Dr. Andy Coates is assistant professor of medicine and psychiatry at Albany Medical College. The internist has been working on the COVID-19 critical care team at Albany Medical Center’s intensive care unit. You might recognize Dr. Coates from his past WAMC commentaries in his role with Physicians for A National Health Program.
What has this time been like for you and your work?
I guess I'm losing track of the weeks, two or three, four weeks. There has been an eerie calm with the command for social distancing. The fact that the St. Patrick's Day week the medical students were abruptly sent home and away from the patients, that all kinds of elective surgeries were one by one canceled until they were entirely canceled. The census of the hospital went down, visitors are banned. And so the pace of the hospital slowed. At the same time that patients with COVID-19 related illness, especially COVID-19 pneumonia, began to fill up the wards. And that's been happening slowly here in Albany. But boy, has it been happening. The eerie calm. I have to say that in my entire life, I've never had a feeling like that where you're reading the medical science, you're reading about the virus, about what it's done to human beings in Wuhan, China or Milan, Italy, you're hearing because the world is a small world, hearing from friends, or friends of friends who are physicians and say in New Orleans or Elmhurst, or in fact directly Milan at one point. You're hearing what they're seeing in the patients. And you know it's coming, but it isn't here yet. So that eeriness is now settled because, oh boy, here it is.
What are you seeing in the patients?
You know, fortunately, many patients are admitted to the hospital with real symptoms and real, real problems that demand intensive monitoring, but that doesn't mean intensive care. And thankfully, I think a majority of those patients are able to go home. There is a subset of patients, however, who follow a kind of a pattern where they're needing some oxygen and they're needing more oxygen. And then, very, very abruptly, they're needing way too much oxygen and they're about to die. And they need to be put on a ventilator. And it's that tipping point that is extremely stressful for their nurses and for all of us leads to thinking about how do we best monitor these patients, knowing that that's what can happen. And then when it when it does happen, the worst case scenario is a diagnosis of an ARDS like picture. In other words, both lungs are completely full of way too much inflammation and without a ventilator, the patient will not live.
Do you know why some patients make that turn and some don't?
We don't. The fact is, we don't. We know from very good observational studies that have been done in a great hurry in other countries. That's age and some comorbidities diabetes, hypertension, I think leading to coronary artery disease, those comorbidities seem to carry out, you know, an unfavorable prognosis. But that's different from saying do we understand exactly why the virus attacks this or that person? I think the bigger picture is harder to get our brains around. The bigger picture is not so much why this would happen to say, Ian or Andy. The bigger picture is we don't have herd immunity as a species. So as you know, we're mammals living on planet Earth. This is a virus that infected many other species in China. Or perhaps here in the United States or in any country where there are factories in the fields, way too many, too many animals pushed together and the virus mutated through evolution. Because it was evolutionary pressure based upon the economic system that was placed upon the virus to mutate and is mutated very cleverly, probably from pigs to humans. But perhaps from another species to humans, perhaps from birds, probably went through about half a dozen or more species and mutated to a place where our immune systems as the species that it is now infecting, our immune system does not recognize it. And frankly, our immune system has the capacity to utterly freak out once infected, once the virus is inside ourselves, replicating, our bodies recognize it as a foreign enemy, but don't recognize it as a foreign enemy that the immune system has ever seen before. And so the immune system basically fires its entire arsenal all at once. And that inflammatory cascade leads to overwhelming organ damage. It can be the lungs. But we're also learning it can be the heart and it can be the kidneys, it can be the clotting system. The bigger picture of the lack of herd immunity, I think is hard for us to get. Because in our time, you know, we, we live in a culture that's not very science based. We live in a culture that's got a lot of magical thinking.
What could we have done? What are we doing wrong? Let's say that American society, the way it's structured now, is a given. You know, there's a political divide, and people travel a lot. Those two things were a fact when this disease started spreading in Asia. So what should we have done?
Well, I think the idea that the mutation of a virus to become deadly and become pandemic is not a new idea. The idea of an avian bird flu, the fear that Ebola could become an international disease, SARS one, which by the way, this is SARS two, right? SARS one was a Coronavirus, a novel Coronavirus, that was novel to the immune system and therefore, was deadly and was an epidemic that killed people in many countries.
We had the pandemic of influenza in 1918, the famous Spanish influenza that I believe started in Kansas, misnomer Spanish influenza. So I think the idea of a pandemic, in terms of the fact that it exists in the world or could exist, shouldn't have been ignored. It's shocking to think that it was shrugged off. And then it was basically appalling as we are learning the news that in early January, the alarm bells were appropriately sounded and if the appropriate measures had been taken in the United States, thousands upon thousands of lives, could have been saved. And I'm saying that based upon comparison to other nations.
If you look at Singapore and if you look at South Korea, you look at Hong Kong you look at Taiwan, certain countries that had SARS one and took it seriously. They're able to bend the curve from the beginning and prevent, prevent what what's happened in New York and Milan and New Orleans. There was a string of text messages that I saw from South Korea. That really made me think. They texted the community along the lines of this: If you were at you know, a middle school, you know, say one of our own communities middle schools, Farnsworth, you know, and you were worried about the student who everyone thought had coronavirus. We want you to know that that student has tested negative and you can rest easy; please wash your hands. Next text message: if you went to the grocery on this date, there's a chance you have been exposed, would you please come in voluntarily and get tested so that we can find out whether or not you're infected. Next, please wash your hands. Next text message. So public health using social media in real time to get the populace moving. And because of that, you would think that would raise enormous consciousness about how the how the virus is spread.
What social you know, social distance, just what does it mean? And I found myself a little bit astonished with, with friends, you know, that I'm catching up with in the community in the evening, for example, and they're asking me, Well, you know, how is it spread and I'm finding myself saying, basic public health lesson, you know, it's a tiny virus, it's less than half a micrometer. That means that tens of thousands – if you line them up in a line, you get 10s of thousands of virions . But before you got to an inch, and that there's that's how small they are. And they're mostly split spread by droplet. So that means that if, if as I'm talking to now every T and P and you know, there's probably a microscopic droplet coming out onto my telephone here and I think coronavirus, lives on plastic for several days. So you know, those droplets if you touch one of those droplets and it's still viable and then you touch your eye or your nose or your mouth, it gets into your mucosa then that little tiny piece of RNA can take over the machinery of yourself in a brilliant way it takes over the internal cellular machinery and it uses your own RNA to pump millions and millions of copies of itself back out, back out so that your droplets you got it from somebody else's droplet. Now this is what it means to have droplet precautions and wash your hands and and for God's sakes don't touch your face and probably why Atul Gawande is right that if you wear a mask at least you're not touching your face. So this is droplets, then is could it aerosolized? Well evidently it does aerosolized. The good news is that it drops to the ground pretty quickly. So the six foot distancing is safe if it drops to the ground within three feet. The bad news is that it could really aerosolized if a patient were very sick and coughing or needing a ventilator. And that's when my nurse colleagues are really at risk.
Yeah. So how are you keeping yourself safe in the hospital? Do you have enough PPE, a phrase that we've all learned this week?
So our or planning for PPE has been a touchy subject because the United States of America did not plan to have enough PPE. So I think I dare say there is nowhere, no healthcare facility in the country that is bragging that it has too much PPE. And it gets a little bit tricky because the leaders of the institutions have to plan for, for the surge. So the plan would be to go to 150% of capacity. We have, you know, ordinarily the way the hospital works is you have enough PPE for the week and you know the average use for the week. And then you keep the keep the supplies coming and to keep the overhead low, you get just in time deliveries and everything kind of rolls along. Incidentally, that's exactly the way the toilet paper works, right? The toilet paper in the supermarket. There's not a toilet paper warehouse behind the supermarket, there's a truck that comes just in time to replenish the shelf. And so if there's a small increase in demand for toilet paper, the shelf is empty. Similarly with the PPE in the hospital, so what the leaders of our hospital have done is come up with a very clever way to extend the life of what are meant to be single use masks. N95 masks with UV, sterilization and another form of sterilization to follow. But the reason they're doing that is because whatever stockpile they're keeping is meant to meet that potential hundred and 50% of capacity surge. The other problem with PPE, of course is that we use a lot more of it. I don't know the facts, right? I don't know, these, these inventory numbers, but we use a lot more when the patient is ill. And absolutely we use appropriate PPE to protect ourselves and to make sure that our nurse colleagues are protected. And so, I think, difficult question from the sense that you wouldn't want healthcare workers to feel that their leadership or the society care about them, bottom line is the whole country was not prepared from the point of view of PPE and still the federal policy is to make the states fight with each other.
