COVID-19 Treatments and Outcomes: Expert Q&A
April 24, 2020
What COVID-19 treatments are working? Why should ventilators be avoided? How quickly are people recovering from this virus? UChicago Medicine experts Dr. Michael O’Connor and Dr. Thomas Spiegel answered audience questions.
And welcome to At the Forefront Live. As you can see, we're practicing social distancing. And our experts will be joining us for the program from remote locations today. I'm the only person in the studio during this program.
And today we are focusing on COVID-19 and taking a look inside our intensive care unit as we talk with physicians and nurses on the front line fighting this pandemic. We'll talk about what treatments are working, how quickly people are recovering, and what you need to know about COVID-19. Plus we'll answer your questions. That's coming up right now on At the Forefront Live.
Dr. Michael O'Connor, chief of our section of critical care medicine and Dr. Thomas Spiegel, medical director of our emergency department, join us to take your questions. We want to remind our viewers that today's program is not designed to take the place of an actual visit with your physician. Now let's start with each of you introducing yourselves to our audience and telling us a little bit about what you do here at UChicago Medicine. And Dr. O'Connor, we'll start with you first, please.
Good afternoon. I'm Michael O'Connor. I'm an anesthesiologist and intensivist. I'm section head of critical care medicine in the department in anaesthesia. I'm also the executive director of critical care of the University of Chicago hospitals and clinics. I've been charged with organizing our ICU response to the COVID-19 pandemic.
Dr. Spiegel, let's hear from you, please.
Yes. Good afternoon. I'm Tom Spiegel. I'm the medical director for the adult emergency department at University of Chicago Medicine. And I'm also one of the hospital incident command system representatives for the emergency department helping to coordinate with Dr. Linda Druelinger the emergency department's overall response to the COVID-19 pandemic.
Great. And Dr. Conner, we had the opportunity together to take a little tour-- for me, it was a virtual tour. But of course, you're up there on a regular basis-- of one of our ICUs-- actually, I think we went to both-- yesterday and kind of got to see really what's happening on the front line. And first, if you can describe to us what cohort unit is and what happens up there with the patients that come to us.
So patients who have COVID-19 who come to the University of Chicago hospitals and clinics are cohorted. They're placed in a unit that's exclusively got patients with COVID-19 in it. And that allows us to kind of provide the highest level of personal protective equipment to the providers taking care of these patients and co-locate everything that we need to generate the care of these patients.
And so for the COVID-19 pandemic, we literally brought down the census in our hospital by stopping elective surgery and used the space or the capacity created by that to, in fact, repurpose 160 beds on the eighth and ninth floors of our hospital. We have 48 beds that are framed as ICU beds that we're operating as intensive care unit beds for COVID-19 patients. And we have the remainder of those beds that are being operated as ward beds.
You know, each of those-- but in both instances, the ward and the ICU, the only kinds of patients in those beds are patients who are diagnosed with having COVID-19. If you come to the hospital and you don't have COVID-19, you aren't on a ward with patients that have that diagnosis.
And I think that's a very important thing to point out. I'm glad you did, because we want to make sure that our other patients are safe as well. And all of our patients, obviously. We want them to be safe as well as the workers in the hospital. And I saw a lot of examples of that as you walked me through some of the units yesterday. And John, if we can, let's go ahead and roll clip three. And this shows a physician working with one of the patients.
And it's just kind of amazing to me, Dr. O'Connor, as we watch this clip just all of the precautions, all of the steps that are taken for these patients and for the docs and the nurses that are working up there just to be very, very careful. And you can see some of the PPE there. Can you describe what we're seeing?
Sure. So that's one of my colleagues, Dr. Avery Tung. And he's wearing surgical scrubs over which he has a yellow gown. And over his surgical scrubs, he has as well a paper jacket. He's wearing a full face plate that protects his face from any kind of splatter from the patient. He's wearing a half face respirator with special filters that are designed for long use. And here you can see he's performing hand hygiene. He's washing his hands after he's already Purelled them as he leaves the room.
And Dr. Spiegel, I want to go to you next and have you tell us a little bit about the kind of life in the emergency department now because that is, I'm sure, has changed significantly as well. And what are you seeing? What are you and your colleagues seeing? And what precautions are you taking?
Sure. When this all started, University of Chicago Medicine has relationships with the University of Wuhan. And we had some early information coming in from Wuhan about the extent of what turned out to be a pandemic. Then when it spread to Italy, also had colleagues there giving us information about the need to be prepared.
So when we looked at this and when we looked at what was going on early on in Seattle and in New York as things progressed, we basically took a big step back. And it's much like the line from the movie Jaws, that famous line when Rory Schneider first sees the shark and turns around and says, "we're going to need a bigger boat."
So I think the first thing we did was we prepared for volumes and volumes of patients. We went out to see what was the best way to approach that. We talked a bit about having a tent out in front of the emergency department. Many emergency departments have done that across the country. We decided we were fortunate in that we had this warehouse space connected to the emergency department that was much larger than any tent.
So we replicated basically a tent process in this much larger space. So we were able to add an additional 80 spots where we can see and treat patients that are all six feet apart from each other so we can maintain social distancing with a much larger area. We had additional backup spots that we had prepared as well. We filled out and completed some electricity design as well as networking design for some additional spaces that we could expand into yet if the need is still there.
But as far as on a day to day basis, what we're doing-- and again, I think this is happening in most emergency departments. We've spoken with many of our colleagues in Chicago and around Illinois. When you first come into the emergency department-- because if you have an illness and you need to come in, feel safe in coming in. You'll be seen right at the door. Literally, you won't even get into the emergency department.
You'll talk to a nurse right at the door. We call this our nurse navigator. And he or she will discuss with you your symptoms. They'll do your temperature. They'll do some basic vital signs. And if you have an influenza-like illness or a COVID-like illness, you'll actually be separated from the rest of the non-COVID-like illness or influenza-like illness patients. And you'll go to a different area.
So we're maintaining what we call our hot zone and our cool zone. The hot zone is anyone that is potentially COVID. And then a cool zone where those patients that if you twist your ankle and you're worried you have a break, if you have some minor complaint and it has nothing to do with something that could be COVID, you go to our cool zone. So the treatment spaces are separated to maintain patient safety as well as maintain staff safety.
And that's just so critical. It was interesting again watching some of the folks that were working with the plastic bags on name tags and things as I mentioned earlier. And just everybody's taking care of themselves. But they're taking care of each other.
And Dr. O'Connor, one thing that I noticed that I thought was quite interesting, and you'd pointed this out a couple of times, the different workers on the units had their names oftentimes in tape on their back or on the front of their PPE so that people knew who they were because they can't see each other without the mask. So that's got to be a little bit of an adjustment as well.
I want to talk a little bit about some of the things that we're doing. Then I'm going to get to as many questions from viewers as we possibly can. We're already getting a ton. And I really want to take as many as possible, because I know how that important that is to the people that are watching.
Can you talk to us a little bit about negative pressure rooms, negative pressure floors, and then we do something called a high flow nasal cannulus I believe and these helmet assemblies which we're going to show here in a moment? Actually, John, let's go ahead and roll the video with the helmet assembly. I think that's clip four if we can. And Dr. O'Connor, you can talk a little bit about that and then launch into the other stuff if you can.
All right. So this is a patient who has got a helmet assembly. And the idea behind this is that the patient doesn't have a mask on their face, doesn't have a breathing tube in their windpipe. They literally get positive pressure through the helmet assembly so they don't require sedation. They're perfectly comfortable. There's nothing that's making them uncomfortable. It's a very effective way to support ventilation in these patients. And it's very natural for them. They can literally talk and you can hear them. You know, this is not a technology that I know how to use.
One of my colleagues, Dr. Kress, who is a national and international expert in this, and my colleagues in the Department of Medicine are all likely using it. So we've got people with the expertise to manage this deployed in every ICU. It's fantastic. And what was the other part of your question?
