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Leadership Through Unprecedented Uncertainty

Being an early career professional in health and science means moving along a continuum of learning and leading. The moment you clear a hurdle, you’re a mentor for people following you. Remember “see one, do one, teach one”? There’s the learning-leading continuum in action. Every day of our working lives, we are becoming leaders as we continue to learn.

For the past month, give or take, the U.S. has been in the midst of a panicked response to the global COVID-19 pandemic. Institutions have been scrambling to respond to rapidly changing conditions with scarce information and mixed messages from government and global bodies. Schools and healthcare organizations, where many of us work, have been particularly impacted. I have felt this stress acutely, as I’m sure many of you have. Will we be caring for affected patients? Will our PPE and medical supplies last? Will our research be put on hold? Will our students be able to graduate? Will we or our loved ones fall ill?

Even as our own anxiety ramps up, we may find ourselves needing our fledgling leadership skills more than ever. The public looks to us as experts. Patients look to us for guidance and comfort. Our students look to us for direction. Staff who work in our facilities look to us for instructions. How can we be there for these folks, even if we don’t feel all there ourselves? Here are some ideas:

  • Be present: find safe ways to be available, whether you’re on the ground, on video chat, sending emails, or anything else you dream up. Let people know they can talk to you and you’re there.
  • Be informed: Stay up to date, find sources of information you trust, and read with intention. This practice can help you be a source of authority and comfort when so much around us is chaotic.
  • Be honest: it’s OK to say “I don’t know” when you don’t know— especially if the next part is “but I promise to do my best.”
  • Be kind: Every person you interact with is facing stress now. Treat them kindly. Ask how they are, and listen to the answer. Allow a little grace where you might otherwise stick to strictly business.
  • Be transparent: If you are working on a plan, say so. If things might change, say so. If you are waiting on a person or a step that can’t be rushed, say so.
  • Be human: you don’t have to be a robot. People can see that you, too, are anxious or uncertain, and that doesn’t undermine your ability to lead. People can see that you have kids, or pets, or a partner, or dirty dishes. Sharing your self can be one of the most powerful ways to connect.

Ultimately, everyone is seeking stability, comfort, and connection. Much of this is beyond our control, but even a little leadership presence goes a long way.

Stay safe, friends, and may you come through these hard times with grace and wisdom.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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#COVID-19: Universal Mask Policy, Universally, Now.

As the COVID-19 pandemic has wrought havoc in major American cities over the past few weeks, particularly in New York City, a common refrain from health care workers (HCWs) on the front line continues to be: “Get Us Personal Protective Equipment (#GetUsPPE).” Yet intertwined in this tragedy of a gross undersupply of PPE has been the problem of mixed messages about the level of PPE that should be used by HCWs, which stemmed from dynamically changing recommendations from the Center for Disease Control (CDC).

Ultimately, the current CDC recommendations, which advise the use of surgical masks when with a symptomatic COVID-19 patient and N95 masks only during aerosolizing procedures, were borne primarily out of an anticipated shortage of PPE, and these recommendations differ from earlier ones that recommended N95-level masks whenever with a patient with suspected COVID-19. Justification for this effective reduction in PPE levels stemmed from the CDC’s thought that COVID-19 is primarily spread via droplet transmission.

In light of this CDC guidance, many hospitals implemented policies that similarly aimed to preserve PPE supply, anchoring on the notion that COVID-19 is transmitted by symptomatic patients via droplets. Many of these policies restricted hospital staff from wearing masks outside of patient rooms, and ultimately led to numerous reports of staff (including house staff trainees) being reprimanded for doing so.

Yet as hospitals in countries like Italy and Spain and in major American cities such as Boston are experiencing alarming numbers of their HCWs test positive for COVID-19, it is crucial for us to reassess whether our current PPE policies are adequate to protect HCWs from infection and to prevent nosocomial spread. Indeed, prominent academic medical centers such as Partners Healthcare, University of Pennsylvania, New York Presbyterian, and University of California San Francisco (UCSF) have already adopted a “Universal Mask Policy” to help address this vital issue.

In order for us to more effectively contain the rapid spread of COVID-19 in our communities, I strongly believe that all hospitals should adopt a Universal Mask Policy, in which hospital staff are required to wear surgical masks in all areas of the hospital. This step is crucial for the safety of our team members, our colleagues, and our patients.

My belief stems from the following:

