to have a left parietal mass enhancing here to the left and hyper intense on the flare to the right. This patient was felt to be probably a grade three glioma or more and was scheduled for an awake craniotomy. But because of the secondary response and the surge that we were seeing in our own hospital, we thought, is there a better approach that would avoid an ICU stay? And instead we did a biopsy similar to the corpus callosum lesion that Dr. Nanda noted, whereas biopsy turned out to be a high grade glioma, IDH1 negative. And we did a lit procedure rather than an open craniotomy to avoid the ICU stay. So that was the secondary response, but thankfully we never reached a point where we had to only do tier three B cases. We never really even approached, came close to that. And in the last couple of weeks, there's been a real, even a slight modification, although there's nothing formal that has changed. I think we see the plateau, we actually see the beginning of a reduction. And I think we have liberalized things to some degree. We currently still do our conferences by video, but we have certainly changed our approach to return visits. Initially, as I stated earlier, they were being mostly postponed and a few by telephone. Now they're almost all doing that by telephone because we have a system for that and you can bill for that and you can make that personal connection with your patients. And then note, this was a big thing as we really are trying to prepare ourselves for re-emergence and postponing all new clinic visits for elective things is not gonna prepare us for that. And the technical aspects of this have been worked out. You can bill for these video, new patient clinic visits. And so we have been really pushing this with our faculty and now we're up to about 60% of our normal volume of new clinic visits over the past week and a half mainly because of the use of video. So I think that is gonna help us re-emerge successfully when the time comes. And it also is a better service to our patients rather than pushing them out weeks or even a month or two. We continue to perform tier 3A and 3B surgeries, but there has been a little bit of a change. I think we did reevaluate our initial tier two cases and found some that because of the time that had passed had moved up to 3A. And the other thing is, I felt that there were some, the definition originally of what we thought a 3A case would be, I liberalized because of the availability and the ICU. So one example was a Cushing patient. Could the patient be put off two or three weeks? Yeah. Could they be pushed out for eight to 12 weeks which is now what it's looking like? I felt that waiting three months for an active Cushing's patient but was probably not the right thing to do. And we moved that into a 3A category, got them pre-op COVID testing and that patient was treated last week. So a little bit of a change, but nothing's formal. And then finally, we are planning for the re-emergence. I already mentioned that we have really pushed our faculty to do the new patient visits via video, some in person to identify additional surgical cases. So when the doors are reopened, we're ready and we can begin our practice and begin to care for patients again. And our institution is doing a lot to develop protocols and I won't go through the details and I'll let perhaps Dr. Abbas touch on this but we are definitely evaluating a number of factors to determine when we can reopen our doors. So with that, I just wanna thank everybody for your attendance. Thanks Dr. Nanda and we'll turn it over to Dr. Abbas. Okay, just waiting for my slides. While we're doing that, I'll just remind the audience that there's a chat box and you can ask questions through the chat box and I'll be monitoring it and we can ask our panel after Dr. Abbas has completed her remarks. Okay, thank you, Greg. Okay, thank you, Greg and Anil for your presentations. I'm gonna go through, there's a lot that I have to discuss that's already been done, covered well by the previous speakers, so I can fly through that. A couple of things to know about Nebraska is it's right in the center of the country. If you take the I-80 from east to west, you'll wind up in Omaha. If you bisect north-south, that's Omaha. So we have a population of about 10,000. So that's a population that's much, much smaller than what Anil and Greg are dealing with. About a million in the Omaha metro and then two million in the rest, in the entire state. That puts us at 16 out of 50 states for landmass, but 43rd out of 50 for population density. So it's a relatively sparse population compared to the other areas you've heard about. We have the highest cattle density though in any other state in the union. And that actually becomes important when I talk about COVID subsequently. We have no direct international flights. So different from New York City, which had a direct flight to Wuhan once a week before all this happened, we have no flights that go directly internationally. And we have a compliant populace. So when the messages started coming out about social distancing, we didn't have to shut down our beaches. First of all, we don't have beaches, but secondly, people are more willing to follow the guidelines. So all of these things, I think, contributed to pushing us out further on the peak. The relative sparsity of the population compared to the coastal cities, the lack of international connections and the compliance of our patient population. The other thing