The high flow nasal cannulus and the negative pressure rooms. How does that work? And how is that beneficial for patients because I think that's, again, something we do here that is fairly unique. And Dr. Spiegel, you can jump in as well on any of these.
So one of our strategies here is to do everything in our power to avoid the institution of mechanical ventilation in patients. That is to say we do everything we can to avoid putting a breathing tube in somebody's windpipe and attaching them to a ventilator. And one of those strategies is to put a high flow nasal cannula on somebody. And this is a cannula that blows oxygen in your nose but at an enormous rate, 50 liters a minute, 30 liters a minute, and a very high FIO2. And it helps the lungs stay inflated in the face of a COVID infection in the lung.
The downside is that oxygen comes out your mouth and it aerosolizes the COVID in the back of your mouth. And it makes a fine mist of COVID-19 in the room. Now that would make it dangerous for any health care provider to walk in your room. This is one of the reasons why, once again, they wear the half face respirators or the N95 mask.
We want them to have that full plate face plate as eye and face protection. But the other key to this is we don't want that fine mist to leave the room. And so instead, every room that we take care of these patients in is a negative pressure room. That is to say when you open the door, air goes from the corridor into the room.
Air goes out of the room and into the filtration system and out the exhaust of the hospital. So there's no threat to other patients. There's no threat anybody in the corridor outside the room. And as long as the practitioner is wearing the appropriate PPE when you walk into the room, there's no hazard to the provider.
But we absolutely need this technology because we couldn't use high flow nasal cannula or non-invasive ventilation as liberal as we need to or want to absent the negative pressure, which, by the way, every room on the eighth and ninth floor of our hospital is negative pressure with respect to the floor. It's one of the fantastic design features of [INAUDIBLE].
That's great. And Dr. Spiegel, one of the things that we've heard about is obviously the attempts-- and we're getting a lot of questions in here on this as well-- ventilators and how much they help patients or don't help patients. I know our efforts are to try to keep patients off the vents if at all possible. Can you talk a little bit about that?
Absolutely. I think the term that we use both up in the ICUs as well as in the emergency department is to prevent the vent, that we don't want to put patients on ventilators if we don't have to. Now the reason being is that there's additional damage that this device can actually do into the lungs.
If you think about on the outside, if you have a fractured rib or if you even have a shingles outbreak along your chest, and if every time you take a deep breath it hurts because there's additional movement to an injury area, well, that's kind of what's going on in the inside of the lungs in a very simplistic fashion. The lungs are damaged. And you're continuing to stretch that tissue that's trying to heal. So you're basically, you're injuring it, reinjuring it as it's trying to heal. It's a very downward spiral that can be created. So what we try to do is to avoid that.
Now one month ago, if you were to come into the emergency department and if you needed additional oxygen beyond the level that we were comfortable delivering through those typical nasal prongs, which is only five liters, that gives you about 40% oxygen into the lungs. With high flow, we're able to get a far higher percentage of oxygen down in the lungs without stretching the lung tissue so as to prevent that reinjuring that injured area.
We've had early success in that. And we've been trying to get the word out. Early publications are coming out from-- there's just actually one yesterday from the Journal of American Medical Association about early findings in New York that have a very high mortality rate when you're put on a ventilator.
So reading those statistics, we're concerned about that and trying to avoid the vents, trying to prevent the vent. We are using high flow nasal cannula to do that. We've had good success. We're trying to get the word out to our colleagues in Chicago. We just had communication.
We just did a broadcast yesterday, a webcast for the American College of Emergency Physicians. We did a national webcast late last week for the organization called Vizient trying to get the word out that high flow nasal cannula, if done correctly, can be a very safe, effective measure to prevent the vent and to prevent that increased mortality for ventilated patients.
One last thing I will say is that we also, in addition to the negative pressure rooms that Dr. O'Connor talked about, we also in the emergency department insist that we have what's called an anteroom, which is in a room outside of the actual patient room before you enter into the emergency department. It's like a mini room outside of the treatment room where we close the doors. We can take off our protective equipment without spreading any of that virus that may be on our clothing out into the rest of the emergency department.