  • Precedent from countries with effective control: On March 18th, the American College of Cardiology held a joint teleconference with the leadership from the Chinese Cardiovascular Association, which included a section on recommendations from their physician leaders on how to adequately control COVID-19 spread at our hospitals in the U.S. They strongly urged us to wear surgical masks in all areas of the hospital, and they also used N95 masks during all encounters with patients with suspected COVID-19. They felt these measures were pivotal in their ability to protect their staff members and control the rampant spread of the virus throughout their hospitals. Further, the Director of the Chinese Center for Disease Control and Prevention, Dr. George Gao, told Science that it is a “big mistake” that people in the U.S. are not wearing masks everywhere in public, let alone not wearing them everywhere in the hospital. Similar public masking policies are in place in South Korea, Japan, and Singapore, where COVID-19 disease spread has also been more effectively controlled.
  • Likelihood of asymptomatic spread among HCWs in the hospital: It is becoming increasingly clear in the literature that a large portion of the disease spread is from asymptomatic individuals (Li et al, Science, March 16, 2020; CDC MMWR March 27, 2020),  with a long incubation time of 5 days median (Lauer et al, Ann Intern Med, March 10, 2020). Hospital staff, who are only advised to stay home from work if symptomatic, may still present to work asymptomatic but infected and contagious. Without at least wearing a surgical mask throughout the hospital, we are at increased risk of spreading infection among each other.
  • Transmission by talking: By the nature of our work, we are not used to routinely standing 6 feet away from each other in the hospital as we communicate; in a small Twitter survey, >60% of respondents said that #SocialDistancing is not currently practiced in their hospital. Further, we are all touching common surfaces (e.g., keyboards, computer mice, phones) that will inevitably carry droplets that are inevitably spread from unmasked mouths when we talk. While surgical masks are not the perfect solution to filter out the droplets emitted from our mouths when we talk, cough, or sneeze, they undoubtedly reduce emission into the ambient air around us (Figure 1) and should reduce the likelihood of asymptomatic hospital staff from transmitting infection among each other and to our patients.

 

Figure 1: Two-way protection provided by masks (from Medium blog post by Sui Huang, MD, PhD at the Institute for Systems Biology)

In summary, I urge all hospitals to implement a Universal Mask Policy to account for these data and expert recommendations. As mentioned above, the lack of a clear, effective message has led to conflict between care teams, leading to discord at a time when unity is so critical. Although no randomized clinical trial has yet to show that a Universal Mask Policy is the most effective way to reduce nosocomial transmission of COVID-19, the “absence of evidence is not evidence of absence.”

When there is enough reason to believe that a Universal Mask Policy should help to protect our staff and patients, we need to err on the side of safety when the consequences are life- and livelihood-threatening. While anticipated mask shortage is clearly an issue, the remarkable resourcefulness, philanthropy, and ingenuity of our communities will come through.

In the meantime, we need a Universal Mask Policy to protect us. We need a Universal Mask Policy to unite us. We need a Universal Mask Policy now.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Social distancing in the time of COVID-19

I was just getting to work when I received a text from one of my chiefs, “can you call me?”. Not usually the start of a conversation you want to have. A person I had been exposed to had tested positive for SARS-CoV-2 and they suggested I put a facemask on and head home to self-quarantine and monitor for symptoms. Walking to my car, I realized I couldn’t stop at a friend’s apartment or my parent’s house for coffee or to decompress. The social distance hit me.

At home we had already been staying in, washing our hands, and seeing the “flatten the curve” graphs floating around twitter and online. But going to work still provided a sense of normalcy, and my social distancing felt more like a choice than an obligation. Over the next few days, keeping in touch with friends, family, and co-workers via iMessage, Whatsapp, or Zoom really helped close that social gap I felt as I was driving home. Keeping my social distance from others has given me a new found respect for what our global community is really doing to fight this thing.

 

[1]           

This past week I’ve been amazed not only at how empty the roads have been, but by how many more people I’ve seen out walking their dogs, jogging, or riding bicycles. When I get back into the clinic, I’m looking forward to talking to patients about how they’re incorporating physical activity among the other AHA Life’s Simple 7 lifestyle changes into their new routines [2]. Unfortunately, in many places around the world curves aren’t flattening yet. All the more reason to stay home and give our healthcare workers and their patients a fighting chance.

 

References:

  1. Attribution: Siouxsie Wiles and Toby Morris, This file is licensed under the Creative Commons Attribution-Share Alike 4.0 International license https://commons.wikimedia.org/wiki/File:Covid-19-curves-graphic-social-v3.gif
  2. The American Heart Association’s “Life’s Simple 7” cardiovascular health risk factors that people can improve though lifestyle changes https://www.heart.org/en/professional/workplace-health/lifes-simple-7

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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COVID-19 Pandemic: 5 lessons about the way we practice medicine

I know that this blog was supposed to be Part 3 of the “building an academic portfolio during medical training” series, however, it’s very difficult these days to talk about anything other than COVID-19. This pandemic that has taken the whole world by storm, and reminded us all about how fragile our whole world is! Amidst all the angst and frustration, it is important to focus on positively learning from such an unprecedented experience in our lifetime. The lessons are innumerable, yet I wanted to share with you 5 points that, in my humble opinion, were highlighted by these extraordinary circumstances:

  1. Telehealth is no longer a luxury. Despite having the technology available for years, the health industry has been lagging behind when it comes to telehealth. It took a pandemic and thousands of lives for us to realize that most of the outpatient services we provide (and arguably some of the inpatient ones even) can safely be delivered virtually. The degree of disruption to one’s life and the time wasted outside the actual doctor’s visit, between taking time off from work, physically making it to the medical facility, parking, checking-in, and so forth, can easily be omitted by a technology that is readily available but we have been reluctant to use (or don’t have insurance approval to do so). There will always be a place for in-person visits, but at least we would have more time for patients that actually need to be seen in-person.
  2. Many hospitalizations and tests are unnecessary. As the pandemic worsens, physicians started to be judicious with ordering tests that require moving patients around the hospital. They also started thinking twice about who needs to be in the hospital, to begin with. We are now realizing how many tests and hospitalizations can safely be avoided, and I am hoping that we will carry these revelations with us as we move past the current circumstances.
  3. Incorporating research into clinical practice needs to be seamless. Despite major advances, the way we conduct research has not yet been optimally incorporated into our daily clinical activities. We are in desperate need to develop the necessary infrastructure that instantaneously translates patient-care input into organized data that can be used to improve the way we manage our patients. Ideally quickly enough to potentially help some of the patients who generated these data. This necessary infrastructure also extends to research regulations, which need to strike the appropriate balance between scrutiny and practicality.
  4. In a world of “evidence-based medicine”, clinical acumen remains paramount. The sudden exposure to this COVID-19 pandemic has reminded us all that often times, as physicians, we are required to operate in evidence-free zones. As much as we need to always look for evidence behind everything we do in medicine, it is essential not to forget that taking care of patients is both a science and an art. And this is why physicians can never be replaced by computers.
  5. Prevention is ALWAYS better than cure. With the great technological and pharmaceutical advances, we tend to develop great confidence in our ability to improve life expectancy. This is particularly true in procedural fields such as Cardiology. Then comes a sobering pandemic, to remind us that when it comes to public health, prevention always wins! Fortunately, we rarely need drastic measures such as quarantines and social distancing. But addressing smoking, obesity and blood pressure control will always have much more impact on our community than stents and ablations.

We will continue to learn from this world tragedy – lessons in medicine, philosophy and life in general. But, above all, this is a reminder of how noble and unique our healthcare profession is. Stay safe everyone!

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

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The COVID-19 pandemic: In this together, a call for collective responsibility

On March 11 2020, following a 13-fold rise in COVID-19 cases outside China, the WHO declared the disease a pandemic. The novel coronavirus is now spreading in exponential proportions across the globe, crippling even some of the best healthcare systems. There are unprecedented events: there’s a sense of uncertainty, and for most of my generation, this is the “war” of our time. Times like these also call for a collective responsibility, for each of us to do our part. We are in this together, for the long haul. And I mean that in the most literal, least metaphorical way possible.

The epidemiology explained

An epidemiological study of the outbreak in China estimated the basic reproduction number (R0) of COVID-19 to be 2.68. 1 That essentially means that early on, every COVID-19 infected person can transmit the disease to an average of 2.5 others.

The epidemic doubling time of COVID-19 is 6.4 days.1 That means every 6-7 days, the number of cases increases by a factor of two. Exponential growthThis is the reason why the spread can be seemingly slow initially, only to lead to a sudden outbreak in a matter of days to weeks. It’s also why reducing transmission as early on in the outbreak as possible can dramatically reduce this exponential explosion of cases.

 Social distancing & “flattening the curve”

Social distancing is key to slowing down rates of transmission and might very well be the most responsible act in the face of this pandemic. This includes keeping a safe distance (at least six feet) between others, avoiding social gatherings, public transport, non-essential travel/ commutes and working from home, if one can. Needless to say, these measures must be accompanied by the consistent practice of healthy hygiene.

And it works: these simulation graphics by Harry Stevens of the Washington Post are a superb demonstration of the impact of social distancing on halting disease transmissions.2

The concept of “flattening the curve” alludes to reducing the number of cases over time by slowing the rate of transmission of the disease so that healthcare systems are not overwhelmed beyond capacity. COVID -19 can be fatal in anyone, with the elderly and those with comorbidities such as diabetes, heart and lung diseases at higher risk of severe infection.3 Latest reports from the WHO now emphasize that young people are not off the hook either, with data from countries showing that people under 50 make up a significant proportion of patients requiring hospitalization.4

The fundamental idea of social distancing is to reduce disease transmission to EVERYONE, not just oneself. The incentive is not just preventing oneself from catching it. Even seemingly healthy individuals might develop a milder or asymptomatic form of the disease, retaining the ability to transmit it to the elderly (the worst hit) and other vulnerable groups they encounter, including young people. This leads to a rapid growth of the pandemic, overwhelming the healthcare systems beyond their capacities. An overwhelmed health care system will not be able to treat all the COVID-19 cases coming its way, and will also be limited in resources to care for someone who has a heart attack, an accident or cancer.

However, turns out staying at home is easier said than done, with some still struggling to grasp the concept. “I’ll just be a while, what can happen?” they’ll say. At a time, where testing for COVID-19 is also rationed, staying away from large gatherings is ever so much more important, especially when one shows symptoms. In the fascinating case of Patient 31 of South Korea, we see the dangerous potential of a “super-spreader” phenomenon, in a 61-year-old woman who by virtue of attending religious gatherings prior to testing positive for COVID-19, transmitted the disease in large clusters, leading to a sudden surge of cases in South Korea.5

Sharing information: Responsible information, not misinformation

In a pandemic such as this, there’s also a tendency for rampant misinformation, easily transmitted through social media channels. This calls for the responsible dissemination of information, and while this is applicable to everyone, the onus is more so on healthcare personnel.

