With the current COVID outbreak in full effect, I wanted to create a series of episodes highlighting some of the servicemen and women who are currently working around the clock to manage, control, and help people who are being effected by the coronavirus.
In today’s episode, I talked to DR. Shelly Farrell about the current situation in Germany, which is where he is currently located. Dr. Farrell is currently working in a military hospital helping to control the spread of the coronavirus.
What’s up everybody? Justin here want to start this episode with a special message. I’m going to be doing some more like unique one time type of episodes in between their regularly scheduled programming on a weekly release schedule to do coronavirus updates and talk to physicians in unique places of leadership, of operations, administration and clinical activities over the coming weeks. Just to provide resources for you, our listeners to talk about what’s going on, what are people seeing and doing what’s been working. I’m obviously not a public health expert, I’m not a doctor, but I want to facilitate as many of these conversations with people who are doing really great work as possible. I would also love to hear your feedback during this time. If there’s anything that would be helpful as far as things that you want to hear on the podcast or even other resources that you’re finding helpful that you could direct my attention to that I could call out on the show.
That would be great. As always, thanks for listening. On a personal note, you know, as a physician spouse, I’m deeply grateful for the sacrifices that our men and women in white coats are making right now to help keep the public safe and during a very scary time. It’s sobering and also heartening to see how quickly the physicians are just throwing themselves into harm’s way. Yeah. In ways where there’s, you know, there’s not a lot of certainty right now, but one thing is certain, that’s the spirit of self sacrifice that exists in the anesthesia community and beyond is something that is really awesome and frankly like our society is going to benefit massively from in ways that they don’t even understand or appreciate. So from me to you, thanks for the work that you’re doing, keep it up. Keep your chin up, hug somebody that well, no, don’t hug them.
Give them, well, maybe an air high five because we’re in this together. And then one quick note about the upcoming episode. The audio quality is a little sketchy on the front end. I’m talking with dr Shelley feral from Germany and our internet connection was a little bit patchy, but things get better a few minutes in. So I think this is really excellent content and we’d love for you to check it out. So if it’s a little weird upfront, hang in there, it gets better. Thanks for tuning in. Hello and welcome to this episode of the anesthesia success podcast. We have a very special guest today who I’m really, really excited to be speaking with dr Shelley feral. If you recognize the voice who is about to follow mine, it’s probably because you’ve listened to his podcast, the anesthesia wise guys podcast. I have enjoyed the bits of nonclinical content that they’ve shared over the years. And I’m really excited to have him joining us from Germany today to talk about how they’ve responded in their anesthesia department there in light of the way that Kobe is evolving. They’re in the Southern part of Germany. So Dr. Farrell, thank you much for joining us today. Thank you for having me Justin. It’s
Dr. Shelly Farrell (03:02):
Kind of a, a privilege for us cause my podcast is just kind of a, a mom and pop like recorded in my attic or basement where we can get in. So, you know, kind of getting to branch out a little bit. It’s kind of exciting for me. So so thank you for having me on as a guest. I’m sorry my, my normal cohost can’t tune in. They’re in various stages of quarantine, slash forging. Slash unavailable. So you, you unfortunately only get me,
Well, we’re, I’m very pleased to be speaking with you today and thanks. I know things are very hectic there. They’re getting pretty crazy here in Philadelphia as well. So I’m really interested in, maybe just give us a brief description of kind of what your current situation is as well as like, you know, how long have you been in Germany? I know you were in the States, you’re in the army, you were at university, Kentucky, on the faculty there for a while. And then describe for us like what’s, what’s going on there.
Dr. Shelly Farrell (03:48):
Yeah, so for our listeners I’ve, I’ve kind of bounced around a little bit by my choice. So I did a military residency and then served in the U S army for eight years total, including my residency time. I want to finish my service obligation. I took a faculty appointment at the university of Kentucky and taught residents for six years there. And then when I was active duty army my wife and I kind of mutually agreed that if we had an opportunity to ever make it over to Europe to a duty assignment over here, and then they got short staffed and launched whole Germany and the army opened up a contract with a contracting company that is my employer. And they got me over to Germany. So I ended up resigning my position at the university of Kentucky, of which I am in talks with our former chair to go back there. So it’s a two year contract here. I’m planning to go back to Kentucky and in two years, but just kind of a, it’s a midlife crisis without buying a house, a car or getting divorced.
That sounds like a great, a little excursion for your family. And obviously when we had started talking, you know, we were interested in talking about, Oh, let’s do like a career overview, talk about your experience in the army and talk about some personal finance stuff that I had done. And since then, obviously the Corona virus situation has been evolving very, very, very, very quickly. Yeah. It’s it’s definitely a, a different landscape. Yeah. I know like at the beginning of last week I was like, Oh, I’m, I’m aware of it. I can see the impact that it’s having on markets. And then I listened to a podcast, it was the Joe Rogan podcast with the epidemiologist from university of Minnesota. And then I was on like red alert and then I’m, you know, all the doctors that I’m following on Twitter who are all, eh, the, the thing that’s really alarming to me is like, it seems like all the people who know the most about what’s going on are the most alarmed and especially as it relates to healthcare policy and public health, like the types of changes that we’re trying to implement at a broad society level. It’s, it feels very urgent. And so I’m really interested to hear, you know, what’s, what’s the climate like right now. Describe a little bit about the hospital that you’re working at and and what kind of precautions are you guys taking?
