Comparison of Patient Perception and Satisfaction of Face-to-Face Versus Telemedicine Encounters in Hand Surgery.

BACKGROUND: The coronavirus disease 2019 (COVID-19) surge has enabled the widespread usage of telemedicine (TM) and presents a unique opportunity to determine the hand surgery patients' perception of care using validated patient satisfaction scores. METHODS: Electronic surveys were distributed to patients aged 18 years and older who underwent a video TM encounter with a single surgeon at an academic medical center during the initial COVID-19 surge (March 23 to October 22, 2020). The study-specific questions were derived from the Press Ganey (PG) Medical Practice TM Survey and compared with institutional PG Outpatient Medical Practice Survey data. Three cohorts were defined: pre-COVID face-to-face, post-COVID TM, and post-COVID face-to-face. RESULTS: Thirty of 65 TM patients (46.2%) responded. No differences in sex, age, or visit type were identified between cohorts. The TM cohort was more likely to live greater than 300 miles from the institution. Median response for all cohorts for the PG care provider and overall experience responses were "very good," and no differences were identified between cohorts. Patient satisfaction with their TM experience was high with median satisfaction scores for arranging and connecting to a TM visit, talking with the provider over a video connection, and having the provider understand the clinical problem were "very good." Patients in the TM cohort reported no difference in preference for face-to-face or TM visits. CONCLUSIONS: Patients are satisfied with TM as a substitute for face-to-face visits suggesting that TM can possibly be used to deliver comparable patient experience for hand surgery encounters.

Learner Preferences and Perceptions of Virtual Hand Surgery Education During the COVID-19 Pandemic.

PURPOSE: In response to the COVID-19 pandemic, many postgraduate medical education lectures and conferences have been moved to a virtual platform. Questions remain regarding the effectiveness of virtual education, what types of educational offerings can be transitioned to a virtual format, and what types of curricula should still take place in person. METHODS: This study surveyed trainees from the United States who participated in a single institution's hand surgery virtual flipped classroom curriculum of 6 week-long modules. Demographics, premodule and postmodule achieved levels of learning based on Bloom's taxonomy, technology usage, and preferences were surveyed. RESULTS: Of the 65 participants, 41 (63.1%) responded to the survey. Trainees included hand surgery fellows (27/41 [65.9%]), orthopedic surgery residents (11/41[26.8%]), and plastic surgery residents (3/41 [7.3%]). On average, most trainees read, viewed, and participated in more than half of the articles (28/41 [68.3%]), electronic videos (31/41 [75.6%]), and conferences (35/41 [85.4%]) per week. The median level of achieved learning increased from "I can apply" to "I can analyze" for all modules. Self-directed learning was preferred for basic facts and knowledge (26/41 [63.4%]) and faculty-directed learning was preferred to review and practice advanced concepts (34/41 [82.9%]). The participants perceived benefits of the virtual curriculum to include increased scheduling flexibility (8/41[19.5%]), expert opinions (7/41 [17.1%]), and diversity of educational formats (3/41 [7.3%]). The perceived drawbacks included decreased interaction (8/41 [19.5%]), technical difficulties (6/41 [14.6%]), excessive detail (3/41 [7.3%]), and single-institution bias (2/41 [4.9%]). CONCLUSIONS: The flipped virtual classroom model is an effective and preferred method of instruction for trainees. Trainees achieved a higher level of learning following the completion of each week-long module. Considerations for the implementation of a virtual curriculum include content quality, quantity, and reducing single-institution bias. CLINICAL RELEVANCE: The implementation of virtual learning can enhance hand surgery education for the modern learner.

Serial rotational thromboelastography (ROTEM) in mechanically ventilated patients with COVID-19 demonstrates hypercoagulopathy despite therapeutic heparinization.

Background: Clinical hypercoagulopathy in patients with COVID-19 has been anecdotally described, but there is lack of evidence due to the novelty of this disease. Our study reports the results of rotational thromboelastography (ROTEM) in relation to traditional laboratory coagulation tests and acute phase markers among a cohort of severely ill, mechanically ventilated patients with COVID-19. Methods: Patients with COVID-19 (N=21) with respiratory failure requiring mechanical ventilation were included in this prospective case series. ROTEM was serially obtained for all patients on three different days during their intensive care unit (ICU) stay and analyzed using repeated measures analysis. Demographic variables, symptoms at the time of presentation, ROTEM values, laboratory values for traditionally measured coagulation profiles, and acute phase reactants were analyzed, in addition to the use of anticoagulation and clinical hypercoagulopathic complications. Results: The average age of our cohort was 57.9 years old (SD=14.4) and 76.2% were male. The mortality rate was 14.3% (3 of 21). Two patients (12.5%) were identified to have new-onset deep vein thrombosis, two patients (12.5%) were found to have ≥3 episodes of central venous catheter thrombosis, and three patients (18.7%) had confirmed stroke. ROTEM demonstrated elevated EXTEM and INTEM clotting times, including elevated FIBTEM maximum clot firmness (MCFFIB). All patients treated with therapeutic anticoagulation still demonstrated hypercoagulopathy within the MCFFIB tests. Discussion: Repeated measure ROTEMs were able to detect hypercoagulopathy in ICU patients with COVID-19 despite therapeutic anticoagulation with heparin. Level of evidence: III.

Combating an invisible enemy: the American military response to global pandemics.

The present moment is not the first time that America has found itself at war with a pathogen during a time of international conflict. Between crowded barracks at home and trenches abroad, wartime conditions helped enable the spread of influenza in the fall of 1918 during World War I such that an estimated 20-40% of U.S. military members were infected. While the coronavirus disease 2019 (COVID-19) pandemic is unparalleled for most of today's population, it is essential to not view it as unprecedented lest the lessons of past pandemics and their effect on the American military be forgotten. This article provides a historical perspective on the effect of the most notable antecedent pandemic, the Spanish Influenza epidemic, on American forces with the goal of understanding the interrelationship of global pandemics and the military, highlighting the unique challenges of the current pandemic, and examining how the American military has fought back against pandemics both at home and abroad, both 100 years ago and today.

Open tracheostomy for COVID-19-positive patients: A method to minimize aerosolization and reduce risk of exposure.

BACKGROUND: The COVID-19 virus is highly contagious, and thus there is a potential of infecting operating staff when operating on these patients. This case series describes a method of performing open tracheostomy for COVID-19 patients while minimizing potential aerosolization of the virus using typically available equipment and supplies. METHODS: This is a case series of 18 patients who were COVID-19-positive and underwent open tracheostomy in the operating room under a negative pressure plastic hood created using readily available equipment and supplies. Patients had to be intubated for at least 14 days, be convalescing from their cytokine storm, and deemed to survive for at least 14 more days. Other indications for tracheostomy were altered mental status, severe deconditioning, respiratory failure and failed extubation attempts. RESULTS: There were 14 men and 4 women with severe SARS-CoV2 infection requiring long-term intubation since March 23 or later. The mean age was 61.7 years, body mass index was 32.6, and the pretracheostomy ventilator day was 20.4 days. The indications for tracheostomy were altered mental status, severe deconditioning and continued respiratory with hypoxia. Failed extubation attempt rate was 16.7% and hemodialysis rate was 38.9%. All patients were hemodynamically stable, without any evidence of accelerating cytokine storm. To date there was one minor bleeding due to postoperative therapeutic anticoagulation. CONCLUSION: This report describes a method of performing open tracheostomy with minimal aerosolization using readily available equipment and supplies in most hospitals. LEVEL OF EVIDENCE: Therapeutic/care management, Level V.