Dr. Arnold Advincula and Dr. Ethan Goldstein discuss office-based and OR strategies as we emerge from COVID-19.
welcome and thank you for attending this event is brought to you by Cooper Surgical, a leading provider of medical devices for women's health care. For 30 years, Cooper Surgical has worked with health care providers to provide highly effective clinic and practice based contraceptive, surgical and obstetric solutions to complement our portfolio of trusted and reliable medical devices. We have also broadened our offerings, investing in the areas of reproductive genomics and in vitro fertilization. We are fully committed to helping improve the delivery of health care to women and their families. Cooper Surgical Manufacturers over 600 clinically relevant medical devices used by health care providers and offices, clinics, operating rooms, labor and delivery suites and reproductive IVF clinics worldwide. Clinicians overwhelmingly say they trust our products for their reliability, innovation and efficiency. Here are some other interesting facts you may not know about Cooper Surgical. Since our inception in 1990 our focus has always been women's health care. With more than 600 medical devices and over 3200 product numbers across a broad range of market segments, physicians know and trust our products. We ship over 1400 orders per day, of which 99.7% are shipped the same day. Our customer service department handles over 2000 inquiries per day. We employ 1750 people worldwide. We are pleased to provide this educational opportunity on behalf of Cooper Surgical. Good evening, everyone. Hello. My name is Kelly McKeon and I am your meetings manager. I'll be assisting in running the ritual presentation this evening. I'd like to welcome you all and thank you very much for your participation. First, I go over a few notes on how this presentation will run. We have our presentation tonight with questions and answers to follow. Please keep in mind that all participants will be a mute for the duration of the meeting. However, you'll have the ability to submit any questions to the Q and A feature during the entire presentation, which you'll see at the bottom of your screen. Both Dr Michaela and Dr Goldstein will participate in a Q and A session upon conclusion of the presentation for any questions that we do not get to this evening, you'll receive a response from Cooper Surgical or the speakers following the meeting. I'd now like to introduce our speakers for this evening. Dr. Arnold Advincula is Levin, family professor of women's health and vice chair for the Department of Obstetrics and Gynecology, as well as the chief of gynecology at the Sloan Hospital for Women at Columbia University Medical Center. New York Presbyterian Hospital. Dr. Ethan Goldstein is an obstetrician and gynecologist at Detroit Medical Center Medical Group Tenant Physician Resources. He's also the founder and president of the Z Pak Surgical Service PLC and the director of G Y N Robotics and minimally invasive surgery at Huron Valley Sinai Hospital. I'll now turn the presentation over our speakers to begin doctors. You now have present your privileges. Good evening, everybody. And welcome to this webinar event sponsored by Cooper Surgical. Uh, first of all, I'd like to start by thanking Cooper Surgical for hosting what Dr Goldstein and I believe will be very educational event as we address what seems to be a constant topic on all of our minds. And that is how to practice medicine, particularly office based strategies and operating room strategies. In the era of Covid 19, it's interesting that when we began to develop this presentation, we talked about it as strategies emerging from covid 19. But given the dynamics and the changes that we have been seeing across the country, it really has evolved into a discussion around. What are the things that we do on a day to day basis to successfully run an office based practice or to successfully manage patients in the operating room? And so hopefully over the next 45 minutes to an hour, we'll be able to address a variety of issues, And I'm really excited to be sharing this evening's platform with Dr Ethan Goldstein. You think? Well, thank you very much, Arnie. Uh, and it's my pleasure to be in your presence. You've been a, uh, sort of a surgical hero of mine for a long time, and I have appreciated all the work you've done and promoting and advancing us in the area. Minimally invasive gynecology. So thank you for that. And it's a pleasure to be here and thank you very much. Cooper Surgical for hosting such a timely event. Well, let's go on. And, uh, we're gonna use some slides this evening to kind of help serve as, uh, sticklers in terms of topics that we'd like to address with you. The audience and in terms of objectives, As I stated earlier, we're really going to focus on the impact that COVID 19 has had on our clinical practices and and how we function in the operating room. Uh, we're going to spend a little bit of time on the role of telemedicine, the role of office based procedures and mitigation strategies. How are we managing keeping ourselves and our patients safe in this era of covid 19. So as we get started, I thought it would be very, very timely and also appropriate to begin with what we do in the office. Uh, and with that, I'm gonna talk to or turn things over. I guess I should say to Ethan, in terms of what are you doing? Um, in the office. What are the considerations that you've been having as you practice in this ever changing clinical environment? Uh, this is obviously on the minds of all of us who practice medicine and specifically as a general o b g y n um, it's pertinent every day and to making sure that we are providing a safe and effective care in this new era of medicine. So as, uh, Arnie mentioned. You know, this is ever evolving situation, and I think we had maybe a three week period of time where most of the country thought maybe we would be sort of on the other end of this. But that's clearly not the case as we are reading and seeing in the news on a daily basis. And I think in talking to my patients in the office, um, I hear quite frequently when I ask them how they're doing. How's your family? How's this pandemic? Uh, you know, affected them. Um, you know the phrase this is the new normal, and it is what it is. And we just need to get used to how things are, and that's really true. I think like most things, change is very difficult, and this is no different. But the sooner that we adapt and, uh, and move forward in understanding and accepting where we are, I think we can actually move forward to to get through this together in a safe and effective way. So in terms of you know how this affects me and my practice as a generalist. Um, I think number one is addressing patient concerns and fears you know, I'll tell you, I've I've seen the gamut in terms of what patients, uh, you know, feel about covid and how it arrived and and all the missteps that were taken, perhaps, and all of the implications and the things that we read about and see in the news. And, you know, obviously I try to take this neutral stance of that as possible and alleviate their fears and try to guide them down the right path of understanding what we do know as opposed to what we don't know and trying to separate fact from fiction because it's very easy to get caught up in all of that. So addressing patient fears and anxieties, especially when it comes to their care and hospital visits. And I think it's really important, as we've seen in the media and the news that a lot of patients have been misdiagnosed or underdiagnosed or have been seriously affected by non covid medical emergencies or calamities because they were too fearful of going to the hospital. And I think while there was a heightened concern early on about going to the hospital for such things, I think now, in most areas, even though different parts of the country are in different stages of dealing with resurgence, hospitals and staff have better protocols in place and better procedures to take care of those patients who are covid versus those patients who need medical attention for other things. So really addressing patient anxieties and fears as a priority for me when it comes to the operating room, Um, and talking preoperative assessment patients will ask me often, is it safe to go to the hospital? And I will always tell them there's ever a place I'm most comfortable. It's always in the operating room, I mean, with the sterility and safety protocols and procedures that we had in place even before covid and the and the stricter, more stringent policies and procedures we have in place now. Of all the areas in the hospital, I think the operating room is one of the safest for our patients. Um, I think something that has been an issue for a lot of my colleagues, both in this area and around the country, as we were initially, you know, uh, not allowed to, or we had to pause doing elective Joanne cases now being able to kind of ramp back up is trying to position some of our Joanne surgeries and along with our fellow colleagues and other disciplines general surgery, orthopedics and et cetera to try to get equal time in the operating room, which has been challenging. I think this talk will will sort of lead down a path of describing ways that we can really focus on moving those surgeries in those cases that we have to take to the operating room and getting them proper recognition and proper proper placement in our our booking and then taking some of those cases and maybe moving them back to the office if we haven't done office based procedures may be thinking about doing that. May be utilizing our local health patient surgery centers for procedures that we don't have to take to the operating room, alleviating some congestion so that everybody can get their patients that need to be operated on into the hospital and timely fashion, which again leads into this whole navigating the surgical backlog. Because all of us are feeling that some of us, when this happened in my practice, we basically just rescheduled patients a few months out and move them some of my colleagues actually just canceled cases altogether. Unfortunately, these are the people that are having a hard time getting their patients rescheduled because those slots were taken and a lot of O. R s that you utilize boarding time. That's kind of gone away for the period for this period of time. While we're trying to address the needs and concerns of all these cases that were pushed off and pushed off because of covid, I think that it's also important to understand that even though we are a wealthy nation and there is a surplus of a lot of things, we've realized that besides just toilet paper and hand sanitizer, we really need to be careful with our PP pp. Even now that we have what's described as adequate supply in most places, I think it's important to be cautious going forward about the supply as Covid is going to be here with us for probably months, if not years to come. Uh, and we are going to need to be able to rely on having a steady supply of PPE, so using it responsibly and effectively is going to be important going forward. Yeah, you know, Ethan, Those are really great points. And you know, some of the things that for me really stand out. That, I think is important for the audience to to keep in mind is that this really is a new normal, and the way we come out of it is that, you know, you have to reimagine and move forward with a new way of doing things and and being entrenched in the way things were done in the past is going to make it very hard to come out of it. And so being able to re imagine and innovate is the key. And just to use an example even today that I noticed in my office as I was seeing patients. As the pandemic has evolved, the patient fears and anxieties have also evolved. So as you said in the beginning, people were afraid to come to the hospital. Now the new perspective is we're okay coming to the hospital. We just want to get in right away because we're worried about a shutdown in the fall. That's what I'm hearing in New York City area. And so that's the new fear and anxiety is can I get surgery this summer because I'm worried that my doctor is going to not be able to operate in the fall when things get bad again. And I think that's going to happen around the country. So, uh, these are really important things. They're more principles than anything else. But, uh, you know, I really think it's something that truly frames what we're gonna be talking about here, uh, over the over the over the next bit. So, Ethan, you know, as you've changed your practice and and sort of what I say reimagined how you do things and innovated What are you doing in the office itself? In terms of, you know, when your patient comes in and they call and they want an appointment with you, how are you managing that flow? Because obviously, things have changed nowadays in your practice. Absolutely. And, um, as we're all doing, we're following you know, our local and state guidelines, uh, for practicing, you know, effective, efficient and obviously safe care in lieu of covid. And so there's been changes that we've had to implement, um, such as limiting the number of staff or a number of patients rather in the waiting room. and we've done this by physically actually taking chairs out of our waiting room so that patients can be have to be at least 6 ft apart. When we have more than three or four patients in the waiting room. We will then move to a car check in system where patients will check in from the car and they'll be texted when appropriate to come back up in order to reduce the number of patients that are coming in and out of the office. And we have. There's four providers in our practice. In order to limit the number of patients, we've actually limit the number of providers that are practicing in each of our two offices on a daily basis, down to one provider, so we have less traffic coming into the office to begin with. Sometimes we have ancillary service like ultrasound. When we have patient, we have days like that where there's more patients coming in. We are going to make sure that patients are spread out sometimes in the hallway or again from their cars, so that we are starting from the very front when the patients arrive, limiting the number of patients that we have and making sure that we're practicing our social distancing. Um, we are also we've also increased our appointment times by 5 to 15 minutes, depending on what type of appointment It is, uh, to allow a little more buffer for patients to get in and out of the office without too much interaction with other patients. Um, we utilize telemedicine whenever possible, and I'll go into that more in detail in a few minutes. But that's been very helpful to sort of, uh, just to space our patients out and make sure those that are coming in have been triaged ahead of time. Um, and we are right now are currently only allowing patients in the office. And so I know this This varies by health system, but ours has been very supportive of just having patients. Only unless obviously we're caring for a minor or somebody that needs a translator. And that's actually helped in many ways, um, to speed up our patient visits and keep people safe from having you know, other possible exposures. Yeah, no, I I like that because we've done the same thing. We we limited to just the patients in the office and you know, we've had some difficulties. I'll admit being in an urban setting with our office practices, the majority of our practices are are not easily done as a check in from the car. But whenever possible, that's what we do. And otherwise, we use texting, uh, so that when people come off the subway or there are walking in from somewhere in the city, uh, we sort of text them and let them know. Okay, it's time to come up, and we literally take them right through the waiting room directly into a into an exam room. So they're just We always make sure that we have a significant number of exam rooms per provider. And like like you, we've dramatically limited the number of providers at any time. Uh, in the in the clinic setting. Uh, you know, I had a quick question for you. Um, you mentioned telehealth, which I know will get into a little bit later. But do you tend to cluster patients that you see in person in a certain part of the day? Or do you alternate your telehealth visits with, uh, with the in person visits? I've been sort of doing a mix of both where I'll do a couple of telehealth visits, an in person visit, go back to a telehealth, and I kind of just sprinkled out throughout the day. I think that's one. That's one way I know. A lot of people are doing it. We sort of moved to dedicated telehealth days, I think initially when we were in the in the middle of the first wave, Um, each practitioner in our practice was only seeing patients live in the office one day a week, and those are pretty much only either do an emergent patients or OV patients, Um, and so the rest of the day is two or three days were spent doing telehealth. So now each of us have about 2 to 3 clinic days per week, and I have one dedicated telehealth day, and for me, for my staff, that's just how they wanted to work it. It was just easier to have it clustered, but I have had some times where patients couldn't make it, or I've kind of gone through my schedule and seeing patients that I feel would be better suited for a telehealth visit and have them plugged in for that day. It just it sometimes can create a little bit of a A jam in the in the system. Just because the Emma that's it's working with me is different from the Emma, who is dedicated for telehealth with that provider. So it's like one provider, one Emma who was doing telehealth per day. And that's just how we've had it worked for us, and so far it's worked out okay, Interesting. Um, now, you know, when you see your patients, are you like we require masks for both the provider and the patient? Are you the same? Absolutely. Any patient facing, uh, staff member has to be wearing, um, has been wearing a mask and not a cloth mask, Um, and all of our patients, when they come in happy wearing masks as well. In addition, uh, they're screened before they come in with questions about their health and certain obviously poignant symptoms relating to covid as well as travel history, exposure, history. They all get a temperature check when they come in, as do we, which is logged every day and then we go from there. We do the same thing we actually are required to do an app in our in our hospital system where we have to do that every day and make sure that we have a the green go sign on the app That means that we're okay to come to work. So well, you know, let's let's jump into telehealth Because, uh, you know, before we get into that, I'm just gonna ask you, uh, first impressions. Are you a fan or not a fan? I am a fan. Um, I was leery. I was definitely leery about it to begin with, um, and I have to, you know, commend our medical group for really jumping on it. Within two weeks. We were providing telehealth, and that was really kind of intrigued to see how that would fit into an O B G y n setting. For obvious reasons, a lot of what we do has, uh, surrounds intimate conversation. And obviously, physical exams that can't be can't be done online. So I was I was intrigued as to how it would work. And I'll tell you, I think patients and providers have been very happy with it so far. How about you? I'm a big fan. I just love the ability to put telehealth anywhere in my schedule. You know, I I don't feel confined by the by the physicality of an office setting. Uh, if I need to see somebody or do an adult, I can add that anywhere in my schedule. And that's something that I truly, uh, truly enjoy. I do telehealth visits in between. Oh, our cases. I mean, it's it's been really something that I've embraced, and I really, uh, you know, see, I enjoy it. Actually, I know it sounds odd, but no, I think I think that's the majority of us. Feel the same way and and asking patients how they feel about it there. I mean, the convenience factor has been amazing. Uh, they just like that they can be at home. Uh, they can be at work and step into a private area and do it, um, and, you know, you know, for for simple things. And, you know, I know you're being in a in a specialty situation in a referral center like you is different than being a journalist like myself. But for patients who are, you know, birth control refills or who have vaginitis symptoms, you may not need an exam. Um, and it's a perfect That's a perfect way to do that. And for me, I'll tell you. And I'm sure you since you do so much surgery, um and you could probably get into this even more. But my pre op and post op visits, I mean, this is a slam dunk. Oh, my God, it's I This has been transformative for my pre op and post op visits. I The only post op visits I really need to do in personnel are vaginal cuff checks after th otherwise. I mean, I've been able to decant all of those cases or patients really out of my office schedule and really focus on the consults. The problem patients and the patients really appreciate that. Um, it's really it's really been a big plus. It's definitely a HIPPA compliant platform. Um, I know that comes up a lot of times, and it's definitely something that, um, you know, as Ethan said, you can really streamline your office schedule and really focus on the you know, the big ticket items, like being able to do your pre and post op visits by telehealth. Absolutely. And for those of us who are generalists. You know, usually, you know, doing the 1 to 2 weeks post op C section incision check. Um, you know, if we're still doing that, this is another great way. You know, new moms at home. Obviously tired and and don't want to take the added risk would come into the office. This has definitely become a staple for them as well. Um, so I can't. I'm very I'm very happy with it. I'm glad. I think it's here to stay for all of us. Yeah, I know. I agree. Um, but why don't we move on, then? You know, one of the things that, um, I know you have a great expertise in, and and, um, I wish I was more fassel with it or even had the time to do it, because, um, it's just I don't think my clinical set up really lends itself well to that is is integrating office based procedures into your office practice. And to me, it's something that I know. I'm I'm definitely being pushed to do more. Um, just by natural evolution, because of the pandemic and the need to try to streamline how I'm working up patients and who needs to go to the operating room and kind of again minimize my old wife, scheduled to the things that really need to go to the operating room. How are you utilizing that in your practice? We've been doing a lot of offers procedures for years in our practice, I think, because we're a young group and we've been kind of just kind of forward thinking in terms of trying to bring as much into our practice as possible. Early on, we were doing, uh, enemy tribulations and leap procedures we were already doing, and those things continue to be something that we enjoy doing in the office, and we have dedicated office space. We have a procedure room that we do these dedicated procedures in. We like to try to group them together. Patients appreciate it because you know, when you do something like a leap or an ablation and you realize how much goes into it and are setting so much, there's, I think, a lot of unnecessary time not just for the patient but for the support person who brings that patient to the hospital, utilizing a day of their schedule. All the pre op anesthesia Labs medications. It's really overkill for a lot of the things that we do, and I understand that a lot of doctors are uncomfortable doing office based procedures. Um, and that's understandable. But I think with the right guidance and time and, um, and an interest, it's really remarkable way to improve patient satisfaction because again, patients really appreciate not having to go to the hospital as well as alleviate your O R schedule. As you know, Arnie, when you go to the O. R. And you're going in for a T l H and you're back to your backed up because the guy in front of you is running late, you've got two more cases to follow. Your day becomes kind of messed up. And, you know, for those of us who are doing some more minor procedures, let's say a D and C, for example. And we have to wait because there's, you know, God forbid of complication or something ahead of us. You know, that puts our day off as well. So then we've got other patients that got got Reshuffle the rescheduled, and it just it's not very convenient doing something like office based procedures, really helps eliminate a lot of that is Endo. See something that you utilize, uh, in in your office, too? Not only, uh, kind of dynamic diagnosis, but also to sort of prepare you for the operating room. I've heard you use this term. Oh, our readiness once and I liked I liked the that concept of really, truly being prepared for the operating room with what you do in the office. So NBC is a perfect example of something that when it was introduced to me, I thought of it as a point of care or same day tool for enemy tree evaluation away to take patients, for example who were presented with abnormal bleeding. And we all know that makes up at least 30% of our benign G Y n visits for those of us in general practice as a way to take that and sort of move our exam from outside in to really evaluate the enemy atrial cavity. So NDC has been, you know, something I've utilized as a point of care device, and I'll go into that more in a minute as well as something that I've had to bring patients back for depending on their on their insurance or their timeline. But it's been a real patient. Satisfy Iran. I'll explain more about that in a minute, but yeah, it's it's a phenomenal tool. And the second generation, the industry advanced is really taken into a whole nother level. Um, and I'm so glad that we have the ability to use it. You know, I know point of care is something that you certainly the concept is being able to do something on the fly, so to speak. But when you see patients, do you try to time things, uh, in terms of like their menstrual cycle to get a better, better visualization or or does that matter at all? When you're doing Endo? See, it does. I mean, obviously, if somebody is actively bleeding or they're getting close to their day of their period, If we're doing something for abnormal bleeding and trying to identify and treatment pathology, that's not an ideal time. So taking cycle timing into consideration, which is very important. Um uh, point of care availability is is an option. If we can use that, patients appreciate. Now I know it kind of goes against the training even when that I had that. You know, we try to maximize, um you know, the the economy of visits in a sense that you bring the patient in, you do an e N m. Visit. You evaluate them, you do your history and physical. You then outlined the next step. You bring them back, maybe for an imaging procedure, you may then bring them back again and do something like an endo C or in offices, raspy or taken to the O. R. You've now taken a problem. You've kind of made several steps out of it. And I understand how that mindset was back, you know, years ago. But I think now it's a different time and especially and Lou of what we're dealing with in terms of like you said decanting the number of patients coming into the office, Um, and making sure that we are streamlining their appointments from time of presentation to treatment, that being able to employ and deploy point of care techniques, Senators NFC is really helpful. So you're really reducing the length of time from presentation to treatment. Patients are happier. They're oftentimes getting results the same day. Um, so it's a it's a it's a real big patients as fire. So, Ethan, from, you know, having spoken with you before, it sounds like, uh the concepts we talked about earlier with how we manage just the the office setting and bringing patients in for an office visit really applies to, um, point of care and and dedicated procedure visits. You have to think the same way in terms of how you're how you're managing your schedule and and the flow through, I guess. Right? Absolutely. Um, you know, point of care. Um, techniques such as NBC take time to implement properly. You have to have full support of your staff. And, um, you know, understanding how it works is important. And for us, it was just seamless, Um, after we started using it, but yeah, absolutely the same. The same principles apply to procedure, visits, point of care, or dedicated other otherwise dedicated procedures, as they would for a regular routine office visits. You know, I know we're going to talk about things like covid testing later. But are you since this is a procedure, are are you doing just basic, uh, you know, PPE in terms of masks for your patients, or are you using? And 95 mask. Are you doing preoperative covid testing. You know, with these procedures for office for our office space procedures, We don't do any covid testing ahead of time. Uh, I know, like you said, we'll get into that in a minute as it pertains to the O. R setting in R o R is arguing that 72 hours ahead of time, but for us, we are not. We do use full people, uh, including the n 95 respirators. If we're doing procedures such as leap procedures, that does create, um, you know, smoke and potential areas. Aerosolization aerosolization risk. Um, we will useful PPE and shields. Otherwise, we're going to use just regular, um, you know, mask and, uh, face coverings. So, Ethan, in the office, when you do either point of care or a scheduled procedure like Ngoc, are you utilizing it to a certain degree for managing your biopsies or polyps? Absolutely. I think in no other area of medicine do we rely on blind biopsy and gynecologist should be no difference. We know that blind endometrial biopsy samples are very limited. Maybe 4 to 12% of the endometrial cavity um, and often misses the diagnosis in our patients with abnormal uterine bleeding, for example. So I won't do an endometrial biopsy without doing an embassy advance A Basically a directed visualization of the mutual cavity without, uh, you know, doing that first, Um, and this is a very well tolerated procedure that can be done in any room at any time. Um, you don't need to do much in the way of anesthesia analgesia. I use a little bit of Motrin. I don't do parasitical blocks. Um, and patients do very well. And the nice thing is, we kind of touched on earlier is you know, we're obviously helping the patient, uh, reach a diagnosis and then obviously a resolution sooner. And like you said, it's been very helpful in terms of our preparedness or our readiness. So when I take a patient back for, let's say, a resection or more isolation history topic, more isolation, I know exactly which tool I'm going to need. It's already set up in primed and ready, which is reducing operating time, reduces cost and again reduces potential exposure for our patients and staff. So it's kind of a win win win for everybody involved. Um, and now with the NBC advance having a five French working channel, you can actually do simple procedures like Politicked Amis. Like I said, directed biopsies, Areas of concern, you d removals. I've been using it even to address things like retained products because we all know how unreliable ultrasound can be for that. So it's really been It's really kind of just, uh it's been a perfect what I call the ODA scope for the gynecologist. We wouldn't go see our primary care for the record sort of throw without getting an evaluation of our ears, nose and throat. So why not have the opportunity to do the same thing for R G Y n patients? Oh, I mean, I think that's fantastic. I mean, to be honest with you, you know, I wish I had the ability to do more of this in my in my office setting because you're absolutely right. I mean, I'm definitely an advocate of not doing things blindly. A lot of folks will do, you know, sort of blind polyp ectomy, sort of the blind DNC. And I'm just not in favor of that. I mean, we should be doing this as a directed, guided removal, similarly directed guided biopsy. And I think the end O. C. Is really It's a great tool, as you said, for transforming how to elevate the standard of care of practice. That is something that we all need to be doing in the office setting. And that's one way to get your patient's fears and anxieties down is by giving them an accurate diagnosis and accurate surgical planning. And I think the Endo See Advanced definitely is a key to that. Absolutely couldn't agree more. Well, let's jump to the operating room. Uh, that's where I spent a lot of my time. Uh, and certainly, uh, it's been It's been a roller coaster ride, I have to say, and and living in New York City, we were on hiatus for quite a while. But some things that I definitely, um, have learned over the last few months are the fact that Covid 19 definitely impacts how you practice surgery. Uh, it requires really good coordination. As you said before, telemedicine is key. It's a key piece of how we prep our patients for surgery and manage them post operatively. I think things that I learned that I never even thought about when we started to go back into the operating room was, uh we were running into initially some difficulties with the authorization process because once they opened up the O. R s, everybody was trying to get into the O. R. And everybody was trying to get their patients authorized and are poor authorization. Folks in my in my office staff were sitting on the phone a lot, you know, waiting on hold, trying to get through to people to make sure their procedures were authorized. So I think that's something people need to keep in mind. As we wax and wane through this era of covid 19, I think again like like we were both talking about your concept of our readiness is, uh is awesome. I think we need to trademark that, Ethan, because that's something that I think is really important in terms of just being prepared for what you're going to deal with in the operating room. And I know what I've been running into is most of my cases going back and been, uh, pretty complicated because, as would be expected, you're going to do this The sicker more symptomatic patients first. And of course, you know, in the setting of covid 19, I don't know what your feelings are about this, but, uh, minimally invasive is still the preferred way. You know, I know there's a lot of discussion in the beginning about Oh, is that gonna put you at risk? Should we just be opening patients? And I think that's the worst thing you can do is revert back to, ah, poor surgical routes. And I think we really need to stick with what's tried and true and practice the mitigation strategy strategies that you and I will talk about later. Absolutely. When I when I saw some of the articles that were coming out, even suggesting perhaps moving away from middle invasive surgery, you know, it was it was it was very hard to see. So I'm glad that that's not the case and that we are still sticking to the principles of minimally invasive Joanne surgery for our patients. Yeah, it's really interesting. We've we've had so much information overload over the last several months. Like like you said, there's just a lot of stuff coming out, and, you know, what we've done is we've really stuck close with following our State Department guidelines, which have been very good, actually in New York, Uh, we follow the CDC guidelines, and just like you said, local laws and regulations really governed a lot of what we do, and then we supplement that with society guidelines and recommendations. Have you been doing a similar thing up in Michigan? Absolutely. And I have to say, I think I've been equally impressed with our state and local guidelines and the input that they've given physicians in terms of management. And I have to actually give hats off to a G L as well. I thought a G l jumped on this really early on in terms of their really informative multi national webinars and around the world incorporating information from everywhere as it was moving towards us to just sort of have that awareness and be ready and prepared, uh, and and understanding how this is going to affect us. So I really give a G l a lot of credit for what they've done. And with covid. Yeah, you know, it's it's, uh as long as you can filter through the important information there, there's definitely a wealth of knowledge out there to tap into, um, you know, one of the things that certainly I think it's important for surgeons out there in the community across the country to keep in mind is, you know, as you manage your surgical schedule, it's really good to be able to organize things into different buckets. You know, for us, uh, we're sort of naturally, um, forced to do so just because we function in subspecialty groupings. But, you know, we definitely organize our surgeries into the major buckets like, uh, oncology, you know, pelvic reconstruction, the benign G y n Sergiy, which I know you and I spend most of our time in the benign bucket. But I think to me helps when you're trying to figure out which patients need to go, which ones are in categories that might be high risk, which are ones that can't be postponed. And then it becomes much easier to think through it, as opposed to looking at, like a mishmash of cases. Because when you start looking at cancer, you can start to say, Hey, those cancer cases definitely. Uh, you know, they need to go. Uh, we can't. We can't postponed those cases. Absolutely. What? Let let me ask you for a quick second. What is, uh what is your hospital require? Um, in terms of any kind of, uh, when you're boarding these cases, do you have to have a checklist of of importance or severity? Uh, so that, you know, they know. You know which of these cases like you mentioned really need to be handled in the time that you wish to do them in? Yeah, that's a great question. And that's really a great lead in to, um, something that I think is really important to talk about. And that is your state, state or local guidelines. You know, for us, um, what's interesting, which we didn't really appreciate until we started looking into It was the fact that what we do, what you and I do, Ethan is considered essential services being able to manage things like fibroids, endometriosis, cancer care, even family planning services. All of those things are considered essential services and technically shouldn't be postponed. And I think it's something that, uh, gynecologists around the country need to be aware of that their state may actually have guidelines like this that actually help you provide the information needed as you adjudicate cases to to show your hospital that, yes, you need to have blocked time and you need to get these patients taken care of. And we also had guidelines passed down to us that show us how we can get back into the operating. What are the metrics that we need to meet to be able to open up the operating room in terms of hospital capacity for beds for ICU care? Those are the things that we needed to follow to be able to open up to elective surgery and essentially to go back to your question. Uh, what we've been doing is we fill out a special form that goes to a governance committee that basically makes sure that we are doing cases that meet the highest tier. So the obviously emergency cases are going to go. But the urgent semi urgent cases. What I what are called the Tier three? A Tier three B cases are the ones that we really have been prioritizing to do first and then after that, are purely elective cases. But most of most of the cases that we've had deferred are really falling into those categories, and it's just really managing the backlog at this point. What about you at your hospital? I practice at a small community hospital. It's part of a larger healthcare system, part of the Detroit Medical Center. But it's a smaller community hospital. And so, you know, I think where you're at your volume is much higher than where I have met. So for us it was basically, you know, the art director just basically said to us that this is something that needs to go. You just have to put the reason why what? You feel, the reason why and they would pretty much approve almost anything I think. As a group, as a collective of G I insurgents were very cautious to sort of sort of follow these guidelines, even though we didn't know we were following them in terms of making sure that we were putting our sickest most, uh, most at risk or in need patients first, uh, to be cognizant of our other colleagues to make sure that everybody had equal opportunity to get those really important cases done First, it's true, and um, you know, for us one of the things that I think was very helpful for throughout this whole process was also letting the hospital know what resources we were tapping into. So every time we schedule a case, we indicate whether or not we need, uh I see you care whether or not we need even simple things like a cell saver. Things like that start to, like, sort of get get really highly requested and utilized when there are a lot of sick patients in the health system. And so it was a way for our health system to manage its resources and determine whether they had the capacity to do a certain type of case. Uh, so that's definitely speaking of PPE. Does your hospital require everybody in the art to wear in 95? So how do you guys manage that? No, I mean that, you know, that's kind of been one of those. Uh, I guess I should say maybe pet peeves of mine is is how we manage PPE because it's pretty clear that, uh, we're seeing areas around the country that are to this day, still lacking adequate numbers of PPE. Uh, the resurgence across the country is certainly not helping our stockpiles. And so we really need to be strategic about PPE. And and as you see, there are a lot of factors that affect resuming surgery. And if we don't manage the PPE correctly, that's definitely going to limit our ability to get into the operating room when we really need to get in there. And, you know, besides the local guidelines, they're definitely, um a lot of national society guidelines that emphasize, uh, these factors that you need to know when you resume elective surgery and with regards to PPE. Uh, a lot of our management is based on testing, which is something I think is really important for us to go over, because when it comes to testing, if the patient is covid negative, there's technically no reason that everybody needs to be wearing n 95. We really, truly reserve that for the patients who are P. U s or a person under investigation or or truly positive, somebody who's not known but worrisome for having it or is truly positive. Those are the cases where, uh, were you utilizing the n 95 mask, but and every other circumstance were doing basic universal precautions that we normally would in any other pre pandemic time. Absolutely. In our institution, I think right now is still the anesthesia department. The crn is anesthesiologist. Those people intimately involved with intubation exhibition are still wearing the respirators. But the rest of the staff are just using regular surgical masks. Yeah, well, before we get into, um, the PPE bit in a little bit more detail. You know, I just wanted to make sure that the folks on this, um, evening event are aware that similar to state guidelines, there are also ranking systems and guidelines that have been put forth by a variety of different societies that helped give you guidance in terms of the types of cases that you can take to the operating room. So I know Ethan, you've been utilizing those guidelines as well to try to help steer, as you said earlier, steer which cases are going to go to the operating room first. And I think to me, that's those have been very helpful resources as we've navigated through things. And one of the recent publications that I think has been really helpful for me in terms of how to think about prioritization is a recent study that was published on medically necessary time sensitive procedures and how to think through that. And in that particular study, what they did is they looked at factors related to the procedure itself, factors related to the disease and then factors related to the actual patient. And every every variable has a has a point. And based on the scoring system, you would either develop too many points that you wouldn't really be allowed. Or it wouldn't be advisable to do that surgery or you would have the least amount of points, meaning that it was an optimal candidate for going to the operating room at a time of low resource. And those are the patients who would go first. And so I think those are the types of things that we need to think about in addition to the tearing cases and and these things also apply to the office setting. So I don't know if you've done the same thing in the office because I know you do a lot of office procedures. Ethan, are you prioritizing which ones get done first in the office versus other ones? We were initially, um and now I think just that, you know, at least in Michigan as it pertains to health care and medical care. We've we've we've had the room and availability to sort of open it up to to do most things as they as we see fit as they come in. That's that's great. Uh, well, you know, let's jump back in the PPE because I don't wanna constantly sort of, you know, beat the PPE drum. But if there's one thing that that I know is there are some places around the country and around the world that are just going full court press, they do everything. And, you know, one of my friends recently sent me this picture, what they're doing in their operating room for all procedures. And I thought that was just to me insane how much PPE they were utilizing, and that's what they were doing. And and so you can either make an argument for universally going full court press or you can be strategic about it. As I said before and for us, and you mentioned testing earlier, Um, we do the covid, uh, swab. We. It's a It's a PCR based rapid test, and that's what we utilize for our patients Pre operatively. We don't do antibody testing because that's not really accurate. Uh, you know, a lot of people ask what? Can I just get my blood drawn? Well, you know, uh, we're interested in knowing whether somebody is acutely ill because there are ramifications for having surgery when you're acutely ill. Those patients don't do well when they're exposed to general anesthesia. So we want to know who is acutely ill, not only for the patients take, but we also don't want to infect the entire operating room team. And people don't necessarily mountain antibody response right away, even if they've had it. Uh, and so we want to make sure that we're getting the acute, uh, infected infectious patients as well as those asymptomatic carriers. Absolutely right. And you'd be surprised how many of those patients we see as we've been testing pre operatively and patients come back and say, I can't believe I tested positive and were like, I can't believe you tested positive either. But but we typically do it within 3 to 5 days now, before the surgery, we've actually expanded the time frame a little bit now into five days are hospitals, allowing us to five days in advance. And and once they get tested, we tell them to basically stay home and don't expose yourself and, you know, they know they're having surgery in a couple of weeks. We tell them, start practicing good mitigation strategies with social distancing and, you know, not putting yourself in a vulnerable situation. Absolutely. But you know what's interesting is I don't know how you manage this, Ethan, but with some of the testing. Um, what's interesting is we've we've We've had patients now because this pandemic has been going on for a few months who have tested positive a while ago and then recovered, and now we're coming for surgery. But they are again showing up positive. We have had patients like that both in the obstetric realm as well as the realm addition. In addition, yeah, yeah, that's an interesting thing to to make note of, because if somebody has a known, documented positive test few months ago and they're coming in now and getting surgery, they can definitely still test positive on the PCR tests. But if they're not infectious, in other words, sometimes you can still pick up with these tests the dead virus particles that trigger the swab to turn positive. But as long as you have an accurate history, and if you really need to get that surgery done, you can do that surgery. That patient is no longer going to be infected because if you look at the infection curves beyond 10 days after initial symptoms, it's really hard to culture, active infection. And so those patients are not going to be, uh, infectious. And so, as long as you know that history, uh, you can go ahead and do that surgery and if you want, you can certainly do the N 95 mask and and and, you know, higher level of PPE. But technically, they're no longer infectious. And if they do come back truly positive for the first time, and that is a true active infection, well, typically postpone their surgery for about three weeks and then bring them back and safely do their surgery. Have you already have you heard of patients being reinfected, though, like with truly being reinfected with active disease a subsequent time? There's a lot of talk about that, about the fact that just because you've had it once doesn't mean you're invincible and that you couldn't get it again. There are definitely cases that are being reported of people being reinfected. Um, I've not come across that yet myself, but it's certainly something that I'm keeping my eyes and ears open to, because I certainly don't want to put patients at risk nor myself in my team at risk. Absolutely. And I think it's also gonna be interesting to see how the antibody studies go going forward to see what the You know how long those antibodies persist and if they are like you said, actually going to help prevent reinfection. Yeah, so you know, let's let's move into mitigation strategies. You know, that's what we're gonna sort of round out this conversation with tonight, you know, And as as we talked before, there's a lot of things to keep in mind, You know, this is just one example of things that we do to help keep us safe. One of things we started practicing in the height of the pandemic in New York because we just still we're figuring things out was we knew intubation and excavation was a high risk area civilization procedure for something that is transmitted by droplets. And so we would just leave the o. R during intubation and excavation, and we limited who was in the o. R. During those procedures of takeoff and landing. Um, this is an example of a of a shield that people were using to protect everybody as they were intubating. But it's certainly something that is important to keep in mind. I know there are a lot of resources out there to help provide guidance because I know that there's a lot of concern because we do laparoscopy about transmission of of covid 19. And a lot of that is really born out of people's concerns for blood borne pathogens, Right? We worry about things like, uh, hepatitis or anything like that that is a blood borne pathogen being aerosolized in somebody contracting it. Uh, there's not a lot of data on the viral particles related to Covid 19. Uh, since it's a respiratory droplets infection that's passed on. But there are a lot of resources, and this is one from stages that certainly you can reference when it comes to looking at what's available to help during our various procedures, what kinds of things are you using in the operating room to reduce your exposure? Well, I mean, we when in a lot of our cases, we use the system here that helps us, you know, filter the smoke as we release it from our laproscopic cases. Similarly to the reference that I that you saw earlier from stages there is a medical device repository that you can find as well that lists all the devices in an agnostic way that you can utilize. What about yourself? Yeah, we use the same thing as well as, uh, air seal technology when we can, for the same reason. And and that's been very effective. Yeah, we do that, too, in our robotic surgery cases, you know, and what's been great as our hospital has been very supportive of us utilizing technologies that facilitate keeping everybody safe. Um, and you know, it's great that, uh, you know, we get to collaborate with companies like Cooper Surgical that really provide devices that help us mitigate against things like covid 19, and you don't even really think about it sometimes. But even you know, manipulators and having a best in class new McClure balloon is extremely helpful because again. If you're managing your normal peritoneum, you're managing smoke. The one thing that you don't want to do is have uncontrolled release of gas into the operating room when you're doing your Copa to me. And so for me, utilizing the new McClure balloon appropriately in surgery really helps with that. And I'm not sure what your experience has been in your O. R with making sure that you control gas flow. But this has been one of those things that we've been a big stickler about. I'm a huge fan of this technology and utilize it and every t LH that we do. Yeah, and you know another thing that we've done, which I utilized it a lot before, you know, Ethan, But I didn't realize how much it would be so impactful. And in fact, it's really been an easy way to for me to justify getting a few more of these in my in the two hospitals that I work at is, you know, one of our concepts around covid has been minimized. The number of members of the team in the operating room, you know, not utilizing too much PPE we don't need to have like five people scrubbed in and keeping it just to the essential personnel. And using the ally uterine positioning system for all of my cases, particularly my robotic cases has been, has been great. I mean, I've utilized it always before, but now I truly think about every case and try to optimize where I can use it to eliminate a body in the operating room so that I don't have to expose another member potentially to, um, covid 19 potentially. Right. Let me tell you, this system has been something I've seen utilized. And I know you're showing a really helpful video to demonstrate how easy it is to use. And I am going to take your video tonight and show it to my O R department and to our executives to try and get this What has been a wish list a device for me for many years and hopefully get into our operating rooms as well. So, uh, well, yeah. You know, Ethan, uh, what you saw in that video was just be demonstrating that the union positioning system mounts behind your stirrup because that's often a question that comes up. So I just wanted to make sure that people know that that bracket goes behind. But if we jump to the following video, you really will see how truly easy it is to set this up. And so there's that bracket that goes behind your stirrup and it literally takes less than a minute to set up. And it is. I call it the Iron Intern because now I've just kind of, you know, decanted all my excess house staff out of my operating room. And I've got this device to hold my uterus when I'm doing procedures like myomectomy or even, uh, laparoscopic hysterectomies, and particularly for robotic surgery, is great. This mounts directly behind your stirrup, its balance. So you hold it by the blue handles, plug it in, turn it on and, uh, you know, then you Then you make sure that you prop it up once it's turned on, and then you can prep and drape your patient. There's a drape that goes on the, uh, the positioning system, and the drapes have adapters that are specific to one of the three Cooper Surgical unit manipulators. And it's been great because if you position your patient correctly and you have this hooked up. It really is, Uh, is that extra hand that you need in the operating room without having an extra body in the operating room? I'll tell you, Arnie, I wish this was around in 2000 and seven and eight when I was just starting out with robotics and having to sit between the legs when the old standard system came. Center Doc And you're sitting there for hours holding the manipulator. This would've been a great thing to have. So, uh, it is it's a it's a it looks like a great device. Something that I hope we can get as well. Yeah, I know. Absolutely. I remember those days. Those are very painful days. Painful. Um, but but yeah, I mean, it's it's, uh there's a lot of things that, you know, we forget that we can leverage technologically to make us more efficient in the operating room. And I know you're you utilize this, I believe Ethan, right in your in your practice. Absolutely. We you know, we use the ins orb skin stapler, Uh, almost always now for all of our caesarean sections, prime and repeat, it really expedites the closing and gives a remarkable cosmetic appearance that patients, we appreciate it. A lot of my colleagues who are still using that technology have quickly moved in Zorba for obviously convenience, uh, for expediting their skin closure as well as not having to have their patients come back to the office for that added step. And now, with telemedicine, we utilize, um, you know, silver impregnated foam dressings over these incisions that the patients keep on for a week and they can shower with them and then take them off during their telemedicine. You know, one week or two weeks post about visit to evaluate their incisions, and they do just great. That's awesome. I mean, you know, again, this is This is the one thing I have to say. If there's a silver lining to this era that we live in now, it's that it's really pushed all of us to be creative and innovative with how we practice medicine, how we practice in the office, how we integrate office based procedures and how we manage our surgical caseload and, you know, sort of just to summarize, you know, the way we've been thinking that you know, Ethan, you and I have talked a lot about these things. Um, you know, there are a lot of things that you can do in the operating room to keep your patients safe, to keep yourself safe and to keep your staff safe. And and certainly, as you heard us say, it could be as simple as a smoke filter. Um, thinking about how you do your papa to me, how you release your gas is at the end of the case, Uh, and then even things like skin closure, which you know, sometimes you can forget about something as commonplace. Mundane is that But if you leverage the right technology, uh, you can really mitigate against infection and also make yourself super efficient. And I'm hoping that, you know, after listening to tonight's discussion, I hope that there are a couple nuggets that people can come away with that can help them in their practice. I think it's really easy, uh, during this time of change and adaptation for all of us, as we move to provide efficient, safe care in the era of covid 19 that we still enjoy what we do, and it's important for our patients to see that too. So it's important to have a little fun in the office. Uh, so my way of doing that is to, uh, Dawn my my, my PPE with quote, new quotations every day of inspiration just to add a positive spin and mood in the office. And I think that that's been a fun, effective way to sort of, um, you know, keep things a little bit lighter when going through all of this. Well, I love your quote on your n 95 mask. If you cannot do great things, I hope I'm reading this right, Do small things in a great way. Is that what that is or yeah, that's fantastic. I mean, that's That's truly what I hope people walk away from. From this is is you know, every little thing that you can do. If you can do it to the best of your ability, it's it's going to have a significant impact. And, uh, and again, you know, hopefully be able to answer some questions here and again. Uh, Ethan, it's been a real pleasure getting any time with you this evening. I hope that we get to see each other in person and not through a webinar or new meeting. And, uh, you know, I hope that, uh, that folks stay safe, and, uh, hopefully they'll walk away with a few nuggets tonight to help their patients. Thank you. In a year, as always, uh, so informative. And you you have a real mastery of taking a lot of information and, like, you say, decanted down to the essentials and make it consumable. Uh, for all of us. So thank you. No, I appreciate it. And thanks again, Cooper Surgical for sponsoring this educational event. Thank you so much. Doctor of Tequila. And Dr Goldstein. I'm going to now turn the Q and a portion of our program over to Chris Kahn and Doug K. From Cooper Surgical, Who will present the questions to the luminaries Chris and Doug, the platforms. All yours. Thank you. My name is Christopher Kahn. I'm the senior product director at Cooper Surgical. Thank you so much to our presenters tonight. Excellent talk and thank you to everyone in our audience who logged in tonight and listen in on this presentation. Let's get to some of the questions. Uh, and what my colleague and I dug we'll do is we'll pass kind of back and forth to get through some of these questions that have been submitted. The first one is, what are you doing to get your office prepared for the next covid surge? Whether that happens in the fall or winter, are you changing the way you're using any medical or surgical products today? And are you considering any staff changes? Well, let me start with that. No, no staff changes for us. We we we did for a little half the staff during the peak of the pandemic that volunteered to take some time off, and we closed one of our offices down to streamline our services. But now that we're on the other side of at least the first surge here in Michigan, we're pretty much back to normal functioning. I think we've learned a lot over the past several months, and I think that has allowed us to be prepared for what's definitely I'm sure to come for all of us again as this becomes part of our everyday existence going forward. Um, you know, we definitely are more conscious about PP utilization and again just trying to do more cost effective, patient centered practices to keep patients out of the hospital even now, if possible, and maintain that going forward? Yeah. Similarly, for me, we we we're not really doing any major staff changes. Uh, we feel like our staff have Really, Um they've been drinking from the firehose over the last few months, so they really kind of in many ways, gotten comfortable. I don't know if that's the best term to use with how to interact with patients coming in and out of the office setting as well as you know, in our oh, ours, but similar to Ethan. You know, we're sort of paying very close attention to our PPE stores and just making sure that our office staff in particular have everything that they need. You know, in the hospital side, they're usually pretty good about making sure we have what we need. But but just in the office setting, we're just seeing patients face to face and with procedures and making sure that everybody is comfortable. Uh, that's been one of our big, big push is just to make sure that that's all buttoned up, uh, particularly going into the fall. Thank you. You both discuss telemedicine at length. This question is How do you balance the use of telemedicine prior to scheduling an appointment with the urgent need to work down your backlog of patient procedures and bring the patients in right away? How do you find a balance between those two things? Are you want to start that? Yeah. I mean, it's been difficult. I'll be honest with, You know, one of the biggest concerns is, you know, um, we want to, you know, we want to make sure we continue to to see patients because, you know, we obviously want to make sure that practices remain viable, that that we keep our O. R. Is running. And certainly as we work through our backlogs, I think we don't want to deter any patients from coming in who are new consultation. So we've been seeing these new new patients as they come along as an example. When we initially shut down in mid March, we differed in our group about 100 and 30 plus surgeries. But then, during the following six weeks of deferring those cases, we also then gained about 70 new cases because we're just seeing telehealth visits and so it's I'll be honest. It's not been easy trying to juggle the differed with the new patients because sometimes you see new patients who have acuity levels that are, uh, putting them in front of a deferred patient. So when we talked about the tearing process and having a sort of strategy about how you're going to prioritize patients, we find that's very important because it really helps manage that sort of clinical conundrum is what do you do about the patient that you see that's brand new but technically, really is a higher acuity than somebody that you deferred. And just by having that level of transparency, I think it's great because it helps us explain things to patients, but also to the hospital staff about why we're shuffling cases around. Why this person all of a sudden leap frogs the wait list? Um, but it's not an easy process. I'll be very honest with you. It's been a you know, something that we're constantly learning as we go along. And Ethan, I don't know what you've been doing or if you've been seeing the same situation. Yeah, you know, our our practice is very similar, but I think the way we're using telehealth is very similar, and I think it is a work in progress. Uh, here to stay, as we say, we said, um, you know, we put patients on a list, Um, you know, the annuals and and the problem patients. And then my my colleagues and I sat down with a list much like You're tearing system before. I think we even saw that in publication to come up with our own sort of list of patients that prioritized need of office visit versus telehealth, and then we also go through. And so when patients call in with problems, they the staff know how to how to sort of shuffle them around. And then we'll go through a week ahead of time, usually the next Sunday night. I look at my schedule for the next week and see which patients might be able to come off the in office list. Let's say birth control refills or, you know, vaginitis. Let's say something simple or apart. Stop like we talked about and put them on Telehealth day. Thursday has happened to me, might telehealth day, and very often they'll go. You know there'll be maybe two or three patients and then on Wednesday all of a sudden, there'll be a nice list of people that could add it on that way. Um, and it's been a nice way to even have access, like you said for some newer patients and gain some surgical consults. That way that can then be streamlines to further evaluation. Thank you. Let me turn it over to Doug. Thanks, Chris. So, Dr Advincula, I think this is for you. There was a question around how I ups you. You showed the system, and I talked about how it benefits you in the O. R. The question was, how do you actually use it during the procedure? Do you manipulate the uterus and then return to it? Or how do you actually work it into the procedure? Yeah, I mean, I I use it. I mean, I do a significant amount of reproductive surgery in my practice, probably 60% of it as reproductive surgery. And as many of you know, when you do those cases, whether it's a myomectomy or a big an excel case or endometriosis surgery, you need to park things in a one location and basically work. And so for me, I usually will, um situate the uterus, uh, in whatever location I needed to be to optimize access, and then I'll operate in these are typically robotic cases. And then, if I need to make an adjustment, I'll either rely on on on a bedside assistant or my scrub tech, or I'll just walk up to the bedside with, um and ask for a sterile blue towel. And I'll grab this the draped handle and just readjusted myself and then go ahead and sit back down and continue to operate. Um, I also do it with hysterectomies, although with a very large history. I typically don't hook it up to the ally because I do a lot of dynamic movement with the with the really big uterus, and so I rely on a bedside assistant for that. But it really has been extremely helpful. I've always used it before the pandemic, but I've just found that its biggest bonus during during this covid 19 era has been just minimizing. The number of bodies in the operating room were really cognizant of that, and not just for safety, but again for like preserving PPE and not wasting gowns unnecessarily, and gloves and mask and things like that. That's good. So another question is coming. We've got several times is and I think both of you touched on this a little bit during the presentation was obviously different. Surgical specialties now are competing for a hard time, right. And and I'll add that we've heard in particular. Uh, you know, a lot of times, the Ortho guys, in some cases, are moving to the front of the line. Right. So how are you making sure that gynecology is properly represented? Want me to take that, Ethan or Yeah, go ahead. Only you had you had a good, uh, some information on that. Yeah. I mean, first of all, you you've got to you've got to walk. Um, you know, head high and go into the O. R. And and nobody's surgery is any more important than what you have to do. I mean, that's my philosophy. I mean, I work in a big health system where there are a lot of big fish, but, you know, we're big fish, too. I mean, we do some pretty important stuff, and it's pretty complex. Surgeries that we do is gynecologic surgeons. And so what I've done is I've utilized a lot of the documentation that exists, like in the state of New York for essential surgeries and pretty much everything that we do. Most of the people who are tuned into this webinar is considered essential surgery, with the caveat being that obviously, you have to have resources to do the surgeries and depending on what the the virus is doing, that affects your ability. But, um, you know, we have a a governance committee that exists. Uh, we fill out surgical case of submission sheets. They go to that group we justify based on a tiered process. And, you know, majority of things that were operating on clearly are high acuity, and we've been able to compete. We certainly have the volume to back it up, but, um, we've been able to get our fair shake of o. R. Time, but I think it does require a lot of active management and having a good plan in place and organizing your surgical cases in a way that allows you to, um, very, uh, very, in a very organized way, make the argument for why they need to need to be done. I'm not sure what you're doing Ethan in your hospital. But that's sort of been our approach. Yeah. I mean, we it hasn't been. I think our hospital just the volume itself has been a little bit, you know, different. So it's it's been a little easier to get back on board. Um, and, uh, you know, we we've everyone's been pretty fair in terms of allowing equal time for those patients that need to get in. You talked a little bit about covid testing. Can you reiterate what you said about the types of patients you do or do not covid test? And even more specifically, if a patient test positive, can you remind us what the protocol should be for when we can do surgery? Yeah. So, um, basically, you know, obviously any air soul lies generating. Um, uh, procedure needs to be covid tested because, I mean, those are those are definitely high risk patients for spewing virus if they were positive. But we basically, from an operative standpoint, we test all of our patients going to the operating room with a PCR based rapid tests that we do as a swab. Um, we do that between two and five days in advance of the surgery, and that's that. We can make sure we get the results, because sometimes there have been delays. So typically, my my my practices, we usually do three days in advance to make sure we have the results in time. Um, if a patient does come back positive, we will cancel that surgery unless it's obviously an emergency. Emergencies go without saying you're going to do the ruptured ectopic. You're going to do the ovarian tourism regardless of status. But, um, if it's if it's a procedure that can be deferred, we will defer that for three weeks. And then after that, three weeks, Um, we will do the do the surgery. But you know, interestingly enough, we are hospital requires that we re swab them. And that's why I brought up that issue earlier. Which is Don't be surprised if even after they've recovered in, you know, three weeks a month, two months go by that you know the test could come back positive. They're healthy. They look great. But these PCR test sometimes pick up the dead virus particles and triggered the test to come back positive. Um, as long as you know the clinical history there should be no reason why you you wouldn't be able to do that surgery. And obviously, if your team is concerned about the positivity, you can certainly do your full PPE with the n 90 five's. But certainly, um, if they're negative, we certainly go forward if they're positive and it's a new positive, Um, we definitely will delay that surgery just because we don't want to take the chance. Not only of getting the rest of the team infected, but certainly it. Those patients don't do as well if they're having an elective surgery with the intubation without active covid infection, Do you perform Endo see same day or schedule out Ethan number one. And, um, the second half of that is, what does it take to set up your office to do undersea advanced? Um, we we do both same day and schedule out depending on cycle timing. Um, you know, patient availability. Um, you know, at my office day how it looks, if it's if it's crazy. I mean, my staff, we've been doing it long enough. Now that they look out ahead of time to see who's coming in, they can kind of pick out those patients that maybe NBC patients at the front, the front staff can look at their insurances to see who might be. I need prior authorization for a same day procedure to have that lined up. Or at least tell me that they can't be. And, you know, it really doesn't take much to to do this. I mean, it takes a little a little practice getting used to in office procedure on an awake patient. But, you know, if you're motivated and I think most of us want to be motivated for our patient's best interests and, um, you know, to help now especially keep more of our patients out of the O. R. Then it's a really handy tool to have, and it doesn't take long to become efficient with it. Okay, excellent. Thank you so much. I really appreciate your time tonight. Both both doctors and again thank you to our audience.
