Pandemic: Coronavirus Edition

The experiential difference between March and November, and Mark weighs in on hospitalizations

November 02, 2020 Dr. Stephen Kissler, Dr. Mark Kissler and Matt Boettger Season 1 Episode 49
Pandemic: Coronavirus Edition
The experiential difference between March and November, and Mark weighs in on hospitalizations
Chapters
Pandemic: Coronavirus Edition
The experiential difference between March and November, and Mark weighs in on hospitalizations
Nov 02, 2020 Season 1 Episode 49
Dr. Stephen Kissler, Dr. Mark Kissler and Matt Boettger

Can you Rate and Give us a Review in Apple Podcasts?

Thank you to all of you who helped us reach our goal to pay off our equipment for this podcast! If you would like to still financially support us for the monthly upkeep and to help hand off some of the editing responsibilities, you can give a one-time donation or become a Patreon member for as little as $5 a month. See the links below. Thank you!

  • Give a one-time gift through Venmo at @mattboettger
  • Give a one-time gift through PayPal here.
  • Give monthly (as little as $5 a month) on our Patreon Page.

Matt's Living the Real Podcast

  • Check out Matt's latest episode on how to live a more frictionless life here.
  • Download Matt's technology cheatsheet (with examples) of what he uses to keep himself as frictionless as possible.

Things Discussed on Episode:

Support the show (https://www.patreon.com/pandemicpodcast)

Show Notes Transcript

Can you Rate and Give us a Review in Apple Podcasts?

Thank you to all of you who helped us reach our goal to pay off our equipment for this podcast! If you would like to still financially support us for the monthly upkeep and to help hand off some of the editing responsibilities, you can give a one-time donation or become a Patreon member for as little as $5 a month. See the links below. Thank you!

  • Give a one-time gift through Venmo at @mattboettger
  • Give a one-time gift through PayPal here.
  • Give monthly (as little as $5 a month) on our Patreon Page.

Matt's Living the Real Podcast

  • Check out Matt's latest episode on how to live a more frictionless life here.
  • Download Matt's technology cheatsheet (with examples) of what he uses to keep himself as frictionless as possible.

Things Discussed on Episode:

Support the show (https://www.patreon.com/pandemicpodcast)

Matt Boettger:

You're listening to the pandemic podcast. We equip you to live the most real life possible in the face today's crisis. My name is and I'm joined with my two good friends, dr. Steven Kissler and epidemiologist at the Harvard school of public health and dr. Mark Kissler he's back. And I feel like only for a little bit before, he's just gone for like, Six months with COVID. Hey, Mark.

Mark Kissler:

How's it going, buddy? How are you doing? It's good to be back for, for a little while. We'll see what happens.

Matt Boettger:

And I don't, and I don't mean like getting COVID. I don't, I just meant like you treating COVID and

Mark Kissler:

the craziness of it, so that's right. Yeah.

Matt Boettger:

So big news. It was Halloween happy Halloween.

Mark Kissler:

Happy hell what'd you guys do, because this is Steven and Boston here. Zoom, we zoom trick or treated with, Steven and my parents and my wife's parents. And a whole bunch of our family were just like lined up a bunch of zoom calls in a row. And then, and then my wife had candy around the house and each of the families gave it. Clue to the kids to go run and find it. and so we had like a little scavenger candy scavenger hunt so that it was okay. It was good. You know, everybody got dressed up. It's fun.

