An Interview with Dr. Miguel Escalon
Unmasking Rehab Medicine During COVID - Narratives & Portraits
Dr. Escalon is a PM&R physician at Mount Sinai, where he specializes in treating spinal cord injury, and is also the director of critical care rehab and the director of the PM&R residency program. Back in medical school, he described stumbling across PM&R randomly, and that it was difficult to explore the field because they didn’t have a dedicated department and the one available rotation was in a back-office doing EMGs (electromyography).
“I took a leap of faith and while interviewing, I got to see what the programs did, I got to talk with the residents and attendings, and really understand what the point of it was. Because everything I heard about [PM&R] before was that it’s neurology without X, Y and Z, or it’s orthopedics without the surgery, but I learned that it’s a lot more than that. It’s really about the person and their quality of life, a lot of which revolves around function but not all of it, and that’s why we sprout so many ways as a field.” During residency he contemplated specializing in sports medicine, then traumatic brain injury (TBI), but ultimately chose to do a fellowship in spinal cord injury (SCI).
In the beginning of the pandemic, Dr. Escalon and his wife had their second child. He remembered how it was a difficult time because his wife could only have one visitor. On top of that, when their baby had to stay in the NICU, Dr. Escalon and his wife were unable to visit their newborn together. Dr. Escalon reflected, “It was a bit stressful figuring out how to manage [the NICU policy], and then we had my other daughter at home. So the nanny was still coming in, taking the subway, though once we were home she stopped coming.” Due to his family’s situation, his department allowed him to work from home, which he was grateful for. Dr. Escalon described how he would spend 8 hours a day on video calls, as he coordinated and helped his teams manage decisions within the hospital. He also reflected how with the non-stop work, the paternity leave he had planned to take was no longer an option.
Back at work, the 50-bed inpatient rehab unit for PM&R was shut down and switched to medical floors for active COVID patients. Meanwhile, the rehab team was converted to a COVID medical team to address the growing number of cases. “The admissions were not rehab anymore, they were people coming in with active COVID, on bi-pap, on high-flow nasal cannula, people coding every day,” said Dr. Escalon.
At Elmhurst Hospital, another site where their PM&R residents rotate at, Dr. Escalon said it was in the news a lot as the “epicenter of the epicenter and had the most deaths in multiple 24-hour periods.” The PM&R residents at this location were also deployed to COVID medical floors. Dr. Escalon remarked that the transitions, “Were hard on everyone, but especially the residents, who were more often placed in more difficult positions than attendings. It could be that an attending was placed in a difficult position once or twice and that was enough to cause a lot of issues or even PTSD. And a resident would have been placed in the same situation five or ten times.”
“When you’re running multiple codes a day or calling families that can’t come in to see their loved ones and telling them that they’re passing or will pass... No one in medicine is mentally prepared, but especially for rehab residents, without warning you go from a place where everyone is supposed to get better to a place where maybe half the people or less are getting better. It’s very different,” said Dr. Escalon. Another difficult part was the uncertainty. Dr. Escalon said how, “We had PPE but we weren’t sure if it was going to run out day to day. You didn’t know if you were going to go in to work that day and have no patients die or five patients die. You didn’t know if your family in Queens or the Bronx were going to get sick. So I think if it had just been the patients it would have been different, but it wasn’t just them... it was a lot of things.”
Dr. Escalon reflected how one of the most startling things he’s seeing is how COVID is affecting young people: “People are weaker than I’ve seen coming out of the ICU, people are cognitively and psychologically in a worse place. And while there’s still plenty of people who are older, the general shift tends to be towards people who are younger, 30, 40, 50, which is different. Usually these patients would be all over 50, probably older than that. That’s been the biggest thing.” In addition, as professional sports leagues are returning, Dr. Escalon noted that, “Just because someone isn’t going to die doesn’t mean they’re not going to get really sick. The death rates [from COVID] are much lower for people in their 20s and 30s, but what people aren’t taking into account is the number of those patients who are going to an ICU setting.”
Another troubling aspect is the health and socioeconomic disparities being accentuated by the pandemic. One example that Dr. Escalon brought up was soap: “There are things that are practical that no one really talks about in these situations like who could buy soap? Nobody could buy soap. If you wanted to buy soap it would be way more expensive. So if you’re poor, you might not have shampoo, you might not have soap, you might not have toilet paper. All of these commercials say ‘wash your hands, wear a face mask, practice social distancing...’ well if you’re poor for whatever reason, live in a one-bedroom apartment with 5 people, you’re an essential worker, what could you really do? Just cross your fingers.”
Dr. Escalon recognized how for so many people, even those who don’t get COVID, their health is at risk because of their inability to access care and regular support. “Imagine not being able to walk and living in a walk-up, so you’re reliant on other people to help you up and down the stairs, and you rely on others to help dress you, make your food, bathe you, and those people stop coming because of COVID. And how do you get groceries? How do you clean yourself? If you’re in bed, how do you get out of bed cause all of your meds are in the kitchen? So there are a lot of people who are hit hard in different ways [due to COVID]. How do you work around this? So video visits came heavily into play there to check on patients who were due for visits.”
Dr. Escalon said how before the pandemic, he and his colleagues had only done telemedicine a couple times, but they were fortunate that they at least had the system to ramp up. Telemedicine became widely used to more safely communicate with patients, with tablets being donated for virtual patient care and to allow patients to FaceTime with their families. Dr. Escalon also noted how, “We needed to think outside of the box in ways that are beyond just helping the people who are super sick in the hospital,” which led them to re-purpose a virtual stroke monitoring program. “The goal was to help the hospital not be so overwhelmed ... the idea [being to] keep people at home who can be home and if someone is trending a certain way, have them come into the hospital in a more coordinated way.”
Through an app, providers could keep track and monitor patients with COVID or suspected COVID who were sent home from the ED, which allowed patients to update their symptoms and have virtual check-in appointments. They also opened “recharge rooms” throughout the hospital for healthcare workers, which Dr. Escalon described as “little oasis with free food, water, juice, a meditation area, and a place for people to go and take a minute and recharge.”
In regards to how COVID is affecting patients, Dr. Escalon said that, “Anecdotally, these patients are sick in ways we haven’t seen before. They may be more prone, lying face down, they may be more sedated than people usually are due to the ventilator needs.” However, Dr. Escalon also said that in his mind, treating patients with COVID is not that different than treating other patients, but just requires more precautions and extra PPE. “When you go in, if you see a certain amount of weakness, if you find that a certain joint is painful, if you find that someone has cognitive deficits, if you find they’re not sleeping well at night... those are all things that you can address.” Dr. Escalon explained from the perspective of PM&R, “What you’re trying to do is help someone get to the point that they can go home and be as functional as they can be. And if we ignore those patients until they get to acute rehab, we’re doing them a disservice.”
Looking to the future, Dr. Escalon thinks, “We will have a lot to say about what happens over the next few years. How do we follow patients after acute rehab, and how do we make sure that a year from now they’re back at work, a year from now they’re not having nightmares about having been in the ICU? There are a lot of social factors we’re going to learn about on the fly, but there’s definitely a lot of post-intensive care syndrome coming. There are people with disabilities who’ve gone months without help, without injections they need for spasticity or pain, without physical therapy they need, so it’s possible that a lot of people regressed. What we want to avoid downstream is a complete overrun of the home care and out-patient system.” Though the pandemic is nowhere near from over, physiatrists like Dr. Escalon emphasize the importance of proactively addressing the chronic care needs of patients affected by COVID.
R. Mayeda is a second year MD candidate at the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania.