Coronavirus Conversations:

Bob Wachter, Pt. 2

Season 1: Episode 19
March 26, 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.

You can hear and read our first conversation with Bob Wachter here.

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

Bob Wachter: The date is a hard question. I’m beginning to feel like Maggie Smith in Downton Abbey, you know, “What’s a weekend?”

Dan Gorenstein: It’s Thursday, March 26. I’m Dan Gorenstein. Over the past few weeks, we’ve talked to people about the tough choices they’re facing during the coronavirus pandemic.

Given how rapidly things are changing, we are reconnecting with some of our guests to provide a window into how the outbreak is playing out over time. Today, from the Annenberg Studio at the University of Pennsylvania, we’re checking back in with Bob Wachter, chair of the department of medicine at the University of California, San Francisco hospital.

Last week, Bob told us he and his colleagues were hunkering down.

BW: It could be a huge tsunami-like hit that then rolls through.

DG: I called Bob on Tuesday, March 24 at 8 a.m. Pacific.

How are things going, Bob? 

BW: It is reasonably calm at UCSF, which is remarkable. We are seeing the number of COVID patients is slowly increasing, but not cataclysmically. We’ve not yet had a death. We see reports from and speak to colleagues in New York where it, in fact, has increased cataclysmically. And it leads to this very odd feeling of not knowing whether that’s going to be us in four days or we’re at least partly dodging the bullet.

DG: We’re reading reports that suggest California is lagging behind New York and other parts of the country when it comes to testing. Do you have the testing capacity that you need?

BW: We are now up to about 400 tests a day. That’s up from 80 about four days ago, and a handful 10 days ago. So, the limiting factor up until yesterday was swabs, which are really glorified Q-tips. There are special swabs that need to be used to get the samples from people’s noses. And we were desperately low on those. Yesterday we got a shipment from the federal emergency supply. It is allowing us to test health care workers who have any symptoms, testing people that are at risk for coronavirus. We’re not testing everybody, we’re not testing asymptomatic people.

DG: Obviously PPE, personal protective equipment, is critical for health care workers. Do you have enough?

BW: We do today because our current standard is not all of them. In fact, the vast minority of them need to use it every day, and that’s a controversial issue. Our current standard is if you were coming to work and taking care of patients who don’t have COVID and seem to be at low risk for COVID, you are not supposed to use any personal protective equipment. You didn’t have to a month ago and you don’t have to now. And that comports with all of the guidelines from the CDC and the WHO.

The tension comes in part from anecdotal experience, from coming from countries like Singapore and from Hong Kong, where one of the things that they did was basically mandate that every worker wears a mask all day long, and they had very low infection rates and seemed to be doing well in COVID and did well in SARS. And based on that Partners System, which is Mass General and the Brigham in Boston has switched to a system where everybody is going to wear a mask every day. If we were to do that, we would run out of PPE in maybe three or four days. And so there’s a lot of discussion about is that the right thing to do? If we had unlimited supply, would we do that? And at this moment, we are choosing not to. We can’t say for sure it’s wrong. And we can’t say for sure that every encounter with a patient who screens negative on the questions is zero risk. It’s not like we’re rationing exactly, but I’d be lying if I said there weren’t people walking around feeling somewhat concerned that they were being under-protected.

DG: When it comes to the standards that you’re using for PPE, you’re following CDC and WHO, World Health Organization, guidelines, and that’s gotta offer some comfort. But then you talk about some of the Harvard teaching hospitals in Boston, which have switched standards, does that leave you feeling that this may be a mistake? That you really should be being more aggressive about the use of PPE to protect staff?

BW: That question has two answers and one is an answer that occurs in a fantasy world that says we have an unlimited stock where you would then say, would a more sort of liberal PPE policy, where the threshold is lower to use it, increase safety marginally and make people feel a little bit less anxious? And the answer is yes. The real world question is in the current state where we know how much we have PPE supplies sitting in the store room, what is the most rational way to keep everybody safe? And I think we’re making good decisions because the alternative, of course, is we say, you know, all right, we’re just going to liberalize the use of PPE. Everybody can put on a mask all the time and people will feel safer for three days until four days from now where we’re out of PPE, period. And therefore, you know, you now have to go in and take care of a patient who we think is at high risk and you don’t have what you need to keep yourself protected.

DG: What steps are you taking to secure more PPE, the gowns the masks, the protective eyewear?

BW: We’re waiting for shipments from anywhere from the federal stockpile, from our suppliers. I get e-mails from faculty who say, I know somebody who knows somebody, you know, who has a contact. It feels like we’re running a mafia loading dock here, you know? Where can they drop off a whole bunch of masks?

Our medical students this weekend who are off from work were standing on street corners in San Francisco with signs saying, “Do you have PPE?” And they got nearly 20,000 masks donated to them from construction companies, from firefighters who had masks left over from fighting the wildfires. It’s really extraordinary and gratifying what we’re seeing in terms of the response from the community. But that will only get us so far.

DG: Bob, last week we talked about UCSF’s decision to put off elective surgeries to make sure you had more room and space for any surge—a tsunami, you talked about. How’s that decision worked out so far?

BW: That has gone well in terms of our ability to execute the plan and the ability to free up space in our hospitals and our clinics to care for patients with COVID or with symptoms that might be COVID. 

DG: Bob says the elective surgery waiting list is now around a thousand patients. And with no COVID surge yet, some at the hospital are wondering if they should start doing those procedures.

BW: When we say elective surgery, it is not having a nose job. It is not plastic surgery. It is you were diagnosed with cancer and we need to remove the cancer. It doesn’t have to be done today, tomorrow or even next week. But, you know, think about putting yourself in that position of that patient. You’re waiting with cancer inside of you. We have surgeons now that are kind of twiddling their thumbs, waiting to take care of those patients. We could go ahead and do that and find out that that was a mistake, because all the sudden the tsunami hits. We’re really trading off the health of our patients that need our services for other things against our ability to care for COVID patients.

DG: What clues are you watching for that you might be on the verge of a New York-like surge?

BW: If we start seeing an uptick in patients coming in and calls into our hotlines from patients, if we start seeing an uptick in our own employees who are calling in sick for work, all those sorts of things may be an early signal.

DG: Amid the many weighty decisions hospital administrators are grappling with, Bob also sees signs of hope.

BW: We had 11 patients in the hospital with COVID yesterday and we have 10 today. And we’re all kind of scratching our heads and saying it’s possible that we will dodge this because of some of the things that were done in the Bay Area and done in California early and probably also just luck. If that’s true, we will be thrilled, although it doesn’t change the fact that it is still really, really terrible in some other places. 

DG: Thanks a lot for talking to us. 

BW: It’s a pleasure, Dan. Thanks.

DG: Join us tomorrow for the next in our series, “Coronavirus Conversations,” the story of one woman who’s lost her job but can’t go without health insurance. 

If you missed earlier “Conversations” you’ll find them in the feed, or at tradeoffs.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

A Look Inside Coronavirus Preparations at a Major U.S. Hospital (Emma Brown, Washington Post, 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)

PPE and Health Worker Safety

Healthcare Supply of Personal Protective Equipment (CDC)

Guidance for Health Workers (WHO)

Keeping the Coronavirus from Infecting Health Care Workers (Atul Gawande; New Yorker, 2020)

Health Care Workers Worry about Coronavirus Protection (Katie Mettler, Arelis Hernández, William Wan and Lenny Bernstein; Washington Post, 2020)

Risk Factors of Healthcare Workers with Corona Virus Disease 2019: A Retrospective Cohort Study in a Designated Hospital of Wuhan in China (Li Ran, et al; Clinical Infectious Diseases, 2020)

Credits

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