'Help Us:' Idaho Doctors Unpack 'Imminent' Crisis Standards Of Care Expansion
Tuesday, Idaho Department of Health and Welfare Director Dave Jeppesen said the COVID-19 picture has only gotten worse since north Idaho entered crisis standards of care last week — and the crisis designation is "imminent" for most of southern Idaho.
At hospitals in the state's largest health system, St. Luke's, unvaccinated people make up between 90% and 96% of all COVID-19 patients. More than four-fifths of patients in St. Luke's ICU beds have COVID-19.
Idaho Matters is joined by St. Luke's Health System's former CEO Dr. David Pate and Saint Alphonsus Health System's Dr. Steven Nemerson to answer your questions and concerns.
“People that have been following all this advice and doing all the right things but might have a heart attack, might fall in their home, have a broken hip...they may have problems getting access to care because we're not all pitching in to do our best to try to contain this spread of this disease.”Dr. David Pate, former CEO of St. Luke's Health System and current member of the Idaho Coronavirus Task Force
Read the full transcript here:
Gemma Gaudette: You are listening to Idaho Matters, I'm Gemma Gaudette. Yesterday, Idaho Department of Health and Welfare director Dave Jeppesen said the COVID-19 picture has only gotten worse since North Idaho entered crisis standards of care last week, and the crisis designation is imminent for most of southern Idaho. Hospitals in the state's largest health system--St. Luke's--unvaccinated people make up between 90-96% of all COVID patients and more than four fifths of patients in St. Luke's ICU beds have COVID 19. Jefferson said the continued increases mean the Treasure Valley and the Magic Valley are close to rationing care as well. And as we continue to cover the coronavirus pandemic, we know so many of you have questions, you have concerns, and here at Idaho Matters, we want to answer those questions with facts. And the best way to do that is to bring in medical experts like we've been doing for the last year and a half. Joining us today, Dr. David Pate, former CEO of St. Luke's Health System and a current member of the Idaho Coronavirus Task Force, as well as Dr. Steven Nemerson, the Chief Clinical Officer at St. Alphonsus Health System. And remember, if you have a question, get them to us email@example.com. Thank you both for joining us today.
Dr.David Pate: Hi, Gemma.
Dr. Steven Nemerson: Thank you, Gemma.
Gemma Gaudette: Dr Nemerson, you heard those numbers about St. Luke's. Can you give us an update on what St. Alphonsus is seeing with regards to COVID?
Dr. Steven Nemerson: Absolutely. They are mirror image of what St. Luke's and all the health systems across Idaho are now experiencing. 95% of our hospitalized patients with COVID are not fully vaccinated, and 99% of COVID deaths across the state are in those that are not fully vaccinated. Fortunately, at St. Alphonsus, we have yet to have a single death in a vaccinated patient.
Gemma Gaudette: Wow. Dr. Nemerson today S. St. Alphonsus 11 urgent care clinics will actually have to close an hour earlier than normal, and this will last indefinitely. Do you know why the hospital decided to make this move?
Dr. Steven Nemerson: Yeah, Gemma. Sadly, the demand on our health care services and our urgent care clinics has gotten to record volumes. And in order to be able to allow our staff to get home and complete their shifts before midnight, we have to close early. The lines are that long.
Gemma Gaudette: Dr. Pate, on Monday, the Emmett school district changed its policy so that their schools won't make students who are exposed to COVID-19 quarantine for 10 days. Instead, they said they want parents in the driver's seat to decide about quarantining. I frankly Dr. Pate just don't have words for that.
Dr.David Pate: Gemma, I'm just about as speechless. It's just I have always believed that leadership is a privilege... when you have that honor to serve people and that as part of that responsibility, you ought to seek to understand the subject matters about what you're going to be making decisions on. And I will tell you the lack of understanding and knowledge of public health and the coronavirus by school boards that are making these decisions is just absolutely astounding. It's fine if they don't understand. But for the love of God, please call in people that do. We have a lot of experts right here in Idaho that can advise them, that can explain what quarantine is, what the purpose of quarantine is, how it's used to control the spread of disease. But it's even more irresponsible Gemma, at a time when our hospital and health system leaders like Dr. Nemerson, like Dr. Souza, have been begging and pleading for schools, businesses, individuals to please support our hospitals and our health care professionals during this time of crisis. And we're not asking people to wear a mask for the rest of their lives. We're saying, can you help us out for a month? Can you wear masks? Can you avoid large gatherings where you're you're likely to be exposed? If you're willing to get vaccinated but have questions, will you get those questions answered and go ahead and get vaccinated? But until you are vaccinated--and even once you're vaccinated--help us right now by wearing a mask and minimizing your contacts to others. And let's just get the disease activity down and protect our...[cut out].
Gemma Gaudette: Did we just lose Dr. Pate? Hello?
Dr.David Pate: Can you hear me?
Gemma Gaudette: Oh, there we go.
Dr.David Pate: Sorry, sorry...Sorry about that.
Gemma Gaudette: That's OK! And Dr. Pate, I mean, I want to expand on that a little bit more because just what shocked me about this decision with, you know, hey, let parents decide if they're going to quarantine their children or not...I feel like that's allowing then other people to make a health decision about my child being exposed to someone.
Dr.David Pate: Well, absolutely right, Gemma. We have tremendously misunderstood what the role of society is in a public health threat. A public health threat is very different than a personal decision. A personal decision about whether I'm going to get a flu shot this year, a personal decision about whether I will get my colonoscopy and my screening mammogram or whatever. Those can be personal decisions because they don't have consequence to others. But when we're in the middle of a pandemic...the way that you contain a public health threat is...the community comes together. We follow public health advice because even if you get infected and maybe you don't get sick, the problem is you can infect somebody else who may very well get sick and may end up being in Dr. Nemerson's hospital and further overwhelming those resources, meaning that other people that have been following all this advice and doing all the right things but might have a heart attack, might fall in their home, have a broken hip...they may have problems getting access to care because we're not all pitching in to do our best to try to contain this spread of this disease.
Gemma Gaudette: Mm hmm. You know, Dr. Nemerson, you have said it's time for responsible people to protect themselves and to do things like give their business to responsible businesses that will keep them safe. I'd really like for you and Dr. Pate to expand on this idea in particular.
Dr. Steven Nemerson: Gemma, I'm glad you brought up that topic because frankly, now that we're at the most extreme of contingency standards of care and considering moving into crisis standards, I personally am done with begging those that won't change their mind to do so. Sadly, we know that there's a large group of people who have been responsible, gotten vaccinated, care about protecting one another. And then there's others who are making different decisions and whose minds are hardened. So my focus now is twofold. First of all, to help those who have been responsible and frankly, all of us, including those that haven't...to think about how they can protect themselves and those that they love. And we'll talk about that in a minute. It's the obvious things that we've talked about and it's also about focusing on places and people to to remain in contact with that are safe. And then the other thing that I'm focused on ,and this is my primary focus as we speak, is keeping our hospitals functioning and providing the best care that's possible under these extreme circumstances. And the situation is only going to get worse for us, sadly, at least for the foreseeable future. And so we need to--in innovative ways--help those that have decided to serve their fellow human beings in health care to expand the number of people that they can take care of and save the most lives. So that's what's keeping me busy right now and my word to those who have been responsible, who are vaccinated, who are practicing face covering, distancing, et cetera, is to begin to think about how to expand that further so that you don't require health care if it's avoidable by staying away from others that might not have that same belief and also selecting the businesses that you frequent that provide an environment that is safe for you.
Gemma Gaudette: Dr. Nemerson, can you give some, some maybe real world advice on...let's just take...I'll give my family for an example. My husband and myself were vaccinated. Our 13 year old is vaccinated, our nine year old cannot be vaccinated yet. You know, my kids, their school finally put a mask mandate back in place so my children are wearing masks in school. We still mask out in public indoors, but I am still concerned because I have a nine year old that can't be vaccinated. So what do you do in those situations? I guess how 'normal' of a life can we have?
Dr. Steven Nemerson: So Gemma, I think about this in a few different components. To start with, let's talk about social planning. And there are many people who are like minded to you and your family, so you need to develop your social pods. Find out among the people that you socialize with--and who they socialized with--who is willing to maintain face covering in settings outside the home and ensure that they vaccinate the maximum number of people in their families? Those are the people you want to socialize with and then do it in safer settings...outdoors with distance. When we talk about frequenting businesses that practice and enforce COVID safety, we're talking about places, if you go to out to eat that are going to have an outdoor patio--or if indoor-- in a fairly well-ventilated space where the tables are still distanced. A nightclub--bad idea, right? Going to a concert--bad idea. Going to a football game with thousands of people en masse drinking alcohol--bad idea. So that's social planning. Then there's practical issues about in the home. Number one, you need to be prepared to receive your medical care, if possible, in the home because of the delays that I talked about, that we're starting to experience and they're only going to get worse. And also knowing that the very best place to receive care if it's safe and effective is in the home. And so you want a medical kit, you want a thermometer, a pulse oximeter, a blood pressure cuff and a scale. You want Tylenol and anti-congestant medications. You want to have then tested electronic communication means with your provider.At St. Alphonsus we have a website called MyEVisit.org. Get that account set up now and be ready if you need to contact a provider to be able to do it virtually and let them know what's going on and have those tools that I mentioned.
Dr. Steven Nemerson: And then the last thing I want to talk about real quick is be prepared if somebody gets sick to get them tested for COVID. Right now, because our systems are becoming overwhelmed, we don't have the capacity to test asymptomatic people the way that we used to. So if you're symptom free and you've had a COVID exposure, we talk about quarantine and we talk about vigilance, monitoring temperature and symptoms. But when and if somebody becomes symptomatic, get to the SaintAlphonsus.org website the StLukes.org website or Coronavirus.Idaho.gov. Get over there, find out where you can get yourself tested and get tested and know whether you're COVID positive or not. And here's why: one, you'll know how to treat yourself and how to quarantine so you don't spread the COVID to somebody else and two, if you've got COVID and you have a high risk condition--and now high risk conditions include pregnancy and include things like asthma and obesity--then you want to get the monoclonal antibody therapy so that you can attack the virus that's starting to spread through your body and constrain its spread so it doesn't throw you in the hospital or worse in an intensive care unit. And therein lies something very important for my unvaccinated friends--we want to take care of you too, and so many of the things that I've talked about are exactly the same for those families that are making a different decision.
"The situation is only going to get worse for us, sadly, at least for the foreseeable future."Dr. Steven Nemerson, Chief Clinical Officer at St. Alphonsus Health System
Gemma Gaudette: Before we get to some questions, I wanted to talk about some information coming out in regards to the Pfizer vaccine, getting maybe emergency approval for five to 11 year olds. Dr. Pate, I believe some information came out yesterday that they may be going to the FDA as soon as early October...
Dr.David Pate: Yes, we've got fingers crossed, and we don't know for sure that that is the case, but we have certainly been hearing information that data, upon which the FDA can make its decision, may be ready to go to the FDA at the end of this month or very beginning of next. And of course, that leads all of us with--children and grandchildren--excited to think that perhaps we might have emergency use authorization for ages five and above by sometime next month. And that's very, very good news. I hope it's true. I don't think that's a certainty, but it is certainly encouraging news.
Gemma Gaudette: And Dr. Pate, you know, before the break, you know, when Dr. Nemerson was was talking, you know about this idea of if you've made the responsible choice, you've gotten vaccinated...what are your your thoughts on that? Because I do think we spend a lot of time talking and trying to get the unvaccinated vaccinated and that's going to help all of us, yet I think it's fair to say a lot of vaccinated people feel like they're in jail a little bit.
Dr.David Pate: Well, I totally understand that. In fact, I feel that way. I'm very discouraged that I've done everything that the public health authorities have recommended, and yet I still have to be concerned for the welfare of myself being older and for the welfare of my children and especially my grandchildren, who like your children, aren't able to be vaccinated. Yet the whole concept of a community response to a public health threat that's infectious is for everyone who can to get vaccinated. So we protect those who cannot. And it's been very disappointing that we have not been rising to this occasion. I think there are several things that give me encouragement. Gemma, first of all, is Idaho's medical leaders like Dr. Nemerson, like Dr. Souza, Dr. McGeorge--many others--that they are giving us fantastic advice. They are giving it freely and willingly. We just have to listen to them. I can tell you, I trust every word out of Dr. Nemerson's mouth. The other thing that is very encouraging is I mentioned before that in these kinds of times...this is like the United States is being invaded. You know, I can't imagine that if another country was invading us, that we would be having all these discussions about our personal rights and we don't feel like fighting it. Well, this is an invader, and we have missed so many opportunities to come together to thwart this enemy. But I think another thing that gives me great help is I have watched our health care systems and hospitals in this state come together.
Dr.David Pate: I tell you, the cooperation between St. Luke's and St. Al's is inspiring. I used to lead one of those organizations and I'm fiercely competitive. But this is not a time for competition, and I'm so proud of how our health care leaders have behaved. And then the last thing I would say Gemma is we tend to think that the number of people that are undermining our efforts is some majority of people. And I think part of that is because they are the most outspoken and many that are supportive of the things that we talk about on this show are afraid to raise their voices because they know they'll be attacked. But I think the West Ada situation showed us the best. Those people in yellow shirts that didn't want to protect children, didn't want to protect our communities, did not want to protect our hospitals, said that they were an overwhelming majority. It turns out they were 31%. So this gets back to Dr. Nemerson's point--I echo everything, he said--but in addition, I have said for some time, we should give our business to businesses that are taking this seriously. And number two, is because those of us that want to do the right thing are actually in the majority, we need to show up at the polls and all of these people that are in elected positions that are promoting conspiracy theories, lies and undermining our hospitals and our health care professionals--we need to come together and vote these people out of office.
