Today, Explained - The emergency room emergency

Episode Date: March 26, 2020

The Atlantic's James Hamblin explains why America has a critical shortage of medical supplies. New York City ER doctor Calvin Sun says, “It’s like a lottery that we don’t want to play, but we’re forced to play.” (Transcript here.) Learn more about your ad choices. Visit podcastchoices.com/adchoices

It's Thursday, March 26th, 2020, and the Senate unanimously agreed on something. I'm Sean Ramos-Firman. This is your coronavirus update from Today Explained. Ninety-six United States senators voted in favor of an 880-page, $2 trillion stimulus package late on Wednesday. We made an entire episode about what's included yesterday, but the big news for people earning up to $75k a year is checks for $1,200. The big news for wealthy corporations is a $500 billion slush fund. The House is expected to pass its own version of the bill tomorrow. After that, it's over to President Trump's desk for sharpie time. Unemployment numbers came in from the Labor Department today, and they were staggering in a history-making kind of way. 3.3 million Americans filed for unemployment benefits last week. For context, in well over a half century of collecting unemployment data,

the highest number of claims ever recorded was something like 700,000 in October of 1982. From grim to grim, more than 1,000 people have now died as a result of COVID-19 in the United States. New York is now reporting close to 40,000 confirmed cases. But keep in mind, the true number of cases is expected to be much, much higher. Louisiana has far fewer cases confirmed at the moment, something like 2,000. But the governor there says his state is experiencing the fastest growth of new cases in the world right now, potentially due to Mardi Gras festivities from a few weeks ago. Meanwhile, the president continues his campaign to get the country back to business as usual.

He tweeted on Wednesday, The lamestream media is the dominant force trying to get me to keep our country closed as long as possible in the hope that it will be detrimental to my election success. So lame. Get in touch with Today Explained. Call 202-688-5944 with any questions about the coronavirus or email todayexplained at vox.com. Also, we are on Twitter at today underscore explained.

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One general medicine resident at Elmhurst Medical Center in Queens told the New York Times, the situation there was apocalyptic. The work of healthcare professionals in these hospitals has never been more important, so it's crucial that they stay safe at work and once their shifts end. Go home, throw all my clothes in the laundry, run them right now, and, you know, take a shower. Dr. Calvin Sun is an ER doctor in New York City who's been picking up shifts in emergency rooms across the city, kind of like a freelancer for matters of life or death.

I asked him what life's been like during this crisis. Usually I come in and there's stretchers lining down the block by EMS, or I walk through the waiting room and it's jam-packed. Probably all with presumed COVID-19 positive patients, all spreading it to each other, one another, not really social distancing. When I enter the emergency room, I already have an emergency room filled with stretchers

in the hallways, outside the rooms. Most of the emergency rooms in New York City don't even have dedicated rooms with doors. It's essentially one giant room with curtains and patients only separated by curtains. Emergency medicine physicians and nurses and staff and PAs, mid-level providers, advanced care practitioners, nurses are all in the center and we're all crammed in together in a small space and we try to see as many patients as possible and doing our best to get people who don't need to be there out of the hospital as soon as possible so they don't infect themselves, right? The longer you're exposed to COVID-19, the more likely you're going to get it. So it's essentially think of like a burning building. And we're trying to get as

many people out of this burning building before it collapses. COVID-19 can be airborne. It's aerosolizable. You sneeze, you cough, or you intubate somebody. It then goes in the air and it can survive in the air for three hours. And we are breathing in this air, especially under the context of not being provided enough protective personal equipment, like N95 masks, to be able to prevent ourselves from getting sick. Let's talk more about protective personal equipment or PPE, like those N95 masks you said you don't have enough of, because there's been a lot of talk about shortages, right? I mean, and these aren't fancy masks. I bought a bunch at Home Depot last year. Do you have enough? We're supposed to be switching out N95 masks per patient. However, there are so few N95 masks or just masks in

general that we have to use one single mask over the course of many days. Over many days? Many days, yes. I've worn the same N95 mask for about five days before I was able to get a donation from my friends just recently. I was wearing my personal protective goggles that I had to steal from a bundle kit from another ER that I worked in. That was supposed to be a disposable goggles. I've kept that one for about eight to nine days until my brother gave me his goggles yesterday. And a face shield that was meant to be disposed with, this plastic, flimsy face shield that I got a week and a half ago, I still have. The paint's wearing off on the front.

