Hello and welcome to a special episode of Checking the Vitals, as we continue to cover the COVID-19 outbreak. I am your host, Todd Schlosser, and today, our guest is Kirti Patel, the National Clinical Specialist for Perfusion at SpecialtyCare. In this episode, we discuss how the COVID-19 outbreak is impacting the Houston area, where Kirti is located. We also discuss in detail, what ECMO is, why a patient might need to be placed on ECMO, and how it is the last line of defense in someone’s fight against COVID-19. We also discuss some uplifting things that are happening in the Houston community to help these front line employees at the hospitals feel supported as they fight this COVID-19 outbreak. Enjoy the conversation.
Todd Schlosser: Kirti, thank you so much for taking the time to join us today here on Checking the Vitals. I would really like to start out with sort of like I started out with Courtney on our special episode yesterday, and just really seeing what things are like on the ground in Texas where you are, because she was from Denver yesterday, and I’d love to see how things are similar and possibly different in Texas where you are.
Kirti Patel: Yeah, absolutely. In Texas, I’m based out of Houston. And as most people are aware, Houston, Texas Medical Center is one of the world’s biggest med center actually in the world. So, we’re going to see a huge influx of patients with COVID-19 for sure. We already are seeing that. Some of the hospitals locally are already maxing out on ICU space because of a COVID-19 patients. And so, it’s challenging times for sure, unprecedented times for sure. But what’s great is that you really see all these hospitals in the medical center coming together and developing algorithms and different management protocols to treat these patients. In this kind of situation, none of these hospitals is standing alone, even though they’re competitors. They’re not standing alone, they’re collaborating, they’re working together and trying to figure out how to best treat these patients.
Kirti Patel: And not only that, but also how they can protect healthcare workers. Because obviously, we’re on the front lines and we need everyone as much as possible to be available to take care of these patients. So, trying to keep them safe is also extremely important.
Todd Schlosser: I once heard someone say that in times of crisis, no one is siloed, and it does seem like you attest it too. There in Houston, I mean, your medical center, all of those competitor hospitals are working together to make sure everyone is safe and just do everything they can for the patients. Have you guys in Houston seeing the influx of COVID patients like New York has?
Kirti Patel: I think we’re just on the upslope of this curve. I think New York is already on this high end of the slope. Half of the cases in this country are based out of New York. I think the last time I checked, we were approaching 100,000 cases that are confirmed.
Todd Schlosser: I think we passed it last night.
Kirti Patel: Yeah. And almost half of that is in New York. So, I think here in Texas and across a lot of these other states, I think we’re just beginning to see this influx of cases. Testing is still an issue. We’re not testing everyone that’s symptomatic, and that’s an issue. So, we haven’t taken an aggressive measure with this as yet as a nation, and I think that’s a problem. But, for Texas, I think we’re just starting. I see, the next four to possibly eight weeks where the numbers are actually going to start peaking. So, we’re just beginning on facing some of these challenges that New York is facing.
Todd Schlosser: Yeah. Now, you guys in Houston, are you seeing shortening of supplies of things like N95 masks, or ventilators, or things like that?
Kirti Patel: As far as the ventilators, we aren’t quite there are yet, the concern’s there. And obviously, we’re not in the situation as like New York is. But, as far as PPE equipment, yeah, those are in short supply and we’re coming up with ways of trying to ration them. My wife’s also a nurse and she actually has a little container that the hospital gave her, how to keep her N95 mask, and they get to keep this one mask that they use, until it’s soiled. And it could be a week, it could be two weeks. So, they’re really rationing N95 masks. But again, fortunately for us, states like Texas and other states where we’re just beginning to see that, we are hopeful that we will have the supply when the time becomes very critical. I think there’s a lot of companies out there, 3M and… There’s lot of companies trying to work on getting a huge supply of N95 and other PPE equipment to hospital.
Kirti Patel: Some are very hopeful that not everybody is going to be facing those issues when they have this influx of cases in their particular location.
Todd Schlosser: Absolutely.
Kirti Patel: But again, absolutely, it is an issue already. Some of the hospitals only have supplies that are read locally, some of them have regular surgical mask supply for next 15 days and that’s it. And that’s alarming, we’re using some of these masks hundreds thousands a day. So, certainly, an issue because if we can’t stay healthy and be protective, protecting our health care, how are we going to take care of these patients? So, it’s certainly in our top item agenda for all hospital systems here in Texas and across the nation.
Todd Schlosser: Oh, yeah, and I know a lot of, well, even at the federal level, although the federal level is usually slower than the state level, I know a lot of state level governments across the U.S. have been doing whatever they could to get ventilators and get PPE equipment such as masks, and scrubs, and the face shields, to protect the front line employees in these hospitals. Because, really, like you said, if our whole front line medical support system goes out sick for COVID-19, there’s no one there to help. So, we’ve really got to do everything we can to protect those people. And you’ve seen a lot of companies like 3M, I even heard some stories about, in L.A. specifically, some TV shows who were shut down, were donating ones that they had purchased for filming purposes, that they just didn’t need. They were giving them to the hospitals in the area.
Todd Schlosser: People around the country are finding creative solutions to fill these gaps, while local and federal governments are trying to fill the pipeline of more protective equipment, which is great.
Kirti Patel: Absolutely.
Todd Schlosser: I would like to shift, if we could, because we talked to Courtney yesterday and she was talking about how some patients are needed to go onto ECMO, and I just didn’t follow up with her as much as I wanted to, about exactly what ECMO is, why someone would need to go on it, and I had some followup questions, if I could ask you though. Let’s start with, what is ECMO? And why would a patient need to go on it?
Kirti Patel: Okay, ECMO is, basically stands for extracorporeal membrane oxygenation. And when you just talk about ECMO, there’s two forms of ECMO, whether it’s a V-A ECMO, which is a veno-arterial ECMO, these are ECMOs that are placed in patients that have a cardiac component associated with them. And so, they need cardiac support. Also, the lung support obviously, because the heart’s not working. And then you have V-V ECMO, which is venous-venous ECMO, where you’re assuming that cardiac function is intact. And that’s a requirement to put patients on V-V ECMO. So, on these COVID-19 patients, you’re seeing patients coming in with a lot of respiratory issues. And so, if you look at any algorithm of a hospital, one of the bottom things that you’ll see on that algorithm flow chart is you’re going to see ECMO.
Kirti Patel: And that’s kind of last therapeutic mode we have of trying to save these patients. And so, in V-V ECMO, what we do is we actually put two catheters in a patient, basically, you could call these tubes, if you want, and they both go in the… they could be put in the neck, in the IJ position, into jugular vein, or, most of these patients, we’re putting them on femoral V-V ECMO. And so, basically, in one leg, you have a catheter, and in another leg, you have a catheter. So, what you’re doing is you’re draining the patient’s venous blood into a circuit that has a oxygenator and a pump. And so, this blood comes in through the right side of the heart, through the cannular, into the circuit, gets oxygenated through the oxygenator, and then warm the patient up, too. It’s got a built-in heat exchanger.
Kirti Patel: So, we try to keep these patients normothermic, and then it returns it back to the patient at the level of the right atrium. So that, now, what you’re doing is you’re basically bypassing the lungs. You’re basically taking the function of the lung using an external… It’s almost like a heart-lung machine, but in a very smaller version of it. Blood comes into it, then we pump it back into the right side of the hardware. The heart literally takes over that oxygenated blood and pumps it to the rest of the body. That’s why you need an intact-
Todd Schlosser: Cardiovascular system.
Kirti Patel: Correct.
Todd Schlosser: Yeah. Let me ask this, I mean, the patient’s still breathing while this is going on, and is it just sort of giving their lungs a break?
