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A Day Inside the ER During Omicron (with Megan Ranney)

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Description

Andy and ER doctor Megan Ranney take you inside her Rhode Island emergency department to hear just how thinly stretched everyone and everything is during the Omicron wave. Nearly two years into this pandemic, we are all exhausted. But as you can hear in Megan’s voice, the people who staff emergency departments have been pushed to their breaking point. Go with her on a recent shift as she treats patients, talks with her colleagues, and reflects on the toll that practicing emergency medicine during COVID has taken on all of them.

Keep up with Andy on Twitter @ASlavitt and Instagram @andyslavitt.

Follow Megan @meganranney on Twitter.

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Transcript

SPEAKERS

Andy Slavitt, Speaker 5, Megan Ranney, Speaker 4, Speaker 3

Megan Ranney  00:01

I’m walking into my shift and signing in. There are fewer patients in the waiting room than we’ve had in the last couple of weeks. It’s only a few dozen. And the weights only about four hours to get seen you tell you; it feels like this could be a good day.

Andy Slavitt 

So welcome IN THE BUBBLE, this is Andy Slavitt. I’m so proud of this episode, we’re gonna take you inside a hospital for a shift to see what Omicron is like inside the hospital. So one place, we don’t normally get to see what goes on. And a wonderful, wonderful emergency room physician named Megan Ranney has basically taking us inside a full day shift. And we’ll learn a lot about what’s going on with Omicron. But just as importantly, we’re also learning what it’s like for physicians and nurses, and a really upfront intimate way. As they say, I’m really proud of this episode I’m really proud of Megan for what she does, and her generosity is so clear and putting it together for us. So we can see this. It’s absolutely riveting at points. It’s just gripping. I also want to do something I should probably do more often, which is thank our team here at IN THE BUBBLE. Thank Kryssy Pease, in particular, the executive producer, who these kinds of episodes take more work, they take creativity, they take that they play the Kryssy strength because she’s all those things, but also Ivan and everyone else on the team for the work putting this together. I also want to welcome back Kryssy’s taste buds, you may know that she has had a little bout with COVID. And those taste buds disappeared. But they’re back.

Andy Slavitt  02:02

What else is going on? Well, we got a little junior variant to Omicron going around Europe, I’ve been calling it the stealth Omicron I think that’s a dumb name. I’m not gonna call it that. I also don’t think it’s yet something to be worried about. So that’s why I’m not gonna spend a lot of time talking about it, I don’t think it’s gonna affect where the pandemic heads from here. I hope you’re living in a community where things are gradually heading in the right direction, it’s going to be a while before they’re back down to real normal type numbers. And then we’re going to have some guests on shortly we’ll talk about what kind of protection did Omicron provide us. And some other really, really great Omicron episodes coming up. I don’t want to take any more time. I want you to put yourself in the headspace of imagining what it’s like to be in the world that Megan’s gonna take us in. Inside Hospital in Rhode Island, one of the peak states during the peak wave. And just really get an idea of what day in and day out for the last several years has been like and what it’s like dealing with this wave now I can tell you one more thing before I start, she talks about the waiting times in the emergency room. They’re four to six hours. I have talked to hospital executives who told me that in his hospital, the waiting time for routine things is now about 12 hours. The waiting time for psychiatric care is now over a week. This is unheard of. And if you’ve ever seen someone in psychological crisis, imagine having to wait a week before you get care in an emergency situation. This is what we’re dealing with. This is really, really something I think most of us aren’t seeing all the time. And so let’s dig into it with Megan Ranney. Here she is.

Andy Slavitt  04:11

I want to welcome you back to IN THE BUBBLE I know you’re in the middle of shifts right now. And you know, you’ve been kind enough. I now on two occasions to share with us what’s going on in the emergency department at your hospital. Just before we kick it, I’d love for you to take us through the day that you spent with us. But can you just give us an overall sense of kind of where we are, you know, Rhode Island feels like it’s still the epicenter of COVID right now. And you’ve been through this in a couple of cycles.

Megan Ranney 

Yeah, it is fascinating to me how frequently Rhode Island hits those top numbers for cases, hospitalizations, per capita. We are certainly right now in the thick of Omicron, we were in the thick of Delta right before micron hit. And although there are some preliminary indications that we may have hit the top of that peak of a micron, our hospitalizations and of course, our deaths are still rising. Worse yet right now is that our hospitals are desperately understaffed. And so our number of hospitalizations for COVID are about what they were last year at this time. We’ve got tons of other really sick people for a lot of other reasons who are in the hospital. And we have no field hospitals open. We are short on folks across the healthcare system. And so the healthcare system is just in a really bad spot.

Andy Slavitt 

Can you give us a sense of like, with the same number of patients, how many fewer clinicians there are to take care of them?

Megan Ranney 

It’s a great question. It’s difficult to get hard numbers from the various healthcare systems on how short they are. But I can tell you that in my emergency departments, were regularly shutting down groups of beds, if not entire units of the various emergency departments, not just in my own hospital system, but really across the state because of short staffing of nurses or having the same issues in psychiatric hospitals where groups of beds are having to be closed because of lack of staff, same issue in nursing homes. And we’re short on emergency medical technicians, EMTs, pre hospital providers, to the point that transportation, there’s obviously emergency transportation, which takes priority, but transportation from one hospital to another, or from a hospital back to a nursing home, from a hospital back to a house for people who are wheelchair bound or bed bound is taking instead of an hour or two. It’s taking 12 plus hours sometimes.

Andy Slavitt  06:54

Wow. I just think about that a real human toll.

Megan Ranney 

Yeah. I’m walking into my shift and signing in. There are fewer patients in the waiting room than we’ve had in the last couple of weeks. It’s only a few dozen. And the waits only about four hours to get seen. So it feels like this could be a good day.

Andy Slavitt 

Good day, that must be very relative.

Megan Ranney 

In emergency medicine, a good day is always relative. We’re used to dealing with overcrowding and boarding. But for the last few months, both here in Rhode Island and across the country, it’s been particularly tough to have a good day. It’s for two reasons. The first is that the patients keep coming in faster than we can see them. Because we don’t have enough beds, don’t have enough staff don’t have enough places to move sick patients to upstairs. The other reason that it’s been awfully tough to have a good day recently is because the COVID cases keep increasing. And at this point in the pandemic, there’s no need for that. There’s no need for us to have people coming into the hospital sick enough to need to be hospitalized or in the intensive care unit. From COVID.

Andy Slavitt  08:10

What when you look at the patients now, does anything look different than earlier in the pandemic? Are they primarily or entirely unvaccinated? Are they’re a different age? Are they are their illness present differently?

Megan Ranney

So the folks that I’m seeing in the emergency department, by and large have the same pattern of illness, as we’ve been seeing throughout the pandemic. So there are folks who are having trouble breathing have low oxygen levels, kidney problems, blood clots, things like that, same thing I’ve been seeing since March of 2020. What’s different now is that the people that are sick enough to need emergency department evaluation really fall into one of two groups. Either they are for the most part young and unvaccinated although there’s still a few folks that are older and didn’t get vaccines, but many, I would say the majority of the unvaccinated people I’m taking care of are younger.

Andy Slavitt 

How do you define younger, because you’re younger than me.

Megan Ranney 

I would say 30s to 50s is younger.

Andy Slavitt 

By the way, thank you for being in my 50s I just wanted to thank you for noting us as being young.

Megan Ranney 

My definition of younger keeps getting older every year.

Andy Slavitt 

So 30s to 50s and unvaccinated would be the first group.

Megan Ranney 

That would be the first group and then the other group of folks that are in their late 80s to 90s and didn’t get a booster. Those tend to not be as sick. They’re just old and frail.

Andy Slavitt 

So the ones that have not been vaccinated are presenting with similar illness than folks before the same sort of pneumonia, low respiratory difficulty breathing issues, because they haven’t been vaccinated.

Megan Ranney 

That’s correct. That is exactly right. And we see that not just in my Experience anecdotally, but certainly we see that in the data. New York City has been particularly strong about giving us data around hospitalization rates among the vaccinated versus unvaccinated during the Omicron surge. And we see over and over again, that those who are unvaccinated are still getting hospitalized for the same reasons that they did throughout the pandemic.

Andy Slavitt  10:20

Interesting. So this idea that Omicron doesn’t like attacking your lungs. How do you describe that? Would you say that it’s true, but eventually it does if you haven’t been vaccinated and don’t have the immune system honed?

Megan Ranney 

So this is this funny paradox from Omicron. Right on a population basis, it’s milder. So if you get infected with COVID, right now, you are less likely to end up with pneumonia, whether you’re vaccinated or not, then you were with prior variance. However, because Omicron is infecting so many people, we are still ending up with similar number of folks in the hospital with COVID related complications. Again, pneumonia being one of the most common as we were in earlier waves. So like, I’ll frequently say it, these are not the exact numbers for Omicron. But if you have a virus that is 10 times as transmissible, and 1/10, as serious, you’re gonna end up with the same number of folks with serious illness, and that’s what we’re seeing for the unvaccinated.

