An Interview with Dr. Ryan Hafner
Unmasking Rehab Medicine During COVID - Narratives & Portraits
Dr. Hafner is a PM&R resident physician at Temple University Hospital. In medical school, Dr. Hafner didn’t feel passionate about a specific field until he came across PM&R. His brother-in-law also trained in PM&R, which provided him with additional learning exposure. He did rotations in inpatient rehab, and since then he said, “I’ve never looked back, and I’ve had a blast in my residency.” After he finishes residency, he’s hoping to specialize in a neurologic-based rehabilitation such as gait analysis, brain injury rehab, or spasticity management, treating patients with, for example, cerebral palsy, stroke, and multiple sclerosis. “I really feel called to work with patients with neurologic disease, to help them function as best as possible post-injury, and we have a big role in that” said Dr. Hafner.
He also said that he likes how rehab medicine has many tools to address patients’ illnesses. For example with stroke patients, in addition to being able to help prevent future strokes, “[I can] meet them where they’re at right now and help as best I can with treatments to help them walk more efficiently, decrease their fall risk, increase their range of motion which can help with self-care, decreasing skin breakdown. There are so many areas that we can affect the quality of life of somebody who might otherwise be disabled from one of those conditions. So it’s very, very rewarding and I wish more people knew about it and were exposed to it.” Overall, Dr. Hafner said that PM&R is a, “sweet spot for me. Everything that we do affects function which is a blend of so many different services.”
Back in late March, Dr. Hafner was personally diagnosed with COVID after being exposed to patients who he later found out were COVID-positive. He developed chills, myalgia, and congestion during his self-quarantine, and eventually lost his sense of taste and smell, though those symptoms only lasted for about a week. In the beginning, Dr. Hafner only let a handful of people know about his diagnosis and he said that hearing people’s sometimes extreme responses built it up in his head to the point where he stopped telling others. “It was definitely scary when it was happening because you read that it’s not until seven days after you’ve been diagnosed that you get the more severe symptoms, and so by about the second week, any time I was feeling a little short of breath or a little lightheaded I was like, oh no, is this going to get worse?” Living with other medical residents, he isolated in his room, but fortunately after two weeks when his symptoms subsided, he was able to return to work. Once he felt better, he also told more people about what had happened.
As a resident, Dr. Hafner said it’s been difficult because they haven’t been able to practice physical exam or ultrasound skills, and they’ve missed the normal camaraderie. Their outpatient PM&R clinic closed due to the pandemic, and Dr. Hafner said that the inpatient rehab unit at Temple University Hospital closed a few years ago.
At Moss Rehab, they formed a new dedicated unit to specifically treat patients with COVID, which Dr. Hafner said has helped offload the burden from other surrounding hospitals. Though Dr. Hafner did not work explicitly on this unit, he worked on the brain injury unit, treating some patients who had COVID and developed neurologic disability as a result. “We’re not treating COVID necessarily, but we’re treating all of the ramifications of COVID including the hypercoaguable condition, whether it’s a stroke or a brain injury, we’re treating all of the aspects of that disability from COVID,” said Dr. Hafner. Working on the brain injury unit, Dr. Hafner said, “COVID is the cause of the injury, but we treat the injury like any other injury... there’s a lot of patients that are affected by spasticity and upper motor neuron syndrome from COVID, and so we’ve been able to do different nerve blocks, ultrasound-guided injections, those types of things that really help the patients. [We] help cast them and brace them, and really maintain as much physical capacity as they can. COVID can be very physically debilitating on the patients. Even if it’s not affecting their neurologic capability, at the very least it can cause what we call generalized debility and deconditioning from just a long hospital stay.”
The younger patients who’ve been affected by COVID have really stood out to Dr. Hafner. He said that many of them were otherwise healthy before getting COVID. Being able to help these younger individuals recover on the brain injury unit has been very meaningful and Dr. Hafner said, “It’s been rewarding to be a part of that process. There have been a lot of feelings from myself and other residents personally, knowing that the patients we’re taking care of could be one of us. Given that I personally was diagnosed with it back in March, there’s been times where I’m sitting, typing a note, and I see one of those patients and I look in their eyes and I say ‘why them and not me?’ ‘why did that individual have a massive stroke or massive cardiac arrest leading to anoxic brain injury, whereas I just loss my taste and smell?’ You have these moments where you become introspective and thankful and blessed and it just reminds you daily that this is not something to mess around with. So when you see people on the news saying it’s not a big deal, it is a big deal, I see it every day... what happens as a result of [COVID].” In terms of the uncertainty, Dr. Hafner said, “Nobody really knows why others have such an acute response that overloads your lungs versus others. Why is somebody asymptomatic versus somebody else dies of it? It’s just crazy. Nobody knows and you can’t assume that if you get it it’s going to be mild. You just can’t.” Dr. Hafner says that until we have an actual vaccine that’s been tested rigorously, we’re going to have to continue adapting and being precautious.
More recently, the outpatient clinics have re-opened with masking and screening protocols in place, and at the inpatient rehab hospital all patients are being tested for COVID. Dr. Hafner said that he personally swabbed several rehab patients who came back COVID-positive, and afterwards they were transferred to the COVID-specific unit because they were actively shedding virus. Dr. Hafner said that, “The other thing with brain injury too is that a lot of [patients] have tracheostomies so they try their best to cover them up, but essentially if you have an active COVID patient, there’s nothing worse you can have than a tracheostomy because they cough and it just comes out of the tube into the open air, so it’s a high risk situation. The best we can do is place a surgical mask over the tracheostomy tube.” Additionally, patients with brain injury still maintain a cough-reflex, which they can’t control and so Dr. Hafner explained that if they’re at risk for aspiration they might cough a lot especially if they’re not tolerating their feeding tube. Luckily, the COVID-specific unit where patients like this would be, are only staffed with the attending physicians, and not the residents, which is a hospital policy that Dr. Hafner said he’s thankful for, even though he does want to give back.
In addition to being one of the chief residents, Dr. Hafner is the chair of his residency’s wellness committee, so he’s been working on various resources like creating an insider’s guide to welcome and support new resident physicians. He is also leading a clinical research project, where he is investigating how 3D-printed orthotic braces can be used to help patients in rehab recover, hopefully reducing pain and skin breakdown. “In that world, there’s so much you can do with 3D printing and it’s exciting to think about. I think that’s a new wave of medicine,” said Dr. Hafner.
R. Mayeda is a second year MD candidate at the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania.