March 29th, 2020
Podcast 261: COVID-19 as a medical disaster
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San Diego County has Dr. Kristi Koenig as medical director of its emergency medical services. That’s fortunate for the county, because she’s co-edited a definitive textbook, “Koenig and Schultz’s Disaster Medicine: Comprehensive principles and practices.”
We’re fortunate to have her as our guest. She’s full of sound advice on organizing a community’s response (for example, setting up “incident command” structures) and evaluating patients as new threats emerge (the well-known “three-I’s” approach — Identify, Isolate, and Inform).
With the number of COVID-19 cases rising quickly there in San Diego, she’s been busy (as have all of you).
Running time: 19 minutes
Links:
Interview from 2016 with Koenig and Schultz on the second edition of their “Disaster Medicine”
Other interviews in this series on COVID-19:
TRANSCRIPT OF THE CONVERSATION WITH DR. KRISTI KOENIG:
Joe Elia:
You’re listening the Clinical Conversations. I’m your host Joe Elia.
Dr. Kristi Koenig is Medical Director for Emergency Medical Services in the county of San Diego, which as of this afternoon, Saturday March 28, had about 420 confirmed COVID-19 cases with six deaths.
The county is lucky to have her, if I may say so, because she’s co-edited a definitive textbook on disaster medicine, and arguably the novel coronavirus epidemic qualifies for entry into that club.
Dr. Koenig is Professor Emeritus of Emergency Medicine and Public Health at the University of California Irvine, School of Medicine, and she was also, I should say, a long-time contributor to NEJM Journal Watch Emergency Medicine.
Welcome to Clinical Conversations, Dr. Koenig.
Dr. Kristi Koenig:
Thank you very much for having me.
Joe Elia:
What are you seeing there in San Diego?
Dr. Kristi Koenig:
Well, we are very concerned in San Diego, as is the rest of the country, and we’re taking a three-pronged approach on the ground in San Diego. Number one is to flatten the epidemic curve. Number two is to increase surge capacity for our healthcare system, and number three is to focus on using an incident command system to coordinate all of our needs and resources, and I can explain each of those in more detail if you’d like.
Joe Elia:
I recognize that, from having looked at your textbook a few years back, so go ahead.
Dr. Kristi Koenig:
In San Diego, we were very early to implement what’s called NPI, non-pharmaceutical interventions, to try to spread out the diseases over time so that we don’t have as a great a chance of hitting a peak number of diseases early on, which could exceed our healthcare capacity.
This so-called flattening of the epi curve, I’m sure people have seen. Even on the news people are getting educated in epidemiology these days.
The idea with that is we won’t necessarily decrease the total number of patients but if we can spread patients out over time we can potentially continue to care for everybody in our healthcare system. This is not only the COVID patients. This is also our regular emergencies.
We know that emergency departments are crowded on a day to day basis. So by using these interventions, which are called things like social distancing (although it’s not really social distancing it’s more physical distancing) we still can keep in contact with people. Other types of interventions to try to prevent the rapid spread of the disease, we can make a huge difference. It’s complicated because we may not see the effects for a week, two weeks, or even more because there are already people in our communities who are incubating the disease that have not had symptoms yet or not. Some people never have symptoms but who have not presented yet to our healthcare system.
The second thing would be for surge capacity, and we’ve developed a concept about 20 years ago along with my colleague, Major General Donna Barbish, for the 3-S concept of surge capacity, which is stuff, staff, and structure. We find it very helpful to organize everything around stuff, staff, and structure, and I can explain that in more detail if you’d like.
Joe Elia:
Yes. I would guess that the “stuff” is going to include things like masks.
Dr. Kristi Koenig:
Absolutely and ventilators and N95 respirators and surgical masks and other types of PPE (personal protective equipment) are very important in an epidemic of this nature. One of the challenges is that the news media and the politicians love to count stuff. You can see it. You can show it on TV. You can touch it. You can count it but one of my famous lines is “Ventilators don’t take care of patients.” Stuff is important but it’s not sufficient. While we do need, certainly, to protect our healthcare workers on the front lines and to have things like ventilators to care for patients in this setting, the stuff component of the 3-S is not enough.