Kirti Patel: Yeah. What you do is, these patients… One of the things about ARDS, ARDS is acute respiratory distress syndrome, that a lot of these patients face. And so, what happens is, in this, when you put these patients on a ventilator, the ventilator is a great strategy of helping these patients. However, it’s a double-ended sword because these patients that already have a lot of lung injury, having high ventilator settings actually injures the lung furthermore. And so, what we call this is called barotrauma, it’s the further barotrauma injury that they get. So, what we try to do is once we put them on ECMO, we try to decrease the ventilator settings, and let the ECMO do most of the work. So, when you start talking about ARDS and ECMO, the term we use is protective ventilator strategies. And this is where we try to minimize what the vent is doing, so that we let the lungs rest, and let the ECMO do majority of the work.
Todd Schlosser: Okay. Let me ask this, and obviously, I’m assuming, and correct me if I’m wrong, clearly, but, a doctor would say, “Okay, this patient needs to go on ECMO.” And then we have a perfusionist come in and set them up on an ECMO circuit. What does it take for a patient to get there? Clearly, this is not the first line of defense. When they come in with symptoms, maybe shortness of breath, or maybe it’s just hard for them to breathe, there are a few steps before then. What are those steps, before we would need to put someone on ECMO?
Kirti Patel: Well, you’ve got, you have patient that comes in, they are not intubated, they’re in room air, they’ll put them on nasal cannular, and eventually end up on a ventilator. And now they’ve maxed out on the ventilator where the setting is extremely high, and they’re still not able to get adequate oxygenation on these patients. So, when these patients’ oxygen levels in their blood are extremely low, then, depending on the physician and institution, they may have a target PO2 level in the blood that they’ll say, “Okay, beyond this, we’re going to go to ECMO.” And of course, they’re looking at other things as comorbidities, as, how old is the patient? Are there underlying conditions, cardiac issues, cancer, age, or history of stroke? All those kinds of things go into decision making.
Kirti Patel: But once they make that decision, it’s usually because the ventilator wasn’t enough to provide them life-sustaining oxygenation.
Todd Schlosser: This may be a question that just no one can answer at this point because everything is so new, but, I’d imagine that it’s a very small subset of people that actually catch COVID-19 that need to end up on ECMO or even a ventilator. Do you have any idea about what those numbers would be?
Kirti Patel: We don’t really have really good data yet. It seems like ECMO has not been utilized. This is information from China. Again, resources is a question that remains to be answered and what kind of resources were available for them for as far as ECMO. But, we can literally put any of these patients on ECMO. The problem is, how many ECMO machines are in the country. Every single institution, depending on their size, may, a small institutions may not have any, a large institution, where I’m employed, we could put up to, easily put, at least, eight ECMOs and possibly be able to rake things up to provide ECMO support on an additional five or six other patients. So, we could potentially provide ECMO for 15 patients, but not all hospitals are able to do this.
Kirti Patel: And the data that we have out there on success, there are reports, I’ve read reports where mortality is extremely high in these patients that are COVID-19 that end up on ECMO. But then I’ve also seen data that says there’s 90% success rate.
Todd Schlosser: Yeah, it seems like it’s just so new at this point that some hospitals are seeing a lot of success with it, some aren’t. And it’s just, there’s not enough data to really determine a figure at this point.
Kirti Patel: Absolutely. Yeah, this is so new, and us as medical professionals, we rely on data and studies. And a lot of these things takes years and years and years before we actually implement. We’re dealing with the infection that’s been around for three, four months, and trying to come up with guidelines, based on experience, and it becomes very difficult to figure out what’s best and what’s right. So, it’s definitely ongoing challenges on what we should do and what we should not do.
Todd Schlosser: Speaking specifically to supply of these ECMO machines, you mentioned you could probably service 15 patients on an ECMO machine. But, from what I understand, someone could be on ECMO for three, four, or five weeks.
Kirti Patel: Absolutely.
Todd Schlosser: So, is that also a concern? How does that short in supply become a concern? What do you in those situations?
Kirti Patel: Yeah, I mean, it’s tough, because, you’re right, when you put these patients on, you’re committing it for a longterm recovery, if there is recovery. And three, four weeks is not uncommon. We’ve done ECMOs V-V for ARDS on patients for six months before, and people have done them even longer. So, resource commitment is huge. And once you put these patients on ECMO, you also need the personnel for ECMO. Fortunately, I’m in a big institution where we have a lot of perfusionists, we also have resources, ECMO specialists available to us, that help us manage these patients on a day-to-day basis. But if you’re dealing with the account where there’s five perfusionists and you have ECMOs possibly in two locations, how do you manage that? Because, now, if you have a perfusion team managing that becomes extremely difficult managing these patients.
Todd Schlosser: Are there other people in the hospital that can run ECMO machines other than perfusionist? I was under the impression that it was just perfusionist that ran ECMO machines.
Kirti Patel: We do have, we have actually a group of trained ECMO specialists in-house. And most of these are actually, there are registered nurses that typically take care of ICU patients. So, they go in and out of rotation depending on needs. But, at this time, almost all our ECMO specialists are assisting in bedside monitoring. Perfusionists initiate all the ECMOs were there for all the circuit changes were there for any transport that’s needed and things like that. But having ECMO specialists really, really helps the staffing. Because just, even though we’re doing elec urgent cases or emergent cases only, because of the size of our institution, we do have a lot of cases still ongoing during this time because we do lung transplants and heart transplants and liver transplants. So, we may still have three or four or five at worse going at any given time. So, resource becomes important when you’re dealing with high number of ECMO patients.
Todd Schlosser: That’s a good thought, too. I mean, a lot of people, I guess, just assume, every element of the hospital is going to be there to service the COVID patients. But there are so many other emergency procedures that go on in a hospital, that is not COVID related. All of those surgeries that are considered elective, may not be done, but you still have people who come in and need surgeries immediately for other emergency purposes and they might need a heart-lung machine that requires a perfusionist. So, that drains the supply of personnel, right?
Kirti Patel: Absolutely.
Todd Schlosser: What do you guys do in those situations? You mentioned you guys have a big team there, so, maybe you guys won’t run into this, but if you have a lot of perfusion stretched then with the need for ECMO, and then these emergency surgeries come up, how do you guys handle that in your area?
Kirti Patel: Yeah, and that’s the thing is, small institutions, those are some of the tough decisions they’ll have to make. It’s like, all that has to be discussed ahead of time and you have to set a limit on how many patients are going to be on ECMO. And then also, really, logistics becomes very important, or you’re going to have all these patients in one area. We’ve created a unit that we call highly infectious unit, and pretty much having all our ECMO, all our COVID patients in that area, so that if they do need to go on ECMO, then, it can be easily managed on a single floor, so that you’re not tying up resources as much.
Todd Schlosser: And traveling back and forth. Yeah.
Kirti Patel: Absolutely. And also, because of just the spread of the infection across the hospital, that helps limit that. But, we have 10, 11 ORs, we could convert all those heart-lung machines into ECMO if we have to. But again, like I stated, what if we do have a liver transplant? And what if we do have a lung transplant? And what if we do have a heart transplant? And we’re a level one trauma hospital, and what if I get a type one dissection in the middle of night? There are days when we’ve had three type one dissections, which are emergent cases and long emergent cases. So, we’re prepared for any of that, just because we have a big team. We’re also been very flexible in how we’re doing things. We’re trying to keep minimal traffic in and out of a hospital. So, our team has actually gone on a different schedule and where we’re doing, half the team’s doing seven days straight, and the other team is going to be home, and then we switch over.
Kirti Patel: So, we’re trying to also protect ourselves within the team as well, and also, less traffic coming into the hospital.
