GA 311A | COVID-19 Q&A with Mark Graban, Dr. Greg Jacobson, and Dr. Mason Mileur

Hey folks, this is Ron Perera from Gemba Academy. Now, we have lots of Lean Thinking related podcasts scheduled and queued up to release every Thursday, including this coming Thursday or next Thursday, depending on when you're listening to this. But today we're releasing a special episode related to the coronavirus pandemic. Now, our friends over at Kinexus recently recorded a webinar called Ask Docs anything that featured Dr. Greg Jacobson and Dr. Mason Malure answering a series of questions related to COVID 19. Now, the webinar was hosted by my good friend Mark Graben, and Mark and the Kinexus team were kind enough to share the audio with us to release across our platform, so I definitely appreciate that. Now, the webinar runs a little over an hour and there's definitely lots to digest, but please try to work through it all. We're also going to link to a series of articles and videos that the Kynexis team and others, including GABA Academy and the TWI Institute, have published, and those will be linked on the Show Notes page, which can be found over@gembapodcast.com just look for episode 311A. Now I'm adding the letter A after 311 since episode 312 has already been edited and is queued to release next Thursday. So again, this is going to be GembaPodcast.com, this will be episode 311A. Finally, I recently saw a post from Mike Rother over on Twitter who suggested that we all practice a specific starter cauda, and the starter cauda is to assume you already have the virus. Now, I know that sounds a little morbid, but I feel like it's a good way to treat the situation. As such, if you did have the virus, you would for sure practice social distancing. You would for sure wash your hands for at least 20 seconds and you would definitely stay home if at all possible. And you also might want to assume that everywhere you go, people around you might have it. And so, you know, the other day I had to go run to the, to the grocery and I was about to run out of gas, so I had to get gas. I pulled up and I pumped my gas and you just don't realize how much stuff you touch when you're doing just everyday task like pumping your gas, so you grab the gas nozzle so that could have germs on it. You press the keypad, that could have germs on it. So what I did is I went ahead and I pumped my gas and then I put it back in and then I walked immediately into the gas station. Luckily, this gas station had those doors that open automatically, so I didn't have to touch a door. And they had a sink. So I went in there, I washed my hands for 20 seconds, and I immediately walked back out and got back into my car and went home. So maybe I'm overreacting. Maybe we don't need to be this intense. But I feel like it's better safe than sorry. So I really would ask everyone to be super, super careful. Take care of yourself, take care of your family, take care of your friends. And if you know any elderly people around, check in on them and make sure that they're okay and see if there's anything that you could do to help them. Okay? So again, show notes for this episode, GembaPodcast.com just look for episode 311A. Okay, enough from me. Let's get to the show.

Hi, everybody. Welcome. The webinar today, we're calling it Ask Docs Anything. I'm Mark Raven from Kynexis. We are joined today by two physicians who are going to answer questions that were all submitted yesterday. Many, many questions. A lot of overlap, but a lot of unique questions. We're going to focus a lot today on individual health, things that you can do in your home to look out for yourself and your family. So let me just introduce real briefly our two physician panelists. First off, Dr. Mason Milor. He's an internist in Austin, Texas. He's affiliated with St. David's Medical Center. He received his medical degree from the University of Texas Medical School and has been in practice for nearly 10 years. Then we're also joined by Dr. Greg Jacobson. He's an emergency medicine physician also in Austin. He is the CEO of Kinexus as well. He's been practicing for over 20 years and continues to practice. Today he received his medical degree from Baylor College of Medicine. With that, Greg has some introductory remarks before we get to the submitted questions.

Perfect. Thank you very much, Mark. I can't tell you how excited I am. I think over the weekend and as this has been progressing, I've tried to take my anxiety and frustration for lack of control of what we can and can't do and really turned it into this campaign of getting information out. I think this, the registration numbers that we've seen come through for this webinar really shows just how kind of the lack of information people have. And I realize that as physicians, we think everybody has access to a doctor.

Right?

Because we're doctors, but there's just a lot of people that don't have access to doctors. And so Mason and I wanted to kind of be that access. So we are your average internal medicine doctor. We're your average emergency medicine doctor. We both feel that society is not doing enough quickly with regard to physical distancing. And so you're gonna hear a lot about that today. We also feel that healthcare isn't responding quickly enough. I was just saying right before you got on, though, we're just starting to see some real leadership step up. And I think by Friday, we're gonna see all elective procedures everywhere be canceled. And so I'm really hopeful that as the days go on, we're gonna be changing our focus. Hopefully next week it's going to be how do we continue to educate our kids for the next several weeks or next several months, and how do we get food and whatnot. But I think today is the day that what we can all do right now is to talk to any person that you have a good relationship with and convince them of these things. And so one of the things I want to say is that Mason and I have done a lot of reading. I think we've probably done as much reading as the average physician out there. You know, it's really great. But the healthcare system is full of really passionate and really smart people. And we're just trying to collect the best information as it's coming out quickly. But we'll probably say some things today that we'll find out next week aren't true. So one of the things that Nathan and I talked about is we're going to try to give advice. I think the advice that we're going to give is going to be, first, do no harm, and then what is the disadvantage of doing this as advice? And so you're going to see us air towards that. So we're going to try to be thoughtful and we're going to try to give logical responses based on kind of basic science with the understanding that we don't know all of the basic science related to this virus. And we are really not going to focus too much on the economy. There's going to be devastating economic consequences. I think we could probably spend many, many days on that. I think those sorts of things we will have a lot of time kind of thinking through. I think right now our primary concern and realization is that if we don't do things now, then whatever economic effects are only going to just continue to be compounded by every minute, by every hour, by Every day that we're not doing anything. And so what we really want to do is try to answer some practical questions so you can figure out how you can start living your lives with this virus. I'll tell you, the outpouring of questions have been phenomenal. They've caused me to do some work last night with regard to the first question that we'll get to in a second. And they've caused me to do a lot of reading and really kind of think through, okay, well, if I'm in this situation, how would I handle it? So that's the preface and here we go. Mark, I'll.

So the first category of questions are going to be focused on individual health. The first one is I've heard a lot of conflicting information, especially online. Where should I go to fact check things related to COVID 19?

So I'm gonna. I'm gonna take this one, Mark. So we have created a resources document. The way I created the resources document is just all the best articles that I read over the last several weeks. I reached out to about 10 people in my network. Physicians, people in media, people that were spread across the country, and then people in different industries. So I tried to get a little bit of a sample size across the US and we are. We either have already published this. I don't know if Maggie and Danielle have done that yet, or we will be by the end of this webinar. But it'll have probably 20 to 30 different links where we think either the best current information or the best explanations that you can use to forward to your family and friends so they can understand a little bit about what's going on.

So currently there is a read only Google Doc. I've shared the link to that in the chat box of the control panel, and we'll get that published on the Connexus website as well.

I searched for that online resources and there was nothing quite that looked like something that I wanted to share with people. And so that's why we created it.

Okay, thanks.

So another person asked, what are the key differences between Coronavirus and flu? SARS, MERS, H1N1? Are things worse or are we just more connected and aware of diseases like this?

Mason, do you want to take a stab at that one?

Yeah, sure. So first of all, I would just say that we don't really know until we have all the data that blows through how bad this really stacks up historically against things like Spanish flu and SARS and all that. But I would say we know for sure that this is more lethal than the flu in terms of its fatality rate, that's for sure. And it also seems to be a little bit more contagious than the flu is as well.

Greg, is there anything you want to add to that?

I mean, I think to me, the important things are, is that at least from a mortality standpoint, correct me if I'm wrong, but I think we've already surpassed SARS and MERS at this point. And so to me, the way I would be thinking about this is that is that this is a less lethal disease than Ebola, but a lot more people are going to get it. And so it's going to affect us as a society more than what we've seen so far. Ebola affect us as a society. So that's kind of the way I'm wrapping my head around it.

Can you confirm the signs and symptoms that one would have when they need to seek medical advice? How soon do you need medical advice after noticing these? And if I become infected, how will I know if I need emergency care?

Mason, do you want to talk about it as an internal medicine doc and then I'll talk about it? Your doc?

