Q&A: UPMC ICU doctor says the challenges of treating COVID-19 patients have changed dramatically since March

It was frightening to treat his first patients, he said, but he has gained more experience and better tools since. At the same time, misinformation has become rampant.

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Dr. John Evankovich is a lung researcher and critical care doctor at UPMC. (Photo by Jay Manning/PublicSource)

Dr. John Evankovich is an ICU doctor at UPMC Presbyterian and UPMC East and a lung researcher at the University of Pittsburgh, so his life has been consumed by COVID-19 in the past six months. He’s in the unique position of both understanding the science of the disease and having seen firsthand what treating patients has been like. 

The conversation with Evankovich has been edited and condensed for brevity and clarity.

Question: When did you start working on COVID-19?

Our lab pivoted around Feb. 12 or 13 to start looking at some of the factors that might regulate how this coronavirus gets into lung cells. In March and April, I was helping prepare hospital staff to get ready for COVID-19. We ran simulations in the hospital, such as donning and doffing (removing) protective equipment. I also did some service time in a number of different coronavirus ICUs in April. 

The week after lockdown, I remember driving back and forth to work: It was surreal, I was the only car on the turnpike for miles. 

Q: I received an email from a reader who asked if every minute she spends out and about at the grocery store or at the post office, for example, cumulatively increase her risk. Does it?

One of my parents works in an eye-glasses place where customers come in and she has to sit pretty much face-to-face with them for some period of time. They have modified safety protocols. The thing about it is, she could wear 35 masks and do all the things right but her risk of being exposed is dependent on how many people in the community have this thing and thus come into the store. Now, I hope at this point that anyone who is sick will not come into the store, but we know there are some fraction of patients who are going to be infectious before they show symptoms.

So let’s say they have 100 customers. If the community prevalence of the virus is 10%, that means 10 of her customers might expose her. Even if those interactions are only two minutes a piece, two x 10 is 20 minutes. She spent 20 minutes a day breathing the same air with someone that is infected.

But if the community prevalence is, say, 1%, and she has a two-minute encounter, that’s only two minutes of total exposure.

So it is a cumulative dose effect. That’s the way I think of it. That’s the way I think of it for people who work in grocery stores or any environment where you’re coming in contact with a lot of people.

Q: How do you convince people to change behavior to lower community prevalence of the virus?

I can’t tell you how many people from my hometown...which is just an hour north of here, a very rural place, were convinced of all of the conspiracies about COVID-19. And they were just not taking any of it seriously. 

A lot of people, especially in my own family, said they’re just really confused. Even though there is so much information out there, they just don’t know who to believe because they see different things on the evening news, versus their Facebook feed, versus talking to me. 

To get those people on board, we’re not going to get them on board by shaming. The behavioral science tells us that doesn’t work. We’re probably not going to get them on board with more information. The research and data have been there for months. 

So I started a Facebook group, Western Pennsylvania COVID-19 Stories, for people to tell stories about COVID and asked people to tell their personal stories about this. I think you can break through some of that confusion and some of the ‘That can’t happen to me' attitude if you see a personal story with someone you have a connection with, someone who lives close to you, who goes to the same church or school district. Those are more powerful than directives from above.

Q: What stories do you have to share with people?

I’ve seen some of these people who are really sick. I’ve seen people pull through. I’ve seen people crying to me on the phone because they are so scared. 

Q: When was your first patient?

At the end of March I had been waiting for a month, knowing that eventually one of these patients would come in. I was worried that they were all throughout the hospital, and we just didn’t know it yet. The very first time I went into a room with a COVID-19 patient was just really, really weird.

And since he was the first one, every single protocol and safety thing the hospital had been getting ready for for weeks was essentially being played out in real time. Once that person was there, and we put this person in airborne precautions [a room where the air is sealed off with negative pressure and medical personnel wear heavy personal protective equipment (PPE)], it was then like: “OK, now we don’t really know if this protective equipment that we’re using really works. Does it? I think so. Logically and scientifically, yeah, it should.” 

But the first time I went into the room, I’m not going to lie, I didn’t know what to expect. Am I going to be one of the first doctors to get sick?  I live in a house with my wife and two kids, and I actually had a backup plan with my parents, if I felt uneasy or had some kind of exposure or I thought I shouldn’t see my family. My parents were going to come park a camper in my driveway and I was going to sleep in it. That was my plan. 

Q: What was that first patient like?

The patient looked like a patient I see all the time. There was all this buildup and anxiety and uncertainty, and the fact that I was basically in a space suit. And I just went in and had a normal conversation with him about how he was feeling, did he like breakfast, was he moving his bowels. 

He didn’t have much of an appetite for the first one or two days and then he started to eat and that was a good sign that he was going to get better. But he was just very quiet and, I don’t know if “nonchalant" is the right word, but very stoic about it. He was really elderly and very zen about it. 

We had a pretty clear idea he got it from travel to the West Coast before the lockdowns, three weeks before he was hospitalized. He was on a couple liters of oxygen. He needed a little bit of support but not a ventilator. He had lots of diarrhea and was dehydrated. He went home.

He was a good first patient for us. I’m so thankful that our first patient wasn’t dozens of patients needing ventilators. 

But I thought: This is the first one, it’s not going to be the last one. How long is this going to last? 

Q: You are working with COVID-19 patients again. Are you still afraid of exposing your family?

We’ve learned so much. I trust PPE, and I trust the safety protocols. I trust the tests. I trust the things that the hospitals did to protect staff. It’s working. People are not letting their guards down. The rapid tests come back in a few hours and are highly accurate. There's no more waiting around or uncertainty.

Q: It’s interesting to hear your experience with testing because so many news reports are about how slow the test results are. When did you start getting results so fast, and how does faster testing change how you can treat patients?

Sometime in May or June. A quick test completely changes the game. For instance, we were very unsure and very hesitant to use some of the respiratory treatments that we use all of the time, such as BiPap. It’s noninvasive ventilation, like a mask. People wear it at home for sleep apnea. It’s for people who have breathing problems but we don’t want to put them on the ventilator. It does some of the work to let that person’s lungs rest and heal.

Those units also basically spew air everywhere and they are connected to a person’s face. So we were definitely hesitant to think about those treatments because if we had a person who had COVID and we didn’t know it and they were on this BiPap machine, they are spewing it all over the place. I think everybody was afraid. At that point, we had no confidence that the PPE would really protect us. 

Q: Do you think any respiratory patients might have not had optimal results because of your fears of using the BiPap masks?

I can tell you there were situations that were very tense and very tight because we didn’t know what we were dealing with. The very first couple of weeks, while we were waiting for the COVID-19 test results, we had to treat them like they had COVID, in airborne isolation, with full PPE. We had only so many physical rooms to do the negative pressure [which uses air pressure to prevent contaminated air from leaving the room]; we only had so many resources to do that. 

It takes time to put the equipment on and take it off. And if you’re in a patient’s room for 30 minutes more, that means you’re giving 30 minutes less to some other patient. So having the quick test really changed that. 

Q: Did you lose any patients to COVID-19?

Some of the people from the first wave passed away. Some of the cases were pretty long and protracted. I just checked the chart for a patient last week who passed away. This was a person who I was pretty confident had followed every single precaution. 

The patient was elderly and had gone out of state on a vehicle trip, sight-seeing, in a very safe manner. They had taken care to go to state parks without crowds. Not staying at hotels. The patient quarantined for two weeks when they got home. And then, got sick after that two weeks ended. I really don’t know if this patient got sick on their trip, and it just took three weeks for them to get sick-sick. Or whether or not, after the two weeks of quarantine, they got it somewhere else.

Q: Do you believe the patient was put at risk by the behavior of others?

If everybody was doing the things that this patient did, the spread would be lower. It might not be zero, but it would be lower. And if it is lower, then his chance of getting it in the first place would have been lower. Everybody sinks or swims together. I don’t like the cliche, "We’re all in this together." People don’t like to hear it. But you really are dependent on how even someone you dislike is doing things. 

Q: You work with eldery patients and mentioned that you think the elderly might be experiencing stigma?

We shouldn’t place any less value or dignity on their health just because of their age. Yes, the preexisting risk is dependent on age but that shouldn’t be a reason to discount public health measures and to justify not being serious about this and not changing personal behaviors.  Those people are no less deserving of protection than everybody else. 

If you look at Pittsburgh and the second surge of cases in July, the numbers of positive cases were overwhelmingly in people who were young, but the deaths were eventually spread through the community to elderly people.

Q: How do you think about whether parents should send their kids to school?

I have a 6-year-old going to school. We’re going to try to send him.

If the percent positive is less than a certain threshold, you can be pretty confident you’re not getting a lot of community transmission and then you can go to schools and probably be OK. Nobody knows for sure, but I think Allegheny County is right on the edge of all those numbers. The average number of cases has gone down. So, to me, the cases are low enough here that I think it’s worth a try. I believe it’s really, really important for kids to be in school.

Evankovich is sending his son back to school full time because he thinks the number of cases in the community is low enough that a good school safety plan could work. (Photo by Jay Manning/PublicSource)

Q: Can first-graders follow a COVID-19 safety plan?

My answer to that question is that it’s more a reflection of the parents and guardians in the community and school districts than the small kids. For my kid, we’re his gatekeepers, so who he is around and who his social contacts are over the summer, really go through us. 

But I would favor being much more gentle with kids. I would hate for them to become vectors of blame if there is an outbreak. That would be incredibly heartbreaking if that was the perception.

Q: Have you talked with your son about the decision to send him to school?

He’s made it clear he’s very excited to go back to school and he can’t wait to see his friends. We wanted to try some mask practice days but he is refusing to do that at home. He assures us when school starts he is going to wear his mask all day. He has worn his mask out in public but not for hours at a time. But I do think he would be pretty upset if school goes all virtual especially if he is in school for a little bit and it shuts down. 

We talked a little bit about how school is going to be a little different. There are going to be less people in their class, and everyone is going to have their own desk. His kindergarten class last year was set up in groups of four or five at a table. He is pretty good about going with the flow. Most younger kids are, too. They don’t come in with expectations. So if the adults set the expectations in a positive manner, I hope the kids follow suit and I hope that’s what happens.

Q: Given your own experiences in the ICU, where you’ve seen real suffering from this disease, how do you think about low-probability but high-impact events? So even if the community infection rate got down to 1%, there is still some chance that you could be unlucky and there would be two kids with COVID-19 in your kid's class.

It’s really tough. As with anything else, it’s a question of trade-offs. There are risks and downstream effects of not going to school, and you have to weigh all these things against each other. 

One way to mitigate it is to have a family plan; hopefully this is something people have talked about. What is my family going to do if one of my kids is identified as a close contact of somebody who tested positive? The way to really minimize the risk for the rest of the family is for someone to go isolate with that kid for 14 days away from the rest of the family. That is really hard to do. I don’t know if people have thought about that or will do that but that is probably the safest thing to do.

Oliver Morrison is PublicSource’s environment and health reporter. He can be reached at oliver@publicsource.org or on Twitter @ORMorrison.

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