that's interesting about Omaha is there is a long history, going back 20 years of biopreparedness, stemming from a previous dean who was an infectious disease expert who set up the Davis Global Health Center for security. And in the Davis Global Health Center is also the National Training Simulation and Quarantine Center, which has been doing simulations for emergency preparedness for pandemics. Not this pandemic, but previous potential pandemics like Ebola and SARS and MERS, which has attracted a whole bunch of resources, I think helped get the public health message out in the region. We're also part of NETAC, which is the three centers around the country that have successfully dealt with Ebola, the few Ebola patients that have come stateside. And then finally, we are CSTAR's location, and these are embedded Air Force medical personnel who specifically deal with pandemics, with infectious disease outbreaks. So it's kind of an interesting environment for all that. We're also a level one trauma center and a safety net hospital. And so that has implications for what I'm gonna talk about. There you see Nebraska and how we've fared with COVID-19 currently or how we're faring currently. This is data printed off of or captured from the Johns Hopkins website as of this afternoon. And that little blue square in the center of the country is Omaha, which is obviously swamped by the redness on the coasts and in other areas. In terms of Nebraska itself, with social distancing and other measures, school going online around March 13th, I think, was when it first started to go online. The rest of the schools followed suit. The universities followed suit by the end of the month. All of these appropriate public health considerations wound up taking our projected peak, which was supposed to happen around April 16th and pushing it out now till May 10th. And this is information from the IHME website on projections that University of Washington maintains. And because of all of this, the total number of COVID cases for our state have just recently hit 56. This is from a week and a half ago. I think now this slide where the deaths were only 28, we're now at 56. So although we've managed to push out the curve for Omaha and the surrounding metropolitan region, the issue has become what I mentioned earlier, which is that we're a big cattle producing state and the meatpacking plants in Central and Western Nebraska and then in approximate regions of Iowa have gone haywire. And so these are plants that are getting shut down because something like 80% of the people working there aren't testing positive. And the problem is that the meatpacking industry happens to be in sparser settled areas. And so the small community hospitals there very quickly get overwhelmed, which means that the air guard winds up life-flighting those people to us. So there is a certain amount of vulnerability there. Now, having said that, as this was playing out, as the pandemic was playing out on the West Coast and the East Coast, we hadn't even seen our first case of COVID that we were aware of, at least, because nobody was being tested at that point, when suddenly things came to a screeching halt because of the absence of PPE. And we went overnight from having a full elective schedule to suddenly having to use the American College of Surgeons guidelines to limit our cases because we were running out of PPE. And our days on hand of necessary equipment were very few. So the community scrambled. There's a 3M plant in the metro area that geared up for masks that were then given to the hospital and also to other sites around the country. We got stockpiles from local Fortune 500 companies of PPE, which is interesting because it's not immediately clear to me why Fortune 500 companies keep their own stockpiles of PPE, but they were kind enough to give it to the healthcare workers who needed it. And then we started getting gifts of similar things from private citizens who could access their stashes from various sources. Local community college went into 3D printing of nasal swabs so that we had ways to test people and started making face shields for our emergency department staff. So the community really came together. It was nice to see. The projections that we made going forward are based largely on doubling time that the School of Public Health was running, and you can see some of those numbers here. And depending upon a doubling time, if you posit a doubling time of three days versus seven days, you get a completely different scenario of when you're going to swamp your ICU and your ventilator use and your PPE. So it's been really useful to keep an eye on the numbers locally and regionally, as I've been mentioning, and come up with the projections for this particular region. We've talked about the American College of Surgeons recommendations, and those went live, not because of COVID-19 in our area, the numbers initially, but because of the shortages of PPE, but it's essentially the same thing. We shut down for emergencies and urgent surgeries that were defined in our population as needed to go in 72 hours, or otherwise a change in outcome, an adverse effect on outcome. And we went overnight, essentially, to 80% decrease in our numbers, and you can see that right there. This is the main hospital setting for our hospital system, and this is where we ran into our shortages for PPE, and then overnight, that 80% decrease in volume, doing only at that point the emergencies and the urgent