J-LSMS 2021 | Spring

Established in 1844, our Journal is one of the oldest in the country. To learn more about the Journal and how to submit articles, please visit https://lsms.org/page/JLSMS.

CONTENTS

JOURNAL EDITORIAL STAFF

EXCEEDING EXPECTATIONS Family medicine physician Dr. Stephen Jones operates an urgent care clinic and nine school- based clinics. He trusts LAMMICO to provide his medical malpractice insurance.

EDITOR D. Luke Glancy, MD

ASSOCIATE EDITOR L.W. Johnson, MD

VOL 173 | ISSUE 1 | SPRING 2021

CHIEF EXECUTIVE OFFICER JeffWilliams

6 COMMUNICATING IN A CRISIS The Louisiana State Medical Society knew that communication would be key when dealing with COVID-19. Read more about howwe have kept our membership informed throughout the pandemic. 10 UNCHARTED WATERS State Health Officer, Joseph Kanter, MD, transitioned into his role in the midst of a global health crisis. Read the exclusive interview here. 16 AN EXAMPLE OF RESILIENCE Internationally recognized infectious disease expert and editor of the Spring 2021 issue of the Journal of the Louisiana State Medical Society , Fred Lopez, MD, gives an update on COVID-19. 18 COVID TIMELINE From the first case of COVID to the approval of three vaccines, join us as we look back at 2020 and COVID-19. 20 SARS-COV-2 AND INFECTIVE ENDOCARDITIS: A CAUSE OF NON-ISCHEMIC ST-SEGMENT ELEVATION A case study of the pathophysiology of SARS-CoV-2 and the infective endocarditis as a cause of cardiac injury along with mimickers of an acute myocardial infarction. 22 PANDEMIC PRACTICING: HOW PHYSICIANS MET THE CHARGE AND WORKED TO KEEP OUR STATE SAFE We asked; you answered. In August 2020, the Louisiana State Medical Society partnered with the Louisiana Board of Medical Examiners to send a statewide survey to all licensed physicians. Here are the results. 24 COVID-19 VACCINE PHOTOS Physicians were among the first in Louisiana to receive the COVID-19 vaccine. Join us as we recognize our members for being part of the historical moment. 26 LESSONS FROM LAMMICO Labeledas essential due to their support of healthcareproviders, LAMMICO learned to adapt and continued to provide service to their insureds. 28 LEADERSHIP IN THE TIME OF COVID Charles Sanders, MD, Department of Medicine Chair for LSU Health Sciences Center – New Orleans School of Medicine, details his time in medical leadership when the pandemic started and the lessons we can learn from a crisis such as COVID-19.

MANAGING EDITOR/ ADVERTISING & SALES Gina Garner

JOURNAL EDITORIAL BOARD Vice Chair, K. Barton Farris, MD Secretary/Treasurer, Richard Paddock, MD

Anthony Blalock, MD D. Luke Glancy, MD L.W. Johnson, MD Fred A. Lopez, MD

LSMS 2021 BOARD OF GOVERNORS OFFICERS

President, Katherine Williams, MD Past President, Lee Stevens, MD

President-Elect, William Freeman, MD Vice President, R. Reece Newsome, MD Speaker of the House, T. Steen Trawick, MD Vice Speaker, William“Beau” Clark, MD Secretary/Treasurer, Richard Paddock, MD Chair, COL, David Broussard, MD COUNCILORS District 1 Member, George Ellis, Jr., MD District 1 Alternate, Anne Borreson, MD District 2 Member, Robert Chugden, MD District 2 Alternate, Gabriel Rivera-Rodriguez, MD District 3 Member, Allen Vander, MD District 3 Alternate, Mark Hebert, MD District 4 Member, F. JeffWhite, MD District 4 Alternate, Susan Veillon, MD District 5 Member, Adrienne Williams, MD District 5 Alternate, Gwenn Jackson, MD District 6 Member, Michael Roppolo, MD District 6 Alternate, Azeen Sadeghian, MD District 7 Member, Brian Gamborg, MD District 7 Alternate, Donald Higgins, MD District 8 Member, Lance Templeton, MD District 8 Alternate, Michael Dole, MD District 9 Member, Andy Blalock, MD District 9 Alternate, Vacant District 10 Member, Nicholas Viviano, MD District 10 Alternate, Jeremy Henderson, MD Senior Physician Member, Robert McCord, MD Senior Physician Alternate, Greg Lord, MD Young Physician Member, Amberly Nunez, MD YoungPhysicianAlternate, Randall G.White, Jr.,MD Resident/Fellow Member, Omar Leonards, MD Resident/Fellow Alternate, Ken Ehrhardt, Jr., MD Medical Student Member, Jacob Boudreaux, MD Medical Student Alternate, Dan Frechtling

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maintain a solid knowledge base and provide important communications, especially during crises like COVID-19. The LAMMICO team provides me with an abundance of valuable resources to ensure my needs as a physician are continuously met. I trust LAMMICO. As a LAMMICO insured, you know someone has your back. – Stephen Jones, M.D., family medicine physician

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J LA MED SOC | VOL 173 | SPRING 2021 3

The COVID-19 pandemic has disrupted virtually all aspects of human activity worldwide more than any other catastrophe in the past 100 years, with the possible exception of the two world wars. COVID-19 is a viral disease that is highly contagious and often lethal, especially to elderly persons with underlying disease. Because little is known about many aspects of the disease, JeffWilliams and I decided to devote an entire issue of the Journal of the Louisiana State Medical Society to COVID-19. Fortunately, Fred Lopez, MD of the LSU Health Sciences Center in New Orleans, an internationally recognized expert in infectious diseases, agreed to be the editor of this issue, and he has assembled other experts to contribute. LETTER FROM THE EDITOR

PRESIDENT’S MESSAGE

It is hard to believe that it has been nearly a year – one year of fear, one year of loss, one year of change and one year of COVID. Who would have thought that the last time LSMS met on January 24, 2020, the House of Delegates would be the last large gathering for many of us without restrictions? And then a virus blankets our nation and our world, and we were called to battle to fight this terrible enemy. Life as we know it came to a halt. Although we continued emergency care at personal risk, many clinics were closed and access to protective gear became limited. All other healthcare needs were put on hold as we focused all of our efforts on controlling the spread of COVID. Many of our peers were the only personal contact in the hospital for many patients dying alone without the embrace of family and friends. We relied on each other for professional and moral support as many of us had to also isolate from friends and family for their protection. It was never a question of if we should fight. The question was how? So, the health care community worked together pooling resources and time to prevail. Not only were we anxious about the risk of COVID to our vulnerable patients but also equally concerned about the lack of attention to other serious health care conditions. On April 26, 2020, after consulting with the LSMS and other health care leaders, Louisiana Department of Health allowed us to resume necessary health care services. For some providers, telemedicine was a welcomed alternative in health care delivery with minimal risk. But not all issues could be addressed virtually, so in-person visits became more challenging for the doctor and patient. Patients were often seen alone without the help of family. The additional screening and the need for supplies were overwhelming at times for providers and staff in an already complicated health care environment. By mid-summer, it was status quo, and we had a new normal with no relief in sight. Many physicians lost a sense of balance, which contributed to further physician burnout. We were dealing with COVID in and out of the office, with little or no opportunity to decompress. Our staff, partners,

and colleagues were becoming infected with COVID which required us to work longer and harder hours. Patients that avoided or neglected other health care needs were presenting in worse conditions, requiring more intense care. And the delay in screening services has resulted in more advanced disease diagnosis of cancer and heart disease, a problem we will all be addressing for years to come. Finally, hope arrived as the vaccine became available in Louisiana on December 18, 2020. We have seen a decline in cases and hospitalizations and are hopeful for a return to normal in the near future. Although this has been a challenging year, I do believe that with every hardship we have an opportunity to learn and grow. Many have implemented telehealth into their clinics, and I believe, will continue to do so long after COVID to improve access and efficiency. We have realized the importance of family and close friends as we relied on each other for support through these difficult times. And we have gotten closer to our patients, as we were the familiar face helping them through their hospital stay or visit without the benefit of other family members present. And I believe we grew stronger as an organization. I was blessed with the opportunity to connect with physicians across the state as we worked together to overcome the crisis. “In the midst of winter, I found there was, within me, an invincible summer. And that makes me happy. For it says that no matter how hard the world pushes against me, within me, there is something stronger-something better pushing right back.” - Albert Camus

All of us, regardless of our medical specialty, need to know more about COVID-19, and this issue of the Journal provides a good starting point in this endeavor. ■

D. Luke Glancy, MD Editor-in-Chief

CAMS-ad-pdf.pdf 2 2/24/21 10:54 AM

Thank you TO OUR MEMBERS.

My fellow physicians enjoy your summer. ■

CMY

Sincerely,

Katherine Williams, MD

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COMMUNICATING IN A CRISIS

The LSMS used social media channels to not only express our gratitude for our members, but also provide patient resources to share and help prevent the spread of COVID-19.

Since thefirst caseof COVIDwas reported inLouisiana, the LSMS has kept in contact with our membership. Through email alerts, social media, and video calls, our efforts were aimed at providing physicians with a consolidated source for information being released through federal and state authorities, as well as regulatory agencies. Being that the pandemic is far from over, please know that LSMS stands behind you and will continue to work on your behalf to facilitate our members’ needs, allowing you to better care for your patients. Thank you for your dedication to the practice of medicine for the past year.

Announcing the publication of

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24 COVID-19 email bulletins

60+ COVID resources on the LSMS website

3 other COVID related emails

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The LSMS understood how imperative it was for the state of Louisiana to support each other during this time of crisis. We shared resources fromhospitals, state and federal agencies, and local news outlets to assist our members in providing the best care. Wemourned each case and death, and we celebrate each milestone with our members as we near the light at the end of the tunnel. ■

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J LA MED SOC | VOL 173 | SPRING 2021

UNCHARTED WATERS Joseph Kanter, MD

ON COMING TO NEW ORLEANS AND TULANE I came down to interview and just really fell in love with New Orleans. I’m a musician. I love seeing music and playing music, and the city really spoke to me. I liked the Tulane program because they have a great Ethos with a focus on community service and providing care to marginalized communities. I was also in the class that began four or five weeks before Hurricane Katrina hit, so my medical school experience was the experience of New Orleans recovering from Katrina—physically and spiritually rebuilding, as well as rebuilding the healthcare infrastructure. Through that experience, I got very, very attached to New Orleans and Louisiana, and I can’t really see myself ever leaving.

Bottom line, I really liked the school and the city. It wasn’t much of a decision at that point.

• Raised in Chicago and South Florida • Undergraduate degree from Northwestern University in Chicago • Medical degree from Tulane University School of Medicine • Emergency Room Physician • Currently serves as State Health Officer

I CAME DOWN TO INTERVIEW AND JUST REALLY FELL IN LOVE WITH NEWORLEANS.

PREVIOUS ROLES:

• Assistant Health Officer • Office of Public Health Interim Secretary • Office of Public Health, Region I Medical Director • New Orleans Department of Health Director • Healthcare for the Homeless Medical Director • Assistant Professor of Medicine, LSU and Tulane

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ON BECOMING STATE HEALTH OFFICER IN THE MIDDLE OF A PANDEMIC I come on the heels of Dr. Jimmy Guidry, who dedicated about 35 years of service to the state, so I have big shoes to fill. I had been working for the Department of Health for about two years as the Medical Director for Region 1, which includes the New Orleans region, and as the Assistant State Health Officer under Dr. Guidry. So, it was a natural progression. I look around at my colleagues in the Health Department and while it’s a lot of work with COVID, and people are stretched quite thin, I think there is a common sense that this is really what we are trained to do. I think people are finding themselves rewarded in that they are able to provide for the community more now than they ever have, and that’s a pretty powerful sentiment to hold—even though these have been the most challenging 12 months that anyone could ever imagine. ON 12 MONTHS IN We’re exactly 12months in. We had our first case diagnosed in Louisiana on March 9, 2020. We have recently hit the anniversary of that. I think some things have gone as fairly as we expected. Some things certainly have not. That said, I feel that we are in a new phase now, and we can clearly see how the pandemic ends. We can see the goal line, if you will, and now it’s just a matter of holding strong until we get there. Right now, we have about 16% of the population of Louisiana that has at least initiated the vaccine series now. That’s not an insubstantial number. That’s not herd immunity, but it’s a really good base to build on, and the vaccine supply is only going to pick up. It really is exciting to think that in two or three months, we’re going to have substantially more vaccine coverage than now. We’re going to be on much better footing. The challenge is to be able to get there intact and to be able to keep transmission down until we get there, especially with these variants circulating.

ON VACCINES AND VARIANTS It is possible that we will need a booster shot. I don’t think that will happen in the next few months, but I think that’s something that could come at the end of this year, perhaps sometime next year. It’s certainly possible. One of the attributes of these Messenger RNA (mRNA) vaccines is that it is relatively easy to create alterations in the vaccine to accommodate a booster to provide protection against the new variants. Taking a step back from that, if COVID transitions from a pandemic to an endemic, it is something that will be with us but not in a way to significantly alter life the way it is now. If we can keep it minimized by taking a booster every year or every two years, that’s okay. That’s how we do it with the flu and other viruses. It’s much better than living under a pandemic. It’s still a win.

I think it’s very important to remain grounded like that. For me, personally, it’s important to never give up the practice of medicine because it’s something I hold dear and is a privilege. ON BEING IN NEW ORLEANS AS COVID EVOLVED Well, I’m takingmyself back tomid-March and April 2020, in my mind. It was a scary time. Clinically, in a sense, we were flying blind because we didn’t have a great understanding of how to treat COVID patients yet. At that point, we thought it was advantageous to intubate early. That turned out not to be true. All of those things were challenges. You are humbled very quickly when you get thrown something in medicine you have never seen before. That was certainly applicable then. I have never been prouder of my physician colleagues, as well as, nurse colleagues and other support staff than I have throughout COVID. They all stepped up, and their primary goal was to care for patients and save lives, and they did so under risk to their own bodies. The conditions in which clinicians had to work under, particularly during those early days of COVID were austere, to say the least. I have very vivid memories of reusing N-95 masks days and weeks on end; wiping down plastic gowns – which are intended to be single-use and disposable – multiple times throughout a day’s work. My colleagues have really shown what drives them, which is to provide care, no matter how difficult circumstances are. The public did a good job of thanking us, and it was nice that they saw it and said it. I think most clinicians thought so, too, but the real sentiment was… it’s nice to be thanked, but just get us PPE. ON PPE It took some time, but it is there now. It’s humbling and off-putting at the same time to think how a country as rich as the United States can be put in such a situation, to be so ill-prepared and scrounging around for PPE to keep their doctors safe. It really is not something that a lot of people thought would have been possible. This has been a humbling experience, and I hope we can come out of this better prepared for the next time. ON BEING PREPARED NEXT TIME I think we invest. We invest in preparedness. We invest in public health. We listen to physicians and nurses about what vulnerabilities are there. It was no secret that the US was vulnerable to the pandemic. It had been spoken about many times. There was a disconnect that recognized vulnerability and thewillingness of policymakers to directly appropriate resources. But if you talk to the infectious disease colleagues, for example, it was no secret or surprise

IT’S HUMBLING AND OFF-PUTTING AT THE SAME TIME TO THINK HOW A COUNTRY AS RICH AS THE UNITED STATES CAN BE PUT IN SUCH A SITUATION....

at all. It was just a matter of when. I hope we take some lessons from this and learn to listen to the medical and public health community about what vulnerabilities exist, and as a community, decide that it’s worth the money to invest ahead of time. ON THE LONG-TERM IMPACT TO THE PRACTICE OF MEDICINE That’s a really great question, and I don’t know the answer. I do think we will be more conscientious about infection- control practices. I think we will be more conscientious about slowing the transmission of whatever the infectious agents may be, but I don’t think we really know yet what all the impacts will be. ON TELEMEDICINE GROWTH AND USE Telemedicine played a huge role and grew more than anyonecouldhaveexpected.Without question, it continues as an adjunct, not as a replacement. Going virtual doesn’t just apply to medicine – I think all types of industries and businesses are now recognizing the potential of virtual work and thinking about how to integrate it into post- COVID life. Medicine should be no different. Telemedicine is a tool that can augment clinical care. It can overcome some of the barriers that exist, such as individuals who are rural, individualswho are homebound, or individualswho require frequent checkups, and it can help clinicians reach patients in a way that they haven’t been able to before. However, it certainly does not and will not ever suffice for the in- person visit. It’s an addition. I’m actually pretty excited about finding new ways to integrate it. It really is going to be a significant tool, so I think people shouldn’t shy away from it. It’s going be with us from here on out, and it’s going to be on us as physicians to figure out how to make it worthwhile. ON HOWWE MANAGE SOCIAL MEDIA There is a great deal of information and misinformation shared through social media. The one part in all of this that gives me comfort is that when people rank the most

ON BEING AN ER PHYSICIAN AND CONTINUING TO WORK IN THE ER

It’s important to me to understand what the challenges are on the ground level. It’s especially important to me to maintain my clinical skills and acumen and to have a first-hand understanding of how policies that are instituted through the Health Department actually pan out in people’s lives. The emergency room is a great laboratory for that because all items that fall through the cracks of society or that don’t get adequately addressed show up in the ER. Whether it is addiction, domestic violence, homelessness, or any other issues that the Department of Health seeks to address, you really see the fallout of that first-hand in the ER from a policy perspective. It helps keep me grounded. It helps give perspective on what’s working, what’s not working, and where the Department of Health needs to focus energy.

IT’S IMPORTANT TO ME TO UNDERSTAND WHAT THE CHALLENGES ARE ON THE GROUND LEVEL.

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trusted sources of information about COVID or the vaccine, the most trusted source of information is consistently their physician. We need to leverage that. There has been so much politicization on COVID. And because of how quickly the vaccines were developed, there are a lot of suspicions out there. Of course, in many communities, this is building on decades of mistrust and marginalization, which are unfortunate realities of the healthcare system. So, we have to be cognizant of that too. But physicians are THE most trusted voice in not only Louisiana but the entire country. We need to make sure our voices are heard. We need to actively quell the myths, and we need to make sure that we rely on the trust people have given us to help get this pandemic over sooner rather than later. I also think we have to champion all vaccines. I think the antivax challenges will only increase from here, but we should not underestimate the power of physician voices in this area. We are the most respected voices on the issue, but we have to show up, and we have to open our mouths. We have to combat the nonsense with facts and anecdotes from the patients and their families that trust us with their care. We have to combat the noise with data, science, and our own expertise. If we don’t, there is going to be a big problem. ON POLITICS AND THE PANDEMIC I think the politicization was the most regrettable part about the pandemic state. This was hard enough to deal with without the infighting and misinformation. I do think Louisiana was blessed with really good leadership from Governor John Bel Edwards. There is nobody who is better in a tough situation or crisis than Governor Edwards. He is so smart. He is so level-headed and data and science- driven. I really admire the way that he was able to cut through a lot of the nonsense and focus on what is needed to keep Louisiana safe. ON THE PANDEMIC AND MULTIPLE HURRICANES AND STORMS It’s already very challenging when you have to respond to any weather event, whether it’s a freeze or a hurricane. But when you have to do it in a COVID environment, the challenges are exponentially multiplied. When we were sheltering tens of thousands of displaced individuals from the Lake Charles area, we had to provide shelter in a COVID environment. We had to do non-congregant sheltering, which is not something we’ve typically done in Louisiana. When we used buses to move people out of harm’s way, we had to space people out and use two to three times the number of buses than we would otherwise. It was very, very challenging, and it was taxing for emergency responders because they were already working really hard withCOVID. I think Louisiana did verywell under really harsh circumstances. Louisianahandles emergencypreparedness

better than any other state, since we certainly have more practice at it. One of the other attributes we have is good working relationships with all levels of government. Parish, municipal, and state governments work very well together here, because we have to. We’re forced to every time we have a storm, and that pays dividends. I think we would have been much worse off during all of this if we didn’t have such a good collaborative framework to work with. ON NEW ORLEANS FROM KATRINA TO COVID I think the resilience of folks has really left an impression on me. We’ve gone through very challenging times and have been able to bounce back for the better. I have no doubt that that’s what’s going to happen this time. I go back and remind myself that for the middle of March 2020, we had the fastest rate of growth of the COVID outbreak than anywhere else in the world to that point in time. At this point, it was largely focused on the greater New Orleans area, but for two weeks in the middle of March, our COVID outbreak was growing faster than it had in China, Italy, and South Korea. We had the worst outbreak in the world at that point in time, and the community responded in ways I didn’t even think possible. I can’t even imagine how bad it would have been if the community hadn’t stayed home, masked up, and distanced. Those things enabled us to flatten the curve, stop the spread, and not completely overwhelm the hospitals. They got very close, but we didn’t completely overwhelm them. We never had to enter a true crisis standard of care. I think this was the same resilience that was shown during Hurricane Katrina to bounce back. To bounce back from something as unspeakable as that shows who we are as a state. We’re a very resilient state, and we all honor each other. And that’s what’s going to get us through this.

I THINK THIS WAS THE SAME RESILIENCE THAT WAS SHOWN DURING HURRICANE KATRINA TO BOUNCE BACK.

stress. It’s okay to acknowledge it. It’s okay to talk about self- care. In fact, you have to or else you end up burning out, and you don’t get to provide the level of care that you want to for your patients. I think self-care and mental hygiene needs to be done on behalf of the patients, because it makes us better physicians. ON MEDICAL SCHOOL IMPACTS AND HOWWE TEACH ABOUT PANDEMICS That’s a great question, and it probably needs to be considered, because it won’t be the last time that we have to brave uncharted waters. We’ve really just begun to scratch the surface of not only how this pandemic will change the practice of medicine and the teaching of medicine, but what the downstream effects of it are. I mean there are going to be all types of downstream side effects of this pandemic. There is going to be collateral damage that we haven’t even begun to be able to articulate yet. It’s going take many years to unpack. ON THE FINAL WORDS YOU WANT TO SHARE… I just want to reiterate how proud I am of my colleagues over these past twelve months. I’ve never been prouder to have the colleagues that I do in the physician community in Louisiana. I think this year has really shown why it is that we do what we do. It has made me very proud to be a member of the physician community. ■

ON FAMILY AND COVID My wife’s been an absolute rock. She works in immigration, and for the past four years, her job was equally challenging, so she knows about stressful job environments. She also knows about having a duty and what it means to be a public servant. She was very supportive. With a two-year- old, I was not blessed with homeschooling. Our daughter went to daycare when it reopened, and that’s actually gone very well. The daycare where she goes has been very conscientious about COVID protocols, and it makes me feel very, very good that she’s in a safe environment.

ON THE ONE THING YOU WISH YOU KNEW THEN

I wish we had known to cancel Mardi Gras. I would have canceledMardi Gras last year. Mardi Gras was not THE cause of our spike March, but it was a cause. No question. We had other importation of cases. We had cases imported to us from conventions that nothing to do with Mardi Gras. We had cases imported from the cruise industry and routine travel. We’ve linked cases back to all of those. But there’s no question that Mardi Gras was an inciting event and made a bad situation worse. ON WHETHER OR NOT YOU’VE HAD COVID I don’t believe I had COVID, but I also had a strong immune reaction to my first dose of the Pfizer vaccine. While it’s not definitive, it makes me think perhaps I did have a mild asymptomatic case of COVID. But no, to my knowledge, I didn’t. I never tested positive, and I got tested a number of times. Same goes for my wife and our child.

ON COVID AND MENTAL HEALTH OF PHYSICIANS

We can’t turn a blind eye to how mentally challenging all of this has been. And you know, we, as a community of physicians, had so much public support particularly in the first few months of the pandemic, so much camaraderie, and so much cheerleading from the public. I think it allowed people to power through, but we shouldn’t lose sight of how challenging this work is, especially as it’s gone far beyond our expectations. There’s a lot of us that think that we’re impervious to mental challenges, but we’re not. This is difficult work, and we have to take cognition of that. We have to do things to promote mental hygiene. We have to acknowledge stress in a way that, perhaps, we haven’t had to as physicians. It’s okay to have

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Local Experts, National Leaders

AN EXAMPLE OF RESILIENCE

Fred A. Lopez, MD, MACP Richard Vial Professor, LSU School of Medicine-New Orleans

HURRICANE KATRINA OR COVID-19?

Several years ago, I wrote a guest editorial entitled “Infectious Diseases in the 21 st Century: No End in Sight.” 1 In it I quoted Dr. Robert Petersdorf, a legend in the field of infectious diseases, who wrote in the late 1970s, when referring to graduating fellows in infectious diseases: “Even

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with my great personal loyalty to [the discipline of] infectious diseases, I cannot conceive of a need for 309 more infectious diseases experts unless they spend their time culturing each other.” 2 Times have definitely changed. Over the past four decades or so, the advent of AIDS and hepatitis C,

iconic Charity Hospital and now caring for patients with the latter at our university teaching hospital. 3 For many involved in healthcare in this state, Hurricane Katrina has provided a referential point to affix experiences in time (i.e., “pre-Katrina” or “post-Katrina”), but with the novel coronavirus

I DO NOT VIEW EITHER DISASTER AS AN EXCLUSIVE HOLDER OF THIS MANTLE BUT RATHER CONSIDER BOTH TO BE EXAMPLES OF THE RESILIENCE OF OUR STATE IN ADDRESSING SOME OF ITS GREATEST RECENT CHALLENGES.

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enhanced vaccine development, the impact of multidrug- resistant bacteria, foodborne epidemics, the emergence of infections due to pathogens such as the Zika and Ebola viruses, and our perpetual struggle with mutating influenza viruses have increasingly positioned the field of infectious diseases at the forefront of medicine and public health. And now, of course, the world is grappling with SARS-CoV-2, the virus responsible for COVID-19, causing the general population to think more about infectious diseases than it ever has before—or ever wanted to. Because of the significance of the global pandemic, the Journal of the Louisiana State Medical Society , a vanguard of the medical community in our state since 1844, is providing an update on COVID-19 in this issue. Articles written by various medical professionals address the disease’s clinical aspects (epidemiology, diagnostics, therapeutics, complications, and prevention); its impact on student and resident training; and the challenges associated with leading a Department of Medicine during a pandemic.

reaching its toxic tentacles into seemingly every aspect of our lives for such a protractedperiod, itmaywell become the new chronological marker in Louisiana. I do not view either disaster as an exclusive holder of this mantle but rather consider both to be examples of the resilience of our state in addressing some of its greatest recent challenges. We hope that you find this issue helpful in your understanding of COVID-19 and its collateral effects, a pandemic whose vast impact will be felt for many years to come. ■ REFERENCES 1. Lopez FA. Infectious diseases in the 21st century: No end in sight. Emergency Medicine 2009;41:8. 2. Petersdorf RG. The doctors’ dilemma. N Engl J Med. 1978;299(12):628- 634. 3. Lopez FA. In the Eye of the Storm: Charity Hospital and Hurricane Katrina. The Pharos Winter 2006; 4-10. I would like to thank Michelle Holt, M.Ed., M.F.A., Managing Editor for the LSU Department of Medicine, for her assistance.

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Humberto Aguilar, MD John Bienvenu, MD David Dies, MD

James Hobley, MD Sathya Jaganmohan, MD L. Webster Johnson, MD

John Kirkikis, MD David Philips, MD Arthur Poch, MD

J. Mark Provenza, MD Douglas Rimmer, MD

To make a referral, call 318-631-9121.

CENTRAL 3217 Mabel Street Shreveport, LA 71103

PIERREMONT 8001 Youree Drive Suite 540 Shreveport, LA 71115

SOUTH SHREVEPORT 8383 Millicent Way Suite B Shreveport, LA 71115

BOSSIER 2400 Hospital Drive Suite 370 Bossier City, LA 71111

MINDEN 216 West Union Street Suite B Minden, LA 71055

16 J LA MED SOC | VOL 173 | SPRING 2021

COVID TIMELINE

27 FEB

11 JUL

State’s First Mass Vaccination Site Announced Through Partnership Between Pennington Biomedical Research Center And Our Lady Of The Lake COVID Vaccine Eligibility Expands To Include K-12 Teachers, Daycare Sta, And Some People With Health Conditions FDA Approves Johnson & Johnson’s Single-dose COVID Vaccine For Emergency-Use Authentication For Individuals Over The Age Of 18 ■

5 JUN

Mask Mandate In Place Bars Close Phase 2 Revised

Phase 2

15 MAY

18 FEB

2020

Stay At Home Lifted Phase 1

23 JUL

Phase 2 Extended Louisiana Surpasses 100,000 COVID Cases

9 MAR

9 FEB

First COVID Case Reported

27 APR

26 AUG

Healthcare Reopens Stay At Home Extended Until May 15

Hurricane Laura Devastates Southwest Louisiana

10 MAR

Additional Cases Reported

5 SEP

15 APR

8 FEB

Louisiana Surpasses 5,000 Deaths

Schools To Be Virtual Until Fall

COVID Vaccine Eligibility Expands To People Age 65 Through 69

11 MAR

Public Health Emergency Declared

11 SEP

14 APR

Phase 3

Louisiana Reports 1,000 Deaths Since First Case Was Reported

28 JAN

UK Department Of Health Conrms 2 Additional Cases Of The Uk COVID Variant

13 MAR

Schools Close

8 OCT

2 APR

Phase 3 Extended

Stay At Home Extended

22 JAN

Governor Limits Gatherings To 250 Or Less

Louisiana Launches The COVID Defense App

14 MAR

24 NOV

Louisiana In Modied Phase 2

31 MAR

First Death Reported

Medical Licenses Portable To Louisiana Louisiana Surpasses 5,000 COVID Cases

16 JAN

UK Reports Its First Case Of The Uk COVID Variant

Rules & Regulations Suspended

7 DEC

Quarantine Reduced To 10 Days; 7 Days With A Negative Test

16 MAR

27 MAR

Governor Limits Gatherings To 50 Or Less

Federal Stimulus Passes

4 JAN

70 & Older Eligible To Receive COVID Vaccine

18 MAR

11 DEC

FDA Approves Pzer-BioNTech For Emergency-Use Authentication For Individuals Over The Age Of 16

Medical/Surgical Shutdown – Emergency Procedures Only

23 MAR

2021

Louisiana Surpasses 1,000 COVID Cases

19 MAR

18 DEC

14 DEC

Telemedicine Encouraged With Payment Parity

22 MAR

FDA Approves Moderna COVID Vaccine For Emergency-Use Authentication For Individuals Over The Age Of 18

Hospitals Administer The First COVID Vaccines To Healthcare Workers

Stay At Home Order

J LA MED SOC | VOL 173 | SPRING 2021

SARS-COV-2 AND INFECTIVE ENDOCARDITIS: A CAUSE OF NON-ISCHEMIC ST-SEGMENT ELEVATION

Omar Leonards, MD and Martin Marak, MD

ABSTRACT: Acute substernal chest pain with diffuse ST-segment elevation and PR-segment depression is a peculiar presentation of both infective endocarditis and SARS-CoV-2 infection. This case presentation of inferior and anterolateral ST-segment elevation with PR-depression was initially concerning for an acute obstructive coronary thrombus. Subsequently, a diagnosis of COVID-19 myopericarditis with coexistent infective endocarditis was made. We therefore will review the pathophysiology of SARS-CoV-2 and infective endocarditis as a cause of cardiac injury along with mimickers of an acute myocardial infarction.

CASE REPORT: In July of 2020, a 66-year-old male with a past medical history of type 2 diabetes mellitus, hypertension, and prostate cancer, status-post recent prostatectomy, presented with a chief complaint of acute onset, non- radiating, substernal chest discomfort associated with diaphoresis and dyspnea. He denied recent fevers, cough, anosmia, ageusia, malaise, gastrointestinal symptoms, recent illness, ill contacts, and had a negative SARS-CoV-2 screen seven days before presentation. on presentation were a temperature of 36.8 °C, a heart rate of 120 beats per minute, a blood pressure of 138/86 mmHg, and oxygen saturation of 97% on room air. Physical examination was notable for an ill appearance and tachycardia. An electrocardiogram obtained during triage demonstrated inferior and anterolateral ST-segment elevation with PR-depression (Figure 1). Emergency cardiac catheterization was performed and demonstrated no significant coronary disease or ventriculardysfunction.Labevaluation, which returned during cardiac The patient’s vital signs catheterization, was remarkable for a leukocytosis of 31.1 x 1000/uL, acute renal injury with a creatinine of 3.73 mg/dL, peak troponin of 0.12 ng/ ml, and hyperkalemia of 5.6 mmol/L. SARS-CoV-2 PCR returned positive six hours later. Clinically the patient

appeared septic and vancomycin with ceftriaxone was initiated after blood cultures were obtained. The following day the blood cultures grew gram-positive cocci. A transthoracic echocardiogram was performed revealing a circumferential pericardial effusion without evidence of cardiac tamponade or valvular vegetations. Speciation of the blood cultures revealed Group G Streptococcus and antibiotic coverage was narrowed to intravenous ceftriaxone. The patient’s blood cultures cleared at 48 hours and he was discharged five days after presentation. He returned 11 days after discharge with worsening lower extremity weakness, generalized malaise, and severe lumbar pain. Magnetic resonance imaging of the lumbar spine revealed osteomyelitis

and discitis at L3-S1 and a small L5 paraspinal epidural abscess. Repeat transthoracic echocardiogram was performed and revealed a tricuspid valve vegetation. Review of the patient’s prior echocardiogram revealed a vegetation on the tricuspid valve that was not initially detected. Subsequent transesophageal echocardiogram found large mobile vegetations on multiple tricuspid leaflets and features concerning for old vegetations involving the anterior and posterior leaflets of the mitral valve. After multispecialty collaboration, the patient was treated with outpatient intravenous antibiotic therapy. ■

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Figure 1. Diffuse PR-segment depression and ST-segment elevation appreciated throughout the inferior and anterolateral leads.

J LA MED SOC | VOL 173 | SPRING 2021

HAS COVID-19 CAUSEDYOU TO EXPERIENCE ANY OF THE FOLLOWING?

WAS YOUR PRACTICE PREPARED?

FINANCIAL IMPACT

PANDEMIC PRACTICING: HOW PHYSICIANS MET THE CHARGE AND WORKED TO KEEP OUR STATE SAFE In August 2020, the Louisiana State Medical Society partnered with the Louisiana State Board of Medical Examiners to send a statewide survey to Louisiana physicians. With over 1,000 responses, questions ranged from telemedicine and PPE to burnout and patient load. The goal was to capture how COVID-19 affected physicians so that the LSMS could work with them to overcome the challenges they have faced since the first case of COVID in Louisiana. Participation in surveys such as this one assists the LSMS in that task and helps us remain the trusted advocate for physicians across the state.

The pandemic took a toll on many businesses, and medical practices were no exception. The LSMS provided many resources regarding nancial assistance and provider relief funding to keep members and non-members alike informed and educated.

We understand that you are more than a physician. You’re an individual, with responsibilities outside of your practice. The LSMS provides resources for physicians on managing mental health and burnout.

334

343

NO (21%) 206

232

272

169

148

187

YES (39%) 376

NO (61%) 600

131

YES (79%) 764

FINANCIAL LOSS AT PRACTICE?

FINANCIAL RELIEF RECEIVED

I wish I had known howmuch this would aect not only physical health but mental health.”

SUPPLY SHORTAGE

Many practices were not equipped for COVID-19. From PPE to sta shortages, these were obstacles many in the medical eld faced in the early days of the pandemic.

HOWDOYOU FEEL ABOUT THE FUTURE OF TELEMEDICINE? When the stay-at-home order was issued, telemedicine became an essential part of medical practice. Physicians adapted to be able to monitor patients from a distance and remain dedicated to the practice of medicine.

OTHER (6%) 92

N-95 MASKS (26%) 372

CLEANING SUPPLIES (21%) 290

PLEASE VISIT LSMS.ORG TO VIEW ALL THE SURVEY RESULTS.

404

299

177

266

277

272

131

DEMOGRAPHICS / PRACTICE SETTING GRAPHICS Physicians surveyed were from a wide range of specialties, practice settings, and age range. Making the survey open to the entire state and not just LSMS membership was essential to provide an accurate depiction of physicians in Louisiana.

105

GLOVES (9%) 127

TESTING KITS (18%) 257

WET GOWNS (8%) 108

OTHER PPE (12%) 165

WHAT PERCENTAGE OF YOUR PRACTICE IS CONDUCTED USING TELEMEDICINE?

806

FEMALE (28%) 292

244

306

273

123

LESS THAN 10%

177

239

BEFORE COVID-19

358

MALE (72%) 742

206

183

UP TO 25%

110

141

DURING THE EMERGENCY SHUT DOWN / OFFICE CLOSURES

141

105

UP TO 50%

TODAY

UP TO 75%

MORE THAN 75% BUT LESS THAN 100%

I wish I had known how to better conduct a telemedicine assessment and visit.” ■

UNDER 40

40-49

50-59

60-69

70+

138

GENDER

AGE

118

100%

J LA MED SOC | VOL 173 | SPRING 2021

COVID-19

PHOTOS

1, 2 Steen Trawick, MD LSMS Speaker

3 Jacob Boudreaux, MD LSMS Medical Student Representative on the Board of Governors

4 Maurice Sholas, MD

LSMS member since 2014

5 Mary Laville, MD Member since 1990

6 Aaron Alokozai Medical student

Member since 2018

7, 8 William Freeman, MD LSMS President-Elect

9 Jeff White, MD

LSMS District 4 Councilor for the Board of Governors

10 Sandeep Chadha, MD Member since 2020

11 Aimee Kramer, MD Member since 2017

24 J LA MED SOC | VOL 173 | SPRING 2021

J LA MED SOC | VOL 173 | SPRING 2021 25

LESSONS FROM LAMMICO

Labeled as essential due to our support of healthcare providers, the professionals at LAMMICO are fortunate. In this time of uncertainty and disruption, the plunge into full remote work generated surprisingly little disruption for LAMMICO and our insureds. We were prepared with technology, security, practices and policies already in place for remote work. This seamless transitionmeant continuous service to our insureds, as we worked to support our healthcare heroes.

LAMMICO and our employees are family and over the years our family has supported one another well. We will continue to do that and are confident we will come through COVID-19 stronger because of it. All of this helps strengthen our resolve and determination to offer frontline healthcare professionals as much support as we possibly can. ■

Overall, we are doing well but, likemany, we are wondering what will come next, worrying about safety and about when life will return to “normal.” Fortunately, we have the reassurance of a strong company and stable jobs.

Our COVID team met daily, working to gather content for a COVID-19 resource webpage that became an invaluable one-stop-shop for insureds to find the latest details on telehealth guidelines, state and federal updates and reopening healthcare. The webpage has been viewed more than 8,700 times since it launched in March 2020. We surveyed our employees and learned many things about how they feel and how they are handling things. Although they are working well remotely, our employees miss being with their LAMMICO family. They have expressed how grateful they are for our constant training in preparing them for a crisis like this. We also asked them what they are doing to stay balanced. Answers included exercise, walking, outdoor activities, reading, meditating, praying, communicating with friends and family, and staying positive. We hear from our employees how important it is to them to take care of others—especially those working tirelessly under stressful conditions to meet the needs of patients. This sense of purpose offers direction during a time of turmoil. We have all grown. Virtual meetings and even social gatherings via technology are common now. After Hurricane Katrina, many of us learned to text, and likewise, COVID has taught us to Zoom.

We were less prepared for the feelings: anxiety, fear, isolation, discomfort and longing for normalcy. To combat those emotions, we have put new spins on past favorites. Employees enjoyed virtual versions of our annual Halloween costume contest, ugly sweater contest and holiday raffle. We also held company meetings via webinar, led by our president. Care packages were mailed to employees, complete with office supplies, snacks and toilet paper! Online exercise classes were offered during lunch breaks.

Know someone pregnant and struggling with opioid addiction?

Care packages were mailed to employees, completewith office

By taking care of our employees, as a team, we were better able to serve our insureds. LAMMICO hosts many live events each year and transitioned them all to webinars for 2020 and 2021. We also worked with

supplies, snacks and toilet paper!

some practices and facilities financially impacted by the pandemic or who were treating fewer patients and reduced their coverage/premium to part-time or deferred some premium payments as another way to support them during this emergency.

Woman’s GRACE Programcanhelp! Womans.org/GRACE • 225-924-8574

J LA MED SOC | VOL 173 | SPRING 2021

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