SPECIAL EPISODE: Leadership and Contingency Planning For COVID at UPenn w. Dr. Meghan Lane-Fall

In this episode of Anesthesia Success I am joined by Dr. Meghan Lane-Fall, an associate professor of anesthesiology and critical care at the University of Pennsylvania. She is currently taking on a leading role in Penn Anesthesia’s departmental efforts to combat COVID-19 in Philadelphia. In what Dr. Lane-Fall calls “a generation defining time” for physicians, we discuss the need for advancements and creativity in medical care to combat the current pandemic.

Dr. Lane-Fall (00:51):
Thanks for having me.

Justin (00:53):
So for starters, I’m curious, what’s the, what’s the climate like among your anesthesiology peers? Does it feel like you’re kind of bracing for impact or is it, you know, still preparing or what are the conversations like right now?

Dr. Lane-Fall (01:06):
I think it’s all of the above. You know, I think our emo is to be pretty calm and collected. And I think where we’re trying to draw on that, that professional identity, at the same time, I think we know or have a good sense of what’s coming. And so we’re trying to plan for every possible contingency, but because there are so many contingencies here that that’s pretty hard.

Justin (01:28):
Absolutely. so as somebody who is also having my own business as a financial person attached to the current event, it’s, it’s very difficult to separate yourself from the news and the headlines and even the medical implications of the things happening out there among the, the conversations among your colleagues. So I’m curious, you know, I’m closely watching like med Twitter to get updates on things and frankly, I told myself today I’ve got to cut the cord. There’s nothing that’s going to happen in the next 24 hours that’s going to, it’s going to, you know, change the way I need to live my life and I need to separate myself a little bit. So I’m curious for someone like you in a position of leadership, who is it, it’s important for you to both disseminate and to take in information? How do you think about that balance of trying to know what’s going on but also trying to maintain the sanity and the collectiveness that you just, that you just mentioned?

Dr. Lane-Fall (02:22):
You know, I’m not sure there’s there’s a skill that comes with being able to take in a lot of knowledge, assimilated, distill it down, and then share it with other people. And I think of that as something that I do well, but I can’t really explain how I do it. Yeah. I think that unlike previous challenges, we actually have too much information right now, not too little. Right. And so I think one of the central challenges here is in figuring out what’s real, what’s not, what’s relevant, what’s not, and really focusing on what we can control. So I think that’s sort of how I approach the of information is some of it’s good to know. Some of it’s interesting, but only a subset of that is immediately relevant to what I need to do.

Justin (03:08):
Right. Makes sense. Maybe you could share a little bit about some of the preparations that that the, the anesthesia department and your colleagues across the specialties are currently enacting here in Philadelphia.

Dr. Lane-Fall (03:20):
Sure. So I think our overall goal is to, it’d be able to manage the surge of patients that we think is coming in from an anesthesia perspective. We’re really concerned with airways because we do a lot of securing of airways and that’s understandably a very high risk procedure for us and for the people that help us. And then we’re also concerned for caring for the patients that may come to surgery. Now, certainly coven 19 is not primarily a surgical disease, but people can develop issues that require surgery and people who are asymptomatic coming in for surgery for some other reason could certainly have Covance spread. So those are the two main arenas that we’re concerned about as an anesthesia department. But we also have a large division of critical care anesthesiologists, so there’s a subset of us that are really concerned about ongoing care in the ICU. So we’re involved in that work as well.

Justin (04:12):
Got it. When did you first start having conversations about these things to to think that man, there might be something coming that we need to brace for

Dr. Lane-Fall (04:20):
Sure. So I think all of us have been following this at some levels since the word first started coming out of China in January. Yeah. I think our efforts really ramped up this month in March. So today is March 18th I was on service last week, so I was on service starting the whatever the day it was. I don’t know the days anymore than nine. The Friday before that we were talking about things. So I’d say probably from the beginning of March is when we started to say, okay, look, things are happening. There’s a really clear presence in Seattle, there’s communities spread in Seattle and we know it’s coming our way. So I think that’s when we really started to stand up teams that would look at this and think about how we would start to respond. Yeah.

Justin (05:06):
What do you view as the biggest obviously this is a multifactorial situation with a lot of challenges and a lot of potential contingencies, but as you’re thinking about anesthesiologist and critical care responsibilities, is there maybe one or two key challenges that rise to the top where you’re thinking, these are the things that I’m really addressing and working on, focusing on to make sure that we’re as prepared as we can be?

