'Our Job Is to Save as Many People as Possible,' ICU Doc Says

Abraham Verghese, MD; Angela J. Rogers, MD, MPH

Disclosures

April 02, 2020

This transcript has been edited for clarity.

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Abraham Verghese, MD: I'm delighted to be chatting with one of my wonderful colleagues, someone with a great reputation among our residents and the faculty. And just as an illustration of how pressing this new issue is that we're all dealing with, Angela has come straight from the ICU and was in the process of transferring a patient to ECMO [extracorporeal membrane oxygenation]. That's a word that I suspect that many, many people would not have even known of before. And now I think it's been in the lay press and people are more than aware of it.

So thank you again for joining us in such trying circumstances. I want to begin by simply asking, how are you doing? How are you coping with all of this?

Angela Rogers, MD: Thank you, Abraham, for inviting me. It's wonderful to get to talk to you. As you know, we work together training young doctors in the practice of medicine. In the ICU, I think a layperson would have the impression that it's a lot of machines that are taking over the work of keeping people alive, which is absolutely true. We're very lucky to have great technology that helps people when they're incredibly sick, to give them a chance to get better. But there is a very human side to the ICU as well, which is usually a lot of talking and reassuring patients and their families, and working very closely with the nursing staff and trainees to do everything we can for the sickest patients in the hospital. And it's true that the COVID pandemic has really heightened the situation for everyone, patients and caregivers alike. So I guess the short answer to your question is, I am doing okay.

It's such an honor to be a doctor. I feel that way all the time that it's wonderful to get to be involved in people's lives at their darkest moments, for patients and their families. It's such a privilege to get to care for them, and I feel that way very much now as well.

Many things are worse now already, even though in California we've been relatively spared. But I would still say I'm very much filled with gratitude to be at work. It is also more exhausting than usual, and there is a little bit of fear from the team about what's coming next.

Talking to people who practice in New York, where it's obviously overwhelming—they've had crushing numbers of patients coming in and really are starting to feel like they can't give their best care to everyone—we're very lucky that we're not there. I can only imagine what they're going through. But even what's happening here has been hard.

Verghese: For many of the physicians coming to Medscape, very much like for me, the ICU is a distant memory. We don't really have much occasion to wander in there anymore. But we've been talking with, for example, the dean of the Stanford Medical School, getting a sense of the institutional response and the stages in the getting ready and the lessons learned along the way. Tell us a little bit about why this disease should bring such focus on the ICU. And also what exactly you have had to learn and do in order to scale up or be ready for what might come next.

Rogers: What we're seeing is that although most people who get COVID-19 have fairly minor symptoms and do fairly well, there is a substantial portion of patients who get quite sick. Even if it's 1% or 2% of people who die, about 10% perhaps get quite sick, especially in the older age groups, and need intensive care. Usually we have plenty of capacity in the ICU at Stanford. I don't remember a time when the ICU was closed or nearly closed. We can usually feel very confident that we can care for more people. But the fear is not only that a number of people will have respiratory failure, but that they will have it for a long time. Some reports are suggesting up to 20 days on average in people who survive their ICU stay. If people are needing a ventilator for that long—if it's any substantial portion of the population—you could imagine very, very quickly running out of ICU space. I think that's why there's a great fear.

I have been in practice now for 15 years or so. Early on when I was a resident or medical student, patients were very sedated in the ICU, the families were not there very often. It was really a colder place than it is now. ICU has evolved in a wonderful way to really be open. Families are welcome anytime. We built this new hospital here at Stanford and every room has a seat that transforms into a couch. So when I was here in January, you would see families that were all here, supporting their loved one and were really involved. Patients were able to be quite awake. It was it was great.

And now with the restriction on visitors, what you find is that the patients are alone. We call the families every day and update them. But it's so different from the practice we've become used to in the ICU.

ARDS Course Is Different

Verghese: Angela, you happen to be an expert in ARDS, acute respiratory distress syndrome, and that seems to be the major reason that these patients are getting intubated. Tell us a little bit more about that. What's special about this virus and its tropism for the lungs?

