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The bigger picture of covid-19. It's not about the 200000 people who died of covid-19, most of them didn't need to die if we took more aggressive steps. It's an unbelievable tragedy, but the magnitude of the tragedy is so much bigger than 200000 deaths. If you looked in New York City during the surge of covid-19 and you calculate the number of deaths from covid-19, and then you look at the excess death rate, that's what we need to look at. And I guarantee you, when we get to 2021 and we look back and we calculate the excess death rate, that's non covid-19 deaths from 2020, it's going to be exceptionally higher than the five years prior.


Hello from the Lincoln Project and welcome back. I'm Ron Stessel. We are now six months into the coronaviruses pandemic and have seen the death toll rise to over 210000 Americans. We've talked a lot about the Trump administration's lack of a response, but I wanted to get a better understanding of what the impact of covid-19 looks like on the ground over the next two episodes. I'm going to talk to three emergency room doctors about their experiences on the front lines battling the pandemic and how the politics around the coronavirus has impacted doctors on the ground.


Before we dive into this conversation. I want to let you know we recorded this episode before Donald Trump was diagnosed with the coronavirus last week. Our hope is that Trump takes this virus more seriously, but our focus will remain on the millions of Americans whose lives have been deeply affected by Trump's recklessness and lies.


Joining me today are Dr. Dan Bobkoff, who's an associate professor of emergency medicine at the University of Vermont. He's a researcher in cardiac arrest and substance abuse and a graduate of Harvard Medical School. Dan is also an ex Navy SEAL and a founder of Veterans for Responsible Leadership. Dr. Berkoff, thank you for coming back on the show. Pleasure to be back. Thanks. I also have Dr. Natasha Kathuria and our doctor based in Austin, Texas. Natasha is also a global health specialist who completed her fellowship at Mount Sinai Medical Center and her master's of Public Health in Epidemiology at Columbia University.


She's a medical journalist whose work has appeared in outlets like ABC News, CBS Fox and Business Insider. Dr. Kathuria. Thank you for making the time to be with us today. Of course. Happy to be here. Thanks. And Dr. Mortaza, doctor and assistant professor at the University of Arizona College of Medicine, Phoenix, where he runs a basic science lab and traumatic brain injury and hemorrhagic stroke. He's also an attending physician in the emergency department at Valley Wise Health Medical Center.


Doctor, Doctor, thank you for being with us. Thank you for having me.


Dan, I think before we dig in here, I'd love for you to talk a little bit about how the coronavirus is different from many of the other national tragedies that we have seen that have made our way into our living rooms. So, you know, from from the Challenger shuttle to 9/11 to Hurricane Katrina, we we often saw in real time the impact that they had. Can you talk about how coronavirus has been different from those?


Yeah, absolutely. So, you know, coronavirus as any pandemic might that comes into, you know, the United States where we're limited in some ways in discussing it and kind of really bringing the true impact of at home. Certainly, you know, that number two hundred thousand American deaths is is staggering. Other other events that have kind of, you know, been in the national consciousness, whether it's, you know, the Kennedy assassination or the Challenger or something like that, you know, there's a lot of video of that kind of stuff.


So, you know, you've got the Zapruder tapes and you've got, you know, the challenger happened on live TV and all these sorts of things. And because of a health care law, which is called the hip, it prevents us from, you know, sharing information on patients. It prevents, you know, cameras in the hospital. It prevents sort of this kind of getting into the national consciousness in a way that, you know, myself and my colleagues are now, at this point all too familiar with.


So, you know, that that image of a healthy young person or, you know, an elderly person from a nursing home or, you know, struggling for air who can't breathe and is febrile and sweating bullets. And, you know, despite all of the things that we would normally do for someone with COPD or pneumonia or something like that, and those things are not working. We're we're limited in being able to really portray that to an American audience because of the health care privacy laws.


And what impact does that have on our our shared sense of what's actually happening in the crisis that we're facing together, in contrast to some of the other national emergencies where we're able to unify around a common threat?


Yeah, and, you know, it's it's tougher because the virus is you know, unfortunately, we it has become politicized at this point. And, you know, you're either on the team, wear a mask or cannot wear a mask. And, you know, this this virus does not care. You know, if it's a blue or a red state, it doesn't care if you know who you voted for. This is a, you know, a national pandemic for which there is no cure and no vaccine.


And so, you know, where we are as a nation, 200000 dead. I mean, that is that's staggering. That's I'm in a really small state in Vermont, but that's a third of our state just gone. That's the entire Marine Corps gone. You know, these are that's for Big Ten football stadiums just gone. Right. So, yeah, you know, it's you know, one death is a tragedy in a million deaths is a statistic.


And unfortunately, I worry that maybe we're getting to the point where, you know, this is becoming a statistic.


So, Natasha, like Dan said, a lot of the conversation around covid-19 has been abstract or hypothetical for a lot of Americans. So I want to spend some time with you and Mortaza to help our listeners understand what the real effects of covid-19 are for people who contract the virus and and for everyone else. So can you talk about just to begin with, what a shift in an E.R. looked like in June or July and then what it looks like now I'm in Austin, Texas, so I work.


All over Texas, I work in Austin, Houston and near New Braunfels, which is kind of the San Antonio area. So as you guys know, our surge hit much later than New York City after we'd already kind of reopened the economy down here and, you know, during the surge when it hit. New York things are actually very chill here because people were avoiding the E.R., our ears were pretty empty. I mean, it was actually dangerous. Patients were coming in very late for cardiac issues and strokes and sepsis, things that are time sensitive.


So we were actually dealing with the fallout of too much fear during the time where we hadn't hit our surge yet.


And then when the surge hit us, it was kind of, you know, we have this E.R. thread that there's like 20 something thousand doctors in paradox and we all kind of communicate. And it's become really a source of us keeping track of this virus. And it's hitting ERs across the country. And people kept warning us like, hey, if it hasn't hit you yet, it's going to and it's going to look like this. And it was it was like a playbook.


It happened just like that one day. No real covid cases. You hear about it, OK, is it coming?


Is it not the next day, just like a tsunami? You know, everybody coming in has covid. You don't know who has it, who doesn't? You know, we were having trauma patients just getting chest x rays for their trauma, their car accidents and having covered and having no covid symptoms at that point. And, you know, that was the rude awakening of, OK, it's here and it's everywhere, whether we're testing or not testing, you know, it's it's everywhere and you have to gear up.


And luckily for us, we were not in the situation and your city was in which was, you know, our medical management had changed quite significantly by the time it had hit us. So we were much more able to manage these patients and prevent them from getting intubated. So, you know, we were able to do, I think, a phenomenal job with what with the resources we had.


But every day was appalling. I mean, going to work and having to put your mask in a plastic bin or a paper bag and, you know, just wondering, like, when's the time I'm going to accidentally contaminate myself from my mask that I'm reusing for a week? I mean, it was devastating. I saw young patients that we were having to intubate and go to the ICU that were young and healthy with no medical problems.


And then you hear you go home and you hear people tell you that this is a hoax and it doesn't affect anyone who's not over the age of 80. And, you know, it was it was hard. I mean, it was a tough time. And the worst part of it, obviously, the worst part is people dying and people getting sick. But the way that we have to cope with their illness without any loved ones being at their bedside using iPads and FaceTime often for for them to say their last words to their loved ones via FaceTime, and they'll never see them again while they're in the hospital if they don't get discharged.


And that was really hard, very sobering. Murtaza, can you talk about what your experience was in the same time period and where were you working at the time?


Yeah, I think it is sort of a similar experience to Dr. Kazuyo, namely that we were in Arizona and hearing the stories in the Northeast, in particular in New York. And so we try to prep for it and we'll say our department chairmen and medical director were very on top of it and they basically restructured the whole E.R. as well as how well we're using PPE to try to prepare. And in the couple of weeks, in early April and late March, things were looking kind of OK.


And volumes are way down the emergency department. So much so that we're wondering if people are staying home too aggressively. And there was this thought of have we have we over planned for it? Almost. But I'm really glad we did, because, boy, if we hadn't when that surge did come in June, it would have been really bad. It was bad as it was. But if our leadership had been like this, is it real or like, well, this is going to hit us as badly.


We had really been in dire straits. And so when that surge did come in June, as I've mentioned before, I was taken aback and I came off of a shift the week before, had a couple of days off, and I came back in and I'm like, what's going on here, guys? And the residents sort of began to get used to it. But one of the things that people, I think, don't necessarily understand outside the field of medicine is that a lot of medicine is a numbers game.


I guess anybody could sort of imagine that where nobody is 100 percent, you know, Doctor Berkoff, Doctor Kathuria, me, none of us is God. We all have Mrs at some point. And our goal as physicians is to catch as many diseases as we can and the ones we feel fairly confident to, to be safely discharged, we discharge them. And so one of the things that people don't realize is it's not like when it came, all the other diseases went away.


Right. Heart attack still happened. Strokes still happened. People still got in car accidents. There's still people driving, less so. But that was still happening. And what ends up happening is when you get these sick patients come in the emergency department, some of them are borderline. Right. This but this case every day we see this every day, the Bush department, our job as emergency physicians is to know what are the most critical, who are somewhat critical, who are kind of sick and who are definitely safe to go home.


That's our forte. The cardiologist are really good at hearts. Anesthesiologists are really good with anesthesia. Emergency physicians are very good with CPR resuscitation. Doctor Mark-Up is an expert in and also what is a true emergency. That's our job. That's what we're trained for. Isn't an emergency or is this person going to be OK? And as you can imagine, sometimes it becomes a risk benefit thing. We have those discussions with patients and we have it amongst ourselves with colleagues.


But what ends up happening that pandemic, when all the beds are taken and more and more sick people come in and they're being intubated and struggling to breathe, as mentioned? And on top of that, you've got heart attacks and strokes and gunshot victims is when you're on the fence and a patient becomes harder to say, hey, what do you think? Do is it better to stay in the hospital? Is it better to go home for a couple of reasons.


For one, because people know in the hospital there's COGAT everywhere, so they don't want to stay even if they're sick and they're in that tough situation. We were telling a patient like, yeah, you're right, we have COGAT in the hospital, but you're also sick. It maybe it is better if you stay, but you're not really sure, even as a physician, whether that's better or not. And to in The Situation Room, a surgery could be done more quickly.


For example, biliary colic or even a mild gall bladder infection, which normally would say antibiotics and remove the gallbladder. Well, that might get delayed because, you know, maybe this patient will be OK at home for a couple more days because their owners are backed up or they're closed because of covid, unless it's true, true emergency. But what a true emergency is. That definition can change a little bit when there's a pandemic. There are no beds available.


And I think that's one of the things that people maybe outside of medicine don't understand. In particular, as Dr. Berkoff was mentioning, when covid has been politicized, even if you think covid isn't as bad as it is, which is crazy in the hospitals, we were seeing it. So I don't know why you would deny what we're seeing on the ground. But anyway, I don't think anybody thinks that, for example, sickle cell disease magically went away.


And so what I would try to remind people and I would still remind them, is that those diseases are still here. And if there aren't beds in the hospital, the operating rooms are delayed, then what kind of care do you think your loved one is going to get if he or she has a heart attack? Because those are real issues that we've had to face. We still partially face, though it's better now, but having to make those decisions during a pandemic when beds are filled is extremely, extremely difficult.


We were trained to be able to do the right thing for patients, that we continue to do the best we can for all of our patients. But if there isn't a bed, it gets pretty hard. And I want people to understand that.


Yeah. And I want to spend some time on some of the stories that you have to share with us today. But before we do, I think we we probably need to just remind our listeners then of the entire purpose of flattening the curve once we once we moved from prevention to management. Which we'll talk about in a little bit, was essentially to keep the the levels in emergency rooms at a at a manageable level. Right. Can you explain just briefly why flattening the curve became the sort of public mandate before we dig into these stories?


Yeah, it's a it's a good point.


So flattening the curve when when the pandemic comes to a specific community, let's say, you know, Toledo, Ohio, or whatever, you know, the the hospital in Toledo, you know, is going to see a spike and it's going to be higher than their capacity. So the whole idea behind the flattening the curve, we know that in the beginning, people were dying, especially overseas in places like Italy. They were dying because there were not enough ICU beds.


So when you have a certain number of people who would live if there were ICU beds, but they would die without an ICU bed, you know, the effort is to ensure that the number of people who never the number of people who need an ICU that never exceeds that that capacity, that was the whole idea behind flattening that curve. Right.


So if you're able to do that by, you know, canceling the, you know, March Madness or, you know, canceling the rest of the NBA playoffs or what have you, that's what we did.


And, you know, I think the public honestly in the beginning did an admirable job of that. For the most part. You know, we you know, Murtaza was talking about, you know, how people stayed home and almost to a fault.


I mean, I don't know a single E.R. doctor who at this point hasn't seen someone with, you know, severe sepsis because they didn't come in two weeks ago for, you know, what would have been a simple bottle of antibiotics became, you know, necrotizing fasciitis or something like that.


So, you know, the public did their part. And, you know, we largely did flatten the curve. And the science is changing as well.


And, you know, what we thought was the best management early in the pandemic, what the Italians were telling us, what the Spanish were telling us, we've learned that there are, you know, different and better ways to to treat this disease. You know, the it's a we're smarter in our patients, you know? Well, there is no panacea. And we still have people get sick and die from this disease.


We're a little bit better than we were in March, you know, but but flattening the curve was all about buying us time as physicians and health care community to to come up with something and to to not exceed that capacity because we knew that people were going to die if they needed an ICU bed and they were going to get it. So, Dr. Kathuria, did you see those kinds of volume in patients that exceeded the capacity of the hospital that you were working at?


Back in June, July?


So our ears were able to manage it, the ones that I've worked in. You know, I think the bigger issue was hospital capacity and ICU bed capacity, not so much our E.R. capacity, because as you can imagine, our general E.R. volume was lower because of people being afraid to come in for other things. So overall, the volume was lower and we had a huge surge in covid patients. So across the board, we were able to manage it.


But you have to remember, like, you don't ever we don't want to be at 100 percent capacity when any percent of this patient has an infectious disease that can easily spread. And that was where we had a lot of trouble. You know, you have a certain capacity with rooms, a certain capacity with hallway beds, a certain capacity with chairs. And once you you only have so many negative pressure rooms, which are the ideal rooms for these covid patients to prevent other people from getting infected in some areas.


Don't have any not all of the hours that I work in have a negative pressure rooms. And so, you know, you're running a risk of not only every patient coming in, but every member of your staff constantly being potentially exposed to this virus. So I would say the biggest issue that we had was. Not only ICU capacity, but staffing, so, for example, at one of the hospitals I work at, we have intensivists that work and there the ICU doctors and they work in-house all day.


And then at night they're at home. So they come in only for emergencies. Otherwise, other people are managing those patients at night. Anyone crashes, we leave the E.R., the E.R. doctor, we run upstairs, we intubate the patient, we run the code, we manage the patient until the ICU doctor comes in house, usually not a big deal. Usually we're able to manage these patients, predict whether or not they're going to decompensate overnight. We kind of know what we're dealing with during covid.


Oh, my God. It was just you can't predict it when they'll, you know, hit this cytokine storm, when they'll quickly become decompensated within hours and these patients are crashing. And at that point, we realize that this is not just a space issue, a ventilator issue, a bed issue. This is a total issue of resources running out of convalescent plasma, running out of room dust. If you're running out of tests, running out of not having enough nurses, not having enough ICU and the doctors, the hospitals are also hemorrhaging money nationwide.


You have no elective procedures which bring in money to the hospital. You've got limited E.R. patients.


Everything that's bringing revenue to the hospital is being cut off.


And so the hospitals are trying to sustain themselves while having to furlough staff while we need those staff.


And so, you know, it was just a nightmare. But things are getting better, we hope.


But I mean, at the peak of things we had just in Texas, we had taken a huge financial hit to all of our hospitals, furloughed a ton of staff and our physicians shifts were changed to help save funding for the hospital where we were working with less resources than ever. And then the surge hit right in the middle of that.


You know, you can't just snap your fingers and bring in another doctor, five more nurses and other necessary therapies. You can't do that. And so we were like, all right, well, we're used to this. We deal with the natural disasters. We deal with emergencies and mass casualties. That's well, that's our training. But we don't deal with it when we are afraid that we are going to die in the process or we're going to contract that patient's heart attack or trauma.


You know, with covid, it was a very unique situation where I'm trying to save someone's life and I don't want to get sick from them and risk my own life or my nurse's life or my restaurant therapist's life.


So a whole nother level of fear. Yeah. So let's let's talk about what it was like during the surge.


So can you first help us understand what it looks like for patients who are hospitalized during that period? And then Doctor, Doctor, I want to I want to go to you next to to hear about your experience.


Typically, of course, this is very different based on the timing of when those patients came in.


They came in in February versus came in in June, July, very different picture. But during our time of managing it during the summer, you know, the typical patient comes in with their symptoms. Either they're really mild and we tell them you can go home. We had no ability to test them. So we could not say, hey, you have covered or you don't. We cannot we could not test anybody who is not being admitted. So we would say, we think you have it.


You should go home, do all of these things, take care of yourself. If you get worse, come back. Do not wait. And we would give them very strict instructions. We would tell them to get a portable oximeter for their finger, things like that, so they could objectively monitor themselves. And then the patients who would need to be admitted typically are hypoxic. So they're really struggling to breathe. Their oxygen levels are low and we're trying to do everything we can to avoid intubating them and intubating.


For those who don't know, it's putting in a breathing tube into the throat, which requires paralyzing a patient and sedating them and is our highest risk procedure for contracting the virus as well. But it is life saving and that is, you know, what we're here for. But we don't want to do that because we know in every patient we want to push that as the last possible resource. So, you know, those patients we would manage, put them on high flow oxygen, whatever we needed to do in the E.R. while containing the virus.


And then there would be admitted whether they if they're critically ill and we think they may decompensate soon and we have rooms in the ICU or if they're already getting intubated in the E.R., they're going to the unit. And when they go to the ICU, you know, they've got 24 hour care. They've got, you know, everything, but they're totally isolated. It doesn't matter if you go to the. Law, which is just the general flaw, you go to telemetry, step down the ICU, every level of the hospital, they are isolated at that point.


And these are not short stays. These are not things that we give antibiotics there better tomorrow and we send them home. These are they're sitting there. They're heavy rock that we're trying to slowly manage over a long period of time.


And they're going through that all by themselves. There are no visitors to the hospital. You know, it's a lonely, lonely experience and it's palpable everywhere. The staff are feeling it, the patients, the patients, families at home, every one covid admission affects at least 20 people. And and that's the magnitude that we're dealing with. You know, it's not 200000 deaths. It's the millions of admissions for however long times, 20 to 30 that each one of those impacted.


That's a lot of people.


Another thing to you know, medically, this disease is so new. I mean, we don't know the the long term sequelae. So, you know, you hear 200000 deaths. But, you know, I've seen studies where, you know, 20 percent of these people are having, you know, Cardium like heart problems and things like that. You know, this disease has been around for less than a year.


So no, literally no one knows what's going to happen to people five years from now who had covered, you know, the long term damage to the health of our country is is incalculable.


Yeah. And I can imagine that even back in the spring and summer, it was even more of an end. And I have to imagine I mean, correct me if I'm wrong, but the the lack of information or the you know, the the newness of the the virus so-called novel coronavirus. Right. Means that there's a lot of stuff that we don't know about it yet. And so can you talk about having to manage, as you described, a tsunami of of cases of people who have a new disease that we knew you knew very little about at that point?


The hard thing, the best thing I've heard anyone say about covid was a med school classmate of mine who's now an ICU doctor down in Boston.


And, you know, early on, we're talking about hydroxyl chloroquine.


And this was when this French study came out. And, you know, it was tiny, it was underpowered and all these things. And he said I said, you know, what do you think? Do you think this is is going to work? And he said, you know, I think we need to be really humble about what we think we know about this disease because we don't know anything. And that is just such a good way of looking at it.


You know, covid causes problems that we as physicians are familiar with. So, for example, it causes hypoxia, right? If someone comes in and they're blue and their oxygen levels very low, we know to give them oxygen. Right. We know to, you know, to get a chest X-ray. We know to check with ultrasound for, you know, various things. If someone has various lab abnormalities, you know, we know how to, you know, to give IV fluids for someone's kidney function or things of this nature.


Right. So we can treat some problems that covid creates. But we have nothing for the underlying disease. We have nothing for a novel coronavirus that attacks these two receptor in people's lungs. We just we are we're grasping at straws. So I'd be curious to hear what your thoughts are things. But, you know, that's that's some it's just so new and unprecedented that in the beginning, especially in the beginning, we were stuck kind of trying to treat the sequela of covid without really having anything for the underlying disease.


And for our listeners, what does that mean? The sequela? So the downstream problems, like I said, we we know that if someone can't breathe and they're getting tired and they're breathing 45 times a minute, that's unsustainable. So that person needs to be intubated. So, you know, we knew that. We've known that all along. We know that from other diseases, pneumonia or the flu or things like that. But, you know, we don't know how to stop coronavirus 19, you know, Mortaza.


Yeah, no, I think it seems like a really challenging task to ask people to be humble these days because everybody's become an expert. You know, we all went to medicine residency and apparently it's meaningless, at least the way some people view it.


And honestly, I tell people this all the time. I've been wrong multiple times. What, the pandemic. Multiple times what the pandemic. It's amazing. People assume I'm an expert because I'm on TV, but I know almost nothing about it. I feel like because I get it wrong so many times, um, but there are a couple of things that everybody should agree on washing your hands. And I can't believe that. For a while was debatable, I mean, there were people out there who were like, well, it builds immunity.


If I don't wash my hands, that's OK. There's just no better way of putting it. That's just dumb. If you're a six month old who still building his adaptive immunity, then maybe there's something to be said about playing in dirt dust.


If you're 40, that's it. Wash your hands. You're not going to all of a sudden become immune to germs. OK, I don't know why they're adults, including the health care field, who think that not washing hands and eating food builds your immunity. It's preposterous. There are other things that there's a clear consensus on germs. Germs are real. They get spread. Whether you're an adult or a kid, you get germs, you spread them.


OK, there's not some magical ghost going around giving covid. It's spread through germs. And so, for example, if you have a cough and you're cough on someone, guess what? You just made that person fairly likely to get sick. There's no that wasn't ever debatable whether you think it's an aerosol, whether you think it's a droplet, if you're sick, stay home, OK? I'm not going to win a Nobel Prize for that. But Dr.


Kathuria is a global health expert, and I'm sure she would agree that one of the most important things she does in other countries is hand hygiene. In addition, it's to explain to people how infections work. I mean, back in the day, even doctors doing bloodletting and crazy things. And when it comes to covid, how it works is it is very humble which drugs will work, which treatments will work.


But we know something about prevention and it's if you're sick, stay home, wash your hands frequently. And oh, if you have to go out, wear a mask. I mean, I don't know why that's become so debatable. We know that mask facial coverings are a great way of preventing your germs or spreading to others. The best is to just not go out if you don't have to. But if you have to wear a mask and some of these things that you know, that seem so commonsensical, some of these things that you didn't have to go to med school residency for, the fact that that's being debated and sometimes even by people in the health care professionals is just really absurd.


That's really what angers me because we have hundreds of years of data for some of this stuff. And I think people, people from before Abraham Lincoln, to use the moniker of this group, would have known better about how to spread to spread germs than we do, which is really absurd to be in twenty first century America and be doing worse than what we're third world countries and preventing a disease that we know how to prevent the transmission of. That's really what's frustrating to me.


What did you learn while cities like New York were hit with a wave of cases in March and April? And and how were you able to prepare in other states?


Yeah, so I think one of the things our department did was to for one of the perks of being in Arizona. I think Texas is somewhat similar, where in April we could say, listen, don't wait in the waiting room, wait outside, you come in, get registered and you wait outside. You can Dist. in Vermont, it was probably snowing in April, but in Arizona was a beautiful weather. So people are able to stay outside and distance.


And the waiting room was used as more of a kind of like a fast track covid region where we separated people who had other symptoms. But you are right. I mean, upper respiratory infection. So whether that's cough, fever, et cetera, and if they looked like they were pretty good, didn't need to be hospitalized, they were kept in what we thought was a Kowit fast track rule out. So they said we don't have people who are coming in with, say, symptoms or like symptoms being put in the same place as people with potential covid symptoms.


So we were able to separate them and keep people waiting outside until the room was available. Of course, if they were critically sick, they came in. The other thing we did and we learned specifically from New York was a horrible images of people wearing like plastic bags to cover their face. It was ridiculous. We knew what was coming and somehow people didn't have it. It's so crazy. One of the things we did was to plan for them.


Prep for that is to it's to sterilize or so, for example, if you had ninety five masks, we set it up such that after you use them, you sent them to our sterilization unit where they were basically sterilized for reuse again the next day. So you had a couple of masks that you were using, but they were sterilized every time you could kind of rotate through them. So we never actually ran out of a ninety five mess. We never ran out of gowns.


And that really helped because as Dr. Castro was mentioning earlier, one of the fears with physicians was, am I going to get sick? And if you're wearing like a plastic bag, this is New York Yankees on it, there's a good chance you're going to get sick. OK, but if you have ninety five masks and face shields and gowns, you really decrease that risk of transmission to yourself. And by the way, to others, because remember, we're still we're generalists where emergency physicians, that's our specialty.


But we see everything. So we have to pop into the patient who has like symptoms, pop out, wash up and then pop into the patient who's got a broken leg from an accident. And so one of the things is if you don't have appropriate PPE is that not only can you get it, but you can spread it. Others, especially elderly patients who are in the emergency department, and that becomes a real concern for multiple diseases, not just covid.


And so having having had that before. Horror stories made us prepare to be able to have enough PPE, which really made me feel lucky because honestly, there are other hospitals, even in the Valley who are writing out of PPE, had multiple colleagues who had horror stories of how demoralized they were. And then we had health care workers who were getting sick. And it's really upsetting to have health care workers get sick, to have my residents get sick.


I'm supervising them. I care about them when they call out sick with covid. And then you see people partying outside like everything is normal and it's very distressing. And so we took the lessons from New York. Our leadership used them, but unfortunately, not everybody in the population did. And that's the problem. It's not like it's not like people often you see both analogies. And I think that's a great example of how legislation eventually changed. But remember, if you don't wear a seatbelt, it hurts you.


If you don't cover your face when you have symptoms, it hurts other people. And that's the thing about infections that are infectious. And so it doesn't just affect you, it affects other people. And that's why it's so critically important that everybody's on board, because in this case, a bad apple really doesn't ruin the bunch. And we see it we see it in the hospital and then have to manage it.


Yeah. Dr. Kathuria, we we heard a lot about shortages of supplies like ventilators and personal protective equipment, PPE early on in the pandemic, like masks and gloves, which you've mentioned. Can you help us understand how those shortages changed the way you do your job as a doctor and what impact they have on medical care for patients? We heard a lot about ethical dilemmas or just the ethics of choosing who gets a ventilator when you're at capacity and you don't have enough of them to go around.


So I really want to give folks a picture of what those decisions look like and how the shortages that we were facing impacted the real experience.


So I fortunately did not have to deal with ventilator shortages at any time, really during this pandemic, because, as I mentioned, we hit hours during the summer versus New York City that hit it very early on. So we were practicing medicine. We were really managing these patients very differently by the time it hit us. And we had a lot more interventions, medications we were giving. We learned every week or two weeks we had, you know, education coming at us from our E.R. groups across the country to keep us up to date on the literature.


And we were actively learning how to manage covid and what the downstream consequences that were far past, just difficulty breathing in these patients, which were pulmonary embolism. So blood clots in the lungs, heart attacks, you know, all the other downstream effects that were arguably more concerning than just coming in with shortness of breath. And so we were really managing everything differently by the time and so is New York. Everyone was by the time chronologically that we hit our surge.


So ventilator's we were fine, especially in Austin and other hospitals as well. We were mostly struggling with shortages of. Staff and medications, you know, treatment options that we had, we were frequently kept up to date and our administrators did a really fantastic job, just like constantly keeping us in the loop, you know, Zoome calls every week of how many tests do we have? Who can get tested? You know, do we have any convalescent plasma left?


We're running out. Can you please spread the word and get people to start donating blood if they've had covered and recovered? You know, really, that was our big shortage that we were struggling with in the hospital itself. You know, our management would change based on the resources that we had. We we have shortages occasionally. I remember, you know, we've had shortages of normal sailin before well before covid. We've had shortages of certain medications that happen, you know, not that infrequently and we manage it.


We've got other options to use. The what we do in our specialty is just adapt to challenges and we're used to that. But it's very difficult when. You're telling me you're telling the patient that that's coming in with this expectation that it's demanding a certain treatment, you know, with all the knowledge that we have because we're doing the research, we have the medical training to go through the literature. We know what evidence based management of this disease is at that point.


And patients are coming in and saying, I want hydroxy chloroquine when I want this.


Give me that. Why haven't you put me why aren't you sending me home with steroids?


Like, you know, the things that we know is not going to help and may make it worse and likely will make it worse? Yeah, that was very challenging. That kind of shortage of just basic knowledge was very difficult for us. But I would say the most the biggest issue for us at my hospitals was staffing, you know, having enough hands, having enough people there to help, you know, whether that was a physician, roster of therapists, nurses, whatever it was, just having enough bodies of us to go around was very challenging.


I want to dig into something that you just said about having a shortage of information, a shortage of knowledge, really. I mean, we could call it a shortage of clarity, really. Dan, I want to talk a bit about the politics of this, because we've seen public health and and medicine become politicized like it maybe never has been before over the last six months. I mean, there have always been political debates around or in public health and health care.


But but as it relates to a very specific disease, um, can you help us understand how that has impacted hospital staff and and how it has shaped the way you care for patients?


Well, let me preface this by saying that Vermont is a very blue state and it has one of the lowest covid rates. And in part, it's because it's a rural state. In part it's because we've done a great job. Our public has done a great job in wearing masks. That being said, you know, the asthma, cause I were saying earlier, there's there's very little that we know truly works. But one thing we do know is, is wearing masks, you know, and for some reason, you know, it blows my mind.


We have a president in the United States who, you know, openly mocks people who wear masks to include his political opponents. But, you know, we'll make fun of reporters for wearing masks or saying, I can't hear you with that mask on or things like that.


You know, he's doing everything in, you know, in his power to to mock individuals for taking not their safety seriously, but the safety of other people. So, you know, a White House reporter in the press room wearing a mask is not necessarily worried for their own safety. They don't want to spread covid, which we know is asymptomatically transmitted to other people who were in that room, including, I might add, the president of the United States who was standing at a lectern less than 15 feet away.


So, you know, it's it's unfortunate. And, you know, it gets to the point. It gets to the inadequacy of Trump for the moment.


You know, he has to paraphrase, you know, the Princess Bride, right? He is he's not a man of action.


He's been able to sort of, you know, shirk his way out of responsibilities and, you know, to get by without paying bills, by, you know, cheating in both professional and personal relationships throughout his entire life.


And he went immediately to what he knows and what he knows is being dishonest. And what would have saved lives would be, to be completely honest. You know, the underlying presumption of Donald Trump is that the United States, the American people can't handle the truth. Right. You know, we're a nation that, you know, when when the Japanese bombed Pearl Harbor, FDR went on the radio and said, you know, this is a day which will live in infamy.


He didn't go on the radio and say, hey, you know, this is not that this will be over in a couple of weeks. Right. That's not how leadership is done. You know, so he went to what he knows, which is to be dishonest and say everything's going to be fine and stick his head in the sand. And, you know, we need someone, you know, thank God for for some of the cooler heads like Dr.


Fauci and other folks at the CDC who push back on that. I'm sure behind the scenes, you know, the pushback against some of the political policies from the administration when it comes to light is going to be just gob smacking. But, you know, it's it's you can't get away from the one statistic, which is, you know, the U.S. has four percent of the population and 25 percent of the global covid does. It is worse here than anywhere else, and that is the fault of our leaders.


I just like to jump in real quickly as I've worked in 11 different countries. I've seen everything I've worked with shortages of everything, the most basic things, you know, all over the world and mostly in developing countries, arguably all of them except America. So I've seen. You know, working clinically, what it feels like to work with a shortage of resources and a shortage of staff and a shortage of everything you can possibly imagine.


I never thought ever that I would feel like that in the United States of America. We are supposed to be the leaders of the free world. We are supposed to be number one. We are supposed to set the bar for health care. We pride ourselves in that. Our medical education is, you know, top notch. We are usually on the forefront of everything. We have the highest standards. People are often wonder, well, why can I get this treatment in Europe and why can I get this surgery in South America but not in the United States?


That's because our standards are extremely high.


We don't accept a lot of risk because we want to give the best possible treatment to our citizens here. And we're we're supposed to be on the forefront of all this.


And that has been my experience working in other countries and then coming to the United States, realizing that we we have been and when covid hit, I remember knowing it was coming.


I mean, we all did in the E.R., we were getting alerts, say, hey, there's this virus as was going on in the news, it's going to come to America. You know, even physicians didn't know what to expect there. I've gotten calls from so many doctors since I've been covering this on air being like, hey, I feel so guilty. I was one of those docs at the beginning who said, this is just like the flu.


We're overreacting and feeling just horrible about themselves because they they felt that way. And then they hit they got the surge. And it's crazy to me that this virus went from through, ravaged so many countries, killed so many people. We watched it go country to country to country and come here. We knew it was coming. We saw other countries. You watched them manage it.


And then we acted like it was nothing when it got here.


And we were all in the ERs panicking that if we don't fear this and if we don't respect this virus for what it is and we don't protect our community and our elderly and our parents and our children, everyone, the way that we should, we're going to be right here where we are right now. We we were fearing that. And it's just crazy to me watching how other countries kind of managed it in that, you know, we just kind of let this we just let it do its thing.


And if it if it I say this all the time, I say it to my patients, to to my family. This virus doesn't hit home until it hits home. That goes for physicians. It doesn't hit home personally until it hits your E.R. or your hospital. It goes for human beings. It doesn't hit your heart until it's your loved one or your best friend that that's dying or that you can't go visit in the hospital. It doesn't hit home until your relative with cancer can't get chemo and can't get surgery to get their cancer out because they're worried about covid and they've canceled all non-emergency cases.


Until it affects you in some way, it's really easy to go out and have your your barbecue and pool party and pretend it doesn't matter because it doesn't personally matter to you. And we value our liberty so much in America, which is great. It's we're free. We're it's so wonderful.


But I think this is really pointed out that we we value our liberty so much so that we really don't value our family members and our citizens and strangers the way that other countries do. Thank you to doctors Kathuria Barkov, an actor for being on today. And thanks to all of you at home for listening. You can listen to the second part of our conversation tomorrow. You can find more information about our movement at Lincoln Project US. If you have advice or questions about the podcast, you can reach us, as always, a podcast link and project us.


But please know that even if we don't respond, we read every email we get and we appreciate hearing from you. If you haven't yet, please make sure you subscribe rate and review the show wherever you get your podcasts. This helps us stay up in the rankings so that more voters can find the show and join our movement to defeat Trump and Trump ism for the Lincoln Project. I'm Ron Tessler. I'll see you in the next episode.