S1E20 / Not Business as Usual / Geoff Baird & Céline Gounder

I'm Dr. Celine Gounder.

And I'm Ron Klain.

And this is Epidemic. Today is Friday, May 15th.

And today we have a very special guest on our podcast, my co-host, Dr. Celine Gounder, who is right now working in the nation's oldest hospital, Bellevue Hospital in New York City, treating patients with COVID We're going to start today with a conversation with Celine about her experience on the front lines right now in what remains the global epicenter of this epidemic.

And we're also going to be speaking with Dr. Jeff Baird at the University of Washington. He's a big reason why the University of Washington in Seattle were so far ahead of the rest of the country when it came to testing for COVID.

COVID. Celine, you've worked at Bellevue Hospital on COVID previously. You were in the hospital this week. How is it different now than it was when you were treating COVID patients, say, in April or March?

You know, things really have changed, Ron. I would say heading into the hospital for a shift back in March and April felt almost like you're like, I don't know, heading into the Death Star or something. I mean, it was this sense of impending doom, and you would go in and it just felt like we didn't totally know what we were doing. I mean, not to say that we know everything there is to know about COVID now, but it very much felt like it was trial and error and trying to figure out what works, what doesn't. And so that definitely feels more, at least a little more comfortable now where we have a better handle on, on some of that. And, um, you know, just, just feel like we're a little bit more in control of things now.

People are hearing on the news, it's coming down in New York, it's better in New York. How much down or better does it feel inside Bellevue Hospital?

Yeah, I mean, we definitely have fewer cases. And that said, you still have parts of the hospital that had not previously been used for hospital beds that are still being used for ICU beds. You know, I think one way I measure it is also what proportion of the patients have COVID. And it's still, you know, like when you go in the hospital, it's still like 90% of our patients are COVID patients. So this is still not normal. Part of what concerns me is some of the patients who might have cancer or heart attack or sort of your other run-of-the-mill stuff may be avoiding the hospital right now, may be coming in late. I mean, really this week is the first time I've started to see some of those patients really starting to come in. This is definitely not business as usual. Let me put it that way. We're still very much in a crisis, even if things are better than they were a month ago.

Yeah, I think it's important to remember things can be better than they were, but still can be a crisis. I mean, if you're working in one of the city's largest hospitals, one of the country's largest hospitals, and 90% of the patients there have COVID, that's still a pretty big problem.

Yeah, yeah, yeah. No, 100%.

How is the treatment of patients perhaps different now? Are you guys doing different things to help people get well from COVID than you were doing before?

More and more, we're trying our hardest to avoid putting people on a ventilator. And it's not that the ventilator per se makes somebody sicker, it's just that you do lose some of your muscle strength. And so when you add that weakness to just the weakness of laying in a bed, and then on top of that, the damage that's happening to your lungs, that can be very difficult to recover from. With the inflammation in your lungs that you get from COVID it's almost like your lungs are so stiff, it's like trying to blow air into a brick. And so there comes a point where the benefit of doing that is gonna be pretty limited. And a lot of the patients who get that sick hit sort of this point of no return where, okay, maybe you get them to live a bit longer on a ventilator, but ultimately many of those patients just really don't do well.

Describe to me, if you can, What kinds of people are you seeing with the more severe cases of COVID Yeah, I think overall it's probably about 2/3 men, 1/3 women.

I would say the worst cases tend to be older, but it's not always. And when I say older, you know, 60s, 70s, and above, but we definitely have patients younger than that. Obesity is clearly a risk factor. And you would have thought that having asthma or emphysema or something like that may be a major risk factor for complications here, but because this is a disease that very much is about your blood vessels, it's actually people who have some kind of risk factor for blood vessel disease. So in other words, cardiovascular disease, high blood pressure, if they have diabetes, if they've been known to have a heart attack or a stroke, these are the people who do the worst. You know, as opposed to somebody who might have been a long-term smoker with emphysema, they might be at risk because of the damage their smoking did to their blood vessels, but not necessarily from the damage that was done to their lungs. And that's, that's been sort of surprising.

So, Celine, early on in this epidemic, we heard that children, to the greater extent, were not really getting sick from this disease. But more recently, there have been reports of a very dangerous infectious inflammatory disease among children called Kawasaki disease. What are you seeing with regard to that? In Bellevue Hospital?

