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Scott Webb: Though we now have three COVID-19 vaccines, residents in the region continue to be hospitalized and die from COVID-19. And this year has been tough for all of us. And as we look to put COVID behind us, it's important to reflect on what our frontline heroes and residents have experienced as we honor the first COVID patients at SVMH a year ago.

And joining me today in part one of a two-part series to share his experiences, expertise, and optimism is Dr. Mario Cole. He's a pulmonary disease and critical care specialist at SVMH.

This is Ask the Experts from Salinas Valley Memorial Healthcare System. I'm Scott Webb. Dr. Cole, thanks for agreeing to do this. This has been a strange time for all of us. And I know you've experienced a lot and learned so much over the past year or so. So let's jump in here. I want to have you paint a picture of what it was like to care for the first or maybe first few COVID-positive patients one year ago in the ICU.

Dr. Mario Cole: Well, obviously, it was a difficult time because there were a lot of unknowns. We weren't really sure if the measures that we were putting into place were adequate to protect the nursing staff and the other workers involved with caring of these patients. We also weren't aware or quite sure as to how quickly this would spread among the population and whether we were going to be overwhelmed. So it was quite a trying time.

Scott Webb: Yeah. I'm sure that it was. And, you know, obviously, we want to protect privacy here, but generally speaking, how sick was that first patient or patients? How alarmed were you when they came through and they ended up in the ICU?

Dr. Mario Cole: The first patients that came through that tested positive were admitted, because we didn't really know how to handle these patients. And many of them went home. I'm a pulmonary critical care physician and so I didn't see many of the first patients. But the patients that were sick enough to get admitted to the ICU. It was quite an eye-opening experience for all of my staff and my colleagues and I.

There was one patient in particular, one of the early ones that I had spoken to. He was doing well. He actually felt better than he did the day before. And I went downstairs to attend to a different patient and was summoned back to the room by the nursing staff stating that he wasn't breathing well and needed to go on life support. I was kind of in disbelief, because I just spoken to the patient in 30 minutes and it's uncommon that someone would decompensate that quickly.

But, sure enough, when I went up to see this patient, he was not going to survive unless we place him on life support, which we did immediately. But it taught me early on that this was a different illness, that this wasn't your standard bacterial pneumonia. This was something very different. And we later learned that the patient's own immune response to the virus is very valuable, but it can progress very quickly and so we had to kind of change how we did things.

Scott Webb: Yeah, no doubt. And that's really remarkable and kind of frightening, that you speak with a patient and 30 minutes later, this patient's going on life support. This was definitely something out of the ordinary.

Dr. Mario Cole: That's correct.

Scott Webb: Yeah. And so when we talk about the damage to lungs or other issues like diabetes, heart disease, hypertension, how did all of those risk factors affect the outcome for those initial patients?

Dr. Mario Cole: Well, certainly, one of the first things that we noticed is that many of the patients that were coming in that were ill and proceeded to worsen, necessitating being placed on life support were obese and some of them severely obese. We had a lot of patients come through the ER and most of the ones that were a more normal weight did well and were either hospitalized for a few days or actually did not require hospitalization.

But those patients that were obese or very obese, and particularly if they had diabetes or kidney disease on dialysis, those patients did quite poorly and they did quite poorly very quickly. We had to understand that these patients had to be monitored in a different way.

Scott Webb: Yeah. And as you say, those suffering from obesity generally tend to have diabetes and heart disease and hypertension and all of those things. So I imagine it was probably a bit of a process there for you early on to figure out, "Okay. So we're seeing worse outcomes or worsening of symptoms with those suffering from obesity." But why is that? And is that maybe part of the reason why you had a sense that things were going to get significantly worse in Monterey County, early on, that there is perhaps more obesity in that area?

Dr. Mario Cole: Yeah, there are a number of factors. One is the prevalence of obesity in this area is high. But there are other factors. The amount of people who are in a household here in general is higher than I would imagine in some other areas of the country. Here, you have some times multiple families living in one household. And so even though a family, parents and the children are doing everything they can to social isolate, another family who's renting a room in the home may not do the same. And therefore, there were instances where one member of the household would get infected and then multiple patients would come from that. And that was an issue for us.

Other thing is there was a huge language barrier that exists in this area. And so that, although, you know, there were public announcements and effort to get information out in other languages, that wasn't always effective. And so some patients really didn't understand what they were supposed to do to kind of protect themselves.

And so we had, again, the obesity, multiple families in a home, language barriers, and then social barriers. Not everyone has access to the internet, not everyone has access to a phone and that kind of thing. And so all of those factors kind of contributed to us eventually really being slammed with patients in the middle part of this disease.

Scott Webb: Yeah. And that's what I've heard from talking with, you know, other folks there is that you really were slammed and that there were a lot of barriers to overcome. And you mentioned family members in households, so during the pandemic, have you treated family members from the same family simultaneously? Were they hospitalized at the same time? A lot to unpack here. And I have some other questions, but let's start there. Have you been treating family members from the same family at the same time and what's that been like?

Dr. Mario Cole: Absolutely. There were multiple times where I had multiple family members in the hospital at the same time. That occurred repeatedly. And what other things that we often saw was one person would be hospitalized. And then seven to ten days later after they had been discharged home, other members from the same household were getting hospitalized and that was more common. There'd be one person who would bring it to the household, get infected and come through the hospital. And then their either siblings or parents, grandparents, they would then be next in line to come into the hospital, you know?

Scott Webb: And what were those conversations like? Whether they were in English. Spanish or Spanglish, a combination of the two, what were those conversations like with their families, especially as you say, when you've got spouses and grandfathers and, you know, various family members, all being treated at the same time?

Dr. Mario Cole: Very difficult, because especially as close as this community is with each other, family members, let’s say a patient was in the hospital, they typically knew someone who had died of COVID. And so they were very fearful. And so they were calling in multiple times during the day to check on their loved one. And then they were also asking questions as to, "I saw my grandfather three days ago right before he got admitted. What should I be looking out for? Is there a vitamin cocktail that I can take? Should I start exercising, stop exercising?" There were a multitude of questions that they had where they were trying to figure out how to protect themselves.

Scott Webb: Yeah. And I'm sure some of those questions you could answer and some of them you couldn't and maybe you could answer them today, but we're talking about the peak back then. And when we talk about that, how many COVID units did SVMH have at the height of the pandemic? How many patients were you treating in a day? Just take us through what life was like there at SVMH.

Dr. Mario Cole: So early on, we recognized that we needed to isolate these patients from the general ICU population. So we took our normal one ICU and split it into two and we moved the COVID aspect of it upstairs to Tower 5. Then that became full of patients. And we ended up having to expand the two additional COVID units on Tower 3 and Tower 4 that were not sick enough to be on life support, but bordering and could be on life support at any moment. So at one point, we were running three COVID units in addition to the regular ICU and regular floor patients.

At the height of the pandemic, from what I can recall, we had, I believe at one point, 77 or 78 patients in total in the hospital at the same time. There was one particular week where I started off with 15 isolated and intubated COVID patients in the ICU. Fifteen of them on ventilators, as I mentioned, all critically ill and potentially at risk of dying.

Scott Webb: Yeah. And of course, you know, you mentioned the regular ICU and maybe somehow lost in all of this that we've heard, people suffering from potential stroke or heart attack haven't been going to the hospital and we've kind of covered that in some other podcasts, but there are regular patients too, right? You have a regular ICU and you have people coming through the emergency department and ending up in the ICU and you've got all these COVID units. How did you manage all that? How did you guys juggle all of that?

Dr. Mario Cole: There are some things that happened that were unfortunate, but we were able to take advantage of, number one, once the pandemic hit this area, everyone was afraid to come into the emergency room or even afraid to come into clinics. So ER visits went down, our clinic volume went down tremendously. And what that did is it freed up additional staff. So we typically have a pulmonologist in the office, but when the patients weren't coming to the office, we recruited that physician out of the office into the hospital and we were able to put one pulmonary critical care physician in the regular ICU and one in the COVID ICU, so that we effectively doubled our coverage.

And we also had, because surgeries were down and ER volume was down, we were able to recruit ER, nurses and post-surgical unit nurses and OR nurses to come up early on until we were able to recruit traveling nurses to kind of help fill in. But, because again, our surgical volume, ER volume and clinic volumes were down, which is not a good thing, we were able to take advantage of the fact that we had that surplus labor force to help us in the COVID ICU.

Scott Webb: Yeah, it does sound like it was all hands on deck and unintended consequences, of course, with not as many folks coming in for stroke, heart attack, whatever it might be. You're able to reallocate some of those, you know, human resources.

Dr. Mario Cole: That's correct.

Scott Webb: Amazing. How did you keep hope alive when things worsened there? Not just in Salinas, but Monterey County, and what we were hearing throughout the rest of the country. How did you personally, and everybody else keep hope alive?

Dr. Mario Cole: When you're dealing with life and death situations, you always try and paint an accurate, but as positive picture as you can. And not everyone with COVID dies. And sometimes, people fixate on that because they'll know someone that died. And they say, "Well, if it happened to them, it can happen to me."

But a majority of the patients that came through that tested positive in our drive-through COVID testing unit survived. The majority of those never ended up requiring hospitalization. And I would imagine the majority of patients that were hospitalized for COVID, who were not put on ventilation or ventilators survived.

And then there was a good percentage of patients that actually ended up on ventilators that did survive. And so when you're talking to a patient who's sitting in front of you and who's suffering from COVID and you're explaining to he or she what it is that we're trying to do and what we can do and what we can offer, you always say, "Most people survive COVID." And so it kind of gives them a ray of hope and it gives them the strength to fight.

Scott Webb: Yeah, you're right. Most people who do develop COVID-19 do tend to survive, but of course, as we know others do not. And so when we talk about the treatment options and things that you employ there, let's talk about some of the medications you used at SVMH. How are you treating COVID-19 patients?

Dr. Mario Cole: It kind of changed. So early on, there was really no effective treatment and so everything was supportive care. You would give them supplemental oxygen. If they couldn't eat, you would give them IV fluids. If they developed a co-infection like a bacterial co-infection, you would give them antibiotics. But it wasn't until a little bit later in the course that we started developing or getting access to medication because remdesivir, an anti-viral agent, was proposed as treatment. But initially, it was very difficult to get. Only a few hospitals in California were given shipments of remdesivir.

Eventually, all hospitals then had access to it. In the meantime, studies came out suggesting that dexamethasone, which is a steroid given a certain dose for a certain duration, actually decreased mortality. And so we actually started giving everyone dexamethazone and then as soon as we had access to remdesivir, the antiviral agent, we were then giving that in addition to the dexamethazone.

And then later on, there was some talk about convalescent plasma, whether it potentially would be beneficial. And so certain patients were given convalescent plasma. And so again, the treatment course kind of changed as our knowledge of the disease and treatment of the disease evolved.

Scott Webb: Yeah, it definitely did. And I'm sure that it was comforting in a way that you had things that you could use. And I remember doing podcasts on convalescent plasma and things and some of the, you know, understanding of that was that if used early enough, it could be effective. But if patients weren't diagnosed or didn't make it into the ICU quickly enough that it wouldn't work.

And so there was a lot to learn about all this, and I'm sure that it was comforting to know that you had some things, you know, some real tangible things that you could use to treat people, to prevent mortality, which is amazing. And I know there's been some recent studies suggesting a possible link between blood type and COVID-19 susceptibility and severity. So do you have any more information on that?

Dr. Mario Cole: Well, there was another study that was just put out, I think, March 3rd, which suggested that, those patients that had blood type A were more susceptible to severe cases of the COVID-19 illness. And that's interesting, but the problem is that you can't control your blood type and that’s something that people don't understand. This is something that's inherited, either type A, B, or AB or O. And most patients don't even know their blood type.

And so it's probably more from an academic or scientific standpoint, but from a practical use, there's not much that you can do alter your blood type. There isn't anything you can do to alter your blood type. So it wasn't something that we found clinically useful. And not all people that had severe courses of COVID were type A, right? And so therefore, we didn't modify our treatment based on blood type. And basically, we treated you based on your phenotype, how your disease course was progressing. That was more important than your blood type.

Yeah, that's interesting. And you're probably so right, most people don't know their blood type. Dr. Cole, thanks so much for your time today. I'm looking forward to continuing our conversation in episode two.

Be sure to check out part two of this series. And for more information on COVID-19, go to svmh.com/coronavirus.

And we hope you found this podcast to be helpful and informative. This is Ask The Experts from Salinas Valley Memorial Healthcare System. I'm Scott Webb. Stay well, and we'll talk again next time.