From Pushkin Industries. This is Deep Background, the show where we explore the stories behind the stories in the news. I'm Noah Feldman. At the beginning of the COVID nineteen outbreak, we spent a lot of time thinking about the doctors, the frontline physicians who were fighting the disease in the hospital. As cases have begun slowly but surely to decline hebred Massachusetts and in other states, we thought it was a good time to revisit the frontline hospital doctors and the experiences that they've had treating patients in intensive care units. We wanted to know what their experience has been and how it's been changing over the last several months. We also wanted to know about the standard of care in the hospitals. It is coronavirus being treated now the same way that it was treated at the outset, or have there been signific developments in how physicians are encountering patients. To discuss these issues, we're joined by doctor Emmy Rubin. She's a critical care pulmonologist at Massachusetts General Hospital. She's been on the front line treating coronavirus patients from the beginning. She's also co chair of the hospital's Optimum Care Committee, which is essentially its leading ethics body for figuring out how to handle difficult ethical questions under circumstances exactly like the ones facing the hospital now. I asked doctor Rubin how things have changed in her ICU since March, So I would say, you know, in the beginning, when the cases were surging, Mass General was particularly hard hit. So in the early days, things were evolving very very quickly. We were extending our capacity in every way that we could very quickly by opening up new ICU spaces within the hospitspital adding staff, changing staffing models, and we got to the point where we had close to two hundred patients with COVID in our intensive care units. So I think in terms of how we individually took care of patients, we took care of them the way we would take care of any IU patient with respiratory failure. And I think we relied on what we know about the basic physiology of these patients, which is the vast majority of them and the intensive care units have what's called acute respiratory distress syndrome or AIRDS. That's something that all of us have a lot of experience taken care of, and we relied on basic principles of management, ventilator management in particular, which we know a lot about from other disease processes. So in many ways, taking care of individual patients was similar to how we take care of individual patients with the flu or airds from other conditions. What was not typical was obviously the volume of patients with one specific condition that months before we had not heard about. What was also different was the kinds of medications we were trying. At first we were using in the early days, we were using a lot of hydroxy chloroquin, a lot of statins. I think people were very quickly trialing things. I think there was a lot of desire among many people to try medications that might work, and has been widely reported. I think in the beginning we were using a lot of medications that have turned out to be of questionable benefit. As things have gone on, there are many many trials up and running at Mass General to look at randomized controlled trials at these medications and try to figure out what actually works and what doesn't. So I would say that early kind of enthusiasm for different medications has waned, and now really it's just taking care of intensive care unipatients with respiratory failure, but on a much larger scale. Let me ask you specifically about the what you described as your normal practice for people with RDS, which includes ventilators right. Has the way that you are treating COVID patients in that regard in terms of putting them on ventilators, who goes on ventilators at what stage? Remain constant or has that shifted? Because I know there was at least some public discussion sort of somewhere in April around the question of whether the ventilators were doing what they ought to be doing for COVID patients or whether it was plausible to think about other oxygen delivery systems. How has that evolved and are we back to sort of where we started in that regard. Yeah, I think an interesting question. I would say it may be that early on we may have had a lower threshold for putting people on ventilators. So one of the things we know about airds is that once people are on a ventilator, the mainstay of treating them on a ventilator is giving them relatively small breaths on the ventilator to prevent what we call ventilator induced lung injury. And there's a concern that if people with developing ards are breathing on their own and taking large, kind of gulping breaths for a long time and they end up needing to have a breathing machine anyway, that during the time they're breathing spontaneously, they may be doing damage to their lungs by taking large breaths and damaging certain portions of their lungs. I think in the beginning we may have had a slightly lower threshold for putting people on a breathing machine. In other words, when people seem to be taking a significant turn for the worse, we may have put them on a little bit earlier. But I would say in general, our management kind of adheres to traditional principles, which is, when somebody has respiratory failure and is not supporting their breathing, either not maintaining their oxygen levels or not getting rid of the carbon dioxide they're tiring out, we support their breathing with a ventilator. There has been a lot of attention to are we putting too many people on ventilators with COVID. I think I can speak for myself certainly and for many of my colleagues that we feel that you look clinically at the patient. If they seem like their breathing is failing, we put them on a breathing machine, the same way we would in any other situation. And how do you feel There must be some statistics on this, but there's also some imperfection in the statistical analysis. But how do you feel in terms of whether the standard of care that you're using is producing better outcomes at this stage than it was at the beginning, or really are people making it or not making it with the excellent treatment that you're giving them pretty much at the same rate as they were at the beginning. I realize there are many confounding factors that would be very hard to run a proper study on this or in movement. So I'm really asking you for an impressionistic response. Yeah, As you alluded to, the data has essentially all been imperfect because we don't have enough long term data on how people are doing. So most of the data about for survival to discharge, for example, or survival to hospital discharge was based on numbers that included a lot of people who were still in the ICU. So I think it is possible that early on, as they said before, we were having a slightly lower threshold to intubate people. So we saw a lot of people getting better, getting off the breathing machine and getting out of the ICU and in many cases leaving the hospital. Now we're seeing a lot of people who have required support for a longer period of time. We have a lot of patients now. This is one way in which things have changed is that many of the patients I would say, who remain in the intensive care units or in other parts of the hospital that are sort of stepped downs from the intensive PERI unit are people who we don't know how they'll how they'll do, whether they will survive, whether they will survived to leave the hospital, whether they'll be able to get successfully off of the VENTI later. So I think things have evolved in that respect that we anticipate that. You know, when we looked at our earlier percentages of people who had survived to hospital discharge, those were quite encouraging. We always expected those numbers to change and to sort of move more towards the numbers that we are familiar with for airds in general, and the mortality rate for airds in general is high. What's the ballpark for air ds in general non COVID airdas I think for moderate to severe airds there's about a forty percent mortality rate, and age is a predictor of mortality for airds in general. And so again that's a way in which we think that this will be quite similar. What's the longest that you've had people still beyond ventilators? I mean there must be people who came in in March. Yeah, are any of those people still on ventilators now? Yes, there are certainly people who came in March who are still needing ventilator supports. So typically, once somebody needs support for a certain period of time that is defined by sort of clinical judgment, but more than a couple of weeks generally, and we consider putting a trade gastome and which is a more durable, more comfortable form of a breathing tube, so that patients can receive mechanical ventilation for longer. There are many patients now who have had trade gustomes, some of whom will then be liberated from the ventilator once they have the trade gastomies. But there are certainly patients who have required many, many weeks of mechanical ventilation. Some of those patients will leave the hospital and go to sort of long term acute care hospitals even while they're still needing support. There are certainly patients in that category, and that is not unique to COVID. I think what is unique is the number of people. So when you start with ten times the number of people who you ordinarily have with AIRDS, you're going to have a huge number of people in the category of what we call chronic critical illness, where people require prolonged mechanical ventilation. It sounds like a remdesse of her which I finderstand correctly has been made available at least at MGH, is not having a transformative impact on the course of disease for most of the patients that you're seeing. I think, based on my understanding of the data, and I think in general this is a shared view, that it does have some effect, apparently on sort of time to recovery. I don't think there's a sense that it will be a game changer for the people who are the sickest. We are giving it and it is the only drug, as you I'm sure are aware that is now not formally approved but authorized use. So we are certainly giving it to patients who meet criteria for it. I think the patients who, for whatever reasons, are destined to become the sickest. I don't know that it will help prevent severe illness or deaf in those patients. There was, as you probably also know, a trend towards mortality in that in the trial, but it wasn't didn't meet technically the threshold for statistical significance, and I don't necessarily think we'll get answers to those questions. By the time we got round severe, we had a hospital full of people who were already, as I said, sort of very far advanced into the illness. I think we're very skeptical that it could help those patients. So I think we think that a certain subset of patients who get it early enough on the severity illness may be less, which is encouraging. It's encouraging to have something to use, but we still think that for certain patients this is a devastating illness and will be. And when Donald Trump informed us that he was taking hydroxy chloroquinn, one of the things that he said was that his impression was that lots of frontline medical workers were also taking it prophylactically in your anecdotal experience at MGH, Do you know anybody who's actually doing that at the stage, I cannot promise it's not happening. I do not know anyone that personally, to be perfectly honest, did it come up with people at the very beginning when it was being used. It didn't. I don't know that any of my friends and colleagues ever actually took it, but there were some people who mentioned early on that they would consider it when there was a lot of enthusiasm for it. Certainly not in recent days. And again I think it's you know, a lot of what we've seen, and I think it's human nature to want to do something for people who are so sick in front of you, So I don't. I think one of the things that's been very interesting and that sort of consistent with human nature, is that throughout the course of this the zeal to use things that sort of seem like they might plausibly help, or where there's a little bit of suggestion of it, like hydrox chloroquint at the beginning. I mean, that was very very thoughtful, smart people. We're using that and recommending using it at the beginning. I think that's just a testament to how much people want to find something to help. And I think, you know, hopefully now we've sort of regressed to the point where we're you know, I think most people are being much more measured about we need to study things in the context of trials and actually get evidence before using things. But you know, it's understandable. It's very hard to watch people sick and dying in front of you with nothing to do other than sort of supportive care, which really is the sort of mainstay of taking care of these people. That's something that you know, as I see, physicians were used to because there are many things that we don't have a specific magic bullet for and we take time and you know, try to have patience and try to get people through it with sort of the best supportive management we can. But it's hard. We'll be right back. How has the psychological experience of being a critical care physician been changing for you? At the beginning, it must have been just a bit overwhelming because of the radical numbers and the changes. I'm curious to know what it was like then, and also how it's evolving now. Yeah, it's a good question. I think at the beginning, first of all, I think, you know, there's a whole lot of adrenaline around sort of, you know, there always is when something is evolving so quickly. I think there was a lot of energy around everybody figuring out how to make this work and extending our capacity, and everybody jumping in and filling roles that they may not have otherwise filled. I think there was a lot of energy around how do we, you know, kind of step up to this moment that is unusual. I think there was also sort of an element that was very surreal the first time I was in an ICU and all of a sudden, every single patient has a disease that you know, we didn't know the name of a few months ago. So I think there was an element of feeling like it was hard to believe it was happening. There was not a lot a lot of time necessarily spent on rounds trying to figure out what was happening. So I would say in general rounding in the intensive care unit, one of the things that was noticeable is that sort of took less time. Everybody was quite similar in terms of what was wrong and the kinds of decisions you were making, so there wasn't a lot of diagnostic dilemma, which was unusual. And also, you know, I think made things kind of go a little bit faster. You would go around taking care of the patients making kind of similar decisions. Examining people took a lot longer because you were dealing with you know, gear that is more time consuming to put on and take off and figure out where to put everything and do things safely. But the actual medicine I would say took less time, both because most of the patients were similar in a lot of ways, and also because families weren't there, and the time that you would ordinarily take either on rounds after rounds, to be talking to families and explaining things you didn't have to take. I would say that is a significant change for a whole lot of reasons. Does it make it easier, I mean, I know it's not great for the families, But does it make it easier for the physicians through their jobs. Well, yes, so in certain ways that made things sort of more streamlined. In other ways, I think it's made things incredibly challenging a lot of what we do as I see doctors, nurses, other people who work in the ICU, is talking to families, having conversations about what's important, what direction to take, a lot of end of life discussions that are very, very challenging, I think, to have over the phone, we rely a lot on developing fairly quick rapport with families. In person, we rely a lot on, or at least I should speak for myself, I rely a lot on nonverbal communication and things that are really challenging over the phone, and I would say, particularly where they're language barriers, I would say those conversations have been much more difficult for me, certainly not being able to see families regularly in person. We have had families come in when patients are approaching or at the end of life, which I think has been helpful. That ordinarily, when somebody is so sick, it's an evolving process over a period of time and a number of conversations that involves establishing trust and coming back to things, and so that's been really really challenging, I think not having families there regularly, and of course that's something we do with some families can't for various reasons or aren't in the ICU routinely when a loved one is sick. But this is a fairly dramatic departure, having very few family members present. What about your morale and the moral of your colleagues. I mean, as you're describing at the beginning, there's a lot of adrenaline and so that in some sense takes care of the moral. You know, what you have to do, the pressures on you do it now that things are maybe by your description a little bit more regularized or routinized, the how's your inner experience of that, and what do you think about that of your colleagues? Yeah, I think people are exhausted. I think we also have no idea now sort of what form this is going to take going forward. I think it was you know, it has become clear that this is not going away in any meaningful way anytime soon. While there is certainly the numbers are down dramatically in terms of the intensive care unit, you know, the number of patients. As I said before, we have a lot of patients who are still very sick in the hospital, who are kind of living through the sequela of critical illness. We don't know what's going to happen to the numbers, you know, next month or in the fall or during flu season. I think people are exhausted. There are many ways in which this has been a very hard to be a part of. I think the fact that this that COVID has hit communities of color so much harder, and you know, we're just watching person after person come in incredibly sick. And you know, as I said before, much of what we can do in the US supportive care and time and patience and taking the best care of people we can and seeing if they get better. It's felt pretty relentless in terms of people coming in, often from the similar communities. Often, you know, we've seen multiple members of a family be critically ill. I think it's you know, the scope of the tragedy of it is, you know, demoralizing and exhausting and very sad. And I think people are physically tired because this is hard work and everybody's generally doing more of it than they typically would, and also emotionally exhausted because we in this you know, line of work, we see a lot of people die in general. That's why we're used to But I think all of this happening all at once in such large numbers. I think has been really hard. I can certainly say for myself personally, you know, the uncertainties of or where it will go from here and what will happen and when we be in the same position a few months from now, it's just it's exhausting. If there's a second wave, it sounds like from what you're saying that under the standard of care, we're going to need a lot of ventilators. Do you have the sense working in the hospital that there will be enough should that occur? I mean, how close to breaking point were you at, you know, one of the great hospitals in the region and indeed in the world. I would say we certainly, you know, we extended our capacity many many fold. We did not get close to the point where we were out of ventilators. I think there was a period of time wherewith the trajectory of cases, we were concerned that we might and so I think in the end, I think because of measures that were taken and people staying at home, things flattened out enough that we fortunately avoided that. And I would hope that now that that was a concern that you know, an interim and you know, again I don't have a I don't know anything more than you do about whether there'll be a second wave, but I certainly think people are concerned that there could be. I think between all of the lessons we learned among all the institutions about sort of balancing loads across hospitals, you know, acquisition of new supplies, hopefully we would be and I think we will be better prepared if there is a second wave. And the answer to that question certainly depends on how large a wave would there be. I think if there is a second wave