So we also need the staff, which is all of us, the people, and we do know that some people unfortunately will get sick and even die and some people will not be able to come to work because they may be caring for a relative or other reasons. So we have to account for probably maybe perhaps 30 percent of people will not be able to come to work or not be willing to come to work. We also need specialists in the staff. So it’s not just the total number but we need people with specialized expertise. For example, infectious disease specialists, critical care specialists.
Then the third component is the structure and that is the physical location where we care for patients. What we’re seeing now is we’re being very innovative and I think actually this is going to help us after we get through all of this to have better capacity in our healthcare system. We’re seeing alternate care sites develop. We’re seeing field hospitals. We’re seeing the military, for example the Mercy just arrived in Los Angeles today I believe. We’re seeing things like tents being put up outside hospitals to do screening.
In San Diego, we’re also looking at behavioral healthcare centers outside hospitals. We’re seeing telemedicine, telehealth popping up. So lots of things for the structure piece as well where we care for patients. So again, stuff, staff, and structure is very helpful to organize all the components we need to increase the surge capacity of the system.
Joe Elia:
We’ve chatted before when the second edition of your textbook came out. You (or maybe it was Dr. Schultz) mentioned that the third edition should include a chapter on how to prepare oneself to participate in responding. Do you have any advice for clinicians now about to face the challenge of a surge in demand?
Dr. Kristi Koenig:
Yes. We definitely need clinicians. One of the most challenging things about this event is the psychological piece of it. People who are working on the front lines are seeing their colleagues get sick and unfortunately likely even die and it’s very difficult. Or they may have a situation where they don’t have enough resources, and we’re used to taking care of everybody. So keep focused on what we’re doing to take care of patients and take care of your own mental health. There’s lots of resources online for mindfulness and other types of techniques you can use. Make sure that even though we’re physically distancing that we’re still connecting socially with others.
Joe Elia:
When I was going through your textbook again, I noticed the mention of the incident command system. Talk a little bit about that if you would.
Dr. Kristi Koenig:
An incident command system is necessary to coordinate all of the resources that we need. What happens is, people want to help, and they have good ideas, and they try to work outside the established system. And we’re seeing it everywhere. It takes up people’s time to respond to well-meaning requests, spontaneous volunteers, spontaneous donations as opposed to if everything can be funneled into the incident command system it can be coordinated as needed to help manage the disaster.
These are systems that are practiced both in hospitals (we usually use something called the Hospital Incident Command System). In the prehospital setting in all levels of government and there are liaisons between the various incident command systems so that you can coordinate and do something that’s on a regional, statewide, and even national basis that otherwise would be overwhelming to try to manage.
Joe Elia:
At the beginning of an incident like this, what would you do typically with the incident command system, would you put out something immediately saying “We understand you’d like to volunteer” or “If you want to volunteer if you want to bring food, masks, or whatever…”
Dr. Kristi Koenig:
One of the portions of the incident command system would be the logistics section. So the incident commander could refer a volunteer idea to that section who could decide how to best integrate it into the overall response.
Joe Elia:
The US is in mitigation mode right now — as opposed to trying to prevent the entry of the virus into the country…
Dr. Kristi Koenig:
Actually, I wouldn’t agree with that.
Joe Elia:
Tell me how I’m wrong there.
Dr. Kristi Koenig:
The US has different phases right now of the disease. So for example, in New York and some other emerging areas at the time we’re making this recording such as New Orleans and Chicago and Los Angeles, they’re a little bit farther along that epidemiological curve in terms of the rise in cases. But there are some parts of the United States where there are very few cases — or at least few that we know of. So they’re probably earlier on in time. I would say in San Diego, for example, we’re not quite on the same upslope as they are in some other parts of the country like New York.
In places where there’s widespread community transmission, certainly we need to do mitigations and that’s probably most places, to be honest, because we see this disease being spread in asymptomatic or minimally symptomatic people and that’s why this stay-at-home message. This social distancing is so important to flatten that curve, but we also still need to isolate people that are sick. We need to identify them and isolate them so that we can prevent rapid spread by known people who are sick. So we’re doing more than just mitigation.
I’ll just say we’re doing identification and contact tracing to prevent spread of disease from known cases in addition to the mitigation.
Joe Elia:
I mean you started the month with one case in San Diego and now we’re up to many more than that. What have you seen over that time, Dr. Koenig, that has changed your mind?