Dr. Shelly Farrell (05:43):
I work at a Lunchable regional medical center, so it’s a U S army hospital in launched old Germany, which is about an hour, hour and 10, 20 minutes Southwest of Frankfurt. So it’s kind of a staging area that the army is used for a very long time. That’s kind of gotten a little bit more of a, a platform for the Wars in Afghanistan interact where it’s kind of a stopping point before Morrowind did that are, you know, stable and stable ish and kind of need to like not be flying and get to like a medical team. So that’s kind of our, our primary mission. But [inaudible] times when we’re not quite so busy with, with the war fighter movement, then, you know, we do regular community hospitals, stuff like hernias and gallbladders and you know, orthopedic surgeries and you know, so, you know, it’s probably right now in 2020, it’s probably about, you know, 80% like routine community type, the cases and then like 20% things that have gone awry in a, a four operating space and, and need kind of some advanced medical attention for trauma management or ICU care, what have you.
Dr. Shelly Farrell (06:52):
So that’s kinda the, the snapshot of our hospitals that, you know, we have a capabilities for trauma and for, you know, ICU I’ll be at, we don’t have a giant ICU. It’s not like we’re actually from the university of Kentucky. That’s a very large level one trauma center that’s, you know, equipped to handle a lot of life, just chaos all the time. So we’re kind of a, you know, get it free and flat out. So this particular type of issue among the healthcare climate is we really kind of are, or getting ahead of it as much as we can with you know, the good thing that we have is that, you know, the primary population will be served here as military population, military populations, fairly compliant because they follow orders, like this is their jam. They’re like, you know, you do this. Yes sir, I’ll do that.
Dr. Shelly Farrell (07:40):
So we don’t have quite the same social challenges as, you know, as what I would expect at our civilian hospital at the university of Kentucky. And, and talking with some of my friends there, I haven’t, I don’t really have a good picture of that and I haven’t gotten into that with enough of my friends there to really got a picture of what it’s like in Lexington right now. But we are you know, we have the control of like, you know, everybody’s paychecks is going to hit. So the financial aspect of it isn’t quite as big a footprint for us, where like, you don’t work your hours, you’ll get your paycheck. Like, you know, that’s a problem. So, you know, our, our, our workings are able to shut down the shut down like the child development centers, which is like the equivalent of like daycare for military.
Dr. Shelly Farrell (08:20):
So, you know, parents are staying kind of home with kids and you know, travel’s been restricted to just, you know, like, you know, kinda everybody’s kinda plugging in to kind of stay home ish. Because the, the epidemiological impact that we are starting to understand from, you know, the professionals that are kind of breaking this down is that the infectivity of this particular virus is substantial. So the, you know, the things that we know so far, we know that it’s very detrimental to immunocompromised patients. Fortunately, we don’t have a whole lot of those within the military landscape, but we do have a lot of here that do get care at our hospital. So secondarily, we also know it’s not great like you know, the numbers for morbidity and mortality start to go up substantially as we start to get like, you know, 50, 60, 70, 80.
Dr. Shelly Farrell (09:08):
So the footprint of that is to kind of prevent the spread population wide to kind of get it to be, you know, a little bit of a, a small during slow burn rather than like a raging fire. They just blast through. Cause most healthcare facilities are going to have a very finite amount of resources like ventilators. You know, an ECMO is not really a capability that we have here. We have ECMO teams that can fly to us if we need that, but that’s, you know, kind of on a case by case basis. That’s not a no on mass like 20 patients. Like that’s, that’s a bad day. That’s, that’s a day that we’re, we’re not going to get to say as many lives as we want cause we don’t have that infinite pool of resources. So you know, so those are some of our kind of concerns in terms of like, this is, we’re in an opportunity and opportunistic window right now, like where we are in Germany to get ahead of it.
Dr. Shelly Farrell (09:59):
So we’ve closed down clinics, the dental clinics who’ve been closed. We’re really trying to kind of you know, kind of snuff down the, you know, build those brick walls. So the fire rage out of control, that’s kind of where we’re at right now. You’d like to have cases are being canceled. We’re actually doing something that I, I’m assuming our department chief kind of spearheading this. So it came from somebody a lot smarter than me. It’s a brilliant idea. But the way that we’re staffed. So we have active duty reservists GS, which is like a government service. It’s like basically the, it’s like you’re paid by the army, but you’re not in Europe. You play by some of the rules, but not all of the rules. You know, it’s generally a good benefits package, good retirement. But it’s not like not like fully in the army.
Dr. Shelly Farrell (10:45):
So it’s kind of an in between for like me, like I’m a contractor, so I get paid by us company. I get a four O one K. You know, I’ve got life insurance, health insurance, dental insurance, kind of conventional civilian model, but like I’m an employee of this contracting company. So so in that landscape of who our providers are, we’ve compartmentalized into like teams. So it’s like, you know, one, two or three docs and CRNs and that’s your team. So like we might work on like Wednesday and Thursday and then have a few days off and we come back next week on like, you know, Monday and Tuesday. And so that way we’re not having department cross contamination of like, you know, I worked with Bob and then I work with Joey and then I work with, you know, whoever. And you know, if somebody gets infected as a crapshoot of who goes down, like you might get a wider spread of the infection, but if you’re just working with the same people all the time, one person goes down, then you can still, you know, the team stands up. So but that was kind of a clever way to compartmentalize it, at least among the healthcare personnel so that we’re not swapping it around between each other round
Dr. Shelly Farrell (11:54):
Robin, that it’s, it’s more of a contained you know pocket there, whereas, you know, you’re on there, but we’re not like decimating the whole department.
So how big is the, you know, the anesthesia or critical care department? How many staff were we talking about where you’re coordinating these efforts?
