An Interview with Dr. David Putrino
Unmasking Rehab Medicine During COVID - Narratives & Portraits
Dr. Putrino found his way to rehab medicine from both a clinical and a research perspective. With his background as a neuroscientist and physical therapist, Dr. Putrino said that he was always interested in neurorehabilitation, and he said, “It was evident to me that we weren’t doing a good job in making space for the latest in neuroscience and neuro-technology to help people with stroke, spinal cord injury, and traumatic brain injury.” After working in a neurophysiology lab during his PhD, he did his post-doctorate in Boston, where he focused on computational neuroscience. “From there I got involved with a lot more targeted, translational work into brain-computer interface. I started thinking about how do we use brain activity to power things,” said Dr. Putrino. While working in NYC, he said, “I realized a lot of the people in the space of NIH-driven science, [have] this idea you can only have one question, you can only have one field, that wasn’t the way that my clinical mind worked. I was always asking people in my lab ‘what’s the upshot of this, how can we help people with the findings we’re making?’ and typically there wasn’t a good answer for that, which was really unsatisfying for me.”
Dr. Putrino then started his own lab to focus on the intersection between new technologies and clinical usage. He remarked how in the United States it can take decades to get a new technology implemented into normal clinical practice, which Dr. Putrino said is a massive problem. Adopting new technology is incredibly slow and Dr. Putrino said, “From a practical sense, think of the phone you were using 18 years ago, you probably weren’t using a phone 18 years ago, and that’s an issue.” “I started to realize the FDA can take some of the blame, but also hospital systems... there’s no one whose job it is to fight for those technologies to actually say let’s change the way we do things, let’s see if we can do things better and faster and more efficiently.”
And it was this idea and vision that landed Dr. Putrino into his current role of Director of Rehabilitation Innovation at Mount Sinai, a position created for him by the hospital. “It’s my job to aggressively advocate for technologies so that if we truly believe they’re better than standard of care, they can get into the hands of patients, they can get into the hands of clinicians as fast as is humanly possible. It is a very fun job,” said Dr. Putrino. He said that he’s only heard of one other position that’s similar to his.
In late February, they made the decision to shut down their research labs as COVID started to spread. Within his clinical research lab in particular, Dr. Putrino said they see a lot of high-risk patients, and so closing the lab was necessary. “The new risk outweighed the benefit of the research we were doing, so we weren’t going to subject any of our patients or research participants to that risk.” After that, Dr. Putrino and his colleagues worked from home. Dr. Putrino said that, “Initially we started to think about our community that we ordinarily serve and what their challenges might be during the COVID pandemic. We started to create resources for individuals we were concerned about. The first thing we did was create a set of infographics that explains to people who were perhaps not so tech-savvy, in a step-by-step way and multilingual way how to order groceries online, order medications online, and there were social support apps that people could download while they were isolating.”
After more brainstorming and thinking about how they could use their technology-focused lab to make an impact, Dr. Putrino and his team noticed a serious gap in COVID management in terms of the triaging responses from urgent care and emergency departments. Dr. Putrino said, “[They] were screening patients and doing one of two things: ‘you’re very sick, let’s admit you [or] you’re not very sick, go home and if you get sicker come back’ which led to 2 responses: ‘okay, I was coughing 2 times per hour yesterday and now I’m coughing 3 times an hour today, I’m sicker, I’m going back to the emergency department, which of course overflows the ED and that is by far the most common response. And then slightly less common response but more dangerous was well the doctor said don’t come back until I’m really sick, and so I’m going to ignore the warning signs and I’ll call 9-11 when I can’t breathe and I’m blue.”
With this problem in mind, Dr. Putrino and his team edited a post-stroke monitoring app to focus on COVID symptoms and another app that they previously used to track patients with cystic fibrosis. With these apps, Dr. Putrino said, “We could rapidly identify patients who were developing a chest infection, so we used that set of screening and deployed it, and what we started to do was simple remote patient monitoring - answer these questions once per day, if something looks out of sorts, a clinician would check in with you, and if that person is really concerned, that would escalate to a physician, and if they think it’s something they can’t manage with you at home, they will arrange for your care so you get to an emergency department and get admitted.”
After deploying the app, Dr. Putrino said, “Soon we were managing the care of about a thousand people, and we started to learn a lot about the disease course of COVID. And we also learned that what was being put out there as the common course of COVID, which is 2 or 3 weeks and you’re fine, really did not match up with the symptoms we were tracking. What we were seeing was that on average people were sick for 30-40 days and then about 5-15% of our cohort were having these long-tail symptoms that didn’t go away or even in some cases morphed into a different sort of condition.”
At that same time, Dr. Putrino learned of an online, self-organized support group called “Survivor Corps” for 70,000+ patients who were experiencing long-lasting symptoms after being diagnosed with COVID and referred to themselves as “COVID Long-haulers.” “They were very much struggling to get access to good healthcare services, access to good doctors who actually believed that they were symptomatic. So we have now followed up our initial app for acute COVID care with a follow-up app for chronic COVID care and we’re collaborating with the hospital’s department of post-COVID care to make sure these individuals get seen and get a good quality of care while also expanding our resources beyond NYC.”