Gemma Gaudette: Dr. Nemerson, I want to get to some listener questions because Paula wrote in and she says she's very angry. She says, 'my surgery was canceled, I am vaccinated, I am ready for my surgery, but I cannot have it because some people can't do the right thing.' So she has questions, Dr. Nemerson, in regards to 'how possible is it that unvaccinated COVID patients could be set up in a tent facility somewhere rather than clogging the hospital?' She also wants to know why can't we have like an army hospital set up for the unvaccinated...Dr. Nemerson, I am curious to know your opinion on this. I mean, because we get these questions quite often. And frankly, I mean...you're a medical provider. You don't get to pick and choose who you care for.
Dr. Steven Nemerson: Yeah. Paula, those are really good questions, and I sense the frustration and despondency in that and the way that we look at it is as a health care system, and as health care providers is we've taken an oath first to do no harm and second to treat all that come to us for care, for relief, for respite. And so we don't do that on the basis of discrimination, even by vaccination status. We do it strictly on the basis of objective criteria when we're in these extreme circumstances. Who is most likely to survive and how can we carry them through their illness most safely and effectively? It's that pure and simple, and we can talk a little bit about crisis standards of care and what this may look like...but even now, while we're doing things in unusual contingency circumstances, we're making these decisions on a regular basis. Who do we see first? And clearly, you are not one of the first people that we need to see because your condition can wait to be treated. Somebody, whether vaccinated or not, that has a more pressing condition is somebody that we'll see first. In do time, this surge, too will pass and we will be able to get back to more normalcy.
Gemma Gaudette: And Dr. Nemerson, I think, you know, you made such a point that it's hard to remain positive when you've done the right thing. Sometimes when now, you know, someone like Paula, she's impacted. But it does go back to, I think, remembering that health care professionals are truly doing the best you can in the circumstance right now.
Dr. Steven Nemerson: Yeah, thanks for saying that, Gemma. And again, you know, it may not seem fair, but we're not in the business of deciding what is fair. We're in the business of just deciding how we can deliver care to the most people we possibly can and do that in a loving, compassionate and thoughtful way. And we're doing that every day. And I just want to also call out that I've been asked many times what can people do to help to support the health care systems and among other things--besides keeping yourself safe and getting vaccinated and behaving COVID safe--is call out to those who are serving in my health system and other health systems and thank them for the work that they're doing because now they're putting in more time and effort than they ever have before and more personal costs. And we need to recognize that and thank them for it because they need to be here for us when we get sick.
Gemma Gaudette: Dr. Pate, Kate sent us this today. She says, 'please help because it feels there is no help in Idaho. I'm wondering why we don't have a mask mandate in Boise--we did last year--but now we are so close to crisis of care and we don't. I have written and I have called, and I wonder if Mayors in the Treasure Valley will even listen to doctors. I am a fully vaccinated, 72 year old grandmother with three grandchildren under seven. I am pretty much staying home again so I can see them. Their mom is a physician at the hospital, so I want to be able to help. I am sitting here crying because it is so depressing.'
Dr.David Pate: Well, that breaks my heart. Thank you for doing the right thing. And thank you to your daughter for being a physician and helping on the front lines to take care of our community. You know, Gemma, I've spent a lot of my adult life studying leadership. I have to say I've been absolutely shocked by the number of people in leadership positions who seem to be more caring about what people think of them, or maybe perhaps their chances of re-election, and less concerned about those that they are privileged to serve. I am a believer in servant leadership. We don't see very much of that. On the other hand, those leaders that are demonstrating real leadership do give me a lot of encouragement. I understand her frustration. I share the frustration. We've got lots of people in leadership positions that--of course, everybody wants to be a leader until you have to make difficult decisions--and they're not willing to make the difficult decisions. And it's too bad and it's going to cost people their lives.