Dr. Shelly Farrell (12:11):
So [inaudible] honestly, I’d have to sit and count how many answers y’all just, so we have bodies that are allocated to us, but they’re not permanent party. So we have a combat support hospital. It’s attached to our facility that has a, I think three or four anesthesiologists that are tied in with that. And, but they’re not like permanent party. Like they’ll come work for like a few days, a week or a day a week. And then they have to go do like army things where they’re training and setting up combats for hospital. And then sometimes they get rotated out for what we call hearts and minds missions, where I’m like, they’ll go to Africa for like a couple of weeks, two or three or four weeks, and they’ll do a medical mission is there are flight, there’s some sort of like weird Ebola outbreak. Then they get rolled out for that. So it’s just kind of a mobile team that they stay with a hospital unit to to keep their core skills up.
Dr. Shelly Farrell (13:02):
So they’re not just completely atrophying, but they like can get snatched away from that environment if the snap your fingers. So we’ve got one group, we’ve got our dedicated active duty people that are probably I think there’s five or six anesthesiologists who fall in that group. And then we have our GS and contractors, including me. And there’s probably two or three of us that, that fill those slots. And then we have reservists that are activated for like, you know, 30 to 90 days at a time. So we have those bodies to kind of filter through and at any given time we may have two or three of those. Sometimes we might not have any. So so that’s kind of the, the constitution of our MDMs physiologists now, our nurse anesthetists kind of also following that, that grouping as well. We have several nurse anesthetists. I can’t venture a guess as to how many we, I’d guess maybe we have 10 nurse anesthetists in that same kind of structure of like active duty and combat support hospital and you know, contract and you know, GS and reservist.
And I was just looking at the you know, the, the Hopkins map that seems to be like a pretty good source of updated information. I’m, I didn’t realize Germany is actually like on the short list of top handful of countries as far as total cases counted. Can you talk, talk a little bit about like the public health response, how’s testing going? How’s isolation and like social distancing going there and how has that been communicated? Has it been coordinated?
Dr. Shelly Farrell (14:29):
So and you know, honestly the, well, we don’t consume the German media, so like newspapers and like German television and things like that. So I don’t have as much exposure to like the, the German speaking aspect of it. But just in like the like, Oh, we’ll give you a for example for like what you would see, like, not connected to like internet or newspaper or things like that. Like don’t want to, to Kroger like a grocery store in the United States, you’re going to see magazines and newspapers and like all of that media stuff that’s, it’s pretty like, you know, weekly cycles are two weeks cycled. They really don’t have that here. So that, that type of presence you know, that I would expect. And, and you know, Germany doesn’t have quite the same technological plugin that we have in the United States.
Dr. Shelly Farrell (15:20):
So people have smart phones here. And, and you know, there, there’s that access to it in that way. But like, it’s not like the United States, like you’ll walk into like a doctor’s waiting room of TV go, and then all of a sudden it’s not like that here. There’s no TV. There’s no so the, the blast of like media everywhere you go from like a, the grocery store to the, you know, the doctor’s office to life, the bank or you know, where they don’t have that here. So like, I don’t know how the average German actually consumes their media, but in terms of like, social interaction, like our next door neighbors we’re going to a birthday party at one of the German, like a, they’ve, they’ve got these like indoor swim areas here. They’re fantastic. Like, you know, just fun places to take your kids go swimming.
Dr. Shelly Farrell (16:09):
But with this, like on Saturday, it was really not populated. So like, you know, the, the Germans were participating in, in isolation. But then on Sunday, my wife and I went to a there’s a like a, a mile and a half from our house. There’s like this little hut that’s outside. Then they serve, you know typical German foods like knock worst and brought worst and Curry worst and you know, pizza on a baguette and beer. And so we walked down there with our dogs and it was, it’s outside. So you know, people aren’t on top of one another, but it was, it was pretty busy and there are probably, there’s probably 70 or 80 people and in a radius of something that would be like maybe like half of like a college football stadiums. It’s a, it’s a big area and people are on top of one another.
Dr. Shelly Farrell (16:54):
But like, you know, everybody’s kinda kinda congregated around and there’s a lineup to like little shack where people are going to get their food and Bayer and so there’s not that like overt fear of it. The grocery stores are not crushed here. I know. And talking with a lot of my friends there that there’s been a lot of kind of like you know, buy, buy, buy, you know, fair for Oregon. That is not the case here. My wife literally just came from the grocery store three hours ago and it looks like a normal day. So Germans also don’t like buy in store things like we do. Like in your, in your house, I mean you’ve got a fridge that could hold enough food for you and your wife and a couple of kids for like probably a week or two are the primary refrigerator that came with the house that we’re renting right now is the size of like what I had in college and like a dorm fridge.
Dr. Shelly Farrell (17:44):
That’s it. That’s what came with the house. It’s like built into like the kitchen cabinet, the freezer part of it. Literally if I could put like a Stouffer’s, like, you know, French bread pizza in there. That’s about it. That’s it. So we actually had to buy, I mean I’ve got five children now. We had to buy another refrigerator and it, they don’t really sell like big refrigerators. Like I bought kind of a, a bigger ish, but it literally will hold it’s got three drawers that would hold probably the equivalent of like, I don’t know, maybe three or four like soft drink cans each and that’s the size of the freezer part. And then the refrigerator part you know, we’ll hold like, you know, like a watermelon and like getting a full sized pizza box in there. It’s like you have to bend the pizza box.
Dr. Shelly Farrell (18:31):
It doesn’t fit straight up. So so they just, they’re not really built to like store a lot of like perishable food. And the typical German will go to the grocery store. Like the way they’re structured here is not like the United States. They’re like, it’s like a village. And then the villages are like where the people live. And then even like the, the rural areas that are like agriculture, where people were farming and doing things like that, there’s a, like they live in the village [inaudible] and then walk or drive out to their, to their farm. You can literally walk doggone near anywhere here. Just because of the way, like, you know, these villages were all built before. Like there was a lot of like husbandry, like animals and stuff. So there’s no fences, but you can walk from village to village and the train networks go to like all of the villages.
Dr. Shelly Farrell (19:19):
So, you know, if it’s simple and further, you can take a train. Like you don’t really have to have a car here. It’s fascinating. But with that type of you know, it’s kind of built to be Iceland. Like it’s not hard for the Germans. They go about their, their day to day life. They want to travel somewhere. They can, they’ve got access to the, the train network, but they just want to sit and hang out and, you know, walk to the grocery store or other bike or whatever. Like it’s, it’s a, it’s a very pedestrian abled community that can exist on a micro or macro chasm. Just because of the way it’s structured. Like our, our, the little neighborhood segment that we live in there are a lot of multifamily homes or a lot of units that will have like three or four families living in.
Dr. Shelly Farrell (20:01):
It’s in a house. It’s like there’s so much variation in the country. It’d be difficult to, to compare something if you can imagine like a, maybe like a holiday Inn express that would be maybe like four rooms of that kind of like mashed together. The German spend a lot of time outside like the houses, like you go in and you, you know, eat and sleep and go to the bathroom there. But like they’re, you know, a lot of Germans spend a lot of time just like outside and doing, you know, going to work or doing outdoor things. They’re not, they’re not, there’s a lot homebound people.
Yeah. Has there been like public health guidance in Germany that has, I mean in, in the States here it’s like sort of like dominoes falling and it’s one by one. It’s like going from recommended you know, social distancing to like mandatory shutdown of nonessential businesses in certain and then they’re ramping up the, you know, 250 or smaller gatherings outlaw down to in the state of Washington now they say no more than 25 and I expect that that’s going to keep on sort of the bars is going to keep on getting lower. Is there anything like that that’s happening right now?
Dr. Shelly Farrell (21:01):
Now that, I mean there’s no like militaristic presence of like they’re really hammering out hard numbers for like it’s just kind of like the culture is, is different from a standpoint of like they had dope better and we do like in the United States it’s almost like, you know, the, the municipalities and the local governments and even if the state and national government, they are very parental in terms of the why like responding to me with this, cause Americans are very rebellious. Germans are not like that. Like in in general like most people like drive the speed limit like and the Autobahn where you can drive like however you want. That’s why they have that. If you want to go draw fast, you guys are fast there. But like in a village, like no, you don’t drive like, you know, 90 kilometers an hour and a 30 kilometer zone and just like you don’t do bonehead things and if you, if you do things like that, you are very much socially like outcast. Like you know that there’s a lot of self policing here for things like that. Like you’re expected to, you know, with great freedom comes great responsibility. Like don’t be a button.
That’s the, I guess the two edge. It’s sort of the spirit of American rugged individualism is that in times like this, it just looks like mass idiocy or we’re looking at, you know, pub crawls on Saint Patty’s day and like these fist bumping dance parties in these clubs and some, some of the cities here and it’s just like you just have to smack your forehead.
Dr. Shelly Farrell (22:19):
Yeah. The Germans don’t seem to be doing that. They’re very into like following rules. There’s not, I’m seeing like just flagrant, like people being, you know, clowns about things. So, you know, there’s, there’s reasonable social distancing, but that’s like the normal hair on. It’s not like somebody is like right up behind you and like line at the, at the grocery store at the gas from that. But that’s like, that’s normal. That was, that was the, the social interaction before this stuff started. It’s not like, you know, people aren’t, they don’t crowd in on one one another.
Is there a sense that the growth rate of things with Corona in Germany or other elsewhere on the European continent is like obviously North Italy is kind of ground zero for the, the warning
Dr. Shelly Farrell (22:59):
And geographically that’s not terribly far from Germany. I mean the Alps are kind of geographically what separates, you know, Switzerland and Austria to a certain degree are there as well. But I think there was enough of a, an effect of Italy and then Germany paying enough attention. They’re like, Oh crud, this is like, this is the thing. Cause I think initially much like most of the world, you know, everybody kind of just discounted, don’t like, you know, the flu will be fine. But you know, the two things that we realized you kind of as as it was happening in Italy is that number one this is an incredibly infectious agents like it, it’s transmission is is substantial. Like it’s a thing. And then number two, we don’t have heard Mina do this, so it’s going to sweep through like wildfire. So in the, the experience of fatalities, yes, it’s good that we’ve pointed out that.
Dr. Shelly Farrell (23:50):
Do you know the age groups, there are certain ones that are going to be more at risk than others. But you know, like I pointed out earlier in the podcast, like, you know, we still have a substantial amount of the population that’s, that’s aged, you know, 50, 60, 70, and when they get sick they get really sick and that, you know, requires a lot of of resource consumption. And then when you couple it in, the fact that like, you know, it, you sort of take out the healthcare workers that are also kind of falling like dominoes with it. But in terms of the, the German hospital experience, you know, I don’t work in one of the German hospitals, but my wife did deliver maybe in one you know, in January,
Congratulations. We’ll sign a little a little Ray of sunshine in a time of like some deep concern.
Dr. Shelly Farrell (24:32):
Yeah. But at the same time I’ve got a two month old at home, so we’re kind of like, well, you know, kind of keep playing it close to the vest.