Matt Boettger:

You guys are creative. I love that. That was really, that's really good. However, the whole concept of a zoom trick or treat that must be the most disappointing thing for a child. Here have a virtual piece of candy. You can't do anything here. Yeah. That'd just be, that'd be, that'd be rough. I'd be really left. Yeah, we were, we had a great time. We were, gosh, we went out trick-or-treating to Nana's house. Which was a really a good time. So the, you know, she knew that they were very limited in what they were going to get. So she gave a lot of stuff to fill up their baskets with one trip. So it's pretty, it's pretty phenomenal. So that was good. We went to a friend's house and we had add a little social destiny in their backyard. The boys never had that much yard to run around and sprint in for about an hour. So that was really, really awesome. And so we were, we were, we were still engrossed in conversation with our friends. They, I w we weren't seeing her boys constantly in their bags, like just like inhaling all of the candy in that one hour. Like, Oh, no, this is really, really bad, but they were excited. So we had an awesome time. The boys loved it. We went, we went a little extra on their outfits this year. Cause we usually shaft them every year. We get like, here's a hoodie, let's just paint it. And, we're good. So this year we, we thought, well, in light of a pandemic, at least they'll have nice outfits. So they were adorable. Steven,

Stephen Kissler:

what did you do, man? I, I feel like I didn't even realize it was Halloween until about two in the afternoon, so there was not an awful lot, but, it was, there were definitely people out and about, kids in costumes and running around. A lot of them were. pretty creative with their mask use, use that as a way to incorporate it into their costumes and, pretty creative ways. so yeah, just like a lot of little groups of like sub 10 year old kids running around parks and stuff, because kind of what Halloween looked like

Matt Boettger:

in Boston, but, that's awesome.

Stephen Kissler:

Didn't do much here other than gave some clues to Marcus kiddos and watched them run around the house.

Matt Boettger:

Brilliant. That's great. Well, I'm glad you had a, well, I'm just thankful you realize it was all the way at some point in time. No. It's really good. Good work.

Mark Kissler:

Good work. Seriously.

Matt Boettger:

Oh man. Well, we have, we have, we've got to cave. Well, man, he could have been Batman, Steven. Perfect. Totally.

Mark Kissler:

We tried to get one of, one of our, any of our kids to dress up as an antibody or as their uncle Steven and none of them, none of them had it. They were like epidemiologists. It's like it's too soon for that sort of connection.

Matt Boettger:

That is way too scary way too scary

Mark Kissler:

for next year. We'll do a, we try to shut

Matt Boettger:

in too soon, too soon. great. Well, all of you guys are listening. Thanks for tuning in. We love reviews. Keep them coming. it helps us move up the ranking. So we hear all these good things, but how we keep it non political, just some with the science. Do you want the practicals of life and want to get into more hands? So if you can give a review, it, raise it kind of raises up and makes us known. Also, if you wanna support us patrion.com/pandemic podcast, as little as $5 a month can help us keep this going or just a one-time gift, PayPal, Venmo all in the show notes. Okay. So let's get going. we did a show on Wednesday, just Steve and I, we got marked back temporarily. There's not a lot to cover, but one of the things Mark, you mentioned. Just riffing on of just getting perspectives and where to get it to you. And just a second Mark, but just the perspectives from March. And now, now cause a similar thing, right? We March there was these increased cases, it was unknown. We're behaving differently. And now it's November and we're seeing increased cases. Again, there's unknowns. How, how are we behaving, acting, perceiving things differently, Mark, I, you know, let's start with you and just kind of seeing with March and include as a doctor as well. You know, Steve and I were talking about on the last week about, it's interesting to see you as a doctor, you have a couple of hats on, right. as a father, as a husband, but then as this unique doctor situation where you came in in March, and I'm sure you were the hospital at large, and you as an individual were treating patients, there's a lot of unknown. Try new things. What was the behavior? Psychosis, psychology of the hospital, you and how is it or is it at all different now on the second kind of big?

Mark Kissler:

Yeah, I mean, I think those are great questions. It's funny. Cause it's hard. And I think it's, it's important in some ways to not disentangle too much, those different hats, like you were saying, you know, that there's this, that, and that's one of the things that I've appreciated about, you know, chatting with you guys through this whole. Process is that it's been about it, you know, everybody's encountering this and this really, kind of this deep way that affects all of your different relationships and your professional identity and everything like that. and so, you know, I'd say that the, the docs that, that myself and the ducks that I've been working with, there's no exception to that. It's funny how fast in some ways, something can become a little bit more normal. and so there was even a sense of that. In the early in the F within the first peak or so that, once we got a certain sense that, you know, what are some of our illness scripts around COVID what are some of our processes in the hospital? not that, you know, necessarily became mundane or every day, but there's this way that I think that people are really resilient and kind of, adapt to it. Really radically different situation relatively quickly. And so it's interesting. you know, one of the, we're looking now, you know, we've seen some, we've seen a pretty significant case increase in Colorado in the last two weeks or so. And we're all expecting to, you know, we're opening new teams again, and we're going through a lot of the same processes that we went through in March to get geared up, to take care of COVID patients again at higher volumes. but a lot of those processes, rather than figuring out what are we going to do? We say, okay, we're going to do what we did in the spring with these tweaks that we learned. And all of a sudden we have a sense of sort of a script and sort of a sense of this is how we move through that uncertainty. And as silly as it is to say it, there's a little bit of a sense of kind of, you know, this is it's being folded into the routine of what we do. and, I remember, I mean, I just a couple, I think quick thoughts to that regard from a medical perspective, w one of them is. Seeing the ways that there was sort of a microcosm of that on each of the individual floors, as they went from being a general medicine floor to a COVID floor or something like that. So you would see, you know, you would get to witness this whole new group of nurses and CNAs and staff, people and housekeepers, and then yourself, you know, I'll go through that process of like, Shifting and having a new sense of, you know, we've already built in sort of our sense of tolerance for all the different contagions we encounter in the hospital, but this is new, you know? And so all these it's just, it was just different. Everything took a huge amount of thinking, you know, putting on enough the equipment and going into the rooms and all of that. Just had such a high, much higher cognitive load, you know, and I wouldn't say that that goes away completely, because we're still in a very unprecedented and in a very, very blunt infection. but there is a way that some of that gets. Routine I've used a little bit, in a way that is positive. and, so that's one of the things that we've seen. you know, the other thing that I'm conscious of too, in the hospital, the hospital is a strange place to work, you know, and because on some level. Almost every person that you encounter, you know, particularly every patient that you encounter is in a moment of personal crisis to a certain degree, and you know, greater and lesser degrees. And some of these things are, you know, some of the things that people come in with are very reversible and treatable, and there's a very clear pathway and other people come in with things that are not either not clear or that represent a really big. Existential shift for them. You know, that all of a sudden they're coming to grips with their disease that they've had for years and years being much more serious this time, or, you know, shifting in their goals of care. And now all of a sudden they're, you know, they're going from a more treatment focused mindset to a more comfort focused mindset or. Just, you know, sort of the realization of I'm frail, you know, I'm aging. I am not the person, you know, these plans that I had are all of a sudden shifting because it's because of the. Interruption of illness. That's something that happens in every single room in that hospital, you know, every single room in the ER, and it doesn't matter in some ways how trivial from a medical perspective, the thing might be, for the person who has it and you know, whose body is affected. It can be the biggest thing in the world, you know, that moment and the people who love them. And so there's a way in which the weird thing about COVID. For me was that it was this very collective experience of that as a society, you know, as all of the people, all at once were experiencing sort of this frailty from a global perspective. but it, but then also at the same time, you have all that stuff kind of going on all the time, under the surface at the hospital. Anyway. And so I think one of the things that I'm still working towards is a way of. just understanding that and articulating that a little bit and recognizing the ways that being, being a doctor in the midst of a pandemic, both is, and is not different from the nature of the work at every other point in time. and I think getting a little bit of a higher resolution in the sense of that, both the differences and similarities for me is really important because that changes my disposition as I go into a room. And as I encounter my colleagues and am aware of, you know, the stresses and things going on around me. So those are some of the things, you know, from a professional perspective, at least that I'm thinking about, and that have shifted a little bit over the last few months.