Let me ask you a question that Governor Cuomo has rejected in his recent comments. He says it's kind of an impossible one to answer but from your perspective inside Albany Med and working on people every day, how does this all end?
So we don't know. I think the answer is we don't know. And I think I think that might be what Governor Cuomo told Professor Chartock today. That, you know, we don't know. I think there are some very, very alarming data from the Imperial College of London that suggests that if, if the social distancing is lifted, if the travel bans are lifted, that ICUs will fill up again and then the social distancing will need to be reimposed. Then the ICUs will empty out and social distancing will be released. And then the ICUs will fill up again. So you see a sawtooth curve of filling up the ICUs, social distancing, emptying the ICUs, relaxing social distancing, and it goes on for over a year. It's a very distressing graph to look at.
And this graph is distressing because of the understanding of the lack of herd immunity that I was talking about before, because we don't have what it takes in our immune systems to treat this like a usual coronavirus, a common cold. It's a novel coronavirus that can kill you so I don't know how it ends except with antibody testing to know that you are immune and then very, very good science that follows the virus to know that it has not evolved into yet another deadly virus to which you're not immune, which is, I think theoretically out there. Or, you know, because it could also mutate into something that's a lot less deadly, we could hope for that. And we could even hope that that's already happening. So I think, a vaccine but realistically with Dr. Fauci, a vaccine is, you know, we're talking what, Halloween 2021? Thanksgiving 2021? And then it has to be produced in mass quantities. So how does it end? It doesn't end quickly. It ends it ends over months, two years.
You started med school in the mid 90s. Is this unique in your years of experience, this situation?
It's unique in everyone's experience, this is you know, this is a world changing event. I think I saw the statistic of jobless claims 16 million in recent weeks. The economy can't go if people can't go to work. The economy can't go at all. The most astonishing thing to me about this pandemic and the social crisis that we're sliding into is the many ways the mask has come off the way our society works. African Americans disproportionately killed by this virus. And the reason is they've been dispossessed. You know, homeless shelters, inner cities. The incredible poverty. Jails. I understand that Rikers Island is per capita, the highest density coronavirus on the planet. Appalling racism that is official as well. You know, think about the Trump family and how they were. They had racist housing policies in their projects when back in the day, how Trump's father was supposed to be sympathetic with the Ku Klux Klan and even protested with the Ku Klux Klan, once upon a time. Trump's own unbelievable comments calling it a Chinese virus, which is an outrage. The mask is off, you know, what it means to be poor. Chris Churchill in our own Times Union today had a beautiful column about the observation that it's a dividing line if you have to use a laundromat. If you're a person that needs to use a laundromat, then you're much more susceptible to dying of the coronavirus because you're much more susceptible to getting it, and the poor neighborhoods of Queens which are being decimated. If, you know, you have to use the subway, you have to and if you don't go to work you don't eat. So I think, you know, the mask is off the society and the cruelty, the injustice, the inequities. We feel that pretty, pretty poignantly. So there's been nothing like that in my life for sure.
And I have to say, dealing with it personally, you know, we have patients from Queens here in Albany. It's so hard to call their family. It's unbelievable. The human saga of being stricken with this, put on a ventilator, flown by helicopter to Albany, because the hospital down there is overwhelmed. And then think about that. You know, I mean, it's just very, very revealing of the planet we live on. And also the American society that we currently have.
Well, Dr. Andy Coates, thank you so much for taking time right now when it is a difficult time to take a half hour. I appreciate it. And, you know, thanks for doing the work you're doing.