Social media can be used positively and responsibly to educate the public and refute myths: platforms such as Instagram, Facebook and Twitter are proving to be a great way for healthcare personnel to reach out to communities, explain epidemiology and create awareness of healthy practices during this pandemic. The WHO website has also detailed some of the more common myth-busters: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters

Keep updated

With the volatility of the situation and the torrent of information flooding in from multiple sources, it can be difficult to sift between what’s reliable and what isn’t. These are some reliable channels you can turn to for correct information and updates. It’s also important to seek out your local source of information depending on geographic location.

Show solidarity

Check on your elderly friends and relatives. Refrain from hoarding essential items, thereby potentially creating a shortage, making things difficult for senior citizens and those living on a daily wage.

 Donate

The economy has taken a hit, but the hit on health care is bigger. With severe shortages of essential items, those of us with the capacity to donate locally, in whatever way we can, should be doing so. The WHO also has a COVID-19 Solidarity Response Fund: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/donate

 Check on your colleagues

For healthcare personnel and their families, this can be a particularly overwhelming time. Some of us may not be on the frontlines, but have friends and family who are. Just those words, “on the frontlines”, sends a chill down my spine.

But that’s exactly what this is. War. War against a common enemy. And when you’re going to war, you don’t make light of the prep.

Which brings to mind this brilliantly appropriate quote by Michael O. Leavitt, Secretary of the U.S. Department of Health and Human Services, 2007:

 “Everything we do before a pandemic will seem alarmist. Everything we do after a pandemic will seem inadequate. This is the dilemma we face, but it should not stop us from doing what we can to prepare. We need to reach out to everyone with words that inform, but not inflame. We need to encourage everyone to prepare, but not panic.”

Unprecedented times call for unprecedented measures. In this global healthcare crisis and the ultimate test of our times, it is on all of us to be responsible.

References

  1. Wu JT, Leung k, Leung GM. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study. Lancet 2020; 395: 689–97
  2. Stevens H. Why outbreaks like coronavirus spread exponentially, and how to “flatten the curve”. The Washington Post March 14, 2020. https://www.washingtonpost.com/graphics/2020/world/corona-simulator/?fbclid=IwAR1ALnyJWXEcBIIh1qFvz1a3JMCtAQP0_jvYIKIRqBnrKpjDKn-sEo1J39A
  3. Centers for Disease Control & Prevention (CDC): Coronavirus Disease 2019 (COVID-19). Are You at Higher Risk for Severe Illness? https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html
  4. WHO Director-General’s opening remarks at the media briefing on COVID-19 – 20 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—20-march-2020
  5. The Korean Clusters. How coronavirus cases exploded in South Korean churches and hospitals. Via Reuters Graphics. Updated March 3, 2020. https://graphics.reuters.com/CHINA-HEALTH-SOUTHKOREA-CLUSTERS/0100B5G33SB/index.html

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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COVID-19; Patients with Congenital Heart Disease (CHD)

This week, the ACHA (American Congenital Heart Association) hosted a webinar in regards to Coronavirus aka SARS-CoV-2, and the illness it causes, COVID-19, 3,000 attended (view the recording here.) CHD patients, parents of CHD patients and CHD providers had the same question, how does this virus affect this special population? Unfortunately, the data is lacking on coronavirus those with CHD and there is a lot we don’t know.

A recent study1 in China looked at 2143 pediatric patients with COVID-19, the majority (94.1%) were asymptomatic or mild, more severe cases, were seen in infants (<1 year old) than older children, and there was only one death. This study lacks details, such as what other medical conditions they may have. Severe cases were 5.9% compared to 18.5% in adult population studies. Although reassuring for the general pediatric population, we still don’t know how this applies to pediatric patients in the United States and those with CHD.

What we do know.

There is a trend toward overgeneralization of “heart disease,” particularly in the media. It has been noted that the COVID-19 affects older adults and those with “heart disease,” meaning cardiovascular disease(CVD), such as coronary artery disease and hypertension, more severely.2 This does not include Congenital Heart Disease.

The virus may also cause myocardial injury, with reports of myocarditis and arrhythmias in those with severe cases.2-4 The effect is thought to be related to Angiotensin-converting enzyme 2(ACE2), which, in animal studies, has a role in the cardiovascular, and immune system and has been identified as a functional receptor for coronaviruses.2,3

Many patients with CVD and CHD take a medication known as ACE inhibitors or an Angiotensin Receptor Blockers (ARBs). The use of these medications is common in both populations, but for different indications, as their “heart disease” is not the same. There are trials assessing the use of these medications and effect on COVID19 in adults, and varying theories on whether they are protective or not, with that said, the HFSA/ACC/AHA currently recommends continuing these medications as prescribed.5

Are patients with CHD considered high risk?

The answer is we don’t know. With a wide range of congenital heart disease, from repaired/“normal” hearts, to those with altered blood flow, lung abnormalities, and arrhythmias. As  mentioned, the CDC places those with “heart disease,” meaning those with CVD, and older adults, at high risk of severe illness,6 this does not include CHD, however, CHD patients aren’t immune to CVD and if a patient has CVD and also CHD they are considered high risk.

