Interview March 31, 2020

Interview with Kartik Valluri, M.D.

by ROMAN TORGOVITSKY
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Main Points Of The Interview

  1. There are currently no approved drugs to treat covid-19. Several trials are ongoing, but it will take time before they are completed.  This presents a clinical problem for physicians:  out of all the anti-viral drugs that could be used, how do we know which drugs to use for which patients (depending on the age comorbidities and disease stage.
  2. There is a severe shortage of N95 masks for physicians. We have got a shortage of N95 masks and other PPEs, so we have to reuse them. It’s against CDC guidelines to be reused, but right now what are we going to do, we have to find a novel, innovative approach. So, physicians at Nebraska developed a protocol for cleaning N95 using UV light: https://www.nebraskamed.com/sites/default/files/documents/covid-19/n-95-decon-process.pdf
  3. People are very anxious about covid19, so we need an educational and mental health effort to educate people about the symptoms. And we need involvement of psychiatrists and psychologists to calm people down.
  4. Disease classification:

Mild Cases

Fever below 38, sore throat, a dry cough, but you’re not short of breath, pulse oxygenation above 92%.

Treatment for mild cases:

  • Need to self-isolate at home for at least 14 days.
  •  Physicians in US recommend supportive care (rest, fluids) with no anti-viral treatments.
  • Avoid NSAID
  • Green tea
  • Dr. Valluri agrees that supplementation with vitamins and minerals might be useful since it is low cost and carry minimal side effects. However, be careful with overdose as it can depress the immune system!
  • Some institutions are using high doses of Vitamin C

Note -1 from Roman: based on clinical experience of Goloborodko M.D. ( Albert Einstein hospitalist in NYC) some covid19 patients might be presenting with symptoms seemingly unrelated to viral RTI. So, some physicians are recommending testing literally everybody who enters hospital doors. If they are hospitalized as non-covid patients, they will infect other patients and hospital stuff)

Note-2 from Roman: ideally patients need to be tested before ending self-isolation to make sure they no longer carry virus and are no longer infectious.

Note-3 from Roman: according to an interview with Italian physicians conducted on

March 28, prior to March 26, they also had instructions not to treat mild cases. However, as of March 26, they started treating mild cases. This change resulted from realization that the earlier they start the treatment, the better the outcomes are. It is not clear if that decision was made based on sound quantitative analysis or doctors’ intuition.   

Note-4 from Roman: There seems to be a strong imperative for advising patients to take multivitamins, large doses of Vitamin C and D, and several natural anti virals that have been show to be effective against other viruses including SARS. More on this in a different article.

Note-5: Green and white tea contain high levels of EGCG. EGCG is also available as a supplement .

Moderate Cases

Fever above 38, it is persistent and you feel worse than you did yesterday. Oxygen saturation is now going below 92%. Findings on chest X-Ray, abnormalities in kidney, heart function or other systemic problems.  Moderate cases should be admitted to the hospital.

Important: chest imaging may have higher sensitivity than covid-19 tests, but taking chest X-Ray and especially chest CT scan will require complete room cleaning after each patient. And this makes imaging impractical. Dr.Goloborodko recommends to use ultra sound chest imaging.

Transcript of Video ‘interview’

0:01           

Q:  Dr. Valluri, thank you so much for taking the time, I know that you’re very busy. Today our guest is Dr. Karthik Valluri. He is Assistant Professor of Cardiovascular Critical Care at Baylor College of Medicine. Thank you so much for taking the time.

A:  Thanks for having me on, it’s great.

0:22           

Q:  Could I ask you how many patients have you had so far and what is it like at the hospital right now in terms of COVID-19?

A:  I’m part of a group of hospitals that’s called the Texas Medical Center. It’s the world’s largest Medical Center in regards to sheer volume and the number of hospitals in one area. Three major hospitals here are Hermann Memorial, Methodist and [0:48] St. Luke’s Medical Center. For us we have multiple satellite hospitals, multiple satellite urgent cares and ERs. So the way Houston is structured is like imagine a circle, and the middle of the circle is us, and every ring outside of it is like the rural or suburban areas that all trickle into us. So we’ve had, as of today, official numbers, I’m not going to quote, but we’ve had a lot of persons of interest. I’m talking around a range of more than 10. Confirmed positives right now we have 2. But that doesn’t mean that’s all we’re seeing because in our satellite centers is pretty much where they’re coming from. So these numbers I don’t know if I’m allowed to release exactly the number in our unit, that’s my higher-ups, but it’s roughly 2 for sure that I’ve been in direct contact with.

1:45           

Q:  You mentioned that right now you’re working on putting together guidelines. Can you talk a little bit more of how do you do that because I know there are several different guidelines from Wisconsin, from MGH, there are Chinese, there are Italian, and it’s a little bit of a mess.