Dr. Lane-Fall (05:28):
Yeah, I think there are probably three things that are at the top of my mind. The first one is safety of the staff and safety. Really, when I think about that, and I’m thinking about personal protective equipment because we have a lot of reports out of China, out of Italy, out of Canada, out of the UK, that give us a sense of what we should be doing to protect our staff. And I have a very real concern that we don’t have enough equipment to do that now. Currently we’re okay, but we know that there are shortages around the world of [inaudible] masks. We know that the powered air purifying respirators we have some, we don’t have enough, we have a lot on order and we think they’ll be coming in soon. But these are resources that are either finite or they’re reusable, but it takes some time to process them.

Dr. Lane-Fall (06:15):
So we’re not, we’re not at the point where people aren’t able to protect themselves, but that’s one of my main worries is being able to ensure the safety of of our staff. The second piece is being able to care for patients appropriately and thankfully everything that we’re hearing about this condition is that for those people that require intensive care, they develop acute respiratory distress syndrome, ERDs but it tends to be not the most difficult type of RDS to manage. Now this is said from the perspective of a critical care person who manages these people every day that not that difficulty. RDS is still critical illness, right? It still firing life support, right? I don’t mean to minimize it in any way, but once you get them intubated, once you have them in an ICU, you can manage them with low tidal volume ventilation and high peep and proning and all the things that we do for people who have already asked.

Dr. Lane-Fall (07:09):
And so we think that part is not the most challenging part. There’s just a limitation in the number of ICU beds. There’s a limitation in the number of events and there’s a limitation in ICU staff. So that’s what worries me with the, with the care of these patients, especially looking at projections for how many critically ill patients we may have in the comparison of that to the number of events that I see, events that we have. Right. And then the third issue is it actually goes back to the staff thinking about how to keep the right numbers of staff and the right people in the right places because it only takes a few people being ill or being quarantined to completely upend your staffing model. So we’re seeing that in some hospitals in the U S and we’re trying to figure out what we would do if certain people went out and how we would fill in for them.

Justin (07:58):
Makes sense. Are you, are you finding that you’re coming up with potential alternative clinical care models in light of the PPE shortages and I, I just read something that’s like, do we have a way to, you know, do like swap out IVs without going into a room maybe having a longer two or something. I don’t know if they’re those types of things that you’re thinking about or if that’s in play at all.

Dr. Lane-Fall (08:18):
We’re definitely thinking about that. We haven’t thought about the long Ivy tubing. I think there’d be too much dead space.

Justin (08:23):
Yeah. I don’t know if that actually works. This is not, this is not medical advice from the CFO.

Dr. Lane-Fall (08:28):
I hear you though. No, this is an interesting idea. Certainly we’re trying to minimize the number of staff in a room, taking care of people who have those condition. And so we’re thinking of a primary nurse who’s got little protective equipment, who’s in the room really most of the time with the door closed with an attending physician and maybe a fellow or a resident who also goes in as needed. Or advanced practice provider. Basically someone new can write orders, the respiratory, especially for those patients who need respiratory support. But that’s kind of it. So one of the interesting things that’s come up for us is for patients who were vented, our hospital policy is the respiratory therapists are the only ones who can touch the vent. And that’s for safety, right? Because they train on these machines, they know how to use them, they’re expert in that.

Dr. Lane-Fall (09:15):
And even though physicians place the orders we aren’t always up to date on the exact equipment and all the widgets and the nephrology. Sure. Right now we’re looking at ways to figure out if we can relax that just for these patients. So if the vent is turned in such a way that you can see it from the door, can the nurse that’s in the room actually make the adjustments with the respiratory therapist sort of going yes, no, no. That one that went over there so that they don’t actually have to go into their room. We’re also looking at the use of telemedicine to help augment our decision making. And so clearly they can be at a distance and they’re not at risk. So that’s that. That’s going to be helpful too.

Justin (09:56):
I’m curious how you’ve been navigating and if you’ve bumped into this at all the, the constraints regulatorily with HIPAA Jayco and some of the, you know, privacy types of questions that come in with telemedicine and like, wow, it’d be great if we could, it would be great if we could FaceTime somebody who had a cough and were wondering if they were positive rather than having them stand in a long line with a bunch of other potentially positive people. Do you have any thoughts about that?