In conjunction with the app, Dr. Putrino helped to rapidly distribute pulse-oximeters to patients across the many burroughs of New York City. Dr. Putrino said, “We worked to make sure that anyone who needed a pulse oximeter got one the next day or the same day depending on urgency, so sometimes that resulted in me jumping in a van and going off delivering, which is quite the pivot from my normal day-to-day, and sometimes it was just next day UPS.” In terms of some of the positives during the pandemic, Dr. Putrino said, “There’s been a lot of bonding with both patients and staff when you’re going through this together.” Dr. Putrino said, “One experience that was kind of crazy to me was this one day where I had to deliver the pulse oximeters and devices all over the city. And on the one hand it was this crazy experience of running around meeting patients face to face, handing these things over, sanitizing, going to the next and seeing patients from all walks of life. It was this really odd situation where everyone had the same needs but one minute I’m walking into a 25 million dollar mansion in Greenwich, Connecticut and the next minute I’m walking into a project house in the Bronx. And it was just this whole blur of really disparate experiences but all the same experience at the same time of everybody collectively having this virus, whilst experiencing it in vastly different socioeconomic environments.” Seeing that kind of wealth disparity up close during the pandemic was eye-opening and really stood out to Dr. Putrino. “We always think that digital health will make us more distant from our patients, but if you use it right of course, it really does end up making you closer to your patients.” Some patients would invite him to have a socially distanced coffee, which he said was the kind of interaction he encountered more often in lower socioeconomic neighborhoods than wealthy ones. Instead, upon arriving at a mansion, he said someone would often yell down from a window to leave the package by the gate, which given the pandemic was not surprising, but just an interesting observation.
In addition to the COVID apps, Dr. Putrino discussed how they transformed their lab spaces into a relief center for COVID frontline workers. “That was another project that we took on because we knew the amount of trauma that was going on in the hospital.” With their 3,000 square-foot of space in the main hospital, they partnered with a design firm to renovate the space using evidence-based research and multi-sensory information to create calming effects. Since March, Dr. Putrino said they’ve had 13,000 visitors to their space, and have since built 9 other rooms across their other hospitals.
Describing the layout of the rooms, Dr. Putrino said, “It’s multi-sensory which means we have a visual experience, an auditory experience, olfactory experience. So you come in and sit down, and the first thing you notice is that the lighting scheme and the landscape is completely different to a hospital. So the fluorescent lights are gone and you have dim mood lighting. Visually, you’re surrounded by scenes of nature because there’s really great evidence around the efficacy of green spaces to create reductions in blood pressure and heart rate, cortisol, etc.” They also had beautiful, silk plants (fake to abide by infection control) which created an atmosphere of greenery and living things, which was aided by soothing aromatherapy like chamomile and lavender scents. In addition, they partnered with a team to produce purposeful music, designed to further create a de-stressing ambience. The wellness rooms were staffed from 4am to 10pm, seven days per week, and so Dr. Putrino would go in to make sure things were running smoothly.
In response to COVID, Dr. Putrino sees the role of rehab medicine as being focal to future long-term care. “I think we’re going to see a big change in the role of rehab medicine coming up. I was sitting in a meeting with the department of post-COVID care, and it’s this wonderful team who believe in multidisciplinary care, so it’s been wonderful to see all of the silos breakdown as you view these complex patients. And we started to discuss the issues and lingering symptoms faced by post-COVID patients.” Dr. Putrino said how the team of cardiologists, endocrinologists, pulmonologists, hospitalists and physiatrists were discussing the need for re-conditioning for post-COVID patients especially those with dysautonomia, and they were unsure who would lead this care, to which Dr. Putrino raised his hand and said, “Rehab, this is exactly rehab.” After he said that, Dr. Putrino remembered that, “Everyone sort of lit up mostly because doctors love it when they realize they can refer off to somebody, but they were also like ‘oh yeah, rehab’ and what I have seen actually throughout this has been this rise to prominence of a specialty that is sometimes often forgotten, often not as well regarded as other specialties that go in and do the surgery and fix things instantly, and now all of a sudden everyone’s like ‘oh my god, we need rehab.’ This is a long course, this is a thing that’s leaving people highly deconditioned and damaged, and rehab is the specialty that needs to step up and manage these patients.”
The COVID pandemic changed his schedule significantly, with longer hours and less sleep, and “doing a lot of urgent things at a pace that has not previously been required in this particular job, [where] everything has to happen now,” said Dr. Putrino. On the plus side, Dr. Putrino said, “My wife and I see more of each other, we get to hang out a lot more, even though we’re often working around each other.” Before the pandemic, Dr. Putrino did a substantial amount of travel for work, often flying out of the country twice a month to places like Spain for conferences. He joked that his recent sleep issues might be attributed to his lack of being jet-lagged, a state he was constantly in before COVID.
Now that the pandemic has become more controlled in NYC, Dr. Putrino says they are planning on resuming some of their clinical trials in the beginning of August. However, Dr. Putrino is also aware that it will be awhile until things actually go back to “normal.” He said that he’s going to be worried until there is a vaccine, and even then, with less than half of people in North America getting the annual flu vaccine and the current anti-vaccination and anti-mask pushback, he will remain wary looking into the future. “We can’t forget that even with a vaccine, certain people aren’t going to be able to get the vaccine, viruses mutate, and vaccines are never 100% effective, so I think we need to do a lot of planning and proofing and making sure that [COVID] stays under control.”
R. Mayeda is a second year MD candidate at the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania.