Speaker 1: From Pushkin Industries. This is Deep Background, the show where
Speaker 1: we explore the stories behind the stories in the news.
Speaker 1: I'm Noah Feldman. At the beginning of the COVID nineteen outbreak,
Speaker 1: we spent a lot of time thinking about the doctors,
Speaker 1: the frontline physicians who were fighting the disease in the hospital.
Speaker 1: As cases have begun slowly but surely to decline hebred
Speaker 1: Massachusetts and in other states, we thought it was a
Speaker 1: good time to revisit the frontline hospital doctors and the
Speaker 1: experiences that they've had treating patients in intensive care units.
Speaker 1: We wanted to know what their experience has been and
Speaker 1: how it's been changing over the last several months. We
Speaker 1: also wanted to know about the standard of care in
Speaker 1: the hospitals. It is coronavirus being treated now the same
Speaker 1: way that it was treated at the outset, or have
Speaker 1: there been signific developments in how physicians are encountering patients.
Speaker 1: To discuss these issues, we're joined by doctor Emmy Rubin.
Speaker 1: She's a critical care pulmonologist at Massachusetts General Hospital. She's
Speaker 1: been on the front line treating coronavirus patients from the beginning.
Speaker 1: She's also co chair of the hospital's Optimum Care Committee,
Speaker 1: which is essentially its leading ethics body for figuring out
Speaker 1: how to handle difficult ethical questions under circumstances exactly like
Speaker 1: the ones facing the hospital now. I asked doctor Rubin
Speaker 1: how things have changed in her ICU since March, So
Speaker 1: I would say, you know, in the beginning, when the
Speaker 1: cases were surging, Mass General was particularly hard hit. So
Speaker 1: in the early days, things were evolving very very quickly.
Speaker 1: We were extending our capacity in every way that we
Speaker 1: could very quickly by opening up new ICU spaces within
Speaker 1: the hospitspital adding staff, changing staffing models, and we got
Speaker 1: to the point where we had close to two hundred
Speaker 1: patients with COVID in our intensive care units. So I
Speaker 1: think in terms of how we individually took care of patients,
Speaker 1: we took care of them the way we would take
Speaker 1: care of any IU patient with respiratory failure. And I
Speaker 1: think we relied on what we know about the basic
Speaker 1: physiology of these patients, which is the vast majority of
Speaker 1: them and the intensive care units have what's called acute
Speaker 1: respiratory distress syndrome or AIRDS. That's something that all of
Speaker 1: us have a lot of experience taken care of, and
Speaker 1: we relied on basic principles of management, ventilator management in particular,
Speaker 1: which we know a lot about from other disease processes.
Speaker 1: So in many ways, taking care of individual patients was
Speaker 1: similar to how we take care of individual patients with
Speaker 1: the flu or airds from other conditions. What was not
Speaker 1: typical was obviously the volume of patients with one specific
Speaker 1: condition that months before we had not heard about. What
Speaker 1: was also different was the kinds of medications we were trying.
Speaker 1: At first we were using in the early days, we
Speaker 1: were using a lot of hydroxy chloroquin, a lot of statins.
Speaker 1: I think people were very quickly trialing things. I think
Speaker 1: there was a lot of desire among many people to
Speaker 1: try medications that might work, and has been widely reported.
Speaker 1: I think in the beginning we were using a lot
Speaker 1: of medications that have turned out to be of questionable benefit.
Speaker 1: As things have gone on, there are many many trials
Speaker 1: up and running at Mass General to look at randomized
Speaker 1: controlled trials at these medications and try to figure out
Speaker 1: what actually works and what doesn't. So I would say
Speaker 1: that early kind of enthusiasm for different medications has waned,
Speaker 1: and now really it's just taking care of intensive care
Speaker 1: unipatients with respiratory failure, but on a much larger scale.
Speaker 1: Let me ask you specifically about the what you described
Speaker 1: as your normal practice for people with RDS, which includes
Speaker 1: ventilators right. Has the way that you are treating COVID
Speaker 1: patients in that regard in terms of putting them on ventilators,
Speaker 1: who goes on ventilators at what stage? Remain constant or
Speaker 1: has that shifted? Because I know there was at least
Speaker 1: some public discussion sort of somewhere in April around the
Speaker 1: question of whether the ventilators were doing what they ought
Speaker 1: to be doing for COVID patients or whether it was
Speaker 1: plausible to think about other oxygen delivery systems. How has
Speaker 1: that evolved and are we back to sort of where
Speaker 1: we started in that regard. Yeah, I think an interesting question.