Wait, you're taking your N95 mask home with you? Like the mask that you use to protect yourself from all these patients who might have COVID-19? Yeah, my stuff right now is in the oven. Because just today, somebody said, well, if you don't have a UV light, which is one theory to disinfect old N95 masks, try putting it in a hot environment that's over 70 degrees Celsius or like 120 degrees Fahrenheit. Wow. I'm guessing that this isn't conventional practice. Yeah. Today was finally a fresh batch. But I'm still that this isn't conventional practice. Yeah. Today was

finally a fresh batch, but I'm still reusing stuff because I never know when it's going to run out again. Is this just a you problem because you're kind of like a, an ER freelancer or are like the full timers who work at these hospitals you go to every day going through this too? No emergency room I know of in New York City has enough personal protective equipment for their entire staff on an unlimited, or at least adequate amount for this pandemic. This sounds bush league. I mean, are you telling me that you wear the same mask,

same goggles, same plastic face shield all day in these hospitals dealing with COVID-19 patients, and then take it home and go back to work and put that same stuff on again the next day? Yes. For the last two weeks, I went in, was able to get a mask on the early stage of the pandemic, but seeing the writing on the wall, I decided to play it safe and then keep that mask after my shift instead of throwing it out. And, you know, rinse and repeat for the face shield and the goggles, anything I got was worth its weight in gold. And I kept it until just yesterday, I got a huge batch of personal donations from friends and family who

came back to my apartment. They literally handed to me and ran away, given what I'm exposed to. And now I have a batch where I can give it to my staff members who've been trying to survive on the same mask in my situation. But only after I went on my social media for two weeks calling for help. It took two weeks. What could have happened those two weeks? I could have been exposed. Other people could have been exposed. Thank God they came out together. But it shouldn't be coming from them. And the doctors and nurses you're working with are reusing masks too? I mean, I used to bring donuts and coffee and pizza for my residents and PAs and nurses and nurse practitioners. Now I bring in masks. Today or this morning, I brought in my donations from my friends and oh my God, people were just taking two or three at a time, putting in their pockets. It's like a lottery that we don't want to play, but we're forced to play. How long can you and your fellow doctors in New York keep this up?

I think if things don't change, I think in about one or two weeks, it may collapse. Collapse how? We don't have enough beds. We don't have enough ventilators. We don't have enough beds. We don't have enough ventilators. We don't have any room. Patients will have to go outside. And then? And then you're going to have to enact New York State's ventilator guidelines that they published on their website in November 2015. Health.ny.gov, I think, is public on the ethical decision making that goes into deciding who gets to get a ventilator or breathing machine to live and who to get palliative compassionate care without a ventilator. Do you know how it works? Who gets to live and who dies?

It is impossible to expect every single clinician to unilaterally decide who gets to live and who gets to die. That's unfair because not all of us have that experience or training in rationing care. It goes to a committee and a committee of ethicists, you know, administrators and doctors takes in the clinical assessment that is provided by the people on the ground and then decides whether to get a ventilator or not. We haven't crossed that bridge there. I think it is hospital dependent. And once we get to that point, I'll get a better idea of what the parameters are. The governor of your state

seems to be taking this pretty seriously. He's been asking for military intervention and more help from the federal government for a while now. But the president seems to be, you know, urging the country towards moving past this to having everyone in the clear by Easter. I mean, if you could talk to the president today, what would you say to him? I would say this is not your lane. You don't know what it's like to be in the trenches taking care of all these patients who are young and healthy, who may die from this, who have spread to other people. You don't know what it's like to come

into the emergency room and know that automatically you're exposed to this virus that you can bring home to your family members. So this is not something that he should comment on. What do you most need right now? We need the military. We need federal support, FEMA. We need disaster infrastructure to be put in place and build a new hospital from scratch with COVID-19 only patients with negative pressure rooms. You activate the millions and millions and millions of dollars that you get when you declare a national emergency. And you put those millions and millions and millions of dollars into building a hospital.

Basically, anyone with COVID-19 gets the best care, the best clinicians, all gowned up in hazmat Tyvek bunny suits, head to toe, so we're all protected, taking care of these patients to the best of our ability, get enough ventilators to take care of the patients that need them, and make sure nobody dies. Then we develop a vaccine by then. And then everyone becomes immune. Once we vaccinate everyone, like we did with smallpox,

we have the money for it. We have the resources for it. But does someone want to pull the trigger and activate all those things? I sense a lot of reluctance because we have developed a habit of trying to find a way to cut corners. And that's how we got in this problem in the first place. All right, Calvin. Well, I really hope you get it. I really hope you all get what you need to stay safe and keep other people healthy as well. Oh, absolutely, too. Because if we don't, in one or two weeks, the system will collapse.