A:  It’s a lot. Let me see it this way. Let me talk about big picture the way I approached it. The beauty of what’s happening right now is that we’re all in this together. Literally the entire world is in this together. The way I’m trying to construct how I look into this is a step-wise fashion. First came Chinese. Look at their guidelines and see what they faced, what did they learn from the disease. Look at Italy, South Korea, what they did. Then we come to the United States and all our major centers here. There are the urban centers, especially New York—God bless them right now that they’re in the midst of the incline, the surge. Looking at individual institutions there in New York, Langone and Lenox Hill, I have friends there that have been able to sort of share what they’ve got. What I do is I put these all together and go to the– first I create a construct, what are the main things: patient classification, symptomatology, disposition, where are you going to put them in the hospital. Are you going to immediately take everyone to the ICU? That’s going to overload us. Are you going to take them to the floors? That’s going to scare the other people that are not…is it functional over there to place them there. Can they go home? There’s that messaging too that we have to figure out. So that’s the next step: how did people classify, so on and so forth, like clinical criteria, who needs what type of care, what kind of oxygen supplementation do they need, who meets the criteria for the specific type of oxygen supplementation and the criteria for that.

3:32            

Then the next step is treatments, the most debated thing right now amongst all centers is treatments. We work in a team of an infectious disease doctors, a big group of them. We work with Dr. Herlihy who’s our Director, the chief of critical care services here. And we work with the hospitalist group. And then we try to get a comprehensive approach to, hey, what’s our standardized view. What I’ve seen in general is comparing all of these—and I’ve gone through as much as I physically could, there’s so much, every day it changes—unique and innovative ideas from everyone. For example, let me tell you, two major types of approaches to coronavirus exist today in general. The first major type is do everything possible despite it being tested or not. Let’s try the physiology based medicine. Let’s try to give them the treatments that are highly debated right now, Remdesivir, Hydroxychloroquine with Azithromycin, Avigan which is Favipiravir, Tocilizumab, these are the big guns. And they’re being tested right now in trials, so that’s the appropriate way, but the problem is on the ground trials take a lot of time to get done. So, do we wait for the trials to get done and just give them supportive treatment, or do we just go ahead and pull the trigger because we’re in a state where we can’t really depend on it and we just have to act. I understand both sides and that’s the hard part about this. But luckily I don’t have to make that decision. It’s more of a group decision. Therefore, the approach that we’re leaning more on right now is absolute, comprehensive critical care, supported care. We have seen studies and outcomes that supported care, appropriate supported care has gotten people through the severe parts of the disease. I’m talking about oxygen supplementation, ventilation strategies, appropriate medications like super infections if there’s antibiotics given, and addressing any other systemic issues that they might have. It’s a work in progress.

5:36            

I’ll tell you one thing. Every part of this guideline, there’s something new happening. For example, Nebraska, they have this really cool innovative way of using UV lights for n95 masks. I’ll tell you why that’s important, we’ve got a shortage of it. We have got a shortage about n95 and other PPEs, so we have to reuse them. It’s against CDC guidelines to be reused, but right now what are we going to do, we have to find a novel, innovative approach. A lot of people are expected to neatly put them into a paper bag, store them and reuse them. Under the circumstances that’s the best thing. Nebraska has this really cool protocol, they have it laid out in pictures, it’s like third grade reading level. They have a room and it’s like a clothesline and what they do is when they’re done with their masks, they hand it over to dry-clean, like a laundromat, they hand it over to the person in charge there and they classify them and turn on the UV lights. And the UV penetrates and ideally sterilizes these masks so they can be reused in a safe way. There’s a lot of stuff out there regarding ovens and autoclaving these things in a way, but it’s such a dynamic situation that we’re all in and everything’s changing, people are trying this and that. So I’m just trying to stay back a little bit, focus on comprehensive care, what we can do with what we have first and then go from there.

7:02            

Q:  What else did you find interesting exploring. I’ve been following discussions in the group and it seems there is a lot of interesting ideas there and there’s a lot of data that is being communicated on Facebook physicians’ groups. Can you share what are the interesting ideas can be picked up?

7:23            

A:  A few interesting ideas that I’ve come across is, as I just explained to you the Nebraska UV sterilization thing. Let’s just go through patient classification and patient testing. I honestly think the biggest burden is on primary care and urgent care in ER, they are literally the point of contact. Other than EMS, our first responders, they are the point of contact. Human psychology behind this is complete anxiety. If you have a call for cold or whatever it is, you’re going to imagine in this day and age it’s Corona, until proven otherwise. So there’s a lot of psychologists and psychiatrists getting involved right in the forefront to calm them down and try to clearly explain what these symptoms are, you might not have it, and even if you do, it’s okay, you can go home because you don’t meet certain criteria, you’re lucky you’re not there yet, so be at ease. There’s that aspect of how you approach patient care anxiety in the social realm.

8:25            

Q:  Can we actually talk a little bit more. There are several categories of mild, moderate, severe and critical severe. Can you tell our listeners about each classification, how do you decide?

8:41           

A:  Sure. We’re still developing this right now so it’s not 100%. However, let’s say if you’re categorized as mild, you have a low-grade or a mid-grade fever 100.2 and above or 100.4 and above, that’s number one. Number two, you might have a sore throat, you might even have a dry cough, but you’re not short of breath, you’re not increasing your work of breathing, and if you check your pulse ox you’re above 92%. At that point the best option for you, if you have these symptoms, is get tested, go home, make sure if you go home you have an isolated room, make sure you practice standard precautions, washing your hands, separating and distancing yourself from loved ones for at least 14 days. It’s hard to do and it puts a lot of burden on our patients to do this but it is the best way to keep them out of the hospital system where they have an increased risk of getting worse, and also it reduces the stress on the hospital systems. That’s number one, they’re mild.

