COVID-19 Operational Guidelines for Pain and Spine Physicians

[drusso]

See attached: I appreciate our colleagues stepping up in these unprecedented times and uncharted waters.


Summary of Recommendations to Outpatient Musculoskeletal and Pain Physicians:


1. Continue to see patients when clinically necessary.

2. Avoid blanket in-office and procedure cancellations, which can potentially lead to
unnecessary patient suffering.

3. Make use of telehealth services as appropriate to meet the needs of our patients.

4. Prevent further emergency room overload and strain by providing acute services when
possible.

5. Reduce requirements for PPE for simple joint and spine procedures that have a very low
risk of infection.

6. Exercise caution with the use of corticosteroids, particularly in higher risk patients who
may be immunocompromised.

As musculoskeletal and spine specialists, we aim to achieve functional improvement in patients
with a variety of impairments and disabilities. We need to strike the balance between exposing
patients and staff to the virus and providing treatment for our patients. Further, a balance is
needed in caring for critical patients with COVID-19 while still being able to care for the
community in need. There will still be patients that have serious medical conditions and require
immediate care. When a procedure is deemed “elective and non-urgent” this does not
necessarily mean that the patient can wait. Some “elective” procedures should be performed in
order to prevent worsening of the condition and further decompensation of the patient. We
recommend that consideration of pain level, suffering and potential for functional loss should
be integrated into future governmental and societal procedure recommendations.
As always, treatment decisions need to be individualized on a case-by-case basis to identify the
optimal approach for each patient. The climate created by COVID-19 is ever-changing and with
it specific treatment recommendations, however with a thoughtful approach we will be able to
navigate the COVID-19 pandemic with the least disruption for our patient population.


Sincerely,

Gene Tekmyster, DO
Board-Certified in Physical Medicine & Rehabilitation and Sports Medicine
Assistant Professor - Keck School of Medicine of USC, Department of Clinical Orthopaedic
Surgery
Team Physician - US Ski & Snowboard

Maxim Moradian, MD
Board-Certified in Physical Medicine & Rehabilitation, Sports Medicine, Pain Medicine, and
Regenerative Medicine

David W. Lee, MD
Board-Certified in Physical Medicine & Rehabilitation, and Pain Medicine

Shounuck I Patel, DO, MMS
Board-Certified in Physical Medicine & Rehabilitation, and Sports Medicine
Clinical Assistant Professor - Western University of Health Sciences
Clinical Assistant Professor - Touro University College of Osteopathic Medicine

Gerard Malanga, MD
Board-Certified in Physical Medicine & Rehabilitation, Sports Medicine, and Pain Medicine
Assistant Professor - Rutgers University

Gary P Chimes, MD, PhD
Board-Certified in Physical Medicine & Rehabilitation, and Sports Medicine

Rahul Desai, MD
Board-Certified in Radiology
President - Interventional Orthobiologics Foundation

Jaspal Ricky Singh, MD
Board-Certified in Physical Medicine & Rehabilitation, Sports Medicine, and Pain Medicine
Vice Chair and Associate Professor - Weill Cornell Medicine, Department of Rehabilitation
Medicine

Prathap Jayaram, MD
Board-Certified in Physical Medicine & Rehabilitation, and Sports Medicine
Director of Regenerative Sports Medicine - Baylor College of Medicine
Assistant Professor - Baylor College of Medicine, Departments of Physical Medicine &
Rehabilitation, and Orthopedic Surgery

References:
1. Haynes BF, Fauci AS. The differential effect of in vivo hydrocortisone on the kinetics of
subpopulations of human peripheral blood thymus-derived lymphocytes. J Clin Invest 1978;
61:703.
2. Dixon WG, Abrahamowicz M, et al. Immediate and delayed impact of oral glucocorticoid
therapy on risk of serious infection in older patients with rheumatoid arthritis: a nested
case-control analysis. Ann Rheum Dis. 2012;71(7):1128.

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[lobelsteve]

Chimes. Miss him.

 

[Doctodd]

#4 is a very compelling reason to continue to do procedures, but with NSAID's and steroids potentially making things worse, ive been using only Traumeel and PRP for injections.

