An ER Doctor Prepares for the Worst

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S1: Hey, everyone, it’s Mary. And before we start the show, I just want to acknowledge. Things are so weird right now. I’m recording this in a closet and I’m going to send the audio to a producer who is in Georgia at Slate, is working from home right now. We’re trying to minimize the spread of this corona virus if the show sounds a little different. The next couple of weeks. That is why I’ve got a feeling that some of you probably a lot of you are finding ways to meet this moment. You’re looking out for each other in funny ways. You’re finding little incentives to get your kids to do the right thing, like wash their hands. One parent I saw decided to start each day by drawing little hearts on each family member’s hand in Sharpie. Whoever scrubbed the Sharpie off by day’s end got a prize. So I’m hoping you can help me out. Let me know about what you’re up to. Tell me how you are helping other people. Helping people in your family. Just keeping healthy. Getting by. Even keeping each other’s spirits up. You can do it a couple ways. You can call and leave a voicemail. Our number is 2 0 2 8 8 8 2 5 8 8. You can also just tweet at me. I’m at Mary’s desk. I’ll share your best ideas as much as I can because I think we all need them right now. All right. Here’s the show and just a quick warning, there is a little bit of cursing from the E.R. doctor I talked to, but he is dealing with a lot right now. OK, here we go.

S2: OK. Testing one, two, three, four, five.

S3: Jeremy Foust is a full time doctor and a part time podcaster.

S2: I’m going to check what’s going on.

S1: This thing, he works up at the emergency department at Brigham and Women’s Hospital in Boston. I dialed them up Sunday night around 5:00. He just clocked out.

S4: He got delayed because my fucking headphones are like tied up in my N-95 mask. And I can’t afford to, like, do what I would normally do and just, like, cut it apart. So I’m like untangling my phones so that I don’t dilator.

S3: Hold it. Are you are you having to re-use your N-95 masks?

S5: Yeah, that’s happening nationally at Jeremy’s hospital. They just built a tent out front to screen incoming patients and they’re waiting for the people they know are coming.

S6: The ones with covered 19.

S2: Yeah. Life in the E.R. is professional. Everyone there is absolutely ready for mayhem. And there’s not mayhem. There’s just weirdness.

S3: What’s your schedule like now? Oh.

S2: There was a period where between Wednesday and Saturday, I slept five hours total. And it wasn’t because necessarily I was working clinically. Some of that was clinical. I did work an overnight shift. But unlike every other overnight shift where I usually come home and just have like a little bite to eat and to see my family, I could not stop thinking and working and trying to think, what’s the next thing that I can do to help move things forward? What’s what is happening and what is not happening and how can I be useful?

S1: The main thing Jeremy is trying to figure out is how to test people who did test when to test them and what that information means.

S7: So it’s this balancing act of what I think is the best thing for everyone, which is for everybody to get tested at the same time, realizing that or rationing. We’re here. We are rationing and having to decide who gets the test and who doesn’t, who is high risk and who is low risk.

S3: How many tests were you able to order today?

S7: I couldn’t quantify that. But what I can say is I’m seeing things that I’ve never had to confront before.

S5: Seeing things we’ve never had to confront before. That’s what everyone’s doing. Governors, mayors and doctors like Jeremy today on the show. Jeremy is going to explain what this thinking on the fly looks like in the E.R. and what being in the E.R. has taught him about all the bigger decisions that are happening right now. Decisions about shutting down schools, decisions about disrupting your life. I’m Mary Harris. You’re listening to what next. Stick with us.

S3: So in your E.R. right now, if I show up and I’m coughing and I have a fever, like what happens, it depends on your risk factors.

S7: You certainly are considered for testing. So I wouldn’t say you wouldn’t be tested. Fever, I think, is being taken very seriously. The tricky part is patients who don’t have a fever, that’s really work. It’s hard. Why? Because we don’t know how many of these patients are running around the community with no symptoms or mild symptoms. There are patients in China that we have heard about. There’s case reports. This is the beautiful thing about the medical literature as we’re learning about this every day. And this is progress. But we know that the case reports come out of China where somebody was tested for coronavirus because they were a known exposure. And this at all. So how many symptoms you don’t have to test me on this. I don’t know what will test to you. That’s what I am. I just happened. And that person tested positive. And we know that that person never got any symptoms. And they were covered and they now tested negative for rotavirus. But we also know that that person transmitted it to five people. And that’s both scary because it says, oh, my goodness, we have so many people who can spread this thing, so many vectors. But it’s also a little reassuring because it’s like, oh, people get it and they don’t even know about it. And they might not even be participating in the statistics that tell us how dangerous this thing is in terms of fatality rate.

S3: I mean, part of the reason I wanted to talk to you was because I feel like you’re riding this line. You wrote an article for Slate where you said basically coronavirus isn’t as deadly as you think it is. But then at the same time, you’re advocating for everyone to be tested. Can you square those two things for me? Because I think some people would think those were in conflict.

S2: Totally. Great question. So the headline was coronavirus is not as deadly as we think. And I was specifically referring to statistics that the W.H.O. have saying that the case fatality rate was three points, four percent, 3.6 percent, something like that. And I stand by that. I don’t think it’s that deadly by far. I think it probably is that deadly for a certain population of people. If you look at patients who acquire coronavirus while already hospitalized, they’re sick enough to have already been hospitalized and then they get it from someone else in the hospital. The fatality rate could be high. It could be that high. But what I was trying to get at was for people who aren’t even hospitalized or already been tested. It’s far, far less fatal. And so the numbers are coming down, the more people we test. So my approach to let’s test everybody is actually a way to measure a lower fatality rate. And I think that has a really good effect, measuring a lower fatality rate. First of all, for accuracy, accuracy is good. Second, it ramps down the fear. And third, it makes it so people who have the virus but don’t have any symptoms or their symptoms are too mild that they shrug it off. It says you have the virus. Please don’t go visit your sick, immunocompromised grandmother. And so what I was writing in Slate was that, yes, the numbers that we’re seeing from around the world are a reflection of fact, that they mostly conducted tests on the very, very sick and very few places have had much larger nets and trying to test people in the community. And South Korea is a place that has done that. They had hundreds of thousands of tests, far more than we’ve been able to do. And so what they found was more cases than anybody expected. They had the courage to detect a higher number of cases. But in exchange, they got something else, which is most people don’t die from this, actually.

S3: It’s interesting because I mean, we’re speaking on Sunday evening and I live in York City where the governor and the mayor are talking about these really stringent steps to control spread of this coronavirus. But what I hear you saying is if we had the tests, we might we might not be resorting to as stringent steps. We might be able to sort of target those steps a little bit better because we’d know more what we were dealing with.

S2: Yes, this is called tracing. And I think that one of the reasons we are so panicked as a society right now is that we don’t know what the hell is going on. And this totally matches my experience as an here doctor. I give good news. Good news. You’ve got nothing. Congratulations. You can go home. Patients usually say, oh, it’s wonderful. Sometimes they say, well, wait a minute, why do I have that symptom? But most of them happy. And then there’s the other part that I think everyone knows that we do, which is to break bad news, whether it’s death or a very dangerous diagnosis or a concerning diagnosis. And what I’ve noticed is a lot of times patients are a little bit relieved to hear the diagnosis. It’s kind of counterintuitive, but it kind of like like, you know, I kind of knew something was off. Thank you. Thank you for telling me, like, what’s next. But what I really see that I think it surprises most people. It’s not bad news that they recoil from. It’s uncertainty. And if I tell them I don’t know. That is untenable for people. They just cannot deal with that because then they imagine the worst and they just can do computations in their brain. And depending on the personality, they can sort of react in many different ways. And what’s happening now in society is we don’t know what’s going on in terms of where the virus is and how many have it, how many are going to be affected by it seriously. And so we’re in that sort of uncertainty phase. The most important thing we can do is to remove that uncertainty by testing everyone and knowing where it is. And then we can say, look, it’s not here. It is there. And here’s what you do. And here’s the fatality rate. We think it is. But right now, it’s it’s the panic of the unknown.

S3: I’m seeing this thing here locally. This bifurcation where people with a lot of money and. Time can have a very different experience of this disease than people who don’t have that. And I guess that’s the story that happens every time. Right. But I wonder if you think about that, because you’re in the E.R., which is like the ultimate place where if something’s going wrong, it’s going to land on your doorstep.