Andy Slavitt 

To your ear in the emergency room, really just get kind of get a sense you are there, triaging people and finding the right treatments for them. We’ve got different types of treatments that we’ve had before.

Megan Ranney  12:24

So we’re trying to order packs out of it for the first time. Sounds like a good plan.

Andy Slavitt 

Okay, so now that’s the new oral antiviral from Pfizer that I believe in January, there’s only some 200,000 being produced across the country meant to be targeted, at least up front for people who are particularly high risk and in need of it. Is that becoming a part of the arsenal? Have you been able to prescribe Paxlovid yet?

Megan Ranney

So this was the first patient that I had prescribed Paxlovid for, and there’s a series of criteria that a patient has to meet, in order for me to prescribe it, I have to be taking care of them within those first few days of illness, they have to be particularly high risk for some reason. And then I also have to make sure that they’re not on any medications that would interact with Paxlovid, and potentially be dangerous. This was the first patient I’d taken care of who met all of those criteria. But the thing that we were struggling with was normally I prescribed prescriptions, I send prescriptions electronically to a patient’s preferred pharmacy, I had to figure out whether that patient’s preferred pharmacy actually had Paxlovid it or not turned out he didn’t. So then we were trying to figure out where else we could send it. And of course, this was, when I recorded it, it was a Friday evening. A little more difficult to get real time information than it would be during say, for example, a daytime shift. So we’re trying to figure that out in real time,

Andy Slavitt 

Would you all be able to get Paxlovid prescribed?

Megan Ranney 

So we were able to prescribe it. I actually don’t know whether or not the patient was able to fill it. One of the things about emergency medicine is that I often don’t get feedback on the other side.

Andy Slavitt  14:02

It’s a world of open loops. You don’t you don’t get to close them. Are you excited about Paxlovid as a new therapy and how do you feel about the overall choices you have as clinician now? Are they being they growing enough to say that they’re really going to change the game?

Megan Ranney 

I’m super excited about Paxlovid. I’m going to be even more excited about it when we have an adequate number of doses. And right now, it is a nice add on for those particularly high-risk patients. I’m looking forward to it being more available. And where it’s really going to become a game changer is when testing is also available. One of our biggest barriers right now, of course is that testing is so backlogged across my state that getting a diagnosis for someone who doesn’t come to the emergency department, getting a diagnosis within that time period where Paxlovid is most likely to work is really difficult.

Andy Slavitt 

Interesting, okay. So you got Paxlovid, you’ve got, you know, a shortage of monoclonal I assume as well, since we’ve had to deal with those. So as you’re seeing patients throughout the day, can you give us a sense of how many of them are you sending to inpatient? And how many are you sending home? How many of you feel like you have a good answer for versus people who just feel like you don’t really have a good solution for?

Megan Ranney

It’s a great question. So I’m actually you asked me earlier, what makes a good day, in normal times during non-COVID surges, I admit somewhere around 20% to 30% of the patients that I see on a given ER shift. And I admit them for a variety of reasons, right? It’s trauma, sepsis, some sort of an acute surgical need, sometimes for psychiatric or behavioral health problems. But most patients who I see I can treat and send out right now, by the time patients wait, and make it back to me, they’re genuinely so sick, that I’m admitting closer to 60% plus, of the patients that I’m taking care of, again, that is not all COVID. There’s a large percentage of those that are COVID, and particularly right at this moment, but it’s also other things like appendicitis or broken hips. So it’s a tough question to answer, Andy,=.

Andy Slavitt  16:18

People waiting for four hours to see you if they have appendicitis? Oh, my goodness.

Megan Ranney 

I mean, people are waiting for. And not just I want to be clear, this is not just the healthcare system where I work, this is true. Across my state, people are waiting four to six hours for appendicitis for acute […] or gallbladder inflammation. For folks with chest pain, we’re getting an EKG quickly to make sure they’re not having a major heart attack. But then they might sit. Even folks with COVID are sitting for hours if they’re not so severely ill that they need immediate treatment.

Andy Slavitt 

If someone came in with a gunshot wound, they were their life was in danger. Would you have the ability to see them quickly?

Megan Ranney 

You read my mind? That was exactly what I was just gonna say that’s. So if someone comes in with something that is going to be life threatening within minutes, yes, we see them. We make space however we can. We’ll take other patients out of rooms. But it’s those folks that are one level down, the people who are sick, but not so sick, that it’s immediately life threatening, those are the folks who have to wait.

Andy Slavitt 

An awful pain. With some of these things I can I can imagine. And I’m glad you said this, you were kind enough to share your day. But the labor shortage, the shortage of nurses, particular doctors and other personnel, as you mentioned, is a national problem right now. And it’s one that we’ll probably we’re gonna spend more time and I imagine as we go through your day, it’ll be even a bigger issue. So now, I think a couple hours in your day. Now I imagine you’re starting to gown up.

Megan Ranney 

Right, I’m now a couple hours into my shift and have seen five COVID positive patients, there’s another half dozen in the waiting room. And a couple one especially not going to be positive on their testing, we’re gowning up, going one patient’s room. In some ways, it feels the same as a year ago, but this time, at least vaccinated. So that God forbid, even if I were to get sick, it’d be okay. The patients who are here tonight […]

Andy Slavitt  18:37

So Megan, let’s talk about the spread of COVID within a hospital, both from patient to patient and to the clinicians. Obviously, a lot of nurses are out with COVID. You were hearing about this phenomenon that people are just talking about people coming in for COVID are people with COVID. And a lot of people who are testing positive for COVID who in the hospital who didn’t necessarily know they had it and not just related to your hospital per se, but how much do you think there is a problem of infectiousness within the hospital? And how much do you worry about it?

Megan Ranney 

So I’ll say it my health care system, I don’t worry much about infection control. I mean, I obviously worry about infection control, but I don’t worry about patients getting infected during a hospital stay. We do test all patients on admission, we all are wearing in the emergency department N90’s or equivalents during patient care. So we’re not going to be infecting patients. And we put great air filters into every patient room to really scrub that air in real time so that patients aren’t infecting each other. We are finding that staff are getting sick. It’s certainly possible that that could be happening from sharing a meal in a break room for example, but we’ve really discouraged that we’ve actually stopped all in person meetings, discourage staff from eating together, which has a social and emotional impact but helps keep them healthy during their shift. The issue is more just that it’s out there in the community. And so it’s bound to come in to the staff who work in a hospital just as we’re seeing with teachers or folks that work in a school, they’re not necessarily getting sick while they’re working at the school, they’re getting sick just because everybody’s got it right now. And it’s so transmissible and people are catching it from their regular day to day activities.

Andy Slavitt  20:23

Got it. Is there much what you would consider to be incidental COVID. I mean, people who test positive, but didn’t know they had it, they’re primarily for something that isn’t very related.

Megan Ranney  

So that’s been happening throughout the pandemic, that someone comes in with an ankle sprain or a car crash, and they just happen to test positive, I think it’s a really important distinction to make from epidemiologic perspective, from, you know, if I take off my ER doc hat and put on my public health hat, I care about those stats, it doesn’t actually matter all that much when I’m working in the hospital, the reality is, is that we’re filling up with patients period, and that patients have COVID, which then makes us put those extra infection control procedures in place when we take care of them. The other thing about that for COVID versus with COVID, is to remember that there are a lot of problems that are caused by COVID. So I could be taking care of someone with a heart attack, with blood clots to their lungs, with acute, diabetic ketoacidosis. With a stroke, all of those are caused or can be caused by COVID. They can of course, be caused by other things too. But to say that that person is just with COVID is false, the COVID, acute COVID infection can cause those complications that lead to hospitalization.

Andy Slavitt 

Sure, but there is one thing that does make me curious, particularly with Omicron, which is whether or not there are people, a high number of asymptomatic people who were catching. In other words, it’s spreading so far and wide. This is one of our ways of trying to understand a sampling society wide. Whether or not this is spreading to so many people who would never have known it if they weren’t getting tested. So I understand from a hospital standpoint, and what you have to do, it doesn’t much matter. But it’s just an interesting fact, because it helps us understand how much immunity is getting spread unknowingly behind the scenes.

Megan Ranney  22:22

Yeah, and that’s a terrific question. I will say the folks that I have been taking care of in the emergency department are not folks for the most part that are asymptomatic But they certainly are out there. And I’ve been so you know, people that are getting admitted. We’re not doing elective surgeries at this point at my hospital. But if we were you could imagine that a high percentage of people could test positive there. We’re seeing it in some psych patients. So we are seeing a higher percentage of asymptomatic positives among our psychiatric patients that we had it to me there, it’s really more run the test positivity rates and just the overall volume of testing at this point. So I’m talking here with one of our head nurses, how many nurses shorter are we today?

Speaker 3 

Right now I am 10 nurses short. And I have to close down multiple assignments. And I’ve been begging people to stay all day long, we offering double time, double incentive, but the nursing stuff is very burnt out and they don’t want to pick up anymore. So what I’m working with right now.