 

[drusso]

Chimes. Miss him.

From the old neighborhood, right?

 

[SSdoc33]

This statement gives license to bring in a 70 year old for an MBB if the injection monkey thinks they are "suffering"

I don't like it.

"Some “elective” procedures should be performed in
order to prevent worsening of the condition and further decompensation of the patient "

yeah, like what? decompensation? that is BS. the only patients who theoretically need an injectionist right now are those who have a big hot disc herniation and who otherwise would get a surgery. that is maybe what, 5% of our patients if that? everything else is in the surgery realm or can wait.

 

[drusso]

This statement gives license to bring in a 70 year old for an MBB if the injection monkey thinks they are "suffering"

I don't like it.

"Some “elective” procedures should be performed in
order to prevent worsening of the condition and further decompensation of the patient "

yeah, like what? decompensation? that is BS. the only patients who theoretically need an injectionist right now are those who have a big hot disc herniation and who otherwise would get a surgery. that is maybe what, 5% of our patients if that? everything else is in the surgery realm or can wait.

We all have to remember our sacred obligation to our patients: "The needs of our patients come first; first do no harm."

 

[callmeanesthesia]

We all have to remember our sacred obligation to our patients: "The needs of our patients come first; first do no harm."

...to my paycheck.

 

[hyperalgesia]

These are really going to depend on the patient population, the local status of COVID, local resources, etc.

I can't help but agree these guidelines are partly financially guided.

 

[painfree23]

How do you justify the potential complications from procedures which may require ER visits followed by in patient hospitalization?? U think the ER docs will be like cool, send over your accidental IT injection for me to babysit?

 

[Doctodd]

How do you justify the potential complications from procedures which may require ER visits followed by in patient hospitalization?? U think the ER docs will be like cool, send over your accidental IT injection for me to babysit?

how often does it really happen especially if you do mostly transforaminal? (Knock on wood).

And why would they automatically go to the ER? A spinal block will go away quickly if you didn’t use a ton of anesthetic.

 

[drusso]

These are really going to depend on the patient population, the local status of COVID, local resources, etc.

I can't help but agree these guidelines are partly financially guided.

Has anyone checked Dollars for Docs to see what potential financial COI's are for the authors? How deep are the conflicts?

Dollars for Docs

ProPublica has compiled the disclosed payments from pharma companies to doctors and other health care providers. Search for your doctor in our interactive database.

projects.propublica.org

 

[lobelsteve]

From the old neighborhood, right?

Dinner in NOLA with PAZ, lonelobo, Taus.
I think that was the crew.

 

[lobelsteve]

Who is this group? Is it just random folks who called each other up and said we want something to sup[port ongoing care?

My bigger concern is lack of access to care for COAT patients. If they do not get Rx and go through withdrawal with flu like symptoms, they show up in ER. Now they are exposed and tested. More risk there than from MBB/TFESI.

 

[DODOCSS]

how often does it really happen especially if you do mostly transforaminal? (Knock on wood).

And why would they automatically go to the ER? A spinal block will go away quickly if you didn’t use a ton of anesthetic.

or any lido

 

[Laryngospasm]

I think by not treating people you are more likely to see them divert to the ER for other reasons than having to go for a complication from an injection. Maybe suspend high risk injections that can be put off without harm to the patient.

 

[ateria radicularis magna]

The % of my patients who will go to the ER if they don’t get an injection is maybe 1%.

 

[ateria radicularis magna]

Who is this group? Is it just random folks who called each other up and said we want something to sup[port ongoing care?

My bigger concern is lack of access to care for COAT patients. If they do not get Rx and go through withdrawal with flu like symptoms, they show up in ER. Now they are exposed and tested. More risk there than from MBB/TFESI.

Agree. Telemedicine solves this issue.

 

[painfree23]

I think by not treating people you are more likely to see them divert to the ER for other reasons than having to go for a complication from an injection. Maybe suspend high risk injections that can be put off without harm to the patient.

Which ones are considered high risk?i stopped all my stim trials. This is CHRONIC PAIN... which by definition has to be more than 3 months.