of the type that we saw, we will be prepared for that. You know, there's always a worst case scenario that you can imagine that would still overwhelm capacity, but I would say we ended up being pretty far from that. While we were, you know, we're stretched in terms of our capacity, we weren't near the breaking point. So hopefully that would be even more true the next time around, because there's been a lot of lessons learned about how to organize across the system and extend capacity not just within a vidual hospital but across the region and the state. So my hope would be we would never get there in this pandemic. But again, it depends on you know, there's always a worst case scenario. You can imagine where we would get there. What have I not asked you that I ought to be asking you? I guess the thing to be asking in some ways is sort of what are the issues? You know? Kind of going forward? Right? We sort of have dealt with this emergently and quickly, and everybody's done the best they can. And I would say people have done an incredible job of stepping forward and being innovative and thinking about how do we best take care of people? How do we learn as much as possible, how do we change the whole way that we practice medicine in a very quick period of time. And it's been incredible to watch that. I think there are a lot of challenges ahead, and one of them, you know, one of the big ones I think has to do with how do we take care? As I say before, we have an exponentially larger number of patients who are going to be dealing with the consequences of critical illness. People who survive a prolonged period of critical illness generally do not you bounce back immediately. And we now have a whole lot of patients who have been incredibly sick, who will be dealing with the consequences of that for a very long time, whether it's being you know, in the hospital now for many many more weeks, two months, being in and out of rehabs or long term acute care hospitals. How do we ensure that there's a frameworkingplace to take care of those patients. That system was already very stretched to begin with. It was often very hard to find appropriate places for people to go following episodes of critical illness, and that system will now be stretched even more, and so I think a lot of the questions going forward will be how do we do right by all of these people who have been so sick. I think people focus on do people leave the ICU, do people leave the hospital? But there's a whole cascade of things that happen after critical illness, both physical, psychological, financial, that I think is sort of the next at least for my subspecialty in terms of sort of ethical issues. I think that becomes a huge issue is how do we take care of the people who have been affected by this going forward? And that's what I worry about a lot, is how are we going to make sure that they're taking care of, and recovery goes, you know, sort of well beyond the hospital stay, and so how do we make sure those people have access to the resources that they need and that they can get back to their lives if they're able to recover from the critical illness. So I think, to me, that's sort of the big thing to be thinking about from my standpoint, one of the big things to be thinking about going forward. Thank you so much for the work that you're doing. We're very fortunate that there are people like you who've trained in the things that turn out to be essential in a crisis like this, and I want to thank you for your analysis, for your candor, and also for the extraordinary work you've been doing. Sure, thanks a lot. Thanks for having me on speaking to doctor Emmy Rubin. I was really struck at how the intense adrenaline driven struggle of the early days of fighting the coronavirus pandemic in her ICU sounds like it has slowly developed into something like a new normal. On the one hand, that means that the standard of care has to a certain extent solidified. No longer are the physicians haphazardly trying every possible drug in the hope that something will work. Instead, they're engaged informalized, randomized clinical trials of different drugs. Yet simultaneously, it sounds as though even remdesevere, the drug that has done best so far in those trials, is not being experienced within the hospital as any kind of a magic bullet, but rather as a mild improvement for some patience, and possibly not for the sickest patience who are still in the hospital. Meanwhile, dealing with all of the suffering and all of the death has been demoralizing and challenging for physicians and unquestionably exhausting for them. Listening to doctor Ruben's description, one can only hope that a slowing down in new cases gives a break to the physicians in the ICUs who are dealing with this extraordinarily challenging process of treatment. Because if there is a second wave, we're going to be relying on exactly the same set of physicians to go to the front lines and do it all over again. We're also going to need ventilators. Even though ventilators have not been in the forefront of the news in recent weeks, it turns out that that is not because they are somehow less important to treatment than was originally thought. They're just as significant to the basic treatment mechanisms. And again, if we have a resurgence, we're going to be discussing once more whether we have enough ventilators to treat everybody. My final thought, and I've had it before in speaking to frontline physicians on Deep Background, We're just extraordinarily fortunate as a society to have people like doctor Reuben who spent their whole careers preparing for moments like this one without any knowledge that suddenly pulmonary care would be at the forefront of our treatment of the global pandemic. We are relying very heavily on a certain group of people specialized knowledge right now. But the truth is that in any crisis, some group of people who are properly trained will rise to the foe and become the people we depend on, and for that we can only be thankful. Until the next time I speak to you, Be careful, be safe, and be well. Deep Background is brought to you by Pushkin Industries. Our producer is Lydia Jane Cott, with research help from zooi Win and mastering by Jason Gambrel and Martin Gonzalez. Our showrunner is Sophie mckibbon. Our theme music is composed by Luis Guerra. Special thanks to the Pushkin Brass, Malcolm Gladwell, Jacob Weisberg, and Mia Lobel. I'm Noah Feldman. I also write a regular column for Bloomberg Opinion, which you can find at Bloomberg dot com slash Feldman. To discover Bloomberg's original slate of podcasts, go to Bloomberg dot com slash podcasts. And one last thing, I just wrote a book called The Arab Winter, a Tragedy. I would be delighted if you checked it out. You can always let me know what you think on Twitter about this episode, or the book or anything else. My handle is Noah R. Feldman. This is deep background

From Pushkin Industries. This is Deep Background, the show where we explore the stories behind the stories in the news. I'm Noah Feldman. At the beginning of the COVID nineteen outbreak, we spent a lot of time thinking about the doctors, the frontline physicians who were fighting the disease in the hospital. As cases have begun slowly but surely to decline hebred Massachusetts and in other states, we thought it was a good time to revisit the frontline hospital doctors and the experiences that they've had treating patients in intensive care units. We wanted to know what their experience has been and how it's been changing over the last several months. We also wanted to know about the standard of care in the hospitals. It is coronavirus being treated now the same way that it was treated at the outset, or have there been signific developments in how physicians are encountering patients. To discuss these issues, we're joined by doctor Emmy Rubin. She's a critical care pulmonologist at Massachusetts General Hospital. She's been on the front line treating coronavirus patients from the beginning. She's also co chair of the hospital's Optimum Care Committee, which is essentially its leading ethics body for figuring out how to handle difficult ethical questions under circumstances exactly like the ones facing the hospital now. I asked doctor Rubin how things have changed in her ICU since March, So I would say, you know, in the beginning, when the cases were surging, Mass General was particularly hard hit. So in the early days, things were evolving very very quickly. We were extending our capacity in every way that we could very quickly by opening up new ICU spaces within the hospitspital adding staff, changing staffing models, and we got to the point where we had close to two hundred patients with COVID in our intensive care units. So I think in terms of how we individually took care of patients, we took care of them the way we would take care of any IU patient with respiratory failure. And I think we relied on what we know about the basic physiology of these patients, which is the vast majority of them and the intensive care units have what's called acute respiratory distress syndrome or AIRDS. That's something that all of us have a lot of experience taken care of, and we relied on basic principles of management, ventilator management in particular, which we know a lot about from other disease processes. So in many ways, taking care of individual patients was similar to how we take care of individual patients with the flu or airds from other conditions. What was not typical was obviously the volume of patients with one specific condition that months before we had not heard about. What was also different was the kinds of medications we were trying. At first we were using in the early days, we were using a lot of hydroxy chloroquin, a lot of statins. I think people were very quickly trialing things. I think there was a lot of desire among many people to try medications that might work, and has been widely reported. I think in the beginning we were using a lot of medications that have turned out to be of questionable benefit. As things have gone on, there are many many trials up and running at Mass General to look at randomized controlled trials at these medications and try to figure out what actually works and what doesn't. So I would say that early kind of enthusiasm for different medications has waned, and now really it's just taking care of intensive care unipatients with respiratory failure, but on a much larger scale. Let me ask you specifically about the what you described as your normal practice for people with RDS, which includes ventilators right. Has the way that you are treating COVID patients in that regard in terms of putting them on ventilators, who goes on ventilators at what stage? Remain constant or has that shifted? Because I know there was at least some public discussion sort of somewhere in April around the question of whether the ventilators were doing what they ought to be doing for COVID patients or whether it was plausible to think about other oxygen delivery systems. How has that evolved and are we back to sort of where we started in that regard. Yeah, I think an interesting question. I would say it may be that early on we may have had a lower threshold for putting people on ventilators. So one of the things we know about airds is that once people are on a ventilator, the mainstay of treating them on a ventilator is giving them relatively small breaths on the ventilator to prevent what we call ventilator induced lung injury. And there's a concern that if people with developing ards are breathing on their own and taking large, kind of gulping breaths for a long time and they end up needing to have a breathing machine anyway, that during the time they're breathing spontaneously, they may be doing damage to their lungs by taking large breaths and damaging certain portions of their lungs. I think in the beginning we may have had a slightly lower threshold for putting people on a breathing machine. In other words, when people seem to be taking a significant turn for the worse, we may have put them on a little bit earlier. But I would say in general, our management kind of adheres to traditional principles, which is, when somebody has respiratory failure and is not supporting their breathing, either not maintaining their oxygen levels or not getting rid of the carbon dioxide they're tiring out, we support their breathing with a ventilator. There has been a lot of attention to are we putting too many people on ventilators with COVID. I think I can speak for myself certainly and for many of my colleagues that we feel that you look clinically at the patient. If they seem like their breathing is failing, we put them on a breathing machine, the same way we would in any other situation. And how do you feel There must be some statistics on this, but there's also some imperfection in the statistical analysis. But how do you feel in terms of whether the standard of care that you're using is producing better outcomes at this stage than it was at the beginning, or really are people making it or not making it with the excellent treatment that you're giving them pretty much at the same rate as they were at the beginning. I realize there are many confounding factors that would be very hard to run a proper study on this or in movement. So I'm really asking you for an impressionistic response. Yeah, As you alluded to, the data has essentially all been imperfect because we don't have enough long term data on how people are doing. So most of the data about for survival to discharge, for example, or survival to hospital discharge was based on numbers that included a lot of people who were still in the ICU. So I think it is possible that early on, as they said before, we were having a slightly lower threshold to intubate people. So we saw a lot of people getting better, getting off the breathing machine and getting out of the ICU and in many cases leaving the hospital. Now we're seeing a lot of people who have required support for a longer period of time. We have a lot of patients now. This is one way in which things have changed is that many of the patients I would say, who remain in the intensive care units or in other parts of the hospital that are sort of stepped downs from the intensive PERI unit are people who we don't know how they'll how they'll do, whether they will survive, whether they will survived to leave the hospital, whether they'll be able to get successfully off of the VENTI later. So I think things have evolved in that respect that we anticipate that. You know, when we looked at our earlier percentages of people who had survived to hospital discharge, those were quite encouraging. We always expected those numbers to change and to sort of move more towards the numbers that we are familiar with for airds in general, and the mortality rate for airds in general is high. What's the ballpark for air ds in general non COVID airdas I think for moderate to severe airds there's about a forty percent mortality rate, and age is a predictor of mortality for airds in general. And so again that's a way in which we think that this will be quite similar. What's the longest that you've had people still beyond ventilators? I mean there must be people who came in in March. Yeah, are any of those people still on ventilators now? Yes, there are certainly people who came in March who are still needing ventilator supports. So typically, once somebody needs support for a certain period of time that is defined by sort of clinical judgment, but more than a couple of weeks generally, and we consider putting a trade gastome and which is a more durable, more comfortable form of a breathing tube, so that patients can receive mechanical ventilation for longer. There are many patients now who have had trade gustomes, some of whom will then be liberated from the ventilator once they have the trade gastomies. But there are certainly patients who have required many, many weeks of mechanical ventilation. Some of those patients will leave the hospital and go to sort of long term acute care hospitals even while they're still needing support. There are certainly patients in that category, and that is not unique to COVID. I think what is unique is the number of people. So when you start with ten times the number of people who you ordinarily have with AIRDS, you're going to have a huge number of people in the category of what we call chronic critical illness, where people require prolonged mechanical ventilation. It sounds like a remdesse of her which I finderstand correctly has been made available at least at MGH, is not having a transformative impact on the course of disease for most of the patients that you're seeing. I think, based on my understanding of the data, and I think in general this is a shared view, that it does have some effect, apparently on sort of time to recovery. I don't think there's a sense that it will be a game changer for the people who are the sickest. We are giving it and it is the only drug, as you I'm sure are aware that is now not formally approved but authorized use. So we are certainly giving it to patients who meet criteria for it. I think the patients who, for whatever reasons, are destined to become the sickest. I don't know that it will help prevent severe illness or deaf in those patients. There was, as you probably also know, a trend towards mortality in that in the trial, but it wasn't didn't meet technically the threshold for statistical significance, and I don't necessarily think we'll get answers to those questions. By the time we got round severe, we had a hospital full of people who were already, as I said, sort of very far advanced into the illness. I think we're very skeptical that it could help those patients. So I think we think that a certain subset of patients who get it early enough on the severity illness may be less, which is encouraging. It's encouraging to have something to use, but we still think that for certain patients this is a devastating illness and will be. And when Donald Trump informed us that he was taking hydroxy chloroquinn, one of the things that he said was that his impression was that lots of frontline medical workers were also taking it prophylactically in your anecdotal experience at MGH, Do you know anybody who's actually doing that at the stage, I cannot promise it's not happening. I do not know anyone that personally, to be perfectly honest, did it come up with people at the very beginning when it was being used. It didn't. I don't know that any of my friends and colleagues ever actually took it, but there were some people who mentioned early on that they would consider it when there was a lot of enthusiasm for it. Certainly not in recent days. And again I think it's you know, a lot of what we've seen, and I think it's human nature to want to do something for people who are so sick in front of you, So I don't. I think one of the things that's been very interesting and that sort of consistent with human nature, is that throughout the course of this the zeal to use things that sort of seem like they might plausibly help, or where there's a little bit of suggestion of it, like hydrox chloroquint at the beginning. I mean, that was very very thoughtful, smart people. We're using that and recommending using it at the beginning. I think that's just a testament to how much people want to find something to help. And I think, you know, hopefully now we've sort of regressed to the point where we're you know, I think most people are being much more measured about we need to study things in the context of trials and actually get evidence before using things. But you know, it's understandable. It's very hard to watch people sick and dying in front of you with nothing to do other than sort of supportive care, which really is the sort of mainstay of taking care of these people. That's something that you know, as I see, physicians were used to because there are many things that we don't have a specific magic bullet for and we take time and you know, try to have patience and try to get people through it with sort of the best supportive management we can. But it's hard. We'll be right back. How has the psychological experience of being a critical care physician been changing for you? At the beginning, it must have been just a bit overwhelming because of the radical numbers and the changes. I'm curious to know what it was like then, and also how it's evolving now. Yeah, it's a good question. I think at the beginning, first of all, I think, you know, there's a whole lot of adrenaline around sort of, you know, there always is when something is evolving so quickly. I think there was a lot of energy around everybody figuring out how to make