Gemma Gaudette: Dr. Nemerson, I want to talk a little bit about Crisis Standards of Care. They've already been acted in North Idaho. It seems that it is imminent in the Treasure Valley and in the Magic Valley. When we think of these crisis standards of care, Dr. Nemerson, what goes through your mind about this? Because I must imagine this is something that no one in the health care profession would ever think that we'd see in the United States. Also explain what they are because they impact all of us, not just someone who's in the ICU with COVID.
Dr. Steven Nemerson: Yeah, Gemma. I never imagined in my lifetime--and I've served in health care for many, many years--that I would ever see this situation emerge...short of being in a war or some sort of natural catastrophe. And yet here we are. What crisis standards of care are, is they're activated when the ability to provide a reasonable community standard of care is exhausted and they are when we enter into contingencies that are so far from normal that we can't deliver the quality of care that patients expect from us. They were declared in North Idaho when hospital patients were being cared for in a classroom by a stretched health care team. And,right now, throughout the Treasure Valley and really most of the state of Idaho, we're already in that circumstance where we're taking care of patients in clinical settings we didn't previously use and with nurse to patient ratios and health care, to health care team, to patient ratios that are beyond the pale. The next step for crisis standards of care than is to recognize that. I do want to emphasize that it doesn't mean that the moment we go into Crisis Standards of Care, that life support is taken from one patient to give to another. That is when we get to the extreme of crisis standards of care.
Dr. Steven Nemerson: So what we're looking at right now is taking care of patients in classrooms, exceeding what we consider to be normal or safe care ratios among care team members, limiting things like bed linen changes and for the sake of just being able to get medicine to patients, decreasing the frequency of the care that we deliver. So those are the steps that will be taken that have not yet needed to be taken at the moment. Sadly too, though, I want to just put out there that the models that we're looking at for the surge predict that we are very, very likely to get into scenarios where we may actually have to fully ration care and may have to make some very difficult choices between who gets what. And I certainly hope we don't get into that situation and we are doing everything we possibly can to avoid that. The last thing I want to say is that--Dr. Pate mentioned this earlier--the coordination that we are doing across the state is extraordinary, and it's in large part to avoid the situation that we've gotten into and to try and avoid at all possible costs, ever having to make a life determining decision.
Gemma Gaudette: Dr. Pate, Stephen wrote in, He says, 'I'm over 70. I have had a low white blood cell count between three and four for many years...is this considered immunocompromised and then would I be eligible for the booster shot?'
Dr.David Pate: So just based on what you have told me in this information, no. There are a number of people that have white blood cell counts in the range you're talking about that it's perfectly benign. On the other hand, there certainly are conditions that can be associated with a low white blood count like yours that are more serious--but you haven't mentioned any of those conditions. So assuming that you have not been diagnosed with another condition and you simply have this level of low white count, which is not extreme, this on its own would not constitute making you immune compromised. But be sure to check with your doctor in case there is some other condition you haven't mentioned to me that would make it so.
Gemma Gaudette: And before we wrap up--we have about a minute left--Dr. Pate, what are your concerns as we potentially enter into crisis standards of care? It sounds like almost in the entire state.
Dr.David Pate: Yes. Gemma thank you for this opportunity. I have to tell you, there are several times I lately I've been moved to tears. I'm not one to cry very much, but I know what this means. I know how this will impact...particularly families. And you just really cannot understand this unless you've been through this or something like it. Of course, none of us have been through something exactly like this. I just want to call on Idahoans to do a couple of things. First of all, like Dr. Nemerson said, our health care workers are physically and emotionally exhausted. Please show them your respect. Please express your appreciation. If you go to the emergency room or the hospital because one of your family members does get ill, don't take it out on the health care leaders. They're trying to help you, these health care professionals. Number two: Help us. I'm not talking about for a year. I'm not talking about for a decade. I'm talking about the next month. Would you please for the next month be careful. Wear a mask. Don't get into large gatherings that aren't going to be masked. Do what you can to prevent the transmission of this disease. If your child is sick or you even suspect they might be sick, keep them home. Let's not spread this in schools. Leaders step up. School boards--it's time to cut out the nonsense. Stop making decisions against public health advice. For the time being--please make responsible decisions. And then again, Gemma, thank you and NPR for what you're doing. I hope that many people will contribute to the fundraising. And to Dr. Nemerson and to all the health care leaders and all the health care professionals out there--thank you, thank you, thank you for what you're doing.
Gemma Gaudette: And we thank you, Dr. Pate and Dr. Nemerson for what you are doing. Dr. Nemerson for being on the front lines. Such appreciation to both of you. Thank you for joining us today.
Dr.David Pate: Thank you, Gemma.
Dr. Steven Nemerson: Thanks, Gemma.