surgeries. And so we essentially flattened the curve, as I said, for Omaha and the surrounding area, which is the main population base for the state and for the region, but central Omaha, western Omaha, and Sioux City, Iowa took off and are continuing to rise exponentially, and so we're, you know, there have been public health missions out to those sites to shut down, recommend shutting down the plants that have hit certain triggers and work with getting the public health message to both the workers, as well as the management of those facilities. Now, I'm going to, in the last couple minutes, I'm going to shift to what we're doing now in our area. The governor of Nebraska, at his conference with the hospital CEOs for the state on April 16th, communicated to the healthcare that he was going to recommend removing limitations on elective procedures by early to mid-May, and that over time became really a mandate to get things back up and running, and so a number of us, of the chairs of surgical departments worked on how we would roll out this return to what we're calling time-sensitive non-emergency surgery. That's not my term, but if you look at the reference down there by Prashanth and colleagues that was published in the Journal of American College of Surgeons talks essentially about the same effort, and Greg alluded to it as well, and so we have classes of surgeries in the left-hand column, the description in the middle, and so A and B would be those emergent to urgent surgeries that have to be done right away or within 24 hours, and then a scoring system on the right-hand column, and so you can see that the number of points is accorded based on the urgency with which the procedure has to be done, and then you combine that with resource utilization, so going back to the whole issue of PPE, hospitalization, days in hospital, whether they're likely to be ventilated, aerosol generation, so in other words, if it's going to be a sinus surgery, which Anil mentioned, and then the surgical team size, and this goes back to the burn rate of PPE, and so again, there's a scoring, there are additional points that you get based on whether you're low-resource utilization, medium-resource utilization, or high utilization. Now, the trigger that has been implemented by the governor's office is that we have to maintain overall occupancy of the hospital, of the ICU, and of our ventilator use of under 70% in order to go forward, so this is not going to be returned to business as usual. It's going to be returned to a new normal, if you will, and then with this, with those less than 70% utilization figures, we also have to maintain days on hand of PPE of more than two weeks, so this is going to be the reality starting actually this week is when we've begun rolling it out. All of that adds up to a priority to schedule score that is high, medium, or low based on those factors that I talked about. Now, before we can actually take the patient to surgery, there are two things that have to happen, the patient has to be COVID tested, and there's now drive-through testing at one of our closed University of Nebraska campuses in town, and the patients need to self-quarantine during the 14 days prior to their surgery, so this was actually, this was all being implemented two weeks ago already, and then the COVID, they have to demonstrate COVID negativity within 24 to 48 hours of the procedure, 72 hours as a max, but they like it to be closer to the time of surgery, so those are the criteria for coming to surgery under the new rules, so I hope that's a good overview of what, how we've approached it and where we're headed with this, and if there are any questions, I'll turn it back to Greg, I guess, who's going to moderate for the questions. Thank you, everyone, and thanks, Dr. Abash. So far in the chat box, the only question that I've seen has to do with a link to the American College of Surgeons' tiering system for elective surgeries, so I responded to all for a link, so hopefully you see that. We do have a few minutes left. If any of the attendees have any specific questions, we have, our panelists are here to answer those questions, so maybe I'll give them a couple of minutes to see if any other questions pop up. Otherwise, we might end a few minutes early. So, Eva, you've got to keep those meatpacking pants going, otherwise, everybody in America is going to turn vegan. Oh, my goodness. It's been interesting, and, you know, it's one of the failures of our public health messaging is getting the information, you know, translated appropriately and implemented, and the implementation has failed because the workers are actually penalized for showing, for calling in sick, and so, you know, these are minimum wage jobs. People are being penalized for staying home with a fever. We have one question. Do false negatives in PCR, do you do two COVID tests pre-op, or is one enough? So, it has to do with the false negative rate of the COVID virus testing through PCR. I can answer that. So, that's a great question. Yeah, yeah. I'm sorry, go ahead, go ahead, go ahead, go ahead, Eva, go ahead. So, it's a great question. The false negative rate in our shop is about 3%, and so, it goes back to what you said. So, we only test people once. We have to show, for people who are asymptomatic and go through the CDC screening survey, then we test them once, and it's with the understanding that they are potentially positive, and so, it goes back to what you said, Greg, about