And I want to say that is that we will all get sick, right? A couple of my colleagues are on life support. I'm filling in shifts for fallen sick colleagues, knowing that I might be next. And if there's enough of me who gets sick, and it might be my night turn, who's going to be around to take care of you? Who's left? Thank you. To be continued... and spend management software designed to help you save time and put money back in your pocket.

Ramp says they give finance teams unprecedented control and insight into company spend. With Ramp, you're able to issue cards to every employee with limits and restrictions and automate expense reporting so you can stop wasting time at the end of every month. Thank you. R-A-M-P dot com slash explained. Cards issued by Sutton Bank. Member FDIC. Terms and conditions apply. Dr. Jim Hamblin doesn't practice medicine anymore, but he writes about it for The Atlantic. And way back in January, he published an article bluntly titled, We Don't Have Enough Masks. Yeah, this level of pandemic has been modeled and warned about as a very real possibility. And yet our country did not invest in the preparation that would be required for it.

And why don't we have enough of these masks to begin with? Don't we have like a stockpile or a reserve or something? We're bad at preparation. We have a tough time allocating funds to potential problems, except for the military. We like to pay for huge military. But the stockpile was started as a way of saying, you know, if there's a biological warfare attack on the country, and we run out of masks or antibiotics or ventilators, anything we could need in that scenario, we should have those kind of hidden away around the country. And then H1N1 hit, which was not an attack, but it was just an outbreak.

And we went through a vast majority of our masks at that time. There was some restocking, but the warning sign that should have been there that said, hey, we almost used this all up. What if something much worse hit us that didn't make it home? And why these N95 masks? These are like surgical masks. Plus, carpenters use them. I use them when I'm cleaning my house. Like, what is it about them that's so essential to healthcare workers?

These are the kind of masks that allow you to get right up in someone's face while they're coughing and put a tube down their throat to ventilate them and keep them alive, which is obviously a super high risk scenario. You know, I mean, we're being told to stand six feet away from somebody who's not even coughing. And you're asking a doctor or a nurse to get their face right up near someone who's definitely sick. They need to be changed regularly

and ideally disposed of right after use. I mean, that's the standard protocol. Without it, they're almost certainly contracting the virus. And even if they don't personally get very sick, they would be spreading it to other people they see, to the rest of the staff. And if the doctor decides to take a risk, they might have to go into isolation or quarantine later or get sick or be totally out of the workforce. So the whole healthcare system breaks down if we don't have this PPE during a pandemic. We just heard from a doctor who says that he's been using the same mask over and over for days and is putting it in his oven when he gets home at night to disinfect it. It's shocking, probably ill-advised. A lot of people have been calling on President Trump to use this

Defense Production Act to ramp up production of masks. What is that act exactly for people who are unfamiliar? This is a Korean War era thing that is not used except in the most extreme circumstances, but it's sort of marching rights for the government to go and say to a private company, hey, we need you to do something right now. You're going to turn this auto factory into making ventilators. And it actually works out kind of well because that auto factory probably wasn't going to sell a lot of cars right now anyway, and if they could stay in business by making ventilators, it's kind of win-win. And the president can order places to stop making, for example,

clothes and figure out how to make these masks. We'll be invoking the Defense Production Act just in case we need it. In other words, I think you all know what it is, and it can do a lot of good things if we need it. It sounds like he doesn't know what it is. It's hard to believe anything that he says because he's lied so consistently, and he's indicated that it hasn't been invoked,

then sort of said that it doesn't need to be because places are doing this already voluntarily. Using it's actually a big deal. I mean, when this was announced, it sent tremors through our business community and through our country. Because basically, what are you doing? You're talking about, you're going to nationalize an industry, or you're going to nationalize, you're going to take away companies, you're going to tell companies what to do.

The truth is, most people, nobody would know where to start. But then the FEMA director said otherwise. On Tuesday, he indicated that it was being invoked. So just a little while ago, my team came in, and we're actually going to use the DPA for the first time today. There's some test kits we need to get our hands on. And the second thing we're going to do is we're going to insert some language into these mask contracts that we have for the 500 million masks. DPA language will be in that today. So we're going to use it. We're going to use it when we need it.