S2: Well, emergency departments are also the place where we see social determinants of health and health care disparities play out every day. So what you’re saying makes total sense. This is why I think that a one size fits all blanket approach to social distancing is not only a bad idea, in some cases it can be harmful. It’s a great idea in some areas. I think it’s good. But I felt like no one’s really doing the analysis. And the problem is there are certain situations like in certain neighborhoods, socioeconomics and all this. We’re closing a school could cause deaths because their parents are still going to work and the kids are gonna be watched by grandma or. And if you think you can quarantine children, not only does that not pass the test, we know from past epidemics that people, children in particular, do not follow lockdown instructions. I saw tweets today from another physician saying, oh, my gosh, like schools closed and the kids were out playing basketball.

S8: Yeah, absolutely. And so closing schools does not necessarily count as effective social distancing. In all cases, it counts as social distancing, but it could backfire.

S9: Over the past few days, state leaders have made tough calls to close schools and restaurants and public events while Jeremy and I were speaking. New York City’s mayor was holding a press conference to announce that he was shutting down the largest school system in the country for a month. People had been waiting for guidance like this here in New York. I can tell you that. And while we waited, we watched each other on the streets online. I saw pictures of people at restaurants and I thought, should you really be doing that?

S2: I think that there is a narrative that sort of his judgey against people who aren’t doing enough as if, oh, you’re sort of virtuous signaling by saying I want more closures. Like the more you know, the more you’re asking for closing, the better person you are. But they actually haven’t analyzed where that line crosses in certain situations.

S3: But doesn’t it make us safer to close more things down and just keep to ourselves for a little while?

S2: That’s true. If you can really actually accomplish that. But we know that that doesn’t happen. We know that kids go out. We know that people have to leave the house. I’ll give an example of this. Just historically, San Francisco one hundred years ago was one of the most draconian cities in the country in terms of what they did in terms of social distancing and shutting the city down in order to prevent the spread of the 1918 19 influenza. But San Francisco ended up actually having one of the worst excess case fatality rates of any large city in the world.

S3: It’s funny you bring that up because, of course, over the last couple of weeks I’ve heard so much about St. Lewis, how St. Louis has shut everything down during the 1918 flu and how it did so much better than I think Philadelphia, which didn’t.

S2: Right. Well, this is the thing we see medicinal time in retrospect. We add narrative to these facts. So we had a narrative, oh, St. Louis did it this way. And that’s why this happened. We can’t know that. And San Francisco did it this way the same way. And it had the opposite effect. So no one can explain to me why those three things are different. I was kind of flabbergasted that in The New York Times there was an article basically making the point you’re making, which is, look, the sooner you the sooner you close schools, the better. The more schools distancing you do, the better, because some cities had better outcomes. But on that, guys, same Web site, an academic Web site, which is very, very well curated. There’s a long article about San Francisco and how screwed up that situation was. So it’s like we’re cherry picking. So I’m sure that a lot of these things are good, but I’m very worried. And I have seen data both in the present and in the past that there are areas where it can backfire. And so think about it and figure out what makes sense in your area. And maybe the pendulum is going to swing towards more social distancing now that I was hoping for. But in some areas it might not. And let’s get the pendulum kind of swinging and figure out where it really need to land.

S10: Dr. Foust, thank you so much for joining us. Thanks for having me. I love Slade. I feel like part of the community. I’m proud of the. Do you proud?

S11: Jeremy Foust is an emergency medicine physician at Brigham and Women’s Hospital up in Boston. He’s an instructor at Harvard Medical School, too, and he contributes to Slate. That’s the show. What next? Is produced by Mary Wilson. Jason de Leon Morris Silvers and Danielle Hewitt. Quick reminder here to call us and tell us how you are getting through this very strange time.

S12: Our number is 2 0 2 8 8 8 2 5 8 8. That’s 2 0 2 8 8 8 2 5 8 8. Or you can just tweeted me. I’m at Mary’s desk. Thanks for listening. I’m Mary Harris. I’ll talk to you tomorrow.