making sure that the people, that the people you're working with, people get the message that they have to take care of themselves, and so, you know, there's N95s available for everyone who's operating. There's PAPRs available if you have to do sinus surgery, and we assume that they're positive, and then, the other thing is that if you can be out of the room, if you're not part of the anesthesia team, you're out of the room during intubation, and you wait for a full air exchange to happen before you enter the room. So, those are the things that we do to minimize risk or to mitigate risk, but obviously, there is still risk to all of us. So, I'll probably move on to a couple other questions, but we have a very similar approach and a very similar low false negative rate, but it's really, my understanding, a play between the false, in terms of the sensitivity of the test and obtaining the specimen and your pre-test probability based on your case incidents, and there's an interplay there, but in an area like Nebraska, or even where we are in Missouri, you know, the false negative rate is actually very low, I'm told. We have questions related to, one question relates to, was there competition for elective surgeries, and basically, the idea is, you know, most places are going to have more than one healthcare system, and if one system shuts down before another, or plans to reopen before another, how is that being handled? And that's probably going to be very different state to state, because some states have specific bans on elective surgery, while others do not. So, does Dr. Nanda or Dr. Abash want to take that question? Whoever you can take, ma'am. Sure. Yeah, so, I think, Greg, you told me the same thing for St. Louis, that the people in charge of the healthcare systems actually got together. In Omaha, that certainly happened, because the rumors were that CHI was going to have their own stockpile of things. They were going to go ahead with elective surgery. So, the civic leaders, together with the CEOs of the healthcare centers, got together, and, you know, said, we're all in this together, and we have, there has to be a unified front in this arena. And so, to be doing elective surgeries, and not testing in one center, and, you know, seeing all the COVID patients in another center made absolutely no sense, given a scarcity of PPE. The same thing, so that was when we were moving into this. Now, as we're moving out, it arose again, where the CEO of one of the three big health centers in town decided that they were not going to be testing anyone. They were just going to do things based on symptoms. And for elective surgery, they're just going to take people who are asymptomatic, which obviously leaves on the table all the people who are asymptomatic and COVID positive. And so, again, there was, you know, a meeting of the CEOs of the hospital, and they enacted a plan to begin testing everyone. So, it's important, I think, from a public health standpoint to be, to have a unified front in terms of how you roll these things out. Yeah, I agree with that. I think the unity point is very important. I mean, you can't get, we saw that in our department, the spying guys want to go, and it was like, no, this is a public health emergency. You know, I think we were really strict. I think Gail has a question about teaching residents and intraoperative risk of infectious support. I mean, we just weren't really teaching. We were just doing emergency cases. It was just trying to keep your head above water. So, I think our teaching was mainly through WebExes, and it would be kept a number of people in the OR to the minimum, you know. They did the case. If they could do it, if I could do it, I did it. You know, it was just, it was sort of a complete war zone approach. Yeah. Yeah. We probably have time for two more questions. There's one about how, what are, does, whether it's a hospital-based elective surgery versus ambulatory surgery center, does that change thresholds for doing the surgery or timing of the surgery? Do either one of you want to take that question? I can say that we, our hospital system shut down our ambulatory surgery centers, and they will be the second wave to reopen. And it has to do more with people being redeployed, and now having to get them back, you know, into that, those sites from where they're working elsewhere in the healthcare system. The hospital system decided not to lay, not to furlough anyone and not to lay anyone off. And because of that, it meant that they were using people from those ambulatory surgery centers in other areas, you know, that, where they were needed. And so now they have to be pulled out of those areas and put back into the surgery centers to send those places back up again. I think somebody, part of the question, the previous question had to do with competition for elective cases. And I will say that the surprising thing about returning to some level of elective cases has been, not that we don't all have patients who were pushed out, you know, every department, every division of every surgical department has patients who were pushed off and could be coming back in for surgery. But we're, patients are frightened to come back, point number one, you know, if they're not, you know, in that urgent or emergent category. Number two, you know, there have been, up until very recently, there's been a penalty to actually doing testing if the result is negative. So, so centers, because there's a, there was a