Hello everyone on the call. I'm Dr. Jim Bradley. I'm the current AOSSM president. On behalf of the AOSSM, we are very happy to have you join us this evening. While the events of the past two weeks certainly have altered, we would have been a, have altered a dynamic educational and events scheduled for our society. We are actively working on opportunities to move forward. No doubt the past few weeks have been unsettling as those of us in the healthcare profession continue to monitor the spread of the Corona 19 virus. We stand united with our colleagues on the front lines treating those who have been affected by the virus. It is a battle we are all fighting in some way or another. In the orthopedic sports medicine community, the intensity of our daily lives have come to a grinding halt. Despite the changes to our work schedule, surgery, patient flow, follow-ups, team meetings, prepping for the upcoming season, we see this time as an opportunity to invest in the upcoming, excuse me, learning and collaborating in a different way through different forums. Tonight's webinar is a great example. Tonight we come together for the first time in a series of excellent webinars developed specifically for our fellows. The AOSSM is here to help assist our fellows in fulfilling their educational and achieving their career goals. To our fellows, we need your passion and your dedication now more than ever. Before I introduce our panel, I would like to remind our audience that the AOSSM fellow series will run every Tuesday evening through June 30th. Our fellowship committee, chaired by Dr. Jeff Dugas along with our AOSSM educational team, including Meredith Herzog, have done an outstanding job preparing this series for you. If you have any questions, our professional team is available to help. Their information can be found on the final slide of the presentation. For this inaugural session, we are fortunate to have three of our esteemed physicians from New York provide us with a first-hand look into how COVID-19 has so dramatically impacted their city and surrounding areas. Dr. Bill Levine, Chairman of Orthopedics at Columbia University, Dr. Kevin Plancher from Plancher Orthopedics and Sports Medicine, and Dr. Tony Romeo, Chief of Orthopedics for the Rothman Orthopedic Institute in New York. Each will share their experience treating this virus from the pandemic's epicenter, that being New York. Following their presentations, they will be available for a Q&A session. So once again, thank you all for being part of this evening's webinar. I hope you will benefit greatly from the insights of Dr. Levine, Plancher, and Romeo. And now I will turn it over to them. Thank you. Good evening. I'm Kevin Plancher, and it's an honor. Thank you, Dr. Bradley, and on behalf of AOSSM, we really want to thank you for allowing us to share with Bill and Tony and myself an evening together to really give you some great information. Please know that these opinions that you hear tonight are those of the three of us and don't per se reflect the policies or procedures of AOSSM. I'd like to start this evening to share some facts with you as we know them. I also want to share some not evidence-based facts and thought I'd like to point out that there's a lot that we don't know about COVID-19. What we do know, though, is that COVID-19 has changed our lives, raising many practical issues, as you'll hear tonight, about safety, patient access, and economic reality. The reality is, as of Sunday, there have been 200 million admissions to one of the hospitals in Long Island, 1.3 million cases worldwide, and 70,000 deaths approximately worldwide. This virus has no borders. As of today, about 140,000 confirmed cases in New York, with 336,000 cases in the United States. Approximately 10,000 deaths in the U.S. with approximately 5,500 cases or deaths, excuse me, alone in New York State alone. It was, though, announced today for the first time while deaths are up in New York City, a glimmer of hope that the number of hospitalizations and intubations in the ICU are, in fact, down, not flat. In the Northwell system, one of the biggest employers of healthcare workers, 2,500 COVID-19 patients occupy approximately 30% of the ICU beds, and 25% of those are in ventilators, with a survival rate, unfortunately, of about 20%, compared to Boston of 28%. Interestingly enough, of a survey of 2,500 patients that were hospitalized here in New York City, approximately 30% are age 20 to 44, not elderly. Younger patients are far less likely to die, but now in New York City, younger patients are getting very ill. Is it the genome? Is it the gene variation in ACE2 inhibitors? Please know that cardiologists have said that we keep our patients on these ACE2 inhibitors, but maybe there is some factor here that changes the receptor. Another possibility why some young people are getting ill is that healthy patients and healthy people have a very reactive immune system, and this reactive immune system leads to a massive inflammatory response that overwhelms the lungs and organs. Maybe it's the amount of surfactant for those who die or survive, and recently, the governor of New York has increased the maximum fine of disobeying social distancing up to $1,000 a person from 500. Mass General is recommending early, not late, intubation over noninvasive positive pressure ventilation, and you'll hear from Dr. Levine and some of his thoughts of what's going on. To deal with nonsteroidals, there's mixed information that the WHO says they don't agree with stopping, yet if you ask the health ministry in France, they announce that no one should take nonsteroidals, only Tylenol. The CDC has not supported this publicly, but it's now accepting that people perhaps should be off nonsteroidals for the time being. There are those that are taking vitamin C, D, and zinc widely as internists are telling their patients to proactively get on this vitamin cocktail, yet we don't have real data, and yet in hospitals, widely accepted treatment is hydrochloroquine and azithromycin, but fatal heart arrhythmias have been noticed, and so alternatives of antivirals are there. Leading to all this seriousness, I'm proud to bring Dr. Romeo and Dr. Levine, and I'd like to start with both Bill and Tony, and Bill, I'd like you to talk about leadership and how things have changed in your practice. I know, unfortunately, you've been dealing with this since mid-March. I say this because some states, like Missouri, only on the weekend, have restricted certain surgical interventions, and recently the governor is telling people to stay in place. Clearly, this has affected your life as you lead a huge department and health system, and there have been changes. Can you talk a little about what you've gone through and your evolution since mid-March when you started to tackle this problem, and thank you for joining. Thanks a lot, Kevin. I was looking back at this, and on Friday, March 13th, we had our normal operating room executive committee meeting at 7 a.m. with our chief operating officer, and at that meeting, we were discussing the next week's elective surgical cases. Remember, that's March 13th, and she said, we've spoken to the CEO, and we