this work and extending our capacity, and everybody jumping in and filling roles that they may not have otherwise filled. I think there was a lot of energy around how do we, you know, kind of step up to this moment that is unusual. I think there was also sort of an element that was very surreal the first time I was in an ICU and all of a sudden, every single patient has a disease that you know, we didn't know the name of a few months ago. So I think there was an element of feeling like it was hard to believe it was happening. There was not a lot a lot of time necessarily spent on rounds trying to figure out what was happening. So I would say in general rounding in the intensive care unit, one of the things that was noticeable is that sort of took less time. Everybody was quite similar in terms of what was wrong and the kinds of decisions you were making, so there wasn't a lot of diagnostic dilemma, which was unusual. And also, you know, I think made things kind of go a little bit faster. You would go around taking care of the patients making kind of similar decisions. Examining people took a lot longer because you were dealing with you know, gear that is more time consuming to put on and take off and figure out where to put everything and do things safely. But the actual medicine I would say took less time, both because most of the patients were similar in a lot of ways, and also because families weren't there, and the time that you would ordinarily take either on rounds after rounds, to be talking to families and explaining things you didn't have to take. I would say that is a significant change for a whole lot of reasons. Does it make it easier, I mean, I know it's not great for the families, But does it make it easier for the physicians through their jobs. Well, yes, so in certain ways that made things sort of more streamlined. In other ways, I think it's made things incredibly challenging a lot of what we do as I see doctors, nurses, other people who work in the ICU, is talking to families, having conversations about what's important, what direction to take, a lot of end of life discussions that are very, very challenging, I think, to have over the phone, we rely a lot on developing fairly quick rapport with families. In person, we rely a lot on, or at least I should speak for myself, I rely a lot on nonverbal communication and things that are really challenging over the phone, and I would say, particularly where they're language barriers, I would say those conversations have been much more difficult for me, certainly not being able to see families regularly in person. We have had families come in when patients are approaching or at the end of life, which I think has been helpful. That ordinarily, when somebody is so sick, it's an evolving process over a period of time and a number of conversations that involves establishing trust and coming back to things, and so that's been really really challenging, I think not having families there regularly, and of course that's something we do with some families can't for various reasons or aren't in the ICU routinely when a loved one is sick. But this is a fairly dramatic departure, having very few family members present. What about your morale and the moral of your colleagues. I mean, as you're describing at the beginning, there's a lot of adrenaline and so that in some sense takes care of the moral. You know, what you have to do, the pressures on you do it now that things are maybe by your description a little bit more regularized or routinized, the how's your inner experience of that, and what do you think about that of your colleagues? Yeah, I think people are exhausted. I think we also have no idea now sort of what form this is going to take going forward. I think it was you know, it has become clear that this is not going away in any meaningful way anytime soon. While there is certainly the numbers are down dramatically in terms of the intensive care unit, you know, the number of patients. As I said before, we have a lot of patients who are still very sick in the hospital, who are kind of living through the sequela of critical illness. We don't know what's going to happen to the numbers, you know, next month or in the fall or during flu season. I think people are exhausted. There are many ways in which this has been a very hard to be a part of. I think the fact that this that COVID has hit communities of color so much harder, and you know, we're just watching person after person come in incredibly sick. And you know, as I said before, much of what we can do in the US supportive care and time and patience and taking the best care of people we can and seeing if they get better. It's felt pretty relentless in terms of people coming in, often from the similar communities. Often, you know, we've seen multiple members of a family be critically ill. I think it's you know, the scope of the tragedy of it is, you know, demoralizing and exhausting and very sad. And I think people are physically tired because this is hard work and everybody's generally doing more of it than they typically would, and also emotionally exhausted because we in this you know, line of work, we see a lot of people die in general. That's why we're used to But I think all of this happening all at once in such large numbers. I think has been really hard. I can certainly say for myself personally, you know, the uncertainties of or where it will go from here and what will happen and when we be in the same position a few months from now, it's just it's exhausting. If there's a second wave, it sounds like from what you're saying that under the standard of care, we're going to need a lot of ventilators. Do you have the sense working in the hospital that there will be enough should that occur? I mean, how close to breaking point were you at, you know, one of the great hospitals in the region and indeed in the world. I would say we certainly, you know, we extended our capacity many many fold. We did not get close to the point where we were out of ventilators. I think there was a period of time wherewith the trajectory of cases, we were concerned that we might and so I think in the end, I think because of measures that were taken and people staying at home, things flattened out enough that we fortunately avoided that. And I would hope that now that that was a concern that you know, an interim and you know, again I don't have a I don't know anything more than you do about whether there'll be a second wave, but I certainly think people are concerned that there could be. I think between all of the lessons we learned among all the institutions about sort of balancing loads across hospitals, you know, acquisition of new supplies, hopefully we would be and I think we will be better prepared if there is a second wave. And the answer to that question certainly depends on how large a wave would there be. I think if there is a second wave