‘We’re Simply Going to Hope for the Best and Plan for the Worst’
An interview with San Francisco General Hospital Chief of Emergency Medicine
Elemental spoke with Christopher Colwell, MD, chief of emergency medicine at Zuckerberg San Francisco General Hospital, to get an inside perspective on what doctors are experiencing on the ground with the novel coronavirus outbreak and how they are preparing to handle the situation if and when it escalates.
The information reported here is from March 22. This interview has been lightly edited for length and clarity.
Elemental: Thank you so much for taking the time to chat with me. I know you must be incredibly busy right now, so I really appreciate it.
Christopher Colwell: It’s a remarkable time, no question.
First of all, what’s the testing situation at your hospital? Do you have enough tests for everybody?
The previous weeks, we were just testing patients that were sick enough to get admitted to the hospital. We didn’t have enough tests to be testing every symptomatic patient, so a lot of patients went home that could have been positive. We told them to assume they were positive and quarantine until they were asymptomatic and could get follow-up, but there were a number of patients that never got tested. Now we’re in a better phase where we’re able to test most symptomatic patients. We still don’t have enough to just test everybody, but we do test most patients that are coming in with symptoms.
What’s the bottleneck in the supply chain for the tests?
It’s the swabs, just the number of swabs. We’ve run into that, UCSF has run into that, Stanford has run into that.
And is there any relief on the horizon?
Yes, we keep hearing that we have more coming, both in terms of swabs and in terms of personal protective gear. We’ll believe it when we see it, but yes, there’s a lot of people that are ramping up on this.
Speaking of personal protective gear, is that a real concern in terms of masks and other equipment?
It’s a very big concern. We have enough today, and we have enough as near as we can tell for tomorrow. But the fact is we’re burning through it quicker than we’re replenishing it. So obviously the simple math is that eventually that’s not sustainable. We have to figure out a way to burn through it less and/or replenish it faster, and we’re trying to anticipate both. We’d love to have it replenished fast enough to keep up with what we’re using now, but it doesn’t look like that’s going to happen, so we need to figure out how to conserve and recycle in some cases.
How about the equipment that you’re using to care for the patients? Are you concerned about running out of ventilators or beds?
That’s the biggest unknown factor. It’s very hard to predict exactly what this is going to look like in each city. Right now, we are not overloaded with patients that need ventilators. That’s one of the most restricted resources — we have 70 ventilators at SF General, we probably have about 750 throughout the city. Of our 70 ventilators, we’re using eight right now, so we’ve got capacity on ventilators. But this is the whole idea behind trying to spread out the curve, to try to prevent having a whole bunch of people showing up all at once that need ventilators.
Have you seen an increase in the number of severe cases that are coming in in the past week?
No, not severe cases. This last week we had a certain number of respiratory patients that we had to put on ventilators, and it was about the same as this week last year — we were finishing up the influenza season last year at about this time. So we haven’t seen an increase in the number of ventilated patients. Now, that doesn’t mean there haven’t been some Covid patients needing to be intubated, there have, but we haven’t seen a dramatic increase in patients needing ventilators, at least this week.
Do you expect that you will?
Yeah. When we talk to our colleagues in other places that have seen bigger numbers, they are seeing more sick patients. Now, it varies, and that’s what’s hard to predict. Some places have gotten high numbers of very sick patients, and others have not gotten those high numbers, so trying to anticipate what’s going to happen here is difficult. We’re simply going to hope for the best and plan for the worst.
What do you think the difference is in terms of the dramatic escalation that cities like New York or Seattle have seen versus the Bay Area, where it seems to have been pretty stable since the virus first emerged there?
We don’t know why it has remained a little bit steadier here. Some people like to say that it’s just because we’re two weeks behind Washington, and what they’re seeing right now we’re going to see in two weeks. I understand why people are saying that, and we’re certainly preparing for that kind of scenario. But it’s fair to say we don’t know that for certain.
Do you think that the response so far at SF General and San Francisco at large has been the right one, or do you think it’s not been enough or been overkill?
Certainly not overkill. I think we’ve got to take this very, very seriously. It’s very important to balance taking something seriously versus panic, that’s really the key. First of all, there’s no point in panicking, it’s not going to help anything at all, and it could potentially hurt. We saw that with the hoarding of certain pieces of equipment. Number two, there isn’t a reason to panic, there’s a reason to be respectful of what we could be seeing.
I worry about the PPE [personal protective equipment], and I worry that if things ramp up substantially, we will not have the personal protective gear that we need from the provider standpoint. And certainly, I worry if we see huge numbers of really sick patients they’ll overwhelm the ventilator capacity. So yes, I do absolutely worry about those things. I hope that worry is unwarranted, but in all honesty, I would rather come back later and say, ‘You probably worried more than you needed to than you didn’t worry enough.’
Have any of the doctors or nurses gotten sick so far from contact with a patient?
We have had three providers that have tested positive that are symptomatic. As near as we can tell, none of those happened with contact with a patient. The common factor is they were together at a conference in New York and developed symptoms shortly after that.
What about mental health and stress levels? I’m sure this is an incredibly stressful time for you running all of this and for physicians and providers. How is general morale? Do people feel like they’re up to the challenge?
Right now, there’s certainly anxiety like there is for everybody. As health-care providers, we are also obviously human beings that are impacted by the financial issues and the family issues and everything else that is involved with this. At the same time, to a certain degree, this is in our wheelhouse. This is what we in medicine face, not exactly like this, certainly, but things like this, on a fairly regular basis in terms of dealing with illness and dealing with the potential for illness to overwhelm our current resources.
But it’s exhausting. I mean, it’s literally 24/7. My leadership role is actually much more taxing than the clinical care itself. When I’m doing a clinical shift, I feel like I can turn the rest of the stuff off and just focus on taking care of my patients, and that’s what I know best. When I get out of the clinical environment and start talking about, “Okay, what do we do if we need 150 ventilators and we only have 70?” I don’t have a good answer for that. There isn’t a good answer for that.
How can people best support you?
The lack of panic is important. We have enough food in this country. We have enough personal protective equipment, I think, to do this — I don’t know that for a fact, but I believe we do. But we don’t if people hoard it. We’ve got people that are hoarding boxes and boxes of N95 masks when they’re essentially of zero use to somebody out in the public. If you’re walking around outside with an N95 mask, it doesn’t make any sense at all. The benefit of an N95 mask is for a health-care provider who’s going into an enclosed small space where aerosolized secretions of a Covid-positive patient are being made. So if you’re hoarding N95s, please send them into health-care areas.
Even more important, please help us reduce the spread of this disease. Please take this seriously.