think we should probably reduce our elective surgery by about 10% starting next week, and so we then talked about it, and the surgical chairs, as well as the anesthesia chair, said, listen, we've had enough self-cancellations from some patients who are getting a little nervous that we thought that that 10% was actually covered for, so at the conclusion of this 7 o'clock meeting, we all basically said we don't have to do anything differently for next week. By 3 o'clock p.m., we got a call from the CEO of the hospital who said all elective surgery would be canceled next week, so that's how rapidly moving. We went from a 7 a.m. meeting saying just reduce by 10% to 3 o'clock in the afternoon to completely eliminate all elective surgery, so then we spent the better part of the weekend starting to call the patients that that would impact for those next five days, and the uncertainty obviously was, well, at first we said we'll cancel for a week, and obviously that turned into two weeks, that turned into a month, and that turned into we don't know very quickly thereafter, so that was on March 13th and then into March 16th when we went into complete shutdown mode, and at that time, just to give everybody, you gave some numbers which are impressive, but just to go over it, on Wednesday, the 18th of March, we had about 25 inpatients, maybe 50 inpatients in the New York Presbyterian system of all of our hospitals. As of this morning, we had 2,200 inpatients who are COVID positive, 660 in the intensive care unit, so about 27%, and 100% of those in the intensive care unit are hospitalized, or excuse me, are intubated. Thank you. Before I get to Tony, I'd like to also have you talk about, so with that shutdown, what was your thought in the office and the clinic hours? Did you then switch to this new telemedicine? And as some offices, you know, I know one office in Delaware calls people from their cars and says, we're now ready for you in a much smaller environment adapting. What did you do? Did you use masks at first? Did you then shut down? How did you deal with the office and clinic? And then we'll turn to Dr. Romeo. Well, again, I think one of the things that I said very early, which was now, I guess, a little bit prescient was to say, when I sent an email to my department early on, and I said, by the time I hit send on this email, half of what I've written is probably going to be inaccurate given how fast and how quickly these things are changing. So initially we thought, okay, we'll take our seven outpatient office sites, we'll cut it down to four and have all the patients come to those office sites. And then we realized as things moved very quickly, that we really wanted to go to a nearly 100% telemedicine platform. And thankfully, we had just switched to Epic on February 1st. It may be the first time anybody's ever said, thankfully, we had just turned to Epic. But in this case, Epic actually became phenomenal because their telemedicine features are really great. So we then cut down to two office sites only. We assigned one faculty member or a nurse practitioner to see any patients that absolutely had to come in, infections, compartment syndrome, perhaps, or fear of neurologic compromise, those post-op patients that absolutely had to have suture removal that couldn't do it locally, and so on. And we went from having 25 telehealth visits the week of March 10th to over 1,000 the following week and a half. Thank you. Tony, could you share a little, some similar experience or different that, how did you approach in mid-March since you're controlling most of New York for the Rothman areas as the chief, how did you approach it with your people leading as a leader in this crisis management? Was it calculated intuition, great communication? Can you share some of your thoughts about hospital as well as clinic changes, please? Yeah, thank you very much, Kevin and Bill. What Bill described to you is exactly what's happened in New York. And a few weeks ago, before that, it happened in Italy. And a few weeks before that, it happened in South Korea. And a few weeks after us, it's going to happen in Philadelphia. And the reason why I bring up this point is because we as a society have a hard time understanding the exponential growth of a medical problem. We're used to linear growth. So we kind of wait until we think it's going to be a problem, and then we decide we're going to start to do something right now. That doesn't work when it's exponential growth. And yet you see repeated across the world, the same experience, and it's human nature until it really is essentially see the whites of the eyes of this virus. We wait, we wait, we wait, and then we decide what to do. And the reason why I bring that up is because I'm in New York, and the center for Rothman is an hour and 15, 20 minute train ride away. And you would think that's very close geography. But the decisions that we had were 10 to 14 days apart. And so decisions in Philadelphia that were being made for this system had to be corrected for what's already happening in New York. I mean, let's realize that the very first case that was diagnosed in the United States was January 20th. The very first case that was diagnosed in Seoul, Korea was January 20th. They have had less than 200 deaths. We already have more than 10,000 deaths. They were ready. They knew about SARS. They had that experience. They had the MERS experience. So their entire community basically was dedicated towards stopping this thing in its tracks. What we did is the same thing that Europe did. We said, well, we don't really know if it's going to affect us that much. So let's wait and see what happens. And then when it came, we said, okay, let's do something about it. By the time March 13th came along, I know that date very well. Why? Because that's the date I got sick and I was diagnosed with COVID-19. So I know that Friday very well too. And what was remarkable about that is I was one of the first 600 people. And now we have more than a hundred thousand people just a short time later that have had a positive test. And when I got a positive test, the commissioner's office sent me a letter saying that you have a communicable disease. You are isolated in your home and you cannot leave, or there will be a potential criminal prosecution of you leaving your house. That was May 13th, excuse me, March 13th. All that's gone away. We don't have enough tests. There's not enough people monitoring. Now we can go in as long as we've had seven days since we've been sick and we have three days with no fever and you don't even have to be checked again. You can go back to work as a healthcare worker. Why? Because we need all the healthcare workers we can get. The reason I bring that up and to bounce off of Bill is because what Bill did is what we've seen and what other people around the country are going to do. They're going to sit back just like Missouri did and say, well, we're Missouri. We're not New York. We're not California. So we'll wait and see what happens. This is a problem that will be in your community before the summer hits. That's just the way it goes. It's going to be everywhere. So I think that it would be great