Dr. Kristi Koenig:
It’s been very interesting in San Diego because we’ve had several disasters within the disaster, if you will. Let me explain what I mean. We have the local military base, Miramar. You may have seen on the news that when we were repatriating people from Wuhan they came into a federal quarantine. So we’ve been closely collaborating and have a strong relationship with the federal entity such as the CDC and what’s called the ASPR, the assistant secretary for preparedness and response, which is located in HHS at the federal level and also the state. Because in the US, the way things are organized it’s local to state to federal in terms of how the resources work.
So we had people coming back from Wuhan that were on quarantine, and we helped support the quarantine on the base. I’ve actually been standing a little bit more than six feet away from a patient who ultimately turned out to be positive from that repatriation. We have systems in place where we have transported patients who became infected or became positive from the base to hospitals and potentially back. Then after we had that mission, which really helped us to get systems in place, we had people coming from the cruise ships. Same thing where we had positive cases in that cohort, and we were able to make sure that those cases did not spread out into the community and that those patients got care and ultimately once their 14-day quarantine was finished they were able to return to where they live.
So that gave us a lot of experience and we’re still actually having more cruise ships coming into San Diego and managing that along with our federal partners. So it’s incredibly complicated, but it’s given us a lot of experience of how to manage this. In addition, you mentioned at the beginning my role in EMS. We put in place screening so that when somebody calls 911, initially several weeks ago when it was more relevant to ask the travel history, we were asking about travel from China and some of the other hotspots, and we were identifying people potentially infected at the level of dispatch so that when our paramedics responded they were already wearing the appropriate personal protective equipment.
When they picked up the patient for transport, they were notifying the hospitals ahead of time, “Hey, we’re coming in with someone who might have COVID” and the hospitals were wearing PPE. Oftentimes, seeing them — if they were stable enough — outside of the emergency department first, to make sure that we weren’t transmitting infection to others.
Joe Elia:
So nothing that you’ve seen so far has changed your mind about the approach that should be taken. Would it be fair to say that it’s reinforced?
Dr. Kristi Koenig:
One of the most challenging things is that the recommendations are changing very frequently. That’s because this is a novel virus. It’s new and we are learning. I’ve actually been following this since December, believe it or not, and I can remember the first report was “It’s not transmitted from person to person,” which I didn’t believe. “Oh, it’s not transmitted to healthcare workers,” which I didn’t believe. But things have been evolving over time in terms of PPE recommendations.
Initially, it was very helpful to identify people traveling from certain international hotspots. Now there’s such widespread disease, that’s less useful at this point. So there is a challenge and there are things that are changing, but one thing that we worked with for all infectious diseases is the concept of the three “I”s. The identify, isolate, and inform. For people working in hospitals, we want to immediately identify patients who are potentially infected, and because this is a disease contagious from person to person we then would immediately isolate them. And the third “I” would be to inform both public health and your hospital infection prevention personnel.
Joe Elia:
Yes. I saw that you had written a paper on the application of the three Is to the epidemic. I’m going to put a link to that on the website.
Dr. Kristi Koenig:
Thank you. And the three-I concept actually developed during the Ebola outbreak in 2014. The idea is that we don’t necessarily think in our day-to-day work about the potential for a patient to be infectious to the point where we could contract the disease or other people in the waiting room to contract the disease, and we have to think about that immediately in something like this epidemic so that we can immediately isolate and protect the patient from exposing both healthcare workers and other patients.
Joe Elia:
As a country, what do you think we could be doing more of or less of at this juncture?
Dr. Kristi Koenig:
It’s important to know that every single person in this country is on the frontlines. For me, this epidemic and every single person’s actions are important to help us stomp out this disease. If you are a non-healthcare person just staying home and washing your hands, as simple as that sounds, can be incredibly helpful, as I talked about earlier, for flattening that epidemiologic curve. So everybody has an essential role in the entire country. As healthcare workers, I would encourage everyone to keep focused. Again, the approach we’re taking in San Diego is this three-pronged approach of the interventions to flatten the curve, coupled with increasing the surge capacity, and making sure we work within an incident command system structure.
Joe Elia:
I know it’s hard to look into the future. How do you think COVID-19 might change clinical practice? Do you see any indication that it might?