Matt Boettger:

And before he headed off the Steven, maybe you kind of touched on it a little bit, but is there a collective, you kind of alluded to this in March? It was, there was unknown and systems were being put in place. Now you're kind of reviewing those systems and tweaking them. Is there, is there a greater sense of like, Hm, like almost, experiential confidence between March and not, I mean, yes. And as a hospital as you, but is this experience, is it at all being perceived by the patients as well? Maybe between March. Cause we, cause we were just talking about last week. We're not about how, why are the death rates so low and you're going to speak to this and just a mimics. You were talking about this and. Whereas, you know, we, there is that general study that a rim disappears, not that effective or the kind of stuff we did, but it didn't really count for the cocktails. Those was kind of combination. So why is this and the speculate, is it a possibility that also just the idea of a greater set of collective confidence puts a patient at a more ease and hopeful state? Or have you felt anything through there? You are there as a hospital?

Mark Kissler:

Well, I think I, you know, I don't think that necessarily that. Changes the outcomes. so I think that the outcomes that we're seeing and, and we'll talk a little bit as to the factors why we're seeing a lower in-hospital mortality with COVID during this wave then. And so I don't, I don't think necessarily it's it's. To kind of the physical outcomes, but I think there's a tremendous amount of, the work of healing that is not just in sort of the physical outcomes that happen. And it's a lot about accompanying and witnessing. and you know, one of the big problems, one of the big things that I felt in a lot of people felt in articulated, you know, more beautifully than I can was the separation between providers and patients. That was introduced because of the masks and the PPE and the sense of contagion, just the sense of vulnerability. and I think if anything, My hope is that in this wave, that there's a little bit of a, more of a sense of how do we accompany these patients again, you know, that we're practicing, we're still going to, at some point be practicing, you know, very high volume medicine. but how do we, how have we adapted around these. Constraints to still be with the patients. I think that's important. And that is part of that's part of the work of healing. And as part of, you know, even if it's not captured in mortality rates and things like that, you know, I don't think we can't miss it. The effect that just being with another person who's, you know, in a vulnerable position. how important that is.

Matt Boettger:

Great. Thanks for sharing. Steven, how are things changed for you perception March you at Harvard, between March and now with this next wave

Stephen Kissler:

types of questions that we're thinking about asking and trying to answer, have shifted hugely. and in some ways I think this might parallel a little bit of what Mark was talking about too, where, In March and April, there was just so much that was unknown. I remember in some of the earlier episodes, we were talking a lot about like standards of care and just how there, there wasn't really one for COVID patients that there's there just wasn't this clear sense of like, what. What is it? How do you care for a patient as they come in? And that seems like it's hugely shifted. And I, and I think that that's, from the epidemiological side, that's also changed as well. It's the questions are not so much, like, what is this? And. What will it do as, we now have a very clear understanding of the epidemiology of this virus. There are still things to learn, including things like duration of immunity and how many people get, what amount of immunity for how long, and is there the possibility of differences in severity for reinfection. But, at this point we're sort of, those, those sorts of questions are really sort of. Trying to shine light on this frontier of knowledge that we've already done a very good job, I think. and we, I mean, as, as, as a society, as a whole, answering, we we've, we've gotten a much better grasp on, on what this virus is. and part of that too comes from the fact that it's, it has continued to behave. a lot, like we expected it to, if it had continued to throwing us many surprises, then I think we would be in a different spot as well. But, given our knowledge of, other respiratory viruses, other pandemic, respiratory viruses, pandemic, flu, things like that. That it's following a relatively well-known script in infectious disease, epidemiology. and so that gives us a little bit more confidence that, that it will continue to as well. Now, of course, a lot of that script remains in our hands. we have some of the things that distinguish it from pandemics that we've seen before most recently, like 2009, for example, or that the 2009, H one N one flu pandemic was just not. Nearly as severe as, as this is. So there, there wasn't really the same risk of overburdening hospitals, and, really mass excess mortality. And so, because of that, people's behaviors didn't change as much in 2009 as, as we expect them to this, this fall in this winter. So there are still some, some questions and some things to account for here. but I think. Now taking a shift from sort of the questions and the intellectual side of things, to how it feels. there is, much more of a sense that we just sort of have a better grip on the problem. there's less of a sense of this sort of generalized threat of, of sort of, contagion coming from who knows where, I think the, the canonical example at the beginning of the year was, Of course UConn and then, the outbreak in Northern Italy. And there was really this concern that like, that could happen anywhere at any time. and, and that's really what we, as epidemiologists were, were trying to forestall. now we have a much better sense of where the disease is, what. what the risk of that kind of outbreak is. And with that increased knowledge, I think that there's less of a sense of randomness and like just total uncertainty, which really helps. And I think, both is, is more, comforting in a way. And I think also helps with, with doing certain types of science. We're, we're not as, paralyzed in a sense of, of this sort of impending disaster, because. Science is interesting because it's one of many activities that you can engage in as a human. Right? And, and so at the beginning of the pandemic, there, there was this real question of is doing science right now. The best thing we can do, or is it something else? Should we be like helping people, stockpile resources? Should we be volunteering at local food shelters? Like there, there are different things that we could be doing and we want to make sure we're doing the most useful thing. And science might not be yet. I think that now at this point, a lot of these other things have sort of. Gained momentum and, and the, the, the, the need for science is there and it's clearer what those questions are and what the benefit could be. and so I think that gives us a little bit more confidence, sort of like we were talking about with what Mark was saying, confidence as we're walking in the room, whereas my room is. There's the cave, it's this room and it's always been this room, but

Matt Boettger:

it's not the room of

Stephen Kissler:

the patient, but there is still sort of this confidence that comes along with it sort of knowing that we know what questions to ask and that those questions are likely to be worth answering

Mark Kissler:

just to, just to interject here. Thank you for your comments for, from, from the perspective of one on the outside who is not doing the science, I would like you to keep doing the science, please. If this happens again, it's just, if you need, do you have the record, keep, just keep doing the science. You know, I think that it's important to recognize that that's, for the rest of us quite important. Yeah. I appreciate that. So, but I know where it's coming from. I mean, I hear where it's coming from, which is this place of. You know, just a sense of being when you're standing up against something as big as a global pandemic like this, you know, you start to ask all sorts of questions about yourself and the good that you're doing in the world. And I think that, you know, that makes a lot of sense to me, so,

Matt Boettger:

yeah. Yeah. Well, I mean, I mean, first of all, yeah, yeah. Feel free to volunteer to. Food pantry for 30 minutes or an hour, if you want to. so, but, don't, don't, don't quit your day job. but on the other thing, you know, I feel, I mean, maybe I'm a little bit divert in this, but I'm just thinking in March and April, it was so incredibly confusing and chaotic. And so here you are as an epidemiologist, trying to bring some sense of clarity in the midst of like, what is going on. And so I feel like in some sense, I. He probably felt there's even more weight upon you. Again, I could be just totally off base because when everything else is chaotic, everything else is kind of folding up and closing down. Right. Like literally closing down. So, outreach services, all these things are being closed down. So then you were probably feeling this pressure of like, What should we be doing? And I, I feel like that's kind of just the natural order of things when things become totally chaotic the expert in that field or the experts in that people come together and try to figure it out. And things began to slow down until we have a course. And then I'm sure you probably feel it now. A sigh of relief. Okay. I don't feel like the world is impending upon me now. Things are kind of, there are services available. There are things helping. I can do my job and not feel like. The weight's upon me to do everything. I mean, I don't know. That's what I came to mind. When, when you were talking about this,

Stephen Kissler:

that's a great way of putting it. yeah, I think it's it's exactly that, there, there is just sort of,

Mark Kissler:

yeah.

Stephen Kissler:

There is still very much a weight to it. And a, in the sense that there's, there's a lot, a lot of work yet to be done, but there's some, some of that has been taken off that it's, it's not so much the weight of trying to bring order to something that, that is utterly chaos, to, to now just sort of like expanding out building upon the order that's that's there and that we know that's, it's just sort of a different, a different type of pursuit.