Rogers: Apparently it uses the angiotensin receptor to gain entry into the lung cells themselves. But why the lungs go in the course that they do is unclear. Often patients with ARDS can bounce back fairly quickly, as long as you carefully ventilate with small tidal volumes, low pressure. In fact, in many of the people who die of ARDS, their lungs have healed but the problem is the rest of their body; their kidneys have failed or they had bad cancer or another infection that led to the ARDS.

Here it seems like we are seeing the opposite, that it's really about the lungs, at least in the early phase. Later there are issues with heart failure that we see as well. But early on, it's really the lungs out of proportion to the other things. And there are certain aspects that seem very different. The lung compliances seems to be quite good relative to the degree of hypoxemia. So there are ways that this syndrome of ARDS seems to be different from others.

Usually in our clinical practice, you feel confident about a lot of the therapies that you're considering. You know to do lung-protective ventilation, or you know to paralyze if they're really out of sync, or you know to use chlorhexidine or wake up your patient every day. There are things that we know that we should do in every ICU patient, but here with COVID-19 there are just a lot of things that we're all learning together. We're texting our friends at other institutions: "Have you had problems with mucus plugging? What are you guys doing with IL-6 levels? Are you checking ferritins?" We're learning on the fly.

And in the meantime, the families are all looking at the news. Even the patients themselves will be sitting there in the ICU on pretty high amounts of oxygen, and they're watching the news of COVID-19 and wondering what's coming for them. It's terribly scary for them. But then they'll ask, "Why aren't you giving me hydroxychloroquine? I was on the remdesivir trial. Now it's over. Which are you starting for me now?"

It's hard to explain that the data for a lot of these therapies are so preliminary. Our tendency in medicine is to try to do something rather than to wait. But there is a real risk of just throwing on therapies based on in vitro studies. That doesn't usually pan out well in medicine. So trying to do the right trials is so, so important. On the flipside, people don't really want to be in a placebo-controlled trial if they're hearing on the news that something might work great.

Fear in the Clinic

Verghese: Angela, I suspect that even though you've been in practice for 15 years, you probably missed the early days of HIV, which is a blessing for you.

How do you think that you and your colleagues and our residents are dealing with all of it? In many ways, this is much scarier than HIV for the physician because I think very early on, we became aware—even before we had a name for the virus that caused AIDS—we had reason to suspect that it was probably spread by blood and body fluids. We didn't feel quite as personally at risk. That's a big difference, but how do you think you and others are coping with the risk? How do you personally feel as you walk into the room, recognizing that you're at risk?

Rogers: You are right that I became a med student in 1997, well after it was established how you would become infected with HIV. But I have heard from others that those early days—especially, in San Francisco or New York City, where it was really blossoming early and you couldn't understand what was happening with your patients—that it was a similar degree of fear. And in those days, the physicians, the residents, and the trainees would draw the blood and it probably felt very frightening.

One thing about the COVID-19 pandemic is this feeling that it mostly is dangerous for older people. That is reassuring for younger trainees. But we have a patient on our service who is in his 30s. Rounding on him, you could see the faces of your trainees: Oh my goodness, this person is like us. There is no guarantee that if we get this illness that we won't get very, very sick too. It is frightening.

I do feel like my institution has my back and is really doing their best to help protect us with training and how to put on equipment safely. There's always this tension between, should we do the full bunny suit like they did in China vs are we really okay with the N95s? Is that enough? You hear about different changes in what level of protection we need and wonder if we are saying we need less protection because we're running out, or are we saying it's really safe? There's a lot of uncertainty. I'm not saying that specific to Stanford. Again, I think we are relatively lucky about the resources that we have and the training that we've had, but it is a frightening time.

You hear about different changes in what level of protection we need and wonder if we are saying we need less protection because we're running out, or are we saying it's really safe?

I see that all across the country. That's people's big fear. Are we doing enough to protect our healthcare workers? And certainly, when you hear about primary care doctors who can barely have one surgical mask for the day, it seems crazy that that would be an acceptable level of protection.

