Society for Vascular Medicine (SVM) Leaders Respond to the COVID-19 Crisis

Past Presidents, Trustees, and Communication Committee Chairs of SVM

We asked SVM Past Presidents, current Trustees, and other leaders to respond to provide a brief update on their institutions’ response to the COVID-19 pandemic, lessons learned, or other messages for our SVM community. These responses are current as of April 7, 2020.

Boston Medical Center; Boston University School of Medicine, Boston, Massachusetts

Robert T. Eberhardt, MD, FSVM, Past Trustee

Naomi Hamburg, MD, FSVM, Publications and Communications Committee Co-Chair

Our initial response to the COVID-19 pandemic was similar to the rest of the world - shock at the devastating impact on every aspect of our lives (including health, financial, social, family, and emotional). We then sought to approach this problem, as we have previously with other vascular problems, by joining our local medical community as part of a multidisciplinary response team. We eased our anxiety through empowerment offered by knowledge and preparedness. We have gained an understanding of the consequences of the disease and potential treatment from the experiences of colleagues from local to international. The resilience of the worldwide medical community to rise to the challenge and offer insight has been inspirational. Our local preparations for the anticipated surge of afflicted patients have involved assisting in development of relevant hospital-specific COVID protocols and best practices (including vascular lab testing and prevention, diagnosis, and treatment of venous thromboembolism, particularly in light of associated coagulopathy). We have been flexible to adopt our clinical roles to provide care, beyond our usual practice, and assist in delivery of care for patients who require hospitalization and intensive care services. We are working as a team to help us all get through this together!

Massachusetts General Hospital, Boston, Massachusetts

Leben Tefera, MD

Ido Weinberg, MD, FSVM, Treasurer

In response to the COVID-19 pandemic, the vascular medicine service at Massachusetts General Hospital (MGH) enacted changes spanning the breadth of our activities. First, nearly all in-person outpatient visits have either been postponed (to a yet unknown date) or transitioned to telemedicine visits. Vascular testing volume has also been distilled to the absolute necessary. Next, our inpatient consult service has largely shifted to remote consultations (e.g., speaking to patients via phones with or without video capabilities) to protect trainees and minimize contact. This has been enacted in patients known and unknown to be positive for COVID-19. Importantly, our fellows are contributing to staffing of MGH COVID ICUs, medicine inpatient units, and cardiology units. These changes have resulted in much disruption to our educational goals. We are still trying to find the best solution for this. Currently, we attend the many hospital virtual lectures, and hold twice weekly Zoom educational conferences with vascular medicine staff and trainees. These changes have reminded us of the importance of fluidity. Over the course of barely a week, many of our team have stepped into roles not traditionally asked of them. We wish the SVM community strength and health in these unprecedented times.

Boston Scientific Corporation, Massachusetts/Minnesota/Global

Michael R. Jaff, DO, MSVM, SVM Past President (2003-2005)

I am Chief Medical Officer of the Peripheral Intervention Division and a core team member of the Boston Scientific “Clinician Emergency Response Team,” whose role is to contact every member of the employee base (40,000) who either had direct exposure to someone with COVID-19 or who are having symptoms and assist in tracing contact with other employees. The primary goal is health of the employees but maintaining business continuity is important. Very impressive culture of this company is to demonstrate empathy and focus on the health and safety of the workforce. It has been challenging to speak with employees all around the world about their specific physical, financial, and emotional challenges. It remains clear to me that all of us need to (a) the accept that it is normal to feel anxious, frustrated, angry; (b) force yourself to take this ‘one day at a time’ rather than project what is going to happen, when things will get back to ‘normal’, etc.; (c) take a deep breath. I urge all of you, my colleagues, to heed these factors and practice them. Be safe and be well.

Alpert Medical School of Brown University; Lifespan Cardiovascular Institute, Providence, Rhode Island

Herbert D. Aronow, MD, FSVM, President-Elect

We have not yet hit our COVID-19 surge, so much of our work has been preparatory. Social distancing and other measures implemented at the state level have afforded us time to plan. Our Cardiovascular Institute senior operations group holds daily 7 AM phone calls to coordinate cardiovascular care. Likewise, there are multiple daily system-wide calls on which leadership receives updates from state, city, and federal governments, individual hospital incident command centers, nursing and medical branch operations, infrastructure, planning, and logistics. As in other centers, all non-essential vascular testing and procedures have been postponed. These efforts have been coordinated across vascular specialties. We continue to perform non-invasive studies for stroke and transient ischemic attack, symptomatic aortic disease, pulmonary embolism, acute and critical and limb ischemia, pseudoaneurysm, and deep vein thrombosis. Likewise, we will continue performing interventions for most of these conditions when deemed life- or limb-threatening. Our response to hospital transfer requests has been modified accordingly. These are challenging times, but we have been comforted and inspired by the heroic efforts of our vascular colleagues from around the world. Together, we will get through this. Please stay safe.