Mark Kissler:

Yep.

Matt Boettger:

Yep. Great. Thank you for sharing Steven, for me, it's the old layman here and I actually pray, emphasize old as well. that, by the way, I got, I got, I told Mark this and Steven, I don't know if you know, but I have high cholesterol now as of like three weeks ago, so I'm really old. So I gotta work on that anyway, side note, just, just, just let you know, I have my cholesterol, it's that time of my life. so yeah, for me in March, it was just really, I think. Kind of what both of you are saying, particularly you, Stephen. It was just so chaotic. So a mess that I hadn't, there was, there was nothing that seemed known in our house. So then there was the six, every precaution was made and it was absolutely exhausting. The amount of everything that we did to try to protect ourselves from this unknown virus. It's so different now. Like I granted there is a different fatigue. I mean, there was a combination of physical and psychological and spiritual fatigue. Now, I think it's a little bit, a lot less physical there. The routines are built in place. I feel like in my, you know, whether it's wrong or not, or right. I also feel in my, Hey, if I do these like three or four things, I'm doing the best I can check, check, check the rest of the world, whatever. Like I wear my mask, keeping social distance, trying to stay outside, doing those things, washing my hands. I've done it. Right. Whatever else happens, happens that wasn't like that in March. And so I feel like now with this other wave it's, it's, it's frightening, but I feel like I, whereas when the first wave came, I felt like it was like this out of control unbearable force that there was no human being could stop this time. I feel like, no, we could actually. I mean, now it's crazy right now, but no there's things we know that we could do that, that actually could slow this down. So in my mind, there's a, there's a pathway to lowering the curve and flattening the curve outside of a lockdown. So my mind is just, it's, it's more restful, physically. I'm just beating the same drum for nine months or eight months. That's killing me. Right. but other than that, I feel better in that way. But just really, you know, and, and maybe there's a sense of maybe a little bit more, less fear. And to be honest, a little more anger, a frustration of just come on, people just do the simple thing. Whereas I didn't know what the simple thing was in March, so I've kind of replaced it, not rage or anything. Yeah. I had that a couple of times, but that's just besides this, between you and me and our audience, but so, but now it's not rage. It's just, just a little bit irritation, irritability and anger. That's a, that's, that's a difference.

Mark Kissler:

Yeah. Yeah, it's funny how tough it is to sustain it. We've talked about this, but I think just, just how tough it is to sustain something difficult over a long period of time. and, to kind of keep coming back to the reasons why we're doing things, even little inconvenient things, that build up. so yeah, it, it is, there is a sense that even though the panic isn't there or the, you know, the kind of the. The huge shift that we're in a different time. That is just as challenging, just challenging in a different way.

Matt Boettger:

It's like we went from an acute mental own illness to now a chronic mental illness. That's really

Mark Kissler:

fun.

Matt Boettger:

So not to make light of any of that with anyone who has that, I don't mean that in that way. I just, it can feel just a lot ever enduring thing. So thank you for sharing. Let's you know, Mark and gonna throw it back to you. Cause we haven't seen it. Waivers seen, you heard, you didn't know if you were alive, thankful your, your art life. So let's bring you back on a few updates and just what's going on with, I mean, I'm curious, watching this stuff going on in Colorado, particularly the rates increase wondering about you in the hospital, what's going on with the hospital, increasing what what's different up there.