We had early success with high flow nasal cannula. In the first few days, we were able to prevent seven patients from getting on the vent. We said, hey, this may be working. Let's continue this. So we doubled our capacity. Our facilities group came in and built us temporary anterooms on another two rooms so as to double our capacity to be able to continue to prevent the vent for patients.
That's incredible. So we have a patient question from someone who is a cancer patient and wants to know if it's safe to come in for their appointments and treatments. And one of the things, Dr. O'Connor, you can, I think, address this. You talked about it a little bit earlier, but the fact that we are keeping our COVID patients on specific floors. Could you talk a little bit about the safety to other patients in the facility?
Right. So once again, one of our strategies is to cohort the COVID patients in specialized units and not have any patients that don't have COVID in those units. Additionally, the routine that we use to clean a hospital in general, you know when we're not in the middle of a pandemic, makes the hospital one of the cleanest places you can visit. And especially now with our doubling down on the cleanliness of the hospital, any surface that you might touch, any place that you might go, it's incredibly clean. In fact, I would argue that the hospital is far safer than going to the grocery store.
So let's talk a little bit about-- well, actually, John, let's roll clip number two. This is an interview with a nurse that you did for us, Dr. O'Connor. And this is one of our nurses directly on the front line. She's going to tell you a little bit about what her day to day like is in one of these COVID units.
It is not comfortable. If we take it off, our faces are very marked up. We feel like it's important because it's protecting us. And we're more confident going into our patients' rooms. It's been hard. At first, it was overwhelming. Like I said, at this point, it seems more normal. We spend every shift we work on this unit so it's becoming a little more normal. But at the same time, it's kind of scary.
And when we talk about health care heroes, it's obviously people like the nurse we just saw there and, obviously, you physicians as well. So we really appreciate what all of you are doing. And I do want to point out if you go on online to uchicagomedicine.org, you can search for thousands of differences or on social media #thousandsofdifferences. You can post pictures and things like that that we actually share with our front line staff. And some of these have just been have been wonderful so far.
Let's get to viewer questions now. So we have some questions from viewers. If people believe they have coronavirus and they're sheltering at home, do things like Advil make the coronavirus worse or is that helpful?
The answer is we don't know the answer to that question. Many medical professionals believe that if you have this virus that you should not take nonsteroidals. But there is no well-established scientific answer to that question.
What about a CPAP machine? That's another question that a viewer had. And if one of you guys could-- either one of you could take that one.
So you know, if you are somebody who has a CPAP machine for sleep apnea at home and you think you have COVID, you should use that machine at home as you would ordinarily do. But you certainly shouldn't have anybody in the room with you. You should self-quarantine at home away from your family and friends and use that CPAP machine only in a room that no one else comes into.
Yeah. I would add real quick that if you don't have COVID, it's not an issue. However, many people have COVID before symptoms show up. So I agree with Dr. O'Connor that if you're going to use a CPAP machine because you need it, sleeping in a separate room would be the safest route.
Another question from a viewer. I had symptoms of COVID in early January before the pandemic was declared. Should I get tested for the antibodies?
When the antibody test is available and reliable, that would be a really good idea. But until then, you should be fine as long as you're not sick.
Kind of a follow up question to one of the ones that we just talked about a moment ago. What sort of medicine should moderate COVID patient positive people take at home?
Yeah. So I'll take that one.
We deal with these patients all the time in the emergency department. But if you're the walking well but COVID positive, the question is what should you do. And really the answer is take the medications that make you feel better. Our overall goal in any area of health care is to make people feel better while their bodies are getting better.
This is a viral infection. Until we have any type of known proven treatment for it, it's what we call supportive care. It's, again, trying to feel better while your body fights this thing. Lots of rest. Lots of fluids. We say that but we mean it. The more dehydrated you get, the more difficult time your body will have fighting that, so lots of fluids and then over-the-counter medications that just make you feel better.
Sometimes if you're nauseous and if you're throwing up or if you have other gastrointestinal problems, then we may need to give you some prescriptions. But overall, most folks do very well with plenty of fluids, plenty of rest, some over-the-counter Tylenol if you're worried about the ibuprofen issue, and just trying to support yourself through this infection.
