Expert Conversations: Managing Resources to Treat COVID-19

In this podcast, Jaspal Singh, MD, MHA, MHS, interviews Ryan Maves, MD, on managing resources to manage patients with COVID-19 when faced with shortages of medications, equipment, staffing, and hospital beds.

Jaspal Singh, MD

Jaspal Singh, MD, MHA, MHS, is the medical director of pulmonary oncology and critical care education, as well as a professor of medicine, at Atrium Health in Charlotte, North Carolina.

Ryan Maves, MD

Ryan Maves, MD, is a professor of medicine and anesthesiology in the sections of infectious diseases and critical care medicine at Wake Forest School of Medicine in Raleigh, North Carolina. 


 

TRANSCRIPTION:

Jessica Bard: Hello everyone, and welcome to another installment of "Podcast360," your go‑to resource for medical news and clinical updates. I'm your moderator, Jessica Bard with Consultant360 Specialty Network.

According to the CDC, by the end of September 2021, nearly 700,000 people died from COVID‑19 in the United States. Dr Jaspal Singh and Dr Ryan Maves are here to speak with us about managing resources when faced with shortages of medications, equipment, staffing, and hospital beds.

Dr Jaspal Singh: Welcome everybody. I'm Jaspal Singh. I'm your pulmonary, critical care and sleep medicine physician in Charlotte, North Carolina and the medical director of critical care at Atrium Health.

I'm here with Consultant360, talking today with Dr Ryan Maves. Ryan, welcome.

Dr Ryan Maves: Thank you so much for having me, Jaspal. It's a real pleasure to be here with you today.

Dr Singh: Our topic today is about this new COVID crisis, and how many surges we've had now in this country. Ryan, you have a unique perspective on this. I don't know if you can introduce yourself. I'm sure the audience would love to hear about your perspective and your background.

Dr Maves: Thank you very much. I'm a infectious disease and critical care physician. I'm just down the road from you in Winston‑Salem, North Carolina, at the Wake Forest School of Medicine where I'm faculty in the sections of infectious diseases and in the sections of critical care.

I actually very recently retired after a 22‑year career in the US Navy where I was clinically an ID physician and an intensivist, and also served as a program director of the Navy's ID fellowship in San Diego and site director for our research group.

Within the DoD, there's a program called the Infectious Diseases Clinical Research Program currently led by Dr Kim Burgess out of the Uniformed Services University in Bethesda, Maryland. This conducts multicenter clinical trials and research at large military medical centers ‑‑ San Diego, Walter Reed, San Antonio, and the like, Madigan up in the Northwest.

What we've spent with an IDCRP and now ongoing here at Wake Forest, our time on is obviously been largely COVID‑related. During my last couple of years in the military, I was able to work with NIH on the adaptive COVID treatment trials, the act, the studies looking at remdesivir, baricitinib and other therapies for hospitalized patients with COVID‑19.

We also have a very large prospective cohort study. It's over 3,000 participants and growing of patients within the military health system with COVID‑19 who voluntarily enrolled in this trial.

We've been following them prospectively over the course of their illness and recovery to better understand both epidemiologic, molecular, immunologic, and other clinical mechanisms, underlying severity of disease. We've started to get out some great publications from EPICC and I'm very excited to see how that protocol goes on. Although I do remember when we were writing it, the EPICC began, it's E‑P‑I‑C‑C, with two Cs, not to be confused with the EMR.

I remember when we were writing the protocol, I made the comment that I've never spent so much time on a study that I hope to never enroll anybody in because we began working on it in January of 2020. Aside from that though, I fell into disaster medicine as an academic interest relatively shortly after finishing my critical care fellowship.

It's a fairly common area of interest for military intensivists to go into. I've had the good or bad fortune, depending on your point of view, to be involved in a number of disasters at various scales and disease outbreaks during the course of my career. I served in Afghanistan in Kandahar at the NATO Combat Hospital for most of 2012 where I was the director of medical services.

Right after my ID fellowship, I lived in Peru for three years and doing research down there. One of the first things that happened shortly after I arrived at was an 8.0 earthquake with the epicenter in the city that I was currently in. I was involved within my own personal disaster of evacuating from the earthquake.

Later on, our team had the chance to support the Peruvian government’s or recovery efforts. From there, I started working on disaster‑related things for the American College of Chest Physicians and the site of critical care medicine writing about pandemic planning and such with a number of great mentors, James Lawler and John Lowe at University of Nebraska, for example, among many others.

Then the pandemic came. All of a sudden the work that had been largely theoretical for much of my career became very, very real.

Dr Singh: Quite a background. Thank you for sharing that. Now, we're knee‑deep in this and my last year‑and‑a‑half has been crazy as like yours has. I'm sure everybody else has.

Dr Maves: Oh, yeah.

Dr Singh: As we're knee‑deep in this, we're in the midst of this, I'll call it third wave. We can argue about what number this is of the wave of patients that we're having. What's different now? We've had issues before.

Early on, I'm going to summarize, we didn't know what we were doing. We're kind of find my seat of our pants, making things up as we go along, all kinds of stuff, but we slowed society down in a lot of ways ‑‑ masking, mandates, social distancing, all the things. That helped us buy a little time, it seemed for a lot of the country, but now things are different.

It seems like we're in a different surge. I was wondering with all the shortages and on all the things that you're seeing, what are you seeing on your side? What do you think we should be focusing in on?

Dr Maves: It's a wonderful question. Certainly, when I was hopeful earlier this year that we would never have to ask. With the first wave of vaccinations, we had a decline in the last big surge and I thought we are all hopeful that maybe all of this would be behind us.

I chair the American College of Chest Physicians COVID task force and we are actually talking about maybe winding down our operations and shifting our focus elsewhere. Sadly, now we are gainfully employed once again.

I think what's different about this...I know many people have said this before me, and much smarter and more eloquent people than me, but this is to a large extent a pandemic of the unvaccinated, as we all know. That leads us to I think some interesting challenges.

We've seen this polarization in our society that has put the unvaccinated and the vaccinated at odds in a way that I think is unique in modern memory. That has got to be a challenge in the bedside for a lot of us about how we approach these patients. I like to think that the overwhelming majority of us have set that aside, just as we set aside the care of a lung cancer patient who still smokes.

At the same time, lung cancer is not a communicable disease and that patient's decision to continue with the habit does not ‑‑ setting aside issues of secondhand smoke ‑‑ directly impact society as a whole. One of the challenges a lot of us at the bedside ‑‑ this will come back to surge planning indirectly ‑‑ have is, the challenge is in maintaining our empathy.

I think that's gotten harder as time has gone on. We're doing it. We're succeeding in doing so, but it does make it hard.

Early on, there was the heroic phase of the pandemic when cities would stop at a certain time of day to applaud for healthcare workers. That time is passed. Those periods of us being called heroes, that came and went. I would say, as a long‑time member of the military, it's a feeling I've experienced before. Now, how does this affect our response?

One part of it is that, earlier in the pandemic, the hardest hit areas tended to be geographically distinct ‑‑ New York, the North West. Later on, other large metro areas. There's still left a pool of staff who could come and provide support to hard‑hit facilities. Travelers could go to New York to backup.

Right now what we have, we have had is a disaster that's affecting all of the country, not uniformly. Obviously, states with low rates of vaccination like Texas, Florida, Mississippi, I think I read the paper today that if Mississippi were its own country, its per capita mortality from COVID would be second only to Peru.

Dr Singh: Yes, we heard the same thing.

Dr Maves: This challenge means that there isn't this pool of people to pull from to augment our staffing, and that affects a lot of how we model our surge responses in response to pandemics.

Where, if you read some of our documents that are grouped with the task force from mass critical care, all led by Dr Jeff Dichter, Dr Asha Devereaux, Dr Vikram Mukherjee at NYU, and myself in a small role of which I'm very grateful, it assumes that there is a pool of people to draw from. For example, using medical and surgical nurses to augment ICU staffing.

To pull from anesthesiology, for example, to provide procedural support in the ICU. Early on in the pandemic that was possible. Hospitals had largely shut down elective surgeries. We could ask people from other regions to provide support and people, I think, weren't as tired. They still had that reserve of extra energy to provide to help beef‑up staffing in a way.

I don't feel like that's possible any more, at least not in the same way. Right now, a lot of our shortages are not some shortages of physical beds but of staff to make those beds operational. There isn't an untapped pool of ICU nurses or med‑surg nurses to augment our capacity in the same way as it was before.

Hospitals are understandably reluctant to shut down a lot of elective procedures. Because, for one reason, a lot of those elective procedures are not that elective. The delayed impact of cancer care, for example, of cancer surgeries, cardiovascular surgeries has a mortality risk that cannot be ignored.

There's a financial need to keep hospitals solvent and they do need to be able to perform procedure so that we can care for others. Lastly, I worry that people are just getting tired. I worry that our colleagues, both in medicine and in nursing, and in respiratory therapy and pharmacy, and others, are starting to feel more worn down.

The burnout threat that haunted critical care for a long time has become much more acute at this last wave, especially because a lot of us saw the end in sight.

Dr Singh: I want to summarize. You've put it a lot there. What's different what you're saying, and correct me if I'm wrong, the politicization or polarization of this aspect of the pandemic, I think things have changed with all the realist staunch aspects of Ivermectin and other therapies that people are really digging deep on, versus vaccination and things that we need to have, for example.

We're going to come back to empathy a little bit because I think ties into burnout. But then the idea how the pandemic's spreading, regional and national. It's no longer just one or two states. Now it's everywhere, in some states, some regions extraordinarily hard hit, including the southeast.

The ability to augment capacity, like you said, is not there for a variety of reasons, whether that be rooms, whether that be operation of the hospital, whether that be help from other disciplines, that's not available to us anymore.

I want to lump in the other part, which is the fatigue, which is coming out in a lot of different ways, including some real concerns about empathy, compassion, all these aspects.

I think it's a great summary, but obviously no great solutions for a lot of these really complex issues. There's one logistic one that you did mention, which I've been struggling with a lot, which is we're back to where we were about shortages of medications. Beds, staffing in a way that I don't think we saw early on the pandemic, at least not where I'm at. I don't know if you can comment on that.

Dr Maves: I think that's a function of geography to some extent. If you talk to our friends who were in Seattle early on, for example, or in New York, they very acutely suffered from that, and I think to some extent, you and I were spared the worst of that.

I was practicing in San Diego during the earlier surges, but even then we saw variability there within the San Diego County where, at the Naval Hospital, we were somewhat spared the worst although we got busy. Whereas a hospital where I had the good luck to moonlight, Scripps Mercy, Chula Vista, it's a small community hospital, with a family medicine and internal medicine residency program.

It is the closest hospital to the Mexican border in San Diego County. So serving a very large Latino population, very large Filipino population as well. We had ventilated patients spilling out into the hallway. Those space considerations became very acute.

Then this even with a very robust load‑leveling system in San Diego County, where the Scripps system and other hospitals would actively try to balance where patients were placed. I think that problem has existed before, I suspect that you and I are just confronting it at a new.

Early on the big fear was ventilator shortages, and the previous administration used the defense production act to ramp up production of ventilators. What we saw was only a proportion of those are what you and I would consider full‑service ventilators. A lot of those would not be adequate for the care of a patient with ARDS.

Now that's not to say these were useless devices, we still have to provide ventilation for say, neurosurgical patients with normal lungs. Similarly, that would fill a need that we could then not have to utilize a full-service ventilator for that patient.

So that kind of thing was a mixed blessing. Medication shortages have been a particular challenge, but, I wonder ‑‑ and this is a thing I wrestle with a bit ‑‑ when I think about our responses to different medication shortages ‑‑ just using that as an example ‑‑ how many of these changes that we are forced to confront.

For example, when you're talking medication shortages, tried to start someone on a ketamine infusion the other day, and we were able to do so. Our pharmacy was wonderful at backing us up in that, but it took some doing.

How many of these medication shortages have been short as fentanyl, hydromorphone, etc. How have we responded to these? One way we have responded is with increased use of enteral sedation in mechanically ventilated patients, and I think, largely successfully.

It doesn't work in every patient and it doesn't work in patients requiring neuromuscular blockade, for example, or the like of people who are on 30 of Levophed, but it works in a lot of patients.

What I wonder is when the dust is settled ‑‑ because all pandemics end eventually, we will not be doing this forever ‑‑ is when we look back, which of these changes that we've adapted in response to shortages, in response to these unique pressures, will turn out to be improvements in care.

I hope that I don't backslide, and go back to using continuous infusions of drugs when I could get away with PRN oxycodone through a dipath. I sincerely wonder about some of these mitigation strategies as genuine improvements and I hope that a number of them turn out to be.

Another good example is actually the more aggressive proning of patients with ARDS. I don't know what your practice out here was, back in San Diego, a few years ago, you basically had to go and rent the giant rotor proner erector set device for a billion dollars a day.

That was the only way you ever proned anyone, and that was a barrier to proning. Now we just prone people in bed, I think that leads to improvements in care down the road.

A lot of these medication shortages. They existed, but they were more geographically limited. I'm hopeful that this increased focus on both alternatives...because it's not just the drug, it's the capability.

If I have access to vec, yes, cisatracurium is easier to use, but vecuronium will work fine. As long as we can preserve capabilities, and people are not excessively rigid in the method by which they provide a certain element of care, I think we can get by reasonably well. Then again, a very...What's the best word I'm looking for here?

Dr Singh: Flexible?

Dr Maves: Flexible is a good word. The word I'm looking for is a view with careful scrutiny into which of our practices that we do routinely, in terms of medication agents, do we just do out of habit? Are those habits something that need to be changed?

Dr Singh: Makes sense. Maybe perhaps look at our systematic approaches, and potentially, really look critically at what needs to happen.

If we can be flexible with certain aspects of whether it be drug delivery, or any shortage, any ventilator usage, then probably we've learned a lot in the last year and a half, maybe we can start applying that, especially if it affects our region.

Dr Maves: Exactly.

Dr Singh: That's helpful. Some parts of the country famously, like in Idaho, invoke this crisis standards of care, which is something you've been very familiar with, with your task force work and such.

I was hoping one of those things like, I think I spent a lot of time last year working on some of that with a local committee. I was hoping to God, "Dear God, please don't let us use this." But it's happening now. What are your thoughts on this and where is this going?

Dr Maves: I will tell you, and I think if we're honest with ourselves, this is not the first time this has been done. Certainly formal implementation. Crisis standards of care ‑‑ as a brief introduction ‑‑ is the idea that in times of extreme shortages of the pillars of disaster response ‑‑ staff, space, and stuff ‑‑ in times of shortages that we need to adapt our standards of care in response to crisis.

There's a continuum of responses to an emergency. Conventional to contingency to crisis. The goal of a lot of this surge planning, this kind of augmentation of staff, is using non‑traditional areas for the provision of critical care like PACUs, or the emergency department.

These sorts of contingency steps, the point of them is to try to prevent entering into crisis standards of care. Part of the idea, and I think the thing where a lot of the focus on crisis standards of care comes in, is in terms of limitations of care.

To put it to the most boldly, you have three vents left and you have five patients. Who gets the vent? A lot of the attention goes around this idea of critical care triage that not our usual triage where we see a patient, the emergency department, and we assess if they can go to the ward or to the intermediate care or intensive unit.

True triage, as in the withholding of care that would normally be a routine. A few elements of that or one are how do we identify the patients most likely to benefit from critical care resources. We focus those resources on those patients. Perhaps if you have a person who has a widely metastatic malignancy and an estimated survival of a month and then you have another person who is a young woman of childbearing age who is also four months pregnant.

That is an extreme example, but we would allocate the one remaining ventilator to the younger person with a higher survival. This is incredibly hard, and I feel fortunate that that is not a decision I've had to personally make at the bedside, although I've written about it quite a bit.

One of the challenges in this is that a lot of the early crisis standard of care models proposed used physiologic scoring systems as a rating scale to say, you have a SOFA score above 11, for example. We believe you are unlikely to survive, and we would not offer that person mechanical ventilation.

The problem is that the data, I would say, does not really support that as a strategy. There is a very nice review done using a state‑level data in the state of Victoria, in Australia, that one can say, "Hey, if we use this kind of SOFA score‑based system," this was published just a little while ago, "how would that help with available resources in our state?"

The answer was not very much because I think, in part, is that COVID is different. That initial baseline physiologic scoring score is not as predictive of survival as we think. That a person who comes in with a certain SOFA score with COVID may be more or less likely to survive than a comparable patient with, say, gram‑negative sepsis.

Dr Singh: I think we all see that, that COVID is different.

Dr Maves: It is.

Dr Singh: It behaves differently. There's a delay sometimes. Patients that are doing well for a few days then all of a sudden, things change or vice versa. They look terrible for a few days then turn around quickly and it's hard to predict. I see that happening.

Dr Maves: Yeah, and the end effect of it is that these physiologic scoring systems aren't predicting the thing we're trying to do. They both miss patients who may have a very high risk of death. They also exclude patients from supportive care who actually may have a pretty good prognosis, all things considered.

Trying to figure out how to select patients under, again, the most horrible of circumstances. A decision that I think none of us ever want to have to make is, what are the real features that actually predict mortality? They may be age, they may be comorbidity and disease, something like the Charlson Comorbidity Index. It may be simple frailty.

There's a large evidence‑based suggesting that frailty is certainly one of the strongest predictors of survival in general critical care populations. This has been seen, or at least described in COVID. There's some series out of the UK that have looked at that specifically. The flipside of all of this is also how do we not amplify inequities in our society by using these sorts of scoring systems?

I gave the example of comorbidity and disease. Comorbidity and disease are often much higher in populations of color. Among black people who have per population, they have a higher incidents of hypertension, say, than other racial and ethnic groups within the United States or groups that have had difficulties accessing care in the past.

Cancer screenings may be deferred or not performed, and then they present with an advanced malignancy. Then we say, "Well, now you can't have a ventilator."

Are we just perpetuating a prior injustice by using a comorbidity index as a tool for ventilator allocation during the pandemic? Because these allocation rules wouldn't apply only to people with COVID. They would apply to all people requiring critical care services.

That's the challenge. In some groups, I'm thinking of Dr Doug White at Pitt, for example, have proposed using something called an area‑deprivation index which is a tool to account for these sorts of inequities as a way to even the playing field for people.

This is a very fraught discussion and I think as a society we're still wrestling with how would we actually do this? When you take the example to Northern Idaho, the panhandle of Idaho between Washington and Montana who is entering into crisis standards of care.

One of the challenges is it's a largely rural state. It has one metropolitan center of any real size, which is Boise. There is one trauma center, one Level 1 Trauma Center that's actually in Seattle, the cares for it. A lot of complex care in Northern Idaho has to be diverted in normal times to Spokane or to Seattle potentially.

Some care could go to Boise, Southern Idaho, can rely on Salt Lake to some extent. You have a limited critical care capacity in normal times. Your typical referral centers, Spokane, Seattle are equally overburdened. Seattle was above its state ICU capacity before the Delta surge hit. The solutions for this have been very difficult.