Todd Schlosser: Absolutely. And with the incubation period for this disease, COVID-19, where you could be infected and never know it, or it may take up to five to seven days before symptoms show up, but you could still get other people sick, just for walking around. That’s a very good preventative measure that you guys are taking. What else are you guys doing to mitigate risk or even protect yourselves while working with these patients that are highly contagious in the hospital?
Kirti Patel: Well, the hospital has done a really good job of developing the PPE, the training of it. If we’re dealing with any of these patients, how you’re supposed to… we’re actually changing scrubs right before we encounter these patients. There’s a designated shower area that we shower immediately after we take care of these patients and then change into a different set of scrubs. So, we have a very nice… and all these patients are in a room where an anteroom, such a room before the actual patient rooms. It’s a negative pressure room. So, a lot of different things are done to protect, not just patients, other patients on the floor, but also the healthcare professionals. When we initiate these ECMOs, we actually do it in a two-person team, where one perfusionist that’s going to stay in there to initiate the ECMO stays in the room. We don’t take anything in there, and as things are needed, they’re handed off through the anteroom, through another perfusionist. So, you’re not taking things into the room.
Kirti Patel: And then, anything that goes in the room is discarded. And so, we’re making sure that we also are not wasting resources by bringing everything in the room. So, we are using a two-man system for placing these patients on ECMO.
Todd Schlosser: It sounds like you guys are taking extra, extra precautions while dealing with these patients, which is, I’m sure, very warranted. A lot of what we’ve been talking about is scary and it’s very serious. And I know that in times of crisis like this, some pretty amazing things happen, as far as people coming together and supporting each other. So, I’d like to ask, is there anything going on in the Houston area where you are located, that has been surprising or has really made you and your team feel supported in this time of crisis?
Kirti Patel: Driving into the medical center and stuff, it’s very uplifting to see all these hospital systems. They’re putting these massive signs outside where employees are entering, and the public to see. And the sign says, “Heroes work here.” You see that, and that’s very uplifting. And the hospitals are really doing everything they can to cheer employees that are on the front lines. And also, a lot of local restaurants and even some of these food chains, they’re delivering food to healthcare workers. And so, it helps to know both the restaurant industry and also cheers up the workers. So, that’s been very positive and uplifting.
Todd Schlosser: Are there any other areas in which you’re getting support that you found surprising, or maybe not surprising, but at least, just uplifting?
Kirti Patel: Yeah, I’m very fortunate, I’m very pleased with the support, leadership support from SpecialtyCare. All the updates we’re getting from Tom Coley, all the updates we’re getting from Sam, updates from the medical team and Al Stammers, concerning questions that we as employees may have. So, that’s been very, very positive. Sam has reached out to my individual employees directly, that are on the front lines. And I’m getting texts from them saying, “Wow, look at this, Sam, our CEO emailed this.” And I’m like, “Absolutely. This is important work you’ve done.”
Todd Schlosser: He’s emailing them directly?
Kirti Patel: Absolutely.
Todd Schlosser: Oh, wow.
Kirti Patel: And that was extremely, for my team, they were really happy to see that. So, that’s been very positive. Unfortunately, there’s a lot of people that are, even in the perfusion industry, that are losing their jobs or having their hours cut or forced to use PTO and things like that. But, as a company, they’ve done a great job of supporting us and I’m just very fortunate to be with SpecialtyCare at this time.
Todd Schlosser: Well, Kirti Patel, I really appreciate you taking the time to speak with us today. And I know things are changing day to day, so, we may have to do one of these again in the future, just to see how things change there. And I hope you guys don’t see quite the influx of patients with COVID-19 that New York has.
Kirti Patel: Yeah, hopefully not. But, unfortunately, I think we will, and I think as a team, I think we’ll be ready for it. Thank you so much for having me on this podcast.
Todd Schlosser: Absolutely. Thank you so much, sir.
Kirti Patel: All right. Have a good one.
Todd Schlosser: You, too.