Megan Ranney 

And we’re having the same problem on the floor, too?

Speaker 3 

Yep, same problems on the floors are there a lot of the times we’re holding down in the emergency department, do inpatients needing to be kept off because of nursing ratios. They’re capped at there. So they you know, close down beds upstairs and it trickles down to the emergency department.

Megan Ranney  24:16

And you and I have had discussions on the fire shifts about what it’s like to be out in front in triage.

Speaker 3 

You kind of feel like you’re in front of the firing squad and you know, it feels like the entire hospital is kind of waiting, like resting on your shoulders because we don’t get to close our doors. So we don’t get to say you know, people have to stop can’t, you can’t come in anymore. So you know, we the ED kind of gets the brunt of it as far as the amount of people that that we’re seeing and we’re trying to push through.

Megan Ranney 

So I hope patients know how lucky they are when you triage them.

Andy Slavitt

A couple things came through for me that part of your day that again, one of which was how, you know, whatever goes wrong, whether it’s public health or science, or people not masking or whatever it is that we wonder where that shows up. Where is the place that as she so heavily put it, you can’t close your doors. It’s the emergency room, that the emergency room feels like it’s the place where everything gets caught. And of course, it falls directly on the nurses and the doctors who that image of feeling like you’re on the firing line. I mean, I don’t know how many of us have jobs where we can actually relate to that.

Megan Ranney

I hope very few of you have jobs where you can relate to that. I mean, I’ll say it’s the privilege of being in emergency medicine, it’s one of the reasons that I chose it as a specialty is that we are the safety net, not just for the healthcare system. But for society. We’re open 24/7, 365 no matter who you are, no matter what kind of insurance you have, no matter what language you speak, we’ll take care of you. But not being able to close is tough, and everybody else sends stuff our way. And we just have to manage it. There’s no choice when you have a sick patient in front of you, but to manage it. And I do want to make that clip as specifically around nurses. But our other support staff, our radiology technicians are certified nursing assistants, our social workers, our physical therapists are under the same stress as my nurses and my doctors. It is a universal feeling among those, even our unit assistants or our secretaries. That feeling is just the world way non us has gotten particularly acute over the last couple of months.

Andy Slavitt  26:53

How long can people put up with that before they break?

Megan Ranney  

So that nurse in particular is one who I’ve had a number of discussions with. She’s sticking with it. But there’s two things that I’m seeing. One is that people are leaving, because they’ve had enough emotionally, mentally, they can’t keep coming back every day. So they either change to a different job like a, you know, something that’s not necessarily patient facing or they leave bedside care altogether. The other thing that I’m seeing happen is that people are putting up walls to protect themselves. And they’re, they’re losing empathy. They’re putting up you know, emotional barriers, in order to be able to keep showing up and doing their job every day. Because you can’t, you know, when you’re facing a waiting room of 40 people who are vomiting are in pain are worried you can’t have empathy for all of them and stand there for eight hours. You’ll crumble. And so one of my worries is that those who stay are going to be permanently changed.

Andy Slavitt 

So what do they feel? Do they feel raw? Do they feel numb? Do they just feel robotic? I mean, what’s that feeling like?

Megan Ranney  28:05

It depends on the person. There’s anger, there’s frustration that we’re in this situation again, and that we are the bulwark against the tide. There is sadness for the patient, and for honestly, yourself. There’s exhaustion. I would say that’s one of the dominant things that I hear these days. My colleague is getting ready for an overnight. Yes, indeed. It’s exhausting, right?

Speaker 4 

It really is physically, mentally.

Megan Ranney 

What is the toughest part for you?

Speaker 4 

The toughest part is really just never having a break. You’re dealing with it in the hospitals, in the clinical setting, you’re dealing with it. Outside of your academic life, you’re dealing with it at home, you’re dealing with it with friends, family, in the community members in the community, so it’s just nonstop and you’re trying to find ways to navigate it all. And it can be challenging when it’s just always omnipresent.

Megan Ranney

And then you look at the waiting room you came in, the first thing you did when you came in was click on the waiting room. Why do you do that?

Speaker 4 

I mean, gives you a sense of both what to expect and then how you’re going to triage your kind of priorities, you know, do you need to see if there’s anyone out there that needs blood work or imaging, or someone out there that you’re worried about? I think a lot of that burden falls to our nursing colleagues and it’s a lot for them to handle too, when there’s no movement. You can’t get anybody anywhere. So I think for me, it’s kind of that initial check of alright, what kind of a night, what do I need to do? What kind of armor do I need to put on tonight?

Megan Ranney 

Every night at this point, it’s a lot of armor. Thank you for doing my checks. I’m very appreciative.