Speaker 1: I would say it may be that early on we
Speaker 1: may have had a lower threshold for putting people on ventilators.
Speaker 1: So one of the things we know about airds is
Speaker 1: that once people are on a ventilator, the mainstay of
Speaker 1: treating them on a ventilator is giving them relatively small
Speaker 1: breaths on the ventilator to prevent what we call ventilator
Speaker 1: induced lung injury. And there's a concern that if people
Speaker 1: with developing ards are breathing on their own and taking large,
Speaker 1: kind of gulping breaths for a long time and they
Speaker 1: end up needing to have a breathing machine anyway, that
Speaker 1: during the time they're breathing spontaneously, they may be doing
Speaker 1: damage to their lungs by taking large breaths and damaging
Speaker 1: certain portions of their lungs. I think in the beginning
Speaker 1: we may have had a slightly lower threshold for putting
Speaker 1: people on a breathing machine. In other words, when people
Speaker 1: seem to be taking a significant turn for the worse,
Speaker 1: we may have put them on a little bit earlier.
Speaker 1: But I would say in general, our management kind of
Speaker 1: adheres to traditional principles, which is, when somebody has respiratory
Speaker 1: failure and is not supporting their breathing, either not maintaining
Speaker 1: their oxygen levels or not getting rid of the carbon
Speaker 1: dioxide they're tiring out, we support their breathing with a ventilator.
Speaker 1: There has been a lot of attention to are we
Speaker 1: putting too many people on ventilators with COVID. I think
Speaker 1: I can speak for myself certainly and for many of
Speaker 1: my colleagues that we feel that you look clinically at
Speaker 1: the patient. If they seem like their breathing is failing,
Speaker 1: we put them on a breathing machine, the same way
Speaker 1: we would in any other situation. And how do you
Speaker 1: feel There must be some statistics on this, but there's
Speaker 1: also some imperfection in the statistical analysis. But how do
Speaker 1: you feel in terms of whether the standard of care
Speaker 1: that you're using is producing better outcomes at this stage
Speaker 1: than it was at the beginning, or really are people
Speaker 1: making it or not making it with the excellent treatment
Speaker 1: that you're giving them pretty much at the same rate
Speaker 1: as they were at the beginning. I realize there are
Speaker 1: many confounding factors that would be very hard to run
Speaker 1: a proper study on this or in movement. So I'm
Speaker 1: really asking you for an impressionistic response. Yeah, As you
Speaker 1: alluded to, the data has essentially all been imperfect because
Speaker 1: we don't have enough long term data on how people
Speaker 1: are doing. So most of the data about for survival
Speaker 1: to discharge, for example, or survival to hospital discharge was
Speaker 1: based on numbers that included a lot of people who
Speaker 1: were still in the ICU. So I think it is
Speaker 1: possible that early on, as they said before, we were
Speaker 1: having a slightly lower threshold to intubate people. So we
Speaker 1: saw a lot of people getting better, getting off the
Speaker 1: breathing machine and getting out of the ICU and in
Speaker 1: many cases leaving the hospital. Now we're seeing a lot
Speaker 1: of people who have required support for a longer period
Speaker 1: of time. We have a lot of patients now. This
Speaker 1: is one way in which things have changed is that
Speaker 1: many of the patients I would say, who remain in
Speaker 1: the intensive care units or in other parts of the
Speaker 1: hospital that are sort of stepped downs from the intensive
Speaker 1: PERI unit are people who we don't know how they'll
Speaker 1: how they'll do, whether they will survive, whether they will
Speaker 1: survived to leave the hospital, whether they'll be able to
Speaker 1: get successfully off of the VENTI later. So I think
Speaker 1: things have evolved in that respect that we anticipate that.
Speaker 1: You know, when we looked at our earlier percentages of
Speaker 1: people who had survived to hospital discharge, those were quite encouraging.
Speaker 1: We always expected those numbers to change and to sort
Speaker 1: of move more towards the numbers that we are familiar
Speaker 1: with for airds in general, and the mortality rate for
Speaker 1: airds in general is high. What's the ballpark for air
Speaker 1: ds in general non COVID airdas I think for moderate
Speaker 1: to severe airds there's about a forty percent mortality rate,
Speaker 1: and age is a predictor of mortality for airds in general.