Cleveland Clinic, Cleveland, Ohio

Natalia Fendrikova Mahlay, MD, FSVM

Jerry Bartholomew, MD, MSVM, Past President (2015-2017)

G. Jay Bishop, MD, FSVM, Trustee

Our response began with early mobilization of resources within the vascular medicine section and engagement with institutional leaders across the enterprise with a comprehensive and proactive approach to the pandemic. Clinical measures included a re-evaluation of core staff needs, addition of a second shift for the inpatient consultation service, conversion of in-person outpatient visits to virtual visit platforms, redeploying vascular medicine physicians to support the hospital needs, and training in the use of mechanical ventilation and the use of PPE. Education and research measures were added including research protocols to study venous and arterial thromboembolism in hospitalized patients with confirmed COVID-19 infection, order set for COVID-19 related DIC, consensus guideline review of anticoagulation use in this population, and use of virtual platforms for education. Vascular lab response has been prompt, transparent, and aligned with institutional policies. Operational adjustments have included consolidation of services, prioritization of testing, emergent backup staff coverage, cross-training of technologists in different clinical settings, and imaging protocols adjusted for COVID-19 cases. Safety and infection control measures included lab-wide PPE training, equipment disinfection protocols, and workplace safety. Clear policies have been created to address staffing of the lab, labor pools, and PTO.

Lesson learned: transparency, innovation, and compassionate teamwork are essential.

University Hospitals, Cleveland, Ohio

Heather L. Gornik, MD, FSVM, Immediate Past President

Mehdi H. Shishehbor, DO, PhD, FSVM, Trustee

We are in the steep phase of the growth curve, but we hope the interventions put in place by our Governor Mike DeWine early on will have helped us “flatten the curve” in Ohio by the time this is published. Our hospitals remain focused on preparedness, preserving PPE, and keeping employees/patients as safe as possible. Our Vascular Center leadership, which includes the two of us and vascular surgeon Dr. Vik Kashyap and administrator Rebecca Kahl, have worked to define essential vs. non-essential endovascular/surgical procedures, office visits, and testing. Our vascular lab directors, Drs. Natalie Evans and Karem Harth, have been working on minimizing non-essential testing, developing abbreviated scanning protocols for venous duplex (rule out DVT) and other exams, and have personally reviewed requests for scans for suspected/confirmed COVID-19+ patients to be sure they are truly indicated. Dr. Terri Carman has been working with our anticoagulation service to transition patients on warfarin to DOACs when possible or decrease frequency of INR testing. The biggest change in terms of care delivery has been the shift to telephone and/or virtual visits. Our institution was doing very little of this prior to COVID-19, and we are now doing almost all of our outpatient care remotely. We hope our SVM family is holding up during this difficult time.

OhioHealth, Columbus, Ohio

Raghu Kolluri, MD, FSVM, President

Mitchell Silver, DO, FACC, FSVM, Trustee

COVID-19 became a harsh reality for OhioHealth initially in the vascular labs. One of our sonographers demonstrated symptoms consistent with COVID-19 infection in the 3^rd week of March. Understandably, there was significant stress amongst the contacts. Rapid testing was not yet available. We had to quarantine some sonographers. We could not risk having COVID-19 decimate the rest of our vascular service. We had to come up with some quick fixes. We divided vascular testing into Emergent, High Acuity, and Elective groups. All Elective testing was postponed. Our health system also agreed to the “Team A and Team B” concept, allowing sonographers and physicians to work in two teams, each working two weeks at a time. A committee of vascular interventional and surgical physicians now provide a weekly list of procedures that are categorized as follows:

GREEN: Should proceed

YELLOW: Needs context to establish a need to proceed

RED: Do not schedule

For example, symptomatic or ruptured aneurysmal disease and Rutherford class 4-6 CLI would be categorized as GREEN and therefore acceptable for treatment at this time. As the stress on our health system evolves, so will our plans.

Stay safe, everyone!

University of Michigan, Ann Arbor, Michigan

Geoffrey D. Barnes, MD, FSVM

James B. Froehlich, MD, MSVM, Past President (2013–2015)

The University of Michigan vascular medicine faculty remain committed to our tripartite mission during the SARS-CoV-2 (COVID-19) pandemic: patient care, research, and education. Our outpatient visits have rapidly converted to video visits. In the hospital, we continue to run our PERT program and some faculty have been re-deployed to staff general medicine teams given the rapidly expanding number of patients with COVID-19. We have also collaborated with a number of colleagues to update our venous thromboembolism (VTE) diagnosis and management guidelines. Given limited imaging availability for COVID-19+ patients (and to minimize exposure to the technologists) and high thrombosis risk, we have instituted guidelines that recommend empiric anticoagulation for select patients at high pre-test probability for VTE without excessive bleeding risk. Simultaneously, we are actively engaged in ongoing research activities, including initiating new clinical trials to explore potential therapeutic agents for COVID-19 infection. Finally, we maintain our commitment to education, including participation in national webinars focused on anticoagulation and VTE management of patients in the era of COVID-19. All in all, we lend our expertise and assistance wherever beneficial for our local community in Ann Arbor, Michigan and beyond.