Yeah. So my perspective is, from an internal medicine standpoint is most of my patients are Medicare agents. So they're obviously unjustifiably concerned about do they have these symptoms or not. And there's kind of the problem with this is that these symptoms are what we call non specific. In other words, they overlap with a lot of other illnesses that you can get. So it can make it difficult, but in general, it's the same thing. You've heard a cough and a fever. Some other ones that go along with that would be like fatigue. I think it's more, a little bit more constructive to think about. If you have symptoms that don't fall neatly into those categories, it usually will point to something else. And that's where it's important to talk to your doctor to get the full story.

So the way I would think about this is really in kind of three categories. You're going to have people that have the infection that are asymptomatic. And from my reading last night, the thought is that those people are much less contagious. Then you're gonna have people, and this is gonna be the vast majority of people with the illness. You're gonna have people that have a mild form of this disease. And it's thought that these people are the ones that are really spreading the disease, either when they're symptomatic or before they're symptomatic because there might be a period of two to 14 days when you have the disease. You're gonna be a symptomatic person, but you're spreading the disease. And that's why social distancing or physical distancing is important. And then the third category of people, which is the category of people that I worry the most about, are the people that are going to need healthcare intervention. And those people are going to need to either be hospitalized or they're going to need to be hospitalized, and then they're going to need an icu. And so as I'm thinking through this as an emergency medicine doctor, the thing that I think is the most important for everyone that's listening to this to understand is do not go to your emergency department to get a test if you are either asymptomatic. And you thought, oh, I just, you know, I just found out, you know, Shirley, that I just visited a couple days ago has now Covid. Or if you're mildly symptomatic, do not go. If you are interested in getting a test. I believe that our capacity to do drive through testing and remote testing, remote from away from healthcare delivery places is going to exponentially increase. So right now, it does not matter at all for your healthcare individually if you are tested or not. If you come into the emergency department with really severe symptoms, which I'll go over in a second, we're going to presumptively treat you as if you have this disease. In fact, if you're really, really, really sick, some of the ICU doctors are saying you will test negative when we test you because the virus has gone deep into the lungs. So it's not like we're going to say, oh, well, you're about to die, but you're COVID negative. So we're not going to treat you. So the healthcare system is going to treat you regardless of what the test shows. Okay, so when would I. And I'm going to talk about this as a healthy person and then I'd love to hear your thoughts about this. As an internal medicine doctor who treats people with a lot of comorbid conditions, to me, the biggest differentiator, because you think about the five biggest symptoms. You got headache, right? I mean, you've got a fever, you got sore throat, maybe some runny nose. You got a cough. So far I'm not really hearing anything right there that's going to kill you. The thing that's going to kill you is shortness of breath or you're really struggling to breathe. So I think if you start getting into that area, that's the time where you're needing to go to the emergency department. And so right now, it looks like a very small percentage of people that are less than the age of 40 or 50 are going to fit into that. But if you have a very, very small percentage of people, but you have a whole bunch of people that are going to get it, that unfortunately, is going to be a lot of people. So that would be my biggest kind of differentiator on when I should go or not. And then I think if I didn't know what to do, the last thing I would do is call 911 and say, come pick me up at any one. The last thing I would do is say, hey, get Granny in the car. We're going to the er. If you're the one with the symptoms, if Granny's the one with the symptoms, that's different. So I would go ahead and pick up the phone and call my pediatrician, my internal medicine doctor. And so let's hear what Mason has to say when he's picking up the phone or he's thinking through this. Right.

So when you're talking to your doctor, they're doing more than just listening to your symptoms. They're looking through your medical history, they looking at your medications or trying to come up with what's called a differential. What other things can this be besides the coronavirus? And I would just kind of add what Greg was saying there as far as if you fall in those first two categories and you don't have shortness of breath, the answer right now is stay home, call your doctor. Certainly that's fine. But there is absolutely no reason, if you're not having shortness of breath, to go to need to be tested, because all it's doing is satisfying a question that you have that is causing panic, and justifiably so. But the people that I worry about are the people with comorbid conditions that are over the age of 60 that have something that could result in a bad outcome. And so what I'm doing is I'm listening to see, do they have any of those other kind of symptoms that Greg just talked about that are potentially going to kill you? And that would be things like shortness of breath, chest pain, other things like that. What we're seeing, people with comorbid conditions, is that when you are exposed to the virus and then start fighting it off, one of two things kind of can happen, or both. One is the virus kind of takes over in a traditional Kind of pneumonia, not really pneumonia, but it causes an inflammatory response in your lungs, and then you start to experience a shortness of breath and things like that. But then the other thing in the process of fighting off the infection, it's not uncommon for you to have your other comorbid conditions start to really cause a problem for you. And the classic one really is like if you have heart failure or coronary artery disease and you have that stent in your heart and start having chest pain, it is absolutely possible for you to have a heart attack indirectly as a result of the COVID 19 virus. Not because the virus attacks your coronaries, but because it puts stress on your entire body. And you already have a problem with your heart and it makes it worse.

Can I add just a little bit to that before you go, Mark? So a couple of things I'm thinking about. Just a physician talking to you on the phone gives a wealth of information, right? So if you're able to complete all your sentences and multiple sentences before you take a deep breath in, I guarantee you Mason knows that's a very different kind of shortness of breath patient than one that's saying, I can't get my, you know. So those type of things, even if they're just audio clues, are super helpful to physicians. And as we get our increase into more video conferencing, we're going to be able to look at you and we're going to be able to tell in just a couple seconds, are you sick? And when I say sick here, I mean like the medical sick where you need to go to the hospital or are you the. I'm sorry, you're sick, you just are going to have to go through this illness with, you know, in your home and in your family. So those give just a wealth of information. And let's keep in mind that all of the normal disease processes that normally go on in the human population are going to continue for this. So COVID 19 does not, like, protect you against everything else going on in your life. I think probably the only thing it's going to protect against are like, sports injuries and other kind of traumatic injuries, because people will be in their house more and more on that later if it comes up. So keep in mind, I mean, I haven't heard there really doesn't appear to be any skin manifestations of this disease. There doesn't appear to be any vomiting and diarrheal illness does not appear to be part of this. Abdominal pain does not be a part of this. So those are all things that you might have something else going on that your physician on the phone can really help you sort through this probably pretty quickly.

So I'm going to jump in. We have a lot of questions to get through, so I'm going to play time cop and play the role of the audience to say, let's move on. But to summarize, if I've got concerns, I should call my doctor or send a message through my physician app. And then if I really. And then please summarize, when should somebody call the emergency room or go to the emergency room? When it gets held back?

I mean, to me, it really relates to shortness of breath. And that's. That's really hard to do. If you feel like you can understand what objective shortness of breath is, then, then that's when I would go. So if I was struggling to walk around my house normally, and I normally could walk around my house without ever having to stop and re catch my breath, if I am struggling to complete a sentence without having to stop and pause, if someone looks at you and says, man, it looks like you just feel like you're running right now. Do you feel short of breath? Like, what's going on? So I think if a person is breathing in their normal, calm way, then that is something they can definitely pick up the phone and talk to their primary care doctor and help sort through. I think if it's one of those things where, oh, I just went up five steps and that normally doesn't bother me at all, and now I'm on step three and I feel like I'm struggling for error, that's something I would think about heading on in. Is that a fair answer?

Definitely. It's always a good idea to call your doctor. That's what we're here for.

Someone else asked, I have asthma. You're talking about shortness of breath. And the COVID 19 symptoms are similar. Shortness of breath, dry cough. How can I be certain it's my Asthma and not COVID19?

That's a great question. Well, really, that's another perfect example of calling your doctor because we're trained to be able to distinguish between Covid essentially and asthma. And it really boils down to if we start hearing other symptoms that we know aren't necessarily associated with COVID and the big ones. When it comes to asthma, wheezing is probably the big one. If you have both wheezing and shortness of breath and you have a history of asthma and you ran out of your albuterol, I kind of put that in my mind together as we just need to get you some albuterol. Because just like Greg recently said here, shortness of breath is probably the number one am I really sick or not? Kind of question. And you can have other reasons to be short of breath. And so for me, I would say it's known history of asthma, because you're probably not going to suddenly develop asthma this week or next week if you've never had it before, known history of asthma, and you're on your normal medications, and so you haven't just stopped them or run out, and then now you're having wheezing or something like that. Triggers for asthma are numerous right now with the oak pollen off the charts here in Austin, allergies can trigger that. If you're indoors and stressed out and suddenly smoking more often, of course, tobacco smoke can trigger your asthma. Dust mites, you're around your pet more. I mean, any number of things can kind of trigger your asthma. And so that's where it's extremely important that you call your doctor. And even better, if they can arrange a telemedicine visit with some sort of visual cues so we can kind of look at you, too. And that can help us to distinguish. But I will say sometimes it can be kind of hard to tell the difference, even for us. And I will tell you, your physician will most often fall on the side of being more conservative and getting you to treatment. But it is very important that you let your doctor be the gatekeeper for you that you trust to know kind of what the next step is.

I just want to add one quick thing on that, because there is a lot of literature coming out that I'm sure most emergency medicine doctors know about. But you're gonna see us if you're coming in for an asthma exacerbation, because again, people are gonna have asthma exacerbations. COVID 19 doesn't protect against them. You're gonna see us not giving you nebulizers, because if it is COVID 19, we're just aerosolizing that into the room. You're gonna see us reaching for the metered dose inhalers, the MDIs, the little pumps. And there's actually good data that's been out there for many decades that those MDIs are as efficacious as nebulizers. So it's not that you're getting an inferior treatment. It's just you're going to be getting a slightly different treatment that's completely appropriate, and that's why it's happening. If you happen to Be an emergency medicine doctor and you're hearing this for the first time. Please read up on it. I think this is really important to keep our healthcare workers safe.

Okay, another question. What first aid supplies or over the counter medications should we have available in case we get infected?

I mean, to me, I'll go quickly here. Tylenol is going to be a really important one. I think that if you can, I just put on the resource a really nice video about how soap and water is even better than hand sanitizer. So if you don't have hand sanitizer, don't freak out. You probably have a bar of soap laying around. So that's really important. I think that if you have someone that's infected in your house, you're going to keep them isolated in one room, going in and out as little as possible, and then you're going to be wiping things down pretty frequently. So if you have ability to wipe down surfaces, you can make an easy diluted bleach solution if you don't have any other cleaning type supplies. So that would be my take, Mason.

I agree. I think Tylenol, I hate to almost mention it, it is a good fever reducer, but it doesn't actually treat coronavirus other than relieve a symptom. It's an important. You can get febrile seizures, especially if you have a child who has a fever. It's very important actually for children to get it, you know, so I would be. We don't really know what the supplies are going to look like for the next eight weeks. And so really if you can just kind of cool off, you know, put some ice under your arms, something like that, and you're able to kind of keep your temperature down okay. It's probably better just so that you can make sure to have Tylenol around. If you have a child, they're the ones that are really going to need it, or the elderly.

And then just the HWO just came out this morning formally was saying try not to use ibuprofen. So there's a concept in medicine called causation or correlation. And basically it means we don't know if ibuprofen is the cause of making your Covid illness worse or if it's just that people that have really bad COVID 19 illness reach for ibuprofen more. But I think either way it's probably the safest thing right now that there is this preliminary data and the HWO is recommending it. And you're not gonna, it's not gonna save you from the illness. Like Macy said, it's not, you know, it's not an antiviral. So it's probably best to lay off of ibuprofen if you get sick.

And to clarify, you mentioned Tylenol. In my own medicine cabinet, we've got different forms of Tylenol, cold and flu and different acetaminophen based pain reliever, slash antihistamines or if I have that. Right. So I mean, when you say Tylenol, do you mean that broadly, Mason?

Yeah, Tylenol being acetaminophen. That's what we're talking about. You do have to be careful. All these mixtures will have other medication in it. A lot of times phenylephrine is used in those Tylenol colds and flus. Same thing with Benadryl can be thrown into there as well. I don't, you know, just, just know what you're taking. Really, there's not a problem that we know of right now with Benadryl or phenylephrine in that setting because one of.

The keys is don't take regular Tylenol and then some other medication that also has acetaminophen. You don't want to over overdo it on acetaminophen.

Right?

Yeah. Remember your pain medication like Norco and things like that have Tylenol in it already. So if you're already taking pain medication chronically, then that has Tylenol in it, then you don't need to take an extra Tylenol.

What are your thoughts on a vaccine? If and when there is one, do you think there will be sufficient supply? I've heard we are six or 12 months from a vaccine. What's the latest that you've heard?

The latest I've heard. And then Mason, if you have anything that's more update, please Chime in. Is the phase one trials are underway. It's probably one of the quickest phase one trials in history. And realistically, we're not going to have a vaccine in the next several months. Typically, vaccines are going to be a 12 to 18 month type of situation. So maybe this goes quickly and it's six to 12 months. And obviously the ability to ramp up how much production we have is going to be exponential. And so I would think that the highest risk people in the community, so the elderly and people with comorbid conditions and healthcare workers are gonna be the first ones to get access to that. So what you can do right now is not worry about it. There are a whole bunch of really smart People working really, really, really fast to make a vaccine and just know that that's happening. That's my take.

And remember, the vaccine is not for this outbreak, it's going to be for the next. Prevent the second.

What can be done to improve your immune system?

Greg? Oh, me, I asked to take this one first because I just recently read a book that kind of blew my mind and it's why We Sleep by Matthew Walker. And if you, I mean, I'm serious, if you want your mind blown, you will read his book. He goes through all of the science forever, but really the science has just really increased in the last 20 years on the importance of sleeping. And they there's several, just amazing studies and I'll just touch on one real quick. But your response to the flu vaccine, meaning how good the flu vaccine will be in you, is significantly impacted by how much sleep you get before and after that vaccine. So if there isn't a better example of the fact that your immune system is really benefited by making sure you get ideally eight hours of sleep a night, but definitely don't drop below seven hours, then I don't know what would be. This is a great time to stop smoking because it's very clear that smoking, you have a much more severe illness with smoking. And obviously things that are also going to impact your immune system are going to be alcohol and sugar. So eating a good life, eating good, living a good life will obviously help. But I think the thing we can do literally tonight is to get as good of a sleep as you can. I'm the worst with it and everyone knows that it's something I struggle with. So I'm doing my best and I managed to get seven hours at least the last several nights and I'm going to push myself to get eight.

So there was a follow up question here about diet. It seems like diet really wouldn't have anything to do with this. This is about what you're inhaling or what gets in the virus droplets get into your body has nothing to do with food.

Well, I think eating well is going to help you if that's what you're asking. I think if you are asking if someone sneezes all over your food and they have COVID 19 and you eat it, you're likely going to get it. So if that's what you're asking, but certainly the best thing you can do, and I was just answering the immune system situation, but the best thing you can do is simply not get in contact with the virus. And the best way not to get in contact with the virus is to decrease your physical distancing. So I felt like the question was aimed at other things versus the thing that we're going to talk the most about. And then I will say, and Mason, I don't think we talked about it yesterday, but I did find an article. I have no idea the validity of any of this, but it's all on the resources page, where a doctor who writes fairly eloquently not only goes through the entire epidemic, all the science, but does talk a little bit about kind of vitamins and other more natural remedies that may or may not help. I have no idea what the validity to do it is, but if people are looking for that, there's a resource in there that is fairly well written. So.

And I guess if anyone's got very particular, specific questions about their own diet or condition, contact your own doctor. Another question. Can you get immunity from having COVID 19. Can you test a person to see if they have immunity?

Well, every time you are exposed to any infection, bacterial, viral in particular, the way your body fights that off is by creating antibodies. And then that's what clears out the infection. So in a sense, yeah, you will be immune to that exact strain. The question that we don't know the answer to right now is for how long and to what extent? In other words, what viral load could your body fight off with the antibodies that it has floating around in its system from your last infection? So it's the same concept as if you got vaccinated. Your body makes antibodies, which then reduces your chance of getting the illness. I mean, you can even look at the influenza vaccination. It's not so much about fermenting infection. At best, you can hope for about a 50% resistance from a great flu vaccination. Last year, I think it was down to something like less than 10% effective resistance. But what it did was it reduced your severity and duration of symptoms. And so I have a feeling that that's probably how we could probably expect the corona virus virus vaccination to work would be. It would probably not make you 100% immune. When you say immune, a lot of people think that means it's impossible for me to get it. And that's really not what we're talking about. It's reducing the chances in a population for it to exponentially grow.

Okay, next question. What kind of treatments are available to those who are effective?