Dr. Kristi Koenig:
Absolutely. Once we get through this I think we’re going to have a much better healthcare system. It’s amazing the collaboration and the innovation we’ve had in such a short time. Things are happening you never would have thought could have happened. I mentioned earlier, telehealth as an example, increasing behavioral health resources, increasing resources for the homeless. There are incredible collaborations happening. We’ve had meetings with all the chief medical officers of our 20 hospitals including VA and military in our county. We’ve had meetings with all the CEOs of all our hospitals along with the board of supervisors and the chief medical officer of the county.
This kind of cooperation and collaboration would not have happened if it weren’t in the face of a crisis.
Joe Elia:
Is there one essential lesson that you want clinicians to take as they’re about to face this?
Dr. Kristi Koenig:
Keep focused. We will get through this if we organize our actions and our thinking. We can save lives. You are the heroes. You’re on the frontlines and we thank you for everything you’re doing every day.
Joe Elia:
I want to thank you for your time today, Dr. Koenig. I wish you good luck in the coming days.
Dr. Kristi Koenig:
Thank you very much. Stay safe.
Joe Elia:
Thank you. That was our 261st episode. Its predecessors are all searchable and available free at Podcasts.JWatch.org. We come to you from Physicians First Watch and NEJM Journal Watch — all part of the NEJM Group. My executive producer is Kristin Kelley and I’m Joe Elia. Thanks for listening and stay healthy.
6 Responses to “Podcast 261: COVID-19 as a medical disaster”
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Excellent comments from Prof Koenig. It is true that everyone is in this fight. There is great need for socially responsible behavior and appropriate social distancing to flatten the curve. Avoid your community healthcare resources from being overrun. There’s still a lot of routine care needed for stroke, diabetic and heart disease patients. This is emphasized in Singapore.
This is clear and very useful information. Unlike so much of the sensational reporting, this actually explains what we are up against, and how we can unite to defeat it. A positive and practical explanation in contrast to the all too common fear and ranting. Very reassuring.
Thank you very much for this. The clarity and utility of the information presented here are In stark contrast to the chaotic output from the daily WH press conferences. Dr. Koenig’s advice on handling this and other medical calamities is invaluable. Thanks again.
Thank you. Dr Koenig”s discussion points are very informative and useful.
I work in a big government hospital in a city north of Manila, Philippines. Our hospital is one of the referral center of our region and identified as a “covid hospital” since logistics is present care-of the government funds. Within the hospital, in every department ( mine is Pediatrics) the consultants and the residents are also grouped into the covid team (frontliners for PUIs and PUMs ) and the Clinical team. At the moment as a consultant neonatologist, I belong to the Clinical (Non covid team) team as our NICU is very busy and I work closely with our residents.
I like your input on the 3S – staff, stuff and structure; the 3Is- Identify, isolate and inform; the importance of NPI – non pharmaceutical intervention – specifically mindfulness and physical distancing…
God’s grace and protection be with you and everyone ….
Thank you Dr Cuarte for your kind thoughts and words.
My very best and warmest wishes to you and the people of the Philippines as we share knowledge throughout the global village to fight this pandemic.
I have created apps, website and tools for doctors and patients to communicate as soon as a new symptom or a combination of symptoms are identified in an area. The most important aspect to stop the epidemic is to identify an infected individual at home and isolate them and also inform others living in the area and public health department.
How can you do this? When doctors identify a new symptom, he or she can go to website 7imed.com/maya/admin and login as a doctor. Then he/she can write information, add video, pictures and also advice. choose the colour code (Red for doctor). Patients who are registered and users of Dr Maya will get information about new symptoms cluster. This will encourage the patient to establish contact or the app will inform doctors and the public health department about the patient.
I ave also created Maya Dr App for doctors.
If politicians and decision-makers had implemented this system, I am sure they would have prevented bankrupting millions of people by forcing lockdown. Dr Maya would have helped identify infected and isolate them.
Please read:
1. https://m.timesofindia.com/life-style/health-fitness/health-news/These-apps-track-infection-isolate-patients-reduce-antibiotics-abuse/articleshow/52304450.cms
2. http://www.the-american-interest.com/2017/01/12/superbug-pandemics-and-how-to-prevent-them/