to take the principles that Bill said, instead of waiting until we know it's here, realize that once you have a few cases in your community, it's everywhere. It's already in your community and that's because of the very unique nature of this virus where people get it in their upper respiratory system and almost 40% of them get little or no symptoms while it sits there for a few days and they're shedding the virus and then somewhere around three to five days, then they feel like something's not right. That's so unique about this respiratory virus. That's why it's so different. The asymptomatic carriers have been a big part of why we haven't been able to manage this. That's why we shut down all the restaurants and bars. That's why we should wear masks for ourselves and for the patients and the people. We don't know if we're positive or negative unless you get a test. And you may think why I never had any symptoms, especially if you're a fellow or a young resident, never had any symptoms. That doesn't mean anything. You can still test positive. So the summary that Bill lined up for you is correct, but I think it should be done sooner. What we found out being just the geography from Philadelphia to New York is that we had to have regionally specific guidelines because people believe that until the virus becomes essentially endemic in your community, you can be careful, but you don't have to be as strict. I don't agree with that. I think the country should have been shut down, which would have been a major disaster, economically, and I understand that, but we would have been over this sooner throughout our country if we were aggressive from the very beginning and shut down the transmission. That's my personal belief. So we did what Bill said, and we did all those things that he talked about, cutting out the elective surgeries. We got masks early where they didn't have them in Philadelphia until the local universities there said, okay, now we have to wear masks. We're going to go against what the WHO and the CDC said. So I think as a leader, we have to recognize both our local community, but also national and in this situation, the global indications for when it's time to act. And as orthopedic surgeons, to be honest with you, we don't really have the power to drive an entire healthcare system, but we have to be a voice of reason and understanding so we can contribute to making sure that we minimize this disease in our community. So thank you, Tony. I want to just deal, because we have so many topics and I appreciate your passion, obviously, and we're going to share your personal story a little later in the program. So let's answer a few questions, then let's go to safety protocols. Social distancing is clearly something that has been effective. We see that it can eradicate and limit this disease. When you're performing social distancing, Bill, do you wear a mask or gloves in the operating room when you approach the office? Where is this a role for you and your people and your residents and other things? What do you see in New York? Yeah, I think that what Tony just said, I think really rings true. I think the biggest challenge that we're all struggling with is that we've had recommendations from the CDC, the recommendations from the World Health Organization, and then those recommendations are often what your local infection prevention and control teams will also use. And so going along those lines, there wasn't any recommendation for people to wear a mask until 24 hours ago, and it's April 7th. So think about all that time that Tony just described those asymptomatic people potentially transmitting the virus to thousands and thousands and thousands and thousands of people. So now at New York Presbyterian, you have to wear a mask everywhere on campus. That's a surgical mask, not an N95. And anybody that has any patient-facing activities has to wear an N95. And so that's what the policy is now. Six feet, you know, it's hard to do that in a hospital, to have six feet between people, although I took a picture the other day standing in the hallway and had this incredible picture where I took a picture north, east, south, and west, and there were no people anywhere. So there's certain areas in the hospital now that are like ghost towns. It's very eerie. You have the ER, which is not crazy like it is in normal times because it's almost 100% COVID positive and intubated, so you don't hear hacking and coughing. It's eerily quiet. And then you have the newly formed ICUs in our operating rooms and all over the rest of the hospital. So it's this dichotomy of kind of an eerie, almost quiet, and then the very, very sick in the ICUs everywhere in the hospital system. And Tony, I think they had a meeting today. So N95 masks are really used in an operating room and for the general anesthesia to avoid aerosolizing. And is that really your understanding right now for these urgent cases, what's going on for the unfortunate fractures? Yeah, so this whole mask thing is really a bit of frustration and a disappointment in many ways. In many places, it's being approached as what can we get away with, as opposed to what's the best thing for the safety of the healthcare worker. The regular surgical mask is a very good blocker for that person to not shed their droplets and micro droplets and most aerosolizations. And so it's nice to have it on so the asymptomatic people are not sharing the virus. But if you're worried about the virus getting towards you and it comes in through your mouth, your nose, and your eyes, you need to have something that protects these small particles from getting towards you. And if you look at the research from Japan and Taiwan and South Korea, they'll show when someone coughs, you get the big droplets, you get the micro droplets, which has created the six-foot barrier, but then you get a plume of these tiny, tiny little droplets that actually carry the virus and they almost float along in space for a few minutes. And so it's really quite remarkable that people have not taken hold of this principle. But I really think the problem with the mask was not the reason that they should be used. It was the unfortunate situation that we didn't have enough masks to give to everybody. Because the right answer, in my opinion, was that anyone that was trying to prevent from getting a COVID-19 infection that was going to be around other people should be wearing an N95 mask. We can't do that. We don't have that supply. So that people have been following the World Health Organization and CDC guidelines, which were based on viruses that generally do not spread until the patient is symptomatic. So it's very easy. So why do you, why this is why we have the screening test where are they coughing or sneezing? And do they have a temperature? Well, that's terrible screening. You're going to miss tons of asymptomatic people that are shedding virus. It's completely worth this to do that as a screening technique. The right thing to do is people should wear a mask to prevent that. You know, the other thing I read a lot about is that people initially said you shouldn't wear a mask because it makes patients feel uncomfortable. In the Asian