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Scott Webb: Whether or not you view the last three years or so as a dream or a nightmare, COVID-19 has left its mark on all of us. On today's podcast, I'm speaking with doctors Mario Cole and David Ramos, and they're here today to talk about their experiences in the ICU and emergency department respectively, and the lessons they've learned from COVID-19. This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb.

So doctors, thanks so much for your time today. We're going to sort of get caught up a little bit here after all these years of COVID and what everybody's been through, both in the emergency department and otherwise. So, Dr. Ramos, I'm going to start with you. How did you mentally prepare for what was coming your way if you could do that? And was it as bad as you thought it was going to be? Or was it somehow maybe even worse?

Dr. David Ramos: It was worse. A lot of these things I'm used to, you know, compartmentalizing disaster or I'm a big denier, right? So, I saw the water go out, as it were for the tsunami, and I'm like, "Nah, it's not this bad." And then, it started coming at us. And everybody reacts a different way, you know, whether you're in the emergency room or upstairs in the ICU or something like that, right? And me, I'm always about minimizing what I'm looking at. I prepare, you know, that is I have my stuff ready for bad things. But there was one guy in our group Dr. Nikolas Greenson, who was looking at the data. He is really a gifted guy looking at these things, even when it's abroad. And he is like, "No, I think this one's real." Any case, we were preparing as it came.

And the other thing was our response was multifaceted. We were thinking it was going to be a bad surge for flu. And we had a guy who ran our area in emergency preparedness. He had come the April before. And so, that was kind of an autopilot. He'd already prepared by getting tents to come to us anyway for what we thought was going to be a bad flu year. And the other thing he did that was just fortuitous is that he had a core of our nursing department go through the FEMA course in Alabama. So, our nurses had already gone through this process even before we decided COVID was out there, and it synchronized beautifully.

So, you're asking me mentally and then physically, I try to prepare for the worst once I decide that it is in fact coming. And it took me about a week or two to decide, yes, it is coming and we need to prepare. So, to answer your question, part of it it's denial. And the other part is career training, be prepared for the worst, and that's always there. I have that in my quiver to pull out.

Scott Webb: So Dr. Cole, turning to you, how did you mentally prepare for what was coming your way? When we think about COVID and all that that implies, was it as bad as you thought it was going to be or potentially worse?

Dr. Mario Cole: You know, I read as much as I could in the online reports about what was happening in New York. And so, I was able to prepare for what turned out to be a very difficult experience for all of us.

Scott Webb: Yeah. I'm wondering if you could just expand on that a little bit. You know, we all sort of heard things, news, social media, whatever. But you, especially as a medical professional, how did you sort of maybe brace for what was coming your way, you know, that kind of thing?

Dr. David Ramos: By reading the reports from other folks who experienced the crisis before us, I was able to understand that we were going to have episodes or instances where we would be short staffed, overworked, and running out of different materials, medications, beds, ventilators. We spent a lot of time preparing alternative ways to ventilate patients and sedate patients. Fortunately for us, we never ran out of ventilators, but we did have to change some of the medications we were using for sedation because we did run out.

Scott Webb: Yeah, I understand. And in doing some of these and talking to Dr. Ramos, you know, he had mentioned that there was some preparation that had been done for what everybody thought was going to be a bad flu season before COVID got here. So, there were some things in place for, you know, flu that were then able to be sort of applied to COVID in terms of the number of the patients and just kind of being flooded with cases and so on. Do I have that right?

Dr. David Ramos: Correct. We knew that there would be a number of patients requiring life support in the form of mechanical ventilation. Each hospital has a limited number of ventilators, and I think we had 20 or 30. But from reading news reports, we knew that that may not be enough. And the hospital had already invested in several different devices that could ventilate more than one person on the same machine. So going into the crisis, we knew that we would be able to keep up with ventilators above our usual capacity, and that was reassuring. Then, we also investigated alternative means of sedation using drugs that we don't routinely use to sedate patients, because sedation is a very important part of keeping someone comfortable on a ventilator. Fortunately, for the most part, we have most of the medications that we were required. But occasionally, we actually had to use some of the alternative agents to sedate patients.

Scott Webb: So Dr. Ramos, back to you. What have the last three years been like for you and your colleagues in the emergency department? I mean, I have been to the emergency department during COVID and seeing doctors and nurses in full PPE was like something out of a movie, something I never expected to see. So just wondering from your perspective, what's it been like in the ED?

Dr. David Ramos: Well, I mean, the first thing you run into is, you know, it slows you down because all of a sudden, you're trying to decide who and who isn't COVID-positive. And at first, we were just struggling to get tests. But any room that you entered where somebody was at risk for COVID, you got to don your PPE, you know, and that's a process, it's a painstaking process and then doffing it too. And so, it's a whole mental difference. You got to pause and you got to do all these things and you got to do it right, especially early on when things were so virulent.

And after being so used to going in and out of rooms and fine tuning the efficiencies without COVID, you do this stuff, it's again, for me, you know, bringing back the army, is what we used to call mission-oriented protected posture, whether we fought chemical, mostly chemical warfare, but we had to do the same thing if it was biological. You had to put on these suits and it slowed you down, that was the most annoying part. And it was the same thing in the emergency department. You know, even though we're doing this, we're trying to stay efficient and try to see the other things that you see. It was like that, and then evolving that. First in the initial time that you see somebody, are they critical? Are they not? Just a whole different way thinking day to day and that's, you know, three years later, still in the back of your mind. Do I need to be doing this even though you think you might be immune? I'm fully vaccinated and, you know, I'm looking back over the last three years and I think I've been infected twice, even though I've never registered positive. So, you know, I think I'm better immunologically, but I still, in the back of my mind, after three years have done this.

And the other thing, after three years, whether we talk about it consciously or not in the emergency department, and I'm not even speaking for the rest of the hospital, it's taken its toll. It's taken its toll. One of the other things that we have that we didn't before, docs come into the hospital to work regardless of how they're feeling, right? "Oh, I got a cold. I'm not coming in," or even maybe the flu. With COVID, that was different. And now, we have to take our sick call seriously. And so, our schedule took hits where we didn't take hits before and that put a extra load on the folks that were back and healthy. And so over the course of three years, yeah, that's taken a toll on morale, big time on morale. And I think we've seen a lot more burnout in our ranks as a result of this. It's exponentially increased, particularly in my group.

Scott Webb: Yeah. And Dr. Cole, what have the last three years been like for you and your colleagues in critical care, in the intensive care unit, taking care of so many severely ill COVID patients?

Dr. Mario Cole: So as a critical care doctor, I take care of the sickest patients in the hospital. I've been doing this now eight years, but I've been in the medical field for 23 years. And routinely, over the course of a year, I would do five or six death summaries. This is a summary basically summarizing why a patient presented to the hospital, what their diagnoses were and why they ended up succumbing to their illness. So, we were used to doing, or I was used to doing five or six of those a year. Well, during COVID, I was doing two or three a week, and that was a tremendous uptick in the number of death summaries that I was performing.

You also heard reports of physicians that come into the illness. In fact, my father, an immersion medicine physician in Los Angeles, lost three of his partners to COVID. And so, certainly, we were all concerned as we were sharing stories of what had happened that we were also going to succumb to the illness. So, it was a quite difficult time, not only watching patients die at a much larger pace than we were accustomed to, but also colleagues dying of the illness that we were taking care of, something that we've not experienced before.

Scott Webb: Yeah, I understand that completely. And just kind of wondering, when we think about your mental health, how did you deal with seeing patients maybe wearing full PPE and as uncomfortable as that could be at times? How'd you take care of your mental health and so on?

Dr. Mario Cole: After speaking to my father and learning that three of his colleagues over a period of several months died, I started to realize that, you know, I wasn't going to live forever. And I started going through a checklist of things that I would want to accomplish prior to succumbing of any illness. One of which was to travel to Europe. We had never gone to Europe, and number two was to get back into playing music. So in addition to booking a trip to Europe, our first trip to Europe for my family, which was a very rewarding experience, I also discovered my old saxophone that my parents had purchased back in the fourth grade and had it tuned up and I started playing music again. I hadn't played in 35 years. And in fact, we actually formed a band and actually perform for the hospital now.

So if there was a positive outcome for COVID from a personal life standpoint was that it encouraged me to start traveling, things that I had wanted to do that I hadn't done because I've been too busy at work. And then two, it got me back into playing music and both of those together had really been uplifting for me.

Scott Webb: Yeah, I hear what you're saying for sure. And wondering, Dr. Ramos, how do you deal when you think about your life and who do you see and who do you not see? How have you personally dealt with that? How do you take care of your own mental health? And as you're saying and what it's been like in the emergency department, you know, you've got some patients who recovered, didn't recover, a lot of times we're saying goodbye over, you know, iPad and messaging, digital messages and things and not directly speaking with people, I'm sure it's just been an entirely weird time. And just wondering how you do it, basically. How are you managing this and how do you take care of your own mental health?

Dr. David Ramos: When you're first starting to see this, you know, how do I decide what to see? You always go into the room, there's a certain level of denial when you go in and say, "Really, I'm not at risk for any bad things happening to me." And I think all of us have a little bit of a degree of that, and that's the tool I use to do the right thing depending on who I'm seeing, what I'm seeing, and how I'm seeing it.

In terms of the physical thing about how do I take care of myself, I just made sure I stuck to my technique, that is, you know, don and doffed really meticulously. Beyond that, when you start seeing folks dying and so many folks dying or begging you to save them and you may or may not be able to help them, there's the psychological ways that you protect yourself and then after you get home. That's 40 years of doing the business and having different wherewithal that you accumulate over time to deal with that. I'm introspective. I've gone in and out of therapy for years, you know, to make sure I'm in touch with the things I need to be and people I'm around, people over the years that are like-minded.

The good part for me is that I lean toward introversion. Even though I sound very social, I lean towards introversion. So, I was able to go home and not worry about being at meetings. And while restaurants are nice, I cook too, and the idea of doing that kind of stuff. And then, walking around, I live in the base of a canyon, and I can walk around pre easily and get outside and relax, you know, burn a fire in the outdoor pit, read the things I like to read, and I was okay. Not great big things to do, but that's what I do.

Scott Webb: Dr. Cole, for you, what are the most important lessons or lesson that we learned from COVID-19?

Dr. Mario Cole: For me, it was about understanding that, depending on your beliefs, that this is a finite experience for us and that we should understand that. And that things that were previously important to you may not be as important, and that you should explore some of the things that you mean to do but haven't done because of other reasons. And so, I think the takeaway message is appreciate life, experience things that you want to experience, and understanding that this is a finite time for us.

Scott Webb: Yeah, absolutely, finite for sure. Is there anything else you want listeners to know about COVID, the last three years, where we are today, your optimism level for the future? How would we sort of, at least for today, put a period at the end of the sentence?

Dr. Mario Cole: I think it's to understand that we're all in this together. And politics aside, you know, geographics aside, we're all in this together. And something that'll affect one part of the world will eventually come and affect the rest of us. And that was very clear during this COVID pandemic. And that's something that we should understand, that we're all in this human experience together.

Scott Webb: Yeah, you're so right. We're all humans. We're all in this together. And I want to give you an opportunity, probably give the last word to you here, Dr. Ramos. If you could look into your crystal ball, if you have it there, what do you see happening with COVID-19 in the next two years? With the understanding, of course, that we're not going to hold you to this because you just never know what's going to happen. But what's your sense of things? Where are we headed over the next couple of years?

Dr. David Ramos: I think it's going to mitigate. I think, you know, we've had experience with a bunch of different infectious disease over the decades, centuries and millennia. And I think experience over time has taught us one way or the other things mitigate. And with regard to COVID, I think, you know, we've effectively learned how to immunize against, it to where it doesn't kill us. It's not so virulent. I'm tapping based on the experience of, you know, different things, like different flus that we've had that have come and gone and the different SARS and then, before that, HIV. You know, HIV used to be a death sentence. And now, we have folks living with it for decades, because we've had effective treatments and whether they're vaccines or medications. You know, it used to be syphilis used to kill you 500 years ago. You got it, you died. And then, over time, it evolved and became it killed you after 30 years or so. And that's just kind of my crystal ball.

In my mind, it was always a foot race to get a vaccine out there in conjunction with us building up immunity and outrunning the lethality of the first one or two strains that was there, knowing that it would mutate into something different and our bodies would respond better. That was the very least of hope, if not, what I felt was an actuality. I felt that was always common. So, we'll do it via immunizations, you know, if not every year, every few months, or every couple of years. And it'll just be a new reality that we have. Some folks are going to get immunized and some aren't.

Scott Webb: I think you're right. I hope you're right. You know, and it's been so great catching up with you both and just hearing your perspectives on the ICU and the ED at Salinas Valley Health after all these years of COVID. I just want to thank you both for joining me. You both stay well.

Dr. David Ramos: All righty. Take care, Scott.

Dr. Mario Cole: All right, you too. Thank you.

Scott Webb: And if you found this podcast to be helpful, please be sure to tell a friend, neighbor, or family member and subscribe, rate, and review this podcast and check out the entire podcast library For additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.