Mark Kissler:

Yeah. So, it looks like the last I could tell somewhere around, increase in national hospitalizations around 40%. So 40% more patients hospitalized in the last, I think month or so than they than previously. So we've definitely seen a national increase. We're seeing the same thing here. We're seeing sort of that pattern that we expected, which was higher testing, you know, higher, higher numbers, higher prevalence in the population than higher. And in hospitals and then, potentially we're going to see that mortality spike down the road. And I'll talk a little bit about the, the data that we have around more in-hospital mortality next, things we're seeing just kind of from the inside perspective, we I'm, I'm very impressed with a lot of our, Kind of administrative, practices and the way that they're doing rapid cycling of, how do we do process improvement and how do we address this second peak? in a way that, you know, taking all those lessons that we learned from the last pandemic, there was an interesting, article that was published in the new England journal catalyst, which is like a. Aside, publication of the new England journal that talks about healthcare delivery. And it's not, that's not, my forte is necessarily as the administrative side of things, but I found it really interesting because this was an article about how seven healthcare systems in Colorado, Got all of their chief medical officers together and had these really robust planning meetings throughout the pandemic. and the first phase and doing things like, you know, addressing provider wellness, addressing patient kind of, how do we. Get patients through these systems, in the safest way possible, especially when we're thinking about the systems being overwhelmed. it looked like between March and July, that these seven systems cared for a little over 6,000 of the 6,400 hospitalized patients in the state. So like 98% of the hospitalized patients with COVID were represented by these people, you know, who were getting together and working across divides that are often. Somewhat competitive, you know, in the, in the healthcare industry. And, and also I was struck by the way that that coalition helped to advise our state government about some of the things that were going on, and are, you know, are safer at home or are stay at home orders and things like that. And so it's always that, that type of communication and that degree of collaboration, I think, is something that is a huge, bright spot, in the midst of a lot of. difficulty. And so just a huge amount of kudos to the people who are involved in that. and as an individual provider, you know, feels very good to have our systems be able to put aside differences and, and focus in this way and in a really agile way when something unprecedented comes up. So that's one of the things that I've been thinking about and that I think. That sort of thing sets a precedent for how we address the second peak. And so the hope is that, you know, all the things we learned and all of those, you know, lines of communication that are now open are going to be there already for us, for when things get busy soon. you know, I think one of the things we'll see, you know, Currently elective procedures are still underway. and we've already had conversations about what are our thresholds, you know, as an institution and as a state. and for, as we kind of March through the wave, as we did in the spring for when do we start to turn down our other activities to try and create a little bit more space in a capacity for COVID patients. So. so that's all, you know, it's all happening. We're having more frequent planning meetings, we're opening more teams, you know, really by the consensually by the last. Two or three weeks, we've continued to open additional teams for higher capacity and a lot of contingency planning. So we'll see, we'll see what happens. I did want to address, because you guys had talked about it a little bit last week and it's been in the news a lot. Is this idea of the changing in hospital, mortality of COVID patients too. and you know, I think globally, this is another piece of really good news, in the midst of things, The journal of hospital medicine published a brief report. it looks like on the 23rd of October. and they, what the researchers here did is important because they. Did it, statistical risk adjustment. So one of the questions that we had had, as you know, is the decline in mortality rates because more frail patients were getting it early. And now we're seeing, you know, generally healthier patients or things like that. Or like maybe it was a lot more older people early in the pandemic and younger people later. But they, but by adjusting for those. demographic and health factors, they could sort of using statistics extract a mortality rate and compare, and it does look like there's a statistically significant improvement, over the over time. And that that's also been, the trend that we've seen there was a study that's I think just been published in pre-print from, England that found, in critical care units, decreased mortality later in the. Pandemic than early on the pandemic. and you know, I think some of this, some of this is probably yeah. Due to the new treatments. So things like REM does severe dexamethazone that we're using. yeah, it's also due to combination of increased clinical experience in a, both from a provider perspective, and also like a clinic perspective and also from nursing. And everybody is just a little bit more experienced with this as we've been talking about, maybe we're. Intervening a little bit earlier, maybe there's a higher community understanding. one of the questions that was raised that I think is fascinating and I don't know exactly how we can get at this answer. but in that journal of hospital medicine study, another thing that they mentioned is maybe people are being exposed to a little bit lower viral loads because of the baseline physical distancing and mass squaring that we have. and that, that perhaps is. Tiny part of that bigger signal, you know, that we're seeing, in the lower mortality rates. and then also some nonpharmacologic treatments like, proning patients. So having people lay on their belly actually helps oxygenation in, some of these critical, you know, respiratory illnesses and things like that. So, so I think what we see is this huge, constellation of. In hospital factors. but the nice thing is that when we extract the, some of those patient characteristics and control for them, we're seeing improved mortality. going into this second wave,