Speaker 4 

You know, we’ll get to do our parts and I think we’re all just doing the best we can.

Andy Slavitt 

And you take all those things you said, and then you add exhaustion to them. And we know how our defenses are, when we’re energetic versus when we’re exhausted. And I can only imagine that and then you take what you didn’t mention, which is the personal risk that people feel they’re under the risks that therefore transfers to their families. And then, of course, some of them are getting sick. And by the way, when they show up every day, they have to cover for more colleagues. And then just to make an obvious point, I think, to make sure I understand that the productivity wise, that length of stay in the emergency room, that length of the triage, it sounds like it’s directly related to how many nurses are able to show up on the floors every day. And for people who don’t know this, hospitals are required to have a certain amount of nurses, it’s a nursing patient ratio, in order to operate by the governing authorities, by the regulatory authorities, or you’re not allowed to operate. In other words, you can’t, you can have a floor with 50 patients and no nurses. So you have to do what she talked about, which is Despard, to is shutting down beds. So you can have whole areas of the hospital that you can’t put people into. And that’s when the weight goes from four hours to six hours to eight hours. Is that basically how it works?

Megan Ranney

That is exactly right, Andy and I will say that that is why so many of our hospitals have shut down surgeries, is because those surgeries take up beds that are needed for emergencies. And so we’ve temporarily shut down anything that can be put off anything that is not an emergency, which of course has its own knock-on effect. But we’ve done that to try to preserve nurses and beds on the floor and in the intensive care units. So that there’s space for the patients coming into the emergency department. But yes, the end crowding is a direct result of floor and Intensive Care Unit crowding.

Andy Slavitt 

Right. So we’re not talking about PPE shortages anymore. We’re not talking about bed shortages or ventilator shortages. We’re talking about literally human capacity.

Megan Ranney  32:05

I will say I do wonder; you know, I obviously did residency when COVID was not a thing. You’ve never done residency without COVID being a thing. Well, your first year, your first year. Your first year, there was no Covid..

Speaker 5 

No, there was, I’ve been here the whole time.

Megan Ranney 

Right. It started but your first half a first year?

Speaker 5 

No, that would be the third the current third years. So yeah, COVID came when I was a fourth year at med school.

Megan Ranney 

So you’ve never practiced in a time without COVID. That’s bonkers.

Speaker 5 

I don’t know any different. So your patient came in with the flu. And I didn’t know how to order Tamiflu, because I’ve only ever seen COVID and never seen before.

Andy Slavitt 

Now you’re learning. So Megan, you’ve clearly lost track of time. You do realize it’s year 2026 right now, right?

Megan Ranney 

Yeah, sorry. I’m about 51.

Andy Slavitt 

Yeah, It must be so timeless and consuming in there. But you know, you’re talking to somebody who doesn’t know emergency medicine without COVID. It’s sort of like, you know, my kids. My younger son was born in 2001. He doesn’t know the world before 9/11. And I wonder, you know, you do a lot of bucking people up. I mean, I heard a lot throughout the day. Have you just thanking people, and recognizing them and being grateful and saying the extra word and the extra sentence. And it sounded very, very personal, like every time you almost like you were recognizing people for the precise thing that they would want to be recognized for, because it’s how they see themselves. It felt very, it felt like a very, really amazing leadership touch.

Megan Ranney  34:05

That means so much, Andy, I love my colleagues. Truthfully, I feel so lucky to get to work with them. And, you know, I’ve been here for 17 years. Of course, my resident, obviously, I’ve known for about two but, so he’s one of my newer colleagues, but the rest of them they’ve been, we’ve been in the trenches together. Isn’t it crazy to think that we have now a generation of medical students and physicians who’ve never practiced without COVID I mean, honestly, these are my residents who are third years now. Some of them I’ve never met without us. Being masked, I’ve never seen their full face. And you and I can talk separately about the value of masking which I think is tremendous and is obviously necessary, particularly in the hospital. But our interactions are shifted, their sense of how to practice medicine is shifted, their ability to triage the differential diagnosis that they have. That same resident had said to me at another point that night, which is what actually led to my doing that recording, he saw a flu patient for the first time in residency that week, he’d never seen flu, which is, like, part of the bread and butter of Emergency Medicine.

Speaker 4 

So, you know, one shift in the last few weeks that felt kind of like a normal shift, you know, doing the good medicine that I was trained to do with good flow with good support. And it really made me stop and think about our learners, and what kind of a practice environment they’re learning and whether this will feel so normal to them, that this is how they’re going to practice. And I think it’s something that we need to think about it study, to better understand whether there’s going to be any long-term impacts on us that go beyond just kind of our immediate frustrations to what kind of new physicians and healthcare providers, are we training? Is there going to be an impact?