Speaker 1: And so again that's a way in which we think
Speaker 1: that this will be quite similar. What's the longest that
Speaker 1: you've had people still beyond ventilators? I mean there must
Speaker 1: be people who came in in March. Yeah, are any
Speaker 1: of those people still on ventilators now? Yes, there are
Speaker 1: certainly people who came in March who are still needing
Speaker 1: ventilator supports. So typically, once somebody needs support for a
Speaker 1: certain period of time that is defined by sort of
Speaker 1: clinical judgment, but more than a couple of weeks generally,
Speaker 1: and we consider putting a trade gastome and which is
Speaker 1: a more durable, more comfortable form of a breathing tube,
Speaker 1: so that patients can receive mechanical ventilation for longer. There
Speaker 1: are many patients now who have had trade gustomes, some
Speaker 1: of whom will then be liberated from the ventilator once
Speaker 1: they have the trade gastomies. But there are certainly patients
Speaker 1: who have required many, many weeks of mechanical ventilation. Some
Speaker 1: of those patients will leave the hospital and go to
Speaker 1: sort of long term acute care hospitals even while they're
Speaker 1: still needing support. There are certainly patients in that category,
Speaker 1: and that is not unique to COVID. I think what
Speaker 1: is unique is the number of people. So when you
Speaker 1: start with ten times the number of people who you
Speaker 1: ordinarily have with AIRDS, you're going to have a huge
Speaker 1: number of people in the category of what we call
Speaker 1: chronic critical illness, where people require prolonged mechanical ventilation. It
Speaker 1: sounds like a remdesse of her which I finderstand correctly
Speaker 1: has been made available at least at MGH, is not
Speaker 1: having a transformative impact on the course of disease for
Speaker 1: most of the patients that you're seeing. I think, based
Speaker 1: on my understanding of the data, and I think in
Speaker 1: general this is a shared view, that it does have
Speaker 1: some effect, apparently on sort of time to recovery. I
Speaker 1: don't think there's a sense that it will be a
Speaker 1: game changer for the people who are the sickest. We
Speaker 1: are giving it and it is the only drug, as
Speaker 1: you I'm sure are aware that is now not formally
Speaker 1: approved but authorized use. So we are certainly giving it
Speaker 1: to patients who meet criteria for it. I think the
Speaker 1: patients who, for whatever reasons, are destined to become the sickest.
Speaker 1: I don't know that it will help prevent severe illness
Speaker 1: or deaf in those patients. There was, as you probably
Speaker 1: also know, a trend towards mortality in that in the trial,
Speaker 1: but it wasn't didn't meet technically the threshold for statistical significance,
Speaker 1: and I don't necessarily think we'll get answers to those questions.
Speaker 1: By the time we got round severe, we had a
Speaker 1: hospital full of people who were already, as I said,
Speaker 1: sort of very far advanced into the illness. I think
Speaker 1: we're very skeptical that it could help those patients. So
Speaker 1: I think we think that a certain subset of patients
Speaker 1: who get it early enough on the severity illness may
Speaker 1: be less, which is encouraging. It's encouraging to have something
Speaker 1: to use, but we still think that for certain patients
Speaker 1: this is a devastating illness and will be. And when
Speaker 1: Donald Trump informed us that he was taking hydroxy chloroquinn,
Speaker 1: one of the things that he said was that his
Speaker 1: impression was that lots of frontline medical workers were also
Speaker 1: taking it prophylactically in your anecdotal experience at MGH, Do
Speaker 1: you know anybody who's actually doing that at the stage,
Speaker 1: I cannot promise it's not happening. I do not know
Speaker 1: anyone that personally, to be perfectly honest, did it come
Speaker 1: up with people at the very beginning when it was
Speaker 1: being used. It didn't. I don't know that any of
Speaker 1: my friends and colleagues ever actually took it, but there
Speaker 1: were some people who mentioned early on that they would
Speaker 1: consider it when there was a lot of enthusiasm for it.