With data lacking in many populations, it is important for those considered at high risk for other viruses, like influenza, such as CHD, asthma and those who are immunocompromised, to take appropriate precautions. It is better to be over prepared and over cautious.

Follow up and Communication.

CHD patients should keep in close contact with their medical team and stay updated with recommendations of their team and the CDC (found in detail here), like social distancing, good hand hygiene and staying home if you are sick. Concerning symptoms that require further evaluation include shortness of breath (or fast breathing in infants), chest pain, and palpitations.

 As far as visiting your doctor, you will likely be asked to either re-schedule or have a telephone visit. You can ask your medical team about this option and even anticipate it for the next few months. Elective procedures, catheterizations and imaging will likely be delayed. If one good thing comes out of this pandemic, it may be better options and availability for telemedicine in the future.

Keep your Mind Healthy

Use this time to support your mental health— pay attention to the news and social media, but set timers so you don’t over-saturate yourself. Find the book you’ve had on your shelves that you’ve been too busy for and set aside time every day to read, call or FaceTime friends, and maybe even fill up your bathtub and relax!

Meditation and exercise are also great options, and many apps offer free trials. Calm and Headspace have some free mediation content and free trials. Peloton & DailyBurn offer free day trials with a variety of classes(Tip: If you do choose a free trial, be sure to set an alarm on your calendar before the free trial is over so you can choose if it’s worth continuing for a fee or not.) There are also options to support your local gyms and studies virtually with on demand classes, just check out their websites and/or Instagram.

There is so much unknown, which causes us to worry and discomfort, but we are learning more each day. Stay informed, stay safe, wash your hands and try to keep your mental health in check.

For more on coronavirus and heart health, read Noora Aljerhi’s blog (3/9/2020) on the early career voice.

  1. Dong, Yuanyuan, et al. “Epidemiological Characteristics of 2143 Pediatric Patients with 2019 Coronavirus Disease in China.” Pediatrics, 2020, doi:10.1542/peds.2020-0702.
  2. Hui, Hui, et al. “Clinical and Radiographic Features of Cardiac Injury in Patients with 2019 Novel Coronavirus Pneumonia.” 2020, doi:10.1101/2020.02.24.20027052.
  3. Zheng, Ying-Ying, et al. “COVID-19 and the Cardiovascular System.” Nature News, Nature Publishing Group, 5 Mar. 2020, nature.com/articles/s41569-020-0360-5?code=85e25438-46d1-4753-bfdd-84496a98b564.
  4. Hu, Hongde, et al. “Coronavirus Fulminant Myocarditis Saved with Glucocorticoid and Human Immunoglobulin.” European Heart Journal, 2020, doi:10.1093/eurheartj/ehaa190.HFS/ACC/AHA statement
  5. “HFSA/ACC/AHA Statement Addresses Concerns Re: Using RAAS Antagonists in COVID-19.” American College of Cardiology, 17 Mar. 2020, acc.org/latest-in-cardiology/articles/2020/03/17/08/59/hfsa-acc-aha-statement-addresses-concerns-re-using-raas-antagonists-in-covid-19.
  6. “If You Are at Higher Risk.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 12 Mar. 2020, www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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The Robotic Technology in Interventional Cardiology

The past few years have witnessed amazing advances in the robotic technology leading to its widespread utilization in both research and clinical aspects across multiple fields, including the cardiovascular field! I have recently attended a few conferences and the footprint of the robotic technology has been remarkable in each of them, emphasizing the great interest in the progress and utility of technology in our field. I decided to talk about robotic technology in interventional cardiology, the advantages and limitations of its use, and how I see it impacting the future of interventional cardiology.

  • How long have we used robotic technology in the cath lab?

Robotic technology has been used in surgical specialties and radiation therapy since the mid-1990s. Then, robotics systems for endovascular interventions were developed and have been utilized for different percutaneous interventions, including simple and complex coronary and peripheral interventions, as well as other structural heart disease procedures, including atrial septal defect closure.

  • Do we have scientific evidence-based trials assessing the robotic technology in interventional cardiology?

There are many prospective trials looking at robotic technology in both coronary and peripheral interventions. The two major studies are:

  1. PRECISE (Percutaneous Robotically Enhanced Coronary Interventions) trial: 164 patients with relatively simple lesions (>87% ACC/AHA type A/B; lesion length 12.2 6 4.8 mm), the investigators reported clinical success of 97.6%, technical success of 98.8% and > 95% median operator radiation reduction. Based on the results of this study, in 2012, the FDA approved the CorPath 200 System as the first robotic system for PCI.
  2. The RAPID (Robotic-Assisted Peripheral Interventions for Peripheral Artery Disease) trial, a prospective single-center, safety and feasibility study demonstrated the utility of the CorPath 200 system for robotic peripheral interventions. The study demonstrated 100% device technical and clinical success. No significant adverse events related to the device were reported, and based on this study, the CorPath 200 system received FDA approval for peripheral interventions.
  • Advantages
  • One of the main advantages of the robotic system in the cath lab is the reduction of radiation exposure for both the operators. The hazards of radiation are well-known and studies have demonstrated that the use of robots led to a reduction in radiation exposure [1]. Operators using the robotic system can either be in the cath lab several feet away from the radiation source or even in a separate room, where they can control the joystick and use the control pad to adjust the robot movements to control wires, the guide catheters and other devices (balloon, stents, etc..).
  • Robots also help avoid wearing heavy lead aprons and thus decrease the orthopedic problems that many operators suffer from in the long run, including back pain and arthritis.
  • Moreover, studies have also shown that robotic system use is associated with good precision and outcomes [1].
  • Robots have been increasingly utilized with around 100 hospitals in the US currently using robots in the cath lab. This quick and widespread utilization of this new technology demonstrates not only how safe and successful the robotic system is, but also how easy and user-friendly it is.

