An Interview with Dr. Jacob Rohrs
Unmasking Rehab Medicine During COVID - Narratives & Portraits
Dr. Rohrs just finished his PM&R residency in Philadelphia at Temple University Hospital. Looking back, he remembered first being introduced to the field of PM&R when he was a high schooler and met a PM&R doctor while shadowing at a local physical therapy office. He was drawn to PM&R because of the hands-on procedures, use of electromyography (EMG) and ultrasound (US) and emphasis on anatomy. After completing his intern year at Hahnemann Hospital, he stayed in Philadelphia for his PM&R residency, and just recently graduated.
Outside of the hospital, COVID took a serious toll on his family, specifically his grandmother. Dr. Rohrs’ maternal family is from Korea, and his mom and grandma came to the United States in 1982. Growing up, he says that his parents decided to not speak to him in Korean, so that his English wouldn’t be affected. “My parents were concerned I wouldn’t be smart enough to speak two languages so they never taught me how to speak Korean” he said, laughing. Similarly, I shared how my mom emigrated from the Philippines, and when I was born my parents only spoke English with me, not Tagalog.
His grandmother was sick for a while and lived in a nursing home in Long Island. She had a stroke 6 years ago and a second stroke 3 years after, leading to significant aphasia and right upper extremity spastic paresis. Dr. Rohrs explained how “Her English was never really perfect, so the fact that she had aphasia compounded with her baseline English... she pretty much stopped speaking English altogether, which was really unfortunate because only my mom could talk to her in Korean.”
He remarked how at the start of the pandemic, he hoped his parents would take his grandma out of the nursing home, but the nursing home re-assured them they had the resources to protect her. Unfortunately, after his grandmother’s roommate contracted COVID-19 and passed the virus to her, she became very ill and passed away a week later. “That was tough in and of itself, but one of the really hard things after that was [figuring out] how do we celebrate her life or have any type of funeral or anything afterwards because you can’t congregate.” Dr. Rohrs and his family later gathered in their side yard, where everyone stood six feet apart, and he and his mom gave speeches about her.
At work, Dr. Rohrs described how the service layout changed to consolidate departments and support the influx in COVID patients. At the rehab hospital in particular, they established a new department called “CORE” to specifically focus on treating COVID patients. To help prevent burnout and protect doctors, attending physicians were put on a rotating schedule and given one week off after being on the CORE rehab service. In mid-March all of the outpatient facilities shut down at the main hospital, which meant that for 4th year residents like Dr. Rohrs, their outpatient rotations at away sites also came to a halt. “It was a very big change for rehab residency... the consults moved to a virtual platform which presented a challenge in and of itself because one of the main things that as PM&R physicians we add value is our physical exam skills, the ability to do a musculoskeletal assessment” said Dr. Rohrs, commenting on how the lack of in-person appointments posed many new challenges, especially to rehab medicine. However, there were ways to be creative and use existing resources to compensate, such as reading through past providers’ physical exam notes, getting input from nurses working directly with the patient in addition to family members, and utilizing the EMR to compare scans and tests done in the past.
Dr. Rohrs wanted to do his part to help out with the pandemic and have the experience of treating COVID patients, so he worked on the COVID hospitalist service at the main hospital. At the peak, the first floor was transformed into what Dr. Rohrs described as resembling an army medical tent: “There was no real partition between patients, just a bunch of stretchers in a lobby. It looked like an army show.”
Dr. Rohrs remembered a patient he met on the COVID hospitalist service during the height of the pandemic. The patient had just been admitted from the emergency department and a nurse was helping him get down from his stretcher. When the patient entered his room, he remarked, “What is this?’ and when the nurse told him this was his bed, he exclaimed, “But this is just another stretcher!” Dr. Rohrs said that all of the patients there had to sleep on stretchers, which was tough especially for prolonged stays.
Working in this service, Dr. Rohrs described a typical day: in the morning he would meet in the PM&R conference room and go through labs and new admissions with his PM&R attending Dr. Maitin. The team would then video call with Dr. Criner, who is a pulmonary attending and served as their point person for the COVID hospitalist service. With him the team would review patients and imaging scans via EMR screen share, and come up with the plan before heading over to the COVID floors.
They would wear N-95 masks with surgical masks on top, in addition to face shields, new gowns and gloves. “Wearing all of that PPE especially around your face [makes it] very difficult to talk, so whenever we’d want to say something to each other we would either have to yell at each other or talk about it after rounding.” Outpatient areas were converted to an inpatient hospital, with plastic covering each of the rooms to seal off spaces. Dr. Rohrs noted how, “In many of [the rooms], the way you got oxygen to your patient is that you had an oxygen tank and the tubing went from outside the room and it was tubed into the room. If you wanted to go into the room, you unzipped the plastic covering, went in, re-zipped it from the inside.”
Once fully dressed with their PPE, they would round on their patients, entering the plastic tented rooms, and meet back up to chart notes, order consults and medications, and call patients’ cell phones to follow up. “One of the big changes that I noticed was that every patient’s cell phone number was added to a stickie note on their EPIC chart so that if you needed to get in touch with somebody it was readily available.” Dr. Rohrs said this allowed for direct communication with patients, unlike before where you would have to figure out whom to call from the department, and then eventually get transferred to the patient. They tried to avoid in-person discussions as much they could.
Dr. Rohrs explained how, “One of the [features] of COVID is a hypercoaguable state, and so one of the labs you want to track is D-dimer. And what that can lead to is DVT, pulmonary embolisms, and stroke in many cases, which can potentially lead to neurologic deficit. So there was a neuro-COVID hospitalist service where the attending was a neurologist and a lot of the stroke patients would be admitted there.” Dr. Rohrs also noted that for patients who developed AKI (acute kidney injury), they would get triaged to the hospitalist service where the attending was a nephrologist. “It was interesting seeing how this all worked out to have the right people taking care of these patients who were mainly there because they had COVID, but also had these comorbidity diseases that they developed related to COVID” said Dr. Rohrs. Having this kind of system in place allowed for better and more efficient patient care.
Dr. Rohrs described an elderly patient he treated with severe spastic cerebral palsy and was bed-ridden. She had gotten COVID from the communal home she was living in, similar to Dr. Rohrs’ grandmother. When Dr. Rohrs checked on her she would look in his direction but because she was non-verbal, she couldn’t communicate. At one point they wanted to sign her up for a Remdesivir trial, a broad-spectrum anti-viral medication, but Dr. Rohrs said, “We couldn’t because apparently there was nobody with official paperwork to make medical decisions for her, that could consent for the trial on her behalf.” Dr. Rohrs was shocked how despite years of being in the medical system with such a severe disease, no one had taken the time to get in touch with family members to determine who would be responsible for medical decisions. Somehow, Dr. Rohrs said, the patient, “had been ebbing and flowing through the medical system one way or the other to get to this point.” Her paperwork listed her as “full-code” and Dr. Rohrs wonders if this would actually be in line with her wishes, but he’ll never know. “I just felt like how many times in this patient’s life could there have been intervention to affect the point where she was at in her disease, but it was precluded by the fact there was no formal decision maker” said Dr. Rohrs. It’s situations like these that have prompted him to have conversations about medical power of attorney and advanced directives with his own family members.
In Philadelphia, Dr. Rohrs is hopeful that things are trending in the right direction. However, as he leaves Pennsylvania and heads to Arizona, he’s worried about how other parts of the country are responding to COVID. In Arizona he is starting a one-year fellowship in interventional spine and sports, but he says he’s uncertain about how the pandemic will impact his fellowship program, which relies heavily on outpatient procedures.
R. Mayeda is a second year MD candidate at the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania.