1 00:00:20,836 --> 00:00:23,956 Speaker 1: From Pushkin Industries. This is Deep Background, the show where 2 00:00:23,956 --> 00:00:26,916 Speaker 1: we explore the stories behind the stories in the news. 3 00:00:27,636 --> 00:00:31,556 Speaker 1: I'm Noah Feldman. At the beginning of the COVID nineteen outbreak, 4 00:00:31,876 --> 00:00:34,956 Speaker 1: we spent a lot of time thinking about the doctors, 5 00:00:35,276 --> 00:00:37,996 Speaker 1: the frontline physicians who were fighting the disease in the hospital. 6 00:00:38,476 --> 00:00:42,236 Speaker 1: As cases have begun slowly but surely to decline hebred 7 00:00:42,316 --> 00:00:45,036 Speaker 1: Massachusetts and in other states, we thought it was a 8 00:00:45,076 --> 00:00:48,596 Speaker 1: good time to revisit the frontline hospital doctors and the 9 00:00:48,636 --> 00:00:53,156 Speaker 1: experiences that they've had treating patients in intensive care units. 10 00:00:53,596 --> 00:00:55,836 Speaker 1: We wanted to know what their experience has been and 11 00:00:55,916 --> 00:00:59,556 Speaker 1: how it's been changing over the last several months. We 12 00:00:59,596 --> 00:01:01,916 Speaker 1: also wanted to know about the standard of care in 13 00:01:01,956 --> 00:01:05,796 Speaker 1: the hospitals. It is coronavirus being treated now the same 14 00:01:05,836 --> 00:01:08,356 Speaker 1: way that it was treated at the outset, or have 15 00:01:08,436 --> 00:01:12,836 Speaker 1: there been signific developments in how physicians are encountering patients. 16 00:01:13,556 --> 00:01:16,596 Speaker 1: To discuss these issues, we're joined by doctor Emmy Rubin. 17 00:01:16,956 --> 00:01:21,036 Speaker 1: She's a critical care pulmonologist at Massachusetts General Hospital. She's 18 00:01:21,036 --> 00:01:25,636 Speaker 1: been on the front line treating coronavirus patients from the beginning. 19 00:01:26,116 --> 00:01:29,516 Speaker 1: She's also co chair of the hospital's Optimum Care Committee, 20 00:01:29,716 --> 00:01:33,556 Speaker 1: which is essentially its leading ethics body for figuring out 21 00:01:33,596 --> 00:01:38,196 Speaker 1: how to handle difficult ethical questions under circumstances exactly like 22 00:01:38,316 --> 00:01:41,676 Speaker 1: the ones facing the hospital now. I asked doctor Rubin 23 00:01:41,916 --> 00:01:48,756 Speaker 1: how things have changed in her ICU since March, So 24 00:01:48,796 --> 00:01:51,636 Speaker 1: I would say, you know, in the beginning, when the 25 00:01:51,716 --> 00:01:57,236 Speaker 1: cases were surging, Mass General was particularly hard hit. So 26 00:01:57,316 --> 00:02:01,916 Speaker 1: in the early days, things were evolving very very quickly. 27 00:02:02,396 --> 00:02:04,676 Speaker 1: We were extending our capacity in every way that we 28 00:02:04,716 --> 00:02:08,596 Speaker 1: could very quickly by opening up new ICU spaces within 29 00:02:08,716 --> 00:02:13,756 Speaker 1: the hospitspital adding staff, changing staffing models, and we got 30 00:02:13,796 --> 00:02:16,316 Speaker 1: to the point where we had close to two hundred 31 00:02:16,676 --> 00:02:20,516 Speaker 1: patients with COVID in our intensive care units. So I 32 00:02:20,556 --> 00:02:24,076 Speaker 1: think in terms of how we individually took care of patients, 33 00:02:24,956 --> 00:02:27,916 Speaker 1: we took care of them the way we would take 34 00:02:27,916 --> 00:02:30,316 Speaker 1: care of any IU patient with respiratory failure. And I 35 00:02:30,316 --> 00:02:33,556 Speaker 1: think we relied on what we know about the basic 36 00:02:33,596 --> 00:02:37,076 Speaker 1: physiology of these patients, which is the vast majority of 37 00:02:37,076 --> 00:02:39,396 Speaker 1: them and the intensive care units have what's called acute 38 00:02:39,396 --> 00:02:43,316 Speaker 1: respiratory distress syndrome or AIRDS. That's something that all of 39 00:02:43,396 --> 00:02:46,076 Speaker 1: us have a lot of experience taken care of, and 40 00:02:46,596 --> 00:02:51,596 Speaker 1: we relied on basic principles of management, ventilator management in particular, 41 00:02:51,956 --> 00:02:54,276 Speaker 1: which we know a lot about from other disease processes. 42 00:02:54,436 --> 00:02:58,276 Speaker 1: So in many ways, taking care of individual patients was 43 00:02:58,596 --> 00:03:01,396 Speaker 1: similar to how we take care of individual patients with 44 00:03:01,636 --> 00:03:05,596 Speaker 1: the flu or airds from other conditions. What was not 45 00:03:05,756 --> 00:03:11,196 Speaker 1: typical was obviously the volume of patients with one specific 46 00:03:11,196 --> 00:03:14,156 Speaker 1: condition that months before we had not heard about. What 47 00:03:14,276 --> 00:03:18,556 Speaker 1: was also different was the kinds of medications we were trying. 48 00:03:18,556 --> 00:03:20,956 Speaker 1: At first we were using in the early days, we 49 00:03:20,956 --> 00:03:25,236 Speaker 1: were using a lot of hydroxy chloroquin, a lot of statins. 50 00:03:25,756 --> 00:03:30,036 Speaker 1: I think people were very quickly trialing things. I think 51 00:03:30,076 --> 00:03:33,036 Speaker 1: there was a lot of desire among many people to 52 00:03:33,156 --> 00:03:36,716 Speaker 1: try medications that might work, and has been widely reported. 53 00:03:36,756 --> 00:03:38,316 Speaker 1: I think in the beginning we were using a lot 54 00:03:38,396 --> 00:03:42,756 Speaker 1: of medications that have turned out to be of questionable benefit. 55 00:03:43,316 --> 00:03:46,316 Speaker 1: As things have gone on, there are many many trials 56 00:03:46,396 --> 00:03:49,596 Speaker 1: up and running at Mass General to look at randomized 57 00:03:49,636 --> 00:03:52,476 Speaker 1: controlled trials at these medications and try to figure out 58 00:03:52,516 --> 00:03:55,116 Speaker 1: what actually works and what doesn't. So I would say 59 00:03:55,636 --> 00:03:59,676 Speaker 1: that early kind of enthusiasm for different medications has waned, 60 00:04:00,236 --> 00:04:04,756 Speaker 1: and now really it's just taking care of intensive care 61 00:04:04,836 --> 00:04:08,116 Speaker 1: unipatients with respiratory failure, but on a much larger scale. 62 00:04:08,796 --> 00:04:12,076 Speaker 1: Let me ask you specifically about the what you described 63 00:04:12,076 --> 00:04:16,356 Speaker 1: as your normal practice for people with RDS, which includes 64 00:04:16,476 --> 00:04:20,796 Speaker 1: ventilators right. Has the way that you are treating COVID 65 00:04:20,876 --> 00:04:23,996 Speaker 1: patients in that regard in terms of putting them on ventilators, 66 00:04:24,036 --> 00:04:27,316 Speaker 1: who goes on ventilators at what stage? Remain constant or 67 00:04:27,356 --> 00:04:29,516 Speaker 1: has that shifted? Because I know there was at least 68 00:04:29,516 --> 00:04:33,756 Speaker 1: some public discussion sort of somewhere in April around the 69 00:04:33,836 --> 00:04:36,836 Speaker 1: question of whether the ventilators were doing what they ought 70 00:04:36,836 --> 00:04:38,836 Speaker 1: to be doing for COVID patients or whether it was 71 00:04:38,876 --> 00:04:42,316 Speaker 1: plausible to think about other oxygen delivery systems. How has 72 00:04:42,356 --> 00:04:44,476 Speaker 1: that evolved and are we back to sort of where 73 00:04:44,476 --> 00:04:47,276 Speaker 1: we started in that regard. Yeah, I think an interesting question. 74 00:04:47,316 --> 00:04:50,596 Speaker 1: I would say it may be that early on we 75 00:04:50,676 --> 00:04:53,876 Speaker 1: may have had a lower threshold for putting people on ventilators. 76 00:04:54,436 --> 00:04:57,116 Speaker 1: So one of the things we know about airds is 77 00:04:57,116 --> 00:05:00,116 Speaker 1: that once people are on a ventilator, the mainstay of 78 00:05:00,276 --> 00:05:04,516 Speaker 1: treating them on a ventilator is giving them relatively small 79 00:05:04,556 --> 00:05:07,316 Speaker 1: breaths on the ventilator to prevent what we call ventilator 80 00:05:07,356 --> 00:05:11,196 Speaker 1: induced lung injury. And there's a concern that if people 81 00:05:11,196 --> 00:05:15,196 Speaker 1: with developing ards are breathing on their own and taking large, 82 00:05:15,516 --> 00:05:18,116 Speaker 1: kind of gulping breaths for a long time and they 83 00:05:18,236 --> 00:05:20,756 Speaker 1: end up needing to have a breathing machine anyway, that 84 00:05:20,836 --> 00:05:23,396 Speaker 1: during the time they're breathing spontaneously, they may be doing 85 00:05:23,476 --> 00:05:27,116 Speaker 1: damage to their lungs by taking large breaths and damaging 86 00:05:27,156 --> 00:05:30,276 Speaker 1: certain portions of their lungs. I think in the beginning 87 00:05:30,556 --> 00:05:33,676 Speaker 1: we may have had a slightly lower threshold for putting 88 00:05:33,676 --> 00:05:36,116 Speaker 1: people on a breathing machine. In other words, when people 89 00:05:36,156 --> 00:05:38,236 Speaker 1: seem to be taking a significant turn for the worse, 90 00:05:38,396 --> 00:05:40,476 Speaker 1: we may have put them on a little bit earlier. 91 00:05:41,156 --> 00:05:43,876 Speaker 1: But I would say in general, our management kind of 92 00:05:43,876 --> 00:05:47,756 Speaker 1: adheres to traditional principles, which is, when somebody has respiratory 93 00:05:47,756 --> 00:05:50,916 Speaker 1: failure and is not supporting their breathing, either not maintaining 94 00:05:50,916 --> 00:05:53,676 Speaker 1: their oxygen levels or not getting rid of the carbon 95 00:05:53,716 --> 00:05:58,476 Speaker 1: dioxide they're tiring out, we support their breathing with a ventilator. 96 00:05:58,716 --> 00:06:01,276 Speaker 1: There has been a lot of attention to are we 97 00:06:01,356 --> 00:06:05,036 Speaker 1: putting too many people on ventilators with COVID. I think 98 00:06:05,116 --> 00:06:07,596 Speaker 1: I can speak for myself certainly and for many of 99 00:06:07,596 --> 00:06:09,876 Speaker 1: my colleagues that we feel that you look clinically at 100 00:06:09,876 --> 00:06:12,156 Speaker 1: the patient. If they seem like their breathing is failing, 101 00:06:12,596 --> 00:06:15,276 Speaker 1: we put them on a breathing machine, the same way 102 00:06:15,316 --> 00:06:19,156 Speaker 1: we would in any other situation. And how do you 103 00:06:19,276 --> 00:06:21,716 Speaker 1: feel There must be some statistics on this, but there's 104 00:06:21,756 --> 00:06:24,476 Speaker 1: also some imperfection in the statistical analysis. But how do 105 00:06:24,516 --> 00:06:27,236 Speaker 1: you feel in terms of whether the standard of care 106 00:06:27,236 --> 00:06:30,516 Speaker 1: that you're using is producing better outcomes at this stage 107 00:06:30,556 --> 00:06:34,076 Speaker 1: than it was at the beginning, or really are people 108 00:06:34,596 --> 00:06:36,916 Speaker 1: making it or not making it with the excellent treatment 109 00:06:36,916 --> 00:06:39,236 Speaker 1: that you're giving them pretty much at the same rate 110 00:06:39,276 --> 00:06:41,196 Speaker 1: as they were at the beginning. I realize there are 111 00:06:41,196 --> 00:06:43,316 Speaker 1: many confounding factors that would be very hard to run 112 00:06:43,356 --> 00:06:45,676 Speaker 1: a proper study on this or in movement. So I'm 113 00:06:45,676 --> 00:06:48,716 Speaker 1: really asking you for an impressionistic response. Yeah, As you 114 00:06:48,756 --> 00:06:52,436 Speaker 1: alluded to, the data has essentially all been imperfect because 115 00:06:52,436 --> 00:06:55,036 Speaker 1: we don't have enough long term data on how people 116 00:06:55,036 --> 00:06:58,036 Speaker 1: are doing. So most of the data about for survival 117 00:06:58,356 --> 00:07:01,396 Speaker 1: to discharge, for example, or survival to hospital discharge was 118 00:07:01,476 --> 00:07:03,876 Speaker 1: based on numbers that included a lot of people who 119 00:07:03,916 --> 00:07:06,876 Speaker 1: were still in the ICU. So I think it is 120 00:07:06,916 --> 00:07:09,556 Speaker 1: possible that early on, as they said before, we were 121 00:07:09,596 --> 00:07:12,236 Speaker 1: having a slightly lower threshold to intubate people. So we 122 00:07:12,276 --> 00:07:15,236 Speaker 1: saw a lot of people getting better, getting off the 123 00:07:15,236 --> 00:07:17,316 Speaker 1: breathing machine and getting out of the ICU and in 124 00:07:17,356 --> 00:07:20,796 Speaker 1: many cases leaving the hospital. Now we're seeing a lot 125 00:07:20,796 --> 00:07:23,196 Speaker 1: of people who have required support for a longer period 126 00:07:23,196 --> 00:07:25,276 Speaker 1: of time. We have a lot of patients now. This 127 00:07:25,356 --> 00:07:27,236 Speaker 1: is one way in which things have changed is that 128 00:07:27,516 --> 00:07:29,636 Speaker 1: many of the patients I would say, who remain in 129 00:07:29,676 --> 00:07:31,876 Speaker 1: the intensive care units or in other parts of the 130 00:07:31,916 --> 00:07:34,556 Speaker 1: hospital that are sort of stepped downs from the intensive 131 00:07:34,556 --> 00:07:37,156 Speaker 1: PERI unit are people who we don't know how they'll 132 00:07:37,276 --> 00:07:40,316 Speaker 1: how they'll do, whether they will survive, whether they will 133 00:07:40,316 --> 00:07:43,316 Speaker 1: survived to leave the hospital, whether they'll be able to 134 00:07:43,356 --> 00:07:47,196 Speaker 1: get successfully off of the VENTI later. So I think 135 00:07:47,196 --> 00:07:50,556 Speaker 1: things have evolved in that respect that we anticipate that. 136 00:07:50,796 --> 00:07:52,876 Speaker 1: You know, when we looked at our earlier percentages of 137 00:07:52,876 --> 00:07:57,236 Speaker 1: people who had survived to hospital discharge, those were quite encouraging. 138 00:07:57,436 --> 00:08:00,476 Speaker 1: We always expected those numbers to change and to sort 139 00:08:00,476 --> 00:08:03,916 Speaker 1: of move more towards the numbers that we are familiar 140 00:08:03,956 --> 00:08:06,276 Speaker 1: with for airds in general, and the mortality rate for 141 00:08:06,316 --> 00:08:08,996 Speaker 1: airds in general is high. What's the ballpark for air 142 00:08:09,156 --> 00:08:11,956 Speaker 1: ds in general non COVID airdas I think for moderate 143 00:08:11,956 --> 00:08:15,036 Speaker 1: to severe airds there's about a forty percent mortality rate, 144 00:08:15,156 --> 00:08:18,836 Speaker 1: and age is a predictor of mortality for airds in general. 145 00:08:18,996 --> 00:08:21,036 Speaker 1: And so again that's a way in which we think 146 00:08:21,076 --> 00:08:24,276 Speaker 1: that this will be quite similar. What's the longest that 147 00:08:24,316 --> 00:08:27,476 Speaker 1: you've had people still beyond ventilators? I mean there must 148 00:08:27,516 --> 00:08:30,596 Speaker 1: be people who came in in March. Yeah, are any 149 00:08:30,636 --> 00:08:33,716 Speaker 1: of those people still on ventilators now? Yes, there are 150 00:08:33,716 --> 00:08:35,956 Speaker 1: certainly people who came in March who are still needing 151 00:08:36,116 --> 00:08:39,516 Speaker 1: ventilator supports. So typically, once somebody needs support for a 152 00:08:39,556 --> 00:08:42,596 Speaker 1: certain period of time that is defined by sort of 153 00:08:42,596 --> 00:08:45,116 Speaker 1: clinical judgment, but more than a couple of weeks generally, 154 00:08:45,156 --> 00:08:47,436 Speaker 1: and we consider putting a trade gastome and which is 155 00:08:47,436 --> 00:08:51,196 Speaker 1: a more durable, more comfortable form of a breathing tube, 156 00:08:51,236 --> 00:08:54,996 Speaker 1: so that patients can receive mechanical ventilation for longer. There 157 00:08:55,036 --> 00:08:58,076 Speaker 1: are many patients now who have had trade gustomes, some 158 00:08:58,116 --> 00:09:00,116 Speaker 1: of whom will then be liberated from the ventilator once 159 00:09:00,156 --> 00:09:02,116 Speaker 1: they have the trade gastomies. But there are certainly patients 160 00:09:02,156 --> 00:09:05,396 Speaker 1: who have required many, many weeks of mechanical ventilation. Some 161 00:09:05,436 --> 00:09:07,156 Speaker 1: of those patients will leave the hospital and go to 162 00:09:07,196 --> 00:09:09,716 Speaker 1: sort of long term acute care hospitals even while they're 163 00:09:09,716 --> 00:09:13,676 Speaker 1: still needing support. There are certainly patients in that category, 164 00:09:14,036 --> 00:09:18,276 Speaker 1: and that is not unique to COVID. I think what 165 00:09:18,436 --> 00:09:21,036 Speaker 1: is unique is the number of people. So when you 166 00:09:21,076 --> 00:09:23,756 Speaker 1: start with ten times the number of people who you 167 00:09:23,836 --> 00:09:27,356 Speaker 1: ordinarily have with AIRDS, you're going to have a huge 168 00:09:27,436 --> 00:09:29,996 Speaker 1: number of people in the category of what we call 169 00:09:30,236 --> 00:09:34,436 Speaker 1: chronic critical illness, where people require prolonged mechanical ventilation. It 170 00:09:34,516 --> 00:09:37,276 Speaker 1: sounds like a remdesse of her which I finderstand correctly 171 00:09:37,316 --> 00:09:40,476 Speaker 1: has been made available at least at MGH, is not 172 00:09:40,596 --> 00:09:43,556 Speaker 1: having a transformative impact on the course of disease for 173 00:09:43,676 --> 00:09:46,436 Speaker 1: most of the patients that you're seeing. I think, based 174 00:09:46,436 --> 00:09:49,196 Speaker 1: on my understanding of the data, and I think in 175 00:09:49,276 --> 00:09:52,236 Speaker 1: general this is a shared view, that it does have 176 00:09:52,356 --> 00:09:56,716 Speaker 1: some effect, apparently on sort of time to recovery. I 177 00:09:56,796 --> 00:09:59,436 Speaker 1: don't think there's a sense that it will be a 178 00:09:59,476 --> 00:10:02,036 Speaker 1: game changer for the people who are the sickest. We 179 00:10:02,116 --> 00:10:04,316 Speaker 1: are giving it and it is the only drug, as 180 00:10:04,356 --> 00:10:07,596 Speaker 1: you I'm sure are aware that is now not formally 181 00:10:07,636 --> 00:10:12,916 Speaker 1: approved but authorized use. So we are certainly giving it 182 00:10:12,996 --> 00:10:17,596 Speaker 1: to patients who meet criteria for it. I think the 183 00:10:17,636 --> 00:10:21,436 Speaker 1: patients who, for whatever reasons, are destined to become the sickest. 184 00:10:21,556 --> 00:10:25,156 Speaker 1: I don't know that it will help prevent severe illness 185 00:10:25,196 --> 00:10:28,276 Speaker 1: or deaf in those patients. There was, as you probably 186 00:10:28,316 --> 00:10:31,396 Speaker 1: also know, a trend towards mortality in that in the trial, 187 00:10:31,516 --> 00:10:35,836 Speaker 1: but it wasn't didn't meet technically the threshold for statistical significance, 188 00:10:35,836 --> 00:10:38,796 Speaker 1: and I don't necessarily think we'll get answers to those questions. 189 00:10:38,836 --> 00:10:41,116 Speaker 1: By the time we got round severe, we had a 190 00:10:41,156 --> 00:10:43,596 Speaker 1: hospital full of people who were already, as I said, 191 00:10:43,636 --> 00:10:46,036 Speaker 1: sort of very far advanced into the illness. I think 192 00:10:46,036 --> 00:10:49,116 Speaker 1: we're very skeptical that it could help those patients. So 193 00:10:49,156 --> 00:10:51,956 Speaker 1: I think we think that a certain subset of patients 194 00:10:51,996 --> 00:10:55,436 Speaker 1: who get it early enough on the severity illness may 195 00:10:55,436 --> 00:10:59,196 Speaker 1: be less, which is encouraging. It's encouraging to have something 196 00:10:59,716 --> 00:11:03,556 Speaker 1: to use, but we still think that for certain patients 197 00:11:03,596 --> 00:11:06,476 Speaker 1: this is a devastating illness and will be. And when 198 00:11:06,556 --> 00:11:09,796 Speaker 1: Donald Trump informed us that he was taking hydroxy chloroquinn, 199 00:11:10,316 --> 00:11:12,356 Speaker 1: one of the things that he said was that his 200 00:11:12,436 --> 00:11:15,436 Speaker 1: impression was that lots of frontline medical workers were also 201 00:11:15,556 --> 00:11:20,476 Speaker 1: taking it prophylactically in your anecdotal experience at MGH, Do 202 00:11:20,556 --> 00:11:22,756 Speaker 1: you know anybody who's actually doing that at the stage, 203 00:11:23,356 --> 00:11:25,356 Speaker 1: I cannot promise it's not happening. I do not know 204 00:11:25,396 --> 00:11:28,996 Speaker 1: anyone that personally, to be perfectly honest, did it come 205 00:11:29,076 --> 00:11:31,356 Speaker 1: up with people at the very beginning when it was 206 00:11:31,396 --> 00:11:33,516 Speaker 1: being used. It didn't. I don't know that any of 207 00:11:33,516 --> 00:11:36,516 Speaker 1: my friends and colleagues ever actually took it, but there 208 00:11:36,516 --> 00:11:39,596 Speaker 1: were some people who mentioned early on that they would 209 00:11:39,596 --> 00:11:42,236 Speaker 1: consider it when there was a lot of enthusiasm for it. 210 00:11:42,316 --> 00:11:46,316 Speaker 1: Certainly not in recent days. And again I think it's 211 00:11:47,156 --> 00:11:48,196 Speaker 1: you know, a lot of what we've seen, and I 212 00:11:48,196 --> 00:11:51,036 Speaker 1: think it's human nature to want to do something for 213 00:11:51,036 --> 00:11:52,796 Speaker 1: people who are so sick in front of you, So 214 00:11:52,876 --> 00:11:55,116 Speaker 1: I don't. I think one of the things that's been 215 00:11:55,196 --> 00:11:58,276 Speaker 1: very interesting and that sort of consistent with human nature, 216 00:11:58,396 --> 00:12:01,996 Speaker 1: is that throughout the course of this the zeal to 217 00:12:02,236 --> 00:12:05,836 Speaker 1: use things that sort of seem like they might plausibly help, 218 00:12:05,916 --> 00:12:08,156 Speaker 1: or where there's a little bit of suggestion of it, 219 00:12:08,436 --> 00:12:10,516 Speaker 1: like hydrox chloroquint at the beginning. I mean, that was 220 00:12:10,676 --> 00:12:16,196 Speaker 1: very very thoughtful, smart people. We're using that and recommending 221 00:12:16,276 --> 00:12:18,636 Speaker 1: using it at the beginning. I think that's just a 222 00:12:18,636 --> 00:12:23,676 Speaker 1: testament to how much people want to find something to help. 223 00:12:23,836 --> 00:12:26,836 Speaker 1: And I think, you know, hopefully now we've sort of 224 00:12:26,836 --> 00:12:29,036 Speaker 1: regressed to the point where we're you know, I think 225 00:12:29,116 --> 00:12:31,316 Speaker 1: most people are being much more measured about we need 226 00:12:31,356 --> 00:12:34,916 Speaker 1: to study things in the context of trials and actually 227 00:12:34,956 --> 00:12:38,596 Speaker 1: get evidence before using things. But you know, it's understandable. 228 00:12:38,596 --> 00:12:41,756 Speaker 1: It's very hard to watch people sick and dying in 229 00:12:41,756 --> 00:12:44,316 Speaker 1: front of you with nothing to do other than sort 230 00:12:44,316 --> 00:12:46,916 Speaker 1: of supportive care, which really is the sort of mainstay 231 00:12:46,916 --> 00:12:49,196 Speaker 1: of taking care of these people. That's something that you know, 232 00:12:49,236 --> 00:12:52,036 Speaker 1: as I see, physicians were used to because there are 233 00:12:52,036 --> 00:12:55,156 Speaker 1: many things that we don't have a specific magic bullet 234 00:12:55,196 --> 00:12:58,836 Speaker 1: for and we take time and you know, try to 235 00:12:58,876 --> 00:13:01,356 Speaker 1: have patience and try to get people through it with 236 00:13:01,396 --> 00:13:04,476 Speaker 1: sort of the best supportive management we can. But it's hard. 237 00:13:05,276 --> 00:13:18,276 Speaker 1: We'll be right back. How has the psychological experience of 238 00:13:18,316 --> 00:13:21,596 Speaker 1: being a critical care physician been changing for you? At 239 00:13:21,636 --> 00:13:24,876 Speaker 1: the beginning, it must have been just a bit overwhelming 240 00:13:24,916 --> 00:13:28,796 Speaker 1: because of the radical numbers and the changes. I'm curious 241 00:13:28,836 --> 00:13:30,916 Speaker 1: to know what it was like then, and also how 242 00:13:30,916 --> 00:13:35,156 Speaker 1: it's evolving now. Yeah, it's a good question. I think 243 00:13:35,156 --> 00:13:38,436 Speaker 1: at the beginning, first of all, I think, you know, 244 00:13:38,436 --> 00:13:41,396 Speaker 1: there's a whole lot of adrenaline around sort of, you know, 245 00:13:41,636 --> 00:13:45,036 Speaker 1: there always is when something is evolving so quickly. I 246 00:13:45,076 --> 00:13:49,396 Speaker 1: think there was a lot of energy around everybody figuring 247 00:13:49,396 --> 00:13:52,236 Speaker 1: out how to make this work and extending our capacity, 248 00:13:52,316 --> 00:13:55,596 Speaker 1: and everybody jumping in and filling roles that they may 249 00:13:55,636 --> 00:13:58,236 Speaker 1: not have otherwise filled. I think there was a lot 250 00:13:58,236 --> 00:14:00,356 Speaker 1: of energy around how do we, you know, kind of 251 00:14:00,356 --> 00:14:03,356 Speaker 1: step up to this moment that is unusual. I think 252 00:14:03,356 --> 00:14:05,436 Speaker 1: there was also sort of an element that was very 253 00:14:05,476 --> 00:14:07,276 Speaker 1: surreal the first time I was in an ICU and 254 00:14:07,316 --> 00:14:09,836 Speaker 1: all of a sudden, every single patient has a disease 255 00:14:10,356 --> 00:14:12,596 Speaker 1: that you know, we didn't know the name of a 256 00:14:12,596 --> 00:14:14,596 Speaker 1: few months ago. So I think there was an element 257 00:14:14,636 --> 00:14:19,276 Speaker 1: of feeling like it was hard to believe it was happening. 258 00:14:20,836 --> 00:14:23,716 Speaker 1: There was not a lot a lot of time necessarily 259 00:14:23,756 --> 00:14:25,876 Speaker 1: spent on rounds trying to figure out what was happening. 260 00:14:25,956 --> 00:14:29,156 Speaker 1: So I would say in general rounding in the intensive 261 00:14:29,156 --> 00:14:31,396 Speaker 1: care unit, one of the things that was noticeable is 262 00:14:31,436 --> 00:14:34,396 Speaker 1: that sort of took less time. Everybody was quite similar 263 00:14:34,636 --> 00:14:37,196 Speaker 1: in terms of what was wrong and the kinds of 264 00:14:37,196 --> 00:14:38,956 Speaker 1: decisions you were making, so there wasn't a lot of 265 00:14:38,996 --> 00:14:43,396 Speaker 1: diagnostic dilemma, which was unusual. And also, you know, I 266 00:14:43,436 --> 00:14:45,156 Speaker 1: think made things kind of go a little bit faster. 267 00:14:45,316 --> 00:14:47,396 Speaker 1: You would go around taking care of the patients making 268 00:14:47,476 --> 00:14:50,236 Speaker 1: kind of similar decisions. Examining people took a lot longer 269 00:14:50,276 --> 00:14:52,556 Speaker 1: because you were dealing with you know, gear that is 270 00:14:52,916 --> 00:14:54,836 Speaker 1: more time consuming to put on and take off and 271 00:14:54,996 --> 00:14:56,996 Speaker 1: figure out where to put everything and do things safely. 272 00:14:57,436 --> 00:14:59,756 Speaker 1: But the actual medicine I would say took less time, 273 00:14:59,796 --> 00:15:02,596 Speaker 1: both because most of the patients were similar in a 274 00:15:02,636 --> 00:15:06,516 Speaker 1: lot of ways, and also because families weren't there, and 275 00:15:06,556 --> 00:15:09,036 Speaker 1: the time that you would ordinarily take either on rounds 276 00:15:09,196 --> 00:15:12,196 Speaker 1: after rounds, to be talking to families and explaining things 277 00:15:12,676 --> 00:15:15,996 Speaker 1: you didn't have to take. I would say that is 278 00:15:15,996 --> 00:15:19,036 Speaker 1: a significant change for a whole lot of reasons. Does 279 00:15:19,036 --> 00:15:20,436 Speaker 1: it make it easier, I mean, I know it's not 280 00:15:20,516 --> 00:15:22,316 Speaker 1: great for the families, But does it make it easier 281 00:15:22,356 --> 00:15:24,356 Speaker 1: for the physicians through their jobs. Well, yes, so in 282 00:15:24,396 --> 00:15:28,556 Speaker 1: certain ways that made things sort of more streamlined. In 283 00:15:28,556 --> 00:15:31,876 Speaker 1: other ways, I think it's made things incredibly challenging a 284 00:15:31,876 --> 00:15:34,916 Speaker 1: lot of what we do as I see doctors, nurses, 285 00:15:35,036 --> 00:15:39,596 Speaker 1: other people who work in the ICU, is talking to families, 286 00:15:39,676 --> 00:15:43,636 Speaker 1: having conversations about what's important, what direction to take, a 287 00:15:43,636 --> 00:15:47,676 Speaker 1: lot of end of life discussions that are very, very challenging, 288 00:15:47,796 --> 00:15:51,276 Speaker 1: I think, to have over the phone, we rely a 289 00:15:51,276 --> 00:15:56,796 Speaker 1: lot on developing fairly quick rapport with families. In person, 290 00:15:57,276 --> 00:15:59,196 Speaker 1: we rely a lot on, or at least I should 291 00:15:59,196 --> 00:16:02,876 Speaker 1: speak for myself, I rely a lot on nonverbal communication 292 00:16:02,996 --> 00:16:05,636 Speaker 1: and things that are really challenging over the phone, and 293 00:16:05,636 --> 00:16:08,916 Speaker 1: I would say, particularly where they're language barriers, I would 294 00:16:08,916 --> 00:16:15,396 Speaker 1: say those conversations have been much more difficult for me, 295 00:16:15,596 --> 00:16:19,716 Speaker 1: certainly not being able to see families regularly in person. 296 00:16:20,076 --> 00:16:22,756 Speaker 1: We have had families come in when patients are approaching 297 00:16:22,836 --> 00:16:24,556 Speaker 1: or at the end of life, which I think has 298 00:16:24,556 --> 00:16:29,116 Speaker 1: been helpful. That ordinarily, when somebody is so sick, it's 299 00:16:29,156 --> 00:16:31,956 Speaker 1: an evolving process over a period of time and a 300 00:16:32,036 --> 00:16:36,516 Speaker 1: number of conversations that involves establishing trust and coming back 301 00:16:36,556 --> 00:16:39,756 Speaker 1: to things, and so that's been really really challenging, I 302 00:16:39,796 --> 00:16:42,476 Speaker 1: think not having families there regularly, and of course that's 303 00:16:42,476 --> 00:16:44,916 Speaker 1: something we do with some families can't for various reasons 304 00:16:45,396 --> 00:16:48,756 Speaker 1: or aren't in the ICU routinely when a loved one 305 00:16:48,796 --> 00:16:52,956 Speaker 1: is sick. But this is a fairly dramatic departure, having 306 00:16:53,076 --> 00:16:57,436 Speaker 1: very few family members present. What about your morale and 307 00:16:57,436 --> 00:16:59,836 Speaker 1: the moral of your colleagues. I mean, as you're describing 308 00:16:59,836 --> 00:17:01,996 Speaker 1: at the beginning, there's a lot of adrenaline and so 309 00:17:02,036 --> 00:17:04,396 Speaker 1: that in some sense takes care of the moral. You know, 310 00:17:04,436 --> 00:17:06,676 Speaker 1: what you have to do, the pressures on you do 311 00:17:06,756 --> 00:17:09,236 Speaker 1: it now that things are maybe by your description a 312 00:17:09,276 --> 00:17:13,596 Speaker 1: little bit more regularized or routinized, the how's your inner 313 00:17:13,996 --> 00:17:15,476 Speaker 1: experience of that, and what do you think about that 314 00:17:15,556 --> 00:17:21,876 Speaker 1: of your colleagues? Yeah, I think people are exhausted. I 315 00:17:21,916 --> 00:17:24,636 Speaker 1: think we also have no idea now sort of what 316 00:17:24,676 --> 00:17:26,716 Speaker 1: form this is going to take going forward. I think 317 00:17:26,796 --> 00:17:29,516 Speaker 1: it was you know, it has become clear that this 318 00:17:29,636 --> 00:17:34,116 Speaker 1: is not going away in any meaningful way anytime soon. 319 00:17:35,036 --> 00:17:37,596 Speaker 1: While there is certainly the numbers are down dramatically in 320 00:17:37,676 --> 00:17:39,956 Speaker 1: terms of the intensive care unit, you know, the number 321 00:17:39,996 --> 00:17:41,796 Speaker 1: of patients. As I said before, we have a lot 322 00:17:41,836 --> 00:17:44,116 Speaker 1: of patients who are still very sick in the hospital, 323 00:17:44,156 --> 00:17:48,036 Speaker 1: who are kind of living through the sequela of critical illness. 324 00:17:48,636 --> 00:17:50,636 Speaker 1: We don't know what's going to happen to the numbers, 325 00:17:50,956 --> 00:17:53,916 Speaker 1: you know, next month or in the fall or during 326 00:17:53,916 --> 00:17:58,156 Speaker 1: flu season. I think people are exhausted. There are many 327 00:17:58,196 --> 00:18:01,396 Speaker 1: ways in which this has been a very hard to 328 00:18:01,636 --> 00:18:04,796 Speaker 1: be a part of. I think the fact that this 329 00:18:05,036 --> 00:18:08,276 Speaker 1: that COVID has hit communities of color so much harder, 330 00:18:09,476 --> 00:18:12,676 Speaker 1: and you know, we're just watching person after person come 331 00:18:12,716 --> 00:18:15,316 Speaker 1: in incredibly sick. And you know, as I said before, 332 00:18:15,396 --> 00:18:17,156 Speaker 1: much of what we can do in the US supportive 333 00:18:17,196 --> 00:18:20,636 Speaker 1: care and time and patience and taking the best care 334 00:18:20,676 --> 00:18:22,276 Speaker 1: of people we can and seeing if they get better. 335 00:18:22,796 --> 00:18:26,156 Speaker 1: It's felt pretty relentless in terms of people coming in, 336 00:18:26,196 --> 00:18:29,156 Speaker 1: often from the similar communities. Often, you know, we've seen 337 00:18:29,276 --> 00:18:32,956 Speaker 1: multiple members of a family be critically ill. I think 338 00:18:33,036 --> 00:18:37,476 Speaker 1: it's you know, the scope of the tragedy of it is, 339 00:18:37,836 --> 00:18:41,196 Speaker 1: you know, demoralizing and exhausting and very sad. And I 340 00:18:41,236 --> 00:18:44,236 Speaker 1: think people are physically tired because this is hard work 341 00:18:44,276 --> 00:18:47,996 Speaker 1: and everybody's generally doing more of it than they typically would, 342 00:18:48,516 --> 00:18:53,556 Speaker 1: and also emotionally exhausted because we in this you know, 343 00:18:53,636 --> 00:18:56,516 Speaker 1: line of work, we see a lot of people die 344 00:18:56,596 --> 00:18:58,676 Speaker 1: in general. That's why we're used to But I think 345 00:18:59,476 --> 00:19:02,076 Speaker 1: all of this happening all at once in such large numbers. 346 00:19:02,236 --> 00:19:05,116 Speaker 1: I think has been really hard. I can certainly say 347 00:19:05,156 --> 00:19:09,556 Speaker 1: for myself personally, you know, the uncertainties of or where 348 00:19:09,556 --> 00:19:11,756 Speaker 1: it will go from here and what will happen and 349 00:19:11,796 --> 00:19:13,716 Speaker 1: when we be in the same position a few months 350 00:19:13,716 --> 00:19:20,636 Speaker 1: from now, it's just it's exhausting. If there's a second wave, 351 00:19:21,196 --> 00:19:22,876 Speaker 1: it sounds like from what you're saying that under the 352 00:19:22,876 --> 00:19:25,476 Speaker 1: standard of care, we're going to need a lot of ventilators. 353 00:19:26,196 --> 00:19:28,796 Speaker 1: Do you have the sense working in the hospital that 354 00:19:28,876 --> 00:19:31,476 Speaker 1: there will be enough should that occur? I mean, how 355 00:19:31,516 --> 00:19:34,596 Speaker 1: close to breaking point were you at, you know, one 356 00:19:34,636 --> 00:19:36,796 Speaker 1: of the great hospitals in the region and indeed in 357 00:19:36,796 --> 00:19:40,436 Speaker 1: the world. I would say we certainly, you know, we 358 00:19:40,596 --> 00:19:45,756 Speaker 1: extended our capacity many many fold. We did not get 359 00:19:45,796 --> 00:19:47,996 Speaker 1: close to the point where we were out of ventilators. 360 00:19:47,996 --> 00:19:49,596 Speaker 1: I think there was a period of time wherewith the 361 00:19:49,596 --> 00:19:53,116 Speaker 1: trajectory of cases, we were concerned that we might and 362 00:19:53,196 --> 00:19:56,476 Speaker 1: so I think in the end, I think because of 363 00:19:56,516 --> 00:19:58,876 Speaker 1: measures that were taken and people staying at home, things 364 00:19:58,916 --> 00:20:03,396 Speaker 1: flattened out enough that we fortunately avoided that. And I 365 00:20:03,396 --> 00:20:08,356 Speaker 1: would hope that now that that was a concern that 366 00:20:08,796 --> 00:20:10,916 Speaker 1: you know, an interim and you know, again I don't 367 00:20:10,956 --> 00:20:13,476 Speaker 1: have a I don't know anything more than you do 368 00:20:13,516 --> 00:20:15,316 Speaker 1: about whether there'll be a second wave, but I certainly 369 00:20:15,356 --> 00:20:18,556 Speaker 1: think people are concerned that there could be. I think 370 00:20:18,596 --> 00:20:21,316 Speaker 1: between all of the lessons we learned among all the 371 00:20:21,356 --> 00:20:25,996 Speaker 1: institutions about sort of balancing loads across hospitals, you know, 372 00:20:26,036 --> 00:20:29,436 Speaker 1: acquisition of new supplies, hopefully we would be and I 373 00:20:29,436 --> 00:20:31,556 Speaker 1: think we will be better prepared if there is a 374 00:20:31,596 --> 00:20:34,676 Speaker 1: second wave. And the answer to that question certainly depends 375 00:20:34,676 --> 00:20:37,876 Speaker 1: on how large a wave would there be. I think 376 00:20:37,876 --> 00:20:39,996 Speaker 1: if there is a second wave of the type that 377 00:20:40,036 --> 00:20:42,556 Speaker 1: we saw, we will be prepared for that. You know, 378 00:20:42,996 --> 00:20:45,596 Speaker 1: there's always a worst case scenario that you can imagine 379 00:20:45,636 --> 00:20:49,316 Speaker 1: that would still overwhelm capacity, but I would say we 380 00:20:49,476 --> 00:20:53,596 Speaker 1: ended up being pretty far from that. While we were, 381 00:20:53,596 --> 00:20:56,676 Speaker 1: you know, we're stretched in terms of our capacity, we 382 00:20:56,676 --> 00:21:00,676 Speaker 1: weren't near the breaking point. So hopefully that would be 383 00:21:00,756 --> 00:21:03,316 Speaker 1: even more true the next time around, because there's been 384 00:21:03,316 --> 00:21:06,636 Speaker 1: a lot of lessons learned about how to organize across 385 00:21:06,676 --> 00:21:09,356 Speaker 1: the system and extend capacity not just within a vidual 386 00:21:09,436 --> 00:21:13,396 Speaker 1: hospital but across the region and the state. So my 387 00:21:13,476 --> 00:21:17,956 Speaker 1: hope would be we would never get there in this pandemic. 388 00:21:18,356 --> 00:21:20,996 Speaker 1: But again, it depends on you know, there's always a 389 00:21:21,036 --> 00:21:24,196 Speaker 1: worst case scenario. You can imagine where we would get there. 390 00:21:25,796 --> 00:21:27,396 Speaker 1: What have I not asked you that I ought to 391 00:21:27,436 --> 00:21:30,596 Speaker 1: be asking you? I guess the thing to be asking 392 00:21:32,236 --> 00:21:34,996 Speaker 1: in some ways is sort of what are the issues? 393 00:21:35,556 --> 00:21:38,236 Speaker 1: You know? Kind of going forward? Right? We sort of 394 00:21:38,236 --> 00:21:42,236 Speaker 1: have dealt with this emergently and quickly, and everybody's done 395 00:21:42,276 --> 00:21:43,956 Speaker 1: the best they can. And I would say people have 396 00:21:43,956 --> 00:21:49,116 Speaker 1: done an incredible job of stepping forward and being innovative 397 00:21:49,116 --> 00:21:50,876 Speaker 1: and thinking about how do we best take care of people? 398 00:21:50,916 --> 00:21:52,556 Speaker 1: How do we learn as much as possible, how do 399 00:21:52,596 --> 00:21:56,676 Speaker 1: we change the whole way that we practice medicine in 400 00:21:56,716 --> 00:21:59,756 Speaker 1: a very quick period of time. And it's been incredible 401 00:21:59,876 --> 00:22:01,436 Speaker 1: to watch that. I think there are a lot of 402 00:22:01,516 --> 00:22:04,836 Speaker 1: challenges ahead, and one of them, you know, one of 403 00:22:04,876 --> 00:22:07,436 Speaker 1: the big ones I think has to do with how 404 00:22:07,436 --> 00:22:09,276 Speaker 1: do we take care? As I say before, we have 405 00:22:09,276 --> 00:22:11,956 Speaker 1: an exponentially larger number of patients who are going to 406 00:22:11,996 --> 00:22:15,756 Speaker 1: be dealing with the consequences of critical illness. People who 407 00:22:15,756 --> 00:22:18,516 Speaker 1: survive a prolonged period of critical illness generally do not 408 00:22:18,836 --> 00:22:22,516 Speaker 1: you bounce back immediately. And we now have a whole 409 00:22:22,516 --> 00:22:24,756 Speaker 1: lot of patients who have been incredibly sick, who will 410 00:22:24,796 --> 00:22:28,116 Speaker 1: be dealing with the consequences of that for a very 411 00:22:28,156 --> 00:22:32,076 Speaker 1: long time, whether it's being you know, in the hospital 412 00:22:32,116 --> 00:22:35,196 Speaker 1: now for many many more weeks, two months, being in 413 00:22:35,236 --> 00:22:38,956 Speaker 1: and out of rehabs or long term acute care hospitals. 414 00:22:38,956 --> 00:22:41,916 Speaker 1: How do we ensure that there's a frameworkingplace to take 415 00:22:41,956 --> 00:22:45,036 Speaker 1: care of those patients. That system was already very stretched 416 00:22:45,316 --> 00:22:47,716 Speaker 1: to begin with. It was often very hard to find 417 00:22:48,196 --> 00:22:51,916 Speaker 1: appropriate places for people to go following episodes of critical illness, 418 00:22:52,716 --> 00:22:56,996 Speaker 1: and that system will now be stretched even more, and 419 00:22:57,076 --> 00:22:58,996 Speaker 1: so I think a lot of the questions going forward 420 00:22:58,996 --> 00:23:01,876 Speaker 1: will be how do we do right by all of 421 00:23:01,876 --> 00:23:06,116 Speaker 1: these people who have been so sick. I think people 422 00:23:06,156 --> 00:23:08,756 Speaker 1: focus on do people leave the ICU, do people leave 423 00:23:08,796 --> 00:23:11,876 Speaker 1: the hospital? But there's a whole cascade of things that 424 00:23:11,916 --> 00:23:17,756 Speaker 1: happen after critical illness, both physical, psychological, financial, that I 425 00:23:17,796 --> 00:23:20,516 Speaker 1: think is sort of the next at least for my 426 00:23:21,196 --> 00:23:25,316 Speaker 1: subspecialty in terms of sort of ethical issues. I think 427 00:23:25,396 --> 00:23:27,756 Speaker 1: that becomes a huge issue is how do we take 428 00:23:27,796 --> 00:23:29,676 Speaker 1: care of the people who have been affected by this 429 00:23:29,796 --> 00:23:33,676 Speaker 1: going forward? And that's what I worry about a lot, 430 00:23:34,276 --> 00:23:36,516 Speaker 1: is how are we going to make sure that they're 431 00:23:36,636 --> 00:23:38,916 Speaker 1: taking care of, and recovery goes, you know, sort of 432 00:23:38,916 --> 00:23:42,716 Speaker 1: well beyond the hospital stay, and so how do we 433 00:23:42,796 --> 00:23:44,756 Speaker 1: make sure those people have access to the resources that 434 00:23:44,796 --> 00:23:48,156 Speaker 1: they need and that they can get back to their 435 00:23:48,356 --> 00:23:50,716 Speaker 1: lives if they're able to recover from the critical illness. 