Chip Kahn (00:11):
Hello and welcome to Hospitals in Focus. I’m your host Chip Kahn. Today we’re going to take you to the front lines of the COVID-19 battlefield with one of the emergency room physicians from the George Washington University Hospital here in Washington DC. He will describe what it’s like to be in an ER in a major city in the middle of the coronavirus pandemic. Our guest, Dr. James Phillips is also an Assistant Professor of Emergency Medicine at the GW School of Medicine and Health Sciences. You may recognize his voice because you’ve likely heard or seen him on CNN where he is a contributor on their COVID coverage. We are honored that he is joining us. Dr. Phillips, thanks so much for being here today.

Dr. James Phillips (00:59):
Thanks a lot for having me. I appreciate the opportunity.

Chip Kahn (01:02):
There’s so many ways we could start this interview. You’re in the front lines of an unprecedented human event, human tragedy, and you see it on the ground in a very personal way. What does your average day at GW look like now?

Dr. James Phillips (01:19):
It’s interesting what’s happening across the country because I think that there’s a general belief that everywhere in the country right now is New York City. And it’s actually not the case. My heart goes out to New York City, New Jersey and some of the other cities like Chicago and New Orleans and even Detroit, where they’re starting to see an enormous number of cases right now. For most of the country, it’s actually probably a little bit slower than usual, including in Washington DC, because we are still waiting for our upslope on that curve.

At GW, where I primarily work, and also at Walter Reed National Memorial Medical Center where I also work in Bethesda, Maryland, we’re actually seeing a slight decrease in our total number of patients that we’re seeing every day. And the reason for that is because people are listening to the message and they’re staying home unless it’s absolutely necessary for them to come out.

Many of the visits that we see in the emergency department from patients are probably not entirely necessary, as far as we look at them from an emergency standpoint. We’re missing a lot of those typical visits that we would see. But additionally, I think patients are also nervous to come to the emergency department because they’re afraid they might get sick. And those are the patients that we’re a little bit more worried about because we have a fear that there’s people staying home when they are sick from not just COVID-19 symptoms but from other things like chest pain or stroke symptoms or difficulty breathing.

And we’re afraid that they’re not coming in because they have anxiety and fear that they might get sicker by coming to see us. For a lot of places right now we have a lower census or a lower number of daily patients for those two major reasons. But most of us look at it from this standpoint. When you think of a tsunami and you’re standing on the beach, the first thing that happens before that big wave comes in is not a rise in the water, it’s actually the water rushing away from the shoreline back out into the ocean. And then the tsunami wave comes in from there. It’s our fear that this is really and truly the calm before the storm as the tide moves away before it comes rushing back in.

Chip Kahn (03:34):
Comparing the situation in Washington, DC, where your hospital is to these other places that are really hot spots, did they experience the same kind of lull before the storm that you’re describing here?

Dr. James Phillips (03:48):
That’s a great question and I’m guessing they probably did. I think New York would be the exception because they were really the first big spot that hit. I’m not sure where that timing was in relation to their initial physical distancing announcements and proclamations by the governor. For most places though we know that 98% of Americans are now living under some form of stay at home a recommendation. I think most people are being cautious about that.

The question is whether or not we will all actually see a surge. Modeling is what we are looking at to try to figure out what to expect because there’s no better way. And if you look at the University of Washington data, which is what the White House Task Force tends to look at, it seems like in Washington DC that we’re actually doing better than expected. I think that that particular model expected us to start to peak earlier this week and we’ve definitely not.

But then there’s additional models that show us that we may not peak until May or June. It’s really, really difficult to predict. And it also shows the importance of using more than one model to try to figure out what’s coming.

Chip Kahn (05:03):
That could be good news for this area and I hope it is. And our hearts go out to the other parts of the country where you described where it’s not the case, but let’s focus a little bit if we could, even with the slower volume, the fact is you are getting COVID patients. What steps are you taking to ensure safety for yourself and the staff and your patients? And how long frankly does it take you to put on and take off the PPE that you have to use now?

Dr. James Phillips (05:36):
Yeah. Well, the first answer to your question is certainly using the appropriate personal protective equipment. We know what … There’s different levels of precaution that you take with different illnesses. For every patient we wear gloves and we do some contact precautions. And then for different types of illnesses we wear different types of PPE. For this one we use droplet and sometimes what we call airborne precautions, which require these masks that you’ve heard of, these N95 masks that are special filters. We wear gowns to protect our clothing and our body from getting droplets on them.

For many of us were wearing head covers as well as a shoe covers. We’re used to putting this equipment on pretty typically every year during the flu season and during more rare outbreaks like the flu pandemic of 2009 when H1N1 hit. We’re not strangers to this, but we are strangers to having to do it for every single patient. And that does take time. In reality, putting the gear on, not that time consuming, putting on a gown, tying it, a couple of pairs of gloves, that’s not so bad. The N95 mask has to be put on in a very particular and very safe way.

In a routine, conventional care sort of situation, we would change that mask for every patient that we see. That’s a onetime use 75 cent mask that you throw away. But for most of us now we’re putting on that mask and we’re leaving it on for eight hours a day. You may take it off once to slurp down a Red Bull or maybe grab a quick something to eat. For the most part that stays on. That also saves us a bit of time. The answer to the first part of your question is that PPE is the major way that we’re keeping ourselves safe.

Depending on the volume of COVI suspected patients that your ER is seeing, and depending on the size of your individual ER, that makes a difference. We try to keep these patients in what we call negative pressure rooms, where the basic meaning of a negative pressure room is that the pressure is lower inside than it is outside. If you open the door, air sucks inside as opposed to virus laden air blowing outside. Now every ER only has a certain number of those rooms, some have none. That’s the additional precaution that we try to take, but it doesn’t take very much to overwhelm the number of negative pressure rooms you have. And it’s at that point where we have to adapt the type of care that we provide.

Chip Kahn (07:59):
You’re talking about the complexity of providing the initial care, particularly in the emergency room and ultimately in other parts of the hospital. How does wearing the equipment and just the overlay of COVID affect your contact with the patient, with that relationship that you need to have with a patient, who is feeling symptoms could be very, very ill?

Dr. James Phillips (08:22):
It’s limited severely, and that’s one of the hardest parts of this. As physicians we sympathize and we empathize with our patients. That face to face contact is critical. That relationship that you form with each and every patient that you see is part of the therapeutic process, particularly whenever patients are having their worst day, which in theory if you’re coming into the emergency department, you’re having a terrible day anyway.

Now you make that more complicated by having a pandemic in which the risk of death is real for every that comes in, the risk of serious illness is real for all of them, and the level of anxiety about those things is through the roof. Compound that with the fact that the amount of nosocomial infection or the spread within the hospitals and the real likelihood of doctors and nurses and other healthcare workers getting sick, it puts us in a very uncomfortable position because now I have some level of fear of my patient and that really interferes with that important therapeutic relationship.

What we’re doing is we’re walking into a room and the first time we meet the patient, all they see is our eyes through goggles. They have no idea what we look like, what our faces, that really interferes with that initial bonding that happens between the doctor and their patient. Subsequent visits, once I’ve seen them, taken their history and examined them and I walk out of the room, it’s not atypical for us to go back into that room several times during a routine emergency department visit.

Say if you came in with appendicitis, I’d probably see you in your room three or four times. Now I see you once and then I hand you a telephone. I walk out and I shut the door and the next time I speak to you I’m going to be waving through the door, the window, talking to you on a cell phone, maybe an iPad, and that really takes away from that therapeutic relationship when our patients truly need it the most.

It’s just really difficult for us to fear our patients in a small way and I know that they fear us too because we’re not just seeing COVID patients, we’re seeing the typical patients that we would normally see with abdominal pain and chest pain and other issues, and they’re afraid of us to a degree too because they’re afraid that we’re going to get them sick. I think that there’s a real detriment being caused by several barriers between us.

Chip Kahn (10:41):
Talking about all the personal safety about the relationship with your patients, you started watching what was happening in China and wrote an article for CNN that you expected, COVID-19 to come. It’s now here. How does it feel to have that reality? How is that affecting you?

Dr. James Phillips (11:04):
It’s a tough position personally. I’m like every other human being, we all like to be right. We like when we make a prediction and that comes true, but I would give anything to be increasingly wrong. I hope I’m wrong about that first op-ed because it says I expect to get coronavirus. The fear is, is that there’s PPE shortages. There is an overwhelming number of patients in parts of the country and soon most, and the risk of getting this disease is a factor of the amount of time you spend in proximity to viral sources and how close you have to get.

And for doctors and nurses on the front lines, we’re at the highest risk. You see the numbers from China and from Italy. And the biggest risk factor for getting this disease seems to be being in healthcare.

Obviously heart disease, diabetes and hypertension are risk factors for patients, but being a healthcare worker is also a serious risk factor for getting it. And we’re starting to see attending physicians, even resident physicians in America die. We’ve seen nurses die and we saw a significant amount of that in other countries. There’s some real concern there.

Chip Kahn (12:20):
Do you think the preparations as the disease began to be viewed across the world, at least at your hospital, were sufficient? And what kind of obstacles did the hospital face in preparing itself at GW for this advent knowing that it’s difficult to get certain supplies now?

Dr. James Phillips (12:41):
Well let’s start at the hospital level. To answer your question, I am fortunate to work in two hospitals that have an embarrassment of riches when it comes to disaster knowledge. Walter Reed obviously is the flagship hospital for our military and they drill regularly, they exercise regularly and they have access to a tremendous amount of equipment and staff. GW Hospital’s similar. Our hospital leadership, our Chief Medical Officer is actually a disaster trained emergency physician who spent the earlier part of his career training people like me in disaster medicine.

We have folks on staff that are medical liaisons for FEMA. We have the Head of The National Center for Disaster Medicine and Public Health on our staff in the emergency department. And, then me, the who is the least of those. And with that we saw this coming and took preparations far ahead of time. I remember sending an email to our CMO saying, Hey sir, do you think that we should probably start screening people from China?

This was back in January saying, I’m afraid that this is something that we’re going to need to do and we should get out way ahead of this. And he’s like, “Dr. Phillips, we started that a week ago”. He was way out in front of me. We’re very fortunate at GW and at Walter Reed to have a tremendous amount of experience. We were in the midst of it during 9/11, during the anthrax crisis here in DC and even through H1N1.

On a national level, it’s a different story. There are certainly some real complexities there that have made it hard for us. In disaster medicine preparation and mitigation are worth their weight in gold because every dollar you spend right of boom, after the boom happens, is far more expensive than spending it left of boom on preparation and mitigation.

We have known for years. Let’s look back at 9/11. When 9/11 happened, a tremendous amount of government funding went towards preparation, mitigation efforts, training and equipment for disasters. I got coupled with anthrax, the Strategic National Stockpile was created. There was increased requirements for hospitals to have regular drills and exercises for mass casualty incidents. And we went on this whole of country emergency medicine preparation for further terrorist events.

But then the country got complacent and we had a couple of changes in administrations. And when nothing was happening from a terrorist standpoint, that money slowly started to get chipped away at to where our government funding for preparation like this dropped dramatically since that time. The idea that we never saw this coming is completely preposterous and I’m so tired of hearing it whenever I watched the President talk.

Because what I can tell you is that even since I moved to DC two and a half years ago, I’ve been two major pandemic national level exercises, one called Clade X and then a big, fully national one called Crimson Contagion where they’re extremely high level people modeling and exercising this exact scenario. And anytime we have a disaster or even a mock disaster like those things were, we derive lessons learned from there. What are the things that we need to prepare for and fix?

And PPE and surge capacity and replenishing the Strategic National Stockpile have always been lessons from that that we realized we needed to learn, but we never quite learned them.

Chip Kahn (16:27):
Thank you so much for your service and for your description of the situation that you’re in, but frankly, we’re all in. And do you have a message? For those of us, like myself, who were sheltering in place and I would say taking a vacation, but I’m working actually harder than I was before, but clearly taking a vacation from our normal lives to try to avoid the virus?

Dr. James Phillips (16:52):
Yeah, I think that there’s a couple of things that I would say first about your own personal health. I think it’s important that people need to know that they’re not completely helpless. Everyone feels some bit of helplessness right now in this virus that you can’t see, that’s coming through and infecting and killing people that we know. But it’s important to know that not everybody’s going to get this. And most of us that get this are not going to get severely sick.

However, there are groups of people that are very vulnerable. The folks over 60 and folks with some of those preexisting medical conditions like diabetes, high blood pressure, heart disease. The message I’ve tried to get out is that you can still maximize your health before you get sick. As an emergency physician, I know the realities of how compliant patients are with their doctor’s recommendations, how often patients actually take their blood pressure medicine.

Less than 50% of people with high blood pressure actually have high blood pressure under control. Diabetes is probably somewhere similar to that number. But let’s say you have two weeks from now to get yourself prepared. Patients should start taking that blood pressure medicine every day. If your wife or loved one has been telling you to use your insulin every day, but you don’t want to because it hurts, get your blood sugars under control right now. Take all of your medicines that you’re supposed to.
Exercise every day to try to get your lung capacity a little bit better. Even two weeks might make a difference.

Even if you improve your health by 1% or 2%, that might be just enough to keep you from going over the edge into severe illness if you do get this. In addition, it lets you feel like you have some say in this fight. You can maximize your own health and feel like you’re fighting. Additionally, you need to stay in touch with your friends. Thank God most of us have access to this incredible technology right now to be able to maintain our own mental wellbeing by remaining in touch with our friends. You can physically be distant, but you can socialize distantly.

Just the other night I had a nice session of beverages with all of my groomsmen from my wedding three years ago. We sat and we could see each other’s faces and tell stories and it was very important. It was just completely refreshing. And the technology exists and people should do that. I talk to my friends now more than I have in years and that’s one of the few things that I think will be good coming out of this pandemic.

Manage your mental health, manage your physical health, be prepared and just listen to good science. The only people you should be taking medical advice from is your doctor, but if you are getting medical advice from TV, like so many millions of people are right now, make sure it’s coming from reputable doctors that have expertise in the field and that the people that are giving it to you have a medical license.

Chip Kahn (19:42):
Well that was really wonderful. Thank you so much for joining us today, Dr. Phillips, and thank you for caring for patients on the front line. If those of you in the audience would like to keep up to date with Dr. Phillips, you can follow him on Twitter at Dr Phillips MD at D-R-P-H-I-L-L-I-P-S-M-D. I hope you’ll follow him and I hope you’ll listen to this podcast and future podcasts on Hospitals in Focus. Thanks so much.

Dr. James Phillips (20:12):
Thank you for having me.

Chip Kahn (20:13):
Join us next time as we speak with experienced leaders on new ideas about healthcare delivery and financing. Please listen, rate and subscribe wherever you get your podcasts. And if you haven’t already, you can follow The Federation on social media at FAH Hospitals and me at Chip Kahn. This was Hospitals in Focus. I’m Chip Kahn. Thanks again for listening.

Dr. James Phillips

James Phillips, MD, is a board-certified Emergency Medicine physician currently serving as Assistant Professor of Emergency Medicine at George Washington University Hospital, section Chief of Emergency Preparedness and Co-Director of the Disaster Medicine Scholarly Concentration.

Dr. Phillips lectures and researches several topics, most notably Healthcare Workplace Violence, Disaster and Counterterrorism Medicine and Tactical (SWAT) Medicine. His most recent paper, Workplace Violence Against Healthcare Workers in the United States, was published in April 2016 in the New England Journal of Medicine. He is a 2014 graduate of the Harvard Disaster Medicine and Emergency Management Fellowship  and was the first Director of Counterterrorism Medicine as faculty in that Fellowship. He functioned as a Tactical Physician for the MA State Police SWAT Team for three years. In 2017 he was selected as a Fellow in the Emerging Leaders in Biosecurity Initiative at the Center for Health Security in the Johns Hopkins School of Public Health.

Dr. Phillips was trained in Plastic and Reconstructive Surgery at the University of Michigan followed by an Emergency Medicine residency in Chicago where he served as chief resident and was awarded as the Outstanding Resident Researcher. He graduated as a Top Ten Senior from Oklahoma State University with a dual bachelor’s degree in microbiology and molecular genetics before matriculating to the University of Oklahoma College of Medicine.

Dr. Phillips’ interests include disaster medicine, tactical medicine and the role of medicine in counterterrorism. He has recently authored textbook chapters on Active Shooter Response, Improvised Explosive Devices, Structure Fires and medical treatment of hostages.