Coronavirus Conversations:

Bob Wachter

March 17, 2020

Photo by Leslie Walker

This episode is part of a limited series of conversations with people who are being forced to make difficult decisions in a rapidly evolving situation with many unknowns.

If you have a story you’d like to share, you can email us at info@tradeoffs.org.

Listen to the conversation below or scroll down for the transcript and more information.

Bob Wachter, Chair of the Department of Medicine at the University of California, San Francisco (Photo by Noah Berger)

Dan Gorenstein: It’s Tuesday, March 17, and I’m Dan Gorenstein with our latest Coronavirus Conversation, stories of people making difficult decisions in the midst of this pandemic.

Today, from the Annenberg Studio at the University of Pennsylvania, we hear from Bob Wachter who oversees 800 physicians as the chair of the department of medicine at the University of California, San Francisco hospital.

Bob Wachter: It really feels like there is this big wave coming over the horizon, and we can see the peaks of it, but not the full extent of what might be coming.

DG: I talked with Bob on Saturday and then called him back yesterday to get the latest since things are changing quickly. That’s why you might hear a bit of a difference in some of Bob’s answers. 

He says as of Monday afternoon, UCSF had six people confirmed with COVID-19 in the hospital, including two in the ICU, and about 10 more suspected cases. Most visitors are now being turned away. Bob says the hospital started making coronavirus plans months ago.

BW: We developed a command center structure where a number of the senior leaders took over a room in the hospital and began meeting for many, many hours a day to create the system and the structure to make the key decisions. 

DG: Bob wasn’t a part of that initial group but as one of the department heads, he has been in on many of the hospital’s biggest decisions in response to the outbreak.

BW: One of the first things that we did when when this began to hit was contact colleagues at some of the hospitals in Singapore, which is sort of known worldwide for having been particularly good in prior epidemics like SARS. And one of their most important recommendations was you want to create specific geographic places where you’re cohorting these patients. And so in the emergency room, for example, there’s now a triage tent outside our emergency department. We’ve also taken one of the patient floors in our hospital and converted it into coronavirus unit, and that means that right now there are several rooms that are empty. But we think that’s wise because we’d rather them be empty for a few days then tomorrow figure out that we we should reserve more room.

DG: How many beds are in this coronavirus unit?

BW: About 30 out of a hospital that has about 600 beds.

DG: And what is your team estimating? Is 30 beds going to be enough?

BW: It may not be. You know, we are a full hospital. Once you get up to reserving too many beds that are sitting there empty, you are now really dialing down your capacity to take care of real people sitting in the emergency room today with, you know, with terrible asthma exacerbations or other kinds of pneumonia or complications of their cancer. We’ve got real patients with real diseases. If they needed to be in the hospital yesterday, they probably still need to be in the hospital. If we’re taking beds out of service, it’s not at all obvious to any of us where those people are gonna go.

DG: Has UCSF started to postpone or cancel surgeries, procedures?

BW: Yes, right now, the directive is to cancel pretty much all truly elective procedures, surgeries. And the trick there, of course, is to figure out what is an elective surgery. A joint replacement is clearly elective. Someone’s surgery to remove a cancer, they’re not gonna be harmed if you wait a week, but they might be if you wait a month. So it’s not so easy to just say we’re canceling all elective surgeries and procedures. 

DG: Obviously you guys are being very careful and judicious about which surgeries to delay, which patients to not accept from other hospitals. Do you worry? I mean, this is guesswork. Do you worry as a doctor, as a human being, that you guys might be making choices the wrong choice?

BW: Of course. How could you not worry? You know, we’re human beings operating in an incredibly rapidly moving environment with imperfect information. And there’s a huge amount of sharing, you know, it’s actually, I have to say, Dan, this is one of the more gratifying things I’ve ever seen in my long life in medicine, because in the early days, we didn’t have as much testing capacity as Stanford had. We compete with Stanford tooth and nail for patients, and it was a no brainer that Stanford said, we have some excess capacity. We will do some of your testing, and we’re doing the same for other places.

DG: What is your testing capacity like right now?

BW: We’re up to being able to do about 100 tests a day. We still have an algorithm about who gets tested. The people that absolutely need to be tested, we’re able to do that. But our ability to do more widespread testing and meet what seems to be a growing public demand is still quite limited. We are worried about a shortage of some of the materials that we need to do the tests. At this point, if we don’t get more, we may have to dial back our testing by the in the next 7-10 days.

DG: Last question, Bob. What’s your biggest worry?

BW: The biggest worry I have in terms of my professional life is that we will be in that kind of wartime situation where there are patients who are desperately ill, can be kept alive if you have an ICU bed and a ventilator, and we don’t have enough and we have to make those choices that none of us really have ever had to make in in the United States, in memory of who gets that scarce resource. You know, I’d be lying if I said the personal part isn’t real. I’m 62 years old, I have mild asthma, and so, I think all of us, you know, we try to focus on the professional, but you come into work every day and you recognize that you’re also a person. And we all have fears, and they’re not overblown. I mean, this thing, it’s a terrible, terrible thing. We’ve never seen anything quite like it. And so I think all of us are doing what we can professionally, and I’m extraordinarily impressed by the people, by my colleagues. But it wouldn’t be right, and it would be not human to say that none of us have personal fears, because I think we all do.

DG: Bob Wachter, thanks for very much for talking with us.

BW: It’s a great pleasure. Thanks very much for having me on.

DG: You can find all of our Coronavirus Conversations online at tradeoffs.dot.org.

I’m Dan Gorenstein, this is Tradeoffs.

Additional Resources & Credits

COVID-19 Information and Updates

World Health Organization

Centers for Disease Control and Prevention

Johns Hopkins University Coronavirus Resource Center

Hospitals and COVID-19

UCSF Visitor Restrictions

A look inside coronavirus preparations at a major U.S. hospital (Emma Brown, Washington Post, 2020)

Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2 (John L. Hick, Dan Hanfling, Matthew K. Wynia and Andrew T. Pavia; National Academy of Medicine, 2020)

How Should U.S. Hospitals Prepare for Coronavirus Disease 2019 (COVID-19)? (Vineet Chopra, Eric Toner, Richard Waldhorn and Laraine Washer; Annals of Internal Medicine, 2020)

Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy Giacomo Grasselli, Antonio Pesenti and Maurizio Cecconi; JAMA, 2020)

Credits

Music in this episode by Miscellaneous, courtesy of Badman Recording.