9:47            

Q:  Let me ask you also about the mild symptoms. What do you recommend, what is the standard of care for the mild?

A:  The standard of care is supportive care. You don’t need to get treatments, you don’t need to get hydroxychloroquine, you don’t need to put yourself with these experimental meds because they have a lot more adverse effects than the benefits right now. If you want to be, you know, I don’t care, I’m going to try everything, individually I can’t stop you from doing that nor can I recommend anything, however what I’m going to operate on and how I believe it is, keep it simple, keep it supported care at home. As I said, nothing, just go through supplements, they are great, there’s some things that even your paper had, which is really cool about corseted and zinc and all these different things. Sure, to try.

10:37          

Q:  I’ve done several more papers, I will share them, send it over to you. So there are some recommendations that vitamin C, D and multivitamin, and in terms of vitamin C and D extra, more than RDA. Is this something that you think is worthwhile from the physician’s perspective for mild?

11:03          

A:  From my standpoint, let me tell you this way, I have yet to see studies that prove it one way or the other. But one thing, number one, they’re over the counter. Number two, the side effect profile for them if you overdose, yeah, anything you overdose you’re going to get them. If you take an appropriate amount, appropriate dozing, what if you do have a benefit, what if suddenly you do get better, who am I to sit here and say it doesn’t work? I can’t do that. I’m not doing studies, I have not tested them. I know one thing, they’re available, why not try them in the appropriate dosing. If you take too much zinc though for two weeks, let’s say you take zinc for more than two weeks, it starts affecting your immune system and the fact that they down regulate or inhibit your white cells. So it sort of reduces your immunity after a certain point. But that’s overload, that’s overdoing it. So things like that you need to look out for. And it’s copper deficiency I think they cause. Hyper zinc causes copper deficiency or something anyway. The point is, yes, try it, try the supplements, it’s safe, you can do it at home, have it brought to you by someone who’s okay or have it delivered to you by delivery people who are still providing us with supplies. Sure, that’s one.

12:09          

Next thing, hygiene. Next thing, rest. Avoid NSAID. Avoid ibuprofen. Avoid anti-inflammatories because there’s a concept out there, my response for that, oh, this is an inflammatory situation. It doesn’t work like that. Just because you take an anti-inflammatory doesn’t mean it reduces your inflammation. You can’t just pop an Advil and expect it to just to go away. It’s a lot more complex than that.

12:35          

Then the next thing that I would recommend for them is green teas. They have been shown to help. This is the time, if you’re mild symptomatic and you’re sent home or you’re asked to be at home, is you try these. This is the best time to try healthy, safe supplements to see if they work. But as a doctor I can’t say yes they work because….

12:57          

Q:  Right. We just don’t have the randomized trials.

A:  Exactly. There’s one protocol called the Merrit protocol out of Virginia and this is usually applied for patients with shock, septic shock, to see if we can mitigate the oppressor requirements or just general outcomes. They’re started on high doses of vitamin C, for example. And I know a few institutions who are just starting it from the get-go. Is it proven or not? No, maybe they’re trying to prove it, I don’t know, but this is the– we’re literally– it’s like the Wild Wild West right now, but it’s an educated Wild Wild West. That’s where we are.

13:36          

Q:  Can you talk more about moderate and severe cases?

A:  Mild, you have these symptoms now. When am I moderate? When do I become moderate risk? Same things apply but now your fever gets a little higher and is persistent. Now we’re talking about 100.2 to 100.4 and it’s persistent and you feel worse than you did yesterday. Number one. Number two, very important finding here, pulse ox on you and your oxygen saturation is now going below 92%. Some people say 90%, some institutions say 94%. 92% is a safe number. If your trend is this way, that means something is not right, something isn’t working. That’s number two. And then number three at this point is a chest x-ray. If your chest x-ray has findings, radiographic findings that a developing process, like a pneumonia or infiltrates or something, that right there buys you a ticket to go inside the hospital. You’re moderate.

14:42         

Q:  What if mild patients would display any chest CAT scan abnormality or it’s only the moderates that will display abnormality?

A:  It’s not so clear-cut as far as this virus sucks, I hate it. The thing is you could have mild symptoms and then you’ll have chest x-ray findings and then you’re immediately upgraded to moderate. You can have mild symptoms and your kidneys are failing, you’re upgraded to moderate. You have mild symptoms and you have elevated troponin that indicates heart involvement, you’re in moderate. Liver enzymes change, you’re in moderate. It’s not clear-cut. It’s very clinical and dynamic. We look at the entire body, not just the lungs, not just the breathing and not just the x-ray. If you have any other organ involvement or any other evidence, without a previous chronic history, a new development of renal disorder, heart dysfunction or liver dysfunction, you’re automatically considered someone who’s at moderate risk.

15:48          

Q:  Would you do in chest CAT scan on the mild?

A:  Depends. This is very institution dependent and it’s very resource dependent. Not everyone will get a CT. I think most people will get a chest x-ray, a portable one, because its ease of access, easy to do and quick turnaround, it’s immediate. So I think the majority of the people who come in with any type of respiratory symptoms in this day and age will automatically get a chest x-ray, at least here they would. Other places, say, if we get deflected before they come into the hospital system by urgent care or primary care which they do auscultation, who still use a stethoscope, and you hear some findings, they might say, hey, listen, you might need to get a chest x-ray or you need to go to the center, you might need to go to your hospital, get that checked out, make sure you have nothing developing.

16:41          

Q:  There was this paper recently that tried to make an argument that chest CAT scan has higher sensitivity than the traditional COVID-19 testing?

A:  Absolutely. Because we have a higher resolution picture, it’s pretty much become gold standard. But there’s three things that are problematic in the situation. If I have sufficient evidence that you have the symptomatology, the clinical signs that you are having impending respiratory failure, and then I find this chest x-ray bilateral opacities that indicate to me that that shouldn’t be there, I don’t need to send you to a CAT scan yet. I might need to use CAT scan later on to see prognostication to see if you’re getting better or not but I pretty much know right there that I am going to treat you as a person under investigation till I get the test back. And when and if they’re positive, you’re done. CAT scan is good when you don’t have radiographic findings on chest x-ray because in early phases of both CAT scan and chest x-ray don’t really show much, but CAT scan has a better chance of picking it up earlier. For example, comes in borderline, let’s say 90-91% oxygen saturation, same symptoms, fever is not exactly 104 but 100/1, chest x-ray is negative. I’m not sure. This guy is a young healthy guy or even old healthy guy, he shouldn’t be having this, let’s put him in a CAT scan. But to put him in a CAT scan remember that’s a fixed radiographic test. It’s in a room. It’s multiple use. You’re increasing chance of cross-contamination for other patients coming in and using it. If you have a stroke you need a CAT scan. We are blessed to have a big center that has a few rooms and a few CAT scans, but there’s community hospitals that only have one. There are some hospitals that might not even be working today. So there’s a lot of things that are involved before that decision is made. It’s not like you walk into the hospital, you’re on a conveyor belt, you go this, you go see that, there’s nuances to it.

18:58          

Q:  Let me get it straight. So you’re saying that a chest CAT scan is going to have higher sensitivity and you will have an opportunity to see much more as compared to the x-ray?

19:09                    

A:  Yes, absolutely, just based on this technology. And that applies to any disorder not just COVID.

19:17                    

Q:  I just want to make it clear for our listeners. The second idea was that there is a higher probability of viral contamination with the CAT scan rather than the x-ray. Is that true?

A:  Yeah, based on common sense. You cover up the patient with this with a surgical mask or n95, whatever you guys have, to prevent him from spreading his droplets. You put them on to the conveyor. We have to imagine we don’t know what his clothes look like, we don’t know how much he’s dispersed, we don’t know his viral load, I’m just saying in general you’re putting a patient that is suspected of having a variant virus into a room that’s used by multiple people. And, yes, it’s not like they’re not going to wipe it down, it’s not like they’re not going to sterilize it after each patient, but that still operator dependent and chance.

20:08                    

Q:  So basically hospitals should have serialization procedures after each patient. But then ultimately you cannot get rid of the aerosols potentially stuck in there unless it’s a negative pressure room. Is that correct?

A:  Correct. So the personal aspect of this thing is, it’s still debated, but they say that it does, the droplets can levitate or exist in the air for several hours, some people say a few minutes, I still have to get a consensus on this. Aerosolization is a different thing, that’s what we do to make it go into the air, for example BiPAPs and all that stuff. But, yes, that’s the key. But the sterilization techniques post every patient should exist. It takes time. Imagine New York City right now. How many people need CAT scans? Every minute there’s people coming in and how many CAT scans are you going to do on every single one of them? And in between those how much can you sterilize? It takes a good amount of time to make sure that room is pristine before the next patient goes in. At this point in time Houston is safe in that aspect, we don’t have the surge yet but we’re preparing for it. We’re looking at our and preparing for it.

21:18                    

Q:  So there is really no good solution here, because essentially we’re exposing patients, if physicians send them for a CAT scan then it could expose uninfected people or asymptomatic people to more viral loaded–

A:  It’s conceptual, conceptually, we don’t have the rates, don’t have epidemiological studies on this right now. But based on just the way this spreads, sure, you have to consider that, you have to be safe for everyone. The techs that are operating the CT scan, the radiologists there, you can send them outpatient diagnostic centers if they have a protocol and a policy to accept from the clinics and stuff like that. And that I’m not sure because my life is inside the hospital.

22:01                    

Q:  Going back to the moderate cases, what is the understanding of treating the moderate cases right now?

A:  Now we’re getting into what…this is the crux of it all, right? Escalation of oxygen supplementation, the basic pathophysiology of this virus is respiratory distress. So once a patient has respiratory distress the first thing you need to do is supplement oxygen. The escalation and subjective—

22:31                    

Q:  Just to clarify for our listeners, respiratory distress is…?

A:  Increased work of breathing, number one, where your  respiratory rate greater than 20. It’s number one. Number two, hypoxemia in which your oxygen is not going into your bloodstream at the adequate amounts of better than 92%, you’re dropping. Any type of respiratory wheezing, pain, chest pain, chest wall pain, pleuritic chest pain that’s causing any type of a discomfort which limits you to breathe. These would be characterized as respiratory distress. Basically oxygen not going into blood in an adequate amount for various reasons. That would be what my answer for respiratory distress would be.

23:15                    

Q:  Thank you for clarifying. Going back to the treatment.

A:  They come in in respiratory distress. Some of these, it’s a spectrum, it’s not one-size-fits-all. They can be very calm people with high pain tolerance and a lot of control, yoga people, so they’ll just be calm and they’ll breathe, but their numbers are reading lower despite them being calm. I consider that respiratory distress, at that point we need to supplement oxygen. The first form of supplementation is nasal cannula, a tube, two prongs that go into your nose, and on the wall we have liters of oxygen per minute. The basic nasal cannula will go anywhere from 1 to 8 to 10, it depends on the institution. So we can do up to ten liters of supplementation on this, but the problem is it’s just passive flow. It depends on the patient to breathe it into their nose and in. We’re giving you more fraction of inspired oxygen in our atmosphere so that’s supplement you. So, good, we do that, we symptomatically treat them. If they have fevers we might consider Tylenol. If we’re suspecting an infection we might give them antibiotics, not for COVID. If we suspect a bacterial infection we will treat that. Renal failure, we’ll try to give them a little bit of fluids. If they have any evidence of any other organ dysfunction, we will address that organ dysfunction. But the point is we’re supplementing oxygen.

24:41          

Now, let’s say I’m doing this and the nasal cannula is not working, it’s not enough, they’re still low. You maxed out your nasal cannula and they’re not saturating above 92%, what are you going to do next? Our next option is something called a high flow nasal cannula. This is debated. As we increase velocities, the speed at which we deliver oxygen, the pressure in which we deliver oxygen, there’s an increased chance for something called aerosolization. This is that debate, oh, it’s airborne. No, no, it’s not airborne, aerosolized, meaning that we are causing air to be pushed into the patient’s respiratory tract, they’re naturally going to cough, they’re naturally going to breathe out, something’s going to happen where that high speed takes it to their respiratory tract and has an exit point, and that puts it into the air, and that’s aerosolization. And that’s why studies have shown that we should avoid aerosolization procedures. It’s not guaranteed. If we have a negative pressure room, that’s okay, because it sucks it up. But ideally how many negative pressure rooms do hospitals have? I don’t know. We have like 10 or 12. But in different units they have more, but the thing is that’s the risk that you’re doing. It’s number two, high flow nasal cannula.

Number three: This is a different type of high flow, it’s higher flow. We basically, based on fraction of inspired oxygen and liters per minute and the velocity that is given, 60 liters per minute, up to 60 liters per minutes is called Vaportherm, that’s the brand name. That is also higher speed. This is also recommended against because you’re increasing your chance for aerosolization. The person delivering it to the patient, setting it up, is our respiratory text. They are the best and they’re right there. So increasing healthcare workers’ risk to it by aerosolization. But we’re also treating the patient. Usually by this time their oxygen saturations are fine and we can supportively take care of them at this stage.

26:53          

The next step. Vaportherms are not working, now what do we do? It’s non-invasive, positive pressure ventilation. That’s when you get what’s called BiPAP or CPAP mask they fit on, tight-fitting mask. You won’t even give it a chance to leave your body, you can’t leak it out anywhere, it pushes this area and uses pressure to jam it down your throat into your lungs and deliver oxygen. Once again, high risk for aerosolization. High risk. This is not invasive at this point. Finally, if this doesn’t work, now you’re left with no option than to intubate.

27:36          

But before we get to the BiPAP, the next thing I forgot to tell you something called a venti mask, it’s a non-rebreather mask, it’s a mask that covers your face without the sealing of the BiPAP. So this is I’m saying, we have multiple modalities, we escalate oxygen supplementation to the point of intubation. Studies have shown and it’s recommended that we don’t wait to the point they need to be intubated, that we decide to do an elective early intubation to prevent all of this stuff in the middle and reduce aerosolization. And that’s the oxygen supplementation part of the treatment.

28:09                    

Q:  Where do you put the line between the moderate and severe and critically severe?

A:  Good question. All the moderate symptoms, hypoxemia, number one, refractory hypoxemia and the fact that none of the basic supplementation’s working, we know this patient is going to crash, increased work of breathing, patient is getting tired, sepsis are shock and the fact that their body’s not able to keep up the blood pressure. Any signs of organ dysfunction, heart gets involved, liver, kidney, as I said earlier, that they’re failing, they’re in multi-organ dysfunction, we don’t wait. That’s a pretty quick progression. Progression of symptoms in 24 hours or going the wrong way despite maximal supportive ICU care, intubate. Severe patient, this is that severe critical point. Severe would be maximum escalation of oxygen supplementation. But if they fail those, we shouldn’t even wait at that point to be honest. But if they fail those they are in critical, that means do intubation. Not invasive mechanical ventilation.

29:18          

Q:  All health care workers, doctors, physicians, other hospital staff are at some of the greatest risk. What are your thoughts on protection. I think we all depend on protecting the physicians and nurses and other health care workers.

A:  This is the he biggest point of contention right now. I released a video yesterday just explaining like how a director thinks like at the critical care unit, because we’re not– There is a system in place for doctor is just doctor, you know. We don’t think about supply chains, we don’t think about inventory stocking, that’s not– it doesn’t fall on us, we take it for granted. Now there’s this shortage, now there’s a scare that as a human I don’t want to get the virus, I don’t as a human. As a doctor I don’t want to get it because that’s going to take me away from the battlefield. It’s going to take whatever I can do for these patients away. So that’s a big detriment and a burden on my colleagues who’re still there. So what do we do? We do have n95 masks which are recommended, if they fit well, they’re not overused and they’re appropriately put on and taking off. That’s very important. And it’s not just doctors. Nurses spend more time at the bedside than doctors. Respiratory techs that take care of all these oxygen supplementation spend time there. The environmental services people that clean these rooms spend time there. All of us, administrators, nurse assistants, you name it, everyone inside that hospital is at risk—period. How do we all get it? In the past use and throw, use and throw, careless, right? It’s a standard protocol and we feel so secure till we realize what’s happening now. What do we do? n95 masks, current policy at least in this hospital, every hospital is different so please don’t blame me for giving false information, let me talk about what I know. We are to reuse our n95 masks in a safe manner in which we can don them and doff them, put them into a bag and put them aside. CDC does not recommend this but what are we going to do?

Another innovative method that people have done is put the m95 on, make sure that’s yours, I put my name on it, put the n95 mask on and on top of it put a surgical mask on, which acts as a cover for it. So while we’re still sort of resources up right now we can take a surgical mask off, throw it away and the n95 is relatively safe.

32:01                    

Q:  Can you say it again, what is the point of putting surgical mask over n95?

A:  We need to reuse the n95, yes. So if we need to reuse the n95, this surgical mask on top of it, it’s not for filtration or anything, it is a cover for the n95 mask so if we are contaminated by anyway, the droplets and the virus will not be on our direct mask, it will be on the cover of the mask. So we take the cover off and throw it away, technically, theoretically, reducing the contamination of the n95 so we can reuse it. That’s another novel approach, a lot of people are actually doing that. But we’re going to run out of surgical masks too so we won’t have that either. The cool thing with Nebraska I told you about, which we’re trying to see if it works, we’re doing a pilot, is sterilizing it. If you’re done seeing your patients, take it off, hand it to the person to sterilize it with UV light. Nebraska did it and it seems to be working for them, it’s really cool. We’ll see how that works out here, if it is practical or not. So these are ways. We just have to be extremely careful. We just have to be extremely careful in how we put things on, how we take them off, not get them dirty, once they’re dirty, soiled, overused, throw them away. Don’t fit well, throw them away, deal with it, tell your administrators you need another mask of find one. In the meantime while we do this process, God-willing the entire country’s mobilizing right now, all our industries are mobilizing to provide and produce and manufacture more masks, and that’s the hope that it’s coming down the pipeline, that we will get more masks in. All we can do really is just–  

33:41                    

Q:  By the way, do you have an understanding or is there even an understanding of when these masks might be coming?

A:  First of all, my rank in the hospitals is not privileged at this level of information, this is more like the executive meetings and stuff like that. But from the emails I’m receiving from colleagues and other suppliers and manufacturers, we’re looking at end of May time frame, end of May for an abundance. So if you imagine at the end of May we have full mass production—don’t quote me please—if end of May is mass production you’ll see a slow ramp up. But my opinion and my honest opinion is majority of these resources should be diverted to surge areas, New York City, LA, Washington, New Orleans, Florida will soon be…the cities that we see the graph go up. After that whatever is left should trickle into the other metropolitan areas, and then after that we should be sending it into the communities, and then after that the general public if we have that much abundance. And that would be a proper roll out. I’m not a policy maker, I just have opinions.

34:59                    

Q:  One other question. How do you differentiate between the Covid-19 pneumonia and non COVID-19? Is it through the tests?

A:  This comes down to infectious disease doctors—they’ll probably destroy me because they’re extremely smart people—but it’s nuanced and it is sort of straightforward. Right now after talking to Dr. Woc-Colburn who is our ID guru here, there is parainfluenza right now, there’s allergy season, pollens out everywhere, it’s spring now. There is other viruses, vinyl viruses. All of these unfortunately have the same symptomatology as coronavirus. In the past when they said, oh, man, he’s positive for coronavirus, they go, yeah, he has a cold. But this is a novel coronavirus, it’s not the same coronavirus. As I said we have to be disciplined in the way we approach symptomatology and clinical science. If they have a cold, good. I had one of my closest friends in Tampa, I was freaking out, he had a severe cold and he was exposed, he’s a healthcare worker, he had a patient. And I was worried, checking on him every day, he stays positive, he’s a doctor, he knows. His wife also started developing symptoms. He was worried. They have two little kids. As a human you freak out. I would too. Man, I hope it’s not this, man. You get tested and it comes out negative, fine. But that’s what I’m saying. Not everyone has the opportunity to get tested yet, it’s getting better. In this day and age you will get the test to differentiate if it’s that or not. But let’s imagine the test didn’t exist, you have to go through it, you can’t go around it? Symptoms, know the symptoms, know what you’re going to feel like, know that this could most likely most definitely be just a common cold from various other viruses. The flu is still around, so it could be the flu, that’s not good either. So you’ve got to cool down a little bit. The things you’re looking for is the breathing, the shortness of breath, increased work of breathing, your body’s going to tell you this is not your normal cold. We’ve all had colds before, every single one of us has had severe colds or has had the  flu. Some of us have had pneumonias. We know what’s different. The quickness of it, the weirdness of it, something’s off, the character of your cough is off, the way you’re breathing is weird. Let your body tell you that this is not the normal thing. But when it happens and you start developing symptoms, just take it easy. Take it easy, you have time, just take it easy. Breathing. It comes down to breathing. If you’re breathing bad, that’s when you know.

37:35          

Q:  Naturally there’s a lot of anxiety and you mentioned earlier that psychologists and psychiatrists are getting involved. So what is your vision for the role that psychiatrists and psychotherapists potentially would play in dealing with the anxiety and helping the physicians on the frontlines?

A:  This is a good question. I sort of got to talk about myself right here real quick. The ability for me to even be talking to you right now is because of a viral video that I made after listening to two health care workers at a different institution in the community debating this virus and debating it symptomatology, not believing in it, being very important to health care workers. At that point I had to get information out there. I told the people. After that video got released the response to that was amazing, first of all, thank you everybody, but the amount of questions that are coming in just showed me how much misinformation is out there. I’m a doctor and I have to be scientifically professional amongst my colleagues. I don’t talk to them the way I talk in my videos. But the people need to feel as if someone’s talking to them directly that knows a little bit more than them. I don’t know everything. I do not. There’s a lot of smarter people out there, I’m just trying to communicate in a way that they can understand, and that’s where the psychology and psychiatry come in: communication. There needs to be transparency between the healthcare environment and the general public. That’s a very important bridge so they know doctors are human too, they’re facing the same fears as they are in the community. But what are we doing scientifically to combat it? How is our anxieties and stuff getting reduced because we know what works, we know social distancing works, because the battlefield is out there, the frontlines are in the community not in the hospital. That’s the most important thing people need to realize. We know that social distancing works, hand washing works, not touching your face—by the way, these are hard things to do not to touch your face, it’s insanely hard for me not to do it. But these are the things that work. Fine. we know medical treatments that work but I hope I don’t see them, I hope it doesn’t come to that where I need to take care of them in the hospital because they practiced good precautions. Psychologists and psychiatrist can come in, they have different methods of talking about how to manage anxiety, how to cope, how to deal with stress, different practices and stuff like that, that’s not my field, that’s their field and they need to o use that expertise for the community in this day and age, especially with the media, especially with me talking about like scary stuff. It’s important. They have a huge role to play. Social media has a huge role to play from educated people. From the people with a skill set, social media has a role to play and I think it’s very important.

40:28                    

Q:  Yes, of course. And the foundation for reducing anxiety is the proper scientifically-based valid information, rather than the fake news which is–

A:  Consensus by scientists and doctors who are dealing with this. When you see a bunch of doctors agreeing on something, you’re going to believe that. When you see one of the doctors saying no, you know, this works, you know, this works, you don’t want that either. That’s why I am very careful when I say “in my opinion”, “possible”, “maybe”, because I cannot sit here and say definitively this work. I don’t know, man. I’m following papers that other scientist have done, who are following other papers other scientists have done, and that’s what research is, that’s what the medical evidence based research is. It takes time but it’s based on appropriate sources, appropriate knowledge, tested scientific knowledge, and that’s what we need to base all of our information on, as much as possible. That’s why these groups are very helpful, the COVID groups, because the people on there predominantly are all healthcare related people. They’re all doctors, they’re scientists, there’s people that are putting it out there. And then the healthy debate that’s happening, not trolling, healthy debate. Hey, that paper is debunk. Like yesterday I was really tired, I came home and some guy put up like guidelines on how to like put your n95 masks in the oven and how to properly sterilize them. I was so excited, like, oh, here’s a protocol written, this must work. And I was about to share it and immediately like six or seven go, no, don’t share it, blah, blah, blah, that’s not proven. And then I was like I have to go back online and read other papers, okay, this is all maybe science and I can’t rely on maybe science right now. It’s just the world we’re all in right now.

42:18                    

Q:  Actually I would like to quote, maybe one of the last questions I would like to go back to how we can support both the health care workers, which are at the highest risk, as well as other groups, people with multiple disorders, comorbidities which are likely to be at a higher risk. And the standard public health protocols usually just talk about standard stuff: washing hands, social isolation, which of course should be taken as of utmost importance. But there are other means of– let me rephrase that. If we know that most of us are going to be exposed to the virus, then the question is how sick we are going to get after being exposed. And this is basically controlled or regulated by the state of the immune system and the nervous system. So basically what we do know from science, not from randomized trials, well, some from randomized trials, is that, for example, micronutrients are intrinsically involved in the regulation of the immune system, so these are vitamins and trace minerals. Sleep, stress…I read some papers actually today that basically talk about that it seems that the supplementation with vitamins and trace minerals seems to be working for those people who are either deficient in them or who are under, for example, physical stress. So it could be that, for example, when physicians and health care providers are working overtime and are sleep-deprived and are under emotional stress, then their immune system will need greater support. And that means that there is probably relatively strong evidence, or there might be evidence for supporting the people who are at the most risk with any kind of supplements. What are your thoughts about supporting health care workers, like additional support, on top of the personal protection stuff.