community, they consider it a sign of respect that you are not going to contaminate them. So when they heard that COVID-19 was in South Korea, everybody wore a mask immediately out in public as a sign of respect to their other people of their community to make sure that they weren't shedding it to other people. We have a problem with that. And we have some of our leadership people saying that if you do this, that's going to be penalized by potentially losing your job as we've seen in other parts of the country. So here's here's my personal opinion. If you're in the operating room, you're a fellow, you should be wearing an N95 mask, you should put a surgical mask over the top. And you have a face shield with plastic over the top of that, because that's going to protect your eyes, nose and throat, which is the most likely place you're going to get this there. It's possible the aerosolization could come from your power tools and electrochloric, but much, much less likely than the respiratory problems. So the anesthesiologist has to be very careful when they wake the patient up, they've got to be very careful. And you and the other workers in your environment can be shedding this virus. And if you can pass a regular mask, the N95, you're safe. So that's what I would recommend. And as Bill said, face to face with someone, you should be wearing an N95 mask. Okay, hey, Kev, Kev, can I add one thing to that, please? And then we'll go on other topics, please. Yeah, just, you know, Stanford was pretty early on Stanford, published some materials and sent it to a lot of surgeons around the country about the risk of the surgical team in the operating room immediately after intubation. And so they came up with a policy and procedure that said, other than the anesthesiologist, and maybe one nurse who was properly protected with PPE, nobody should be in the operating room for 30 minutes, which is amazing because of the risk from the intubation itself. So that's not happening in emergency rooms, obviously, that's not happening in ICUs. But in the operating room, when you're doing a, let's call it a semi urgent case, there's no reason for our fellows and faculty and the rest of the OR team to have increased exposure if they can afford that time to, to not be in harm's way. Great point. And Kevin, I want to make one last point because people do like Kevin. Just 20 seconds. Go ahead. Yeah. And the evidence is there's a publication in the Journal of Bone and Joint Surgery, it was an express publication, it was helped and sponsored by Orthopedic Today. The lead author is Gao Juo. He is from, from the province in China, where this all started. And it's clear evidence that those orthopedic surgeons, the 23 orthopedic surgeons that came down with COVID-19, were not wearing the N95 mask, the other surgeons were wearing them. So there is clear evidence that it makes a difference in the surgical team being infected. So this is one where I really don't think there should be a strong argument against it. So testing is really everything. And so the thought, let's transition is, antibody tests will prove perhaps essential. Bill, if you believe that becomes a saliva test in predicting what if we have antibodies, do you think that will change who we return to work? That's the first question. And the second is, what are we doing or helping our healthcare workers, because they may be asymptomatic, as Tony talked about, but they're going home to their family. Is what's happening, you know, to how some of these people may be, because they're concerned affecting their family. Has anything been able to move in that direction? Unlike Italy and the UK, that has these, what they call them, fever places, fever places that they can, clinics that they can stay in. So one, testing and the saliva test, two, housing people when they're done with their shift. Your thoughts? Well, the testing, there's not one of the topics that we're going to cover that's not incredibly controversial. And this testing is probably as controversial as anything. Remember, there's two kinds of tests. There's the RNA test, which we've been doing, that's to find out if you have the infection. What we're talking about now is, can we get a serological test, either from blood or from saliva, that will be fast acting, like 15 minutes, and give us the answer, do you have the antibodies to the virus? And there's one FDA approved test so far, it's not widely validated yet. And one of the unknown hypotheses, we just have to be honest about, is we don't know for certain that having an antibody positive test means that you are immune from getting it the second time. The hope is, like other antibodies, that that would be the case, but that's yet to be proven. So as far as what far-reaching policies and procedures this will have, it remains to be seen. It would be great to know for our healthcare workers, and when we do reopen elective surgery, it'd be great to know if our patients that we're about to operate on have our antibody positive. So that part of it, I think we have to just, I've told my department and staff, right now, as eager as everybody is to get the antibody test, we don't have one that's been validated thoroughly, and we don't know if it's going to actually prove immunity. With respect to the second question about housing, again, very controversial. Our ER staff goes home to their loved ones, and they've been in harm's way, the ICU staff, many of them do. We opened up Bard Hall, which is normally filled with students, and we opened up three local hotels, and we made them free of charge for any healthcare worker, nurse, nurse practitioner, respiratory therapist, MD, and over 1,500 of the NYP staff, doctors, employees have taken advantage of that, because they don't want to put their loved ones at risk, even though we don't know for sure. But if you want to really be safe, and you don't have the luxury of a second home, or of a space in a home that's not around other loved ones, then certainly being able to go to another place and be safe is nice, and thankfully, NYP has been able to do that. So Tony, I am going to get to you. Just hold off for a minute on a personal reflection. So I'd like to jump for a minute, if any of our audience has fellows, I want to point out there is a pre-recorded program that was led by Brian Biscani, Jeff Dugas, and yourself, Bill, that went over some of the rules of ACGME and Pam Durstein. And some programs have claimed that stage one, not yet significantly affected business as usual. Other fellowships and residency stage two with an increased clinical demand guidance and redeployment they have filed. And some have filed for stage three, that pandemic emergency status where there's secession of all these milestones and case logs and duty hours. What has happened in your institution to share as this, as Tony has said, spreads from state to state, moving perhaps to other areas in the country that people should anticipate so that fellow education is down? What are you doing perhaps for the didactics and academics and have you filed and what do you think you're going to do with these residents and fellows now? Yeah, I mean, I think it's pretty obvious, at least