of the type that we saw, we will be prepared for that. You know, there's always a worst case scenario that you can imagine that would still overwhelm capacity, but I would say we ended up being pretty far from that. While we were, you know, we're stretched in terms of our capacity, we weren't near the breaking point. So hopefully that would be even more true the next time around, because there's been a lot of lessons learned about how to organize across the system and extend capacity not just within a vidual hospital but across the region and the state. So my hope would be we would never get there in this pandemic. But again, it depends on you know, there's always a worst case scenario. You can imagine where we would get there. What have I not asked you that I ought to be asking you? I guess the thing to be asking in some ways is sort of what are the issues? You know? Kind of going forward? Right? We sort of have dealt with this emergently and quickly, and everybody's done the best they can. And I would say people have done an incredible job of stepping forward and being innovative and thinking about how do we best take care of people? How do we learn as much as possible, how do we change the whole way that we practice medicine in a very quick period of time. And it's been incredible to watch that. I think there are a lot of challenges ahead, and one of them, you know, one of the big ones I think has to do with how do we take care? As I say before, we have an exponentially larger number of patients who are going to be dealing with the consequences of critical illness. People who survive a prolonged period of critical illness generally do not you bounce back immediately. And we now have a whole lot of patients who have been incredibly sick, who will be dealing with the consequences of that for a very long time, whether it's being you know, in the hospital now for many many more weeks, two months, being in and out of rehabs or long term acute care hospitals. How do we ensure that there's a frameworkingplace to take care of those patients. That system was already very stretched to begin with. It was often very hard to find appropriate places for people to go following episodes of critical illness, and that system will now be stretched even more, and so I think a lot of the questions going forward will be how do we do right by all of these people who have been so sick. I think people focus on do people leave the ICU, do people leave the hospital? But there's a whole cascade of things that happen after critical illness, both physical, psychological, financial, that I think is sort of the next at least for my subspecialty in terms of sort of ethical issues. I think that becomes a huge issue is how do we take care of the people who have been affected by this going forward? And that's what I worry about a lot, is how are we going to make sure that they're taking care of, and recovery goes, you know, sort of well beyond the hospital stay, and so how do we make sure those people have access to the resources that they need and that they can get back to their lives if they're able to recover from the critical illness. So I think, to me, that's sort of the big thing to be thinking about from my standpoint, one of the big things to be thinking about going forward. Thank you so much for the work that you're doing. We're very fortunate that there are people like you who've trained in the things that turn out to be essential in a crisis like this, and I want to thank you for your analysis, for your candor, and also for the extraordinary work you've been doing. Sure, thanks a lot. Thanks for having me on speaking to doctor Emmy Rubin. I was really struck at how the intense adrenaline driven struggle of the early days of fighting the coronavirus pandemic in her ICU sounds like it has slowly developed into something like a new normal. On the one hand, that means that the standard of care has to a certain extent solidified. No longer are the physicians haphazardly trying every possible drug in the hope that something will work. Instead, they're engaged informalized, randomized clinical trials of different drugs. Yet simultaneously, it sounds as though even remdesevere, the drug that has done best so far in those trials, is not being experienced within the hospital as any kind of a magic bullet, but rather as a mild improvement for some patience, and possibly not for the sickest patience who are still in the hospital. Meanwhile, dealing with all of the suffering and all of the death has been demoralizing and challenging for physicians and unquestionably exhausting for them. Listening to doctor Ruben's description, one can only hope that a slowing down in new cases gives a break to the physicians in the ICUs who are dealing with this extraordinarily challenging process of treatment. Because if there is a second wave, we're going to be relying on exactly the same set of physicians to go to the front lines and do it all over again. We're also going to need ventilators. Even though ventilators have not been in the forefront of the news in recent weeks, it turns out that that is not because they are somehow less important to treatment than was originally thought. They're just as significant to the basic treatment mechanisms. And again, if we have a resurgence, we're going to be discussing once more whether we have enough ventilators to treat everybody. My final thought, and I've had it before in speaking to frontline physicians on Deep Background, We're just extraordinarily fortunate as a society to have people like doctor Reuben who spent their whole careers preparing for moments like this one without any knowledge that suddenly pulmonary care would be at the forefront of our treatment of the global pandemic. We are relying very heavily on a certain group of people specialized knowledge right now. But the truth is that in any crisis, some group of people who are properly trained will rise to the foe and become the people we depend on, and for that we can only be thankful. Until the next time I speak to you, Be careful, be safe, and be well. Deep Background is brought to you by Pushkin Industries. Our producer is Lydia Jane Cott, with research help from zooi Win and mastering by Jason Gambrel and Martin Gonzalez. Our showrunner is Sophie mckibbon. Our theme music is composed by Luis Guerra. Special thanks to the Pushkin Brass, Malcolm Gladwell, Jacob Weisberg, and Mia Lobel. I'm Noah Feldman. I also write a regular column for Bloomberg Opinion, which you can find at Bloomberg dot com slash Feldman. To discover Bloomberg's original slate of podcasts, go to Bloomberg dot com slash podcasts. And one last thing, I just wrote a book called The Arab Winter, a Tragedy. I would be delighted if you checked it out. You can always let me know what you think on Twitter about this episode, or the book or anything else. My handle is Noah R. Feldman. This is deep background