Speaker 1: Certainly not in recent days. And again I think it's
Speaker 1: you know, a lot of what we've seen, and I
Speaker 1: think it's human nature to want to do something for
Speaker 1: people who are so sick in front of you, So
Speaker 1: I don't. I think one of the things that's been
Speaker 1: very interesting and that sort of consistent with human nature,
Speaker 1: is that throughout the course of this the zeal to
Speaker 1: use things that sort of seem like they might plausibly help,
Speaker 1: or where there's a little bit of suggestion of it,
Speaker 1: like hydrox chloroquint at the beginning. I mean, that was
Speaker 1: very very thoughtful, smart people. We're using that and recommending
Speaker 1: using it at the beginning. I think that's just a
Speaker 1: testament to how much people want to find something to help.
Speaker 1: And I think, you know, hopefully now we've sort of
Speaker 1: regressed to the point where we're you know, I think
Speaker 1: most people are being much more measured about we need
Speaker 1: to study things in the context of trials and actually
Speaker 1: get evidence before using things. But you know, it's understandable.
Speaker 1: It's very hard to watch people sick and dying in
Speaker 1: front of you with nothing to do other than sort
Speaker 1: of supportive care, which really is the sort of mainstay
Speaker 1: of taking care of these people. That's something that you know,
Speaker 1: as I see, physicians were used to because there are
Speaker 1: many things that we don't have a specific magic bullet
Speaker 1: for and we take time and you know, try to
Speaker 1: have patience and try to get people through it with
Speaker 1: sort of the best supportive management we can. But it's hard.
Speaker 1: We'll be right back. How has the psychological experience of
Speaker 1: being a critical care physician been changing for you? At
Speaker 1: the beginning, it must have been just a bit overwhelming
Speaker 1: because of the radical numbers and the changes. I'm curious
Speaker 1: to know what it was like then, and also how
Speaker 1: it's evolving now. Yeah, it's a good question. I think
Speaker 1: at the beginning, first of all, I think, you know,
Speaker 1: there's a whole lot of adrenaline around sort of, you know,
Speaker 1: there always is when something is evolving so quickly. I
Speaker 1: think there was a lot of energy around everybody figuring
Speaker 1: out how to make this work and extending our capacity,
Speaker 1: and everybody jumping in and filling roles that they may
Speaker 1: not have otherwise filled. I think there was a lot
Speaker 1: of energy around how do we, you know, kind of
Speaker 1: step up to this moment that is unusual. I think
Speaker 1: there was also sort of an element that was very
Speaker 1: surreal the first time I was in an ICU and
Speaker 1: all of a sudden, every single patient has a disease
Speaker 1: that you know, we didn't know the name of a
Speaker 1: few months ago. So I think there was an element
Speaker 1: of feeling like it was hard to believe it was happening.
Speaker 1: There was not a lot a lot of time necessarily
Speaker 1: spent on rounds trying to figure out what was happening.
Speaker 1: So I would say in general rounding in the intensive
Speaker 1: care unit, one of the things that was noticeable is
Speaker 1: that sort of took less time. Everybody was quite similar
Speaker 1: in terms of what was wrong and the kinds of
Speaker 1: decisions you were making, so there wasn't a lot of
Speaker 1: diagnostic dilemma, which was unusual. And also, you know, I
Speaker 1: think made things kind of go a little bit faster.
Speaker 1: You would go around taking care of the patients making
Speaker 1: kind of similar decisions. Examining people took a lot longer
Speaker 1: because you were dealing with you know, gear that is
Speaker 1: more time consuming to put on and take off and
Speaker 1: figure out where to put everything and do things safely.
Speaker 1: But the actual medicine I would say took less time,
Speaker 1: both because most of the patients were similar in a
Speaker 1: lot of ways, and also because families weren't there, and
Speaker 1: the time that you would ordinarily take either on rounds
Speaker 1: after rounds, to be talking to families and explaining things
Speaker 1: you didn't have to take. I would say that is
Speaker 1: a significant change for a whole lot of reasons. Does
Speaker 1: it make it easier, I mean, I know it's not
Speaker 1: great for the families, But does it make it easier
Speaker 1: for the physicians through their jobs. Well, yes, so in
Speaker 1: certain ways that made things sort of more streamlined. In
Speaker 1: other ways, I think it's made things incredibly challenging a
Speaker 1: lot of what we do as I see doctors, nurses,
Speaker 1: other people who work in the ICU, is talking to families,
Speaker 1: having conversations about what's important, what direction to take, a
Speaker 1: lot of end of life discussions that are very, very challenging,
Speaker 1: I think, to have over the phone, we rely a
Speaker 1: lot on developing fairly quick rapport with families. In person,
Speaker 1: we rely a lot on, or at least I should
Speaker 1: speak for myself, I rely a lot on nonverbal communication
Speaker 1: and things that are really challenging over the phone, and
Speaker 1: I would say, particularly where they're language barriers, I would
Speaker 1: say those conversations have been much more difficult for me,
Speaker 1: certainly not being able to see families regularly in person.
