An Update From the Frontlines, With Dr Esther Choo

John Whyte, MD, MPH; Esther Choo, MD, MPH


May 13, 2020

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  • Emergency departments in Oregon are seeing a steady influx (neither up nor down) of patients with COVID-like illness—a sign of successful flattening of the curve.

  • The volume of non-COVID emergencies is down, which is a concern because treatment of such conditions should not be delayed.

  • The limited availability and uneven distribution of PPE is still a concern as physicians plan for an extended or unexpected surge.

  • Resuming business operations and social lives must be done in a smart and cautious manner.

This transcript has been edited for clarity.

John Whyte, MD, MPH: 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 Health & Science University. Dr Choo, thanks for joining me.

Esther Choo, MD, MPH: Thank you. It's good to be here.

Whyte: You're on the front lines in the emergency department (ED). What are you seeing?

Choo: Here in Oregon, where we've done a really great job of social distancing, we haven't experienced the big surge. 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; it's kind of consistently there.

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

I work at one of the two Level 1 trauma centers in our state, so trauma is really part of our bread and butter, and we've really seen that go down. It's not absent, certainly, but it has gone down.

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

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

Choo: That's the big question, right? Where are those entities? It's not like they got a notice that there's a COVID [pandemic] and so they're occurring less. 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 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 illness, morbidity, and death to be very quiet until much later.

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

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

You don't just build off your existing burnout. You have that surge of adrenaline when you're hitting a crisis, and I think there 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 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 there is something really inspiring about seeing what your colleagues bring to the table. 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 COVID, I think we're starting to see people cycle through the natural stages of dealing with a large-scale disaster, which is fatigue, ongoing fear, a lot of depression, and anxiety.

People are kind of hitting a wall in terms of that adrenaline. I think people are also very angry because of so much of what we see. There's a broad perception in [healthcare workers] that so much could have been handled better upfront and we wouldn't need to do this.

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

Choo: Nationally, we're simply not where we need to be. There have been tremendous grassroots efforts, and I think we've managed to plug many holes. I think the kinds of things that keep me awake at night thinking about PPE are just how thin that supply is, how we don't plan to be good for the duration. 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, we just plan our supply chains so that [we have them] for that moment but not much else. 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—it's just not sufficient for that kind of extended 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 of 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. You see that 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.

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

Choo: Yes. 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—when you don't have a data-driven, centralized, organized approach to manufacturing, procurement, distribution, there's almost no opportunity for equity.

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. And when you think about rural places or community health centers that are in more impoverished areas and that at baseline were struggling to make ends meet, how do they enter a competitive bidding war over overpriced PPE? How do they have the political leverage to get doses of remdesivir when it's in very short supply and the process for getting it is so not transparent or equitable?

Whyte: I want to talk about equity from a little bit of a different perspective. You've also 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?

Choo: I think it is. I mean, on the one hand, nothing is new, for sure. I think "exacerbating" is probably the right word. I think [this pandemic] makes it so much more obvious that it's happening. And it also shows very starkly to me what people's natural inclinations are.

When you have to pull something together fast, 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 "man-els." I think it's the most visible manifestation of this. How is it that for panel after panel, expert committee after committee—for COVID—when you need to scramble and pull together your A team, it's always a bunch of white guys?

Whyte: Smart white guys, but there are smart other people too.

Choo: Everyone has something to add. But we're not seeing everyone, which is my point. So it's not targeted against any one group. I'm just saying that you don't have a variety of voices.

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

Choo: First of all, we cannot say that this is something that we'll need to fix later because of this pandemic. COVID is not going anywhere, and so we can't wait for this to be over. When is that? Are we going to wait a couple of years until we've 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 put together with equity." We will not get it in things that matter unless we get it in every little thing.

Whyte: How is COVID impacting your community in Portland and communities more broadly?

Choo: We're struggling like everybody else to try to maintain best public health practices but also have compassion for the fact that businesses are stretched. Even where I work and my peers, we're very stressed about the financial hit to our institution.

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

And then in my local community, you know, I have four kids. I'm home with them a lot. I'm trying to figure out 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.

It's not binary. It's not "[don't] open" or "people die." I think there's smart reopening. And we need to really start defining the details around smart reopening.

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

Choo: I think very cautious reopening. And I don't just mean reopening in terms of businesses; people need to reopen their social lives in a smart way too. People should define their very close, immediate circles that they're going to open to, so that if later, if one person gets sick and you need to do contact tracing or figure out who needs to self-quarantine, that can be a very limited circle. So, not walking out of our homes and going straight into a 25-person block party or a family reunion, but really thinking of opening to a tight social circle and maintaining social distancing in that setting. Maintain masks and hand hygiene. Stay away if you have any sickness symptoms at all.

And then, just be prepared to pull back if community surveillance data show that it is not safe to actually start reopening our business and our social circles. Be prepared to go back. We're used to public health measures that turn on or turn off: We now recommend that everybody wears a seat belt or some other everyday practice, and then we forever continue in that way. For this, the right public health thing to do may change week to week. We're not used to doing that as a larger population or community, but that's the kind of thinking that we need to have. And it's a totally different mindset. It will take a lot of pulling together and communication.

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

Choo: I think that pretty much everybody I know in healthcare is operating at the top of their level when it comes to contributing to this, whatever the skillset is. I see educators stepping up to really get good information out. I see ultrasound specialists trying to figure out how they can apply their skills and knowledge to make the care better. I see people from every specialty stepping in to try to figure out one piece of the COVID puzzle, and people giving so much of their time and selves.

In a sustained effort, there's also this element of needing to step out for a time and recover, get some recovery and take care of themselves and their families.

And the nice thing is that when we all pull together as a community, 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 that this is taking on everybody, particularly those within healthcare, and they're creating these innovative and easily accessible resources.

So it's really wonderful to see what everybody is doing within their own domain. The way medical students have stepped up, creating free babysitting services for people on the frontline. They've been on the ground delivering PPE. I just created a volunteer research workforce that will deliver actionable knowledge to people who need it.

It's just incredible to see the effort. And I find that if the worries keep me up at night, when I get up in the morning and I need something for inspiration, it's all of that.

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

Choo: Thank you so much, John. I appreciate it.

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

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