Matt Boettger:

I had a question for you, Mark. I asked the Steven last week, but since you're kind of on the ground ground floor, and this is maybe a little bit of a difficult question, but it was Mars with all the heavy influence on ventilators. And now less influence and ventilators and more now go into the stomach, which is, seems to be another great approach to help get oxygen. Is there any, is it just probably anecdotal or I've seen some reports of suggestions suggesting that maybe the ventilators may have done some more harm than good in some patients which could have led to a slight increase in mortality of scarring of the lungs or no.

Mark Kissler:

It's an interesting, so I think it's, this is a tough thing to tease out. I would say that, you know, I don't want to propose like proning as an alternative to, mechanical ventilation or anything like that, that at a certain point, you know, at a certain point you need to have mechanical ventilation to preserve sure. Oxygen and, or, you know, even more advanced, thing, you know, past that. So that's. that's still going to be a mainstay and having an offender laters and having enough ICU beds is going to be critical, absolutely critical. we do know that mechanical ventilation is isn't as good as normal ventilation. You know, it's always better to breathe on your own if you can. and that there are risks to mechanical ventilation, some of which include, you know, the Barrow trauma from, having air pumped into the lungs, things like that, the risks I would say. Yeah. the benefits outweigh the risks in these cases of severe COVID pneumonia. Absolutely. And I think it's important, but clinicians, you know, our, our critical care colleagues are always very attentive to trying to prevent intubation, unless it's absolutely absolutely necessary precisely because of those reasons for, you know, in COVID and in other illnesses, you don't want to intubate somebody who doesn't need it, you know, ideally. but if they need it, we've. I think that, you know, there's ways of doing it safely. And so that's definitely not something that I would, you know, I don't think that our listeners should be afraid of that. If someone they know or love needs that intervention, I think it's really important to get it. and that the benefits of that outweigh the risks. Okay.

Matt Boettger:

And then a follow up question on the coalition. You mentioned, you talked about the article in a journal article about this coalition in Colorado, you either in the, in the journal itself, or you talking to your other friends, not in Colorado. Who are other hospitals has ever been seen as like, Oh no. I mean, wow. I'm so glad to be a part of hospital. You were like this, we were not like this. I mean, are there examples?

Mark Kissler:

Yeah. I mean, I think there is some pretty significant geographic variation. I did hear, I had the opportunity to speak with an ER doc from New York, a few weeks ago. And he was part of a similar coalition of emergency physicians in New York city. and so I know that there are places that were doing this sort of collaboration, and I'm sure that there are other places that didn't have nearly as robust, collaboration also. and so I think that's one of the other reasons why it's so important for these groups to say what they did, you know, publish what they did and get it out there so that other people can find best practices and follow along.

Matt Boettger:

Great. Awesome. Anything, any, any, last word, Steve and Mark, before you move on. Great. Okay. Well, I think we'll probably end here because there was not too much more time, except for look, there's an increase of cases. We're all, we all know this, but things to see what a Mark, I think there's a lot of hope on the horizon to seen, this unknown of a lack of increase in death rates in a hospital. But. There's a lot of good reasons to be thankful for this and a lot of hard work because of Mark and Steven. So thank you both for what you've done in helping us to be able to remain safe and healthy and to get the message out of how we can actually continue to deal with this pandemic in a way that still brings some joy to us and hope. And so thank you guys for, for contributing to that. I appreciate it. Okay. We're to end, we're doing this. I hope you guys have a wonderful week. We're back to theoretically on Mondays now until another obstacle happens, then we won't be on Mondays. so we will hopefully see you all next week when the world will be a different place. Take care. Bye bye.