 

  • Limitations

In my opinion, this tool was developed to help operators, but not to replace them. Like any tool, the machine can potentially stop working, for a technical reason or other reasons, and at the end of the day, it is the physician’s responsibility to deal with the situation and solve the problem. In addition, the use of robotic system is limited in the following:

  • The use of robotics in STEMI or bifurcation lesions has not been well-established yet, although reports and smaller studies have shown it can be performed safely.
  • There are technical limitations of the robotic system, and if a lesion could not be treated, manual conversion is recommended.
  • Limited devices used by the current generation of robotic technology: use of over-the-wire balloons, intra-vascular imaging catheter, or mechanical circulatory support is not available with the current generation of robotics.
  • How will robots change the future of interventional cardiology?

The robotic technology has been increasingly utilized in multiple hospitals across the world. With more experience with robotic technology utilization, more knowledge and future upgrade of robotic systems, I think this tool will be increasingly utilized and updated to conform to the needs of patients, operators and different kinds of procedures and interventions; in fact, the robotic system is being studied in the utility of transcatheter aortic valve replacement (TAVR) procedures! Moreover, the utility of the robotic technology could potentially enable experienced operators to remotely perform complex interventional procedures in patients in different hospitals in rural or urban areas, different states, different countries or even different continents!

With the rapid progress in technology in all fields of our life, I think it is very important to establish and encourage more collaborations between technology and medical sciences, especially in procedural specialties, where precision and safety can be provided by these advanced robotics systems for optimal outcomes. I look forward to seeing how these technologies will evolve and transform our practice in the future!!

 

I would like to thank my colleague and friend, Dr. Jeff Hsu, for his help on this blog and for being an awesome senior buddy!!

References

  • Mahmud et al: Robotic technology in interventional cardiology: Current status and future perspectives. Catheter Cardiovasc Interv.2017 Nov 15;90(6):956-962.

https://onlinelibrary.wiley.com/doi/abs/10.1002/ccd.27209

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Why Should We Care About Sex Differences in Do Not Attempt Resuscitation Orders After In-Hospital Cardiac Arrest?

As an AHA Early Career Blogger and member of the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation (3CPR), I am pleased to have the opportunity to summarize the recently published paper in the Journal of the American Heart Association (JAHA), “Do Sex Differences Exist in the Establishment of ‘Do Not Attempt Resuscitation’ Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest?”1 This paper was published in February during American Heart Month in the JAHA Spotlight: Go Red for Women 2020 series in conjunction with AHA’s Go Red for Women initiative.

In summary, Perman et al.1 used the Get With The Guidelines®-Resuscitation registry to determine whether there are sex differences in the establishment of “do not attempt resuscitation” (DNAR) orders after resuscitation from in-hospital cardiac arrest and whether the differences in DNAR use lead to differences in survival. They examined 71820 patients across 571 hospitals who had return of spontaneous circulation (ROSC) after in-hospital cardiac arrest and examined the association between de novo DNAR orders (any time after ROSC, within 12 hours of ROSC, or within 72 hours of ROSC) and sex and the association between sex, DNAR orders, and survival. The 72-hour time point was selected since after this time is when patients who are comatose after cardiac arrest begin to have neurologic findings that indicate poor prognosis and AHA guidelines recommend that the determination of neurologic prognosis should be delayed until at least 72 hours after ROSC (or 72 hours after reaching normothermia if targeted temperature management is used).

Of the 71820 patients, 42.4% of the cohort were women and women were on average older (mean±SD: 65.5±15.8 vs. 64.6±15.1 years; P<0.0001), less frequently of non-Hispanic white race (61.7% vs. 67.5%, P<0.0001), more likely to have a non-shockable cardiac arrest rhythm such as pulseless electrical activity (PEA) or asystole (81.6% vs. 78.0%, P<0.0001), and more likely to have a noncardiac illness at the time of admission (47.2% vs. 41.1%, P<0.0001) while men had a higher incidence of cardiac premorbid conditions.