Megan Ranney 

I mean, there’s got to be right. I mean, I think it’s difficult to maintain the degree of empathy, when you’re stealing yourself up for the fact that the patient has been waiting six hours before you walk in the room.

Speaker 4  36:09

That’s right. And, you know, we build a lot of our clinical reasoning in our illness scripts, and our ability to kind of recognize and treat things quickly based on those repetitive experiences. And when they have, when they’re just built in with all these barriers, it makes you wonder is that the practice pattern, people will develop over time naturally, without even realizing

Andy Slavitt 

What do they lose? And what do they gain? Like? What will be different about them as physicians and as practicing nurses, the young ones who are going through this for the first time? But will they have and what will they have lost compared to you and your colleagues of your generation?

Megan Ranney 

I am hopeful that what will they will have been a commitment to public health. And a commitment to the importance of us as medical professionals being involved in society, and interpreting the science in the cases that we see. They’re certainly going to have a lot more knowledge about COVID. I fear that what they will have lost is some of the empathy and the way that medicine used to be I mean, even simple things like sitting down with a family. And I know we talked about this last time I was on the podcast with you. But most of our family interactions now happened via phone rather than in person. That’s a skill set. And it’s changed.

Andy Slavitt 

Interesting. I have to say, all of your colleagues you talked to do not sound the least bit cynical, they did not send the least bit disconnected. They sound very businesslike and very focused and very busy. But boy, I tell you, they all have that reassuring quality to their voice that I like to hear when I’m scared. I’m in a hospital or I have a family member that’s scared. And so I recognize that they may feel like over at times that they lose it. But at least for the people that you introduced this to in your course of your day, they all felt like really remarkably human clinicians.

Megan Ranney  38:14

Thank you. And I like to think that those of us that go into medicine, do it because we deeply care. And, yeah, thank you. I’ll have them all listen to this so that you can hear that phrase, that’ll mean a lot to all of them. Blocking out of my shift. It is super cold. And I’m an hour late from leaving. And I just left my colleague with more patients in the waiting room. And there were when I started, or ambulances in the background. Spent a lot of time on the phone with the police. Who can’t come into the ER to see their loved ones. Spent all the time talking to my nurses and staff. I’m just tired as everybody I work with but we will keep showing up because it’s the right thing to do for our patients. And I wish that some of them could have gotten vaccinated a little earlier.

Andy Slavitt 

So listen to their again. And I know you somewhat over the last couple years. And in most people a lot of people have seen you on television, and you’re just remarkable demeanor. And boy you just sound exhausted. You just sound like it’s everything you can do to kind of keep moving and keep feeling it some sense of positivity or hope.

Megan Ranney  40:04

You know, you walk out of an ER shift in normal times, and you’re tired, because you’ve been on your feet for eight to 12 hours and dealing with all kinds of different emergencies. There’s generally an adrenaline rush too, that adrenaline rush has gone at this point in emergency medicine for the most part. And I think the part that makes me so tired was that walking out and knowing what I was leaving my colleagues with, it wasn’t even about me, it was about the system that I was leading..

Andy Slavitt 

Do you feel guilty?

Megan Ranney 

Oh, horribly, horribly guilty.

Andy Slavitt 

You know, I think that like, it’s important to remind you, but that’s got to be one of the things that is exhausting. But when a patient’s in the emergency room, and they’ve been waiting, and they’ve been waiting, and they’ve been in various parts of triage, the waiting room, you know, then sitting in, sitting in a chair or bed wherever they’re at. And when the emergency room doc finally comes, and opens the curtain. And you see the emergency room physicians face, the world gets at least 50% of that 75% better at that moment. Because you feel like help has arrived, you feel like somebody who’s trained for exactly the circumstances there. And you can feel someone being in charge of the situation. And this helpless feeling of nobody’s in charge people have forgotten about me, it’s out there kind of goes away. And I’m wondering if you if you’re conscious of that, if you’re not conscious of that any longer. And you once were in? If so, is that a positive feeling? Was that feel empowering? Or is that a negative feeling, because it’s such a burden?

Megan Ranney 

So one of my favorite things in the world is to help. And that feeling of I’m walking in the room, and I can create a connection with my patient and their family. And I can get to the bottom of what’s going on, I can assuage any frustration or exhaustion from waiting, and I can get them help. That is one of the best feelings in the world. And it’s one of the reasons that I went into medicine. I think that what’s really tough right now is both sometimes that exhaustion and annoyance on my patients part is too great for me to make up for it. And sometimes I am emotionally exhausted enough that I can’t create that connection, which is to me such an important part of being a great doctor. So it’s both the system sometimes works against it now, but also I know that I’m sometimes a barrier myself, I try not to be all my colleagues try not to be but we’re human. And then that eats at us, because we want to do exactly what you just described.

Andy Slavitt 

Wow. Okay, let’s end the episode with actually the same way we ended the last one.

Megan Ranney 

The Rocky theme keeps going. That means, there was a COVID patient discharged. But I can tell you, I’ve admitted a lot more than that tonight.

Andy Slavitt 

So they play the Rocky theme when discharging a COVID patient, still.

Megan Ranney 

But at this point, to be honest, we all kind of roll our eyes.

Andy Slavitt 

You may roll your eyes, but I could bet you that there are people there who are there for the first time. Who are maybe patients to whom that’s an uplifting touch. And I’m sure it doesn’t feel the same to hear it anymore. Because you must feel like for every time you hear it, there’s three new patients for everyone. That comes out. To me, it also speaks to culture. I know you’ve got to get to a shift. So I don’t want to keep you. And I hope you have one of your really, really good taste today. But just tell me in the remaining minute we have what it is you go home to. Because I think the way we don’t always look at our doctors and nurses. And we look at them as superheroes. We look at them in the context of the room that they’re in. And sometimes we forget that part of this whole process is that you have things to go home to that matter to you and that you’ve got whole lives outside of this that you really put aside for us, frankly, for the times that you’re in the hospital and were there and we need you.

Megan Ranney  44:38

Thank you. I go home to two incredible children. I have a 13-year-old and a 10-year-old and I am so lucky to be their mom. And I go home to an incredible husband who I actually met right around 911 And we’ve been together now for more than 20 years. I feel so lucky. I also go home to my world outside of COVID, to all of the work in public health and emergency medicine that I care so deeply about, that preceded this pandemic. And that has become all the more important during it.

Andy Slavitt 

Do your kids think like their mom’s a hero.

Megan Ranney 

It depends on the day, they’re still my kids. They’ll sometimes say that, you know, their teacher saw me on TV or something like that. But I’m still the one that makes them do their homework and brush their teeth. So I’m still their mom.

Andy Slavitt 

Well, I’ll let you get to your shift. And I wish you nothing but more time with the people you love. And the people you work with every day that they get a break, and then we treat every day, get healthier, and we move on and Omicron is, is turning the corner, it may take a while for turn the corner and all of our hospitals. But I want to thank you for sharing what we don’t get to see every day we see one part of this pandemic, through the oftentimes, thankfully, increasingly, very mild cases, and restrictions on our lives. But we don’t get it, we don’t get an insight into what you see every day. And Dr. Ranney, thank you for everything you do and for sharing it with us and in the bubble.

Megan Ranney  46:20

Thank you. It’s a joy to join you and I look forward to a day when we don’t have to talk about this anymore.

Andy Slavitt 

Next time you’re back.

Megan Ranney 

It’s a deal.

Andy Slavitt 

Alright, I am exhausted from running up the steps of that Philadelphia Museum, which I have to do every time I hear that song. Pretty amazing. Thank you again, to Megan brandy, for sharing all of this. Thank you also to the nurses and doctors and technicians and other professionals that are your colleagues, Megan, and what they bring every day. And thanks to all the medical professionals, clinical and otherwise, who are there for us in so many ways that are invisible, so hard to thank you except to hear the residents of your voice making going through the day. I think it’s important that we all figure out how to way to do that. Okay, I hope for better times for all of you. We have coming up a great safe or unsafe episode, where we are going to have two amazing people that I think you know and love Katelyn Jetelina, Lena and Dr. Bob Wachter, they’re going to answer your questions about what’s safe and unsafe. And then we’re going to have the next couple of episodes that are going to talk about where we are in Omicron and what’s coming next. And I think you’re gonna love those two. Thank you for staying with me. Thank you for listening to this marvelous episode. Have a great rest of the week.

CREDITS

Thanks for listening to IN THE BUBBLE. Hope you rate us highly. We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced the show. Our mix is by Ivan Kuraev and Veronica Rodriguez. Jessica Cordova Kramer and Stephanie Wittels Wachs are the executive producers of the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, and additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia. And you can find me at @ASlavitt on Twitter or at @AndySlavitt on Instagram. If you like what you heard today, please tell your friends and please stay safe, share some joy and we will definitely get through this together.

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