Dr Steve Mitchell at Harborview Medical Center in Seattle is one of the Washington State's real leaders in this in figuring out how to coordinate ICU care and ICU movement and hospital movement for patients in an overburdened system to provide some manner of load leveling so that you can at least even out the burden in a way that provides optimum care and try to again prevent this transition into crisis standards of care.

I would say this, Northern Idaho declared crisis standards. They're unique in that they're the first ones to say it out loud. I, personally, have not been in this position to make this decision. I have friends and I suspect you may as well who have had to make that decision previously as well.

The decision to remove someone from a ventilator in times of overwhelming crisis. I think that Northern Idaho saying it out loud, shed some casts needed attention on this problem they were facing, because obviously it doesn't just affect COVID patients. We all probably read in the paper about the gentleman who died of an MI after trying to find 40 hospitals to be transferred to for care.

Dr Singh: We don't want to see that happen too often here.

Dr Maves: No. Exactly. That's really the focus on these crisis standards. What's worth saying is that crisis standards of care are still standards. It is not a free for all. These decisions for, say, ventilator allocation should not be made by clinicians at the bedside.

They need to be done by independent teams who are removed from direct patient care, so that the clinician can focus on advocating and caring for their individual patients as best they can.

I hope to potentially remove some of the moral burden to the greatest extent possible from the individual, the individual at the bedside. The other thing is that the decision to transition into formal crisis standards of care is not the decision of an individual hospital. It is a decision of a government. That can be a county government, a state government, the federal government, conceivably.

While we as institutions need to prepare these plans, they first of all need to be done transparently. We can't do this in secret. We have to have community involvement. There are things that are our neighbors in the community we'll think of in terms of justice of equity that may not occur to us on the first pass. They need to be done in collaboration with civic authorities.

The state of Washington, among others, where it was sued early in the pandemic for their prices, standards of care plan under the notion that they were violations of the Americans with Disabilities Act, for example, because they would potentially have disproportionately affected the people, say, living with ALS upon ventilators just as an example.

Dr Singh: It sounds like what you're describing is essentially that the crisis standards of care, I think it's a lot of press and a lot of attention. In reality, it's probably already happening in some shape or form. Because resources are limited, we do to in transplantation work, for example, all the time [inaudible 26:32] .

Dr Maves: Absolutely.

Dr Singh: The idea of that how to do it is important to make sure that you do it with collaboration and through a separate body of work that there's a lot of precedents for this. Some of the things that are proposed currently may or may need to also be looked at critically because they may not be apply things like SOFA scoring or simple scoring allocation system may have some undue consequences.

We're going to be very critical and deliberate how we roll this out. I say publicly announced. What you're saying also gives me hope that basically this is only a crisis standard, but still a standard.

Dr Maves: It is.

Dr Singh: That actually that there's a lot of thought and a lot of good people behind this, trying to work through this and thinking about things like social justice, all those aspects that a lot of us may not find intuitively very easy.

Dr Maves: Absolutely. This will resonate with you. We all know critical care is a concept, not a location. The ventilator is not the center of the ICU. We are the center of the ICU. Our patients, our nurses, ourselves, the respiratory therapists, it's the team that makes it work.

Even those patients who under a crisis standard of care model are, for example, not allocated a ventilator. That doesn't mean we can't care for them. That doesn't mean that we can't provide the best available care, meaning perhaps that would be high‑flow nasal cannula, oxygenation or non‑invasive.

Perhaps it would be good, aggressive palliative care, but we still have that duty to care for all of those patients even if there are certain resources that simply aren't available during that crisis.

Dr Singh: I think that's well said. Dr Maves, we're out of time, but I want to say thank you so much for being on this podcast with us. You've covered a lot of ground related to this current surge of the pandemic. We greatly appreciate expertise.

For our listeners, there's a couple of references on the website. Feel free to peruse those as well. Dr Maves, I just want to thank you on behalf of Consultant360 for joining us today.

Dr Maves: Thank you so much for having me. It was a real pleasure to talk to you. Thank you, again.

Dr Singh: Take care.

Dr Maves: Take care.

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