Of the total cohort, 44.1% had a de novo DNAR order placed after ROSC. Of the entire cohort, 45.0% of women and 43.5% of men had a DNAR order after ROSC (unadjusted RR: 1.16; 95% CI, 1.12-1.21; adjusted RR [ARR]: 1.15; 95% CI, 1.10-1.20). Women had a higher rate of DNAR status early after resuscitation. Of those who had any DNAR order during the hospitalization, 51.8% of women compared to 46.5% of men had a DNAR order placed <12 hours after ROSC and 75.9% of women compared to 70.9% of men had a DNAR order placed <72 hours after ROSC. When adjusting for the patients’ demographics and cardiac arrest characteristics, female sex was associated with a higher likelihood of early DNAR <12 hours after ROSC (ARR: 1.40; 95% CI, 1.30-1.52) and DNAR <72 hours after ROSC (ARR: 1.35; 95% CI, 1.26-1.45) among those who had a DNAR order any time after ROSC.

Interestingly, after adjusting for patient and arrest characteristics, female sex was mildly associated with lower rates of survival to hospital discharge (ARR: 0.98; 95% CI, 0.96-1.00; P=0.04) and there were no differences in survival rate between men and women after adjusting for DNAR status within 72 hours. However, early DNAR status made within 72 hours of ROSC (combining data from men and women) was associated with decreased survival rate compared to those without a DNAR order or a DNAR order placed ≥72 hours after arrest (RR: 0.15; 95% CI, 0.14-0.17; P<0.0001).

This study by Perman et al.1 is not the first study to note differences in rates of do not resuscitate (DNR)/DNAR orders between men and women. Nakagawa et al.2 showed that women with acute intracranial hemorrhage were more likely to receive early (<24 hours from presentation) DNR orders than men. In a study of patients who received emergency surgery, women were more likely to receive a DNR order but morbidity and mortality rates were similar between men and women3.

Unfortunately, the reasons for women to more likely receive earlier DNR/DNAR orders are unknown at this time. Perhaps these differences could be due to patient preferences (e.g. women having earlier end of life discussions with family/surrogate decision-makers), implicit provider biases (e.g. female cancer patients were found to be more likely to receive early DNR orders from female physicians4), surrogate decision-maker biases, sociocultural factors, religious factors, situational influences, etc. Although DNR/DNAR orders are not requests for withdrawal of life-sustaining therapy, the presence of DNR/DNAR orders has previously been associated with decreased aggressive interventions and decreased survival to discharge for patients with out-of-hospital cardiac arrest5. This suggests that health care providers should be vigilant of the tendency to be less aggressive with care for patients with DNR/DNAR orders and ensure that their management plans align with the expectations of surrogate decision-makers. More robust qualitative data are needed in order to understand these differences.

References:

  1. Perman SM, Beaty BL, Daugherty SL, Havranek EP, Haukoos JS, Juarez-Colunga E, Bradley SM, Fendler TJ, Chan PS, † AHAGWTGRI. Do sex differences exist in the establishment of “Do not attempt resuscitation” Orders and survival in patients successfully resuscitated from in-hospital cardiac arrest? J Am Heart Assoc. 2020;9:e014200
  2. Nakagawa K, Vento MA, Seto TB, Koenig MA, Asai SM, Chang CW, Hemphill JC. Sex differences in the use of early do-not-resuscitate orders after intracerebral hemorrhage. Stroke. 2013;44:3229-3231
  3. Eachempati SR, Hydo L, Shou J, Barie PS. Sex differences in creation of do-not-resuscitate orders for critically ill elderly patients following emergency surgery. J Trauma. 2006;60:193-197; discussion 197-198
  4. Crosby MA, Cheng L, DeJesus AY, Travis EL, Rodriguez MA. Provider and patient gender influence on timing of do-not-resuscitate orders in hospitalized patients with cancer. J Palliat Med. 2016;19:728-733
  5. Richardson DK, Zive D, Daya M, Newgard CD. The impact of early do not resuscitate (dnr) orders on patient care and outcomes following resuscitation from out of hospital cardiac arrest. Resuscitation. 2013;84:483-487

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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How to Shine the Light on Hidden Figures in Science and Medicine

March is Women’s History month and like last year, I wanted to find a way to use this blog as a way to highlight some amazing women scientists and cardiologists. When writing my piece last year, I had a really hard time finding enough information about trailblazing women in cardiology — which was incredibly frustrating since we all know women are a driving force in our field.

I then came to realize, although I wasn’t surprised, that this isn’t specific to our field. One of the main reasons it was hard to make a list of notable women in cardiology is that less than 20% of Wikipedia articles are about women. Even Marie Curie shared her Wikipedia biography with her husband until recently. If winning a Nobel Prize doesn’t make you worthy of your own Wikipedia page, I’m not sure what does. This bias has become an issue in part because most of Wikipedia editors are men.

So, how do we fix this? What can you do?

It turns out, the answer to these questions is actually really easy! Since anyone can become an editor on Wikipedia, you yourself can edit or write pages for notable women and other under-represented scientists/physicians. This practice has actually become a popular grassroots movement, with Women in STEM Wikipedia-edit-a-thons sprouting up all over the country — I’ve been to three in the last year!