436 00:23:50,716 --> 00:23:52,676 Speaker 1: So I think, to me, that's sort of the big 437 00:23:52,716 --> 00:23:55,636 Speaker 1: thing to be thinking about from my standpoint, one of 438 00:23:55,676 --> 00:23:57,996 Speaker 1: the big things to be thinking about going forward. Thank 439 00:23:58,036 --> 00:24:00,076 Speaker 1: you so much for the work that you're doing. We're 440 00:24:00,196 --> 00:24:02,436 Speaker 1: very fortunate that there are people like you who've trained 441 00:24:02,636 --> 00:24:05,636 Speaker 1: in the things that turn out to be essential in 442 00:24:05,676 --> 00:24:07,996 Speaker 1: a crisis like this, and I want to thank you 443 00:24:08,036 --> 00:24:10,556 Speaker 1: for your analysis, for your candor, and also for the 444 00:24:10,636 --> 00:24:13,196 Speaker 1: extraordinary work you've been doing. Sure, thanks a lot. Thanks 445 00:24:13,236 --> 00:24:17,036 Speaker 1: for having me on speaking to doctor Emmy Rubin. I 446 00:24:17,156 --> 00:24:21,596 Speaker 1: was really struck at how the intense adrenaline driven struggle 447 00:24:21,676 --> 00:24:24,756 Speaker 1: of the early days of fighting the coronavirus pandemic in 448 00:24:24,836 --> 00:24:28,556 Speaker 1: her ICU sounds like it has slowly developed into something 449 00:24:28,636 --> 00:24:32,316 Speaker 1: like a new normal. On the one hand, that means 450 00:24:32,316 --> 00:24:35,076 Speaker 1: that the standard of care has to a certain extent solidified. 451 00:24:35,636 --> 00:24:39,596 Speaker 1: No longer are the physicians haphazardly trying every possible drug 452 00:24:39,636 --> 00:24:43,996 Speaker 1: in the hope that something will work. Instead, they're engaged informalized, 453 00:24:44,556 --> 00:24:49,316 Speaker 1: randomized clinical trials of different drugs. Yet simultaneously, it sounds 454 00:24:49,316 --> 00:24:51,756 Speaker 1: as though even remdesevere, the drug that has done best 455 00:24:51,796 --> 00:24:55,236 Speaker 1: so far in those trials, is not being experienced within 456 00:24:55,356 --> 00:24:57,916 Speaker 1: the hospital as any kind of a magic bullet, but 457 00:24:58,036 --> 00:25:00,916 Speaker 1: rather as a mild improvement for some patience, and possibly 458 00:25:01,196 --> 00:25:05,196 Speaker 1: not for the sickest patience who are still in the hospital. Meanwhile, 459 00:25:05,716 --> 00:25:07,916 Speaker 1: dealing with all of the suffering and all of the 460 00:25:07,996 --> 00:25:13,516 Speaker 1: death has been demoralizing and challenging for physicians and unquestionably 461 00:25:13,556 --> 00:25:18,036 Speaker 1: exhausting for them. Listening to doctor Ruben's description, one can 462 00:25:18,116 --> 00:25:21,516 Speaker 1: only hope that a slowing down in new cases gives 463 00:25:21,596 --> 00:25:24,716 Speaker 1: a break to the physicians in the ICUs who are 464 00:25:24,756 --> 00:25:29,516 Speaker 1: dealing with this extraordinarily challenging process of treatment. Because if 465 00:25:29,516 --> 00:25:31,516 Speaker 1: there is a second wave, we're going to be relying 466 00:25:31,556 --> 00:25:34,636 Speaker 1: on exactly the same set of physicians to go to 467 00:25:34,676 --> 00:25:39,116 Speaker 1: the front lines and do it all over again. We're 468 00:25:39,116 --> 00:25:43,036 Speaker 1: also going to need ventilators. Even though ventilators have not 469 00:25:43,156 --> 00:25:45,676 Speaker 1: been in the forefront of the news in recent weeks, 470 00:25:45,836 --> 00:25:47,876 Speaker 1: it turns out that that is not because they are 471 00:25:47,916 --> 00:25:52,036 Speaker 1: somehow less important to treatment than was originally thought. They're 472 00:25:52,076 --> 00:25:55,356 Speaker 1: just as significant to the basic treatment mechanisms. And again, 473 00:25:55,676 --> 00:25:57,996 Speaker 1: if we have a resurgence, we're going to be discussing 474 00:25:58,116 --> 00:26:02,756 Speaker 1: once more whether we have enough ventilators to treat everybody. 475 00:26:03,036 --> 00:26:05,276 Speaker 1: My final thought, and I've had it before in speaking 476 00:26:05,316 --> 00:26:09,756 Speaker 1: to frontline physicians on Deep Background, We're just extraordinarily fortunate 477 00:26:09,796 --> 00:26:12,996 Speaker 1: as a society to have people like doctor Reuben who 478 00:26:13,076 --> 00:26:16,236 Speaker 1: spent their whole careers preparing for moments like this one 479 00:26:16,556 --> 00:26:20,316 Speaker 1: without any knowledge that suddenly pulmonary care would be at 480 00:26:20,356 --> 00:26:24,516 Speaker 1: the forefront of our treatment of the global pandemic. We 481 00:26:24,596 --> 00:26:27,476 Speaker 1: are relying very heavily on a certain group of people 482 00:26:27,596 --> 00:26:30,796 Speaker 1: specialized knowledge right now. But the truth is that in 483 00:26:30,836 --> 00:26:34,076 Speaker 1: any crisis, some group of people who are properly trained 484 00:26:34,316 --> 00:26:36,876 Speaker 1: will rise to the foe and become the people we 485 00:26:37,276 --> 00:26:40,316 Speaker 1: depend on, and for that we can only be thankful. 486 00:26:41,196 --> 00:26:43,556 Speaker 1: Until the next time I speak to you, Be careful, 487 00:26:43,996 --> 00:26:49,756 Speaker 1: be safe, and be well. Deep Background is brought to 488 00:26:49,836 --> 00:26:53,316 Speaker 1: you by Pushkin Industries. Our producer is Lydia Jane Cott, 489 00:26:53,516 --> 00:26:56,676 Speaker 1: with research help from zooi Win and mastering by Jason 490 00:26:56,716 --> 00:27:01,396 Speaker 1: Gambrel and Martin Gonzalez. Our showrunner is Sophie mckibbon. Our 491 00:27:01,436 --> 00:27:04,596 Speaker 1: theme music is composed by Luis Guerra. Special thanks to 492 00:27:04,636 --> 00:27:08,276 Speaker 1: the Pushkin Brass, Malcolm Gladwell, Jacob Weisberg, and Mia Lobel. 493 00:27:09,116 --> 00:27:11,876 Speaker 1: I'm Noah Feldman. I also write a regular column for 494 00:27:11,996 --> 00:27:15,436 Speaker 1: Bloomberg Opinion, which you can find at Bloomberg dot com 495 00:27:15,436 --> 00:27:19,716 Speaker 1: slash Feldman. To discover Bloomberg's original slate of podcasts, go 496 00:27:19,796 --> 00:27:23,996 Speaker 1: to Bloomberg dot com slash podcasts. And one last thing, 497 00:27:24,476 --> 00:27:27,596 Speaker 1: I just wrote a book called The Arab Winter, a Tragedy. 498 00:27:27,996 --> 00:27:29,916 Speaker 1: I would be delighted if you checked it out. You 499 00:27:29,956 --> 00:27:31,596 Speaker 1: can always let me know what you think on Twitter 500 00:27:31,836 --> 00:27:34,796 Speaker 1: about this episode, or the book or anything else. My 501 00:27:34,876 --> 00:27:38,516 Speaker 1: handle is Noah R. Feldman. This is deep background