We've seen a lot of questions about grocery delivery, at home delivery, which makes a lot of sense. A lot of people are taking advantage of those services. How can people be safe with grocery delivery, both at home and even if you go to the grocery store. If you're wearing a mask but you're touching a lot of things at grocery stores, what should people do?
So there's no one right answer there. I mean so the most important thing is while you're touching other things, don't touch your face. That's number one. So one of the great advantages of wearing a mask is that it prevents you from touching your face, which is one of the ways that people get this infection.
They touch something that has the virus and then they touch their face. They scratch their nose. They scratch their mouth. And so the great advantage for a mask is it prevents you from touching your face. So don't touch your face.
And then when you leave an environment like that, and most grocery stores have done this, perform hand hygiene. They've got a Purell dispenser at the exit. Go ahead and clean your hands off. Really take your time. Make sure that you spend a couple of minutes, you get all the surfaces. And that should be fine. When you get home, you're welcome to go ahead and unload your groceries or whatever it is you purchased wearing gloves. And once again, when you're done with that, wash your hands.
And Dr. Spiegel, one of the things that I thought was kind of interesting, we've actually seen our flu numbers I think decline pretty substantially this year. Again, I would imagine because of some of the hygiene that people are practicing. But that's something that people always need to remember. Wash your hands often. And soap and water works really, really well, as good or better even than the sanitizers. Is that right?
That's absolutely correct. In fact, the answer I had was to protect yourself like Dr. O'Connor said with a mask and then to wash your hands when you're done to get all that virus off. And the influenza decline was fairly expected. It followed the seasonal distribution and patterns that we typically see. So we were expecting to see that in influenza. Was it helped by this additional precautions from COVID? Possibly, which is a good thing. But again, it goes back to protecting yourself and washing those hands.
Another question from a viewer. It's when do you recommend coming to the ED-- when the fever is high or only for oxygen if someone is short of breath?
That's a great question. So like Dr. O'Connor said earlier, our hospital is safe. It's safer than the grocery store. So if you have a concern, whether it's COVID related or not, again, if you twist your ankle, if you fall, and you cut your arm, and it's a large gash that won't stop bleeding, you may need to continue to come to the emergency department, which is fine. Most ERs, again, you'll be seen at the door. And if you have no influenza-like illness or no COVID possible illness, you'll come into a cleaner area than the rest of the emergency department. So don't be afraid of the emergency department.
One of the things at a national level that emergency medicine is concerned about is that we overall have seen a decline in some of our significant symptoms. You know, stroke patients, some heart attack patients. Are we seeing less of those because those disease processes haven't gone away with COVID. In fact, some may argue that there could be worse exacerbations of some of these critical illnesses. And the concern is we've seen a decline in some of these serious patients because people are afraid to come to the emergency department.
I will say again, do not be afraid of emergency department. If you have an issue, please do come. Now that's not to say just come, because if you don't have something serious, you should be staying at home. You shouldn't be coming anywhere. So I think staying at home is the safest thing. If you have any concerns though, do come in.
I think the question was when should I come in. It really boils down to if you're concerned. What we're seeing with COVID patients is that many of them have fevers. Many of them are short of breath. So if you have any shortness of breath, please come in. That's the safest thing to do because you can get checked out fairly quickly. And you'll be seen in a cohorted area where you're protected from the rest of the patient population.
Dr. O'Connor, here's one for you. I was hospitalized right before the coronavirus was declared with a fever, sore throat, pneumonia, dry cough. Should I be tested to see if I did have COVID-19.
Once again, when there is an antibody test, when there is a serologic test for having had the infection, that would be worthwhile to know. It's not absolutely necessary but it would be nice for you to know that you've had the virus and that you've cleared it.
John, we do have a clip I think that we haven't hit yet. That's clip number five. That's an interview with Dr. Allison Dalton. And she's also one of our health care heroes that's right there on the front lines fighting this. Let's go ahead and roll her clip and come out. We'll take a few more questions from our viewers.