Vanderbilt University Medical Center, Nashville, Tennessee

Aaron W. Aday, MD, FSVM

Joshua A. Beckman, MD, MSVM, Past President (2011-2013)

Esther S.H. Kim, MD, FSVM, Trustee

Every day, the COVID-19 pandemic brings both tragic news as well as inspiring lessons. At Vanderbilt, one of the most notable lessons has been the value of decisive leadership. Within days, our institute secured emergency medical licenses in surrounding states. This has allowed us to provide telehealth visits for our patients throughout the South, and this technology was also fully functioning in a matter of days. These steps, which seemed like insurmountable regulatory hurdles in the past, turned out to be readily solvable with focused, dedicated institutional leadership. We are also reminded daily the value of our medical community. Our day doesn’t feel complete until we read our Chair’s e-mail update each evening. Attendance at meetings and conferences is also greater than ever. Within our Vascular Medicine Section, we quickly reestablished our weekly meeting and journal club via video, and this has provided a critical opportunity to decompress, laugh, and learn with each other. We are also amazed that some of our most trusted sources during this time are our other vascular medicine colleagues around the world. We always knew we had a strong medical family, and our new reality has provided a wonderful reminder of the power of our professional community.

Mayo Clinic, Rochester, Minnesota

Paul W. Wennberg MD, FSVM, Trustee

Thomas W. Rooke, MD, MSVM, Past President (2009-2011)

Lessons Learned: The Tele-Lecture.

The phrase “Truth of the Moment” is heard frequently at Mayo the past several weeks. The emotional turbulence in the news, emails, web meetings are like a sporting event. Even when momentum is favorable, we remain on edge expecting the truth to change soon. Cleveland sports fans understand this.

COVID-19 has forced a change in how we interact with both new and established patients, determining the best alternative, while inducing the least anxiety for each patient (and provider). One of us (PWW) has been banished to triage duties and telemedicine from home. The other (TWR) is the established Master of eConsults. Often, the question asked of us is unclear. Despite the dichotomous roles played, we have independently found a phone call to the requesting provider is often more helpful for the requestor than for ourselves. The key is transforming each call from a two minute inquisition to a five minute teaching session. Anxiety is decreased. Gratitude is high. There is a moment of joy. We have a lot of teaching to do, and a hungry audience. Our jobs are secure. And the crowd goes wild.

Houston Methodist Hospital; Houston Methodist Research Institute, Houston, Texas

John P. Cooke, MD, PhD, MSVM, Past President (2005–2007)

We are in the Texas Medical Center in Houston, and our doctors and researchers are working from dawn to dusk to develop better approaches to treating COVID-19. Our task force meets daily to review the standard of care for patients with COVID-19, modifying the approach as reports come in from around the world. We have at least 12 new therapies under development and were the first in the nation to administer convalescent plasma (all patients recovering so far). Our machine shop is churning out aerosol containers and plexiglass isolation pods to protect our health care providers caring for hospitalized patients. We have industry-sponsored trials underway with antiviral and anti-cytokine therapies. Our RNA therapeutics team has generated and is testing a novel RNA vaccine against the spike protein of SARS-CoV-2. What used to take months (e.g., IRB review of a clinical trial protocol) now takes hours; what took days, now takes minutes. Everyone from the CEO to the doctors, nurses, and scientists to the housekeeping staff and the guys on the docks are engaged and filled with purpose. Together, we will beat this thing. #slayingitwithscience

Stanford University, Palo Alto, California

Eri Fukaya, MD, PhD, FSVM

Nicholas J. Leeper MD, FSVM, Trustee

Like many programs, Stanford has decided that flexibility, teamwork, and pragmatism provide the best chance for us to stay ahead of the coronavirus pandemic. We have adopted a crisis mentality, emphasizing common sense and a re-assessment of historical norms. In a matter of days, we developed a triage system to determine who requires ‘usual’ in-person care, and which appointments or imaging studies can be deferred (and for how long). We found that direct communication with patients was key, so they could be reassured that each of their cases had been individually considered and that no one would be ‘left behind’. From the outset, we made telehealth an absolute priority, allowing conversion of nearly 100% of clinic visits within two weeks of the Nation’s first ‘shelter in place order’. We were delighted that reason supplanted bureaucracy, and that emergency action was taken to lift onerous administrative and regulatory burdens that otherwise would have made such drastic innovations impossible. Our focus is now on protecting ourselves (with limited PPE) so we can provide essential vascular services in the weeks to come. Necessity truly is the mother of invention, and we are committed to revisiting any and all decisions, adapting in real time.