Yeah. We have a three month old here, so
Dr. Shelly Farrell (24:41):
Yeah. Well you’re in the same boat.
So are there any concerns about like supply constraints, PPE or like ventilators or beds or staff, you know, to be able to, if sort of the rising tide continues to the extent that you expect that, do you feel like you’re going to be able to meet the demands for incoming patients?
Dr. Shelly Farrell (24:58):
So we have the ability to expand to like more time surge in the military, stock pals, things all over the place. So we have rudimentary abilities for kind of like, yeah, to be able to take care of, of someone in a stable environment until we can kind of like ship them around to a bigger space. So in terms of like, you know, expansiveness you know, we can, we can absorb a lot of that. But the, in the same town, depending on how much of the stress level as it would also be an Avenue where we would have to kind of move bodies around to compensate for the workload. So we have, you know, the space and the equipment for it. But right now our personnel would have to be AGU. We kind of get the ball rolling and get it started. But it would be a situation where if we didn’t get a, you know, kind of reinforcements, you know, within a week or two, that it will be, it would become overwhelming.
Do you, do you feel like there is a place from which those reinforcements can be drawn or is it, I mean, it’s not hard to imagine in the States here and I don’t want to be alarmist, but I’m looking at some of these numbers and some of these growth rates in some places as well as some other locales in the States where there seems to be like total blow a blind eye being turned where I, I have to think that it may be all hands on deck back home pretty soon.
Dr. Shelly Farrell (26:15):
Yeah. So the nice thing about the military is that depending on the relative need and the way that they’re communicating if something’s really bad, we can generally get the bodies moved where we need them. That being said, it’s very disconnecting for like, you know, someone that lives in like San Antonio or Washington D C you know, to all of a sudden get loaded up onto a plane and like, Hey, you’re heading in Germany and we’re going to be there for some time period. We don’t know how long, but like get your butt out of there now. So there’s that degree of disruption that like, if, if something’s bad enough, like things happen like that, you know, their, their orders and, and things that have to have to go down and something gets really sad ways. You know, we have that ability to just to kind of like, you know, drop orders, move people and, and you know, cause the military has its own network of, you know, helicopters and planes and lions and tigers and bears or Maya.
Dr. Shelly Farrell (27:07):
And that’s one of the reasons that I want to come back to. Most of our hospitals, military personnel are generally very selfless. Like, you know, they’re, they’re used to kind of get knocked around a little bit cause it’s, you know, uncle Sam does what uncle Sam does and sometimes it’s in the service member’s best interest and sometimes it isn’t. But generally it’s you know, sometimes you get, you get the thing that you don’t want, but you know, maybe the next time that we’ll get you in the thing that you want. Cause we know that you took one for the team to take this job that nobody else wanted, but you know, we can, we can help you up on the backend. So so we have that access to those resources in terms of like you know, we’re not, we’re not on an Island by herself. It’s just that we have to be built to survive a lean time for, you know, for a while. You know, the, the, the cavalry will come. It’s just the, the, the, how the machine will move to get us the things that we need, you know, where we need them.
I’m sure there’s a lot of things from an organizational and like a mindset and a, just a scale standpoint that, you know, you’re uniquely, you could argue like the army hospital is uniquely positioned. You know, if you kind of look at historically if there’s a big battle and all of a sudden you get like a thousand people that show up that are all like in bad shape, you’ve got to be able to quickly, you know, the wartime triage that frankly like we’re hearing about what’s happening in Italy right now. I’m curious, what advice would you give as somebody with you know, military experience, army anesthesia experience and somebody who’s in a hospital that can, does have this ability to scale based on that sort of mindset? What word would you want to give to the big academic centers and the bigger, you know, groups here in the States that are trying to like prepare for this rising tide to be able to address perhaps overwhelming patient need?
Dr. Shelly Farrell (28:46):
I think because of the unique nature of this disease, the the infectivity, I think the, one of the first goals that every facility has to have is to maximize protection of their personnel because the facilities and all the equipment and all that stuff doesn’t matter or at all. If you don’t have effective bodies there to make the machine go. So the first priority in all of these environments has to be protection of the hospital personnel because that populace has a very unique skillset that when taken out, it’s not just one domino falling, it’s multiple dominoes because the footprint that person will have on making a difference in other sick people is it’s, it’s a force detractors. So in the army we have things that are forced multipliers and forced attractors and force multipliers. Something that makes one person have the effect of 10.
Dr. Shelly Farrell (29:41):
So like an anesthesiologist is forced multiplied by nurse anesthetists and you know, your, your nursing staff and for any physician or hospital, cause they’re, they make you able to be in like five or six or 10 places at the same time. But if those, those items aren’t supported and you don’t have your nurses and you don’t have your respiratory therapists and you know, you’re in physiologists and nurse anesthetists are, are sick they can’t function. So that, you know, that has to be a primary goal of like, you know, protect your personal first. Secondarily, you know, I think that that just knowing what your capabilities are and then figuring out ways to either augment them or move things around or have a, have a trans for line to get somebody to facility that you know, gets the capabilities that they need. Now, not, unfortunately, not everybody’s going to need to grow from this, but you know, if you’re a small community hospital, like you have to know, you have to make those connections now before it’s like, you know, John Q public just showed up and like his lungs are not functioning and he’s going to die.