for us in New York in the eye of the storm, our residents, I was just speaking to one of my chief residents before we came on and she's not gonna have another elective surgical case before she finishes residency. We will not be doing elective surgery till at least June 15th, if we are lucky. For our fellows, it's very possible they have done their last elective surgical case, but maybe they'll get some in for the last month in July, but that's unclear. Pam Durston was very clear and it was awesome for her to be on that webinar because there's no difference in the policy. Remember for all the fellowship directors out there and for the fellows, ultimately it's not the number of cases that you perform, it's not the number of months that you train. We as fellowship directors have to be able to say that you have achieved the skills necessary to be able to operate independently and without supervision when you leave the fellowship. So if we feel comfortable with that, then the last five months, which is unfortunate and catastrophic in many ways, doesn't really matter. If as a fellow or as a fellowship director, you feel like you need more time, you can easily stay an extra month without doing anything. And you can then, if you wanna stay longer than a month, you can apply for a waiver through the ACGME, which will obviously be granted given this historic and epic catastrophe. So thank you. I wanna point out that Tony, the president, has waived HIPAA compliance for the good faith practices for COVID. To get back to your institution, first of all, that May 4th, I think it was announced today, no elective surgeries until then, and then they're gonna decide in Northwell and then move the date and maybe a moving target, as you say. And AOSSM next week is gonna have a whole issue on telemedicine options and billing. So I don't wanna steal their thunder because we're really excited for another wonderful webinar. But are you volunteering? Are you thinking about virtual education for the didactic portions? And the second question for you is, how do you think we can help our fellows in their job search after fellowship, given that this is a very different year? And have fellows, I'll say it again, say to you, I'm taking another fellowship, and I don't feel comfortable delaying a job. So one, do you use didactic portions for virtual education? Two, how can we help our fellows for a job search after fellowship? Any thoughts? Yeah, so to question number one, I think we've recognized with the inability to have groups of people together, we've been very fortunate that the technology that's available to now to have WebExes and webinars is applied to the actual residency and fellowship program. And so what's happened is that many programs are running a somewhat typical academic schedule that they would normally have, but then even advancing it even more. Now, when an institution gets so busy that the residents get repurposed and they're working in different environments, you're gonna have to make another adjustment. But the idea is that you try to maintain the lectureship series, but you move it over to the web. And you use one of the devices, Zoom or whatever, to be able to contact and communicate with your residents and your fellows. So that's a didactic portion. Another benefit that's been recognized is that we oftentimes, because of the training and residency programs, we're separated into different locations and with different people. And with the web technology, actually there are some advantages in a certain way. And that is many times the junior residents feel a little bit left out in terms of the education, especially if they're put just with a attending physician. Having the senior residents and fellows sort of direct the education, the old philosophy of see one, do one, teach one. Well, the point about that is is that once you learn how to do it with your own hands, the next level of being able to really be qualified and competent with your proficiency is being able to actually teach it. So you give the senior residents and the fellows the opportunity to actually get more involved in the educational component. And that actually improves their skillset too. So from the didactic part, we think we can do a pretty good job with that in a lot of different places. The big issue is our hands. Surgery is not a spectator sport. And how do we get better with that? There's no doubt that the new simulators that are out there that are better, but most of them have showed that they work pretty well for the first couple of years, but they're not giving us advanced skills. So there's things to do. You can have cadaver labs where people essentially wear a protective equipment, but we've been asked not to do those kinds of things because we don't have the resources at this time. You can do individual labs and you can try some other things, video conferencing and teaching through the techniques, but that isn't gonna be a deficiency. It's gonna be very, very hard to do because we don't have the hands-on technique to make all of that come together as much as we'd like. So that's what's happening with many of the residency programs. Kevin, the second question was related to- Find out job search and how someone gets a job later. Yeah, I mean, the reason why people try to do fellowships is because the people they're doing fellowships with are connected with the community of people that they wanna work with. And you're gonna have to work with your fellowship director to have them make the effort to get inside of that community and say, listen, I've got this wonderful person. We didn't have four or five months to work with them, but I think they have a real talent and I think this will work out. But the bottom line is that there's not gonna be many jobs out there that are gonna be listed. And there's probably, sadly, there's probably gonna be orthopedic surgeons looking for a job that are in practice already. That's not that unlikely to happen very, very soon, especially in the private practice, single specialty practices. It's all orthopedics and they're down 90% of their revenue and that is a big, big problem. And so where the institutions can float it a little bit, the private practice models, the bigger models have huge overhead, huge revenue, but when that revenue's only 10%, they've gotta cut back and some of that includes personnel and some of that, for the first time ever, is gonna be selling orthopedic surgeons. I unfortunately don't have a job for you. So your point is good. I think it's just working the networking as best as you possibly can and the sooner the better. This is an unprecedented event and I think I don't have a specific answer, but it's always been my experience that most of the fellows that I trained, the job that they got was heavily related to my interaction with the person they were going to work with and the way we discussed how that person was doing. So it was a very personal level of referral and recommendations because if it was my fellow and they went there and they did a crappy job, that reflects poorly on me. So I wanted to make sure that I had the responsibility that they're well-trained and that if I help them