 

[paindoc007]

Which ones are considered high risk?i stopped all my stim trials. This is CHRONIC PAIN... which by definition has to be more than 3 months.

Where I work, I’m the only spine guy. So I see plenty of acute things. disc herniations, compression fx, etc.

 

[ateria radicularis magna]

Where I work, I’m the only spine guy. So I see plenty of acute things. disc herniations, compression fx, etc.

Is it your intention to treat only acute herniations or fractures?
That is my intention.

 

[drusso]

Who is this group? Is it just random folks who called each other up and said we want something to sup[port ongoing care?

My bigger concern is lack of access to care for COAT patients. If they do not get Rx and go through withdrawal with flu like symptoms, they show up in ER. Now they are exposed and tested. More risk there than from MBB/TFESI.

I think they're like PROP--super-concerned doctors stepping up to fill a leadership void.

 

[painfree23]

Is it your intention to treat only acute herniations or fractures?
That is my intention.

How are you treating acute discs? PT is shut down here.

 

[paindoc007]

Is it your intention to treat only acute herniations or fractures?
That is my intention.

yea basically, we see patients in the office on a case by case basis. Otherwise, everything is telemedicine right now

 

[paindoc007]

How are you treating acute discs? PT is shut down here.

PT is up and running here. Prob not smart to refer there tho for high risk folks.

 

[iwumd07]

My unsolicited $0.02:

Everything I'm doing is Telemedicine since 3/17. From my brief experience from the last week, so far everything (even acute pain from car accidents that does not require surgery) can be handled over the videoconference. Before all this, my patients that I had seen after acute injuries would go to the ER, get a half-a** evaluation, and then sent home with acetaminophen. Also, I've canceled all procedures since 3/17. None of my patients have ever gone to the hospital ER because they didn't have a procedure. ASCs should be giving their PPE to hospitals, and not continue to try to order more for themselves at the moment.

 

[clubdeac]

Guys this is insane! Am I the only one who sees this complete societal lock down as economic suicide? The dems blocked the stimulus bill tonight. Tomorrow the market is going to respond and plummet another 10%. My hospital just told me it wouldn't be until May when we're back up and running with elective procedures. Is this response necessary? And don't tell me it is because of how things are in Italy. Look at Germany. I believe they were very slow to implement social distancing. I think we need to be cautious and follow the recommendations, but there has to be a balance. I fear economic collapse at what cost. H1N1 killed 12,000. The societal/media reaction was nothing like this.

 

[hyperalgesia]

Guys this is insane! Am I the only one who sees this complete societal lock down as economic suicide? The dems blocked the stimulus bill tonight. Tomorrow the market is going to respond and plummet another 10%. My hospital just told me it wouldn't be until May when we're back up and running with elective procedures. Is this response necessary? And don't tell me it is because of how things are in Italy. Look at Germany. I believe they were very slow to implement social distancing. I think we need to be cautious and follow the recommendations, but there has to be a balance. I fear economic collapse at what cost. H1N1 killed 12,000. The societal/media reaction was nothing like this.

This virus is apparently at least 50% more contagious than H1N1 and 10x more deadly. Not to be overly dramatic but it's literally an order of magnitude more dangerous than H1N1. PLUS, we had a vaccine in a few months for H1N1. It was a flu.

Maybe we'll get lucky and be like Germany. We will know that in 2-3 weeks. If that's the case, we can lick our wounds and count our blessings and start to let up on the restrictions.

OTOH, if our healthcare system is completely over-run with patients suffocating on stretchers in the hallways all across the country, the current restrictions will look like play time.