Dr. Shelly Farrell (30:48):
Can we send them to you for ECMO? It was like, well, this is the first time you’re calling me. We don’t really have any, any plan in place for this. So, you know, we’ve got to answer some questions before this guy shows up and like sheds deadly virus all over our facility. So so if the, you know, the community hospital hospitals haven’t had those conversations with the bigger centers, then that’s a problem as far as the bigger centers go. You know, at the university of Kentucky, we had, they would do these drills every month, every couple months where it was basically just kind of almost like a mass casualty drill. And it varied from things like you know, Lexington is a hub of like industrial liquids that come through. And I mean, they’ve had a small but kind of contained things where they’ve had, you know, like you know, oil or some sort of like weird hazardous material where they, you know, were kind of spun up and ready to take a massive group of patients.
Dr. Shelly Farrell (31:40):
I mean, a year or two after I left Lexington they had a an aircraft go down at the Lexington airport. So that was a big mass casualty response. When I was on call one night, they had a train that derailed and was right next to a trailer park. Fortunately, you know, we were, we’re literally probably about a hundred yards from a giant catastrophe. But thanks to the way the, the trains had, didn’t have people on them. They were cargo trains and were derailed next to a trailer park. We didn’t like invade the trailer park. You know, we, we dodged a giant bullet there, but we were prepared for it. I mean, when I got the bedroom through, like I got everything spun up, I got people in place, like we were ready for, you know, and then it turned out instead of the end of 102, so that was a little more manageable.
Dr. Shelly Farrell (32:29):
Oh. So a lot of these, a lot of the bigger facilities have these contingency plans in place. You know, so they’ve thought about these things. They’ve got the, but an infectious disease presents a very unique risk relative, something like the army prepares for these of this chemical tack. I was, I was the only anesthesiologist and Fort Leonard wood, Missouri, where they have the the CRT training for the army there. So they go through those drills all the time because that’s the thing that all of those people have to know how to do. So we set up shuffle pits, we set up decontamination, we set up you know, educational sessions for them, how to use the, the Mark to, to Pam chloride, atrophying kids. So you know, the, the army trains for these things a lot. We kind of take it for granted the active duty folks and we grumble about it cause it’s like all of this crap that they put over their plate all the time and then like, it actually goes down, you’re like crap downs useful.
Dr. Shelly Farrell (33:23):
So you know, somebody has thought about this and we’ve kind of, we’ve got a game plan for it and but just kind of getting the mechanics of like, this is how we do this. That’s, that’s the first round of takeouts or like it, it looks ugly, you know, the, the first little bit of it, but then, you know, once the, the numbers start to kind of calm and pile up, then you, you’ve got, okay, we did this, this way, loss, we’re gonna do it again. Now we’re going gonna do it again. They’ll renew it again. So,
In your opinion is, is there enough of this type of like mass casualty type training that has happened in our healthcare system that we’re going to be able to adequately deal with some of the issues that we’re going to hit? Or is this going to, are a lot of people are going to be obviously probably learning on the job?
Dr. Shelly Farrell (34:03):
I think there are two things that are going to make a big difference in terms of kind of how this plays out. Number one it’s going to make a difference in how the American public treats it, you know, if they are like the Italians and you know, I, I was deployed with a lot of Italians so I’ve got a, you know, kind of a general feel of of kinda how the Italian culture is. It’s very much a lot of bravado machismo like I can’t get sick this, you know, and so I think they really didn’t take it serious initially and really kind of gave it best case scenario for kind of getting out of control. So I think if the American public really you know, kind of gives it its due, like we’re not super afraid of it cause like 20 year olds, you know, there’s not gonna be a mass of 20 year olds that we’re digging graves for.
Dr. Shelly Farrell (34:47):
But like we need to keep it, we need to keep the social contact down because while you might not be afraid of it, like you know Bob’s, you know, Papaw over there, he can get killed by it and it’s going to get transmitted more distinctly if we all just kind of say this isn’t so bad. People aren’t dying on mezcal. It’s not that people are dying on mass. It’s that as it sweeps through a populace, there is a vulnerable population and you’re going to expose them at a higher rate. If everybody else acts like, you know, I can’t be damaged. I’m 20 years old and I’m Bulletproof, look at me, jump off this building. That’s great. You know, maybe, maybe you’re laying on your feet cause you’re going to create enough shockwaves where, how you hit these, all the disease vector that you pour out cause you got sick cause you were bound head and now 10 other people are sick.
Dr. Shelly Farrell (35:37):
It’s a magnifying effect. So I think that’s gonna really shape how this impacts our health care system. And then kind of the last crux of it is how the health care workers and you know, the doctors and the nurses and the, you know, the hospital administrators, how they prepare for it. Cause on the spectrum of, of, you know, what can happen, it all ranges from like everybody’s super well prepared and it goes off without a hitch. That’s not going to be most hospitals, most hospitals are going to be kind of somewhere in the middle where they’re going to make some mistakes. They’re going to, you know, they’re going to have some gaps but learn from it and then adapt quickly. And then the, the dangerous ones are going to be the ones on the other end of it that are like scared to death and try to put their head in the sand like an ostrich, you know, and don’t don’t face it bravely and smartly and try to educate themselves about, you know, proper practices.
Dr. Shelly Farrell (36:34):
The CDC has been tremendous. And, and several university centers. One of my partners, I went to the university of Washington for her for training and they’ve been, university of Washington has been very good about putting out like, you know, flow charts and protocols and there’s an EMR critical care doc website that I was looking at today. Those fantastic that had a very good kind of breakdown of all the things you need to know as a professional to like to understand the pathogen and like how to get a game plan for it. Because or still in those early stages of really learning what the, what the footprint is going to be on our society. But like the things that we know are the things that you need to really plan for. The like, you know started out in the podcast and so we know it’s going to be super contagious cause we don’t have a herd immunity for it.
Dr. Shelly Farrell (37:29):
And so we need to, we need to play that game. There was a reference that I’d come across where they’d referenced the 1918 flu epidemic in Philadelphia. Didn’t do a particularly good job of cutting down on those public gatherings and you know, like church services and all the things that got people together and their mortality rate per 100,000 at that time I think was, you know, this reference that are, is like 250 deaths per, per 100,000, which is not a huge number, but still, you know, that spike spiking infectivity and the populace that was affecting was substantial. Whereas st Louis you know, within a couple of days of, cause, you know, they already, they’re already seen the experience. What’s going on in Philadelphia. There’s a lag time with this found out a month, they’d already seen how it was sleeping through Philadelphia. They’re like, Oh crap, we need to like shut everything down now.
Dr. Shelly Farrell (38:22):
So their, their arc of what their disease you know, foundation was among the populace, had a mortality rate of 50 per 100,000. What’s a five fold decrease just for a few weeks of like not going to the theater and not going to church. Like just kinda hanging out and just, you know, staying close to home and the, the cost of that a individual family isn’t substantial, you know, in 2020, 20 and maybe some lost wages from work that’s missed. You know, I, I don’t know what the answer is for, for families that are financial, a little more at risk, but for people that can afford to stay, how more? Like, you know, just, just the obvious things. Like we didn’t go to that water park on Saturday. It was if I were to pick a Petri dish and something that’s going to transmit virus, I pick a waterpark talking about droplet transmission. But you know, it’s just kind of being smart. You don’t, you don’t have to be afraid of the world. You don’t have to like, you know, outdoor stuff like hiking, like, you know, I went and went through like the woods or was it like open Corona in the woods, cause the respiratory droplet Barden there’s not high. It’s not as not an infection from, you know, dogs or cats or deer or whatever. I don’t know what sort of wet market stuff they were doing a woof on. But yeah.
Yeah. and that’s one of the things, I guess that’s, and even today I was talking to a client of mine closer to the Midwest and they’re, they’re still doing elective cases at all these big hospitals and they don’t, they’re doing like no additional PPE for even at risk faculty. And it’s, it’s so slow. This is, the thing that frustrates me is it’s so slow to see these changes being implemented. And unfortunately, you know, especially in some instances if you have a, a surgeon who’s got a bunch of elective surgeries lined up, there’s sort of this inverse incentive, you know, to, to cancel and it’s, it’s a tougher thing to do. But in the interest of public health, it’s, it seems like at this point it’s a no brainer. And I’m just looking across you know, med Twitter and all these how slow it is even even in this day and age.
And it’s, it’s, it’s it is a little bit like watching that train wreck in slow motion. So I’m, I’m, you know, this is just, I think an opportunity for me to reflect and say I’m really grateful for the people out there on the front lines. People like you, Dr. Farrell, and like my wife here at university of Pennsylvania and all of her colleagues who are gonna be doing a lot work in a lot of overtime, putting in a lot of hours and a lot of hard work as we see this thing continue to probably pick up steam and really putting themselves at risk to try to keep our populace safe. So [inaudible]
Dr. Shelly Farrell (40:52):
Yeah, I think that’s, that’s what makes, you know, military medicine and university medicine different than a lot of the community hospitals. It’s like money makes things perverse. And I, I worked in a small community hospital that was private practice moonlighting when I was was in the military and I got to see a little snippet of that and I got to see, you know, surgeons that were [inaudible] not necessarily that they were, they were openly willing to sacrifice, you know, the wellbeing of their patients, but like they were going to make money every chance they got. And unless I saw something that was a clear barrier or like terrible practice or something that’s going to hurt people, then they were just going to do it their way. Damn the torpedoes, you know, Mike money and like, you know, just take a whiz on everybody else.
Dr. Shelly Farrell (41:42):
So I have seen that and that that is an ugly way to practice. It’s one of the reasons that I, I didn’t go into a private practice environment cause I didn’t want to have to be compromised. And in that, that aspect where like money makes decisions for me. Well at that point it’s really up to the administrators to just kind of like, cause they’re, they’re going to be the final gatekeeper as much as I, I’m not a big fan of strong hospital administration period. But I think that if they have a role of any kind of gatekeeper guardianship, like if, if there’s a part of the machine that can, can stop a [inaudible] because you know, physicians are held in a very revered a platform, but we’re human too. You know, there, there are things that affect our decision making. We can’t function in a vacuum.
Dr. Shelly Farrell (42:31):
You have to have other brains chiming in and have the courage to kind of speak up and say, Hey, like that’s not a good idea. Like this thing that you’re doing right now, this is the playbook for the bonehead way to do it. So you really have to have somebody. And as hard as communities there, I’ve been there, like your kids go to school together, you know, you have barbecues together like your cousin and, and you know, somebody else’s sister married zero. Why does somebody, so it’s a very tight niche group that is very easy to fall into group think because you know, there’s an alpha within that pack and then, you know, so-and-so said such and such and that’s gospel. So you know, that’s the, the part of what gets weird about it
And then it becomes what we see is like least common denominator, both medicine and society where it’s like, Oh, well, so-and-so is still doing it. So it must be okay. And that was what’s happening for this person I was talking to at this big, you know, center closer to the Midwest where it’s like, well the big academic place in town is still running electives. So the smaller private group is going to keep running electives until the big group says no and then it’s like it’s advocation of responsibility. In my opinion
Dr. Shelly Farrell (43:41):
It’s to light them. That’s the problem. It’s too late then because we don’t really know the incubation period of this thing is right now kind of guessing and it might be as it might be as long as it’s like a week or two and that’s just going to be absolutely devastating if that’s kind of how it plays out. The other thing that I, that I found personally most concerning is that there seem to be a substantial amount of of patients kind of out in the community that are like infected shedding virus showing no clinical symptoms and that’s like a perfect vector for just laying Weiss to entire populace. Cause that person’s going to have, especially if they’re working in the hospital because they’re going to have contact with a bunch of, of compromised patients and it’s going to get ugly. So I think at least until we kind of get on the downside of this, I think it really needs to strongly consider pairing us in those cases.