From an emergency medicine standpoint, this is what medical folks call supportive care. So if you are having difficulty breathing, we're going to give you oxygen, and they are. We're going to work your lungs to make your lungs work better. If you can't keep up with your breathing needs, then you're going to go on a ventilator. And so those are the biggest kind of categories I would think of. There is an ICU doctor would probably, especially one from Seattle, would be much more prepared to answer that question. All the experimental things that they're doing, but certainly they're testing out a lot of antiviral or retroviral kind of medications and whatnot. But I think the big take home for everybody sort of this being a lecture for ICU doctors, is that we don't have a medication that can treat Covid specifically. So we're going to treat all of the side effects that a rampant COVID infection is having in your body, and those appear to be mostly related to your breathing.

Okay, so we've got a lot of questions and scenarios here kind of going into the category of protecting ourselves and protecting others. But, Greg, I think you wanted to start off by talking a little bit first off about physical distancing, what some have called social distancing, flattening the curve. So, like protecting ourselves and how that affects public health more broadly.

Perfect, thank you. So this is just going to be kind of an introductory concept introduction, if you will. I highly recommend you go to the resources page that we've put together, spend an hour to really digest these articles. But it's super important to understand basic germ theory, number one. So illness is caused by germs. We figured it out 150 years ago, and germs are spread in lots of different ways. But it looks like this germ is spread by respiratory droplets. And so that's how you're going to get it. Once you understand that that's the way you're going to get it, then you kind of move to the concept of exponential growth, meaning that if I give it to one person, that person has the ability to give it to other people. And so if I give it to two people, then two people have the ability to give it to more people. And so if I give it to 10 people, then 10 people and all those people. And so if you just take a minute or two look at those resources, there's some amazing articles and some really great videos that will explain what exponential growth means. The bottom line is, what it means is that it looks super boring at the beginning. We have a blog post that says if you were given a penny or $1,000, but the penny. We would double what you have every day. Which would you rather have? And we'll do the doubling for 30 days. And if you do that math, it's super boring at the beginning. It's like after five or ten days you have like 30 cents or something, but by the end you have something like $5 million. And so what we realized is that because this is acting like an exponential curve, so it's growing at this more and more and more rapid rate because the virus replicates super, super quick in somebody. So they can just get one, you know, they can, they can. One person can contaminate a bunch of people that it looks like it's doing that. And if it's doing it, then we need to do something to make it stop going up and up and up and up. And there's videos that explain that. Yes, it's true. There's only 8 billion people. So eventually it would, it would flatten out by us doing nothing. But what we're really trying to do is to prevent that because we know that a certain percentage of people are going to get really sick. I mean, it looks like, depending on what you read, about 10 to 15% of all people will need to be hospitalized when they get this illness. And then about 5% of all people will need a ventilator when we get a hold of this. Well, we unfortunately don't have an endless supply of ventilators. And so if we don't do something to stop this curve going directly up, it's just a matter of mathematics and science that we will have more people that will need ventilators than ventilators. The great news is that when you need a ventilator, you don't need it for the rest of your life. Right? You're only going to need a ventilator for on average of about 10 days if you live. And so once that ventilator becomes available, we can get the next person that needs a ventilator. So the idea is if you have this exponential curve and you can just push down what our peak is at and push it below, we get underneath the capacity of our healthcare system. What we can do is prevent a lot of deaths that don't need to happen. We can't do anything about the deaths that happen where we gave maximal care. But what we can do right now is we can prevent all the deaths that happen because we just didn't have enough care. And so that's, I think, the importance of stopping this when you don't know anybody or anybody you know, doesn't know anybody that has this disease because next week we're all going to know people that have this disease. And in the backdrop of a population where we don't have enough tests, it's even that much more frightening. So please take some time to understand. I think everyone understands germ theory. If you don't understand germ theory, then, then you might need a little bit more time to go back. But assuming you understand germ theory, then take some time to understand exponential growth and then take some time to think about, okay, we have 95,000 ventilators in the United States. And then I think it all kind of becomes clear why it's super important to overreact. The only way we'll know if we're successful is not from anything else other than, oh, well, we clearly overreacted. There's no way we could have overreacted. If we believe in germ theory, we understand exponential growth, it just simply means that we acted fast enough. So that's, that's where we're trying to get. We're trying to get to a point where we have a lot of people that are going to ruminate on, oh, we overreacted and all this stuff, and we didn't need to go through all these economic things. And those are the conversations that we want to be having in the future. We do not want to be having conversations about the number of people that died because they didn't have ventilators.

So there's a number of very specific sort of situations people have asked about. But more generally, we talk about the virus surviving on surfaces such as countertops, clothing, door handles, stairwells, steering wheels. What's the current thinking on how long the virus lives on non porous surfaces? Indoors, outdoors, porous surfaces, playground equipment. What are your thoughts?

Well, there's two things to think of. There is a difference between survivability of a virus on a surface and its rate of infecting you on that surface. And so it's easy to hear, oh, man, you know, this virus can survive for three or four days on a plastic surface. That's not the same thing. After four days of touching a surface like a plastic surface that happens to, to be on as someone sneezing on you as far as its rate of infecting you. So I think that's really important to realize. And even the. All that to say is, yes, it does survive at different rates on various surfaces. Longer on surfaces like plastic and stainless steel, shorter. The shortest is on copper containing substances. Plastic bags, I mean, not plastic bags. Paper bags, things like that. Cardboard is. Another really important to realize is that within 20 hours that virus is basically gone. I mean, so I think that's important to think about whenever you're talking about mail or delivery of items to your house.

So as a follow up question, is there anything specific I should do to sanitize mail, packages, deliveries?

Just, you know, waiting a day, even if you're worried about it, if you just wait a day, if that cardboard box that shows up on your front, if you just let it sit there for a day or move it inside with some plastic gloves on, or secure it in some way, wash your hands right afterwards. And honestly, you could let it sit for a day and then you're fine if you're that worried about it. But if I think sanitizing a box is gonna, I don't know how you do that, but you can certainly wash your hands after opening it.

You know, I think, I don't know if we're gonna get to a separate question about takeout food, but, you know, or going to the bank teller, for instance. But if you're transacting with someone through a window or minimally, just remember that viruses are tiny. And so humans, if they can get through the area, that a virus can get through the area, and remember that the virus is going to start dying as soon as it's out of the body. So if literally someone sneezes on a cardboard box and hands it to you, that's a very different scenario than someone puts a cardboard box down and then a day or two later you pick it up. Because the virus is just, it's just starting to die as soon as it goes outside the human body. And so my, my take is we should not be doing takeout right now. Or if you are doing takeout, you are, you know, using gloves and you are, or keeping it, you know, contained in some way and then, and then wiping those surfaces down when you go in. I think we're gonna figure out what.

I'm sorry, what do you mean wiping those surfaces? I don't understand what you mean.

Yeah, so like if there's a, I mean, some, some takeout comes in those plastic, you know, opening containers, like that's an easy thing to wipe down before you would kind of utilize and whatnot. So I don't really know what the best practices are going to be. I would just try to think logically and try to understand germ theory, understand that the number of virus on a container and what the material of the container is and then how quickly you touch it are all going to play into it. So I would also keep in mind that these are all things that are way less than interacting with someone directly that has this disease. So even if you're interacting with someone and they're touching something and hands it to you, even though you don't touch them, that's a much higher risk activity than someone who has the disease. Putting a box on your, on your front porch or in your mailbox, and then it just sits for a really, really long time. So all the experts are saying that it would be highly unlikely to get the disease through your mail. So I think your. You're much safer in that kind of environment versus, you know, having the nanny come over or doing annual maintenance or having a play date. Those are the things that are really going to help things. Does that help clarify so well, so.

You'Re saying, no, don't have the nanny, the maid, the tutor, H vac people. I mean, like home maintenance just right now. Don't do that, you're saying?

I think if it's an annual maintenance. And I wrote a blog post where I literally had scheduled an AC annual maintenance a couple weeks ago, and it just totally forgot with all the COVID stuff going on. And he showed up and he did he have a rental house? And he went to one of the rental houses, about to go to the other one, and I was just like. And he called and I was like, oh, wait, hold on, we don't really have to do this right now. And so I think if one of the articles has a bunch of little balls, and so those little balls are all kind of moving around and touching, and then when one ball touches the other ball, then that other ball changes. And it's representing how something exponential spreads. The social or physical distancing is decreasing the speed at which those balls are going to contact. We don't have a way to contain this where it's not going to get out of. I mean, it's in so many different places. So all we're trying to do is just decrease the speed at which it goes through our population. And if we do that, then we're going to be able to really maximize how many people we can help.

Okay, so we already had a question plan, and one of the attendees asked, okay, so what about groceries? Do we need to disinfect things that we bring home from the store? Does cooking kill the virus? What about freezing? What do you do about groceries that you go out and get?

Think of it as the human element that's involved in Whatever you're getting your groceries from, if there are higher levels of risk and lower levels of risk for you to get your groceries. So the highest risk way of getting your groceries is to show up to a busy supermarket and wait in line and touch all the different things that are touched in there and then go check out and then drive home. The lowest risk way probably, I would think, is if someone delivered your groceries to your house and then left them maybe on your front porch and then you pick them up after they leave. The medium risk is probably like a curbside pickup. So is there a hundred percent effective way at making sure you don't get exposed to the virus based on groceries? No, but you have to eat, you know, so spraying, I mean, I don't know. I definitely would not recommend anybody using any kind of bactericidal or virusidal spray on their fresh produce or anything like that. You know, maybe if there's a self sealed container and you can just wipe it down. Certainly if you can minimize your exposure to the bags that they're carried in, that's a good idea too. But probably the practical way of is just try to as much as you can, do curbside or delivery for your grocery needs.

So maybe we can do some of these questions as more or less a yes, no answer because we have a lot of these to go through. You already touched on it, but are play dates okay for kids who are off of school? And for the podcast listeners, say it out loud, Greg.

No. If you are doing play dates, you might as well send your kids to school, in my opinion. Now granted your decrease in the number of balls touching each other based on that analogy, but the answer is no. Playdates are not okay.

Is it safer for them to play outdoors?

It is safe for them to play outdoors without other kids. They should be playing with their brothers and sisters or with their parents. And I would probably just stay off of playground equipment for now. Be the easiest thing to do.

Okay. When paying at the store, the grocery store, would you use cash or credit card?

By the time you're there paying, you're already just as exposed as you would be.

Okay, so that's not the most important question to be asked, right?

I wasn't gonna answer it. I never carry cash, so I would have to pay with a credit card. I guess the Apple pay or the Google solution might be really like the best. But yeah, I agree. You're gonna be washing your hands or wiping or sanitizing.

If I'm social distancing, should I let other people pet my Dog, I don't know.

I'll tell you this. I think if you had a person who had a very high viral load and was shedding a ton of virus and it was all over their dog because they just had it in their hands and then you picked the dog up right afterwards and the virus didn't have a chance to die on the dog, then I think that's a theoretical way to do it. So, you know, if I was a person over 60 or had comb over conditions, the easiest thing to do is just not do it. I think we're talking about much lower theoretical risks. I definitely have not read anything that a human could give it to a dog. A dog could have the illness, the virus replicates in the dog and then goes to another person and then gives that person the illness. So it would be like a kind of, like a package kind of scenario is the way I would think through it.

And not only that, but someone probably has to get within six feet of you to pet your dog.

You know, so someone here talks about they're instituting a standard practice at home. They come in, they immediately discard their outer clothing into dirty laundry, whatever they wore out of the house or anything that would. So they're coming in basically taking off their clothes, putting it in the hamper, taking a shower or at least scrubbing exposed area of skin, changing in the clean clothes to try to prevent the spread of virus on the furniture or before hugging, hugging loved ones. Am I on the right track or overreacting?

How consistent are you and everybody else in your house of doing that procedure? Because if the answer is everybody doesn't do it and I'm the only one that does it, then you might as well not do it unless you happen to do something extremely high risk now. I mean, hey, I think about these things as I go home to my family after being in the clinic or, you know, so if you're, certainly, if you're high risk, it's a great idea to decontaminate before going back into your home. But if all you're doing is running out and playing with your kids and coming back inside and you didn't do a play date, there was no playground equipment, you didn't go to the grocery store on the way home, your chances of, you know, of that, I don't know how much you're really mitigating at.

That point, I'd love to take a stab at that too, because I talked to my wife before we started and she's been doing a process and as an ER Doc, we kind of always have done this process even before COVID where we usually, when we come in after a shift, like I said, even before this kind of one of the first things we do is kind of take off our scrubs and kind of get into some other clothes and wash our hands. So she's been taking off her scrubs before she gets in the house, getting down to undergarments and then putting that in a laundry right there. Not then carrying those clothes and throwing them all over the house. Just kind of keeping it contained. I think ideally, if you had the ability just to toss them right into a washing machine, that'd be great. And then she goes in immediately, takes a shower and puts on clean clothes. And so she's obviously an incredibly high risk area with getting exposure to it. So I think that makes a lot of sense. I don't know. I, I don't know why a whole bunch of people from a household would need to be leaving. The best would be is the people that can't work remotely and are that are in critical industries, then they would have to leave. But hopefully you're decreasing the number of people that are going in into society. But I, I, I love Mason's way he's thinking through it is like what, how high risk is the activity that you're going to do? So if you're going out for a walk and you don't get within six feet of each of anyone and you're not touching anything, well, then there's zero reason to do it. So if, I mean he's, he, he's in his clinic. I think you're in your clinic right now. If you're, if you're in your clinic, then I'll bet he's going to go home and he's gonna, he's gonna do this because there's a reasonable chance that he's going to come in contact with someone that has Covid at some point in the next several months.

There's a couple of questions about exercise. How much exercise should we be getting as a precaution? I know other people have asked what kind of exercise should I be doing? Should I avoid going to group classes? Should I stop using shared exercise equipment? What about going out for a run?

You definitely shouldn't be going to the gym in my opinion. So you should not be going to a shirt class or using anyone's exercise equipment that is not yours. I mean that, that's just my thoughts automatically. I think going out for a run is fine. Going for a walk is great. Doing Any kind of calisthenics at home are great. It's amazing what kind of exercise you can get with some bands and push ups and sit ups. So it's a new question, I see. We identified it as new. Mason, do you have any other thoughts?

I think it's important to exercise. I think that's the, you know, whether you're. You just need to do it in a safe way. And so right now, safe means minimizing your exposure. So in your home, I think you can really get crazy with this. Like, what happens if your spouse works in a high risk area and uses the exercise bike that you both share? You know, like, what do you do? And I think it's just like, if you're worried about it, wipe it down. In a home situation, it's very obvious you don't need to be going to your gym class with 20 other people that you don't know and sweating over each other, you know. But yeah, outdoors should be fine as long as you know. But you got to realize, like, running around Town Lake, that's a social experiment just as much as an exercise one, you know, so running outside, I probably wouldn't go around Town Lake or whatever. I would. I would probably just go around my neighborhood and I wouldn't stop and talk to anybody. So it's just hard to kind of get out and do some things even though it's outside without, you know, violating that 6ft of distance between people.

There's questions about masks. Would it help to wear a mask when running necessity errands? Are there are any types of masks better than none? Maybe we should start with that.

I'm happy to take a first stabilizer. So I think if you have access to a mask, you should wear it. If you are certainly symptomatic. I think if you are asymptomatic and you don't do a high risk thing, then you're probably okay going around. Adrian and I are wearing masks in public places. I'm an ER doctor as well as Adrian, my wife, so I think that makes a lot of sense. And certainly I think a lot of the mask is. If you have Covid and you cough or sneeze, you're going to limit the amount of virus that goes out. You won't eliminate it, but you will limit it. You will also, if you touch something with COVID and you have a mask, then you will prevent yourself from touching your face. Do I think you should go out and buy a thousand masks? No, because the people that need those masks the most are Health care. So I think if you have something laying around, that's great. I don't think it's 100% necessary based on kind of the criteria stated. Mason?

Yeah, it just depends on what you're doing. You know, if you're traveling, if you're, if you have to go through an airport. I mean, I would definitely not go through an airport unless you absolutely had to. But that'd be a perfect situation where wearing a mask and, you know, being very careful about what you touch is a really good idea, both in terms of exposing other people to your asymptomatic COVID infection, if that's what you have, or obtaining it yourself. But as it goes, you know, grocery store, probably something a little more that people are asking about. And yeah, it's not a bad idea in a grocery store because you're closer to other people and you're minimizing your chances of infection or infecting others. But yeah, the, and then the types of masks, you know, you have the surgical mask and then you have the N95 mask and stuff. And I think a lot of times people say, I don't have an N95, so I can't wear one actually outdoors. A regular surgical mask is considered to be just about as effective as an N95 in terms of preventing illness, attaining it. So as far as I get, from what I've read.

So there's a question. If somebody is symptomatic, how much do you have to isolate yourself from family or roommates? Should you be wearing a mask at home, staying in separate rooms? What do you say?

Well, I think it's quarantine means, you know, isolation. So if you're in their home, then yeah, you're in your room. Someone is designated as a person to deliver you what you need in terms of food and then they need to exercise, extra precaution. You know, it gets really dicey if you have someone who's elderly with comorbid conditions in the same home. I mean, that's a really tough situation and that patient will be really careful. You probably already exposed them if you just found out you have Covid by this point. So. But yeah, you definitely don't need to be doing anything other than staying in that room that you've designated as your quarantine room. Oh, and when you have to use the restroom, that's a prime place to spread it. You know, it's going to be washing your hands, you know, when you're washing your hands, touching the soap. So having your own soap dispenser or your own bar of soap or whatever if you're infected? That's what I would recommend, too.

So let's touch on maybe a couple of population health questions, because a lot of this is covered in the documents that have been shared. That resources list Greg mentioned is now on the Connexus website. I've put a link in the chat box and I'll share that in the YouTube comments when we get to that. But one question you were talking about flattening the curve and you see the graph that shows the kind of the high bell curve versus the longer, shorter bell curve. And somebody asked, doesn't flattening the curve just drag things out longer? Does it really reduce the number of people who get sick and die, or is it just more spread out over time? Or does it mean more than might survive if we're not overburdening hospitals beyond ICU beds and ventilators and staff? Can you explain that a little bit?

Sure, I'm happy to take a stab at that first. So to me, the answer is yes, exactly. It spreads this out. That's what we're trying to do. I think we, we all understand at this point that the virus will not be able to be contained in the current location, so it's going to run its course through the population as it would normally. And so the way that we're going to save lives with this is to make sure that the peak of whatever the natural progression of this disease is, and there's a lot of estimates, some I've read, that say 5 million people are going to get infected, and some say 150 million people are going to get infected. But however many people are going to get infected, that cat's out of the bag. So let's not even talk or worry about that. All we're trying to do is, is increase the time that that infection is going to happen, so the peak of it stays below the healthcare capacity. And so right now, with the fact that the curve is just going straight up, every day it's getting more and more and more. If you understand math, you'll understand that it's going to get really, really, really every day, instead of there being, I think there were 2,000 new cases. Maybe today there'll be 3,000 new cases, maybe tomorrow there'll be four. If every day there's more and more new cases, that that curve is going to get very high. So, yes, the idea is 100% to spread this out.

Well, yeah, I mean, it's. Some people may say, well, why would you want to spread? Why would you want to make this longer? Why would you make this? And the idea is lethality, like, you know, a sudden spike that's concentrated. If we had all of Americans or 90% of Americans or whatever that is, get infected in a matter of four weeks, then we have swamped the health care system and people will die not just because they have the virus, because it's preventable death. At that point that you're seeing, someone's not given oxygen therapy because there's no more oxygen tanks to give. So yeah, you do want to spread this out to where you know, instead of in a four week period, it's over as long as you can. Really, there's not like an ideal time. It's as long as you can make it so that way that your healthcare system isn't swamped.

And I'd love to add that for folks that are, I mean really, it looks like the mortality percentage really starts going up when you cross 60 years of age. Ideally, every person that's over 60 will never get this infection because their mortality rate, even with optimal care is dangerously high. So if you're lower than that age, it's certainly higher than a standard flu. But it's not like one, there's nothing we can do about it. I mean, we're not going to all be able to all live in our houses indefinitely and never see another human. But two, those mortality percentages are far less. Every time I say that, someone reminds me though, please let people know that there are lots of people that are in those age groups that are going to be on ventilators and some of even young people, there will be some that will die. Fortunately, there appears to be no cases of death for anyone less than about nine or 10 years of age, which that's amazing.

The other thing too, I'd say is that not all 70 year olds are the same in terms of their general health. And so, you know, we're looking at this cohort of 60 plus or 65 plus or 70 plus. And if you're sitting there as a patient or as a person, just saying, man, I am 72, does that mean I have a 10% or 20% mortality rate? If I get this? And the answer is no, the population does. And so there's a difference between the individual and the population.

Is there anything known about why children? I've seen reports of children getting sick, but like you said, there have been no deaths. Is that understood why that is?

I haven't read anything compelling to repeat Mason have you no.

Couple other questions about spread and containment? Someone asked, I understand limited exposure and social distancing, but how will the decision makers know when it's safe to resume normal life?

I think it's based on the curve, right?

And that's 100% based on the curve. And then I think a bunch of smart epidemiologists and virologists and kind of people that understand the epidemics probably more than Mason and I, all I know is that we can probably look at China. We just need to realize that China's lockdown measures are way different than the US Lockdown measures. And then we just need to also realize is that things are going to start getting better and if we let off our restrictions too soon, we're going to get another spike. So I've read some really interesting things about the Spanish flu. They have data on different cities and Philadelphia started their lockdown, I think six days after St. Louis. They had much higher counts of mortality. And then, I don't remember, there was a third city that they used to compare and they, once it got under control, released restrictions and their second spike had more mortality than their first spike. So I think the thing we need to focus on now is physical distancing. When that's going to be peeled back is all going to depend on how good we do this today.

Now, when you talk about the curve, does that mean the curve is no longer going up in an exponential way or that the curve has actually started going down? The number of active non recovered cases.

Is that the curve? I mean, I again, I'm not a virologist or an epidemiologist, but based on just kind of logic sense that the curve is going to have to start going down because it's going to be.

The latest stuff, you know, because they, you hear, I don't know if this is true or not, but you hear that they're returning to kind of normalcy in terms of turning to work and their curve has not gone down as much as it's flattened. You know, from what I can see, I mean, just looking at a couple graphs.

But I do know that a good friend of ours, Colby Evans, a local dermatologist here in Austin who actually connected Mason and I yesterday, his wife is communicating with friends on texting that are in China and they are saying that life is starting to return back to a little bit more normalcy. So there is 100% hope that this is not going to be the new normal forever. This is just going to be the new normal for now.

So There was another question and I've heard, like, for example, I've read reports that in China all of the temporary hospitals that they built or opened have now been shut down, that some people are getting back to work again. And somebody had asked, here is, what I don't understand is how do you prevent the virus from spiking again once you restart the economy? And that people are interacting again. China and South Korea looks like they've completely arrested the virus, but without a vaccine, I don't get it. What am I missing?

Yeah, so I would say there's a number of factors at play. First of all, the number of cases that were reported and actually occurred are probably two totally different numbers there in China. And so there's a significant portion of the population that probably were infected and didn't know it. And therefore that means that they've created antibodies to that, which means they're less likely to develop it again in the future. Now, how long that lasts again, we talked about it before, we don't really know right now. And the other thing too is that when it comes to the spread of a virus or any other infection through a population, there has to be a certain kind of base amount to really start to do the exponential numbers that you're seeing right now happening in the US and so I have a feeling that there, it's not like China is going back to how they were a year ago. I'm sure what they're doing is they're still exercising some caution to keep that small number of active virus contained.

And just keep in mind that whatever action you do today will only know the effect of that action for several weeks down the line. So all we're trying to do is just stop that, the growth going straight up. So the actions we do today, in about two weeks, we'll start to see that that curve is going to get, you know, go from a black slope on a ski mountain, hopefully to a blue, then to a green and then to a bunny. And. And so the changes that we're going to have to do are going to be slow and incremental as we're coming out of this is. Again, I'm imagining that's how they're going to approach it.

Are pregnant women considered being any more vulnerable to this?

My wife's a gynecologist, she's been looking into this and from what we can tell right now that the answer is no.

Another question here. How concerned should a 60 year old with multiple sclerosis, how concerned should they be about this?

Well, I Think a lot of it depends on which medications you're on when it comes to multiple sclerosis. You know, I don't think there's something inherently in that disease process that puts you at greater risk specifically. But in general, you know, with Ms. In particular, you may have a number of other conditions at play as well. So it's kind of hard to say, just carte blanc. I don't see a big tie into increased mortality rate. That's where your doctor, who knows exactly which medications you're on and your history and everything else kind of comes.

So I had a question about disinfecting boxes. Would you use. Is Lysol spray something that would be.

Useful to kill it? I think the problem is that the cardboard is a porous surface, and so will your Lysol get down into all the different, you know, nooks and crannies. It's better than nothing, probably.

Any special concerns or implications for somebody who's known to carry the cystic fibrosis gene?

Definitely. Oh, Carrie, you don't mean an actual.

I think the way they wrote it was actually carrying the gene. Like, for example, I'm a gene carrier, but I don't have cystic fibrosis.

I would just say I don't know. I don't know if carriers have any difference in their biology. I probably should, and I probably knew it at one point in medical school. But I'll tell you, I'm not a.

Pulmonologist and I haven't had to think about cystic fibrosis all that much lately. But my recollection is that a carrier just doesn't have. It doesn't have, quite obviously the same effect as if you actually have the disease. I mean, if you have the disease, you're at the highest risk category. You can be when you're talking about comorbid conditions with this, I just don't know as it comes to a carrier.

I will tell you, Danielle, if you could just write a note for me that says, I have a ER doctor friend in town that has, unfortunately, with two children with cystic fibrosis, and I know 100% she will know an answer to that that's infinitely better than either of us. So I will. We will make sure to communicate that back to the question, or we can.

Go back into the records for the webinar and see who asked that question so we can follow up. Even if they've dropped off. Can we take on a couple of questions, people asked, I assume, who work in health care about ppe? And protecting themselves. The first question was, are surgical masks, or what they call ear loop masks sufficient to protect patient safety? Patient facing staff in non clinical situations like housekeeping, billing, registration. Now some of those people might be patient facing if they're at registration, but let's say they're sitting in an office or would those masks be sufficient or are N95s required? What are your thoughts about healthcare workers? What staff? The guidance? Is there consistent guidance in practice?

I mean my, my take on this question is a lot of this is going to have to deal with supply, it seems like. I think what we're going to end up coming to is if someone is really sick, they obviously have a very high viral load and you should definitely be wearing an N95 if you're interacting with them. I think that's going to be appropriate. And obviously if you're part of putting someone on a breathing machine, all those people are going to have to be in full protective gear. I think what we're going to end up realizing is that there's probably a lot of COVID virus out there and I think a simple surgical mast is going to be what will end up being recommended for places that are high risk. Places like emergency departments and regular, probably even, you know, beyond. So that I don't know that directly answers it. Mason, do you?

I think right now the big concern and a real issue is just the supply of N95s since it is not ubiquitous, they're going to be rationing that to people at the highest risk, which just like you mentioned what those people are. So where does the office staff fall in that spectrum? I mean, you're at a higher risk than someone who just stays home all day, but you're at a much lower risk than someone who's, you know, intubating somebody with COVID So I would say depending on your supply status, I tell right now, I mean my office is practicing a screening, outdoor screening protocol before people even walk in to interact with our forward patient facing staff. So we're reducing that. That way, you know, we have a certain supply of masks that are not going to be able to get us through the next eight weeks without the ability to purchase more. So we have to be really careful how we use it.

And if I can go on just a short rant, Mark, I think it is approaching criminality if your emergency departments are not practicing some type of triage before you enter into the emergency department. There is, I think, zero reason in my mind that a emergency department can't come up with some kind of solution to do what Mason's talking about in his, in his clinic, that's going to decrease the virus. I think encountering people before they touch anybody or anything, where they can see some information that says, hey, we're not going to test you here, you need to go to these places or, you know, if you have mild illness, please don't check in. I mean, you know, we're not going to do anything different for you. You're just exposing yourself to the virus if you don't already have it, or if you do have it, you're exposing other people. And then we're going to be able to see immediately if someone's sick. And if someone's sick, you know, capturing them as quickly as possible so they can one be, you know, covered up so they're not spreading their virus, but also so they can get care really, really quickly. So this is my appeal. If you have any influence or control or power, please implement those policies and procedures. Not tomorrow at 9am when you're going to have the meeting that you may or may not have, but today, right now. Get those people that are doing elective surgeries and they're still going to need a job. Get them. You don't need to. I mean, basic medical training will allow you to be able to institute some kind of logical thing. And are you going to get better yet? Absolutely. We're going to get better at this over the next several weeks. We don't have to have a perfect solution, but better is the enemy of good. And so I think doing something right now is going to help protect our healthcare workers and other patients that are getting care but don't have Covid yet. So that's my feeling.

You made a couple recommendations. Let me ask you real specifically because I know I shared with you, you read a blog post that I published this morning of stories from a hospital's emergency room where they were. They had a security guard posted outside the ER handing people a card with four questions. This guard's not wearing a mask. So, like, let's give blunt advice. So my first thoughts are, why is it a security guard triaging people? Why is the guard not wearing a mask? And why is the guard physically handing something to random people who you don't know yet if they're even symptomatic? Recommendations?

I mean, I think the way you, you asked the recommend, the question speaks volumes.

So was I leading the witness?

Sorry, that. No, but I mean, it's great. I mean, to me, is that better than having people come in? Absolutely. It's better. But if, if by, you know, the end of today, that's not better. If by tomorrow, that's not better. You know, we said we weren't going to talk process improvement lingo, but there is a concept of PDSA or PDCA where we do an experiment and then we, and then we study and then we adjust and we can keep doing the cycle. This cycle needs to be, you know, in my mind, by the hour, you know, certainly several times a day, thinking through how can we make this better. So obviously having a non medically trained person as your first person that you're going to encounter, that doesn't seem like the best idea. Especially when, I mean, I don't think you need extensive medical training. And pretty much anyone that works in an emergency department in some kind of clinical capacity could certainly be better than the security guard. And then figuring out and realizing that one, whoever you encounter could have Covid and whoever that person encounters could have Covid. So having some kind of protection would make sense. And then do you really need to hand someone a card? I mean, can't you just have the table where they can or why do you. I mean, I don't even know why they need a card. Like, here are the four questions. Yeah, up on the wall.

Language might become an issue and then you have to worry about how do you have translation? Do you have one of these iPad kiosks with a translator service, like bigger.

Probably in every community there within two or three languages, you're going to capture the vast majority of people. So I wouldn't wait till there's 26 translations of this, like, well, do it in your one or two or three most common languages and like get it out there and then keep getting it.

Better and iterating from there. Yes, I would look at a Pareto chart of languages and work my way through those. But then in that case, the ER doc said that patients who had respiratory symptoms were being brought into the one and only same waiting room with non respiratory symptom patients, somebody who might have had a broken ankle. Your recommendation on that would be to do something different.

We need to start thinking like, obviously we're not going to be able tomorrow to build a second waiting room. What about just having some ideas of like, why don't we put tape on the floor and at least separate the room into two. Why don't we try to put a barrier up? Why don't we use another room that's close to it? I mean there has to be something. I bet if you would Just ask the nurses and doctors and techs of this emergency department. Hey, you guys have any ideas? We're talking about basic germ theory and we're talking about protecting you and we're talking about like, I guarantee you, in a 30 minute brainstorming session they could probably come up with some, you know, zero cost, couple ideas that would be better than what you just described.

My recommendation as the engineer and the process improvement person here would be listen, as you're saying, listen to your staff. I've seen news reports of nurses on the west coast not being listened to, not having their questions answered, being ridiculed for expressing concerns like that all seems really dysfunctional, if not harmful. It seems to violate the, for what it's worth, the lean Toyota principle of respect for people. You know, we've got to do better.

But maybe one last, I mean, so if I'm a leader of a really big system, I don't know, five hospitals, 10 hospitals, 40 hospitals, I'm not going to understand the complexities of all of those emergency departments, right? I'm not going to understand the complexities of Mason's clinic, right. So all we need to do is just give some guidance, right? And so like he's taking some really basic, appropriate measures. Oh, well, I don't know what his layout looks like, but there's obviously an outside to his clinic and he's obviously encountering people before they come in, before they touch anything. And so if we just give some basic guidance to the people and say, hey, solve it for your emergency department, we're going to give you the autonomy, a reasonable, appropriate solution. We're not going to make a medical director kind of wait for the edict to come from, from above. Then that's all you have to do. I mean, that doesn't, doesn't take any thought. Like I mean a CEO of a, of a 50 hospital system, he or she could simply say, oh, just do these, try to accomplish these four things. And I mean it literally could be accomplished, I would assume, at least in one of those emergency departments within a day and probably within all of them, it could be accomplished within a day.

Thoughts on how process improvement staff can offer assistance to EDS and other high flow service areas from an improvement, safety and quality perspective when we're banned from the facility and instructed to work from home. So maybe let me address that because as an outside consultant to organizations, I am now banned from, from those facilities who don't want additional outside people. I'm still in touch with one healthcare client. I think, you know, whether you're internal or external, there are things that you can talk through. Talk me through the process and let's map out the flow on the digital whiteboard of what is happening when a patient is arriving. And I think there are things that can be done away from the workplace that are better than nothing if you're. Well, if you're invited to that discussion as a process improvement person, to ask questions, to point out things, hey, wait a minute, have you thought about this? What is the risk involved in doing this? Because, you know, it's not just about Kaizen or pdca, I'd argue it's also about being proactive and using a tool like fmea, Failure mode effects analysis. What are the ways this process could fail and cause exposure to somebody in a way that's preventable? Those are things that we can and should talk through in a phone call, in a web meeting, in any number of platforms, as long as the people who are running things aren't too busy to stop and get input.

Maybe.

And I feel fortunate every time I'm asked to provide a little bit of input on something. That's my attempt to try to help a little bit where I can. But I hope process improvement, it can't grind to a halt because everything has just changed and it continues to change. That's when we need process improvement.

I'll get out of my soapbox.

It'll be fascinating if anyone's able to do studies afterwards to find out the organizations that have a continuous improvement mindset or discipline discipline or lean Six Sigma transformation or practice in their systems, how did they react from a time perspective? Because it's pretty clear that at least from a business perspective and from a whole bunch of other things, safety and quality and cost and retention, that people, I'm sorry, that organizations that do this well have better outcomes. My gut feeling is that those organizations are already mobilized to empower the worker and to start making change versus asking permission. I'll bet they're already responding. And it's a great example of how these disciplines can save lives.

So maybe to wrap up here, we'll wrap up before the 90 minute mark, maybe. But just to bring things back and maybe to recap and kind of bring it home, Mason and Greg with a bit of a summary. What are the key. This is an unplanned question, but what are the key points? If somebody watching this is still having the battle with a family member or a friend who is really opposed to social distancing, they think this is overblown. And what are the Key points that you would try to make that case of why people need to take this seriously and get on board with some of these practices now.

Right. I would just tell you that whether they think it's overblown or not, it's not about them, it's about the community. You know, that these are proven methods. And I would just basically ask them, do you want to be Italy or do you want to be South Korea?

You know, and you might have to explain to that family member.

Right? Yeah. Hand them a chart and just say, here's the mortality rate in both countries. You know, and so yeah, I mean I think a lot of skepticism has been from, you know, they told me to evacuate because of this hurricane that never came. And you know, or you know, the mortality rate isn't all that bad. The flu is worse. It's just kind of like some common myths and hopefully you have the tools now to be able to debunk some of that and then just say, listen, this isn't about you, this is about your parents, about your co worker, you know, things like that.

The three fundamental things that a person needs to understand is one, germ theory, so that we get ill from germs and this germ happens to be a virus and that if you believe this really exists, then you have, if you do not believe that coronavirus exists, then there's no convincing person. Right. So establish with that person that they understand that people get sick from viruses and that get them to agree that there is a coronavirus and that people are getting sick. And then I think at that point then you have to walk them through the concept of exponential growth and you have to walk them through that China locked everything down when they had 300 cases and they did it. China style lockdown, they didn't do elective lockdown. 300, we're at 6 or 7,000. I haven't looked in the last hour what we're at. We're probably in that case and we still haven't done the China style lockdown. So if they understand germ theory and then send the virus and they understand they're going to get the virus before they are going to get symptomatic and they understand that we're not testing so we really don't know how it is and that it's going to take a couple weeks before these measures like you have to walk them through all that and then they have to understand and get them to appreciate that some percentage, whether it's 1%, 5%, 10% are going to need A ventilator, then, you know, get them to like, communicate back to you. Do you understand how many ventilators there are in the US and no, I don't. There are hundred thousand ventilators. So what's going to happen when there are 200,000 people that need a ventilator? Like, get them to walk through that process and be like, so imagine you're sitting with your doctor and your doctor is literally telling you, oh, we're not going to be able to put your mother on a ventilator because we just don't have one. You know, get them to kind of think through that whole process and what that conversation is going to be like. And if we don't do something fast, I mean, we may not. May already be done, but, you know, pretty hopeful that we're still okay if we really start locking down that this is going to be a conversation not happening once or twice, but it's going to be happening at in the thousands and hopefully not tens of thousands. And so it's going to take some time. But I think that that's the progression of a thought process to walk someone through. I don't think you start with the ICU ventilators because they're like, dude, I don't know what you're talking about. And I think that the closer you are to the person and the more you can slowly get them to kind of just tiny little changes in their mind of how to get there, I think is the way to do it. And it's going to take time. I don't think if someone's not there yet, you're just going to be able to get on the phone. There are people that have really good relationships with. That literally took me 20 seconds to convince them because they were just like, oh, I just trust Greg. And I've never heard of Greg be a reactionary ever since I've known him. And he's saying some stuff. But I think for the vast majority of people we're talking to all of our people at Kynexis and they have friends and extended family and so a sample size of 100 or 200 people, and some of them are really meeting big challenges. And so I think that's where the real work is happening right now, is on those people that don't feel like they're changing people's minds, but they really are slowly getting there, sending these explanations and whatnot for an emergency medicine doctor. I literally think the work that I've done in the last five days or so is going to Impact more lives than my entire career of seeing in an ER doctor. You know, now I haven't been full time, but an ER doctor might see anywhere between 20 to 50,000 patients, depending on how busy of a place they work. And you figure not all those people would have died. So I don't know, maybe an ER doctor saves, I don't know, a thousand lives in their career, 5,000 lives in their career, something like, I don't know, but literally. And then. So I think I've done more work in the last five days than my entire career by just educating people. So imagine if you're a person that does a job that doesn't save lives, right? You literally have the ability today, tomorrow, until really everyone is there with this understanding, physical distancing to literally go save lives. I mean, it's such a remarkable opportunity that we have right now in doing good. And it's taken my opinion of just total doomsday gloom and really giving me so much hope. So many people are interacting and so many people are thanking. And so if you start doing that and you're doing a place out of love and keep politics out of this, and you're doing out at a place out of caring and connection, I think this, this is going to make humanity stronger at the end. I have no doubt whatsoever. And we're just in the process of that. We're going to be releasing some blog posts in the next couple days about some of the amazing work that the Lynchburg ISD is starting to figure out, like just immediately starting to figure out how to get food to their. I was going to say customers, their students. And just story after story, we're going to start disseminating all these innovative ways that we're going to find this kind of new temporary environment normal. And I think that we are going to be. I mean, we all remember what it was like right after 9 11. I mean, you know, there was a period after 9 11. There was a ton of grieving that went on. But we came together like a nation. And if there was ever a time that our nation needs us all to come together, we've been so divisive, we've been so apart for so long. I'm sorry, I'm on my soapbox going on here. But I think this is, this is, to me, this is this, this huge hope and opportunity that we have right now to reach out. And every single person, whether you're going into the emergency department right now or you're staying at home, has the ability to impact this and that is remarkable. I mean, most natural disasters, all we can do is at the most, give money. We can't all go fight a fire, because if you don't know how to fight a fire, you're just making it harder for people to fight the fires. And this is literally every single person can. Can contribute in a meaningful way. So.

All right, well, thank you to everybody who tuned in. Thank you for submitting questions. We had so many questions that we couldn't even get to all of them, but we tried intentionally to prioritize the questions that were about individual practices. As Greg said, the things we can all do to help in this battle, things that we can do to protect ourselves and our communities and everybody more broadly. So, Mason, thank you for taking time as well. Greg, thank you for spearheading this effort and dedicating so much time to try to help educate people. I want to say thanks. Thanks to you both for everything that you'll continue to do here.

Thank you very Mark for leading this.

Thanks.

And we just. One final point for everybody. There were a couple questions that, yes, this was recorded. Yes, I will work. I'm going to be working this afternoon on getting this posted on YouTube and on our podcast channel. And we encourage people to share this with friends and family and colleagues and others. So, again, thank you. Thank you, everyone.

Stay physically distant.