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On the first day of President Biden’s term, Dr. Bob takes a look at the toll the pandemic is having right now in Los Angeles – the epicenter of the nation’s winter surge – with emergency room physician Erika Flores Uribe and Hal Yee, Chief Medical Officer with the Los Angeles County Department of Health Services. They discuss who’s most affected, what it’s like on the front lines, what they’re doing to turn things around, and how the vaccine rollout is going in L.A. Dr. Bob also reflects on what we can look forward to after Inauguration Day in the fight against COVID-19.

 

Follow Dr. Bob on Twitter @Bob_Wachter and check out In the Bubble’s new Twitter account @inthebubblepod.

 

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

 

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Check out these resources from today’s episode: 

 

• Keep track of the COVID-19 situation in California with The Los Angeles Times: https://www.latimes.com/projects/california-coronavirus-cases-tracking-outbreak/
• Learn about the 5 new vaccination super sites opening up in Los Angeles: https://laist.com/latest/post/20210118/5-more-vaccination-super-sites-open-tomorrow-in-LA-county
• Check out this article about Los Angeles lifting its cremation limits due to a backlog caused by skyrocketing COVID-19 deaths: https://www.npr.org/sections/coronavirus-live-updates/2021/01/19/958354466/cremation-limits-lifted-in-la-due-to-backlog-as-covid-19-deaths-skyrocket
• Watch the full clip of CNN reporter Sara Sidner choking up after reporting from a hospital in Los Angeles: https://www.youtube.com/watch?v=Du5HjRpAliE
• Learn more about Dr. Bob Wachter and the UCSF Department of Medicine here: https://medicine.ucsf.edu/

 

To follow along with a transcript and/or take notes for friends and family, go to www.lemonadamedia.com/show/in-the-bubble shortly after the air date.

 

Stay up to date with us on Twitter, Facebook, and Instagram at @LemonadaMedia. For additional resources, information, and a transcript of the episode, visit lemonadamedia.com.

Transcript

SPEAKERS

Dr. Erika Flores Uribe, Sarah Snyder, Dr. Bob Wachter, Dr. Hal Yee

Sarah Snyder  00:00

You know, this is the 10th hospital that I have been. I’m sorry. This is the 10th. I apologize. I did try to get through this. This is the 10th hospital that I have been in, and to see the way that these families have to live after this and the heartache that goes so far and so wide. It’s really hard to take. I’m sorry, Alison.

Dr. Bob Wachter 

Welcome to IN THE BUBBLE from the frontlines. I’m Dr. Bob Wachter. That was CNN reporter Sarah Snyder reacting to the tragedies in LA, it’s just unbelievable. You know, when we watched the scenes in New York over last spring, or Italy before that, or Phoenix after that, the hope was it would be last time we would see those kinds of surges that really overwhelmed the healthcare system. But it’s the fact that we’re a year into it. And we’re still seeing it as is really quite something. Nationally, we’re not in a good place. We’ve just passed 400,000 deaths in the United States, 2 million deaths in the world. And so many people devastated by this, this virus and its impact on health and the economy.

Dr. Bob Wachter 

And watching that reporter break up, I actually found comforting in an odd way. Because sometimes you have to let yourself cry and mourn for what has happened. But I’m actually quite hopeful today, today is the day of the inauguration. And with that we have a new administration, one that has signaled that it’s going to be approaching this pandemic as it should as priority one. It’s making bold plans or ambitious targets, push to have everybody mask for 100 days a push to vaccinate 100 million people in 100 days, these are realistic, but appropriate targets. And carrying out these plants are really an amazingly impressive group of leaders, I happen to know several of them, including that guy named Slavitt.

Dr. Bob Wachter  02:18

So I think there’s a lot to be hopeful for. And one of the things I like best about how things feel in the last couple of weeks watching this new administration begin to get at sea legs is that it feels like we’re being treated like adults for the first time. They’re making clear that it’s not going to turn around on a dime. There are more tragedies to come, sadly. But we’re being told what to expect what’s going to be done by our government, what needs to be done by our other institutions, and what we all need to be doing to make ourselves and our families and our community safe. So that’s as it should be, and hadn’t been that way for the past year, things might have felt very different.

Dr. Bob Wachter

Today, we’re gonna focus on one particularly hard-hit corner of the country that being Los Angeles in Southern California, it’s not entirely clear why LA has been so devastated in the last couple of months. California, I can say as someone who lives here has been generally well governed. There were early stay at home orders, thoughtful triggers for reinstituting restrictions. There’s been some pushback on masks and the like, but not the wholesale rebellions you’ve seen in other parts of the country. And, you know, part of the rationale for or part of the explanation for why there might be a surge over the winter was that the winter weather would force people inside and I don’t know if you’ve ever been in LA in December in January, but it’s not cold.

Dr. Bob Wachter 

So not entirely clear what has gone wrong. I suspect that most of it is pandemic fatigue. But let’s hear from some folks on the ground, who are going to tell us not only what it feels like from a policy and political standpoint, you know, what are the rules that are working or not working? What are the systems that are in place and what’s going on with those, but also seeing through the lens of a frontline emergency medicine physician, what it really feels like and to be seeing this many patients this sick to have to talk to patients and families all day long about the toll of this pandemic. We’re dealing with real people and real families and some real tragedy. So that’s what we’re going to hear today.

Dr. Bob Wachter  04:22

And some of it is hard and painful. But there really is hope. I think we’re going to be entering a very new phase of the pandemic. And I think there’s a lot to be hopeful about. The two people we’re gonna hear from are Erika Flores Uribe who’s an emergency physician with LA County USC Medical Center, the huge safety net Hospital in Los Angeles, one of the great public hospitals in the country. Erica also leads the COVID-19 testing equity collaborative at LA County USC. And then an old friend Hal Yee, who used to be at UCSF and then moved down to Los Angeles a couple of decades ago. Hal is the Chief Medical Officer for the Los Angeles County Department of Health Services.

Dr. Bob Wachter

The second largest health department in the nation, he’s a GI doctor by training. And in his role as Chief Medical Officer, it’s his job to oversee the entire response of this large public health system. So it’s going to be a nice opportunity here, not only what it feels like from 35,000 feet, but also what it feels like from often less than six feet, as Erica is they’re taking care of patients and their families under very trying circumstances. So let’s get Hal Yee and Erica Uribe on the line and talk about LA.

Dr. Hal Yee

Hi.

Dr. Erika Flores Uribe

Hello.

Dr. Bob Wachter 

Erika, we have not met before, it’s nice to meet you. Thank you for doing this.

Dr. Erika Flores Uribe 

Nice to meet you too. Hi, Hal.

Dr. Hal Yee 

Hi, Erika.

Dr. Bob Wachter 

So welcome to both of you. Hal, I went over your bio, I left out the most important part, which is that you were a high school classmate of Barack Obama’s. Is it true that you were voted the most likely to succeed in your class?

Dr. Hal Yee  06:02

No, I wasn’t. But neither was very.

Dr. Bob Wachter 

Give us a 30 second thumbnail on what it was Barry was like in high school.

Dr. Hal Yee 

I didn’t know very particularly well, but it was a school of only about 400 people in our class. So I didn’t know him. I was in algebra with him in eighth grade. Mr. Martin, he was a pretty regular dude, you know, and I think it was fantastic that somebody from high school got to be the President of the United States of America.

Dr. Bob Wachter 

That is pretty cool. Well, let’s start on the situation that you find yourself in LA. So for those of us outside of Los Angeles, can you just paint a picture for us of what’s going on now?

Dr. Hal Yee 

In Los Angeles, as most folks know, we’ve had a big surge, it started in November, was compounded after Thanksgiving. But we are at a point now, which is, I guess I would call it stable. Our numbers are down a little bit from last week. I think we have stabilization as a result of Christmas and New Year’s Eve. But I think it’s really important to recognize that being stable and having just enough staff right now in the surge, doesn’t really tell you about the fact that for 9-10 months, our staff has been working extremely hard under very, very difficult conditions. So people are tired, they’re exhausted. And so the fact that the health system in Los Angeles and elsewhere in the country is stable, doesn’t really give you the full scoop.

Dr. Bob Wachter 

Can you give us any of the numbers, the numbers in terms of how many deaths a day you’re seeing are patients in hospitals and give us a sense of what it’s like now, maybe compared to what it was like two or three months ago?

Dr. Hal Yee

So in Los Angeles, I would consider that we had about three surges. Back in March and April, we thought it was terrible. We peaked at about 120 total patients in our four hospitals. During the summer after July 4. We thought it was terrible again. We peaked in the two hundreds. Starting in November, the numbers started climbing till we got to about 550 total patients with COVID. In our four hospitals, in terms of, for example, ICU beds, we have as of today 250 ICU beds, 60 of them are surge, and they’re 95% capacity. So we have more patients in the ICU now than we have licensed ICU beds still.

Dr. Bob Wachter  08:44

Wow, and just to make it clear, you’re talking about the hospitals that are that are run and owned by the county, as opposed to all of the hospitals of Los Angeles.

Dr. Hal Yee 

That’s right. We represent about 5% of the hospital beds, and COVID patients in the county.

Dr. Bob Wachter

So Erica, your practicing physician in the emergency department, why don’t you just give us a feel of what’s happening now? And Hal makes the point that even as things are stabilizing, they’re stabilizing at a pretty bad level. So what does it feel like for you and your colleagues to be practicing there now?

Dr. Erika Flores Uribe 

I’d like to start a little bit in terms of what this means for us on the ground in the emergency department. As an emergency doctor, I’ve had to deliver bad news many times. But with COVID-19 it’s different. Because the intensity, as well as the amount of care that we need to provide. And the difficult conversations that come with that is overwhelming. So, when I speak about intensity, whenever we lose a patient in the ER, it’s hard, and it’s hard for all of us in different ways. For me it’s challenging when a patient resembles my family, when a patient dies unexpectedly or when that death was preventable.

Dr. Erika Flores Uribe  10:01

And since the pandemic has started, I’ve had to had more conversations in those space than I ever thought I would ever have to have in my career. The other day, for example, in the ER, I’m explaining to a wife that her husband just died. And she says, “How did this happen? My husband is healthy. He’s only had a broken toe; we were waiting for our COVID-19 test results. He can’t be dead. And this can’t be true. Why did this happen to us?” So being the face, and the voice of that message, and witnessing this incredible loss for so many families? It’s heartbreaking.

Dr. Bob Wachter

Erika, that is so tough. What did you tell her?

Dr. Erika Flores Uribe 

You know, in that space, I mean, all we can do is listen and hear. I told her that she did everything that she could, that her family is not alone. And Unfortunately, we’re seeing so much of this loss, particularly in our community. And LA County Health Services is special in that way. And this is why I work there as an ER doctor; we see millions of patients 2.5 million visits from patients. And our population is one of the populations that’s most impacted by COVID. In fact, most of our patients are limited English proficient, and three out of four identify as communities of color. We see that data in LA County, the communities of color, Black and Latinx are two to three times higher in mortality than white populations. And this is what we’re seeing on the ground caring for our communities at LA County Health Services.

Dr. Bob Wachter

And Erika, you said that part of what is so hard for you is many of these people, the patients, the families are from community, a community that your from is I assume your Latinx and can you describe what the feeling is taking care of people from the Latinx community in Los Angeles.

Dr. Erika Flores Uribe  12:00

I grew up in southeast LA, this is my home. It feels very personal. It feels like I’m taking care of my family. In fact, one of the reasons I chose to practice in LA County is because of the diversity of the community here. And in previous occasions before COVID-19, when I walked into the room and spoke Spanish to some of my patients, who are monolingual Spanish speakers, this would create trust, this would create immediate relatability, it’s different now because I walk into the room and I’m covered from head to toe, my hair’s covered, my face is covered, I have a face mask, I have a gown, even my shoes are covered, my hands are covered. So in very difficult moments when what I could do is offer my humanity and offer my compassion to a patient sit by the bedside, hold their hand, look at their face, all they see is the mask provider.

Dr. Erika Flores Uribe 

And it’s hard for them to, you know, to tell us apart. So some of us actually have written our names on our gowns on tape, some of us have pictures of ourselves that we put on our gowns, to create that relatability. But it has been really impactful because this feels like my family. And I’ve made it you know a priority like many of other providers at LAC+USC to bring in however we can communicate with family like iPads into the room, so that the family can be there. It’s very isolating not only from the PPE perspective, but in the way that we communicate with patients. So it’s been impactful in many ways. And I certainly feel for our communities that you know, are there without family and see all of us that may look the same because of our PPE.

Dr. Bob Wachter 

Hal, when all of the hospitals in your system are packed? One of the things that’s important, I think, for people to know is you’re the safety net system of Los Angeles, you are the system that takes care of people with no insurance or if they have Medicaid and other places won’t see them. Are you able to transfer your patients out of the system to private hospitals? Or is it feel like the resources available to within the safety net system are essentially all you have to work with?

Dr. Hal Yee  14:22

You know, one of the remarkable things that I’m very proud of is during the pandemic, the fact that the safety net, historically, and traditionally response to crises and disasters, has really permitted our team, our staff, our hospitals our clinics to step up. It’s one of the unfortunate economic realities of America that we rarely transfer patients out of our hospitals to other hospitals. Whereas we have historically before the pandemic and even during the pandemic been the hospitals that other facilities private nonprofits, private, for profits, transfer patients too.

Dr. Bob Wachter

Erika, we were hearing about all sorts of rationing and we read about not having enough oxygen for patients and ambulances needing to make choices of who they take in and who they don’t take in. How much of that is real? How much of that is hyperbolic? What are you actually seeing in terms of hard rationing decisions? And if you have to make them, how do you handle that?

Dr. Erika Flores Uribe

Yeah, so I would say that, in theory, we’ve learned from our colleagues in New York in terms of how to manage shortages of beds and ventilators and create capacity for patients. As Hal also shared. You know, we work in a system that is always thought about how to create space and care for those who need the care the most. We’ve been very flexible and have gotten support from our leadership at the health services and getting staff from the outpatient setting to care for patients in the ER and inpatient setting. We’ve gotten support from the Department of Defense, which makes it feel like we’re not alone in the fighting against COVID-19.

Dr. Erika Flores Uribe  16:24

But, you know, part of our work in the ER even before COVID-19 was around difficult ethical decisions. And we’re trying to make those decisions in the fairest way possible. And, you know, I very much appreciate the guidance that’s coming from our health system, from health services in terms of how to manage those difficult, ethical questions, things have been a little bit more stable right now. But it’s always challenging,  in practice is challenging to look at a patient to have a daughter on an iPad, saying, “Do everything you can. Save my dad’s life, please don’t let him die, please don’t.”

Dr. Erika Flores Uribe 

When I know I have a number of patients in that unit. And I know I have a number of resources, that may not care for all of them, I don’t have a good answer other than we’re doing the best that we can. And through the guidance of trying to do the best for most people and show up and you know, try to do the best we can, it’s still uncomfortable. And I do go into my shifts, hoping that there are enough ICU beds and hoping that I don’t get a patient that could be treated with medical issues that require more resources than what we have.

Dr. Bob Wachter 

But it sounds like there are patients who if in the pre COVID days, you would be sending to the ICU and putting on a ventilator, that today you have to make that choice that we just can’t do that there are not enough beds, there’s not enough ventilators open.

Dr. Erika Flores Uribe

So the conversation has shifted. Because it’s such a short turnaround. Again, with COVID, you could be working a week before and could be your normal self and two weeks from then can be requiring to stay in the hospital. So the conversations have shifted for us in the ER as well, to say this is a reality, we have to talk about intubation or breathing treatments that may or may not help in the long term. So it is conversations that are coming up more frontline for us in the emergency department. In the current state, we’ve had enough resources at LAC+USC, and I hope that those who are listening, again, hear the message here that if we can’t stay home to stay home, to wear our face coverings to wash our hands to stay six feet away. So that doesn’t become you know, the day-to-day reality of how we care for patients.

Dr. Bob Wachter  18:48

Also hear about people coming into the ER and saying, you know, “I thought it was a hoax. And I can’t believe this has happened to me.” Have you seen that?

Dr. Erika Flores Uribe 

You know, we do get that more often than I would, then I would have expected. A lot of times it doesn’t become a reality until it hits home. So it’s a young family member that may have had some gatherings and then lives in a multi-generational home. And now their family becomes sick. So it is something that has been part of some of the narrative in the community. But with the numbers becoming so widespread, I think it’s becoming more clear that this is a real issue. And we’re having to have these really difficult conversations about lives lost with family and I don’t want to keep doing that. I mean, when I drive home from my shift and see the wraparound lines in Starbucks and Costco, I want to say “Please go home.” I don’t want to have a conversation of losing a family member with you in 14 days. So we all have to do everything that we can to care for our communities.

Dr. Erika Flores Uribe  20:00

Bob?

Dr. Bob Wachter 

Yeah?

Dr. Hal Yee 

Your question about what we’re doing that’s different. I think one of the silver linings if there are any silver linings to the pandemic is the recognition that so much of American Medical Care historically, has been unnecessary, non-essential, possibly even harmful. As you probably know, historically, people have used the emergency room for all kinds of care well beyond just emergencies. And I think one of the ways that our health system and others has actually gotten through this is because of the reduction of the patients who ordinarily might have come into the ED, are not coming into EDI appropriately. And that has given us some capacity to take care of those patients. In the decisions as to who to put on a ventilator, or who to transport to the hospital, one of the decisions.

Dr. Hal Yee

It was a very hard decision that had to be made by our emergency medical services a couple of weeks ago, was an order that when EMTs are out in the field, and they’re called to see a patient or an individual who is do not resuscitate. Those patients are not brought to the emergency room, when historically they would have been. And so there’s a lot of care that historically has taken place in the United States, which for obvious reasons, can’t be taken care of. And we’re making those decisions that are actually appropriate not to provide that care now. Because we have to, and perhaps when we come out of this, one of the things that will grow with that will return to a better normal, or we’ll get to a better normal is by understanding that we really want to focus on giving care that has benefit to patients, not necessarily for the other reasons people get care.

Dr. Bob Wachter 

Yeah, thank you. That’s an important point. Because people often see patients staying away from the ER and see that as all bad, some of it’s probably okay. But I assume there is some bad or there probably are patients with strokes and heart attacks, who you’re not seeing if you either of you kind of seeing that in terms of non COVID patients.

Dr. Erika Flores Uribe  22:17

On the ground in the ER, we have seen patients that come in a day or two later, when they first started symptoms. It’s been challenging, because some of them may have had COVID. And in the setting of COVID, it’s hard for them to know, is this a heart attack? Is this something new a stroke? When do we actually go into the ER. So there are cases of that, but we are, you know, doing what we can to care for our communities.

Dr. Bob Wachter 

Let’s move out to kind of the big picture and what’s happened. And maybe I’ll start with you Hal. What’s gone wrong? People talked about the California miracle during the first three months and LA could have gotten slammed the way New York was in March or April, didn’t happen. December, there was something of a surge, but nowhere near this one. People sometimes say well, we’re going to have a winter surge. But I think I checked the temperature in LA yesterday it was 80. So the things we talked about in terms of driving people inside are not the same in Los Angeles. So what is your set of theories about what has gone wrong in the last couple of months?

Dr. Hal Yee 

Yeah, I think it’s complicated. Obviously, we haven’t had time to do the science to truly understand it. In addition to sort of the behavioral choices that the residents of Los Angeles have made, which are probably no different than the residents elsewhere in the state and United States, has, I think some of the key thoughts that I’ve had in Los Angeles are that we’ve had a sort of COVID transmission loop that’s related to our very diverse economy in a county of 10 million people. So if you think about how diverse our economy is, it’s created very diverse and sometimes risky workplaces. In addition to normal retail, we have factory, we have agriculture, we have a lot of service industries. And because of that diversity of different workplaces, I think we have conditions where there are frequent outbreaks.

Dr. Hal Yee  24:11

In addition to that because of the high housing density in Los Angeles. As you may know, if you look at affordability of housing. Los Angeles, has often been in the top three, if not the most expensive place for people to rent. Because of that very high housing density. There’s a lot of household risk. And even though in Beverly Hills, it may not be the case. In most of Los Angeles, people are living often enough in multi-generational households where it’s very difficult. We have 88 cities across our 4000 square mile county that leads to a lot of commuting. And so you can imagine that if you have high risk work conditions, and you have people going home where there are multiple people, even multiple generations at home, and then those people are commuting from work to home.

Dr. Hal Yee

All of these things really set us up for this kind of increased surge. You know, when after nine months, people become tired, and they get fatigued about the physical distancing and the use of masks. And then obviously, because of our demographics, when can predict, there’s probably a likelihood that the health disparities and social determinants of health have had an impact. And although, you know, smog has always been an issue in Los Angeles, the reality is the fires that we’ve had have really created some air quality conditions that may have contributed as well.

Dr. Bob Wachter 

Erika, do you want to add anything? As you see these patients flowing through the emergency department? Do you have thoughts about why now and why not, let’s say in August or in April?

Dr. Erika Flores Uribe

I certainly think that there’s an element of fatigue. There’s also, you know, the holiday celebrations that happen in November in December in January, and a lot of the communities that we care for are diverse populations that are very family centric. And so when things become more stressful, when things become more challenging, there’s a leaning on religion on faith-based organizations on family for support. And that becomes like a very, you know, challenging space to continue to maintain for nine months, in addition to that there’s true challenges with some of our communities that are faced with, you know, having enough money to pay for their rent and for their food. While also trying to stay physically distinct in order not to get COVID-19. So if we see that there’s limitations and economy limitations in the work that people can do, right?

Dr. Erika Flores Uribe  26:46

Construction, or handyman or cleaning houses for a lot of our populations, that’s the work that they did to make sure that they can keep their family fed and housed. There’s limitation in that way of working in the current state. So then they have to do other things to make sure that they can get those resources. And the county has provided resources in terms of food, and access to information on rent assistance. But the volumes in the 10-million-person County are very high, and the need is very high. And so I think that it’s faced with a lot of economic and social issues, where the multigenerational house is not just because of financial issues, but also because of cultural issues. And it’s been a long nine months. So there’s it’s very multifaceted.

Dr. Bob Wachter

Hal, as you think about your ability to respond. There’s obviously the things that you within this system can do with the city and the county are doing, but you’re also dependent on the state and the federal government. So can you talk about what you’ve received from both state and federal government and what has worked? And also what should have happened and has not happened?

Dr. Hal Yee  28:09

You know, that’s a really good question, Bob. I think that one of the things that we and our team has realized over the past nine months, is that the novelty of this pandemic, the unpredictability of it has actually created an awareness that we as a healthcare system, have to figure it out ourselves. What I’ve realized is that the federal government, the state government, and even the county government, the public health departments, they’ve worked like crazy, they’ve tried to be thoughtful. But because of the unknown, because of the unpredictable, because of the politics, it’s turned out that the decisions that we’ve had to make as a health care system are the ones that were important.

Dr. Hal Yee

That, in fact, the feds in the States, if anything have trailed us because they don’t have people like Erika who have feet on the ground, who were listening to, who allow us to pivot who will allow us to source things. An example that I would give, which I just think is what the safety net does is very early on in the pandemic. I would say this was probably March 10th or so. One of the CMOS at one of our hospitals called me and said, “Hal, we’ve got to figure it out if there’s community spread. Right now, public health is using a containment method. But we’ve got to figure this out.” And I said, “Well, there just aren’t the labs, right? That can test for COVID. This is the second week in March. I said public health is testing though. Let me go talk to somebody in public health. Let’s arrange a call.”

Dr. Hal Yee 

So the next day, it was a Tuesday, second week in March, public health guy  Prabhu Gounder, the CMO, Brad Spellberg and myself had a phone call. And we decided that we were going to do a small study to look at patients who had flu like illness and test them in the LAC+USC emergency department. That study was done on the Thursday, the following Thursday and Friday, Sunday and Monday. Our results showed that there was a 5% COVID positivity in patients with flu like illness suggesting community spread. Two days later, LA County DPH announced safer at home, sheltering in place. An hour later, the governor announced, sheltering in place the following day, Governor Cuomo sheltering in place for New York State.

Dr. Hal Yee  30:53

And I guess this is the example where the nimbleness of our health system close to the ground, made the decision to do this study was able to do this study in the course of four days. And literally nine days after we decided to do this study, we had the data that helped the Department of Public Health in Los Angeles make the decision to shelter in place, which was followed quickly by our state, New York and other states.

Dr. Bob Wachter

That’s a nice example. I think people often see the relative lack of federal, particularly federal leadership over the last year as being problematic, and I certainly do, but the importance of feet on the ground and people at the local and local hospitals and health departments really understanding what was going on better and faster, I think it’s important to have it, it’s important to have a balance there. So I appreciate you sharing that. Let’s talk for a second about vaccination. So here’s the newest hard thing that we all have to do, which is to figure out how to vaccinate our healthcare workers and our patients. Maybe both of you tell us how it’s going from your perspective?

Dr. Erika Flores Uribe  32:02

Well, I think it is a glimmer of hope, as we think about a long nine to 10 months, I actually got my second dose of vaccine last week. So it certainly makes me feel more protected. And I’m grateful to the Department of Health Services in that quick rollout to all of our providers, at least as an emergency doctor, it was easy to sign up for it and get my testing my vaccination done before the ER shift. You know, there is some hesitancy in the community. And there are some questions about trust and trust in vaccination in general in terms of communications, but I did want to say that I you know, I got vaccinated not only to protect myself, but to protect my patients, my community and my family. And I do think that this is one way for us to, you know, protect our communities and hopefully get us closer to what normal could look like.

Dr. Bob Wachter

You understand your community well, and I know you’ve worked in the community for a long time. Any pearls about how we should be trying to address issues of vaccine hesitancy, particularly in the Latinx community?

Dr. Erika Flores Uribe 

Yeah, so as we talked a little bit earlier about the question on boots on the ground, or the community itself is really important. So as LA County Health Services has not only been the lead on community testing, so in April, we became the lead in community testing, and since then have erected over 180 community testing sites. And being able to have close partnership with trusted messengers, like community organizations, faith-based organizations, allows us to work through programs that will be most impactful, like mobile testing, and at home testing so that we can reach our communities in that way.

Dr. Erika Flores Uribe

In similar way for vaccines. I think that being able to connect with messengers and partners in the community that have the history, have a shared experience, the culture, the language of those communities that we’re trying to reach is going to be critical. And we’ve had the opportunity to work and bond community-based organizations as partners, through information on how to stay safe and testing. And I think there’ll be opportunity to continue to leverage those spaces, so that it is a trusted voice, and trusted space for community to ask their questions.

Dr. Bob Wachter  34:28

Right. Hal, how’s vaccination been going from your perspective?

Dr. Hal Yee

You know, I think vaccination is a really good example of one of the things that I think we’ve all learned during the pandemic, that execution and the ability to operationalize things and manage the logistics of something that’s so unpredictable, is critical. I think we’re pretty proud that we started thinking about the vaccination created a team and identified a leader for vaccination back in June. Knowing that it was at least two of the vaccines were going to be mRNA based. We actually ordered our supercooled freezers back at the beginning of August, and took delivery of them in November, all in preparation for the potential FDA approval. After working for so many months, we had our plan in place. So when we took the vaccine on that first Tuesday after the FDA emergency use authorization, we were ready to go with 1500 doses on that Friday.

Dr. Hal Yee 

It’s kind of paradoxical that one of the complaints we got was that we didn’t give those vaccinations that day that we received them. But as I think has been discovered, a lot of those first day vaccinations were a little bit of a dog and pony show, which we didn’t want to do, we really wanted to make sure that our staff people like Erika, our nurses, our custodians, were getting it all at the same time, because not only is our system equity based with regards to our patients, but we really have taken the approach during the whole pandemic, that only by protecting our staff, do we protect our patients. So we were ready to go. But it was a six-month logistical planning process.

Dr. Bob Wachter  36:11

Yeah. We have a lot of listeners in Los Angeles and surrounding region, what message do you have for them right now?

Dr. Erika Flores Uribe

I know it’s been a long nine to 10 months. And for those of who are listening who have lost a family member, I am incredibly saddened and sorry for your loss, I want to make sure that the listeners who are listening, understand that it’s a reality. And I don’t ever want to share that news with anyone who is listening. But the reality is that it will happen and it will continue to happen. I will keep it in terms of making sure that we have something actionable from this conversation. If you have a job that allows you to stay home, stay home, if you can stay home, please do.

Dr. Erika Flores Uribe 

For those of us that do have to go out and work in a physical setting where your face coverings stay six feet apart, wash your hands with a vaccine when it does become available to all of us. It’s going to take all of us to be able to protect our community. So I hope that my story and the fact that I got it and I’m safe and can still take care of patients motivates others listening to do so when it becomes available to them.

Dr. Bob Wachter 

Great. Hal?

Dr. Hal Yee

I guess I wanted to just let everybody know that this is the worst health crisis that the United States has had in over a century. And despite the real challenges and losses, in people in economic development that Los Angeles has had, there are 10s of 1000s of health care workers that have done everything possible, to try to help, to try to mitigate this health crisis. We will get through it. I think that the vaccination is going to go a long way. I think that all of us working together, will pull through, I am trusting that we will get to a better normal, it won’t be the same normal, but I hope it’s a better normal, where we’ll have thought through things and come together and that we’re in a better place when we come out of this crisis. So hang in there, everyone.

Dr. Bob Wachter  38:29

Well, thank you both for coming on. And for describing the situation there. It sounds like at least things are plateauing now. Although at a pretty bad level. I appreciate all of the work that you have done, both frontline work and in the planning and management of this. It’s been pretty brutal, but better days are ahead. And the vaccination is key. And thank you for all you’ve done for the people of Los Angeles. Thanks for describing it to us today.

Dr. Hal Yee

I appreciate the conversation.

Dr. Erika Flores Uribe 

Thank you.

Dr. Bob Wachter

Well, that was an extraordinarily powerful episode, I have to say that, you know, I’m around people all the time taking care of COVID patients and I know what it feels like. But to hear particularly from Erika, what it feels like to be on the front line, completely every inch of your skin covered with PPE, not being able to sort of have the personal relationship with the patients and their families and seeing so many people come in and die, particularly. Erika has spent her entire career focused on the Latinx community in Los Angeles, particularly from it being people from this community, who could easily be members of your family. It’s just tough to listen to, but really, really important. It helps remind us of what’s going on and what’s behind all the numbers that we’re hearing. And again, it’s a hard time but I really do think this week feels like a turning point in the pandemic.

Dr. Bob Wachter  40:04

Because so much of the problems we’ve seen over the past year have related to the political response and the kinds of leadership that we’ve lacked, frankly. And I think we will now have it and that is going to get us to a better place faster. So I am actually very, very hopeful, even as we absorb what we just heard. So thanks for listening to IN THE BUBBLE. Join us next week for a toolkit on vaccines. It’s going to be a terrific episode; we’ll be covering both the rollout of vaccines and why it’s been so bumpy so far. And also some of the really profound ethical issues that arise as we try to figure out how to prioritize who goes first and second, and we will have a special guest appearance by my wife who’s going to talk about living in a family with vaccine dissonance where one person is vaccinated, namely me, and the other is not namely her.

Dr. Bob Wachter

On top of that we have a number of other amazing guests coming in the next few weeks. Don Berwick, who is probably the world leader in the field of healthcare quality, the founder of the Institute for Healthcare Improvement, and former head of Medicare and Medicaid Services before Andy. We’ll talk to Julie Gerberding. Julie sees this world from two very important angles. Julie was head of the CDC for nearly a decade, and also is a senior leader at Merck. She was in charge of vaccine development at Merck for a number of years. And finally, we’ll talk to Atul Gawande, the acclaimed Harvard surgeon who has gone on to lead the new company haven developed by Amazon, Berkshire Hathaway, and Citi group which unfortunately is closing down, but also has been an innovator, a prolific author, both have books and have many, many articles in the New Yorker, and has just finished a stint on President Biden’s COVID taskforce. So an extraordinary group of guests who will help us understand COVID from a lot of different perspectives. Until next time, stay safe, and I look forward to speaking with you soon. Thanks very much.

CREDITS

We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced our show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produced the show. 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 @InTheBubblePod. Until next time, stay safe and stay sane. Thanks so much for listening.