Coronavirus in Context: Successes and Challenges on the Front Lines

[MUSIC PLAYING]

You're watching Coronavirus in Context. I'm Dr. John Whyte, Chief Medical Officer at WebMD. I'm joined today by Dr. Esther Choo, an emergency medicine physician and associate professor at Oregon Science and Health University. Dr. Choo, thanks for joining me.

Thank you. It's good to be here.

You're on the front lines in the emergency room. What are you seeing?

Well, here in Oregon, where we've done a really great job of social distancing, we haven't experienced the big surge. But what we're experiencing is what we predicted would happen if you successfully flatten the curve, which is that we have this steady influx of patients with COVID-like illness. It doesn't go up. It doesn't really go down. But it's-- and it's kind of consistently there.

And then except for that, almost everything else has gone down in volume. So people aren't around, particularly because they're being so compliant with stay at home orders, and so they're not driving. They're not going out to socialize. And so there's a lot less trauma.

I work at, uh, one of the two level one trauma centers in our state, and so trauma is really part of our bread and butter, and we've really seen that go down. It's not absent, certainly. That's gone down.

And then almost everything else that we normally see-- I mean, true emergencies-- some things that maybe could be handled at home but people will come into the ED at some point for them. Everything else has really gone down, which is also a concern because many things shouldn't wait. And so--

Where are those heart attacks going? Where are those strokes going?

That's the big question, right? Where are those entities that-- that really, uh, you know-- it's not like they got a notice that it's COVID, and so they're occurring less. So there's a lot of-- you know, we do see cases that come in later on in their course than they otherwise would have, you know, appendicitis that has ruptured because people waited, things like that.

But what's more concerning is what we don't even see, and I think that will just come out in the data as we track, um, you know, vital statistics and start to see what is happening out there in homes. In Oregon, we have big stretches of rural areas, so it's possible for it to be very quiet, for illness morbidity and death to be very quiet, until much later.

What's been the mindset of your colleagues, both your physician colleagues and your nurse colleagues? You know, we were talking about burnout pre-COVID. What's the atmosphere like now for your colleagues in terms of, you know, emotionally and physically addressing this epidemic?

You know, I was just thinking that, how burnout was such a big issue before all of this stress. And, you know, uh, it's hard to remember now, but this was a very tough flu year. I remember in December and January thinking, wow, this is really-- people are really sick with influenza B. This is a tough flu year. And then-- and then we came into COVID.

I mean, I think there's a certain amount of-- you know, you don't just build off your existing burnout. I mean, I think people brought in a lot of-- you know, you have that-- that surge of adrenaline when you're hitting a crisis. And I think there actually has been something very uplifting about needing to pull together and seeing everybody bring their best to the table.

I think moments like those sometimes can make you appreciate your workplace and your colleagues in a way that you haven't been before that can be-- I don't want to say a positive experience because this has been so tragic to our entire country and to the entire world, but-- but there is something really inspiring about seeing what-- you know, what your colleagues bring to the table. Um, and I think that can really carry you through a lot.

But as this goes on and on and on and there's no end in sight in needing to deal with-- with COVID, I think we're starting to see people cycle through the natural stages of dealing with a-- you know, a large scale disaster, which is fatigue, ongoing fear, a lot of depression, anxiety.

People are kind of hitting a wall in terms of that adrenaline. And then, I think people are also very angry because so much of what we see. You know, I think there's just the broad perception in health that so much could have been handled better upfront, and we wouldn't need to do this.

Let's talk about that anger because you've been very active on social media. You were out early on saying, we don't have enough PPE. Where are we on the availability of PPE at most institutions, including your own?

Yeah. I mean, I think nationally, we're simply not where we need to be. There-- uh, there has been tremendous grassroots efforts, and I think we've managed to plug many holes. I think the kind of things that keep me awake at night thinking about PPE are just how-- you know, how thin that supply is, how we-- how we simply just-- we don't plan to be good for the duration, you know.

So it's not like we filled up for the year, and we're good now, you know. This is something where, even in the best of circumstances, um, we just plan our supply chains so that we're-- where it's on-- on demand for that moment but not much else. And so when you're trying to plan for a potential surge at some point-- we're talking about the second wave or maybe just this rolling wave that keeps on hitting places at different times. We're not plan-- we're not-- we're just not sufficient for that kind of extended or, you know-- or unexpected surge.

And then you add to that all of the corruption that's come into the process. I mean, everybody who could possibly make money off this is doing it. I thought maybe social pressure or goodwill would keep prices where they needed to be, but actually, without a coordinated and centralized process to this, there's so much corruption coming in. I mean, you see even places that are able to get PPE are paying so much more than they would in ordinary times. That is making it very tough for places that are not well resourced.

And is that contributing to anger as well when you see that from the part of practitioners?

Yeah. I mean, what really makes me feel sick-- it's anger and sadness-- is how in this kind of environment, when it comes to any type of supply, I mean, the PPE and all the other equipment and resources and medications, there-- when you don't have a data-driven, centralized, organized approach to manufacturing, you know, procurement distribution, whatever it is, there's almost no opportunity for equity.

And so, um, there-- you know, it really is the squeaky wheel, the voices, and the people and institutions that are well-connected and well-resourced that are going to get supply. Um, and-- you know, and when you think about rural places or, uh, community health centers that are, uh, in more impoverished areas that at baseline are struggling to make ends meet, how do they enter a competitive bidding war over overpriced PPE? You know, how do they have the political leverage to get doses of remdesivir when that's in very short supply and the process for getting it is so not transparent or-- or equitable? So, um--

I want to talk about equity maybe from a little bit of a different perspective. You've also, uh, tweeted about your concerns about sexism and racism in medicine. You've talked about sitting on tenure committees and how factors are determined as to whether one gets tenure or not. Is COVID-19 exacerbating sexism and racism in the medical community?

I-- I think it is. I mean, on the one hand, if you-- it's all, you know-- nothing has-- nothing is new for sure. I think exacerbating is probably the right word. I think it makes it so much more obvious that it's happening. And it also shows very starkly to me what people's natural inclinations are.

I mean, when you have to pull something together fast, you-- you turn to what's available to you and what instinctively feels right. And it is clear that when we pull together these task forces, these committees, these panels-- I mean, at every level, in the institution, nationally, I've never seen so many manels, I think is the most visible manifestation of this. It's like, how is it that, you know, panel after panel after expert committee after, um--

And now. It's now on COVID.

--for COVID-- how is it that when you need to scramble and pull together, you know, your A team-- how is that always a bunch of white guys? And I'm not saying that there aren't--

Hm? Smart white guys, but there are smart other people too.

Yeah. [INAUDIBLE] Everyone has something to add. But we're not seeing everyone, I guess is my point. So it's not-- you know, it's not targeted against any one group. I'm just saying, um, you don't have, uh-- you know, you don't have a variety of voices. I mean, clearly--

You're speaking out on that. How do we fix it, Dr. Choo?

I think people need to-- first of all, we cannot say this is something that we'll need to fix later. I mean, this-- this pandemic issue-- I mean, it-- COVID is not going anywhere, and so we can't wait for this to be over. When is that-- you know, are we going to wait a couple of years until we've really gotten a vaccine out there? Then, we can stop and talk about equity all over again?

It has to be an in the moment process. And I honestly think people have to make the commitment right now to say anything that I am a part of needs to be built-- um, put together with equity. Um, we will not get it in things that matter unless we get it in every little thing, you know.

And then how is COVID impacting your community in Portland and then communities broader?

Yeah. I mean, we're-- we're struggling like everybody else to try to maintain, you know, best public health practices but also have compassion for the fact that, um, you know, businesses are stretched. And, you know, even where I work and, you know, my peers, we're very stressed about the financial hit to our institution.

I think it's really making-- in terms of the health-- my local healthcare community, it's raising a lot of conversations about, you know, how in the future moving forward do we build a health system that is not so dependent, um, on, uh, so-called elective surgeries in order to maintain financial viability? How can we be creative about finding different types of healthcare that's also valued and compensated? Um, I think we'll see a lot of, uh, health system innovation coming out of this.

And then in my local community, you know, uh, I have four kids. I'm home with them a lot. [LAUGHTER] I'm trying to figure out how-- how-- you know, how school is going to happen, trying to figure out what are best practices in our communities so that we can have kids go to some summer activities or start to see their friends.

I think, you know, I'm-- it's not binary. It's not open or-- or people die. I think there's smart reopening. And we need to really start defining the details around smart reopening. Uh--

What would you say are some of those details? What comes to mind that we need to do?

I think very cautious reopening. And I don't just mean-- I mean, when you talk about reopening in terms of businesses, people need to reopen their social lives in a smart way too. So I think people should define their very close, immediate circles that they're going to open to, you know, so that if later, one person gets sick, you need to do contact tracing or figure out who needs to self quarantine, that can be a very limited circle. So I think, you know, not walking out of our homes and going straight into a 25 person block party or a family reunion but really thinking of open to a tight social circle--

Sure.

--and, uh, maintain social distancing in that setting. Maintain masks, hand hygiene. Stay away if you have any ill-- you know, sick symptoms at all. And then just be prepared to pull back if community surveillance data shows that-- that it is not safe to actually start reopening our business and our social circles. And just be prepared to go back.

I think we're used to public health measures that turn on or turn off, you know. We now recommend that everybody does x--

Mhm.

--a seat belt or doesn't, uh, do some sort of, you know, everyday practice. And then we forever continue in that way. I think-- I think for this, it has to be-- the right public health thing to do may change from week to week. We're not used to doing that as-- as a larger population or community, but that's the kind of-- uh, that's the kind of thinking that we need to have. And it's a totally different mindset. Uh, and, um-- and it will take a lot of, uh, pulling together and communication.

You talked about, what keeps you up at night. What are you optimistic about?

Well, I think, um-- I think that pretty much everybody I know in healthcare is-- is operating at the top of their level when it comes to contributing to this, whatever the skill set is. I see educators stepping up to really get good information out. I see ultrasound specialists trying to figure out, you know, how they can apply their skills and knowledge to-- um, to making the care better.

Um, I see, you know, people from every specialty sort of stepping in to try to figure out one piece of the COVID puzzle and people really giving so much of their time and selves. Um, you know, I-- I think there's also just this element of in a sustained effort, people need to step out for time-- you know, for a while at different times and just get, uh, recovery-- you know, get some recovery and take care of themselves and their families.

And the nice thing is that there is-- there is-- when we all pull together as a community, there's-- there's a deep bench, and people can step out and other people step in and support them. There's been a tremendous effort from our mental health community. Psychiatrists and psychologists are seeing the toll this is taking on everybody, particularly those within healthcare, and they're creating these really innovative and easily accessible resources.

So, um, really wonderful to see what everybody is doing, um, within their own domain. I mean, the way medical students have stepped up, created free babysitting services for people on the front line. They've been on the ground delivering PPE. I've been-- I just created a volunteer research, um, workforce that-- that will deliver actionable knowledge to people who need it. So, I mean, it's just incredible to see the effort. And-- and I find that, um, you know, I mean, if-- if the worries keep me up at night, when I get up in the morning and I need something for inspiration, it's, uh-- it's all of that.

Absolutely. Well, Dr. Esther Choo, I want to thank you for sharing your insights today.

Thank you so much, John. I appreciate it.

And I want to thank you for watching Coronavirus in Context. I'm Dr. John Whyte.