In terms of how do I feel? Most of the time, I feel very secure. We have a good plan for getting in and out of the rooms and taking care of patients. I have two young kids at home. So when I get home, I change right away and hop into the shower and wipe down my phone more than I've ever done before. Some people, when they go on the COVID surge teams, are wanting to stay in a hotel for the whole time, just to stay away from their families. As physicians, nurses, and respiratory therapists, all of us have taken an oath that we're going to care for patients and this is our job. But, obviously, our families didn't. If anything, that's probably the fear that people have more.

Verghese: How is your family coping with this very real sense of mom being at some risk?

Rogers: My kids are very reassured that I'm young enough; I'm going to be fine. I don't dwell on the fact that there are young people here too that are getting sick. They have seen that data and feel like I'm okay. What they see is that I'm working all the time and staying late, but I think they feel proud that I can do something to help patients and, to a certain extent, that by giving up their mom, they're doing their part too. There's a sense of pride in them about what's happening right now.

Adequate Training Is Essential

Verghese: To circle back to personal protection, even though it's commonplace for us to have to don garb for various kinds of precautions, to have to do this for almost everyone you see, especially everyone without a diagnosis, is challenging. You've taken the lead at Stanford with the residents, coaching how to properly don personal protective equipment (PPE). I imagine that there was a learning curve for you. Would you talk a little bit about that?

Rogers: Sure. We wear yellow gowns all the time for MRSA, for flu—that's another respiratory virus. You just slap on your yellow gown and do a quick handwash and go in. I have not heard of a fellow physician getting the flu from any of that and it didn't feel perilous to do that.

As I mentioned, now, with the coronavirus, a big question is what is enough protection? Certainly I would say that doing a very thorough education plan around correct donning and doffing is so important. I feel so much better now, having not only watched the CDC videos, which changed my practice, but then going through a one-on-one 40-minute session where I watched someone doff and we went through all the steps. And then she watched me doff and said, "Nope, you contaminated yourself there. No, you did it again."

It's not until you start going into the rooms that you realize, How am I going to use a stethoscope on this patient? Because I'm sticking the terribly bad-quality stethoscope that's in the room into my naked ear, is that clean enough? I wipe everything down.

But as an internist, the idea that I wouldn't listen to my patients on the ventilator just seems crazy. As internists, our procedure really is the physical exam and the history. So the degree to which it's difficult to be in common communication with your patient and to just pop in and say, "Oh, is their belly softer now? And their PIPs [peak inspiratory pressures] are higher. Are they wheezing?" It really is a decision to go into every room, in part because it's going to take a long time. And secondly, because you're spending PPE that might be needed a week from now, if things start to get worse.

Maximizing Ventilators

Verghese: The interesting thing about this epidemic—I mean, there's nothing about it that's not interesting, even as it's horrifying—is that the ventilator has become almost the focal point for all kinds of discussion. It harks back almost to the polio era when they had big halls full of people on iron lungs with the external breathing devices.

What are your thoughts on ventilators and increasing the capacity of ventilators by using one machine for two patients or other alternatives? At one level it's a fairly simple machine that blows air into the lungs, but obviously you can do much more with them.

Rogers: There is a widely circulating YouTube video that I've had emailed my way many times of someone explaining how you could potentially tie multiple ventilators together to use one machine for multiple people. And I believe that that was used in Las Vegas at the time of the mass shooting because they couldn't get more ventilators very quickly.

The problem is ARDS and the lung-stiffening syndrome that people have in coronavirus. People's lungs are really different, as you know. Early on when patients are very sick, someone may have stiff lungs, the other person has not as stiff lungs, and then one person coughs out a mucus plug and the other person doesn't. You can imagine that in Las Vegas, when you have a bunch of traumas but relatively healthy lungs, that that would be a lot safer to share a ventilator than especially early on in the phase of ARDS.

I know that in New York, they're already facing this idea of Do we need to start using one ventilator for two people? And maybe there would be a role for that later in the syndrome, for example, as people are starting to recover; they're still sleepy from their sedation, so their lungs are better, but it's other problems. Maybe at that point, you could imagine that that would be a way to stretch things.

Obviously, in desperate times, you would try anything. Our job is to save as many people as possible. But obviously it's a kind of worst-case scenario to have to get there.

We all really, really hope that the social distancing that everyone is doing works. It really seems like people are starting to take this seriously as you look around the country and see what's happening. We really obviously hope very much that we don't get there.

Verghese: I must say that some of our projections were that we would have a surge this week, and we still may well, but I think we're hoping that because we were a little earlier than most—this county especially but also the state—that perhaps we've warded that off.

Preparing in Community Hospitals

Verghese: I wonder if you would reflect on a hospital without some of the great advantages that we have—say, a hospital with no intensivist but with an ICU and two or three ventilators. If you have to advise a place like that, which has so far not faced the onslaught but will shortly, how do you even begin to prepare for something like that in a small community hospital?

Rogers: As you mentioned, Abraham, so far, we have had sort of a slow increase. We're expecting that we'll open a third ICU team, probably on Monday [March 30], as things are getting busier. So we have had a relatively slow amount of time.

For the past 2 weeks, I have spent at least 4 hours a day working on getting protocols in order, working on the donning and doffing training, figuring things out: "Okay, now we have a person who it's going to take 15 minutes potentially to get everyone in the room if there's an emergency. So given that, do we use slightly deeper sedation? Do we change certain practices?" those kind of things.

If you, right now, are in the luxurious situation where you don't have any of these patients and your community has been relatively spared, it's still critical right now to be getting started on your training. Really train your staff about how to use PPE, because for the first few days, before I did my in-person trainings, I was not being thorough enough with my handwashing. Again, I've been handwashing for 15 years. I was not doing it a full 20 seconds and doing the thumbs, doing the fingernails—really more like scrubbing into the OR is what we're being taught for our PPE. And the first few times I took off my mask and my N95, it kind of flipped and hit me in the nose, and that probably did me more harm than good. Or I didn't take a really deep breath and make sure I had no fogging on my glasses. Get that stuff right so that your staff knows how to protect themselves.

And it's not just the nurses and the respiratory therapists and the doctors. It's the x-ray techs who are going into the rooms. It's the housekeeping people who are coming in and taking out the trash. Everyone deserves an extremely thorough training. And that's just the PPE part of things.

But the second part is that there's an increasing body of literature from the places that are ahead of you that have protocols for what they're doing for proning, for example. Think about how it's different. We're taping stuff to get patients ready to prone so that nothing pops off when the patient is turned. Start reviewing those protocols from other institutions that are being made widely available. Get those adapted for your community setting so that when it happens, which it almost certainly will, you'll be ready and can give the best care for your patients.

Lasting Memories

Verghese: Angela, this has been a wonderful insight into the world of the ICU that I think our listeners will greatly appreciate. Also, it is important to hear from someone very thoughtful because I think the human experience of this, especially on the patient side, but to no small degree on the physician side, is so important. If you would share with us, what are two memories you have that you will take with you the rest of your life out of this experience so far?

Rogers: I guess one of the things I would say is that I am moved by the extent to which my colleagues are all stepping up to help these patients. I constantly see nurses rushing in to help the physician team. Again at Stanford, we're relatively lucky that we have a lot of people who aren't in ICU all the time and do a lot of research. So we have a number of physicians who are willing to step up and start staffing more ICUs; we have a plan to staff up to 100 extra ICU beds above our normal with all of these doctors who are just willing to step in and do it.

Obviously it will take a lot of nurses. It's a team effort, for sure. From the residents, there is no question in their minds about helping. If you ask, their answer is, "How can I help the fellows? What can I do? X, Y, and Z are canceled; I don't want to just sit home. I am a critical care physician. What can I do to help get us through this period?"

The first thing people should know is that we have an amazing profession. This audience is doctors. I'm proud to be one of you. I think we are doing an amazing job in this time.

I guess the second thing I would say is in terms of the patient experience. There are so many moments with patients who have COVID-19 that are very moving. I had a patient on my service this week who was quite young and quite ill with a lot of chronic medical problems and had come in with pneumonia. He was waking up from the ventilator. He was wanting to write, but he still had his breathing tube in so he couldn't rise. We untied him and he's writing and you can't really tell what he's saying—he's saying "community"? But what he was writing was "coronavirus," wondering if he had coronavirus. We said, "No, your coronavirus test was negative," and he just started to cry. He was sobbing. He was so happy. Even a patient critically ill in the ICU who has pneumonia and is on a vent—his big concern was "Is what I have coronavirus?" Things like that are really important—really being there with the patients. The families cannot be with them, so it really is again on us and the nurses to be the support system for our patients who are tremendously frightened of what's happening. Getting to be a physician in these times for our patients is such an honor, as is being a physician with our colleagues.

Verghese: Well, I would say that any patient who has you would be enormously lucky. Your humanity comes through even in this mechanism of a podcast, and more so in person. Thank you so much for being with us.

Angela, I wanted to ask you if, in the course of this, you've had moments where you've had to steel yourself. I wouldn't say a negative experience, but certainly something that you've had to overcome. We've talked about moments of great inspiration and joy, but have there been moments of the opposite nature?

Rogers: For me, the worst part has been the fear among fellow staff and physicians about whether the PPE is enough. Whether our country is sort of sending us in without adequate protection. In one online thread I read, someone said, "It feels like we're being sent into a war with pool noodles."

You look at the pictures in China. They have full protective gear and they're in completely isolated wards, and they go in for 4 hours and then they come out. It's much, much more intense. Is it really okay for us, in the outpatient setting, to be wearing a surgical mask? Is an N95 enough? Is it okay that my hair gets touched by a stethoscope? Does the country have our back? Why isn't the army coming in and making more ventilators if that's what is needed in New York? People are truly running out of PPE. Have we done everything we could to flood our healthcare workforce with protection? I would say that that, for me, has been the hardest thing.

And, early on, I think watching people not isolating. It was like you hear the drumbeats, and you are hearing from Italy that they're running out of ventilators and bagging patients. You're getting these boots-on-the-ground reports from the future, it feels like. Then you look online and you see that people are still at the beach, and you think, How can we help people listen?

For a lot of us—and I'm sure that that's true of your listeners who are physicians—I'd say that was the hardest part at the beginning: the feeling like we could save lives if everyone would stay home, but they're not. Then later, this feeling that the workforce isn't adequately protected by doing everything we can to really, really rapidly escalate the PPE if it's needed.

Verghese: Are there other things that you'd like to share with us? Any other special moments that have inspired you or tested you? Please don't wait for me to ask because I sense that you're just bursting with reactions to this unique time in our lives.

Rogers: For me overall, I feel like this is an amazing time to be a physician and in the ICUs. If people are being called to join the ICU team, which I think a lot of people in New York already are, you didn't do a full fellowship in intensive care. But I always tell my trainees that 90-plus percent of ICU is medicine. It's watching for heart failure; it's watching for kidney failure. You can learn the vents again. So anyone who has done an internship or a medicine residency and has been in the ICU a few times, or if you're willing to come back and help in the ICU, it's an amazing place to get to care for patients. You can get back up to speed on vents fairly quickly and really help to hopefully save lives. So please consider if you're in a specialty that's relatively underutilized right now—because a lot of places are locked down—consider helping in the places that you're needed most. It sounds scary, but it's really medicine, 90% of it. And then vents and pressors, which you can be taught by someone who's there to guide you. More hands are definitely better.

Verghese: I don't know if you know this, Angela, but I'm board certified in infectious disease but also in pulmonary medicine, although it was more infectious disease that had my interest. So I guess if I came to you, you would be able to show me the ropes again?

Rogers: I would love nothing more, Abraham, than for you to be on my team.

Verghese: It would be an honor. It's been amazing to have you with us, and I know that we literally took you out of the ICU after a very long day. We're the only thing standing in your way right now from seeing your family, so we're not going to keep you any longer.

Rogers: It's this conversation, and about 20 notes. Thank you for having me.

Abraham Verghese, MD, is a critically acclaimed best-selling author and a physician with an international reputation for his focus on healing in an era when technology often overwhelms the human side of medicine.

Angela Rogers, MD, is a critical care specialist with a particular interest in acute respiratory distress syndrome. She is active in teaching residents and fellows about critical care.

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