Dr. Lane-Fall (10:17):
Yeah. So thankfully most of the resources that we are using are in house and everybody sort of the UN all the same HIPAA umbrella. So our telemedicine group is in house. So that’s not an issue with us. In terms of seeing patients virtually, we have something called and Madison on demand, which is a in house service that are staffed by telemedicine nurse practitioners and they can FaceTime with with patients and talk to them. You can also set up appointments for them to get drive through testing. But right now that’s very much a homegrown within our health system sort of set up. But we’re very cognizant that we don’t want to create a situation where we’re exposing people to risk as they’re trying to figure out how to, how to get care.

Justin (11:02):
Do you view this as a time at which it may make sense? Are there certain segments of either HIPAA or something similar where where we need to relax things intentionally, strategically for a period of time to try to get care to the most people possible without endangering the health care professionals?

Dr. Lane-Fall (11:19):
Without a doubt. Yes. I think we need to look at ways to relax privacy regulations in a way that is strategic in a way that, that facilitates care without creating an undue burden on patients in terms of interrupting their privacy. But we are in a very, very unusual time. This is the generation defining moment of crisis for us. And we have to get out of our heads the idea that this is normal, this is not normal. And so bureaucracy is great for keeping things sort of on track and keeping people following the rules, but it can also get in the way when you need to be nimble. And so if there’s somebody who needs to come in from another health system, you know, I need to know what their medical history is and I don’t have time to get to sign a form to get faxed over to make sure that everything’s okay according to HIPAA. So anything that legislators can do that policymakers can do to help facilitate care would be useful.

Justin (12:16):
You mentioned one of the constraining factors being the ICU beds, ventilators. That’s obviously a bit of a discreet universe of like, we’ve got so many rooms, we’ve got so many beds. You know, I’m sure there’s some extent to which you can maybe augment them by like grabbing the vents from other places. But, but there it’s

Dr. Lane-Fall (12:34):
Be very creative. Yes.

Justin (12:35):
Yeah. So I’m curious, what does creativity look like in this area?

Dr. Lane-Fall (12:39):
Creativity means looking at any type of machine that can ventilate a human, whether it’s meant to do that or not. So certainly we have our mechanical ventilators. There are mechanical ventilators really built into every anesthesia machine that’s in the operating room. So you effectively have more ventilators that way. And going back to what I mentioned about this being sort of a quote unquote typical MRDs, you don’t need really fancy vent settings. Yeah. The anesthesia machines are not fancy events or they can do sort of basic stuff, but that, that’s probably enough. We’re were talking to children’s hospitals because children thankfully aren’t being hit very hard by this. So if that continues to be the case, then that may be a way that we could, could ventilate people. We’re even talking to the vet school, I mean anything because they do surgeries, they have anesthesia machines, they have animators. So really anything,

Justin (13:35):
It’s funny you say that. I was just thinking Penn vet is like right across the street. I wonder if you know, if that, if that had hit the radar at all. Yep. We’re talking to him. Oh my gosh, that’s so crazy. In very strange times right now. Oh yeah. I mean you, you had this phrase, a generation defining time and I more and more, it really seems like that’s what it is.

Dr. Lane-Fall (13:58):
Hear about this. The more we think it’s going to be months of disruption, whether that’s financial, social, healthcare related. This is, this is a big deal.

Justin (14:10):
Yeah. Tell me a little bit about cultivating. You know, obviously anesthesiologists are as a class of professional, I would say among the best of people who are going to remain, remain calm under fire, so to speak. So, so this comes with the, the person, but how do you work to sort of continue to cultivate that spirit of like, we can do this control you can control. Don’t worry about the rest among your peers to try to, I mean, this is crazy. And I’m looking at, you know, my wife is like just wrapping up maternity leave. She’s going to be headed back next week and to, and she was saying like she might be rotating into the ICU even this week, which is our vacation week, just because things are crazy. So how do you, what would you want to tell the people out there listening right now who are looking at, you know, what’s happening abroad and listening to some of this and thinking who are just intimidated.

Dr. Lane-Fall (15:03):
So I would say that’s normal. I would say that’s a very reasonable response. I think that if you have the choice between curling up into a ball and doing something, do something, it’s natural to want to curl up into a ball. But I think there are some very real things that we can do that actually all of us could do to help, whether we’re healthcare providers or not, but within a healthcare setting, there are some things we have control over. And so I think concentrating our efforts on the things that we’re able to do and helping people understand how important they are, how much we’re part of a team, whether that’s thanking the environmental services professionals, whether that’s checking in with people who aren’t in a leadership team. And I do that very deliberately. I’ll reach out to people who are in the rank and file I haven’t talked to in a while and I just go, Hey, are we missing anything?