find the job, which I would obviously do, I wanna make sure they knew they had a responsibility to me to live up to the expectation. So I think that's the way it's always been and I think that works today. It's just a little bit trickier because we don't have a whole year to see that experience. Thank you. I wanna just remind people while we will have in a week the telemedicine options and billing, that at the moment, if you're looking, 99442 pays up to $50 for 20 minutes and 99443 is 30 minutes or more and pays approximately $76. I'd like to switch a topic for a minute that the financial implications of postponing elective surgeries required and surgery and clinic appointments are obviously on many of the private practitioners mind as well as the academic and big institution. So while tonight will not be the night and I will say that again, AOSSM I'm sure is going to do a whole series on financial relief. I do wanna say for those that haven't had a chance because they're busy, it's complex, the CARES Act, but in fact, there's money to hospitals, telehealth and Medicare and Good Samaritan Protection. For the small businesses, you can file as of last Friday for a forgiveness loan for up to eight weeks securing money from your bank. If you have 500 or less employees and you are allowed for the first time to pay using that money to pay for payroll, rent, utilities and retention on a furlough basis for these employees. And so I encourage you to look into these opportunities and contact your tax accountant accordingly because there are many things. I will tell you in New York City, you can defer paying premiums for many insurance policies and malpractice until June 30th at the present time. So there's some exciting things that people are caring about what we are doing as physicians to help our patients at this time. I'd like to ask just quickly because we're gonna do a lot of topics still. Bill, I don't know if you even have a moment to think about all these financial implications and your employees and you house so many, what are you doing? Are you being instructed from above from the administration or are you just so bogged down with patient care right now as you tell us, as this comment is a conversation? Oh, it's a lot more than a conversation but it's tricky, right? Because we're in the midst of a pandemic and we're in the midst of taking care of these critically ill patients. And so on the one hand, that's where your focus is and you don't wanna really think about, have to say, oh, I've got to think about how we're gonna pay our bills. But you know what? We do have to think about how we're gonna pay our bills. I'm doing, as you know, one of my roles, Kevin, is that I am the editor in chief for JAOS. And so we are going to have a special COVID edition. It's gonna go live online starting tomorrow. And one of the articles that I asked a few people that you all know well to write is a conglomerate from Rothman, Rush and Wortho Carolina, three of the largest orthopedic groups in the country and exactly what they have done to try to deal with this never before seen crisis. You know, we've had one week crises, we've had two week crises, but we've never had a crisis where you shut down everything for maybe three, four, five, maybe six months. And so it affects every one of us. It affects, you know, Kaiser, it affects the private demics and it certainly affects the academic model. So for right now, what we've done at Columbia is we've been told to not furlough anybody, to not fire anybody. That's from the dean and the CEO, but that would imply that they're going to backstop our Delta since our budget is nowhere near where it's supposed to be. And that has not been said explicitly to us yet. So we are making contingency plans, obviously, because if there is no backstop, then we're going to have to obviously take care of things on our own. Tony, in the Rothman Institute as chief, you know, in the New York area, have you been given instructions? Are you concerned? Obviously, I know you're concerned. That's unwise for me to say. There are financial indications. Do you have some thoughts and what's happening with your staff as you're trying to move forward to stay afloat? Yeah, I think that I'll leave that up to the article that Bill is going to be publishing online tomorrow as the official response to all of that. I would just say that in larger single specialty groups like Rothman, there's a mosaic of practice patterns. There's this sort of the central core practice in Center City, Philadelphia. There are practices that are primarily run off of management service organization. And there's other practices like the one in New York, which is kind of a startup practice where they hadn't had this here before 18 months ago. And each one of them is being addressed in a specific way. And I know that the people that are looking at these things are trying their best to do crisis management, the ABCs. The first thing is they've got to be accountable and trustworthy so that the people believe in them and they keep everybody together. The second thing is they've got to be able to really bring together the strength of the entire organization, the finance people and the positions to group together or not to have a single group of people making decisions, but to really have the group decide what are our priorities right now? And hopefully it'll focus on the people. And then the last thing is there has to be a continual effort that still trying to make the practice better. So the way that Rothman's doing that is they basically daily messages out to the entire organization about some of the things they've accomplished and what they're working on. They have not let anybody go yet, but as this gets deeper and deeper into that two and three months as Bill talked about, it makes complete financial reality that there's going to have to be some cuts somewhere and they'll decide what they feel are the most appropriate things to do for their business to remain solvent. I mean, it's really to that level when you have a business that is generating a revenue that three months of that revenue becomes almost to the point where you cannot make that up, you've got to figure out a way to reduce your overhead. There's just no choice, you have to do that. And so some places like Midwest Orthopedics have furloughed 75% of their staff. Rothman has taken the choice of reducing their staff to 50% of their revenue, but they're gonna do some other things with their staffing very soon too. And most likely very soon they'll be shutting down some of their practice locations and consolidating because again, these are huge overheads that they've got to figure out. But there are a variety of different ways to manage this depending on your business structure and these talented groups that have had success in the development of the orthopedic business are working as hard as they possibly can to figure out the right recipe for their practice. Thank you. So I want to talk for a moment about recognizing stress, burnout and anxiety, then we're gonna come to you Tony on a personal reflection. So Bill, as a leader, clearly around the clock now there aren't enough hours in the day. How are you relieving your own personal anxiety and stress? And then is that helping you to understand your residents and fellows? So you must have various reactions from residents ranging from great fear, to severe anger, to resignation, to desperation. What advice can you give people because you're in the front line, it's going to hit them as both you and Tony said, if you don't believe that, you're not listening tonight. The point is, how do you relieve your own personal anxiety and stress? And what advice can we give to those training and the fellows and our membership when this hits? Well, about a year ago, Kevin, I named a director of wellness for our department. Tom Bottiglieri is one of our non-operative sports specialists. And so Tom has been phenomenal. He's partnered with Dr. Laurel Mayer at Columbia, who's a psychiatrist who runs all of the wellness and mental health clinics specifically for providers. And so Laurel did a Zoom conference with our residents very early on, because this is obviously something that we were very in tune with. For our faculty, we've been talking about it. We've been having, there's a lot of people who've offered free services to try to deal with this unprecedented stress. So I think that's been helpful. Tom coordinated a buddy system with the residents to make sure that they have somebody that they can share their thoughts with. I shared an email about two weeks ago with a bunch of friends, chairs and leaders around the country. And my observation was this, that this is something where every single one of us and the three of us are no different on this webinar are gonna process this crisis in a very personal and very different way. And we can't possibly expect that everybody is going to do it the same way. Some people are gonna volunteer and say, let me go to the ER and the ICU right now. And some people are gonna say, I would, you would be crazy to think I'm going to the ER or ICU right now. I'm an orthopedic surgeon, that's not my calling. And you cannot pass a value or have a value judgment on people for that. So I've just tried to let people come at this on their own. There's a certain amount of volunteerism that's expected from us as a department. We've all been redeployed to do something, but I've tried to respect people's opinions on what they want to do, what their comorbidities are and the like. And finally, I just think that to not think that mental health and wellness is critically important right now would probably be as grave a mistake as how slow we were to act on COVID-19 in our country as Tony indicated, because it is a critical problem. And to that end, Tony, I'd like, we have to watch our time carefully because there are some questions coming in. I'd like you to answer the following and we're sorry that you fell ill and we're more ecstatic that you're here with us tonight. What do you do if you think you have the virus? Did you lose your taste and smell? Did you have the cytokine storm that you think helped? Did Tylenol help? Should you avoid the hospital? Did you go? Did you have that bronchospasm episode? What would you do? Do you want to donate blood now with antibodies? Could you just share with us some personal reflection at this moment, please? Yeah, and Kevin, to be honest with you, my personal reflections have gradually evolved and hopefully matured over the last three weeks because we've learned so much about this now that it's in our community. So when I first came down with this, the honest truth is I had a wonderful date night with my wife on Thursday night at a wonderful restaurant in Manhattan that often takes weeks or months to get a reservation and the food was fabulous. And then I got up in the morning, I'd like to work out in the morning, that's one of my stress relievers. And I realized, I felt like someone had poured cement into my chest. It was the weirdest feeling, like it wasn't in my upper respiratory region, it was, I couldn't take a deep breath. And as I walked into the closet just to change it to get into my gym clothes, I started coughing when I tried to, I just tried to open up my lungs, I started coughing. So I got dressed in my gym clothes and I realized my muscles were sore and achy. I went downstairs and I said, I'm not going to work out today, this is going to be a problem. And I sat down to do some administrative stuff. I literally started feeling febrile. It was like this amazing event. And I know that that virus had to be with me for three to five or seven days before that actual event happened. But the amazing thing about that is by Friday night, I lost my taste and smell. And so I knew what was going on, but because I had a fever and we were new to the practice, I was the first one in our practice that I thought had it. I went to the emergency department at one of the hospitals that we work at to ask for their advice. And the emergency director said, well, with all these symptoms and who you are, we're going to go and get this test. They tested me for influenza and RSV, which they don't do anymore. They did the COVID test. And the next day I was positive. I didn't need the test to tell you I was positive. I was more miserable on day two than I was. It was harder to breathe. I had this dry cough. And it's a remarkable feeling when you walk up a flight of stairs and you have to stop and catch your breath because you just can't seem to bring in the oxygen. And two days before you were working out for an hour and then running two miles to be able to stay in shape. And it hits you like that. And unfortunately, my wife by Saturday was feeling bad and she got it too. And so we struggled for the next seven days with waking up every morning thinking we're going to get better. And some mornings we felt a little bit better, but then by later in the day, it felt awful again. And then that timeframe somewhere around seven to 10 days is what you're talking about. Something changes. And what we felt is I actually got a little nervous and I'm not afraid to say that people had talked to it. I talked to my friends in France and they said, you've got to do the hydroxychloroquine and the Zithromax. So I went on it and I got it from my wife, but my wife is still breastfeeding our eight month old. And she said, I'm not taking the medicine because there's no safety factor there. And I can tell you in two to three days, I felt remarkably better and my wife did not. Very anecdotal. Can't say that that had anything to do with it, but here we are at almost 21, a little more than 21 days out. I feel fine. I'm back to my early morning running and things like that. Can't go to the gym because they're all closed, but my wife still is short of breath when she exerts herself walking up a flight of stairs. So we did a telehealth appointment with the pulmonologist and he says, oh, don't worry about it. This can last like six weeks in some people. So you'll be fine as long as you've gotten better, your fevers are gone away. That's just some of the pulmonary tissues gotta heal. So don't worry about it. So that was our personal experience. So a couple of things. Number one, I'm glad I got tested. I think it was helpful early on in understanding what