 

[SSdoc33]

Guys this is insane! Am I the only one who sees this complete societal lock down as economic suicide? The dems blocked the stimulus bill tonight. Tomorrow the market is going to respond and plummet another 10%. My hospital just told me it wouldn't be until May when we're back up and running with elective procedures. Is this response necessary? And don't tell me it is because of how things are in Italy. Look at Germany. I believe they were very slow to implement social distancing. I think we need to be cautious and follow the recommendations, but there has to be a balance. I fear economic collapse at what cost. H1N1 killed 12,000. The societal/media reaction was nothing like this.

seriously, i would like to know what media you are consuming. because you are either seriously misinformed or under-informed. even DJT has come around (somewhat)

we all worry about the financial impact, but you cant go to work. period. if you havent noticed yet: this is a big deal. every one of use who goes to work unnecessarily exposes more of us to danger. more people who think like your = more people dead. its just that simple

Germany isnt doing all that great either, FWIW

 

[Ducttape]

the patient population that is sitting in your waiting area getting ready to come back is exactly the patient population that has 10% risk of death if they become infected.

for those of you seeing patients, are you doing terminal cleaning after every patient? are you doing social distancing when they are in the waiting room (or at least, have them stay in their car and call them to come in). are you doing intense cleaning after their appointment?

fwiw, Germany currently has 26,220 cases with 111 deaths. 4th in the world. Cancellor Angela Merkel is under quarantine. not sure that is "doing well".

 

[lobelsteve]

Germany: 111x100 / 26220 = 0.4% mortality rate

USA: 458x100 / 35070 = 1.3% mortality rate

Pick your metrics. Data above is a slice in time and varies based on cases existing, cases tested, deaths attributed to Covid. Too many variables especially when noting we do not know where we are on our curves....

 

[callmeanesthesia]

Also need to keep in mind that deaths/cases may underestimate mortality when on the steep growth portion of the curve, especially with rigorous early testing - many are diagnosed, not yet very sick, but will be. True mortality rate will be somewhere between deaths/cases and deaths/(recovered+deaths)

 

[Ducttape]

Germany: 111x100 / 26220 = 0.4% mortality rate

USA: 458x100 / 35070 = 1.3% mortality rate

Pick your metrics. Data above is a slice in time and varies based on cases existing, cases tested, deaths attributed to Covid. Too many variables especially when noting we do not know where we are on our curves....

problem is that there is a group of people who have much higher mortality rate.

mortality of those >70, those with concurrent medical illnesses maybe 10%???

 

[clubdeac]

seriously, i would like to know what media you are consuming. because you are either seriously misinformed or under-informed. even DJT has come around (somewhat)

we all worry about the financial impact, but you cant go to work. period. if you havent noticed yet: this is a big deal. every one of use who goes to work unnecessarily exposes more of us to danger. more people who think like your = more people dead. its just that simple

Germany isnt doing all that great either, FWIW

I’m reading as much as I can from the CDC, WHO and reputable journals. Look at this data from Nature. Particularly look at the graph mapping out lethality and transmissibility compared to other viruses. Idk, you tell me

The coronavirus pandemic in five powerful charts

From papers published to carbon emissions to confirmed cases, these data reveal an unprecedented viral outbreak and its impacts around the world.

www.nature.com

 

[Ducttape]

all relative, right?

it seems nice that coronavirus may be less fatal than MERS or SARS, but remember that overall deaths from SARS was 774 people. coronavirus so far has 15,433. and the 1918 flu pandemic is estimated to kill 50-100 million people...

 

[Doctodd]

the CPP has a "novel" way of enforcing social distancing. In Miami we can only close the boat ramps.

 

[hyperalgesia]

I’m reading as much as I can from the CDC, WHO and reportable journals. Look at this data from Nature. Particularly look at the graph mapping out lethality and transmissibility compared to other viruses. Idk, you tell me

The coronavirus pandemic in five powerful charts

From papers published to carbon emissions to confirmed cases, these data reveal an unprecedented viral outbreak and its impacts around the world.

www.nature.com

The chart in this article is referring to the 1918 H1N1 outbreak, not the 2009 H1N1 outbreak.

From Wikipedia:
The Spanish flu, also known as the 1918 flu pandemic,[1] was an unusually deadly influenza pandemic. Lasting from January 1918 to December 1920, it infected 500 million people—about a quarter of the world's population at the time.[2] The death toll is estimated to have been anywhere from 17 million[3] to 50 million, and possibly as high as 100 million, making it one of the deadliest epidemics in human history.[4][5]

Regarding the 2009 outbreak:
A follow-up study done in September 2010 showed that the risk of serious illness resulting from the 2009 H1N1 flu was no higher than that of the yearly seasonal flu.[11]

 

[clubdeac]

The chart in this article is referring to the 1918 H1N1 outbreak, not the 2009 H1N1 outbreak.

