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1

When Physical Medicine and Rehabilitation became Medicine—Life in the

Time of COVID-19

Ihsan Y. Balkaya, MD1, Jose A. Fernandez, MD1, Wessam Gerguis, MD1,

Mahmut T. Kaner, MD1, Matthew Lamagna, DO1, Anusha Lekshminarayanan, MD1,

He Meng, MD1, S.M. Monir Mohar, MD1, Sonika Randev, MD1, Iliana Sanchez, MD1,

Sumankumar Brahmbhatt, MD1, Mohammed Islam, MD1,

Michael Frankenthaler, MD2, Paul T. Diamond, MD1, Eric L. Altschuler, MD, PhD1

1Department of Physical Medicine and Rehabilitation, 2Department of Pain and Palliative

Medicine, Metropolitan Hospital, New York, NY, USA

Ihsan Y. Balkaya, Jose A. Fernandez, Wessam Gerguis, Mahmut T. Kaner, Matthew Lamagna,

Anusha Lekshminarayanan, He Meng, S.M. Monir Mohar, Sonika Randev, and Iliana Sanchez

contributed equally.

To whom correspondence should be addressed:

Eric L Altschuler, MD, PhD

American Journal of Physical Medicine & Rehabilitation Articles Ahead of Print DOI: 10.1097/PHM.0000000000001454

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2

Metropolitan Hospital

1901 First Avenue

New York, NY, 10029, USA

email: altschue@nychhc.org

Phone: (212) 423-6448

Fax: (212) 423-6326

We have no financial or other conflicts. No funding was received for this study.

This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses

in any form or by any means with acknowledgement of the original source. These permissions are

granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing.

Upon expiration of these permissions, PMC is granted a perpetual license to make this article

available via PMC and Europe PMC, consistent with existing copyright protections.

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3

The first COVID-19 infection was reported in New York State on March 1, 2020; the first

person died from COVID-19 infection in New York City on March 14, 2020. The number of

COVID-19+ cases in New York City was increasing and on March 12th 358 cases were reported.

It soon became clear that most of our hospital would be devoted to care of COVID-19 patients. In

order to ensure that adequate acute care beds would be available for the surge in patients, we made

the decision to stop accepting referrals to our twenty-bed acute inpatient rehabilitation unit and

discharge the remaining patients as safely and quickly as possible. On March 12th, we admitted

the last patient for acute rehabilitation to our unit. Daily COVID-19 admissions to New York City

hospitals quickly escalated (https://www1.nyc.gov/site/doh/covid/covid-19-data.page): on March

12th NYC hospitals admitted 75 patients. On March 19th hospitals admitted 512 patients and by

March 24th daily admissions had increased to 1045. Admissions continued to increase and on

March 30th had reached a new daily high of 1565.

Initially, the plan was for internal medicine and other services to admit and care for non-

COVID positive patients on our unit. However, with the rapid influx of patients and critical need

for physicians, we were asked by hospital administration to consider running a medical unit on our

floor; we agreed and our acute rehab unit was transitioned to a medical unit.

The initial plan was to transfer non-COVID+ patients who were medically stable to our

unit for post-discharge planning. Leveraging and utilizing our experience and infrastructure on

matters related to disposition, we were able to efficiently and quickly discharge these patients. But,

as the hospital began to exceed capacity and additional ICU units were opened, the medical service

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began transferring patients requiring active medical management to our unit where we assumed

their care. We also started accepting low acuity admissions—of both COVID negative and positive

patients—directly from the ED as requested. Along with the patients we were covering on our

floor, other available rooms in the rehab unit started to be filled with COVID+ patients who were

being taken care of by medicine services. As the need for medical residents and staff became

greater in the ICUs, we began caring for COVID+ patients with less severe symptoms.

As the hospital’s needs continued to evolve, we were asked to accept critically ill patients

from our ICUs, on ventilators. All of these patients had been seen by our palliative care team prior

to transfer and goals of care were clearly delineated. These were patients that were not expected

to survive and no longer required the interventions only available in an intensive care setting.

Palliative continued to consult on all these patients and were instrumental in the care plans. An

advantage for these patients was the ability to allow visitation by loved ones prior to death. Visitors

were limited to one at a time and they had to be healthy as well as wear masks and other appropriate

protective gear. Visitors could not be allowed in our ICUs due to the sheer volume of critical work

by staff and the high likelihood of COVID-19 exposure.

In addition to managing medical patients on our unit and covering a busy in-house PM&R

consult service, some PM&R residents volunteered to work on the medicine wards or ICU with

COVID+ patients. PM&R residents and attendings also staffed the COVID screening annex of our

hospital’s Emergency Department. PM&R resident work hours were adjusted and coordinated

with medicine so as to stay well within ACGME duty hour guidelines. Despite busy and ever-

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5

changing clinical demands and varying schedules, we have been able to continue our PM&R

didactics by shifting to guided independent study.

Some lessons and points we would like to share with other PM&R departments during this

pandemic: It is crucial to establish a formal and robust procurement process for personal protective

equipment (PPE) for physiatrists who are working with COVID+ patients. Close communication

with internal medicine, their subspecialties and other services such as palliative care has been key

to the successful transfer of patients from the medical services to the care of the PM&R service.

The transfer protocol included a detailed handoff with a clearly delineated plan of care before

transfer or admission of medical patients to a Physiatry service. Patients with higher medical acuity

should remain under the care of the medical service and therefore appropriate triaging is critical.

The spirit of teamwork within physiatry is of great benefit when taking care of any patient, but

especially so for medical patients. Interestingly, we have also found that a thorough physiatric

history and physical examination, assessment and plan is an extremely effective tool and resource

even when applied to the care of non-rehab medical patients.

As of April 15th there seems to be a plateau in COVID admissions in NYC and our hospital.

But as with everything else about this novel human coronavirus there is uncertainty about the

future and we have not yet made plans to transition back to running an acute inpatient rehabilitation

unit.

Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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