Medical: Heart and cancer care
Hospital cardiac and cancer centers navigate safely amid virus concerns.
More than a month before Mission Health saw its first COVID-19 patient on March 20, the Asheville hospital made plans to battle a virus with no known cure or vaccine.
Virtual conferences regarding testing and patient care helped several N.C. hospitals and medical centers get a jump on the pandemic. In the often-urgent fields
of cardiology and oncology, practices juggled essential and nonessential procedures to best serve patients, caregivers and families.
“About early February, we were getting national directives to start preparing for a surge, and we had some tabletop exercises early on,” says William Hathaway, Mission’s senior vice president and chief medical officer.
“I think it was [then] when I started to panic, when the news reports out of New York City started, and we’d seen things in Italy and Iran and China. It was like it would never happen here. … But it became a reality, and so we knew this was the time [to prepare]. Do we have beds? Do we have the staff to take care of those beds? We went into all the details.”
Mission’s rural, 18-county region’s population exceeds 1 million. The Buncombe County hospital initiated entry screening and visitation limits. Clinical trials were underway in July — including at Levine Children’s Hospital in Charlotte, one of 30 worldwide sites to test an antiviral treatment for COVID-19, and Atrium Health, which is testing an oral medication used to treat cancer in bone marrow and has shown to have an effect against COVID-19.
By July 27, Buncombe County had 1,445 confirmed virus cases. North Carolina had more than 113,000.
PREPARING FOR THE WORST
Coronavirus concerns created a fear factor, doctors say, causing people who otherwise would have sought treatment to stay home — even when care was necessary.
“Cardiology and oncology are a bit different in that a lot of patients with heart disease cannot wait,” says Sun Moon Kim, an interventional and structural cardiologist with FirstHealth of the Carolinas’ Reid Heart Center in Pinehurst. “There are cases that delay their presentation because there’s COVID-19, and they’re afraid of exposure and they miss their golden opportunity to be treated.”
When COVID-19 first became evident in the U.S., FirstHealth stopped all non-urgent elective heart procedures. In addition, the system implemented telemedicine visits for patients who were concerned about coming to the hospital or clinic but had cardiology issues that needed to be addressed.
“We are here 24/7, so if there’s a problem, seek our advice,” Kim says. “Call our clinic. It’s better to call our clinic and speak to a health care provider than to be guessing and waiting at home.”
When the pandemic first began, many health care providers were unsure of how long it would last.
“You could look at China, and they ran through it pretty quickly, all things considered,” says Dr. Derek Raghavan, president of Atrium Health’s Levine Cancer Institute in Charlotte. “It began in December, and by March they had it in control.”
Raghavan says the staff at Atrium participated in conference calls with other international doctors who had experienced the virus firsthand in order
to learn from them and prepare, including meetings with Taiwanese and Chinese health care providers. “I have two physicians who work with me who speak fluent Cantonese and Mandarin, and they have a colleague who was the head of the COVID-19 task force in Wuhan. We were able to get a lot of information early, like late February, so we had advance plans.”
Most health care workers knew it was only a matter of time till the coronavirus spread to the U.S.; they just didn’t know when.
“Early on, we thought we might need to set up field hospitals in North Carolina,” says Dr. Kevin High, president of Wake Forest Baptist Health system in Winston-Salem. “We’ve been lucky in keeping aspects of society closed down and opening them up slowly. Early on, in phone calls with the governor, we asked for two things, personal protective equipment and testing materials. … We’re lucky we had a steady climb instead of a big surge.”
High says the difficult thing about planning ahead has been the changing nature of the virus spread.
“You make a decision in the morning back in March and April, and by afternoon, it’s wrong. … We’ve had to make adjustments in the emergency room and operating rooms, with deep cleaning and big-time ventilation changes. But the most difficult [thing] is social distancing in crowded spaces. Emergency waiting rooms are crowded.”
In early March, UNC REX Healthcare in Raleigh renovated part of its intensive care unit to a Special Respiratory Isolation Unit — or SRIU — to safely care for COVID-19 patients, reconfigured its emergency room to add outdoor triage tents, prescreened surgery patients, and expanded virtual care.
Dr. Geoffrey Rose, president of Sanger Heart & Vascular Institute in Charlotte, recalls March as a turning point. “We went from no cases to a very steady increase, and it became very clear that we needed to make changes, not just in heart and vascular, but in our lives because of the nature of our work. With cardiology, you have medical emergencies that don’t follow any scripts, and we don’t know the volumes [in advance]. … We were able to transform in a very short time to 95% virtual.”
Rose says when Gov. Roy Cooper ordered the state to shelter-in-place, health care providers saw an increase in care avoidance and a 30% drop in patients seeking emergency care for heart attacks. “COVID-19 does many things, but it doesn’t cure heart attacks.”
Dr. Michael Pritchett, a pulmonary specialist with FirstHealth Moore Regional, says it’s extremely important for high-risk patients to have a safe way to connect with their health care providers, even during a pandemic. “There were so many facets you never thought of, like breathing-function tests and the aerosol generating procedures [such as bronchoscopy], and it’s high risk if it’s an infected patient. But we needed to see those [possible] lung cancers, so we needed to see a safe way to do this.”
CARE REMAINS STRONG
Raghavan and eight other specialists composed a letter, “Levine Cancer Institute Approach to Pandemic Care of Patients With Cancer,” published in April, detailing the importance of continuing cancer care during a pandemic.
“Limited data exist for COVID-19 infection outcomes in patients with cancer,” the report reads. “Early reports from China have suggested that patients with cancer are twice as likely to become infected and are at high risk for severe clinical events defined as a need for ventilation, admission to an intensive care unit, or death.”
“If you delay a screening for three months, it wouldn’t have an effect on survival,” Raghavan says. “But there will be surgeries where the longer you delay, the larger the risk.”
“In the end, cancer doesn’t care about pandemics,” says Pritchett.
Pinehurst resident Jane Sandor was diagnosed with lung cancer in March after a CT scan by her primary care physician found a nodule in her lung, and a follow-up warranted a biopsy. FirstHealth was chosen in 2019 as the nation’s first site for clinical trials for a robotic technology, the Ion Endoluminal Robotic Bronchoscopy Platform, which can reach nodules deep within the lung using robotic-assisted, catheter-based technology through natural openings such as the mouth.
Sanders was the hospital’s 100th patient to use the procedure.
“Dr. [Peter] Ellman and I had many conversations about whether it was the right time to proceed with Jane’s surgery, given the current pandemic,” says Pritchett. “Additional safety precautions were taken for the patient as well as for staff. While elective procedures were placed on hold, we don’t consider treatment for an aggressive cancer to be elective.”
On July 2, FirstHealth’s Kim performed a groundbreaking procedure at Reid called transcatheter mitral valve repair, or MitraClip, which he says is “for patients with severe mitral regurgitation who are not viable candidates for traditional surgery options like open-heart surgery.” The MitraClip “is implanted in the heart and connects to areas of the mitral valve to significantly reduce the backflow of blood and decrease the risk of heart failure.”
“A lot of procedures we do are nonelective,” he says. “If any patient has a change in symptoms or requires hospitalization, we have to take necessary precautions.”
Mission Cancer Center added a Rapid Access Anemia Clinic in July, founded by Albert Quiery, medical director of Mission Medical Oncology. The clinic performs anemia evaluations, transfusions, iron infusions, bone marrow examinations and follow-up. “Anemia is one of the most common clinical problems encountered by primary-care providers,” Quiery says, adding that the clinic brings together hematologists and specially training nurses and pharmacists.
Mission, named a Top 50 Cardiovascular Hospital nationwide 14 times by AI platform IBM Watson, also recently opened a Heart Failure Clinic for continuing care, run by Vinay Thohan, a cardiologist and medical director of Mission’s Advanced Heart Failure Therapies.
One heart failure treatment option used by Thohan is the LVAD, or left ventricular assist devices, a pump surgically connected to the heart. It is used for patients whose heart is weak but who aren’t candidates for transplant. “This groundbreaking technology has changed the natural history of an illness that would otherwise take the lives of patients,” he says.
Mission’s cancer arsenal includes the da Vinci XI robot, for minimally invasive surgery; CyberKnife Radiosurgery for lung, brain and prostate cancers; and out-patient palliative care, which includes a fellowship to train doctors in the field.
Since 2014, CarolinaEast Cancer Center in New Bern has partnered with UNC Health Care to provide cancer treatment to patients in coastal Carolina. Like Mission, it also utilizes the da Vinci surgical system for cancer patients and offers cancer treatments such as radiation, chemotherapy, immunotherapy, biologics, hormone therapy and clinical trials. CarolinaEast’s Cardiovascular Center of Excellence is the only hospital in the state with an accredited catheterization lab by the American College of Cardiology. The center is also home to an electrophysiology lab, a surgery center for inpatient care, and cardiac rehabilitation and support groups.
“It’s a good time to be a physician because what we do matters,” says Levine’s Raghavan. “What it has done for the medical staff is refocused what’s important, and that’s taking care of people in the community.”
LOOKING TOWARD THE FUTURE
Medical leaders and physicians agree changes such as virtual visits and telemedicine will remain necessary when possible, especially in demographics where in-person visits are riskier.
“The COVID-19 pandemic has been challenging because we need to provide ongoing care to our patients without increasing their risk of exposure and infection,” says UNC Health cardiologist Christopher Kelly with North Carolina Heart and Vascular. “So far, we have successfully achieved that by maintaining a strict PPE policy for all hospital staff, patients and visitors; limiting visitors and the overall number of people in the hospital; requiring negative COVID-19 testing before any elective procedure; and screening our sicker patients at the time of admission.”
UNC McLendon Labs was performing about 2,000 COVID-19 tests per day in July and expected to increase to 3,000 by mid-August, and the UNC Medical Center is using plasma from virus survivors for research to learn about antibodies as therapy. As of Aug. 17, there were 5.41 million confirmed coronavirus cases in the U.S., with 170,000 deaths.
“I think until we have a vaccine, we’re going to be living with COVID-19,” Rose says. “I think if we are collectively able as a society to do things regularly that need to be done to contain the pandemic, it will be manageable.”
Physicians and administrators want patients with chronic or ongoing conditions to know precautions have been put in place to ensure hospitals are safe. Cancer and heart issues are two vital areas, doctors insist, where people must understand — medical facilities are safe.
“There are studies that show patients are staying home,” Pritchett says. “Patients with lung cancer, patients with heart attacks, diabetes that is out of control. We have precautions in place [at the hospitals]. We’re ready to handle anything.”
— Kathy Blake is a freelance writer from eastern North Carolina.
Click here to view the full PDF.