One of the main drivers of this movement is a physicist at Imperial College London, Dr. Jess Wade, has written over 900 biographies on Wikipedia in just the last couple of years. While writing almost a thousand articles seems a bit overwhelming, you can easily edit a page you think deserves to be beefed up or create one of your own by following this beginner’s guide, which also includes information about how to run your own edit-a-thon if you know of others who are interested. Writing with friends is always more fun. The last edit-a-thon focused on creating pages for under-represented scientists that I attended was this past weekend on International Women’s Day and had a wonderful keynote address from Dr.Maryam Zaringhalam, who has been another driver of making Wikipedia a more inclusive space. In just a couple of hours at this edit-a-thon we added 5 new biographies, made over 200 edits and added over 12,000 words to Wikipedia! This was just our group — on this day, there were actually more than 12 other groups working with us virtually and collectively we added over 60,000 words to Wikipedia. You can actually catch the livestream of this event, including Dr. Zaringhalam’s phenomenal keynote here.

So this Women’s History Month, take action to make our community more inclusive by starting with the internet — it’s easy, rewarding and fun, I promise!

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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The Health Costs of Hunger Part 2: What we can do about it

If you read my February blog, you know that food insecurity is a complex and overwhelming issue in the United States. In 2018, 37.2 million Americans were food insecure and of that, 6 million were children. The health consequences of food insecurity are significant and contribute to growing rates of chronic disease American’s have experienced in the past few decades. With recent changes to programs such as the supplemental nutritional assistance program (or SNAP), more Americans are at risk for becoming food insecure.

The lack of stable access to adequate safe food affects a persons’ health and well-being in profound ways. And as health care providers used to acting, we want to do something about food insecurity in our communities.  But what can be done and where to start?  To answer these critical questions, I spoke with Alissa Glenn, consultant of food as medicine program at the Greater Cleveland Food Bank, who offered this advice.

  1. Acknowledge that food insecurity is pervasive and talk about it. Hunger affects people of every gender, age, race and ethnicity throughout the United States. Yet, an important reason people often do not pursue supportive programs such as SNAP, is the longstanding stigma around assistance. One of the best ways to break this stigma is by talking openly and compassionately about food insecurity in your community.
  2. Educate yourself and your colleagues. My February blog, had a lot of scientific resources on food insecurity hyperlinked. Last year, the AHA published a science advisory on innovative strategies to create a healthy and sustainable food system that can provide useful context. In addition, lay resources such as the Feeding America website and books like Stuffed and Starved can help explain this complex issue. Finally, consider inviting your local food bank to conduct a continuing education or a Grand Rounds session on addressing food insecurity in clinical settings. They can describe local resources in your own community and practice poverty simulations to help healthcare providers feel more comfortable discussing food insecurity with patients.
  3. Ask your patients about it. Screening for food insecurity is recommended by groups such as the American Association of Pediatrics which suggests incorporating such a screening at every patient visit. I know, we have to fit so much into each patient encounter that trying to fit in one more thing seems impossible. But a quick, simple strategy is to administer the Hunger Vital Sign™ (Left Insert).

It can be hard for patients to acknowledge they are food insecure so helping them feel comfortable can result in more honest answers. Best practices include asking screening questions after the patient has been with the provider for a while, having a team member with a longstanding relationship ask screening questions, and if possible, to ask them via tablet or computer to reduce awkwardness.

  1. Refer patients and family members who are food insecure and may need immediate help to local resources. This can include local food pantries, produce distribution sites, hot meals, and perhaps, onsite therapeutic food clinics. If your clinical setting is lucky enough to have to have a registered dietitian, involve them in developing a list of local resources to be distributed to patients. Case managers and outreach workers can also provide patients resources about short and long-term support for food insecurity. To find a food bank near you, please check out the Feeding America
  2. Advocate for anti-hunger programs. SNAP is the first line of defense against food insecurity. For every meal that a food bank provides, SNAP provides 9 meals. As the largest effort to address hunger in the U.S., changes to this program that reduce eligibility or benefits will increase the number of hungry Americans. Working with your community and engaging with your elected officials about how hunger influences the health care you provide are powerful ways to advocate for their continued support. To find out more about advocating for SNAP and the Child Nutrition Reauthorization Act, please review the Advocating for a Hunger-Free America
  3. Use your professional associations. As healthcare professionals, we have a powerful voice. Every day we talk with dozens of patients and family members about how to improve their health and well-being. As you get more comfortable talking with your patients talking about food insecurity, you will likely hear stories about how hunger affects their health. Work with your professional associations to collect those stories and with one voice advocate for changes in practice, education, and policy.

 Last month, the AHA released its 2030 Impact Goal. This ambitious statement recognized the importance of structural changes to achieve a world of more equitable, longer, healthier lives. It creates a framework from which professional organizations can harness the energy and experience of its members to initiate conversations about food insecurity, incorporate food insecurity education into the training of providers, increase food insecurity screening in clinical settings, and use the collective voice of 40 million volunteers and members to effectively advocate for anti-hunger programs.

There are many ways you can work with the AHA to reduce food insecurity in America. Consider working with your scientific council to propose a scientific statement on the effects of food insecurity on cardiovascular health, propose a workshop on clinical food insecurity protocols at a Scientific Sessions meeting, or write an editorial on your experiences helping a patient with food insecurity. The enormity of hunger in America, and its deleterious effects on the health of our patients, can be overwhelming. But even small steps such as reading a book on food insecurity, screening patients in your clinic, or advocating for structural change, can be powerful ways to help to reduce food insecurity.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”