national shortage of reagents for the COVID testing, if, if your rate, if your institutional rate of negative tests was too high, you got put to the bottom of the list for testing reagents. So, that's only recently changed. So, these are the things, these are the sorts of obstacles that have factored into getting back to business as usual on, you know, on a supply side and on a patient side. I think there's a question on transphenoidal and where it says open craniotomy. You know, the Australian neurosurgeons actually, in their official communication of their society said, go crani, and I showed you a case where we still went transphenoidal because we thought for a 78-year-old, that would be easier. But the main thing is a paper from Singapore came out that you must have serious PAPR on and full, you know, full protective gear on. I think there's two more questions, Ben, and Greg on, on Ben and. Yeah, one of the questions relates to how do you, when do you think you'll resume in-person office visits? And I think, Anil, you actually talked a little bit about the video, the visit as being part of the future. So, you want to comment on that? I mean, I think this is a paradigm shift. You know, before September 11th, if somebody told you you had 300,000 TSA agents, you would have laughed. And now, I mean, I mean, this is the new reality that patient contact, the art of medicine as we know it has irreversibly changed. And it may be that we have to do all this. Till a vaccine comes, we may have to sort of do, you know, telephone follow-up, moon checks and things like that. So, I think that it's irreversible. And if we don't adapt to it, we'll lose it. And yeah, one last question. Well, what are the panel's experience with you or faculty members operating on COVID-positive patients and viral transmission to the surgeons or other healthcare workers in the operating room, either with standard procedures or with transphenoidals? What's your, any experiences that you've had with that? So, we had a transphenoidal patient, and our resident went positive. And then everybody got quarantined, and then the staff went positive. So, it's not pretty. You know, it was scary. And, you know, initially, I think the fear was so high on this that, I mean, the entire residency was shaken up, and he was isolated, and he fortunately made a great recovery. Staff made a great recovery, but he was on a transphenoidal patient. So, there's a real risk on that. Were you guys wearing N95 masks and eye shields and all that? No, we didn't have N95. This is early. Earlier, some of the hospital looked down on wearing masks. You know, we should have gone the mask way a lot earlier, and we didn't. This was when it was not mandatory to wear masks. This was very early. But now, of course, everybody's N95 mask, and it's a better system. But earlier on, it was not good. Yeah. We've asked that question in our own experiences. We haven't had anybody, if they're wearing N95 masks and eye shields and the proper gear, we haven't had an experience of a healthcare worker turning up positive when operating on a COVID-positive patient. There's an interesting article in Nature two weeks ago. One of the things that we were talking about is what's an aerosolizing procedure? Besides inhibition and surgical procedures involving the nasal-oral pharynx, you know, what about drilling a burr hole or a craniotomy or drilling the mastoid? Drilling the mastoid is, yeah, supposed to be aerosolizing. Yeah. So, I mean, the mastoid, I can't answer the question on mastoid, but I can answer the question that Nature article looked at about 10 COVID-positive patients, really rigorous evaluation of a variety of body compartment and the presence of a virus. And the only place they found it was in the oral pharynx and nasal pharynx. They didn't find it in blood, not in urine, not in stool. So, the idea is, I guess for me, the blood and the way our infectious disease experts have viewed this, is if smoke comes from a body due to its interaction with blood, you know, this paper from Nature suggests that there is no virus in the blood. So, that shouldn't be a risk, a very risky procedure. Now, anything involving the nasal pharynx is different. The mastoid, I think, is somewhere in between. I'm not sure if there's any data that suggests or would that, so we know whether the virus is in the mastoid or not. I think that's open, that's an open question. So, the ENT surgeons in our shock have a protocol if they get into the mastoid ear cells. And they're using it. And I honestly don't know if it was carried over from the end of, you know, the sinus surgery to the mastoid ear cells, but they're pretty rigorous about it. And I would, you know, it's one of those things, again, where if we have residents scrubbed on those cases, or if my surgeons are, you know, helping with those cases, I encourage them to protect themselves. Sure. Okay, well, it's 8.07, so we're a little bit over our time allotment. But thank you very much for the panelists for outstanding presentations. And thanks very much for all the audience members and the wonderful questions at the end of the presentation. So, I hope you all have a good night. And stay safe. And hopefully, we get through this crisis sooner rather than later. Thank you, everybody. Thanks, Craig. Thanks, Aleeva. Bye.

neurosurgical cases

COVID-19 pandemic

triage

Dr. Anil Nanda

Dr. Aviva Abash

Dr. Greg Zipfel

healthcare system

PPE shortage

telemedicine

video visits