Dr. Shelly Farrell (44:34):
And I, I get that it’s, it’s hardships on the patients that are coming in for these elective surgeries for like, you know, their cataract surgeries. You know, that, that their son’s taken off work to take care of him for a day and they planned to have their followup visit, you know, the next week. And like all of this stuff’s in place and it just stopped the brakes on that. That’s a hardship to the patients. But what’s going to be more of a hardship is if this really starts to get out in the community and just bashes everyone like [inaudible] yeah, get your eyeball fixed, but now you’re fighting for your life on a ventilator. So what was the better decision? We don’t know the answer to that. We don’t know. We don’t have a crystal ball, but I think, you know, by the time you’re reacting to it, it’s already too liked.
Yeah. And there’s so much unpredictability, I think more than any one thing that this is making me think about, and I’m curious in your perspectives on this and then we’ll wrap it up here is that it’s important to sort of acknowledge our shared humanity and the fact that there’s a lot of freaked out people and a lot of vulnerable people and a lot of people who are powerless to improve their own situation or to protect themselves or who don’t have an economic safety net. I’m looking around, you know, here in university city in Philadelphia where I live and I could throw a rock and hit 20 different houses where people don’t have six months of savings in the bank and they’re working on an hourly job and they’re, the way that they’re thinking about this is it’s very different from like me and my wife and our household.
And it’s important to acknowledge that and to reach out to people around us and say, Hey, neighbor, friend, family member, like we’re in this together. And maybe we can only talk on the phone instead of hanging out together for a while. But that acknowledgement of shared humanity, of saying like, if you need something, I’ll give, I don’t have a lot, but I’ll give you some of what I have. And creating that person to person, community bond. Again in a, you know, in this age, it’s like, it’s dissolved to some extent because of the way we interact electronically, I think. But I think restoring that it’s going to be part of what makes this easier and better for us to get through as a, as a society, as a community and a, I think it’s as important as it’s ever been.
Dr. Shelly Farrell (46:36):
Well, I think this is an opportunity for, you know, the America, Germany, the world, cause everything’s a lot smaller. I mean, you know, the four, the virus broke out, you know, you get on a plane and be back in United States and you know, eight, 10 hours and you know, the world’s, you know, as big as it is, as smaller now as it’s ever been. So this is almost like a dry run for like, it’s the way we’re connected is the perfect Patriot dish for like something really bad. Like if we had some sort of like sustainable like Ebola stream and it’s like a 90% kill rate. So how we respond to this now in terms of both kind of the panic, the education, the knowledge dissemination really kind of gives us a framework for, for how we’re going to respond for something that is clinically more significant.
Dr. Shelly Farrell (47:26):
So we’re, we’re blessed from a standpoint that, you know, for the majority of population, it’s not going to be a catastrophic illness, but we have an opportunity to kind of learn the social changes that we need to make to get into a place where if this were a more substantial pathogen that we already know what to do. So, and it, it’s very much in something like this, this is not a, a MI item. This is an us item. This is we, this is our community. This is, you know, our world. And so the way we respond and learn from this event or don’t learn, you know, we’ll really kind of set the stage for, for, you know, it’s not if it’s when, how bad. Like we’re, we’re, you know, genetic vectors for, for bacteria and viruses and all kinds of other things. What infect us. And you know, this is a, an example of, of how we can work together. [inaudible] Get everybody through this. You know, we see it in the economy, we see, you know, the stock market going down and panic and like, that’s, that’s not the answer. Like there are certain aspects of a business as usual that can continue on, but you know that there’s certain like things that we do socially that we can modify so that we’re helping each other collectively.
Dr Shelly feral, thank you very much for joining us today and for sharing your experience on the anesthesia success podcast. Hope to talk to you again soon.
Dr. Shelly Farrell (48:52):
Yeah. Well, and then the last little nugget for the anesthesia providers out there, like, you know, take care of yourself. No, there’s a lot of guidelines that are out for wearing a and 95 masking and personal protective equipment. Cause I think anesthesia personnel are taking a substantial amount of, of exposure and infectivity of, of patients exposing the health care providers to it. So [inaudible] protection the in 95 mask. I mean that’s, that’s what we’re doing in our hospital to cut back on some of those. So I know that’s going to be a, the in 95 masks, we don’t have the same prevalence as like the surgical mass, but it’s, it’s the ownness of the hospital to find, know routes to kind of get that equipment in. And, and you know, the militaries also learned that like, you can reuse these things. Like you can decontaminate the outside of the masks and you know, so you don’t have to like use one, throw it away. You use, this isn’t Jayco town. This is like pathogens, survival town. So you know, you can, you can decontaminate, you know, masks and, and, you know, reduce that risk. But so they’ll see people out there, you know, take care of yourself cause we, we really need that and be people to stay in the fight.
Yeah, that’s absolutely right. Well, Dr. Farrell, thank you very much for your time today and your perspective.