WEBVTT - On the Front Lines 0:00:20.836 --> 0:00:23.956 From Pushkin Industries. This is Deep Background, the show where 0:00:23.956 --> 0:00:26.916 we explore the stories behind the stories in the news. 0:00:27.636 --> 0:00:31.556 I'm Noah Feldman. At the beginning of the COVID nineteen outbreak, 0:00:31.876 --> 0:00:34.956 we spent a lot of time thinking about the doctors, 0:00:35.276 --> 0:00:37.996 the frontline physicians who were fighting the disease in the hospital. 0:00:38.476 --> 0:00:42.236 As cases have begun slowly but surely to decline hebred 0:00:42.316 --> 0:00:45.036 Massachusetts and in other states, we thought it was a 0:00:45.076 --> 0:00:48.596 good time to revisit the frontline hospital doctors and the 0:00:48.636 --> 0:00:53.156 experiences that they've had treating patients in intensive care units. 0:00:53.596 --> 0:00:55.836 We wanted to know what their experience has been and 0:00:55.916 --> 0:00:59.556 how it's been changing over the last several months. We 0:00:59.596 --> 0:01:01.916 also wanted to know about the standard of care in 0:01:01.956 --> 0:01:05.796 the hospitals. It is coronavirus being treated now the same 0:01:05.836 --> 0:01:08.356 way that it was treated at the outset, or have 0:01:08.436 --> 0:01:12.836 there been signific developments in how physicians are encountering patients. 0:01:13.556 --> 0:01:16.596 To discuss these issues, we're joined by doctor Emmy Rubin. 0:01:16.956 --> 0:01:21.036 She's a critical care pulmonologist at Massachusetts General Hospital. She's 0:01:21.036 --> 0:01:25.636 been on the front line treating coronavirus patients from the beginning. 0:01:26.116 --> 0:01:29.516 She's also co chair of the hospital's Optimum Care Committee, 0:01:29.716 --> 0:01:33.556 which is essentially its leading ethics body for figuring out 0:01:33.596 --> 0:01:38.196 how to handle difficult ethical questions under circumstances exactly like 0:01:38.316 --> 0:01:41.676 the ones facing the hospital now. I asked doctor Rubin 0:01:41.916 --> 0:01:48.756 how things have changed in her ICU since March, So 0:01:48.796 --> 0:01:51.636 I would say, you know, in the beginning, when the 0:01:51.716 --> 0:01:57.236 cases were surging, Mass General was particularly hard hit. So 0:01:57.316 --> 0:02:01.916 in the early days, things were evolving very very quickly. 0:02:02.396 --> 0:02:04.676 We were extending our capacity in every way that we 0:02:04.716 --> 0:02:08.596 could very quickly by opening up new ICU spaces within 0:02:08.716 --> 0:02:13.756 the hospitspital adding staff, changing staffing models, and we got 0:02:13.796 --> 0:02:16.316 to the point where we had close to two hundred 0:02:16.676 --> 0:02:20.516 patients with COVID in our intensive care units. So I 0:02:20.556 --> 0:02:24.076 think in terms of how we individually took care of patients, 0:02:24.956 --> 0:02:27.916 we took care of them the way we would take 0:02:27.916 --> 0:02:30.316 care of any IU patient with respiratory failure. And I 0:02:30.316 --> 0:02:33.556 think we relied on what we know about the basic 0:02:33.596 --> 0:02:37.076 physiology of these patients, which is the vast majority of 0:02:37.076 --> 0:02:39.396 them and the intensive care units have what's called acute 0:02:39.396 --> 0:02:43.316 respiratory distress syndrome or AIRDS. That's something that all of 0:02:43.396 --> 0:02:46.076 us have a lot of experience taken care of, and 0:02:46.596 --> 0:02:51.596 we relied on basic principles of management, ventilator management in particular, 0:02:51.956 --> 0:02:54.276 which we know a lot about from other disease processes. 0:02:54.436 --> 0:02:58.276 So in many ways, taking care of individual patients was 0:02:58.596 --> 0:03:01.396 similar to how we take care of individual patients with 0:03:01.636 --> 0:03:05.596 the flu or airds from other conditions. What was not 0:03:05.756 --> 0:03:11.196 typical was obviously the volume of patients with one specific 0:03:11.196 --> 0:03:14.156 condition that months before we had not heard about. What 0:03:14.276 --> 0:03:18.556 was also different was the kinds of medications we were trying. 0:03:18.556 --> 0:03:20.956 At first we were using in the early days, we 0:03:20.956 --> 0:03:25.236 were using a lot of hydroxy chloroquin, a lot of statins. 0:03:25.756 --> 0:03:30.036 I think people were very quickly trialing things. I think 0:03:30.076 --> 0:03:33.036 there was a lot of desire among many people to 0:03:33.156 --> 0:03:36.716 try medications that might work, and has been widely reported. 0:03:36.756 --> 0:03:38.316 I think in the beginning we were using a lot 0:03:38.396 --> 0:03:42.756 of medications that have turned out to be of questionable benefit. 0:03:43.316 --> 0:03:46.316 As things have gone on, there are many many trials 0:03:46.396 --> 0:03:49.596 up and running at Mass General to look at randomized 0:03:49.636 --> 0:03:52.476 controlled trials at these medications and try to figure out 0:03:52.516 --> 0:03:55.116 what actually works and what doesn't. So I would say 0:03:55.636 --> 0:03:59.676 that early kind of enthusiasm for different medications has waned, 0:04:00.236 --> 0:04:04.756 and now really it's just taking care of intensive care 0:04:04.836 --> 0:04:08.116 unipatients with respiratory failure, but on a much larger scale. 0:04:08.796 --> 0:04:12.076 Let me ask you specifically about the what you described 0:04:12.076 --> 0:04:16.356 as your normal practice for people with RDS, which includes 0:04:16.476 --> 0:04:20.796 ventilators right. Has the way that you are treating COVID 0:04:20.876 --> 0:04:23.996 patients in that regard in terms of putting them on ventilators, 0:04:24.036 --> 0:04:27.316 who goes on ventilators at what stage? Remain constant or 0:04:27.356 --> 0:04:29.516 has that shifted? Because I know there was at least 0:04:29.516 --> 0:04:33.756 some public discussion sort of somewhere in April around the 0:04:33.836 --> 0:04:36.836 question of whether the ventilators were doing what they ought 0:04:36.836 --> 0:04:38.836 to be doing for COVID patients or whether it was 0:04:38.876 --> 0:04:42.316 plausible to think about other oxygen delivery systems. How has 0:04:42.356 --> 0:04:44.476 that evolved and are we back to sort of where 0:04:44.476 --> 0:04:47.276 we started in that regard. Yeah, I think an interesting question. 0:04:47.316 --> 0:04:50.596 I would say it may be that early on we 0:04:50.676 --> 0:04:53.876 may have had a lower threshold for putting people on ventilators. 0:04:54.436 --> 0:04:57.116 So one of the things we know about airds is 0:04:57.116 --> 0:05:00.116 that once people are on a ventilator, the mainstay of 0:05:00.276 --> 0:05:04.516 treating them on a ventilator is giving them relatively small 0:05:04.556 --> 0:05:07.316 breaths on the ventilator to prevent what we call ventilator 0:05:07.356 --> 0:05:11.196 induced lung injury. And there's a concern that if people 0:05:11.196 --> 0:05:15.196 with developing ards are breathing on their own and taking large, 0:05:15.516 --> 0:05:18.116 kind of gulping breaths for a long time and they 0:05:18.236 --> 0:05:20.756 end up needing to have a breathing machine anyway, that 0:05:20.836 --> 0:05:23.396 during the time they're breathing spontaneously, they may be doing 0:05:23.476 --> 0:05:27.116 damage to their lungs by taking large breaths and damaging 0:05:27.156 --> 0:05:30.276 certain portions of their lungs. I think in the beginning 0:05:30.556 --> 0:05:33.676 we may have had a slightly lower threshold for putting 0:05:33.676 --> 0:05:36.116 people on a breathing machine. In other words, when people 0:05:36.156 --> 0:05:38.236 seem to be taking a significant turn for the worse, 0:05:38.396 --> 0:05:40.476 we may have put them on a little bit earlier. 0:05:41.156 --> 0:05:43.876 But I would say in general, our management kind of 0:05:43.876 --> 0:05:47.756 adheres to traditional principles, which is, when somebody has respiratory 0:05:47.756 --> 0:05:50.916 failure and is not supporting their breathing, either not maintaining 0:05:50.916 --> 0:05:53.676 their oxygen levels or not getting rid of the carbon 0:05:53.716 --> 0:05:58.476 dioxide they're tiring out, we support their breathing with a ventilator. 0:05:58.716 --> 0:06:01.276 There has been a lot of attention to are we 0:06:01.356 --> 0:06:05.036 putting too many people on ventilators with COVID. I think 0:06:05.116 --> 0:06:07.596 I can speak for myself certainly and for many of 0:06:07.596 --> 0:06:09.876 my colleagues that we feel that you look clinically at 0:06:09.876 --> 0:06:12.156 the patient. If they seem like their breathing is failing, 0:06:12.596 --> 0:06:15.276 we put them on a breathing machine, the same way 0:06:15.316 --> 0:06:19.156 we would in any other situation. And how do you 0:06:19.276 --> 0:06:21.716 feel There must be some statistics on this, but there's 0:06:21.756 --> 0:06:24.476 also some imperfection in the statistical analysis. But how do 0:06:24.516 --> 0:06:27.236 you feel in terms of whether the standard of care 0:06:27.236 --> 0:06:30.516 that you're using is producing better outcomes at this stage 0:06:30.556 --> 0:06:34.076 than it was at the beginning, or really are people 0:06:34.596 --> 0:06:36.916 making it or not making it with the excellent treatment 0:06:36.916 --> 0:06:39.236 that you're giving them pretty much at the same rate 0:06:39.276 --> 0:06:41.196 as they were at the beginning. I realize there are 0:06:41.196 --> 0:06:43.316 many confounding factors that would be very hard to run 0:06:43.356 --> 0:06:45.676 a proper study on this or in movement. So I'm 0:06:45.676 --> 0:06:48.716 really asking you for an impressionistic response. Yeah, As you 0:06:48.756 --> 0:06:52.436 alluded to, the data has essentially all been imperfect because 0:06:52.436 --> 0:06:55.036 we don't have enough long term data on how people 0:06:55.036 --> 0:06:58.036 are doing. So most of the data about for survival 0:06:58.356 --> 0:07:01.396 to discharge, for example, or survival to hospital discharge was 0:07:01.476 --> 0:07:03.876 based on numbers that included a lot of people who 0:07:03.916 --> 0:07:06.876 were still in the ICU. So I think it is 0:07:06.916 --> 0:07:09.556 possible that early on, as they said before, we were 0:07:09.596 --> 0:07:12.236 having a slightly lower threshold to intubate people. So we 0:07:12.276 --> 0:07:15.236 saw a lot of people getting better, getting off the 0:07:15.236 --> 0:07:17.316 breathing machine and getting out of the ICU and in 0:07:17.356 --> 0:07:20.796 many cases leaving the hospital. Now we're seeing a lot 0:07:20.796 --> 0:07:23.196 of people who have required support for a longer period 0:07:23.196 --> 0:07:25.276 of time. We have a lot of patients now. This 0:07:25.356 --> 0:07:27.236 is one way in which things have changed is that 0:07:27.516 --> 0:07:29.636 many of the patients I would say, who remain in 0:07:29.676 --> 0:07:31.876 the intensive care units or in other parts of the 0:07:31.916 --> 0:07:34.556 hospital that are sort of stepped downs from the intensive 0:07:34.556 --> 0:07:37.156 PERI unit are people who we don't know how they'll 0:07:37.276 --> 0:07:40.316 how they'll do, whether they will survive, whether they will 0:07:40.316 --> 0:07:43.316 survived to leave the hospital, whether they'll be able to 0:07:43.356 --> 0:07:47.196 get successfully off of the VENTI later. So I think 0:07:47.196 --> 0:07:50.556 things have evolved in that respect that we anticipate that. 0:07:50.796 --> 0:07:52.876 You know, when we looked at our earlier percentages of 0:07:52.876 --> 0:07:57.236 people who had survived to hospital discharge, those were quite encouraging. 0:07:57.436 --> 0:08:00.476 We always expected those numbers to change and to sort 0:08:00.476 --> 0:08:03.916 of move more towards the numbers that we are familiar 0:08:03.956 --> 0:08:06.276 with for airds in general, and the mortality rate for 0:08:06.316 --> 0:08:08.996 airds in general is high. What's the ballpark for air 0:08:09.156 --> 0:08:11.956 ds in general non COVID airdas I think for moderate 0:08:11.956 --> 0:08:15.036 to severe airds there's about a forty percent mortality rate, 0:08:15.156 --> 0:08:18.836 and age is a predictor of mortality for airds in general. 0:08:18.996 --> 0:08:21.036 And so again that's a way in which we think 0:08:21.076 --> 0:08:24.276 that this will be quite similar. What's the longest that 0:08:24.316 --> 0:08:27.476 you've had people still beyond ventilators? I mean there must 0:08:27.516 --> 0:08:30.596 be people who came in in March. Yeah, are any 0:08:30.636 --> 0:08:33.716 of those people still on ventilators now? Yes, there are 0:08:33.716 --> 0:08:35.956 certainly people who came in March who are still needing 0:08:36.116 --> 0:08:39.516 ventilator supports. So typically, once somebody needs support for a 0:08:39.556 --> 0:08:42.596 certain period of time that is defined by sort of 0:08:42.596 --> 0:08:45.116 clinical judgment, but more than a couple of weeks generally, 0:08:45.156 --> 0:08:47.436 and we consider putting a trade gastome and which is 0:08:47.436 --> 0:08:51.196 a more durable, more comfortable form of a breathing tube, 0:08:51.236 --> 0:08:54.996 so that patients can receive mechanical ventilation for longer. There 0:08:55.036 --> 0:08:58.076 are many patients now who have had trade gustomes, some 0:08:58.116 --> 0:09:00.116 of whom will then be liberated from the ventilator once 0:09:00.156 --> 0:09:02.116 they have the trade gastomies. But there are certainly patients 0:09:02.156 --> 0:09:05.396 who have required many, many weeks of mechanical ventilation. Some 0:09:05.436 --> 0:09:07.156 of those patients will leave the hospital and go to 0:09:07.196 --> 0:09:09.716 sort of long term acute care hospitals even while they're 0:09:09.716 --> 0:09:13.676 still needing support. There are certainly patients in that category, 0:09:14.036 --> 0:09:18.276 and that is not unique to COVID. I think what 0:09:18.436 --> 0:09:21.036 is unique is the number of people. So when you 0:09:21.076 --> 0:09:23.756 start with ten times the number of people who you 0:09:23.836 --> 0:09:27.356 ordinarily have with AIRDS, you're going to have a huge 0:09:27.436 --> 0:09:29.996 number of people in the category of what we call 0:09:30.236 --> 0:09:34.436 chronic critical illness, where people require prolonged mechanical ventilation. It 0:09:34.516 --> 0:09:37.276 sounds like a remdesse of her which I finderstand correctly 0:09:37.316 --> 0:09:40.476 has been made available at least at MGH, is not 0:09:40.596 --> 0:09:43.556 having a transformative impact on the course of disease for 0:09:43.676 --> 0:09:46.436 most of the patients that you're seeing. I think, based 0:09:46.436 --> 0:09:49.196 on my understanding of the data, and I think in 0:09:49.276 --> 0:09:52.236 general this is a shared view, that it does have 0:09:52.356 --> 0:09:56.716 some effect, apparently on sort of time to recovery. I 0:09:56.796 --> 0:09:59.436 don't think there's a sense that it will be a 0:09:59.476 --> 0:10:02.036 game changer for the people who are the sickest. We 0:10:02.116 --> 0:10:04.316 are giving it and it is the only drug, as 0:10:04.356 --> 0:10:07.596 you I'm sure are aware that is now not formally 0:10:07.636 --> 0:10:12.916 approved but authorized use. So we are certainly giving it 0:10:12.996 --> 0:10:17.596 to patients who meet criteria for it. I think the 0:10:17.636 --> 0:10:21.436 patients who, for whatever reasons, are destined to become the sickest. 0:10:21.556 --> 0:10:25.156 I don't know that it will help prevent severe illness 0:10:25.196 --> 0:10:28.276 or deaf in those patients. There was, as you probably 0:10:28.316 --> 0:10:31.396 also know, a trend towards mortality in that in the trial, 0:10:31.516 --> 0:10:35.836 but it wasn't didn't meet technically the threshold for statistical significance, 0:10:35.836 --> 0:10:38.796 and I don't necessarily think we'll get answers to those questions. 0:10:38.836 --> 0:10:41.116 By the time we got round severe, we had a 0:10:41.156 --> 0:10:43.596 hospital full of people who were already, as I said, 0:10:43.636 --> 0:10:46.036 sort of very far advanced into the illness. I think 0:10:46.036 --> 0:10:49.116 we're very skeptical that it could help those patients. So 0:10:49.156 --> 0:10:51.956 I think we think that a certain subset of patients 0:10:51.996 --> 0:10:55.436 who get it early enough on the severity illness may 0:10:55.436 --> 0:10:59.196 be less, which is encouraging. It's encouraging to have something 0:10:59.716 --> 0:11:03.556 to use, but we still think that for certain patients 0:11:03.596 --> 0:11:06.476 this is a devastating illness and will be. And when 0:11:06.556 --> 0:11:09.796 Donald Trump informed us that he was taking hydroxy chloroquinn, 0:11:10.316 --> 0:11:12.356 one of the things that he said was that his 0:11:12.436 --> 0:11:15.436 impression was that lots of frontline medical workers were also 0:11:15.556 --> 0:11:20.476 taking it prophylactically in your anecdotal experience at MGH, Do 0:11:20.556 --> 0:11:22.756 you know anybody who's actually doing that at the stage, 0:11:23.356 --> 0:11:25.356 I cannot promise it's not happening. I do not know 0:11:25.396 --> 0:11:28.996 anyone that personally, to be perfectly honest, did it come 0:11:29.076 --> 0:11:31.356 up with people at the very beginning when it was 0:11:31.396 --> 0:11:33.516 being used. It didn't. I don't know that any of 0:11:33.516 --> 0:11:36.516 my friends and colleagues ever actually took it, but there 0:11:36.516 --> 0:11:39.596 were some people who mentioned early on that they would 0:11:39.596 --> 0:11:42.236 consider it when there was a lot of enthusiasm for it. 0:11:42.316 --> 0:11:46.316 Certainly not in recent days. And again I think it's 0:11:47.156 --> 0:11:48.196 you know, a lot of what we've seen, and I 0:11:48.196 --> 0:11:51.036 think it's human nature to want to do something for 0:11:51.036 --> 0:11:52.796 people who are so sick in front of you, So 0:11:52.876 --> 0:11:55.116 I don't. I think one of the things that's been 0:11:55.196 --> 0:11:58.276 very interesting and that sort of consistent with human nature, 0:11:58.396 --> 0:12:01.996 is that throughout the course of this the zeal to 0:12:02.236 --> 0:12:05.836 use things that sort of seem like they might plausibly help, 0:12:05.916 --> 0:12:08.156 or where there's a little bit of suggestion of it, 0:12:08.436 --> 0:12:10.516 like hydrox chloroquint at the beginning. I mean, that was 0:12:10.676 --> 0:12:16.196 very very thoughtful, smart people. We're using that and recommending 0:12:16.276 --> 0:12:18.636 using it at the beginning. I think that's just a 0:12:18.636 --> 0:12:23.676 testament to how much people want to find something to help. 0:12:23.836 --> 0:12:26.836 And I think, you know, hopefully now we've sort of 0:12:26.836 --> 0:12:29.036 regressed to the point where we're you know, I think 0:12:29.116 --> 0:12:31.316 most people are being much more measured about we need 0:12:31.356 --> 0:12:34.916 to study things in the context of trials and actually 0:12:34.956 --> 0:12:38.596 get evidence before using things. But you know, it's understandable. 0:12:38.596 --> 0:12:41.756 It's very hard to watch people sick and dying in 0:12:41.756 --> 0:12:44.316 front of you with nothing to do other than sort 0:12:44.316 --> 0:12:46.916 of supportive care, which really is the sort of mainstay 0:12:46.916 --> 0:12:49.196 of taking care of these people. That's something that you know, 0:12:49.236 --> 0:12:52.036 as I see, physicians were used to because there are 0:12:52.036 --> 0:12:55.156 many things that we don't have a specific magic bullet 0:12:55.196 --> 0:12:58.836 for and we take time and you know, try to 0:12:58.876 --> 0:13:01.356 have patience and try to get people through it with 0:13:01.396 --> 0:13:04.476 sort of the best supportive management we can. But it's hard. 0:13:05.276 --> 0:13:18.276 We'll be right back. How has the psychological experience of 0:13:18.316 --> 0:13:21.596 being a critical care physician been changing for you? At 0:13:21.636 --> 0:13:24.876 the beginning, it must have been just a bit overwhelming 0:13:24.916 --> 0:13:28.796 because of the radical numbers and the changes. I'm curious 0:13:28.836 --> 0:13:30.916 to know what it was like then, and also how 0:13:30.916 --> 0:13:35.156 it's evolving now. Yeah, it's a good question. I think 0:13:35.156 --> 0:13:38.436 at the beginning, first of all, I think, you know, 0:13:38.436 --> 0:13:41.396 there's a whole lot of adrenaline around sort of, you know, 0:13:41.636 --> 0:13:45.036 there always is when something is evolving so quickly. I 0:13:45.076 --> 0:13:49.396 think there was a lot of energy around everybody figuring 0:13:49.396 --> 0:13:52.236 out how to make this work and extending our capacity, 0:13:52.316 --> 0:13:55.596 and everybody jumping in and filling roles that they may 0:13:55.636 --> 0:13:58.236 not have otherwise filled. I think there was a lot 0:13:58.236 --> 0:14:00.356 of energy around how do we, you know, kind of 0:14:00.356 --> 0:14:03.356 step up to this moment that is unusual. I think 0:14:03.356 --> 0:14:05.436 there was also sort of an element that was very 0:14:05.476 --> 0:14:07.276 surreal the first time I was in an ICU and 0:14:07.316 --> 0:14:09.836 all of a sudden, every single patient has a disease 0:14:10.356 --> 0:14:12.596 that you know, we didn't know the name of a 0:14:12.596 --> 0:14:14.596 few months ago. So I think there was an element 0:14:14.636 --> 0:14:19.276 of feeling like it was hard to believe it was happening. 0:14:20.836 --> 0:14:23.716 There was not a lot a lot of time necessarily 0:14:23.756 --> 0:14:25.876 spent on rounds trying to figure out what was happening. 0:14:25.956 --> 0:14:29.156 So I would say in general rounding in the intensive 0:14:29.156 --> 0:14:31.396 care unit, one of the things that was noticeable is 0:14:31.436 --> 0:14:34.396 that sort of took less time. Everybody was quite similar 0:14:34.636 --> 0:14:37.196 in terms of what was wrong and the kinds of 0:14:37.196 --> 0:14:38.956 decisions you were making, so there wasn't a lot of 0:14:38.996 --> 0:14:43.396 diagnostic dilemma, which was unusual. And also, you know, I 0:14:43.436 --> 0:14:45.156 think made things kind of go a little bit faster. 0:14:45.316 --> 0:14:47.396 You would go around taking care of the patients making 0:14:47.476 --> 0:14:50.236 kind of similar decisions. Examining people took a lot longer 0:14:50.276 --> 0:14:52.556 because you were dealing with you know, gear that is 0:14:52.916 --> 0:14:54.836 more time consuming to put on and take off and 0:14:54.996 --> 0:14:56.996 figure out where to put everything and do things safely. 0:14:57.436 --> 0:14:59.756 But the actual medicine I would say took less time, 0:14:59.796 --> 0:15:02.596 both because most of the patients were similar in a 0:15:02.636 --> 0:15:06.516 lot of ways, and also because families weren't there, and 0:15:06.556 --> 0:15:09.036 the time that you would ordinarily take either on rounds 0:15:09.196 --> 0:15:12.196 after rounds, to be talking to families and explaining things 0:15:12.676 --> 0:15:15.996 you didn't have to take. I would say that is 0:15:15.996 --> 0:15:19.036 a significant change for a whole lot of reasons. Does 0:15:19.036 --> 0:15:20.436 it make it easier, I mean, I know it's not 0:15:20.516 --> 0:15:22.316 great for the families, But does it make it easier 0:15:22.356 --> 0:15:24.356 for the physicians through their jobs. Well, yes, so in 0:15:24.396 --> 0:15:28.556 certain ways that made things sort of more streamlined. In 0:15:28.556 --> 0:15:31.876 other ways, I think it's made things incredibly challenging a 0:15:31.876 --> 0:15:34.916 lot of what we do as I see doctors, nurses, 0:15:35.036 --> 0:15:39.596 other people who work in the ICU, is talking to families, 0:15:39.676 --> 0:15:43.636 having conversations about what's important, what direction to take, a 0:15:43.636 --> 0:15:47.676 lot of end of life discussions that are very, very challenging, 0:15:47.796 --> 0:15:51.276 I think, to have over the phone, we rely a 0:15:51.276 --> 0:15:56.796 lot on developing fairly quick rapport with families. In person, 0:15:57.276 --> 0:15:59.196 we rely a lot on, or at least I should 0:15:59.196 --> 0:16:02.876 speak for myself, I rely a lot on nonverbal communication 0:16:02.996 --> 0:16:05.636 and things that are really challenging over the phone, and 0:16:05.636 --> 0:16:08.916 I would say, particularly where they're language barriers, I would 0:16:08.916 --> 0:16:15.396 say those conversations have been much more difficult for me, 0:16:15.596 --> 0:16:19.716 certainly not being able to see families regularly in person. 0:16:20.076 --> 0:16:22.756 We have had families come in when patients are approaching 0:16:22.836 --> 0:16:24.556 or at the end of life, which I think has 0:16:24.556 --> 0:16:29.116 been helpful. That ordinarily, when somebody is so sick, it's 0:16:29.156 --> 0:16:31.956 an evolving process over a period of time and a 0:16:32.036 --> 0:16:36.516 number of conversations that involves establishing trust and coming back 0:16:36.556 --> 0:16:39.756 to things, and so that's been really really challenging, I 0:16:39.796 --> 0:16:42.476 think not having families there regularly, and of course that's 0:16:42.476 --> 0:16:44.916 something we do with some families can't for various reasons 0:16:45.396 --> 0:16:48.756 or aren't in the ICU routinely when a loved one 0:16:48.796 --> 0:16:52.956 is sick. But this is a fairly dramatic departure, having 0:16:53.076 --> 0:16:57.436 very few family members present. What about your morale and 0:16:57.436 --> 0:16:59.836 the moral of your colleagues. I mean, as you're describing 0:16:59.836 --> 0:17:01.996 at the beginning, there's a lot of adrenaline and so 0:17:02.036 --> 0:17:04.396 that in some sense takes care of the moral. You know, 0:17:04.436 --> 0:17:06.676 what you have to do, the pressures on you do 0:17:06.756 --> 0:17:09.236 it now that things are maybe by your description a 0:17:09.276 --> 0:17:13.596 little bit more regularized or routinized, the how's your inner 0:17:13.996 --> 0:17:15.476 experience of that, and what do you think about that 0:17:15.556 --> 0:17:21.876 of your colleagues? Yeah, I think people are exhausted. I 0:17:21.916 --> 0:17:24.636 think we also have no idea now sort of what 0:17:24.676 --> 0:17:26.716 form this is going to take going forward. I think 0:17:26.796 --> 0:17:29.516 it was you know, it has become clear that this 0:17:29.636 --> 0:17:34.116 is not going away in any meaningful way anytime soon. 0:17:35.036 --> 0:17:37.596 While there is certainly the numbers are down dramatically in 0:17:37.676 --> 0:17:39.956 terms of the intensive care unit, you know, the number 0:17:39.996 --> 0:17:41.796 of patients. As I said before, we have a lot 0:17:41.836 --> 0:17:44.116 of patients who are still very sick in the hospital, 0:17:44.156 --> 0:17:48.036 who are kind of living through the sequela of critical illness. 0:17:48.636 --> 0:17:50.636 We don't know what's going to happen to the numbers, 0:17:50.956 --> 0:17:53.916 you know, next month or in the fall or during 0:17:53.916 --> 0:17:58.156 flu season. I think people are exhausted. There are many 0:17:58.196 --> 0:18:01.396 ways in which this has been a very hard to 0:18:01.636 --> 0:18:04.796 be a part of. I think the fact that this 0:18:05.036 --> 0:18:08.276 that COVID has hit communities of color so much harder, 0:18:09.476 --> 0:18:12.676 and you know, we're just watching person after person come 0:18:12.716 --> 0:18:15.316 in incredibly sick. And you know, as I said before, 0:18:15.396 --> 0:18:17.156 much of what we can do in the US supportive 0:18:17.196 --> 0:18:20.636 care and time and patience and taking the best care 0:18:20.676 --> 0:18:22.276 of people we can and seeing if they get better. 0:18:22.796 --> 0:18:26.156 It's felt pretty relentless in terms of people coming in, 0:18:26.196 --> 0:18:29.156 often from the similar communities. Often, you know, we've seen 0:18:29.276 --> 0:18:32.956 multiple members of a family be critically ill. I think 0:18:33.036 --> 0:18:37.476 it's you know, the scope of the tragedy of it is, 0:18:37.836 --> 0:18:41.196 you know, demoralizing and exhausting and very sad. And I 0:18:41.236 --> 0:18:44.236 think people are physically tired because this is hard work 0:18:44.276 --> 0:18:47.996 and everybody's generally doing more of it than they typically would, 0:18:48.516 --> 0:18:53.556 and also emotionally exhausted because we in this you know, 0:18:53.636 --> 0:18:56.516 line of work, we see a lot of people die 0:18:56.596 --> 0:18:58.676 in general. That's why we're used to But I think 0:18:59.476 --> 0:19:02.076 all of this happening all at once in such large numbers. 0:19:02.236 --> 0:19:05.116 I think has been really hard. I can certainly say 0:19:05.156 --> 0:19:09.556 for myself personally, you know, the uncertainties of or where 0:19:09.556 --> 0:19:11.756 it will go from here and what will happen and 0:19:11.796 --> 0:19:13.716 when we be in the same position a few months 0:19:13.716 --> 0:19:20.636 from now, it's just it's exhausting. If there's a second wave, 0:19:21.196 --> 0:19:22.876 it sounds like from what you're saying that under the 0:19:22.876 --> 0:19:25.476 standard of care, we're going to need a lot of ventilators. 0:19:26.196 --> 0:19:28.796 Do you have the sense working in the hospital that 0:19:28.876 --> 0:19:31.476 there will be enough should that occur? I mean, how 0:19:31.516 --> 0:19:34.596 close to breaking point were you at, you know, one 0:19:34.636 --> 0:19:36.796 of the great hospitals in the region and indeed in 0:19:36.796 --> 0:19:40.436 the world. I would say we certainly, you know, we 0:19:40.596 --> 0:19:45.756 extended our capacity many many fold. We did not get 0:19:45.796 --> 0:19:47.996 close to the point where we were out of ventilators. 0:19:47.996 --> 0:19:49.596 I think there was a period of time wherewith the 0:19:49.596 --> 0:19:53.116 trajectory of cases, we were concerned that we might and 0:19:53.196 --> 0:19:56.476 so I think in the end, I think because of 0:19:56.516 --> 0:19:58.876 measures that were taken and people staying at home, things 0:19:58.916 --> 0:20:03.396 flattened out enough that we fortunately avoided that. And I 0:20:03.396 --> 0:20:08.356 would hope that now that that was a concern that 0:20:08.796 --> 0:20:10.916 you know, an interim and you know, again I don't 0:20:10.956 --> 0:20:13.476 have a I don't know anything more than you do 0:20:13.516 --> 0:20:15.316 about whether there'll be a second wave, but I certainly 0:20:15.356 --> 0:20:18.556 think people are concerned that there could be. I think 0:20:18.596 --> 0:20:21.316 between all of the lessons we learned among all the 0:20:21.356 --> 0:20:25.996 institutions about sort of balancing loads across hospitals, you know, 0:20:26.036 --> 0:20:29.436 acquisition of new supplies, hopefully we would be and I 0:20:29.436 --> 0:20:31.556 think we will be better prepared if there is a 0:20:31.596 --> 0:20:34.676 second wave. And the answer to that question certainly depends 0:20:34.676 --> 0:20:37.876 on how large a wave would there be. I think 0:20:37.876 --> 0:20:39.996 if there is a second wave of the type that 0:20:40.036 --> 0:20:42.556 we saw, we will be prepared for that. You know, 0:20:42.996 --> 0:20:45.596 there's always a worst case scenario that you can imagine 0:20:45.636 --> 0:20:49.316 that would still overwhelm capacity, but I would say we 0:20:49.476 --> 0:20:53.596 ended up being pretty far from that. While we were, 0:20:53.596 --> 0:20:56.676 you know, we're stretched in terms of our capacity, we 0:20:56.676 --> 0:21:00.676 weren't near the breaking point. So hopefully that would be 0:21:00.756 --> 0:21:03.316 even more true the next time around, because there's been 0:21:03.316 --> 0:21:06.636 a lot of lessons learned about how to organize across 0:21:06.676 --> 0:21:09.356 the system and extend capacity not just within a vidual 0:21:09.436 --> 0:21:13.396 hospital but across the region and the state. So my 0:21:13.476 --> 0:21:17.956 hope would be we would never get there in this pandemic. 0:21:18.356 --> 0:21:20.996 But again, it depends on you know, there's always a 0:21:21.036 --> 0:21:24.196 worst case scenario. You can imagine where we would get there. 0:21:25.796 --> 0:21:27.396 What have I not asked you that I ought to 0:21:27.436 --> 0:21:30.596 be asking you? I guess the thing to be asking 0:21:32.236 --> 0:21:34.996 in some ways is sort of what are the issues? 0:21:35.556 --> 0:21:38.236 You know? Kind of going forward? Right? We sort of 0:21:38.236 --> 0:21:42.236 have dealt with this emergently and quickly, and everybody's done 0:21:42.276 --> 0:21:43.956 the best they can. And I would say people have 0:21:43.956 --> 0:21:49.116 done an incredible job of stepping forward and being innovative 0:21:49.116 --> 0:21:50.876 and thinking about how do we best take care of people? 0:21:50.916 --> 0:21:52.556 How do we learn as much as possible, how do 0:21:52.596 --> 0:21:56.676 we change the whole way that we practice medicine in 0:21:56.716 --> 0:21:59.756 a very quick period of time. And it's been incredible 0:21:59.876 --> 0:22:01.436