“The other point I 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.” –David Lat, COVID-19 survivor
In today’s episode, Ron Klain and Dr Celine Gounder speak with David Lat, a 44-year-old legal journalist who endured days unconscious on a ventilator to survive COVID-19. Still on a path to recovery, he shares his experience and the impact the disease has had on his family and his career, and how he is making a contribution to research going forward.
This episode also includes a first-hand account from a frontline healthcare provider in Michigan, Dr. Scott Regenbogen who candidly discusses how doctors are preparing for potentially very difficult decisions in the weeks ahead.
Celine Gounder: I’m Dr. Celine Gounder.
Ron Klain: And I’m Ron Klain.
Celine Gounder: And this is Epidemic. Today is Tuesday, April 14th.
Ron Klain: 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 survive 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.
Celine Gounder: 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.
Ron Klain: We’re delighted to be joined on the podcast by David Lat. 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.
Ron Klain: 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 at David Lat on Twitter.
Ron Klain: David, welcome to the show.
David Lat: Ron, Celine. Thank you so much for having me.
Ron Klain: David, you’re a young, relatively healthy person. How did you wind up so sick with COVID?
David Lat: 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. It didn’t stop me from finishing the marathon twice, admittedly, a long time ago. Not very fast, but I finished it or didn’t stop me from exercising at the gym doing high intensity interval training classes.
David Lat: 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.
David Lat: Uh, I’ve been tweeting about my coronavirus battle, and I heard from one woman. Who found it 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.
David Lat: 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.
Celine Gounder: How did your symptoms come on?
David Lat: So initially, uh, I started getting symptoms the weekend of March seven to eight, and it was just fatigue, uh, just an intense tiredness.
David Lat: 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.
Ron Klain: And in the middle of this, David, right, you went to the emergency room and you could not get tested.
David Lat: That’s right. Like many Americans, I had that frustration. I went to the emergency room with flu like symptoms. Uh, they gave me a cold/flu test, which determines whether or not your symptoms are caused by a common strain of a cold or flu.
David Lat: 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.
David Lat: That was on Monday, March 16 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.
Celine Gounder: 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?
David Lat: So I was admitted to the hospital on Monday, and sometime after that, my father, who’s a physician, uh, 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, a very late at night, someone I can’t remember who came into my room and said,
David Lat: Your oxygen levels are dropping. We are going to have to intubate. We’re going to have to put you on a ventilator.” And remembering my father’s words, I was terrified.
Celine Gounder: How was your husband informed about this? And I think your son’s only two. What kind of conversation did he have with your son about that?
David Lat: 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. Uh, 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, uh, luckily, uh, it seems my, my parents didn’t get anything from him.
David Lat: I would FaceTime with him from the hospital, but he never really fully understood what was going on. For 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.
David Lat: And he called back. But because the hospital is just NYU Langone, I 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, uh, then, uh, he talked to my parents and told them the news and my parents, my mother started crying and my husband, everyone, everyone started crying.
David Lat: 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.
David Lat: And then they’ll basically keep you under. So for six 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 six 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.
David Lat: 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.
Ron Klain: Talk about the symptoms you still have, obviously your horse and your voice. What other kind of day to day symptoms are you still experiencing.
David Lat: So I’m hoarse, as you mentioned, from my time on the ventilator. Ventilators are amazing devices, but, uh, as I just wrote in a piece for the Washington post, they have side effects.
David Lat: A lot of ventilated patients suffer from cognitive problems or suffer from, uh, more minor things like what I have like this, this damaged voice. Um, they, some sometimes suffer from psychological issues. Uh, luckily I haven’t had any of that. I’ve just had this horse voice. My main symptom is just reduced pulmonary function.
David Lat: I need to rebuild my lungs. Ventilator was essentially doing the work for me, uh, 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.
David Lat: I’m recording this, uh, 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. Uh, you know, just little things like. For a shower, I can’t scan 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.
David Lat: Uh, 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, uh, considering the alternative, I’m, I’m not complaining.
Celine Gounder: 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’ve got hydroxychloroquine with azithromycin. Hydroxychloroquine is the medication that the president’s been talking a lot about, and you got an interleukin-six inhibitor called clazakizumab.
Celine Gounder: What was the discussion between you and your doctors about what to try and why? And did you have a say in this?
David Lat: 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. Um, then the hydroxychloroquine and azithromycin was something they were also using.
David Lat: It was something that my mother, who is a pathologist, uh, was advocating for me to try. She had read some of the literature. Now the literature is 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 clazakizumab 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, um, Zach had my medical proxy, and he said yes to giving me the drug, and that’s the decision I would’ve made too.
Celine Gounder: And having gone through this now, how do you think these medications should be used?
David Lat: Unlike you, I have no medical expertise. I’ve 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 hydrochlorquine 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.
Celine Gounder: David, you’ve donated a lot of plasma, as I understand it, and the plasma is the part of the blood that’s rich and antibodies. Why did you do this and what have you been told about your own antibody levels?
David Lat: 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.
David Lat: 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.
Ron Klain: 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? Uh, obviously your, your life was saved by one in a city that’s facing a potential shortage. What do you think should be done about that?
David Lat: Well, first I think it’s really outrageous that, uh, in a country as wealthy as ours, we were even having this discussion. Uh, there’ve 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.
David Lat: 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.
Ron Klain: 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 health care issues, make this part of your professional activities in some way going forward?
David Lat: Yes, I definitely think so, Ron. I think my tweeting about it and now writing about it as well, uh, 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.
Ron Klain: Right. 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.
David Lat: Thank you so much for having me. It’s a great podcast.
Celine Gounder: Before we get to our story from the frontlines 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.”
Celine Gounder: 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.
Scott Regenbogen: 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 two weeks from now might look like.
Celine Gounder: So maybe if you can just describe what are those projections? What do you anticipate?
Scott Regenbogen: The expectation is that our supply chain and our physical space will be under real pressures within two or three weeks. And so, you know, we’re, we’re a hospital that usually runs at a hundred plus percent capacity. We usually have more patients in the hospital than we have beds and um, you know, we are actively creating space so that right now the hospital feels quiet, but the pace of activity is huge.
Celine Gounder: 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?
Scott Regenbogen: 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 over capacity to a hospital 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.
Scott Regenbogen: We have to have plans in place to deal with missing workforce if people get sick or, or our 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 soon.
Celine Gounder: Do you have concerns about your PPE stock right now, and where are you at with that?
Scott Regenbogen: 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.
Celine Gounder: Scott and I caught up again yesterday, a month ago. That feels like a lifetime ago now.
Scott Regenbogen: 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.
Celine Gounder: 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 it’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.
Scott Regenbogen: Yeah. So 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 going to be a real epicenter, but the modeling, even at that point, suggested that we were gonna be at a point where we had probably eight to ten times as many patients as we could house in our hospital.
Scott Regenbogen: So we put, you know, we had a huge, um, phase up plan with, with three potential field hospital spaces, but it now looks like we probably won’t need it. So what’s happened in Michigan is, sort of, two important trends. The first important trend was that the two counties that we draw from most heavily, which are Washtenaw and Livingston Counties, um, the, the counties right around Ann Arbor and Brighton, Michigan, they’ve 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 to right after the governor’s order, which would have been like kind of 24 through 27th of March. And what you saw was we went from that three-day doubling period where we were just tracking right with these terrifying models.
Scott Regenbogen: 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.
Scott Regenbogen: 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, Livingston counties to the tri County area around Detroit. Now that being said, we still, you know, we’re still having a thousand plus cases, new cases per day.
Scott Regenbogen: Our deaths per day have not really slowed. But what’s really changed is, um, the proportion of critically ill patients we’re taking care of is actually substantially higher than expected. So what’s happened is we had to build out our capacity for intensive care in this hospital. We nearly doubled the number of available ICU beds.
Scott Regenbogen: And now what the challenge is going to be is how you keep it staffed. Cause 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. Um, the difference between the things that I thought would be our biggest challenges and what have turned out to be the challenges we had going forward are not all the same things.
Celine Gounder: What did you think the challenges would be in, what did they turn out to be?
Scott Regenbogen: So, for example, we worried about PPE, and it turns out we’ve had a reasonable supply of N95s. It’s been touching go on certain days, and we’ve had to be really, um, creative about sourcing and policymaking, and we’ve instituted a reprocessing that we never thought we would have done before.
Scott Regenbogen: 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. You know, we’d have to figure out how to make really hard ethical choices about who would put on a ventilator.
Scott Regenbogen: It turns out ventilators haven’t been our problem. The thing that we’ve had to very carefully make 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.
Scott Regenbogen: ECMO stands for extra corporeal 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. Um, we solve the ICU capacity problem by just building out and making huge parts of our hospital into ICU 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.
Scott Regenbogen: 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.
Celine Gounder: Can you speak to why Detroit has been hit so much harder than the Ann Arbor area?
Scott Regenbogen: 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. So, and not to mention the auto industry, which connects them with Asia.
Scott Regenbogen: 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 of it kind of dense, um, residential living, probably lots more use of public transport in an area that is pretty geographically dispersed.
Scott Regenbogen: 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.
Scott Regenbogen: 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 some stance in our region that resulted in us suddenly becoming one of the real epicenters in the country.
Scott Regenbogen: 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.
Scott Regenbogen: I worry about Flint for all those reasons. It’s, it’s a potential area for rapid case growth.
Celine Gounder: 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?
Scott Regenbogen: As an institution, what we’re thinking about is I think two big categories.
Scott Regenbogen: 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.
Scott Regenbogen: 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.
Celine Gounder: 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.
Celine Gounder: 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.
Celine Gounder: 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.
Celine Gounder: “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 Sonya Bharadwa, Isabel Ricke, and Claire Halverson. 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.
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Celine Gounder: 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 one, we covered youth and mental health; in season two, the opioid overdose crisis; and in season three, gun violence in America. I’m Dr. Celine Gounder.
Ron Klain: And I’m Ron Klain.
Celine Gounder: Thanks for listening to “Epidemic.”