S1E11 / Surviving COVID / David Lat

I'm Dr. Celine Gounder.

And I'm Ron Klain.

And this is Epidemic. Today is Tuesday, April 14th.

Every day we read tragic accounts of people being lost to COVID-19. Over 10,000 Americans last week and probably the same number or more this week as well. Many of us have friends or loved ones who have been lost. But in the midst of all the sadness, there are other stories too. COVID survivor stories. And we're going to hear one today from a prominent journalist who endured days unconscious on a ventilator and survived to talk about it. He'll tell us about his experience, its impact on his family, on his career, and his contribution to research on the disease as a result of his illness.

In this episode, you'll also hear from a surgeon and health administrator in Michigan who's been contending with the next wave of COVID as the virus has spread from the coasts into the middle of the country.

We're delighted to be joined on the podcast by David Latt. I often say that as the lawyer on this podcast, I rarely get to have very high-profile legal guests on a medical podcast. So it's a special pleasure to have David. He's one of the nation's most well-regarded legal writers. He was the founding editor of Above the Law. His book, Supreme Ambitions: A Novel, was described by the New York Times as the most buzzed-about novel of the year among legal elites. He's a former federal prosecutor, a law clerk on the Ninth Circuit Court of Appeals. And by the way, you can find him @DavidLatt on Twitter. David, welcome to the show.

Ron, Celine, thank you so much for having me.

David, you're a young, relatively healthy person.

How did you wind up so sick with COVID So, as you mentioned, Ron, I'm generally a healthy person. I'm 44. I don't smoke. I rarely drink. I don't use drugs, not overweight, not diabetic, don't have hypertension. But one thing I do have is I have exercise-induced asthma. I get short of breath if I exercise too vigorously. Now, it never really bothered me. I have an inhaler, so I manage it. Didn't stop me from finishing the marathon twice, admittedly a long time ago, and not very fast, but I finished it. Or didn't stop me from exercising at the gym, doing high-intensity interval training classes. But I do think that this asthma made me more vulnerable to severe respiratory problems associated with COVID-19. And what I would say to folks out there is, even if you're in generally good health, you could have some condition which you may or may not know about that could make you more vulnerable. I've been tweeting about my coronavirus battle, and I heard from one woman who found out fortuitously when she got tested for something totally different that she's missing an enzyme that protects her lungs. And the doctors told her after they found this out that she really needs to not get pneumonia. This was before COVID-19, so now she needs to not get COVID-19. There are a lot of people out there who may think that this disease would be nothing more than the flu for them, and they might be wrong.

How did your symptoms come on?

So initially, I started getting symptoms the weekend of March 7th to 8th, and it was just fatigue, just an intense tiredness. And then in the following days, I started to get fever and chills. And then around that Thursday, Friday, I started getting a cough, and as the second weekend hit, I started getting shortness of breath. I also briefly early on had that weird symptom that some people have talked about where food lost its taste, but that didn't last very long.

And in the middle of this, David, right, you went to the emergency room and you could not get tested?

That's right. Like many Americans, I had that frustration. I went to the emergency room. With flu-like symptoms. They gave me a cold flu test, which determines whether or not your symptoms are caused by a common strain of the cold or flu. It came back negative. So they then told me, you know, you can get tested, but you have to come back tomorrow. I have no idea why they would send a potentially sick person with breathing problems back into the community, but they did. And sure enough, I came back the next day, not just because I wanted a coronavirus test, but because my breathing problems had worsened. That was on Monday, March 16th, when I returned. I was admitted to the emergency room because I couldn't breathe. They did give me a test, and as I later found out from my hospital bed, it was positive.

When did you realize, David, that you were going to need the help of a ventilator, and what went through your mind as you came to that realization?

So I was admitted to the hospital on Monday. And sometime after that, my father, who's a physician, said something to me like, "You better not get intubated," meaning put on a ventilator. "Not everyone comes back from that." And then on a Friday of my, first Friday of my hospital stay, very late at night, someone, I can't remember who, came into my room and said, "Your oxygen levels are dropping. We are going to have to intubate. We're gonna have to put you on a ventilator." And remembering my father's words, I was terrified.

How was your husband informed about this? And I think your son's only 2. What kind of conversation did he have with your son about that?

My husband Zach ended up getting sick too. So maybe the Wednesday or Thursday when I first started having symptoms, my parents came to Manhattan where we live and picked up our son. They didn't interact with us because of course we were quite scared then. We were also nervous about our son being a carrier. But luckily, it seems my parents didn't get anything from him. I would FaceTime with him from the hospital, but he never really fully understood what was going on. My husband, he saw on Saturday morning when he woke up that he had had a missed call essentially in the middle of the night. And that's the worst thing when you see you have a missed call from a number, an unknown number, but probably the hospital. And he called back, but because the hospital— this is NYU Langone— was so busy dealing with patients, it took a little while for them to get back to him. So maybe he knew on Saturday morning at 10 or 11 that I had been intubated. And then he talked to my parents and told them the news. And my parent— my mother started crying. And then my husband— everyone started crying. They spared me this while I was in the hospital. It was only after I was discharged that they told me what a scare they had been through. The experience was in some ways far worse for my family and friends than it was for me, because when they intubate you, they give you sedation, then often they'll give you a paralytic so you don't move as the breathing tube is inserted in your mouth, and then they'll basically keep you under. So for 6 days, I was oblivious. I, unlike many other ventilator patients, I had no hallucinations, no dreams. I remember nothing from this period. Whereas for these 6 days, my husband and my parents were waiting in agony to see what was going to happen to me, whether I would live or die. And we've seen some very sobering statistics about how perhaps under 50% of ventilated patients from COVID-19 actually survive. And one thing I should remind everyone of is coronavirus patients are not allowed visitors. So my parents and my husband just had to wait by their phones and get updates from the hospital every afternoon or every other afternoon. They couldn't be there on site with me.

Talk about the symptoms you still have. Obviously you're hoarse in your voice. What other kind of day-to-day symptoms are you still experiencing?

So I'm hoarse, as you mentioned, from my time on the ventilator. Ventilators are amazing devices, but as I just wrote in a piece for the Washington Post, they have side effects. A lot of ventilated patients suffer from cognitive problems, or suffer from more minor things like what I have, like this damaged voice. They sometimes suffer from psychological issues. Luckily, I haven't had any of that. I've just had this hoarse voice. My main symptom is just reduced pulmonary function. I need to rebuild my lungs. The ventilator was essentially doing the work for me for that period. Plus, when I was in the hospital, I didn't get any exercise. You're stuck in your room, as a COVID-19 patient for understandable reasons. My main problem right now is I will get winded from walking across a room or two, from climbing a flight of stairs. I'm recording this with you both from an upstairs room in our house, so I knew I had to basically relocate to this room 10 minutes ahead of our call because if I didn't, I'd be panting the whole time. You know, just little things like for a shower, I can't stand for the entire time of my shower, so I plunked a little plastic stool in the bathtub so I can take breaks and sit down. So I just need to take it easy. I have this contraption called a spirometer to sort of train my lungs with breathing exercises, but it will take weeks or even months to get my capacity back, and we'll see if it turns out to be my full capacity. It may or may not be, but Considering the alternative, I'm, I'm not complaining.

You received a number of experimental medications while you were in the hospital. You got Kaletra, which is a combination pill for the treatment of HIV. You got hydroxychloroquine with azithromycin. Hydroxychloroquine is the medication that the president's been talking a lot about. And you got an interleukin-6 inhibitor called clazekizumab. What was the discussion between you and your doctors about what to try and why? And did you have a say in this?

So the Kaletra, I think at the time, was their standard first-line response. I don't know what they do now, but I said sure. Then the hydroxychloroquine and azithromycin was something they were also using. It was something that my mother, who is a pathologist, was advocating for me to try. She had read some of the literature. Now the literature's, you know, very conflicting, but at the time, she had read some of the literature and she thought it seemed at least worth a shot. So they did administer that. The Klasikizumab was interesting. I was actually given that while I was on the ventilator. They were trying to see if it could improve lung function in patients with severely compromised pulmonary capacity, but I was out of it at this time. So my husband had to be called by the doctor who was leading the study And it was kind of a scary call because the doctor was essentially like, congratulations, your husband's eligible to be in this study. Why is he eligible? Because he has potentially fatal pulmonary failure. So it was kind of this really scary call, but Zach had my medical proxy and he said yes to giving me the drug. And that's the decision I would've made too.

And having gone through this now, how do you think these medications should be used?

Unlike you, I have no medical expertise. I have no public health expertise. I'm just a patient who got some things and got well. When you're in a potentially life-threatening situation, I do think your perspective changes and your risk calculus changes. And even though some of these drugs, such as hydroxychloroquine, have documented side effects, to the extent that I was fighting for my life, I mean, I was willing to try anything at that point.

David, you've donated a lot of plasma, as I understand it, and the plasma is the part of the blood that's rich in antibodies. Why did you do this? And what have you been told about your own antibody levels?

So it's interesting. I haven't been told anything about my own antibody levels. I would actually love to know, but a number of researchers at NYU Langone came by and asked us if we would be willing to donate our plasma for research. So I happily said yes. They took from me what seemed like a gallon of blood. They had all these different vials with different color codes, but I think the plasma of people who have been through COVID-19 could be potentially valuable in terms of research or in terms of finding a cure. When I'm stronger, I think I would be up for donating more, maybe even to other patients, but I did donate to researchers and I hope it's useful to them.

So David, right now we're having a big debate in the country about ventilators and the adequacy or inadequacy of the supply, what needs to be done about that. Obviously your life was saved by one in a city that's facing a potential shortage. What do you think should be done about that?

Well, first, I think it's really outrageous that in a country as wealthy as ours, we're even having this discussion. There have been other countries that have been through this that haven't had these types of problems. But the other point I have made about ventilators is they're not a panacea. Many patients don't survive them, but I don't think that reduces their importance. I think if anything, the fact that many patients don't survive means we need to make sure that as many patients as could benefit from them actually get them. I hope that one thing we get out of this crisis is enough of a supply so that if and when we have a future pandemic like this, we are ready.

Well, speaking of things coming out of the crisis, let me ask you one last question, which is, do you think that your experience with this is going to lead you to be more active and involved in healthcare issues, make this part of your professional activities in some way going forward?

Yes, I definitely think so, Ron. I think my tweeting about it and now writing about it as well really struck a chord, and I think these issues are very important. Now, I do also recognize the limits of my expertise. I've been writing mainly from a first-person perspective. I certainly try to talk to experts But I'm trying to share my experience, and I suspect this is something I'm going to be doing for quite some time. Even when this settles down in terms of the immediate crisis, I suspect it will be with us for a while in terms of talking about it, evaluating the response to it, trying to learn lessons from it. And I do hope we learn lessons.

Great. Well, David, we're grateful that you are with us today. We're grateful for your time, mostly We're grateful that you are on the path to recovery. We appreciate you taking the time to chat with us on The Epidemic Podcast.

Thank you so much for having me. It's a, it's a great podcast.

Before we get to our story from the front lines this week, there's something I wanted to share. In the new podcast Making the Call, doctors and hosts Zeke Emanuel and Jonathan Moreno guide us on the code of ethics that are the backbone of modern medicine and are being put to the test by COVID-19. Making the Call will explore the human dimensions of the pandemic and answer key questions like, how do you decide who gets a ventilator? And when there's a vaccine, who'll get it first? Listen each week wherever you get your podcasts as they interrogate critical thinking in a time of crisis and show us what it means to be the ones making the call. About a month ago, I reached out to my old college buddy, Dr. Scott Regenbogen. He's a surgeon at the University of Michigan in Ann Arbor.

My surgical practice is essentially on hold except for urgent and emergency things. Frankly, I think we are as prepared as anybody, but it is scary to see the projections of what 2 weeks from now might look like.

So maybe if you can just describe what are those projections, what do you anticipate?

The expectation is that our supply chain and our physical space will be under real pressures within 2 or 3 weeks. And so, you know, we're a hospital that usually runs at 100-plus percent capacity. We usually have more patients in the hospital than we have beds. We are actively creating space so that right now the hospital feels quiet, but the pace of activity is huge.

And so what does that look like? You know, for somebody who— like, you and I work in a hospital, so I have some sense of what you might be talking about, but what are you actually doing?

The first thing was identifying anybody who would normally be in our hospital who could safely not be here. So that's mostly elective surgery. But elective is a really hard word because much of elective surgery is not really just totally by choice. It's things that affect people's health that need to be taken care of. And we had to assess whether there were things that could be taken care of weeks or months from now without excessively harming patients. So we went from a hospital that's usually overcapacity to a hospital with, with space, mostly by reducing operations that we thought could safely wait. Now, you know, as you walk around, there are, there are empty beds, there are empty intensive care unit beds, something that we almost never have. We have to have plans in place to deal with missing workforce if people get sick or need to be quarantined on isolation, and we are beginning to organize our whole structure around how to take care of a different set of patients.

Do you have concerns about your PPE stock right now, and where are you at with that?

That is, for us, a big concern. It's clear that we are using protective equipment at a rate that will not be sustainable through weeks of seeing patients. We'll have to rethink what the recommendations are around when to use certain pieces of equipment. I do think the protective equipment issue is the one that needs a lot of attention because it seems like a problem that can be overcome with massive dedication of resources and industry. And it's the one that could potentially really limit our ability to safely take care of patients. It's scary and it's a lot, it's a lot to have riding on our shoulders right now.

Scott and I caught up again yesterday. A month ago, That feels like a lifetime ago now.

It was funny for me to read the transcript and look at my calendar, like when that conversation happened. It's just unbelievable what's happened in that amount of time.

You know, I've been following the news out of Michigan. I've been really concerned because obviously Detroit is one of the areas after New York that's been hit really hard. Can you talk a little bit about what's happening in the Michigan area, you know, and how you guys are dealing with that?

Yes, when we last spoke, we really had no good feel for the actual case volume. I don't think we recognized yet that Detroit was gonna be a real epicenter, but the modeling, even at that point, suggested that we were gonna be at a point where we had probably 8 to 10 times as many patients as we could house in our hospital. So we put, you know, we had a huge phase-up plan with 3 potential field hospital spaces, but it now looks like we probably won't need it. So what's happened in Michigan is sort of 2 important trends. The first important trend was that the 2 counties that we draw from most heavily, which are Washtenaw and Livingston County, the counties right around Ann Arbor and Brighton, Michigan, they very rapidly reacted to the stay-at-home orders, there was a massive reduction in mobility and a very abrupt change in the growth rate that probably happened right after the governor's order, which would have been like kind of 24th through 27th of March. And what you saw was we went from that 3-day doubling period where we were just tracking right with these terrifying models. And if you sort of back-calculated how much social isolation there was amongst Washtenaw County, where Ann Arbor is, it was something on the order of 80, 90-plus percent reduction in the interactions between people. Suddenly our local epidemic came to a halt very quickly. Detroit was a little slower, and I think all the narrative around socioeconomic disadvantage and its effects on people's ability to isolate— this is a perfect example when you compare Washtenaw and Livingston Counties to the tri-county area around Detroit. Now, that being said, we still, you know, we're still having 1,000+ new cases per day. Our deaths per day have not really slowed. But what's really changed is the proportion of critically ill patients we're taking care of is actually substantially higher than expected. So what's happened is we, we had to build out our capacity for intensive care in this hospital. We nearly doubled the number of available ICU beds. And now what the challenge is going to be is how you keep it staffed, because we're really making use of every critical care expert in our institution all at once. And it's not really clear how long we can sustain that. So I think what's been really interesting is the difference between the things that I thought would be our biggest challenges and what have turned out to be the challenges we have going forward are not all the same things.

What did you think the challenges would be and what did they turn out to be?

So for example, we worried about PPE and it turns out we've had a reasonable supply of N95s. It's been touch and go on certain days and we've had to be really creative about sourcing and policymaking, and we've instituted reprocessing that we never thought we would have done before. So to say that PPE supply was not a problem would be completely false, but we've come up with creative ways to keep everyone safe. Likewise, I think we all thought that ventilators were going to be a problem. We'd have to figure out how to make really hard ethical choices about who would put on a ventilator. It turns out ventilators haven't been our problem. The thing we've had to very carefully decisions about are the CRRT machines, the continuous renal replacement therapy machines that do continuous dialysis, and we've had to be very careful about ECMO. ECMO stands for extracorporeal membrane oxygenation. It is essentially putting patients whose lungs are in such bad condition that even a ventilator is not keeping up with what they need. We solved the ICU capacity problem by just building out and making huge parts of our hospital into ICUs that they hadn't been before, but we haven't yet solved the people problem of how do you keep it staffed with enough critical care staff. Last time we spoke, we were in the midst of very careful kind of staffing model development on the assumption that we were going to deal with a lot of sick healthcare workers. That was the experience in Italy. And that's really not been the case. I mean, I'm really proud actually to say that we've had very few of our employees get seriously ill.

Can you speak to why Detroit has been hit so much harder than the Ann Arbor area?

The epidemic in Detroit was a real combination of it being a portal. So the Detroit airport is a very important connector to Asia in terms of air transport, and not to mention the auto industry, which connects them with Asia. So I think we had people going back and forth between the origin site and our region. Compounding that with real socioeconomic differences between Ann Arbor and the Detroit area, so a lot more poverty, a lot more kind of dense residential living, probably lots more use of public transport in an area that is pretty geographically dispersed, so people who are on buses for a long period of time, probably a population that was much less economically capable of social isolation, you know, in Ann Arbor, frankly, You have a lot of people who have the internet at home who do jobs that can be done from home versus service jobs and others that were still having to go to work every day. And then I think the last thing is testing. And then compound that with, I think, what you've seen a lot of attention to, which is the kind of racial and socioeconomic disparities. And I think all those things created a circumstance in our region that resulted in us suddenly becoming one of the real epicenters in the country. I'm also concerned about as things maybe slow down in the epicenter around Detroit, I worry about some of the other cities. The city and the region I'm watching kind of right now is the Flint and Genesee County area. Flint is another city with substantial socioeconomic deprivation. Nationwide, people know about Flint from the water crisis, which really unearthed, you know, real racial and socioeconomic challenges in Flint. I worry about Flint for all those reasons. It's a potential area for rapid case growth.

What are you thinking about moving forward? What are you worrying about? I mean, you sort of touched on that with Flint, but like big picture, what are the things you're thinking about now?

As an institution, what we're thinking about is, I think, two big categories. Number one, how do we handle all these patients who are currently critically ill, and how do we manage that long, long tail to get all those patients through their course, which is probably, as I say, going to take weeks to months. And then the second part is, how do we manage the recovery phase of the rest of our operation? We already had clinics and operating rooms that were operating at full capacity. And now we have a month or more of backlog of patients who have real problems, who really need to get into our system and we need to get taken care of. Because I'm really worried also about people who may have on their own restricted their medical care simply out of fear. And I do worry about the fact that there's a secondary kind of epidemic of people whose other problems get worse because we didn't take care of them when they were needed.

As of Sunday, Michigan had reported almost 25,000 cases of COVID-19, including almost 1,500 deaths. The Michigan case curve is just as steep as New York's. African American communities, which have suffered from health disparities for generations, and people living in nursing homes are bearing the brunt of this. Although African Americans account for only 14% of the state's population, they account for 40% of deaths from COVID in Michigan, and 35% of all confirmed COVID deaths have been among nursing home residents. The lack of testing remains a major challenge to curbing the spread of disease. The epicenter of the battle in Michigan is in Detroit, but other cities like Flint, Michigan, where the drinking water was contaminated with lead, where public health has deteriorated in recent years or was never a priority, remain in great danger. Epidemic is brought to you by Just Human Productions. Today's episode was produced by Zach Dyer and me. Our music is by the Blue Dot Sessions. Our interns are Sonia Baradwa, Isabel Ricci, and Claire Halvorson. If you enjoy the show, please tell a friend about it today. And if you haven't already done so, leave us a review on Apple Podcasts. It helps more people find out about the show. You can learn more about this podcast, how to engage with us on social media, and how to support the podcast at epidemic.fm. That's epidemic.fm. Just Human Productions is a 501(c)(3) nonprofit organization, so your donations to support our podcasts are tax deductible. Go to epidemic.fm to make a donation. We release Epidemic twice a week on Tuesdays and Fridays, but producing a podcast costs money. We've got to pay Zach, so please make a donation to help us keep this going. Check out our sister podcast, American Diagnosis. You can find it wherever you listen to podcasts. Or at americandiagnosis.fm. On American Diagnosis, we cover some of the biggest public health challenges affecting the nation today. In Season 1, we covered youth and mental health. In Season 2, the opioid overdose crisis. And in Season 3, gun violence in America. I'm Dr. Celine Gounder.

And I'm Ron Klain.

Thanks for listening to Epidemic.