So I guess there's a couple of different facets that we're really interested in. One is taking care of the actual patients. And these patients behave and have different physiology than really anything we've seen in the past.
And we see a bunch of different types of patients. We see patients that are very sick from their COVID infections. We also have numerous patients on the service medical issues that have happened to test positive for COVID as well and are more incidentally in our unit just because of their COVID positive status.
The other obvious difference from what we normally do on a day to day basis is the amount of PPE and the effort that we take care to protect ourselves and our colleagues. You know, the hospital has done a great job making sure that we have negative pressure rooms, that we have negative pressure floors, and being able to utilize that to take care of our patients in ways that are more familiar to us that we haven't been able to do necessarily at other institutions like using high flow nasal cannula and instituting even new devices to us here like helmet ventilation.
Having kind of that curiosity being a medical professional, it's interesting to be able to be on the front lines and experiencing the new ways that we're taking care of patients and how the physiology of this disease is different than anything we've really seen in the past.
From a more personal standpoint, being in the unit has changed my day to day lifestyle. When I leave the unit, I have to be much more cautious. When I go home at night, I'm not able to interact with my family in the way that I'm used to. We are living in separate rooms of my house. I'm masking at all times when I leave those rooms. I'm not touching my family for a week or two after leaving the unit. So it's changed from that standpoint.
We've also started finding that we know some of the people who are here with us in the ICU. And taking care of people that I know has not been the easiest transition. So it's an important thing to kind of think about.
Couple more questions from viewers that I'd like to get to and then we'll wrap it up with a final comment or thought from each one of you. First one. How long after symptoms and fever can you stop quarantine?
What a good question. So you know, that's one that we don't know the answer to. I mean, generally speaking, at our institution, we say that 14 days after you test positive for the virus, you're probably not shedding the virus anymore, particularly if you've recovered. And so if you're better and it's been 14 days since you tested positive, it's reasonable for you to presume that you're not shedding virus. But once again, this is a question that our answer to will change as the science evolves.
Sure. And here's a question we've actually received from multiple people. So let's get to this one. Will doing nebulizer asthma meds help if we get COVID?
I could take that one.
If you get COVID, the concern with nebulized medications is that you could be taking some of the virus that's living up in your upper respiratory airway. And the nebulized medications will take that as a mist and spread it throughout the room. So anyone you're around or anyone in that room may be exposed to COVID virus, which is the reason that we've stopped giving nebulizer medications for the most part in the emergency department, that if it's even possible that you have COVID, you could be spreading it to everyone.
Now if you have known COVID, it's even more dangerous because you know you're spreading virus at that point. So while nebulized medications have been a reliable treatment for many, many years, they've taken on a new level of concern and danger in the COVID pandemic.
Interesting. And so let's wrap it up now with just a closing thought from each one of you. And Dr. O'Connor, I want to start with you. Just what would you tell patients out there that are watching this?
You know, we're learning more about how to take care of these patients every day. We're producing better outcomes every day. And you know, I don't know if there is a cure down the road. But I will tell you that our ability to generate good outcomes with what we already have is getting better every day.
You know, I would say we've given some scary statistics today. We talked about a high mortality rate if you're ventilated. I want everyone to know that statistics are one thing, but every single patient we care for individually. And if you and your family is telling us to do everything we can, we will stand with you. We will fight with you. We will fight for you to the best of our abilities on a case by case basis.
And this is truly a wonderful team. Your teams are doing fantastic work. It's a large group effort. And my sincere thanks goes to you, and the people we saw in the little video clips, and all the people that are working out there. You guys are really doing wonderful work.
That's all the time we have for the program. Please remember to check out our Facebook page for future programs and health information. Also, if you want more information about UChicago Medicine, take a look at our website at uchicagomedicine.org. If you need an appointment, you can give us a call at 888-824-0200.
And we will be doing another Facebook Live that will involve answers about COVID next week at approximately this time next Thursday. Just keep checking our Facebook page. And you'll see the schedule. Thanks for being with us today. Hope you have a great week.
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