Dr. Lane-Fall (15:54):
Like how you do it and what’s going on? Yeah, I’ll just kind of randomly walk into workspaces and talk to people. So I think reinforcing that idea that we’re all in this together is really important. Helping people understand that we don’t have all the answers right now. So, you know, it’s not my saying, but I would say we’re, we’re built, we’re flying the plane as we’re building it. Are we building the plane as we’re flying it? I didn’t think the way you say it. We, there’s a lot we don’t know, but we’re being very transparent with our teams about what we do know, what we don’t know. And when something changes to try to let them know, look, we know this is different than what we told you yesterday, but this is what we think is the right answer. Now.

Justin (16:32):
Can you take me, give me a little snapshot into one of those conversations you had with maybe somebody you don’t normally interact with and you’re saying like, listen, what’s going on? What are you seeing and thinking and feeling and how’s this working for you?

Dr. Lane-Fall (16:42):
Yeah, so I, I went into there are two main hospitals where I work and I went into one of them in the work room and there weren’t a lot of people there cause it was the middle of the day and they’re all working. But I said, I ran into one of them and I just said, what’s up? And she’s like, Oh, I’m fine. I was like, no, like, what’s up? Like are you doing, how are things? And she kind of told me about an experience she had when she was covering airways and wanted to go down and get personal protective equipment just to have on her person. And some of the difficulty she had in acquiring that because we tend to link up this personal protective equipment to one particular patient. So if you’re caring for a patient, it’s easy to get. But if it’s a, I just want to have it because I know I’m at high risk of going into one of these procedures, then it’s a little bit harder. And so she and I were just talking about that experience, but it’s interactions like those where you let people know that they’re being heard and that you really care about them and that you’ll, you’ll help them as much as you can. Yeah.

Justin (17:40):
I’m curious, has this impact, so I’m not sure if you’re, if you’re married to a physician, I’m obviously not a physician, but I’m curious, does this impact like what are you doing when you go home? Like do you continue to interact with each other or like if you were to get sick, are you going to like stay in the basement while your rest of the family is upstairs or how? I’m guessing, I guess I’m asking like what should I be doing right now?

Dr. Lane-Fall (18:03):
Right. No, that’s a, that’s a good question that we don’t have a good answer to. When I was clinical last week, I would make sure that I left my white coat at home, that I left all my sort of hospitals, soiled clothes at home, take a shower when I get home. Now for the last three days I’ve been working from home. But I’m sure I’ll be headed into the hospital at some point soon. Yeah, I heard about an ER doc that’s sequestered in the garage. There’s an Emory doc who because he’s working with these people in front of the lines and his wife is on maternity leave. He deliberately self isolated in the garage and so she drops off food at the door for him to eat, but then they don’t really see each other. They don’t, I don’t know. I don’t know.

Dr. Lane-Fall (18:50):
I wish I could tell you what we’re supposed to be doing. I feel okay. I wash my hands all the time. I tell my kids to wash your hands all the time. My husband does the same thing. If I were to start to get sick, I would probably distance myself from them. And right now I’m in an attic and that’s sort of my workspace, but it has a bed, it has a bathroom. So I would probably just hang out here. But I have the luxury to do that. I know a lot of people don’t. Right.

Justin (19:20):
Yeah, I have washed my hands more than the last like two weeks. Then like the three months prior I don’t, I probably should wash my hands more to begin with, but I’m like paranoid about it now for sure. Stop touching your face. Yeah, it’s hard with the beard. Yeah. And the glasses, I’ll, I’ll try to figure something out. Have there been, have you been in any meetings where somebody said something and you’re like, this is an amazing idea. We need to take this idea and share it with everyone who maybe is asking a similar question right now or any other like best practice or things that you’re doing to scale capacity that you think is, is worth, you know, sharing with this, the, the anesthesia community.

Dr. Lane-Fall (20:00):
We definitely have had some revelations around the talent that we have already in our institution. And so I remember being at a meeting where someone was talking about our CRNs or certified registered nurse anesthetists and someone goes, wait, they’re all ICU nurses because that’s part of their trading as they come up. And you know, of course we know this. Like if someone had said, what is the training pathway for a CRN, we could all say it, but it’s easy to forget in the moment when you’re thinking about, Oh look, I only have so many ICU nurses. And if they call out then I’m in trouble. And then someone goes, wait, no, we have like a hundred people. I think we have more than that at this point. Who are all ICU nurses who could be deputized to do this if they needed to. And so I think we’ve, we’ve had multiple situations.

