S1E20: Not Business as Usual / Geoff Baird & Céline Gounder
“Still, like 90% of our patients are COVID patients. This is still not normal.” -Dr. Celine Gounder
In this episode, our co-host, Dr. Celine Gounder, shares how her experience treating patients at Bellevue Hospital in New York City is different in early May 2020 than it was March and April.
In addition, Dr. Gounder and co-host Ron Klain speak with Dr. Geoffrey Baird at the University of Washington School of Medicine in Seattle on why his hospital was way head of the rest of the country in testing for COVID-19 and what some of the challenges are likely to be going forward.
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Dr. Celine Gounder: I’m Dr Celine Gounder
Ron Klain: and I’m Ron Klain.
Dr. Celine Gounder: and this is “Epidemic.” Today is Friday, May 15th.
Ron Klain: And today we have a very special guest on our podcast. My cohost, 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.
Dr. Celine Gounder: And we’re also going to be speaking with Dr. Jeff Baird at the University of Washington. He is a big reason why the University of Washington and Seattle were so far ahead of the rest of the country when it came to testing for COVID.
Ron Klain: 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?
Dr. Celine Gounder: You know, things really have changed, Ron. I would say I’m heading into the hospital for a shift back in March and April felt almost like you’re like, I dunno, 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 feel like we’re a little bit more in control of things now.
Ron Klain: People are hearing on the news. It’s coming down in New York. It’s better New York. How much down or better does it feel inside Bellevue hospital?
Dr. Celine Gounder: 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 into 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.
Ron Klain: Yeah. I think it’s important to remember things can be better than they were, but still could be a crisis. I mean, if you’re working in one of the city’s largest hospitals, one of the country’s largest hospitals, at 90% of the patients there have COVID. That’s still a pretty big problem.
Dr. Celine Gounder: Yeah, yeah, yeah. No, a hundred percent yeah.
Ron Klain: 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?
Dr. Celine Gounder: More and more. We’re trying our hardest to avoid putting people on a ventilator. And it’s not that the ventilator, per se, make 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 going to 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.
Ron Klain: Describe for me if you can, what kinds of people are you seeing with the more severe cases of COVID.
Dr. Celine Gounder: Yeah. I think overall it’s probably about two thirds men, one-third women. I would say the worst cases tend to be older, but it’s not always. You know, and when I say older, um, you know, sixties seventies 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’ve 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.
Dr. Ron Klain: So Celine early on in this epidemic, we heard that children, to the greater extent, we’re not really getting sick from this disease, but more recently there have been reports of a very dangerous infectious inflammatory disease among children Kawasaki disease. What are you seeing with regard to that in Bellevue hospital?
Dr. Celine Gounder: I am an adult 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. Um, 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.
Dr. Ron Klain: Are you seeing any people, these so-called re-infection 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?
Dr. Celine Gounder: 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 or not? Um, is there intermittent shedding of virus where it’s sometimes they’re shedding the virus, sometimes they’re not. Um, 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 test negative, I really think twice about, you know, do I, do I feel safe not wearing a gown and gloves? You know, do I feel safe not putting on all that personal protective equipment? And there are patients where I still put that stuff on even though they’ve tested negative because I don’t, I don’t quite believe the test.
Ron Klain: 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?
Dr. Celine Gounder: So when you first walk into the hospital, you go through a temperature screening. Um, 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’s 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, and all of that stuff. And. I think one thing that has been really striking to me is just the, 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 loudspeaker. 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.
Ron Klain: That’s great. So great to hear. What a great story. For those of us who are lay people. 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 our families going through as you deal with that?
Dr. Celine Gounder: 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, you know, five minutes apart from each other in the hospital. Um, and having to tell him that, having to tell his, um, son-in-law and his daughter about that, um, that was really hard. And. You know, 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, uh, 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 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, but it has turned out to be a really important thing.
Ron Klain: Do you have the kinds of supplies and protection you need? And how about the rest of the staff of the hospital more generally?
Dr. Celine Gounder: 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 of days, but it’s a much more controlled, safe situation than it was, you know, a month ago.
Ron Klain: 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?
Dr. Celine Gounder: 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.
Ron Klain: 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?
Dr. Celine Gounder: Well, you come into the hospital and you have these homemade posters that are posted at the entrance and in the hallways. Hero’s work here and thank you, superheroes and that sort of thing, which is really pretty cool. Then you also have, you know, folks like Jose Andreas with World Central Kitchen who you know, we talked to in an earlier episode of our podcast. I think episode seven. 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, I think what’s hard for some of us working, uh, in the hospital right now is it feels like we, 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, um, really does make a difference.
Ron Klain: 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?
Dr. Celine Gounder: 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 flat iron 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 you know, with their dogs and their kids, and maybe half of people had masks on. And I have to say, you know, here I am walking with my, my mask on and I’ve been wearing my scrubs and you know, I’m dragging myself back home and there’s a part of me that really was shaking my head of like, Oh, how many of these people are going to be on our wards at the hospital or at a hospital before too long. That, 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.
Ron Klain: 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 and doing that 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.
Dr. Celine Gounder: Well, thanks Ron.
Dr. Geoff Baird: There’s almost no time in really history where anyone cares too much about laboratory tests, clinical laboratory testing.
Dr. Celine Gounder: This is Dr. Geoff 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-19 erupted in Seattle.
Dr. Geoff Baird: It’s about 4% of the national healthcare budget so it gets about that much attention. You know the labs downstairs, the, you know, maybe in the basement and, you know, people don’t see too many people there. Um, a lot of people don’t even understand that doctors work there, like myself. Um, and now, you know, with COVID, basically there’s three things you can do in the medical approach to COVID. You can, you know, socially distance, quarantine, isolate, that sort of stuff. You can do supportive therapy, which means like use like ventilators and things. And then you can do laboratory testing. It’s one of the three things that we can actually do medically.
Dr. Celine Gounder: Geoff and his team have a big job right now.
Dr. Geoff Baird: I worry a lot. And so I really do see my role as protecting folks from stuff that goes wrong. And, um, I, I can tell you I don’t sleep well much anymore. I just, I’m, I’m, I’m sort of constantly worried about things.
Dr. Celine Gounder: 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. Um, 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?
Dr. Geoff Baird: So we had the infrastructure, the people, um, and the resources necessary. And by resources, I do mean money, uh, ready, uh, to, uh, 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, a potential pandemic in China our virology staff went about developing a test for this, uh, 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, um, 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, 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. At the time that we did this we had some departmental reserves and in the, in the span of about a month and a half, I spent nearly all of it, uh, about $20 million. The last thing I would say that ended up allowing us to do this is that, um, 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.
Dr. Celine Gounder: Seattle was really 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.
Dr. Geoff Baird: 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, 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 we had things in coolers sitting around where we had a backlog. And then people were saying, “well wait a second, its taking too long.” So it’s been very stressful, especially since at the beginning, um, working, you know, many, many hours but, uh, 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 that.
Dr. Celine Gounder: So I also read in the Seattle Times this interesting story that involved a couple characters. So you have Anita Nadelson, who’s the Seattle business woman who imports things from China. You have this woman named Strawberry, in China, who she works with, and then you have Jeff Wilke, 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.
Dr. Geoff Baird: You could buy a, a instrument, like a, a box from a manufacturer that does testing, and it might say on the, in the manual can do 3000 tests a day, but if you don’t have the consumables, the reagents, the supplies for it, then it can’t do 3000 so you could either count it as 3000 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 QTIP, but importantly is not a QTIP. Um, there are, uh, it is, 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, to rub cells and viruses onto and to stick them there. And so these swabs have been, uh, has been a real choke point.
Dr. Celine Gounder: So what did you do?
Dr. Geoff Baird: 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 were able to find that we could, could in fact buy some swabs, um, and some tubes of what are called transport media. Um, so that’s what, 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 labs 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, out of China at that time, uh, 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 Wilke, I shot a quick email and said, I have this problem, could you maybe help? And, um, through the story that sort of recounted in the Seattle times there, um, yes, they were able to help and, and Amazon was able to get us these swabs.
Dr. Celine Gounder: 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 what does that mean and how good these tests are?
Dr. Geoff Baird: Normally in the process of FDA. You know, uh, 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, um… We would call them in the business, “lateral flow.” They also look like, um, they look like those point-of-care pregnancy tests. You might get in the drug store where, you know, if you’re a pregnancy test, you put a drop of urine on it. Then you look and see if you get one stripe or two. Um, and for these, uh, COVID tests what 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 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 tasks that have an EUA happened to be some of these lateral flow point of care tests, um, that don’t have as good performance. And so it’s the, the EUA designation itself doesn’t actually mean that it’s, it’s, 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, in a, in a test.
Dr. Celine Gounder: So what problems are coming up because these tests aren’t as reliable as the laboratory testing you do?
Dr. Geoff Baird: It’s the false positives that caused the biggest problem. It sounds really great when someone says the 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. When only 1% of the people actually had it, but you tell another 5% of them that they actually had it falsely, um, 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. Um, 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, uh, to, to have a test perform that way.
Dr. Celine Gounder: So one follow up question about that. So, um, for example, the Santa Clara County prevalent study for a number of reasons, that study has been ripped apart. The study found that over 4 percent 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, may of the people who tested positive may not have been positive at all. Aren’t these studies misleading in a potentially dangerous way?
Dr. Geoff Baird: Yeah. To my knowledge, there’s at least one study, um, so that study that you talked about, and then. Uh, the study that was done, study that was done in Los Angeles too, uh, relied on these lateral flow tests. So, um, 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. Um, 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, anything like that. And so we ended up having to take samples of convenience and samples that are representational of things. A lot of these sero-prevalence studies, the antibody studies to see how many people have antibodies, um, 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 we know 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.
Dr. Celine Gounder: So, Geoff, 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?
Dr. Geoff Baird: 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. Um, and so it’s a, 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, uh, know exactly what level of trust you should put in all the data that that’s been out there.
Dr. Celine Gounder: So, what’s next, Geoff? From your perspective, what are you expecting in the coming months.
Dr. Geoff Baird: 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, uh, till we get a vaccine. Uh, I don’t, I don’t see the, the end in sight before that because, um, what this virus has shown is that it can spread real, real fast. And I’m very, very worried that the states that are starting to open this up, in about a month and a half, we’re going to see another big surge, um, because yeah, you know, the not following the rules. Now, it might not happen. Um, 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 at 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.
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Dr. Celine Gounder: I’m Dr. Celine Gounder.
Ron Klain: And I’m Ron Klain.
Dr. Celine Gounder Thanks for listening to “Epidemic.”