I'm an adult, you know, internist, infectious disease specialist. I don't see children myself, but we have a cluster of Kawasaki's cases here in New York City right now. I am hearing about it from my colleagues. And Kawasaki's is basically a disease of basically the two processes I've just described, so inflammation and diseases of blood vessels. So in Kawasaki's, for example, the blood vessels that feed the heart can become inflamed. Children can develop aneurysms. Of those blood vessels, they can have a heart attack. And so this is very much part of this spectrum that you see with COVID It may not be common, but it is a horrible disease when a child gets something like this.

Are you seeing any people, these so-called reinfection cases, in the hospital? What do we know about that, about whether or not having the disease once makes you immune from getting it a second time?

Well, we just do not have the data on that yet. We are hopeful that if you've had the disease that you will be immune, but we definitely are having patients who test positive, then test negative, then test positive again. And how much of that is related to how we sample, you know, are you getting a good enough specimen, um, or not? Um, is there intermittent shedding of virus where sometimes they're shedding the virus, sometimes they're not? Is this just old fragments of DNA of the virus, RNA of the virus that we're picking up, but there's really no virus there anymore? It's really hard to say, but I will say when I have a patient who is positive and then tests negative, I really think twice about, you know, do I feel safe not wearing a gown and gloves? You know, do I feel safe not putting on all that personal protective equipment? There are patients where I still put that stuff on even though they've tested negative because I don't quite believe the test.

So, Celine, I want to move from the disease and the patients to you and your colleagues there at Bellevue. What's it like to do the work you're doing?

So when you first walk into the hospital, you go through a temperature screening. I am walking about 20, 25 minutes across town to get to the hospital, and so They always pick me up as hypothermic. So my, my temperature is too low. And so they keep having to check me different places until they finally decide I'm, you know, without a fever. And so you have to line up and do that. And then you go into the hospital. And once I get to the hospital, once I get up to the floor where we have our offices, I have a whole routine of like wiping down my whole workspace and disinfecting it and then putting away my things and masking up, switching out from my outdoor mask to my indoor mask and putting on, you know, head covering and all of that stuff. And I think one thing that has been really striking to me is just the sound of the hospital. So, you know, back in March and April, it was really, really, really quiet. And that quiet was punctuated by overhead pages every hour or so for a patient who needed to be put on a ventilator. The sounds of the hospital now are really about the excitement for patients when they get to leave. And so a couple of times a day now, the hospital overhead, you will hear Jay-Z's Empire State of Mind played over the loudspeakers. So go see him, tell her to go see him. Tell her to probably go in and come back. And the nurses will come out and they will be in some of the units with their tambourines and their maracas, you know, cheering the patients on as they're leaving the hospital. And there's something super exciting and empowering. It's this amazing feeling of solidarity with everybody who's working there.

That's great. So great to hear. What a great story. For those of us who are laypeople, when we think about doctors, we think about the difficult task of not only treating a patient, but dealing with that patient's families. What's that like, and how are you talking to families, and what are families going through as you deal with that?

Yeah, I think that's one of the hardest things right now because families are not allowed to come visit because of the risk of infection to them. I had a patient recently, both he and his wife were both in the hospital. She was in the ICU, he was on one of the regular medicine wards, and she passed away over the weekend, and he did not get a chance to say his goodbyes even though they were 5 minutes apart from each other in the hospital. And having to tell him that, having to tell his son-in-law and his daughter about that, that was really hard. And I think one of the hardest things that we've been seeing are patients who, even as they're getting better maybe, really anxious to go home because they're getting so depressed being away from family. And that's really, really been hard. And all these people being brought in by ambulances, and they maybe they have their phone on them, but they don't have their charger. And so their phones go dead and then they have no way of communicating with family. And so we have these big boxes of iPhone and Android chargers in our offices now. And, you know, who would have thought that would be part of your supply chain for a COVID response, you know, but it has turned out to be a really important thing.

Do you have the kinds of supplies and protection you need? And how about the rest of the staff in the hospital more generally?

We are in a dramatically better place than we were late March and early April in terms of our personal protective equipment. I no longer go into the hospital worried about that. I mean, it's not to say that it's perfect. You know, we do have to reuse our N95 masks for a couple days, but it's a much more controlled, safe situation than it was, you know, a month ago.

And in terms of safety, Celine, have you tested for COVID? Have you tested positive? And what do you think the state of your own health is?

Yeah, so I have not had any symptoms during all of this, so I've been very lucky in that sense. And Bellevue just started offering antibody testing to its employees about a week ago, So I did have my antibody test last week. I did test negative, and the majority of my colleagues who I've spoken to have also tested negative. So we must be doing something right, you know, so that, that's all good news.

So Celine, you know, New York is famous for being a city that wears its heart on its sleeve in many ways. What are people in New York doing to show their love?

Well, you come into the hospital and you have these homemade posters that are posted in the entrance and in the hallways. Heroes work here and thank you superheroes and that sort of thing, which is really pretty cool. Then you also have, you know, folks like José Andrés with World Central Kitchen, who, you know, we talked to in an earlier episode of our podcast, I think episode 7. World Central Kitchen brings us lunch every day. And it's hard enough to steal away a little time to eat when you're supposed to be wearing a mask all day, like where are you going to go do that? And then for somebody to bring you a hot meal, it really is a pretty, a pretty supportive thing in a way that really matters. You know, I think what's hard for some of us working in the hospital right now is it feels like we've been forgotten, like we had our 15 minutes of fame, and it's not about fame, but it is about knowing that we're here and we're still doing our jobs, that we've been doing our jobs all along, and what that job is. And so for people to be recognizing that and supporting us day in and day out with just a hot lunch really does make a difference.

When you leave the hospital, you talked about your walk to the hospital, how does it feel to walk out of Bellevue and walk home at the end of one of these shifts?

That can be hard. So my walk home from Bellevue, I basically walk straight west from Bellevue from the east side to the west side of Manhattan. And I walk through Madison Square Park right near the Flatiron Building. It was probably 60-ish degrees when I was walking back in the evening, and the park was full of people sitting out on beach towels on the lawn and with their dogs and their kids. And maybe half of people had masks on. And I have to say, here I am walking with my mask on and I've been wearing my scrubs. Dragging myself back home. And there's a part of me that really was shaking my head of like, how many of these people are gonna be on our wards at the hospital or at a hospital before too long? That really stresses me out, honestly. I get it. Look, I wish I could be out on the lawn in Central Park or Madison Square Park too. But I also know what that could cost me and others. And it's really frightening to me to see that.

Well, Celine, on behalf of our listeners, on behalf of people in New York, I just want to say everyone's so grateful for your courage and heroism in doing that, and for your colleagues, and grateful that you continue to both serve your patients in the hospital and then inform all the rest of us about what that's like and what's going on. So thank you for what you do in the hospital. Thank you for what you do here on the Epidemic Podcast.

Well, thanks, Ron.

There's almost no time in really history where anyone really cares too much about laboratory tests, clinical laboratory testing.

This is Dr. Jeff Baird. He's a professor of laboratory medicine at the University of Washington School of Medicine. He's also the man who happened to be in charge of the university's virology testing laboratory when COVID erupted in Seattle.

It's about 4% of the national healthcare budget, so it gets about that much attention. The lab's downstairs, maybe in the basement, and people don't see too many people there. A lot of people don't even understand that doctors work there, like myself. And now, with COVID basically there's 3 things you can do in the medical approach to COVID. You can socially distance, quarantine, isolate, that sort of stuff. You can do supportive therapy, which means use ventilators and things. And then you can do laboratory testing. It's one of the 3 things that we can actually do medically.

Jeff and his team have a big job right now.

I worry a lot. And so I really do see my role as protecting folks from stuff that goes wrong. And I, I can tell you, I don't sleep well much anymore. Just, I'm sort of constantly worried about things.

So we've been hearing sort of this refrain for weeks now that lab testing is a major obstacle to responding to COVID in the country. The University of Washington has really been among those at the forefront of this work. Why were you guys able to ramp up both the PCR as well as antibody testing so much more quickly than most?

So we had the infrastructure, the people, and the resources necessary, and by resources, I do mean money, ready to develop new tests and offer new tests should we need to. When things got to the point where it was clear that there was a brewing potential pandemic in China, our virology staff went about developing a test for this really in January. And most of our barriers were actually regulatory barriers where the CDC and the FDA were limiting who could get testing and who could do testing, et cetera. And when finally the FDA relented, allowed folks to do this testing at other laboratories like our own on February 29th, that was a Saturday, We accepted samples on Sunday and then ran our first clinical tests on Monday, but we had been prepared for it for quite some time. Next reason we were allowed to get started early was simply money, and at the time that we did this, we had some departmental reserves, and in the span of about a month and a half, I spent nearly all of it, about $20 million. The last thing I would say that ended up allowing us to do this is that things started happening here first in Washington State. And so at the time we needed to make some of the investments and buy things, there had not yet been a national run on, on some of these things. And so while there are still very strong constrictions in the supply chain, we were able to at least get a couple things done before everything collapsed.

Seattle was really the the first epicenter for this in the United States. You know, what was it like working in a lab at the University of Washington in Seattle as this was taking off?

There were some terrifying times, honestly, when it was touch and go as to whether or not we were going to be able to test tomorrow, you know, with all these specimens piling up and all this worry out there. We had a Friday night, I still remember, you know, not knowing, you know, if we would have enough supplies to go past, say, 4:00 AM.. And then, you know, we had things in coolers sitting around where we had a backlog and then, you know, people were saying, well, wait a second, it's taking too long. So it's been very stressful, especially since the beginning, working, you know, many, many hours. But, you know, we've also been able to meet a lot of needs too, which has been sort of gratifying. And I, you know, looking back on it, I'm really, really proud of all the people who work in the department. It was actually difficult with some of the staff at the beginning, you know, just telling them they had to go home and actually just, you know, self-care because people were just, you know, doing everything they can and giving every ounce of their body into making sure it got done.

So I also read in the Seattle Times this interesting story that involved a couple characters. So you have Anita Nadelson, who's this Seattle businesswoman who imports things from China. You have this woman named Strawberry in China who she works with, and then you have Jeff Wilkie, I think, who's an executive of Amazon. Do you mind, you know, sharing that story? Because I think at the center of that story is this whole issue with the swabs that we use to collect specimens.

You could buy an instrument, like a box, from a manufacturer that does testing, and it might say in the manual, can do 3,000 tests a day, but if you don't have the consumables, the reagents, the supplies, for it, then it can't do 3,000. So you could either count it as 3,000 or you could count it as zero. And one of the things that we need for that type of testing is a swab. So it, you know, it looks like a Q-tip, but importantly is not a Q-tip. It is a specially made medical device. Some of them look like little pipe cleaners that have lots of little hairs sticking off of them to rub cells and viruses onto and to stick them there. And so these swabs have been a real choke point.

So what did you do?

A friend of mine who works with some factories in China, and she said, well, maybe we could, you know, look at some of the neighboring factories near where the factories that I work with are, and we could see if they could make things like PPE. And she said that one of them had some masks and we need just a few masks. And I said, well, actually, maybe not masks, but what about swabs? And eventually we're able to find that we could in fact buy some swabs and some tubes of what are called transport media. So that's after you stick the swab into someone's nose, you would then put it into a test tube that has some preservative liquid in it so you can then transport to the lab so it doesn't dry out. We made that order. It was going to be quite delayed just trying to get a large shipment of these very large boxes out of China at that time when things were very, very hectic. I had been in a conversation on an unrelated matter with one of the leaders in Amazon, that individual you mentioned, Jeff Wilkie. I shot a quick email and said, I have this problem. Could you maybe help? And through the story that's sort of recounted in the Seattle times there. Yes, they were able to help, and Amazon was able to get us these swabs.

There are a handful now of antibody tests that have an emergency use authorization from the FDA, and then there's a bunch of commercial tests that the FDA have said, you know, you can go ahead and sell, but these have not been granted an EUA. Can you sort of just break down for us what does that mean and how good these tests are?

Normally in the process of FDA approvals, you would have a test, like if you were a big device manufacturer and you want to get it approved, you would go through a very lengthy process. But in an emergency, as you would imagine, they have a fast track and that generates this emergency use authorization or EUA, and that's what's been generated so far. A lot of the tests that have been out there that you've seen and that have been responsible or behind some of these population studies that give, I think, less plausible results are tests that are, we would call them in the business lateral flow. They look like those point-of-care pregnancy tests you might get in the drugstore where, you know, if for a pregnancy test you put a drop of urine on it, then you'd look and see if you get one stripe or two. And for these COVID tests, they basically offer is the ability to prick your finger and put a drop of blood on it. And then if there's antibodies, you could get, you know, two stripes as opposed to one stripe., and those tests do not generally perform as well as the sort of the professional testing that we're doing in the central laboratory. Right now, the tests that have an EUA happen to be some of these lateral flow point-of-care tests that don't have as good performance, and so it's the— the EUA designation itself doesn't actually mean that it's a better test or a worse test, or in the fact that a test doesn't have an EUA right now doesn't mean anything. Now that's, again, FDA approval is worth something, and that's not what I'm saying. I'm just saying that in this case, that shouldn't be the one thing that folks are looking to, to say trust in a test.

So what problems are coming up because these tests aren't as reliable as the laboratory testing you do?

It's the false positives that cause the biggest problem. It sounds really great when someone says a test is 95% sensitive and 95% specific. That means that 95% of the time when someone has the disease, the test will be positive, and 95% of the time when they don't have the disease, it'll be negative. But for this problem, that's actually really bad. You know, when only 1% of the people actually had it, but you tell another 5% of them that they actually had it falsely, you might actually give them confidence that they're immune. You certainly don't want to be telling a few percent of the people that they're immune when they're not. And so really as frustrating as it is, you really want to get to a test that is not 95% specific or not even 98% specific, but like 99.5% specific, and that's really, really hard to have a test performed that way.

So one follow-up question about that. So for example, the Santa Clara County prevalence study, for a number of reasons, that study has been ripped apart. The study found that over 4% of people had already had COVID by April, And if those numbers are accurate, it would mean COVID might be a lot less deadly than we'd feared. But one of the big problems with that study and others like it is that it used one of these lateral flow antibody tests you've been talking about.

They don't have FDA approval.

They aren't all that accurate. In other words, many of the people who tested positive may not have been positive at all. Aren't these studies misleading in a potentially dangerous way?

Yeah, to my knowledge, there's at least one study. So that study that you talked about, and then the study that was done in Los Angeles too, relied on these lateral flow tests. So those are some of the ones that I still worry about when I get, you know, see them and they, you know, they show that, you know, the prevalence is much, much, much higher than anyone ever thought. And a perfectly plausible explanation for that is that the test is just giving a lot of false positives and it's calling a lot of people COVID exposed when in fact they weren't. So ideally it would be great to just test every single human being whether or not they wanted to or not, but that's not realistic. That's not, that's not how medicine works. That's not how consent works or anything like that. And so we end up having to take samples of convenience and samples that are representational of things. A lot of these seroprevalence studies, antibody studies to see how many people have antibodies, could be easily biased by selecting patients. If you went into an at-risk population that was, you know, maybe, you know, living in closer quarters or, you know, we know nurses Nursing home populations are at risk too. If you tested in any one of those, you might see a higher number, and then that might bias your overall assumptions.

So, Jeff, one thing in common here is how fast everything is moving, like the FDA's emergency approvals or even waiving through tests without any kind of approval. Is this impacting these studies too?

A lot of the problems that I just mentioned and that you mentioned too, that's what's supposed to happen in peer review. I mean, that's the point is for, you know, people who are experts to look at these papers and to say, well, you know, that doesn't make sense to me. Did we control for that variable? Did we do this? Did we do that? And none of that has really happened just yet. And so it's, the people want to get data out very, very quickly. And I think there's a reason to do that, but in the absence of peer review, it's actually pretty difficult to know exactly what level of trust you should put in all the data that's been out there.

So what's next, Jeff, from your perspective? What are you expecting in the coming months?

We basically have to do old school epidemiology of contact tracing, testing, et cetera, probably a lot of population asymptomatic testing. So we're talking many, many fold times as much testing as we're doing right now. And we got to hold it through till we get a vaccine. I don't see the end in sight before that because what this virus has shown is that it can spread real, real fast. I'm very, very worried that the states that are starting to open this up in about a month and a half are going to see another big surge. Now, it might not happen.

I don't know.

I'm not smart enough to know what's going to happen, but I do know that what we have been doing has really reduced transmission, this staying away, and some of the places that seem to be opening up right now are doing so maybe even at peaks, not even the decrescendo. We're going to need to do a lot of testing and continue doing what we're doing It's a big bummer. It's going to be tough to do, and it's tough on the economy, et cetera. But if we want to get past this thing, we're going to need to do a hell of a lot more of all the things that we've been doing already.

In our next few Tuesday episodes, we're going to break down some of the science. What does antibody testing mean?

Who's already been exposed?

How do our immune systems respond to the coronavirus? And where are we with a vaccine?

Epidemic is brought to you by Just Human Productions. We're powered and distributed by Simplecast. Today's episode was produced by Zach Dyer and me, Our music is by the Blue Dot Sessions. Our interns are Sonia Baradwa, Annabel Chen, Isabel Ricci, Claire Halverson, and Julie Levy. 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 Zac. So please make a donation to help us keep this going. And 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.