45:04                    

A:  This is great. I think this is very cool. Supplementing our bodies, that’s literally what it is, supplementing our bodies to withstand stress, to maintain a healthy sleep cycle, and to not have a vitamin deficiency of some sort which can further harm our body or ability to fight an infection. Let me base on two things: number one, we can’t talk about evidence-based medicine at this point, we’re going to talk about physiology-based medicine. That’s how we can talk about this, physiology based medicine. If we have to go down to evidence-based medicine, forget about it, not right now, because the general thing is, oh, man, you take those vitamins, you’re just going to pee it out, which, yeah, you do get rid of most of it. But the thing is this, if you are deficient in any of these things, absolutely, obviously you’re going to need supplementation. If you have a deficiency of anything, that’s not homeostasis, you need to refill, replenish in that. Do we know we have deficiencies of certain things? Overt cases of vitamin deficiencies have clinical syndromes, we have diagnoses, we have tested, we have evidence-based medicine on how to treat them. If you have a riboflavin deficiency, give them riboflavin. Iodine deficiency, iodine. That’s the physiological approach. Now, we do know and studies are there medical school, stress affects your immune system. How? Catecholamine release adrenergic activity, I don’t know, there’s a lot of physiological theories. Sleep cycle is the same thing, your regulation of sleep cycle. You’re looking at a healthcare worker who has to either double shifts or is already anxious, it’s so draining. Being a critical care doctor I know exactly what that feels like, very exhausting, because all you need is one patient to not do well and that’s your day. Supplements, I read your treatise on this and it’s really cool, like quercetin, zinc, the micronutrients. I’ve got to be simple about it. Do I have evidence-based knowledge that these are going to work 100%? No. Do they cause severe side effects? Only if they’re overdosed. What if you take them on a regular basis and your body doesn’t need them? You pee them out. Your body automatically gets rid of them, it doesn’t need it. But what if they do help, either psychologically, physically or preventively? How are we going to know that? By taking them, simple as that. Does it hurt you to take them? It might hurt your wallet, it might be a little expensive, but why not? Let’s throw everything we can against this virus as long as it’s the right thing and it’s a safe thing to do. What’s the difference of me saying, oh, yeah, man, Hydroxychloroquine and Azithromycin, just do it, man, but no zinc, no, no, no. Makes no sense, right? We’re at a stage where we don’t have the luxury of waiting for evidence-based medicine. We hope for it and we’re being patient for it, but if you’re in a surge situation you’re going to try to do everything you can. But when you’re doing that process don’t forget what’s right. Hydroxychloroquine has a lot of side effects, people taking it prophylactically I’ve seen a lot of myocarditis patients right now because of the damn drug. Erythromycin messes up your QTC, your EKG, basically your heart rate, and that can lead you to cardiac arrest unnecessarily. So there’s a lot of harm involved in all these drugs. When we have vitamins that we know that can either supplement us or they get excreted from our body and we’re just wasting money, who cares? Take it, do it, as long as it doesn’t harm you. Don’t overdo it. Don’t let it harm you. Read about it before you take it. Make sure it doesn’t interact with other medications in your body, that’s very important. This is a beautiful topic to talk to your primary care doctor about, your family medicine doctors, they are the ones that have this knowledge. Critical care doctors, we’ve just got to pull you out of a nosedive. A primary care doctor takes care of your lifestyle. A critical care doctor just takes care of your life at a certain point. It’s important to engage people with more knowledge on this topic, people who have both an MD background or [49:20?] background or whatever, empiric science background, versus a holistic science background. Get them together and let’s see and try. Maybe this is the age we find out that micronutrients and supplements might actually be beneficial. That’s my don’t-choose-a-side way of saying it.

49:38                    

Q:  I’m thinking that maybe I will put together a post in the group because I think it might be a valuable information to distribute first of all among physicians to support the physicians’ health first and foremost. It’s a good thing for physicians. Then if our health care system, if physicians start falling sick then it’s going to be a disaster for absolutely everybody. And unfortunately I don’t see a lot of conversation about how to protect the physicians aside from the most needed and also the most obvious. But I think there is something missing from that.

A:  Yeah, this is awesome because it’s another branch of how we can protect our bodies to fight this thing, other than mechanical stuff like masks.

50:44          

Q:  Thank you so much for your time. It was very interesting and very educational for me.

A:  Awesome. Likewise. Thanks for asking these questions man, it’s my first interview ever.

50:55          

Q:  Excellent. I hope we will be able to pull up in the week or two to see your progress in putting together the guidelines and how things will be rolling out.

A:  Yeah. My deadline is Friday, so that’s what I’ve been told [chuckles]. Thanks a lot for your support, I really like the group that we’re in, it’s so helpful, for me at least it’s so good to hear different voices and different opinions.

51:26          

Q:  I love your videos, so keep making them, keep educating. And thank you so much for the knowledge that you’re spreading.

A:  We’re all in this together. Thank you very much Roman.

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