Speaker 1: We have had families come in when patients are approaching
Speaker 1: or at the end of life, which I think has
Speaker 1: been helpful. That ordinarily, when somebody is so sick, it's
Speaker 1: an evolving process over a period of time and a
Speaker 1: number of conversations that involves establishing trust and coming back
Speaker 1: to things, and so that's been really really challenging, I
Speaker 1: think not having families there regularly, and of course that's
Speaker 1: something we do with some families can't for various reasons
Speaker 1: or aren't in the ICU routinely when a loved one
Speaker 1: is sick. But this is a fairly dramatic departure, having
Speaker 1: very few family members present. What about your morale and
Speaker 1: the moral of your colleagues. I mean, as you're describing
Speaker 1: at the beginning, there's a lot of adrenaline and so
Speaker 1: that in some sense takes care of the moral. You know,
Speaker 1: what you have to do, the pressures on you do
Speaker 1: it now that things are maybe by your description a
Speaker 1: little bit more regularized or routinized, the how's your inner
Speaker 1: experience of that, and what do you think about that
Speaker 1: of your colleagues? Yeah, I think people are exhausted. I
Speaker 1: think we also have no idea now sort of what
Speaker 1: form this is going to take going forward. I think
Speaker 1: it was you know, it has become clear that this
Speaker 1: is not going away in any meaningful way anytime soon.
Speaker 1: While there is certainly the numbers are down dramatically in
Speaker 1: terms of the intensive care unit, you know, the number
Speaker 1: of patients. As I said before, we have a lot
Speaker 1: of patients who are still very sick in the hospital,
Speaker 1: who are kind of living through the sequela of critical illness.
Speaker 1: We don't know what's going to happen to the numbers,
Speaker 1: you know, next month or in the fall or during
Speaker 1: flu season. I think people are exhausted. There are many
Speaker 1: ways in which this has been a very hard to
Speaker 1: be a part of. I think the fact that this
Speaker 1: that COVID has hit communities of color so much harder,
Speaker 1: and you know, we're just watching person after person come
Speaker 1: in incredibly sick. And you know, as I said before,
Speaker 1: much of what we can do in the US supportive
Speaker 1: care and time and patience and taking the best care
Speaker 1: of people we can and seeing if they get better.
Speaker 1: It's felt pretty relentless in terms of people coming in,
Speaker 1: often from the similar communities. Often, you know, we've seen
Speaker 1: multiple members of a family be critically ill. I think
Speaker 1: it's you know, the scope of the tragedy of it is,
Speaker 1: you know, demoralizing and exhausting and very sad. And I
Speaker 1: think people are physically tired because this is hard work
Speaker 1: and everybody's generally doing more of it than they typically would,
Speaker 1: and also emotionally exhausted because we in this you know,
Speaker 1: line of work, we see a lot of people die
Speaker 1: in general. That's why we're used to But I think
Speaker 1: all of this happening all at once in such large numbers.
Speaker 1: I think has been really hard. I can certainly say
Speaker 1: for myself personally, you know, the uncertainties of or where
Speaker 1: it will go from here and what will happen and
Speaker 1: when we be in the same position a few months
Speaker 1: from now, it's just it's exhausting. If there's a second wave,
Speaker 1: it sounds like from what you're saying that under the
Speaker 1: standard of care, we're going to need a lot of ventilators.
Speaker 1: Do you have the sense working in the hospital that
Speaker 1: there will be enough should that occur? I mean, how
Speaker 1: close to breaking point were you at, you know, one
Speaker 1: of the great hospitals in the region and indeed in
Speaker 1: the world. I would say we certainly, you know, we
Speaker 1: extended our capacity many many fold. We did not get
Speaker 1: close to the point where we were out of ventilators.
Speaker 1: I think there was a period of time wherewith the
Speaker 1: trajectory of cases, we were concerned that we might and
Speaker 1: so I think in the end, I think because of
Speaker 1: measures that were taken and people staying at home, things
Speaker 1: flattened out enough that we fortunately avoided that. And I
Speaker 1: would hope that now that that was a concern that
Speaker 1: you know, an interim and you know, again I don't
Speaker 1: have a I don't know anything more than you do
Speaker 1: about whether there'll be a second wave, but I certainly
Speaker 1: think people are concerned that there could be. I think
Speaker 1: between all of the lessons we learned among all the
Speaker 1: institutions about sort of balancing loads across hospitals, you know,
Speaker 1: acquisition of new supplies, hopefully we would be and I
Speaker 1: think we will be better prepared if there is a
Speaker 1: second wave. And the answer to that question certainly depends
Speaker 1: on how large a wave would there be. I think
Speaker 1: if there is a second wave of the type that
Speaker 1: we saw, we will be prepared for that. You know,
Speaker 1: there's always a worst case scenario that you can imagine
Speaker 1: that would still overwhelm capacity, but I would say we
Speaker 1: ended up being pretty far from that. While we were,
Speaker 1: you know, we're stretched in terms of our capacity, we
Speaker 1: weren't near the breaking point. So hopefully that would be
Speaker 1: even more true the next time around, because there's been
Speaker 1: a lot of lessons learned about how to organize across
Speaker 1: the system and extend capacity not just within a vidual
Speaker 1: hospital but across the region and the state. So my
Speaker 1: hope would be we would never get there in this pandemic.
Speaker 1: But again, it depends on you know, there's always a
Speaker 1: worst case scenario. You can imagine where we would get there.
Speaker 1: What have I not asked you that I ought to
Speaker 1: be asking you? I guess the thing to be asking
Speaker 1: in some ways is sort of what are the issues?
Speaker 1: You know? Kind of going forward? Right? We sort of
Speaker 1: have dealt with this emergently and quickly, and everybody's done
Speaker 1: the best they can. And I would say people have
Speaker 1: done an incredible job of stepping forward and being innovative
Speaker 1: and thinking about how do we best take care of people?
Speaker 1: How do we learn as much as possible, how do
Speaker 1: we change the whole way that we practice medicine in
Speaker 1: a very quick period of time. And it's been incredible
Speaker 1: to watch that. I think there are a lot of
Speaker 1: challenges ahead, and one of them, you know, one of
Speaker 1: the big ones I think has to do with how
Speaker 1: do we take care? As I say before, we have
Speaker 1: an exponentially larger number of patients who are going to
Speaker 1: be dealing with the consequences of critical illness. People who
Speaker 1: survive a prolonged period of critical illness generally do not
Speaker 1: you bounce back immediately. And we now have a whole
Speaker 1: lot of patients who have been incredibly sick, who will
Speaker 1: be dealing with the consequences of that for a very
Speaker 1: long time, whether it's being you know, in the hospital
Speaker 1: now for many many more weeks, two months, being in
Speaker 1: and out of rehabs or long term acute care hospitals.
Speaker 1: How do we ensure that there's a frameworkingplace to take
Speaker 1: care of those patients. That system was already very stretched
Speaker 1: to begin with. It was often very hard to find
Speaker 1: appropriate places for people to go following episodes of critical illness,
Speaker 1: and that system will now be stretched even more, and
Speaker 1: so I think a lot of the questions going forward
Speaker 1: will be how do we do right by all of
Speaker 1: these people who have been so sick. I think people
Speaker 1: focus on do people leave the ICU, do people leave
Speaker 1: the hospital? But there's a whole cascade of things that
Speaker 1: happen after critical illness, both physical, psychological, financial, that I
Speaker 1: think is sort of the next at least for my
Speaker 1: subspecialty in terms of sort of ethical issues. I think
Speaker 1: that becomes a huge issue is how do we take
Speaker 1: care of the people who have been affected by this
Speaker 1: going forward? And that's what I worry about a lot,
Speaker 1: is how are we going to make sure that they're
Speaker 1: taking care of, and recovery goes, you know, sort of
Speaker 1: well beyond the hospital stay, and so how do we
Speaker 1: make sure those people have access to the resources that
Speaker 1: they need and that they can get back to their
Speaker 1: lives if they're able to recover from the critical illness.
Speaker 1: So I think, to me, that's sort of the big
Speaker 1: thing to be thinking about from my standpoint, one of
Speaker 1: the big things to be thinking about going forward. Thank
Speaker 1: you so much for the work that you're doing. We're
Speaker 1: very fortunate that there are people like you who've trained
Speaker 1: in the things that turn out to be essential in
Speaker 1: a crisis like this, and I want to thank you
Speaker 1: for your analysis, for your candor, and also for the
Speaker 1: extraordinary work you've been doing. Sure, thanks a lot. Thanks
Speaker 1: for having me on speaking to doctor Emmy Rubin. I
Speaker 1: was really struck at how the intense adrenaline driven struggle
Speaker 1: of the early days of fighting the coronavirus pandemic in
Speaker 1: her ICU sounds like it has slowly developed into something
Speaker 1: like a new normal. On the one hand, that means
Speaker 1: that the standard of care has to a certain extent solidified.
Speaker 1: No longer are the physicians haphazardly trying every possible drug
Speaker 1: in the hope that something will work. Instead, they're engaged informalized,
Speaker 1: randomized clinical trials of different drugs. Yet simultaneously, it sounds
Speaker 1: as though even remdesevere, the drug that has done best
Speaker 1: so far in those trials, is not being experienced within
Speaker 1: the hospital as any kind of a magic bullet, but
Speaker 1: rather as a mild improvement for some patience, and possibly
Speaker 1: not for the sickest patience who are still in the hospital. Meanwhile,
Speaker 1: dealing with all of the suffering and all of the
Speaker 1: death has been demoralizing and challenging for physicians and unquestionably
Speaker 1: exhausting for them. Listening to doctor Ruben's description, one can
Speaker 1: only hope that a slowing down in new cases gives
Speaker 1: a break to the physicians in the ICUs who are
Speaker 1: dealing with this extraordinarily challenging process of treatment. Because if
Speaker 1: there is a second wave, we're going to be relying
Speaker 1: on exactly the same set of physicians to go to
Speaker 1: the front lines and do it all over again. We're
Speaker 1: also going to need ventilators. Even though ventilators have not
Speaker 1: been in the forefront of the news in recent weeks,
Speaker 1: it turns out that that is not because they are
Speaker 1: somehow less important to treatment than was originally thought. They're
Speaker 1: just as significant to the basic treatment mechanisms. And again,
Speaker 1: if we have a resurgence, we're going to be discussing
Speaker 1: once more whether we have enough ventilators to treat everybody.
Speaker 1: My final thought, and I've had it before in speaking
Speaker 1: to frontline physicians on Deep Background, We're just extraordinarily fortunate
Speaker 1: as a society to have people like doctor Reuben who
Speaker 1: spent their whole careers preparing for moments like this one
Speaker 1: without any knowledge that suddenly pulmonary care would be at
Speaker 1: the forefront of our treatment of the global pandemic. We
Speaker 1: are relying very heavily on a certain group of people
Speaker 1: specialized knowledge right now. But the truth is that in
Speaker 1: any crisis, some group of people who are properly trained
Speaker 1: will rise to the foe and become the people we
Speaker 1: depend on, and for that we can only be thankful.
Speaker 1: Until the next time I speak to you, Be careful,
Speaker 1: be safe, and be well. Deep Background is brought to
Speaker 1: you by Pushkin Industries. Our producer is Lydia Jane Cott,
Speaker 1: with research help from zooi Win and mastering by Jason
Speaker 1: Gambrel and Martin Gonzalez. Our showrunner is Sophie mckibbon. Our
Speaker 1: theme music is composed by Luis Guerra. Special thanks to
Speaker 1: the Pushkin Brass, Malcolm Gladwell, Jacob Weisberg, and Mia Lobel.
Speaker 1: I'm Noah Feldman. I also write a regular column for
Speaker 1: Bloomberg Opinion, which you can find at Bloomberg dot com
Speaker 1: slash Feldman. To discover Bloomberg's original slate of podcasts, go
Speaker 1: to Bloomberg dot com slash podcasts. And one last thing,
Speaker 1: I just wrote a book called The Arab Winter, a Tragedy.
Speaker 1: I would be delighted if you checked it out. You
Speaker 1: can always let me know what you think on Twitter
Speaker 1: about this episode, or the book or anything else. My
Speaker 1: handle is Noah R. Feldman. This is deep background