From Wikipedia:
The Spanish flu, also known as the 1918 flu pandemic,[1] was an unusually deadly influenza pandemic. Lasting from January 1918 to December 1920, it infected 500 million people—about a quarter of the world's population at the time.[2] The death toll is estimated to have been anywhere from 17 million[3] to 50 million, and possibly as high as 100 million, making it one of the deadliest epidemics in human history.[4][5]

Regarding the 2009 outbreak:
A follow-up study done in September 2010 showed that the risk of serious illness resulting from the 2009 H1N1 flu was no higher than that of the yearly seasonal flu.[11]

Good point, was the high fatality rate of the Spanish flu more a result of the virus or the medical capabilities at that time? I’m inclined to think it had more to do with the latter

 

[hyperalgesia]

Good point, was the high fatality rate of the Spanish flu more a result of the virus or the medical capabilities at that time? I’m inclined to think it had more to do with the latter

Probably that, and they didn't have communication like us to implement "social distancing", they had poor sanitation/hygiene, etc.

 

[iwumd07]

We, physicians even, are forgetting that mortality isn't the only thing that is important. This virus causes (from available data of reported positive cases, which is likely a huge underestimation on the magnitude of 6-7x) severe respiratory illness and 2-3 weeks of hospitalization in 20 PERCENT of those infected! We have about 20 hospitals in our city. ALL of them are full of patients with severe respiratory illnesses that are NOT influenza. We have only been able to test a small percentage of them, because we don't have tests. Also, don't forget that you can test negative and still have coronavirus. What else is causing all of this illness? Tons of people coming in with bilateral pneumonia, secondary to flu-like symptoms, but do not have the flu. Working adults having to be hospitalized for 2-3 weeks. The fact that they are not dead or wont die is not a good reason to continue 'business as usual'. If you're worried about the economy now, imaging if 20% of our working population HAD to be hospitalized for 3 weeks all at the same time.

 

[Baron Samedi]

The amount of people who will develop CIP/CIM, pulmonary fibrosis, extensive deconditioning and require extensive rehabilitation after recovery will also be staggering. Many of those patients will later die of complications from their illness, such as PE/DVT and MI.

 

[Ducttape]

Probably that, and they didn't have communication like us to implement "social distancing", they had poor sanitation/hygiene, etc.

there definitely was a "lack" of communication, possibly purposeful. this was during the Great War/War to End All Wars... reporting was limited to avoid giving the enemy impression that the flu was devastating either side.

I watched a documentary that stated that it profoundly affected Germany's decision to end the war, although other sources have refuted this position.

 

[painfree23]

The amount of people who will develop CIP/CIM, pulmonary fibrosis, extensive deconditioning and require extensive rehabilitation after recovery will also be staggering. Many of those patients will later die of complications from their illness, such as PE/DVT and MI.

Where are they gonna rehab? In patient facilities are gonna start shutting down left and right because of spread in their facilities

 

[Baron Samedi]

Where are they gonna rehab? In patient facilities are gonna start shutting down left and right because of spread in their facilities

Great question. My guess is that physical therapists will give them a handout with some exercises to try at home and say, "good luck." Or many of them will remain in acute care hospitals for prolonged durations.

One narrative that has been pushed is that the mortality rate is low so don't stress about it. They(I'll keep that vague) are completely overlooking all the associated morbidity and mortality that will come after the initial surge in cases.

 

[drusso]

Great question. My guess is that physical therapists will give them a handout with some exercises to try at home and say, "good luck." Or many of them will remain in acute care hospitals for prolonged durations.

One narrative that has been pushed is that the mortality rate is low so don't stress about it. They(I'll keep that vague) are completely overlooking all the associated morbidity and mortality that will come after the initial surge in cases.

We're working locally to create rehab SWAT teams based upon a palliative care/home health model. Hopefully, get some money from the Feds!

 

[lobelsteve]

Don’t forget that March is National MS and CP month.