Dr. Lane-Fall (20:47):
We have these like, Oh wait, we could do that, or we could do this thing. Or the most recent one today was putting the respiratory therapist or a respiratory therapist in our telemedicine hub so that they could serve as a resource to the 200 critical care beds that we have. Because our respiratory therapists, we don’t have a lot of them. Right. They serve a lot of different patients so we could potentially simultaneously keep one of them off the front lines so that they don’t get infected, but then they could also help care for so many different patients. So it’s things like that. That I found really interesting.

Justin (21:20):
Yeah. Awesome. Have you, I’m sure you’ve given thought to this, but what about when, you know, some healthcare professionals inevitably start to get infected or is there a PR I know in Italy or I guess else, I’m trying to think of all the different places I’ve sort of been tracking, but there are places where they segment the, the infected, you know doctors and nurses to do covert only and then they partition the hospital itself to say, if you’re a negative for coven, then you’re somebody who can care for the negative patients and vice versa. Are there those kinds of conversations happening as well?

Dr. Lane-Fall (21:56):
Only the beginnings of those. Yeah. And certainly we’ve talked about in sort of offhand discussions. Oh one somebody has coven and they’ve recovered, then they should take care of the coven patients. And I think we’re open to that, hitting the challenges that we’re starting to see now, some evidence that people can be reinfected. And we also know that there are two different strains of the COBIT virus. And so it’s not clear that if you get infected with one that you can get infected with the other one. So I think that that logic makes sense at some level, but it probably falls apart when you, when you dig down into the immunology of it. But there’s also the issue that you have so many people that are asymptomatic that even in your quote unquote coven negative patients, you probably still may have some circulating. There’s going to be a point at which you have so many people, you know, in Italy there are places where it’s 30% or more of the patients in the entire hospital have it. Yeah. So it’s hard to imagine that you could effectively keep them in one one part.

Justin (22:53):
Right. Is there anything else you’d like to add or any other thoughts or insights you want to share before I let you go? Dr landfall,

Dr. Lane-Fall (23:02):
I appreciate all the all the energy and enthusiasm and the love that’s been sent toward health care providers. I’m I following med Twitter as well and certainly I get the sense that people understand what we’re facing and they want to help in any way possible. And I think that I really, really appreciate that for the people that are just coming up in their careers, I would say look to see how people are responding to this. Look to see how leaders are responding. Try to learn about what you think is good leadership behavior. Maybe will you don’t want to do, but these, you’re, you’re going to be battle tested. All of us are going to be battle-tested in the next weeks to months. So yeah, try to try to take some time and sit, reflect and I’ve been, I’ve been journaling and keeping an archive. I take screenshots of the Johns Hopkins website every day.

Justin (23:52):
Oh wow. Oh wow.

Dr. Lane-Fall (23:55):
And it’s amazing even just to go back a week and to look at it, I it’s, it just blows your mind.

Justin (24:00):
Yeah. Yeah. I was thinking that today I was taking Calvin for a walk. I hadn’t gotten any vitamin D and like four days, Calvin is our son. And so I was like, I need to get out of the house. So I was walking and just thinking about leadership and thinking about, I wonder how we’re going to look back at this time and the leadership questions that arise. And you know, I, I th I do think this is a time when leaders are going to be formed and where leadership is going to be built and what you said at the beginning, like you can either curl up into a ball or you can like get to work. I think that is absolutely, you know, it’s a leader can do attitude and something to which people are going to gravitate. And I was thinking even for myself and my community as a member of a family and as a member of my block and as a member of, you know, the citizenry Philadelphia, like what does it look like to be a leader, to be a neighbor?

Justin (24:44):
Those are really important questions for all of us to be asking right now and trying to say we can’t control everything. We can’t control the headlines. We can’t control how high, that big red, scary number on the top left side of that screen, the Hopkins webpage is going to go, but we can do what we can do and try to encourage one another. And so let me take this opportunity to thank you and all of your colleagues for all the work that you’re doing to prepare and to continue to as a society like work to protect the, the, the, the wellbeing of the citizenry of this city. And we’re, we’re just really grateful for, for what you’re doing. So thank you for joining me today, Dr. Lane fall.

Dr. Lane-Fall (25:21):
My pleasure. Good luck.