And we're going to use it today. What should be happening is that it should be invoked to its fullest potential to get these masks to people because without them, there is no health care system. We can have all the ventilators we want. We can have all the ventilators we want. We can have all the doctors. But if you can't protect them, it's a played out analogy, but you're sending soldiers to war without guns. And of course, once we get the masks, if we do, there is the issue you just referenced of ventilators and also just space. How is this situation looking, not just in New york but across the country right now with with ventilators and hospital beds not good so new york is adapting for field hospitals right now

they're called field hospitals but they're kind of just modified public spaces like the javits convention center where you could go and ideally receive some care and they're calling into service or asking for volunteers from doctors who are retired. NYU just said that medical students could graduate early and be recruited into the cause. Wow. Yeah. Because we're also running out of doctors and nurses? That potential certainly exists. And it's hand in hand with the mask situation, right? Yeah. And that supply chain of the number of providers you have can quickly break down as soon as people don't feel safe coming to work or have sick family members at home,

have kids they have to take care of, all these different reasons that they can't do their job as they normally would. And as we heard from Dr. Sun, when we don't have enough masks, we lose doctors and nurses. When we lose doctors and nurses, we have to start making some difficult decisions, right? Yeah. And we're already starting to make those decisions. In New York, you're being urged not to seek care unless you are very sick. And doctors are being told not to test except among people, you know, if they would require hospitalization, if they got a positive test. So we're already rationing who's getting

tested, who can come to the ER, who can wait it out at home. And so those are rationing decisions that haven't posed extreme ethical challenges, but you could very quickly get into a situation, and we certainly will in places around the country, we'll get into decisions about who gets the ICU beds and who doesn't, who gets to come into the hospital and who doesn't, even when you're in a situation where, yeah, under ideal circumstances, I would give you a hospital bed, but you need to go over to the convention center and be treated by a glorified medical student. And that's going to make some people very uncomfortable. I mean, are we going to get to the point where we have to let people die?

I don't want to forecast here, but that's something we need to absolutely treat as a very real possibility. There are always decisions about, you know, how care should be pursued. When there's a 99-year-old person with advanced dementia and metastatic cancer who develops pneumonia, you know, it's not the correct course of action to take them to the ICU. It is the correct course of action to help them be comfortable. Those are discussions that we don't like to talk about, but will have to be made. Factoring in other concerns right now, like could that bed be used by a 30-year-old school teacher

versus that 99-year-old person? And if a doctor has the two of them sitting in front of them, a decision has to be made in some way. So I think that's the level we should be thinking of right now. Yeah, I mean, just hearing you present that scenario, it just feels like so foreign to our culture. This is America. Yeah. We tend to ration care based on who has jobs and money. And so it makes people very uncomfortable to think about rationing care. Even if you are able to pay and even if you have insurance, there's no hospital bed for you to

purchase. The scary thing for Americans is being a normal, working, employed person who's always been able to see a doctor, always been able to get into the hospital if they really needed to, who will have to go to a convention center or a gym or a hotel or be asked to stay at home. And that uncertainty, yeah, it can be terrifying to people. You know, Jim, as someone who thinks about health care all the time when everyone else is, you know, quibbling about politics and everything else, do you think this might be the moment that America thinks about seriously rethinking the way our health system works. I mean, we did this episode on Tuesday, all about how Taiwan and Hong Kong and Singapore handled this really well, initially, at least. And the big reason was because they had been through SARS in a way that we hadn't. And they had set up infrastructure, and they had the familiarity to deal with a problem like this. And it seems like we just weren't there. Yeah, you know, you would think this would be cause for us to invest in prevention and preparation.

You know, we just passed a $2 trillion economic stabilization act, and all of that money could have just been way better spent in preparation. Each dollar goes much farther when you spend it up front. A pandemic is always going to be bad. But depending how prepared you are, that completely determines how much shutdown has to happen. And, you know, South Korea barely had to shut down. They just got really out in front of the testing and tracking,

and they were real successful. And we are not at all. Jim Hamblin is a staff writer at The Atlantic. He also hosts a brand new podcast called Social Distance. It's all about living through this pandemic. You can find it and subscribe wherever you're listening to this right now. Just search for Social Distance. It's all about living through this pandemic. You can find it and subscribe wherever you're listening to this right now. Just search for Social Distance. During his daily press conference earlier today, New York Governor Andrew Cuomo was asked about the personal protective equipment shortage, PPE. Equipment and PPE is an ongoing issue. Right now we do have enough PPE for the immediate future.

Now, that was very confusing to us considering what Dr. Calvin's son and other New York City healthcare workers had told us. So we reached out to Governor Cuomo's office for comment and the New York State Department of Health responded, We remain confident that we have enough PPE in stock for the immediate need. But for long-term requirements, we continue working with manufacturers and distributors to maintain and increase our supply. They did not respond to questions about whether there was enough PPE to change masks every day or between each patient or whether there was enough PPE to change masks every day, or between each patient, or whether there was enough PPE at all New York City hospitals. We reached out to Dr. Sun, and he replied,

I hope that's not a joke. I haven't seen anything yet. It's Today Explained. you