was going on with this condition. Today, I probably would not be a candidate for testing in communities where they're limited testing because my fever wasn't high enough. And they would have probably said, we'll just go home and keep an eye and see how things go, but you should quarantine yourself. So there's some places like New York or others where you can do drive-through testing so you can get that. Other places are still being very restrictive in their testing. But I think the test was helpful just to know and I quarantined myself from everybody. Secondly, is that this is very variable. I've heard of some people only having it for a few days and I've heard of people two weeks out that are finally going into the hospital because they're feeling so awful. So I think that the key point is somewhere around, I would say between six and 10 days could be where your immune system decides to go a little bit crazy and you get a cytokine storm and you can lose your oxygen saturation and really get into trouble. And so I think you just have to be very observant during that time. Most of the people on this phone are gonna be healthy, they're gonna be at home. And I think you just have to be careful around that time to make sure things don't go bad. In fact, I actually got a pulse oximeter for my wife and I checked her out throughout the evening two of the nights when she was short of breath and I was concerned that she was gonna desat. And she fortunately stayed at a comfortable level so we were good. So just be careful about that. The medications, I don't know if they work. I want you to go, yeah, we have to leave some time for the questions. Sure, I'll quickly finish up. So the medications, I don't know if they work for me. The last thing with regards to going back to work, the guidelines are now if it's seven days since your problem and you've had three days without symptoms, you go back to wear a mask for two weeks. There's no more testing requirements to go back to work. And then the last thing is I would just say to the fellows, it's a real illness. You have to treat yourself well. Bill talked to you about some of the things that alleviate stress, the same things for this. Make sure you get your rest. Make sure you have good nutrition. Make sure you have a good hydration. I would take over-the-counter medicines. As Kevin said, I'd stay away from non-steroidals right now and just use Tylenol which I think worked pretty well for me and then it's up to you whether you would try the hydroxychloroquine and Zithromax but you're gonna need a real physician's prescription to get them now because of the fact that there's a fairly limited. So that's my recommendations. Thank you. So just like Tony said, remember your patients are important but your own wellbeing, as Bill has also said, is essential. You're not alone in this. It's a huge group of healthcare workers that we're all pitching in. So this is a 20-second response, guys. I'll cut you off otherwise. Here it comes. Thank you for the discussion. Have any of you had to deal with an administrative gag order on media being asked to treat patients without adequate PPE or being given salary cuts with apparent contract breaches? Yes or no? No. Tony? No, it's been in the media but I have not had to do it at the institutions I work at. Okay. Just to get other questions and we can be contacted afterwards. Our OR has negative pressure airflow and they calculated the recirculation air rate based on volume and determined that 21 minutes is the time to completely recirculate the air. So only anesthesia is in the room but during this time at intubation, extubation. Are you seeing that other ORs are calculating this? Should they? Bill? I don't think they need to. We have the studies already from Stanford and if they showed 21 instead of 30, I think the answer is it's around 20 to 25 minutes. I don't know that you need to calculate it. Tony? Any information? No, I agree with Bill. They're actually developing these anesthesia tents to try to limit that. So there's gonna be some innovations on the anesthesia side where they essentially create a tent over the patient so that there's no chance of any type of droplets or aerosol being an issue. So I think we know that it's an issue and it's being worked on from their side too. In the operating room, should you wear arthroplasty-like hoods in all patients? No test at my hospital. Thoughts? Yes or no? Brief, watching the time. Bill? I've gone back and forth. I think N95, surgical mask, and a face shield has been shown to be very effective. I don't think you need spacesuits. Tony? My only comment is that even the company that makes the hoods will tell you that if you're concerned about a respiratory illness, you still have to wear an N95 underneath that surgical hood. So I think a mask, as Bill said, works perfectly. If you decide to wear like an arthroplasty hood, you should still wear your N95 mask. Keep it to 10 seconds. Here you go. Do you feel that in the future, telemedicine will lay a greater role in our practice as a result of this? Yes or no? Bill? 100% yes. Tony? Yes. Do you feel that there'll be less school participation in athletics due to this going forward? Yes or no? I know you can both speak for years on this topic. Yes or no? No. Tony's no? No. Good. When do you feel it's safe to resume elective surgery in New York City? I want a month. It's a guess. It's a moving target, but it was a question that was asked. Bill? No sooner than June 15th. Tony? Yeah, it's gonna be June. Okay. One more. What do you anticipate will be the long-term ramifications of COVID-19 on elective surgery? I'm not gonna do that one. We can't. There is a wonderful AALS guidelines that was set that mimics ALSSM for elective surgery, and I encourage you to look at it tremendously. I'm telling you that I want you to think about this in closing. Remember all the heroes of sports that we have had and will treat and even admire are now on hold, sadly so. Instead, those of you who are going to work treating patients with COVID-19 are the heroes of today. All of us should be proud of each other and continue to elevate this great profession to its highest heights. We need to let the world know that we are the cheerleaders and the providers for our patients, to encourage them to be courageous as we spread the word, hashtag orthopods care about you. I need to thank you, Drs. Levine and Romeo and the ALSSM for allowing us to share our thoughts this evening. I encourage you to stay healthy, stay calm, stay home if you can and social distance because this is truly about life and death. And we thank you for joining us this evening. Thank you all and have a good night. Thanks Kevin. Thanks to all. Kevin, thank you, Bill. Be safe everyone. Thank you, Jim, Bradley. Good night now. Thank you so much. Thank you to the presenters. I also wanted to make a note that we do have an AJSM webinar that's taking place this evening at nine o'clock Eastern time. And you may register for that through the ALSSM website, sportsmed.org. Thank you everyone for joining us. Thank you to the presenters. Thank you for your time. Thank you.

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